## Clinical Context The patient presents with menorrhagia and a uniformly enlarged uterus with heterogeneous myometrium on ultrasound — classic for **adenomyosis**. The small echogenic lesions represent ectopic endometrial tissue within the myometrium. ## Investigation of Choice: MRI Pelvis **Key Point:** MRI is the gold standard for diagnosis of adenomyosis, with sensitivity 70–90% and specificity 86–91%. **High-Yield:** MRI findings in adenomyosis include: - Junctional zone thickening (>12 mm) - Junctional zone irregularity - T2 hyperintense lesions in the myometrium - Heterogeneous signal intensity ## Why MRI Over Other Modalities | Investigation | Role in Adenomyosis | Limitation | | --- | --- | --- | | Transvaginal ultrasound | First-line screening; operator-dependent | Sensitivity only 60–70%; cannot reliably assess junctional zone | | MRI pelvis | Gold standard for diagnosis | Confirmatory imaging; excellent soft-tissue contrast | | Hysteroscopy + biopsy | Assesses endometrium; rules out endometrial pathology | Does not visualize myometrial adenomyosis; invasive | | HSG | Assesses tubal patency | No role in adenomyosis diagnosis | **Clinical Pearl:** In a woman with menorrhagia, uniformly enlarged uterus, and inconclusive ultrasound findings, MRI is the next logical step before committing to medical or surgical management. **Tip:** Remember: adenomyosis = diffuse myometrial involvement (MRI best); fibroids = focal lesions (ultrasound often sufficient).
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