Approach to chronic pelvic pain (GYN) Quiz: Ace Your Exams

A 43-year-old woman presents to her gynecologist with heavy and prolonged menstrual bleeding that began 2 years ago and has been worsening during the past 6 months. Her periods previously lasted  5 days and now last 9 to 11 days. She often uses more than 100 tampons per month and soaks through pads at night. She reports constant aching pelvic pain that significantly worsens with menstruation. The pain is partially relieved with naproxen but interferes with her daily activities. She denies postcoital bleeding but has occasional spontaneous intermenstrual spotting. She also has mild dyspareunia. She does not have changes in urination or bowel habits, fever, or vaginal discharge. Her medical history is significant for type 2 diabetes controlled by diet. She has had 3 uncomplicated pregnancies and deliveries. Her last PAP smear 9 months ago was normal. Family history is significant for a sister with fibroids. Abdominal exam reveals mild lower abdominal tenderness without rebound. Pelvic examination reveals a mobile, soft, tender uterus, uniformly enlarged to 12 cm, and no adnexal tenderness or masses. hCG is negative. Which of the following findings on ultrasound will help confirm the most likely diagnosis?