Superficial Endometriosis at Ultrasound Examination-A Diagnostic Criteria Proposal.

The actual prevalence of superficial endometriosis is not known. However, it is considered the most common subtype of endometriosis. The diagnosis of superficial endometriosis remains difficult. In fact, little is known about the ultrasound features of superficial endometriotic lesions. In this study, we aimed to describe the appearance of superficial endometriosis lesions at ultrasound examination, with laparoscopic and/or histologic correlation. This is a prospective study on a series of 52 women with clinical suspicion of pelvic endometriosis who underwent preoperative transvaginal ultrasound and received a confirmed diagnosis of superficial endometriosis via laparoscopy. Women with ultrasound or laparoscopic findings of deep endometriosis were not included. We observed that superficial endometriotic lesions may appear as a solitary lesions, multiple separate lesions, and cluster lesions. The lesions may exhibit the presence of hypoechogenic associated tissue, hyperechoic foci, and/or velamentous (filmy) adhesions. The lesion may be convex, protruding from the peritoneal surface, or it may appear as a concave defect in the peritoneum. Most lesions exhibited several features. We conclude that transvaginal ultrasound may be useful for diagnosing superficial endometriosis, as these lesions may exhibit different ultrasound features.

Transvaginal Ultrasound Accuracy in the Hydrosalpinx Diagnosis: A Systematic Review and Meta-Analysis.

Hydrosalpinx is a condition with a crucial prognostic role in reproduction, and its diagnosis by a non-invasive technique such as ultrasound is key in achieving an adequate reproductive assessment while avoiding unnecessary laparoscopies. The aim of the present systematic review and meta-analysis is to synthetize and report the current evidence on transvaginal sonography (TVS) accuracy to diagnose hydrosalpinx. Articles on the topic published between January 1990 and December 2022 were searched in five electronic databases. Data from the six selected studies, comprising 4144 adnexal masses in 3974 women, 118 of which were hydrosalpinxes, were analyzed as follows: overall, TVS had a pooled estimated sensitivity for hydrosalpinx of 84% (95% confidence interval (CI) = 76-89%), specificity of 99% (95% CI = 98-100%), positive likelihood ratio of 80.7 (95% CI = 33.7-193.0), and negative likelihood ratio of 0.16 (95% CI = 0.11-0.25) and DOR of 496 (95% CI = 178-1381). The mean prevalence of hydrosalpinx was 4%. The quality of the studies and their risk of bias were assessed using QUADAS-2, evidencing an overall acceptable quality of the selected articles. We concluded that TVS has a good specificity and sensitivity for diagnosing hydrosalpinx.

O-RADS Classification for Ultrasound Assessment of Adnexal Masses: Agreement between IOTA Lexicon and ADNEX Model for Assigning Risk Group.

BACKGROUND: The O-RADS system is a new proposal for establishing the risk of malignancy of adnexal masses using ultrasound. The objective of this study is to assess the agreement and diagnostic performance of O-RADS when using the IOTA lexicon or ADNEX model for assigning the O-RADS risk group. METHODS: Retrospective analysis of prospectively collected data. All women diagnosed as having an adnexal mass underwent transvaginal/transabdominal ultrasound. Adnexal masses were classified according to the O-RADS classification, using the criterion of the IOTA lexicon and according to the risk of malignancy determined by the ADNEX model. The agreement between both methods for assigning the O-RADS group was estimated using weighted Kappa and the percentage of agreement. The sensitivity and specificity of both approaches were calculated. RESULTS: 454 adnexal masses in 412 women were evaluated during the study period. There were 64 malignant masses. The agreement between the two approaches was moderate (Kappa: 0.47), and the percentage of agreement was 46%. Most disagreements occurred for the groups O-RADS 2 and 3 and for groups O-RADS 3 and 4. The sensitivity and specificity for O-RADS using the IOTA lexicon and O-RADS using the ADNEX model were 92.2% and 86.1%, and 85.9% and 87.4%, respectively. CONCLUSION: The diagnostic performance of O-RADS classification using the IOTA lexicon as opposed to the IOTA ADNEX model is similar. However, O-RADS group assignment varies significantly, depending on the use of the IOTA lexicon or the risk estimation using the ADNEX model. This fact might be clinically relevant and deserves further research.

How Frequently Benign Uterine Myomas Appear Suspicious for Sarcoma as Assessed by Transvaginal Ultrasound?

BACKGROUND: Uterine myomas may resemble uterine sarcomas in some cases. However, the rate of benign myomas appearing as sarcomas at an ultrasound examination is not known. The objective of this study is to determine the percentage of benign myomas that appear suspicious for uterine sarcoma on ultrasound examination. This is a prospective observational multicenter study (June 2019-December 2021) comprising a consecutive series of patients with histologically proven uterine myoma after hysterectomy or myomectomy who underwent transvaginal and/or transabdominal ultrasound prior to surgery. All ultrasound examinations were performed by expert examiners. MUSA criteria were used to describe the lesions (1). Suspicion of sarcoma was established when three or more sonographic features, described by Ludovisi et al. as "frequently seen in uterine sarcoma", were present (2). These features are no visible myometrium, irregular cystic areas, non-uniform echogenicity, irregular contour, "cooked" appearance, and a Doppler color score of 3-4. In addition, the examiners had to classify the lesion as suspicious based on her/his impression, independent of the number of features present. Eight hundred and ten women were included. The median maximum diameter of the myomas was 58.7 mm (range: 10.0-263.0 mm). Three hundred and forty-nine (43.1%) of the patients had more than one myoma. Using the criterion of >3 suspicious features, 40 (4.9%) of the myomas had suspicious appearance. By subjective impression, the examiners considered 40 (4.9%) cases suspicious. The cases were not exactly the same. We conclude that approximately 5% of benign uterine myomas may exhibit sonographic suspicion of sarcoma. Although it is a small percentage, it is not negligible.

Transvaginal ultrasound versus magnetic resonance imaging for diagnosing adenomyosis: A systematic review and head-to-head meta-analysis.

BACKGROUND: Transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) are used for the clinical diagnosis of adenomyosis. OBJECTIVES: To compare the diagnostic accuracy of TVS and MRI for the diagnosis of adenomyosis. SEARCH STRATEGY: A search of studies was performed in five databases comparing TVS and MRI for the diagnosis of adenomyosis from January 1990 to May 2022. SELECTION CRITERIA: Studies were eligible if they reported on the use of TVS and MRI in the same set of patients. The reference standard must be pathology (hysterectomy). DATA COLLECTION AND ANALYSIS: The quality of studies was assessed using the QUADAS-2 tool. Pooled sensitivity and specificity of both techniques were estimated and compared. MAIN RESULTS: Six studies comprising 595 women were included. The risk of bias of patient selection was high in three studies. The risk of bias for index tests and reference test was low. Pooled estimated sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio for TVS were 75%, 81%, 3.9, and 0.31, respectively. These figures for MRI were 69%, 80%, 3.5, and 0.39, respectively. No statistically significant differences were found (p = 0.7509). Heterogeneity was high. CONCLUSIONS: MRI and TVS have similar performances for the diagnosis of adenomyosis.

Advances in Imaging for Assessing Pelvic Endometriosis.

In recent years, due to the development of standardized diagnostic protocols associated with an improvement in the associated technology, the diagnosis of pelvic endometriosis using imaging is becoming a reality. In particular, transvaginal ultrasound and magnetic resonance are today the two imaging techniques that can accurately identify the majority of the phenotypes of endometriosis. This review focuses not only on these most common imaging modalities but also on some additional radiological techniques that were proposed for rectosigmoid colon endometriosis, such as double-contrast barium enema, rectal endoscopic ultrasonography, multidetector computed tomography enema, computed tomography colonography and positron emission tomography-computed tomography with 16α-[18F]fluoro-17ß-estradiol.

Extra-Gynecological Pelvic Pathology: A Challenge in the Differential Diagnosis of the Female Pelvis.

Ultrasound technology with or without color Doppler allows a real-time evaluation of the entire female pelvis including gynecologic and non-gynecological organs, as well as their pathology. As ultrasound is an accurate tool for gynecological diagnosis and is less invasive and less expensive than other techniques, it should be the first imaging modality used in the evaluation of the female pelvis. We present a miscellany of non-gynecological pelvic images observed during the realization of gynecological ultrasound. Transvaginal and transabdominal ultrasound is the first choice among diagnostic techniques for the study of the female pelvis, providing information about gynecological and extra-gynecological organs, allowing for an orientation toward the pathology of a specific organ or system as well as for additional tests to be performed that are necessary for definitive diagnosis.

The Reproducibility of Ultrasonographic Findings of Rectosigmoid Endometriosis Among Examiners With Different Level of Expertise.

OBJECTIVE: To analyze the reproducibility of ultrasonographic (US) findings of rectosigmoid endometriosis among examiners with different level of expertise using stored three-dimensional (3D) volumes of the posterior compartment of the pelvis as a part of SANABA (Sardinia-Navarra-Barcelona) collaborative study. MATERIALS AND METHODS: Six examiners in 3 academic Department of Obstetrics and Gynecology, with different levels of experience and blinded to each other, evaluated 60 stored 3D volumes from the posterior compartment of the pelvis and looked for the presence or absence of features of rectosigmoid endometriotic lesions defined as an irregular hypoechoic nodule with or without hypoechoic foci at the level of the muscularis propria of the anterior wall rectum sigma. Multiplanar view and virtual navigation were used. All examiners had to assess the 3D volume of posterior compartment of the pelvis and classify it as present or absent disease. To analyze intra-observer and the inter-observer agreements, each examiner performed the assessment twice with a 2-week interval between the first and second assessments. Reproducibility was assessed by calculating the weighted Kappa index. RESULTS: Intra-observer reproducibility was moderate to very good for all observers (Kappa index ranging from 0.49 to 0.96) associated with a good diagnostic accuracy of each reader. Inter-observer reproducibility was fair to very good (Kappa index range: 0.21-0.87). CONCLUSIONS: The typical US sign of rectosigmoid endometriosis is reasonably recognizable to observers with different level of expertise when assessed in stored 3D volumes.

Artificial intelligence (AI) in the detection of rectosigmoid deep endometriosis.

OBJECTIVES: The aim of this study was to compare the accuracy of seven classical Machine Learning (ML) models trained with ultrasound (US) soft markers to raise suspicion of endometriotic bowel involvement. MATERIALS AND METHODS: Input data to the models was retrieved from a database of a previously published study on bowel endometriosis performed on 333 patients. The following models have been tested: k-nearest neighbors algorithm (k-NN), Naive Bayes, Neural Networks (NNET-neuralnet), Support Vector Machine (SVM), Decision Tree, Random Forest, and Logistic Regression. The data driven strategy has been to split randomly the complete dataset in two different datasets. The training dataset and the test dataset with a 67 % and 33 % of the original cases respectively. All models were trained on the training dataset and the predictions have been evaluated using the test dataset. The best model was chosen based on the accuracy demonstrated on the test dataset. The information used in all the models were: age; presence of US signs of uterine adenomyosis; presence of an endometrioma; adhesions of the ovary to the uterus; presence of "kissing ovaries"; absence of sliding sign. All models have been trained using CARET package in R with ten repeated 10-fold cross-validation. Accuracy, Sensitivity, Specificity, positive (PPV) and negative (NPV) predictive value were calculated using a 50 % threshold. Presence of intestinal involvement was defined in all cases in the test dataset with an estimated probability greater than 0.5. RESULTS: In our previous study from where the inputs were retrieved, 106 women had a final expert US diagnosis of rectosigmoid endometriosis. In term of diagnostic accuracy the best model was the Neural Net (Accuracy, 0.73; sensitivity, 0.72; specificity 0.73; PPV 0.52; and NPV 0.86) but without significant difference with the others. CONCLUSIONS: The accuracy of ultrasound soft markers in raising suspicion of rectosigmoid endometriosis using Artificial Intelligence (AI) models showed similar results to the logistic model.

COVID-19 and ART: the view of the Italian Society of Fertility and Sterility and Reproductive Medicine.

The COVID-19 pandemic is an unprecedented global situation. As assisted reproductive technology (ART) specialists, we should be cautious, carefully monitoring the situation while contributing by sharing novel evidence to counsel our patients, both pregnant women and would-be mothers. Time to egg collection and drop-out rates are critical parameters for scheduling treatments once the curve of infections has peaked and plateaued in each country. In order to reduce the values for these two parameters, infertile patients now require even more support from their IVF team: urgent oocyte collection for oncology patients must be guaranteed, and oocyte retrievals for women of advanced maternal age and/or reduced ovarian reserve cannot be postponed indefinitely. This document represents the position of the Italian Society of Fertility and Sterility and Reproductive Medicine (SIFES-MR) in outlining ART priorities during and after this emergency.

Ultrasonography and Atypical Sites of Endometriosis.

In the present pictorial we show the ultrasonographic appearances of endometriosis in atypical sites. Scar endometriosis may present as a hypoechoic solid nodule with hyperechoic spots while umbilical endometriosis may appear as solid or partially cystic areas with ill-defined margins. In the case of endometriosis of the rectus muscle, ultrasonography usually demonstrates a heterogeneous hypoechogenic formation with indistinct edges. Inguinal endometriosis is quite variable in its ultrasonographic presentation showing a completely solid mass or a mixed solid and cystic mass. The typical ultrasonographic finding associated with perineal endometriosis is the presence of a solid lesion near to the episiotomy scar. Under ultrasonography, appendiceal endometriosis is characterized by a solid lesion in the wall of the small bowel, usually well defined. Superficial hepatic endometriosis is characterized by a small hypoechoic lesion interrupting the hepatic capsula, usually hyperechoic. Ultrasound endometriosis of the pancreas is characterized by a small hypoechoic lesion while endometriosis of the kidney is characterized by a hyperechoic small nodule. Diaphragmatic endometriosis showed typically small hypoechoic lesions. Only peripheral nerves can be investigated using ultrasound, with a typical solid appearance. In conclusion, ultrasonography seems to have a fundamental role in the majority of endometriosis cases in "atypical" sites, in all the cases where "typical" clinical findings are present.

Repeated two cycles of ulipristal acetate treatment improve the quality of life in premenopausal women with heavy menstrual bleeding dependent on uterine myomas, without impairment of bone health.

This observational study was conducted in premenopausal women who presented themselves at the Obstetrics and Gynecology Department of the University Hospital of Cagliari (Italy), for heavy menstrual bleeding (HMB) dependent on uterine myomas. After a screening visit, 19 women without contraindications to ulipristal acetate (UPA) treatment, were included in the study that envisaged 12 months of observation in which each subject was asked to assume UPA (tablet of 5 mg, ESMYA®, one tablet a day for 3 months: first cycle) two menstrual cycles of interruption and a second ESMYA® cycle, followed by 3 months of observation (third follow-up month, visit 4). The significant decrease of myoma volume, diagnosed after the first ESMYA® cycle, persisted until the visit 4. The HMB significantly decreased during the ESMYA® treatment and persisted until visit 4. The quality of life (QoL), evaluated with the questionnaire SF-36, significantly improved during the study. The values of estradiol (E2), biochemical parameters of bone metabolism, as well as those of lumbar and hip bone mineral density, did not change during the study in comparison with basal levels. The efficacy of two repeated ESMYA® cycles to treat uterine myomas and their related symptoms improves the QoL without interfering with bone health.

Does the clinical information play a role in the magnetic resonance diagnostic confidence analysis of ovarian and deep endometriosis?

OBJECTIVE:: Some recent studies have explored how the experience in the observers change their performance in the endometriosis detection using MRI but the effects of the clinical information remains uncertain. The purpose of this study was to assess the effect of the clinical information in the diagnostic confidence in the MRI diagnosis of endometriosis. METHODS AND MATERIALS:: Institutional Review Board was obtained. This study is compliant to STARD method. 80 patients (mean age 32 years; range 19 - 46 years) who had undergone MRI study and surgery for suspected endometriosis were retrospectively evaluated. MRI exams were performed with a 1.5 T scanner and the following five locations were assessed: ovary, anterior compartment, vaginal fornix, utero-sacral ligaments, and Rectum\Sigmoid\Pouch of Douglas. Data sets were evaluated twice on a 5-point scale by four radiologists with different level of expertise; the first time blinded to the clinical information and the second time, after 3 months together with the clinical chart. Statistical analysis included receiver operating characteristics curve analysis, the Cohen weighted test and sensitivity, specificity, positive predictive value, negative predictive value, accuracy, LR+ and LR-. RESULTS:: A total of 140 localization of endometriosis (47 endometriomas and 93 endometriotic nodules) were found. The pairwise comparison demonstrated that in all cases the presence of clinical information improved the Az value. The concordance analysis indicated a mixed pattern from modest agreement (weighted κ value 0.556 for anterior compartment) to excellent agreement values (weighted κ value 0.867 for ovarian endometriomas). CONCLUSION:: The results of our study suggest that clinical information is useful in diagnosing endometriosis in general anterior compartment, but not in other locations. Less experienced radiologists (resident) may benefit from it at utero-sacral ligaments or Rectum\Sigmoid\Pouch of Douglas. ADVANCES IN KNOWLEDGE:: In this era of sometimes indiscriminate use of diagnostic methods, it is important to emphasis the context for interpretation of diagnostic results. Our paper confirms that clinical information is useful in diagnosing endometriosis.

Vilaprisan for treating uterine fibroids.

INTRODUCTION: The medical strategy to antagonize myoma size and related-symptoms is to reduce estrogen and progesterone activity on myomas. This can be obtained with the GnRH agonist (GnRHa) or with compounds that antagonize progesterone stimulatory activity on myomas. Selective progesterone receptor modulators (SPRMs) bind progesterone receptor (PR), leading to both agonist and antagonist effects. The result of SPRMs's action is tissue-specific and it depends on the particular affinity and strength of each SPRM. Area covered: Ulipristal acetate (UPA) is the first SPRM registered for myoma treatment. UPA reduces heavy uterine bleeding within 7 days from the onset of treatment, whereas a longer time is required with GnRHa treatment. Vilaprisan is a novel powerful SPRM. Phase I and II studies give encouraging results on the efficacy of vilaprisan at different doses. Like other SPRMs, vilaprisan induces benign changes of endometrium (PR modulator-associated endometrial changes, PAECs). These disappear as treatment is discontinued. Unlike GnRHa treatment, neither UPA nor vilaprisan induce hypoestrogenism and associated symptoms. Phase III studies are ongoing to confirm efficacy and safety of vilaprisan in long-term treatment of symptomatic fibroids. Expert opinion: It is fundamental to underline the rapidity of action (only 3 days) in the control of myoma-related bleeding.

Deep Infiltrating Endometriosis: Comparison Between 2-Dimensional Ultrasonography (US), 3-Dimensional US, and Magnetic Resonance Imaging.

OBJECTIVES: To evaluate the diagnostic accuracy of 2-dimensional (2D) and 3-dimensional (3D) transvaginal ultrasonography (US) in comparison with magnetic resonance imaging (MRI) for identification of deep infiltrating endometriosis. METHODS: In this prospective observational study, 159 premenopausal women who underwent surgery for a clinical suspicion of deep infiltrating endometriosis were prospectively enrolled. All women underwent 2DUS, 3DUS, and MRI. The following 3 locations of deep endometriosis were considered: (1) intestinal; (2) other posterior lesions (retrocervical septum, rectovaginal septum, uterosacral ligaments, and vaginal fornix); and (3) anterior. The sensitivity, specificity, positive predictive value, and negative predictive value of 2D and 3D transvaginal US in comparison with MRI were determined. RESULTS: Intestinal deep infiltrating endometriosis was identified by 2DUS in 56 of 66 patients, by 3DUS in 59 of 66, and by MRI in 61 of 66. A receiver operating characteristic curve analysis showed optimal results for 2DUS, 3DUS, and MRI (areas under the curve, 0.86, 0.915, and 0.935, respectively) with a statistically significant difference between 2DUS and MRI (P = .0103), even when the 95% confidence interval showed an overlap. Other posterior deep infiltrating endometriosis was identified by 2DUS in 55 of 75 patients, by 3DUS in 65 of 75, and by MRI in 66 of 75. A receiver operating characteristic curve analysis showed very good results for 2DUS, 3DUS, and MRI (areas under the curve, 0.801, 0.838, and 0.857) with no statistically significant differences. In the 12 women with deep infiltrating endometriosis in the anterior location, the nodules were correctly identified by 2DUS in 3 of 12 patients, by 3DUS in 5 of 12, and by MRI in 6 of 12. CONCLUSIONS: Our results seem to suggest that there is a statistically significant difference between 2DUS and MRI for the intestinal location of deep infiltrating endometriosis, whereas no differences were found among the techniques for the other locations.

Long-term Results for Expectant Management of Ultrasonographically Diagnosed Benign Ovarian Teratomas.

OBJECTIVE: To assess the natural history of ultrasonographically diagnosed benign ovarian teratomas in asymptomatic women. METHODS: We conducted a retrospective observational cohort study of 408 women (mean age 36.6 years, range 14-81 years) diagnosed as having an ovarian teratoma by transvaginal ultrasonography (except eight who only had a transabdominal study done) between January 2003 and December 2013 at a single tertiary care institution. Six hundred thirteen women were diagnosed with ovarian teratoma of whom 205 were promptly treated surgically, leaving 408 patients followed conservatively with follow-up scans at 3 and 6 months from diagnosis and then yearly. The ultrasonographic diagnosis of a benign ovarian teratoma required at least one of the following features: a cystic mass with mixed echogenicity, thick band-like echoes, a fat-fluid level, or echogenic tubercle with posterior shadowing. Clinical, ultrasonographic, and histologic data (in case of surgery) were retrieved for analysis. RESULTS: During follow-up, 130 of 408 (31.8%) women underwent surgery. The main reason for surgery was the physician's recommendation according to our protocol (n=115). One patient had adnexal torsion. Most surgeries (112/130 [86.2%]) were performed within the first 5 years after diagnosis. The remainder (278/408) is still being followed (median time 45.6 months, range 6-147 months). The vast majority of these lesions had no change and women remain asymptomatic. Histologic diagnosis of tumors removed surgically revealed a benign ovarian teratoma in 103 of 130 (79.2%) of the women. There were two borderline tumors, four endometriomas, three fibromas, seven serous cysts, two mucinous cysts, two stroma ovarii, seven other benign, and no case of malignant tumor. CONCLUSION: Our results demonstrate that expectant management might be a reasonable option for managing asymptomatic women who receive a ultrasonographic diagnosis of a benign ovarian teratoma. The risk of undergoing surgery for this lesion decreases significantly after 5 years to follow-up. With careful observation, the risk of missing a diagnosis of malignancy is low.

Reproducibility of the International Endometrial Analysis Group Color Score for Assigning the Amount of Flow Within the Endometrium Using Stored 3-Dimensional Volumes.

OBJECTIVES: To estimate intraobserver and interobserver reproducibility for assigning an International Endometrial Tumor Analysis (IETA) group color score for endometrial vascularization on color Doppler imaging. METHODS: Sixty-eight endometrial 3-dimensional volumes from endometrial color Doppler assessments of women with different endometrial disorders were evaluated by 8 different examiners (4 skilled examiners and 4 obstetric and gynecologic trainees). One skilled examiner who did not participate in the assessments selected the 68 volumes from a database to select a balanced number of each IETA score. Each examiner evaluated the 68 endometrial volumes to assign the IETA color score (1, absence of vascularization; 2, low vascularization; 3, moderate vascularization; or 4, abundant vascularization) using tomographic ultrasound imaging. The analysis was repeated 4 weeks later, and interobserver and intraobserver reproducibility was analyzed by calculating the weighted κ index. The second of the measurements made by each observer was used to estimate interobserver reproducibility. RESULTS: The intraobserver reproducibility was very good for all examiners, with a weighted κ index ranging from 0.84 to 0.91. The interobserver reproducibility was good or very good for all estimated comparisons, with a weighted κ index ranging from 0.77 to 0.96, regardless of experience level. CONCLUSIONS: The reproducibility of assigning the IETA color score for assessing endometrial vascularization using 3-dimensional volumes is good or very good regardless of the experience of the examiner.

Malignancy risk of sonographically benign appearing purely solid adnexal masses in asymptomatic postmenopausal women.

OBJECTIVE: To assess the natural history of benign appearing purely solid ovarian lesions in asymptomatic postmenopausal women. METHODS: Retrospective observational cohort study comprising 99 women (mean age, 58.2 years, ranging from 50 to 77 years) diagnosed as having a purely solid ovarian lesion at transvaginal ultrasound between April 2001 and October 2015. Inclusion criteria were as follows: asymptomatic postmenopausal women with a well-defined purely solid ovarian lesion with International Ovarian Tumor Analysis color score 1 or 2, without ascites and/or signs of carcinomatosis. Clinical, sonographic, biochemical (CA-125), and histologic data (in case of surgery) were retrieved for analysis. Patients who were managed conservatively were assessed by transvaginal sonography every 6 months for a minimum of a year. In case of bilateral lesions we used the largest one for analysis. RESULTS: Five women (5.1%) had bilateral lesions. Mean size of the lesion was 2.9 cm (range, 1.0-7.8 cm). Most lesions were homogeneous (96.0%). Acoustic shadowing was present in 59.6% of cases. International Ovarian Tumor Analysis color score was 1 in 77.8% and 2 in 22.2% of the cases, respectively. Median CA-125 was 10.8 IU/mL (range, 3.0-403.0 IU/mL). Forty-two women underwent surgery after diagnosis (histologic diagnoses were as follows: fibroma (n = 26), fibrothecoma (n = 5), dermoid (n = 3), Brenner tumor (n = 3), endometrioma (n = 2), thecoma (n = 1), primary invasive cancer (n = 2). One case of invasive cancer CA-125 was 403.0 IU/mL and in the other case CA-125 was 6.0 IU/mL. They both were stage 1. Fifty-seven women were managed with serial follow-up. With a median follow-up time of 36 months (range, 12-142 months) all these lesions had no change and women remain asymptomatic. Considering all 99 cases the risk of malignancy is 2% (95% CI, 0.1-7.5). CONCLUSIONS: The risk of malignancy of benign appearing purely solid adnexal masses in asymptomatic postmenopausal women is low. Conservative management of these lesions might be an option.

Age-related differences in the sonographic characteristics of endometriomas.

STUDY QUESTION: Do sonographic characteristics of ovarian endometriomas vary with age in premenopausal women? SUMMARY ANSWER: With increasing age, multilocular cysts and cysts with papillations and other solid components become more common whereas ground glass echogenicity of cyst fluid becomes less common. WHAT IS KNOWN ALREADY: Expectant or medical management of women with endometriomas is now accepted. Therefore, the accuracy of non-invasive diagnosis of these cysts is pivotal. A clinically relevant question is whether the sonographic characteristics of ovarian endometriomas are the same irrespective of the age of the woman. STUDY DESIGN, SIZE, DURATION: This is a secondary analysis of cross-sectional data in the International Ovarian Tumor Analysis (IOTA) database. The database contains clinical and ultrasound information collected pre-operatively between 1999 and 2012 from 5914 patients with adnexal masses in 24 ultrasound centres in 10 countries. PARTICIPANTS/MATERIALS, SETTING, METHODS: There were 1005 histologically confirmed endometriomas in adult premenopausal patients found in the database and these were used in our analysis. The following ultrasound variables (defined using IOTA terminology) were used to describe the ultrasound appearance of the endometriomas: tender mass at ultrasound, largest diameter of lesion, tumour type (unilocular, unilocular-solid, multilocular, multilocular-solid, solid), echogenicity of cyst content, presence of papillations, number of papillations, height (mm) of largest papillation, presence and proportion of solid tissue and number of cyst locules, as well as vascularity in papillations and colour content of the tumour scan (colour score) on colour or power Doppler ultrasounds. Results are reported as median difference or odds ratio (OR) per 10 years increase in age. MAIN RESULTS AND THE ROLE OF CHANCE: Maximal lesion diameter did not vary substantially with age (+1.3 mm difference per 10 years increase in age, 95% confidence interval (CI) -1.4 to 4.0). Tender mass at scan was less common in the older the woman (OR 0.75, 95% CI 0.63-0.89), as were unilocular cysts relative to multilocular cysts (OR 0.70, 95% CI 0.57-0.85) and to lesions with solid components (OR 0.61, 95% CI 0.48-0.77), and ground glass echogenicity relative to homogeneous low-level echogenicity (OR 0.74, 95% CI 0.58-0.94) and other types of echogenicity of cyst contents (OR 0.64, 95% CI 0.50-0.81). Papillations were more common the older the woman (OR 1.65, 95% CI 1.24-2.21), but their height and vascularization showed no clear relation to age. LIMITATIONS, REASONS FOR CAUTION: It is a limitation that we have little clinical information on the women included, e.g. previous surgery or medical treatment for endometriosis. It is important to emphasize that we do not know the age of the endometrioma itself and that our study is not longitudinal and so does not describe changes in endometriomas over time. The differences in the ultrasound appearance of endometriomas between women of different ages might be explained by previous surgery or medical treatment and might not be an effect of age per se. WIDER IMPLICATIONS OF THE FINDINGS: Awareness of physicians that the ultrasound appearance of endometriomas differs between women of different ages may facilitate a correct diagnosis of endometrioma. STUDY FUNDING/COMPETING INTERESTS: This study was supported in part by the Regione Autonoma della Sardegna (project code CPR-24750). B.V.C., A.C. and D.T. are supported by the Fund for Scientific Research Flanders, Belgium (FWO). The authors declare that there is no conflict of interest.