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Diagnostic Radiology · Diagnostic Radiology of the Abdominal Organs

Adenomyosis and endometriosis

Endometriosis et Adenomyosis

Endometriosis is the proliferation of endometrial tissue outside the uterine cavity, whereas adenomyosis is the invasion of this tissue directly into the myometrium. Both conditions are common causes of chronic pelvic pain and infertility, requiring precise imaging to guide treatment strategy.

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Gold standardLaparoscopy with histological confirmation for endometriosis.
MRI criterionMyometrial junctional zone thickening ≥12 mm indicates adenomyosis.
MRI sign«T2 shading» is a sign of old blood in endometriomas.
LocalizationOvaries, uterine ligaments, rectovaginal septum, urinary bladder.
2 min readFor medical studentsUpdated Sep 25, 2026
Material prepared by WhiteCoat Pro editorial team based on platform study guidesReviewed by medical editor: Aulov A. A., general practitioner · 09/24/2026

Endometriosis: Imaging and Forms

Endometriosis manifests as the presence of ectopic foci, which can affect both pelvic organs and distant structures.

  • Endometriomas (ovarian cysts): on ultrasound, they appear as masses with low-level echoes. On MRI, they are hyperintense on T1-weighted images and show variable signal intensity on T2-weighted images.
  • Deep infiltrative endometriosis: visualized as hypoechoic nodules or organ wall thickenings.
  • Adhesive disease: leads to the formation of «kissing ovaries» (kissing ovaries) and fixation of bowel loops to the uterus.

Adenomyosis: Diagnostic Signs

Adenomyosis is characterized by secondary hyperplasia of the uterine smooth muscle. The main diagnostic methods include transvaginal ultrasound (TVUS) and MRI.

  1. Ultrasound signs: globular uterine configuration, subendometrial cysts (2–6 mm), and the «falling raindrop» sign.
  2. MRI criteria: the main sign is alteration of the junctional zone (junctional zone). A thickness of more than 12 mm is highly specific for the diagnosis, whereas less than 8 mm allows it to be ruled out.
  3. Additional markers: the presence of foci with a hyperintense signal on T1-weighted images within the myometrium indicates punctate hemorrhages, which has high prognostic value.
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Differential Diagnosis and Risks

It is important to differentiate benign processes from malignant neoplasms.

  • Malignant transformation: occurs in 2.5% of endometriomas. Red flags on MRI include the loss of the «shading» sign and the appearance of contrast-enhancing mural nodules.
  • Mimics: adenomyosis is frequently differentiated from uterine fibroids, endometrial carcinoma, and physiological myometrial contractions.

Briefly: answers to topical questions

In which anatomical structures are foci of deep infiltrative endometriosis most commonly localized?

Foci of deep infiltrative endometriosis may be localized in the following pelvic structures and adjacent organs:

  • uterosacral ligaments;
  • rectovaginal septum;
  • vaginal walls;
  • pouch of Douglas;
  • rectum and rectosigmoid colon;
  • urinary bladder and ureter.

What radiological signs of adenomyosis are revealed during hysterosalpingography (HSG)?

During hysterosalpingography, the diagnosis of nodular adenomyosis is revealed by specific «diverticular-like shadows». Contrast administration fills the tracts of endometrial heterotopias.

How to memorize

For the MRI diagnosis of adenomyosis, remember the «8-12» rule: <8 mm — normal, >12 mm — adenomyosis, 8–12 mm — «grey zone», requiring the search for additional signs (T1-hyperintense foci).

Class and exam questions

How does an endometrioma differ from a hemorrhagic cyst on MRI?

Endometriomas present with the «T2 shading» sign and often retain a fat-suppressed hyperintense signal on T1-weighted images, confirming the presence of blood breakdown products.

What are «kissing ovaries»?

This is a sign of severe adhesive disease in endometriosis, where the ovaries are adhered to each other in the midline posterior to the uterus.

What is the role of Doppler ultrasound in adenomyosis?

Color Doppler mapping reveals a «mottled pattern» of increased vascularization within heterogeneous myometrial zones.

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What else to study on this topic

  • Fitz-Hugh-Curtis syndrome as a complication of PID
  • Differential diagnosis of hydrosalpinx and pyosalpinx
  • Diagnostic features of thoracic endometriosis (catamenial pneumothorax)
  • Radiological signs of actinomycosis associated with an IUD
  • Management in suspected malignant transformation of an endometrioma

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Other topics in the section "Diagnostic Radiology of the Abdominal Organs"

Imaging modalities in gynecologyMullerian duct anomaliesUterine fibroidsPelvic inflammatory diseaseBenign ovarian diseasesOvarian torsionVaginal cystsEctopic pregnancyPlacental and uterine vascular pathologyTissue radiodensity on CTMRI in endometriosisNormal ovarian ultrasoundTransvaginal ultrasound examinationUltrasound examination contraindications
Entire section "Diagnostic Radiology of the Abdominal Organs"

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