The switch from anatomopathological diagnosis to imaging diagnosis in adenomyosis

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Adenomyosis is defined by the inappropriate proliferation of the endometrial glandular and stromal tissue within the smooth muscle of the uterine myometrium. The symptoms and signs vary widely, but the most common are dysmenorrhea and/or chronic pelvic pain and menorrhagia. It was classically described as a multiparous, pre-menopausal disease in women in their thirties to forties, but the improvement of the diagnostic ability of ultrasound and MRI shed more light on the affected population (Fig 1.). Therefore, more cases of adenomyosis in women under thirties have been described lately [1].

Color Doppler is an efficient imaging modality to demonstrate increased tortuous vessels throughout the myometrium (Fig 2). The 3D ultrasound technology has recently helped establish stronger criteria for diagnosing adenomyosis, allowing to assess of the lateral and fundal aspects of the Junctional Zone (JZ) and providing a sharper visualization of the endometrial protrusions in the uterine wall (Fig 3), (Fig.4) [2]. The Junctional Zone is the endo-myometrial junction, that identifies a functionally and structurally different tissue from the myometrium [3]. The most specific parameters in 3D-transvaginal ultrasonography are JZmax>8mm, hypoechoic striation, and myometrial asymmetry [4]. The levonorgestrel-releasing intrauterine device (LNG-IUD) is a successful treatment option, but the hysterectomy or the focal excision is the definitive cure when the disease is refractory to medical treatment (Fig 5) [5].