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Adenomyosis and junctional zone changes in patients with endometriosis

S.B. Larsena,*, E. Lundorfb, A. Forman a, M. Dueholm a

aDepartment of Gynaecology and Obstetrics, Aarhus University Hospital, Skejby, DenmarkbDepartment of Diagnostic Imaging, Aarhus University Hospital, Skejby, Denmark

1. Introduction

Adenomyosis and endometriosis are both characterised by

ectopic growth of endometrium-like or endometrium-derived

tissue [1,2] and might be causally related. Leyendecker suggested

that abnormal function of the inner smoothmuscle of the uterus,

the archimetra, or the junctional zone (JZ), could represent a

common pathogenetic factor [3]. Alterations in the JZ thickness

and fibre orientation may change the uterine contractions leading

to disturbed peristalsis [46]. The hyperperistalsis induces uterine

auto-traumatisation and desquamation of basal endometrium

which is transported into the peritoneal cavity [7]. Basal

endometrium has an increased potential for implantation and

proliferation resulting in pelvic endometriosis [7]. In addition,

traumatization of the basal endometrium and the JZ could allow

endometrial glands topenetrate into themyometrium anddevelop

adenomyosis [7]. In particular, infiltrating endometriosis might be

related to adenomyosis due to the infiltrating growth pattern.

The JZ is easily visualized by MRI. Abnormal widening (diffuse

or focal) of the innermyometrium or JZ is one of the MRI features

associated with adenomyosis (Fig. 1). It is the consequence of

uncoordinated inner myocyte proliferation called JZ hyperplasia

[5]. TheJZ hyperplasia and accompanying disruption could initiate

endometrial mucosal penetration of endometrial glands into the

myometrium [8].

MRI is highly accurate in the diagnosis of uterine adenomyosis

[911]. At MRI the heterotopic endometrial tissue may be seen as

small foci of increased signal intensity in theJZ. This signhas ahigh

diagnostic specificity for adenomyosisbut cannot stand as the only

criterion, as it may only be seen in less thanhalf the cases. In peri-

and post-menopausal women, a JZ thickness of !12mm was

established as the optimal isolated criterion for adenomyosis [9].

TheJZ thickness, however, is hormone dependent and increases in

the premenopause [12], and therefore other criteri describing the

invasion of the JZ related to unaffected JZ or total uterine wall

thickness should be added [10,11]. With the use of these criteria in

combination, MRI is highly accurate in the diagnosis of uterine

adenomyosis [13].

European Journal of Obstetrics & Gynecology and Reproductive Biology 157 (2011) 206211

A R T I C L E I N F O

Article history:

Received 1 September 2010

Received in revised form 21 December 2010

Accepted 6 March 2011

Keywords:

Adenomyosis

Endometriosis

Magnetic resonance imaging

A B S T R A C T

Objectives: To evaluate image findings in the junctional zone (JZ) in patients with endometriosis and

correlate with image findings of adenomyosis. To attempt a correlation of the degree of adenomyotic

infiltration with the degree of infiltration and stage of endometriosis.

Study design: Magnetic resonance imaging (MRI) of the uterus was performed in 153 women with

suspecteddeeply infiltratingendometriosisandplanned surgery,and in a referencegroup of129women

without endometriosis, verified during hysterectomy. Changes in theJZ and endometriosis in the pelvis

were described in detail. Diagnosis of adenomyosis at MRI was based on optimal criteria derived from

the hysterectomy control group. The stage of endometriosis (AFS stage) wasdetermined during surgery.

Results: In the group ofwomenwith endometriosis 34.6% had adenomyosis compared with19.4% in the

reference group (p


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The association between endometriosis and adenomyosis has

beenevaluated inonly a fewstudies [1416] and in only one study

with optimal criteria [14]. In the present study, the occurrence of

adenomyosis and image changes in the JZ was assessed by MRI in

patientswith rectovaginal endometriosis, as compared to findings

in patients with other forms of endometriosis, and in patients

without the disease.

2.

Material and

methods

2.1. Patients

2.1.1. Group 1: patients with suspected rectovaginal endometriosis

(N = 153)

From 1 January 2001 until 1 June 2005, 153 patients were

referred for MRI and subsequent laparoscopy due to suspected

deeply infiltrating endometriosis. In this period all patients with

suspicion of deeply infiltrating endometriosis were routinely

referred for preoperative MRI to map out and describe the relation

of endometriotic nodules to the rectum and ureters. All patients

were booked fordiagnosticlaparoscopy and laparoscopicresection

of all visible endometriotic lesions. Patients with laparoscopically

confirmed

rectovaginal

endometriosis

were

treated

mainly

with

shaving of endometriotic tissue from the bowel wall, and discoid

resection when needed. The operative findings represented the

definitive diagnosis of endometriosis. Deeply infiltrating endome-

triosis was defined as more than 5 mm invasion (assessed during

surgery) of endometriosis into underlying tissues. The AFS stage

and extent of endometriosis were determined during surgery

according to the revised classification of the American Society for

Reproductive Medicine (1996) [17].

2.1.2. Group 2: patients with cervical cancer (N =29)

These women participated in a study concerning urological

complications following radical hysterectomy. The women under-

wentMRIbefore surgery (1December2001until1April2005), and

the occurrence of endometriosis was noted peroperatively.

2.1.3. Group 3: patients undergoing hysterectomy for benign

conditions (N = 100)

This group consisted of all consecutive pre-menopausal women

who had a hysterectomy due to a benign condition at Aarhus

University Hospital, from September 1998 to February 2000. The

study population included 178 patients. Three were not invited to

participate because of language problems, 14 could not be reached

by phone for an appointment, 53 declined the invitation, and 2

patients were excluded because the uterus was morcellated athysterectomy. All patients underwent MRI followed by hysterec-

tomy within 14 days. The prevalence of adenomyosis in the

excluded patients was 22%, which was no different from the

prevalence in the included patients. In six patients, endometriosis

was diagnosed during surgery. These patientswere excluded from

the present study, leaving 100 patients without endometriosis for

analysis. The main indications for surgery were: abnormal

bleeding 51, symptomatic myomas 35, lower abdominal pain 11

(9 of these 11 patients had concomitant myomas or abnormal

bleeding), dysplasia and borderline ovarian tumour 3. MRI

diagnoses of adenomyosis based on different MRI criteria were

compared with the findings of the pathologic examinations. The

experience of our team for evaluation of adenomyosis, with a high

accuracy ofMRI fordiagnosis of adenomyosis,hasbeenestablishedin this previous study [10], and we used MRI criteria with the

histologically confirmed highest diagnostic accuracy of 84%

(sensitivity 65%, specificity 89%).

2.2. MRI

Before 2000, MRI was performed with 1.5 T scanners (Signa,

General Electric Medical systems, Milwaukee, WI and Gyroscan

ACS.NT, Philips). We acquired 4-mm slices with 1-mm spacing in

the sagittal, coronal, and axial planes relative to the orientation of

the uterine cavity, using T2-weighted fast (turbo) spin echo

sequences (TR/TeEf,35004000ms/90ms, echo train length16) in

all three planes using a matrix of 512 448.We used surface coils

(phase

array

pelvic coils) for data

collection and

completed

theexamination in 3045 min. After 2000, MRI was performed with

new 1.5 T scanners (Signa, Twin-Speed, General Electric Medical

systems, and Achieva, Philips). We optimized our sequences in

each system, which gave us different settings of the sequences in

the two systems. The Philips system provided 4 mm slices with

0.5 mm spacing in the sagittal, coronal, and axial planes relative to

theorientationof theuterine cavity, using T2-weighted fast (turbo)

spin echo sequences (TR/TeEf, 35004000ms/110ms, echo train

length 22) in all three planes. We used a surface coil (sense cardiac

phase array) for data collection using a matrix of 512 448. The

GeneralElectricsystemprovided4 mm sliceswith 0.5-mm spacing

in the sagittal, coronal, and axial planes relative to the orientation

of the uterine cavity, using T2-weighted fast (turbo) spin echo

sequences (TR/TeEf,35004000ms/90ms, echo

train length12) in

Fig. 1. Magnetic resonance imaging. (a) Normal uterus, (b) Adenomyosis.

S.B. Larsen et al./ European Journal of Obstetrics & Gynecology and Reproductive Biology 157 (2011) 206211 207


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all tree planes. We used a pelvic phased array surface coil for data

collection using a matrix of 512 448. All examinations were

completed in 3045 min.

The thickness was measured at the thinnest (JZ-min) and

thickest (JZ-max) parts of the anterior and posterior wall in the

sagittal slices. The differencebetween JZ-max and JZ-min (JZ-dif)

was calculated for the anterior and posterior border. The largest

parameter, either anterior or posterior, was used in all calcula-

tions. For each patient all areas with poorly defined margins

suspected of being adenomyosis were described. For these areas

we registered their size, the JZ-max, and presence of high

signal foci.

In patientswith endometriosis the maximal anterior (AW) and

posterior (PW) uterine wall thicknesswasmeasured and invasion

depth of the anterior and posteriorwall was calculated as JZ-max/

maximum wall thickness. The largest invasion depth in either the

anterior or posterior wall was used. In the reference group of

women this parameter was inappropriate as several patients had

myomas, which increased AW and PW.

Adenomyosis was thought to be present: (a) in the presence of

focal poorly demarcated low intensity areas in the myometrium

with high intensity myometrial spots arising from the endometrial

myometrial boarder, or (b) with >15 mm junztional thickness, or

(c) when a JZ-dif of >5 mm was present.At MRI the presence and size of infiltrating recto-vaginal

endometriosis were measured in three perpendicular planes (d1,

d2, d3) and the relation to rectum and ureters was described.

Volume of infiltrations was calculated according to ellipse volume

p/6 d1 d2 d3. MRI scans were evaluated by the same MRI

specialist (EL).

2.2.1. Data analysis and statistics

The statistical analyses were performed using X2, Fishers exact

test (F), and KruskalWallis test (KW) whennon-parametrictests

were appropriate. Median and 1090 percentiles (p10p90) were

used for distributions where means and standard deviations (SD)

were unsuitable.MantelHaenszel test wasused when two groups

were compared and adjusted for control variables. The group of

patients with endometriosis (group 1) were compared to the

groups of controls (groups 2 + 3) in the analysis.

3. Results

Mostwomenwithendometriosishad severe infiltrating disease

(Table1). Thewomenwithendometriosiswere younger, had fewer

children and were more often on hormone therapy.

The prevalence of adenomyosis in the group of women with

endometriosis was34.6%, and higher than the prevalence found in

the control group (groups 2 + 3) (19.4%) (Table 2). Among women

with endometriosis,more women had an irregular JZ compared to

the control group. Moreover the irregularity was more pro-

nounced, with higher values of JZ-dif in patients with endometri-

osis.

The JZ was not so broad among endometriosis patients (lower

median ofJZ-max). Fifty percent of the womenwithendometriosis

had a JZ-max of 7 mm or lower. Among women without

adenomyosis, the group of endometriosis patients had a signifi-

cantly thinner JZ-max compared with group (2 + 3) (median, p10

p90: 6.0 mm, 3.010.4, vs 9.0 mm, 5.012.0) (p


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Among womenwith severe endometriosis (AFS stage IV) 42.8%

had adenomyosis compared to 29.4% among women in the other 3

stages (AFS stages I + II + III) (p = 0.10) (Table 3). Deeper wall

invasion and JZ-dif were seen in more women with AFS stage IV

compared to stages IIII (Table 4). Adjustment for the presence of

endometriomas did not change the estimates for AFS stage.

MRI revealed deeply infiltrating recto-vaginal endometriosis

among 75.8%of theendometrioticpatients,and 34.5%of thesehadadenomyosis compared to 35.1% in the group without recto-

vaginal endometriosis (p > 0.05). There were no more cases of

adenomyosis in patients with large infiltrations, and the depth of

infiltration of adenomyosis was no deeper in patients with large

volumes of infiltrations (Table 3).No more patientswithboth AFS

stage IVand rectovaginal infiltrations had adenomyosis, and there

was no deeper infiltration of adenomyosis in these patients.

4. Comments

One third of young women with clinically suspected deeply

infiltrating endometriosis had MRI findings of uterine adenomyo-

sis. Symptomatic and severe infiltrating endometriosis seems to becorrelated with adenomyosis and should motivate a diagnostic

evaluation of adenomyosis among these patients. Persistence of

dysmenorrhoea and non-menstrual pain after optimal surgical

resection of peritoneal endometriosis are more likely in patients

with increasing JZ thickness suggesting adenomyosis [1921].

Postoperative treatment of these patients may thus be needed.

Moreover, adenomyosis may be an important cause of infertility

[7,22], which seems to improve after proper treatment [23].

Classic adenomyosis is present in 2035% of patients

undergoing hysterectomy [24], and is more commonly diagnosed

in the forties or fifties, whereas endometriosis is diagnosed in

younger age groups [25]. Younger patientswithendometriosis had

a thin JZ, whereas the control group of older womenhad a broader

Table 2

Characteristics of the junctional zone (JZ) in the three groups of women.

Group 1 Group 2 Group 3 Significance

Patients with

endometriosis (N=153)

Patients with cervical

cancer (N=29)

Patients who had a

hysterectomy (N=100)

(p)**

Adenomyosis

Yes, N (%) 53 (34.6%) 6 (20.7%) 19 (19.0%)


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JZ. The JZ increase with age before the menopause [12,26] and a

regular broader symmetric JZ may most likely just be a hormone-

dependent age-related change [27]. It may have clinical signifi-

cance but shouldbe separated from, and seemsnot to be related to,

adenomyosis [28].

Adenomyosis requires infiltration of endometrial glands and

stroma into the myometrium, and image reflection of invasion as

jzmax/wall thickness >40% [11] or JZ-diff >5 [10] should be used.

The latter might not correlate to patients custom JZ and be more

appropriate in the presence of myomas. It should be distinguished

from uterine contractions, which are seen as transient regular

swellings of the JZ. Even these measures, however, should be

evaluated in a young age group with histopathology for verifica-

tion. In younger patients with endometriosis, adenomyosis was

seen as localized irregular burst in a thin JZ. It could indicate that

adenomyosis is initiated by a primary break in the endomyome-

trial border followed by, but not preceded by, localised muscular

JZ-hypertrophy. It may be caused by intrinsic auto-traumatic

factors [7,29], or external traumatisation by, for example,

pregnancy [30].

Nevertheless, although JZ thickness differed, the depth of

invasion of adenomyosis was the same in patients with

adenomyosis in the group with endometriosis compared to the

control group. Thus image findings in this young population ofpatients might most likely just be an earlier manifestation of

adenomyosis found in the older populationwithadenomyosis, and

JZ changes in endometriosis are not histologically verified and may

constitute disease other than adenomyosis [28]. More studies are

needed to clarify the cause of different image findings.

The association between endometriosis and adenomyosis has

beenevaluated inonly a fewstudies.Ourfindingswere in linewith

the finding in another study [14] but differed from the results in a

study of infertility patients [15], where the prevalence of

adenomyosis was 79% and 28% in patients with and without

endometriosis, respectively. This was unexpected since the

majority of our patients had deeply infiltrating disease, where

more aggressive adenomyosis might have been expected. The

diverging findings might be due to different MRI criteria for thediagnosis of adenomyosis, which are still controversial. Kunz et al.

used aJZ of 10mm fordiagnosisof adenomyosis [15] in contrast to

others, where MRI findings were correlated with histopathology

[9,10,31]. Our use of a restrictive MRI diagnosis of adenomyosis

compared to the criteria proposed by Reinhold et al. [32] resulted

in a lower prevalence of adenomyosis in both groups without

changing the difference between the groups.

Adenomyotic changes were not evident in two thirds of the

patients with endometriosis, and the presence and size of

rectovaginal infiltrating endometriosis was not correlated with

adenomyosis or depth of infiltration of adenomyosis. The theory of

endometriosis as a primary disease of the archiometra [7] was not

clearly reinforced in this study, as no correspondence in level of

invasive

potential

in the

myometrium

and

peritoneum

was seen.This goes against a common intrinsic abnormality in eutopic and

ectopic endometrium. There could, however, be different expres-

sionsof invasive potential dependent on local factorsaccounting for

the different findings.

Nevertheless, in line with Kunz et al. [15], adenomyosis seemed

tobemore invasive inAFSstage4.TheAFS scoredoesnotaddress the

clinically most important extentofdisease whichis deep infiltrating

endometriosis. The AFS score corresponds more with the inflam-

matory and adhesive components of endometriosis and with

endometriomas. Dysperistalsis and menorrhagia in adenomyosis

couldgive rise toa larger loadofperitoneal endometrial cells during

menstruation,which couldpromoteadhesionand inflammationand

account for this finding, but this inflammation did not seem to give

rise

to

more

deep

infiltration.

The optimal control group would have been an age-matched

group of patients with no clinical symptoms. It is very difficult and

expensive, however, to establish such a group with a sufficient

number of patients, and no histopathology verification can be

established. The diagnostic criteria at MRI for diagnosis of

adenomyosis are still controversial, and motivate our use of a

control group with histopathology confirmation of the diagnostic

criteria used [13]. Thus the prevalence of adenomyosis would be

expected to be lower in a control group of younger asymptomatic

patients compared to theusedcontrol groupofolderpremenopausal

womenundergoinghysterectomy forbenign conditions. Thoughno

endometriosis was seen at histopathology and described during

operation, exclusion of minorendometriosiswould have required a

uniform staging of a single experienced observer.

In spite of the above-mentioned conditions the group ofwomen

with severe endometriosis demonstrated a higher prevalence of

adenomyosis than the control groups and illustrates the need for

an imaging technique for diagnosis of adenomyosis in patients

with endometriosis. This should be by MRI or transvaginal

ultrasound (TVS) by a clinician skilled in the sonographic findings

of adenomyosis. The diagnostic accuracy of TVS [33] is in line with

MRI [13]. TVS is very observer-dependent in the evaluation of

adenomyosis [34]. MRI has the advantage of being able to predict

deep infiltrating endometriosis at all locations even outside thepelvis and to define the exact extent of both endometriosis and

adenomyosis [35,36].

In summary,in this study a systematic description ofJZ changes

in endometriosis implied an association of severe symptomatic

endometriosis with adenomyosis, but the invasive potential of

endometrial cells in the uterusand peritoneum corresponded only

to a limited extent.

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