Important aspects in diagnosing adenomyosis

F Kleinsorge, Monika Schmidmayr, Vanadin Seifert‐Klauss
In: Geburtshilfe und Frauenheilkunde · 2015 · vol. 75(07) · doi:10.1055/s-0035-1558387 · W2617725655
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This paper reviews transvaginal sonographic criteria for diagnosing adenomyosis, noting that while definitive diagnosis currently requires hysterectomy, ultrasound offers a non-invasive alternative to guide treatment beyond surgery.

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This study evaluated the clinical relevance of nine specific transvaginal sonographic criteria for diagnosing adenomyosis in patients attending an endometriosis center. The researchers analyzed the association between these imaging features and patient-reported outcomes, including pain intensity, dyspareunia, and ovulatory status. Results indicated that pain symptoms were inconsistently linked to sonographic signs, whereas anovulatory cycles were associated with a higher presence of adenomyosis indicators. This paper is centrally about adenomyosis — specifically assessing the diagnostic accuracy and symptom correlation of ultrasound criteria for this condition.

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Abstract

Adenomyosis is defined as focal or diffuse endometrial tissue within the myometrium. Patients may present with dysmenorrhoea, irregular bleeding, pelvic pain and/or dyspareunia, symptoms which may also be due in part to other hormone-dependant pelvic lesions e.g. uterine fibroids, endometriosis, endometrial hyperplasia and/or polyps. Up to now adenomyosis can be suspected, but not diagnosed by clinicians, and a definite diagnosis is only reached by pathologists after hysterectomy. Current literature suggests transvaginal sonographic criteria which in combination may be a fairly accurate diagnostic test (Meredith et al 2009, AJOG). The possibility of ultrasound diagnoses offers options for effective treatment apart from hysterectomy. The clinical relevance of these signs has not been evaluated extensively.
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Introduction

Adenomyosis is defined as focal or diffuse endometrial tissue within the myometrium. Patients may present with dysmenorrhoea, irregular bleeding, pelvic pain and/or dyspareunia, symptoms which may also be due in part to other hormone-dependant pelvic lesions e.g. uterine fibroids, endometriosis, endometrial hyperplasia and/or polyps. Up to now adenomyosis can be suspected, but not diagnosed by clinicians, and a definite diagnosis is only reached by pathologists after hysterectomy. Current literature suggests transvaginal sonographic criteria which in combination may be a fairly accurate diagnostic test (Meredith et al 2009, AJOG). The possibility of ultrasound diagnoses offers options for effective treatment apart from hysterectomy. The clinical relevance of these signs has not been evaluated extensively.

Methods

Various ultrasound features of adenomyosis have been described in the literature and nine of these diagnostic criteria are currently applied routinely in our endometriosis center: 1. Sub-endometrial microcysts (1 – 7 mm), 2. subendometrial hyperdense linear striations, 3. subendometrial myometrial cysts, 4. poor definition of the endometrial-myometrial junction, 5. hyperechoic nodules, 6. question mark-sign, 7. linear pattern of vascularisation on Doppler sonography, 8. asymmetrical myometrial walls, 9. enlarged uterus walls. The association of VAS pain score, dyspareunia and ovulatory activity with these features in patients attending the endoemtriosis outpatient clinic were analyzed. Visual analog pain scale was used to quantify intensity of pain.

Results

Pain intensity, dypareunia and pain during orgasm were inconsistently associated with signs of adenomyosis. In patients attempting to become pregnant, information on ovulatory vs. anovulatory cycles was also analyzed. Anovulatory cycles were associated with more signs of adenomyosis, which may also reflect a pathogenetic factor.

Discussion

Sonographic diagnosis of adenomyosis has been suggested, if three of the nine suggested signs of adenomyosis are present. Apart from the correlation between the single and combined sonographic criteria and histology, the correlation of these criteria with pain intensity, burden of symptoms and anovulation will help to adequately assess the clinical relevance of adenomyosis and open a field for early treatment in women not undergoing hysterectomy.

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endometriosisadenomyosisdysmenorrheadyspareunia

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