# Preoperative Diagnosis of Symptomatic Adenomyosis: Limitations and Clinical Insights

## TL;DR

This study shows that transvaginal ultrasound is not reliable for diagnosing adenomyosis, but gynecologists can improve accuracy by combining clinical exams and ultrasound.

## Contribution

The study highlights the limitations of radiologist-interpreted TVUS and emphasizes the value of gynecologist-led clinical assessments for diagnosing adenomyosis.

## Key findings

- Radiologist-interpreted TVUS had 0% accuracy for pure adenomyosis and combined cases.
- MIGS interpretation showed 83.3% sensitivity for pure adenomyosis but dropped to 30.6% with fibroids.
- Uterine tenderness was an independent predictor of adenomyosis regardless of fibroids or uterine size.

## Abstract

Objectives: To assess the diagnostic accuracy of adenomyosis on transvaginal ultrasound (TVUS) in a community hospital.

Design: Retrospective cohort study

Participants: A total of 124 patients who underwent hysterectomy between September 2022 and August 2024.

Setting: A tertiary referral academic center

Methods: All patients were referred to the Fibroid Clinic (BronxCare Health System) with symptomatic uterine fibroids or adenomyosis and underwent total hysterectomy. Postoperative pathological results were used as the reference standard. Collective data on TVUS, history, physical examination, and preoperative diagnosis were all studied. The primary goal was to evaluate the accuracy of TVUS in diagnosing adenomyosis by either radiologists or minimally invasive gynecologic surgeon (MIGS). The secondary objective was to identify the clinical factors associated with preoperative diagnosis of adenomyosis.

Result: According to histologic reports from the surgical specimen, 61 (49.2%) patients had uterine fibroids only, 50 (40.3%) had concomitant fibroids and adenomyosis, and 13 (10.5 %) had adenomyosis only. There were no significant differences in age, race, or BMI among patients in the three groups. The accuracy of radiologist-interpreted TVUS for adenomyosis was found to be low in patients with pure adenomyosis (0 out of 13) and in those with both fibroids and adenomyosis (0 out of 50). In contrast, MIGS interpretation demonstrated 83.3% sensitivity for pure adenomyosis, which decreased to 30.6% in the presence of concomitant fibroids. The presence of uterine tenderness (UT) on bimanual examination is an independent predictor of adenomyosis, even with the presence of uterine fibroids or a uterine size larger than 14 weeks. When the uterine size was less than 14 weeks, the clinical presence of dysmenorrhea, dyspareunia, or UT was significantly associated with adenomyosis. The clinical assessment and TVUS interpretation by MIGS resulted in a 62.0% sensitivity and 84.0% specificity for adenomyosis in our cohort.

Conclusion: The diagnosis of adenomyosis based on TVUS or a radiologist’s interpretation of TVUS can be underestimated. A comprehensive assessment, including clinical history, physical examination, and ultrasound interpretation by gynecologists, is essential for accurate diagnosis, patient counseling, and appropriate management.