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Section 1

Adenomyosis
Synonyms/Description
Endometriosis of the uterus or myometrium

Etiology
Adenomyosis is defined pathologically when
endometrial glands and stroma are found in the
myometrium, distant from the endometrial cavity itself. This ectopic endometrial tissue has the
ability to induce hypertrophy of the surrounding
myometrium. This process can be focal or diffuse
and thus accounts for the variability in the ultrasound appearances noted. The endometriummyometrium junctional zone is jagged and fuzzy
because the endometrial mucosa essentially
invades the underlying myometrium, thus blurring the interface between these two, typically
distinct zones. (This may be focal or global.)

outline of the endometrial cavity on 3-D coronal


view of the uterus.
Although magnetic resonance imaging (MRI)
has been useful for diagnosing adenomyosis, it is
unnecessary because ultrasound has similar
accuracy. A comparison between ultrasound and
MRI was reported using 23 articles (involving
2312 women). Transvaginal ultrasound had a
sensitivity and specificity of 72% and 81%,
respectively, whereas MRI had a sensitivity and
specificity of 77% and 89%, respectively.
Doppler evaluation of adenomyosis usually
does not add to the diagnosis because the
amount of vascularity is variable and
nonspecific.

Differential Diagnosis

The uterus is typically enlarged and globular


with heterogeneous myometrium, which is typically wider on one side than the other. The heterogeneous myometrium often contains
myometrial cysts, which likely represent areas of
glandular dilatation or hemorrhage caused by
repeated bleeding. These cysts are also frequently
seen in a subendometrial location.

If the area of adenomyosis is focal, it may be confused with a fibroid or a polyp if it projects into
the endometrial cavity. Because of the lucencies
and heterogeneities in the myometrium, uterine
malignancy (though very rare) is sometimes considered. The clue to the correct diagnosis is the
asymmetry of the width of the myometrium
comparing the posterior to the anterior aspect
on longitudinal view as well as the shaggy
appearance of the endometrial echo in a patient
with chronic pain and abnormal bleeding.

Adenomyoma

Clinical Aspects and Recommendations

An adenomyoma appears as a focal, somewhat


circumscribed island of heterogeneity in the
myometrium, suggesting a fibroid, but typically
without clear borders. When the borders are
sharp, one cannot distinguish an adenomyoma
from a fibroid. The adenomyoma may project
into the cavity in the form of a broad-based
polyp (polypoid adenomyoma).
Three-dimensional (3-D) ultrasound is helpful
to demonstrate the multitude of linear hyperechoic bands emanating from the endometrium
into the myometrium, producing the shaggy

Historically, heavy menstrual bleeding (menorrhagia) and painful menstruation (dysmenorrhea) are the major symptoms of adenomyosis
and are said to occur in approximately 60% and
25% of women, respectively. It has also been
implicated in some cases of chronic pelvic pain.
In the past, symptoms typically developed in
women in the fourth and fifth decade of life
(perimenopausally); however, this probably
reflects the fact that in the past the diagnosis of
adenomyosis historically was made at the time
of hysterectomy and not with sophisticated

Ultrasound Findings
Generalized Adenomyosis

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Section 1

Adenomyosis

imaging techniques as are currently available. In


fact the obvious presence of endometrial glands
and stroma contained within the myometrium
in a large number of asymptomatic women
should cause clinicians to rethink whether adenomyosis is truly a disease or whether in some
cases it may be co-existing and not causal of the
patients symptoms. The exact percentage of
patients who will have classic findings of adenomyosis on sophisticated ultrasound studies and
yet be totally asymptomatic is unknown.
When present, the menorrhagia is probably
related to the increased endometrial surface area
of the enlarged uterus. Dysmenorrhea may be
caused by the cyclic bleeding and swelling of the

endometrial tissue confined within the


myometrium.
Definitive treatment for adenomyosis is hysterectomy. Because disease is confined to the
uterus, ovarian conservation can be considered
unless there are other reasons for their removal.
As there is no true plane separating the adenomyotic tissue from normal myometrium, surgical
excision as in myomectomy is not appropriate.
Various medical (nonsurgical) approaches have
been employed, including oral contraceptive
pills for treatment of the dysmenorrhea and
menorrhagia, progestin only therapy, and more
recently levonorgestrel-releasing intrauterine
devices (IUDs).

Figure A1-1 Two different patients. Typical appearance of the myometrium, which is asymmetric because of
adenomyosis. Note that the endometrial echo is closer to the anterior than the posterior wall of the uterus.

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Section 1

Adenomyosis

Figure A1-2 Heterogeneous myometrium containing small echolucencies, typical of adenomyosis (two different
patients).

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Figure A1-3 Adenomyoma projecting into the endometrial cavity from a broad base within the myometrium.
A shows the mass as ill-defined within the cavity, worrisome for a malignancy, especially in a postmenopausal patient.
B from the same patient shows the sonohysterogram with saline outlining the adenomyoma diagnosed by pathology.

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Section 1

Adenomyosis

Figure A1-4 Three-dimensional ultrasound of two different patients with extensive adenomyosis. A shows the
reconstructed coronal view of the uterus with a fuzzy, ill-defined junction and linear echogenicities emanating out
from the edges of the endometrium. B shows a different patient with adenomyosis and a right-sided fibroid
demonstrating similar echolucencies. C (same patient as B) shows the inverse mode of the 3-D image that accentuates the lack of a clear border at the junction of the endometrium and myometrium.

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Section 1

Adenomyosis

Suggested Reading
Bocca SM, Oehninger S, Stadtmauer L, Agard J,
Duran EH, Sarhan A, Horton S, Abuhamad AZ.
A study of the cost, accuracy, and benefits of
3-dimensional sonography compared with hysterosalpingography in women with uterine abnormalities. J Ultrasound Med. 2012;31:81-85.
Champaneria R, Abedin P, Daniels J, Balogun M,
Khan KS. Ultrasound scan and magnetic resonance
imaging for the diagnosis of adenomyosis: systematic review comparing test accuracy. Acta Obstet
Gynecol Scand. 2010;89:1374-1384.
Exacoustos C, Brienza L, Di Giovanni A, Szabolcs B,
Romanini ME, Zupi E, Arduini D. Adenomyosis
three-dimensional sonographic findings of the
junctional zone and correlation with histology.
Ultrasound Obstet Gynecol. 2011;37:471-479.

Maheshwari A, Gurunath S, Fatima F, Bhattacharya S.


Adenomyosis and subfertility: a systematic review
of prevalence, diagnosis, treatment and fertility
outcomes. Hum Reprod Update. 2012;18:374-392.
Valentini AL, Speca S, Gui B, Soglia G, Micc M,
Bonomo L. Adenomyosis: from the sign to the
diagnosis. Imaging, diagnostic pitfalls and differential diagnosis: a pictorial review. Radiol Med.
2011;116:1267-1287.
Wry O, Thille A, Gaspard U, van den Brule F. Adenomyosis: update on a frequent but difficult diagnosis.
J Gynecol Obstet Biol Reprod. 2005;34:633-648.

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For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.

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