Diagnostic Ultrasound - Abdomen and Pelvis

Adenomyosis
Diagnoses: Female Pelvis
PATHOLOGY
General Features
• Etiology
○ Ectopic endometrial tissue within myometrium
○ Reactive hypertrophy and hyperplasia of surrounding
smooth muscle
○ Etiology poorly understood, but may involve invagination
of endometrium directly into myometrium vs. de novo
development from müllerian rests
• Associated abnormalities
○ Endometriosis
Gross Pathologic & Surgical Features
• Enlarged and boggy uterus
○ With thickened myometrial wall and islands of
endometrial bleeding
• Adenomyoma may resemble leiomyoma, but cannot be
easily excised
Microscopic Features
• Ectopic endometrial tissue within myometrium at least 1
low-power field from endomyometrial interface
• Adjacent smooth muscle hypertrophy and hyperplasia
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Diffusely enlarged uterus, may be tender
○ Often associated with menorrhagia
– Less commonly dysmenorrhea or metrorrhagia
○ Commonly associated with endometriosis
○ Controversial association with infertility
• Other signs/symptoms
○ Often mistaken for fibroids given similar symptoms and
ultrasound findings
Demographics
• Age
○ Pre- or perimenopausal
• Epidemiology
○ Often have coexistent leiomyomas
○ Most commonly multiparous
○ Association with cesarean sections
Treatment
• Medical treatment with oral contraceptives or
gonadotropin releasing hormone agonists to control
symptoms
• Adenomyosis cannot be resected
• Hysterectomy is definitive treatment
• Uterine artery embolization is effective alternative
treatment
○ Results not as reproducible as for leiomyoma
Image Interpretation Pearls
• Loss of endomyometrial interface due to thickening of
junctional zone
• Abnormal myometrial echogenicity, most commonly
hypoechoic, due to smooth muscle hyperplasia
• Echogenic linear striations due to endometrial extension
into myometrium
• If findings are equivocal, obtain MR to evaluate for
thickened junctional zone (> 12 mm is diagnostic)
○ However, diagnosis can be made at lower threshold if
T1/T2-bright foci or linear high T2 signal striations are
present
SELECTED REFERENCES
1. Van den Bosch T et al: Terms and definitions for describing myometrial
pathology using ultrasonography. Ultrasound Obstet Gynecol. ePub, 2015
2. Boeer B et al: Differences in the clinical phenotype of adenomyosis and
leiomyomas: a retrospective, questionnaire-based study. Arch Gynecol
Obstet. 289(6):1235-9, 2014
3. Genc M et al: Adenomyosis and accompanying gynecological pathologies.
Arch Gynecol Obstet. ePub, 2014
4. Pistofidis G et al: Distinct types of uterine adenomyosis based on
laparoscopic and histopathologic criteria. Clin Exp Obstet Gynecol.
41(2):113-8, 2014
5. Riggs JC et al: Cesarean section as a risk factor for the development of
adenomyosis uteri. J Reprod Med. 59(1-2):20-4, 2014
6. Levy G et al: An update on adenomyosis. Diagn Interv Imaging. 94(1):3-25,
2013
7. Taran FA et al: Adenomyosis: Epidemiology, Risk Factors, Clinical Phenotype
and Surgical and Interventional Alternatives to Hysterectomy. Geburtshilfe
Frauenheilkd. 73(9):924-931, 2013
8. Naftalin J et al: How common is adenomyosis? A prospective study of
prevalence using transvaginal ultrasound in a gynaecology clinic. Hum
Reprod. 27(12):3432-9, 2012
9. Smeets AJ et al: Long-term follow-up of uterine artery embolization for
symptomatic adenomyosis. Cardiovasc Intervent Radiol. 35(4):815-9, 2012
10. Stamatopoulos CP et al: Value of magnetic resonance imaging in diagnosis
of adenomyosis and myomas of the uterus. J Minim Invasive Gynecol.
19(5):620-6, 2012
11. Manyonda IT et al: Uterine Artery Embolization versus Myomectomy: Impact
on Quality of Life-Results of the FUME (Fibroids of the Uterus: Myomectomy
versus Embolization) Trial. Cardiovasc Intervent Radiol. Epub ahead of print,
2011
DIAGNOSTIC CHECKLIST
Consider
• Enlarged, tender uterus in patient with menorrhagia
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