Adenomyosis is a common gynecological disease associated with heavy, painful periods as well as infertility. Recent advances in imaging methods allow us to diagnose adenomyosis with conventional, transvaginal ultrasound, opening new horizons in the application of novel management methods.

Are there, however, certain criteria based on which we can confidently diagnose adenomyosis by ultrasound? Although in many cases, diagnosis remains empirical, based on the overall appearance of the uterus on the ultrasound, certain criteria exist and we will analyse them in the following paragraphs.

Based on relevant research (1), we recognise 9 relevant ultrasound criteria: myometrial cysts, hyperechoic islands in the myometrium, echogenic sub-endometrial lines [direct criteria], as well as irregular thickening of the myometrium, fan-shaped shadowing, translesional vascularity, irregular or interrupted junctional zone and globular uterus (indirect criteria).

Following the ultrasound diagnosis of adenomyosis, we need to specify the location of the lesion: anterior, posterior, right or left lateral, fundal. Moreover, adenomyosis is classified in diffuse and focal, although the 2 types can co-exist in the same patient. We need to mention separately the entity of ‘’adenomyoma’’ (2), focal adenomyosis surrounded by hypertrophic myometrium. Adenomyosis can also be cystic or non-cystic. Another important parameter is the depth of infiltration in the myometrial layers, a potential marker of disease severity (we can, based on this, recognise 3 types of adenomyosis). In focal adenomyosis, the exact size of the lesion can be measured and recorded.

  Is there, however, a link between the ultrasound appearance of adenomyosis and the severity of symptoms and fertility outcomes? Various studies have suggested that disease severity is linked to the number of ultrasound criteria present (that is to say, the more criteria present on the same patient, the more severe the symptoms of adenomyosis and the less likely are fertility treatments to work) (3-5). However, this is not always the case, since patients with mild ultrasound appearance of adenomyosis may present with more severe symptoms.

Another question worth answering is the following: Is the ultrasound diagnosis of adenomyosis feasible by the majority of gynecologists? Or do we require high level of expertise and cutting-edge technology machines to achieve accurate diagnosis? In a recent publication of our group on ultrasound diagnosis of endometriosis (6), the majority of gynecologists asked admitted that they did not feel confident in diagnosing most of deep endometriosis localisations. The same could apply to adenomyosis, although its diagnostic accuracy may be comparable to that of MRI (7).

  In summary, adenomyosis can be diagnosed with adequate reliability by transvaginal ultrasound, when performed by clinicians with adequate expertise in pelvic imaging. This can lead to a reduction in diagnostic delays as well as potential avoidance of surgical interventions. The use of certain criteria for the ultrasound diagnosis of adenomyosis helps in the objectivity of diagnosis and may form the basis for future staging and classification systems for adenomyosis.

References:

1. Van den Bosch T, de Bruijn AM, de Leeuw RA, Dueholm M, Exacoustos C, Valentin L, Bourne T, Timmerman D, Huirne JAF. Sonographic classification and reporting system for diagnosing adenomyosis. Ultrasound Obstet Gynecol. 2019 May;53(5):576-582. doi: 10.1002/uog.19096. PMID: 29790217.
2. Exacoustos C. Adenomyosis and ultrasound: the role of ultrasound and its impact on understanding the disease. In Uterine Adenomyosis, Habiba M, Benagiano G (eds). Springer: Heidelberg, 2016; 141–152.
3. Mavrelos D, Holland TK, O’Donovan O, Khalil M, Ploumpidis G, Jurkovic D, Khalaf Y. The impact of adenomyosis on the outcome of IVF-embryo transfer. Reprod Biomed Online 2017; 35: 549–554.
4. Naftalin J, Hoo W, Nunes N, Holland T, Mavrelos D, Jurkovic D. Association between ultrasound features of adenomyosis and severity of menstrual pain. Ultrasound Obstet Gynecol 2016; 47: 779–783.
5. Naftalin J, Hoo W, Pateman K, Mavrelos D, Foo X, Jurkovic D. Is adenomyosis associated with menorrhagia? Hum Reprod 2014; 29: 473–479.
6. Grigoriadis G, Roman H, Kalaitzopoulos DR, Christoforidis N, Pados G, Daniilidis A. Diagnosis of Endometriosis by Transvaginal Ultrasound: An Online Survey of Gynecologists Practising in Greece. Cureus. 2023 Apr 21;15(4):e37950. doi: 10.7759/cureus.37950.
7. Maudot C, Vernet T, Debras E, Fernandez H, Capmas P. Diagnostic accuracy study of sonography in adenomyosis: A study of current practice. J Gynecol Obstet Hum Reprod. 2023 Sep;52(7):102604. doi: 10.1016/j.jogoh.2023.102604.