IS Case 436: Adenomyosis

Daniel O'Connor, MD

University of Rochester

Imaging Sciences URMC 2010
Publication Date: 2010-08-30


Patient is a 30-year-old female with uterine enlargement on physical exam and confirmed in outside gynecologic ultrasound. Chief complaint of long-standing was abdominal and pelvic pain, and urinary frequency.


Pelvic MRI demonstrated a globally, symmetrically enlarged uterus with prominent appearance of transitional zone, best appreciated in sagittal T2-weighted images. No focal mass or lesion was appreciated. Endometrial stripe was normal in size and appearance. Also, greater than expected simple free fluid in dependant portions of the pelvis, including the pouch of Douglas, layering above the bladder, and in more caudal portions of the abdominal cavity.




Adenomyosis is a common cause of pelvic and lower abdominal pain, present in 20 - 60% of hysterectomy specimens. Differentiation from leiomyoma is critical for management purposes, as adenomyosis is commonly refractory to conservative management with hysterectomy the only definitive cure. The above case depicts the classic clinical presentation and MR appearance of diffuse-type adenomyosis, which is the result of widespread heterotopic endometrial glands and stroma extending into the myometrium, often with adjacent hypertrophy of the surrounding uterine myometrium and reactive simple fluid in the pelvis. Segmental-type adenomyosis is less diffuse in its involvement, but is otherwise similar.

Classic MR findings include diffuse uterine enlargement with thickening of the junctional zone >12 mm with ill-defined, irregular margins with or without hyperintense foci representing dilated endometrial glands. Ultrasound is more variable, with heterogeneous echotexture of myometrium ranging from hyper- to hypo-echoic in appearance. Subcentimeter myometrial cysts are a specific finding. Doppler ultrasound demonstrates increased small vessel vascularity.

Differential diagnoses include adenomyoma, uterine malignancy, diffuse myometrial hypertrophy, and leiomyoma, although MR is usually diagnostic.


  1. Reuter KL. Uterus, Adenomyosis. eMedicine. February 12, 2009.
  2. Rumack C, Wilson S, Charboneau JW, Johnson J. Diagnostic Ultrasound. 3rd edition. Mosby 2004.

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