eMedicine Specialties > Radiology > Obstetrics/Gynecology

Uterus, Adenomyosis

Karen L Reuter, MD, FACR, Professor, Department of Radiology, Lahey Clinic Medical Center

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 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).

• 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

Magnetic Resonance Imaging

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).

Findings

The second modality commonly used for diagnosing adenomyosis, MRI, although more expensive than ultrasonography, can be employed in cases with indeterminate sonographic results or in patients who are undergoing uterine-sparing surgery for leiomyomas.

Thin-section, high-resolution MRI scans obtained with a pelvic multicoil array are optimal for diagnosing adenomyosis. The uterine zonal anatomy is best seen on T2-weighted images.

Variations in the normal thickness of the inner myometrium, or junctional zone, have been reported, with a mean thickness of 2-8 mm. Widening of this junctional zone has been associated with adenomyosis (see Image 3). Furthermore, the thickness of a normal junctional zone changes with the menstrual cycle, while the thickness of diffuse adenomyosis does not. However the MRI appearance of adenomyosis can change in response to hormonal stimulation and treatment. Findings from an MRI study of 20 healthy volunteers suggested that the upper limits of a normal junctional zone should be at least 7-8 mm to avoid a high false-positive rate in the diagnosis of adenomyosis. These authors noted that myometrial contractions can appear as adenomyosis.

Haimovici and Tempany reported that a junctional zone of 12 mm or less is normal.² They used findings of focal hyperintensity on T2-weighted images (see Image 3) to confirm the diagnosis of adenomyosis. These authors did not recommend the use of gadolinium enhancement to diagnose adenomyomas in their review article.

In their review of the endovaginal ultrasonographic and MRI features of adenomyosis, Reinhold and colleagues concluded that adenomyosis could be diagnosed with a high degree of accuracy when the junctional zone thickness was 12 mm or greater.^3,4 A maximum thickness of 8 mm or less usually excluded the disease. When the maximum junctional zone diameter was 8-12 mm, secondary findings, such as high–signal-intensity foci on T1- or T2-weighted images, were necessary to make the diagnosis.

The bright foci seen in the myometrium on T2-weighted images in 50% of patients (see Image 3) are islands of heterotopic endometrial tissue, cystic dilation of heterotopic glands, or hemorrhage. Whether the hemorrhage is from hormonal changes or from spontaneous causes is not known. Sometimes, linear striations of decreased signal intensity can be seen radiating out from the endometrium into the myometrium on T2-weighted images. These striations are the direct invasion of the basal endometrium into the myometrium. When the striations blend or become indistinct, pseudo-widening of the endometrium is seen.

Focal adenomyosis, as opposed to diffuse adenomyosis, is seen as a localized, low–signal-intensity mass within the myometrium on both T2-weighted and contrast-enhanced T1-weighted MRIs. In one series of T1-weighted images, most of these masses were isointense relative to the surrounding myometrium. These focal adenomyomas were 2-7 cm in diameter, round or oval, and located in the posterior wall. They also had a poorly defined margin.

In addition to depicting adenomyosis, MRI can be used to distinguish a focal adenomyoma from a leiomyoma. Adenomyomas lack distinct borders and any mass effect on both T2-weighted and contrast-enhanced T1-weighted MRI scans. Furthermore, most focal adenomyomas are in the posterior myometrium. Leiomyomas do not have this predilection. Both adenomyomas and leiomyomas have low signal intensity, although some leiomyomas with hemorrhage have high signal intensity.^5,6,7,8

The most common lesion of adenomyosis seen on magnetic resonance images is a low–signal-intensity area on T2-weighted images that often gives the appearance of diffuse or focal widening of the junctional zone (see Image 3). This hypointense area is smooth-muscle hyperplasia accompanying the heterotopic endometrial glands.

Rarely, endometrial carcinoma may arise from adenomyosis.  It has been shown that when adenomyosis coexists with endometrial carcinoma at the same site on T2-weighted images, contrast-enhanced T1-weighted images improve the accuracy of staging.

Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or magnetic resonance angiography (MRA) scans. 

NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble  moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.

Degree of Confidence

The reported accuracy of MRI for diagnosing adenomyosis is high. Its sensitivity and specificity are 80-100%, with an overall accuracy of 85-90.5%.

Ultrasonography

Findings

The gross ultrasonographic description of adenomyosis includes irregular, myometrial, cystic spaces predominantly involving the posterior uterine wall, an enlarged uterus with a widened posterior wall (see Image 1), an eccentric endometrial cavity, and decreased uterine echogenicity without lobulations, contour abnormality, or mass effects (which is more commonly seen with leiomyomas). Sonograms may also show an ill-defined margin between the normal myometrium and the abnormal myometrium, as well as an elliptically shaped myometrial abnormality. However, the occurrence of adenomyosis cannot be consistently differentiated from the presence of leiomyomas by using TAUS.^9,10,11

Transvaginal sonogram of an enlarged uterus with a thickened posterior myometrium (arrows).

Sagittal transabdominal sonogram of an enlarged uterus with a thickened posterior myometrium (arrows).

From a series of 29 women with evidence of adenomyosis at hysterectomy, the morphologic criterion for adenomyosis at endovaginal ultrasonography was the presence of myometrial heterogeneous and hypoechoic areas with or without cysts. The sensitivity in that series was 86%, the specificity was 86%, and the positive and negative predictive values were 71% and 94%, respectively.

Endovaginal ultrasonography, especially with a Doppler technique, can be used as the initial imaging modality to determine the presence of adenomyosis. It must be performed meticulously and with real-time imaging. Chiang and colleagues used color Doppler ultrasonography with the morphologic criteria to improve the diagnostic accuracy of ultrasonography in differentiating adenomyosis from leiomyomas.¹² They found that 87% of the cases of adenomyosis had randomly scattered vessels or intratumoral signals. In 88% of leiomyoma cases, they observed peripheral scattered vessels or outer feeding vessels. In addition, in 82% of the adenomyomas, arteries within or around the uterine tumors had a pulsatility index (PI) greater than 1.17, and 84% of leiomyomas had a PI of 1.17 or less.

On sonograms, the most common appearance of adenomyosis is areas of decreased echogenicity or heterogeneity in the myometrium. Specific details of this observation have been analyzed. The areas of decreased echogenicity are those where smooth-muscle hyperplasia has occurred. The areas of heterogeneity are small, echogenic islands of heterotopic endometrial tissues surrounded by hypoechoic smooth muscle. Dilated cystic glands or hemorrhagic foci within the heterotopic endometrial tissue cause the appearance of small myometrial cysts that are smaller than 5 mm in diameter. These are seen in about 50% of patients.

Multimedia

Media file 1: Transvaginal sonogram of an enlarged uterus with a thickened posterior myometrium (arrows).

Media file 2: Sagittal transabdominal sonogram of an enlarged uterus with a thickened posterior myometrium (arrows).

Media file 3: 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).

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].

Keywords

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

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.

Related eMedicine topics:

Endometrioma/Endometriosis

Endometriosis (from Obstetrics & Gynecology)

Endometriosis (from Emergency Medicine)

Endometriosis (from Pediatrics: Surgery)

Malposition of the Uterus

Guidelines:

Gynaecological Ultrasound Examination

The Investigation and Management of Endometriosis

Clinical trials:

Proliferation of Endometrial Stromal Cells in Adenomyosis

Evaluation of Endometrial Stromal Cell Apoptosis in Adenomyosis

Progestin Treatment for Endometrial Stromal Cells in Adenomyosis

Uterine Artery Embolization for Symptomatic Fibroids

Health-Related QoL Among Women Receiving Hysterectomy in NTUH

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