Question mark form of uterus: a simple sonographic sign associated with the presence of adenomyosis.

Adenomyosis as the presence of ectopic endometrial glands and stroma within the myometrium is an elusive condition that is challenging to diagnose due to the similarity between its clinical symptoms and ultrasound characteristics and those of other frequent benign conditions such as leiomyomatosis1. Over recent years, transvaginal sonography (TVS) has been recommended as an appropriate tool for visualization of adenomyosis, with a sensitivity of 65–81% and a specificity of 65–100%2. We performed a prospective study between January 2012 and January 2014 including 50 symptomatic fertile women who were scheduled to undergo elective hysterectomy because of symptoms of endometriosis/adenomyosis. Adenomyosis was diagnosed on TVS, in accordance with previous studies3,4, in the presence of one or more of the following criteria: heterogeneous myometrium, irregular cystic areas, hypoechoic linear striations, asymmetry of uterine walls and poor definition of the endometrial–myometrial junctional zone (JZ). Moreover, a novel sign, which we called ‘question mark Figure 1 Transvaginal ultrasound image and representative diagram showing the question mark form of the uterus as a marker for adenomyosis.