الفهرس 
REVIEW OF LITERATUREOnly 14 pages are availabe for public view
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Abstract
A
denomyosis is defined as benign invasion of endometrium into the myometrium in for endometrial glands and stroma surrounded by hypertrophic and hyperplastic smooth muscles.
For several decades, the diagnosis of uterine adenomyosis was made in hysterectomy specimens either coincidently or in women treated surgically for chronic pelvic pain and / or abnormal uterine bleeding. This led to considering it a disease of late reproductive or premenopausal women.
Over the past 20-30 years, more and more cases of adenomyosis are diagnosed with non-invasive methods as transvaginal sonography and magnetic resonance imaging. The shift towards non-invasive diagnostic modalities has been pivotal in changing our understanding of the natural history and clinical spectrum of this disorder.
Till recently, the most common treatment method of uterine adenomyosis has been hysterectomy with many drawbacks as high health cost, lower quality of women’s life and this method is not suitable for women who wish to get pregnant and those who refuse the operation.
There is need for non-invasive diagnostic methods of this gynecological disorder that will lead to many advancements: 1)to know true prevalence, 2)to study risk factors and pathogenesis of this condition that may lead to development of preventive strategies and 3)to study and develop non-invasive treatment methods.
To summerize the diagnostic methods of uterine adenomyosis that could be used: clinical diagnosis, TVS, MRI, elastosonography and the gold standard method which is pathological examination of hysterectomy samples
Clincal picture: Clinical manifestations of this condition are dysmenorrhea, menorrhagia, and uterine enlargement. Clinical manifestations allow only presumptive diagnosis of this disorder. This is because one third of patients are asymptomatic and when there are symptoms; the symptoms are non-specific.
Transabdominal ultrasound: TAS features of this disorder are uterine enlargement in absence of uterine fibroid and / or myometrial cysts. TAUS had a poor sensitivity of 30% but a good specificity specificity of 97%. The study TAS has a little value in the diagnosis of uterine adenomyosis because it does not allow discriminating this condition from other myometrial pathologies such as uterine myoma.
2D-Transvaginal sonography: the following 2D-TVS features are associated with uterine adenomyosis: myometrial cysts, subendometrial linear striations, subendometrial echogenic nodules, myometrial antero-posterior asymmetry, globular uterus and straight vessels within the hypertrophic myometrium on color Doppler. TVS had sensitivity and specificity of 81.1% and 86% with overall accuracy of 86%.
3D-Transvaginal sonography: This diagnostic might be superior to 2D-TVS in the diagnosis of uterine adenomyosis. The 3D-TVS features of uterine adenomyosis are JZmax more than 8 mm, JZmax / total myometrial thickness of 50% or more, JZ diff 4 mm or more, JZ irregularity and JZ interruprion. It showed that 3D-TVS for diagnosis of uterine adenomyosis had sensitivity, specificity and overall accuracy of 90%, 92.8% and 92.4% respectively.
Magnetic resonance imaging: T2-Weighted MRI features of uterine adenomyosis are: JZmax 12 mm or more, JZmax / total myometrial thickness more than 40%, higher intensity myometrial foci and large regular asymmetric uterus. In this study suggested that MRI was more useful than TVS in diagnosis of uterine adenomyosis when there are associated uterine lesions. The study recommended TVS as the first line diagnostic modality and MRI as a second line diagnostic method if TVS is inconclusive.
Elastosonography: Uterine adenomyosis can be diagnosed by strain elastography. With strain elastography, adenomyotic area presents more softness (red and green) compared to surrounding normal myometrium (blue). In this study strain elastography to diagnose uterine adenomyosis had excellent agreement with that of MRI. In this study evaluated the role of shear wave elastography as a diagnostic modality for uterine adenomyosis. They found that sensitivity, specificity, PPV, NPV of SWE were 89.7%, 92.9%, 97.2% and 76.5% respectively.
Pathological diagnosis: Done on hysterectomy specimens. Gross appearance in the form of uterine enlargement, globular or asymmetric uterus. The affected area may show trabeculated cut surface with petiche – like grey foci. The histopathologic examination is the gold standard diagnostic modality. On microscopic examination, ectopic endometrial tissue is seen more than 2.5 mm below the basal layer of endometrium. The focuses of endometrial glands and stroma invading the myometrium are typically surrounded by hypertrophic and hyperplastic myometrial tissue. The histological diagnosis of adenomyosis can be time consuming. The rate of detection depends on the quantity and quality of sections examined and can vary from 31% to 62% in the same uterus.
This study aims to assess the accuracy of shear wave elastography in the diagnosis of adenomyosis compared to MRI.
In the current pilot study, 59 premenopausal patients planned for total hysterectomy at Ain Shams Obstetrics and Gynecology Hospital, due to benign pelvic conditions were enrolled.
Inclusion criteria for the study were: women in reproductive age with abnormal uterine bleeding who had failed medical treatment, women with endometriosis and patients having chronic pelvic pain with failed medical treatment for more than six months. Also, some patients included in the study had hysterectomy performed due to CIN 3 or vaginal prolapse. The exclusion criteria were women before age of menarche, or after menopause, fibroid uterus, and women in whom vaginal examination cannot be done (virgin or patient refusal).
Approval of the study was obtained before its initiation. Only the usual consent for hysterectomy was needed. No consent for entering the study.
Three cases were excluded from the study due to postponed surgery; 2 cases were excluded because patients refused operation. They changed their decision and asked for Mirena insertion. 4 more cases were excluded because the operation was done before completing the imaging procedures.
The remaining fifty patients comprised the study group. Each one of the study patients had TVS, SWE and MRI done between day 7 and 14 of the menstrual cycle and the hysterectomy operation was done within 2 months from imaging.
Total hysterectomy was done abdominally in 39 cases and vaginally in eleven cases. One stitch was put at each cornu on anterior uterine wall for orientation, the uterus was bisected longitudinally, fixed in formalin, and sent to pathology department.
TVS and SWE were done in Ain Shams University Hospital, Ultrasound and Special Care Unit for the Fetus Department by use of Samsung HS60. Uterine adenomyosis was diagnosed, in the presence of one or more of the following sonographic features: subendometrial echogenic linear striations, intramyometrial cysts 2-7 mm in diameter, a heterogenous myometrial echo- texture, poor definition of endometrial myometrial interface, globular uterus or myometrial antero - posterior asymmetry.
After doing the transvaginal sonographic examination, the shear wave elastography mode was activated. The transducer was put vaginally at a depth of 3 cm. Scanning was done without additional compression by movement of the hand and transducer. Color mapping and determination of the Young’s modulus value were done in area of interest (AOI) 5 mm in diameter. The area of interest was put in suspected pathology by ultrasound or in anterior uterine wall in absence of suspected pathology. Adenomyosis was diagnosed if the Young’s modulus value above the cut off value of 34.6 Kpa.
With magnetic resonance imaging, adenomyosis was diagnosed in the presence of one or more of the following features: JZmax equal or more than 12 mm, JZdiff more than 5 mm, JZmax / total myometrial thickness more than 40%. This protocol consisted of pelvic T2-WI sagittal, axial and coronal planes and T1 3D fast suppressed axial and coronal planes.
The histopathologist without knowing the imaging findings was asked to see if there is uterine adenomyosis (no comment was needed for extent or severity of the lesion). Histopathological sections were studied from the following sites: fundus, anterior wall, posterior wall, left lateral wall, right lateral wall and from macroscopically suspect myometrial area. The uterine adenomyosis was diagnosed if ectopic endometrium was present at 2.5 mm or more from the basal endometrium.
The histopathological results were used to see the incidence of uterine adenomyosis in the study patients and to study the values of risk factors mentioned in previous studies (age, gravidity, parity, history of uterine surgery, smoking, depression, oral contraceptive use and of IUD insertion.
Also, the results of histopathological examination were used as a reference to study the diagnostic value of the methods used to diagnose uterine adenomyosis: TVS, SWE and MRI.
Twenty seven patients (54%) had histopathological diagnosis of uterine adenomyosis. The clinical manifestations that may be related to uterine adenomyosis were AUB (43%) and chronic pelvic pain (44%). The specificities of TVS, SWE and MRI are comparable, while, the sensitivity of TVS is non-significantly less than those of either SWE or MRI. The sensitivity of SWE and MRI were comparable.
This study shows that the prevalence of uterine adenomyosis is 54% in premenopausal patients treated by hysterectomy for some gynecological disorders. This prevalence is overestimation because of indication- bias and because women who need treatment by hysterectomy do not represent the general women population.
SWE, TVS and MRI are accurate as non-invasive methods to diagnose uterine adenomyosis, however, TVS has non-significant less sensitivity.
SWE; a new diagnostic method that tests mechanical characteristics of tissue, is non-invasive, easy to perform, easy to interprete, does not increase TVS examination time significantly and has short learning curve towards becoming skilled in the procedure.
It can be recommended to do more trials on SWE in diagnosis of uterine adenomyosis in all age groups of reproductive period that may clarify prevalence and risk factors of this condition. Also, development of non-invasive method to diagnose this problem can open way for preventive strategies and non- invasive treatment methods of uterine adenomyosis.
Training of sonographers working in gynecology on SWE is recommended.