{"paper_id":"c096334b-9dda-49b0-bf60-e04114ddf229","body_text":"Citation: Akter, K., Khatun, F., Urmi, R. H., Kauser, U. S., & Alam, S. (2026). Diagnostic Value of Individual \nTransvaginal Ultrasound Criteria for Adenomyosis and Leiomyoma. Sch Int J Obstet Gynec, 9(8), 176-181. \nhttps://doi.org/10.36348/sijog.2026.v09i08.005 \n \n         176 \n \n \n \nScholars International Journal of Obstetrics and Gynecology \nAbbreviated Key Title: Sch Int J Obstet Gynec \nISSN 2616-8235 (Print) | ISSN 2617-3492 (Online) \nScholars Middle East Publishers, Dubai, United Arab Emirates \nJournal homepage: https://saudijournals.com  \n \n Original Research Article \n \nDiagnostic Value of Individual Transvaginal Ultrasound Criteria for \nAdenomyosis and Leiomyoma \nDr. Khadiza Akter1*, Dr. Mst. Faima Khatun2, Dr. Rukshana Haque Urmi3, Dr. Umme Sakia Kauser4, Dr. Shahrina Alam5 \n \n1Specialist, Department of Obstetrics and Gynecology, United Healthcare Services Ltd, Dhaka, Bangladesh \n2Specialist, Department of Obstetrics and Gynecology, BRB Hospitals Limited, Dhaka, Bangladesh \n3Specialist, Department of Obstetrics and Gynecology, United Healthcare Services Ltd, Dhaka, Bangladesh \n4Medical Officer, Directorate General of Health Services (DGHS), Dhaka, Bangladesh \n5Resident, Department of Obstetrics and Gynecology, BIRDEM Academy, Dhaka, Bangladesh  \n \nDOI: https://doi.org/10.36348/sijog.2026.v09i08.005     | Received: 28.06.2026 | Accepted: 22.08.2026 | Published: 29.08.2026 \n \n*Corresponding author: Dr. Khadiza Akter \nSpecialist, Department of Obstetrics and Gynecology, United Healthcare Services Ltd, Dhaka, Bangladesh \n \nAbstract  \n \nBackground: Adenomyosis and leiomyoma are common benign uterine disorders with overlapping clinical and imaging \nfeatures, making accurate preoperative diagnosis challenging. This study evaluated the diagnostic value of individual \ntransvaginal ultrasonography (TVS) cr iteria for adenomyosis and leiomyoma using histopathology as the reference \nstandard. Methods: This analytical cross-sectional study was conducted among 150 women aged 30 –55 years with TVS-\ndiagnosed adenomyosis, leiomyoma, or both who subsequently underwent  hysterectomy, myomectomy, or \nadenomyomectomy and had histopathological confirmation. Participants were enrolled using purposive sampling. \nIndividual TVS criteria for adenomyosis and leiomyoma were compared with corresponding histopathological findings. \nStatistical analyses were performed using SPSS version 26.0, with p<0.05 considered statistically significant.  Results: \nLeiomyoma was the most common diagnosis (61.33%), followed by combined adenomyosis and leiomyoma (26.00%) and \nadenomyosis alone (12.67%). For adenomyosis, no distinction of the endometrial-myometrial junction (78.9%), asymmetry \nof the anterior and posterior myometrium (83.3%), heterogeneous myometrial echotexture (80.3%) and myometrial cysts \nwith fibrosis (62.5%) showed significant associati ons with histopathology (all p<0.0001). For leiomyoma, clear tumor \nmargin demarcation (96.7%), peripheral vascularity on color Doppler (95.6%), irregular uterine surface (93.5%) and \nirregular endometrial surface (95.7%) were also significantly associated w ith histopathological confirmation (p≤0.005).  \nConclusion: Individual TVS criteria demonstrated significant diagnostic value for adenomyosis and leiomyoma. \nRecognition of these sonographic features may improve preoperative diagnostic accuracy and support appropriate clinical \nmanagement. \nKeywords: Adenomyosis; Leiomyoma; Transvaginal ultrasonography; Histopathology; Diagnostic accuracy . \nCopyright © 2026 The Author(s): This is an open -access article distributed under the terms of the Creative Commons Attribution 4.0 International \nLicense (CC BY-NC 4.0) which permits unrestricted use, distribution, and reproduction in any medium for non -commercial use provided the original \nauthor and source are credited. \n \nINTRODUCTION \nAdenomyosis and leiomyoma are among the \nmost common benign uterine disorders affecting women \nof reproductive age and are important causes of \nabnormal uterine bleeding, dysmenorrhea, chronic \npelvic pain, infertility and reduced quality of life [1]. \nThese co nditions frequently coexist, making accurate \npreoperative diagnosis challenging because of \noverlapping clinical manifestations and imaging findings \n[2]. Precise differentiation between adenomyosis and \nleiomyoma is essential for selecting appropriate \ntreatment, planning surgical interventions and \ncounseling patients regarding fertility preservation and \nlong-term management [3]. \n \nHistopathological examination remains the gold \nstandard for confirming the diagnosis of adenomyosis \nand leiomyoma [4]. However, histopathological \nconfirmation is only possible after surgical removal of \nuterine tissue, limiting its role in preoperative deci sion-\nmaking [5]. Therefore, reliable noninvasive imaging \ntechniques are essential for the accurate evaluation of \nwomen presenting with suspected uterine pathology [6]. \n \n\n\n \n \nAkter, K. et al; Sch Int J Obstet Gynec, Aug. 2026; 9(8): 176-181 \n© 2026 | Published by Scholars Middle East Publishers, Dubai, United Arab Emirates      177                                                                                     \n  \n \nTransvaginal ultrasonography (TVS) is widely \naccepted as the first -line imaging modality for the \nassessment of uterine abnormalities because it is readily \navailable, cost -effective, noninvasive and capable of \nproviding high-resolution visualization of the uterus and \nadnexa [7]. Advances in ultrasound technology, \nincluding high-frequency transvaginal probes and color \nDoppler imaging, have improved the detection of \ncharacteristic sonographic features associated with \nadenomyosis and leiomyoma [8]. In clinical practice, \nTVS plays a pivotal role in distinguishing between these \nconditions and guiding subsequent management [9]. \n \nSeveral individual sonographic criteria have \nbeen described for the diagnosis of adenomyosis, \nincluding loss of the endometrial -myometrial junction, \nasymmetry of the anterior and posterior myometrium, \nsubendometrial myometrial striations, myometrial cysts \nwith fibrosis and heterogeneous myometrial echotexture \n[10]. Similarly, characteristic ultrasound features of \nleiomyoma include clear tumor margin demarcation, a \nwhorled appearance of the lesion, peripheral vascularity \non color Doppler, irregularities of the uterine surface and \ndistortion of the endometrial surface in submucosal \ntumors [11]. Although combinations of these features are \ncommonly used to establish a diagnosis, the diagnostic \ncontribution of each individual criterion has not been \nfully elucidated [12]. \n \nThe present study was undertaken to evaluate \nthe diagnostic value of individual transvaginal \nultrasound criteria for adenomyosis and leiomyoma by \ncomparing each sonographic feature with the \ncorresponding histopathological diagnosis, thereby \nidentifying the  ultrasound findings that provide the \ngreatest diagnostic utility in clinical practice. \n \nMETHODOLOGY & MATERIALS \nThis analytical cross -sectional study was \nconducted in the Department of Obstetrics and \nGynecology, Bangladesh Institute of Research and \nRehabilitation in Diabetes, Endocrine and Metabolic \nDisorders (BIRDEM) General Hospital, Dhaka, from \nJanuary 2023 to Ju ne 2024. A total of 150 women aged \n30–55 years with transvaginal ultrasonography (TVS) -\ndiagnosed adenomyosis, leiomyoma, or both who \nsubsequently underwent hysterectomy, myomectomy, or \nadenomyomectomy and had available histopathological \nreports were enroll ed using purposive sampling. \nPostmenopausal women, patients with a uterus larger \nthan 16 weeks' size, uterine malignancy, endometriosis, \nor pelvic inflammatory disease were excluded. Data on \nsociodemographic characteristics, symptoms, menstrual \nand obstetr ic history, TVS findings and \nhistopathological results were collected using a pretested \nsemi-structured questionnaire. TVS examinations were \nperformed before surgery using a LOGIQ 9 ultrasound \nsystem (GE Healthcare, Milwaukee, WI, USA) equipped \nwith a 7–9 MHz endovaginal probe, with color Doppler \nevaluation. All examinations were interpreted by the \nsame investigator with 5 years of experience in female \npelvic sonography to minimize interobserver variation. \nThe assessed sonographic criteria for adenomyosis \nincluded no distinction of the endometrial -myometrial \njunction, asymmetry of the anterior and posterior \nmyometrium, subendometrial myometrial striations, \nmyometrial cysts and fibrosis and heterogeneous \nmyometrial echotexture, while those for leiomyoma \nincluded clear tumor margin demarcation, whorly tumor \nappearance, peripheral vascularity on color Doppler, \nirregular uterine surface and irregular endometrial \nsurface. Histopathological examination of the surgical \nspecimens served as the reference standard. Sta tistical \nanalysis was performed using SPSS version 26.0. \nContinuous variables were expressed as mean ± standard \ndeviation and categorical variables as frequency and \npercentage. Chi -square test, Fisher's exact test and \nANOVA were applied as appropriate, wit h a p -value \n<0.05 considered statistically significant. Ethical \napproval was obtained from the Institutional Review \nBoard of BIRDEM and written informed consent was \nobtained from all participants before enrollment. \n \nRESULTS \nThis analytical cross - sectional study was \nconducted to diagnose of adenomyosis, leiomyoma, or \ncombined adenomyosis and leiomyoma by the use of \ntransvaginal ultrasonography (TVS) which was \ncompared with histopathological findings. A total of 150 \nwomen who underwent hysterectomy or myomectomy \nor adenomyomectomy due to leiomyoma, adenomyosis \nor combined in the inpatient department of Obstetrics \nand Gynecology, BIRDEM General Hospital were \nenrolled for the study. The results, including tables, are \npresented within this chapter. \n \nTable I: Categorization of the respondents according to sociodemographic characteristic by groups  \nSociodemographic \ncharacteristic \nAdenomyosis \n(n=19) \nLeiomyoma \n(n=92) \nCombination of Adenomyosis \nand Leiomyoma (n=39) \nP value \nAge     \nMean ±SD 42.7 ± 2.3 41.3 ± 3.6 45.2 ± 2.0 0.523c \nEducational qualification     \nClass I-V 7 (36.8) 42 (45.6) 18 (46.2) 0.177* \nClass VI-X 5 (26.3) 30 (32.6) 14 (35.9) \nClass XI-XII 5 (26.3) 16 (17.3) 3 (7.7) \nGraduate 2 (10.5) 4 (4.3) 2 (10.3) \n\n \n \nAkter, K. et al; Sch Int J Obstet Gynec, Aug. 2026; 9(8): 176-181 \n© 2026 | Published by Scholars Middle East Publishers, Dubai, United Arab Emirates      178                                                                                     \n  \n \nSociodemographic \ncharacteristic \nAdenomyosis \n(n=19) \nLeiomyoma \n(n=92) \nCombination of Adenomyosis \nand Leiomyoma (n=39) \nP value \nOccupation     \nHousewife 18 (94.7) 76 (42.6) 33 (84.6) 0.042* \nWorking woman 1 (5.3) 15 (16.3) 6 (15.4) \nMonthly income     \nMean ±SD 40473.7 ± 5368.3 45695.7 ± 5395.8  38230.7 ± 7001.7 0.074c \nBMI (Mean ± SD) 23.7 ± 1.3 26.3 ± 1.3 25.8 ± 1.3 0.774c \ncANOVA test, * Fisher’s Exact test \n \nTable I shows that the mean age was similar \nacross groups (adenomyosis: 42.7 ± 2.3 years, \nleiomyoma: 41.3 ± 3.6 years, combination: 45.2 ± 2.0 \nyears; p = 0.523). In terms of education, most had a Class \nI-V education (adenomyosis: 36.8%, leiomyoma: 45.6%, \ncombination: 46.2%; p = 0.177). The majority were \nhousewives (adenomyosis: 94.7%, leiomyoma: 42.6%, \ncombination: 84.6%; p = 0.042). The mean monthly \nincome varied slightly (adenomyosis: 40,473.7 ± \n5,368.3, leiomyoma: 45,695.7 ± 5,395.8, combination: \n38,230.7 ± 7,001.7; p = 0.074). BMI averages are similar \nacross groups, approximately 23.7± 1.3 for \nAdenomyosis, 26.3± 1.3 for Leiomyoma and 25.8 ± 1.3 \nfor the combination group (p=0.774). \n \n \nFigure 1: TVS findings of uterine pathology \n \nFigure 1 illustrates that among the respondents, \nthe majority (61.33%) had leiomyoma, followed by \n26.00% with both adenomyosis and leiomyoma and \n12.67% had adenomyosis. \n \nTable II: Comparison of Various Diagnostic Criteria of Transvaginal Ultrasound (TVS) Findings with \nHistopathology for Diagnosis of Adenomyosis \nTVS (Adenomyosis) Histopathology (Adenomyosis) P value \nYes No \nNo distinction of the endometrial‑myometrial junction    \nYes  30 (78.9) 2 (1.7) <0.0001* \nNo 8 (21.0) 110 (98.2) \nAsymmetry of the anterior and posterior myometrium    \nYes  50 (83.3) 3 (3.3) <0.0001a \nNo 10 (16.6) 87 (96.6) \nMyometrial cysts and fibrosis    \nYes  10 (62.5) 1 (1.0) <0.0001*  \nNo 6 (37.5) 133 (99.0) \nHeterogeneous myometrial echotexture    \nYes  53 (80.3) 5 (5.9) <0.0001* \nNo 13 (19.6) 79 (94.0) \naChi square test, * Fisher’s Exact test \n \n\n\n \n \nAkter, K. et al; Sch Int J Obstet Gynec, Aug. 2026; 9(8): 176-181 \n© 2026 | Published by Scholars Middle East Publishers, Dubai, United Arab Emirates      179                                                                                     \n  \n \nTable II illustrates significant correlations \nbetween various Transvaginal Ultrasound (TVS) \nfindings for adenomyosis and their confirmation by \nhistopathology. TVS identified 78.9% of cases with no \ndistinction of the endometrial -myometrial junction, \nconfirmed by histopathology (p < 0.0001). Regarding \nasymmetry of the anterior and posterior myometrium, \n83.3% identified by TVS were confirmed by \nhistopathology (p < 0.0001). TVS identified myometrial \ncysts and fibrosis in 62.5% of cases confirmed by \nhistopathology (p < 0.0001). For heterogeneous \nmyometrial echotexture, 80.3% identified by TVS were \nconfirmed by histopathology (p < 0.0001). \n \nTable III: Comparison of Various Diagnostic Criteria of Transvaginal Ultrasound (TVS) Findings with \nHistopathology for Diagnosis of Leiomyoma \nTVS (Leiomyoma) Histopathology \n(Leiomyoma) \nP value \nYes No \nClear demarcation of the tumor margin    \nYes  120 (96.7) 11 (42.3) <0.0001* \nNo 4 (3.2) 15 (57.6) \nThe presence of blood vessels (by color Doppler) surrounding the tumor     \nYes  88 (95.6) 02 (3.4) 0.004a \nNo 4 (4.3) 56 (96.5) \nIrregularities of the uterine surface (subserous and intramural tumors)     \nYes  58 (93.5) 8 (9.0) 0.005a  \nNo 4 (6.4) 80 (90.9) \nIrregularities of the endometrial surface (submucous tumors type 1 and 2)     \nYes  67 (95.7) 2 (2.5) 0.004a \nNo 3 (4.2) 78 (97.5) \naChi square test, * Fisher’s Exact test \n \nTable III shows the comparison of transvaginal \nultrasound (TVS) findings with histopathology for \ndiagnosing leiomyoma showed that clear tumor margin \ndemarcation on TVS was highly correlated (96.7%) with \nhistopathological confirmation (p < 0.0001). TVS \nidentified 95.6% of cases of leiomyoma with presence of \nsurrounding blood vessels on color Doppler, confirmed \nby histopathology (p = 0.004). The irregularities of the \nuterine surface and irregularities of the endometrial \nsurface in TVS were significantly assoc iated with \nhistopathological confirmation of leiomyoma (93.5% \nand 95.7%, p= 0.005 and p = 0.004 respectively). \n \nDISCUSSION \nThe present study evaluated the diagnostic \nvalue of individual transvaginal ultrasonography (TVS) \ncriteria for adenomyosis and leiomyoma using \nhistopathology as the reference standard. TVS \ndemonstrated significant associations between \nindividual sonographi c features and histopathological \ndiagnosis for both conditions. Among adenomyosis \ncases, no distinction of the endometrial -myometrial \njunction (78.9%), asymmetry of the anterior and \nposterior myometrium (83.3%), myometrial cysts and \nfibrosis (62.5%) and he terogeneous myometrial \nechotexture (80.3%) were all significantly associated \nwith histopathological confirmation (all p<0.0001). For \nleiomyoma, clear tumor margin demarcation (96.7%), \nperipheral vascularity on color Doppler (95.6%), \nirregular uterine surfa ce (93.5%) and irregular \nendometrial surface (95.7%) also demonstrated \nsignificant correlations with histopathology. \n \nThe distribution of uterine pathology in the \npresent study showed that leiomyoma was the most \nfrequent diagnosis (61.33%), followed by the \ncoexistence of adenomyosis and leiomyoma (26.00%), \nwhile isolated adenomyosis accounted for 12.67% of \ncases. Similar observations have been reported by Lonky \net al.,  who demonstrated that adenomyosis frequently \ncoexists with uterine leiomyomas in women undergoing \nhysterectomy, emphasizing the importance of careful \npreoperative imaging to identify both pathologies \nsimultaneously [13]. Likewise, Moawad et al.,  and \nMoldassarina described the considerable overlap \nbetween adenomyosis and leiomyoma and highlighted \nthe need for standardized ultrasound criteria to improve \ndiagnostic precision [14,15]. \n \nThe present study demonstrated that loss of the \nendometrial-myometrial junction and asymmetry of the \nmyometrium were among the strongest sonographic \nindicators of adenomyosis. These findings are consistent \nwith those reported by Farooqui et al., who found that \ndisruption of the junctional zone and asymmetrical \nmyometrial thickening were highly predictive of \nhistopathologically confirmed adenomyosis [16]. \nSimilarly, Sayer Dayer et al., reported that characteristic \nTVS findings showed a strong association wit h \nhistopathological diagnosis, supporting the value of \nultrasound as a reliable preoperative diagnostic tool [17]. \nFurthermore, Yavuz et al.,  demonstrated that \nMorphological Uterus Sonographic Assessment \n(MUSA) features, particularly junctional zone \n\n \n \nAkter, K. et al; Sch Int J Obstet Gynec, Aug. 2026; 9(8): 176-181 \n© 2026 | Published by Scholars Middle East Publishers, Dubai, United Arab Emirates      180                                                                                     \n  \n \nabnormalities and myometrial asymmetry, significantly \nimproved the prediction of adenomyosis [18]. \n \nHeterogeneous myometrial echotexture was \nidentified in 80.3% of histopathologically confirmed \nadenomyosis cases in the current study, while \nmyometrial cysts and fibrosis were observed in 62.5%. \nComparable findings have been described by Harmsen et \nal., who reported good agreement between transvaginal \nultrasound, MRI and histopathology for evaluating \njunctional zone abnormalities and heterogeneous \nmyometrium [19]. Ren et al.,  also emphasized that \nheterogeneous myometrial echotexture and myometrial \ncysts are valuable sonographic markers reflecting \ndisease severity and are useful for monitoring treatment \nresponse [20]. \n \nFor leiomyoma, clear tumor margin \ndemarcation demonstrated the highest correlation with \nhistopathology (96.7%), followed closely by peripheral \nvascularity on color Doppler (95.6%). These findings are \nin agreement with Abou Elela et al., who concluded that \npelvic ultrasonography effectively identifies uterine \nmyomas through characteristic well-defined margins and \nvascular patterns [21]. Likewise, Zhang et al., reported \nthat vascular characteristics and lesion morphology are \nimportant sonographic features for  differentiating \nleiomyomas from focal adenomyosis [22]. Kaya \nNarçiçeği et al.,  further demonstrated that combining \nconventional ultrasound features with tissue elasticity \nassessment improves discrimination between \nadenomyosis and leiomyoma [23]. \n \nRecent advances in ultrasound technology have \nfurther strengthened the diagnostic capability of TVS. \nZanolli et al.,  reported high diagnostic accuracy of \nclinically interpreted pelvic ultrasound compared with \nsurgical pathology for adenomyosis [24]. Similarly, \nRaimondo et al., demonstrated that deep learning models \napplied to ultrasound images further improve the \nidentification of adenomyosis by recognizing subtle \nsonographic features [25]. These developments support \nthe growing role of ultrasound as an accurate, accessible \nand noninvasive diagnostic modality. \n \nLimitations of the study \nThis study was conducted at a single tertiary \ncare center using purposive sampling, which may limit \nthe generalizability of the findings. In addition, only \nwomen who underwent surgical management with \navailable histopathological reports were included, \npotentially introducing selection bias. Interobserver \nvariability could not be assessed because all transvaginal \nultrasound examinations were interpreted by a single \nexperienced investigator. \n \nCONCLUSION  \nIndividual transvaginal ultrasound criteria \nshowed significant diagnostic value for identifying \nadenomyosis and leiomyoma when compared with \nhistopathological findings. Features such as loss of the \nendometrial-myometrial junction, myometrial \nasymmetry, heterogeneous myometrial echotexture, \nclear tumor margin demarcation, peripheral vascularity \nand surface irregularities were strongly associated  with \nhistopathological diagnosis. 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