Adenomyosis is a common gynecological disorder, affecting about 45% of women in reproductive age. It is defined as the presence of endometrial glands and stroma within the myometrium associated with myometrial hypertrophy and hyperplasia. The cause of adenomyosis is unknown, but interesting theories have considered adenomyosis a pathology of the endo-myometrial junctional zone. Clinical presentation of adenomyosis could be heterogeneous. It can be asymptomatic in about 35% of patients. Typical presentation of disease (70% of women) includes abnormal uterine bleeding (AUB), and pelvic painful symptoms. The definitive diagnosis is usually based on histological examination in surgical specimens. However transvaginal ultrasound (TV-US) and MRI are widely accepted as valid instrument to reach a presurgical diagnosis. Several studies showed that the sensitivity and specificity of two-dimensional transvaginal scan in diagnosing adenomyosis are comparable to those of MRI, histology, or both, ranging from 75%¿88% and 67%¿93%, respectively. Although several tentative of defining criteria for a universally accepted diagnosis of adenomyosis were proposed, nowadays is still not well defined a score of the severity of adenomyosis. This prospective observational study aims to identify a score derived by a combination of clinical, imaging features correlated to pathology. There would be 2 major sections, both subdivided. All subdivisions would be given a total score of 3, ranging from 1 and the final addition would determine an overall classification into 4 main groups based on severity. This score will address the physicians to the best therapeutic approach.
A better understanding of the relationship between adenomyosis and pain can help improve counseling of women regarding the signi¿cance of this common condition and make treatment options more focused. The adenomyosis should be standardized according to universally accepted criteria in terms of disease severity.
The definitive diagnosis of adenomyosis is based on histological examination in surgical specimens. Hysterectomy has been advised for women with severe symptoms from adenomyosis, although alternative conservative treatment can preserve the uterus. For this reason during the last decade, the progress of imaging techniques has allowed a non-invasive diagnosis of this pathology. The role of preoperative diagnostic tools became fundamental to defining the location and extent of endometriotic lesions in order to find the best treatment strategy avoiding unnecessary surgery. Nowadays two imaging techniques are used most regularly to recognize and describe lesions in endometriosis: transvaginal sonography [Benagiano 2012, Hendrickson M 1987] and magnetic resonance imaging. [Taran 2010]. Early studies reported very poor diagnostic accuracy of adenomyosis using sonography (Weseley 1982). During the years several changes in 2D transvaginal ultrasound technology and higher awareness of the ultrasonographers improved diagnostic accuracy [Vercellini 1998,) and current studies report very high accuracy using this modality (Exacoustos 2013, Exacoustos 2011). With the addition of 3D ultrasound and a closer evaluation of the junctional zone from the endometrium to the myometrium (the JZ), ultrasound evaluation for adenomyosis showed improving diagnostic accuracy. For 2D and 3D TVS, respectively, the overall accuracy for the diagnosis of adenomyosis was 83% and 89%, sensitivity was 75% and 91%, specificity was 90% and 88%, positive predictive value was 86% and 85%, and negative predictive value was 82% and 92% (Ota, 1992).MRI is considered the gold standard for adenomyosis diagnosis. However, transvaginal ultrasound shows a good correlation and strong agreement with MRI.Ultrasound has the advantages of lower cost and easier access compared to MRI that can result less widely available, more expensive and not tolerated by all patients. From a meta-analysis published in 2010, 23 studies examining 2312 women using ultrasound and MRI concluded that both techniques have a high accuracy for the noninvasive diagnosis of adenomyosis, although MRI was determined to more often result in the correct diagnosis . The pooled sensitivity of ultrasound from this assessment was 72% and specificity was 81%, whereas the sensitivity of MRI was 77% and specificity was 89%. In cases of enlarged uterus or coexisting myomas, MRI has been proved to have higher sensitivity than US in discriminating adenomyosis and fibromatosis .The introduction of three-dimensional technique allows, above all, a better visualization of the junctional zone and helps the diagnosis of adenomyosis .(Exacoustos 2011).Several authors showed a statistically significant positive relationship between severity of menstrual pain or bleeding and the number of ultrasound features of adenomyosis.(J.J.Naftalin- Pinzauti 2015). Ying-Lung Sun and colleagues evaluated the accuracy of different transvaginal sonographic criteria in the diagnosis of adenomyosis and furthermore to determine the most useful sonographic feature by comparison with histopathologic results. (ying lung ).Recently Kepkep and in his prospective study showed the sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and accuracy of transvaginal ultrasound.He found that a regularly enlarged uterus with a globular appearance, subendometrial echogenic linear striations and myometrial cysts had the highest accuracy for the diagnosis of adenomyosis. (Kepler et al). The positive correlation between the number of ultrasound features of adenomyosis and the severity of menstrual pain could form the basis of a clinically relevant grading system for adenomyosis. Although these features of defining a universally diagnosis of adenomyosis , nowadays is still not well defined a score of the severity of adenomyosis. A better understanding of the relationship between adenomyosis and pain can help improve counseling of women regarding the signi¿cance of this common condition and make treatment options more focused. Our methodological approach re¿ects modern clinical practice and that our ¿ndings will be helpful to clinicians looking after gynecology patients. The adenomyosis should be standardized according to universally accepted criteria to define populations in terms of disease severity.