Ultrasound features of adenomyosis and diagnostic challenges

Background Adenomyosis 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.

To 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.

A 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).

The 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.

Adenomyosis 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. Data availability The datasets used in the current study may be available from the corresponding author upon reasonable request.

Borghese 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. (2024) Progression of adenomyosis: Rate and associated factors. Intern J Gynecol Obst. Early View Kitawaki J (2006) Adenomyosis: the pathophysiology of an oestrogen-dependent disease. Best Pract Res Clin Obstet Gynaecol 20:493–502 Orlov S, Sladkevicius P, Jokubkiene L (2024) Evaluating the development of endometriosis and adenomyosis lesions over time: An ultrasound study of symptomatic women. Acta Obstetricia et Gynecologica Scandinavica. 103(8) Park JH, Chae KH, Kim S, Park JY, Song JY, Chung YJ, Kim MR (2024) Prevalence, incidence, and treatment trends of adenomyosis in South Korean women for 15 years: A national population-based study. Intern J Gynecol Obstet. Early View. 19 Kishi Y, Suginami H, Kuramori R, Yabuta M, Suginami R, Taniguchi F (2012) Four subtypes of adenomyosis assessed by magnetic resonance imaging and their specification. Am J Obstet Gynecol 207:114.e1–7 Van den Bosch T, Dueholm M, Leone F. P.G., Valentin L, Rasmussen CK, Votino A, Van Schoubroeck D, Landolfo C, Installé AJF, Guerriero S, Exacoustos C, Gordts S, Benacerraf B, D'Hooghe T, De Moor B, Brölmann H, Goldstein S, Epstein E., Bourne T, Timmerman D (2015). Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses: a consensus opinion from the Morphological Uterus Sonographic Assessment (MUSA) group. Ultrasound in Obstetrics & Gynecology. 46(3) Meredith SM, Sanchez-Ramos L, Kaunitz AM (2009) Diagnostic accuracy of transvaginal sonography for the diagnosis of adenomyosis: systematic review and metaanalysis. Am J Obstet Gynecol 201(1):107.e1-107.e1076. https://doi.org/10.1016/j.ajog.2009.03.021 Tellum T, Nygaard S, Lieng M (2020) Noninvasive diagnosis of adenomyosis: A structured review and meta-analysis of diagnostic accuracy in imaging. J Minim Invasive Gynecol 27(2):408-418.e3. https://doi.org/10.1016/j.jmig.2019.11.001 Campo S, Campo V, Benagiano G. Adenomyosis and infertility.Reprod Biomed Online 2012a; 24:35 – 46 Campo S, Campo V, Benagiano G. Response: Effect of adenomyosis on implantation. Reprod. Biomed Online 2012b; 24:585 Martínez-Conejero JA, Morgan M, Montesinos M, Fortuño S, Meseguer M, Simón C, Horcajadas JA, Pellicer A (2011) Adenomyosis does not affect implantation, but is associated with miscarriage in patients undergoing oocyte donation. Fertil Steril 96(1):943–950 Abbott JA (2017) Adenomyosis and abnormal uterine bleeding (AUB-A)–Pathogenesis, diagnosis, and management. Best Pract Res Clin Obstet Gynaecol 40(1):68–81 Mishra I, Melo P, Easter C, Sephton V, Dhillon-Smith R, Coomarasamy A (2023) Prevalence of adenomyosis in women with subfertility: systematic review and meta-analysis. Ultrasound Obstet Gynecol. https://doi.org/10.1002/uog.26159 Yajima R, Kido A, Kurata Y, Fujimoto K, Nakao KK, Kuwahara R, Nishio N, Minamiguchi S, Mandai M, Togashi K. (2021). Diffusion-weighted imaging of uterine adenomyosis: Correlation with clinical backgrounds and comparison with malignant uterine tumors. J Obst Gynaecol Research. 47(3) Yeniel O, Cirpan T, Ulukus M, Ozbal A, Gundem G, Ozsener S, Zekioglu O, Yilmaz H (2007) Adenomyosis: prevalence risk factors symptoms and findings. Clin Exp Obstet Gynecol 34(1):163–167 Van den Bosch T, De Bruijn AM, De Leeuw RA, Dueholm M, Exacoustos C, Valentin L, Bourne T, Timmerman D and Huirne JAF. (2019) Sonographic classification and reporting system for diagnosing adenomyosis. Ultrasound Obstet Gynecol 53: 576–582. Published online in Wiley Online Library (wileyonlinelibrary.com). https://doi.org/10.1002/uog.19096 Morosetti G, Lazzeri L, De Felice G, Piccione E, Zupi E, Exacoustos C (2017) New sonographic score of adenomyosis: classification of type and degree of the myometrial involvement and correlation to symptoms. Ultras Obs Gynecol. 50(S1) Raimondo D, Lazzeri L, Raffone A, Giorgi M, Orsini B, Verrelli L, Lenzi J, Travaglino A, Meis L, Mollo A, Zupi E, Seracchioli R, Casadio P (2022) Sonographic assessment of uterine biometry for the diagnosis of diffuse adenomyosis in a tertiary outpatient clinic. J Personal Med. https://doi.org/10.3390/jpm12101572 Lin C, Huang W, Li X, Wang L, Yan F, Zhou X, Jiang W, Zhao Y (2023) Diagnostic value of combined pelvic floor ultrasound parameters for pelvic floor dysfunction and risk factors. Journal of clinical ultrasound : JCU 51(3):465–471. https://doi.org/10.1002/jcu.23397 Exacoustos C (2016) Adenomyosis and ultrasound: the role of ultrasound and its impact on understanding the disease. In: Habiba M, Benagiano G (eds) Uterine adenomyosis. Springer, Heidelberg, pp 141–152 Breton Z, Gouesbet S, Indersie E, Gabillet M, Tran VT, Aflak N, Borghese B, Petit E, Roman H, Millepied AC, Nève De Mevergnies M, Kvaskoff M. Endometriosis Diagnostic Delay and Its Correlates: Results from the ComPaRe-Endometriosis Cohort. J Womens Health. https://doi.org/10.1177/15409996251380129. Mishra I, Melo P, Easter C, Sephton V, Dhillon-Smith R, Coomarasamy A (2023) Prevalence of adenomyosis in women with subfertility: systematic review and meta-analysis. Ultrasound Obstet Gynecol 62(1):23–41 Taran FA, Stewart EA, Brucker S (2013) Adenomyosis: epidemiology, risk factors, clinical phenotype and surgical and interventional alternatives to hysterectomy. Geburtshilfe Frauenheilkd 73(9):924–931. https://doi.org/10.1055/s-0033-1350840 Pontis A, D’Alterio MN, Pirarba S, de Angelis C, Tinelli R, Angioni S (2016) Adenomyosis: a systematic review of medical treatment. Gynecol Endocrinol 32(9):696–700. https://doi.org/10.1080/09513590.2016.1197200 Harmsen MJ, Van den Bosch T, de Leeuw RA et al (2022) Consensus on revised definitions of morphological uterus sonographic assessment (MUSA) features of adenomyosis: results of modified Delphi procedure. Ultrasound Obstet Gynecol 60(1):118–131. https://doi.org/10.1002/uog.24786 Dueholm M (2006) Transvaginal ultrasound for diagnosis of adenomyosis: a review. Best Pract Res Clin Obstet Gynaecol 20(4):569–582. https://doi.org/10.1016/j.bpobgyn.2006.01.005 Champaneria R, Abedin P, Daniels J, Balogun M, Khan KS (2010) Ultrasound scan and magnetic resonance imaging for the diagnosis of adenomyosis: systematic review comparing test accuracy. Acta Obstet Gynecol Scand 89(11):1374–1384. https://doi.org/10.3109/00016349.2010.512061 Tokhunts 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

We would like to thank all the participants, medical staff of Research Center for Obstetrics, Gynecology, and Reproductive Medicine, “ElIT MED” and “GLASBO” Clinics. Funding None. Author information Authors and Affiliations Contributions Karine 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. Corresponding author Ethics declarations Conflict of interest The authors declare that there is no conflict of interest. Ethical approval The 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. Consent to participate Not applicable. Additional information Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Rights and permissions Springer 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. About this article Cite this article Tokhunts, 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 Received: Accepted: Published: Version of record: DOI: https://doi.org/10.1007/s40477-026-01132-0