44 INTRODUCTION: Adenomyosis is a prevalent and potentially debilitating gynaecological condition characterized by dysmenorrhoea and heavy menstrual bleeding. Adenomyosis is thought to arise from and lead to disruptions in the uterine ‘junctional zone’ (JZ) between the uterine endometrium and myometrium. With the advent of improving imaging techniques, adenomyosis has been more frequently diagnosed in younger, nulliparous women. Along with greatly affecting their quality of life, it is also increasingly linked to sub- or infertility and adverse pregnancy outcomes (81,85,107). The relationship between (the extent of) adenomyosis and these clinical outcomes remains largely unknown. One barrier to elucidating the relationship of adenomyosis (severity) to clinical outcomes is the accurate diagnosis of adenomyosis. Despite continuing advances in 2D and 3D transvaginal ultrasound imaging, MRI is generally considered to be the most consistently accurate in the diagnosis of adenomyosis (29,32); however, there is still no accepted classification system or a set of diagnostic criteria to evaluate adenomyosis on MRI. While much has been reported about typical, atypical, direct and indirect MRI manifestations of adenomyosis (33,42) , the recognition of these features often still depends on the experience and expertise of the radiologist and/or gynaecologist. Furthermore, it is still disputed which of the wide range of features reported is the most accurate. This makes it difficult to assess the true diagnostic accuracy of MRI for adenomyosis as different centres and physicians may use different criteria. If adenomyosis could be noninvasively and objectively quantified (e.g. on MRI), the burden of disease could be correlated with various clinical outcomes, such as symptom severity, therapy response, or fertility outcomes. Similarly, potential changes in adenomyosis could be more easily followed over a patient’s lifetime, or during their menstrual cycle (33,34,47,113). To the best of our knowledge, there is currently no comprehensive overview describing the quantitative analysis of adenomyosis on MRI imaging. The objectives of this review are thus as follows: the primary objective is to evaluate the diagnostic accuracy of MRI features for adenomyosis versus histopathology, with secondary objectives being to (1) summarize in a
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