Making the Diagnosis of Adenomyosis
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Dept. of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, Associate Editor for OB/GYN Clinical Alert.
Synopsis: Despite technology such as transvaginal sonography, magnetic resonance imaging, computed tomography, and even myometrial biopsy, the clinician's ability to make an accurate preoperative diagnosis of adenomyosis is still limited.
Source: Levgur M. Diagnosis of Adenomyosis: A Review. J Reprod Med. 2007;52:177-193.
The author has systematically reviewed the literature between 1949 and 2005, searching for research related to adenomyosis as well as the diagnosis thereof. Although superior to transabdominal sonography, the transvaginal route has a sensitivity of only 50-87%. MRI is comparable to ultrasound and is most effective for both focal and diffuse adenomyosis. CT is of limited value because normal myometrium and adenomyosis result in similar images. Myometrial biopsy is superior to ultrasound, but its routine use is brought into question.
Do you want my bottom line first? OK, here it is: in my opinion, there's really nothing new under the sun relating to adenomyosis. Now, in the words of Paul Harvey, if you want "the rest of the story," read on.
The author has systematically looked at the English literature over the past half-century to see what is helpful in diagnosing adenomyosis. The histologic criterion of endometrial glands and stroma existing 2.5 mm or half a lower-power field below the endomyometrial border is still useful. It is recognized that the posterior uterine wall is most affected, with the condition being either diffuse or focal. Except in rare circumstances, the uterus is rarely over 12 weeks in size. The classic description of patients presenting with pelvic pain, menorrhagia, and dysmenorrheal still works, as does the expected physical finding of a tender uterus. That's all the same as we could find if we looked at a gynecologic textbook of 25 years ago. (I know because I did look it up.)
The difference is that we now have alternative imaging and minimally invasive diagnostic modalities available to us. Whether any of them have true clinical relevance in the diagnosis of adenomyosis appears well-documented. The author reviews data that don't seem to lend credence to any of them being very useful. The interesting phenomenon, however, is that these tests are still being done. Why?
First, we must remember that not everyone who orders tests in women who ultimately have adenomyosis as a diagnosis is familiar with the gynecologic literature, or is even a gynecologist for that matter. Second, tests are often performed to rule out other conditions which are amenable to different types of treatment. For example, an endometrial polyp and/or small fibroids could certainly present like adenomyosis and would be more readily treated with surgery short of hysterectomy. The issue of treatment of adenomyosis was not addressed in the article, but suffice it to say that there isn't anything new in that regard either. Third, patients often drive what tests are ordered and clinicians must balance what they believe is helpful with what they feel is needed to treat the overall patient.
I highly recommend the article to anyone who sees patients with suspected adenomyosis, ie, I recommend the article to anyone who treats women with pain and menorrhagia. My guess is that includes anyone and everyone who reads this periodical. The condition is common and the management is not complicated. Sometimes we can be our worst enemy in making a diagnosis. Let's face it: common things occur commonly. Patients who present with signs and symptoms suggestive of adenomyosis may well have it. How you diagnose and treat it hopefully has not changed a lot over the years, because there isn't anything available that should have altered good medical decision-making. Doesn't that make you feel good? Sometimes the tried and true methods are still the best.