A brief description on Adenomyosis and how to diagnose it including the new MUSA criteria for describing and diagnosing adenomyosis

1. Diagnosing Adenomyosis
Dr. Chandana Jayasundara
MBBS, MD, MRCOG (UK)
Senior Lecturer in Obstetrics and Gynaecology
Faculty of Medicine,
University of Colombo
Honorary Consultant Obstetrician and Gynaecologist
DSHW and NHSL

2. Introduction
• ADENOMYOSIS………….
• Dr Rokitanski was the first to describe the existence of ectopic
endometrium in the uterine musculature in 1860 and named it
“Adenomyoma”
• Von Reklinghausen in 1896 described the diffuse involvement
myometrium as Adenomyosis
• In 1925, Frankl formaly introduced the term Adenomyosis

3. Adenomyosis: Prevalence
• Studies have reported a wide range (9-62%) in women undergoing
hysterectomy
• Diagnosing Adenomyosis by ultrasound has revolutionized the
detection of Adenomyosis
• These studies suggest Adenomyosis to occur at younger ages with a
prevalence of 20-35% (Pinsauti S et al)
• The mean age of 26 years has been quoted in one study (Naftalin J et
al)

4. Pathogenesis
• Four theories
• Endomyometrial invagination of the endometrium
• De novo from the Mullarian remnants
• Microtrauma of the endometrial/myometrial interface (Junctional zone [JZ])
• Establishment of lesions from retrograde menstruation

5. Lack of basement membrane between endometrium and myometrium and
damage to the JZ will influence the process
This explain ultrasound findings of subendometrial lines and buds with expansion
to hyperechogenic islands in the myometrium

6. Pathogenesis -
• Infiltration of endometriosis from outside the uterus, with disruption
of the serosa and infiltration of the external myometrium inducing
another subtype of Adenomyosis (Kishi et al)

7. Histopathological diagnosis of adenomyosis
• Disruption of the normal boundary between the endometrium and
myometrium
• Presence of ectopic endometrium that is basal-type non-secretory
tissue with a direct connection to the basalis layer
• Myometrial invasion by endometrium > 4 mm below the basalis layer
• Myometrial invasion by endometrium > 2.5 mm below the basalis
layer
• Endometrial invasion to > 25% of the thickness of the uterine
musculature, as measured from the endometrial–myometrial junction

8. Histological diagnosis cont……
• Different classifications have been suggested depending on
histological disease severity , but without international consensus
1. Focal Adenomyosis :-circumscribed nodular aggregates of endometrial
glands and stroma surrounded by normal myometrium
2. Diffuse Adenomyosis:- presence of endometrial glands and stroma
distributed diffusely throughout the myometrium
3. Adenomyoma:-a subgroup of focal adenomyosis surrounded by
hypertrophic myometrium

9. Diagnosing Adenomyosis
• Clinical presentation
• Dysmenorrhoea
• Abnormal uterine bleeding
(Heavy)
• Pelvic pain
• Dysphareunia
• Reduced fertility
• Asymptomatic
• History
• Age
• Age at menarche
• Gravidity and parity
• Clinical presentation of symp/signs
• Effect on quality of life

10. Examination
• Bimanual examination of the pelvis can help physicians to gauge the
uterine size and mobility, and adnexal masses
• Assessment of pelvic pain, and, if so, type, severity, and localization of
pain, to raise or rule out the possibility of the presence of deep
endometriosis in the retrocervical region.

11. Non invasive imaging for the diagnosis of
Adenomyosis
• Magnetic resonance imaging (MRI) and ultrasound have gradually
become the mainstay for the diagnosis of Adenomyosis.
• Trans-vaginal ultrasound (TVUS) is the first‐line technique in
gynecological work‐up (Tellum et al, 2019; Liu et al., 2021; Chapron et al., 2020; Bazot et al.,
2018)
• Through two‐dimensional (2D) and 3D settings and color flow Doppler
versions of TVUS, a good view of the uterus and its pathology can be obtained
• Compared with TVUS, trans-abdominal ultrasonography has limited value.
• Compared with 2D and 3D TVUS, color flow Doppler ultrasonography has the
added advantage of providing information on the location, amount, and type
of blood flow.
• MRI should be used as second line in diagnosing Adenomyosis

12. Morphological Uterus Sonographic Assessment
(MUSA) consensus
• This guidance was published by an international expert panel in 2015.
Van den Bosch, Dueholm et al., Ultrasound Obstet Gynecol 2015
• It describes both the features for diagnosing adenomyosis as well as
guidance on reporting adenomyosis ultrasonically

13. The MUSA consensus on diagnosing
Adenomyosis with TVUS
• Measure asymmetry, look for the globular shape
• Evaluate myometrial architecture
• Intramyometrial cysts
• Echogenic subendometrial lines and buds
• Hyperechoic islands
• Fan-shaped shadowing
• Translesional vascularity
• Study the junctional zone with 3D TVUS junctional Zones
• Thickness, Disruption, irregularity and difference between minimum &
maximum thickness etc

14. Globular Shape
“Question mark sign”
Uterine enlargement
Asymmetry of walls

15. Intramyometrial cysts

16. Trans-lesional flow

17. Hyperechogenic Islands
Fan-shaped
shadowing

18. The Junctional Zone

20. MUSA guidance on reporting Adenomyosis
• Seven items should be assessed when examining and describing a
uterus with Adenomyosis
Presence Classify as normal or abnormal and if abnormal whether it is Adenomyosis, myoma or sarcoma.
Use MUSA diagnosing criteria to identify adenomyosis
location Describe the location:- Anterior, Posterior, Right lateral, Left lateral, Fundal.

21. Distribution Focal 25% or more of the lesion is surrounded by normal endometrium. When focal
adenomyosis is formed by invasion from outside to inside, it is referred to as
Focal Adenomyosis of the Outer Myometrium (FOAM)
Adenomyoma Lesion is demarcated distinctly and is totally surrounded by hypertrophic
myometrium
Diffuse Present throughout myometrium
Mixed Both the focal and diffuse disease present
Presence of Cysts Cystic/non-cystic Presence or absence of intra-myometrial cysts measuring 2 mm or more

22. Layer of uterine
involvement
Type 1 Involvement of the junctional zone
Type 2 Involvement of the middle myometrium
Type 3 Involvement of the outer myometrium. Demarcation between middle and
outer myometrium is determined by using colour Doppler to delineate
the vascular arcade
Multiple layers Involvement of more than one layer (1-2, 1-3)
Extent Mild <25% affected
moderate 25-50% affected
severe >50% affected
Lesion size Lesion/s is/are measured in their longest diameter/s

24. Guidance of Asian Society of endometriosis
recommendation Level of
recommendation
Grade of
recommendation
Transvaginal ultrasound (TVUS) and Magnetic Resonance Imaging (MRI)
are good noninvasive methods of diagnosing adenomyosis.
1a A
TVUS should be considered the first‐line diagnostic method while MRI is
recommended as a second‐line method when TVUS is inconclusive.
1a A
Most diagnostic features of adenomyosis could be demonstrated using
two‐dimensional (2D) TVUS and the addition of three‐dimensional (3D)
TVUS will not increase the diagnostic accuracy significantly.
1a A

25. Transabdominal ultrasound is of limited value but may be of use when
TVUS is not possible or with grossly enlarged uteri. The method has a low
specificity (30%) compared to TVUS (up to 100%).
4 C