Adenomyosis examination

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I now have comprehensive content from multiple authoritative textbooks. Here is a detailed, well-structured answer on the examination of adenomyosis.

Adenomyosis: Examination & Diagnosis

Definition

Adenomyosis is a benign uterine disorder characterised by the presence of ectopic endometrial glands and stroma within the myometrium, accompanied by smooth muscle hypertrophy or hyperplasia. The ectopic tissue may be distributed diffusely or focally. When focal, the lesion is termed an adenomyoma.

Robbins & Kumar Basic Pathology, p. 608; Bailey and Love's Surgery 28th Ed., p. 1604

Clinical Presentation (History)

Symptoms are often non-specific and overlap with fibroids and endometriosis. The classic triad is:

Symptom	Notes
Dysmenorrhea	Secondary dysmenorrhea; pain typically begins 1-2 weeks before menses and persists until a few days after cessation
Abnormal uterine bleeding (menorrhagia)	Heavy or prolonged menstrual bleeding
Chronic pelvic pain	Can be constant or cyclical

Other symptoms include:

Subfertility / infertility
Dyspareunia
Uterine enlargement and tenderness
33% of cases are asymptomatic (found incidentally on imaging or at hysterectomy)
Predominantly affects women in the 4th and 5th decades of life
Grainger & Allison's Diagnostic Radiology, p. 898; Bailey and Love's Surgery, p. 1604

Physical Examination Findings

Bimanual Pelvic Examination

The key finding is a uniformly enlarged, globular, tender uterus:

Uterine enlargement: Symmetrically enlarged, often described as "boggy" - the myometrium is thickened due to reactive smooth-muscle hypertrophy from the ectopic tissue
Uterine tenderness: Particularly noticeable just prior to and during menstruation
Globular configuration: Unlike fibroid-related enlargement which is typically irregular/nodular, adenomyosis produces a more uniformly round, smooth enlargement
No adnexal masses unless coexisting endometriosis (endometrioma) is present

The examination is often normal or non-specific, which explains why imaging is required for diagnosis. Adenomyosis cannot be reliably diagnosed on physical examination alone.

Berek & Novak's Gynecology, p. 576; Bailey and Love's Surgery, p. 1604

Risk Factors (Relevant to Clinical Assessment)

Increased/prolonged oestrogen exposure (early menarche ≤10 years, short cycles ≤24 days, elevated BMI, tamoxifen use)
Multiparity; spontaneous miscarriage
Prior uterine instrumentation or surgery: caesarean section, surgical termination of pregnancy, endometrial curettage
Coexisting leiomyomas, endometriosis, or endometrial hyperplasia
Smoking
Bailey and Love's Surgery, p. 1604

Imaging Examination

The diagnosis of adenomyosis is now primarily made by imaging. Histology at hysterectomy remains the definitive gold standard, but imaging has largely replaced surgical diagnosis for initial evaluation.

1. Transvaginal Ultrasound (TVUS) - First-Line

Accuracy: 68-86% for diffuse adenomyosis.

The MUSA (Morphological Uterus Sonographic Assessment) group recommends commenting on 8 features: presence, location, differentiation, cystic vs. non-cystic, myometrial layer involvement, extent, lesion size, and vascularity.

Key ultrasound features:

Feature	Description
Enlarged, globular uterus	Often with asymmetry of anterior/posterior walls
Myometrial cysts	2-6 mm subendometrial cysts, present in ~50%; represent haemorrhagic foci
Echogenic subendometrial lesions	Diffuse echogenic nodules and linear striations
Hyperechogenic islands	Scattered echogenic foci in the myometrium
Irregular junctional zone	Poor definition of the endomyometrial interface
Fan-shaped shadowing	Also called "rain shower" appearance - multiple fine areas of attenuation throughout
Colour Doppler	Speckled pattern of increased vascularity within heterogeneous areas

At least 3 sonographic criteria are usually required to make a diagnosis.

Grainger & Allison's Diagnostic Radiology, p. 898; Bailey and Love's Surgery, p. 1604

2. MRI - Problem-Solving and Definitive Imaging

MRI is the most accurate non-invasive method and is particularly valuable in distinguishing adenomyosis from fibroids, which has direct management implications.

MRI is not technique-dependent and has low interobserver variability compared with TVUS, SIS, and hysteroscopy. - Berek & Novak's Gynecology, p. 508

Key MRI features on T2-weighted imaging:

Finding	Significance
Junctional zone (JZ) thickening ≥ 12 mm	Predicts adenomyosis with high accuracy (diffuse)
JZ ≤ 8 mm	Excludes adenomyosis with high accuracy
JZ 8-12 mm	Indeterminate - use ancillary criteria below
High T2 signal foci within low-signal myometrium	Islands of ectopic endometrial tissue
Cystic dilatation of glands in myometrium	Ancillary criterion
High T2 linear striations (finger-like projections) extending from endometrium into myometrium	Represents direct myometrial invasion
High T1 signal foci (punctate haemorrhage)	95% positive predictive value for adenomyosis
High T1 + intermediate-low T2 foci	Cystic adenomyosis (extensive bleeding)

Grainger & Allison's Diagnostic Radiology, p. 898

MRI of adenomyosis - coronal view (U = uterus, B = bladder):

MRI of adenomyosis showing enlarged globular uterus with junctional zone thickening

MRI - axial view showing adenomyosis with bilateral ovarian endometriomas (asterisk = endometrioma, + = adenomyotic uterus, R = rectum):

Axial MRI of adenomyosis with endometriomas

3. Hysteroscopy

Abnormal findings may include:

Irregular endometrium with endometrial defects
Cystic haemorrhagic lesions
Altered vascularisation
"Strawberry-like" appearance

4. Histology (Gold Standard)

Classically obtained at hysterectomy. Diagnostic criteria:

Endometrial glands and/or stroma found deep in the myometrium, interposed between muscle bundles
Reactive hypertrophy of surrounding smooth muscle
Limited in women wishing to preserve fertility
Robbins & Kumar Basic Pathology, p. 608

Differential Diagnosis

Condition	Distinguishing Features
Uterine fibroids (leiomyomas)	Irregular, nodular uterine contour; well-defined lesions on MRI with T2 low-signal, distinct margins
Endometriosis	Adnexal masses, uterosacral nodularity, fixed retroverted uterus on exam; normal-sized uterus
Endometrial polyp	Focal lesion on sonohysterography
Endometrial carcinoma	Postmenopausal bleeding; abnormal endometrial thickness
PID / chronic endometritis	Infection history, cervical motion tenderness

Summary of Diagnostic Approach

Clinical Suspicion
(dysmenorrhea + menorrhagia + tender enlarged uterus)
         ↓
Transvaginal Ultrasound (first-line)
≥3 MUSA criteria → Diagnosis of adenomyosis
         ↓ (if equivocal)
MRI Pelvis
JZ ≥12 mm → Adenomyosis confirmed
JZ ≤8 mm  → Adenomyosis excluded
JZ 8-12 mm → Ancillary criteria (T2 foci, T1 haemorrhage)
         ↓ (definitive, fertility treatment complete)
Histology at hysterectomy (gold standard)

Recent Evidence

A 2024 systematic review on ultrasound features predicting symptom severity (PMID: 37584856) found that specific ultrasound characteristics correlate with the degree of menorrhagia and pain, supporting a more nuanced sonographic classification. A 2025 systematic review on adenomyosis in adolescents (PMID: 39469820) highlights that the condition is underdiagnosed in younger patients where classic features may be absent.

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