what are the ultra sound features of adenomyosis
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adenomyosis ultrasound transvaginal features
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Ultrasound Features of Adenomyosis
Adenomyosis is the presence of endometrial glands and stroma within the myometrium, causing secondary smooth-muscle hyperplasia. Transvaginal ultrasound (TVUS) has a diagnostic accuracy of 68–86% for diffuse adenomyosis; accuracy falls with coexisting fibroids or focal disease.
Uterine Morphology
| Feature | Detail |
|---|---|
| Globular uterine enlargement | Uterus is diffusely enlarged but typically < 14 cm; adopts a rounded, globular shape |
| Asymmetric wall thickening | Anterior and posterior myometrial walls are unequal in thickness — a key indirect sign |
| "Question mark" uterus | On sagittal view, the uterus curves into a question-mark shape due to loss of normal contour |
Fig. 35.25 — Grainger & Allison's Diagnostic Radiology: Sagittal (A) and axial (B) TVUS showing a globular uterus with echogenic subendometrial striations and poor endomyometrial interface definition.
Myometrial Echotexture (Direct Features)
- Heterogeneous myometrium — Diffuse mixed echogenicity throughout the myometrium; mottled or "moth-eaten" texture
- Subendometrial echogenic nodules and linear striations — Hyperechoic foci and linear tracks projecting from the endometrium into the myometrium, representing ectopic endometrial tissue
- Subendometrial cysts (myometrial cysts) — Small anechoic cysts, 2–6 mm, present in ~50% of cases; represent haemorrhagic foci or dilated glands — the most specific TVUS sign
- Fan-shaped / "rain shower" shadowing — Multiple fine areas of acoustic attenuation radiating from the echogenic foci, creating vertical stripe-like shadowing through the myometrium
- Hyperechoic islands — Scattered bright islands within heterogeneous myometrium
Endometrial Interface
- Poor definition of the endomyometrial (junctional zone) interface — Irregular, blurred, or indistinct border between endometrium and myometrium
- Endometrial pseudowidening — The endometrium may appear falsely thickened due to irregular infiltration of the junctional zone
Colour / Power Doppler Features
- Translesional / diffuse internal vascularity — Colour Doppler shows a speckled pattern of increased vascularity within the heterogeneous myometrium, with vessels running through (not around) the lesion
- Distinguishes adenomyosis from fibroids, which typically show peripheral/circumferential flow
Focal Adenomyosis (Adenomyoma)
- Appears as an ill-defined, heterogeneous hypoechoic mass within the myometrium
- Lacks the well-defined, smooth echogenic pseudocapsule seen in fibroids
- Internal echogenic foci or small cysts may be present
- Margins are irregular and blend into surrounding myometrium
- Doppler shows internal rather than peripheral flow
Composite Image — MUSA Criteria
The image below illustrates the full spectrum of Morphological Uterus Sonographic Assessment (MUSA) features:
Panels: (A,B) AP wall asymmetry; (C) blurred junctional zone; (D) "question mark" uterus; (E) Rainforest phenomenon — linear subendometrial shadowing; (F,H) intramural lacunae and diffuse Doppler vascularity; (G) heterogeneous echogenicity; (I) globular fundus.
Summary Table
| Feature | Direct or Indirect | Specificity |
|---|---|---|
| Myometrial cysts (2–6 mm) | Direct | High |
| Subendometrial echogenic striations | Direct | High |
| Echogenic nodules | Direct | Moderate–High |
| Heterogeneous myometrium | Direct | Moderate |
| Globular uterine enlargement | Indirect | Low |
| AP wall asymmetry | Indirect | Moderate |
| Blurred endomyometrial interface | Direct | Moderate |
| Translesional Doppler flow | Direct | High (vs fibroids) |
| Fan/rain-shower shadowing | Direct | Moderate–High |
Diagnostic Notes
- TVUS is the first-line imaging modality; MRI is reserved for indeterminate cases or pre-operative planning
- Accuracy decreases with coexisting fibroids or focal (rather than diffuse) disease
- Definitive diagnosis remains histological (post-hysterectomy)
- No recent systematic reviews from 2024–2025 significantly alter or contradict established TVUS criteria
— Grainger & Allison's Diagnostic Radiology, p. 898; Berek & Novak's Gynecology, p. 581
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