Interactive Transcript
0:01
Our next lesson is adenomyosis.
0:04
So adenomyosis is ectopic endometrial gland
0:08
and stroma in an abnormal position,
0:11
in particular in the myometrium.
0:14
That can result in muscular hyperplasia in
0:16
reaction to it, muscular hypertrophy, and
0:19
it can result in increased vascularity.
0:23
Ultrasound is easily available and it can look
0:25
for a lot of different reasons for most of the
0:28
common symptoms that adenomyosis can also mimic.
0:31
It's cheaper, it's easier and more often
0:33
available than MRI, which of course can do all
0:35
the same things ultrasound can, potentially
0:37
even better in diagnosing adenomyosis.
0:39
But you need to be familiar with it with
0:41
ultrasound because that's often where
0:43
you're going to start when you come in
0:44
with abnormal bleeding, a big boggy uterus,
0:47
or bloating-type symptoms like that.
0:50
So what is adenomyosis actually?
0:52
There are three different categories of it, and
0:55
the imaging often correlates with the pathology.
0:57
It's important to remember this can coexist with
1:00
endometriosis, and it can coexist with fibroids.
1:04
So some of those findings,
1:04
what are we looking for?
1:06
You can see ectopic endometrial glands.
1:10
So you can get striations.
1:13
If they are fluid-filled, they'll
1:14
appear as myometrial cysts.
1:16
They're often subendometrial or submyometrial
1:19
right next to the endometrium, but not in it.
1:21
So these little cystic changes, those
1:23
are your ectopic endometrial glands.
1:27
You can have hypertrophy, this thickening,
1:30
you can have these endometrial glands that
1:31
are ectopic, are hormonally active glands.
1:34
They can incite a local reaction and
1:36
that results in the thickening of
1:38
the smooth muscle of the myometrium.
1:40
This is much harder to see on an
1:41
ultrasound than it is on an MRI, and
1:43
that's your junctional zone thickening.
1:45
We'll go over that a bit later as well.
1:47
But hypertrophy on ultrasound, you can see focal
1:49
or you can see diffuse myometrial thickening.
1:53
This works for MRI as well.
1:54
You can see globular enlargement of
1:56
the uterus in general, and that's
1:57
the uterine body, not necessarily the
1:59
lower uterine segment or the cervix.
2:00
Not the whole uterus is big; it's
2:02
the body of the uterus is globular.
2:05
Something called the Venetian blind
2:06
appearance, and we'll go over that.
2:08
And then a poorly defined interface
2:10
between the endometrium and myometrium,
2:12
meaning it's hard to pinpoint the exact
2:14
area where the endometrium ends and the
2:15
myometrium begins, which normally you can.
2:20
And then you have vascularity,
2:22
this kind of category.
2:24
With that, you can see penetrating
2:25
tortuous vessels on color Doppler.
2:28
Putting all these together, you can
2:29
get a really heterogeneous appearance
2:31
of the myometrium with a blurring of
2:33
that endometrium-myometrium interface.
2:35
It's probably the least specific sign if you
2:38
just kind of have this heterogeneous appearance.
2:40
So then you have to kind of try and
2:41
pick out all of these little different
2:42
findings that could be put together
2:44
and you get a diagnosis of adenomyosis.
2:47
It's important when we talk about
2:48
vascularity to jump back there for a moment.
2:50
Fibroids are going to be vascular as
2:52
well, but usually you have more of a
2:54
circumferential pattern of vascularity
2:56
and it will have displaced vessels
2:58
as opposed to adenomyosis, which will
3:00
have these penetrating tortuous ones.
3:02
And again, we'll show you some of those
3:04
examples in the case-based format.
3:07
So quickly, some findings on MRI
3:09
specifically, you're going to look for
3:11
a thickened T2 dark junctional zone.
3:13
So remember your T2 is really your heavy
3:15
weight for female pelvis imaging of the uterus.
3:18
The endometrium is going to be T2 bright.
3:21
You're going to have the junctional
3:22
zone, which is this T2 dark
3:24
area immediately external to the
3:26
endometrium there, and you're going
3:27
to have just the myometrium itself
3:29
here, and then the T2 dark serosa here.
3:31
So you look for thickened T2 dark junctional
3:34
zone; you can look for indistinct margins.
3:36
The fibroid is going to have very distinct
3:38
margins; you can measure exactly where it
3:40
starts and where it ends, as opposed to
3:42
let's say this structure right here, where
3:43
it kind of just blends into the myometrium
3:45
adjacent to it. We do have some breathing
3:47
artifact, but it's hard to tell you exactly
3:49
where this starts and where this ends.
3:51
And it's really helpful if you have
3:53
these T2 bright foci throughout it.
3:55
And that's going to be similar
3:56
to the endometrium, right?
3:57
T2 bright endometrium, T2 bright
3:59
ectopic endometrial glands within this
4:03
structure right here of adenomyosis.
4:07
So patients, who gets this, right?
4:09
The classic teaching is multiparous.
4:12
Perimenopausal patients are the ones who
4:14
get adenomyosis, but this was based off of
4:18
hysterectomy specimens, which introduced
4:20
that sort of bias because it's generally
4:22
going to be people who are multiparous or around
4:24
menopause who may have their uterus taken out.
4:27
So more recently, analysis has shown that
4:29
it's also present in nulliparous women who
4:31
have not been pregnant or had children, and
4:33
even as young as the teens and twenties,
4:35
although that's certainly less common.
4:39
Early menarche, higher estrogen states.
4:41
That puts you at a higher risk
4:43
of developing adenomyosis.
4:46
That also would include things
4:47
like short cycles and obesity.
4:49
Again, anything to get those
4:50
higher estrogen states.
4:53
There is some reported increase in incidence
4:55
of those with a history of a D&C or C
4:57
sections, and that may be because there's
5:00
a disruption of the endometrial-myometrial
5:03
interface that could allow for this ectopic
5:05
implantation of the endometrial tissue.
5:08
But it's not entirely clear if
5:09
that's a true risk factor or not.
5:12
So symptoms, what do they come in with?
5:14
They're really quite nonspecific, which is
5:16
why, again, they often start with ultrasound.
5:18
They can have menorrhagia; they can
5:20
have chronic pelvic pain; they can have
5:22
dysmenorrhea; and they can have dyspareunia.
5:25
And again, ultrasound can
5:27
diagnose and evaluate for a lot of
5:30
indications for this to find what's
5:31
going on, adenomyosis being one of those.
5:34
So with that, let's move
5:35
on to some of the cases.
© 2024 MRI Online. All Rights Reserved.