Is It Possible To Detect Adenomyosis on Ultrasound?

Diagnosing Adenomyosis

So, what is the best way to diagnose adenomyosis? Today both magnetic resonance imaging (MRI) and transvaginal ultrasound (TVUS) may be used as means to diagnose adenomyosis and each has its own set of benefits and drawbacks.

Magnetic resonance imaging or MRI is the best way to accurately diagnose adenomyosis. In years past, MRI was significantly more expensive than ultrasound, but that gap has all but disappeared if one compares the price of a pelvic ultrasound to a pelvic MRI performed in an independent (i.e. non-hospital owned) imaging center.

Viewing adenomyosis with MRI, doctors can easily distinguish details that are commonly too subtle for an ultrasound to pick up as the resolution of MRI images are significantly higher than ultrasound images. Adenomyosis is when the lining cells of the uterus (aka endometrium) penetrate into the adjacent muscle which makes up the vast majority of a woman’s uterus (aka myometrium) and lies directly beneath the endometrium. The MRI diagnosis of adenomyosis is made by the following which includes:

1. Thickening of the transition zone between the endometrium and the myometrium (aka junctional zone). This is usually <9 mm thick. Between 9-12 mm it is equivocal, and 12 mm or greater too thick. This thickening is often missed entirely or misinterpreted on pelvic ultrasound to represent fibroids (expectation bias), particularly in African-American women who present with similar symptoms seen in fibroids, e.g. heavy periods, and pelvic pain. This thickening can be focal or more commonly diffuse;
2. Presence of junctional zone or myometrial cysts. This is 100% specific for adenomyosis, but almost never seen on a pelvic ultrasound.

There are some drawbacks with MRI. Access to this equipment may be difficult, particularly in rural areas. The cost of the exam can be significantly higher than ultrasound in certain areas where hospital systems own outpatient imaging centers. Ultrasound equipment is much more available and is usually present in the Gynecologist’s office.

Identifying the Source of Symptoms: Adenomyosis Ultrasound

Many women experience debilitating symptoms during their menstrual cycles and when adenomyosis is the culprit, it is often overlooked as a diagnosis. With the advancements in technology, it is now possible to obtain adenomyosis ultrasound images that allow medical professionals to identify certain patterns that are indicative of adenomyosis.

Using transvaginal ultrasound (TVUS), adenomyosis can now be accurately diagnosed when performed by an expert sonographer who has been specifically trained to scan for adenomyosis. According to recent research, TVUS has a sensitivity rate of 65% – 81% in detection, and the resulting adenomyosis ultrasound images have a specificity range of 65% to 100%. This means in the best of circumstances with excellent ultrasound equipment and expert sonographers, cases of adenomyosis will be visible on the ultrasound. A significant problem here is that many Gynecology offices cannot afford the latest ultrasound technology and often use old equipment. Also, the Gynecologists are usually not the ones that scan the patient. Therefore, they have to rely on the Sonographer’s expertise which can be variable.

Assessment criteria have been recently revised for the Morphological Uterus Sonographic Assessment (MUSA), which outlines specific features the sonographer should look for when investigating an adenomyosis diagnosis through ultrasound. Some of the patterns that the sonographer will look for that may indicate the presence of adenomyosis include:

• The uterine junctional zone appears irregular or interrupted;
• The uterus lining thickness is asymmetrical. i.e one of the walls is thicker than the other;
• The uterus is enlarged;
• Linear shadowing (looks like a fan) is present in the uterine wall;
• Stripes or lines that resemble streaks of light are present.

The benefit of using transvaginal ultrasound is that it is more readily available and may not be as costly as MRI imaging. The drawbacks are that the ultrasound may miss superficial or subtle signs of the condition, such as when adenomyosis is diffuse and small texture changes may be missed.

The accuracy of the ultrasound imaging depends greatly on the equipment used and the expertise of the medical professional performing it, so it is critical when performing an adenomyosis ultrasound that the sonographer is specifically trained on the proper technique.

What Clues Suggest an Adenomyosis Diagnosis?

Some women who have adenomyosis exhibit no symptoms, but others may suffer greatly every month and even between their periods. Some of the symptoms of adenomyosis include:

• Significantly heavy menstrual bleeding that lasts longer than normal;
• Painful menstrual cramps;
• Abdominal bloating that may be accompanied by pressure;
• Chronic abdominal pain;
• Pain during sex.

These symptoms are shared by many other gynecologic health issues, so it is important to contact your doctor and look at all the symptoms as a whole to avoid an inaccurate diagnosis.

When thinking about your gynecologic health and a possible adenomyosis diagnosis, consider the following:

• If you have pelvic pain and heavy periods, but the pelvic pain is the more significant symptom, you may have adenomyosis;
• If you have been diagnosed with endometriosis, you have a greater chance of also having adenomyosis;
• If you have been told that your uterus is enlarged after having a pelvic ultrasound or the texture of the uterus is described in the ultrasound report as “heterogeneous” with or without finding discrete fibroids, you are likely to have adenomyosis.

Adenomyosis is often missed on a physical exam or pelvic ultrasound or mistaken for uterine fibroids. Women who are misdiagnosed do not receive the answers they are looking for and are often subjected to unnecessary treatments that do not relieve their symptoms.

You may need a pelvic MRI to confirm the presence of adenomyosis so contacting the Atlanta Fibroid Center for a second opinion would be a great step in finding relief for your symptoms.

If you suffer from ongoing heavy menstrual bleeding and/or chronic pelvic pain, it is time for you to stop suffering! Get a second opinion from an experienced Interventional Radiologist like Dr. Lipman or Dr. Ermentrout of Atlanta Fibroid Center. Call us to make an appointment or set up a convenient teleconsult visit.