Case Review: Ultrasound of Uterine Adenomyosis

Radiology Lectures | Radiologist Headquarters

In this radiology lecture, we review the ultrasound appearance of adenomyosis through three unique cases, including an MRI example.

Key teaching points include:

• Adenomyosis results from ectopic endometrial tissue in myometrium. Leads to dysfunctional smooth muscle hyperplasia/hypertrophy surrounding ectopic glands.
• Cause unknown.
• Common, usually multiparous women of reproductive age.
• Additional risk factors: Early menarche, short menstrual cycles, high BMI = High estrogen exposure.
• Rarely seen in postmenopausal patients, unless treated with tamoxifen for breast cancer.
• Often asymptomatic, but can present with menorrhagia, dysmenorrhea, dyspareunia, and chronic pelvic pain.
• For diagnosing adenomyosis, transvaginal US much more sensitive and specific (89%) than transabdominal imaging.
• Most specific US findings: Linear echogenic striations/nodules radiating from endometrium into inner myometrium. Tiny myometrial and subendometrial cysts = Fluid-filled glands.
• Additional US findings: Enlarged, globular uterus with diffuse myometrial bulkiness, myometrial heterogeneity, irregular endometrial-myometrial interface, hyperechoic islands, and pencil-thin “venetian blind” or “rain shower” shadowing. Cine clips extremely helpful.
• Adenomyosis can cause asymmetric myometrial thickening.
• Focal adenomyosis (adenomyoma) has ill-defined margins compared to fibroids, typically elliptical as opposed to rounded in shape.
• May see abnormal vascular flow: Increased vascularity with tortuous vessels penetrating myometrium. Helps differentiate adenomyosis from fibroids, which tend to displace vessels and show circumferential flow.
• On US, thickened junctional zone may manifest as a hypoechoic halo surrounding echogenic endometrium.
• MRI “traditionally” the modality of choice to diagnose adenomyosis, and junctional zone thickened to 12 mm or greater highly specific. May contain punctate T2 hyperintense cystic foci/T1 hyperintense hemorrhage.
• However, modern TV US shows comparable accuracy to MRI with no statistical significance between sensitivities and specificities: “Transvaginal US should be considered the primary imaging modality for the diagnosis of adenomyosis.”*
• Treatment: Pain management, tranexamic acid, OCPs, GnRH agonists.
• If severe, not relieved medically, and no desire for fertility: Hysterectomy.

*Cunningham RK, Horrow MM, Smith RJ, et al. Adenomyosis: A Sonographic Diagnosis. RadioGraphics. 2018; 38:1576-1589

To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4

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