Adenomyosis: A Sonographic Diagnosis

Abstract

Adenomyosis is a common benign uterine condition and a frequent cause of pelvic pain in premenopausal women. Transvaginal US is now considered the primary imaging modality for the diagnosis of adenomyosis, and thus radiologists should be familiar with its sonographic appearance. US findings can be divided into three categories, which parallel the histology of adenomyosis: (a) ectopic endometrial glands and stroma, (b) muscular hyperplasia/hypertrophy, and (c) increased vascularity. Ectopic endometrial glands manifest as echogenic nodules and striations, radiating from the endometrium into the myometrium. When the glands contain fluid, myometrial cysts and fluid-filled striations may be visible at US. Muscular hyperplasia and hypertrophy cause focal or diffuse myometrial thickening and globular uterine enlargement, often with thin "venetian blind" shadows. The combination of these findings results in a heterogeneous myometrium, with blurring of the endometrial border. Adenomyosis increases uterine vascularity, depicted as a pattern of penetrating vessels at color Doppler US. Other US techniques that are helpful in the diagnosis of adenomyosis include obtaining cine clips and coronal reformatted images, both of which can survey the entire endometrial-myometrial border, and performing saline-infusion sonohysterography, during which ectopic glands frequently fill with either air or fluid. While most cases of adenomyosis develop spontaneously, there are specific inciting causes that include tamoxifen use, postendometrial ablation syndrome, and deep-infiltrating endometriosis. Mimics of adenomyosis include leiomyomas, uterine contractions, neoplasms, and vascular malformations. This article reviews the pathophysiology of adenomyosis and correlates it with the US findings, highlights specific causes of adenomyosis, and describes how to distinguish this common diagnosis from a variety of mimics. Online supplemental material is available for this article. RSNA, 2018.

Adenomyosis incidence, prevalence and treatment: United States population-based study 2006–2015

“…Despite considerable public health burden, associated costs of care, and impacts on the lives of many women, reliable population-based incidence estimates of adenomyosis do not exist 3 and studies on prevalence vary widely. 9 To address this gap, we conducted a retrospective cohort study using electronic health records (EHR) to estimate the incidence of symptomatic adenomyosis over a 10-year period (2006e2015) and symptomatic adenomyosis prevalence (2015) in a U.S. population. Secondary aims were to estimate incidence rates by age and by race/ ethnicity, to evaluate trends, and to describe symptoms and treatment practice patterns.…”

Evaluation and Management of Abnormal Uterine Bleeding

“…19 Definitive diagnosis is by histologic examination at hysterectomy; however, specific TVUS and magnetic resonance imaging (MRI) criteria help establish the diagnosis. 20,21 Transvaginal ultrasound may include echogenic striations, myometrial cysts, globular uterus configuration or asymmetrical thickening of the myometrium, and heterogeneity of the myometrium leading to poor definition of the endometrialmyometrial interface (sensitivity, 89%; specificity, 89%). 20 Given that adenomyosis increases uterine vascularity, a pattern of penetrating vessels can be seen at color Doppler ultrasound.…”

“…20,21 Transvaginal ultrasound may include echogenic striations, myometrial cysts, globular uterus configuration or asymmetrical thickening of the myometrium, and heterogeneity of the myometrium leading to poor definition of the endometrialmyometrial interface (sensitivity, 89%; specificity, 89%). 20 Given that adenomyosis increases uterine vascularity, a pattern of penetrating vessels can be seen at color Doppler ultrasound. 20 T2-weight MRI findings may show diffuse or focal endometrialmyometrial junctional zone widening of 12 mm or more, islands of heterotopic endometrial tissue, cystic dilation of heterotopic glands, and punctate hyperintense foci of hemorrhage (sensitivity, 86%; specificity, 86%) 21 (Figure 2).…”

Adenomyosis and infertility: is there a causal link?

“…At TVUS, ectopic endometrial glands appear as echogenic nodules, striations radiating from the endometrium into the myometrium or myometrial cysts, whereas muscular hyperplasia and hypertrophy are seen as focal or diffuse myometrial thickening or asymmetric globular uterine enlargement. MRI is particularly useful in detecting the thickening, hyperplasia, or disruption of the uterine junctional zone (JZ) located between the endometrium and the internal myometrium [8,9]. It has been shown that the accuracies of two-dimensional TVUS, MRI, and histology are comparable in diagnosing adenomyosis [8].…”

“…Diagnostic imaging has improved the understanding of adenomyosis in women of all ages and has allowed to investigate the relationship between adenomyosis and infertility [9].…”