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Human Reproduction Vol.16, No.11 pp. 2427–2433, 2001
Ultrasonography compared with magnetic resonance
imaging for the diagnosis of adenomyosis: correlation with
histopathology
Marc Bazot
1,4
, Annie Cortez
2
, Emile Darai
3
,Je
´
rome Rouger
1
, Jocelyne Chopier
1
,
Jean-Marie Antoine
3
and Serge Uzan
3
Departments of
1
Radiology,
2
Pathology and
3
Obstetrics and Gynecology, Ho
ˆ
pital Tenon, 4 rue de la Chine, 75020, France
4
To whom correspondence should be addressed at: Service de Radiologie, Ho
ˆ
pital Tenon, 4 rue de la Chine, 75020, Paris, France.
E-mail: marc.bazot@tnn.ap-hop-paris.fr
BACKGROUND: The objective of this study was to compare the accuracy of transabdominal (TAUS) and
transvaginal sonography (TVUS) and magnetic resonance imaging (MRI) for the diagnosis of adenomyosis, and to
correlate imaging with histological findings. METHODS: In a prospective study, 120 consecutive patients referred
for hysterectomy underwent TAUS, TVUS and MRI. Results of these examinations were interpreted blindly to
histopathological findings. RESULTS: Histological prevalence of adenomyosis and leiomyomas was 33.0 and 47.5%
respectively. Adenomyotic uteri were accompanied by additional pelvic disorders in 82.5% of cases. Sensitivity,
specificity, and positive and negative predictive values of TAUS and TVUS were 32.5 and 65.0%, 95.0 and 97.5%,
76.4 and 92.8%, and 73.8 and 88.8% respectively. Myometrial cyst was the most sensitive and specific TVUS
criterion. In MRI, the presence of a high-signal-intensity myometrial spot was as specific but less sensitive than a
maximal junctional zone thickness (JZ
max
) >12 mm and a JZ
max
to myometrial thickness ratio >40%. Sensitivity,
specificity, and positive and negative predictive values of MRI were 77.5, 92.5, 83.8 and 89.2% respectively. No
difference in accuracy was found between TVUS and MRI, but sensitivity was lower with sonography in women
with associated myomas. CONCLUSIONS: TVUS is as efficient as MRI for the diagnosis of adenomyosis in women
without myoma, while MRI could be recommended for women with associated leiomyoma.
Key words: adenomyosis/leiomyoma/MRI/ultrasound/uterus
Introduction
Adenomyosis is a common gynaecological disorder defined
by the presence of ectopic endometrial glands and stroma
within the myometrium (Zaloudek and Norris, 1994). Two
distinct forms, diffuse and focal, have been described. In the
diffuse form, foci of adenomyosis are distributed within the
myometrium (Azziz, 1989; McCausland and McCausland,
1996). In the focal form, nodules of hypertrophic myometrium
and ectopic endometrium (so-called adenomyoma) are
observed. The histological frequency of adenomyosis ranges
from 5–70% according to the series, depending on the histo-
logical criteria and the number of sections examined (Azziz,
1989; Siegler and Camillien, 1994; Ferenczy, 1998).
Adenomyosis is a cause of uterine enlargement, menorrhagia
and dysmenorrhea. Clinical diagnosis of adenomyosis is diffi-
cult, because of the non-specific nature of symptoms. Further-
more, leiomyomas are frequently associated with adenomyosis,
hindering the differential diagnosis. Transabdominal (TAUS)
and transvaginal ultrasound examination (TVUS) have been
recommended for the diagnosis of adenomyosis (Walsh et al.,
1979; Bohlman et al., 1987; Siedler et al., 1987; Fedele et al.,
© European Society of Human Reproduction and Embryology 2427
1992; Arnold et al., 1995; Reinhold et al., 1995, 1996). The
reported sensitivity and specificity of TAUS or TVUS are
53–89% and 50–89% respectively (Fedele et al., 1992; Ascher
et al., 1994; Reinhold et al., 1995, 1996). The sensitivity and
specificity of magnetic resonance imaging (MRI) have been
reported to be as high as 88–93 and 67–91% respectively
(Ascher et al., 1994; Reinhold et al., 1996). Few studies
have compared sonographic and MRI accuracy rates for the
diagnosis of adenomyosis (Ascher et al., 1994; Reinhold et al.,
1996). Reinhold et al. reported similar diagnostic efficiencies
with TVUS and MRI (Reinhold et al., 1996). In contrast,
Ascher et al. suggested that MRI was the diagnostic modality
of choice in this setting (Ascher et al., 1994). However, MRI
diagnostic criteria for adenomyosis are controversial (Mark
et al., 1987; Togashi et al., 1988; Hricak et al., 1992; Ascher
et al., 1994; Reinhold et al., 1996).
The aims of this prospective study of a large series of
patients were: (i) to determine the diagnostic performance of
sonography and MRI for histologically proven adenomyosis,
(ii) to compare their accuracy, and (iii) to identify the most
specific sonographic and MRI features for adenomyosis.
M.Bazot et al.
Materials and methods
Patients
From January 1996 to April 1998, 167 patients referred for hysterec-
tomy to the Gynecology Department of Ho
ˆ
pital Tenon, Paris, had
pre-operative sonographic and MRI examinations. Forty-seven
patients were excluded from the study for various reasons, including
a lack of ultrasound and/or MRI findings due to technical reasons or
patient-related factors (n ⫽ 26), cancelled surgery (n ⫽ 4), or
conservative surgery including myomectomy (n ⫽ 5) and endometrial
resection (n ⫽ 9). The study population thus consisted of 120 women,
with a mean age of 51 years (range 30–88). The indications for
surgery were menorrhagia and/or metrorrhagia (n ⫽ 61), post-
menopausal bleeding (n ⫽ 17), adnexal masses (n ⫽ 15), cervical
intraepithelial neoplasia (n ⫽ 12), pelvic pain (n ⫽ 16), genital
prolapse (n ⫽ 11) and miscellaneous (n ⫽ 3). Eighty-three women
were premenopausal (69%) and 37 post-menopausal (31%). Among
the premenopausal women, 20 were on progestin and three were on
GnRH analogues. Two of the 37 post-menopausal women were
undergoing hormone replacement therapy.
All patients had TAUS, TVUS and MRI examinations.
Ultrasound examination
Sonographic examinations were performed with an Ultramark HDI
3000 unit (ATL, Bothell, WA, USA). Pelvic TAUS was performed
using a wide-band 2- to 4-MHz transducer, and TVUS examination
with a wide-band 5- to 9-MHz transducer. Colour Doppler examination
was performed using a pulse repetitive frequency of 1000–1500 Hz,
a wall filter of 50 Hz and a high-priority colour setup. Each
examination was interpreted in real time and videotaped. During each
sonographic examination, the uterine borders (regular or irregular),
uterine size, myometrial echotexture and the presence of associated
abnormalities (including myomas) were noted.
Diagnosis of adenomyosis by TAUS was based on criteria including
an enlarged regular uterus with no evidence of leiomyoma and/or
presence of myometrial cysts. For TVUS, in accordance with previous
studies (Fedele et al., 1992; Reinhold et al., 1995), criteria for
adenomyosis were as follows: myometrial cyst, distorted and hetero-
geneous myometrial echotexture, poorly defined focus of abnormal
myometrial echotexture, and a globular and/or asymmetric uterus.
Myometrial cyst was defined as a round anechoic area of 1–7mm
diameter (Fedele et al., 1992; Reinhold et al., 1995). Heterogeneous
myometrium was defined by the presence of an indistinctly marginated
myometrial area with decreased or increased echogenicity (Brosens
et al., 1995b; Reinhold et al., 1995). Globular and/or asymmetric
uterus was defined as a regular enlarged uterus with possible myo-
metrial asymmetry unrelated to leiomyoma. Adenomyosis was not
diagnosed if these criteria were not met.
Colour Doppler was used to distinguish between myometrial cyst
and a vascular component, and between supposed leiomyoma and
focal adenomyosis. Localized adenomyosis and adenomyoma were
characterized by the absence of flow or by the presence of straight
vessels traversing a hypertrophic myometrium.
Adenomyosis was classified according to its uterine location and
size, and the depth of myometrial involvement.
MRI examination
MRI was performed on a 1.5-T system (Gyroscan, Philips, Eindhoven
or Magnetom Vision, Siemens, Erlangen, Germany) with T2-weighted
spin-echo or T2-weighted turbo spin-echo (TSE) sequences in sagittal,
oblique axial or coronal planes, and T1-weighted spin-echo in sagittal
or axial planes. Using abdomen compression, MRI sections were
acquired every 5 mm with a gap of 1 mm. Data were collected in a
2428
Figure 1. Representative example of adenomyosis showing
endomyometrial junction featuring basalis endometrium
invaginating into myometrium, deep location of endometrial glands
and stroma surrounded by hypertrophic myometrium, and a focus
of adenomyosis (Harris haematoxylin; original magnification ⫻20).
256⫻256 matrix and a 300 mm field of view. In addition, 34 patients
underwent two breath-hold fast T2-weighted pulse sequences (Trufisp
and Tirm) in the sagittal and/or axial planes. Patients were required
to fast for 3 h before MRI. Antispasmodic drugs were not used.
MRI results were interpreted by two independent observers. Four
criteria were evaluated on T2-weighted sequences: (i) borders, size
and uterine symmetry, (ii) maximal junctional zone (JZ
max
) thickness
and/or presence of an ill-defined, relatively homogeneous, low-signal-
intensity myometrial area (IDMA), (iii) maximal JZ thickness to
myometrial thickness ratio (ratio
max
), using the maximal thickness of
the JZ and the corresponding thickness of the entire myometrium
obtained at the same level, and (iv) high-intensity spots within the
myometrium. Leiomyomas, adnexal masses, and endometrial or
cervical abnormalities were also recorded.
Adenomyosis was defined by: (i) a large, regular, asymmetric
uterus without leiomyomas, (ii) JZ
max
of at least 12 mm and/or an
ill-defined, low-signal-intensity myometrial area distinguished from
well-circumscribed masses related to myoma, (iii) ratio
max
⬎40%
and (iv) punctate high-intensity myometrial foci (Reinhold et al.,
1996). Small hypointense spots within the myometrium on contrast-
enhanced (gadolinium injection) T1-weighted images were attributed
to adenomyosis.
Adenomyosis was classified according to its uterine location and
size, and the depth of myometrial involvement.
Ultrasonography versus magnetic resonance imaging in adenomyosis
Table I. Sensitivity, specificity, PPV, NPV and accuracy of ultrasound criteria for the diagnosis of
adenomyosis
US findings Sensitivity (%) Specificity (%) PPV (%) NPV (%) Accuracy (%)
TAUS 32.5 95.0 76.4 73.8 74.1
TVUS 1: myometrial cyst 60.0 98.8 96.0 83.2 84.2
TVUS 2: focal abnormal myometrial echotexture 38.0 99.0 94.0 77.0 79.0
TVUS 3: distorted heterogeneous
myometrial echotexture 52.5 90.0 33.8 40.1 90.0
TVUS 4: globular uterine configuration 30.0 96.3 80.0 73.3 74.0
TVUS 5: criteria ‘TVUS 1 and 2’ 65.0 97.5 92.8 88.8 86.6
Combination of TAUS and TVUS 70.0 97.5 93.8 86.6 88.3
PPV ⫽ positive predictive value; NPV ⫽ negative predictive value.
Histopathological findings
Histopathological examinations were all performed by the same
pathologist, who was blinded to sonographic and MRI data. Gross
and microscopic histopathological examinations were performed
according to Molitor’s method (Molitor, 1971). Specimens were
orientated by a fixed mark on the anterior uterine wall. Uterus weight,
macroscopic appearance and associated pathologic abnormalities were
recorded. Fundal, anterior, posterior, right and left maximal uterine
wall thicknesses were measured.
Macroscopically, adenomyosis was diagnosed as an enlarged uterus,
a globular and/or asymmetric uterus, and a dense anarchically
fasciculated unlimited myometrium with small cavities (0.5–10 mm).
Focal adenomyosis was defined by the presence of (i) adenomyoma
(circumscribed nodular lesion) mimicking intramural myoma, or
(ii) when lesions were restricted to one uterine wall (localized
adenomyosis). In other cases, adenomyosis was defined as diffuse
pathology.
Block sections were taken from the fundal, anterior, posterior, right
and left uterine walls, and from macroscopically abnormal areas. The
number of slides ranged from 5–15 depending on myometrial
thickness.
Histopathological criteria used for the diagnosis of adenomyosis
included the presence of ectopic endometrial tissue within the
myometrium, located 2.5 mm beyond the endometrial-myometrial
junction (Figure 1). Smooth-muscle cells surrounding ectopic endo-
metrial areas were noted. Adenomyosis was graded according to the
depth of myometrial involvement. Grades 1, 2 and 3 corresponded
respectively to adenomyotic involvement of the inner third (superficial
adenomyosis), two-thirds and entire myometrium (deep adenomyosis).
Adenomyosis was also graded as mild, moderate or severe according
to the number of endometrial islets observed (1–3, 4–9 and 艌10 foci
respectively).
Statistical analysis
Statistical analysis was performed using Student’s t-test and Mann–
Whitney test for parametric and non-parametric continuous variables
respectively, and the χ
2
test or Fisher’s exact test, where appropriate,
for categorical variables. A P value ⬍ 0.05 was considered statistically
significant.
Results
Histopathological findings
Uterine bleeding was the main indication for hysterectomy
(65%), and was due to various uterine diseases, including
leiomyomas (n ⫽ 57), adenomyosis (n ⫽ 40), uterine carcinoma
2429
(n ⫽ 32), adnexal tumours (n ⫽ 16) and miscellaneous causes
(n ⫽ 7). The histological prevalence rates of adenomyosis and
leiomyomas were 33 and 47.5% respectively. Adenomyomas
were found in seven patients (5.8%). Adenomyotic uteri were
accompanied by additional pelvic disorders in 82.5% of cases.
Thirty-one women were premenopausal (77.5%) and nine post-
menopausal (22.5%).
Gross examination
Adenomyosis was recognized only after opening the uterine
specimens. All cases but one were related to diffuse aden-
omyosis without leiomyoma. Seven adenomyomas had a
macroscopic aspect resembling that of a leiomyomatous
tumour. The sensitivity, specificity and positive and negative
predictive values of gross examination for the diagnosis of
adenomyosis were 47.5, 100, 100 and 79.2% respectively.
Using systematic microscopic evaluation, we found an overall
rate of adenomyosis of 47.5% in symptomatic women, even
in the absence of macroscopic evidence. A significant differ-
ence in mean uterine weight was noted between adenomyotic
uteri without leiomyomas (167 g) and non-adenomyotic uteri
without leiomyomas (63 g) (P ⬍ 0.01).
Microscopic examination
The adenomyosis was fundal in 26 cases, posterior in 21 cases,
anterior in 19 cases, right-sided in 12 cases and left-sided in
10 cases.
Twenty-three patients (57.5%) had diffuse adenomyosis,
including two patients with associated adenomyoma.
Seventeen cases of focal adenomyosis were diagnosed
(42.5%), comprising five adenomyomas and 12 cases of
localized adenomyosis. Two patients had isolated adeno-
myoma. All cases of focal adenomyosis were of grade 1 or 2,
and were located in the fundus in eight cases, the anterior wall
in three cases and the posterior wall in six cases.
Adenomyosis was grade 1 in 13 cases, grade 2 in 15 cases
and grade 3 in 12 cases; in other words, there were 13 cases
of superficial adenomyosis and 27 cases of deep adenomyosis.
The degree of adenomyosis was minimal in six cases, moderate
in 19 cases and severe in 15 cases.
A hyperplastic muscular myometrium surrounding ectopic
endometrial islets was observed in 32 cases (80%), in 30
premenopausal and two post-menopausal women. The preval-
M.Bazot et al.
Figure 2. Sagittal transvaginal sonography demonstrates myometrial anechoic lacunae specific of adenomyosis involving the ventral and the
dorsal myometrium (A). Transversal transabdominal examination shows a very large asymmetric uterus with thickening of the dorsal
myometrium. Note the decreased echogenicity and heterogeneity of the dorsal myometrium not related to leiomyoma. There is poor
definition of the endo-myometrial junction. All these findings suggest diffuse adenomyosis (B). Transvaginal sonography demonstrates
diffuse adenomyosis involving the ventral myometrium and a dorsal subserous leiomyoma. Distinguishing features of adenomyosis include
poor definition of lesion borders and lack of mass effect on the endometrium. In contrast, the leiomyoma has a round shape with well-
defined borders and edge shadowing (C). Sagittal T2-weighted magnetic resonance image through the uterus shows numerous high-intensity
spots in the inner myometrium, thickening of junctional zone (JZ) (13 mm) and ratio
max
⬎40% (D). Axial T2-weighted magnetic resonance
image demonstrates diffuse thickening of JZ both ventrally and dorsally, consistent with severe adenomyosis. Numerous foci of high signal
representing the heterotopic endometrium are present (E). Sagittal T2-weighted magnetic resonance image through the uterus (F): there is an
ill-defined mass centred around the endometrium. Several foci of increased signal consistent with heterotopic endometrium are present in the
inner myometrium without mass effect on the endometrial cavity. In contrast, leiomyoma is very hypointense and has well-defined borders (F).
ence of a hyperplastic muscular reaction was higher in pre-
menopausal women (P ⬍ 0.01). Differences in the prevalence
of hyperplastic reactions according to the grade of the disease
were not statistically significant.
2430
Sonography
TAUS yielded a diagnosis of adenomyosis in 17 women. The
sensitivity, specificity and positive and negative predictive
values of TAUS for the diagnosis of adenomyosis were 32.5,
Ultrasonography versus magnetic resonance imaging in adenomyosis
Table II. Sensitivity, specificity, PPV, NPV and accuracy of magnetic resonance imaging criteria for the
diagnosis of adenomyosis. Results are given as percentages
Criterion 1 Criterion 2 Criterion 3 Criterion 4 Criterion 5 Gado
Sensitivity 22.5 47.5 62.5 65.0 77.5 35.7
Specificity 97.5 98.8 96.3 92.5 92.5 96.4
PPV 81.8 95.0 89.3 81.3 83.8 83.3
NPV 72.5 79.0 83.7 84.0 89.2 75.0
Accuracy 72.5 81.7 85.0 83.3 87.5 76.2
Criterion 1 ⫽ regular homogeneous uterine enlargement without definite leiomyoma; Criterion 2 ⫽ high-
signal-intensity myometrial spots; Criterion 3 ⫽ JZ visible with a threshold value ⬎12 mm and/or presence
of an ill-defined low-signal-intensity myometrial area (IDMA); Criterion 4 ⫽ JZ
max
/entire myometrium
⬎40%; Criterion 5 ⫽ combination of criteria 2⫹3⫹4; Gado ⫽ Contrast-enhanced T1-weighted images after
gadolinium injection; PPV ⫽ positive predictive value; NPV ⫽ negative predictive value.
95.0, 76.4 and 73.8% respectively (Table I). The accuracy of
TAUS was 74.1%.
If we used only myometrial cysts and focal heterogeneous
myometrial areas as firm diagnostic criteria for adenomyosis,
TVUS was diagnostic of adenomyosis in 28 women. The
sensitivity, specificity and positive and negative predictive
values of TVUS for the diagnosis of adenomyosis were 65.0,
97.5, 92.8 and 88.8% respectively. The accuracy of TVUS
was 86.6%. The most sensitive and specific criterion for
adenomyosis was the presence of a myometrial cyst (Figure
2A). Two cases of adenomyosis were missed by TVUS in
enlarged abdomino-pelvic uteri without associated myoma
(Figure 2B). Combined TAUS and TVUS increased the
diagnostic yield of adenomyosis, with a sensitivity, specificity,
positive and negative predictive values and accuracy of 70.0,
97.5, 93.8, 86.6 and 88.3% respectively (Table I).
The sensitivity and specificity of TVUS for the diagnosis
of adenomyosis in the patients with and without leiomyomas
were respectively 33.3 and 78.0%, and 97.8 and 97.1%
(Figure 2C).
The sonographic location of adenomyosis concorded with
histopathological findings in the 26 true-positive cases. How-
ever, no correlation was found between sonography and
histopathology regarding the grade or degree of adenomyosis.
Sonographic and histopathological grading concurred in only
15 cases (57%), while sonography underestimated the grade
in seven cases (27%) and overestimated it in four cases (15%)
relative to histopathology. Likewise, the degree of adenomyosis
estimated sonographically concurred with histopathological
findings in six cases (23%) and was underestimated in 20
cases (77%).
MRI findings
The sensitivity, specificity, positive and negative predictive
values and accuracy of MRI criteria for adenomyosis are given
in Table II. On TSE-T2, JZ was not visible in 36 women
(30%). The most specific MRI criteria on TSE-T2 were high-
signal-intensity myometrial spots, a visible JZ with a threshold
value ⬎12 mm and/or the presence of an ill-defined low-
signal-intensity area of myometrium (IDMA), and ratio
max
⬎40% (Figure 2D, E). Combination of these three criteria had
a diagnostic accuracy for adenomyosis of 87.5%.
The sensitivity and specificity of MR imaging for the
2431
diagnosis of adenomyosis in patients with and without leio-
myomas were respectively 66.6 and 82.1%, and 86.7 and
100% (Figure 2F).
The location of adenomyosis on T2-weighted MR images
concurred with histopathological findings in 27 cases (91%)
and disagreed in four cases (13%). The degree of myometrial
involvement concurred with histopathological findings in 20
cases (65%), was underestimated in five cases (16%) and
overestimated in six cases (19%).
Unenhanced T1-weighted images
T1-weighted images showed increased signal intensity in
four patients (10%) with local haemorrhage confirmed by
histological examination.
Contrast-enhanced T1-weighted images
Eighty-one (67.5%) of the 120 women had contrast-enhanced
T1-weighted images. Of these, 27 (33.3%) had adenomyosis
on pathological examination and 54 (66.6%) had no evidence
of disease. The sensitivity, specificity, positive and negative
predictive values and accuracy of contrast-enhanced T1-
weighted MRI for adenomyosis were 35.7, 96.4, 83.3, 75.0
and 76.2% respectively.
Discussion
Adenomyosis refers to endometrial glands and stroma located
deep within the myometrium (Ferenczy, 1998). In this study,
we found that the accuracy of gross examination for the
diagnosis of adenomyosis was low. This may explain the wide
range of prevalence rates of adenomyosis observed in previous
studies (Azziz, 1989; Siegler and Camillien, 1994; Ferenczy,
1998). In addition to endometrial glands and stroma located
within myometrium, Bird et al. suggested that the diagnosis
of adenomyosis required the identification of a smooth-muscle
hyperplasia reaction (Bird et al., 1972). We observed such a
reaction in 80% of women with adenomyosis. Furthermore,
smooth muscle hyperplasia was more frequent in premeno-
pausal women. These results are in keeping with those of
previous studies showing the absence of this reaction in uteri
from post-menopausal and pregnant women (Hendrickson and
Kempson, 1990). Moreover, in contrast to previous studies,
but in accordance with Emge, adenomyotic lesions were mainly
M.Bazot et al.
located in the fundus and were observed with a similar
prevalence in the posterior and anterior uterine walls (Emge,
1962).
In our study, the accuracy of TAUS for the diagnosis of
adenomyosis was low. Our results contrast with those of
Siedler et al. showing a high accuracy of TAUS (Siedler et al.,
1987): in a retrospective study of TAUS for the diagnosis of
adenomyosis, Siedler reported sensitivity and specificity values
of 63 and 97% respectively (Siedler, 1987). The low sensitivity
obtained in our study could be explained by the inclusion
of patients with associated disorders such as leiomyoma.
Furthermore, our data are in keeping with those of Reinhold
et al. suggesting that TAUS resolution is insufficient to
reproducibly detect subtle sonographic features of adenomyosis
(Reinhold et al., 1998).
We found that TVUS allowed the diagnosis of adenomyosis
with high accuracy. In accordance with a previous report
(Hricak, 1998), our accuracy rate was influenced by associated
disorders. Among the sonographic criteria, myometrial cyst
was the most sensitive and specific. Fedele et al. were the first
to report the diagnostic value of myometrial anechoic lakes
for adenomyosis (Fedele et al., 1992). In their experience,
in women without leiomyoma or endometrial disease, the
sensitivity and specificity values of this sonographic feature
were 80 and 74% respectively. Despite the inclusion of patients
with other disorders in addition to adenomyosis, the specificity
of myometrial cyst remained high in our study, possibly
because of an improvement in sonographic resolution. This
reinforces the diagnostic value of myometrial cysts for adeno-
myosis.
It is difficult to compare our data with those of previous
studies, in which the main criterion used for adenomyosis was
an alteration of myometrial echotexture, not myometrial cyst
(Ascher et al., 1994; Brosens et al., 1995b; Reinhold et al.,
1995, 1996; Vercellini et al., 1998). Interestingly, those studies
reporting a high accuracy of TVUS excluded women with
distorted uteri related to leiomyomata or endocavitary lesions
(Fedele et al., 1992; Ascher et al., 1994; Brosens et al., 1995b;
Reinhold et al., 1995, 1996; Vercellini et al., 1998). Myometrial
heterogeneity has been correlated with a smooth-muscle hyper-
trophic-hyperplasia reaction (Atri et al., 2000). However, in
contrast to previous studies (Ascher et al., 1994; Brosens et al.,
1995b; Reinhold et al., 1995, 1996; Vercellini et al., 1998),
indistinctly heterogeneous myometrial areas had poor accuracy
for the diagnosis of adenomyosis in the present study.
The sensitivity and specificity of MRI for the diagnosis of
adenomyosis was 77.5 and 92.5% respectively. These results
are in accordance with previous studies (Ascher et al., 1994;
Reinhold et al., 1996). Nevertheless, even in women without
myoma, regular homogeneous uterine enlargement was unreli-
able as an MRI criterion for adenomyosis. In contrast, a JZ of
at least 12 mm and/or an ill-defined myometrial area, ratio
max
⬎40% and high-signal-intensity myometrial spots had similar
high accuracy rates. However, the JZ was not measurable in
nearly one-third of our population, in which 22.5% of women
had proven adenomyosis. These results contrast with those of
Reinhold et al., who reported no cases of adenomyosis when
the JZ was not visible (Reinhold et al., 1996). In previous
2432
reports the JZ was not visible in nearly 50% of post-menopausal
patients (48.5% in our series) or women with gonadotrophin
releasing-hormone analogue therapy (Brosens et al., 1995a;
Byun et al., 1999). Foci of high signal intensity have been
correlated with non-bleeding endometrial tissue (Togashi et al.,
1988). However, in our experience and that of others (Reinhold
et al., 1996), this MRI feature has low sensitivity. Our results
suggest the possibility of using these imaging modalities to
evaluate the incidence of adenomyosis in symptomatic and
non-symptomatic women.
Fast spin-echo images and Trufisp and Tirm sequences
appeared to have comparable yields in the diagnosis of
adenomyosis. However, a formal analysis is necessary to
determine whether these breath-hold rapid T2 sequences can
routinely replace fast spin-echo sequences. As previously
reported by Hricak et al. the use of contrast-enhanced T1-
weighted images in our series did not improve the diagnostic
yield for adenomyosis (Hricak et al., 1992). A particular
diagnostic value of perfusion abnormalities on dynamic early-
phase gadolinium-enhanced images has been reported in this
setting (Outwater et al., 1998), but further studies are necessary
to confirm these preliminary results.
In our experience, in women free of associated disorders,
transvaginal sonography allows the diagnosis of adenomyosis
with a similar accuracy to MRI. In contrast, in women with
myomas, the accuracy of transvaginal sonography is lower
than that of MRI. Ascher et al. suggested that MRI was the
modality of choice for the diagnosis of adenomyosis, whereas
Reinhold et al. recommended transvaginal sonography (Ascher
et al., 1994; Reinhold et al., 1996). In accordance with Wood
our results underline the limitations of sonography for the
diagnosis of adenomyosis in women with uterine fibroids
(Wood, 1998). Furthermore, our study shows a lack of correla-
tion between histopathology and both sonography and MRI
regarding the grade and degree of adenomyosis.
In conclusion, our results suggest that transvaginal sono-
graphy and MRI have similar accuracy rates for the diagnosis
of adenomyosis. However, decreased sonographic accuracy
was found in women with associated disorders. Therefore,
MRI can be recommended for the diagnosis of adenomyosis
in women with additional lesions.
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Received on June 14, 2001; accepted on August 8, 2001
