Comparative study of transvaginal ultra sonography versus MRI in early detection of adenomyosis

Background Adenomyosis is a benign gynaecological disorder defined by ectopic presence of endometrial glands and stroma. True prevalence of adenomyosis is difficult to determine because some women are asymptomatic and it non -specifically mimics other uterine pathology. Hence, non -invasive techniques, TVUS and MRI were used to study and compare the proper diagnosis of adenomyosis.

60 (sixty) premenopausal women having suggestive symptoms of adenomyosis, underwent TVS followed by MRI within a two-week interval prior to hysterectomy using TVS high -resolution endovaginal transducer (5 -9 MHz) on a GE Voluson S8 ultrasound system. A pelvic MRI was performed using 1.5 Tesla scanners (GE SIGNA creator). The hysterectomy specimen was proces sed and studied according to standard protocol.

Comparison of diagnostic performance of TVUS versus MRI for adenomysis detection. True positive, true negative, false positive, and false negative had high rates of MRI detection. And more sensitivity, specificity, PPV, NPV, and overall accuracy (AUS) were observed in the MRI study. 41 diffused adenomyosis, 23 focal adenomyosis, co-existence of leiomyomas, and interobserver agreement (k) had a significant p value (p<0.005), and the MRI study was almost perfect.

MRI study demonstrates significantly higher diagnostic accuracy than TVUS, but TVUS can be used as a first-line screening tool.

TVUS, MRI, Specificity, sensitivity, benign adenemyosis, Histo-pothology

Adenomyosis is a benign gynaecological disorder where ectopic endometrium is present within the myometrial wall of the uterus. The true prevalence of adenomyosis is difficult to determine but has been quoted to range from 5 to 70% among hysterectomy specimens de pending on the baseline demographics and population sampled [1]. While some women are asymptomatic, the classic symptoms of adenomyosis are pain and heavy menstrual bleeding; it can be associated with infertility [2]. The clinical diagnosis of adenomyosis is challenging, as signs and symptoms of adenomyosis are non -specific and may mimic other uterine pathology. It is paramount that a non-invasive diagnosis is achievable for women, especially those who wish for conservative management or to preserve their fertility [3]. Both ultrasound and magnetic imaging (MRI) have been used to provide a non -invasive diagnosis. Ultrasound, especially transvaginal ultrasound (TVUS), is often the first line of diagnosis of adenomyosis. MRI can be useful in defining the exten t and location of adenomyosis. Like three -dimensional (3D) ultrasound, the zonal anatomy of the uterus is well demonstrated on a T2-weighted image [4]. Hence, images of adenomyosis were observed, studied and compared in TVS and MRI and confirmed by histopathological study.

and Method 60 (sixty) adult premenopausal women aged between 30 -48 years who regularly visited SKS Medical College, research center, and hospital, Mathura, Uttar Pradesh-281406 were studied. Inclusion Criteria Patients who pres ented symptoms suggestive of adenomyosis and scheduled for hysterectomy for various benign gynaecological indications. The patients who gave their consent in writing for study were selected. International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 1507 ~ Exclusion Criteria Patients with post-menopausal status, prior uterine surgery other than caeserian section. Malignant uterus patient’s contraindications to MRI (e.g., metallic implants, claustrophobia), hormonal therapy within the preceding three months, and pregnancy were excluded from studies.

Imaging pr otocol: All patients underwent TVS followed by pelvic MRI within two weeks interval prior to hysterectomy. TVS was performed during the early proliferative phase (cycle days 5 -10) using a high -resolution endovaginal transducer (5 -9 MHz) on a GE Voluson S8 ultrasound system. Examinations were conducted using standardized TVS diagnostic criteria for adenomyosis, which included heterogeneous myometrial echotexture, myometrial cysts, subendometrial linear striations, and asymmetric myometrium. Standardized TVS diagnosis criteria for adenomyometrial echofexture, myometrial cysts, subendometrial linear striations, asymmetric striations, asymmetric myometrial thickening, and fan shaped shadowing. A pelvic MRI was performed (GE SIGNA Creators 1.5 tesla) with a phase d array pelvic coil the imaging protocol coil. The imaging protocol included T2 -weighted turbo spin -echo sequences in sagittal, coronal, and axial planes; T1 weighted sequences and diffusing weighted sequences. MRI Diagnosis criteria included JZ minimum th ickness ratio >2.2, the presence of high -signal foci within the myometrium on a T2 -weighted images, and ill -defined low -signal myometrial foci within the myometrial masses. Histopathology examination Hysterectomy specimens were processed according to sta ndard protocols. Multiple systemic sections (minimum four per specimen) were obtained from representative area. Histopathological diagnoses of adenomyosis were established when endometrial glands and stroma were identified at a depth of >2.5 mm from the en dometrial-myometrial junction. Adenomyosis was further classified as diffuse or focal based on histological distribution. The duration of study was from November 2022 to August 2023. Statistical Analysis The sample size of 60 (sixty) patients was compared and calculated, assuming a sensitivity of 85% for TVS and 92% for MRI with an alpha error of 0.05 and a power of 80%, yielding a minimum requirement of 50 subjects. Sensitivity, specificity, PPV, NPV, and overall accuracy were calculated for each modality with 95% confidence intervals. The McNemar's test was used to compare paired proportions. ROC curve analysis was performed. AUC values were compared using the De Lang method. Interobserver reliability using Cohen's kappa coefficient. A p -value (p < 0.005) was considered statistically significant. Statistical analysis was carried out in SPSS software version 28.0 and MedCalc version 20.1. Fig 1: Transvaginal ultrasound images of adenomyosis highlighting the diagnostic criteria. Fig 2: Magnetic resonance images of adenomyosis highlighting the diagnostic criteria. Observation and Results 1. Table 1: Clinical manifestations: 2 (1 -3) parity Median (ICR), 43 (71.6%) Menorragia, 39 (65%) Dsymenorrhea, 29 (48.3%) Chronic pelvic pain, 17 (28.3%) Dyspareunia, 142.4 (±12.8) uterine volume (cm3) (mean ±SD), 40 (66.6%) Histologically confirmed adenomyosis, 41 (68.3%) diffuse adenomyosis, 23 (38.3%) focaladenomyosis, 15 (25%) co-existance adinomyosis 2. Table 2: Diagnostic performance of TVS versus MRI for adenomyosis detection True positive, True negative, False negative, False positive value percentage were quite higher in MRI. Sensitivity percentage and specificity percentage studied had higher percentage MRI values were observed PPV (%), NPV (%) and overall accur acy and AUC also had significant values in MRI as compared to TVS. International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 1508 ~ 3. Table 3: Study of diagnostic performance by Adenomyosis subtype and inter observer agreement: Diffuse adenomyosis, Focal adenomyosis, co -existance Leiomyomas, Inter - observer agreement MRI increased p value and significant p value (p<0.001). MRI had almost perfect agreement as compared to TVS studies (p<0.001).

Present a comparative study of transvaginal ultrasonography versus MRI in early detection of adenomyosis. The clinical manifestations were 2 (1 -3) parity, 43 (71.6%) menorrhagia, 39 (65%) dysmenorrhea, 29 (48.3%) chronic pelvic pain, 17 (28.3%) dyspareunia, 142.4 (±12.8) uterine volume, 40 (66.6%) histologically confirmed adenomyosis, 41 (68.3%) diffuse adenomyosis, 23 (38. 3%) focal adenomyosis, and 15 (25%) co - existent leiomyomas (Table 1). The comparative study of diagnostic performance of TVUS versus MRI for adenomyosis detection as true positive, true negative, false positive, and false negative has increased performance in MRI studies. Moreover, specificity, sensitivity, PPV, NPV, overall accuracy, and AUC had more significant values that were observed in MRI studies (Table 2). In a comparative study of diagnostic performance by adenomyosis subtype and interobserver agre ement study, accurate diagnosis was observed in MRI more than TVUS studies, with higher sensitivity and specificity observed in diffuse adenomyosis and focal adenomyosis; coexistence of leiomyosis was observed in MRI studies (Table 3) and (Figures 1 and 2) . These findings are more or less in agreement with previous studies [5, 6, 7]. TVUS is a more cost -effective and readily available imaging technique that is generally well tolerated by most patients. MRI, on the other hand, is advantageous, as the images produced are in standard planes, resulting in more reproducibility among studies [8]. It has also long been regarded as the imaging modality of choice in evaluating zonal anatomy [9]. However, its use is limited by factors such as morbid obesity or claustrophobia. MRI is generally reserved as a second line for the diagnosis of adenomyosis, mainly after a non -conclusive ultrasound study [10]. Moreover correlation to a histopathological meant a more accurate analysis of the index test, as the current gold sta ndard is histology via hysterectomy, especially in regard to fertility [11]. Summary and Conclusion It is proved that TVUS is more cost -effective, widely available, and easily accessible; it is likely to remain the first imaging modality of choice, defaul ting to an MRI where ultrasound is difficult or inconclusive. More studies are required to evaluate the different ultrasound modalities, further including elastography and 3D TVUS. Future research is needed to evaluate the individual MUSA (morphological ut erus sonographic assessment) criteria and adopt standardized reporting guidelines.

of study: Owing to remote location of research centre, small number of patients, lack of latest techniques, we have limited findings and results  This research wo rk was approved by the ethical committee of SKS Medical College, research center, and hospital, Mathura, Uttar Pradesh-281406  No Conflict of Interest  Self Funding Table 1: Clinical manifestations of the adenomyosis patients Clinical Manifestations Variables Value Parity Median (TQR) 2 (1-3) Mennorragia (N)(%) 43 (71.6%) Dysmenorrhea N (%) 39 (65%) Chronic Palvic Pain N (%) 29 (48.3%) Dyspareunia N (%) 17 (28.3%) Uterine volume (cm3), Mean (±SD) 142.4 (±12.8) Histological confirmed adenomyosis N (%) 40 (66.6%) Diffuse adenomyosis N (%) 41 (68.3%) Focal adenomyosis N (%) 23 (38.3%) Coexistent leiomyomas 15 (25%) International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 1509 ~ Table 2: Comparison of Diagnostic performance of TVUS versus MRI for adenomyosis detection Parameter TVS (95%) CI MRI (95%) CI p value True positive 33 37 -- True Negatives 16 18 -- False Positives 4 3 -- False Negative 7 2 -- Sensitivity (%) 83 (73.2 – 84.1) 90.8 (83.5 – 94.7) 0.032 Specificity (%) 78.4 (65.4 – 88.2) 90.2 (80-96.2) 0.038 PPV (%) 88.6 (80.5 – 92.3) 95.0 (88.2 – 98.2) 0.016 NPV (%) 70.0 (55.8 – 80.2) 84.4 (72.0 – 90.4) 0.025 Overall accuracy 81.5 (73.2 – 85.0) 91.2 (84.2 – 95.0) 0.001 AUC 0.841 (0.78 – 0.916) 0.940 (0.901 – 977) 0.006 Table 3: Study of diagnostic performance by Adenomyosis subtype and inter observer agreement Parameter TVS MRI p value Diffuse adenomyosis (n=41) Sensitivity 89.2 92.0 0.314 Specificity 78.0 90.1 0.04 Focal adenomyosis (n=23) sensitivity 68.2 89.2 0.0016 Specificity 78.0 90.1 0.042 Coexistence Leiomyomas (n=15) Sensitivity (%) 74.1 88.4 0.027 Specificity (%) 75.0 91.5 0.034 Inter-observer agreement (K) 0.70 0.87 -- Agreement classification Subsntial Almost perfect -- In the cases of Co -existent leiomyomas (N=15) MRI maintained significantly higher sensitivity (88.4%) versus 74.1% p value 0.027 (p<0.002) (highly significant) (p<0.002) and specificity 91.5% in MRI versus 75% TVS study and p value 0.034 (p<0.003) p value is highly significant. International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 1510 ~ Conflict of Interest Not available Financial Support Not available

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