Suspected Adenomyosis in a 27-Year-Old Woman with Infertility and Dysmenorrhea

Case at a Glance

A 27-year-old nulligravid woman presents with a history of severe dysmenorrhea, previous menorrhagia, and recurrent pregnancy loss while attempting conception. Transvaginal ultrasound shows possible myometrial changes raising suspicion for adenomyosis.

Patient's Story

The patient has a lifelong history of extremely painful menstrual cramps and previously experienced very heavy menstrual bleeding. She was on hormonal contraception for 15 years until April 2024 when she discontinued it to attempt conception. Since then, she has experienced four early pregnancy losses (chemical pregnancies) and has been referred to a reproductive endocrinologist for evaluation of unexplained infertility. She recently developed midcycle bleeding, prompting imaging evaluation.

Initial Assessment

Transvaginal ultrasound was performed in July 2024 following an episode of intermenstrual bleeding. The official radiology report described findings as 'normal pelvic ultrasound' with documentation of ovarian measurements only. However, the patient noted dark cyst-like spots on the images that raised her concern for adenomyosis given her symptom profile.

The Diagnostic Journey

Review of the ultrasound images by a specialist revealed small dark spots consistent with arcuate vessels rather than pathological cysts. There was possible mild myometrial heterogeneity that could suggest adenomyosis, though this finding alone is not diagnostic. Classical ultrasound signs of adenomyosis such as pencil shadowing, subendometrial cysts, bulbous uterine contour, focal myometrial thickening, or blurring of the endometrial-myometrial interface were not clearly present.

Final Diagnosis

Possible early or mild adenomyosis based on subtle myometrial heterogeneity, though ultrasound findings are not definitively diagnostic. The patient's clinical presentation of severe dysmenorrhea and reproductive difficulties supports the suspicion.

Treatment Plan

Given the clinical suspicion and the need for definitive diagnosis, particularly in the context of infertility evaluation, pelvic MRI was recommended as the next diagnostic step. MRI provides superior soft tissue contrast and is more sensitive for detecting adenomyosis, especially in early or mild cases where ultrasound findings may be subtle.

Outcome and Follow-up

The patient expressed gratitude for the detailed image review and explanation. She was advised to discuss MRI evaluation with her reproductive endocrinologist to confirm or rule out adenomyosis as a contributing factor to her infertility and symptoms. Further management would depend on MRI findings and correlation with her reproductive treatment plan.