Adenomyosis

BALTIMORE--A cratered appearance of the endometrial cavity on hysteroscopy can be used to diagnose adenomyosis preoperatively and may be used to individualize therapy for menorrhagia, according to Dr. Andrea Wang. In a prospective study, she and her associates used hysteroscopy to evaluate 56 women with menorrhagia, first looking for adenomyosis and then performing a full resection of the endometrial cavity with loop electrocautery and rollerball ablation. They undertook the study after finding nothing in the literature on the hysteroscopic diagnosis of adenomyosis, Dr. Wang said at a symposium on women's health sponsored by Mercy Medical Center.

The diagnosis of adenomyosis was made in resected specimens when the endometrial glands penetrated more than 2.5 mm below the endomyometrial junction. Based on these criteria, the incidence of adenomyosis was about 36%, said Dr. Wang, administrative chief resident in the department of ob.gyn. at the University of Maryland Medical System, Baltimore.

The sensitivity of using the cratered appearance on hysteroscopy to diagnose adenomyosis was about 75%, which Dr. Wang described as "pretty good" and comparable to that of ultrasound. The specificity was 42%, an indication that this method tends to overdiagnose adenomyosis.

The positive predictive value was 42% and the negative predictive value was 75%, "so if we're not seeing a cratered appearance, there's a pretty good chance" that adenomyosis is not present, she observed.

Of the 56 patients in the study, 1 required a hysterectomy for continued bleeding.

The presence or absence of a cratered appearance "can be used to individualize therapy for menorrhagia," Dr. Wang said. Early studies indicate that the depth of endometrial penetration into the myometrium correlates with the outcome of endometrial ablation, so "perhaps patients with the cratered appearance may have a better response to treatments that remove a larger portion of the uterine cavity" If there is no cratered appearance, a less destructive treatment might be indicated.

Until recently, the only way to diagnose adenomyosis was with a pathologic sample from a hysterectomy Pathologic confirmation of clinically suspected cases is low, ranging from 10% to 38%.

There are also multiple standards for the histopathologic diagnosis: In the six gynecology textbooks Dr. Wang reviewed, there was no consensus on the depth of endometrial penetration required for a diagnosis, with cutoffs ranging from 0.5 mm to 5 mm. Adenomyosis can be diagnosed preoperatively with noninvasive methods, which have their limitations. When the disease is diagnosed with hysterography which may show the contrast extending perpendicularly from the uterine cavity into the myometrium, the sensitivity is only 25%. Ultrasonography has sensitivities ranging from 53% to 89%, she added.

The sensitivity of MRI scans ranges from 86% to 100%, depending on how strict the criteria are, Dr. Wang continued. But hysteroscopic diagnosis is something that gynecologists can do preoperatively, before sending the patient to a radiologist, she said.

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