Can ultrasonography diagnose adenomyosis? this talk may present an answer to this

1. Accuracy of TVUS in
Adenomyosis

2. Introduction
• Adenomyosis is a frequent gynecologic
pathology which affects women particularly in
the fifth decade complaining of abnormal
uterine bleeding.

3. • Adenomyosis is thought to affect 1% of
women.
• The aetiology is unclear.

4. clinical presentation
• parous, perimenopausal patient with
dysmenorrhea and menorrhagia.
• Physical examination may reveal an enlarged,
tender uterus,

5. Adenomyosis
• clinical presentation may suggest
adenomyosis
• imaging is often used prior to treatment
selected

6. • but the diagnosis has been difficult to obtain
without histologic confirmation.

7. Invasive

8. TVUS
• Available
• Non invasive
• Low cost
• Operator dependent
• ?? accurate

10. • asymmetric thickening of the anterior or
posterior uterine wall or myometrial cysts
which are small anechoic lakes of 2-6 mm in
diameter which may represent cystic
endometrial implants or focal myometrial
hemorrhage, colour doppler can be used to
differentiate it from myometrial vessels.

14. Aim of the study
• to measure the accuracy of the TVUS features
in diagnosing adenomyosis
• to determine the diagnostic role of uterine
artery Doppler in these cases.

15. • Study design:a prospective comparative study.
• Setting: Cairo University hospital

16. 363 Women
• scheduled for hysterectomy either abdominal,
vaginal
• TVUS was done to detect adenomyosis
• then compare the results with
histopathological findings
• then evaluate if there is any relation of
adenomyosis with uterine artery Doppler
indices

17. 352 women
• 11 patients were excluded from the study
either because that they diagnosed as being
unfit for surgery.
• 198 Patients were premenopausal (56.3 %)
while 154 were postmenopausal (43.8 %).

18. TVUS
• Ultrasound scanning was performed with
Accuvix (Medison, Seoul, Korea) scanner
using 4-7 MHZ endovaginal probe.
• Scanning was done in early morning to avoid
fluctuations due to circadian rhythm of
uterine artery blood flow.

19. Moreover
• There are different ultrasonographic features
which are suggested by many studies in order
to reach a diagnosis of adenomyosis.
• This lead to different accuracy in transvaginal
detection of adenomyosis

20. Criteria examined
• uterine diameters, outline
• myometrial echotexture,
• myometrial linear striation,
• myometrial cysts (its number if present),
• endometrial myometrial junction,
• uterine wall asymmetry and if there was any
associated gynecological pathology

21. Criteria Details
• Myometrial cysts were defined as rounded
anechoic area of 2-6 mm in diameter .
• Color Doppler was used to differentiate the
myometrial cysts from myometrial blood
vessels.
• Heterogenous myometrium was defined by
the presence of an indistinctly marginated
myometrial area with decreased or increased
echogenicity

23. More details
• heterotopic endometrium extending into the
inner myometrium can appear as echogenic
linear striations. When these lines are small or
indistinct, pseudo-widening of the endometrium
or poor delineation of the endomyometrial
junctional zone is seen.
• Globular and/or asymmetric uterus was defined
as a regular enlarged uterus with possible
myometrial asymmetry unrelated to leiomyoma.

24. Histopathology
• the pathologist was blinded to the US and
clinical findings.
• adenomyosis was diagnosed by migration of
the endometrial glands from the stratum
basale into the myometrium. The ectopic
glands tend to be at least 2-3 mm below the
endometrial-myometrial junction.

25. • Adenomyosis was found in 37/352 (10.5 %)
patients at the histopathological examination.
Other pelvic pathology was associated in
10/37 of the adenomyotic cases (27.77%).

26. • Leiomyomas were the most commonly
associated gynecological pathology with
adenomyosis (6/37, 16.2%) then endometrial
hyperplasia (3/37, 8.3 %) and ovarian cyst
(1/37, 2.7%).

27. • Transvaginal ultrasound diagnosed
adenomyosis in 48 cases out of 352 cases
scheduled for hysterectomy, of whom, only 37
cases had a histopathological diagnosis of
adenomyosis. (~10%)

28. • The sensitivity, specificity, negative predictive
value, positive predictive value and accuracy
of transvaginal ultrasound in the diagnosis of
adenomyosis were: 7 5.68%, 90.79%, 49.12%,
96.95% and 89.20 %respectively.

29. Adenomyosis
(n = 37)
No adenomyosis
(n = 315)
P
Globular uterus
Yes
No
25(67.6)
12(32.4)
228(72.4)
87(27,6)
0.538
Asymmetrical anterior-posterior uterine wall
Yes
No
12(32.4)
25(67.6)
86(27.3)
229(72.7)
0.510
Heterogeneous myometrial echotexture
Yes
No
35(94.6)
2(5.4)
175(55.6)
140(44.4)
< 0.001
Poor Endometrial Delineation
Yes
No
28(75.7)
9(24.3)
144(45.7)
171(54.3)
< 0.001
Linear myometrial striation
Yes
No
18(48.6)
19(51.4)
29(9.2)
286(90.8)
< 0.001
The Presence of myometrial cysts
Yes
No
26(70.3)
11(29.7)
144(45.7)
171(54.3)
0.005

30. Accuracy of different ultrasonographic features
for diagnosing adenomyosis
Sensitivity Specificity PPV NPV accuracy
Heterogeneous
myometrial echotexture
94.59 44.44 16.67 98.59 49.72
Poor Endometrial
Delineation 75.68 54.29 16.28 95.00 56.53
Linear myometrial
striation 48.65 90.79 38.30 93.77 86.36
The Presence of
myometrial cysts 70.27 54.29 15.29 93.96 55.97
Myometrial cysts > 2 96.15 100.00 100.00 99.31 99.41

31. ultrasonographic features(myometrial
cysts (arrows) and linear striations

32. Doppler study of the uterine artery in a
case documented to have adenomyosis.

33. Comparison of uterine artery Doppler indices (RI
and PI)
Adenomyotic cases
(n = 37)
Non adenomyotic cases
(n = 315)
P value
Uterine artery RI:
- Min
- Max
- Mean
- SD
0.72
0.93
0.865
0.051
0.75
0.94
0.847
0.063
0.107
Uterine artery PI:
- Min
- Max
- Mean
- SD
1.35
3.10
2.473
0.472
1.65
3.01
2.317
0.539
0.093

34. • no previous study measure the uterine artery
Doppler in cases of adenomyosis and compare
them with those who are not documented
histopathologicaly to have it ,
• Also there was no other study specify the
number of myometrial cysts in cases of
adenomyosis

35. Other studies
Prevalence Sensitivity Specificity PPV NPV
Siedler et al. 8/80(10) 63 97 71 _
Fedele etal 22/43 (51) 80 74 73 81
Asher etal 17/20 (85) 86 50 90 20
Reinholdet al. 29/100 (29) 86 86 71 94
Brosen et al 28/56 (50) 53 75 86 77
Reinhold et al. 18/119 (`15) 89 89 71 96
Atzori et al. 15/175 (8.6) 86 96.2 68.4 98
Vercelini et al. 29/102(28) 82.7 67 50 90.7
Atri et al. 30/102(29.4) 81 71 54 90
Bazot et al. 40/120(33) 65 97.5 92.8 88.8
Bazot et al. 23/106(21.7) 80.9/38.4 100/97.5 100/83.3 40/82.9
Kepkek et al. 26/70(37.1) 80.8 61.4 55.3 84.4
Our study 37/352(10.5) 75.6 90.79 49.12 96.95

36. • This study had the privilege of including a
large sample volume but still there may be a
need of further studies with larger sample
volume to put a scoring system including both
the clinical and ultrasonographic criteria for
diagnosis of adenomyosis with a high
accuracy.

37. • We try to find if we can add uterine artery
Doppler in the ultrasound features for
adenomyosis but there was no statistical
difference in either uterine artery Doppler
indices (RI,PI) in both adenomyotic cases and
non adenomyotic ones.

38. Limitations
• different pathologists examine the
hysterectomy specimens
• in cases where there is focal adenomyosis
• the inclusion of only hysterectomized cases

39. Conclusion
• subendometrial linear echogenic striations
showed the highest specificity and accuracy .
• The myometrial cysts show a high negative
predictive value and their number (if more
than 2) represent the highest accuracy.
• Uterine artery Doppler study can't be used to
diagnose adenomyosis.