Because it is so like fibroids, the adenomyotic disease must
A new era in diagnosing
adenomyosis is coming
Adenomyosis is a frequent gynecological disease, character-
ized by the migration of glands and stroma from basal layer
of the endometrium to the myometrium. Until now the
concept that this disease could be diagnosed only by histology
was very diffused. Since this disease is often found in women
over 40 years of age who underwent hysterectomy, it was
common thinking that it was not a real disease. Imaging
(magnetic resonance imaging and ultrasound) showed that
adenomyosis had a typical appearance (1) and that this could
also be detected in younger women with or without typical
symptoms. Transvaginal sonography (TVS) especially is often
performed in women of all ages, showed typical sonographic
features. Several ultrasound imaging studies have been per-
formed to analyse the diagnostic accuracy to detect adeno-
myosis in comparison to histological examination of
hysterectomy specimens. Beyond the evaluation of different
ultrasound features and their numbers, in relation to presence
or absence of adenomyosis on hysterectomy specimens, also
the correlation to symptoms has been performed. The main
problem with the use of histology for the diagnosis of adeno-
myosis in these studies is the heavy selection bias incurred.
Patients who underwent hysterectomy are generally in
advanced age and showed heavy symptoms which indicate
surgery and do not represent the general population. Younger
fertile patients with or without pain symptoms very seldom
had a histological confirmation of adenomyosis, despite
TVS often detecting typical features of adenomyosis (2).
Despite this, the comparison of TVS features to histology,
also performed by Tellum et al. (3), is the basis to assess TVS
accuracy in diagnosis of adenomyosis. Since transvaginal ul-
trasound has been used for the non-invasive diagnosis of ad-
enomyosis and several studies such as the one by Tellum et al.
(3) showed a high accuracy in the diagnosis, we must accept
now that diagnosis of adenomyosis could be based on ultra-
sound. This will give us the opportunity to correlate this dis-
ease to real symptoms and fertility in the general population.
In fact, the presence of one or more of the ultrasound features
has often been noticed in asymptomatic young women.
There are obviously some problems, since the studies
published up until now on TVS and adenomyosis show is
not always very clear how many features should be consid-
ered for the final diagnosis of adenomyosis, as the prevalence
of the disease is in inhomogeneous study populations. On
the other hand, TVS is able to detect not only different
features, but also different configuration and localization
inside the uterus according to different histopahological
adenomyosis types in the myometrium: diffuse, focal, and
adenomyoma (4).
The number of features does not play an important role in
evaluating adenomyosis since several features could be pre-
sent in a small focal adenomyosis and few features in a diffuse
disease. It also seems that localization according the inner
myometrium (junctional zone) or middle or outer myome-
trium, as the degree of myometrial involvement, could be
important in describing, by ultrasound, the adenomyosis (5).
858
be better described inside the uterus to evaluate the impact
on symptoms especially on infertility and treatment. In
some ways the study of Tellum et al. (3), including several fea-
tures and the thickness of the wall in their predictive model,
confirmed that the number of single ultrasound features is
not enough to give an accurate diagnosis of adenomyosis.
However, the prediction model developed in this study for
diagnosing adenomyosis cannot still be used in the general
population since the age, fertility, association to deep infil-
trating endometriosis, the type (focal, diffuse), and the exten-
sion inside the myometrium of the adenomyosis are not
considered. Also, the correlation to pain symptoms and
menorrhagia is in this study seems questionable as it included
all patients who underwent surgery (mostly for symptoms
indication) and 48% of the patients with adenomyosis had
endometriosis which can cause similar symptoms.
In conclusion, diagnosing adenomyosis should now be
based mostly on TVS since it is an accurate and easy method
which can be performed on all types of patients. Only the
presence of single TVS features is not enough to diagnose
accurately the adenomyotic disease inside the uterus. As
well as the only correlation of presence or absence of adeno-
myosis to symptoms seems actually too superficial. Like the
endometriotic disease where ovarian, retroperitoneal, and su-
perficial disease had different impacts on symptoms, treat-
ment, and prognosis, type and degree of adenomyosis may
also be considered in the management of this disease. In the
future, transvaginal ultrasound diagnosis will be a key point
in the evaluation of adenomyosis and may require expert so-
nographers in dedicated centers.
Caterina Exacoustos, M.D.
Errico Zupi, M.D.
Department of Biomedicine and Prevention Obstetrics and
Gynecological Clinic, University of Rome ‘‘Tor Vergata,’’
Rome, Italy
https://doi.org/10.1016/j.fertnstert.2018.07.005
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VOL. 110 NO. 5 / OCTOBER 2018