Adenomyosis

Dr Henry Knipe and A.Prof Frank Gaillard et al.

Adenomyosis is a common, benign uterine pathology. It is thought by many to be on the spectrum of endometriosis, with ectopic endometrial tissue in the myometrium. Adenomyosis may present with menorrhagia and dysmenorrhoea. Ultrasound and MRI are imaging modalities that may show characteristic findings.

Classically, it has been taught that adenomyosis most commonly affects multiparous women of reproductive age. However, this was based on the results of pathologic examinations of hysterectomy specimens with studies therefore biased towards patients who had surgery. Similarly, this may be the reason adenomyosis is seen with higher frequency in women with a history of uterine surgical procedures (e.g. Caesarean section, dilatation and curettage). Patients with high estrogen exposure (e.g. short menstrual cycles, early menarche) have an increased risk of adenomyosis. It has a reported incidence that ranges widely from 5-70% (mean 20-30%), depending on the histological definition or the imaging modality used 12.

Most patients with adenomyosis are asymptomatic. Symptoms related to adenomyosis include dysmenorrhoea, menorrhagia, dyspareunia, chronic pelvic pain, and menometrorrhagia 11. The ectopic endometrial glands within the myometrium do not respond to cyclic ovarian hormones, unlike those of endometriosis. Pelvic tenderness on examination is associated with diffuse enlargement of the uterus.

Adenomyosis is histologically-defined by the presence of ectopic endometrial tissue within the myometrium. The exact cause of adenomyosis is unknown, but it is thought that endometrial glands directly invade the myometrium, resulting in spiral vessel angiogenesis, adjacent smooth muscle hyperplasia and hypertrophy. It has been postulated that this dysfunctional hypertrophied muscular tissue surrounding the ectopic endometrial glands prevents uterine contractions from tamponading bleeding myometrial arterioles; hence, these patients frequently present with dysfunctional uterine bleeding or menorrhagia.

Other hypotheses include invagination of the endometrium through the basalis alongside the intramyometrial lymphatics and embryologically displaced pluripotent mullerian remnants.

Imaging features are variable and in many instances very subtle. Three (some say four) forms can be distinguished:

Adenomyosis is usually relatively generalised, affecting large portions of the uterus (typically the posterior wall), but sparing the cervix. Despite often marked enlargement of the uterus, the overall contour is usually preserved 5.

In some cases, adenomyosis may be localised, forming a mass. In such cases, the term adenomyoma may be used, although there appears to be some disagreement about whether the terms focal adenomyosis and adenomyoma refer to exactly the same entity (please refer to the article on adenomyoma for further discussion).

A rare variant is cystic adenomyosis which is believed to be the result of repeated focal haemorrhages resulting in cystic spaces filled with altered blood products 5.

Pelvic ultrasound is usually the first and often the only imaging modality employed to investigate menorrhagia and dysmenorrhoea. Unfortunately, the sonographic features of adenomyosis are variable and may be absent. The reported sensitivity and specificity of transabdominal ultrasound are 32-63% and 95-97% respectively 7. However, it has been reported that transvaginal ultrasound is as sensitive (89%) and specific (89%) as MRI in diagnosing adenomyosis.

It may be useful to categorise ultrasound findings into three groups that mirror the histological findings 15-17:

  • "adeno": ectopic endometrial glands
    • subendometrial echogenic linear striations and/or nodules (specific sign) which extend from the endometrium and into the inner myometrium
    • tiny (1-5 mm) anechoic myometrial and subendometrial cysts (specific sign): reflecting glands filled with fluid
    • cystic striations
  • "myosis": muscular hyperplasia +/- hypertrophy, which may be hypoechoic
    • focal or diffuse myometrial bulkiness which may be asymmetric, typically of the fundal region and posterior wall 5
    • focal areas have relatively indistinct borders compared with those of leiomyomas
    • thickening of the transition zone can sometimes be visualised as a hypoechoic halo surrounding the endometrial layer of ≥12 mm thickness (less specific)
  • vascularity: on colour Doppler
    • generally increased
    • areas of increased vascularity reciprocate distribution of lesions
    • pattern is of an increased number of tortuous vessels that penetrate myometrium

A "Venetian blind" appearance may be seen as a combination of the aforementioned features: heterogeneous 1,2, coarsened echotexture of the myometrium, and acoustic shadowing where endometrial tissues cause a hyperplastic reaction. The combination of this heterogeneity and the subendometrial echogenic nodular and linear striations is not dissimilar to the appearance of chronic liver parenchymal disease - hence, “cirrhosis of the uterus.”

When an adenomyoma is present, appearances may closely mimic those of a uterine fibroid, which may also co-exist.

May show diverticula extending into the myometrium 3.

CT is unable to diagnose adenomyosis but may suggest its presence when uterine enlargement is present. Distinguishing between adenomyosis and uterine fibroids on CT is difficult, if not impossible, although the presence of calcifications strongly favours the latter 5.

Pelvic MRI is the modality of choice to diagnose and characterise adenomyosis, and T2-weighted images (sagittal and axial) are most useful. MRI has a sensitivity of 78-88% and a specificity of 67-93% 7.

The most easily recognised feature is thickening of the junctional zone of the uterus to more than 12 mm, either diffusely or focally (normal junctional zone thickness is up to ~5 mm) 5.

  • T1
    • foci of high T1 signal are often seen, indicating menstrual haemorrhage into the ectopic endometrial tissues 7
  • T2
    • typically a region of adenomyosis appears as an ill-defined ovoid/diffuse region of thickening, often with small high T2 signal regions representing small areas of cystic change
    • the region may also have a striated appearance 5
  • T1 C+ (Gd)
    • contrast-enhanced MRI evaluation is usually not indicated for evaluation of adenomyosis, however, if performed, it shows enhancement of the ectopic endometrial glands

Treatment depends on the severity of symptoms and the need to preserve fertility. In some instances, suppression of normal cyclical hormone-induced proliferation of endometrial tissue (e.g. GnRH agonist) is sufficient.

In women with severe symptoms not relieved medically, and in whom fertility is no longer desirable, a hysterectomy may be performed.

It was first described by Rokitansky in 1860 as “cystosarcoma adenoides uterinum” and was later defined by Von Recklinghausen in 1896 11

The differential depends on the macroscopic distribution of endometrial tissue.

For diffuse disease consider:

For focal disease (adenomyoma) consider:

Whether focal or diffuse, another potential differential is treatment of breast cancer with tamoxifen which can lead to poorly-defined endometrial hyperplasia and endometrial polyps that can mimic adenomyosis 4 (see: tamoxifen-associated endometrial changes).

Ultrasound - gynaecology
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Article information

rID: 10171
System: Gynaecology
Synonyms or Alternate Spellings:
  • Adenomyosis of the uterus
  • Uterine adenomyosis
  • Adenomyosis of uterus
  • Adenomyosis (uterus)

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Cases and figures

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    Figure 1: gross pathology
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    Case 1: MRI T2
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    Figure 2: histology H and E stain
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    Case 2: T2
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    Case 3
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    Case 4: MRI T2
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    Case 5: MRI T2
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    Case 6
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     Case 7
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    Case 8: with concurrent uterine fibroid
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    Case 9: with concurrent cervical polyp
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    Case 10: on HSG
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    Case 11: focal adenomyosis
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    Case 12: diffuse adenomyosis
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    Case 13
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    Case 14
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    Case 15
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