O&G · Gynaecological health — menstrual disorders
Adenomyosis: pathophysiology, MUSA imaging features & management (the A of PALM-COEIN)
Also known as Adenomyosis · Endometriosis interna · Adenomyoma · AUB-A · Junctional zone disorder · Diffuse adenomyosis
Exam-exhaustive FRANZCOG fellowship topic on adenomyosis — the A of FIGO PALM-COEIN. Covers the pathophysiology (endometrial glands and stroma within the myometrium), the MUSA-consensus transvaginal ultrasound features (globular uterus, asymmetrical thickening, myometrial cysts, fan-shaped shadowing), the MRI junctional-zone threshold of at least 12 mm (Reinhold), the symptom overlap with fibroids and endometriosis, stepwise medical-to-surgical management (LNG-IUS, GnRH analogues, dienogest, hysterectomy endpoint) and the fertility and pregnancy implications. RANZCOG-primary, globally tagged to MRCOG, ABOG, FRCSC and MRCPI.
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- New postmenopausal bleeding in a woman with adenomyosis is malignancy until proven otherwise — biopsy, do not attribute it to adenomyosis
- Enlarged tender uterus with dysmenorrhoea and heavy bleeding — think adenomyosis, but finish the PALM-COEIN workup because fibroids and endometriosis frequently coexist
- Adenomyosis in a woman seeking fertility — counsel on adverse obstetric outcomes (miscarriage, preterm birth) before any uterine-sparing surgery
- Acute heavy adenomyotic bleeding causing haemodynamic compromise — resuscitate first; the workup comes after
- An asymptomatic enlarged uterus on imaging does not itself need treatment — burden, not presence, drives the decision
A 42-year-old multiparous woman sits in your clinic with progressively heavier, more painful periods over two years, deep dyspareunia, and a tender, boggy uterus on bimanual exam. For a generation she would have been told "your uterus is just bulky" and offered a hysterectomy. Today you image her, define the burden, manage her medically and operate only when she has completed her family. This topic teaches the imaging vocabulary and the management ladder — and the discipline of finishing the PALM-COEIN workup.[9][10]
References12ShowHide
- [1]Munro MG, Critchley HO, Broder MS, et al. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet, 2011.PMID 21345435
- [2]Munro MG, Critchley HOD, Fraser IS The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Gynaecol Obstet, 2018.PMID 30198563
- [3]Jain V, Munro MG, Critchley HOD Contemporary evaluation of women and girls with abnormal uterine bleeding: FIGO Systems 1 and 2. Int J Gynaecol Obstet, 2023.PMID 37538019
- [4]Reinhold C, McCarthy S, Bret PM, et al. Diffuse adenomyosis: comparison of endovaginal US and MR imaging with histopathologic correlation. Radiology, 1996.PMID 8633139
- [5]Champaneria R, Abedin P, Daniels J, Balogun M, Khan KS Ultrasound scan and magnetic resonance imaging for the diagnosis of adenomyosis: systematic review comparing test accuracy. Acta Obstet Gynecol Scand, 2010.PMID 20932128
- [6]Van den Bosch T, Dueholm M, Leone FP, et al. Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses: a consensus opinion from the Morphological Uterus Sonographic Assessment (MUSA) group. Ultrasound Obstet Gynecol, 2015.PMID 25652685
- [7]Reinhold C, Tafazoli F, Mehio A, Wang L, Atri M, Siegelman ES, Rohoman L Uterine adenomyosis: endovaginal US and MR imaging features with histopathologic correlation. Radiographics, 1999.PMID 10517451
- [8]Reinhold C, Tafazoli F, Wang L Imaging features of adenomyosis. Hum Reprod Update, 1998.PMID 9825849
- [9]Vannuccini S, Petraglia F Recent advances in understanding and managing adenomyosis. F1000Res, 2019.PMID 30918629
- [10]Habiba M, Guo SW, Benagiano G Adenomyosis and Abnormal Uterine Bleeding: Review of the Evidence. Biomolecules, 2024.PMID 38927019
- [11]Zhang B, Shi J, Gu Z, et al. The role of different LNG-IUS therapies in the management of adenomyosis: a systematic review and meta-analysis. Reprod Biol Endocrinol, 2025.PMID 39948612
- [12]Liu L, Wang T, Li Y, et al. Reproductive outcomes after fertility-sparing interventions for symptomatic adenomyosis: a systematic review and meta-analysis. BMC Pregnancy Childbirth, 2025.PMID 41206447