Adenomyosis and endometriosis. Re-visiting their association and further insights into the mechanisms of auto-traumatisation. An MRI study

G Leyendecker, A Bilgicyildirim, M Inacker, T Stalf, Peter Huppert, P Huppert, G Mall, Bettina Böttcher, B Böttcher, L Wildt
Archives of gynecology and obstetrics · 2014 · vol. 291(4) , pp. 917–932 · doi:10.1007/s00404-014-3437-8 · PMID:25241270 · PMC4355446 · W2144222114
article OA: gold CC0 ⤵ 187 in-corpus citations
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⚙ AI-generated summary by claude@2026-06, 2026-06-07 ⓘ

This MRI study found a high association between adenomyosis and endometriosis, suggesting uterine auto-traumatization from contractions and peristalsis is a primary mechanism.

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⚙ AI-generated deep summary by claude@2026-06, 2026-06-07 ⓘ

This MRI study of 143 women attending a fertility center investigated (a) the association between uterine adenomyosis and pelvic endometriosis and (b) mechanisms of uterine auto-traumatization by assessing the junctional zone (JZ) and lesion localization. Using a detailed “visualization” approach across MRI planes to distinguish true adenomyosis from transient JZ enlargement (and to lower the detection threshold), the authors verified adenomyosis in 127/143; endometriosis prevalence in adenomyosis was 80.6%, and adenomyosis prevalence in endometriosis was 91.1%, with lesions mainly in the median region of the upper two-thirds of the uterine wall, and cystic cornual angle adenomyosis only in cases with extreme primary dysmenorrhea. They concluded that mechanical strain from “archimetral compression by neometral contractions” (in addition to uterine peristalsis/hyperperistalsis) may be a predominant contributor to tissue injury and repair, but a stated limitation is that endometriosis diagnosis was often based on historical documentation rather than uniform surgical confirmation. This paper is centrally about endometriosis — it directly studies the adenomyosis–endometriosis association and proposes a shared TIAR/auto-traumatization mechanism using MRI lesion patterns.

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Abstract

PURPOSE: In a series of publications, we had developed the concept that uterine adenomyosis and pelvic endometriosis as well as endometriotic lesions at distant sites of the body share a common pathophysiology with endometriosis constituting a secondary phenomenon. Uterine auto-traumatization and the initiation of the mechanism of tissue injury and repair (TIAR) were considered the primary events in the disease process. The present MRI study was undertaken (1) to corroborate this concept by re-visiting, in view of discrepant results in the literature, the association of adenomyosis with endometriosis and (2) to extend our views concerning the mechanisms of uterine auto-traumatization. PATIENTS AND METHODS: MRI was performed in 143 women attending our center, in whom, on the basis of transvaginal sonography (TVS) and historical data, such as documented endometriosis and dysmenorrhea of various degrees of severity, the presence of uterine adenomyosis was suspected. In addition to the measurement of the diameter of junctional zone (JZ) of the anterior and posterior walls in the mid-sagittal plane, the diagnosis of adenomyosis was based on visualization, in that all planes were analyzed with scrutiny. By this method of "visualization" all transient enlargement of the JZ, such as peristaltic waves of the archimyometrium and sporadic neometral contractions that might mimic adenomyotic lesions could be excluded. At the same time, this method allowed to lower the limit of detection in terms of thickness of the JZ for assured diagnosis of adenomyosis. Furthermore, the localizations of the individual lesions, their shapes and patterns were described. RESULTS: With the method of 'visualization', the diagnosis of uterine adenomyosis could be verified in 127 of the 143 patients studied. The prevalence of endometriosis in adenomyosis was 80.6% and the prevalence of adenomyosis in endometriosis was 91.1%. As concluded from their localization within the uterine wall, the adenomyotic lesions predominantly developed in the median region of the upper two-thirds of the uterine wall. Cystic cornual angle adenomyosis was a distinct phenomenon that was only observed in patients suffering from extreme primary dysmenorrhea. Aside from this, the majority of the patients complained of primary dysmenorrhea (80%). On the basis of these findings and the fact that particularly extreme primary dysmenorrhea is associated with high intrauterine pressure, menstrual 'archimetral compression by neometral contraction' has to be considered as an important cause of uterine auto-traumatization in addition to uterine peristalsis and hyperperistalsis. Both mechanical functions of the non-pregnant uterus exert their strongest power in the upper region of the uterus, which is compatible with the predominant localization of the adenomyotic lesions. CONCLUSIONS: The data confirm our previous results of a high association of adenomyosis with endometriosis and vice versa. Our view of the mechanism of uterine auto-traumatization by mechanical functions of the non-pregnant uterus has to be extended, in that 'archimetral compression by neometral contractions' could be realized as the predominant cause of mechanical strain to the non-pregnant uterus. The data of this study confirm our concept of the etiology and pathophysiology of adenomyosis and endometriosis in that the process of chronic proliferation and inflammation is induced at the level of the archimetra by chronic uterine auto-traumatization. Furthermore, with respect to the diagnosis of uterine adenomyosis (and consequently endometriosis) this study shows a high degree of accordance between the findings in real-time TVS and MRI.

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Condition tags

dysmenorrheaendometriosisadenomyosis

MeSH descriptors

Adenomyosis Adenomyosis Dysmenorrhea Endometriosis Endometriosis Magnetic Resonance Imaging Adenomyosis Adenomyosis Adult Dysmenorrhea Dysmenorrhea Endometriosis Endometriosis Female Germany Germany Humans Magnetic Resonance Imaging Prevalence Severity of Illness Index

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