| 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
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
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
The adenomyosis is rarely isolated. It is associated to uterine
fibroma in 62% of cases. Their symptoms and signs are often the
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.
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).
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. email@example.com
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,
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. firstname.lastname@example.org
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. email@example.com
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. firstname.lastname@example.org
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,
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.