66 Imaging of the uterine anatomy and function has progressed rapidly over the last few decades, with sophisticated functional imaging of the uterus becoming more common. This is leading to new insights into different aspects of uterine function such as uterine movement, blood flow and structural and functional changes during the menstrual cycle (174,175). Techniques employed now include DWI, blood oxygenation function studies and cine MRI (176–178). More recently, the use of DTI has also been explored in uterine and gynaecological disorders like endometriosis, malignancies and uterine fibroids, suggesting great potential in the use of these techniques in gynaecological conditions (179,180). Their diagnostic potential remains to be definitively evaluated, however the one study which investigated DTI for its diagnostic potential showed superior accuracy over conventional MRI (119). There are several limitations which may impact our results. First, despite their benefits, our broad inclusion criteria inevitably led to a heterogeneous selection of study designs and populations. This makes it difficult to apply the MRI parameters presented to specific patient groups (i.e. pre- or postmenopausal, symptomatic or asymptomatic, with or without concomitant fibroids or endometriosis etc.). Furthermore, many studies did not report on the specific diagnostic performance of individual parameters, meaning we could only include a small number of studies in our quantitative analysis. Studies which did report on individual MRI parameters also showed varied quality and results, leading to broad confidence intervals in our pooled analysis. As a result, we were not able to answer one of the objectives of our review; namely, which individual parameter is most accurate. Few studies corrected for influence of the menstrual cycle. Evaluation of the JZ can be problematic as its thickness changes during the menstrual cycle and is affected by hormonal therapy, making it difficult to distinguish between ‘normal’ JZ and adenomyosis foci (42). This thought has been echoed in previous reviews bringing the reliability of only JZ evaluation as a diagnostic marker for adenomyosis into question (29,45). It is debatable how much adenomyotic tissue in the JZ responds to these hormonal stimuli (42), but it is accepted that MRI diagnosis should take place in the proliferative phase of the menstrual cycle to minimize hormonal influence. Furthermore, only eight studies used 3.0T MRI, with the majority using 1.5T coils, which impacts overall image quality and thus diagnostic potential.
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