Differentials
Leiomyomas (fibroids)
SIGNS / SYMPTOMS
Presenting symptoms may be similar to adenomyosis although pelvic pain/pressure may be non-cyclical in patients with leiomyoma. Pelvic examination may reveal an enlarged, nodular pelvic mass that can vary in size or shape.
Note that leiomyomas may co-exist with adenomyosis; the prevalence of adenomyosis in uterine specimens from women who have undergone hysterectomy for leiomyoma has been found to range from 15% to 57%.[39][40][41]
INVESTIGATIONS
Transvaginal ultrasound (TVUS): fibroids usually appear as well-defined hypoechoic lesions within the myometrium. Numerous small and diffuse intramural fibroids may appear as subtle heterogeneous echoes within the confines of the myometrium. Moderate to large fibroids may show gross uterine contour irregularities with a hypoechoic and heterogeneous echotexture.
Large pedunculated subserous fibroids can be difficult to distinguish from solid adnexal masses.
A degenerating fibroid that has outstripped its blood supply can have cystic areas within the fibroid. Calcification may be seen in degenerating fibroids.
MRI: pelvic or abdominal masses involving the uterus and adjacent structures.
Endometriosis
SIGNS / SYMPTOMS
Symptoms may be identical to those of adenomyosis.
Note that endometriosis may co-exist with adenomyosis; adenomyosis has been shown to be present in approximately 65% of women with histologically proven endometriosis.[17][38]
INVESTIGATIONS
TVUS: may show ovarian endometrioma (homogeneous, low-level echoes) or deep pelvic endometriosis such as uterosacral ligament involvement (hypoechoic linear thickening) or parametrium, bladder, or rectovaginal septum involvement.
MRI: hypointense, irregular thickening or mass of uterosacral ligament; replacement of fat tissue plane between uterus and rectum/sigmoid with tissue mass.
Definitive diagnosis is via direct visualisation on diagnostic laparoscopy and histopathology of suspected lesions confirming endometrial glands/stroma outside the uterine cavity.
Endometrial hyperplasia
SIGNS / SYMPTOMS
Obesity is a strong risk factor for atypical endometrial hyperplasia.[84][85] There may be a history of nulliparity and unopposed oestrogen use.[84]
Postmenopausal women may present with postmenopausal bleeding.[84] Premenopausal women may present with intermenstrual bleeding or a history of irregular heavy periods, oligomenorrhoea, or amenorrhoea.[84]
Note that both conditions may co-exist; some studies have indicated a strong correlation between adenomyosis and endometrial hyperplasia.[4][39]
INVESTIGATIONS
Endometrial biopsy provides differentiation and can also distinguish atypical from benign hyperplasia.
Polyps
SIGNS / SYMPTOMS
History of intermenstrual bleeding.
Polyp may be seen at the cervix on pelvic examination if arising from the cervical canal.
Note that polyps may co-exist with adenomyosis in approximately 7% of cases.[16][86]
INVESTIGATIONS
TVUS: well-defined homogeneous lesion that is isoechoic to endometrium, with stalk and centralised feeding vessel; preservation of endometrial-myometrial interface.
Sonohysterography: endometrial polyps appear as smooth, well-defined echogenic masses.
Endometrial cancer
SIGNS / SYMPTOMS
Older age (usually >50 years). There may be a history of intermenstrual or postmenopausal bleeding, obesity, nulliparity, unopposed oestrogen use, infertility, smoking, family history of endometrial cancer, and a personal or family history of hereditary nonpolyposis colon cancer (HNPCC).
Bimanual examination may detect a uterine or adnexal mass and/or a fixed uterus.
INVESTIGATIONS
TVUS: focally thickened endometrium (stripe) >4 mm in a postmenopausal woman merits further investigation.
Endometrial biopsy: adenocarcinoma present on histopathological examination; may be positive for genetic variant.
Ovarian cancer
SIGNS / SYMPTOMS
Typical symptoms represent advanced-stage cancer, and include early satiety, increased abdominal girth or bloating, and altered bowel habit. Urinary urgency or frequency may be present, and a palpable adnexal mass may be detectable on pelvic examination.
INVESTIGATIONS
CA-125: may be elevated (>35 units/mL).
TVUS: complex adnexal mass (solid and cystic) with multiple loculations or thick septa; ascites.
Histopathology: infiltrative destructive growth best demonstrated by clusters of disorganised cells, usually with desmoplasia.
Cervical cancer
SIGNS / SYMPTOMS
Post-coital bleeding, intermenstrual bleeding; there may be associated back pain and vaginal discharge; a history of epithelial cell abnormalities on screening and/or a positive test for human papillomavirus (HPV).
Cervical mass or bleeding may be present on pelvic examination.
INVESTIGATIONS
Colposcopy: abnormal cervical lesions.
Cervical biopsy: malignant cells.
Endometrial atrophy
SIGNS / SYMPTOMS
Most commonly occurs in postmenopausal women; often presenting with postmenopausal bleeding.
INVESTIGATIONS
TVUS or MRI: reduced endometrial thickness.
Interstitial cystitis
SIGNS / SYMPTOMS
Symptoms primarily localised to the bladder, e.g., urinary frequency and urgency. The patient may report pain with a full bladder that is relieved upon voiding.
INVESTIGATIONS
Cystoscopy with hydrodistension shows glomerulations (pinpoint mucosal haemorrhages) and Hunner's ulcers.
Pelvic inflammatory disease (PID)
SIGNS / SYMPTOMS
Fever, acute pain along with malodorous vaginal discharge and cervical motion tenderness or adnexal tenderness is a typical presentation of acute PID.
Chronic PID may be indistinguishable from adenomyosis.
INVESTIGATIONS
Vaginal cultures for Neisseria gonorrhoeae or Chlamydia trachomatis may be positive.
White blood cell count may be elevated.
TVUS: in advanced cases, may show complex adnexal masses with a heterogeneous echo-pattern.
Irritable bowel syndrome
SIGNS / SYMPTOMS
Change in bowel habits (constipation, diarrhoea, or alternating between the two); bloating. Pain is relieved by defecation or passing flatus.
INVESTIGATIONS
Diagnosis is usually clinical and based on an absence of ultrasound or MRI findings and negative laboratory tests (e.g., inflammatory markers, faecal calprotectin, faecal immunochemical test) to exclude other differential diagnoses.
Polycystic ovary syndrome (PCOS)
SIGNS / SYMPTOMS
Irregular menstrual cycle length, acne, hirsutism, obesity. There may be a family history of PCOS.
INVESTIGATIONS
TVUS: ≥20 follicles in each ovary measuring 2-9 mm in diameter, and/or increased ovarian volume (≥10 mL) in either or both ovaries.
Serum total and free testosterone: elevated.
Serum androstenedione ± dehydroepiandrosterone sulfate: elevated.
Serum luteinising hormone (LH)/follicle-stimulating hormone (FSH) ratio: >3.
Luteal phase serum progesterone: decreased.
Coagulopathy
SIGNS / SYMPTOMS
There may be a personal or family history of a bleeding disorder (e.g., von Willebrand disease [VWD]), easy bruising, bleeding gums, epistaxis, history of heavy menses from onset of menarche.
INVESTIGATIONS
Prothrombin time (PT): prolonged or normal.
Activated partial thromboplastin time (aPTT): prolonged or normal.
VWF antigen: diagnostic for VWD if <0.30 IU/mL.
Iatrogenic abnormal uterine bleeding
SIGNS / SYMPTOMS
May present with unpredictable or intermenstrual bleeding.
There may be a history of use of drugs associated with abnormal uterine bleeding (e.g., hormonal contraception, hormone replacement therapy, copper intrauterine device, anticoagulants, drugs affecting dopamine metabolism such as tricyclic antidepressants or phenothiazines).
INVESTIGATIONS
Clinical diagnosis.
Hypothyroidism
SIGNS / SYMPTOMS
History of weight gain, cold intolerance, hair loss, fatigue, or constipation.
Brittle nails, dry skin, non-pitting oedema, and delayed relaxation of deep tendon reflexes may be found on examination.
INVESTIGATIONS
Serum thyroid-stimulating hormone (TSH): elevated.
Free serum thyroxine (T4): low.
Anti-thyroid peroxidase antibodies: normal or elevated.
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