The acquisition angle chosen should include the entire uterine volume of interest. In optimal conditions, the midsagittal plane allows visualization of the entire length of the endometrium as well as the endocervical canal. To acquire the 3D volume of the uterus, an adequately enlarged midsagittal or transverse section of the uterine body is obtained. In difficult cases this may facilitate access to a second opinion from an expert examiner. Three-dimensional (3D) ultrasonography enables the offline examination and manipulation of ultrasound images. This layer is composed of longitudinal and circular closely packed smooth-muscle fibers 7. The junctional zone (JZ) (also referred to as inner myometrium, archimyometrium or stratum subvasculare) is visible as a hypoechogenic subendometrial halo. On a sonographic cross-section through the uterus, the arcuate venous and arterial vessels can be seen in close proximity to the outer myometrial border. Some gentle pressure applied by either the probe or the examiner's free hand may be required to assess uterine mobility and to screen for site-specific tenderness 6. Examination by TVS commences with a dynamic two-dimensional (2D) scan of the uterus in two perpendicular planes. Image quality during TAS may be hampered by adiposity, scar tissue or uterine retroversion. For adequate visualization of the uterus, some bladder filling will be required to displace the small bowel from the field of view. Although examination by high-resolution TVS is preferred generally, allowing for detailed assessment of the myometrium within a limited depth of view, TAS may be necessary for imaging beyond the small pelvis. Ultrasound examination of the myometrium may be performed using a transabdominal (TAS) or transvaginal (TVS) approach. Amongst the authors were members from the IOTA (International Ovarian Tumor Analysis) and IETA groups and, in order to produce a consensus paper that includes opinions from both ultrasound and endoscopic interest groups, members of the ESGE (European Society of Gynaecological Endoscopy) were also included. This Morphological Uterus Sonographic Assessment (MUSA) consensus paper is based on the opinion of a panel of clinicians with expertise that includes gynecological ultrasonography, fertility treatment, hysteroscopy, general gynecology and clinical research. A secondary aim was to illustrate use of the terminology when describing the two most common myometrial lesions: fibroids and adenomyosis. These terms and definitions should be relevant both for clinicians reporting ultrasound examinations in day-to-day practice and for clinical research. The primary aim of this paper was to present a consensus opinion on the terminology to be used when describing the ultrasonographic features of the myometrium and myometrial lesions. Reliable predictors of benign pathology are essential clinically to allow safe use of minimally invasive techniques, such as selective uterine artery embolization, fibroid ablation or laparoscopic morcellation 5, for the treatment of uterine myomas. Moreover, common terminology is necessary for comparison of studies and when combining data in meta-analyses. In clinical practice and research, standardized reporting of ultrasound findings, with regard to the myometrium, is essential to reduce intra- and interobserver variability in the evaluation of pathology, to assess the effect of medical or surgical treatment and to compare ultrasound imaging with other imaging techniques. Standardized terms to be used when describing ultrasound images of the endometrium and uterine cavity have been suggested by the IETA (International Endometrial Tumor Analysis) group 3, but there remains no standardized terminology for describing ultrasound images of normal or pathological myometrium, or uterine masses 4. However, implementation of this classification system in daily clinical practice is hampered by the lack of standardization of the terms and definitions used to describe ultrasound findings. Recently, the International Federation of Gynecology and Obstetrics (FIGO) PALM-COEIN system (polyp adenomyosis leiomyoma malignancy and hyperplasia coagulopathy ovulatory dysfunction endometrial iatrogenic not yet classified) 1, 2 was published, which classifies the etiology of abnormal uterine bleeding, including the myometrial pathologies adenomyosis and fibroids. Ultrasonography is a first-stage imaging technique for assessing the myometrium and requires findings to be reported consistently.
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