In this radiology lecture, we review the ultrasound appearance of adenomyosis through three unique cases, including an MRI example. Key teaching points include: * Adenomyosis results from ectopic endometrial tissue in myometrium. Leads to dysfunctional smooth muscle hyperplasia/hypertrophy surrounding ectopic glands. * Cause unknown. * Common, usually multiparous women of reproductive age. * Additional risk factors: Early menarche, short menstrual cycles, high BMI = High estrogen exposure. * Rarely seen in postmenopausal patients, unless treated with tamoxifen for breast cancer. * Often asymptomatic, but can present with menorrhagia, dysmenorrhea, dyspareunia, and chronic pelvic pain. * For diagnosing adenomyosis, transvaginal US much more sensitive and specific (89%) than transabdominal imaging. * Most specific US findings: Linear echogenic striations/nodules radiating from endometrium into inner myometrium. Tiny myometrial and subendometrial cysts = Fluid-filled glands. * Additional US findings: Enlarged, globular uterus with diffuse myometrial bulkiness, myometrial heterogeneity, irregular endometrial-myometrial interface, hyperechoic islands, and pencil-thin “venetian blind” or “rain shower” shadowing. Cine clips extremely helpful. * Adenomyosis can cause asymmetric myometrial thickening. * Focal adenomyosis (adenomyoma) has ill-defined margins compared to fibroids, typically elliptical as opposed to rounded in shape. * May see abnormal vascular flow: Increased vascularity with tortuous vessels penetrating myometrium. Helps differentiate adenomyosis from fibroids, which tend to displace vessels and show circumferential flow. * On US, thickened junctional zone may manifest as a hypoechoic halo surrounding echogenic endometrium. * MRI “traditionally” the modality of choice to diagnose adenomyosis, and junctional zone thickened to 12 mm or greater highly specific. May contain punctate T2 hyperintense cystic foci/T1 hyperintense hemorrhage. * However, modern TV US shows comparable accuracy to MRI with no statistical significance between sensitivities and specificities: “Transvaginal US should be considered the primary imaging modality for the diagnosis of adenomyosis.”* * Treatment: Pain management, tranexamic acid, OCPs, GnRH agonists. * If severe, not relieved medically, and no desire for fertility: Hysterectomy. *Cunningham RK, Horrow MM, Smith RJ, et al. Adenomyosis: A Sonographic Diagnosis. RadioGraphics. 2018; 38:1576-1589 To learn more about the Samsung RS85 Prestige ultrasound system, please visit: https://www.bostonimaging.com/rs85-prestige-ultrasound-system-4 Click the YouTube Community tab or follow on social media for bonus teaching material posted throughout the week! Instagram: https://www.instagram.com/radiologistHQ/ Facebook: https://www.facebook.com/radiologistHeadQuarters/ Twitter: https://twitter.com/radiologistHQ