NEW YORK--Too many sonographers see fibrodis where they should be seeing adenomyosis, Dr. Edward A. Lyons said at the 12th World Congress on Ultrasound in Obstetrics and Gynecology.
"Adenomyois is probably the single most underdiagnosed pelvic condition and one of the most common causes of pelvic pain in all manner of women," said Dr. Lyons, professor of radiology and ob.gyn. at the University of Manitoba, Winnipeg.
If a woman who isn't pregnant presents with pelvic pain, start with a good history and a transabdominal ultrasound, which will detect large, solid masses that may not be seen on endovaginal ultrasound, he advised. Then do an endovaginal ultrasound and check all pelvic organs.
Consider other causes of pelvic pain, including menstrual contractions, hematometras, endometritis, myometritis, or a misplaced intrauterine device.
Use the endovaginal probe as an 8-inch extension of your finger to push on different areas of the uterus and ask the patient if she feels pain. Adenomyosis produces a focal, not generalized, tenderness. A fibroid by itself very rarely causes pain.
"I've seen a billion fibroids, and only one that was tender," he said at the meeting, which was sponsored by the International Society of Ultrasound in Obstetrics and Gynecology. "If the uterus is tender and you see a fibroid, she also has adenomyosis."
A fibroid is a well-defined, focal mass, whereas adenomyosis is a diffuse infiltrative process. A hypoechoic periphery or compressed myometrium can be seen with a fibroid by endovaginal ultrasound, but not necessarily by transabdominal ultrasound. Ultrasounds of fibroids show peripheral vascularity, distal shadowing, and calcification.
Fibroids come in a variety of appearances--hypoechoic, isoechoic, or hyperdense--but if a myometrial cyst is present, the patient has adenoryosis. It's not unusual for a myometrial cyst to be misreported as "cystic degeneration in a fibroid," he added.
The cysts of adenomyosis are small (2-3 mm), avascular, and usually subendometrial. They come and go and may be more common in the second half of the menstrual cycle. There may be multiple myometrial cysts. The sonographer must look for them and ask the patient about focal tenderness to elicit these findings. On ultrasound, adenomyosis also has mixed echogenicity, central vascularity, and irregular, streaky shadowing.
Fibroids are more common in nulliparous women, and adenomyosis is more common in multiparous women, although either can appear in women regardless of parity. Clinically, more than 80% of patients with adenomyosis present with pain, he said.
The patient may report unexplained pelvic pain or pain throughout the menstrual cycle, during menstruation or with intercourse.
A history of menorrhagia with clots plus focal tenderness on endovaginal ultrasound is adenomyosis "unless they have a huge prolapsed fibroid," Dr. Lyons said.
At his institution, fibroids are slightly more common than adenomyosis in patients who undergo gynecologic ultrasound scans, a review of cases found. Patients underwent ultrasound because of bleeding, pain, or an abdominal mass.
Patients with fibroids presented most commonly with abnormal bleeding, which was the indication for ultrasound in 40% of gynecologic patients. Of the 50% of gynecologic patients who got an ultrasound because of pelvic pain, 55% had adenomyosis.
Others were normal or had an intrauterine pregnancy or pelvic inflammatory disease.
RELATED ARTICLE: Adenomyosis Vs. Fibroid
* Ill defined (a diffuse infiltrative process)
* Asymmetric myometrial thickening
* Irregualar, streaky shadowing
* Presence of myometrial cyst(s)
* Mainly in multiparous women
* Presents with focal myometrial tenderness; menorrhagia with clots also common
* Well defined
* Compressed myometricin or hypoechoic periphery
* Distal shadowing
* No myometrial cyst(s)
* Mainly in nulliparous women
* Presents with abnormal bleeding; fibroids very rarely cause pain by themselves
Source: Dr. Edward A. Lyons
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