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Uterine MRI: A review
of technique and diagnosis
Brian D. Sydow, MD, and Evan S. Seigelman, MD
M
agnetic resonance imaging
(MRI) is a commonly used
technique in the workup of
obstetric and gynecologic abnormalities
and in the pre- and postprocedural eval-
uation for uterine artery embolization.
This article summarizes the MRI tech-
niques for evaluating the uterus and
describes the MRI findings of the most
commonly encountered conditions in-
volving the uterus.
MRI techniques
Optimal MRI of the female pelvis and
uterus should be performed on a high–
field-strength MRI system that uses local
phased-array coils. The increased signal-
to-noise ratio provided by the surface coils
allows for small field-of-view imaging
that results in higher spatial resolution.
The typical imaging protocol for the
uterus uses both T1-weighted (T1W) and
T2-weighted (T2W) images. Axial T1W
images are obtained to evaluate the uter-
ine contour, lymph nodes, and bone mar-
row. We perform T2W imaging in 3 or-
thogonal planes. One of these planes usu-
ally shows the endometrial complex along
Dr. Sydow is a Radiologist, Northside
Radiology Associates, Atlanta, GA. At
the time this article was written, Dr.
Sydow was a radiology Resident at the
Hospital of the University of Pennsylvania.
Dr. Seigelman is an Associate Profes-
sor, Department of Radiology, Hospital
of the University of Pennsylvania,
Philadelphia, PA.
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with the long and short axis of the uterus
to good advantage. T2-weighted imaging
depicts the zonal anatomy of the uterus.
Fat-suppressed T1W imaging is used to
differentiate between pelvic masses that
contain fat and those that contain protein
or hemorrhage. Contrast enhancement is
used to document the extent of endome-
trial carcinoma invasion or to detect the
presence of necrosis in uterine leiomy-
omas. Dynamic contrast injection can be
used in women who are considering uter-
ine artery embolization (UAE) in order to
evaluate the uterine arteries and the poten-
tial collateral gonadal arterial supply.1 In
the evaluation of congenital uterine anom-
alies, sagittal T2W images should be
acquired first to determine the long-axis
orientation of the uterus. Subsequently,
images should then be obtained parallel to
the long axis of the uterus in order to show
the outer uterine contour.2
Normal uterine anatomy
T1-weighted images show poor con-
trast distinction between the endo-
metrium and myometrium. The zonal
anatomy of the uterus has a trilaminar
appearance on T2W images (Figure 1).3
The central endometrium has high signal
intensity secondary to mucinous rich
endometrial glands and stroma. The en-
dometrium varies in thickness with the
menstrual cycle and menopausal status.
The endometrium may measure up to
14 mm during the secretory phase in
menstruating women but is thinned dur-
ing the follicular phase.4 Postmenopausal
women should have a homogeneous
endometrium with a width of <5 mm.5
The myometrium can be separated into
the inner myometrium, also known as the
junctional zone, and the outer myo-
metrium (Figure 1). The junctional zone
contains compact smooth muscle with a
paucity of intercellular matrix and has rel-
atively low T2 signal intensity. The nor-
mal junctional zone measures <12 mm.6
The outer myometrium has less compact
smooth muscle and increased intercellu-
lar matrix and vessels compared with the
junctional zone, which results in a higher
T2 signal intensity. This zonal anatomy is
best visualized during the reproductive
years and may be poorly depicted or
absent in prepubertal and postmeno-
pausal women. In women taking birth
control pills, the junctional zone and
endometrium are thinner than in other
women and the outer myometrium is
higher in signal intensity.4
Uterine leiomyoma
Uterine leiomyomas are neoplasms
derived from the smooth muscle cells of
the myometrium. Uterine leiomyomas are
common, occurring in >20% in women
over 30 years of age. Most patients with
uterine leiomyomas are asymptomatic.
Among symptomatic patients, dysmenor-
rhea and irregular menstrual bleeding are
the most common complaints. Leiomy-
omas may be intramural, subserosal,
or submucosal in location. Intramural
leiomyomas are centered in the uterine
wall and are the most common subtype.
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UTERINE MRI

FIGURE 1. This sagittal T2-weighted MR image in a premenopausal B

woman shows the normal uterine zonal anatomy. Centrally there is the
high-signal-intensity endometrial stripe (black asterisk), which is bor-
dered by a low-signal-intensity junctional zone (white asterisk) and
intermediate-signal-intensity outer myometrium (arrows).

A submucosal leiomyoma has a component in the endometrial

canal. An intracavitary leiomyoma is almost entirely within the
endometrial canal (Figure 2). Subserosal leiomyomas are cen-
tered external to the uterus (Figure 3). Nondegenerated uterine
leiomyomas have lower T2 signal intensity than the outer
myometrium; in addition, they are well circumscribed and can
exhibit mass effect. On postcontrast imaging, nondegenerated
uterine leiomyomas enhance homogeneously. Uterine leiomy-
omas can appear heterogeneous in signal intensity on T2W
images and show decreased enhancement when they undergo
degeneration. Some subsets of degeneration include hemor- C
rhagic, fatty (lipoleiomyoma) (Figure 4), myxoid, hyaline, and
cystic.7 Leiomyosarcoma may have an appearance similar to a
degenerated leiomyoma, but, fortunately, leiomyosarcoma is
rare. It is difficult to establish a prospective diagnosis of
leiomyosarcoma in the absence of metastatic disease. In our
experience, degenerated atypical leiomyomas are much more
common than leiomyosarcomas.
Subserosal leiomyomas can simulate fibrous or smooth-
muscle ovarian masses, such as ovarian fibromas, fibrotheco-
mas, or Brenner tumors. Subserosal leiomyomas can be
differentiated from ovarian lesions since they show a normal
ipsilateral ovary or a bridging vessel from the uterus to the
fibroid.8 Subserosal fibroids on a stalk <2 cm in width are con-
sidered a relative contraindication for UAE, as they may lose
their connection to the adjacent uterus.9 Submucosal fibroids
can simulate endometrial masses such as endometrial polyps.
FIGURE 2. MRI of an intracavitary leiomyoma in a symptomatic
Leiomyomas can be separated from polyps by evaluating their
woman. (A) Sagittal and (B) axial and (C) fat-suppressed coronal T2-
signal intensity on T2W images. Leiomyomas usually have weighted images show an intracavitary fibroid as a low signal inten-
low T2 signal intensity and have a stalk that originates within sity mass (white arrows in A and B) within the endometrial canal. The
the myometrium, while polyps have heterogeneous T2 signal stalk is imaged in the coronal plane in C (black arrow).

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A B

FIGURE 3. MRI depiction of a subserosal fibroid. (A) Axial T1-weighted (T1W) and (B) axial T2-weighted (T2W) MR images show a subserosal
fibroid as a low-signal-intensity mass (asterisks) exophytic from the uterine fundus via a stalk (arrows) with a bridging vessel as evidenced by a flow
void on both T1W and T2W images.

A B

FIGURE 4. Fat-suppressed T1-weighted (T1W) MRI shows the presence of intralesional fat in a lipoleiomyoma. Axial T1W images obtained
(A) without and (B) with fat suppression show a uterine mass that contains fat [*], establishing a diagnosis of lipoleiomyoma. Separate ovaries
were shown on other images.

intensity. Submucosal and intracavitary
fibroids are a common cause of infertil-
ity or miscarriages by creating an ad-
verse environment for implantation or
prohibiting sufficient blood flow to sup-
port a developing embryo.
MRI can be used in the evaluation of
patients who undergo UAE for treatment
of symptomatic leiomyomas. Preopera-
tively, MRI can aide in selecting patients
who may benefit from UAE. MRI docu-
ments the size, location, and vascularity
of the fibroids. Leiomyomas that have
high signal intensity on T1W images and
no enhancement have a poor response to
UAE.10 Detection of a large intracavitary
fibroid is a relative contraindication to
UAE. Submucosal fibroids may be ex-
pelled from the uterus.11 These women
may benefit from hysteroscopic resec-
tion rather than UAE.12 Leiomyomas that
show high signal intensity on T2W
imaging and homogeneous enhancement
have the best response to UAE.13 Mag-
netic resonance angiography (MRA) can
evaluate the uterine arteries and identify
potential collateral arterial supply from
the gonadal vessels that may need to be
embolized as well.1 MR can also identify
other potential causes for a woman’s
signs or symptoms, such as adenomyosis
or endometriosis.
MR findings of successful UAE
include a decrease in size and enhance-
ment of fibroids, preserved enhance-
ment of the remainder of the uterus,
and lack of visualization of the uterine
arteries (Figure 5).14 Treated fibroids
have increased T1 signal and do not
enhance, in keeping with hemorrhagic
necrosis (Figure 5). Fibroids that con-
tinue to enhance are viable and usually

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A B C

FIGURE 5. MRI of successful uterine artery embolization (UAE) in a 48-year-old woman. (A) Pre-UAE sagittal T2-weighted image and (B and C)
fat-saturated enhanced sagittal T1-weighted images obtained (B) before and (C) 6 months after UAE show an interval decrease in size and
absent enhancement of the dominant intramural-submucosal leiomyoma.

with the expectation that >50% of

A B women will have significant decrease in
symptoms after 2 years.21 Successfully
treated adenomyosis shows a decrease in
the width of the junctional zone on MRI.22

FIGURE 6. Maximum intensity projection (MIP) images from sagittal 3-dimensional gradient-
echo fat-saturated postgadolinium source images from (A) frontal and (B) oblique sagittal pro-
jections show right ovarian collateral arterial supply (arrows).
grow in time and may result in recur-
rent symptoms.15,16 The angiographic
images should be carefully inspected
for a possible cause of failure such as
uterine artery revascularization or col-
lateral arterial supply from the ovarian
arteries (Figure 6).
Uterine adenomyosis
Adenomyosis is the presence of ec-
topic endometrial tissue in the uterine
myometrium with smooth muscle hyper-
plasia. Adenomyosis may be focal or
diffuse, with the latter being more com-
mon. On T2W images, adenomyosis
appears as a thickening of the low-signal-
intensity junctional zone corresponding
to the smooth muscle hyperplasia (Fig-
ure 7).17 Thickening of the junctional
zone >12 mm is specific for the diagno-
sis, while a measurement of 8 to 12 mm is
indeterminate and a measurement <8 mm
excludes the diagnosis with high speci-
ficity.18 One- to 4-mm hyperintense
T2 foci within the junctional zone repre-
sent the ectopic foci of endometrial tissue
and, when present, add specificity to the
MR diagnosis (Figure 8).19 MR can usu-
ally differentiate between focal adeno-
myosis and a leiomyoma.20 Adenomyosis
has poorly defined margins, is often ori-
ented parallel to the endometrial stripe,
contains 1- to 5-mm foci of ectopic
endometrial glands, and has minimal
mass effect on the endometrial canal.
Leiomyomas have well-defined margins
and mass effect. Adenomyosis can be
treated with uterine artery embolization
Endometrial carcinoma
Endometrial carcinoma is the most
common gynecologic malignancy.
Roughly 75% of endometrial carcino-
mas occur in postmenopausal women.
Excessive estrogen stimulation is the
most recognized association with endo-
metrial cancer. Women taking tamoxifen
are also at increased risk of endometrial
cancer. The most common symptom of
endometrial cancer is postmenopausal
bleeding. The initial procedure of choice
in the evaluation of a woman with sus-
pected endometrial carcinoma is trans-
vaginal sonography or hysteroscopy
with biopsy. MR is not used to screen
women for endometrial carcinoma.
However, in women with biopsy-proven
endometrial carcinoma, MRI can be
used to determine the depth of myome-
trial invasion.23 On dynamic contrast-
enhanced MRI, endometrial carcinoma
enhances less than the subjacent myo-
metrium.23 Malignant adenopathy is
associated with muscle-invasive endo-
metrial carcinomas. Some surgeons use
the information provided by preopera-
tive MRI to determine the need to per-
form lymphadenectomy. As opposed to
evaluating secondary findings of node-
positive disease (muscle invasion), it

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Table 1. American Fertility

A B
Society classification scheme26
Class I Segmental agenesis and
variable degrees of
uterovaginal hypoplasia
Class II Unicornuate uteri
Class III Uterus didelphys
Class IV Bicornuate uterus
Class V Septate uterus
Class VI Arcuate uteri
Class VII Sequela of in uteri DES
exposure
DES = diethylstilbestrol

FIGURE 7. MRI depiction of severe adenomyosis. (A) Sagittal and (B) coronal T2-weighted include endometrial atrophy, hyperpla-
images in a 43-year-old woman show marked thickening of the junctional zone with ectopic 1- sia, polypoid glandular-cystic prolifera-
to 4-mm foci of endometrial glands (arrows). The poorly defined margins and relative absence
of a mass effect on the endometrium also suggest a diagnosis of adenomyosis.
tion, polyps, and endometrial cancer.25
Endometrial sampling is often needed
in these women, especially those with
A B abnormal uterine bleeding.

Müllerian duct anomalies

FIGURE 8. MRI depiction of endometrial hyperplasia. (A) Axial and (B) sagittal T2-weighted
images of the uterus show cystic thickening of the endometrial canal (arrows) in a patient on
tamoxifen for breast cancer.
would be ideal to develop MRI tech-
niques to both detect and characterize
lymph nodes as benign or malignant in
order to guide therapy.24
When abnormal signal within the
endometrial canal invades the junctional
zone on T2W or contrast-enhanced
images, then endometrial carcinoma is
the likely diagnosis. The differential diag-
nosis of a thickened endometrial stripe
without myometrial extension is superfi-
cial endometrial carcinoma, endometrial
polyps, and endometrial hyperplasia.
Polyps may depict a zonal phenomenon
with a low T2-signal-intensity fibrous
core and outer high-signal-intensity
glands. Endometrial hyperplasia often
has a “Swiss cheese” configuration on
T2W and enhanced imaging, with inter-
nal nonenhancing cysts surrounded by
enhancing glandular tissue.
Tamoxifen
Tamoxifen is used in the treatment
of breast cancer. While tamoxifen
exhibits antiestrogenic effects within
the breast, it can also show proestro-
genic activity within the endometrium.
Thus, tamoxifen can produce endome-
trial thickening on MRI (Figure 8).
Pathologically, the endometrial abnor-
malities associated with tamoxifen use
The incidence of müllerian duct
anomalies is approximately 1% but
varies by population. In patients with
infertility, it is estimated to be 3%. Most
müllerian duct anomalies are thought to
be sporadic or multifactorial in nature.
The most widely quoted classification
scheme for müllerian duct anomalies is
the American Fertility Society classifi-
cation that has 7 classes (Table 1).26 A
simplified framework for the discussion
of müllerian duct defects consists of
3 categories: duct agenesis and hypopla-
sia, defects of vertical fusion of the ducts
with the ascending urogenital sinus, and
defects of lateral duct fusion.27
Patients with müllerian duct anom-
alies may manifest with primary amen-
orrhea in the adolescent age group.
MRI can evaluate for the presence or
absence of the vagina, cervix, or uterus
and also depicts any associated renal
anomalies (Figure 9). MRI can show
the level of obstruction of antegrade
menstrual flow in women with func-
tioning endometrium as well as depict
findings of retrograde menstruation
such as hematosalpinx or endometrio-
sis. In the reproductive years, women
with uterine anomalies may present
with spontaneous abortion, premature
delivery, and abnormal fetal lie.

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UTERINE MRI

women can present with nonviable preg-

nancy, endometriosis, or ectopic preg-
A B
nancy. Therefore, rudimentary horns
that contain endometrium, whether they
are communicating or noncommunicat-
ing, are usually removed. Among all of
the müllerian duct anomalies, unicornu-
ate uteri have the highest association of
renal abnormalities, present in up to
40% of these women. The renal anom-
aly is ipsilateral to the abnormal horn.
MRI shows a banana-shaped uterus.29
When the endometrium is absent, the
horn is of low T2 signal intensity, with
loss of normal zonal anatomy. When the
C D endometrium is present, zonal anatomy
may be preserved.

Disorders of vertical fusion

(vaginal septum)
A transverse vaginal septum consists
of a band of fibrous connective tissue
with vascular and muscular components.
It is the most common disorder of verti-
cal fusion. A transverse vaginal septum
can occur anywhere along the vagina,
FIGURE 9. MRI evaluation in a young woman with primary amenorrhea who has a form of but most commonly occurs at the junc-
Mayer-Rokitansky-Küster-Hauser syndrome. (A) Sagittal and (B) axial T2-weighted (T2W) tion of the upper and middle third.
images and (C and D) axial fat-saturated T1-weighted (T1W) images do not show the pres- Patients typically present with primary
ence of the cervix or vagina. (A and B) A normal uterus is seen on the T2W images, while amenorrhea. In patients with a uterus and
(C and D) bilateral endometriomas, in keeping with retrograde menstruation, are seen on the
functioning endometrium, hematocolpos
T1W images (arrows).
can be depicted with MR with less severe
Absence of the müllerian ducts includes androgen insensitivity syndrome; dilation of the endometrial cavity.27 This
(agenesis and hypoplasia) affected individuals have rudimentary finding is secondary to the decreased
Mayer-Rokitansky-Küster-Hauser syn- testes and absent ovaries on MR. compliance of the more muscular myo-
drome represents failure of vaginal devel- metrium. A transverse vaginal septum
opment with varying degrees of cervical Unicornuate uterus can be present in conjunction with other
and uterine agenesis/hypoplasia. In 90% Unicornuate uterus is a type of uterine müllerian duct anomalies. The most
of cases, there is complete uterine agene- hypoplasia in which there is incomplete common association is a uterus didel-
sis. In the remaining 10% of cases, there or absent development of 1 müllerian phys and complex duplication anom-
may be an obstructed or small rudimentary duct and represents 20% of müllerian alies. The differential diagnosis for pri-
uterus. The ovaries are usually normal. duct anomalies. The abnormal uterine mary amenorrhea with a present uterus
Mayer-Rokitansky-Küster-Hauser syn- horn can be completely absent (one third includes an imperforate hymen, which
drome is the most common cause of amen- of cases) or rudimentary (two thirds can also cause hematocolpos. Imperfo-
orrhea in women with breast development, of cases). Of those patients with a rudi- rate hymen is not a müllerian anomaly,
reflecting the normal ovarian development mentary horn, 50% do not contain an and distinction from a transverse vaginal
with this condition. A rudimentary uterus endometrial canal and 50% have an septum can be difficult—although the
may contain functioning endometrial tis- endometrial-lined cavity. The endome- treatment is similar.
sue. MRI can be used to detect associated trial lined cavity within a rudimentary
abnormalities such as endometriosis, renal horn communicates with the contralat- Disorders of lateral fusion
anomalies, and collecting system abnor- eral horn in approximately one third of Disorders of lateral fusions result in
malities (Figure 9).28 The differential diag- women.27 A unicornuate uterus is usually varying degrees of duplication of the
nosis of primary amenorrhea with normal an incidental finding unless a cavitary uterus and cervix. Possibilities include
breast development and an absent uterus rudimentary horn is present. These didelphys, septate uterus, and bicornuate

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FIGURE 11. MRI depiction of uterine didelphys in a 23-year-old

FIGURE 10. MRI of a septate uterus in a 25-year-old woman. This long-axis woman. This T2-weighted image obtained through the long axis of
T2-weighted image shows a flat outer fundal contour and a fibromuscular the uterus shows complete separation of the uterine horns (asterisks)
central septum (asterisk) extending into the endocervical canal. with 2 endocervical canals, which is indicative of uterine didelphys.

uterus. With a septate uterus (Figure 10),
a fibromuscular central septum is incom-
pletely resorbed after müllerian duct
fusion. The septate uterus represents
approximately 55% of müllerian duct
anomalies. Septate uteri may result in
first trimester miscarriages caused by
implantation on the septum. Reproduc-
tive outcome improves after hystero-
scopic resection of the septum. In uterine
didelphys (Figure 11), there is complete
separation of distinct left and right uteri
and accounts for 5% of müllerian duct
anomalies. The cervix is usually dupli-
cated as well. Women with uterine didel-
phys have normal or nearly normal
fertility. The bicornuate uterus is caused
by incomplete fusion of the uterovaginal
horns at the level of the fundus and repre-
sents approximately 10% of müllerian
duct anomalies.
Differentiating between the lateral
fusion anomalies has important impli-
cations for treatment decisions. For
instance, a septate uterus is often treated
with hysteroscopic resection of the sep-
tum, while women with bicornuate uteri
are treated with a transabdominal metro-
plasty if they have a history of repeated
pregnancy loss. The key in imaging lat-
eral fusion anomalies is the evaluation
of the external uterine fundal contour.
The best imaging plane for evaluation
of the fundal contour is one that passes
through the long axis of the uterus. In
a normal or septate uterus, the outer
contour is convex, flat, or <10 mm of
concavity. The myometrial fundal inden-
tation is smooth and broad, and the sig-
nal intensity of this region is isointense
to normal myometrium. The outer con-
tour concavity of a bicornuate uterus
or uterine didelphys, to the contrary,
should be >10 mm. Two measurements
that may be helpful include the intercor-
nual distance and the intercornual angle.
In a septate uterus, the intercornual dis-
tance is <4 cm and the intercornual
angle is <60˚, as compared with the bi-
cornuate uterus, in which these values
are >4 cm and >60˚, respectively.30,31
Lateral fusion anomalies may also re-
sult in vaginal duplication. Vertical
vaginal septa are present in 75% of
women with didelphys, 25% with bicor-
nuate, and 5% with septate uteri.
Conclusion
Because of its superb soft tissue con-
trast and direct multiplanar capabilities,
MRI can detect and characterize normal
uterine anatomy and focal and diffuse
uterine conditions. In patients with pri-
mary amenorrhea, MRI can be used to
confirm the absence or presence of the
uterus as well as evaluate for any asso-
ciated urogenital abnormalities such as
renal agenesis. In patients with infertil-
ity, MRI can confirm the presence and
extent of a septate uterus and define the
fibrous and muscular components. In
patients with pelvic pain, MRI is more
sensitive and specific than ultrasound
for the findings of adenomyosis. In
patients with known leiomyomas, MRI

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is used in the preoperative evaluation
for uterine artery embolization. In oncol-
ogy, MRI can be used to stage women
with known endometrial carcinoma.
Understanding the appearance of the
common pathologic entities involving
the uterus along with the strengths and
limitations of MRI will help radiologists
be more confident in their approach to
pelvic MR interpretation.
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