The effect of transcervical endometrial resection on clinical symptoms related to intrinsic adenomyosis and junctional zone changes.

OBJECTIVES: To assess the effect of transcervical endometrial resection on clinical symptoms related to histopathological findings of the junctional zone. STUDY DESIGN: This prospective study took place at a university hospital. Premenopausal women suffering from abnormal uterine bleeding and/or pelvic pain and scheduled for transcervical endometrial resection were enrolled (n = 112). Histopathological findings of the endomyometrial biopsies were categorized as follows: Adenomyosis of the inner myometrium (intrinsic adenomyosis): ≥ 2 mm myometrial invasion without contact to the basal endometrium, serrated junctional zone: > 3 mm myometrial invasion with contact to the basal endometrium and linear junctional zone: No or marginal myometrial invasion (≤ 3 mm) with contact to the basal endometrium. All study participants received a baseline and two follow-up questionnaires (6 and 18 months after surgery) regarding symptom severity, health-related quality of life and pelvic pain. Data regarding reintervention surgery was obtained from the National Database Patoweb. The rate of reintervention surgery and the improvement in symptom severity, health-related quality of life and pelvic pain were correlated to histopathological findings. RESULTS: Twenty-four patients had intrinsic adenomyosis, 31 had serrated junctional zone and 57 had linear junctional zone. Fifteen patients (13%) underwent reintervention surgery; three (20%) within 6 months, nine (60%) between 6-18 months and three (20%) > 18 months after transcervical endometrial resection. Reintervention surgery was more common in women with intrinsic adenomyosis compared to women without (33% (95% CI: 16-55) vs 8% (95% CI: 3-16)) (p-value: < .05). Nine patients (38%) with intrinsic adenomyosis were asymptomatic based on low symptom severity score, high health-related quality of life and no pelvic pain at 18 months follow-up. Patients with linear junctional zone had a higher improvement in symptom severity and health-related quality of life than patients with intrinsic adenomyosis or serrated junctional zone at 6 months follow-up after surgery (p-value < .05). However, there was no significant difference in pelvic pain reduction. CONCLUSION: The effect of transcervical endometrial resection may depend upon the degree of junctional zone changes, and patients with intrinsic adenomyosis are more likely to undergo reintervention surgery than patients with either linear or serrated junctional zone. However, intrinsic adenomyosis may also be successfully treated with endometrial resection.

Two- and three-dimensional transvaginal ultrasonography for diagnosis of adenomyosis of the inner myometrium.

RESEARCH QUESTION: How diagnostically accurate is two-dimensional (2D-TVS) compared with three-dimensional transvaginal ultrasonography (3D-TVS) in diagnosing adenomyosis of the inner myometrium. What is the most accurate combination of ultrasonographic features? DESIGN: Premenopausal women (n = 110) scheduled for hysterectomy or transcervical resection of the endomyometrium owing to abnormal uterine bleeding were consecutively enrolled. All participants had real-time 2D-TVS and, later, blinded off-line 3D-TVS to diagnose adenomyosis. Results were compared with a detailed histopathological examination of the inner myometrium as gold standard. RESULTS: Prevalence of adenomyosis of the inner myometrium was 29%. For 2D-TVS and 3D-TVS, respectively, the diagnostic accuracy was sensitivity 72% (95% CI 53 to 86) and 69% (95% CI 50 to 84); specificity 76% (95% CI 65 to 85) and 86% (95% CI 76-93); and area under the curve (AUC) 0.74 (95% CI 0.7 to 0.8) and 0.77 (95% CI 0.7 to 0.9). Specificity of 3D-TVS was not statistically significantly better than 2D-TVS; the difference between them almost reached statistical significance (P = 0.06). The most accurate three-dimensional feature was junctional zone irregularity (JZmax-JZmin ≥5mm) (AUC: 0.78). A combination of two or more two-dimensional and two or more three-dimensional features was highly accurate (AUC: 0.77). CONCLUSIONS: For diagnosing adenomyosis of the inner myometrium, 3D-TVS offers a high accuracy similar to 2D-TVS. Identification of junctional zone irregularity with 3D-TVS may be beneficial to diagnosis. Two or more two-dimensional features and two or more three-dimensional features combined may give a more objective diagnosis, and may be useful for clinical practice and future research.

Inter-rater agreement in the diagnosis of adenomyosis by 2- and 3-dimensional transvaginal ultrasonography.

OBJECTIVES: To assess the inter-rater agreement of 2-dimensional (2D) and 3-dimensional (3D) transvaginal ultrasonography (TVUS) in the diagnosis of adenomyosis. METHODS: This prospective study included premenopausal women (n = 96) with heavy menstrual bleeding, menstrual pain, or both who were scheduled for hysterectomy or transcervical resection of the endometrium. All women underwent real-time 2D TVUS and subsequently offline 3D TVUS, which was blinded to 2D TVUS, by a single expert rater and a single nonexpert rater for the diagnosis of adenomyosis based on standardized pattern recognition and junctional zone measurements. Three-dimensional TVUS was done on a computer with 3D volumes recorded during 2D TVUS by both raters. The expert rater reported the image quality of all 3D volumes (n = 192). Inter-rater agreement (Cohen's κ) was assessed for both techniques, and the improvement over time was assessed for 2D TVUS. RESULTS: Diagnosis of adenomyosis showed good (κ = 0.69) and poor (κ = 0.21) inter-rater agreement with 2D and 3D TVUS, respectively (P < .05). The agreement with 2D TVUS improved over time. The agreement with 3D TVUS was slightly better for expert-recorded 3D volumes (κ = 0.40), which also had better image quality (P < .05). The most reproducible 2D and 3D features were anechoic lacunae (κ = 0.52) and junctional zone irregularity (κ = 0.27), respectively. CONCLUSIONS: Standardized pattern recognition during real-time 2D TVUS may result in good agreement between expert and nonexpert raters for the diagnosis of adenomyosis. Offline 3D TVUS is less reproducible, and junctional zone measurements do not improve the inter-rater agreement. The low inter-rater agreement may be related to a lack of experience and low image quality of nonexpert-recorded 3D volumes.

Quantitative sonoelastography of the uterine cervix prior to induction of labor as a predictor of cervical dilation time.

OBJECTIVE: To evaluate how the approximate Young's modulus of the uterine cervix assessed by quantitative sonoelastography in patients undergoing induction of labor is associated with the cervical dilation time and to evaluate the approximate Young's modulus as a predictor of prolonged cervical dilation time. DESIGN: Cross-sectional study. SETTING: Aarhus University Hospital, Aarhus, Denmark. POPULATION: Term-pregnant women. METHODS: A total of 49 term-pregnant women were included before induction of labor. The approximate Young's modulus of the anterior cervical lip was determined by the use of a reference cap applied on the end of the transvaginal transducer during sonoelastography. MAIN OUTCOME MEASURES: Cervical dilation time during active labor. RESULTS: The approximate Young's modulus was associated with the cervical dilation time during active labor (R(2) log  = 0.24, p < 0.01) and predicted prolonged duration of cervical dilation time (>330 min) with the area under the receiver operating characteristic (ROC) curve of 0.71, sensitivity 74%, and specificity 69%. Equivalent figures for the Bishop's score were R(2) log  = 0.02 (p = 0.37), the area under the ROC curve 0.53, sensitivity 53%, and specificity 46%. For the cervical length measurements the corresponding results were: R(2) log  = 0.02, p = 0.35, area under the ROC curve 0.57, sensitivity 66% and specificity 54%. The intra-observer and inter-observer intraclass correlations were 88% and 58%, respectively, with quantitative elastography. CONCLUSIONS: The approximate Young's modulus is superior to the Bishop score and the cervical length measurements concerning the prediction of cervical dilation time and the risk of prolonged dilation time after induction of labor.