Invited lecture by Dr Sujoy Dasgupta in the Ultrasound Workshop of the Annual National Conference of Indian Association of Gynaecological Endoscopists (IAGE) held on 15 March 2024 at the Taj Ganges, Varanasi

1. Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (New Delhi)
MRCOG (London)
Advanced ART Course for Clinicians (NUHS, Singapore)
M Sc, Sexual and Reproductive Medicine (South Wales, UK)
Clinical Director, Genome Fertility Centre, Kolkata
Managing Committee Member, BOGS, 2023-24
Executive Committee Member, ISAR Bengal, 2022-24
Clinical Examiner, MRCOG Part 3 Examination
Winner, Prof Geoffrey Chamberlain Award, RCOG World Congress, London, 2019
Delivered, Dr Kamini Rao Oration, AICOG, 2024

2. Adenomyosis or Fibroid-
Making the right diagnosis

3. Why making right diagnosis important?
• Symptoms overlapping- pain, bleeding. Pelvic pressure, subfertility
• Focal adenomyosis often confused with fibroid.
• Effect on reproductive outcomes are different in Fibroid / Adenomyosis
• Subfertility d/t fibroid →myomectomy
• Adenomyosis→ medical management
• Surgical procedure difficult

4. Ultrasound is the FIRST tool
2015 MUSA (Morphological Uterus Sonographic Assessment)
Radiol Bras. 2023 Mar/Abr;56(2):86–94

5. Uterus measurement
Volume of corpus= d1 (cm) × d2 (cm) × d3 (cm) × 0.523

6. Serosal contour

7. Myometrial walls

8. Site of the lesion
Radiol Bras. 2023 Mar/Abr;56(2):86–94

9. Location- 2011 FIGO classification of fibroids
Menopause Rev 2017; 16(4): 113-117

10. Hybrid fibroid
Radiol Bras. 2023 Mar/Abr;56(2):86–94

11. Inner lesion-free margin
Outer lesion-free margin (Myometrial mantle)
Radiol Bras. 2023 Mar/Abr;56(2):86–94
• In FIGO 2 fibroids,
greater chance of
uterine rupture during
resection if the outer
myometrial mantle is
<0.5 cm.

12. Echogenicity

13. Shadowing

14. Vascularization of myometrium and lesions

15. Lesion vascularity score

16. Ultrasound for fibroids
• usually well-defined, solid, concentric
mass
• Hypo- to hyper-echoic- depending on the
ratio of smooth muscle to connective
tissue and the presence of degenerative
substances.
• Calcifications are seen as echogenic foci
with shadowing- randomly scattered
throughout the mass.
• Sometimes leiomyomas may have
anechogenic components as a result of
progressing necrosis.
• If small and isoechogenic- difficult to
diagnose- only sign may be a bulge in
the uterine contour. Menopause Rev 2017; 16(4): 113-117

17. Number, size of fibroids
Radiol Bras. 2023 Mar/Abr;56(2):86–94
•consider reporting a range of 10–20.
•Not necessary to describe all lesions
•Describe ≤4 non-submucosal fibroids
•Describe all submucosal fibroids

18. TAS or TVS
TAS
• Superior in the diagnosis of large or
pedunculated myomas (compared to
shallow depth and short focal lengths
of TVS probe)
TVS
• More sensitive in the detection of small
leiomyoma myomas
• More useful in cases of retroverted
and/or retroflexed uteruses.
• No bladder filling, no problem with
bowel gas/ obesity
Menopause Rev 2017; 16(4): 113-117

19. Doppler in fibroid
• Power Doppler-
superior
• Circumferential
vascularity
• Necrotic leiomyomas
or those that undergo
torsion do not present
any blood flow
Menopause Rev 2017; 16(4): 113-117

20. Leiomyo-sarcoma

21. Menopause Rev 2017; 16(4): 113-117
Endometrial polyp vs fibroid

22. 3D SIS for fibroid
HumanReproductionVol.20,No.1pp.253–257,2005
Sensitivity Specificity
SIS 92% 90%
TVS 64% 90%

23. Menopause Rev 2017; 16(4): 113-117

24. Ultrasound for Adenomyosis
• Features that help to differentiate from leiomyomas
– Indistinct border
– Minimal mass effect on serosa/endometrium relative to the size
of the lesion
– Lack of Calcification

25. Junctional zone thickening
JZ= exclude endometrium, mid-sagital plane, perpendicular to endo

26. Myometrial cysts, Hyperechoic islands, echogenic spots

27. Subendometrium- lines, buds

28. Ultrasound for Adenomyosis
Direct features
• Tiny myometrial cysts (2- 9 mm) → cystic or
hemorrhagic endometrial glands, mainly located in
the superficial myometrium- highly specific (98%),
but of low sensitivity (50%–65%).
• Hyperechoic islands, echogenic spots,
subendometrial lines and buds, poor definition
of JZ→ Non-cystic endometrial tissue
Indirect features
• Related to hypertrophic myometrial reaction.
• Diffuse myometrial heterogeneity- high
sensitivity (80.8%–100%), but low specificity
(30%–65%).
• Hypoechoic linear striations in absence of
leiomyomas
• Diffuse asymmetric or symmetric widening
of the myometrial wall(s)
Fertility and Sterility® Vol. 109, No. 3, March 2018

29. Fertility and Sterility® Vol. 109, No. 3, March 2018

30. https://doi.org/10.1148/rg.201818008

31. Hanafi M. Ultrasound diagnosis of adenomyosis, leiomyoma, or combined with histopathological correlation. J
Hum Reprod Sci. 2013 Jul;6(3):189-93. doi: 10.4103/0974-1208.121421.
Adenomyosis
2 of the 5 criteria
(1) No distinction of the endometrial-
myometrial junction
(2) Asymmetry of the anterior and
posterior myometrium
(3) Subendometrial myometrial striations
(4) Myometrial cysts and fibrosis
(5) Heterogeneous myometrial
echotexture.
Fibroid
2 of the 5 criteria
(1) Clear demarcation of the tumor margin
(2) Whorly appearance of the tumor content
(3) Circumferential blood flow (by color
Doppler)
(4) Irregularities of the uterine surface
(subserous and intramural tumors)
(5) Irregularities of the endometrial surface
(submucous tumors type 1 and 2)

32. TVS diagnosis of adenomyosis was sensitive but not specific.
TVS was sensitive, specific, and accurate in the diagnosis of leiomyoma and
combined adenomyosis and leiomyoma.

33. Doppler
Adenomyoma Fibroid
Intralesional vascualirity 78.3% cases Mainly circumferential
(13% cases intralesional)
Resistance indices high resistance flow
(PI >1.2 and RI >0.7)
Sensitivity, specificity, PPV, and NPV were
78.26, 82.05, 72, and 86.49%, respectively
(Vishalakhsi, 2022)
high velocity flow
(PI <1.2 and RI <0.7)
Uterine artery PI Not significant difference

34. Reporting adenomyosis in ultrasound
(Bosch et al., 2018)

35. Role of hysteroscopy
Fibroid

36. Hysteroscopy in Adenomyosis
• Irregular endometrium with
tiny openings seen on the
endometrial surface
• Pronounced
hypervascularization
- “strawberry” pattern
• Fibrous cystic appearance of
intrauterine lesions
• Haemorrhagic cystic lesions
assuming a dark blue or
chocolate brown appearance

37. MRI in fibroids
• If uterine volume exceeds
375 mL, fibroid mapping
better with MRI than TVS
• specificity 100%, accuracy
97%, and sensitivity 86-92%,
• T1 and T2 MRI- of low or
intermediate signal with
sharps margins
Radiol Bras. 2023 Mar/Abr;56(2):86–94

38. MRI in Adenomyosis
• Second-line, mainly after a non-conclusive US evaluation.
• MRI can differentiate between the subtypes of adenomyosis.
Fertility and Sterility® Vol. 109, No. 3, March 2018

39. MRI features of adenomyosis
• Differentiates with firboid
• Shows fibroids not visible on
ultrasound.
• Junctional zone thickness >12
mm- most frequent criterion
• High-signal intensity
myometrial foci

40. Take home messages
• Ultrasound is the first line investigation for both fibroid and
adenomyosis
• Ultrasound for fibroid- accurate, sensitive, specific
• Adenomyosis- challenging in ultrasound
• Fibroids- peripherally distributed vascularity with low impedance
• Adenomyosis has intralesional vascularity with high resistance flow
• MRI is more useful than TVS in the diagnosis of adenomyosis