{"paper_id":"87aa26f1-39b8-486c-ae32-d95e527660d9","body_text":"CLINICAL PRACTICE\nLuteal phase transvaginal scan examinations\nhave better diagnostic potential for showing\nfocal subendometrial adenomyosis\nAhmed Abdel-Gadir & Oluseye O. Oyawoye &\nBina P. Chander\nReceived: 11 November 2010 / Accepted: 4 February 2011 / Published online: 22 February 2011\n# Springer-V erlag 2011\nAbstract The objective of this preliminary observational\nstudy was to monitor changes in focal cystic and non-cystic\nsubendometrial lesions reminiscent of adenomyosis seen\nduring the luteal phase of the cycle by repeating trans-\nvaginal ultrasound scan examinations during the follicular\nphase. Five patients who presented with abnormal uterine\nbleeding with or without dysmenorrhoea showed such\nlesions, following luteal phase transvaginal scanning. All\nlesions became smaller and less conspicuous, or an\nindiscriminate endometrial/myometrial interface was seen\nin the suspected areas during the follicular phase. Midcycle\nscanning of one patient showed enhancement of the\nirregular subendometrial area, but still without reaching\nthe same size, or attaining an echogenic pattern as seen\nduring the initial luteal phase examination. We hypothesise\nthat luteal phase transvaginal scan examinations of the\nuterus may have better potential for diagnosing focal\nsubendometrial adenomyosis than follicular phase scan-\nning. This is because of the echogenic characteristics of a\nsecretory endometrium relative to the neighbouring inner\nmyometrium. More work is needed to verify these findings\nand to test our hypothesis.\nKeywords Focal adenomyosis . Luteal ultrasound .\nEndometrial myometrial junction\nBackground\nAdenomyosis is a common cause of abnormal uterine\nbleeding and menstrual pain. Both magnetic resonance\nimaging (MRI) and transvaginal ultrasound scanning (TVS)\nhave been used for its diagnosis, and had good correlation\nto the histological examination results. However, MRI\nfindings are less observer-dependent than TVS, but still\nrely on the experience of the MRI observer in gynaeco-\nlogical imaging [ 1]. Furthermore, findings could fluctuate\nin response to hormonal changes [ 2]. Selective hystero-\nscopic resection could be helpful to remove lesions up to\n3-mm deep in patients presenting with excessive uterine\nbleeding [ 3]. To facilitate such resection, accurate pre\nsurgical localisation of these lesions is essential. Trans-\nabdominal uterine biopsy performed with an ultrasound-\ndirected biopsy gun had 100% accuracy in diagnosing\nmyometrial disease [ 4]. This is in contrast to blind\nmyometrial needle biopsies, which showed very low\nsensitivity for the diagnosis of subendometrial adenomyo-\nsis, even with multiple biopsies as reported by Brosens and\nBarker [ 5]. Two random myometrial biopsies picked 2.3%\nof adenomyotic lesions within the inner third of the\nmyometrium, and eight biopsies were only 9.0% sensitive\nfor diagnosing similar lesions as shown by the same\nauthors. MRI proved to be very sensitive in this respect.\nIt could show diffuse or focal thickening of the junctional\nzone, punctate foci of high-signal intensity, and ill-defined\nareas of low-signal intens ity in the myometrium on\nT2-weighted imaging [ 2]. However, MRI is not readily\navailable in many developing countries, and when present,\nservices are usually prioritised to deal with more urgent\nmedical and surgical problems. Even within the indepen-\ndent sector, the fees for having MRI examination are\nusually prohibitively high. Accordingly, efforts should be\nA. Abdel-Gadir ( *) : B. P . Chander\nLondon Female and Male Fertility Centre, Highgate Hospital,\n17-19 View Road,\nLondon N6 4DJ, UK\ne-mail: AhmedAGadir@aol.com\nO. O. Oyawoye\nDepartment of Obstetrics and Gynaecology,\nNewham University Hospital,\nGlen Road, Plaistow,\nLondon E13 8SL, UK\nGynecol Surg (2012) 9:43 –46\nDOI 10.1007/s10397-011-0666-8\n\nmade to improve the accuracy of ultrasound scanning,\nwhich is the natural first-choice imaging technique for\ninvestigation of abnormal uterine bleeding and pelvic pain.\nThis would also help with accurate selection of the right\nsites for needle biopsies, or hysteroscopic resection, when\nindicated. This is especially so as ultrasound machines are\nmore readily available and cheaper to use than MRI for that\npurpose. The objective behind this observational study was\nto monitor changes in focal subendometrial lesions remi-\nniscent of adenomyosis seen during the luteal phase of the\ncycle, by repeating the scan examinations during the\nfollicular phase.\nMethod\nFive patients who showed subendometrial focal lesions\nreminiscent of adenomyosis during luteal phase trans-\nvaginal ultrasound scan examinations were re-examined\nduring the follicular phase. Changes in the size and\nechotexture of the focal lesions were noted. All patients\nhad their initial scan because of recent episodes of\nabnormal uterine bleeding, with or without painful men-\nstruation. There was no evidence of endometrial polyps or\nintracavitary uterine fibroids.\nFindings\nLuteal phase transvaginal ultrasound scan examination\nshowed echogenic endometrium in all five cases, with\nsubendometrial cysts with echogenic margins or non-cystic\nechogenic lesions reminiscent of focal adenomyosis. This\npicture was represented by Figs. 1a, 2a, 3a and 4a in four\ndifferent patients. Follow-up scans during the follicular\nphase showed diminution in the size or loss of these\nsubendometrial lesions in all cases. Instead, the lesions\nwere represented by indiscriminate EMI or by small\nFig. 1 a Shows an oblique transvaginal ultrasound scan view of a\nuterus during the luteal phase. Subendometrial cysts with echogenic\nmargins are seen on the right side and in front of the left edge of a\nsimilarly echogenic endometrium. b Shows a similar view of the same\nspecimen depicted in a. It reveals indiscriminate EMI during the early\nfollicular phase. The cystic areas with echogenic margins seen in a are\nno longer visible\nFig. 2 a Shows an anterior/posterior transvaginal ultrasound view of\na uterus with a large hypoechoic cyst with an echogenic margin in\nfront of the endometrial echo. Examination was done during the late\nluteal phase of the cycle. b Shows an early follicular phase ultrasound\npicture of the same specimen depicted in a. The abnormal cystic area\nis represented by indiscriminate EMI marked by two arrows\n44 Gynecol Surg (2012) 9:43 –46\n\nirregular areas, as seen in Figs.1b, 2b, 3b and 4b respectively.\nMidcycle scanning of one patient showed enhancement of\nthe irregular subendometrial area, but still without reaching\nthe same size, or attaining an echogenic pattern as seen\nduring the initial luteal phase examination. 3D rendering of\nthe uterus during the luteal phase in the fifth patient revealed\nfundal adenomyotic striations which were not shown by the\n2D sagittal or axial views, as shown in Fig. 5.\nDiscussion\nIn a histologically verified ultrasound study, Kepkep et al.\n2007 [6] found subendometrial linear striations, myometrial\ncysts and globular appearance of the uterus had very high\naccuracy for the diagnosis of adenomyosis. Subendometrial\nlinear striations were the most specific sonographic feature\n(95.5%), and had the highest positive predictive value\n(80.0%). However, they stressed the point that transvaginal\nscan examination was more useful in excluding than\nFig. 3 a Image is an anterior/posterior view of a uterus showing\nsubendometrial cysts with echogenic margin in the posterior uterine\nwall during the luteal phase of the cycle. b Image is a similar\nultrasound view to the one shown in a. It shows early follicular phase\nindiscriminate EMI and disappearance of the cystic subendometrial\nlesions depicted in a\nFig. 4 a Shows an oblique view of a uterus during the luteal phase\nwith 14.8×8.6 mm circumscribed area of similar texture and\nechogenicity to the overlying and adjacent endometrium, reminiscent\nof adenomyosis. b Shows early follicular phase anterior/posterior\nultrasound picture of the same uterus depicted in a. The size of the\nsuspected adenomyotic area shown in a is reduced to 5.3×3.8 mm\nFig. 5 Shows multiplanar views of a uterus with luteal phase echogenic\nendometrium. SectionsA and B represent sagittal and axial views of the\nuterus, respectively and show no evidence of endometrial incursions\ninto the myometrium. Fundal adenomyotic lesions are shown in section\nD, which is a rendered 3D view of the same uterus\nGynecol Surg (2012) 9:43 –46 45\n\nconfirming the diagnosis, as the negative and positive\npredictive values were 84.4% and 55.3% respectively. A\nhigher negative predictive value of 96% for transvaginal scan\nexamination was reported previously by Reinhold et al. in\n1996 [7]. These authors found 2 –6m mm y o m e t r i a lc y s t si n\n46% of the patients with histologically diagnosed adeno-\nmyosis. More important, none of the patients who proved\nhistologically free from adenomyosis showed any myome-\ntrial cysts on presurgical transvaginal scan examination.\nIn this preliminary study, we used a reversed strategy, by\nfollowing well-defined subendometrial cystic lesions with\nechogenic margins and non-cystic echogenic lesions seen\nduring the luteal phase, to ascertain their echotexture and\nsize during the follicular phase of the cycle. All lesions\nbecame less conspicuous, or an indiscriminate EMI was\nseen instead in the affected area. Since an echogenic\nendometrium is a luteal phase ultrasound characteristic, it\nis expected that luteal phase scanning would be more\nsensitive to reveal areas of intramural echogenic endome-\ntrial growth or cystic areas with echogenic margins, against\nthe non-echogenic inner myometrium, compared to exami-\nnations performed at other times of the cycle. V ariations in\nthe echotexture of these subendometrial lesions during the\ndifferent phases of the cycle could be a factor in explaining\nthe differences in the quoted statistical accuracy of\nultrasound scanning in diagnosing adenomyosis, depending\nwhen the scans were preformed. When available, 3D\nultrasonography could help in making the diagnosis\nespecially with fundal lesions which were not shown by\nroutine 2D scanning, as shown in Fig. 5. With all this in\nmind, we put forward a hypothesis that scanning the uterus\nduring the luteal phase might reveal focal subendometrial\nlesions reminiscent of adenomyosis and help with the\ndiagnosis in patients presenting with abnormal uterine\nbleeding and inconclusive follicular phase ultrasound\nresults. This could add to the diagnostic value of ultraso-\nnography taking into account the very high specificity of\nboth cystic and non-cystic lesions, and the high negative\npredictive value of ultrasound scanning [ 6, 7]. Alternative\nmethods to help with the diagnosis in such cases are either\ntoo expensive (MRI), insensitive (hysteroscopy) or unavail-\nable in certain areas. In agreement with a statement made\nby Margit and Erik in 2007 [ 1], MRI would be needed only\nwhen transvaginal ultrasound scan examination gives\nindefinite findings and in difficult cases with coexisting\nother uterine abnormalities. .\nConclusion\nFocal cystic and non-cystic subendometrial lesions remi-\nniscent of adenomyosis were detected more readily during\nluteal rather than follicular phase transvaginal ultrasound\nscanning in this small study. More work is needed to verify\nthis finding and to test our hypothesis regarding the value\nof luteal phase transvaginal scanning of the uterus in the\ndiagnosis of focal subendometrial adenomyosis. Positive\nfindings would improve the accuracy of needle biopsies for\nhistological diagnosis, and facilitate hysteroscopic resection\nwhen indicated. This is especially important in countries\nwhere MRI is not readily available or too expensive to\nafford.\nDeclaration of interest The authors report no conflicts of interest.\nReferences\n1. Margit D, Erik L (2007) Transvaginal ultrasound or MRI for\ndiagnosis of adenomyosis. Curr Opin Obstet Gynecol 19(6):505 –\n512\n2. Tamai K, Koyama T, Umeoka S, Saga T, Fujii S, Togashi K (2006)\nSpectrum of MR features in adenomyosis. Best Pract Res Clin\nObstet Gynaecol 20(4):583– 602\n3. Levgur M (2007) Therapeutic options for adenomyosis: a review.\nArch Gynecol Obstet 276(1):1 –15\n4. Wood C, Hurley V A, Fortune DW, Leoni M (1993) Percutaneous\nultrasound guided uterine needle biopsy. Med J Aust 158(7):458 –\n460\n5. Brosens JJ, Barker FG (1995) The role of myometrial biopsies in\nthe diagnosis of adenomyosis. Fertil Steril 63(6):1347 –1349\n6. Kepkep K, Tuncay Y A, Tutal GE (2007) Transvaginal sonography\nin the diagnosis of adenomyosis: which findings are most accurate?\nUltrasound Obstet Gynecol 30(3):341 –345\n7. Reinhold C, McCarthy S, Bret PM, Mehio A, Atri M, Zakarian R,\nGlaude Y , Liang L, Seymour R (1996) Diffuse adenomyosis:\ncomparison of endovaginal US and MR imaging with histopatho-\nlogical correlation. Radiology 199:151 –158\n46 Gynecol Surg (2012) 9:43 –46","source_license":"CC0","license_restricted":false}