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Our next lesson is adenomyosis.

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So adenomyosis is ectopic endometrial gland

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and stroma in an abnormal position,

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in particular in the myometrium.

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That can result in muscular hyperplasia in

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reaction to it, muscular hypertrophy, and

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it can result in increased vascularity.

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Ultrasound is easily available and it can look

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for a lot of different reasons for most of the

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common symptoms that adenomyosis can also mimic.

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It's cheaper, it's easier and more often

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available than MRI, which of course can do all

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the same things ultrasound can, potentially

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even better in diagnosing adenomyosis.

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But you need to be familiar with it with

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ultrasound because that's often where

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you're going to start when you come in

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with abnormal bleeding, a big boggy uterus,

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or bloating-type symptoms like that.

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So what is adenomyosis actually?

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There are three different categories of it, and

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the imaging often correlates with the pathology.

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It's important to remember this can coexist with

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endometriosis, and it can coexist with fibroids.

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So some of those findings,

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what are we looking for?

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You can see ectopic endometrial glands.

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So you can get striations.

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If they are fluid-filled, they'll

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appear as myometrial cysts.

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They're often subendometrial or submyometrial

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right next to the endometrium, but not in it.

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So these little cystic changes, those

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are your ectopic endometrial glands.

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You can have hypertrophy, this thickening,

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you can have these endometrial glands that

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are ectopic, are hormonally active glands.

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They can incite a local reaction and

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that results in the thickening of

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the smooth muscle of the myometrium.

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This is much harder to see on an

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ultrasound than it is on an MRI, and

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that's your junctional zone thickening.

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We'll go over that a bit later as well.

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But hypertrophy on ultrasound, you can see focal

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or you can see diffuse myometrial thickening.

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This works for MRI as well.

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You can see globular enlargement of

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the uterus in general, and that's

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the uterine body, not necessarily the

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lower uterine segment or the cervix.

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Not the whole uterus is big; it's

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the body of the uterus is globular.

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Something called the Venetian blind

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appearance, and we'll go over that.

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And then a poorly defined interface

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between the endometrium and myometrium,

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meaning it's hard to pinpoint the exact

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area where the endometrium ends and the

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myometrium begins, which normally you can.

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And then you have vascularity,

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this kind of category.

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With that, you can see penetrating

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tortuous vessels on color Doppler.

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Putting all these together, you can

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get a really heterogeneous appearance

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of the myometrium with a blurring of

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that endometrium-myometrium interface.

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It's probably the least specific sign if you

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just kind of have this heterogeneous appearance.

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So then you have to kind of try and

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pick out all of these little different

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findings that could be put together

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and you get a diagnosis of adenomyosis.

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It's important when we talk about

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vascularity to jump back there for a moment.

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Fibroids are going to be vascular as

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well, but usually you have more of a

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circumferential pattern of vascularity

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and it will have displaced vessels

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as opposed to adenomyosis, which will

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have these penetrating tortuous ones.

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And again, we'll show you some of those

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examples in the case-based format.

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So quickly, some findings on MRI

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specifically, you're going to look for

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a thickened T2 dark junctional zone.

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So remember your T2 is really your heavy

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weight for female pelvis imaging of the uterus.

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The endometrium is going to be T2 bright.

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You're going to have the junctional

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zone, which is this T2 dark

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area immediately external to the

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endometrium there, and you're going

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to have just the myometrium itself

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here, and then the T2 dark serosa here.

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So you look for thickened T2 dark junctional

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zone; you can look for indistinct margins.

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The fibroid is going to have very distinct

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margins; you can measure exactly where it

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starts and where it ends, as opposed to

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let's say this structure right here, where

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it kind of just blends into the myometrium

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adjacent to it. We do have some breathing

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artifact, but it's hard to tell you exactly

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where this starts and where this ends.

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And it's really helpful if you have

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these T2 bright foci throughout it.

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And that's going to be similar

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to the endometrium, right?

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T2 bright endometrium, T2 bright

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ectopic endometrial glands within this

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structure right here of adenomyosis.

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So patients, who gets this, right?

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The classic teaching is multiparous.

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Perimenopausal patients are the ones who

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get adenomyosis, but this was based off of

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hysterectomy specimens, which introduced

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that sort of bias because it's generally

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going to be people who are multiparous or around

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menopause who may have their uterus taken out.

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So more recently, analysis has shown that

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it's also present in nulliparous women who

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have not been pregnant or had children, and

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even as young as the teens and twenties,

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although that's certainly less common.

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Early menarche, higher estrogen states.

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That puts you at a higher risk

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of developing adenomyosis.

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That also would include things

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like short cycles and obesity.

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Again, anything to get those

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higher estrogen states.

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There is some reported increase in incidence

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of those with a history of a D&C or C

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sections, and that may be because there's

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a disruption of the endometrial-myometrial

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interface that could allow for this ectopic

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implantation of the endometrial tissue.

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But it's not entirely clear if

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that's a true risk factor or not.

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So symptoms, what do they come in with?

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They're really quite nonspecific, which is

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why, again, they often start with ultrasound.

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They can have menorrhagia; they can

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have chronic pelvic pain; they can have

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dysmenorrhea; and they can have dyspareunia.

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And again, ultrasound can

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diagnose and evaluate for a lot of

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indications for this to find what's

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going on, adenomyosis being one of those.

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So with that, let's move

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on to some of the cases.