## Why Adenomyosis is right Adenomyosis is characterized by thickening of the junctional zone (inner myometrium) **B** to >12 mm on T2-weighted MRI, often with focal hyperintense foci representing ectopic endometrial glands and stroma within the myometrium. The clinical presentation of dysmenorrhea and menorrhagia, combined with the imaging finding of a thickened junctional zone (14 mm in this case) with bright signal foci, is pathognomonic for adenomyosis. The normal outer myometrium excludes diffuse myometrial pathology. [Sutton Radiology; Williams Gynecology 4e] ## Why each distractor is wrong - **Uterine fibroid (leiomyoma)**: Fibroids appear as well-circumscribed T2-dark masses, typically within the myometrium or submucosal space. They do not cause diffuse or focal junctional zone thickening with hyperintense foci. The imaging pattern described is not consistent with a fibroid. - **Endometrial cancer**: Endometrial cancer would present as thickening of the endometrium (marked **A**), not the junctional zone (**B**). The anchor finding is junctional zone pathology, not endometrial pathology. Additionally, postmenopausal status is the typical risk factor, not a 42-year-old woman. - **Müllerian anomaly (septate uterus)**: Müllerian anomalies are congenital structural variants characterized by abnormal uterine morphology (e.g., a fibrous or myometrial septum dividing the cavity). They do not cause junctional zone thickening with hyperintense foci on T2 imaging. **High-Yield:** Junctional zone thickening >12 mm with hyperintense foci on T2 MRI = adenomyosis; presents with dysmenorrhea and menorrhagia. [cite: Sutton Radiology; Williams Gynecology 4e]
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