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Uterine Adenomyosis: Endovaginal US and MR Imaging Features with Histopathologic Correlation¹

¹ From the Departments of Radiology (C.R., F.T., L.W., L.R.) and Pathology (A.M.), Montreal General Hospital and McGill University, 1650 Cedar Ave, Montreal, Quebec, Canada H3G 1A4; the Department of Radiology, Princess Margaret Hospital, Toronto, Ontario, Canada (M.A.); and the Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia (E.S.S.). Recipient of a Certificate of Merit award for a scientific exhibit at the 1998 RSNA scientific assembly. Received March 4, 1999; revision requested April 16 and received July 7; accepted July 7. Address reprint requests to C.R.

View larger version (116K): [in a new window]   Figure 1.   Normal uterus. Sagittal endovaginal US scan shows a normal myometrium (M), which is moderately echogenic and has a homogeneous echotexture. The subendometrial halo, which represents the innermost layer of the myometrium, is visualized subjacent to the endometrium (E) as a thin hypoechoic band (arrows). The endometrium is uniformly echogenic in this patient, who was in the secretory phase of the menstrual cycle.

View larger version (137K): [in a new window]   Figure 2a.   Imaging signs of adenomyosis. E = endometrium. (a) Sagittal oblique endovaginal US scan shows that the myometrium is thickened ventrally and has a heterogeneous echotexture (straight arrows). The echogenicity of the ventral myometrium is decreased relative to that of the dorsal myometrium. Additional features of adenomyosis seen in this image include poor definition of the endomyometrial junction and a myometrial cyst (curved arrow). (b) Corresponding sagittal T2-weighted MR image shows marked thickening of the junctional zone. The result is a poorly defined low-signal-intensity mass that replaces the ventral myometrium (arrows). The numerous bright foci, some of which have a rounded appearance whereas others have a linear or fingerlike appearance, represent the heterotopic endometrium. Bl = bladder. (c) Photomicrograph (hematoxylin-eosin stain) of a section through the middle aspect of the ventral myometrium shows foci of heterotopic endometrium scattered throughout the inner two-thirds of the myometrium (small arrows). The heterotopic islands have a linear or rounded appearance (see magnified views). The smooth muscle hyperplasia (dark pink stain) surrounds the heterotopic endometrium. Cysts of adenomyosis are noted in the outer myometrium (large arrows). The endometrial tissue extending into the myometrium results in poor definition of the endomyometrial junction at imaging.

View larger version (135K): [in a new window]   Figure 2b.   Imaging signs of adenomyosis. E = endometrium. (a) Sagittal oblique endovaginal US scan shows that the myometrium is thickened ventrally and has a heterogeneous echotexture (straight arrows). The echogenicity of the ventral myometrium is decreased relative to that of the dorsal myometrium. Additional features of adenomyosis seen in this image include poor definition of the endomyometrial junction and a myometrial cyst (curved arrow). (b) Corresponding sagittal T2-weighted MR image shows marked thickening of the junctional zone. The result is a poorly defined low-signal-intensity mass that replaces the ventral myometrium (arrows). The numerous bright foci, some of which have a rounded appearance whereas others have a linear or fingerlike appearance, represent the heterotopic endometrium. Bl = bladder. (c) Photomicrograph (hematoxylin-eosin stain) of a section through the middle aspect of the ventral myometrium shows foci of heterotopic endometrium scattered throughout the inner two-thirds of the myometrium (small arrows). The heterotopic islands have a linear or rounded appearance (see magnified views). The smooth muscle hyperplasia (dark pink stain) surrounds the heterotopic endometrium. Cysts of adenomyosis are noted in the outer myometrium (large arrows). The endometrial tissue extending into the myometrium results in poor definition of the endomyometrial junction at imaging.

View larger version (89K): [in a new window]   Figure 2c.   Imaging signs of adenomyosis. E = endometrium. (a) Sagittal oblique endovaginal US scan shows that the myometrium is thickened ventrally and has a heterogeneous echotexture (straight arrows). The echogenicity of the ventral myometrium is decreased relative to that of the dorsal myometrium. Additional features of adenomyosis seen in this image include poor definition of the endomyometrial junction and a myometrial cyst (curved arrow). (b) Corresponding sagittal T2-weighted MR image shows marked thickening of the junctional zone. The result is a poorly defined low-signal-intensity mass that replaces the ventral myometrium (arrows). The numerous bright foci, some of which have a rounded appearance whereas others have a linear or fingerlike appearance, represent the heterotopic endometrium. Bl = bladder. (c) Photomicrograph (hematoxylin-eosin stain) of a section through the middle aspect of the ventral myometrium shows foci of heterotopic endometrium scattered throughout the inner two-thirds of the myometrium (small arrows). The heterotopic islands have a linear or rounded appearance (see magnified views). The smooth muscle hyperplasia (dark pink stain) surrounds the heterotopic endometrium. Cysts of adenomyosis are noted in the outer myometrium (large arrows). The endometrial tissue extending into the myometrium results in poor definition of the endomyometrial junction at imaging.

View larger version (113K): [in a new window]   Figure 3a.   Variable echogenicity in a patient with diffuse adenomyosis extending into the outer myometrium. (a) Sagittal oblique endovaginal US scan shows that most regions of the myometrium are hypoechoic and heterogeneous. However, an area of increased echogenicity (arrows) is seen in the ventral myometrium adjacent to the fundus and immediately deep to the endometrium (E) dorsally. The borders of the endometrium are obscured at this level due to the increased echogenicity of the adjacent myometrium, thus resulting in pseudowidening of the endometrium. (b) Photomicrograph (hematoxylin-eosin stain) shows that the ratio of heterotopic endometrial tissue (arrows) to smooth muscle hyperplasia (dark pink stain) is greatest in the ventral myometrium (VM), which corresponds to the area of increased echogenicity on the endovaginal US scan (a). E = endometrium.

View larger version (125K): [in a new window]   Figure 3b.   Variable echogenicity in a patient with diffuse adenomyosis extending into the outer myometrium. (a) Sagittal oblique endovaginal US scan shows that most regions of the myometrium are hypoechoic and heterogeneous. However, an area of increased echogenicity (arrows) is seen in the ventral myometrium adjacent to the fundus and immediately deep to the endometrium (E) dorsally. The borders of the endometrium are obscured at this level due to the increased echogenicity of the adjacent myometrium, thus resulting in pseudowidening of the endometrium. (b) Photomicrograph (hematoxylin-eosin stain) shows that the ratio of heterotopic endometrial tissue (arrows) to smooth muscle hyperplasia (dark pink stain) is greatest in the ventral myometrium (VM), which corresponds to the area of increased echogenicity on the endovaginal US scan (a). E = endometrium.

View larger version (99K): [in a new window]   Figure 4a.   Myometrial cyst. E = endometrium. (a) Transverse oblique endovaginal US scan shows a 6-mm-diameter cyst in the left dorsal aspect of the inner myometrium (arrow). (b) Photomicrograph (hematoxylin-eosin stain) of a section through the dorsal myometrium shows the cyst (magnified view).

View larger version (115K): [in a new window]   Figure 4b.   Myometrial cyst. E = endometrium. (a) Transverse oblique endovaginal US scan shows a 6-mm-diameter cyst in the left dorsal aspect of the inner myometrium (arrow). (b) Photomicrograph (hematoxylin-eosin stain) of a section through the dorsal myometrium shows the cyst (magnified view).

View larger version (109K): [in a new window]   Figure 5a.   Hyperechoic nodules. E = endometrium. (a) Sagittal oblique endovaginal US scan of a patient receiving tamoxifen therapy shows that the inner myometrium is hypoechoic and heterogeneous. Several echogenic nodules consistent with large islands of heterotopic endometrium are seen (short arrows). A myometrial cyst is also present (long arrow). (b) Transverse oblique endovaginal US scan of another patient shows a large echogenic nodule with a central cystic area in the inner aspect of the dorsal myometrium (arrows). (c) Photomicrograph (hematoxylin-eosin stain) of a section through the dorsal uterus (same patient as in b) shows a large heterotopic island of endometrial tissue in the inner myometrium (arrows).

View larger version (101K): [in a new window]   Figure 5b.   Hyperechoic nodules. E = endometrium. (a) Sagittal oblique endovaginal US scan of a patient receiving tamoxifen therapy shows that the inner myometrium is hypoechoic and heterogeneous. Several echogenic nodules consistent with large islands of heterotopic endometrium are seen (short arrows). A myometrial cyst is also present (long arrow). (b) Transverse oblique endovaginal US scan of another patient shows a large echogenic nodule with a central cystic area in the inner aspect of the dorsal myometrium (arrows). (c) Photomicrograph (hematoxylin-eosin stain) of a section through the dorsal uterus (same patient as in b) shows a large heterotopic island of endometrial tissue in the inner myometrium (arrows).

View larger version (130K): [in a new window]   Figure 5c.   Hyperechoic nodules. E = endometrium. (a) Sagittal oblique endovaginal US scan of a patient receiving tamoxifen therapy shows that the inner myometrium is hypoechoic and heterogeneous. Several echogenic nodules consistent with large islands of heterotopic endometrium are seen (short arrows). A myometrial cyst is also present (long arrow). (b) Transverse oblique endovaginal US scan of another patient shows a large echogenic nodule with a central cystic area in the inner aspect of the dorsal myometrium (arrows). (c) Photomicrograph (hematoxylin-eosin stain) of a section through the dorsal uterus (same patient as in b) shows a large heterotopic island of endometrial tissue in the inner myometrium (arrows).

View larger version (119K): [in a new window]   Figures 6, 7.   (6) Echogenic linear striations. Transverse oblique endovaginal US scan shows that the myometrium is hypoechoic and slightly heterogeneous, an appearance consistent with diffuse adenomyosis. Echogenic linear striations (arrows) can be seen radiating out from the endometrium (E) dorsally. The linear striations represent the ectopic endometrial tissue that is in direct continuity with the endometrium. (7) Linear striations. (a) Sagittal endovaginal US scan shows that the myometrium is heterogeneous and of decreased echogenicity. There is pseudowidening of the endometrium (E) at the level of the fundus. Echogenic linear striations can be seen radiating out from the endometrium (arrows). (b) Corresponding sagittal T2-weighted MR image shows diffuse widening of the junctional zone. Linear striations of high signal intensity (arrows) can be seen radiating out from the endometrium (E) at the level of the fundus. Si = sigmoid colon.

View larger version (141K): [in a new window]   Figures 6, 7.   (6) Echogenic linear striations. Transverse oblique endovaginal US scan shows that the myometrium is hypoechoic and slightly heterogeneous, an appearance consistent with diffuse adenomyosis. Echogenic linear striations (arrows) can be seen radiating out from the endometrium (E) dorsally. The linear striations represent the ectopic endometrial tissue that is in direct continuity with the endometrium. (7) Linear striations. (a) Sagittal endovaginal US scan shows that the myometrium is heterogeneous and of decreased echogenicity. There is pseudowidening of the endometrium (E) at the level of the fundus. Echogenic linear striations can be seen radiating out from the endometrium (arrows). (b) Corresponding sagittal T2-weighted MR image shows diffuse widening of the junctional zone. Linear striations of high signal intensity (arrows) can be seen radiating out from the endometrium (E) at the level of the fundus. Si = sigmoid colon.

View larger version (139K): [in a new window]   Figures 6, 7.   (6) Echogenic linear striations. Transverse oblique endovaginal US scan shows that the myometrium is hypoechoic and slightly heterogeneous, an appearance consistent with diffuse adenomyosis. Echogenic linear striations (arrows) can be seen radiating out from the endometrium (E) dorsally. The linear striations represent the ectopic endometrial tissue that is in direct continuity with the endometrium. (7) Linear striations. (a) Sagittal endovaginal US scan shows that the myometrium is heterogeneous and of decreased echogenicity. There is pseudowidening of the endometrium (E) at the level of the fundus. Echogenic linear striations can be seen radiating out from the endometrium (arrows). (b) Corresponding sagittal T2-weighted MR image shows diffuse widening of the junctional zone. Linear striations of high signal intensity (arrows) can be seen radiating out from the endometrium (E) at the level of the fundus. Si = sigmoid colon.

View larger version (119K): [in a new window]   Figure 8a.   Poor definition of the endomyometrial junction. E = endometrium. (a) Transverse oblique endovaginal US scan shows that the ventral myometrium (VM) is markedly heterogeneous, with areas of increased and decreased echogenicity. The abnormal myometrial echotexture results in poor definition of the endomyometrial junction ventrally (arrows). Contrast this appearance with the well-defined appearance of the endomyometrial junction dorsally. (b) Corresponding axial T2-weighted MR image shows thickening of the junctional zone that is most marked ventrally (VM), with multiple foci of increased signal intensity. Owing to the differences in signal intensity between the endometrium (E) and the adjacent myometrium, the endomyometrial junction remains relatively well defined. Cx = cervix. (c) Photomicrograph (hematoxylin-eosin stain) of a section through the ventral myometrium shows extensive adenomyosis with numerous foci of heterotopic endometrial tissue throughout the myometrium (arrows). Note the poor definition of the endomyometrial junction. (d) Photomicrograph (hematoxylin-eosin stain) of a section through a normal uterus shows deep crypts of endometrial glands (arrow), which result in an undulating appearance of the endomyometrial junction. However, the endomyometrial junction remains well defined.

View larger version (127K): [in a new window]   Figure 8b.   Poor definition of the endomyometrial junction. E = endometrium. (a) Transverse oblique endovaginal US scan shows that the ventral myometrium (VM) is markedly heterogeneous, with areas of increased and decreased echogenicity. The abnormal myometrial echotexture results in poor definition of the endomyometrial junction ventrally (arrows). Contrast this appearance with the well-defined appearance of the endomyometrial junction dorsally. (b) Corresponding axial T2-weighted MR image shows thickening of the junctional zone that is most marked ventrally (VM), with multiple foci of increased signal intensity. Owing to the differences in signal intensity between the endometrium (E) and the adjacent myometrium, the endomyometrial junction remains relatively well defined. Cx = cervix. (c) Photomicrograph (hematoxylin-eosin stain) of a section through the ventral myometrium shows extensive adenomyosis with numerous foci of heterotopic endometrial tissue throughout the myometrium (arrows). Note the poor definition of the endomyometrial junction. (d) Photomicrograph (hematoxylin-eosin stain) of a section through a normal uterus shows deep crypts of endometrial glands (arrow), which result in an undulating appearance of the endomyometrial junction. However, the endomyometrial junction remains well defined.

View larger version (130K): [in a new window]   Figure 8c.   Poor definition of the endomyometrial junction. E = endometrium. (a) Transverse oblique endovaginal US scan shows that the ventral myometrium (VM) is markedly heterogeneous, with areas of increased and decreased echogenicity. The abnormal myometrial echotexture results in poor definition of the endomyometrial junction ventrally (arrows). Contrast this appearance with the well-defined appearance of the endomyometrial junction dorsally. (b) Corresponding axial T2-weighted MR image shows thickening of the junctional zone that is most marked ventrally (VM), with multiple foci of increased signal intensity. Owing to the differences in signal intensity between the endometrium (E) and the adjacent myometrium, the endomyometrial junction remains relatively well defined. Cx = cervix. (c) Photomicrograph (hematoxylin-eosin stain) of a section through the ventral myometrium shows extensive adenomyosis with numerous foci of heterotopic endometrial tissue throughout the myometrium (arrows). Note the poor definition of the endomyometrial junction. (d) Photomicrograph (hematoxylin-eosin stain) of a section through a normal uterus shows deep crypts of endometrial glands (arrow), which result in an undulating appearance of the endomyometrial junction. However, the endomyometrial junction remains well defined.

View larger version (130K): [in a new window]   Figure 8d.   Poor definition of the endomyometrial junction. E = endometrium. (a) Transverse oblique endovaginal US scan shows that the ventral myometrium (VM) is markedly heterogeneous, with areas of increased and decreased echogenicity. The abnormal myometrial echotexture results in poor definition of the endomyometrial junction ventrally (arrows). Contrast this appearance with the well-defined appearance of the endomyometrial junction dorsally. (b) Corresponding axial T2-weighted MR image shows thickening of the junctional zone that is most marked ventrally (VM), with multiple foci of increased signal intensity. Owing to the differences in signal intensity between the endometrium (E) and the adjacent myometrium, the endomyometrial junction remains relatively well defined. Cx = cervix. (c) Photomicrograph (hematoxylin-eosin stain) of a section through the ventral myometrium shows extensive adenomyosis with numerous foci of heterotopic endometrial tissue throughout the myometrium (arrows). Note the poor definition of the endomyometrial junction. (d) Photomicrograph (hematoxylin-eosin stain) of a section through a normal uterus shows deep crypts of endometrial glands (arrow), which result in an undulating appearance of the endomyometrial junction. However, the endomyometrial junction remains well defined.

View larger version (118K): [in a new window]   Figure 9.   Normal uterus. Sagittal T2-weighted MR image shows a centrally located high-signal-intensity stripe, which represents the endometrium (E). Immediately subjacent is a band of low signal intensity, which is located within the inner myometrium and represents the junctional zone (JZ). The outer myometrium is of intermediate signal intensity. Bl = bladder.

View larger version (136K): [in a new window]   Figure 10.   Focal thickening of the junctional zone. Sagittal T2-weighted MR image shows focal thickening of the junctional zone at the level of the fundus (arrows). Although the maximal thickness of the junctional zone was more than 12 mm in this patient, any focal thickening of the junctional zone should raise the possibility of adenomyosis. Bl = bladder, E = endometrium.

View larger version (128K): [in a new window]   Figure 11a.   High-signal-intensity foci. C = left ovarian cyst, Cx = cervix, E = endometrium. (a) Axial T2-weighted MR image shows an ill-defined low-signal-intensity mass with numerous foci of increased signal intensity that replaces the left side of the myometrium (arrows). (b) Axial T1-weighted MR image shows several foci of increased signal intensity (arrowheads), which correspond to areas of hemorrhage within the adenomyotic tissue. (c) Photomicrograph (hematoxylin-eosin stain) of a section through the uterus shows numerous foci of heterotopic endometrial tissue throughout the myometrium (arrowheads). Note also the smooth muscle hyperplasia (dark pink stain) surrounding the heterotopic tissue.

View larger version (85K): [in a new window]   Figure 11b.   High-signal-intensity foci. C = left ovarian cyst, Cx = cervix, E = endometrium. (a) Axial T2-weighted MR image shows an ill-defined low-signal-intensity mass with numerous foci of increased signal intensity that replaces the left side of the myometrium (arrows). (b) Axial T1-weighted MR image shows several foci of increased signal intensity (arrowheads), which correspond to areas of hemorrhage within the adenomyotic tissue. (c) Photomicrograph (hematoxylin-eosin stain) of a section through the uterus shows numerous foci of heterotopic endometrial tissue throughout the myometrium (arrowheads). Note also the smooth muscle hyperplasia (dark pink stain) surrounding the heterotopic tissue.

View larger version (142K): [in a new window]   Figure 11c.   High-signal-intensity foci. C = left ovarian cyst, Cx = cervix, E = endometrium. (a) Axial T2-weighted MR image shows an ill-defined low-signal-intensity mass with numerous foci of increased signal intensity that replaces the left side of the myometrium (arrows). (b) Axial T1-weighted MR image shows several foci of increased signal intensity (arrowheads), which correspond to areas of hemorrhage within the adenomyotic tissue. (c) Photomicrograph (hematoxylin-eosin stain) of a section through the uterus shows numerous foci of heterotopic endometrial tissue throughout the myometrium (arrowheads). Note also the smooth muscle hyperplasia (dark pink stain) surrounding the heterotopic tissue.

View larger version (126K): [in a new window]   Figure 12a.   Pseudowidening of the endometrium. Sagittal (a) and axial (b) T2-weighted MR images show diffuse thickening of the junctional zone, aside from a central area of the dorsal myometrium. Note the blending of the fine linear hyperintense striations that extend out into the ventral myometrium (arrows); this blending results in pseudowidening of the endometrium (E). N = nabothian cysts.

View larger version (117K): [in a new window]   Figure 12b.   Pseudowidening of the endometrium. Sagittal (a) and axial (b) T2-weighted MR images show diffuse thickening of the junctional zone, aside from a central area of the dorsal myometrium. Note the blending of the fine linear hyperintense striations that extend out into the ventral myometrium (arrows); this blending results in pseudowidening of the endometrium (E). N = nabothian cysts.

View larger version (107K): [in a new window]   Figure 13a.   Cystic adenomyosis. (a) Coronal T2-weighted MR image shows focal thickening of the junctional zone both ventrally and dorsally (black arrows) with multiple foci of high signal intensity, findings consistent with adenomyosis. In addition, there is a well-circumscribed, cystic mass of high signal intensity with a low-signal-intensity rim in the right aspect of the ventral myometrium (white arrow). Bl = bladder. (b) Axial T1-weighted MR image shows the cystic mass (arrow), which has intermediate signal intensity and a high-signal-intensity rim. N = nabothian cyst.

View larger version (106K): [in a new window]   Figure 13b.   Cystic adenomyosis. (a) Coronal T2-weighted MR image shows focal thickening of the junctional zone both ventrally and dorsally (black arrows) with multiple foci of high signal intensity, findings consistent with adenomyosis. In addition, there is a well-circumscribed, cystic mass of high signal intensity with a low-signal-intensity rim in the right aspect of the ventral myometrium (white arrow). Bl = bladder. (b) Axial T1-weighted MR image shows the cystic mass (arrow), which has intermediate signal intensity and a high-signal-intensity rim. N = nabothian cyst.

View larger version (110K): [in a new window]   Figure 14a.   Cystic adenomyosis. A = diffuse adenomyosis, Cx = cervix. Sagittal T2-weighted (a), fat-suppressed T1-weighted (b), and gadolinium-enhanced fat-suppressed T1-weighted (c) MR images show a complex cystic mass originating from the dorsal myometrium (arrows). Note the variable signal intensity of the mass on the T2-weighted (a) and fat-suppressed T1-weighted (b) images, which indicates hemorrhage in differential stages of organization.

View larger version (140K): [in a new window]   Figure 14b.   Cystic adenomyosis. A = diffuse adenomyosis, Cx = cervix. Sagittal T2-weighted (a), fat-suppressed T1-weighted (b), and gadolinium-enhanced fat-suppressed T1-weighted (c) MR images show a complex cystic mass originating from the dorsal myometrium (arrows). Note the variable signal intensity of the mass on the T2-weighted (a) and fat-suppressed T1-weighted (b) images, which indicates hemorrhage in differential stages of organization.

View larger version (116K): [in a new window]   Figure 14c.   Cystic adenomyosis. A = diffuse adenomyosis, Cx = cervix. Sagittal T2-weighted (a), fat-suppressed T1-weighted (b), and gadolinium-enhanced fat-suppressed T1-weighted (c) MR images show a complex cystic mass originating from the dorsal myometrium (arrows). Note the variable signal intensity of the mass on the T2-weighted (a) and fat-suppressed T1-weighted (b) images, which indicates hemorrhage in differential stages of organization.

View larger version (129K): [in a new window]   Figure 15a.   Adenomyoma. (a) Sagittal T2-weighted MR image shows a low-signal-intensity mass with an elliptical shape in the ventral myometrium (arrows). Poorly defined borders and lack of significant mass effect allow differentiation of this adenomyoma from a leiomyoma. E = endometrium. (Reprinted, with permission, from reference 10.) (b) Photomicrograph (hematoxylin-eosin stain) of a section through the ventral myometrium shows the adenomyoma (arrows).

View larger version (111K): [in a new window]   Figure 15b.   Adenomyoma. (a) Sagittal T2-weighted MR image shows a low-signal-intensity mass with an elliptical shape in the ventral myometrium (arrows). Poorly defined borders and lack of significant mass effect allow differentiation of this adenomyoma from a leiomyoma. E = endometrium. (Reprinted, with permission, from reference 10.) (b) Photomicrograph (hematoxylin-eosin stain) of a section through the ventral myometrium shows the adenomyoma (arrows).

View larger version (94K): [in a new window]   Figure 16a.   Adenomyosis versus leiomyoma. Transverse endovaginal US scans through the uterus in different patients show extensive adenomyosis (a) and a mural leiomyoma (b) involving the dorsal myometrium. Distinguishing features of the adenomyosis (arrows in a) include poorly defined borders, lack of mass effect on the endometrium (E), and an elliptical shape. In contradistinction, the leiomyoma (large arrows in b) has edge shadowing, mass effect on the endometrium (small arrows in b), and a round shape with well-defined borders.

View larger version (107K): [in a new window]   Figure 16b.   Adenomyosis versus leiomyoma. Transverse endovaginal US scans through the uterus in different patients show extensive adenomyosis (a) and a mural leiomyoma (b) involving the dorsal myometrium. Distinguishing features of the adenomyosis (arrows in a) include poorly defined borders, lack of mass effect on the endometrium (E), and an elliptical shape. In contradistinction, the leiomyoma (large arrows in b) has edge shadowing, mass effect on the endometrium (small arrows in b), and a round shape with well-defined borders.

View larger version (117K): [in a new window]   Figure 17a.   Adenomyosis versus leiomyoma. E = endometrium. (a) Sagittal T2-weighted MR image of a patient with adenomyosis shows thickening of the junctional zone ventrally, thus giving the appearance of an ill-defined myometrial mass (arrows). Note the minimal mass effect on the endometrial cavity and outer uterine contours relative to the size of the lesion. (b) Sagittal T2-weighted MR image of a patient with a leiomyoma shows a mass with well-defined borders (arrows) and considerable mass effect on the endometrial cavity and uterine contours. Bl = bladder.

View larger version (122K): [in a new window]   Figure 17b.   Adenomyosis versus leiomyoma. E = endometrium. (a) Sagittal T2-weighted MR image of a patient with adenomyosis shows thickening of the junctional zone ventrally, thus giving the appearance of an ill-defined myometrial mass (arrows). Note the minimal mass effect on the endometrial cavity and outer uterine contours relative to the size of the lesion. (b) Sagittal T2-weighted MR image of a patient with a leiomyoma shows a mass with well-defined borders (arrows) and considerable mass effect on the endometrial cavity and uterine contours. Bl = bladder.

View larger version (119K): [in a new window]   Figure 18a.   Adenomyosis versus endometrial carcinoma. Bl = bladder. (a) Sagittal T2-weighted MR image shows a small endometrial mass of intermediate signal intensity (M), a finding consistent with the clinical diagnosis of endometrial carcinoma. The abnormal signal intensity extends into the inner one-third of the myometrium dorsally (arrows). At histopathologic analysis, only microscopic myometrial invasion was present with extensive subjacent adenomyosis. (b) Axial T2-weighted MR image of another patient shows a small endometrium-based mass displacing the endometrial cavity ventrally (large straight arrow). This mass was proved to be an endometrial carcinoma with superficial myometrial invasion at histopathologic analysis. Similar-appearing abnormal areas of high signal intensity are seen in the inner aspect of the ventral myometrium (small straight arrows). These were proved to be areas of adenomyosis at histopathologic analysis. Note the associated thickening of the junctional zone ventrally, as well as the presence of a myometrial cyst (curved arrow).

View larger version (118K): [in a new window]   Figure 18b.   Adenomyosis versus endometrial carcinoma. Bl = bladder. (a) Sagittal T2-weighted MR image shows a small endometrial mass of intermediate signal intensity (M), a finding consistent with the clinical diagnosis of endometrial carcinoma. The abnormal signal intensity extends into the inner one-third of the myometrium dorsally (arrows). At histopathologic analysis, only microscopic myometrial invasion was present with extensive subjacent adenomyosis. (b) Axial T2-weighted MR image of another patient shows a small endometrium-based mass displacing the endometrial cavity ventrally (large straight arrow). This mass was proved to be an endometrial carcinoma with superficial myometrial invasion at histopathologic analysis. Similar-appearing abnormal areas of high signal intensity are seen in the inner aspect of the ventral myometrium (small straight arrows). These were proved to be areas of adenomyosis at histopathologic analysis. Note the associated thickening of the junctional zone ventrally, as well as the presence of a myometrial cyst (curved arrow).

View larger version (98K): [in a new window]   Figure 19a.   Myometrial contraction. (a) Transverse endovaginal US scan shows a hypoechoic, elliptical mass within the inner half of the ventral myometrium (arrows). The mass results in distortion of the endometrial cavity (E). (b) Transverse endovaginal US scan obtained 30 minutes later shows complete resolution of the mass, a finding consistent with a myometrial contraction. The echogenic contents within the endometrial cavity (between cursors) represent menstrual blood. (c) Sagittal T2-weighted MR image of another patient shows an elliptical, low-signal-intensity mass in the inner aspect of the dorsal myometrium (arrows). Note the associated distortion of the endometrium (E). These findings are consistent with a myometrial contraction.

View larger version (109K): [in a new window]   Figure 19b.   Myometrial contraction. (a) Transverse endovaginal US scan shows a hypoechoic, elliptical mass within the inner half of the ventral myometrium (arrows). The mass results in distortion of the endometrial cavity (E). (b) Transverse endovaginal US scan obtained 30 minutes later shows complete resolution of the mass, a finding consistent with a myometrial contraction. The echogenic contents within the endometrial cavity (between cursors) represent menstrual blood. (c) Sagittal T2-weighted MR image of another patient shows an elliptical, low-signal-intensity mass in the inner aspect of the dorsal myometrium (arrows). Note the associated distortion of the endometrium (E). These findings are consistent with a myometrial contraction.

View larger version (133K): [in a new window]   Figure 19c.   Myometrial contraction. (a) Transverse endovaginal US scan shows a hypoechoic, elliptical mass within the inner half of the ventral myometrium (arrows). The mass results in distortion of the endometrial cavity (E). (b) Transverse endovaginal US scan obtained 30 minutes later shows complete resolution of the mass, a finding consistent with a myometrial contraction. The echogenic contents within the endometrial cavity (between cursors) represent menstrual blood. (c) Sagittal T2-weighted MR image of another patient shows an elliptical, low-signal-intensity mass in the inner aspect of the dorsal myometrium (arrows). Note the associated distortion of the endometrium (E). These findings are consistent with a myometrial contraction.