There is a lack of an international consensus on adenomyosis classification that is useful for clinical practice and research. This article reviews advancements in the classification of adenomyosis, and the existing limitations. We collected a literature search from PubMed and Embase database up to March 2019. The proposed adenomyosis classification is based on magnetic resonance imaging and clinically relevant parameters. Adenomyosis is not a disease of homogeneity but is composed of multiple heterogeneous subtypes. Adenomyosis represents a spectrum of lesions, ranging from increased thickness of the junctional zone to focal or diffuse lesions involving the entire uterine wall. Potentially important parameters to be included in the classification could be affected area (internal or external adenomyosis), pattern (focal or diffuse), size or volume (myometrial involvement <1/3, <2/3, or >2/3 of uterine wall), concomitant pathologies (none, peritoneal endometriosis, ovarian endometrioma, deep infiltrating endometriosis, uterine fibroids, or others) and localization (anterior, posterior, left lateral, right lateral, or fundal). We propose a simplified classification system to monitor symptom severity against morphological types or extent of adenomyosis using the combination of previously published classifications as a starting point. More studies are needed to investigate whether this classification represents a useful tool for disease assessment in clinical practice and research.

Harada T, Khine YM, Kaponis A, Nikellis T, Decavalas G, Taniguchi F. The Impact of Adenomyosis on Women’s Fertility. Obstet Gynecol Surv. 2016 Sep;71(9):557–68.
Vannuccini S, Petraglia F. Recent advances in understanding and managing adenomyosis. F1000Res. 2019 Mar;8:pii:F1000 Faculty Rev-283.
Bergholt T, Eriksen L, Berendt N, Jacobsen M, Hertz JB. Prevalence and risk factors of adenomyosis at hysterectomy. Hum Reprod. 2001 Nov;16(11):2418–21.
Gordts S, Grimbizis G, Campo R. Symptoms and classification of uterine adenomyosis, including the place of hysteroscopy in diagnosis. Fertil Steril. 2018 Mar;109(3):380–388.e1.
Leyendecker G, Bilgicyildirim A, Inacker M, Stalf T, Huppert P, Mall G, et al. Adenomyosis and endometriosis. Re-visiting their association and further insights into the mechanisms of auto-traumatisation. An MRI study. Arch Gynecol Obstet. 2015 Apr;291(4):917–32.
Cunningham RK, Horrow MM, Smith RJ, Springer J. Adenomyosis: A Sonographic Diagnosis. Radiographics. 2018 Sep-Oct;38(5):1576–89.
Rasmussen CK, Hansen ES, Dueholm M. Inter-rater agreement in the diagnosis of adenomyosis by 2- and 3-dimensional transvaginal ultrasonography. J Ultrasound Med. 2019 Mar;38(3):657–66.
Dueholm M, Lundorf E, Sørensen JS, Ledertoug S, Olesen F, Laursen H. Reproducibility of evaluation of the uterus by transvaginal sonography, hysterosonographic examination, hysteroscopy and magnetic resonance imaging. Hum Reprod. 2002 Jan;17(1):195–200.
Bird CC, McElin TW, Manalo-Estrella P. The elusive adenomyosis of the uterus – revisited. Am J Obstet Gynecol. 1972 Mar;112(5):583–93.
Vercellini P, Viganò P, Somigliana E, Daguati R, Abbiati A, Fedele L. Adenomyosis: epidemiological factors. Best Pract Res Clin Obstet Gynaecol. 2006 Aug;20(4):465–77.
Levgur M, Abadi MA, Tucker A. Adenomyosis: symptoms, histology, and pregnancy terminations. Obstet Gynecol. 2000 May;95(5):688–91.
Gordts S, Brosens JJ, Fusi L, Benagiano G, Brosens I. Uterine adenomyosis: a need for uniform terminology and consensus classification. Reprod Biomed Online. 2008 Aug;17(2):244–8.
Kishi Y, Suginami H, Kuramori R, Yabuta M, Suginami R, Taniguchi F. Four subtypes of adenomyosis assessed by magnetic resonance imaging and their specification. Am J Obstet Gynecol. 2012 Aug;207(2):114.e1–7.
Pistofidis G, Makrakis E, Koukoura O, Bardis N, Balinakos P, Anaf V. Distinct types of uterine adenomyosis based on laparoscopic and histopathologic criteria. Clin Exp Obstet Gynecol. 2014;41(2):113–8.
Grimbizis GF, Mikos T, Tarlatzis B. Uterus-sparing operative treatment for adenomyosis. Fertil Steril. 2014 Feb;101(2):472–87.
Bazot M, Daraï E. Role of transvaginal sonography and magnetic resonance imaging in the diagnosis of uterine adenomyosis. Fertil Steril. 2018 Mar;109(3):389–97.
Dessouky R, Gamil SA, Nada MG, Mousa R, Libda Y. Management of uterine adenomyosis: current trends and uterine artery embolization as a potential alternative to hysterectomy. Insights Imaging. 2019 Apr;10(1):48.
Rokitansky C. Über Uterusdrüsen-neudildung in uterus and ovarial-sarcomen. Zeitsch Gesellschaft der Aerzte in Wien. 1860;16:577–81.
Cullen TS. The distribution of adenomyomas containing uterine mucosa. Arch Surg. 1920;1(2):215–83.
Cullen TS. Adeno-myoma of the round ligament. Johns Hopkins Hosp Bull. 1896;7:112–4.
Cullen TS. Adenoma-myoma uteri diffusum benignum. Johns Hopkins Hosp Bull. 1896;6:133–7.
Cullen TS. The distribution of adenomyomata containing uterine mucosa. Am J Obstet Gynecol. 1919;80:130–8.
Sampson JA. Perforating hemorrhagic (chocolate) cysts of the ovary. Their importance and especially their relation to pelvic adenomas of endometrial type. Adenomyoma of the uterus, rectovaginal septum, sigmoid, etc. Arch Surg. 1921;3(2):245–323.
Brosens I, Benagiano G. Endometriosis, a modern syndrome. Indian J Med Res. 2011 Jun;133:581–93.
Togashi K, Nishimura K, Itoh K, Fujisawa I, Noma S, Kanaoka M, et al. Adenomyosis: diagnosis with MR imaging. Radiology. 1988 Jan;166(1 Pt 1):111–4.
Gordts S, Koninckx P, Brosens I. Pathogenesis of deep endometriosis. Fertil Steril. 2017 Dec;108(6):872–885.e1.
Koninckx PR, Ussia A, Adamyan L, Wattiez A, Donnez J. Deep endometriosis: definition, diagnosis, and treatment. Fertil Steril. 2012 Sep;98(3):564–71.
Novellas S, Chassang M, Delotte J, Toullalan O, Chevallier A, Bouaziz J, et al. MRI characteristics of the uterine junctional zone: from normal to the diagnosis of adenomyosis. AJR Am J Roentgenol. 2011 May;196(5):1206–13.
Chapron C, Fauconnier A, Vieira M, Barakat H, Dousset B, Pansini V, et al. Anatomical distribution of deeply infiltrating endometriosis: surgical implications and proposition for a classification. Hum Reprod. 2003 Jan;18(1):157–61.
Bergeron C, Amant F, Ferenczy A. Pathology and physiopathology of adenomyosis. Best Pract Res Clin Obstet Gynaecol. 2006 Aug;20(4):511–21.
Vinci V, Saldari M, Sergi ME, Bernardo S, Rizzo G, Porpora MG, et al. MRI, US or real-time virtual sonography in the evaluation of adenomyosis? Radiol Med (Torino). 2017 May;122(5):361–8.
Takeuchi M, Matsuzaki K. Adenomyosis: usual and unusual imaging manifestations, pitfalls, and problem-solving MR imaging techniques. Radiographics. 2011 Jan-Feb;31(1):99–115.
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 Nov;89(11):1374–84.
García-Solares J, Donnez J, Donnez O, Dolmans MM. Pathogenesis of uterine adenomyosis: invagination or metaplasia? Fertil Steril. 2018 Mar;109(3):371–9.
Bazot M, Fiori O, Darai E. Adenomyosis in endometriosis – prevalence and impact on fertility. Evidence from magnetic resonance imaging. Hum Reprod. 2006 Apr;21(4):1101–2.
Sammour A, Pirwany I, Usubutun A, Arseneau J, Tulandi T. Correlations between extent and spread of adenomyosis and clinical symptoms. Gynecol Obstet Invest. 2002;54(4):213–6.
Brosens JJ, Barker FG, de Souza NM. Myometrial zonal differentiation and uterine junctional zone hyperplasia in the non-pregnant uterus. Hum Reprod Update. 1998 Sep-Oct;4(5):496–502.
Kunz G, Herbertz M, Beil D, Huppert P, Leyendecker G. Adenomyosis as a disorder of the early and late human reproductive period. Reprod Biomed Online. 2007 Dec;15(6):681–5.
Hauth EA, Jaeger HJ, Libera H, Lange S, Forsting M. MR imaging of the uterus and cervix in healthy women: determination of normal values. Eur Radiol. 2007 Mar;17(3):734–42.
Wildt L, Kissler S, Licht P, Becker W. Sperm transport in the human female genital tract and its modulation by oxytocin as assessed by hysterosalpingoscintigraphy, hysterotonography, electrohysterography and Doppler sonography. Hum Reprod Update. 1998 Sep-Oct;4(5):655–66.
Kissler S, Zangos S, Wiegratz I, Kohl J, Rody A, Gaetje R, et al. Utero-tubal sperm transport and its impairment in endometriosis and adenomyosis. Ann N Y Acad Sci. 2007 Apr;1101(1):38–48.
Reinhold C, McCarthy S, Bret PM, Mehio A, Atri M, Zakarian R, et al. Diffuse adenomyosis: comparison of endovaginal US and MR imaging with histopathologic correlation. Radiology. 1996 Apr;199(1):151–8.
Bazot M, Cortez A, Darai E, Rouger J, Chopier J, Antoine JM, et al. Ultrasonography compared with magnetic resonance imaging for the diagnosis of adenomyosis: correlation with histopathology. Hum Reprod. 2001 Nov;16(11):2427–33.
Agostinho L, Cruz R, Osório F, Alves J, Setúbal A, Guerra A. MRI for adenomyosis: a pictorial review. Insights Imaging. 2017 Dec;8(6):549–56.
Tocci A, Greco E, Ubaldi FM. Adenomyosis and ‘endometrial-subendometrial myometrium unit disruption disease’ are two different entities. Reprod Biomed Online. 2008 Aug;17(2):281–91.
Tamai K, Togashi K, Ito T, Morisawa N, Fujiwara T, Koyama T. MR imaging findings of adenomyosis: correlation with histopathologic features and diagnostic pitfalls. Radiographics. 2005 Jan-Feb;25(1):21–40.
Tellum T, Matic GV, Dormagen JB, Nygaard S, Viktil E, Qvigstad E, et al. Diagnosing adenomyosis with MRI: a prospective study revisiting the junctional zone thickness cutoff of 12 mm as a diagnostic marker. Eur Radiol. 2019 Dec;29(12):6971–81.
Koninckx PR, Martin DC. Deep endometriosis: a consequence of infiltration or retraction or possibly adenomyosis externa? Fertil Steril. 1992 Nov;58(5):924–8.
Leyendecker G, Herbertz M, Kunz G, Mall G. Endometriosis results from the dislocation of basal endometrium. Hum Reprod. 2002 Oct;17(10):2725–36.
Kunz G, Beil D, Huppert P, Noe M, Kissler S, Leyendecker G. Adenomyosis in endometriosis – prevalence and impact on fertility. Evidence from magnetic resonance imaging. Hum Reprod. 2005 Aug;20(8):2309–16.
Donnez J, Nisolle M, Casanas-Roux F, Bassil S, Anaf V. Rectovaginal septum, endometriosis or adenomyosis: laparoscopic management in a series of 231 patients. Hum Reprod. 1995 Mar;10(3):630–5.
Levy G, Dehaene A, Laurent N, Lernout M, Collinet P, Lucot JP, et al. An update on adenomyosis. Diagn Interv Imaging. 2013 Jan;94(1):3–25.
Bazot M, Darai E, Hourani R, Thomassin I, Cortez A, Uzan S, et al. Deep pelvic endometriosis: MR imaging for diagnosis and prediction of extension of disease. Radiology. 2004 Aug;232(2):379–89.
Huang RT, Chou CY, Chang CH, Yu CH, Huang SC, Yao BL. Differentiation between adenomyoma and leiomyoma with transvaginal ultrasonography. Ultrasound Obstet Gynecol. 1995 Jan;5(1):47–50.
Chapron C, Tosti C, Marcellin L, Bourdon M, Lafay-Pillet MC, Millischer AE, et al. Relationship between the magnetic resonance imaging appearance of adenomyosis and endometriosis phenotypes. Hum Reprod. 2017 Jul;32(7):1393–401.
Takeda A, Sakai K, Mitsui T, Nakamura H. Laparoscopic management of juvenile cystic adenomyoma of the uterus: report of two cases and review of the literature. J Minim Invasive Gynecol. 2007 May-Jun;14(3):370–4.
Naftalin J, Hoo W, Pateman K, Mavrelos D, Foo X, Jurkovic D. Is adenomyosis associated with menorrhagia? Hum Reprod. 2014 Mar;29(3):473–9.
Naftalin J, Hoo W, Nunes N, Holland T, Mavrelos D, Jurkovic D. Association between ultrasound features of adenomyosis and severity of menstrual pain. Ultrasound Obstet Gynecol. 2016 Jun;47(6):779–83.
Younes G, Tulandi T. Effects of adenomyosis on in vitro fertilization treatment outcomes: a meta-analysis. Fertil Steril. 2017 Sep;108(3):483–490.e3.
Shrestha A. Risk factors for adenomyosis. J Nepal Health Res Counc. 2012 Sep;10(22):229–33.
Kishi Y, Shimada K, Fujii T, Uchiyama T, Yoshimoto C, Konishi N, et al. Phenotypic characterization of adenomyosis occurring at the inner and outer myometrium. PLoS One. 2017 Dec;12(12):e0189522.
Hirata T, Izumi G, Takamura M, Saito A, Nakazawa A, Harada M, et al. Efficacy of dienogest in the treatment of symptomatic adenomyosis: a pilot study. Gynecol Endocrinol. 2014 Oct;30(10):726–9.
Matsubara S, Kawaguchi R, Akinishi M, Nagayasu M, Iwai K, Niiro E, et al. Subtype I (intrinsic) adenomyosis is an independent risk factor for dienogest-related serious unpredictable bleeding in patients with symptomatic adenomyosis. Sci Rep. 2019 Nov;9(1):17654.
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