{"paper_id":"0e3ca814-9eae-4476-8ed6-f442df393aa6","body_text":"Abstract\nBackground\nAdenomyosis is a common but frequently underdiagnosed gynecological disorder with significant implications for fertility and reproductive outcomes. Despite advances in imaging, accurate recognition remains challenging due to operator dependency, uterine anatomical variations, and ultrasound artifacts that may mimic disease features.\nObjective\nTo illustrate the sonographic spectrum of adenomyosis in subfertile women using two-dimensional (2D) and three-dimensional (3D) transvaginal ultrasound, evaluate age-related differences in ultrasound lesion morphology, and identify common diagnostic pitfalls encountered during routine scanning.\nMethods\nA prospective observational study was conducted between 2022 and 2024 across three reproductive medicine centers. A total of 658 women aged 20–40 years undergoing infertility assessment were examined by 2D and 3D transvaginal ultrasound. After excluding 140 cases with inadequate visualization, 518 participants were analyzed. Adenomyosis was diagnosed in 149 women (28.8%) according to the Morphological Uterus Sonographic Assessment (MUSA) criteria. Ultrasound features were compared between two age groups: 20–35 years (n = 103) and 36–40 years (n = 46).\nResults\nThe prevalence of adenomyosis was higher in the 36–40-year group (35.9%) compared to the younger group (26.4%). The diffuse form of adenomyosis predominated (65.1%) and was significantly more frequent in the older age group (p = 0.027). Significant age-related differences were observed for myometrial cysts (87.0% vs 63.1%; p = 0.003), asymmetric wall thickening (91.3% vs 33.0%; p < 0.0001), and fan-shaped shadowing (91.3% vs 67.0%; p = 0.002). Diagnostic challenges were primarily linked to uterine rotation, retroversion, and acoustic shadowing simulating junctional zone irregularity.\nConclusion\nAdenomyosis in subfertile women exhibits distinct age-related phenotypes, with higher prevalence in 36–40 age group. The increased frequency of specific structural markers in older women—suggests that the sonographic expression of adenomyosis progresses with age. Furthermore, the identification of diagnostic pitfalls, such as uterine retroversion and acoustic shadowing mimicking junctional zone irregularity, indicates that uterine positioning remains a critical confounding factor in the sonographic assessment of adenomyosis.\nData availability\nThe datasets used in the current study may be available from the corresponding author upon reasonable request.\nReferences\nBorghese G, Doglioli M, Orsini B, Raffone A, Neola D, Travaglino A, Rovero G, Del Forno S, Meis L, Locci M, Guida M, Lenzi J, Seracchioli R, Raimondo D. 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Acta Obstet Gynecol Scand 89(11):1374–1384. https://doi.org/10.3109/00016349.2010.512061\nTokhunts K, Khudaverdyan A, Julhakyan KS, Abgaryan N (2014) OP.1606: The assessment of risk factors for expulsion of Levonorgestrel-releasing system Mirena with the use of three-dimensional transvaginal ultrasound. Ultrasound Obstet Gynecol. https://doi.org/10.1002/uog.13792\nAcknowledgements\nWe would like to thank all the participants, medical staff of Research Center for Obstetrics, Gynecology, and Reproductive Medicine, “ElIT MED” and “GLASBO” Clinics.\nFunding\nNone.\nAuthor information\nAuthors and Affiliations\nContributions\nKarine Tokhunts- project development, expert revision of materials, manuscript writing and editing. Izabella Mazmanian—data collection, manuscript writing. Karine Arustamyan- data collection. Nelly Abgaryan- data collection. Shushanik Sargsyan- data collection. Armine Chopikyan- statistic analysis. Marianna Adamya- expert revision of materials, manuscript editing.\nCorresponding author\nEthics declarations\nConflict of interest\nThe authors declare that there is no conflict of interest.\nEthical approval\nThe study was approved by the Ethics Committee of of Research Center for Obstetrics, Gynecology, and Reproductive Medicine and complied with the Declaration of Helsinki principles.\nConsent to participate\nNot applicable.\nAdditional information\nPublisher's Note\nSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.\nRights and permissions\nSpringer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.\nAbout this article\nCite this article\nTokhunts, K., Mazmanyan, I., Chopikyan, A. et al. Ultrasound features of adenomyosis and diagnostic challenges. J Ultrasound (2026). https://doi.org/10.1007/s40477-026-01132-0\nReceived:\nAccepted:\nPublished:\nVersion of record:\nDOI: https://doi.org/10.1007/s40477-026-01132-0","source_license":"public-domain-us","license_restricted":false}