Endometriosis and Adenomyosis MCQs

Explanation: Evaluating statements about pelvic endometriosis:

• a) Is premalignant (False): Endometriosis is a benign condition. While there's a very slightly increased risk of certain ovarian cancers (endometrioid, clear cell) arising in association with endometriosis (particularly atypical endometriosis), it is not considered a premalignant condition in itself. The vast majority of cases remain benign.
• b) Treated with Mirena (True): The Levonorgestrel-Intrauterine System (LNG-IUS, Mirena) is an effective treatment for endometriosis-associated pain, particularly HMB and dysmenorrhea. It releases progestogen locally, causing endometrial decidualization/atrophy and reducing inflammation. It's recommended by NICE NG73.
• c) Diagnosed by USS (False): While ultrasound (especially specialist TVS) can detect endometriomas ('chocolate cysts') and sometimes deep infiltrating endometriosis (DIE) nodules or adhesions ('soft markers'), the gold standard for diagnosis remains visual inspection via laparoscopy, preferably with histological confirmation of biopsies. USS can suggest the diagnosis but cannot definitively confirm or exclude it, especially for superficial peritoneal disease.
• d) Infertility caused by an ovulation (False): Endometriosis typically does not cause anovulation. Infertility is usually due to mechanical factors (adhesions, distorted anatomy), inflammation affecting gametes/embryos, and potentially altered oocyte quality, rather than a lack of ovulation. Most women with endometriosis ovulate regularly.
• e) Family history is present (True): There is a recognized genetic predisposition. Women with an affected first-degree relative (mother, sister) have a significantly higher risk (up to 7-10 times) of developing endometriosis compared to the general population.

References:

• NICE Guideline NG73: Endometriosis: diagnosis and management (September 2017) (Link)
• RCOG Green-top Guideline No. 24: The Investigation and Management of Endometriosis (Sept 2022) (Link)

Explanation: Assessing treatment statements for endometriosis:

• a) Drainage an endometrioma compared to cystectomy reduces the risk of recurrence (False): Simple drainage or ablation of an endometrioma cyst wall has a significantly higher recurrence rate compared to excisional cystectomy (removing the cyst wall). Cystectomy is generally preferred for reducing recurrence, although it carries a higher risk of reducing ovarian reserve. NICE NG73 recommends excision over ablation for endometriomas.
• b) Hormone replacement therapy is contraindicated following hysterectomy and bilateral salpingo-oophorectomy (False): HRT is NOT absolutely contraindicated. In women undergoing hysterectomy and BSO for severe endometriosis, residual microscopic deposits might remain. Estrogen-only HRT could potentially stimulate these deposits. Therefore, combined estrogen-progestogen HRT is often recommended, even without a uterus, to suppress potential residual disease. Alternatively, careful monitoring on estrogen-only HRT is possible. It's a nuanced decision, but not a strict contraindication.
• c) It is treated with gonadotrophin releasing hormone analogues (True): GnRH analogues (e.g., leuprolide, goserelin) are effective medical treatments for endometriosis-associated pain. They induce a hypoestrogenic state ('medical menopause'), suppressing endometrial implant activity. They are usually used short-term (3-6 months) due to side effects (menopausal symptoms, bone density loss), often with add-back therapy.
• d) It is treated with the combined oral contraceptive pills (True): COCPs, used continuously or cyclically, are a first-line medical treatment for managing endometriosis-associated pain (dysmenorrhea, non-menstrual pelvic pain). They suppress ovulation and reduce menstrual flow.
• e) Medical treatment improves fertility (False): As previously discussed, medical treatments suppress ovarian function and do not enhance spontaneous fertility.

References:

• NICE Guideline NG73: Endometriosis: diagnosis and management (September 2017) (Link)
• RCOG Green-top Guideline No. 24: The Investigation and Management of Endometriosis (Sept 2022) (Link)

Explanation: This 46-year-old woman has severe symptoms (dysmenorrhea, dyspareunia) suggestive of significant endometriosis, confirmed by bilateral endometriomas on USS and a raised CA125 (often elevated in endometriosis, though non-specific). Given her age (likely nearing menopause, fertility may not be a primary concern) and the severity of symptoms impacting quality of life:

• a) Laparoscopic bilateral cystectomy (Possible but perhaps not best): While removing the endometriomas might alleviate symptoms, recurrence is possible, and she may still have underlying adenomyosis or diffuse peritoneal endometriosis causing pain. Given her age, a more definitive solution might be preferred.
• b) Laparoscopic hysterectomy (Incomplete): Removing the uterus would treat potential adenomyosis and stop menstruation (dysmenorrhea), but leaving the ovaries with endometriomas means the source of estrogen driving the disease remains, and the cysts themselves aren't treated.
• c) Total hysterectomy and bilateral salphingo-oophorectomy (Most Appropriate): This offers definitive treatment by removing the uterus (addressing dysmenorrhea, potential adenomyosis) and the ovaries (removing the endometriomas and the source of estrogen driving the disease). This is often considered the best option for severe symptoms in women nearing menopause who do not desire future fertility. Post-operative HRT would likely be discussed.
• d) Treat with regular opioids (Inappropriate): Opioids only mask pain, don't treat the underlying cause, and have significant side effects and risk of dependence. Not a primary treatment strategy.
• e) Treat with GnRH analogues (Temporary): GnRH analogues could provide temporary symptom relief but are not a long-term solution due to side effects and symptom return upon cessation. They might be used pre-operatively, but not as the primary definitive treatment here.

References:

• NICE Guideline NG73: Endometriosis: diagnosis and management (September 2017) (Link) - Discusses surgical options including hysterectomy +/- BSO.
• RCOG Green-top Guideline No. 24: The Investigation and Management of Endometriosis (Sept 2022) (Link)

Explanation: This clinical presentation (triad of pelvic pain, dysmenorrhea, deep dyspareunia) along with examination findings (fixed retroverted uterus, tender nodules in the Pouch of Douglas/uterosacral ligaments) is highly suggestive of deep infiltrating endometriosis. Mefenamic acid (NSAID) has provided insufficient relief. NICE guideline CG143 (Endometriosis) recommends hormonal treatment or surgery.

• A (Correct - based on NICE): NICE guidelines generally recommend trying hormonal treatments first before resorting to complex surgery for endometriosis-associated pain, unless there are specific indications for primary surgery (e.g., large endometrioma, suspected severe disease where diagnosis confirmation is needed). COCPs (continuous or cyclical) or progestogens (like LNG-IUS, dienogest, depot injection) are first-line hormonal options. Given NSAIDs failed, starting a COCP is a standard next step.
• B (Incorrect): GnRH analogues are effective but considered second-line hormonal treatment due to side effects; usually used short-term or with add-back HRT.
• C (Incorrect): Laparoscopic excision of endometriotic deposits is the definitive surgical treatment, but guidelines often recommend trying hormonal therapy first unless patient preference or clinical indication points towards primary surgery. Excision, especially of deep infiltrating nodules, is complex surgery.
• D, E (Incorrect): Hysterectomy (+/- BSO) is reserved for severe cases where other treatments have failed and fertility is not desired; it's not the initial approach.

Decision rationale: Following NICE pathway - failed analgesia -> offer hormonal treatment (COCP/progestogen) -> if fails or unsuitable -> consider GnRH or surgery.

References:

• NICE Guideline CG143: Endometriosis: diagnosis and management (Published Sep 2017)

Explanation: This young woman (26) presents primarily with subfertility. Examination findings (fixed retroverted uterus, adnexal mass) and USS confirm a 5cm endometrioma, suggestive of moderate-severe endometriosis (Stage III/IV), which is likely contributing to her infertility. Management should focus on improving fertility chances.

• a) COCP (Incorrect): COCPs suppress ovulation and are used for pain management, not fertility enhancement.
• b) Cystectomy (Best Option): Laparoscopic excision (cystectomy) of the endometrioma is often recommended in women with subfertility and endometriomas >3-4cm, especially prior to attempting Assisted Reproductive Technology (ART) like IVF. Surgery aims to restore anatomy, potentially improve pelvic environment, and facilitate oocyte retrieval if IVF is needed. While surgery carries a risk of reducing ovarian reserve, NICE NG73 suggests considering excision for endometriomas ≥3 cm before IVF. RCOG GTG 24 also discusses surgery for fertility.
• c) Danazol (Incorrect): Danazol is an older medical therapy with significant androgenic side effects, used for pain suppression, not fertility.
• d) Oophorectomy (Incorrect): Removal of the ovary is inappropriate in a young woman desiring fertility.

Rationale for Surgery before ART:

• May improve access for oocyte retrieval during IVF.
• May reduce inflammation potentially harmful to gametes/embryos.
• Confirms diagnosis and allows staging/treatment of other endometriosis lesions.

References:

• NICE Guideline NG73: Endometriosis: diagnosis and management (September 2017) (Link) - Recommends considering laparoscopic excision of endometriomas ≥3 cm before IVF.
• RCOG Green-top Guideline No. 24: The Investigation and Management of Endometriosis (Sept 2022) (Link)

Explanation: This clinical picture is highly suggestive of adenomyosis.

• A (Incorrect): Endometriosis causes dysmenorrhea but usually not HMB or significant uterine enlargement.
• B (Incorrect): Uterine fibroids can cause HMB and uterine enlargement (often irregular), but tenderness and severe dysmenorrhea associated with symmetrical enlargement point more towards adenomyosis.
• C (Correct): Adenomyosis classically presents in multiparous women in their late reproductive years with heavy, painful periods (HMB and dysmenorrhea) and a symmetrically enlarged, often tender or 'boggy' uterus.
• D (Incorrect): Pelvic inflammatory disease is an infection, typically presenting with pain, discharge, fever, and cervical motion tenderness; not chronic HMB and uterine enlargement like this.
• E (Incorrect): Uterine polyps cause HMB or intermenstrual bleeding but not typically uterine enlargement or significant dysmenorrhea.

Explanation: Adenomyosis is the presence of endometrial tissue within the myometrium.

• (a) Is uncommon in nulliparous women (True): Adenomyosis is more commonly diagnosed in parous women, particularly those in their 40s and 50s. Prior uterine surgery (like C-section) is also a risk factor. Therefore, it is relatively uncommon in nulliparous women.
• (b) Common in 3rd decade of the life (False): While it can occur earlier, it's most commonly diagnosed in women in their 4th and 5th decades (ages 30s and 40s, peaking around 40-50).
• (c) Associated with deep dyspareunia (True): Symptoms often overlap with endometriosis and can include heavy menstrual bleeding (HMB), dysmenorrhea (painful periods), chronic pelvic pain, and deep dyspareunia (pain during deep intercourse).
• (d) Typically presents with uterine enlargement (True): The infiltration of endometrial glands and stroma causes myometrial hypertrophy, leading to a diffusely enlarged, often globular and tender uterus.
• (e) Predispose to uterine malignancy (False): Adenomyosis itself is benign and is not considered a premalignant condition or a direct risk factor for endometrial cancer, unlike atypical endometrial hyperplasia.

References:

• NICE Guideline NG88: Heavy Menstrual Bleeding: assessment and management (March 2018, updated May 2021) - Mentions adenomyosis as a cause of HMB.
• RCOG Patient Information Leaflet: Adenomyosis (Link)

Explanation: This clinical scenario is classic for adenomyosis.

• A (Correct): Adenomyosis typically presents in women aged 35-50, especially multiparous, with heavy menstrual bleeding (HMB), dysmenorrhea, and often a symmetrically enlarged, tender ('boggy') uterus.
• B (Incorrect): Pelvic endometriosis causes dysmenorrhea and pelvic pain but usually not HMB or significant uterine enlargement.
• C (Incorrect): PID is an infection causing pain, discharge, fever, not typically chronic HMB with a tender, enlarged uterus.
• D (Incorrect): Pyometra is a collection of pus in the uterus, usually occurring postmenopausally or with cervical stenosis, presenting with discharge, pain, and fever.
• E (Incorrect): Submucosal fibroids cause HMB but usually not significant tenderness or the classic 'boggy' feel associated with adenomyosis.

Explanation: This constellation of symptoms and signs points strongly towards adenomyosis.

• A (Correct): Adenomyosis typically affects multiparous women in their 40s, causing dysmenorrhea (painful periods), menorrhagia (HMB), and a symmetrically enlarged, often tender, uterus (10 weeks size is enlarged).
• B (Incorrect): Leiomyomata (fibroids) can cause HMB and enlarged uterus, but dysmenorrhea might be less prominent unless degenerating, and the uterus might be irregularly enlarged.
• C (Incorrect): Chronic PID causes chronic pain but not typically cyclical HMB and uterine enlargement like this.
• D (Incorrect): DUB (Dysfunctional Uterine Bleeding) is HMB without identifiable structural pathology; here, the enlarged uterus suggests pathology.
• E (Incorrect): Pelvic endometriosis causes dysmenorrhea and pain but usually not significant HMB or uterine enlargement.

Explanation: This patient has HMB refractory to COCPs, along with features suggestive of endometriosis or potentially adenomyosis (retroverted uterus, tender posterior fornix - suggesting uterosacral ligament involvement or Pouch of Douglas disease). While ultrasound should be done first (implied perhaps already done if OCPs tried?), the failure of hormonal treatment and specific tenderness point towards needing definitive diagnosis, especially for endometriosis.

• A (Incorrect): CRP is non-specific.
• B (Incorrect): High vaginal swab is for infection.
• C (Correct): Laparoscopy is the gold standard investigation for diagnosing endometriosis. Given the symptoms (HMB possibly secondary to adenomyosis, pain suggested by tender fornix) unresponsive to COCPs and the specific examination finding, laparoscopy allows direct visualization and histological confirmation of endometriosis, and assessment for adenomyosis appearance.
• D (Incorrect): MRI can be useful for diagnosing deep infiltrating endometriosis or adenomyosis but is usually second-line to TVS and laparoscopy is often still needed for confirmation/treatment.
• E (Incorrect): USS (presumably TVS) is the first-line imaging but may miss superficial endometriosis deposits. Given the failure of OCPs and specific tenderness, proceeding to laparoscopy is often the next step to confirm diagnosis and plan further management.

References:

• NICE Guideline CG143: Endometriosis: diagnosis and management

Explanation: The combination of heavy menstrual bleeding (HMB), dysmenorrhea (painful periods), and a symmetrically enlarged, often tender, uterus (described as 14-week size here) in a multiparous woman in her 40s is highly characteristic of adenomyosis.

• A (Correct): Adenomyosis is the presence of endometrial tissue within the myometrium (uterine wall), leading to uterine enlargement, HMB, and dysmenorrhea.
• B (Incorrect): Endometrial polyps typically cause intermenstrual bleeding or HMB but usually don't cause significant uterine enlargement or dysmenorrhea.
• C (Incorrect): Submucosal fibroids cause HMB and can enlarge the uterus, but the enlargement is often irregular, and severe dysmenorrhea may be less typical than with adenomyosis unless the fibroid is degenerating or very large.
• D (Incorrect): Pelvic endometriosis causes dysmenorrhea, pelvic pain, and dyspareunia, but typically does not cause HMB or significant uterine enlargement (unless co-existing with adenomyosis).
• E (Incorrect): Pelvic Inflammatory Disease (PID) causes pelvic pain, discharge, and possibly irregular bleeding, but typically presents more acutely with fever and tenderness, and doesn't cause chronic uterine enlargement like this.

Explanation: The patient presents with dyspareunia (painful intercourse) and menorrhagia (HMB). Examination shows a retroverted uterus but no specific tenderness suggestive of active PID or significant endometriosis nodules (though absence of tenderness doesn't rule out endometriosis). Investigation should aim to identify structural causes for HMB and potential causes for dyspareunia.

• A (Correct): Transvaginal Ultrasound Scan (TVUSS) is the recommended first-line imaging investigation (NICE NG88 for HMB, NICE CG143 for endometriosis suspicion). It can assess the uterus for fibroids, adenomyosis (potential causes of HMB and sometimes dyspareunia), evaluate the endometrium, and visualize the ovaries (e.g., for endometriomas, though none suspected on exam here). It provides valuable anatomical information non-invasively.
• B (Incorrect): Abdominal USS is less detailed for pelvic structures than TVUSS.
• C (Incorrect): Laparoscopy is the gold standard for diagnosing endometriosis but is invasive and not the first-line investigation for these symptoms without more specific findings or failure of initial management.
• D (Incorrect): CPR (likely meant CRP - C-Reactive Protein) is a marker of inflammation, not a primary investigation here.
• E (Incorrect): High vaginal swab is for detecting infection (like PID), but no specific signs of infection were noted.

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management
• NICE Guideline CG143: Endometriosis: diagnosis and management

Explanation: Assessing statements about endometriosis:

• a) It’s a condition where functional endometrial cells grow outside the endometrial lining (True): This is the definition of endometriosis – the presence of endometrial-like tissue (glands and stroma) outside the uterus, primarily in the pelvis. This tissue responds to hormonal changes, causing inflammation, pain, and adhesions.
• b) Medical treatment of endometriosis enhances fertility (False): Medical treatments (hormonal therapies like COCPs, progestogens, GnRH analogues) aim to manage pain symptoms by suppressing ovulation and menstruation. They do not enhance natural fertility; conception often requires stopping these treatments or using assisted reproductive technologies (ART).
• c) Oocyte maturation defects contribute to infertility (True): Endometriosis-associated infertility is multifactorial. Contributing factors include pelvic adhesions distorting anatomy, inflammation affecting sperm/egg/embryo function and transport, and potentially impaired folliculogenesis and oocyte quality/maturation.
• d) Surgery for endometrioma reduces ovarian reserves (True): Surgical excision (cystectomy) of ovarian endometriomas, while often necessary for symptom control or prior to ART, can inadvertently remove healthy ovarian tissue surrounding the cyst wall, leading to a reduction in ovarian reserve (measured by AMH levels or antral follicle count).
• e) Surgical removal of an endometrioma increases fertility (False): While surgery might improve pain and potentially remove inflammatory factors, evidence that excising endometriomas definitively increases spontaneous pregnancy rates is limited and debated, especially for smaller cysts. It may be recommended before IVF in specific cases (e.g., large cysts hindering oocyte retrieval), but it doesn't guarantee increased natural fertility and carries the risk of reducing ovarian reserve. NICE guideline NG73 states "Do not offer surgery to women with endometriomas solely to improve spontaneous fertility as there is no evidence that this improves spontaneous pregnancy rates.".

References:

• NICE Guideline NG73: Endometriosis: diagnosis and management (September 2017) (Link)
• RCOG Green-top Guideline No. 24: The Investigation and Management of Endometriosis (Sept 2022) (Link)

Explanation: Reviewing the features of adenomyosis:

• a) Basal endometrium invades into myometrium (True): This is the defining pathological feature of adenomyosis – the presence of endometrial glands and stroma from the stratum basalis deep within the myometrium (>2.5 mm from the endo-myometrial junction).
• b) Present with painful heavy bleeding (True): Heavy menstrual bleeding (HMB) and dysmenorrhea (painful periods) are the classic symptoms. Chronic pelvic pain can also occur.
• c) Is a risk factor for leiomyosarcoma (False): Adenomyosis is benign. Leiomyosarcoma is a rare malignancy of the uterine smooth muscle (myometrium) and is not directly linked to adenomyosis.
• d) Nulliparity is a risk factor (False): Parity (having given birth) is generally considered a risk factor, not nulliparity. Increased exposure to estrogen and progesterone cycles might play a role.
• e) Uterine tenderness - bimanual examination (True): A diffusely enlarged, globular, and often tender uterus on bimanual pelvic examination is a typical clinical finding.

References:

• NICE Guideline NG88: Heavy Menstrual Bleeding: assessment and management (March 2018, updated May 2021)
• RCOG Patient Information Leaflet: Adenomyosis (Link)

Explanation: Evaluating statements on adenomyosis:

• a) Cesarean section is a causative factor (True): Prior uterine surgery, including Cesarean section, D&C, or myomectomy, is recognized as a risk factor. It's theorized that these procedures can disrupt the endo-myometrial junction, allowing endometrial tissue invasion.
• b) Causes intermenstrual bleeding (False): The classic bleeding pattern is heavy menstrual bleeding (HMB or menorrhagia). Intermenstrual bleeding (IMB) is less typical of adenomyosis itself, although it can occur, potentially due to associated conditions or dysfunctional uterine bleeding patterns. HMB is the hallmark.
• c) Causes secondary dysmenorrhea (True): Adenomyosis typically presents later in reproductive life (40s-50s) and causes worsening menstrual pain, fitting the definition of secondary dysmenorrhea (pain developing after years of relatively painless periods), as opposed to primary dysmenorrhea which starts with menarche.
• d) Predispose to adenocarcinoma of endometrium (False): As mentioned before, adenomyosis is benign and not considered a precursor to endometrial cancer.
• e) MRI is better than USS (True): Magnetic Resonance Imaging (MRI) generally has higher sensitivity and specificity than Transvaginal Ultrasound (TVS) for diagnosing adenomyosis, particularly in differentiating it from fibroids or assessing the extent of infiltration. TVS is often used first due to availability and cost, but MRI is considered superior for diagnostic accuracy.

References:

• RCOG Patient Information Leaflet: Adenomyosis (Link) - Mentions previous surgery as a risk factor.
• Dueholm M, Lundorf E. Transvaginal ultrasound or MRI for diagnosis of adenomyosis. Curr Opin Obstet Gynecol. 2007 Dec;19(6):505-12. (General medical knowledge supports MRI superiority)

Explanation: Reviewing endometriosis characteristics:

• a) Has a genetic predisposition (True): As noted previously, family history is a significant risk factor, indicating a genetic component.
• b) Causes superficial dyspareunia (False): While any pelvic pain can potentially manifest during intercourse, endometriosis is more classically associated with *deep* dyspareunia (pain on deep penetration), often due to involvement of the uterosacral ligaments, Pouch of Douglas, or rectovaginal septum. Superficial dyspareunia (pain at the vaginal entrance) is more commonly linked to conditions like vulvodynia, vaginitis, or inadequate lubrication.
• c) More in multipara than in nullipara (False): Endometriosis is generally considered more common or at least more commonly diagnosed in nulliparous women. Pregnancy and breastfeeding induce amenorrhea and hormonal changes that tend to suppress endometriosis progression and symptoms.
• d) Is treated with tibolone (False): Tibolone is a synthetic steroid with estrogenic, progestogenic, and androgenic properties, primarily used for HRT in postmenopausal women. It is not a standard treatment for managing active endometriosis in premenopausal women. Standard hormonal treatments include COCPs, progestogens, and GnRH analogues.
• e) Pain outstands the periods (True): While dysmenorrhea (pain *during* periods) is common, chronic pelvic pain (CPP) that occurs outside of menstruation is also a hallmark symptom for many women with endometriosis. The pain is not limited strictly to the days of bleeding.

References:

• NICE Guideline NG73: Endometriosis: diagnosis and management (September 2017) (Link)
• RCOG Green-top Guideline No. 24: The Investigation and Management of Endometriosis (Sept 2022) (Link)

Explanation: This patient has symptomatic adenomyosis (HMB, dysmenorrhea, enlarged uterus on USS) causing anaemia (Hb 8). She is 48, multiparous, and has ischaemic heart disease (IHD), which influences treatment choices (contraindication to COCPs). NICE NG88 provides guidance.

• A (Incorrect): DMPA (Depot medroxyprogesterone acetate) can be used for HMB but may have less favourable cardiovascular risk profile considerations with IHD compared to LNG-IUS.
• B (Incorrect): GnRH analogues are effective for symptoms but cause hypoestrogenism (menopausal side effects, bone loss) and are usually short-term; not ideal long-term management.
• C (Correct): Levonorgestrel Intrauterine System (LNG-IUS) is recommended as a first-line medical treatment for HMB by NICE NG88, including cases presumed to be due to adenomyosis. It significantly reduces bleeding, can improve dysmenorrhea, and has minimal systemic absorption, making it generally safe with IHD (UKMEC 2 - benefits usually outweigh risks, use with caution). It avoids surgery and systemic hormones like COCPs/GnRH.
• D (Incorrect): Total abdominal hysterectomy is definitive treatment but is major surgery; less invasive options like LNG-IUS should be tried first according to guidelines, especially given her comorbidity (IHD increases surgical risk).
• E (Incorrect): Transcervical resection of the endometrium (endometrial ablation) is less effective for adenomyosis (as the pathology is within the myometrium) and less favoured than LNG-IUS or hysterectomy for this condition.

References:

• NICE Guideline NG88: Heavy menstrual bleeding: assessment and management (Published March 2018, last updated Nov 2020)
• FSRH Guideline: Progestogen-only Methods (for UKMEC categories)

Explanation: Adenomyosis features revisited:

• a) Causes dyspareunia (True): Deep dyspareunia is a recognized symptom, likely due to uterine enlargement, tenderness, and associated pelvic congestion or inflammation.
• b) Periodic bleeding into sub endometrial space (True): This statement likely refers to the bleeding from the ectopic endometrial glands within the myometrium during menstruation, contributing to pain (dysmenorrhea) and uterine enlargement. While not strictly 'sub-endometrial', it's bleeding within the uterine wall.
• c) Common in nulliparous women (False): As established earlier, adenomyosis is more common in parous women.
• d) Hysterectomy is the definitive management (True): Hysterectomy (surgical removal of the uterus) is the only definitive cure for adenomyosis as it removes the source of the symptoms. It's typically reserved for women who have completed their family and have severe symptoms unresponsive to conservative measures.
• e) TVS is the mainstay of diagnosis (False): While transvaginal ultrasound (TVS) is often the first-line imaging modality and can suggest adenomyosis (features like globular uterus, asymmetrical myometrial thickening, myometrial cysts, indistinct endo-myometrial junction), MRI is considered more accurate for diagnosis, especially in differentiating it from fibroids. However, definitive diagnosis is histological, after hysterectomy. TVS is a key *initial* tool, but perhaps not the 'mainstay' for definitive diagnosis compared to histology or potentially MRI. Given the options, hysterectomy being definitive is a stronger 'true' statement than TVS being the 'mainstay'. (Revisiting based on common clinical practice: TVS is very frequently used and relied upon, so some might argue it *is* the practical mainstay. Let's check guideline emphasis.) NICE NG88 suggests TVS first line. RCOG info states diagnosis is 'suspected' based on symptoms/exam and imaging (TVS/MRI). Let's reconsider 'mainstay'. MRI has higher specificity/sensitivity. Let's mark (e) False because MRI is superior and histology definitive.

References:

• NICE Guideline NG88: Heavy Menstrual Bleeding: assessment and management (March 2018, updated May 2021)
• RCOG Patient Information Leaflet: Adenomyosis (Link)