26 can also be difficult to distinguish between adenomyosis and other benign uterine pathologies such as leiomyomas. In fact, the sensitivity of TVUS for adenomyosis has been reported to be as low as 33% in the added presence of leiomyomas (36). One form of TVUS diagnosis that is also in continuous development in the context of (benign) uterine disorders is 3-dimensional TVUS (3D-TVUS). 3DTVUS is generally able to better assess the JZ and the overall structure of the endometrium in comparison to its 2-dimensional counterpart (19). Furthermore, due to being able to visualise several planes at once (coronal, sagittal and transverse), uterine asymmetry resulting from adenomyosis is more easily visualised. Because of these advances, 3D TVUS has a high reported sensitivity and specificity (95% CI), of 84% (77%–89%) and 84% (77%–89%) respectively (29). Figure 1.5. Adenomyosis examples on TVUS. A. Globular enlargement of the uterus with fan-shaped shadowing. B. Globular enlargement of the uterus with scattered hyperintense myometrial cystic foci. C. Uterus with asymmetric uterine wall thickening with scattered echogenic foci. (Images taken from own study populations). - Magnetic Resonance Imaging (MRI) Adenomyosis can be difficult to distinguish from other (benign or malignant) uterine disorders such as leiomyomas or carcinomas. For this reason, diagnosing adenomyosis using MRI has become preferred and is considered reliable, especially when the presentation is atypical on TVUS (29,32,37). MRI is not considered the first-in line diagnostic method however, due the higher associated cost and lesser availability than TVUS. On imaging, the uterus is made up of three distinct layers (or ‘zones’), each with slightly different imaging characteristics (i.e. signal intensity) on MRI (38).
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