X. Foo

Is adenomyosis associated with menorrhagia

STUDY QUESTION Is the presence of adenomyosis associated with menorrhagia? SUMMARY ANSWER There was no significant association between adenomyosis and menorrhagia, but there was a significant positive correlation between the severity of adenomyosis on ultrasound and the amount of menstrual loss estimated using pictorial blood loss assessment charts. WHAT IS KNOWN ALREADY There is no consensus in the literature with regards to the association between adenomyosis and menorrhagia. Previous studies have been limited to retrospective studies of highly selected populations which mainly included women who underwent hysterectomy. There are no large prospective studies evaluating the association between adenomyosis and menorrhagia, either in the general population of women or in a general gynaecology clinic setting. STUDY DESIGN, SIZE, DURATION This was a prospective observational study set in the general gynaecology clinic of a university teaching hospital between January 2009 and January 2010. PARTICIPANTS/MATERIALS, SETTING, METHODS There were 714 consecutive premenopausal women who attended the clinic and underwent structured clinical and transvaginal ultrasound examination in accordance with the study protocol. Morphological features of adenomyosis were systematically recorded on ultrasound scan. Menorrhagia was determined subjectively by direct questioning and objectively by completion of pictorial blood loss analysis charts. MAIN RESULTS AND THE ROLE OF CHANCE A diagnosis of adenomyosis was made in 157/714 women [22.0% (95% CI: 19.1-25.2%)]. Multivariable analysis showed significant associations between submucous fibroids [OR 5.60 (95% CI: 2.69-11.6)], any fibroids [OR 1.53 (95% CI: 0.91-2.58)] and endometrial polyps [OR 2.81 (95% CI: 1.15-11.7)] and menorrhagia. There were also significant associations between increasing gravidity and BMI and menorrhagia (P < 0.01). There was no significant association between adenomyosis and menorrhagia in the study population, when adenomyosis was assessed as a binary outcome. When severity of adenomyosis was assessed by counting the number of morphological features of adenomyosis in each woman, we found a significant 22% increase in menstrual loss for each additional feature of adenomyosis [OR 1.21 (95% CI: 1.04-1.40)]. LIMITATIONS, REASONS FOR CAUTION A classification of severity of adenomyosis based on the number of ultrasound features present is a novel concept that should be prospectively evaluated in different populations. WIDER IMPLICATIONS OF THE FINDINGS A better understanding of the relationship between adenomyosis and menorrhagia can help improve counselling of women regarding the significance of this common condition and facilitate future studies assessing the effectiveness of different conservative treatments protocols. STUDY FUNDING/COMPETING INTEREST(S) The authors have no competing interests. The study was not supported by an external grant.

Use of IOTA simple rules for diagnosis of ovarian cancer: meta-analysis

To present data on prospective evaluation of the International Ovarian Tumor Analysis (IOTA) ‘simple‐rules’ tool for the diagnosis of ovarian cancer and to perform a meta‐analysis of studies that utilized the same diagnostic method.

A Prospective Validation of the IOTA Logistic Regression Models (LR1 and LR2) in Comparison to Subjective Pattern Recognition for the Diagnosis of Ovarian Cancer

Objectives This study aimed to assess the accuracy of the International Ovarian Tumour Analysis (IOTA) logistic regression models (LR1 and LR2) and that of subjective pattern recognition (PR) for the diagnosis of ovarian cancer. Methods and Materials This was a prospective single-center study in a general gynecology unit of a tertiary hospital during 33 months. There were 292 consecutive women who underwent surgery after an ultrasound diagnosis of an adnexal tumor. All examinations were by a single level 2 ultrasound operator, according to the IOTA guidelines. The malignancy likelihood was calculated using the IOTA LR1 and LR2. The women were then examined separately by an expert operator using subjective PR. These were compared to operative findings and histology. The sensitivity, specificity, area under the curve (AUC), and accuracy of the 3 methods were calculated and compared. Results The AUCs for LR1 and LR2 were 0.94 [95% confidence interval (CI), 0.92–0.97] and 0.93 (95% CI, 0.90–0.96), respectively. Subjective PR gave a positive likelihood ratio (LR+ve) of 13.9 (95% CI, 7.84–24.6) and a LR−ve of 0.049 (95% CI, 0.022–0.107). The corresponding LR+ve and LR−ve for LR1 were 3.33 (95% CI, 2.85–3.55) and 0.03 (95% CI, 0.01–0.10), and for LR2 were 3.58 (95% CI, 2.77–4.63) and 0.052 (95% CI, 0.022–0.123). The accuracy of PR was 0.942 (95% CI, 0.908–0.966), which was significantly higher when compared with 0.829 (95% CI, 0.781–0.870) for LR1 and 0.836 (95% CI, 0.788–0.872) for LR2 (P < 0.001). Conclusions The AUC of the IOTA LR1 and LR2 were similar in nonexpert’s hands when compared to the original and validation IOTA studies. The PR method was the more accurate test to diagnose ovarian cancer than either of the IOTA models.

Natural history of ovarian endometrioma in pregnancy

BackgroundOvarian endometriomas are classified as benign ovarian lesions. During pregnancy endometriomas may undergo major morphological changes which are referred to as ‘decidualisation’. Decidualised ovarian endometrioma may resemble malignant ovarian tumours on ultrasound examination. The aim was to study variations in the morphology and size of ovarian endometriomas diagnosed on ultrasound during pregnancy.MethodsWe searched our database to identify pregnant women who were diagnosed with ovarian endometriomas on ultrasound in order to study the effect of pregnancy on their morphological characteristics. In women who underwent serial scans during pregnancy we examined the changes in the size of endometriomas with advancing gestation.ResultsTwenty four patients with a total of 34 endometriomas were included in the analysis. All women were managed expectantly during pregnancy. On the first ultrasound scan 29/34 (85.3%, 95% CI 73.4 - 97.2) endometriomas appeared unilocular with fine internal echoes (‘ground glass’ contents) and they were poorly vascularised on Doppler examination. 1/34 (2.9% 95% CI 0.0 - 8.5) endometrioma was multilocular, with regular margins, ‘ground glass’ contents and it was also poorly vascularised. 4/34 (11.8%, 95% CI 1.0 - 22.6) had sonographic features suggestive of decidualisation such as thick and irregular inner wall, papillary projections and highly vascular on Doppler examination. The endometriomas showed a tendency to decrease in size during pregnancy.ConclusionsPregnancy has a major effect on the size and morphological appearances of ovarian endometriomas. Rapid regression of decidualised endometriomas is a helpful feature which could be used to confirm their benign nature.

A randomised controlled trial comparing surgical intervention rates between two protocols for the management of asymptomatic adnexal tumours in postmenopausal women

Introduction Detection of asymptomatic adnexal tumours in postmenopausal women has increased due to wider use of diagnostic ultrasound and imaging quality improvements. Reliable methods to differentiate between benign and malignant tumours are required to avoid delays in treating ovarian cancer and to prevent unnecessary interventions for benign lesions. In the UK, the Royal College of Obstetricians and Gynaecologists has issued guidance for the management of adnexal cysts in postmenopausal women, which is considered standard in routine clinical practice. The protocol utilises the Risk of Malignancy Index to assess the risk of adnexal lesion being malignant. This protocol has a relatively high intervention rate in order to avoid a delay in a cancer diagnosis. The Simple Rules Protocol designed by International Ovarian Tumour Analysis Group reports a low false-positive rate in the diagnosis of ovarian cancer without a loss of sensitivity and therefore has the potential to reduce unnecessary interventions in asymptomatic postmenopausal women with benign cysts. Methods and analysis 140 postmenopausal women aged 40–80, with incidentally detected adnexal tumours on ultrasound scan will be recruited to this study. They will be randomly allocated, to be assessed and managed according to either of the two protocols under investigation. In both arms of the study the tumours will be classified into three groups: high, intermediate or low risk of malignancy. Women with high risk of malignancy will be referred for management in a tertiary cancer centre, women with low-risk tumours will be managed expectantly, while those with intermediate risk findings have surgery in their local hospital units. Analysis will be on an intention-to-treat basis. Ethics and dissemination Research ethical approval was granted by the North London Research Ethical Committee 2 (10/H0724/48). Trial results will be published according to the CONSORT statement. Trial registration number Registration at http://www.controlled-trials.com/ISRCTN89034131/. ISRCTN89034131

Ultrasound diagnosis of serous surface papillary borderline ovarian tumor: A case series with a review of the literature

Serous surface papillary borderline ovarian tumors (SSPBOTs) are a rare morphologic variant of serous ovarian tumors that are typically confined to the ovarian surface, while the ovaries themselves tend to appear normal in size and shape. In this report, we describe the findings from five premenopausal women diagnosed with SSPBOTs, in whom ultrasound showed grossly normal ovaries that were partially or wholly covered with irregular solid tumors. In all five cases, histologic examination showed evidence of borderline serous tumors. These findings demonstrate that SSPBOTs can be diagnosed on a preoperative sonographic examination, which could facilitate conservative, fertility‐sparing surgery in young women affected by this condition.

Comparison of two protocols for the management of asymptomatic postmenopausal women with adnexal tumours - a randomised controlled trial of RMI/RCOG vs Simple Rules

Background:Adnexal tumours are frequently diagnosed in asymptomatic postmenopausal women due to more liberal use of modern high-resolution imaging. This study’s objective was to determine if there would be a difference in the intervention rates when using the Simple Rules Management Protocol (SRMP) as compared to the Risk of Malignancy Index in the Royal College of Obstetricians and Gynaecologists guideline (RMI/RCOG).Methods:This was a prospective randomised controlled trial with the participants and the researchers non-blinded, and the surgeons and pathologists blinded. We recruited pain-free postmenopausal women who were diagnosed with an adnexal tumour on ultrasound scan. Women were randomised to either of the two protocols, which then determined if they were offered conservative or surgical management. An intention-to-treat analysis was performed. The primary outcome measure was rate of surgical interventions for ovarian cysts up to 12 months after randomisation. The secondary outcome measures were the number of staging surgical procedures, surgical complications and number of delayed diagnoses of ovarian cancer.Results:A total of 148 women were randomised over 39 months with 73 in the RMI/RCOG arm and 75 in the SRMP arm with outcome data for 136 at 12 months. The two groups were balanced in terms of age, length of time since menopause and use of hormone replacement therapy. There were 18 out of 68 (28.1%) women in the RMI/RCOG arm who had surgery vs 7 out of 68 (10.3%) women in the SRMP arm (P=0.015, χ2-test). The difference in these proportions was 16.2% (95% confidence interval (CI): 3.4–28.9%) and the relative risk was 2.57 (95% CI: 1.15–5.76). There were no significant differences in the number of staging surgical procedures and the surgical complications between the two groups and there were no delayed diagnoses of ovarian cancer at 12 months.Conclusions:Surgical intervention rates in asymptomatic postmenopausal women with an ultrasound diagnosis of adnexal tumours are significantly lower when the novel SRMP protocol is used for triaging compared to the standard RMI/RCOG protocol without an increase in delayed malignant diagnoses.

Diagnosis of uterine vein thrombosis on transvaginal ultrasound

Deep venous thrombosis (DVT) is a potentially serious medical disorder, which may result in pulmonary embolism and death. Compression ultrasound is the investigation modality of choice for the diagnosis of DVT of the lower limb. Diagnosis of proximal thrombosis involving the pelvic veins is difficult and is usually made only after the thrombus extends into the veins of the lower limb. We present six cases of incidental uterine vein thrombosis diagnosed by transvaginal ultrasound. Our aim is to describe the technique of the examination of pelvic veins and criteria that could be used to diagnose uterine vein thrombosis. We also highlight difficulties in the management of women diagnosed with asymptomatic uterine vein thrombi as there is little evidence to guide clinicians in choosing between different treatment options. Copyright

A prospective evaluation of the IOTA Logistic Regression Models (LR1 and LR2) in comparison to Subjective Pattern Recognition for the diagnosis of ovarian cancer in the outpatient setting

To determine whether International Ovarian Tumor Analysis (IOTA) logistic regression models LR1 and LR2 developed for the preoperative diagnosis of ovarian cancer could also be used to differentiate between benign and malignant adnexal tumors in the population of women attending gynecology outpatient clinics.

Diagnosis of distal ureteric stones on routine gynecological ultrasound examination in women presenting with pelvic pain.

Women presenting with typical symptoms of ureteric stones, such as renal colic, are referred to urologists for further examination and treatment. Atypical presentation includes pelvic pain which may be misdiagnosed as being of gynecological origin. Previous studies1–3 have shown that distal ureteric stones can be diagnosed using transvaginal ultrasound (TVS) examination in women with clinical suspicion of renal colic. There are no data, however, on the prevalence of ureteric stones in women presenting to gynecological clinics with pelvic pain. In 2012 we developed a technique for visualizing ureters on routine TVS4 examination and, subsequently, visualization of both ureters has been integrated into every pelvic ultrasound examination undertaken in our unit since January 2013. We used a previously described systematic approach for assessment of women presenting with pain5. The ureters were examined using TVS, at rest and during peristalsis, to identify any evidence of ureteric dilatation or abnormal bending. Ureteric dilatation was diagnosed in women who had widening of the ureter proximal to the level of obstruction and in those who demonstrated evidence of fluid retention within the ureteric lumen at rest. We evaluated the impact of our new policy for detection of distal ureteric stones in women presenting with acute and chronic pelvic pain. Records of 5594 women presenting with pelvic pain between January 2013 and August 2014 were reviewed retrospectively. In total, seven (0.1%) women were diagnosed with ureteric calculi (Table 1). Other urinary tract abnormalities observed were simple renal cyst (11/5594 (0.2%)), ureteric obstruction secondary to severe endometriosis (6/5594 (0.1%)), ureterocele (7/5594 (0.1%)), bladder endometriosis (2/5594 (0.04%)) and bladder polyp (2/5594 (0.04%)). All stones seen on TVS examination had the appearance of hyperechoic swellings located within the lumen of the ureter. Acoustic shadowing was seen in six of seven (85.7%) cases (Figure 1). Our results show that a policy of routine TVS examination of the ureters enables the detection of distal ureteric stones in women presenting with pelvic pain. In most units, visualization of the ureters is not included in standard TVS examinations. Since our examination protocols were changed, we have identified seven cases of ureteric stones whilst no cases were detected in the previous 20 years. Timely diagnosis of ureteric stones is important as the pain can be debilitating and, in women presenting with atypical symptoms, the cause of the pain may be missed on both TVS examination and laparoscopy. A proportion of women may not pass the stones spontaneously and may suffer prolonged distress and develop renal obstruction, with consequent loss of kidney function. Our technique of visualizing the ureters is highly effective and it usually takes less than 1 min to locate and examine each ureter on TVS examination. Although the number of women presenting to gynecology clinics with ureteric stones is relatively small, prompt ultrasound diagnosis avoids delays in treating the severe pain caused by ureterolithiasis and helps prevent loss of renal function in women with complete ureteric obstruction. In view of this, we believe that routine visualization of the ureters should become a standard part of the examination of any woman presenting with pelvic pain.