298 One element of adenomyosis MRI diagnosis in particular, and imaging diagnosis in general, that has recently come into the debate is the (un)importance of the JZ. JZ thickness is by far the most often reported diagnostic criteria for adenomyosis on MRI (33,47), albeit with a variety of cut-off values. It is also an important feature assessed as a part of the MUSA criteria on TVUS (197). Yet, in recent years, the concept of the uterine junctional zone as a physiological and anatomical entity has been put into question (45,198). We know that is a distinct visible element of uterine anatomy on both transvaginal ultrasound (TVUS) and MRI; however, it cannot be defined as such on histopathology (198). The junctional zone also appears differently on TVUS and MRI begging the question which of the phenotypes is most clinically relevant. In addition, the reported cut-off values are repeatedly brought into question in the literature (45,95,98). It is generally accepted that the junctional zone or ‘endo-myometrial unit’ has a physiological function, especially in terms of uterine contractility, and hence most probably affects uterine reproductive function (46,73,111,148). Clinically, it is therefore arguably important to be able identify when it is (functioning) abnormal(ly), for example in the context of adenomyosis. As adenomyosis is known to invade or inhabit this region, it is thus logical that this is the area is where most imaging abnormalities are found. In this thesis, we did confirm that the junctional zone is an important diagnostic marker for adenomyosis (Chapters 3 and 4) with irregularities and widening hereof showing a significant relationship with eventual histopathological adenomyosis diagnosis. Crucially however, we did not define a specific cut-off value for the JZ, finding instead that the relative irregularity and JZ thickness are of more importance than an absolute value. One overarching aspect that should be addressed in the context of adenomyosis diagnosis in general is the reliability of the gold standard of adenomyosis diagnosis – histopathology. As mentioned prior, diagnostic criteria for adenomyosis on histology in fact can also vary, and can differ depending on the pathologist. The eye of the pathologist, much like that of the radiologist, is also often (at least in part) lead by the indication and query supplied by the treating gynaecologist when examining tissue. If the gynaecologist does not ask the pathologist directly to look for adenomyosis, or does not supply them with the right clinical context for them to suspect its possible presence there is a risk for underreporting the diagnosis. The very
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