MRI and the Diagnosis of Adenomyosis
By Dr Graham Tronc, Graham Tronc Medical
MRI means Magnetic Resonance Imaging.
When I laparoscope a patient and diagnose and treat endometriosis, I also look carefully at the uterus. There are some signs that the uterus will give out that are suggestive of adenomyosis. Adenomyosis is where the endometrium grows into the muscle of the uterus. The signs that I see laparoscopically are a soft bulky irregular shaped outline to the uterus with perhaps small subtle bumps on it. In severe cases, there may be adhesions coming off the uterus itself. The use of MRI scans is certainly not new with the French reporting in 2010 in the J Obstet Gynaecol Res 2010; 36 (3): 611-618 that the uterine junctional zone at Magnetic Resonance Imaging was a predictor of in vitro fertilisation implantation failure. This was further reported in the Australia Journal of Obstetrics and Gynaecology in 2011 (Addition 51 pages 280-283), which commented on adenomyosis as a potential cause of recurrent implantation failure during IVF treatment (Tremellen and Russell).
Obviously, not all of you will need IVF! However, when a patient presents to me with symptoms of endometriosis and I suspect adenomyosis, I think it is very important to diagnose whether or not that patient also has adenomyosis because adenomyosis can certainly cause many of the same symptoms that endometriosis does and can lead to IVF failure! I have made it my goal to try and diagnose as many cases in young women, even teenagers, so that we can protect their fertility and improve their symptom profile earlier. Obviously, like endometriosis, the worse the disease gets, the harder it is to treat. Adenomyosis is particularly hard to treat because we cannot cut it out of the uterus.
Back to the MRI scan - all of my patients are referred preferentially to the Wesley Hospital Imaging Department. Over the last 10 years, I have sent approximately one hundred patients per year to have a MRI scan. On an initial search of my MRI results, I found twenty cases in adolescents alone in the last 5 years with four cases so far in 2018. This so called rare disease in adolescents may not be that rare!
All of the MRI scans are read by one of three Radiologists. I have met with them on several occasions and we discuss laparoscopic findings and MRI findings.
What the Radiologist is looking for is the measurement of the junctional zone (J/Z). The junctional zone is the junction between the endometrium and the myometrium (the muscle of the uterus).
The junctional zone should measure no more than 5 mm if it is done in the late proliferative phase of the cycle (that is just before ovulation occurs on Day 10, 11 or 12 in a 28 Day cycle).
The absolute diagnosis of adenomyosis is made when the junctional zone is more than 12 mm and/or the ratio of the junctional zone to the myometrium is more than 0.4. Sometimes there is full penetration of all of the muscle ie 100% penetration. Less commonly, the Radiologists will see microcysts, which are an accumulation of blood in the muscle and adenomyomas, which are large accumulations of blood inside the uterine muscle. These are obviously much harder to treat. There will also, of course, be those patients where the junctional zone measures somewhere between 5 and 12 mm and I usually have my suspicions that these patients will also develop adenomyosis if they are not treated. The treatment that I use for MRI proven adenomyosis is the following. If the patient consents to it, I will either use one Mirena device or if there is severe adenomyosis, I will use two Mirena devices. The reason for two Mirena devices is because there is so much target tissue to treat, such that one is not enough. I often add the contraceptive pill continuously (don't take any sugar pills) to try and get the bleeding under control more quickly and also to prevent ovarian cysts happening. There is a 12% risk of a larger than normal ovarian cyst in a patient with a Mirena.
Very severe cases may also need the addition of a GnRH analogue - this is either Zoladex or Synarel for six months.
Adenomyosis is often a cause of lower back pain and pain down the legs in a patient and it is important that we do diagnose this condition not only for the patients' pain but also for the patients' future fertility.
A quick mention of ultrasound scans in the diagnosis of adenomyosis - generally adenomyosis is not well seen on ultrasound scan. However, there are some good scanners who will see adenomyosis and they look in particular for the venetian blind sign. This is shadowing cast by the adenomyosis.
However, a negative ultrasound scan, just like a negative ultrasound scan with endometriosis, should not preclude the diagnosis of adenomyosis.
Finally, sometimes endometriosis may be seen on a MRI scan but as I always say, the only way to diagnose endometriosis is to laparoscope the patient and then excise as much endometriosis as possible on the first laparoscopy.
I hope this is of some help to you all.
Dr Graham Tronc
(Gynaecologist; Founder of the Brisbane Endometriosis Clinic)
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