This MRI report describes findings for a 45-year-old woman with chronic pelvic pain. The MRI showed a bulky uterus with diffuse wall thickening up to 13 mm, consistent with adenomyosis. A well-defined cyst was also seen in the right adnexa. Adenomyosis is a common condition where endometrial tissue grows in the uterine wall and can cause symptoms like heavy periods. The MRI is helpful for diagnosing adenomyosis based on junctional zone thickening of 12 mm or more. In this case, the findings of diffuse uterine wall thickening and enhancement support a diagnosis of adenomyosis with an additional right adnexal cyst.

1. MRI Case
Dr Muhammad Tahir Javed
PGR Radiology KEMU/MHL

2. History
 A 45 year women presented with more than 6 month hx of
chronic pelvic pain , dysmenorrhea and menorrhagia.
 MRI pelvis with contrast is advised to rule out pelvic
pathology which is performed in our department

3. Sagittal T2WI Axial T2WI

4. Axial T1WI Axial T2 STIR
Axial T1 post Contrast

5. Coronal T2WI Coronal T2 STIR

6. DWI/ADC

7. Findings
 Uterus is bulky with diffuse junctional wall widening upto 13 mm
in anterior wall. However No internal cystic degeneration seen
 Uterus shows homogenous post contrast enhancement. No
diffusion restriction seen in that widened junctional zone.
 A well defined thin walled cystic lesion seen in right adnexa.
 No pelvic adenopathy/pelvic free fluid seen.

8. Diagnosis
Diffuse adenomyosis with right adnexal cyst.

9. Adenomyosis
 Adenomyosis (or uterine adenomyosis) is a common
uterine condition of ectopic endometrial tissue in the
myometrium.
 Although most commonly asymptomatic, it may present with
menorrhagia and dysmenorrhea.
 Pelvic imaging (i.e. ultrasound, MRI) may show characteristic
findings

10. Epidemiology
 Classically, adenomyosis most commonly affects multiparous women of
reproductive age.
 Adenomyosis is seen with higher frequency in women with a history of uterine
surgical procedures (e.g. Caesarean section, dilatation and curettage).
 Patients with high oestrogen exposure (e.g. short menstrual cycles, early
menarche) have an increased risk of adenomyosis.
 Adenomyosis is relatively rare in postmenopausal women
 but a higher incidence of adenomyosis has been reported in women treated
with tamoxifen for breast cancer.

11. CLINICAL PRESENTATION
 Most patients with adenomyosis are asymptomatic.
 Symptoms related to adenomyosis include dysmenorrhoea,
menorrhagia, dyspareunia, chronic pelvic pain, and
menometrorrhagia.
 The ectopic endometrial glands within the myometrium do
not respond to cyclic ovarian hormones, unlike those
of endometriosis.
 Pelvic tenderness on examination is associated with diffuse
enlargement of the uterus.

12. PATHPHSIOLOGY
 Adenomyosis is histologically-defined as the presence of
ectopic endometrial glandular and stromal tissue within
the myometrium.
 The exact cause of adenomyosis is unknown, but it is thought
that endometrial glands directly invade the myometrium
resulting in spiral vessel angiogenesis, and adjacent smooth
muscle hyperplasia and hypertrophy.

13. Types
 Three forms can be distinguished:
• diffuse adenomyosis: most common
• focal adenomyosis / adenomyoma: sometimes considered
distinct
• cystic adenomyosis and adenomyotic cyst: rare

14. MRI features:
Pelvic MRI is the modality of choice to diagnose and characterise
adenomyosis. Small field of view T2-weighted images (sagittal and axial)
are most useful.
MRI has a sensitivity of 78-88% and specificity of 67-93%
 The most easily recognised feature is thickening of the junctional zone
≥12 mm, either diffusely or focally (normal junctional zone thickness is
up to ~5 mm) .
• T1
• foci of high T1 signal are often seen, indicating menstrual haemorrhage into the
ectopic endometrial tissues

15. • T2
• typically a region of adenomyosis appears as an ill-defined ovoid/diffuse
region of thickening, often with small high T2 signal regions representing
small areas of cystic change
• the region may also have a striated appearance
• T1 C+
• contrast-enhanced MRI evaluation is usually not required for evaluation of
adenomyosis, however, if performed, shows enhancement of the ectopic
endometrial glands

16. Differentials:
 For diffuse disease consider:
• normal uterus
• diffuse uterine leiomyomatosis (uterus appears diffusely enlarged
showing multiple innumerable ill-defined leiomyomas without discrete
margins)
• myometrial contraction: transient finding , may appear as focal lesion of
low-signal-intensity. This finding disappeared on subsequent (axial and
coronal) T2W images.
• malignancy
• endometrial carcinoma (the usual symptom of a postmenopausal bleed. A thickened
endometrium requires endometrial sampling. carcinomatous tissue will enhance
less than normal endometrium. DWI: show impeded diffusion)

17.  For focal disease (adenomyoma) consider:
• uterine fibroid (leiomyoma)
• better defined than adenomyoma
• may have pseudocapsule of compressed adjacent myometrial tissue 5
• on colour Doppler: tend to displace vessels, demonstrating circumferential peripheral
flow
• vascular malformations
• does not disrupt the endometrial-myometrial interface
• on colour Doppler: demonstrates turbulent high-velocity flow

18. THANK YOU