Correlation between ultrasound features and histopathological finding in cases of adenomyosis: a cross-sectional study

Adenomyosis is a gynecological disorder which is characterized by hypertrophy and hyperplasia of the surrounding myometrium as well as the presence of ectopic endometrial glands and stroma inside the myometrium []. It is associated with menometrorrhagia, dyspareunia, and dysmenorrhea; however, these symptoms are typically nonspecific and frequently occur with other illnesses such as leiomyoma, and endometriosis. Adenomyosis is difficult to diagnose clinically and is suspected in women who exhibit pelvic sensitivity and uterine hypertrophy during physical examination [,]. Therefore, our study aims to compare the accuracy of preoperative ultrasound (US) features with the histopathological results to diagnose adenomyosis, and to determine its sensitivity []. Patients and methods Type of study This was an observational cross-sectional study. Study setting The study was conducted at the Department of Obstetrics and Gynecology, Tanta University Hospital from 1-5-2021 to 1-5-2023. Sample size Among patients attending, 100 perimenopausal and postmenopausal patients were included. Version 2002 of the Epi-Info statistical package, developed by the WHO and the Centers for Disease Control and Prevention in Atlanta, Georgia, USA, was used to compute the sample size and power analysis. The following criteria were applied while calculating sample size: (a) 95% confidence interval. (b) Expected frequency of 60% as reported in a similar study with a margin of error 10%. (c) The sample size based on the previously mentioned criteria was found at N greater than 92. It will be increased to 100 for compensation for missed data and improving the quality of the study. Criteria of patient selection Inclusion criteria (a) Age ranged from 40 to 60 years old. (b) Patients were presented with abnormal uterine bleeding. (c) Symptoms suggest adenomyosis like dysmenorrhea and pelvic pain. Exclusion criteria (a) Unavailable postoperative histopathological examination. Trial design and assessments All patients were subjected to complete history taking, complete general examination, and pelvic examination. Also, patients made complete laboratory investigations including complete blood picture, clotting time and prothrombin activity, and random blood sugar. Abdominal and vaginal ultrasound examinations performed to all patients to assess the adenomyosis site, size, and blood flow in every patient. A 5–7.5-MHz transducers were used for vaginal US studies, and 3–5-MHz transducers (SAMSUNG MEDISON H60, Korea) were used for abdominal US studies. In the outpatient department’s operating room, a single, skilled doctor performed all ultrasonographic tests. Uterine size, boundaries (including the thicknesses of the anterior and posterior myometrial walls), width, myometrial cyst, myometrial echotexture, existence of concomitant abnormalities, and endometrial abnormality were measured during the ultrasonographic examination. The thickest part of the myometrium in a sagittal plane was measured anteroposteriorly (from the endometrial-myometrial junction to the uterine serosa) to determine the myometrial thickness of each anterior and posterior wall. The breadth of the uterus was measured in the transverse plane between two sites at its widest point. In the current study, the normal thickness of the anterior and posterior myometrial walls was less than or equal to 2.0 cm based on a prior study []. Under ultrasound supervision, the endometrial cavity was investigated by inserting a No. 1 Hegar dilator or a curved uterine sound when a discernible sonographic endometrial lining was absent due to severe deep adenomyosis. This procedure made the endometrial cavity to be identified by ultrasonography; thus, the myometrial thickness could be measured. Diagnostic criteria of uterine adenomyosis include two of the five sonographic features on transvaginal sonography (TVS): (1) The endometrial-myometrial junction is not distinct; (2) the anterior and posterior myometrium are asymmetric; (3) sub endometrial myometrial striations; (4) myometrial cysts and fibrosis; and (5) the myometrial echotexture is heterogeneous []. Following a vaginal or abdominal hysterectomy, a histological analysis was conducted. Data entry and statistical analysis A spreadsheet in Excel was created to enter the data. SPSS (Statistical Package for the Social Sciences, version 24, SSPS Inc, Chicago, IL, USA) was used to conduct the analyses. For categorical data, frequency tables with percentages were utilized, and for numerical variables, descriptive statistics (mean and standard deviation) were employed. Ethical considerations Tanta University’s Faculty of Medicine Ethics Committee gave its approval to the project. Code of approval 34584/3/21. Enough safeguards were in place to protect participant privacy and data confidentiality: patients were given the choice to opt out of the study if they so desired, participant names and addresses were coded and kept in a separate file, and patient identities were concealed. Before the commencement of the trial, each participant provided informed consent. We did not use the study’s results for any other purpose than a scientific one.

Demographic data of the study participants Regarding baseline characteristics of the studied patients, age ranged from 40 to 60 years with a mean of 53.10 ± 4.88 years, BMI ranged from 22 to 38 kg/m2 with a mean of 30.22 ± 2.89 kg/m2. Regarding the history of chronic diseases, 29 (29%) participants had diabetes mellitus, 37 (37%) patients had hypertension, and eight (8%) patients had CAD. Symptoms of the study participants Figure 1 shows the symptoms of the study participants, 48 (48%) patients had dysmenorrhea, 91 (91%) patients had Menorrhagia, 73 (73%) patients had abnormal bleeding, and 66 (66%) patients had pelvic pain. Pelvic examination of the study participants Table 1 shows that 59 (59%) patients had normal vagina, 13 (13%) patients had vaginal infection, five (5%) patients had vaginal mass, and 29 (29%) patients had vaginal prolapse. Regarding cervix position, 77 (77%) patients had posterior cervix while 23 (23%) patients had anterior cervix. Regarding uterus size, 34 (34%) patients had normal uterus, 72 (72%) patients had regular palpation, and 64 (64%) patients had normal adnexa. Transvaginal ultrasound findings in the study participants Regarding transvaginal ultrasound findings in the study participants, 45 (45%) patients had adenomyosis, 36 (36%) patients had fibroids, 13 (13%) patients had thickened endometrium and six (6%) patients had endometriotic cyst (Fig. 2). Histopathological results in adenomyosis and non-adenomyosis cases Table 2 shows that 52 patients had adenomyosis in histopathology; 29 (55.77%) had adenomyosis without other pelvic lesion, 13 (25%) had adenomyosis with fibroids and 10 (19.23%) had adenomyosis with ovarian cyst. There were 48 patients without adenomyosis in histopathology; 35 (72.92%) had Fibroids, 10 (20.83%) had endometrial hyperplasia, one (2.08%) patient had an endometriotic cyst and two (4.17%) patients had neoplastic. Comparison between diagnosis of adenomyosis by transvaginal US and histopathological study. No significant difference was observed in the number of adenomyosis cases diagnosed by transvaginal US and cases diagnosed by the histopathological study as the P value was 0.105 (Table 3). Accuracy of transvaginal US for the diagnosis of adenomyosis in comparison to histopathological study. Table 4 shows that transvaginal ultrasound is a significant diagnostic tool for adenomyosis with an accuracy of 89.0%. It showed a sensitivity of 82.7%, specificity of 95.8%, positive predictive value of 95.6%, and negative predictive value (NPV) of 83.6%. Transvaginal ultrasound features in the study participants 26 (57.78%) patients had junctional zone maximum thickness, 37 (82.22%) patients had junctional zone minimal thickness, 33 (73.33%) patients had junctional zone thickness difference, 22 (48.89%) patients had junctional zone myometrial ratio, 41 (91.11%) had myometrial asymmetry, 42 (93.33%) patients had myometrial cysts, 43 (95.56%) patients had hyperechoic striation and 40 (88.89%) patients had heterogeneous myometrium. As shown in (Figs. 2–5). The sensitivity, specificity, PPV, and NPV of TVS in the diagnosis of adenomyosis of this study compared with several prior studies is shown in (Table 5).

This cross-sectional study was conducted on 100 perimenopausal and postmenopausal patients (aged 40 to 60 years old) who presented with abnormal uterine bleeding. All patients were subjected to complete history taking, general and pelvic examination. The selected patients were subjected to all laboratory investigations as; complete blood picture, clotting time and prothrombin activity, random blood sugar, abdominal and vaginal ultrasound, and abdominal or vaginal hysterectomy followed by histopathological examination. Current study results regarding transvaginal ultrasound outcomes in the study participants, 45 (45%) patients had adenomyosis. According to histopathology, 52 patients had adenomyosis and 48 patients without adenomyosis. Our results revealed that there was no significant difference in the number of adenomyosis cases diagnosed by transvaginal US and cases diagnosed by histopathological study. Also, we found that the accuracy of transvaginal ultrasound was 89.0% with a sensitivity of 82.7%, specificity of 95.8%, PPV of 95.6%, and NPV of 83.6%. So, TVS is a significant diagnostic tool for adenomyosis. Observational research was conducted by Bazot and colleagues to assess the diagnostic accuracy of transvaginal and transabdominal sonography for adenomyosis []. They reported that regarding TVS in group 1; patients with menometrorrhagia who were free of myoma and endometrial disorders on TAS (n=23), TVS yielded a diagnosis of adenomyosis in 17 of the 21 women, with no false-positive diagnoses and four false-negative cases. In group 2 (n=106), TVS yielded a diagnosis of adenomyosis in 12 women, including two false positive diagnoses and 16 false-negative cases. They concluded that TVS alone was poor in patients with an enlarged uterus. The difference from our results may be due to that they compared TVS to TAS yet ours as we compared TVS to histopathological. They also noted that the specificity, sensitivity, and accuracy of transvaginal ultrasound for the diagnosis of adenomyosis in group 1 were 100, 80.9, and 82.6%, respectively. Indeed, they found that in patients with an enlarged uterus, the accuracy of transvaginal ultrasound was poor, because of incomplete evaluation of the uterus []. Kepkep and colleagues compared transvaginal US findings with histopathological findings to assess the accuracy of US findings in adenomyosis. Of the 70 patients, 38 had an adenomyosis diagnosis made by transvaginal ultrasonography; nevertheless, 21 (55.3%) of them had an adenomyosis histological diagnosis (17 false-positive diagnoses). Of 32 patients where none of the transvaginal US diagnostic criteria for adenomyosis were seen, five (15.7%) had a histological diagnosis of adenomyosis (five false-negative diagnoses) []. According to Rizvi and colleagues there was a strong correlation between the histological findings and the US diagnosis. An adenomyosis diagnosis was made for 18 cases. Histopathology validated the adenomyosis diagnosis in 14 of the cases []. Regarding sensitivity of TVS in diagnosing adenomyosis, a retrospective study conducted by Hanafi on patients with a preoperative TVS diagnosis of adenomyosis, leiomyoma, or combined, found that the sensitivity of TVS was 84.6% whereas it was 82.7% in our study []. Also, Bazot et al., [] discovered that transvaginal US had high sensitivity, specificity, PPV, and NPV for diagnosing adenomyosis; these values were 65.0, 97.5, 92.8, and 88.8%, respectively. Similarly, transvaginal US was shown to have an 86% specificity and comparable diagnostic efficacy to MRI by Reinhold et al. [].

This study shows that there is no significant difference between ultrasound and histopathology in diagnosis of adenomyosis and transvaginal ultrasound is a significant diagnostic tool for adenomyosis with an accuracy of 89.0%. It showed a sensitivity of 82.7%, specificity of 95.8%, PPV of 95.6% and NPV of 83.6%. Recommendation and limitation This study was a single-center study, and the results may differ elsewhere, so a multicenter study with larger sample size is recommended. Also, we recommend performing prospective rather than retrospective studies with a control group. Financial support and sponsorship Nil. Conflicts of interest The authors declare that there is no conflict of interest associated with this work.

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