Images in GYN Ultrasound

Uterine adenomyosis: Noninvasive diagnosis

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These experts share color Doppler and 3-D ultrasound imaging demonstrating signs of adenomyosis, including myometrial heterogeneity, increased vascularity, and asymmetric posterior myometrial thickening




Steven R. Goldstein, MD, CCD, NCMP
Professor, Department of Obstetrics and Gynecology, New York University School of Medicine; Director, Gynecologic Ultrasound; and Co-Director, Bone Densitometry, New York University Medical Center, New York

In this month’s installment of Images in GYN Ultrasound, Drs. Stalnaker and Kaunitz have done an excellent job of describing what adenomyosis will look like on transvaginal ultrasound

In my first book, entitled Endovaginal Ultrasound,1 I coined the phrase “sonomicoscopy.” I maintain that we are seeing things with transvaginal ultrasound that you could not see with your naked eye if you could hold the structure at arms length and squint at it.

Adenomyosis is defined as endometrial glands and stroma embedded within the myometrium. Literature has shown that if you do three sections on a routine hysterectomy specimen the incidence of adenomyosis is 31%; with six sections the incidence is 61%! In other words, it is a very prevalent occurrence.

There is no question that adenomyosis CAN be a source of uterine enlargement, pain, and bleeding. But it is such a prevalent finding that the real question is: What percent of women, especially parous women, will have sonographic evidence of adenomyosis but be totally asymptomatic? Such women represent the denominator while the symptomatic ones represent the numerator. I worry about labeling asymptomatic patients with this entity—when they become perimenopausal and oligo-ovulatory, and may have irregular bleeding—their symptoms can be judged to be FROM adenomyosis and surgical correction is offered.

An important part of successful ultrasound use is being sure that we redefine what is “normal” as we examine patients with this “low power microscope.” So, while transvaginal ultrasound CAN identify glands and stroma within the myometrium, we must be careful not to automatically label this finding as a “disease.”

1. Goldstein SR. Endovaginal Ultrasound. 2nd ed. John Wiley & Sons, Inc: Hoboken, NJ; January 1991.

Uterine adenomyosis: Noninvasive diagnosis

Michelle L. Stalnaker, MD
Assistant Professor and Associate Program Director, Obstetrics and Gynecology Residency, Department of Obstetrics and Gynecology at the University of Florida College of Medicine–Jacksonville

Andrew M. Kaunitz, MD
University of Florida Research Foundation Professor and Associate Chairman, Department of Obstetrics and Gynecology at the University of Florida College of Medicine–Jacksonville. Dr. Kaunitz is a member of the OBG Management Board of Editors.

Uterine adenomyosis is a pathologic condition in which endometrial glands and stroma are present in the uterine myometrium. Uterine adenomyosis is common, and may coexist with leiomyomata or endometriosis. When present, it may cause dysmenorrhea and heavy menses.

Until recently, the best way to establish a diagnosis of uterine adenomyosis was through histologic examination of a hysterectomy specimen. However, transvaginal ultrasound and pelvic magnetic resonance imaging have been shown to be accurate for noninvasive diagnosis.

Signs on imaging include:

  • Globular/bulky uterus
  • Asymmetric thickening of myometrium
  • Loss of clarity of endo-myometrial interface
  • Diffuse heterogenous myometrial echogenicity
  • Myometrial cysts
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