DSJUOG

Mihaela Grigore 10.5005/jp-journals-10009-1404

Review article

Adenomyosis: Pictorial Essay of Two-Dimensional and

Three-Dimensional Ultrasonography Findings
Mihaela Grigore

ABSTRACT of the disease is not well known, but it is estimated to be

Purpose: Adenomyosis is a common gynecological disease present in 20 to 30% of the general population and up to
that is defined as the presence of nonneoplastic ectopic 70% of hysterectomy specimens.1,2
endo­metrial glands and stroma in the myometrium. These Adenomyosis is not a uniform disease. Rather, it
charac­teristics are associated with reactive overgrowth of the represents a spectrum of lesions, ranging from increased
musculature. The aim of this pictorial essay was to delineate the
specific sonographic features of adenomyosis as seen with two- thickness of the endometrial-myometrial junction (EMJ)
dimensional (2D) and three-dimensional (3D) ultrasonography. to overt adenomyosis and adenomyomas. The EMJ is the
Methods: Evaluation of the adenomyosis is best achieved in
transitional zone between the mucous membrane that
daily practice with transvaginal ultrasonography. is the endometrium and the outer smooth muscle layer
of the myometrium. Diffuse adenomyosis, which affects
Results: The most important features of adenomyosis are
anechoic foci, striation, heterogeneous myometrium, and an the entire endometrium, is the type most frequently
asym­metrical uterine wall. All of these features were seen in encountered and affects the entire myometrium. Focal
this study by 2D ultrasonography. Three-dimensional ultra­ adenomyosis displays isolated ill-defined nodules of
sonography allowed visualization of the thickness and disrup­tion
hypertrophic myometrium and ectopic endometrium,
of the endometrial-myometrial junction.
sometimes referred to as adenomyomas. Recent studies
Conclusion: Two-dimensional and 3D ultra­sonography are
indicate that adenomyosis is a progressive disease whose
valuable tools for diagnosing adenomyosis even in early
stages of the disease because they make it possible to eva­ appearance changes during the reproductive years. 3
luate both the myometrium and the endometrial-myometrial Many patients with adenomyosis are asymptomatic.
junction. The combined information gained from the 2D and When the disease is symptomatic, it is characterized by
3D ultrasonography examinations not only allows diagnosis of
dysmenorrhea, dyspareunia, chronic pelvic pain, and
adenomyosis but also pinpoints the current stage of the disease.
menometrorrhagia. Because adenomyosis can coexist
Keywords: Adenomyosis, Endometrial-myometrial junction, with another gynecological conditions (e.g. myoma,
Three-dimensional ultrasonography, Two-dimensional
ultrasonography. endometrial polyps, endometriosis), it is sometimes
difficult to determine to what extent the symptomatology
How to cite this article: Grigore M. Adenomyosis: Pictorial
Essay of Two-Dimensional and Three-Dimensional Ultra­
is caused by adenomyosis. Myometrial hypertrophy,
sonography Findings. Donald School J Ultra­sound Obstet which causes a clinically enlarged, often soft uterus, is
Gynecol 2015;9(2):188-192. commonly seen in conjunction with both the diffuse
Source of support: Nil and focal forms.4 The final diagnosis is confirmed by
pathology examination of the surgically removed uterus.
Conflict of interest: None

Introduction Ultrasonography Findings

Adenomyosis is a common gynecological disease defined Imaging techniques play an important role in the diag­
as the presence of nonneoplastic ectopic endometrial nosis of adenomyosis, the main diagnostic tech­niques
glands and stroma in the myometrium associated with being ultrasonography (US) and magnetic resonance
reactive overgrowth of the musculature. The incidence imaging (MRI). A recent meta-analysis showed that
transvaginal US and MRI have high levels of accuracy
for the noninvasive diagnosis of adenomyosis. Transvagi-
Consultant nal US had a sensitivity of 72% [95% confidence interval
Department of Obstetrics and Gynecology, University of
(CI) 65-79%], specificity of 81% (95% CI 77-85%), positive
Medicine and Pharmacy ‘Grigore T. Popa’, Iaşi, Romania likelihood ratio of 3.7 (95% CI 2.1-6.4), and negative like-
Corresponding Author: Mihaela Grigore, Consultant, Depart­ lihood ratio of 0.3 (95% CI 0.1-0.5). Magnetic resonance
ment of Obstetrics and Gynecology, University of Medicine and imaging had a sensitivity of 77% (95 % CI 67-85%),
Pharmacy ‘Grigore T Popa’, Str. Universitatii 16, Iaşi, 700115 specificity of 89% (95% CI 84-92%), positive likelihood
Romania, Phone: +40 744 438024, Fax: +40 232 221516, e-mail:
ratio of 6.5 (95% CI 4.5-9.3), and negative likelihood
[email protected]
ratio of 0.2 (95% CI 0.1-0.4).5 The US technique has been

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Adenomyosis: Pictorial Essay of Two-Dimensional and Three-Dimensional Ultrasonography Findings

improved steadily. The use of high-frequency transvagi- Asymmetrical myometrial thickening (Fig. 3): When the
nal transductors improved the sensitivity and specificity disease is focal, the uterine enlargement is asymmetrical.
of the examination. There is a difference in size between the anterior and
posterior walls of the uterus in the longi­tudinal or
Two-dimensional Ultrasonography transverse plane.13
Two-dimensional (2D) US has a clearly established place Cysts of variable size throughout the myomet­rium (Figs 4 and 5):
in the diagnosis of adenomyosis.6-8 Many studies have In most cases, cyst sizes vary by a few millimeters (1-7
compared 2D US with MRI and concluded that the former mm), although they sometimes vary as much as 2 to 4
is a highly useful tool for diagnosing adenomyosis, cm. Doppler examination is useful for differentiating
especially in the hands of a trained sonographer. Magnetic anechoic images from vein dilatation. A myometrial cyst
resonance imaging is useful in difficult cases in which the has been cited as the most specific and sensitive feature
US results do not definitively establish the diagnosis.9-11 for diagnosing adenomyosis.12
The most important features of adenomyosis seen with
Hyperechoic linear striations (Fig. 6): These striations can
2D US are the following:
be seen radiating out from the endo­metrial surface.
Uterine enlargement (Fig. 1): Uterine length may be up to According to Kepkep et al the striations are the most
12 cm without a myoma inside the uterus. The borders accurate sign of adenomyosis on transvaginal US.14
of the uterus are usually normal (not modified by the
Subendometrial hyperechogenic nodules: The nodules are
disease).7,12
composed of ectopic endometrium.8
Heterogeneous myometrium with architectural dis­tur­
Adenomyoma (Fig. 7): This lesion is a focal presence of
bances (Fig. 2): Hyperechoic regions are surroun­ded by
adenomyosis and must not be misdiagnosed as a myoma.
hypoechoic areas, which correspond to smooth muscle
The contour of the adenomyoma is not neat. Doppler
hyperplasia. Sakhel and Abuhamad regarded this feature
imaging shows randomly scattered vessels—in contrast
as the most predictive of adenomyosis.12
to a myoma where the vessels are on the periphery.15,16
All of these sonographic features have been reported to
have high sensitivity (80-87%) and specificity (94-98%)
for distinguishing between adenomyosis and leiomyoma
based on comparisons between transvaginal US and
histo­logical confirmation.17
Poor definition of the EMJ compared to that in normal uterus
(Figs 8 to 10): It suggests diffuse adenomyosis and is
caused by invasion of the endometrial glands in the
myometrium.
Thickening of the EMJ (Figs 11A and B): It appears as a hypo­
echoic halo around the endometrium. When associated
with adenomyosis, this layer has been reported to exceed
Fig. 1: Large uterus. The contour of the uterus is usually unaltered 12 mm.12

Fig. 2: Heterogenous areas within the myometrium Fig. 3: Asymmetrical myometrial thickening

Donald School Journal of Ultrasound in Obstetrics and Gynecology, April-June 2015;9(2):188-192 189
Mihaela Grigore

Figs 4A and B: Myometrial cysts

Fig. 5: Large myometrial cysts Fig. 6: Hyperechoic linear striations radiating from the
endometrial surface

Fig. 7: Adenomyoma mass with poorly defined margins Fig. 8: Poor definition of the endometrial-myometrial junction

Three-dimensional Ultrasonography zone has been assigned various names in the literature:
The use of three-dimensional (3D) US provided new endomyometrial junctional zone, inner myometrium,
possibilities for diagnosing gynecological disease. Its uterine junctional zone,20 endometrial-subendometrial
obvious advantages are that it offers more rapid, repro­ unit or stratum subvasculare,21 subendometrial myo­
ducible image acquisition and enhanced visualization metrium 22, archimetra, 23 archimyometrium, 24 inner
and postprocessing capabilities.18 Three-dimensional US myometrium.25 Traditionally, assessment of the EMJ
enables visualization of the coronal plane of the uterus has been part of the MRI evaluation of the uterus, with
and consequently gives a clear image of the EMJ.19 This changes in this area key to diagnosing adenomyosis.26

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 DSJUOG

Adenomyosis: Pictorial Essay of Two-Dimensional and Three-Dimensional Ultrasonography Findings

Fig. 9: Three-dimensional ultrasonography shows a

normal uterus

Figs 11A and B: Three-dimensional ultrasonography shows

disruption of the endometrial-myometrial junction

is almost impossible to observe with 2D imaging. The 3D

US features of adenomyosis are the following:
• Thickening of the EMJ: It is measured from the basal
endometrium to the internal layer of the outer
myometrium. A value > 8 mm suggests adenomyosis.27
• A difference of > 4 mm between the maximum and
minimum EMJ values.27
• Disruption of the EMJ by infiltration of hyperechoic
endometrial tissue.27
Three-dimensional US not only visualize the EMJ, it
meets all the other criteria for a diagnosis of adenomyosis
found with 2D US: anechoic foci, striation, heterogeneous
Figs 10A and B: Three-dimensional ultrasonography with myo­metrium. Also, it is believed that the features
volume contrast imaging in a normal uterus revealed by 3D US define the stage of the disease. It
has been reported that changes in the thickness of the
Because of the possibility of visualizing the EMJ, 3D US junc­tional zone and protrusion of the endometrium
opens up new horizons for the diagnosis of adenomyosis. into the inner myometrium represent an early stage
The EMJ appears on the coronal plane as a hypoechoic in the development of adenomyosis.19,27 Conventional
zone around the endometrium.27 Adding volume contrast findings, such as myometrial cysts and asymmetry of
imaging (VCI) to the coronal plane provides a clearer the myometrium are more likely to be signs of advanced
view of the junctional zone (JZ). Because of the clear disease. Thus, although 3D US seems to be a promising
view with VCI, it is the modality for best analyzing and tool for diagnosing adenomyosis, further study is needed
measuring the junctional zone.27 Three-dimensional US to certify our findings and especially to compare 3D US
allows visualization of the lateral and fundal EMJ, which and MRI for diagnosing this disease.

Donald School Journal of Ultrasound in Obstetrics and Gynecology, April-June 2015;9(2):188-192 191
Mihaela Grigore

Another interesting aspect of adenomyosis is that it 11. Dueholm M. Transvaginal ultrasound for diagnosis of adeno­
may play a role in infertility—it may interfere with the myosis: a review. Best Pract Res Clin Obstet Gynecol 2006;
20(4):569-582.
process of implantation.27,28 A precocious diagnosis using
12. Sakhel K, Abuhamad A. Sonography of adenomyosis. J Ultra­
2D and 3D US could perhaps initiate correct management sound Med 2012;31(5):805-808.
of even asymptomatic disease with the aim of preserving 13. Andreotti RF, Fleischer AC. The sonographic diagnosis of
fertility. adenomyosis. Ultrasound Q 2005;21(3):167-170.
14. Kepkep K, Tuncay YA, Goynumer G, Tutal E. Transvaginal
sono­graphy in the diagnosis of adenomyosis: which findings
Conclusion are most accurate? Ultrasound Obstet Gynecol 2007;30(3):
Because 2D and 3D US allow us to examine both the 341-345.
15. Chiang CH, Chang MY, Hsu JJ, et al. Tumor vascular pattern
myometrium and the EMJ, they are valuable tools for and blood flow impedance in the differential diagnosis of
establishing a diagnosis of adenomyosis even during leiomyoma and adenomyosis by color Doppler sonography.
early stages of the disease. The combined information J Assist Reprod Genet 1999;16(5):268-275.
gained from the 2D and 3D US examinations not only 16. Botsis D, Kassanos D, Antonioc G, et al. Adenomyoma and
allows diagnosis of adenomyosis but also pinpoints leiomyoma: differential diagnosis with transvaginal sono­
graphy. J Clin Ultrasound 1998;26(1):21-25.
the stage of the disease. Once clear criteria have been
17. Fedele L, Bianchi S, Dorta M, et al. Transvaginal ultra­
established for such staging, we can set up proper pro­ sonography in the differential diagnosis of adenomyoma
tocols for managing the disease. versus leiomyoma. Am J Obstet Gynecol 1992;167(3):603-606.
18. Grigore, Mare A. Applications of 3-D ultrasound in female
infer­tility. Rev Med Chir Soc Med Nat Iasi 2009;113(4):1113-1118.
References
19. Naftalin J, Jurkovic D. The endometrial-myometrial junction:
1. Azziz R. Adenomyosis: current perspectives. Obstet Gynecol a fresh look at a busy crossing. Ultrasound Obstet Gynecol
Clin North Am 1998;16(1):221-235. 2009;34(1):1-11.
2. Naftalin J, Hoo W, Pateman K, Mavrelos D, Holland T, 20. Fusi L, Cloke B, Brosens JJ. The uterine junctional zone. Best
Jurkovic D. How common is adenomyosis? A prospective Prac Res Clin Obstet Gynaecol 2006;20(4):479-491.
study of prevalence using transvaginal ultrasound in a 21. Noe M, Kunz G, Herbertz M, Mall G, Leyendecker G. The
gynaecology clinic. Hum Reprod 2012;27(12):3432-3439. cyclic pattern of the immunocytochemical expression of
3. Gordts S, Brosens JJ, Fusi L, Benagiano G, Brosens I. Uterine oestrogen and progesterone receptors in human myometrial
adeno­myosis: a need for uniform terminology and consensus and endometrial layers: characterization of the endometrial-
classification. Reprod Biomed Online 2008;17(2):244-248. subendometrial unit. Hum Reprod 1999;14(1):190-197.
4. Cirpan T, Yeniel O, Ulukus M, et al. Clinical symptoms and 22. Lyons EA, Taylor PJ, Zheng XH, Ballard G, Levi CS,
histopathological findings in subjects with adenomyosis Kredentser JV. Characterization of subendometrial myo­
metrial contractions throughout the menstrual cycle in
uteri. Clin Exp Obstet Gynecol 2008;35(1):48-53.
normal fertile women. Fertil Steril 1991;55(4):771-774.
5. Champaneria R, Abedin P, Daniels J, Balogun M, Khan KS.
23. Leyendecker G, Kunz G, Noe M, Herbertz M, Mall G.
Ultrasound scan and magnetic resonance imaging for the
Endometriosis: a dysfunction and disease of the archimetra.
diagnosis of adenomyosis: systematic review comparing test
Hum Reprod Update 1998;4(5):752-762.
accuracy. Acta Obstet Gynecol Scand 2010;89(11):1374-1384.
24. Leyendecker G, Kunz G, Kissler S, Wildt L. Adenomyosis
6. Reinold C, Tafazoli F, Wang L. Imaging features of adeno­
and reproduction. Best Prac Res Clin Obstet Gynaecol
myosis. Hum Reprod Update 1989;4(4):337-349.
2006;20(4):523-546.
7. Bromley B, Shipp TD, Benacerraf B. Adenomyosis: sono­
25. Brosens JJ, Barker FG, de Souza NM. Myometrial zonal
graphic findings and diagnostic accuracy. J Ultrasound Med differentiation and uterine junctional zone hyperplasia in the
2000;19(8):529-534. non-pregnant uterus. Hum Reprod Update 1998;4(5):496-502.
8. Atri M, Reinhold C, Mehio AR, Chapman WB, Bret PM. 26. Dueholm M, Lundorf E, Hansen ES, Sorensen JS, Ledertoug S,
Adenomyosis: US features with histologic correlation in an Olesen F. Magnetic resonance imaging and transvaginal
in vitro study. Radiol 2000;215(3):783-790. ultra­sonography for the diagnosis of adenomyosis. Fertil
9. Dueholm M, Lundorf E. Transvaginal ultrasound or MRI Steril 2001;76(3):588-594.
for diagnosis of adenomyosis. Curr Opin Obstet Gynecol 27. Exacoustos C, Brienza L, Giovanni A, et al. Adenomyosis:
2007;19(6):505-512. three-dimensional sonographic findings of the junctional
10. Bazot M, Darai R, Rouger J, Detchev R, Cortez A, Uzan S. zone and correlation with histology. Ultrasound Obstet
Limi­tations of transvaginal sonography for the diagnosis of Gynecol 2011;37(4):471-479.
adenomyosis, with histopathological correlation. Ultrasound 28. Campo S, Campo V, Benagiano G. Infertility and adenomyosis.
Obstet Gynecol 2002;20(6):605-611. Obstet Gynecol Int 2012;2012:786132. Published online 26 Dec 2011.

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