How do you score adenomyosis?

Scoring Adenomyosis: Diagnostic Criteria and Classification Systems

Adenomyosis should be scored using a combination of transvaginal ultrasound (TVUS) features with optional MRI confirmation in complex cases, focusing on both the type (diffuse vs. focal) and degree of myometrial involvement. 1

Primary Diagnostic Imaging Modalities

Transvaginal Ultrasound (First-Line)

TVUS is the recommended first-line imaging modality for diagnosing and scoring adenomyosis with a pooled sensitivity of 82.5% and specificity of 84.6% 1. Key scoring features include:

• Type classification:

  • Diffuse adenomyosis
  • Focal adenomyosis
  • Adenomyoma (focal nodular form)

• Key diagnostic features to score:

  • Heterogeneous myometrium (highest sensitivity)
  • Globular uterine enlargement (highest specificity)
  • Ill-defined endometrial-myometrial interface
  • Asymmetric myometrial wall thickening
  • Myometrial cysts
  • Hyperechoic islands or striations

• Color/Power Doppler assessment:

  • Pattern of penetrating vessels (differentiates from fibroids)
  • Resistive index (<0.7)
  • Pulsatility index (<1.2) 1

MRI (Second-Line)

MRI offers higher specificity (93%) and should be used when TVUS findings are inconclusive or when planning treatment options 1. Key MRI scoring features:

• Widening of the junctional zone (>12 mm is diagnostic)
• Presence of myometrial cysts (simple or hemorrhagic)
• T2 hyperintense foci within the myometrium 1

Adenomyosis Scoring Systems

1. Type-Based Classification

Score adenomyosis based on distribution pattern 2, 3:

• Diffuse adenomyosis: Widespread involvement throughout myometrium
• Focal adenomyosis: Limited to specific areas
• Adenomyoma: Nodular form resembling fibroids

2. Degree-Based Scoring

Score the severity based on extent of myometrial involvement 2, 3:

• Mild: Limited involvement (<1/3 of myometrial thickness)
• Moderate: Intermediate involvement (1/3-2/3 of myometrial thickness)
• Severe: Extensive involvement (>2/3 of myometrial thickness)

3. Semi-Quantifiable Methods

For more objective scoring, consider these validated approaches 4:

• XI VOCAL counting: Count affected slices from 20 parallel slices in 3D volume (demonstrated good interobserver reliability)
• 2D-clip estimation: Grade volume in 2D clips (good reliability)

Pitfalls and Considerations

1. Coexisting conditions: The presence of fibroids significantly reduces TVUS sensitivity for adenomyosis (33.3% vs. 97.8% without fibroids) 1

2. Combined approach: Always use transabdominal and transvaginal ultrasound together for optimal assessment, particularly for significantly enlarged uterus 5, 1

3. 3D ultrasound advantages: Consider 3D ultrasound which allows multiplanar imaging and surface rendering, improving specificity (82.9% vs. 63.9%) 1

4. Sonohysterography utility: Use when focal endometrial abnormalities are present to better differentiate submucosal fibroids from adenomyosis 5

5. Elastography benefit: Adenomyosis appears as brighter irregular lesions on elastography, while fibroids appear as well-delineated dark areas 5

Clinical Correlation

When scoring adenomyosis, note these clinical correlations 2:

• Diffuse adenomyosis correlates with heavier menstrual bleeding, especially in severe cases
• Focal disease may have stronger association with infertility
• Focal involvement of the junctional zone shows higher percentage of miscarriage

By systematically scoring adenomyosis using these criteria, clinicians can better characterize the condition, predict symptom severity, and guide appropriate management decisions.