Adenomyosis Routine US and SIS with Multimodality Correlative Imaging - HD

Introduction

My name is Mindy Harrow.
I'm a physician at the Einstein Medical Center in Philadelphia, where I'm the vice chair of radiology.
Today I'm going to talk about adenomyosis on ultrasound, on regular gray scale ultrasound with sonohysterography, and then with a variety of correlative imaging such as CT and MR.

Educational Objectives

Today I will discuss adenomyosis both with routine ultrasound imaging, sonohysterography and multimodality correlative imaging.
The overall educational objectives of this talk will be initially and briefly to discuss pathophysiology, risk factors and symptoms of adenomyosis, and then go on in the main bulk of the talk to describe the sonographic findings that allow us to make this diagnosis, and particularly to distinguish from myomas in the uterus.
In so doing, I'll give a list of imaging, ultrasound imaging pearls that you can use and go on afterwards to correlate with sonohysterography and other modalities including CT MR and routine contrast hysterosalpingography.

Epidemiology

The epidemiology of this process has been historically based upon hysterectomy, and therein lies the problems because it varies as to who gets her hysterectomy for what, when, and why.
And the rate of hysterectomy across the world varies dramatically.
So, not surprisingly, the incidence listed in the pathology literature varies very widely of adenomyosis.
In the United States, probably between 20 and 30% of hysterectomy specimens show adenomyosis.
There are a variety of racial ethnic parity and age variations, but again, many of these, if not most of them, are related to the rate of hysterectomy.
Nowadays, often the uterus is taken out in pieces and sectioned during a laparoscopic resection, and this can certainly restrict the confidence of the pathologist or even the diagnosis at all of adenomyosis.
In addition, and this is very important, the likelihood of even making this diagnosis is related to the number of tissue samples taken by the pathologist and whether they've even been alerted to do so beforehand.
So as you can see, it's very, very difficult to understand clearly what the epidemiology is.

Risk Factors and Symptoms

Then as we turn to risk factors, it's sort of the same thing.
Many of these have been quoted as risk factors for adenomyosis, but may all in part just be due to who's having a hysterectomy.
So it tends to be older women.
It tends to be multiparous women who have already had their children.
Other things, as you can see on this list, including tamoxifen, which we'll talk about, have been listed as risk factors.
The symptoms were a little bit more clear on, many women have symptoms, of course, the symptoms overlap.
Many other things that go on in the pelvis, they do include menorrhagia, chronic pelvic pain, and significant dysmenorrhea.
Interestingly enough, previously it was thought that adenomyosis was just some sort of incidental finding that was there, but the symptoms were caused by other pelvic diseases.
We now know certainly that adenomyosis causes significant symptoms.
Myomas are the other major pathology of the myometrium, and they are common as are adenomyosis, and so commonly they coexist, and the data suggests that women who have both of these processes have significantly more symptoms than women only with myomas.

Pathophysiology

The pathophysiology of adenomyosis is also not particularly clear, but I will give you one of the leading possibilities in this etiology.
So peristalsis goes on in the uterus over time and causes strain on the tissues, which cause tissue injury and small areas of microtrauma in the uterus.
In a woman of menstruating age, this causes more estrogen to be produced in these local areas, which then causes more peristalsis.
So it's almost as if these very active areas in the uterus are going on.
And then this is thought to result in dehiscence in the myometrium and desquamation of the endometrium, which then breaks down the border between the endometrium and the myometrium.
That borderland is the junctional zone of the uterus, which becomes infiltrated by the basal endometrium of the uterus, and that's the definition of this disease, that endometrial tissue, the endometrial glands are implanted and are within the myometrium.
This then goes on to cause an angiogenesis, which is different in the myometrium from normal myometrial tissue, and the disease progresses for some reason.
The area in the uterus that seems to be most susceptible and often has this more and earlier, is what's called the fundal cornu.
This is a micro diagram taken from this article, and it shows you where that fundal cornu is.
It's the place where the paired mullerian ducts that form the uterus come together, and these fibers are thought to originate and coordinate peristaltic activity in the uterus and seem to be most susceptible to adenomyosis.
So if you know where that is, it's sort of the sagittal area of the uterus towards the fundus, that's where you would want to look.
And for this process, it is helpful to look at both a gross and a microscopic specimen of the uterus to understand adenomyosis and to differentiate it from the uterus.

Gross and Microscopic Pathology

So here we have a specimen, and along here is the endometrial surface.
This is the serosal surface in the back.
And if you look at this image, you'll see there's a nice smooth round structure sitting right here close to the endometrium.
And this is a typical fibroid, very round and very well marginated.
If you look elsewhere, you'll notice as the arrows show you two reddish areas which are also within the myometrium.
These are islands of ectopic endometrium, and this is exactly what the definition of adenomyosis is.
If you look around those areas, you'll notice that there's a bit of hypertrophy and change in the muscle of the uterus, and it conforms to the shape of the glands versus the round contour of the fibroid.
So the islands of tissue give you these irregular shaped stromal hypertrophy areas compared to the smooth whorling of the myoma.
Now turning to the histologic slide again, at the top of this image, this is the endometrium and the serosal surface would be back here.
If you look, these are the glands of the endometrium embedded within the myometrium.
This is what a pathologist would look at and make the diagnosis of adenomyosis.
They are areas of endometrial glands, the clear areas surrounding stroma, which is the purple and completely separate from the endometrial surface.

History of Ultrasound Diagnosis

In the early years of ultrasound, certainly before transvaginal days, we very rarely made the diagnosis of adenomyosis if it was even suggested at all.
It was when someone noticed that the uterus seemed rather large, but there was no discreet mass in it.
Then people got a little bit more savvy and noted that sometimes the anterior or the posterior myometrium was just much thicker than the other side, and this was abnormal, and again, not due to fibroids.
As equipment got better, we were able to notice heterogeneous areas in the myometrium again, that had no contour or real mass in them.
And this is how sometimes the diagnosis of adenomyosis could be suggested.
As ultrasound technology improved, so did our ability to make this diagnosis, and I would postulate that the best equipment that you can get with the highest frequency that you are able to scan the uterus will allow you to make this most confidently in your diagnosis.

Ultrasound Findings

So with modern ultrasound technology, this allows us to see a variety of findings, as you can see on this list, that are very specific and sensitive to adenomyosis.
It's not just a diagnosis of absence, if you will, and this includes cysts and blurring of the endometrial junctions, striations, et cetera, using these kinds of findings.
The literature currently shows that we can get very high specificity for adenomyosis, and this comes from data with 7.5 megahertz transducers, and you can nowadays have even higher frequency transducers.
The other important thing to remember about using ultrasound to make this diagnosis with, especially with an endovaginal probe, is that it allows us to correlate the patient's pain with us pressing.
So, press towards the ovary, that doesn't hurt press towards the uterus.
That's what simulates the patient's pain.
I would point out however, that the more fibroids there are in the uterus, especially with significant shadowing, the more difficult it can be to make this diagnosis, and you should be aware of that possibility.
This is from the literature.
Over the past 20 or so years in the nineties and early to early two thousands, sensitivities and specificities were in a pretty good range for adenomyosis.
But in the recent literature, this has improved even more and is certainly well within the range of MRI for the diagnosis of adenomyosis.
And that's important because we don't do MRI for every woman that has pelvic pain.
We wouldn't have enough MRI scanners to do that, and if we can make the diagnosis most of the time with ultrasound, the patients will benefit.

Categories of Ultrasound Findings

Let's turn now to the ultrasound findings, and I would characterize these into three specific areas that will help you in making this diagnosis.
First is the ectopic endometrial glands themselves.
Can we actually see those glands or as sort of the footprint of those glands within the myometrium?
The second thing that happens is that the glands being there and being hormonally sensitive cause a stromal muscular hyperplasia to occur within the normal myometrium, and we'll look at the findings of that.
And third, there is a vascularity that adenomyosis exhibits, which is different in many cases from fibroids and can be very helpful.

Scanning Pearls

I'm going to also list first the my different scanning pearls, and these are going to crop up in all of the images and I'll highlight them.
So the first pearl that I would leave you with is that the highest, as I mentioned, the highest frequency.
Usually transvaginal imaging is best for seeing the heterogeneity and the shadowing of adenomyosis.
If you have a penetration mode, that may allow you to notice the hyperplasia of the stroma and muscle very well.
Often with adenomyosis, because it is a migration of glands from the endometrium into the junctional zone, it blurs the border of the endometrium.
And this effect is more visual, more prominent on endovaginal scanning, and actually a lower frequency transabdominal transducer may better allow for a more accurate measurement of the endometrium itself.
The subtle little echogenic striations that propagate from the endometrium into the junctional zone, which are highly likely the little footprints of the glands are much better appreciated if you're able to see them in real time and if not in a room with the patient than using cine or cine video clips from high frequency imaging.
And fifth, if you also happen to have the ability to make reformats of the uterus into the coronal plane, that may allow you to better actually understand, appreciate, and convey where the adenomyosis is located in the uterus.

Ectopic Endometrial Glands

So first ectopic endometrial glands.
These are actually, you can actually see the cysts in the junctional zone on ultrasound, these very tiny cysts, you can see them on MR.
And as you'll see also on CT often, what you'll find is that the running perpendicular to the endometrium are hyperintense for MR or hyperechoic for ultrasound linear striations, they extend from the endometrium into the junctional zone, and often the little cysts are at the end of them.
Sometimes you'll see small echogenic nodules in the endomyometrium when you do sonohysterography, which puts saline in the endometrium of the uterus or hysterosalpingography, which puts contrast in sometimes if the glands are still open to the endometrium, they will fill with either fluid or air in a sonohysterogram or with contrast in a hysterosalpingogram.
Here's our first case.
This is a 48-year-old multiparous woman who comes with symptoms of menorrhagia and dysmenorrhea, and as you can see, this is sagittal and transverse.
There are many of the classic findings of adenomyosis.
Here's the endometrium.
There's a much thicker anterior myometrium than posterior.
Numerous small cysts are visualized here, as well as small echogenic nodules, as you can see in the curved arrows.
The cine clips, as I mentioned, are very helpful to appreciate the findings of adenomyosis.
And here's the same patient.
As you go through.
You can see these linear echogenicity, the tiny cysts that connect to them, echogenic nodules, striations.
All of these findings are adenomyosis, and that line that goes through was the measurement of the anterior myometrium that was quite thick.

Stromal Muscular Hyperplasia

Stromal muscular hyperplasia is what causes the enlargement of the uterus, and this is often rounded and globular in shape.
As I mentioned, you can have asymmetric myometrial thickening, but it can be also symmetric.
This is what causes the thickened junctional zone on MR, which is quoted as greater than 12 millimeters and can certainly be measured on ultrasound as well.
In addition to all of this thickening ultrasound can actually show the very hypoechoic, heterogeneous myometrium.
Those thin little shadows, which are also known as Venetian blind shadows or pencil thin shadows are from the whorls of the muscle fibers that have hypertrophied.
These are different from the edge shadows and calcification shadows of myomas.
The stromal muscular hyperplasia often results in the endometrial myometrial interface being blurred.
All of these findings are classically seen on ultrasound and MR very, very similarly, sometimes you can appreciate them on CT as well.
So here's an example of two different patients, a diffuse adenomyosis case on the left and an asymmetric adenomyosis case on the right.
Notice if you will, all of these thin little lines, lots of heterogeneity, the endometrium is virtually impossible to find in the second patient.
There's an area of adenomyosis here in this retroflexed uterus.
The myometrium on the other side is normal.

Transabdominal vs. Transvaginal Imaging

Now let's turn to transabdominal versus transvaginal imaging for adenomyosis.
Here we have a patient in both sagittal and transverse, and if you look at the uterus, it looks a little bit big, it's kind of rounded.
There's nothing really focal.
The endometrium looks like it's here, it's a little bit hard to see.
You might certainly begin to think that there is some adenomyosis, but look at the difference of the appearance when you go to the transvaginal and how much that helps you.
So pearl one is that high frequency imaging is most helpful and you can see the heterogeneity, the cyst, the shadowing all around the place on routine transvaginal.
Here's another patient with significant diffuse adenomyosis, more prominent in the posterior myometrium, and we do see some faint shadowing, but it's almost as if we're just not penetrating this uterus that well.
And so if we use a penetration mode, which slightly actually lowers the frequency with much, it's much easier to see the thin little shadows, the striations, the echogenic nodules, and the little bit of cysts.
So that's the difference.
They're both on transvaginal sometimes, however, you really cannot do adequate transvaginal imaging in some patients, especially if the uterus is very big or if there's been significant scarring and tethering from prior cesarean section, which pulls the uterus out of the pelvis and takes it far away from the transvaginal probe.
In those situations, some patients who are thinner, you can still use a higher frequency transabdominal probe as we did here.
And I've lined up the sagittal ultrasound on the left and the MR on the right in this same patient.
So you can see here's the endometrium, significant adenomyosis with little echogenic areas, tiny cysts, nodules, et cetera.
And here on the MR the cysts are bright as you can see them here.
There's a lot of generalized adenomyosis, but much more focal here in the posterior myometrium.

Blurring of the Endometrial Border

I mentioned the blurring of the endometrial border.
This has been called pseudo widening of the endometrium, and you need to take that into account and not over measure the endometrium in such a situation.
Here's the patient on transvaginal.
You can see some of the endometrium, well marginated here, but in the back of the endometrium, you sort of lose the border of where it is and it would be difficult to actually measure.
And you can see that on the sagittal as well.
So where the adenomyosis is more prominent and more focal, that border is significantly blurred.
However, in this situation, if you switch to a transabdominal transducer, as I'll show you, you might actually see the endometrium better because of the lower frequency and better measure it more accurately.
Again, another example which highlights the importance of using the absolutely highest frequency transvaginal probe that you can.
This was a patient who came at that time when we were switching from an 8.4 megahertz transducer to a higher frequency.
She was actually three years post-menopausal and had this image, which looked like a pretty reasonable looking uterus.
Here's the body of the uterus.
We actually tried the 10.3, which was our new probe, 10.3 megahertz transducer, and all of a sudden it allowed us to see significant improvement in our ability to make this diagnosis with clarity that we had not been able to appreciate with the 8.4.
So if you look at the right hand image, you'll see a tiny cyst and addition, you'll see those little echogenic, linear striations, which we really could not appreciate at all before.
And I mentioned this case in particular because you can still make the diagnosis of adenomyosis in postmenopausal patients who are not that many years postmenopausal.
Remember pearl five said that location of adenomyosis may be better appreciated with coronal reformats.
This was a patient who was also postmenopausal and we thought there was an area of adenomyosis here, which was blurring the endometrium.
The patient went on to have a coronal reformat, and so now you can see the shield shape endometrium, and right here it looks like it's blurring and bulging out into the myometrium, which it is, and that's the area of adenomyosis.

Vascularity

The vascularity of adenomyosis, as I mentioned initially, is different from that of fibroids, which are its big competitor for diagnosis in the uterus.
Generally there is a significant increase in overall density of uterine vessels that you are able to appreciate in an area of adenomyosis.
These vessels are somewhat tortuous and known as penetrating, so they just spread through the area of adenomyosis rather than outlining any particular shape.
This increased vascularity leads to their enhancement when using contrast on both MR and CT.
Here's an example of adenomyosis with a large area in the myometrium here.
This is the area of adenomyosis, and as you can see in color, there are many more vessels.
They're sort of linear and curly and they're penetrating through this area.
Compare that with a small myoma elsewhere in the uterus.
When you turn the color on, you can see the circumferential type of peripheral flow, which is typical of a myoma.
And this helps distinguish the two.
Sometimes adenomyosis can be quite focal, and in those cases it may be very difficult to decide whether this is a myoma or focal adenomyosis.
This was such a case where you can see a somewhat focal area of different echogenicity.
Here's the endometrium. It's a little bit blurred.
There are some small cystic areas which can happen in fibroids.
There's no shadowing to help at all.
So we turned on the color and certainly there's absolutely none of that peripheral curvilinear vascularity that's typical of a myoma, but instead vessels that penetrate through this region and that helps to distinguish that this is much more likely to be focal adenomyosis.

Differentiating Adenomyosis from Myomas

Here's a list giving you different characteristics of adenomyosis and myoma that may help you to differentiate the two.
And just to reiterate, adenomyosis is clearly less well marginated has less of a mass effect.
The shape of it is not going to be very round and smooth as you saw on the histologic slices.
Calcifications can be of significant help because they are distinctly absent in adenomyosis.
Both adenomyosis and myomas have shadowing, but the adenomyosis shadowing tends to be those very, very thin little lines sort of all over the place, not coming from any one place.
Generally, adenomyosis looks infiltrative, whereas myoma are whorled in appearance.
Adenomyosis vessels tend to penetrate.
Myomas are circumferential and adenomyosis is contiguous with the endometrium.
You're not gonna see a focal area of it far from the endometrium.
It should be a continuous process from the migration of the glands out of the endometrium into the myometrium, whereas myomas can be quite variable in location.
Let's look at some comparisons and see how we can make the diagnosis of whether this is adenomyosis or myoma.
This is a transabdominal image of the uterus anteverted, and this was interpreted initially as a fairly large myoma, which was thought to be submucosal in location, and it looks kind of round and looks sort of like a myoma, but I would urge you not to stop there.
It is valuable to do transvaginal imaging.
And as you can see on the transvaginal view, there is absolutely no large myoma in this uterus.
This is just diffuse heterogeneity, little thin shadows, and this is all adenomyosis.
Here's the transverse image of the same uterus.
The endometrium is literally totally almost obscured.
And when we turn on the color, we just had penetrating vascularity, no circumferential peripheral flow Contrast that case with this companion case.
Here is a large myoma and we turn the color on in the transabdominal, and you can see this is circumferential flow more typical of a myoma, and you can see the mass effect of it.
One of the things that people who do ultrasound do is they measure things.
And I would caution you to be careful with that because as soon as you decide to measure something, somebody will interpret it as there is a thing there that I need to report.
And things that are measurable in the uterus tend to be fibroids.
So these are sagittal views of a patient.
This is taken straight out of the study.
These are the images before measurement, and these are the images after measurement.
So the person doing this study, the sonographer doing it, chose to measure this area and chose to measure this area.
And as soon as they were measured, and you just look at the measurements, you tend to call them fibroids.
But if you go back and look at the original source images, there really is nothing focal specific to measure there.
It's diffuse adenomyosis.
I mentioned that fibroids.
Once you figure out that it's a fibroid versus a adenomyoma, fibroids can obscure or make the diagnosis of adenomyosis less obvious.
This is a transverse view of the uterus on a transvaginal scan, and this is the endometrium.
This patient had a fairly large, what we thought was intracavitary myoma, and we were happy that we made that diagnosis and we thought that was good and we helped the patient.
The patient went on to have an MR and that certainly confirmed that there was a very large intracavitary myoma.
However, adenomyosis is these dark, thick areas and if you look around the myometrium of the uterus, all of a sudden over here between say nine o'clock and 11 o'clock, you'll notice that there's a bulgy area that's heterogeneous and it's dark in signal and that is adenomyosis.
Now go back to the original ultrasound and I think you can appreciate that that area of adenomyosis was actually there.
We just didn't really appreciate it and notice it.
We sort of had satisfaction of search, if you will, and we stopped looking and didn't notice that there was also an area of adenomyosis.

Other Considerations

Some other issues to consider are that sometimes adenomyosis can be very, very focal, as I mentioned, and those are more difficult to distinguish from myomas.
Adenomyosis polyps in the uterus can be associated with use of tamoxifen.
There are actually adenomyotic cysts, and these are larger cysts than I showed you.
I showed you tiny two, three millimeter size cysts.
These would be almost like having an endometrioma in the myometrium.
These can be due to adenomyosis.
You can also over time see the progression of adenomyosis in patients.
Some patients have both adenomyosis and endometriosis because there is an overlap of these diagnoses.
And as I mentioned, there is still adenomyosis in menopause at least in the few years in the perimenopausal time period.
Here's the patient. This is a transabdominal view as a rather large uterus, and it looks like there's a focal mass here.
It's slightly hypoechoic, it doesn't have shadowing, it doesn't absorb the sound.
It is a bit heterogeneous.
And the patient had an MRI, which showed also this area, lots of little cystic high intensity foci in it.
And this was a focal area of adenomyosis.
Here I've paired up in the same patient coronal reformatted views of the uterus and the coronal MRI of the uterus so that you can see the similar kinds of findings that you can appreciate.
So here's the endometrium.
This echogenic area and a small portion of the myometrium was involved with adenomyosis.
It's slightly more echogenic and it's slightly nodular in that area.
And on the MR here was the area of adenomyosis, which is the darker signal with the small high intensity areas.
And it was slightly obscuring the endometrium in this area and I think correlates nicely with the ultrasound.

Progression of Adenomyosis

Adenomyosis can be progressive.
And I'm gonna show you a patient over time in which that happened.
So here we are in 2006 and then by 2012 here we're measuring the junctional zone.
What we thought was the junctional zone, it was slightly thickened.
And by 2012, that junctional zone had become even thicker.
These are the MRIs.
She didn't have one in 2006, she had one in 2009.
And you can see just a slightly thickened junctional zone here around the endometrium, which is high signal.
And here in 2012, the junctional zone had gotten significantly thicker.
This patient had an initial ultrasound.
You can see there's a cyst here, and that was mostly the finding of the adenomyosis.
And three years later now, I think you can appreciate these echogenic striations, a different cyst heterogeneity.
And the uterus has gotten fatter and bulkier and rounder even though there's no mass.
So this adenomyosis has progressed.

Coexistence with Endometriosis

I mentioned that endometriosis and adenomyosis can come together and that they likely share the underlying pathophysiology.
It's thought that endometriosis is related to very long estrogen cycles, which occur in early menstrual life.
Adenomyosis often is also related to estrogen production, and that's what it grows under both in a microenvironment and in a macro environment.
So adenomyosis is certainly quite common in women with endometriosis.
And it's thought that perimenopausal women who have very long estrogen cycles have this longer span of trauma and repair and hence the adenomyosis.
So here's an example of a patient.
The uterus is quite large on ultrasound and in the posterior aspect there's a somewhat hypoechoic area.
It doesn't really look like a fibroid other than its focal.
It's well away from the endometrium on the MR.
The entire uterus is essentially filled with adenomyosis.
And in the posterior aspect, there was a focal region bulging back with some high intensity areas, and that was an area of focal deep endometriosis.
This patient also had endometriomas, as you can see here, one, two.
And this is a dilated fallopian tube, which was a hydrosalpinx filled with blood as well.
And here's where that deep endometrial implant was.

Adenomyosis and Tamoxifen

Adenomyosis and tamoxifen.
This is a topic that also deserves some to speak about that.
Tamoxifen is a drug, which is an anti-estrogen drug on the breast, and hence is used in many women as treatment for and prevention of future breast cancer.
As far as its effect on the uterus, that is actually the opposite.
It has an estrogenic effect on the endometrium and the myometrium.
And therefore, if there was underlying adenomyosis in the uterus, it can inflame or flare up this dormant adenomyosis.
It often can cause significant pseudo thickening of the endometrium and regular thickening of the endometrium, which can be difficult to measure because there's adenomyosis in the junctional zone and there's endometrial thickening as well.
Here's such a case. This patient had actually had a lumbosacral MRI and on the edge of the images, it was noted that the endometrium looked quite thick and there were all these little cystic areas.
She went on to have this sonogram, sagittal and transverse of the uterus.
And somewhere in here is the endometrium.
It was impossible to measure and actually know where the endometrium started and stopped and where the adenomyosis was.
So this was all reactivation or flare up of adenomyosis and endometrial hyperplasia under the influence of tamoxifen.

Postmenopausal Adenomyosis

Postmenopausal adenomyosis, as I mentioned, is certainly well documented on both imaging and in pathology.
It's probably in a resting state after menopause and really shouldn't cause symptoms, but as I mentioned, can be revitalized with tamoxifen.
It can however cause issues with diagnosis.
So this is a 59-year-old patient who came to us for postmenopausal bleeding.
She was a few years postmenopausal.
This is sagittal and transverse, and as you can see, here's the endometrium in the lower uterus, and then it looks as though the whole thing becomes very thick.
The borders become indistinct as you can see here.
And it was interpreted in this patient who was bleeding as highly suspicious for invasive endometrial carcinoma, a thick endometrium with cancer that had invaded the myometrium.
She went on to have an MRI for staging, and lo and behold, we were able to see in the uterus a fairly normal endometrium, this thin little high intensity line, and then little cysts and lines and striations radiating out from there into the junctional zone, which was thickened and low signal here.
And that was all adenomyosis, not endometrial cancer.

Sonohysterography

Now let's turn to some other ways that you can see adenomyosis.
Sonohysterography, as you know, is a technique where you put a catheter in the endometrial cavity and inject saline while scanning.
And it's useful to evaluate predominantly the endometrium.
It can however, show adenomyosis.
Not that you would necessarily do this technique for that purpose, but if you think about it, if the glands have migrated out of the endometrium into the junctional zone, it is possible that they are still open.
And with good distension of the cavity, you can get either fluid or air that extravasates into the myometrium.
It looks like there are little cracks and they just fill up with fluid and air.
The better that you are able to distend the cavity, the better that you'll be able to see these.
And likely these are the glands communicating with the endometrial cavity.
So here we have a uterus transverse and this is the endometrium.
And there's a very thick junctional zone here, diffuse adenomyosis and notice, if you will, one or a few of these little echogenic striations radiating from the endometrium.
We were asked to do sonohysterography for other reasons, and you can see these tiny little cracks right here.
And it correlates. That opened up with fluid as we injected in this patient who had adenomyosis.
Sonohysterography can allow you to see these cracks as well as polyps and other things that are difficult to appreciate.
This is a sagittal view of the uterus.
The endometrium looks over right here, here.
Is this thickened or is this just adenomyosis with stromal hypertrophy?
We did a sonohysterogram.
And again, you can see these tiny little thin cracks that are going on here.
These are the bubbles inside.
And this patient turned out to also have polyps.
Sometimes air gets into these cracks because it's impossible to inject without getting a little bit of air and it gets trapped in them and it can actually shadow then and make the examination difficult.
So this patient transverse view of the uterus, an area of adenomyosis here and here, lots of little cysts.
We injected fluid in air and you can see some fluid here, but also several bright foci with shadowing as air was trapped within that large area of adenomyosis that was coincident and opened up to the endometrial cavity.
We did a coronal reformat as we were able to inject and get the cavity even thicker.
So here everything was fine with the endometrium.
And this is the air that went into this large area that you can see over here from the adenomyosis.
Here's a problem case.
This is sagittal and transverse and we're looking at this very bulky, large heterogeneous uterus where it's difficult to see the endometrium.
Is this adenomyosis, is this an abnormal endometrium or both?
So we went on to do the sonohysterography, had a lot of trouble distending the cavity, and that was because there was a very large polyp inside.
This polyp was partially in the cervicoendocervical canal, as you can see here.
And then there was a portion of it in the cavity of the uterus.
Also, as we injected numerous foci of bright air started to sate into the junctional zone as well, and we were having so much difficulty figuring out one or the other that we suggested the patient have an MR, which indeed showed a very large polyp, one big polyp, cervical and endometrial and diffuse adenomyosis throughout the remainder of the uterus.
This is another case, diffusely heterogeneous uterus.
We injected the little bright bubbles were lining up in the endometrium and then fluid got right into this large crack over here, which if you look at the shape of it, does look something like a lollipop.
These are lollipop diverticula have been described for hysterosalpingography, but you can also appreciate them with sonohysterography.
Eventually there was so much air that we got into the junctional zone that it just obscured everything and that occasionally happens.
Unfortunately. Adenomyosis on hysterosalpingography.
This is a very low sensitivity for this diagnosis, but occasionally you can distend the little clefts and see these lollipop diverticula or get a honeycomb appearance of the myometrium.
This was a patient having a hysterosalpingogram to evaluate her Essure or IUD devices and they were fine.
And then you see all these little fine little hairy things coming out of the endometrium.
This is adenomyosis and this was this patient's sonohysterogram, excuse me, her regular ultrasound on MR.

Correlative Imaging: MRI and CT

I've shown you some examples.
Stromal anatomy is best if you visualize it on a sagittal T2 image.
The MR findings are that of a widened junctional zone and usually 12 millimeters is used as the cutoff.
There's a gray zone, if you will, such that if it's less than or equal to eight millimeters, that pretty much excludes adenomyosis.
And then between eight to 12, it can be, this is the in-between area.
Usually the uterus will be bulky and the areas of adenomyosis are relatively ill-defined.
And low signal on T2, the same findings that we discussed for ultrasound.
Poor definition of the myometrial endometrial interface.
The endometrial glands are bright foci within the dark, smooth muscle and often the linear striations are bright as well.
MR has high sensitivity and varied, but usually fairly high specificity for this diagnosis.
We don't usually think about adenomyosis on CT and CT would not be a study of choice to particularly evaluate for it.
However, you need to remember that with, if you use contrast on CT, you may be able to suggest this diagnosis.
And in patients having CT for a variety of different kinds of pain, it should be therefore considered as one of the possibilities for the patient.
Again, you'll look for a thickened myometrium, smooth, large enlargement of the uterus.
You might actually see some small myometrial cysts, but you absolutely need to have contrast to help you in this circumstance.
So let's look at some cases back to back.
This is the same patient who had CT with contrast and ultrasound.
I'm lining up the sagittal reformats and the transverse views of the uterus.
The uterus is round, it's slightly heterogeneous.
It's hard to see the endometrium as it is here.
And the same thing on the ultrasound.
And this is adenomyosis.
You can see the tiny little cysts here.
This is the same patient on all three modalities and I flipped the ultrasound to line up with the MR and CT.
You can see a somewhat focal area of adenomyosis here.
You better appreciated on the MR.
And here's the area on the ultrasound.
Another patient, same exact patient. Oh, CT and MR.
Diffuse adenomyosis.
A smooth, round, bulky uterus, not a fibroid to be seen.
Same thing on MR.

Mimics of Adenomyosis

There are a variety of mimics that you should remember we already saw an endometrial carcinoma that was diagnosed, which was just adenomyosis.
There can be transient myometrial contractions.
A variety of some vascular lesions can occur.
And sometimes tumors can overlap and this should be remembered.
So here we have a 68-year-old woman with post-menopausal bleeding.
Looking at this, it's hard to see where the endometrium is.
It looks heterogeneous.
If I told you the patient was 35, you'd say adenomyosis.
However, at 68, presumably quite a number of years after menopause, even if she had adenomyosis, it shouldn't be this big and robust.
As in this case, the color is a bit helpful.
It's a little bit odd.
It's not as colorful as you might think in the more abnormal areas.
This is the CT she had for staging.
You can see there's some increased flow here.
And this is typical endometrial carcinoma.
This patient is younger and was still menstruating.
She was having very severe menorrhagia and this is a coronal reformat sag and sag with color views of a fairly significant area of increased echogenicity, a little bit heterogeneous, but really quite focal nonetheless, it does not at all look like a fibroid.
The endometrium is involved as is the junctional zone, and there's significant deep vascularity.
So this is also rather odd.
She had a CT which shows you that this lesion, and I've lined them up exactly is highly, highly vascular, too vascular, much too vascular to the adenomyosis or a fibroid.
And this was a carcinosarcoma.
Here's another patient, a sagittal view of the uterus in which there's an area of heterogeneity, maybe some little cysts.
It's sort of hypoechoic, it does abut the endometrium, but there's a very nice border with the endometrium here.
The color is helpful when we turned on the color, this is a brilliant area of numerous speckles of different types of color.
Yellow, red, blue, all alternating together actually with a normal endometrium.
We have a very low resistance waveform from this, and this is an arteriovenous malformation to finish.

Treatment

Now I'd like to turn a bit to treatment of adenomyosis, which there are a variety of drugs that have been used.
Overall, there's generally limited success with medications.
Surgical techniques, minimally invasive ones, also somewhat limited.
Uterine artery embolization is probably the best non-surgical technique that we have, and there's some promising results, but no randomized or controlled trials have ever been done to substantiate this technique.
This is probably the best and largest trial which showed significant short term relief of 83 to 93%, but it definitely recurred over time.
And I'll just show you this one case.
This was a patient who had adenomyosis on initial imaging studies.
The ultrasound shows the big bulky uterus.
MR showed a large area of adenomyosis, which brilliantly enhanced.
After contrast, she was treated with UAE and her post imaging studies showed the area here.
This is the pre-study, and she happened to have a post CT, which showed the area of adenomyosis, but it was no longer enhancing and the uterus had gotten a bit smaller.
Other issues related to adenomyosis.
There can be decidualization during pregnancy.
Occasionally adenocarcinoma can arise in an area of adenomyosis and that can be a difficult diagnosis as well as if there is coincidental endometrial carcinoma that can be difficult to stage with adenomyosis.
Newer approaches, I've mentioned that you can use 2D and 3D reformats to measure and localize adenomyosis and elastography may eventually provide some information to distinguish fibroids from adenomyosis.

Summary

But in summary, I'd like to again say that if the findings on sonography are classic as they were in this patient that we began the lecture with, with thickened myometrium, increased echogenicity, thin shadows, echogenic nodules, small cysts, areas of shadowing, then it's really unnecessary to have any other imaging.
This patient did have MR.
She happened to also have CT, which showed the same findings, but I do believe that the diagnosis can be easily and well and confidently made using ultrasound.
Thank you.