eMedicine Specialties > Radiology > Obstetrics/Gynecology

Uterus, Adenomyosis

Author: Karen L Reuter, MD, FACR, Professor, Department of Radiology, Lahey Clinic Medical Center
Contributor Information and Disclosures

Updated: Feb 12, 2009

Introduction

Background

Adenomyosis, although considered a variant of endometriosis, is different because of its behavior. Adenomyosis was first described by Rokitansky in 1860 and then clearly defined by Von Recklinghausen in 1896. It causes chronic bleeding unresponsive to hormonal therapy or uterine evacuation.

Sagittal magnetic resonance image of an enlarged ...

Sagittal magnetic resonance image of an enlarged uterus with a thickened posterior myometrium. T2-weighted image without gadolinium enhancement shows a widened junctional zone of 23 mm (arrows) and focal high signal intensity (arrowheads).

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Sagittal magnetic resonance image of an enlarged ...

Sagittal magnetic resonance image of an enlarged uterus with a thickened posterior myometrium. T2-weighted image without gadolinium enhancement shows a widened junctional zone of 23 mm (arrows) and focal high signal intensity (arrowheads).


In 1991, Sathyanarayana divided adenomyosis into 3 categories, depending on the location of the lesion. The classifications were as follows:
  • Lesions limited to the basal layer
  • Lesions in the deep layers,
  • Lesions in the surface layers

Iribarne and colleagues have suggested a new category: intramyometrial cystic adenomyosis.1

Related eMedicine topics:

 Endometrioma/Endometriosis
Endometriosis (from Obstetrics & Gynecology)

Endometriosis (from Emergency Medicine)

Endometriosis (from Pediatrics: Surgery)

Malposition of the Uterus

Presentation

Demographics
The reported prevalence of adenomyosis in random hysterectomy specimens is 8.8-31% or 5-70%. Iatrogenic adenomyosis has occurred after laparoscopic myomectomy when the myometrium was not sutured in layers.

Adenomyosis affects premenopausal and perimenopausal women, usually those who are multiparous and older than 30 years.

Natural history and presentation

Pathologically, uterine adenomyosis is a condition in which the stroma and/or heterotopic endometrial glands are located more than 1 high-power field deeper than the endometrial-myometrial junction. The stratum basale of the endometrium gives rise to the heterotopic endometrial tissue.

At histopathologic analysis, an adenomyoma is described as a circumscribed, nodular aggregate of smooth muscle and endometrial glands, with compensatory hypertrophy of the myometrium surrounding the ectopic endometrium.

Clinical signs and symptoms of adenomyosis include dysmenorrhea, menorrhagia, and pelvic pain. Other findings include chronic vaginal bleeding and unresponsiveness to hormonal therapy or uterine evacuation. Adenomyosis can cause infertility.

Treatment
The treatment for symptomatic adenomyosis has been hysterectomy. The reported mortality and morbidity rates for this procedure are 1-2 deaths per 1000 cases and 25-50%, respectively.

More conservative treatments are increasingly being used to treat adenomyosis. Gonadotropin-releasing hormone (GnRH) agonists have been used to treat the infertility that can result from adenomyosis. Adenomyosis has also responded to estrogen.13

Embolization with polyvinyl particles through the uterine arteries may decrease the size of leiomyomas, which are seen as vascular masses, and it may also relieve the signs or symptoms of adenomyosis. For example, uterine-artery embolization may relieve the heavy vaginal bleeding that patients with adenomyosis often experience. Kim and colleagues were able to relieve the symptoms in 3 patients with MRI and/or ultrasonographic findings of adenomyosis. Long-term follow-up analysis of these patients, including their fertility subsequent to the procedure, is being conducted.

Preferred Examination

The imaging diagnosis of adenomyosis is usually made by means of transvaginal ultrasonography (TVUS) or magnetic resonance imaging (MRI).

Limitations of Techniques

The imaging diagnosis of adenomyosis is usually made by using TVUS or MRI. Hysterosalpingography (HSG) and transabdominal ultrasonography (TAUS) often lack specificity for this diagnosis. The inability to resolve subtle differences in soft-tissue attenuation limits the usefulness of computed tomography (CT) scanning in diagnosing adenomyosis.

The MRI appearance of adenomyosis can change as a result of hormonal stimulation and treatment. Rarely, endometrial carcinoma arises from adenomyosis. When adenomyosis coexists with endometrial carcinoma at the same site on T2-weighted images, contrast-enhanced T1-weighted images improve the accuracy of staging.

Differential Diagnoses

Endometrium, Carcinoma

Other Problems to Be Considered

Adenomatoid tumor
Endometrial stromal sarcoma
Leiomyoma: This cannot be consistently differentiated from adenomyosis with TAUS.
Metastasis
Myometrial contraction

More on Uterus, Adenomyosis

Overview: Uterus, Adenomyosis
Imaging: Uterus, Adenomyosis
Multimedia: Uterus, Adenomyosis
References
Further Reading
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References

  1. Iribarne C, Plaza J, De la Fuente P, et al. Intramyometrial cystic adenomyosis. J Clin Ultrasound. Jun 1994;22(5):348-50. [Medline].

  2. Haimovici JB, Tempany CM. MR of the female pelvis: benign disease. Appl Radiol. Jun 1994;7:21.

  3. Reinhold C, Atri M, Mehio A, et al. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology. Dec 1995;197(3):609-14. [Medline].

  4. Reinhold C, Tafazoli F, Mehio A, et al. Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics. Oct 1999;19 Spec No:S147-60. [Medline].

  5. Tamai K, Koyama T, Umeoka S, et al. Spectrum of MR features in adenomyosis. Best Pract Res Clin Obstet Gynaecol. Aug 2006;20(4):583-602. [Medline].

  6. Tamai K, Togashi K, Ito T, et al. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. Jan-Feb 2005;25(1):21-40. [Medline]. [Full Text].

  7. Jarlot C, Anglade E, Paillocher N, Moreau D, Catala L, Aubé C. [MR imaging features of deep pelvic endometriosis: correlation with laparoscopy.]. J Radiol. Nov 2008;89(11 Pt 1):1745-54. [Medline].

  8. Bazot M, Daraï E. [Evaluation of pelvic endometriosis: the role of MRI.]. J Radiol. Nov 2008;89(11 Pt 1):1695-6. [Medline].

  9. Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;[Medline].

  10. Piketty M, Chopin N, Dousset B, Millischer-Bellaische AE, Roseau G, Leconte M, et al. Preoperative work-up for patients with deeply infiltrating endometriosis: transvaginal ultrasonography must definitely be the first-line imaging examination. Hum Reprod. Dec 17 2008;[Medline].

  11. Kim MD, Lee HS, Lee MH, Kim HJ, Cho JH, Cha SH. Long-term results of symptomatic fibroids treated with uterine artery embolization: In conjunction with MR evaluation. Eur J Radiol. Dec 10 2008;[Medline].

  12. Chiang CH, Chang MY, Hsu JJ. Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J Assist Reprod Genet. May 1999;16(5):268-75. [Medline].

  13. Huang HY. Medical treatment of endometriosis. Chang Gung Med J. Sep-Oct 2008;31(5):431-40. [Medline].

  14. Atri M, Reinhold C, Mehio AR. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology. Jun 2000;215(3):783-90. [Medline]. [Full Text].

  15. Batzer FR, Hansen L. Bizarre sonographic appearance of an adenomyoma and its presentation. J Ultrasound Med. Aug 1996;15(8):599-602. [Medline].

  16. Byun JY, Kim SE, Choi BG, et al. Diffuse and focal adenomyosis: MR imaging findings. Radiographics. Oct 1999;19 Spec No:S161-70. [Medline].

  17. Guilbeault H, Wilson SR, Lickrish GM. Massive uterine enlargement with necrosis: an unusual manifestation of adenomyosis. J Ultrasound Med. Apr 1994;13(4):326-8. [Medline].

  18. Kang S, Turner DA, Foster GS, et al. Adenomyosis: specificity of 5 mm as the maximum normal uterine junctional zone thickness in MR images. AJR Am J Roentgenol. May 1996;166(5):1145-50. [Medline].

  19. Ostrzenski A. Extensive iatrogenic adenomyosis after laparoscopic myomectomy. Fertil Steril. Jan 1998;69(1):143-5. [Medline].

  20. Utsunomiya D, Notsute S, Hayashida Y, et al. Endometrial carcinoma in adenomyosis: assessment of myometrial invasion on T2-weighted spin-echo and gadolinium-enhanced T1-weighted images. AJR Am J Roentgenol. Feb 2004;182(2):399-404. [Medline]. [Full Text].

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Keywords

adenomyosis of the uterus, endometriosis, chronic bleeding, ectopic endometrium, heterotopic endometrial tissue, dysmenorrhea, menorrhagia, pelvic pain, infertility, intramyometrial cystic adenomyosis, adenomyoma, endometrial carcinoma

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Contributor Information and Disclosures

Author

Karen L Reuter, MD, FACR, Professor, Department of Radiology, Lahey Clinic Medical Center
Karen L Reuter, MD, FACR is a member of the following medical societies: American Association for Women Radiologists, American College of Radiology, American Institute of Ultrasound in Medicine, American Roentgen Ray Society, and Radiological Society of North America
Disclosure: Nothing to disclose.

Medical Editor

Harris L Cohen, MD, FACR, Vice Chairman/Associate Chairman (Research Activities), Director, Division of Body Imaging, Professor of Radiology, Stony Brook School of Medicine; Visiting Professor of Radiology, Johns Hopkins School of Medicine
Harris L Cohen, MD, FACR is a member of the following medical societies: American College of Radiology, American Institute of Ultrasound in Medicine, Association of Program Directors in Radiology, Radiological Society of North America, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

Spencer B Gay, MD, Professor of Radiology, Director of Body Computed Tomography, Department of Radiology, University of Virginia Health Sciences Center
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD, Consulting Radiologist, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, and Society of Nuclear Medicine
Disclosure: Nothing to disclose.

 
 
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