Differential Diagnosis for Pelvic Pain in a 42-year-old Woman
- Single most likely diagnosis
- Adenomyosis: This condition is characterized by the presence of endometrial tissue within the uterine wall, leading to a boggy uterus, painful menses (dysmenorrhea), and heavy menstrual bleeding (menorrhagia). The patient's symptoms of painful menses that have worsened over time, heavy bleeding, and a boggy uterus on examination are consistent with adenomyosis.
- Other Likely diagnoses
- Uterine Fibroids: These are common in women of reproductive age and can cause pelvic pain, heavy menstrual bleeding, and a palpable abdominal mass. While the patient's symptoms could be consistent with fibroids, the description of a boggy uterus is more suggestive of adenomyosis.
- Endometriosis: Although the patient's symptoms of pelvic pain and heavy menstrual bleeding could suggest endometriosis, the absence of other classic symptoms such as dyspareunia (painful intercourse) and the presence of a boggy uterus make this diagnosis less likely.
- Do Not Miss (ddxs that may not be likely, but would be deadly if missed)
- Ovarian Cancer: Although less likely given the patient's age and symptoms, ovarian cancer can present with pelvic pain and should be considered, especially given the patient's lack of recent cervical cancer screening.
- Ectopic Pregnancy: Despite the patient's history of tubal ligation, the possibility of an ectopic pregnancy, although rare, should not be entirely ruled out without further evaluation, given the potential for catastrophic consequences if missed.
- Rare diagnoses
- Uterine Sarcoma: A rare type of cancer that could present with pelvic pain and abnormal uterine bleeding. The patient's symptoms and examination findings are not highly suggestive of this diagnosis, but it remains a consideration in the broader differential.
- Pelvic Inflammatory Disease (PID): Given the patient's reported lack of sexual activity, PID is less likely, but it should be considered if there's any possibility of sexual activity not disclosed or if the patient has had recent instrumentation of the uterus.