Goubaa Mohamed MD Djerba Tunisia

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This is a 43-year-old female with history of infertility. The patient also complained constipation and increasing abdominal girth. An ultrasound study was performed. Voici le cas d'une patiente de 43 ans avec une histoire de stérilité primaire. Elle se plaint de constipation et d'une distension abdominale. Un examen échographique a été pratiquée.


Transvaginal sonography Echographie endovaginale

definitive treatment is hysterectomy : the removed mass : En Chirurgie: hystérectomie et ablation d'un gros utérus en boule.

The follow-up study : 2 years later : only the cervix Contrôle : 2 ans plus tard

Click on the image below
Cliquez sur les images en bas













2 years later
2 ans plus tard

A15-cm solid mass is seen above the bladder. The mass abuts the uterine fundus (Scan 1) but is not separate from the uterus (Scan 2 : transvaginal scanning). Here, It is difficult to tell the difference between adenomyosis and fibroids. Adenomyosis were confirmed by pathologic examination.
Abdominal hysterectomy were performed. The postoperative period of the patient was uneventful.

Extreme enlargement of the uterus is possible due to adenomyosis alone (1).

Masse solide de 15 cm est visible au dessus de la vessie (cliché 1). la masse est au dépend de l'utérus et c'est visible par échographie endovaginale (cliché 2). Ici, il est difficile de différencier, ici, entre une fibrome et une adénomyose utérine. L'étude anatomopathologique confirme l'adénomyose.
Conclusion :
l'élargissement important de l'utérus peut avoir comme unique cause l'adénomyose.
Adenomyosis Adénomyose Utérine _______________



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Adenomyosis characteristically affects porous women over the age of 40 years. It is related to a diffuse or focal invasion of the myometrium by nests of endometrial tissue causing uterine enlargement.
The diagnosis of adenomyosis is suspected if the uterus feels enlarged and tender to the touch during the pelvic examination. However, the diagnosis of adenomyosis based on these findings is often inaccurate, and other causes-fibroids, endometriosis, or polyps-are often found as the cause for the bleeding or discomfort. The diagnosis may be suggested by the appearance of the uterus on a sonogram, although it is often difficult to tell the difference between adenomyosis and fibroids.
TVUS is as efficient as MRI for the diagnosis of adenomyosis in women without myoma, while MRI could be recommended for women with associated leiomyoma (6). The combination of MRI and TVS produced the highest level of accuracy for exclusion of adenomyosis (7).
Adenomyosis, although considered a variant of endometriosis, is different because of its behavior.
Adenomyosis is classified into 3 categories depending on the location of the lesion: those limited to the basal layer, those in the deep layers, and those in the surface layers. Iribarne et al suggest a new category: intramyometrial cystic adenomyosis.

Pathologically, uterine adenomyosis is a condition in which the stroma and/or heterotopic endometrial glands are located deeper than the endometrial-myometrial junction by more than 1 high-power field. The stratum basale of the endometrium gives rise to the heterotopic endometrial tissue. Invasion by nests of endornetrial tissue causes utérine enlargement.
In the absence of focal fibroids, a diffuse uterine process seen on sonography relates to the severity of adenomyosis. The visualization of the endometrium does not relate to the severity of adenomyosis (4).
The adenomyosis is rarely isolated. It is associated to uterine fibroma in 62% of cases. Their symptoms and signs are often the same (5)

Adenomyosis may be asymptomatic.
symptoms : painful menses, heavy but regular bleeding, pelvic pain (20), unresponsiveness to hormonal therapy or uterine evacuation. Adenomyosis can cause infertility.

Sonography :
Pelvic sonography provides an accurate diagnosis of adenomyosis in the majority of cases. Endovaginal US was as accurate as MR imaging in the diagnosis of uterine adenomyosis (13).
The sensitivity and specificity of transvaginal ultrasonography were 82 - 89 and 67- 89 % respectively (12 , 13 , 14 , 16).
The myometrial écho pattern, central écho comples and utérine contour may he normal. Occasion-ally, adenomyosis is focal, which may result in contour ahnormality, although the central echo complex is normal. Rarely a honeycomb appearance caused by cystic spaces is encountered. Pelvis endometriosis and adenomyosis may coexist in 30% of patients.
A diagnosis of adenomyosis was suggested if the uterus was diffusely enlarged, but the myometrial texture, contour, and central cavity echoes were each normal. Leiomyoma, or other focal uterine pathology was characterized by focal or globular uterine enlargement with abnormal echo texture and contour, as well as nonvisualization or displacement of the central cavity echo complex (17).
Sonographic features used in the diagnosis of adenomyosis : a mottled inhomogeneous myometrial texture, enlargement of the uterus and globular appearing uterus, small cystic spaces within the myometrium, and a "shaggy" indistinct endometrial stripe (8 , 18).
The presence of subendometrial linear striations, subendometrial echogenic nodules, or asymmetric myometrial thickness improves the specificity and PPV of US in diagnosing adenomyosis (9). The ultrasonographical demonstration of endometrial cyst of the ovary may contribute to an accurate diagnosis of adenomyosis (19).

Endometrium Carcinoma.

The treatment for symptomatic adenomyosis has been hysterectomy. Patients without or with only minimal endometrial penetration of <2.5 mm (superficial adenomyosis) have good results from the ablation. Patients with deep endometrial penetration of >2.5 mm (deep adenomyosis) usually have persistent problems and should be offered hysterectomy over repeat ablation (10). Hysterectomy will still be necessary in severe cases of adenomyosis (11).
More conservative treatments are increasingly used to treat adenomyosis. Gonadotropin-releasing hormone (GnRH) agonists have been used to treat the infertility that can result from adenomyosis. Adenomyosis also has responded to estrogen. Recently,uterine-artery embolization may relieve the signs or symptoms of adenomyosis(2).


1: Gynecol Obstet Invest. 2004 Aug 24;58(4):216-218. A Case of Adenomyosis per se with a Uterine Weight of 475 g. Harmanli OH, Shen T, Zhu S, Chatwani AJ. Department of Obstetrics and Gynecology, Temple University School of Medicine, Philadelphia, Pa., USA.
2: Clin Radiol. 2004 Jun;59(6):520-6. Uterine artery embolization for adenomyosis without fibroids. Kim MD, Won JW, Lee DY, Ahn CS. Diagnostic Radiology, Bundang CHA General Hospital, Pochon CHA University, 351 Yatap-dong, Bundang-gu, Sungnam-si, Kyonggi-do, Sungnam, South Korea. mdkim@cha.ac.kr
3: Ultrasound Obstet Gynecol. 2002 Dec;20(6):605-11. Comment in: Ultrasound Obstet Gynecol. 2003 Jun;21(6):626-7. Limitations of transvaginal sonography for the diagnosis of adenomyosis, with histopathological correlation. Bazot M, Darai E, Rouger J, Detchev R, Cortez A, Uzan S. Department of Radiology, Hopital Tenon, Paris, France. marc.bazot@tnn.ap-hop-paris.fr
4: AJR Am J Roentgenol. 2002 Aug;179(2):379-83. Sonographic findings in patients with adenomyosis: can sonography assist in predicting extent of disease? Hulka CA, Hall DA, McCarthy K, Simeone J. Department of Radiology, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114, USA.
5: Tunis Med. 2001 Aug-Sep;79(8-9):447-51. [Adenomyosis: analysis of 35 cases] Ben Aissia N, Berriri H, Gara F. Service de gynecologie-obstetrique, CHU Mongi Slim La Marsa.
6: Hum Reprod. 2001 Nov;16(11):2427-33. Ultrasonography compared with magnetic resonance imaging for the diagnosis of adenomyosis: correlation with histopathology. Bazot M, Cortez A, Darai E, Rouger J, Chopier J, Antoine JM, Uzan S. Department of Radiology, Hopital Tenon, 4 rue de la Chine, 75020, France. marc.bazot@tnn.ap-hop-paris.fr
7: Fertil Steril. 2001 Sep;76(3):588-94. Magnetic resonance imaging and transvaginal ultrasonography for the diagnosis of adenomyosis. Dueholm M, Lundorf E, Hansen ES, Sorensen JS, Ledertoug S, Olesen F. Department of Gynecology and Obstetrics, Aarhus University and Aarhus University Hospital, Aarhus, Denmark. hjorth@dadlnet.dk
8: J Ultrasound Med. 2000 Aug;19(8):529-34; quiz 535-6. Adenomyosis: sonographic findings and diagnostic accuracy. Bromley B, Shipp TD, Benacerraf B. Department of Obstetrics and Gynecology, Massachusetts General Hospital, and Brigham and Women's Hospital, Harvard Medical School, Boston, USA.
9: Radiology. 2000 Jun;215(3):783-90. Adenomyosis: US features with histologic correlation in an in-vitro study. Atri M, Reinhold C, Mehio AR, Chapman WB, Bret PM. Department of Radiology, McGill University, Montreal General Hospital, Quebec, Canada. mostafa_atri@pmh.toronto.on.ca
10: Hum Reprod Update. 1998 Jul-Aug;4(4):350-9. The response of adenomyosis to endometrial ablation/resection. McCausland V, McCausland A. Department of Obstetrics and Gynecology, University of Southern California, Los Angeles County Medical Center, Women and Children's Hospital, Los Angeles, 90033, USA.
11: Hum Reprod Update. 1998 Jul-Aug;4(4):323-36. Surgical and medical treatment of adenomyosis. Wood C. Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia.
12: Hum Reprod. 1998 Oct;13(1O):2884-7. Transvaginal ultrasonography versus uterine needle biopsy in the diagnosis of diffuse adenomyosis. Vercellini P, Cortesi I, De Giorgi O, Merlo D, Carinelli SG, Crosignani PG. Clinica Ostetrica e Ginecologica Luigi Mangiagalli, University of Milano, Italy.
13: Radiology. 1996 Apr;199(1):151-8. Diffuse adenomyosis: comparison of endovaginal US and MR imaging with histopathologic correlation. Reinhold C, McCarthy S, Bret PM, Mehio A, Atri M, Zakarian R, Glaude Y, Liang L, Seymour RJ. Department of Diagnostic Radiology, Montreal General Hospital, McGill University School of Medicine, Quebec, Canada.
14: Radiology. 1995 Dec;197(3):609- 14. Diffuse uterine adenomyosis: morphologic criteria and diagnostic accuracy of endovaginal sonography. Reinhold C, Atri M, Mehio A, Zakarian R, Aldis AE, Bret PM. Department of Diagnostic Radiology, Montreal General Hospital, Quebec, Canada.
15: Akush Ginekol (Mosk). 1994;(2):40-3. [A clinico-morphological comparison of the ultrasonic criteria of adenomyosis] [Article in Russian] Damirov MM, Bakuleva LP, Shabanov AM, Sliusar' NN.
16: Fertil Steril. 1992 Jul;58(1):94-7. Comment in: Fertil Steril. 1993 Feb;59(2):479. Transvaginal ultrasonography in the diagnosis of diffuse adenomyosis. Fedele L, Bianchi S, Dorta M, Arcaini L, Zanotti F, Carinelli S. Istituto Ostetrico-Ginecologico L. Mangiagalli, Universita di Milano, Italy.
17: J Ultrasound Med. 1987 Jul;6(7):345-9. Uterine adenomyosis. A difficult sonographic diagnosis. Siedler D, Laing FC, Jeffrey RB Jr, Wing VW.
18: AJR Am J Roentgenol. 1987 Apr;148(4):765-6. Sonographic findings in adenomyosis of the uterus. Bohlman ME, Ensor RE, Sanders RC.
19: Nippon Sanka Fujinka Gakkai Zasshi. 1986 Nov;38(11):2073-7. Ultrasonography for the diagnosis of adenomyosis. Murao F, Hata K, Shin K, Hata T, Yoshino K, Yamamoto K, Takahashi K, Kitao M.
20: Diagn Gynecol Obstet. 1982 Summer;4(2):105-6. The preoperative diagnosis of adenomyosis. Weseley AC.