Adenomyosis ultrasonographic

diagnostic
Prof. univ. dr.
Mircea Onofriescu
Obstetrics Gynecology
University of Medicine
IAŞI

2016 BUCURESTI IAN DONALD

1
COURSE
 Adenomyosis is the benign, non-
neoplastic infiltration of the endometrium
into the myometrium characterised by
ectopic glands and stroma, surrounded by
hypertrophic and hyperplastic myometrium.

Risk factors for adenomyosis are essentially

related to: (1) reproductive activity, with an increased
risk in multiparity, miscarriage and endometriosis;
(2) lifestyle factors such as smoking; and
(3) surgical trauma such as Caesarean section,
induced abortion or curettage.

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 The incidence in the population at risk
varies in the literature from 8.1% to 16.7%.

In around one third of cases, adenomyosis is

completely asymptomatic.
In the remaining two thirds, the most frequent
symptoms are menorrhagia (50%),
dysmenorrhoea (30%) and metrorrhagia (20%).
Dyspareunia and infertility may also occur.
Around 20% of cases of adenomyosis involve
women of reproductive age (<40 years). The remaining
80% of cases involve women between 40 and 50 years,
and the most severe symptoms are associated with this
age group.

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Munro. FIGO classification system for
causes of AUB. Fertil Steril 2011.
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The ultrasound features of
adenomyosis
Globally enlarged
uterus: the fundus of
the uterus appears
enlarged;
Asymmetrically
enlarged uterus (e.g.
anterior wall thicker
than posteriorwall, or
vice versa) unrelated to
leiomyoma

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The ultrasound features of
adenomyosis

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The ultrasound features of
adenomyosis

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The ultrasound features of
adenomyosis

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The ultrasound features of
adenomyosis

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The ultrasound features of
adenomyosis
Myometrial
hypoechoic linear
striations seen as a
radiating pattern of
thin acoustic
shadows not
arising from
echogenic foci or
leiomyoma

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The ultrasound features of
adenomyosis

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The ultrasound features of
adenomyosis

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The ultrasound features of
adenomyosis

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The ultrasound features of
adenomyosis

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 The ultrasound features of
adenomyosis
Finding at least three of these signs
is highly suggestive of adenomyosis.
Sensitivity, specificity and accuracy of
TVUS on the basis of the described signs vary
between 80–86%, 50–96% and 68–86%,
respectively.
However, the diffuse from of uterine
adenomyosis can be confused with fibromatosis,
especially if the signs are moderate in size.

Dueholm M (2006) TVUS for diagnosis of adenomyosis: a

review. Best Pract Res Clin Obstet Gynaecol 20:569–682

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 The ultrasound features of
adenomyosis
Several studies have shown that the sensitivity
and specificity of two-dimensional transvaginal
scan in diagnosing adenomyosis are comparable to
those of MRI, histology, or both, ranging from 75%–
88% and 67%–93%, respectively.
Three-dimensional transvaginal scan
features were compared with histology of the uterus
after hysterectomies, and it was shown that
junctional zone thickness JZmax ≥ 8mm and JZmax-
JZmin ≥ 4mm were significantly more associated with
adenomyosis.
Larsen SB, et al. Adenomyosis and junctional zone changes in patients with
endometriosis. Eur J Obstet Gynecol Reprod Biol 2011;157:206–11.

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US image of the uterus obtained using 3D US
and VCI with 4-mm slices.

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 The ultrasound features of
adenomyosis

Caterina Exacoustos, et.al. Imaging for the evaluation of endometriosis and

Adenomyosis. Best Practice & Research Clinical Obstetrics and Gynaecology 28
(2014) 655–681.
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The ultrasound features of
adenomyosis should be
reported and quantified

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 The junctional zone (JZ)
 The JZ is a distinct, hormone-dependent
uterine compartment at the endomyometrial
interface, revealed more than 20 years ago by
MRI. It is also called archimyometrium or inner
myometrium.
 On high-resolution transvaginal scan, the
junctional zone is often visualised as a
subendometrial hypoechoic ‘halo’.
 Despite the apparent lack of histological
distinction between the junctional zone and the
outer myometrium on light microscopy, these
two zones are, in reality, structurally and
biologically different

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The junctional zone (JZ)

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 The junctional zone (JZ)
JZ can often be visualized on 2D US,
acquisition of a 3D volume enables a more
complete assessment in the sagittal, transverse
and coronal planes, as shown in a standardized
multiplanar view.
Using the standardized multiplanar view
reduces interobserver variation in
measurements.
Imaging of the JZ may be optimized by
using a postprocessing rendering mode, for
example VCI.
The thickness of the slices or render box
may be selected from between 1 mm and 4 mm.

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The junctional zone (JZ)

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The junctional zone (JZ)

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The junctional zone (JZ)

 The uterine JZ seems to

play a central role in the
implantation process.
 3D ultrasound criteria for
alteration of the JZ show a
high accuracy for
adenomyosis diagnosis.
 Evaluation of JZ before
conception may be
useful in identifying those
women affected by initial
grade of adenomyosis.

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 Schematic drawings and ultrasound images
illustrating different types of lesion echogenicity

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Schematic diagrams and ultrasound
images

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Myometrial Ultrasound images

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Myometrial Ultrasound images

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Vascular pattern within the myometrium
and in myometrial lesions.

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Vascular pattern within the myometrium
and in myometrial lesions.

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 The relative proportions of endometrial
glandular structures, endometrial
stroma and hypertrophic muscle
elements within a lesion probably
explain the different ultrasound features
reported to be typical of adenomyosis.

 The link between ultrasound features

and histopathology has yet to be
confirmed and requires further research.

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Reporting the myometrium in general
clinical practice

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 Features considered important in
diagnosis of fibroids and adenomyosis

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The FIGO classification of myomas

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 Adenomyosis may be difficult to diagnose
with US.
 Different US features have been suggested
to be associated with adenomyosis, but at
present it is not clear which of the various
ultrasound criteria are most important for
diagnosis.
 Some features may carry a greater
diagnostic weight than others and the
presence of more than one US feature
associated with adenomyosis might increase
the likelihood of the diagnosis.

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 We have not included in our
consensus statement the so called
‘question-mark sign’, suggested
to be typical of adenomyosis, because
this sign occurs when there is also deep
infiltrating endometriosis in the
posterior compartment.

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‘question-mark sign’

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‘question-mark sign’

N. Di Donato et. al.

Bologna – 2015, UOG 46,
124-127

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 ‘question-mark sign’
N. Di Donato et. al.
Bologna – 2015, UOG 46,
124-127.

Following inclusion of the question-

mark sign in the criteria for diagnosis of
adenomyosis, the sensitivity, specificity, PPV and
NPV were 92%, 88%, 88% and 92% respectively.
It is a good level of agreement between
diagnosis of adenomyosis by TVUS and by
histology. 2016 BUCURESTI IAN DONALD COURSE 43
 The clinical relevance of
myometrial lesions for abnormal
uterine bleeding, pelvic pain,
subfertility and pregnancy outcome
is an important topic for research.

 Certain ultrasound features might

prove to be more clinically relevant
than others.

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 The role of a systematic
evaluation of the sonographic
features of myometrial lesions
when choosing management
(expectant management, medical
therapy, selective embolization,
high-intensity focused ultrasound
or surgical treatment) and in the
follow-up during or after treatment
is another important topic for
future research.
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 Beyond infertility: obstetrical and
postpartum complications associated
with endometriosis and adenomyosis

Complications in early pregnancy

(miscarriage), late pregnancy (gestational
diabetes mellitus, preeclampsia, prematurity,
placenta previa, placental abruption, cesarean
section, hemorrhages) and neonatal
outcomes (weight at birth) between
endometriosis and adenomyosis patients
versus control subjects.

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