Role of ultrasound with doppler in differentiating clinically suspected cases of leiomyoma and adenomyosis of uterus 

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These patients underwent either myomectomy or total abdominal hysterectomy and the specimens were sent for histopathology. The data collected was analysed using statistical tools and sensitivity and specificity analysis was conducted to estimate the accuracy of ultrasound in differentiating leiomyoma and adenomyosis. Results Out of total of 60 patients 41 were diagnosed clinically as Leiomyoma, of which USG detected 36 cases to be Leiomyoma, leaving 5 cases unconfirmed. 19 patients were diagnosed clinically as Adenomyosis and USG detected 15 cases as Adenomyosis, leaving 4 cases unconfirmed. Out of 41 cases detected clinically as leiomyoma 37 were confirmed by histopathology. Out of 19 cases clinically diagnosed as adenomyosis 15 cases were confirmed by histopathology as adenomyosis. Conclusion The study revealed that USG findings for both Leiomyoma and Adenomyosis had a very strong correlation with histopathology with a P value of less than 0.001 which is statistically significant. These findings could be useful in clinical practice for differentiating between these two conditions, thereby facilitating better management and treatment of the patients. " } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/14-178", "name": "Role of ultrasound with doppler in differentiating clinically suspected..." } } ] } Home Browse Role of ultrasound with doppler in differentiating clinically suspected... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Mahale N, V S, Mahale A et al. Role of ultrasound with doppler in differentiating clinically suspected cases of leiomyoma and adenomyosis of uterus [version 1; peer review: 1 approved] . F1000Research 2025, 14 :178 ( https://doi.org/10.12688/f1000research.157457.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Role of ultrasound with doppler in differentiating clinically suspected cases of leiomyoma and adenomyosis of uterus [version 1; peer review: 1 approved] Nina Mahale 1 , Shruthi V 1 , Ajit Mahale https://orcid.org/0000-0001-6617-7333 2 , Sonali Ullal 2 , Merwyn Fernandes https://orcid.org/0000-0001-7505-4386 2 , Sonali Prabhu 2 Nina Mahale 1 , Shruthi V 1 , [...] Ajit Mahale https://orcid.org/0000-0001-6617-7333 2 , Sonali Ullal 2 , Merwyn Fernandes https://orcid.org/0000-0001-7505-4386 2 , Sonali Prabhu 2 PUBLISHED 10 Feb 2025 Author details Author details 1 Department of Obstetrics and Gynecology, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Karnataka, Manipal, 576104, India 2 Department of Radiodiagnosis, Kasturba medical College Mangalore, Manipal Academy of Higher Education, Karnataka, Manipal, 576104, India Nina Mahale Roles: Conceptualization, Methodology Shruthi V Roles: Data Curation, Writing – Review & Editing Ajit Mahale Roles: Formal Analysis, Project Administration, Validation Sonali Ullal Roles: Supervision Merwyn Fernandes Roles: Software, Validation Sonali Prabhu Roles: Writing – Original Draft Preparation OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Global Public Health gateway. This article is included in the Manipal Academy of Higher Education gateway. Abstract Aim The aim of this study was to differentiate clinically suspected cases of leiomyoma and adenomyosis using 2d grey scale ultrasound with doppler.P Methods and materials 60 patients with a history of abnormal uterine bleeding (aub) and clinically suspected cases of uterine leiomyoma and adenomyosis were subjected to ultrasound. These patients underwent either myomectomy or total abdominal hysterectomy and the specimens were sent for histopathology. The data collected was analysed using statistical tools and sensitivity and specificity analysis was conducted to estimate the accuracy of ultrasound in differentiating leiomyoma and adenomyosis. Results Out of total of 60 patients 41 were diagnosed clinically as Leiomyoma, of which USG detected 36 cases to be Leiomyoma, leaving 5 cases unconfirmed. 19 patients were diagnosed clinically as Adenomyosis and USG detected 15 cases as Adenomyosis, leaving 4 cases unconfirmed. Out of 41 cases detected clinically as leiomyoma 37 were confirmed by histopathology. Out of 19 cases clinically diagnosed as adenomyosis 15 cases were confirmed by histopathology as adenomyosis. Conclusion The study revealed that USG findings for both Leiomyoma and Adenomyosis had a very strong correlation with histopathology with a P value of less than 0.001 which is statistically significant. These findings could be useful in clinical practice for differentiating between these two conditions, thereby facilitating better management and treatment of the patients. READ ALL READ LESS Keywords Ultrasound; Doppler;Leiomyomas;Adenomyosis;AUB. Corresponding Author(s) Ajit Mahale ( [email protected] ) Close Corresponding author: Ajit Mahale Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Mahale N et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Mahale N, V S, Mahale A et al. Role of ultrasound with doppler in differentiating clinically suspected cases of leiomyoma and adenomyosis of uterus [version 1; peer review: 1 approved] . F1000Research 2025, 14 :178 ( https://doi.org/10.12688/f1000research.157457.1 ) First published: 10 Feb 2025, 14 :178 ( https://doi.org/10.12688/f1000research.157457.1 ) Latest published: 10 Feb 2025, 14 :178 ( https://doi.org/10.12688/f1000research.157457.1 ) Introduction Abnormal uterine bleeding (AUB) is a common problem among women in the reproductive age group. 1 It accounts for approximately 70% of the pathology in perimenopausal and post-menopausal women. AUB may occur because of hormonal imbalances or as a result of benign or malignant lesions. 2 Benign myometrial lesions are common in women of reproductive age and can cause significant morbidity. 3 The most common causes of uterine bleeding are adenomyosis and uterine leiomyoma. Leiomyomas are benign masses of uterine smooth muscles that can be surgically removed. Adenomyosis is an ill-defined lesion in which endometrial glands and stroma are interspersed with the myometrium, making complete removal through surgery challenging. 4 Therefore, accurate preoperative diagnosis of these two conditions is critical. Imaging techniques play a crucial role in distinguishing leiomyomas from adenomyosis. Histopathology, considered a corner stone in confirming the diagnosis, remains a gold standard. 4 Transabdominal/transvaginal sonography is often performed and is planned as a first line imaging modality. The ability to globally visualise the pelvic structures and organs combined with colour Doppler greatly enhances diagnostic ability. 5 This study aimed to differentiate clinically suspected cases of uterine Leiomyoma and Adenomyosis using grey-scale 2D ultrasonography with color Doppler to determine its accuracy and confirm histopathological findings. Owing to similar clinical signs and symptoms, misdiagnosing one in favour of the other is not uncommon. The organic cause responsible for menstrual disorders should be ruled out to provide a final cure for a broad range of gynecological diseases and preoperative diagnosis of these two conditions is vital for patients wishing to retain their fertility. Aims ➢ To differentiate clinically suspected cases of Leiomyoma and Adenomyosis using 2D grey scale ultrasound with Doppler. Objective ➢ To diagnose Leiomyoma and Adenomyosis using ultrasound and Doppler. ➢ To determine the accuracy of preoperative sonography with Doppler in evaluating Leiomyoma and Adenomyosis and to confirm the histopathological findings. Methods Study design : Observational Study. Study period : August 2018 to August 2020. Study setting: This study was carried out in tertiary care centres attached to the Kasturba Medical College, Mangaluru, Government Lady Goschen Hospital, and KMC Hospital Attavar. Study population : Women reporting with complaint of Abnormal uterine bleeding in pre and perimenopausal age and clinically suspected cases of uterine Leiomyoma and Adenomyosis were selected. Inclusion criteria • Patients with clinical symptoms of abnormal uterine bleeding, dysmenorrhea, abdominal mass and pelvic pain. • Patients with complaints of AUB for which hysterectomy or myomectomy was the treatment of choice. Exclusion criteria • Patients for whom surgery was not the preferred treatment of choice. • Confirmed cases of CA cervix, CA endometrium, and endometrial polyps. Sample size n = ( Zα 2 pq ) + Zβ p 1 q 1 + p 2 q 2 ) ( p 1 − p 2 ) 2 Zα = 1.96 at 95% confidence level Zβ = 1.28 at 90% power, the sample size calculated as 60. Method of collection The study included 60 patients with a history of Abnormal Uterine bleeding. Clinically suspected cases of Uterine Leiomyoma and Adenomyosis were included. Institutional ethical board clearance was also obtained. Informed written consent was obtained after explaining the study details in the language that was best understood by the study group. Pre-operative assessment was performed by detailed history taking with respect to age, symptoms, parity, menstrual pattern, other coexisting medical conditions, gynaecological complaints, treatment taken prior to this visit and relevant family history. General and pelvic examinations and relevant investigations were performed. The clinical diagnosis was made based on the chief complaints and clinical examination. The study subjects underwent ultrasonography to confirm the clinical diagnosis. The equipment used for transabdominal sonographic imaging was GELOGIQ S7, GES8, GEVOLUSON EXPERT730, PHILLIPS HD7, SAMSUNG 70A using a 2-5 MHz curvilinear and 6-12 MHz transvaginal transducer. Images were evaluated with respect to morphology. Sonographic images were recorded and stored for archiving purposes. A treatment plan was suggested based on radiological diagnosis. After obtaining fitness, surgery was performed individualizing the approach for each patient. Myomectomy or total hysterectomy was performed according to standard surgical protocols. The specimens were subjected to histopathological evaluation. The final diagnosis was made based on the histological diagnosis. The collected data were subjected to statistical analyses. The clinical diagnosis, ultrasonographic findings, and histopathological reports were compared. With this background, this study aimed to establish the accuracy of ultrasonography in diagnosing uterine leiomyoma and adenomyosis. Statistical analysis This is an observational clinical study. The Statistical Package for Social Sciences (SPSS) for Windows, Version 22.0 released 2013. Armonk, NY: IBM Corp. Chi square test was used for comparison. Independent student “t” test to compare the mean values of Doppler parameters. Sensitivity and specificity analysis was done to estimate the accuracy of USG in differentiating Leiomyoma and Adenomyosis. Significance level was set at P value of <0.05. Results This study included 60 patients with a history of AUB and clinically suspected uterine leiomyoma and Adenomyosis ( Table 1 ). Table 1. Age distribution and incidence of Leiomyoma and Adenomyosis. Variable Category Number of Leiomyoma Cases (n) % Number of Adenomyosis Cases (n) % Age 21-30 Years 2 3.33 0 0.00 31– 40 Years 7 11.67 3 5.00 41– 50 Years 31 51.67 13 21.67 51-60 Years 1 1.67 3 5.00 Total 41 68.33 19 31.67 The study patients were in the age range of 28–53 years. The maximum number of patients was 41 – 50 years (n=44, 73.3%). The mean age was 44.45 yrs. The maximum incidence of fibroids and adenomyosis was found to between 41-50 yrs. We found 31 (51.67%) cases of leiomyoma and 13 (21.67%) cases of Adenomyosis within 41-51 yrs range. When compared to other age categories, both conditions were found to be comparatively less prevalent especially in those aged 51 years. More uterine leiomyomas n= 28 (46.67%) and adenomyosis n= 18(30%) were found in multiparas. Eight cases (13.33%) of leiomyoma were observed in the primiparous group followed by five cases (8.33%) in the nulligravida group. In the case of adenomyosis, one case (1.67%) was observed in primiparous patients and none in Nulligravida ( Table 2 ). Table 2. Parity distribution with occurrence of Leiomyoma and Adenomyosis. Variable Category Leiomyoma (n) % Adenomyosis (n) % Parity Nulligravida 5 8.33 0 Primiparous 8 13.33 1 1.67 Multiparous 28 46.67 18 30.00 Total 41 68.33 19 31.67 The most common clinical symptom among the study patients was heavy menstrual bleeding 50 (83.3%), followed by pelvic pain n= 42 (70%), and dysmenorrhea n =36(60%). Near equal distribution of mass per abdomen and Urinary Tract complaints were observed in 15 (25%) and 14 (23.3%) cases respectively ( Table 3 ). Table 3. Distribution of study patients based on clinical symptoms. Variable Category Number of patients (n) % Clinical Symptoms Heavy Menstrual Bleeding 50 83.3% Chronic pelvic pain 42 70.0% Dysmenorrhea 36 60.0% Mass per abdomen 15 25.0% Urinary Tract Complaint 14 23.3% Out of 60 cases, 41 were suspected clinically as leiomyomas. USG detected leiomyoma in 36 cases (60.0%) ( Figure 1 ). Nineteen cases were suspected clinically as Adenomyosis, out of which USG detected 15 cases (25%) to be adenomyosis. USG also detected nine cases which were categorized as other conditions. ( Note: Other conditions are pathologies other than Leiomyoma and Adenomyosis.) Figure 1. Ultrasound showing large anterior wall fundal and upper anterior body fibroid Figo4/5. While imaging patients with leiomyomas using USG and color Doppler, peripheral vascularity was observed in 39 cases (95.12%). The morphological features of USG findings with well-defined margins were present more in 39 cases (95.12%) followed by absence of cystic space 31 (75.61%) and least observed was edge shadowing 5 (12.20%) ( Table 4 ). Table 4. Distribution of study patients based on the morphological features of USG and doppler for Leiomyoma. Variable Category Number of features detected by USG (n) % Morphological Features of USG for Leiomyoma (n=41) Peripheral Vascularity 39 95.12 Well defined Margin 39 95.12 Absence of Cystic Space 31 75.61 Acoustic Shadow 30 73.17 Hypoechogenic Areas 23 56.10 Lobulated Bulge of Uterus 16 39.02 Well Defined Junctional Zone 10 24.39 Edge Shadowing 5 12.20 Imaging adenomyosis using USG with color Doppler central vascularity accounted for 18 (94.70%) ( Figure 2 ). The morphological features of USG findings accounted for a more ill-defined margin 19(100.0%), near equal distribution of globular uterus 18 (94.70%), uterine wall thickening 16 (84.20%) and least observed was hypoechoic linear striations 3(15.80%) ( Table 5 ). Figure 2. Ultrasound and doppler showing adenomyosis in anterior wall of upper body. Table 5. Distribution of study patients based on the morphological features of USG and doppler for adenomyosis. Variable Category Number of features detected by USG (n) % Morphological Features of USG for Adenomyosis (n=19) (MUSA FEATRURES) Central Vascularity (translesional vascularity) 18 94.70% Ill-defined Margin 19 100.00% Globular Uterus 18 94.70% Uterine Wall Thickening (asymmetrical thickening of myometrial walls) 16 84.20% Anechoic Cystic Space (cysts within the myometrium) 9 47.40% Thickened irregular Junctional Zone (irregular junctional zone) 8 42.10% Mixed Echogenicity (hyperechogenic islands within the myometrium) 6 31.60% Heterogenous Myometrial Echotexture (echogenic subendometrial lines and buds) 6 31.60% Poor definition of Junctional Zone 5 26.30% Hypoechoic linear Striations (fan-shaped shadowing) 3 15.80% Total abdominal hysterectomy was the most common type of surgery performed than myomectomy. The distribution of the type of surgery performed among the study patients revealed that total abdominal hysterectomy was done in 40 cases (66.67%) and myomectomy in 20 cases (33.33%) ( Table 6 ). Table 6. Age distribution based on surgical procedure. Age Abdominal Hysterectomy Myomectomy Cases % Cases % 21-30 Years 1 2.50 1 5.00 31-40 Years 5 12.50 5 25.00 41-50 Years 31 77.50 13 65.00 51-60 Years 3 7.50 1 5.00 Total 40 20 Both surgical procedures were found to be performed in the age range of 41-50 years. Histopathological features of leiomyoma revealed more specimens with smooth muscle whorls 36 (97.3%), followed by pseudo capsule 30 (81.1%), Dense Connective tissue 27 (73.0%) and hyalinization 26 (70.3%) ( Table 7 ). Table 7. Distribution of study patients based on the Histopathological Features for Leiomyoma. Variable Category Number of features in the specimens (n) % Histopathology Features for Leiomyoma (n=37) Smooth Muscle Whorls 36 97.3% Pseudo capsule 30 81.1% Dense connective tissue 27 73.0% Hyalinization 26 70.3% Histopathological features of adenomyosis revealed specimens with equal distribution of endometrial glands and smooth muscle hyperplasia in 15 cases (100%) each followed by disruption of the endometrium and myometrium in 12 cases (80.0%) ( Table 8 ). Table 8. Distribution of study patients based on the Histopathological Features for Adenomyosis. Variable Histological Features Number of features in the specimens (n) % Histopathology Features for Adenomyosis (n=15) Endometrial Gland 15 100.0% Smooth Muscle Hyperplasia 15 100.0% Disruption of Endometrium & Myometrium 12 80.0% The test results demonstrated that the mean PI scores among adenomyosis cases [1.722 ± 0.205] were significantly higher than those in leiomyoma cases [0.994 ± 0.190] at P<0.001 ( Table 9 ). Table 9. Comparison of mean values of PI, RI and Vmax Doppler parameters between Leiomyoma and Adenomyosis using Independent Student t Test. Doppler parameters USG findings Number of cases Mean SD Mean T Value PI (Pulsality Index) Leiomyoma 36 0.994 0.190 -0.728 -12.188 P<0.001* Adenomyosis 15 1.722 0.205 Vmax cm sec (Max. Velocity ) Leiomyoma 36 10.836 1.448 3.556 7.334 P<0.001* Adenomyosis 15 7.280 1.864 RI (Resistive Index) Leiomyoma 36 0.679 0.147 -0.771 -12.535 P<0.001* Adenomyosis 15 1.450 0.293 Similarly, the mean RI scores among adenomyosis cases [1.450 ± 0.293] was significantly higher than that compared to leiomyoma cases [0.679 ± 0.147] at P<0.001. In contrast the mean Vmax scores among leiomyoma cases [10.836 ± 1.448] were significantly higher than those of adenomyosis cases [7.280 ± 1.864] at P<0.001. This difference was Statistically Significant. Out of the 60 cases, clinical diagnosis over estimated 9 cases as follows: • 5 cases in Leiomyoma category. • 4 cases in Adenomyosis. However, Imaging was correctly performed in up to 51 cases (83.33%)-36 cases of Leiomyoma and 15 cases of adenomyosis. The test results demonstrated that the clinical diagnosis was strongly correlated with USG findings P <0.001was considered statistically significant. Histopathological diagnosis unveiled the falsified USG diagnosis in 9 cases and diagnosed all 52 (86.66%) cases appropriately. However, imaging was correctly performed in 51 (85.0%) cases of Leiomyoma and Adenomyosis. The comparison analysis test results demonstrated that the USG findings had a very strong correlation with histopathological diagnosis P < 0.001 which was found to be statistically significant ( Table 10 ). Table 10. Comparison of USG Findings and histopathological diagnosis among study patients. USG findings Histopathological diagnosis χ 2 Value P-Value Leiomyoma Adenomyosis Other pathology n % n % n % Leiomyoma 36 100.0% 0 0.0% 0 0.0% 111.89 <0.001 * Adenomyosis 0 0.0% 15 100% 0 0.0% Other pathology 1 11.1% 0 0.0% 8 88.9% Accuracy was calculated using the area under the receiver operating characteristics (ROC) curve. An area of 1 denotes a perfect test indicating that USG findings can be a good test to accurately detect leiomyoma ( Figure 3 and Table 11 ). Figure 3. Accuracy was calculated using the area under the receiver operator characteristics curve (ROC)curve. An area of 1 denotes a perfect test indicating that USG findings can be a good test to accurately detect leiomyoma. Table 11. USG findings as compared to HPE report Correlation in ROC curve Figure 3 for Leiomyomas. Area under curve Std Error P-Value 95% CI Lower Upper 0.85 0.13 0.02 * 0.59 1.00 * Statistically significant. Accuracy was calculated using the area under the receiver operating characteristics (ROC) curve. An area of 1 denotes a perfect test indicating that USG findings would be a good test to accurately detect Adenomyosis ( Figure 4 and Table 12 ). Figure 4. Accuracy was calculated using the area under the receiver operating characteristics (ROC)curve. An area of 1 denotes a perfect test indicating that USG findings would be a good test to accurately detect adenomyosis. Table 12. USG findings and HPE report correlation as per ROC curve in Figure 4 For adenomyosis. Area under curve Std Error P-Value 95% CI Lower Upper 0.84 0.14 0.04 * 0.57 1.00 * Statistically significant. Discussion AUB is a common clinical symptom. It encompasses bleeding due to systemic causes, pathology of the genital tract and dysfunctional uterine bleeding. 6 Myometrial lesions form various groups among which leiomyoma (benign smooth muscle tumour) is the most common followed by adenomyosis, leiomyosarcoma, endometrial stromal tumours, secondary tumours, and vascular lesions. Leiomyoma is a benign neoplasm that affects women of reproductive age. They are observed clinically in 20-30% of women above 30 years of age. Large tumours give rise to diffuse enlargement of the uterus with irregular uterine contours, which may be related to infertility. 7 Ultrasonography is a dependable method for diagnosing tumours, supplemented with Doppler mode to provide additional hemodynamic information. 8 In obstetrics and gynaecology the pulsatility index (PI) is presently the preferred Doppler index due to its sensitivity to change in waveform appearance and it analyzes the entire cardiac cycle. Doppler is a principle supplement to ultrasonography playing a vital role in the assessment of uterine leiomyomas, pelvic hormone replacement therapy, infertility, arteriovenous malformations, etc. 8 The vascularity of the leiomyoma and flow patterns were evaluated using Doppler. Velocimetry is of practical use for the management of uterine leiomyomas. Ultrasonography of arteries is useful in observing leiomyomas in response to therapy, distinguishing Adenomyosis from Leiomyomas, and evaluating tumor size changes in response to uterine artery embolization. The degree of vascularity reflects the growth pattern of the tumour and increase the bleeding risk during surgery. The leiomyoma vascular pattern showed multiple vessels located peripherally surrounding the tumour and the vessels were longer than 1 cm when only a few vessels were close to the tumor. Focal Adenomyosis intramural signals seen without peripheral vessels, and less than 1 cm long if peripheral vessels are present. 8 This was an observational study of 60 patients of reproductive age group. Women with history of heavy menstrual bleeding and clinically suspected case of Leiomyoma and Adenomyosis were included. All study patients were subjected to ultrasonography. Depending upon the treatment suggested surgery was carried out individualising the approach to each patient. Myomectomy or transabdominal hysterectomy was performed with standard surgical protocols. Ultimate diagnosis was made on the basis of histology report. Histopathological report of the specimens was collected and maintained as a record. The collected data were subjected to statistical analysis. Finally, Clinical diagnosis, Ultrasonographic findings and Histopathological reports were compared. In the present study the age of the patients ranged from 21 to 53 years. The majority of patients were predominantly aged 4150years. Majority of patients were of the perimenopausal group contributing to 73.3% of total sample size. A similar finding was reported by Kumari G et al. with age > 40 years. 9 Supria et al. 10 found maximum patients in 40-49 years (40.22%). A wide age range was observed in all the study samples. The increased incidence of AUB in this age group may be due to their climacteric period, prior to which changes occur in ovarian-pituitary function. 10 The present study revealed that the maximum number of multiparous patients was 46(76.7%). Lithingo Lotha et al. 11 (76.7%) and Dinesh et al. 12 (79.3%) observed the maximum number of patients in the multiparous group. In this study the parity distribution among women ranged from 0-4. The maximum number of leiomyoma cases was observed in women with a parity score of 2(48.7%) and adenomyosis cases in women with a parity score of 3 (52.63%). However, 12.40% of leiomyoma cases were also found in nulliparous women. This could be related to a family history of the disease. Singh et al. 13 found the maximum number of cases was 44.15% in para 3. A study by Mohamed Ranaei 14 found that adenomyosis is common in multiparous women. This age distribution may be because the effects are hypothesized to occur as a result of a decrease in menstrual cycle changes in levels of ovarian hormones and growth factors, and a reduction in oestrogen receptor levels in myometrial tissue. 15 In a study by Gupta et al., the authors found heavy menstrual bleeding was present in 97.83% of subjects, 60.87% had chronic pelvic pain, 93.48% had dysmenorrhea, 43.48% had dyspareunia, and 84.78% had a uterine size of ≥8 weeks on clinical examination. 16 As per FIGO The causes of AUB have been broadly classified into structural/organic causes and non-structural/functional causes. 17 Menorrhagia is a subjective complaint evidenced by women as the heaviness of their period. AUB presents with different patterns of bleeding. In the present study a greater number of cases of leiomyoma were clinically suspected than adenomyosis. Among the 60 patients, 41 (68.3%) Leiomyoma cases and Adenomyosis19 (31.7%) was observed. As the endometrium is a dynamic and hormonally sensitive and responsive tissue, it continually experiences variations throughout reproductive life; thus it is vulnerable to pathological lesions and manifests as different symptoms 17 Unopposed estrogen stimulation may lead to endometrial proliferation and hyperplasia, which may cause menorrhagia. In the present study the most common clinical presentation was heavy menstrual bleeding (83.3%) followed by chronic pelvic pain. The study patients presented with a combination of clinical symptoms, including dysmenorrhea and mass per abdomen. Adenomyosis may be asymptomatic but is also a structural cause of AUB. Adenomyosis is extremely variable and exact etiology may be hyper-estrogenism, endometriosis, pregnancy, and prior uterine surgeries. 17 In the present study, using color Doppler imaging in patients with leiomyomas, peripheral vascularity was observed in 39 cases (95.12%).The morphological features of leiomyoma revealed maximum cases with well defined margins which accounted for 39 cases (95.12%) edge shadowing accounted for 5 cases(12.20%), and using several sonographic morphological and color Doppler imaging was able to correctly diagnose 85% of the total cases. Other studies have observed higher blood velocity and lower PI and RI in uterine arteries with uterine fibroids. Fibroids significantly change the velocity flow of blood in the arteries and PI Values < 1.0 in fibrooids. 18 In the present study color Doppler central vascularity was observed in 18 (94.73%) cases, and the morphological features of USG accounted for adenomyosis with ill-defined margins in 19 cases (100%) globular uterus in 18 cases (94.70%), and hypoechoic linear striations in 3 cases (15.80%). The contribution of various sonographic morphological features and color Doppler imaging correctly diagnosed 36 cases (60%) of leiomyoma and 15 (25%) cases of adenomyosis. However imaging was accurately performed in 51 cases (85%) in the total sample. The presence of myometrial cysts, deformed or heterogeneous echo texture, and scanty foci of abnormal myometrium observed by TAS characterize adenomyosis. The presence of ill-defined myometrial heterogeneity is a prognostic ultrasound feature in adenomyosis. The absence of a distinct margin and morphological features of linear striations appears to have high specificity of sonography in evaluating adenomyosis. 19 In our study, the test results demonstrated the validity of USG findings in the detection of leiomyoma in patients as compared to histopathological methods, with a P value of 0.001 which was statistically significant. In the diagnosis of submucosal fibroids and small fibroids (<5 mm) TVS is more sensitive, but they recommend that TAS and TVS should be performed in conjunction. 20 MUSA criteria have enhanced the potential of diagnosing adenomyosis using ultrasound. 21 The receiver operating characteristic curve (ROC) is a plot of the true positive rate against the false positive rate for the different possible cut-off points of a diagnostic test. ROC Curve demonstrated area under curve value of 0.85 (95% CI 0.59-1.00) with a significance of P=0.02. An area of 1 represented a perfect test. This indicate that USG findings can be a good test for accurately detecting leiomyoma. The ROC Curve demonstrated an area under the curve value of 0.88 (95% CI 0.68-1.00) with a significance of P=0.01 indicating that USG findings would be a good test to accurately detect cases of adenomyosis. An area of 1 represents a perfect test. Limitations of the study Ultrasonography is operator dependent and operator sensitive. Transabdominal views are often of limited value if the patient is obese. Lack of uniformity in defining the diagnostic criteria for Leiomyoma or Adenomyosis. Conclusion This study revealed a USG Sensitivity of 97% and a positive predictive value of 97% for leiomyoma and 100% sensitivity and positive predictive value for adenomyosis. Doppler velocimetry revealed that a lower pulsatility index and resistive index were highly suggestive of leiomyoma, and vice versa in cases of adenomyosis. Histopathology correlated with ultrasound and colour Doppler velocimetry findings in identifying and differentiating clinically suspected cases of Leiomyoma and Adenomyosis. Ethics and consent The study was approved by Intsitutional Ethics Committee of Kasturba Medical College, Mangaluru (IEC KMC MLR 09-18/240) on 19 th September 2018. Informed written consent was obtained after explaining the study details in the language that was best understood by the study group. Data availability statement Underlying data Repository name- Mendeley: TITLE-ROLE OF ULTRASOUND WITH DOPPLER IN DIFFERENTIATING CLINICALLY SUSPECTED CASES OF LEIOMYOMA AND ADENOMYOSIS OF UTERUS. https://doi.org/10.17632/y4c6bk9h2m.2 . 22 This project contains the following underlying data: - shruthi Master Chart_ultimate (1).xlsx Data is available under the terms of the CC0 1.0 Acknowledgements Nil. References 1. 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PubMed Abstract | Publisher Full Text | Free Full Text 18. Chiang CH, Chang MY, Hsu JJ, et al. : Tumor vascular pattern and blood flow impedance in the differential diagnosis of leiomyoma and adenomyosis by color Doppler sonography. J. Assist. Reprod. Genet. 1999 May; 16 (5): 268–275. PubMed Abstract | Publisher Full Text | Free Full Text 19. Chopra S, Anna S: Adenomyosis: Common and Uncommon Manifestations on Sonography and Magnetic Resonance Imaging. J. Ultrasound Med. 2006; 25 : 617–627. PubMed Abstract | Publisher Full Text 20. Wilde S, Scott-Barrett S: Radiological appearances of uterine fibroids. Indian J. Radiol. Imaging. 2009 Jul-Sep; 19 (3): 222–231. PubMed Abstract | Publisher Full Text | Free Full Text 21. Harmsen MJ, Van den Bosch T, de Leeuw RA , et al. : Consensus on revised definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis: results of modified Delphi procedure. Ultrasound Obstet. Gynecol. 2022; 60 : 118–131. PubMed Abstract | Publisher Full Text | Free Full Text 22. Mahale AJIT, Mahale N: ROLE OF ULTRASOUND WITH DOPPLER IN DIFFERENTIATING CLINICALLY SUSPECTED CASES OF LEIOMYOMA AND ADENOMYOSIS OF UTERUS. (Dataset). Mendeley Data. 2024; V2 . Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 10 Feb 2025 ADD YOUR COMMENT Comment Author details Author details 1 Department of Obstetrics and Gynecology, Kasturba Medical College Mangalore, Manipal Academy of Higher Education, Karnataka, Manipal, 576104, India 2 Department of Radiodiagnosis, Kasturba medical College Mangalore, Manipal Academy of Higher Education, Karnataka, Manipal, 576104, India Nina Mahale Roles: Conceptualization, Methodology Shruthi V Roles: Data Curation, Writing – Review & Editing Ajit Mahale Roles: Formal Analysis, Project Administration, Validation Sonali Ullal Roles: Supervision Merwyn Fernandes Roles: Software, Validation Sonali Prabhu Roles: Writing – Original Draft Preparation Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (1) version 1 Published: 10 Feb 2025, 14:178 https://doi.org/10.12688/f1000research.157457.1 Copyright © 2025 Mahale N et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Mahale N, V S, Mahale A et al. Role of ultrasound with doppler in differentiating clinically suspected cases of leiomyoma and adenomyosis of uterus [version 1; peer review: 1 approved] . F1000Research 2025, 14 :178 ( https://doi.org/10.12688/f1000research.157457.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 10 Feb 2025 Views 0 Cite How to cite this report: Ji X. Reviewer Report For: Role of ultrasound with doppler in differentiating clinically suspected cases of leiomyoma and adenomyosis of uterus [version 1; peer review: 1 approved] . F1000Research 2025, 14 :178 ( https://doi.org/10.5256/f1000research.172907.r365923 ) The direct URL for this report is: https://f1000research.com/articles/14-178/v1#referee-response-365923 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 11 Mar 2025 Xiang Ji , Shanghai Jiao Tong University, Shanghai, China Approved VIEWS 0 https://doi.org/10.5256/f1000research.172907.r365923 Uterine fibroid and adenomyosis are common diseases of women. The detection of the difference between the two diseases is important, and ultrasound Doppler flow imaging could be used to obtain the right results. This study has provided the clinical study ... Continue reading READ ALL Uterine fibroid and adenomyosis are common diseases of women. The detection of the difference between the two diseases is important, and ultrasound Doppler flow imaging could be used to obtain the right results. This study has provided the clinical study to prove the hypothesis. This reviewer has only minor comments. Please explain the p1, q1, p2 and q2 in the Equation. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: ultrasound imaging I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Ji X. Reviewer Report For: Role of ultrasound with doppler in differentiating clinically suspected cases of leiomyoma and adenomyosis of uterus [version 1; peer review: 1 approved] . F1000Research 2025, 14 :178 ( https://doi.org/10.5256/f1000research.172907.r365923 ) The direct URL for this report is: https://f1000research.com/articles/14-178/v1#referee-response-365923 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 14 Mar 2025 AJIT Mahale , Department of Radiodiagnosis, Kasturba medical College Mangalore, Manipal Academy of Higher Education, Karnataka, 576104, India 14 Mar 2025 Author Response As per reviewers advise I am sending details required for equation for sample size as follows n= (Zα2pq)+Zβp1q1+p2q2)n=(Zα2pq)+Zβp1q1+p2q2) ... Continue reading As per reviewers advise I am sending details required for equation for sample size as follows n= (Zα2pq)+Zβp1q1+p2q2)n=(Zα2pq)+Zβp1q1+p2q2) (p1−p2)2 n =sample size Zα = 1.96 at 95% confidence level Zβ = 1.28 at 90% power, the sample size calculated as 60. p= prevalence of proportion of interest q=1-p p1=proportion of outcome for group 1 p2=proportion 0f outcome for group 2 q1=1-p1 q2=1-p2 As per reviewers advise I am sending details required for equation for sample size as follows n= (Zα2pq)+Zβp1q1+p2q2)n=(Zα2pq)+Zβp1q1+p2q2) (p1−p2)2 n =sample size Zα = 1.96 at 95% confidence level Zβ = 1.28 at 90% power, the sample size calculated as 60. p= prevalence of proportion of interest q=1-p p1=proportion of outcome for group 1 p2=proportion 0f outcome for group 2 q1=1-p1 q2=1-p2 Competing Interests: no competing interests Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 14 Mar 2025 AJIT Mahale , Department of Radiodiagnosis, Kasturba medical College Mangalore, Manipal Academy of Higher Education, Karnataka, 576104, India 14 Mar 2025 Author Response As per reviewers advise I am sending details required for equation for sample size as follows n= (Zα2pq)+Zβp1q1+p2q2)n=(Zα2pq)+Zβp1q1+p2q2) ... Continue reading As per reviewers advise I am sending details required for equation for sample size as follows n= (Zα2pq)+Zβp1q1+p2q2)n=(Zα2pq)+Zβp1q1+p2q2) (p1−p2)2 n =sample size Zα = 1.96 at 95% confidence level Zβ = 1.28 at 90% power, the sample size calculated as 60. p= prevalence of proportion of interest q=1-p p1=proportion of outcome for group 1 p2=proportion 0f outcome for group 2 q1=1-p1 q2=1-p2 As per reviewers advise I am sending details required for equation for sample size as follows n= (Zα2pq)+Zβp1q1+p2q2)n=(Zα2pq)+Zβp1q1+p2q2) (p1−p2)2 n =sample size Zα = 1.96 at 95% confidence level Zβ = 1.28 at 90% power, the sample size calculated as 60. p= prevalence of proportion of interest q=1-p p1=proportion of outcome for group 1 p2=proportion 0f outcome for group 2 q1=1-p1 q2=1-p2 Competing Interests: no competing interests Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 10 Feb 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 Version 1 10 Feb 25 read Xiang Ji , Shanghai Jiao Tong University, Shanghai, China Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Ji X. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 11 Mar 2025 | for Version 1 Xiang Ji , Shanghai Jiao Tong University, Shanghai, China 0 Views copyright © 2025 Ji X. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Uterine fibroid and adenomyosis are common diseases of women. The detection of the difference between the two diseases is important, and ultrasound Doppler flow imaging could be used to obtain the right results. This study has provided the clinical study to prove the hypothesis. This reviewer has only minor comments. Please explain the p1, q1, p2 and q2 in the Equation. Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise ultrasound imaging I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (1) Author Response 14 Mar 2025 AJIT Mahale, Department of Radiodiagnosis, Kasturba medical College Mangalore, Manipal Academy of Higher Education, Karnataka, 576104, India As per reviewers advise I am sending details required for equation for sample size as follows n= (Zα2pq)+Zβp1q1+p2q2)n=(Zα2pq)+Zβp1q1+p2q2) (p1−p2)2 n =sample size Zα = 1.96 at 95% confidence level Zβ = 1.28 at 90% power, the sample size calculated as 60. p= prevalence of proportion of interest q=1-p p1=proportion of outcome for group 1 p2=proportion 0f outcome for group 2 q1=1-p1 q2=1-p2 View more View less Competing Interests no competing interests reply Respond Report a concern Ji X. Peer Review Report For: Role of ultrasound with doppler in differentiating clinically suspected cases of leiomyoma and adenomyosis of uterus [version 1; peer review: 1 approved] . F1000Research 2025, 14 :178 ( https://doi.org/10.5256/f1000research.172907.r365923) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/14-178/v1#referee-response-365923 Alongside their report, reviewers assign a status to the article: Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. 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