When diagnosing a boggy uterus, physical examination of the individual and review of their medical history are necessary to identify the underlying cause. Uterine atony is usually diagnosed during physical examination immediately upon vaginal or cesarean delivery. To assess the uterine tone, direct palpation of the uterus is performed after a cesarean section, and indirect bimanual examination, which involves examining the abdomen with one hand while performing a vaginal examination with the other hand, is performed after vaginal delivery.
Often, physical examination is enough to reveal the characteristic enlarged uterus. Regardless, a transabdominal or transvaginal ultrasound is typically performed in order to confirm diagnosis, especially when adenomyosis is suspected. There are three characteristic findings in individuals with adenomyosis. First, ectopic endometrial tissue is identified on ultrasound as echogenic, or bright, nodules and stripes emerging from the endometrium to the myometrium. Second, diverse echotexture (i.e.,the characteristic pattern of tissue layers as seen in an ultrasound) can be identified on ultrasound due to uneven myometrial thickening. Finally, ultrasound will generally reveal increased vascularity.
An MRI scan can also be performed and may reveal the same findings as to the ultrasound. It is advised to perform both imaging techniques in the late proliferative or secretory phase of the menstrual cycle (i.e., days 7 to 28), as the myometrium is typically more difficult to identify during this period of time.
Treatment options for a boggy uterus vary depending on the underlying cause. Uterine atony is considered a medical emergency, so immediate medical management is required. The administration of medications -- such as oxytocin, prostaglandins, and uterotonic agents -- can help to improve the tone of the uterus and induce uterine contractions. In the case of excessive postpartum hemorrhage, uterine massage in combination with tamponade, which applies pressure to the uterine walls, may be performed. Artery ligation, which involves applying stitches to the main artery that supplies blood to the uterus, and other surgical techniques may be needed to stop the bleeding. When the bleeding is unmanageable, a hysterectomy, the surgical removal of the uterus, may be necessary to save the individual’s life.
Treatment for adenomyosis largely depends on whether the individual wants to be able to give birth to children in the future. Most treatment options target the symptoms associated with this condition. For example, non-steroidal anti-inflammatory drugs (NSAIDs) may provide some relief for heavy periods with painful cramping. Various hormonal therapies, including oral contraceptive pills (OCPs) and hormonal intrauterine devices (IUD), are also available. These therapies reduce the effects of estrogen on the endometrium, preventing the rapid growth of the endometrial tissue, including the ectopic endometrial tissue present in the myometrium.
When medication cannot sufficiently manage the symptoms of adenomyosis, minimally invasive and surgical therapies are suggested. For example, one available treatment option is MRI-guided or ultrasound-guided thermal ablation (i.e., removal) of sites of adenomyosis. Uterine artery embolization, a procedure during which the overall blood flow to the uterus is reduced to decrease the size of the uterus, can also be helpful in individuals with adenomyosis. A partial hysterectomy is a more invasive treatment option. While this procedure may preserve fertility, scarring between the endometrial and myometrial layers is a potential complication. Total hysterectomy remains the most definitive treatment for adenomyosis, although complete surgical removal of the uterus is typically suggested only when all other options have been exhausted.
