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PubMed This is a summary of 23 peer-reviewed journal articles Updated
Gynecology

Subtypes & Diagnosis of Adenomyosis

At a Glance

Adenomyosis is diagnosed using transvaginal ultrasound and MRI to map the disease within the uterine muscle. Doctors classify it into subtypes—diffuse, focal, or adenomyoma—which directly guides whether treatment should be broad hormonal therapy or a targeted, uterus-sparing procedure.

Modern medicine has moved beyond the era when adenomyosis could only be “proven” after a hysterectomy. Today, advanced imaging allows doctors to map the disease inside your uterus with high precision [1][2]. Understanding the technical terms in your imaging report—such as the MUSA criteria and the Junctional Zone—is essential for evaluating your treatment options and understanding how the disease may behave [3][4].

Understanding Your Ultrasound: The MUSA Criteria

To ensure doctors around the world speak the same language, the MUSA (Morphological Uterus Sonographic Assessment) group created a standardized checklist for diagnosing adenomyosis via transvaginal ultrasound (TVUS) [3][5]. If you look at your report, you might see these terms:

  • Asymmetric Wall Thickening: One wall of your uterus (usually the back wall) appears much thicker than the other [6].
  • Myometrial Cysts: Small, fluid-filled pockets within the uterine muscle. These are actually tiny islands of endometrial tissue that are bleeding and swelling inside the muscle [7].
  • Fan-Shaped Shadowing: A specific pattern of shadows on the ultrasound screen caused by the way the diseased tissue reflects sound waves [3].
  • Globular Uterus: Instead of its normal pear shape, the uterus looks rounded and enlarged (often called “bulky”) [7].

The MRI and the “Junctional Zone”

While ultrasound is usually the first step, MRI is often used for a more detailed “map” [2][8]. The most critical feature an MRI looks at is the Junctional Zone (JZ) [9].

The JZ is a thin, dark layer of muscle that sits between the inner lining of the uterus and the outer muscular wall [10]. In a healthy uterus, this zone is thin and smooth. In adenomyosis, the JZ becomes thickened and irregular as endometrial cells invade it [4][11].

  • The “12mm Rule”: Traditionally, a JZ thickness of more than 12 millimeters is a key indicator of adenomyosis [4].
  • JZ Irregularity: Even if the zone isn’t very thick, if the borders look “ragged” or irregular, it can still point to a diagnosis [12].

Subtypes: Diffuse, Focal, and Adenomyomas

Not all adenomyosis looks or acts the same. Your doctor will likely classify your condition into one of three subtypes:

  1. Diffuse Adenomyosis: This is the most common form, where the disease is scattered throughout the uterine muscle [13]. It is often associated with more severe pain, older age, and a higher risk of complications during pregnancy, such as preterm labor or postpartum bleeding [14][15].
  2. Focal Adenomyosis: The disease is limited to a specific area or “spot” in the uterine wall [16]. This subtype is frequently seen in younger patients and may co-occur with endometriosis [16].
  3. Adenomyoma: This is a localized, solid mass of adenomyosis [17]. These are often mistaken for fibroids because they look like tumors. However, unlike a fibroid—which is a separate “lump” that can be easily peeled out—an adenomyoma is part of the uterine muscle itself, making it more complex to remove surgically [18].

Why Subtypes Matter

The subtype of your adenomyosis directly influences your care plan [14]. For instance, Diffuse Adenomyosis often requires more intensive hormonal suppression or “global” treatments [19]. Conversely, Focal Adenomyosis or Adenomyomas may sometimes be treated with more targeted, uterine-sparing procedures like HIFU (High-Intensity Focused Ultrasound) or specialized surgery [20][21]. Knowing your subtype helps your care team tailor a strategy that balances your need for pain relief with your future fertility goals [22][23].

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Common questions in this guide

What does a globular or bulky uterus mean on my ultrasound?
A globular or bulky uterus means your uterus has lost its normal pear shape and become rounded and enlarged. This is a classic ultrasound finding in adenomyosis, caused by endometrial tissue swelling inside the uterine muscle.
What is the junctional zone on a pelvic MRI?
The junctional zone is a thin layer of muscle between the inner lining of the uterus and the outer muscular wall. In adenomyosis, MRI scans often show this zone becoming thicker than 12 millimeters or developing irregular borders as tissue invades the muscle.
What is the difference between diffuse and focal adenomyosis?
Diffuse adenomyosis is scattered throughout the entire uterine muscle and often causes more severe, widespread pelvic pain. Focal adenomyosis is confined to one specific area in the uterine wall and is frequently seen in younger patients.
Is an adenomyoma the same thing as a uterine fibroid?
No, an adenomyoma is a localized mass of adenomyosis that grows within and blends into the uterine muscle, making it difficult to separate from healthy tissue. A fibroid is a distinct, separate tumor that can usually be peeled out more easily during surgery.
How does my adenomyosis subtype affect my treatment options?
Diffuse adenomyosis often requires global treatments like hormonal suppression. In contrast, focal adenomyosis or adenomyomas may sometimes be treated with targeted, uterus-sparing procedures like high-intensity focused ultrasound (HIFU) or specialized surgery.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Does my ultrasound report mention any specific MUSA features, like 'fan-shaped shadowing' or 'myometrial cysts'?
  2. 2.On my MRI, what was the measurement of my junctional zone, and was it described as 'irregular'?
  3. 3.Is my adenomyosis classified as diffuse or focal, and how does that specific subtype affect my treatment options?
  4. 4.If I have an adenomyoma, how can we be sure it isn't a fibroid, and does that change the plan for surgery or management?
  5. 5.Given my subtype, what are the specific risks I should be aware of regarding future pregnancy or IVF success?

Questions For You

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References

References (23)
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    Accuracy of findings in the diagnosis of uterine adenomyosis on ultrasound.

    Sam M, Raubenheimer M, Manolea F, et al.

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    Imaging Diagnosis of Adenomyosis.

    O'Shea A, Figueiredo G, Lee SI

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    Sonographic classification and reporting system for diagnosing adenomyosis.

    Van den Bosch T, de Bruijn AM, de Leeuw RA, et al.

    Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology 2019; (53(5)):576-582 doi:10.1002/uog.19096.

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    The Significance of MRI Evaluation of the Uterine Junctional Zone in the Early Diagnosis of Adenomyosis.

    Sofic A, Husic-Selimovic A, Carovac A, et al.

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    Diagnosing adenomyosis using transvaginal ultrasound in current practice: A scoping review and service evaluation.

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    Imaging for Adenomyosis: Making the Diagnosis by Sonography.

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    Importance of transient myometrial contractions in diagnosis of adenomyosis and congenital uterine anomalies.

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    Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology 2021; (57(4)):651-653 doi:10.1002/uog.22036.

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    Transvaginal Sonographic Imaging and Associated Techniques for Diagnosis of Ovarian, Deep Endometriosis, and Adenomyosis: A Comprehensive Review.

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    Uterine junctional zone and adenomyosis: comparison of MRI, transvaginal ultrasound and histology.

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    Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology 2023; (62(1)):42-60 doi:10.1002/uog.26117.

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    Two- and three-dimensional ultrasonographic features related to histopathology of the uterine endometrial-myometrial junctional zone.

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    Diagnosing adenomyosis with MRI: a prospective study revisiting the junctional zone thickness cutoff of 12 mm as a diagnostic marker.

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    Association of 2D and 3D transvaginal ultrasound findings with adenomyosis in symptomatic women of reproductive age: a prospective study.

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    The etiology differs regards to the locations of the lesion: a clinical experience of 1350 patients with adenomyosis confirmed by postoperative pathology.

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    Adenomyosis as a Potential Risk Factor for Adverse Pregnancy Outcomes: A Multicenter Case-Control Study.

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    Association between adenomyosis subtypes and concurrent endometrial lesions: a propensity score-matched retrospective study.

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This page is for informational purposes only and does not replace professional medical advice. Always consult your gynecologist or healthcare provider for an official diagnosis and to review your imaging reports.

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