Includes abstract. / Includes bibliographical references. / Adenomyosis, defined as the presence of ectopic endometrial tissue in the myometrium, is a cause of morbidity in afflicted women. Classically it presents with menorrhagia, dysmenorrhoea and dyspareunia. Traditionally the diagnosis has been by histology of post-hysterectomy specimens with reported prevalence of 5%-70%. With advances in imaging techniques, pre-surgical diagnosis can be made with a reasonable accuracy using trans-vaginal ultrasound (TVS) and magnetic resonance imaging (MRI) with the former being preferred due to cost effectiveness. Accurate presurgical diagnosis would facilitate alternative treatment options to hysterectomy. Different sonographic features of adenomyosis have been reported and well correlated with histology; there is however no general consensus as to the most specific features and whether the frequencies of these sonographic features hold true in other population settings like South Africa. We therefore conducted a cross-sectional diagnostic study of presurgical TVS diagnosis of adenomyosis with post-hysterectomy histological correlation. The primary objective was to determine the diagnostic performance of TVS for the diagnosis of adenomyosis using posthysterectomy histology as the reference standard. Secondary objectives were to determine the signs and symptoms in women with histologically confirmed adenomyosis and the prevalence of histological adenomyosis. The study was conducted at Groote Schuur Hospital and New Somerset Hospital over a period of 11 months (May 2011 to April 2012). There were two study groups. In study group A, women scheduled for hysterectomy completed a questionnaire capturing clinical symptoms and underwent TVS examination. A TVS diagnosis of adenomyosis was made if three or more features suggestive of adenomyosis were present. After hysterectomy, the uteri were examined by histopathologists. Both ultrasonographers and histopathologists were blinded to other findings. The TVS diagnosis of adenomyosis was compared with histopatholgy results. In study group B, histopathological results were collected prospectively in all women undergoing hysterectomy during the study period (including those in study group A). From the results, a histopathological profile of posthysterectomy specimens was made. There were 78 participants in group A. Histologically confirmed adenomyosis was found in 16 of the 78 women (20.5%). Seventy one clinical questionnaires were completed (missing data n=7). The only clinical finding that reached statistical significance was presence of a tender uterus in 31.5% of women with adenomyosis compared to 5.4% without adenomyosis (p<;0.05). Other clinical features seen in women with adenomyosis were heavy menstrual bleeding (62.5%), dysmenorrhea (50%) and a uterus that was less than twelve weeks gestation (62.5%) but these findings did not reach statistical significance compared to women without adenomyosis (p>0.05). Despite presence of characteristic signs and symptoms, a preoperative clinical diagnosis of adenomyosis was made in only 12.5% [95% CI: 3.5 - 36] of patients with histologically confirmed adenomyosis. TVS diagnosis of adenomyosis had a sensitivity of 50% [95% CI: 28-72], specificity of 80.6% [95% CI: 69.2 -88.6], accuracy of 74.4% [95% CI: 63.7- 82.7] and diagnostic odds ratio of 4.2 [95% CI: 1.3-13.4]. Of all TVS diagnostic features evaluated, heterogenous myometrial echotexture had the highest sensitivity 68.8% [95% CI: 44.4-85.8] but a poor specificity 62.9% [95% CI: 50.5-73.8]. The presence of subendometrial echogenic linear striations had the highest specificity 96.8% [95%CI: 89-99] and accuracy 78.2% [95% CI: 67.8-85.9] for the diagnosis of adenomyosis. TVS diagnosis of adenomyosis was ultrasonographer dependent. Study group B comprised 261 women. Leiomyomas were the most prevalent histopathological diagnosis (63.2% ; 95% CI: 57.2-68.4), followed byadenomyosis with a prevalence of 20.3% [95% CI: 15.9-25.6]. Data from this prospective study showed that a clinical presentation of menorrhagia, dysmenorrhea and a tender uterus less than twelve weeks suggested a diagnosis of adenomyosis. Despite characteristic signs and symptoms, clinicians only diagnosed adenomyosis in about one in ten women.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:uct/oai:localhost:11427/3039 |
| Date | January 2013 |
| Creators | Chunda, Reginald George |
| Contributors | Dyer, Silke, Stewart, Chantal |
| Publisher | University of Cape Town, Faculty of Health Sciences, Department of Obstetrics and Gynaecology |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Master Thesis, Masters, MMed |
| Format | application/pdf |
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