{"paper_id":"30c874e4-9600-4cd3-b9ed-894efd7cf3a1","body_text":"- Visibility 1.2k Views\n- Downloads 233 Downloads\n- Permissions\n- CrossMark\n- Citation\nRole of TVS and MRI imaging in perimenopausal bleeding\n- Author Details:\n-\nNirmala C Chudasama\n-\nJaykumar D Goti *\n-\nKinjalben R Patel\n-\nBhagyesh V Prajapati\nAbstract\nIntroduction: Abnormal uterine bleeding is any variation in the normal menstrual cycle, Includes: changes in frequency, duration and amount of blood loss during or in between the cycles. Approximately 70% of all gynecological consultations in perimenopausal and postmenopausal women are for abnormal uterine bleeding. There complaints may significantly affect the quality of life and lead to surgical intervention. TVS is an inexpensive, non-invasive, easly available and a convenient method to assess the uterine pathology. It is recommended as the 1st line diagnostic tool for assessing uterine pathology in perimenopausal age women presenting with abnormal uterine bleeding.\nAims and Objectives: To differentiate and characterize uterine and ovarian lesions based on MRI and TVS findings. To identify organ of origin of uterine and ovarian lesions based on MRI and TVS findings. To diagnose pathologies which have a difficulty in detection with TVS.\nMaterials and Methods: 40 patients in perimenopausal age group with complain of abnormal uterine bleeding were subjected to TVS and MRI examination. Final correlation with histopathology was done wherever it was acquired.\nResults: Among 40 females, majority of them were in pre menopause period 25 (62.5%) and the rest in the post menopause period 15(37.5%). Among 40, majority were diagnose fibroids 14(37.5%), adnexal lesions 11(27.5%), carcinoma of cervix 5(12.5%), endometrial lesions 6(12.5%)and adenomyosis 4(10.0%). Adnexal lesions start in early age itself (35±2). Endometrial lesions(51±8) and carcinoma of cervix(55±6) were reported mostly in the post menopausal periods. Fibroids (40±5)and Adenomyosis(42±4) were reported in middle age. Among 11 patients TVS diagnosed 4 as Complex Adnexal Cysts, 3 as Dermoid, 2 as Simple ovarian Cyst, 1 as haemorrhagic Cyst and 1 as Possibly hydrosalphinx and MRI diagnosed 3 as Complex Adnexal Cysts, 3 as Dermoid, 2 as Simple ovarian cysts, 2 as haemorrhagic cyst and 1 as Hydrosalphinx.\nConclusions: MRI is found to be more accurate and precise in comparison to ultrasound to characterize, localize and evaluate the number of lesions both benign and malignant along with its staging in pelvic pathologies. While TVS lacks specificity and sensitivity in relation to MRI but acts as a great screening tool in evaluation and further management. MRI is accordingly a more precise preoperative imaging modality for portraying and distinguishing the distinct features of varied lesions.\nIntroduction\nAbnormal uterine bleeding is any variation in the normal menstrual cycle, Includes: changes in frequency, duration and amount of blood loss during or in between the cycles.[1]\nApproximately 70% of all gynecological consultations in perimenopausal and postmenopausal women are for abnormal uterine bleeding. There complaints may significantly affect the quality of life and lead to surgical intervention.[2]\nAbnormal perimenopausal or postmenopausal bleeding is associated with endometrial carcinoma in approximately 10% of cases and is considered to be caused by endometrial neoplasia until proven otherwise.[3], [4]\nApproximately 90% of women with endometrial carcinoma present with vaginal bleeding.\nIn 18% to 40% of women, benign focal lesions, such as endometrial polyps and fibroids, are common. Although PMB is most commonly due to other conditions, it is essential to exclude endometrial carcinoma.[5]\nTVS is an inexpensive, non-invasive, easily available and a convenient method to assess the uterine pathology.\nIt is recommended as the 1st line diagnostic tool for assessing uterine pathology in perimenopausal age women presenting with abnormal uterine bleeding.[2], [4]\nDrawbacks include- limited field of view, obscuration of pelvis by bowel gas and its dependence on the skill expertise.[6]\nIn the pelvis, MRI appears to have a 91-93% overall precision for characterising benign and malignant lesions particularly when contrast techniques are used.[5], [7], [8]\nMagnetic resonance imaging because of its high resolution and multi planar imaging and its capability to characterize multiple lesions is becoming the modality of choice to assess the pathologies of pelvis.[9]\nClassification of lesions[10]\nLesions of myometrium - Leiomyoma and adenomyosis.\nLesions of endometrium - Endometrial polyp, endometrial hyperplasia and endometrial carcinoma.\nLesions of cervix - Cervical carcinoma, cervicitis.\nAdnexal lesions - Hydrosalpinx, hematosalpinx, pyosalpinx, simple. ovarian cysts, hemorrhagic ovarian cyst, endometriotic cysts and dermoid cysts.\nAims and Objectives\nTo differentiate and characterize uterine and ovarian lesions based on MRI and TVS findings.\nTo identify organ of origin of uterine and ovarian lesions based on MRI and TVS findings.\nTo diagnose abnormalities which have a difficulty in detection with TVS.\nMaterials and Methods\nStudy design\nProspective case control study.\nSample size\n40 patients in perimenopausal age group with complain of abnormal uterine bleeding attending OPD at C.U. Shah medical college and hospital.\nAll patients were subjected to TVS and MRI examination.\nFinal correlation with histopathology was done wherever it was acquired.\nTVS was performed on Affinity Philips 70G transvaginal transducer.\nMagnetic resonance imaging of pelvis was performed with 1.5T SIEMENS machine.\nClinical history was taken, TVS was done and the findings were noted.\nInformed consent was taken from all patients & MRI was done using standard protocol.\nAll patients were followed up when it was possible.\nHistopathology reports were collected when necessary from patients who underwent surgery or biopsy.\nExclusion criteria\nPatients of low socioeconomic status who didn’t agree to be a part of study.\nPatients who had claustrophobia (afraid of closed spaces).\nPatients inculcated with metallic bioimplants and grafts.\nUnmarried women were not considered for TVS.\nResult\nAmong 40 females, majority of them were in pre menopause period 25 (62.5%) and the rest in the post menopause period 15 (37.5%).\n|\n|\nFrequency |\nPercent |\n|\nPre menopause |\n25 |\n62.5 |\n|\nPost menopause |\n15 |\n37.5 |\n|\nTotal |\n40 |\n100 |\nAmong 40, majority were diagnose fibroids 14 (37.5%), adnexal lesions 11 (27.5%), carcinoma of cervix 5 (12.5%), endometrial lesions 6(12.5%) and adenomyosis 4 (10.0%).\n|\nNumber of Cases |\nFrequency |\nPercent |\n|\nFibroids |\n14 |\n35.5 |\n|\nAdenomyosis |\n4 |\n10.0 |\n|\nCarcinoma of cervix |\n5 |\n12.5 |\n|\nAdnexal lesions |\n11 |\n27.5 |\n|\nEndometrial lesions |\n6 |\n15 |\n|\nTotal |\n40 |\n100 |\n[Table 2] describes that adnexal lesions start in early age itself (35±2). Endometrial lesions (51±8) and carcinoma of cervix (55±6) were reported mostly in the post menopausal periods. Fibroids (40±5) and Adenomyosis (42±4) were reported in middle age.\n|\nFinal diagnosis |\nMean Age |\n|\nFibroids |\n40±5 |\n|\nAdenomyosis |\n42±4 |\n|\nCarcinoma of cervix |\n55±6 |\n|\nAdnexal lesions |\n35±2 |\n|\nEndometrial lesions |\n51±8 |\n[Table 3] describes that out of 4 cases TVS could detect only 2 as Adenomyosis and other 2 were? Adenomyosis.\nThis explains that there is significant difference in diagnosing adenomyosis using TVS and MRI.\n|\nTVS Diagnosis |\nMRI Diagnosis |\nTotal |\n|\n|\n|\nAdenomyosis |\nAdenomyosis with fibroid uterus |\n|\n|\n? Adenomyosis |\n2 |\n0 |\n2 |\n|\n? Adenomyosis with fibroid uterus |\n0 |\n1 |\n1 |\n|\nAdenomyosis |\n1 |\n0 |\n1 |\n|\nTotal |\n3 |\n1 |\n4 |\nAmong 4 cases of adenomyosis MRI detect all (100%) where in TVS showed only 2 cases as positive.\nSensitivity =50%\nPositive likelihood ratio = 0.5\nSensitivity = 60%\nPositive predictive value (PPV) = 60%\nPositive likelihood ratio = 0.9\nOut of 8 cases TVS picked up 3 cases as positives were as HPE picked up all 5 cases of ca cervix. The true positives were 3 and true negatives were 1, there were 2 false negative and 2 false positives by the diagnosing test. There is no significant association detected.\n|\nCa Cervix TVS |\nHPE |\n||\n|\nPresent |\nAbsent |\nTotal |\n|\n|\nPresent |\n3 |\n2 |\n5 |\n|\nAbsent |\n2 |\n1 |\n3 |\n|\nTotal |\n5 |\n3 |\n8 |\nSensitivity 100%,\nPPV = 100%\nOut of 8 samples MRI and HPE picked all 5 cases of ca cervix. The true positives were 5 and true negatives were 3. There is significant association detected.\n|\nMRI |\nCa Cervix HPE |\n||\n|\nPresent |\nAbsent |\nTotal |\n|\n|\nPresent |\n5 |\n0 |\n5 |\n|\nAbsent |\n0 |\n3 |\n3 |\n|\nTotal |\n5 |\n3 |\n8 |\nOut of 16 samples TVS picked up 6 cases as positive whereas HPE picked 6 cases of Endometrial Lesions. The true positives were 4 and true negatives were 8, there were 2 false positives and 2 false negatives by the diagnosing test.\nSensitivity = 66.6%\nSpecificity = 80%\nPositive predictive value (PPV) = 66.6%\nNegative predictive value (NPV) = 80%\n|\nTVS |\nEndo Lesions HPE |\n||\n|\nPresent |\nAbsent |\nTotal |\n|\n|\nPresent |\n4 |\n2 |\n6 |\n|\nAbsent |\n2 |\n8 |\n10 |\n|\nTotal |\n6 |\n10 |\n16 |\n|\nMRI |\nEndo Lesions HPE |\n||\n|\nPresent |\nAbsent |\nTotal |\n|\n|\nPresent |\n5 |\n1 |\n6 |\n|\nAbsent |\n1 |\n9 |\n10 |\n|\nTotal |\n6 |\n10 |\n16 |\nOut of 16 samples MRI picked up 5 cases as positive whereas HPE picked 6 cases of endometrial lesions. The true positives were 5 and true negatives were 9, there were 1 false positive and 1 false negative by the diagnosing test.\nSensitivity = 83.3%\nSpecificity = 90%\nPositive predictive Value (PPV) = 83.3%\nNegative predictive value (NPV) = 90%\n|\nTVS |\nMRI |\n|\n|\nSingle |\nMultiple |\n|\n|\nSingle |\n6 |\n3 |\n|\nMultiple |\nNIL |\n5 |\nThere is significant association between TVS and MRI.\nSensitivity =100%\nSpecificity = 62.5%\nPositive predictive value (PPV) = 66.6%\nNegative predictive value (NPV) =100%\n|\nTVS Diagnosis |\nFrequency |\nMRI Diagnosis |\nFrequency |\n|\nComplex Adnexal Cysts |\n4 |\nComplex Adnexal Cysts |\n3 |\n|\nDermoid |\n3 |\nDermoid |\n3 |\n|\nSimple Ovarian Cysts |\n2 |\nSimple Ovarian Cysts |\n2 |\n|\nHaemorrhagic Cyst |\n1 |\nHaemorrhagic Cyst |\n2 |\n|\nPossibly Hydrosalphinx |\n1 |\nHydrosalphinx |\n1 |\nThere is significant association between TVS and MRI.\nSensitivity =100%\nPositive predictive value (PPV) = 66.6%\nAmong 11 patients TVS diagnosed 4 as complex adnexal cysts, 3 as dermoid, 2 as simple ovarian Cyst, 1 as haemorrhagic cyst and 1 as possibly hydrosalphinx and MRI diagnosed 3 as complex adnexal cysts, 3 as dermoid, 2 as simple ovarian cysts, 2 as haemorrhagic cyst and 1 as hydrosalphinx.\nConclusions\nAbnormal uterine bleeding is a common symptom in perimenopausal women. Accurate diagnosis is essential to rule out benign or malignant conditions and provide the most appropriate treatment.[2], [4]\nTo characterize, localize and evaluate the number of lesions both benign and malignant along with its staging in pelvic pathologies, MRI is found to be more precise and many a times gold standard in comparison to ultrasound.[6], [11]\nIn cases of adenomyosis, MRI turned out to be more accurate in its diagnosis where as ultrasound was found indeterminate in visualizing the junctional zone.[12], [13]\nIn cases of fibroids in aiding their number and location, MRI turned out to be more superior than transabdominal and transvaginal ultrasound. In endometrial lesions, TVS can be used as a great screening tool. MRI was found to be crucial in determining myometrial invasion.[14]\nExtent of carcinoma cervix and its invasion to adjacent viscera was found to be superior in MRI compared to ultrasound.\nIn the adnexa lesions, characterization and differentiation of various types of lesions, TVS was less specific in contrast to MRI.\nFinally, we conclude that TVS lacks specificity and sensitivity in relation to MRI but acts as a better screening tool in evaluation and further management as it is cost effective, easily available and less time consuming. MRI is accordingly a more precise preoperative imaging modality for portraying and distinguishing the distinct features of varied lesions.\nSource of Funding\nNone.\nConflict of Interest\nNone.\nReferences\n- Saini A, Dina R, Mcindoe G, Soutter WP, Gishen P, deSouza N. Characterization of adnexal masses with MRI. AJR Am J Roentgenol. 2005;184(3):1004-9. [Google Scholar]\n- Schwartz L, Panageas E, Lange R. 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Indian Journal of Obstetrics and Gynecology Research, 9(4), 522-527. https://doi.org/10.18231/j.ijogr.2022.099\nMLA\nChudasama, Nirmala C, Goti, Jaykumar D, Patel, Kinjalben R, Prajapati, Bhagyesh V. \"Role of TVS and MRI imaging in perimenopausal bleeding.\" Indian J Obstet Gynecol Res, vol. 9, no. 4, 2022, pp. 522-527. https://doi.org/10.18231/j.ijogr.2022.099\nChicago\nChudasama, N. C., Goti, J. D., Patel, K. R., Prajapati, B. V.. \"Role of TVS and MRI imaging in perimenopausal bleeding.\" Indian J Obstet Gynecol Res 9, no. 4 (2022): 522-527. https://doi.org/10.18231/j.ijogr.2022.099","source_license":"CC0","license_restricted":false}