PELVIC IMAGING

Uterine Adenomyosis:
Endovaginal US and
MR Imaging Features
with Histopathologic
Correlation1
Caroline Reinhold, MD • Faranak Tafazoli, MD • Amira Mehio,
MD • Lin Wang, MD • Mostafa Atri, MD • Evan S. Siegelman, MD
Lori Rohoman, ACR, RTMR

Uterine adenomyosis is a common gynecologic condition that is charac-

terized by the presence of heterotopic endometrial glands and stroma in
the myometrium with adjacent smooth muscle hyperplasia. The histo-
pathologic features of adenomyosis are varied and contribute to its imag-
ing appearance. The accompanying smooth muscle hyperplasia pro-
duces the typical gross appearance of adenomyosis and corresponds to
areas of decreased echogenicity at endovaginal ultrasonography (US) and
areas of decreased signal intensity at magnetic resonance (MR) imaging.
Endovaginal US also shows heterogeneity of the myometrial echotex-
ture, which corresponds to small echogenic islands of heterotopic en-
dometrial tissue surrounded by the hypoechoic smooth muscle. On T2-
weighted MR images, bright foci are seen in areas of abnormal low signal
intensity within the myometrium in approximately 50% of patients.
These foci correspond to islands of heterotopic endometrial tissue, cys-
tic dilatation of heterotopic glands, or hemorrhagic foci. With the advent
of high-resolution imaging techniques, signs associated with the pres-
ence of heterotopic endometrial tissue are being detected with increas-
ing frequency. These signs include myometrial cysts, myometrial nod-
ules, linear striations, pseudowidening of the endometrium, and poor
definition of the endomyometrial junction. Pitfalls in diagnosis of uterine
adenomyosis include leiomyoma, endometrial carcinoma, myometrial
contractions, and muscular hypertrophy.

Index terms: Endometriosis, 854.3192 • Uterus, diseases, 854.3192 • Uterus, MR, 854.1214 • Uterus, US, 854.12989

RadioGraphics 1999; 19:S147–S160

1From the Departments of Radiology (C.R., F.T., L.W., L.R.) and Pathology (A.M.), Montreal General Hospital and McGill
University, 1650 Cedar Ave, Montreal, Quebec, Canada H3G 1A4; the Department of Radiology, Princess Margaret Hospi-
tal, Toronto, Ontario, Canada (M.A.); and the Department of Radiology, Hospital of the University of Pennsylvania, Phila-
delphia (E.S.S.). Recipient of a Certificate of Merit award for a scientific exhibit at the 1998 RSNA scientific assembly. Re-
ceived March 4, 1999; revision requested April 16 and received July 7; accepted July 7. Address reprint requests to
C.R.
© RSNA, 1999

S147
 n INTRODUCTION
Uterine adenomyosis is a common gynecologic
condition that is characterized at histopatho-
logic analysis by the presence of heterotopic
endometrial glands and stroma in the myometri-
um with adjacent smooth muscle hyperplasia.
The typical symptoms include pelvic pain, dys-
menorrhea, and menorrhagia. However, these
symptoms are nonspecific and can be encoun-
tered in disorders such as dysfunctional uterine
bleeding, leiomyoma, and endometriosis. The
role of imaging in evaluating patients with sus-
pected adenomyosis is as follows.
First, the correct diagnosis is established
with imaging. Uterus-conserving therapy is pos-
sible in cases of leiomyoma, whereas hysterec-
tomy is the definitive treatment for debilitating
adenomyosis. Second, imaging is performed to
determine the extent and depth of myometrial
penetration. Symptoms have been shown to
correlate with the extent of disease. Determin-
ing the depth of myometrial penetration is im-
portant for treatment planning because superfi-
cial adenomyosis responds significantly better
to endometrial ablation than does deep adeno-
myosis. Third, imaging is used to monitor the
evolution of the disease in patients receiving
conservative therapy.
With the advent of high-resolution imaging
techniques, adenomyosis can be diagnosed
with a high degree of accuracy. The imaging
signs demonstrated with endovaginal ultrasonog-
raphy (US) and magnetic resonance (MR) imag-
ing correspond closely to the varied appear-
ances of this disease at histopathologic analysis.
In this article, histopathologic features, endo-
vaginal US, MR imaging, and diagnostic pitfalls
of uterine adenomyosis are discussed.
n HISTOPATHOLOGIC FEATURES
Understanding the gross and histopathologic
features associated with adenomyosis is crucial
when interpreting the associated imaging find-
ings. The smooth muscle hyperplasia accompa-
nying the heterotopic endometrial tissue actu-
ally produces the characteristic gross appearance
of this disease. Nevertheless, the heterotopic en-
dometrial tissue also contributes to the imaging
S148 n Pelvic Imaging
Figure 1. Normal uterus. Sagittal endovaginal US
scan shows a normal myometrium (M), which is mod-
erately echogenic and has a homogeneous echotex-
ture. The subendometrial halo, which represents the
innermost layer of the myometrium, is visualized sub-
jacent to the endometrium (E) as a thin hypoechoic
band (arrows). The endometrium is uniformly echo-
genic in this patient, who was in the secretory phase
of the menstrual cycle.
appearance of adenomyosis. With the advent
of high-resolution imaging techniques, these
changes are being detected with increasing fre-
quency.
n ENDOVAGINAL US
Transducers used for endovaginal US operate at
high frequencies, usually on the order of 5–7
MHz. Endovaginal US produces high-resolution
images of the uterus, thus facilitating the detec-
tion of adenomyosis. The US signs of adenomy-
osis must be identified during the real-time ex-
amination; they cannot be reliably identified on
static images.
The normal uterus shows zones with differ-
ent degrees of echogenicity at endovaginal US
(Fig 1). It is the stratum basale of the endo-
metrium that gives rise to the heterotopic en-
dometrial tissue in adenomyosis. However, this
layer is very thin and cannot be identified as a
separate entity at US. The presence of adeno-
myosis can alter and distort the US appearance
of these uterine zones.
l Features of Adenomyosis
Adenomyosis most commonly appears as areas
of decreased echogenicity or heterogeneity of
the myometrium, a sign found in approximately
Volume 19, Special Issue
Figure 2. Imaging signs of adenomyosis. E = endometrium. (a) Sagittal oblique endovaginal US scan shows
that the myometrium is thickened ventrally and has a heterogeneous echotexture (straight arrows). The echo-
genicity of the ventral myometrium is decreased relative to that of the dorsal myometrium. Additional features of
adenomyosis seen in this image include poor definition of the endomyometrial junction and a myometrial cyst
(curved arrow). (b) Corresponding sagittal T2-weighted MR image shows marked thickening of the junctional
zone. The result is a poorly defined low-signal-intensity mass that replaces the ventral myometrium (arrows). The
numerous bright foci, some of which have a rounded appearance whereas others have a linear or fingerlike ap-
pearance, represent the heterotopic endometrium. Bl = bladder. (c) Photomicrograph (hematoxylin-eosin stain)
of a section through the middle aspect of the ventral myometrium shows foci of heterotopic endometrium scat-
tered throughout the inner two-thirds of the myometrium (small arrows). The heterotopic islands have a linear
or rounded appearance (see magnified views). The smooth muscle hyperplasia (dark pink stain) surrounds the
heterotopic endometrium. Cysts of adenomyosis are noted in the outer myometrium (large arrows). The endo-
metrial tissue extending into the myometrium results in poor definition of the endomyometrial junction at imaging.

a. b.

c.

75% of patients (1–3). The areas of decreased muscle (Fig 2). The ratio of heterotopic en-
echogenicity correspond to areas of smooth dometrial tissue to smooth muscle partly de-
muscle hyperplasia at histopathologic analysis. termines the imaging appearance (Fig 3). The
The areas of heterogeneity correspond to small
echogenic islands of heterotopic endometrial
tissue surrounded by the hypoechoic smooth

October 1999, Special Issue Reinhold et al n RadioGraphics n S149

 a.
Figure 3. Variable echogenicity in a patient with
diffuse adenomyosis extending into the outer myo-
metrium. (a) Sagittal oblique endovaginal US scan
shows that most regions of the myometrium are hypo-
echoic and heterogeneous. However, an area of in-
creased echogenicity (arrows) is seen in the ventral
myometrium adjacent to the fundus and immediately
deep to the endometrium (E) dorsally. The borders of
the endometrium are obscured at this level due to the
increased echogenicity of the adjacent myometrium,
thus resulting in pseudowidening of the endometrium.
(b) Photomicrograph (hematoxylin-eosin stain) shows
that the ratio of heterotopic endometrial tissue (arrows)
to smooth muscle hyperplasia (dark pink stain) is great-
est in the ventral myometrium (VM), which corre-
sponds to the area of increased echogenicity on the
endovaginal US scan (a). E = endometrium.
b.

Figure 4. Myometrial cyst. E = endometrium.

(a) Transverse oblique endovaginal US scan shows a
6-mm-diameter cyst in the left dorsal aspect of the inner
myometrium (arrow). (b) Photomicrograph (hema-
toxylin-eosin stain) of a section through the dorsal
myometrium shows the cyst (magnified view).

a.

b.

S150 n Pelvic Imaging Volume 19, Special Issue

a.
c.
presence of dilated cystic glands or hemorrhagic
foci within the heterotopic endometrial tissue
results in the presence of small myometrial
cysts (usually <5 mm in diameter) in approxi-
mately 50% of patients (Figs 4, 5). However, in
a rare form of adenomyosis called cystic ad-
enomyosis, the extent and degree of hemor-
rhage within the ectopic endometrial glands are
October 1999, Special Issue
b.
Figure 5. Hyperechoic nodules. E = endometrium.
(a) Sagittal oblique endovaginal US scan of a patient
receiving tamoxifen therapy shows that the inner
myometrium is hypoechoic and heterogeneous. Sev-
eral echogenic nodules consistent with large islands
of heterotopic endometrium are seen (short arrows).
A myometrial cyst is also present (long arrow).
(b) Transverse oblique endovaginal US scan of an-
other patient shows a large echogenic nodule with a
central cystic area in the inner aspect of the dorsal
myometrium (arrows). (c) Photomicrograph (hema-
toxylin-eosin stain) of a section through the dorsal
uterus (same patient as in b) shows a large hetero-
topic island of endometrial tissue in the inner myo-
metrium (arrows).
more extensive (4). When large or confluent, the
areas of heterotopic endometrial tissue result in
discrete echogenic nodules (³5 mm in diam-
eter) within the myometrium (Fig 5). Hetero-
topic endometrium extending into the inner
Reinhold et al n RadioGraphics n S151
 Endovaginal US and MR Imaging Signs of Uterine Adenomyosis
Endovaginal US Signs MR Imaging Signs
Abnormal myometrial echogenicity Abnormal myometrial signal intensity
Hypoechoic (75% of cases) Low signal intensity (predominant)
Isoechoic Areas of high signal intensity
Hyperechoic (subendometrial)
Heterogeneous myometrial echotexture Thickening of junctional zone
Focal Focal
Diffuse Diffuse (³12 mm thick)
Myometrial cysts Myometrial foci of high signal intensity
Echogenic nodules or linear striations Linear striations of high signal intensity
Pseudowidening of endometrium Pseudowidening of endometrium
Poor definition of endomyometrial junction Poor definition of endomyometrial junction
Relative absence of mass effect Relative absence of mass effect
Poor definition of lesion borders Poor definition of lesion borders
Elliptical myometrial abnormality Elliptical myometrial abnormality

Figures 6, 7. (6) Echogenic linear striations. Transverse oblique endovaginal US scan shows that the
myometrium is hypoechoic and slightly heterogeneous, an appearance consistent with diffuse adeno-
myosis. Echogenic linear striations (arrows) can be seen radiating out from the endometrium (E) dor-
sally. The linear striations represent the ectopic endometrial tissue that is in direct continuity with the
endometrium. (7) Linear striations. (a) Sagittal endovaginal US scan shows that the myometrium is het-
erogeneous and of decreased echogenicity. There is pseudowidening of the endometrium (E) at the
level of the fundus. Echogenic linear striations can be seen radiating out from the endometrium (ar-
rows). (b) Corresponding sagittal T2-weighted MR image shows diffuse widening of the junctional
zone. Linear striations of high signal intensity (arrows) can be seen radiating out from the endometri-
um (E) at the level of the fundus. Si = sigmoid colon.

6. 7a.

7b.

S152 n Pelvic Imaging Volume 19, Special Issue

Figure 8. Poor definition of the endomyometrial junction. E = endometrium. (a) Transverse oblique endovaginal
US scan shows that the ventral myometrium (VM) is markedly heterogeneous, with areas of increased and de-
creased echogenicity. The abnormal myometrial echotexture results in poor definition of the endomyometrial
junction ventrally (arrows). Contrast this appearance with the well-defined appearance of the endomyometrial
junction dorsally. (b) Corresponding axial T2-weighted MR image shows thickening of the junctional zone that
is most marked ventrally (VM), with multiple foci of increased signal intensity. Owing to the differences in signal
intensity between the endometrium (E) and the adjacent myometrium, the endomyometrial junction remains rela-
tively well defined. Cx = cervix. (c) Photomicrograph (hematoxylin-eosin stain) of a section through the ventral
myometrium shows extensive adenomyosis with numerous foci of heterotopic endometrial tissue throughout the
myometrium (arrows). Note the poor definition of the endomyometrial junction. (d) Photomicrograph (hema-
toxylin-eosin stain) of a section through a normal uterus shows deep crypts of endometrial glands (arrow),
which result in an undulating appearance of the endomyometrial junction. However, the endomyometrial junc-
tion remains well defined.

a. b.

c. d.

myometrium can give the appearance of echo-
genic linear striations (Figs 6, 7). When these
striations are small or indistinct, the US appear-
ance is that of pseudowidening of the endome-
trium or poor definition of the endomyometrial
junction (Figs 7, 8). Other endovaginal US signs
of adenomyosis include lack of contour abnor-
mality or mass effect (Figs 2, 3, 5), ill-defined
margins between normal and abnormal myo-
metrium (Figs 2, 3, 5, 8), and an elliptical shape
of a myometrial abnormality (Figs 2, 5). The
endovaginal US signs of adenomyosis are sum-
marized in the Table.
l Accuracy of Diagnosis
When the previously described endovaginal US
criteria for diagnosing adenomyosis are used,
the sensitivity of endovaginal US has been re-
ported to be 80%–86%, the specificity 50%–
96%, and the overall accuracy 68%–86% (1–3).

October 1999, Special Issue Reinhold et al n RadioGraphics n S153

 Figure 9. Normal uterus. Sagittal T2-weighted MR
image shows a centrally located high-signal-intensity
stripe, which represents the endometrium (E). Im-
mediately subjacent is a band of low signal intensity,
which is located within the inner myometrium and
represents the junctional zone (JZ). The outer myo-
metrium is of intermediate signal intensity. Bl = blad-
der.
n MR IMAGING
Thin-section high-resolution MR images ac-
quired with a pelvic multicoil array are optimal
for diagnosis of adenomyosis. At MR imaging,
the uterine zonal anatomy is best demonstrated
with sagittal T2-weighted sequences. In women
of reproductive age, three zones can be identi-
fied within the uterine corpus on T2-weighted
images (Fig 9).
Considerable variation in the normal thick-
ness of the inner myometrium or junctional
zone has been reported, with a mean thickness
of 2–8 mm. Abnormal widening of the junc-
tional zone is one of the MR imaging features
associated with adenomyosis.
l Features of Adenomyosis
The predominant lesion of adenomyosis at MR
imaging consists of a low-signal-intensity area
on T2-weighted images, which frequently gives
the appearance of diffuse or focal widening of
the junctional zone (5) (Figs 7b, 8b, 10). These
areas of low signal intensity have been shown
to correspond to the smooth muscle hyperpla-
sia accompanying the heterotopic endometrial
tissue. In a prospective study of 119 patients,
28 of whom had histopathologically diagnosed
S154 n Pelvic Imaging
Figure 10. Focal thickening of the junctional zone.
Sagittal T2-weighted MR image shows focal thicken-
ing of the junctional zone at the level of the fundus
(arrows). Although the maximal thickness of the
junctional zone was more than 12 mm in this pa-
tient, any focal thickening of the junctional zone
should raise the possibility of adenomyosis. Bl =
bladder, E = endometrium.
adenomyosis, a significant difference in mean
junctional zone thickness at MR imaging was
found between patients with and patients with-
out the disease (5). When the maximal junc-
tional zone thickness was 12 mm or greater, ad-
enomyosis was diagnosed with a high degree of
accuracy; conversely, a maximal junctional zone
thickness of 8 mm or less usually allowed ex-
clusion of the disease. In patients with a max-
imal junctional zone thickness of 8–12 mm, sec-
ondary findings such as relative thickening of
the junctional zone in a localized area, poor
definition of borders, or high-signal-intensity
foci on T2- or T1-weighted images can be used
to diagnose adenomyosis.
On T2-weighted images, bright foci are seen
in areas of abnormal low signal intensity within
the myometrium in approximately 50% of pa-
tients (5). These foci correspond to islands of
heterotopic endometrial tissue, cystic dilatation
of heterotopic glands, or hemorrhagic foci (Figs
2b, 11a). In addition to bright foci, linear stria-
tions of increased signal intensity can be seen
radiating out from the endometrium into the
myometrium on T2-weighted images. These
striations represent direct invasion of the basal
endometrium into the myometrium (Figs 2b,
7b). When these striations blend or become in-
distinct, the resulting appearance is that of
pseudowidening of the endometrium (Fig 12).
Volume 19, Special Issue
a. b.
Figure 11. High-signal-intensity foci. C = left ovarian
cyst, Cx = cervix, E = endometrium. (a) Axial T2-
weighted MR image shows an ill-defined low-signal-
intensity mass with numerous foci of increased signal
intensity that replaces the left side of the myometrium
(arrows). (b) Axial T1-weighted MR image shows sev-
eral foci of increased signal intensity (arrowheads),
which correspond to areas of hemorrhage within
the adenomyotic tissue. (c) Photomicrograph (hema-
toxylin-eosin stain) of a section through the uterus
shows numerous foci of heterotopic endometrial tissue
throughout the myometrium (arrowheads). Note also
the smooth muscle hyperplasia (dark pink stain) sur-
rounding the heterotopic tissue.

c.

a. b.
Figure 12. Pseudowidening of the endometrium. Sagittal (a) and axial (b) T2-weighted MR images show dif-
fuse thickening of the junctional zone, aside from a central area of the dorsal myometrium. Note the blending of
the fine linear hyperintense striations that extend out into the ventral myometrium (arrows); this blending re-
sults in pseudowidening of the endometrium (E). N = nabothian cysts.

October 1999, Special Issue Reinhold et al n RadioGraphics n S155

 a. b.
Figure 13. Cystic adenomyosis. (a) Coronal T2-weighted MR image shows focal thickening of the junctional
zone both ventrally and dorsally (black arrows) with multiple foci of high signal intensity, findings consistent
with adenomyosis. In addition, there is a well-circumscribed, cystic mass of high signal intensity with a low-
signal-intensity rim in the right aspect of the ventral myometrium (white arrow). Bl = bladder. (b) Axial T1-
weighted MR image shows the cystic mass (arrow), which has intermediate signal intensity and a high-signal-in-
tensity rim. N = nabothian cyst.

Bright foci on T1-weighted images are seen
much less frequently and correspond to areas
of hemorrhage (6) (Fig 11b). The exact mecha-
nism of the hemorrhage is unclear because ad-
enomyosis involves only the basal layer of the
endometrium, not the functional layer. Never-
theless, hormonal receptors exhibiting some de-
gree of proliferative and secretory changes dur-
ing the menstrual cycle have been identified in
adenomyotic implants (7,8). However, whether
the hemorrhage within implants of adenomyo-
sis represents a sequela of hormonal changes
during the menstrual cycle or is the result of
spontaneous hemorrhage has not yet been elu-
cidated. When the degree of hemorrhage is ex-
tensive, cystic adenomyosis can result. Cystic
adenomyosis is characterized by a well-circum-
scribed, cystic myometrial lesion that demon-
strates hemorrhage in differential stages of orga-
nization at MR imaging (9) (Figs 13, 14). On T2-
weighted images, cystic adenomyosis typically
demonstrates a low-signal-intensity rim (Fig 13a).
Other signs of adenomyosis at MR imaging
include lack of contour abnormality or mass ef-
fect (Figs 2b, 10, 11a, 15a), ill-defined margins
between normal and abnormal myometrium
(Figs 2b, 8b, 12a), and an elliptical shape of a
low-signal-intensity myometrial abnormality
(Figs 2b, 12a, 15a). The MR imaging signs of
adenomyosis are summarized in the Table.
l Accuracy of Diagnosis
Several studies have demonstrated MR imaging
to be highly accurate in diagnosis of adenomyo-
sis, with a sensitivity and specificity of 86%–
100% and an overall accuracy of 85%–90.5%
(5,6,11–14).
n DIAGNOSTIC PITFALLS
Differentiation of adenomyosis from leiomyoma
is critical because this is the most frequently en-
countered pitfall and the therapeutic options
differ. Imaging features that favor adenomyosis
instead of leiomyoma are poorly defined bor-
ders, minimal mass effect, an elliptical instead
of globular shape, and absence of large vessels
at the margin of the lesion (5,11) (Figs 15–17).

S156 n Pelvic Imaging Volume 19, Special Issue

a. b.
Figure 14. Cystic adenomyosis. A = diffuse adenomyo-
sis, Cx = cervix. Sagittal T2-weighted (a), fat-suppressed
T1-weighted (b), and gadolinium-enhanced fat-sup-
pressed T1-weighted (c) MR images show a complex
cystic mass originating from the dorsal myometrium
(arrows). Note the variable signal intensity of the mass
on the T2-weighted (a) and fat-suppressed T1-weighted
(b) images, which indicates hemorrhage in differential
stages of organization.

c.

Figure 15. Adenomyoma. (a) Sagittal T2-

weighted MR image shows a low-signal-inten-
sity mass with an elliptical shape in the ventral
myometrium (arrows). Poorly defined borders
and lack of significant mass effect allow differ-
entiation of this adenomyoma from a leiomyo-
ma. E = endometrium. (Reprinted, with per-
mission, from reference 10.) (b) Photomicro-
graph (hematoxylin-eosin stain) of a section
through the ventral myometrium shows the
adenomyoma (arrows).

a.

b.

October 1999, Special Issue Reinhold et al n RadioGraphics n S157

 a. b.
Figure 16. Adenomyosis versus leiomyoma. Transverse endovaginal US scans through the uterus in different
patients show extensive adenomyosis (a) and a mural leiomyoma (b) involving the dorsal myometrium. Distin-
guishing features of the adenomyosis (arrows in a) include poorly defined borders, lack of mass effect on the en-
dometrium (E), and an elliptical shape. In contradistinction, the leiomyoma (large arrows in b) has edge shadow-
ing, mass effect on the endometrium (small arrows in b), and a round shape with well-defined borders.

At endovaginal US, absence of calcification,

edge shadowing, and a whorled appearance
and the presence of echogenic nodules or lin-
ear striations favor the diagnosis of adenomyo-
sis (15) (Fig 16). At MR imaging, hyperintense
linear striations are specific for adenomyosis.
Adenomyoma, the nodular form of adenomyo-
sis, may be indistinguishable from leiomyoma at
imaging (5,12). Adenomyosis can mimic en-
dometrial carcinoma at imaging and may result
in staging errors when the two conditions coex-
ist (16,17) (Fig 18). The appearance of myome-
trial contractions may closely resemble that of a.
focal adenomyosis. Contractions can be differ-
entiated from true myometrial disease by their
transient nature and changing appearance over
time (10) (Fig 19). Muscular hypertrophy may
demonstrate a hypoechoic inner myometrium
at endovaginal US and diffuse junctional zone
thickening at MR imaging, thus mimicking the
appearance of adenomyosis. Cystic adenomyo-
sis may be mistaken for a leiomyoma with hem-
orrhagic degeneration or a hematometra within
a noncommunicating uterine segment (Figs 13,
14).

n CONCLUSIONS
With the advent of high-resolution imaging
techniques, adenomyosis can be diagnosed
with a high degree of accuracy. The imaging
signs demonstrated with endovaginal US and
MR imaging correspond closely to the varied
b.
Figure 17. Adenomyosis versus leiomyoma. E = en-
dometrium. (a) Sagittal T2-weighted MR image of a
patient with adenomyosis shows thickening of the
junctional zone ventrally, thus giving the appearance
of an ill-defined myometrial mass (arrows). Note the
minimal mass effect on the endometrial cavity and
outer uterine contours relative to the size of the le-
sion. (b) Sagittal T2-weighted MR image of a patient
with a leiomyoma shows a mass with well-defined
borders (arrows) and considerable mass effect on the
endometrial cavity and uterine contours. Bl = bladder.

S158 n Pelvic Imaging Volume 19, Special Issue

a. b.
Figure 18. Adenomyosis versus endometrial carcinoma. Bl = bladder. (a) Sagittal T2-weighted MR image
shows a small endometrial mass of intermediate signal intensity (M), a finding consistent with the clinical diag-
nosis of endometrial carcinoma. The abnormal signal intensity extends into the inner one-third of the myome-
trium dorsally (arrows). At histopathologic analysis, only microscopic myometrial invasion was present with ex-
tensive subjacent adenomyosis. (b) Axial T2-weighted MR image of another patient shows a small endometrium-
based mass displacing the endometrial cavity ventrally (large straight arrow). This mass was proved to be an
endometrial carcinoma with superficial myometrial invasion at histopathologic analysis. Similar-appearing abnor-
mal areas of high signal intensity are seen in the inner aspect of the ventral myometrium (small straight arrows).
These were proved to be areas of adenomyosis at histopathologic analysis. Note the associated thickening of the
junctional zone ventrally, as well as the presence of a myometrial cyst (curved arrow).

a. b.
Figure 19. Myometrial contraction. (a) Transverse
endovaginal US scan shows a hypoechoic, elliptical
mass within the inner half of the ventral myometrium
(arrows). The mass results in distortion of the endo-
metrial cavity (E). (b) Transverse endovaginal US scan
obtained 30 minutes later shows complete resolution
of the mass, a finding consistent with a myometrial
contraction. The echogenic contents within the en-
dometrial cavity (between cursors) represent men-
strual blood. (c) Sagittal T2-weighted MR image of an-
other patient shows an elliptical, low-signal-intensity
mass in the inner aspect of the dorsal myometrium (ar-
rows). Note the associated distortion of the endometri-
um (E). These findings are consistent with a myome-
trial contraction.
c.

October 1999, Special Issue Reinhold et al n RadioGraphics n S159

 appearances of this disease at histopathologic
analysis. Sonologists and sonographers should
familiarize themselves with the endovaginal US
appearance of this disease. Endovaginal US can
be used as the initial imaging modality in pa-
tients suspected of having adenomyosis, but US
must be performed meticulously and in real
time. MR imaging can be reserved for cases that
are indeterminate at endovaginal US and for pa-
tients who will undergo uterus-sparing surgery.
n REFERENCES
1. Reinhold C, Atri M, Mehio A, Zakarian R, Aldis
AE, Bret PM. Diffuse uterine adenomyosis: mor-
phologic criteria and diagnostic accuracy of
endovaginal sonography. Radiology 1995; 197:
609–614.
2. Brosens JJ, de Souza NM, Barker FG, Paraschos
T, Winston RM. Endovaginal ultrasonography
in the diagnosis of adenomyosis uteri: identify-
ing the predictive characteristics. Br J Obstet
Gynecol 1995; 102:471–474.
3. Fedele L, Bianchi S, Dorta M, Arcaini L, Zanotti
F, Carinelli S. Transvaginal ultrasonography in
the diagnosis of diffuse adenomyosis. Fertil
Steril 1992; 58:94–97.
4. Iribarne C, Plaza J, De la Fuente P. Intramyo-
metrial cystic adenomyosis. JCU 1994; 22:348–
350.
5. Reinhold C, McCarthy S, Bret PM, et al. Diffuse
adenomyosis: comparison of endovaginal US
and MR imaging with histopathologic correla-
tion. Radiology 1996; 199:151–158.
6. Togashi K, Ozasa H, Konishi I, et al. Enlarged
uterus: differentiation between adenomyosis
and leiomyoma with MR imaging. Radiology
1989; 171:531–534.
S160 n Pelvic Imaging
7. Hirata JD, Moghissi KS, Ginsburg KA. Preg-
nancy after medical therapy of adenomyosis
with a gonadotropin-releasing hormone ago-
nist. Fertil Steril 1993; 59:444–445.
8. Ginsburg KA, Quereshi F, Thomas M, et al. In-
tramural ectopic pregnancy implanting in ad-
enomyosis. Fertil Steril 1989; 51:354–356.
9. Troiano RN, Flynn SD, McCarthy S. Cystic ad-
enomyosis of the uterus: MRI. JMRI 1998; 8:
1198–1202.
10. Reinhold C, Gallix BP, Ascher SM. Uterus and
cervix. In: Semelka RC, Ascher SM, Reinhold C,
eds. MRI of the abdomen and pelvis. New York,
NY: Wiley-Liss, 1997; 617–620.
11. Mark AS, Hricak H, Heinrichs LW, et al. Adeno-
myosis and leiomyoma: differential diagnosis
with MR imaging. Radiology 1987; 163:527–
529.
12. Ascher SM, Arnold LL, Patt RH, et al. Adeno-
myosis: prospective comparison of MR imaging
and transvaginal sonography. Radiology 1994;
190:803–806.
13. Hricak H, Finck S, Honda G, Goranson H. MR
imaging in the evaluation of benign uterine
masses: value of gadopentetate dimeglumine–
enhanced T1-weighted images. AJR 1992; 158:
1043–1050.
14. Togashi K, Nishimura K, Itoh K, et al. Adeno-
myosis: diagnosis with MR imaging. Radiology
1988; 166:111–114.
15. Reinhold C, Tafazoli F, Wang L. Imaging fea-
tures of adenomyosis. Hum Reprod Update
1998; 4:337–349.
16. Teefey SA, Stahl JA, Middleton WD, et al. Local
staging of endometrial carcinoma: comparison
of transvaginal and intraoperative sonography
and gross visual inspection. AJR 1996; 166:
547–552.
17. Hirai M, Shibata K, Sagai H, Sekiya S, Goldberg
BB. Transvaginal pulsed and color Doppler
sonography for the evaluation of adenomyosis.
J Ultrasound Med 1995; 14:529–532.
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