Interpret the pelvic ultrasound findings: anteverted uterus measuring approximately 7.4 × 3.8 × 5.9 cm with heterogeneous myometrium and a subtle striated pattern suggestive of adenomyosis, a 2.1‑cm subserosal hypoechoic lesion at the fundus possibly representing a fibroid, adenomyoma, or focal adenomyosis, thin endometrium 4 mm with poor endometrial‑myometrial interface, non‑visualized right ovary, and left ovary measuring 5.6 × 2.3 × 4.2 cm (≈28 cc) containing multiple follicles up to 1.9 cm?

Pelvic Ultrasound Interpretation: Adenomyosis with Possible Fibroid and Polycystic Ovarian Morphology

This ultrasound demonstrates features highly suggestive of adenomyosis with a subserosal lesion that is most likely a fibroid, and the left ovary shows polycystic morphology requiring clinical correlation for PCOS diagnosis.

Uterine Findings

Myometrial Changes Consistent with Adenomyosis

The heterogeneous myometrium with subtle striated appearance represents direct ultrasound features of adenomyosis, specifically echogenic striations radiating from the endometrium into the myometrium 1, 2. These findings, combined with poor endometrial-myometrial delineation, are among the most clinically focused-upon criteria for diagnosing adenomyosis 3.

• Heterogeneous myometrium is one of the two ultrasound markers most clinicians prioritize when evaluating for adenomyosis, with sensitivity and specificity both exceeding 50% 4, 3
• The striated pattern represents ectopic endometrial glands and stroma within the myometrium, classified as a direct sign of adenomyosis 1, 2
• Poor endometrial-myometrial interface is an indirect feature reflecting myometrial structural changes secondary to endometrial tissue invasion 1, 5

The combination of heterogeneous myometrium with ill-defined endometrial-myometrial interface demonstrates 93% specificity for adenomyosis when compared to MRI as the reference standard 4.

Subserosal Lesion Assessment

The 2.1 cm subserosal hypoechoic lesion at the fundus is most consistent with a subserosal fibroid rather than adenomyoma or focal adenomyosis based on its location and characteristics 6.

• Subserosal location makes this lesion amenable to various treatment modalities if symptomatic, including myomectomy or uterine artery embolization 6, 7
• Adenomyomas typically present as ill-defined lesions with heterogeneous echotexture and are more commonly intramural rather than subserosal 2, 5
• The well-defined hypoechoic appearance favors fibroid over adenomyosis-related pathology 6, 8

Clinical significance: This small subserosal fibroid is unlikely to cause significant symptoms or impact fertility given its size and location 7.

Endometrial Assessment

The thin 4 mm endometrium is appropriate for early proliferative phase or postmenopausal status, but requires clinical correlation with menstrual history 5.

Ovarian Findings

Left Ovary: Polycystic Morphology

The left ovary measuring 28 cc (normal upper limit ~10 cc) with multiple follicles up to 1.9 cm demonstrates polycystic ovarian morphology (PCOM) 5.

• Enlarged ovarian volume (28 cc versus normal ~10 cc) combined with multiple follicles meets ultrasound criteria for PCOM
• This finding alone does not establish a diagnosis of polycystic ovary syndrome (PCOS), which requires clinical and biochemical correlation (hyperandrogenism, oligo-anovulation) 5
• The follicle size up to 1.9 cm may represent a dominant follicle rather than pathology

Right Ovary: Non-visualization

The non-visualized right ovary is a common technical limitation of transvaginal ultrasound and does not necessarily indicate pathology 6.

• Recommendation: If clinically indicated (pelvic pain, adnexal mass concern), consider repeat ultrasound with full bladder or pelvic MRI for complete ovarian assessment 6
• In asymptomatic patients with normal left ovary, observation is reasonable

Clinical Implications and Management Considerations

Adenomyosis Management

Symptom assessment is critical as adenomyosis severity correlates with specific clinical manifestations 3:

• Diffuse adenomyosis associates with dysmenorrhea and abnormal uterine bleeding 3
• Lesion thickness and spread correlate with symptom severity 3
• For symptomatic patients desiring uterine preservation, uterine artery embolization demonstrates superior 6-month outcomes compared to medical management (86.7% vs 50% composite success rate) 9

Further Imaging Considerations

MRI is not routinely necessary but should be considered if 6:

• Surgical planning is required for symptomatic disease
• Differentiation between adenomyosis and fibroids impacts treatment decisions
• Atypical features raise concern for malignancy (though not present in this case)

Transvaginal ultrasound demonstrates 91.8% specificity for adenomyosis diagnosis, making it the appropriate first-line imaging modality 4.

Key Clinical Pitfalls to Avoid

• Do not diagnose PCOS based on ultrasound alone—clinical and biochemical criteria are required 5
• Do not assume the non-visualized right ovary is abnormal—this is a common technical limitation requiring clinical correlation 6
• Do not overlook the need for symptom assessment—adenomyosis findings on ultrasound do not automatically warrant treatment 3
• Distinguish between adenomyosis and fibroids as treatment approaches differ significantly 6, 9