{"paper_id":"7b103385-80c8-4d0a-9f38-a4c47a798955","body_text":"154Copyright © All rights are reserved by Kulvinder Kochar Kaur.\nOpen Access Journal of Reproductive  \nSystem and Sexual Disorders\nShort Communication\nAdvances in Adenomyosis Diagnosis Utilizing \nTransvaginal Ultrasonography-A Short Summary\nKulvinder Kochar Kaur1*, Gautam Allahbadia2 and Mandeep Singh3\n1Department of Human Reproduction, India\n2Department of Obstetrics & Gynecology, India\n3Department of Neurology, India\n*Corresponding author: Kulvinder Kochar Kaur, Scientific Director, Centre of Human Reproduction, 721, G.T .B. Nagar, \nJalandhar-144001, Punjab, India\nReceived: \n  December 05, 2018                                                                                                                           Published: \n  December 10, 2018\nShort Communication\nAdenomyosis is a frequent condition, being present in 20% \nof general gynae population [1,2] and 30-40% of those attending \nassisted reproductive technology clinics, having a detrimental \neffect on cases of in vitro fertilization (IVF) [3,4]. Its main \ncharacteristics are presence of heterotopic endometrial glands and \nstroma within the myometrium, >2.5mm in depth of myometrium \nor more than one microscopic field at 10times magnification from \nthe endometrium-myometrium junction, along with a variable \ndegree of adjacent myometrial hyperplasia, causing globular and \ncystic enlargement of the myometrium, with some cysts filled with \nextravasated, hemolyzed red blood cells and siderophages [5]. Till \nnow the main belief was that this could only get diagnosed with the \nuse of histology only. As this disease gets commonly encountered \nin women over 40yrs, a belief got created that it was not a real \ndisease. With the use of some imaging techniques like the magnetic \nresonance imaging and transvaginal ultrasound (TVS), it was \nfound that adenomyosis had a typical appearance, which could be \nalso detected in younger women, in the presence of symptoms or \nwithout, where it was found to have a typical appearance [6]. \nTVS is done in women of all ages and it showed typical \nsonographic findings, Different ultrasound imaging studies \nhave been done to examine the diagnostic accuracy for finding \nadenomyosis as compared to that of histological examination of \nhysterectomy specimens. Also, the correlation of symptoms has \nbeen done. Biggest problem of using histology for adenomyosis \ndiagnosis remains the big selection bias that has been observed. It  \n \nhad been seen that patients who had hysterectomy were usually in \nan advanced age and revealed heavy symptoms justifying surgery \nand thus do not represent the normal population. When a diagnosis \nof diffuse adenomyosis was done using TVS in younger fertile \nwomen who were with or without pain symptoms, a histological   \nconfirmation was found very occasionally of adenomyosis [7].\nInspite of this recently Tellum et al [8] tried to find the accuracy \nof TVS in diagnosis of adenomyosis. Using both 2D and 3D TVS, \nalong with clinical symptoms, confirmed by histopathological \nexamination they gave a predictive model, which showed a good \ntest quality (area under curve [AUC]=0.86 [95% confidence \ninterval=0.79-0.94], optimal cutoff 0.56, sensitivity of 85%, \nspecificity78%).  These 9 predictors were included ([sensitivity, \nspecificity, β] or [AUCβ]; presence of myometrial cysts (51%,86%, \nβ=0.86), fan shaped echo (36%, 92%, β=0.54), hyperechoic islets \n(51%, 78%, β=0.62), globular uterus (61%, 83%, β=0.2), normal \nuterine shape (83%, 61%, β=-0.75), thickest to thinnest ratio for \nuterine wall (0.61, β=0.26), maximum width of the junctional zone \nin sagittal plane (0.71, β=0.1), regular appearance of junctional \nzone (31%, 92%, β=-1.0) and grade of dysmenorrhea measured on \na verbal numerical scaling (0.61, β=0.08). In view of various other \nstudies, including that of Tellum et al. [8] showing a high accuracy \nof diagnosis, one can accept that one can make the diagnosis of \nadenomyosis just using ultrasonography (USG). One will be able to \ncorrelate the disease to real symptoms and fertility in the general \npopulation. Presence of one or more of USG features has often been \nobserved in asymptomatic young ladies.\nISSN: 2641-1644\nDOI: 10.32474/OAJRSD.2018.02.000128\n\nCitation: Kulvinder Kochar K, Gautam Allahbadia, Mandeep S. Advances in Adenomyosis Diagnosis Utilizing Transvaginal Ultrasonography-A \nShort Summary. Open Acc J Repro & Sexual Disord 2(1)- 2018. OAJRSD.MS.ID.000128. DOI: 10.32474/OAJRSD.2018.02.000128.\n                                                                                                                                                                              Volume 2 - Issue 1Open Acc J Repro & Sexual Disord. Copyrights @ Kulvinder Kochar Kaur, et al. 155\nThe big problem encountered in this is that studies published \ntill now on TVS and adenomyosis do not clearly represent how \nmany features need to be considered for the final diagnosis of \nadenomyosis, since the prevalence of disease is in homogenous \nstudy populations. Yet TVS not only finds different features but \ncan also give different configurations and localization inside the \nuterus as per the different histopathological adenomyosis types in \nthe myometrium, namely the diffuse, focal and adenomyoma [9]. \nImportant is not the number of features for finding adenomyosis \nsince different features might be present in small focal adenomyosis \nand little features in a diffuse disease. Further the localization \nas per inner myometrium (junctional zone), or middle or outer \nmyometrium, as per the degree of myometrium involvement may \nbe important in describing adenomyosis by USG [10].\nSince it is so like fibroids, adenomyosis must be described better \ninside to uterus for evaluating the impact on symptoms especially \nof infertility and treatment and utilize CA125 for differentiating the \n2 [11]. Tellum et al [8] studies in certain ways like several features \nand thickness of the wall in their  predictive model, confirmed that \nnumber of single USG features was not enough for providing an \naccurate diagnosis of adenomyosis .Still their   predictive model \ncan’t be used in the general population as age, fertility, association \nto deep infiltrating endometriosis, the type (focal, diffuse) and the \nextension inside the myometrium of the adenomyosis have not been \nconsidered. Further, the correlation to pain symptoms correlating \nwith menorrhagia in this study is to be queried as they included all \npatients who had surgery (mostly for symptomatic indications), of \nwhich 48% of patients having adenomyosis also had endometriosis, \nboth can’t cause similar symptoms.\n Thus, although relevant one can use TVS for the diagnosis \nof adenomyosis, in view of it being an accurate and easy along \nwith cheaper method that can be done on all types of patients. \nPresence of just a single TVS feature is not enough for the \ndiagnosis of adenomyosis. Also, the correlation of presence or \nabsence of symptoms to adenomyosis appears very superficial. \nJust as endometriotic disease where ovarian, retroperitoneal and \nsuperficial disease had different effects in symptoms, treatment, \nprognosis, type and degree of adenomyosis might also be \nconsidered in the management of adenomyosis. Thus, in future TVS \nwill have an important role in evaluating adenomyosis, which might \nrequire expert sonologists in centers dedicated for diagnosing this.\nReferences\n1. Naftalin J, Hoo W, Pateman K, Mavrelos D, Holland T , et al. (2012) How \ncommon is adenomyosis? Aprospective study of prevalence using \ntransvaginal ultrasound in gynaecology clinic. Hum Reprod 27(12): \n3432-3439.\n2. Maheshwari A, Gurunath S, Fatima E, Bhattacharya S (2012) Adenomyosis \nand sub fertility: a systematic review of prevalence, diagnosis, treatment \nand fertility outcomes. Hum Reprod Update 18(4): 374-392.\n3. Younes G, Tulndi T (2017) Effects of adenomyosis on in vitro fertilization \ntreatment outcomes: a meta-analysis. Fertil Steril 108(3): 483-490.\n4. Li X, Liu X, Guo SW (2014) Clinical profiles of 710 premenopausal women \nwith adenomyosis who underwent hysterectomy. J Obstet Gynecol Res \n40(2): 485-494.\n5. Tsui KH, Lee WL, Chen CY, Sheu BC, Yen MS, et al. (2014) Medical \ntreatment for adenomyosis and/or adenomyoma. Taiwan J Obstet \nGynecol 53(4): 459-465.\n6. Exacoustos C, Manganaro L, Zupi E (2014) Imaging for the evaluation \nof endometriosis and adenomyosis. Best Pract Res Clin Obstet Gynaecol \n28(5): 655-681.\n7. Pinzauti S, Lazzeri L, Tosti C, Centini G, Orlandini C, et al. (2015) \nTransvaginal sonographic features of diffuse adenomyosis in 18-30 \nyrs-old nullugravid women without endometriosis: association with \nsymptoms. Ultrasound Obstet Gynaecol 46(6): 730-736.\n8. Tellum T , Nygaard S, Skovholt EK, Qvigstad E, Lieng M (2018) \nDevelopment of a clinical prediction model for diagnosing adenomyosis. \nFertil Steril 110(5): 957-964.\n9. Ferenczy A (1998) Pathophysiology of adenomyosis. Hum Reprod \nUpdate 4(4): 312-322.\n10. Van de Boch T , De Bruijn AM, De Leeuw RA, Dueholm M, Exacoustos \nC, et al. (2018) A sonographic classification and reporting system for \ndiagnosing adenomyosis. Ultrasound Obstet Gynaecol.\n11. Pal K, Chung JE, Pak HJ, Jeung IC, Kim JH, et al. (2015) Usefulness of \nCA125 in the differential diagnosis of uterine adenomyosis and myoma. \nEur J Obstet Gynaecol Reprod Biol 185: 131-135.\n Open Access Journal of Reproductive System and \nSexual Disorders\nAssets of Publishing with us\n• Global archiving of articles\n• Immediate, unrestricted online access\n• Rigorous Peer Review Process\n• Authors Retain Copyrights\n• Unique DOI for all articles\nThis work is licensed under Creative\nCommons Attribution 4.0 License\nSubmission Link:         \nSubmit Article\nDOI: 10.32474/OAJRSD.2018.02.000128","source_license":"CC0","license_restricted":false}