Diagnosing adenomyosis: An integrated clinical and imaging approach
Pathogenesis of adenomyosis involves sex steroid hormone abnormalities, inflammation, fibrosis and neuro angiogenesis, even though the proposed mechanisms are not fully understood. Nowadays, adenomyosis may also be diagnosed by non-invasive techniques, because of imaging advancements.
Adenomyosis often coexists with other gynecological comorbidities, such as endometriosis and uterine fibroids, and the diagnostic criteria are still not universally agreed. Therefore, the diagnostic process for adenomyosis is challenging.
Pathophysiology of adenomyosis, different theories and potential mechanisms involved.
Clinical and imaging diagnosis of adenomyosis:
(A) Invagination of the endometrium into the myometrium through an altered or interrupted junctional zone (JZ) and the contribution of the mechanism of tissue injury and repair (TIAR).
(B) Metaplasia of intra myometrial embryonic or adult stem cells.
(C) Migration and differentiation of adult endometrial and stromal stem cells after retrograde menstruation through the invasion from outside.
Symptoms possibly associated with or caused by adenomyosis
.
1. Abnormal uterine bleeding (AUB)
a. Heavy menstrual bleeding
b. Prolonged menstrual bleeding
c. Inter-menstrual bleeding
d. pre-menstrual spotting
2. Gynecological pain symptoms
a. Dysmenorrhea
b. Dyspareunia
c. Chronic pelvic pain
3. Infertility and recurrent miscarriage
4. Local pressure symptoms
5. Bladder and gastrointestinal symptoms
a. Dysuria
b. Dyschezia
Reporting system of ultrasound findings of adenomyosis: considering location, type, involved layer, extent and size of the adenomyotic lesions
Figure: Two-dimensional (2D) and three-dimensional (3D) transvaginal ultrasound sonography (TVUS) features of adenomyosis, according to Morphological Uterus Sonographic Assessment (MUSA) protocol.
Other techniques and emerging technologies
· Sonohysterography
· Hysteroscopy
· Elastography
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In the last two decades, the understanding on adenomyosis has significantly improved and the awareness of this condition among clinicians has increased. In addition, the development of noninvasive diagnostic tools has made possible an accurate diagnosis of adenomyosis, without any surgical intervention.
The introduction of MRI and 2D-3D Doppler TVUS has represented a major breakthrough, considering the clinical consequences of this disease. From a clinical perspective, an ideal imaging technique should not only diagnose adenomyosis accurately but also be helpful in deciding the best treatment modality be it surgical, medical or otherwise no or minimally invasive procedures.
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