Diagnostic steps in adenomyosis – an updated review

Adenomyosis is defined by the presence of ectopic endometrial glands and stroma inside the myometrium. Definite diagnosis is made only on hysterectomy specimens, but all the progress in modern imaging techniques has increased the paraclinical diagnostic chances. The diagnostic algorithm is based on patient’s history (main complaints, menstrual, obstetrical and gynecological history), clinical examination, imaging studies – ultrasound and MRI. Definitive diagnosis is certainly histopathological. We present an updated review of diagnostic steps in adenomyosis, based on the existing consensus opinions of experts in the field. The Morphological Uterus Sonographic Assessment (MUSA) group published a consensus statement on terms, definitions and measurements that helps clinicians to characterize uterine pathology, accordingly to the modern classification system for abnormal uterine bleeding implemented by the International Federation of Gynecology and Obstetrics (FIGO). The direct signs of adenomyosis are: the myometrial cysts, the non-homogenous myometrium (linear hyperchogenic striae inside the myometrium (the venetian blinds sign), the fan shaped shadowing, hypoechogenic subendometrial zones – lines and buds, hyperechogenic islands, hypoechogenic ill-defined pseudonodularities, ill-defined endometrial-myometrial delimitation as irregular or thick junctional zone. The indirect signs of adenomyosis are: globular, enlarged uterus; asymmetrical myometrial walls; linear, translesional vascularization; a retroverted uterus, with a characteristic appearance of the endometrium (the question mark sign). Ademoyosis has nowadays good criteria of non-invasive diagnosis and the appropriate diagnosis algorithm should be applied in all women with complaints of bleeding. Ultrasound imaging requires no special preparation, has no contraindication, is available and cost-effective. Ultrasound accuracy is very good in diagnosing adenomyosis, leading to prompt treatment in younger patients, who are especially interested in conserving their reproductive function.