Association between ultrasound features of adenomyosis and severity of menstrual pain.

OBJECTIVE: To investigate the association between the ultrasound features of adenomyosis and the severity of menstrual pain. METHODS: This was a prospective observational study set in the general gynecology clinic of a university teaching hospital between January 2009 and January 2010. A total of 718 consecutive premenopausal women aged between 17 and 55 years attended the clinic and underwent structured clinical and transvaginal ultrasound examinations in accordance with the study protocol. Morphological features of adenomyosis on ultrasound scan were recorded systematically. A quantitative assessment of menstrual pain was made by completion of a numerical rating scale (NRS). RESULTS: One hundred and fifty-seven (21.9% (95% CI, 18.8-24.9%)) women were diagnosed with adenomyosis on ultrasound. Multiple linear regression analysis showed that an ultrasound diagnosis of adenomyosis and ultrasound and laparoscopic diagnoses of endometriosis were significantly associated with menstrual pain when measured by an NRS. In addition, there was a statistically significant positive correlation between the severity of menstrual pain and the number of ultrasound features of adenomyosis seen. CONCLUSIONS: Women with ultrasound features of adenomyosis have more severe menstrual pain than do women without these features. 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. A classification of severity of adenomyosis based on the number of ultrasound features present is a novel concept that should be evaluated prospectively in different populations. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Prevalence of pelvic adhesions on ultrasound examination in women with a history of Cesarean section.

OBJECTIVES: To investigate the prevalence and location of pelvic adhesions in women with a history of Cesarean section and to identify risk factors for their formation and symptoms associated with their presence. METHODS: This was a prospective observational study of women in whom one or more Cesarean sections had been performed > 12 months previously and who attended for a gynecological ultrasound examination. In all women, both transvaginal and transabdominal scans were performed in order to identify the presence of pelvic adhesions. Medical and surgical history was recorded and a structured questionnaire was used to enquire about any history of pelvic pain and urinary symptoms. RESULTS: A total of 308 women were recruited into the study. On ultrasound examination, 139 (45.1% (95% CI, 39.7-50.7%)) women showed evidence of adhesions within the pelvis. Adhesions in the vesicouterine pouch were the most common and were found in a total of 79 (25.6% (95% CI, 20.7-30.5%)) women. In women with a history of no surgery other than Cesarean section(s) (n = 220), an increasing number of Cesarean sections (odds ratio (OR) 3.4 (95% CI, 2.1-5.5)) and a postoperative wound infection (OR 11.7 (95% CI, 3.5-39.5)) increased the likelihood of adhesions developing in the anterior pelvic compartment. There was a significant association between the presence of anterior compartment adhesions and chronic pelvic pain. Multivariable logistic regression analysis identified anterior abdominal wall adhesions (OR 2.4 (95% CI, 1.0-5.9)) and any adhesions present on ultrasound scan (OR 2.6 (95% CI, 1.2-5.7)) as independent predictors of chronic pelvic pain. CONCLUSIONS: Pelvic adhesions are present in more than a third of women with a history of Cesarean section and they are associated with chronic pelvic pain.

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.

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.

Visualization of ureters on standard gynecological transvaginal scan: a feasibility study.

OBJECTIVE: To investigate the feasibility of identifying pelvic segments of normal ureters and measuring their size on standard transvaginal ultrasound examination. METHODS: This was a prospective observational study from June to July 2012. All women in the study underwent a transvaginal ultrasound examination performed for various indications either by an expert or by an intermediate-level operator. A standardized assessment of the pelvic organs was performed, recording any congenital or acquired uterine pathology and ovarian abnormalities. Visualization of pelvic segments of both ureters was attempted in all cases. The success in finding the ureters, the time required to identify them and their dimensions at rest and while exhibiting peristalsis were all recorded. RESULTS: A total of 245 consecutive women were included in the study. In all women at least one ureter was successfully identified. Both ureters were seen in 227 women (92.7% (95% CI, 89.4-96.0%)). In 17 (6.9% (95% CI, 3.7-10.1%)) the left ureter was not seen and in one woman (0.4% (95% CI, 0.0-1.2%)) the right ureter could not be visualized (P < 0.001). There were no significant differences in the median time required to visualize the right and left ureters (9.0 (interquartile range (IQR), 6.0-14.0) s vs 8.0 (IQR, 6.0 -14.0) s, respectively; P = 0.9). The median diameter of the right ureter was 1.7 (IQR, 1.4-2.2) mm at rest and 2.9 (IQR, 2.4-3.6) mm during peristalsis. The median diameter of the left ureter was 1.9 (IQR, 1.6-2.3) mm at rest and 2.9 (IQR, 2.4-3.6) mm during peristalsis. CONCLUSION: Pelvic segments of normal ureters can be identified in most women on transvaginal ultrasound examination. Visualization of the ureters could be integrated into the routine pelvic ultrasound examination, particularly in women presenting with pelvic pain or in those with suspected pelvic endometriosis.

Rationalizing the management of pregnancies of unknown location: temporal and external validation of a risk prediction model on 1962 pregnancies.

STUDY QUESTION: Can we accurately define a group of pregnancies of unknown location (PULs) as low risk in order to safely reduce follow-up for these pregnancies and allocate resources to pregnancies at an increased risk of being ectopic? SUMMARY ANSWER: Prediction model M4 classified around 70% of PULs as low risk, of which around 97% were later characterized as failed PULs or intrauterine pregnancies (IUPs), while still classifying 88% of ectopic pregnancies as high risk. WHAT IS KNOWN ALREADY: Depending on the level of suspicion of ectopic pregnancy (EP), women with a PUL receive a lengthy follow-up in order to confirm the location and viability of the pregnancy. STUDY DESIGN, SIZE, DURATION: A multi-centre diagnostic accuracy study of 1962 patients was carried out between 2003 and 2007 for retrospective temporal validation and between 2009 and 2011 for prospective external validation. The reference standard is the final characterization of PUL as failed pregnancies or IUPs (low risk), or as ectopic pregnancies (high risk). M4 is a multinomial logistic regression model based on the serum human chorionic gonadotrophin (hCG) levels at presentation and 48 h later. PARTICIPANTS/MATERIALS, SETTING, METHODS: Temporal validation data from 1341 PULs collected at St George's Hospital in London were available, of which 53% were failed, 39% were intrauterine and 8% were ectopic pregnancies. External validation data from 621 PULs collected at four other London-based teaching hospitals were available, of which 63% were failed, 22% were intrauterine and 15% were ectopic pregnancies. MAIN RESULTS AND THE ROLE OF CHANCE: The EP rate varied between 8 and 16% across the five hospitals. At St George's, 980 [73.1%, 95% confidence interval (CI): 70.5-75.4] PULs were considered low risk. Of these, 963 were failed PULs or IUPs (98.3%, 95% CI: 97.2-98.9) and 17 were ectopic pregnancies. At the other four hospitals, 62-75% were considered low risk, with 96-98% of these turning out to be failed PUL or IUP. Eighty-five percent (95% CI: 76.8-90.2) of the ectopic pregnancies were considered high risk at St George's, compared with 80-92% in the other hospitals. LIMITATIONS, REASONS FOR CAUTION: Of total, 120 patients had been excluded due to loss to follow-up, and a further 102 patients because of missing hCG levels due to differences in local clinical practice. There are variations in the definition of a PUL used in different countries. WIDER IMPLICATIONS OF THE FINDINGS: The suggested protocol could safely reduce the follow-up in the majority of PUL such that units could increase the focus on women at a risk of complications. This would lead to a change in the management of the majority of women with a PUL and a more efficient use of resources. At the end of the manuscript, we provide a link to enable clinicians to use the protocol. STUDY FUNDING/COMPETING INTEREST(S): B.V.C. is supported by a postdoctoral fellowship from the Research Foundation Flanders (FWO). K.V.H. is supported by a fellowship from the Flanders' Agency for Innovation by Science and Technology (IWT-Vlaanderen), by the Research Council KU Leuven (GOA MaNet), by the Flemish Government (iMinds) and by the Belgian Federal Science Policy Office (IUAP P7/DYSCO). T.B. is supported by the Imperial Healthcare NHS Trust NIHR Biomedical Research Centre. No competing interests are declared.

Efficacy and safety of a clinical protocol for expectant management of selected women diagnosed with a tubal ectopic pregnancy.

OBJECTIVE: To validate the efficacy and safety of our clinical protocol for expectant management of selected women diagnosed with tubal ectopic pregnancy. METHODS: This was a prospective observational study carried out in the early pregnancy unit of a London inner-city university teaching hospital from 1(st) January 2008 to 31(st) May 2011. All women presenting with suspected early pregnancy complications were assessed clinically and by transvaginal ultrasound. Those with a conclusive ultrasound diagnosis of tubal ectopic pregnancy were selected for either surgical or expectant management. Selection criteria for expectant management were clinical stability with no or minimal abdominal pain, no evidence of significant hemoperitoneum on ultrasound scan, ectopic pregnancy measuring < 30 mm in mean diameter with no evidence of embryonic cardiac activity, serum ß-human chorionic gonadotropin (ß-hCG) < 1500 IU/L and the woman's consent. All women selected for expectant management were followed up as outpatients until the ectopic pregnancy regressed spontaneously (resolution of clinical symptoms, serum ß-hCG < 20 IU/L/negative urine pregnancy test) or surgical intervention was required. We recorded the rate of interventions, complications and length of follow-up. RESULTS: During the study period 339/11 520 (2.9% (95% CI, 2.59-3.21%)) women were diagnosed with tubal ectopic pregnancy. Six women opted to participate in an ongoing randomized controlled trial and were excluded from further analysis. One hundred and sixty-five (49.5% (95% CI, 44.2-55.0%)) of the 333 remaining women met the criteria for expectant management; 146/333 (43.8% (95% CI, 38.5-49.1%)) of them opted for expectant management and 104/333 (31.2% (95% CI, 26.2-36.2%)) of all tubal ectopics resolved without requiring any intervention. All women with failed expectant management were treated by laparoscopic salpingectomy/salpingotomy and none of them required a blood transfusion. CONCLUSION: Our clinical protocol for expectant management of tubal ectopic pregnancies eliminates the need for medical or surgical treatment in more than a third of women diagnosed with tubal ectopic pregnancy with a minimum risk of adverse outcome.

Reproducibility of assessment of severity of pelvic endometriosis using transvaginal ultrasound.

OBJECTIVE: To examine the reproducibility of assessment of severity of pelvic endometriosis by transvaginal sonography (TVS). METHODS: This was a prospective observational study conducted from August 2006 to July 2009 in two academic departments of obstetrics and gynecology. Women with clinically suspected or proven pelvic endometriosis were invited to join the study. All patients included underwent TVS performed by two observers and a laparoscopic assessment of pelvic endometriosis. The ultrasound observers were blinded to each other's results. The reproducibility of TVS was examined by evaluation of interobserver agreement for the American Society of Reproductive Medicine (ASRM) score by Bland-Altman analysis and the stage and the diagnosis of deeply infiltrating endometriosis (DIE) by calculation of kappa coefficients. Agreement between the findings on TVS for each observer and those on laparoscopy was also evaluated. RESULTS: Thirty-four patients were recruited to the study, and TVS was performed by two ultrasound observers. Of these patients, one did not undergo laparoscopy and was therefore excluded from the final analysis. No endometriosis was found in 12 (36.4%) patients. One patient (3%) had minimal disease, one (3%) had mild disease, five (15.2%) had moderate disease and 14 (42.4%) had severe disease. Interobserver agreement was very good for disease classification on TVS (Cohen's kappa, 0.931). Agreement between TVS and laparoscopy findings was also very good (Cohen's kappa, 0.955 and 0.966 for the two examiners). For ASRM score on TVS, the interobserver 95% limits of agreement were -16.6 to 12.7, with a mean difference of -1.9 (95% CI, -4.35 to 0.71). CONCLUSION: TVS is a reproducible method for assessment of the severity of pelvic endometriosis and shows good agreement with findings on laparoscopy.

How common is adenomyosis? A prospective study of prevalence using transvaginal ultrasound in a gynaecology clinic.

STUDY QUESTION: What is the prevalence of adenomyosis in a population of women attending a general gynaecological clinic? SUMMARY ANSWER: Adenomyosis was present in 206 of 985 [20.9%; 95% confidence interval (CI): 18.5-23.6%] women included in the study. WHAT IS KNOWN ALREADY: Previous studies of occurrence of adenomyosis have been limited to women who underwent hysterectomy, which is likely to overestimate its prevalence compared with the general population of women. There are no large prospective studies on the prevalence of adenomyosis, 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 985 consecutive 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 with the ultrasound scan to determine its prevalence and factors which may affect its occurrence. MAIN RESULTS AND THE ROLE OF CHANCE: Adenomyosis was present in 206/985 [20.9% (95% CI: 18.5-23.6%)] women included in the study. Multivariate analysis showed that the prevalence of adenomyosis was significantly associated with women's age, gravidity and pelvic endometriosis (P< 0.001). In women who subsequently underwent hysterectomy, there was a good level of agreement between the ultrasound and histological diagnosis of adenomyosis [κ = 0.62 (P = 0.001), 95% CI (0.324, 0.912)]. LIMITATIONS, REASONS FOR CAUTION: Our estimate of prevalence of adenomyosis is likely to be higher than in the general population as we studied symptomatic women attending a gynaecology clinic. WIDER IMPLICATIONS OF THE FINDINGS: Better estimates of the prevalence of adenomyosis can improve our understanding of the burden of the disease, help to identify women at high risk of developing the condition and facilitate the development of preventative strategies and effective treatment. STUDY FUNDING/COMPETING INTEREST(S): The authors have no competing interests to declare. The study was not supported by an external grant.

Prospective evaluation of the IOTA logistic regression model LR2 for the diagnosis of ovarian cancer.

OBJECTIVES: To assess the accuracy of the IOTA logistic regression model LR2 for the diagnosis of ovarian cancer. METHODS: This was a prospective single-center study of women with an ultrasound diagnosis of an adnexal tumor. They were all examined by a single Level-II ultrasound operator, who had received training in the systematic examination of ovarian tumors in accordance with the IOTA guidelines. In all women the likelihood of the adnexal lesion being malignant was calculated using the IOTA LR2 model. All women underwent surgery within 120 days of ultrasound examination and the ultrasound findings were compared with operative findings and the final histological diagnosis. RESULTS: One hundred and twenty-four women were included in the final analysis. The mean age was 53.2 (range, 20-91) years and 61/124 (49.2%) women were postmenopausal. 66/124 (53.2%) women had malignant lesions on postoperative histological examination. The IOTA LR2 model had a sensitivity of 97.0% (95% CI, 89.5-99.6%) and a specificity of 69.0% (95% CI, 55.5-80.5%). The area under the receiver-operating characteristics curve was 0.93 (SE, 0.022; 95% CI, 0.89-0.97), which was not significantly different from 0.92 (SE, 0.018) reported in the original study (P > 0.05). CONCLUSION: When evaluated prospectively, the accuracy of the IOTA LR2 model was similar to that reported in the original study.

Endometrial cancer and ultrasound: why measuring endometrial thickness is sometimes not enough.

Endometrial cancer is the commonest cancer of the female genital tract in the developed world. Ultrasound measurement of endometrial thickness is commonly used to triage patients with postmenopausal bleeding for histological sampling. The sensitivity of ultrasound in diagnosing endometrial cancer is high, but it has a small, well-defined false-negative rate. In this report we describe two cases, with histological confirmation, of postmenopausal women without any vaginal bleeding, who were subsequently diagnosed with advanced endometrial cancer. They were found to have a thin, normal endometrium on ultrasound. In both cases, histological examination was suggestive of endometrial cancer originating from foci of adenomyosis. These findings suggest that a proportion of the false-negative diagnoses of endometrial cancer on ultrasound could be caused by the disease being confined to the myometrium rather than as a result of suboptimal performance of ultrasound examination.

Inter- and intraobserver variability in three-dimensional ultrasound assessment of the endometrial-myometrial junction and factors affecting its visualization.

OBJECTIVE: To assess the inter- and intraobserver variability of three-dimensional (3D) ultrasound assessment of the endometrial-myometrial junction (EMJ), and to assess demographic and physiological factors that affect the quality of its imaging. METHODS: Women attending our gynecology clinic, who were deemed to have normal uteri on transvaginal ultrasound examination, were enrolled in this prospective study. They underwent 3D volume acquisition of the entire uterus in order to acquire a coronal view of the organ. Visualization of EMJs was classified as optimal, satisfactory or unsatisfactory. In order to assess the intra- and interobserver variabilities of the classification system, the volumes were classified by two independent observers on two separate occasions. The same classification system was then used to evaluate the EMJs of 101 women who were deemed to have normal uteri on transvaginal ultrasound examination. The results were correlated with age, parity, stage of cycle, menopausal status and endometrial thickness in order to assess whether any of these factors affect visualization of the EMJ. RESULTS: A total of 30 uterine volumes were examined in the first analysis. Both the inter- and intraobserver variability were good (kappa values of 0.77 and 0.83). Of the 101 EMJs assessed in the second analysis, 47 were classified as optimal, 42 as satisfactory and 12 as unsatisfactory. Endometrial thickness was positively associated with EMJ visualization and parity was negatively associated with EMJ visualization. CONCLUSIONS: Assessment of EMJ visualization has both good inter- and intraobserver variability in women with normal uteri. Parity and endometrial thickness have contrasting, statistically significant, effects on visualization of the EMJ.

Preoperative assessment of submucous fibroids by three-dimensional saline contrast sonohysterography.

OBJECTIVE: Submucous fibroids are a common cause of menstrual disturbance that can be treated by hysteroscopic resection. Preoperative patient selection is critical for the success of surgery and it is usually based on hysteroscopic assessment of fibroid protrusion into the uterine cavity. Three-dimensional saline contrast sonohysterography (3D-SCSH) provides additional information about the size and location of submucous fibroids, but it has not yet been evaluated for its usefulness in preoperative assessment. The aim of this study was to examine the potential value of various demographic and ultrasound variables for the prediction of successful submucous fibroid resection. METHODS: This was a prospective study of symptomatic women diagnosed with submucous fibroids who underwent 3D-SCSH prior to hysteroscopic resection. The women's age and parity and fibroid position, diameter, protrusion ratio, size of the intramural component and distance from the internal cervical os were all recorded. The outcome measure was success of a single hysteroscopic resection in achieving a complete excision of the fibroid. Univariate analysis and multivariate logistic regression analysis using a training set and a testing set were performed to investigate the prediction of successful fibroid resection. RESULTS: A total of 61 women with 67 fibroids were included in the study. There was a statistically significant difference between women who had complete and those who had incomplete resection in the mean protrusion ratio (67.8 (SD 14.5)% vs. 47.0 (SD 17.8)%; P = 0.001), the median maximum fibroid diameter (24.0 (interquartile range (IQR), 19.0-30.5) mm vs. 45.0 (IQR, 28.8-51.3) mm; P = 0.001) and the median size of the intramural component of the fibroid (8.0 (IQR, 4.0-11.5) mm vs. 16.5 (IQR, 12.5-29.3) mm; P = 0.001). Stepwise multivariate logistic regression analysis retained size of intramural component (odds ratio (OR) 0.511), parity (OR 0.002) and fibroid diameter (OR 0.843) as significant independent predictors of a complete fibroid resection. The model had an area under the receiver-operating characteristics curve of 0.975 (SE 0.039) for the training set (n = 39) and 0.864 (SE 0.090) for the testing set (n = 28). CONCLUSION: Submucous fibroid protrusion ratio, fibroid diameter and size of the fibroid's intramural component are significantly associated with the likelihood of successful fibroid resection. A logistic regression model can calculate individual probability of complete resection and may improve preoperative counseling of patients.

Using fallout plutonium as a probe for erosion assessment.

A study has been carried out to assess the potential of using fallout plutonium (Pu), which originated from atmospheric nuclear-weapons tests, as a tool to investigate recent erosional processes within the lower Cotter water-supply catchment in the Australian Capital Territory. This catchment, which was predominantly pine plantation, was severely affected by a major bush fire in 2003. Accelerator mass spectrometry has been used to measure Pu in soil samples collected from a number of sites across the catchment. The results indicate that less than 1cm of surface soil had been lost since the early 1960s over much of the catchment. Areas of more erodible soil have, however, lost 2-4cm of topsoil, and a loss of ∼6cm of soil was identified at one particular site.

Value of transvaginal ultrasound in assessing severity of pelvic endometriosis.

OBJECTIVE: The objective of this study was to examine the ability of preoperative transvaginal ultrasound (TVS) scanning to assess the severity of pelvic endometriosis. METHODS: Consecutive women with clinically suspected or proven pelvic endometriosis, who were booked for laparoscopy, were invited to join the study. The severity of endometriosis was assessed preoperatively using TVS and the findings were compared with the results obtained by laparoscopy using the American Society for Reproductive Medicine (ASRM) classification. RESULTS: In total, 201 women had preoperative TVS and laparoscopies. Of these, no endometriosis was found at laparoscopy for 62/201 (30.8%; 95% CI, 24.8-37.5), whereas 33/201 (16.4%; 95% CI, 11.9-22.2) had minimal endometriosis, 31/201 (15.4%; 95% CI, 11.1-21.1) had mild endometriosis, 27/201 (13.4%; 95% CI, 9.4-18.8) had moderate endometriosis and 48/201 (23.9%; 95% CI, 18.5-30.2) had severe endometriosis. The sensitivity and specificity of the TVS diagnosis of severe pelvic endometriosis were 0.85 (95% CI, 0.716-0.934) and 0.98 (95% CI, 0.939-0.994), respectively, and the positive and negative likelihood ratios were 43.5 (95% CI, 14.1-134) and 0.15 (95% CI, 0.075-0.295), respectively. Overall, there was a good level of agreement between ultrasound and laparoscopy in identifying absent, minimal, mild, moderate and severe disease (quadratic weighted kappa = 0.786). The mean ASRM score difference between TVS and laparoscopy in assessing severity of endometriosis was -2.398 (95% CI, -4.685 to -0.1112) and the limits of agreement were -34.62 (95% CI, -38.54 to -30.709) to 29.83 (95% CI, 25.91-33.74). CONCLUSIONS: TVS is a good test for assessing the severity of pelvic endometriosis. TVS is particularly accurate in detecting severe disease, which could facilitate more effective triaging of women for appropriate surgical care.

Expectant management of ultrasonically diagnosed ovarian dermoid cysts: is it possible to predict outcome?

OBJECTIVE: The aim of this study was to assess the natural history of ultrasonically diagnosed ovarian dermoid cysts in a large group of women who were managed expectantly, and to assess the factors that were associated with failure of expectant management. METHODS: Our database was searched for dermoid cysts diagnosed on ultrasonography by a single expert operator between 2001 and 2007 in this retrospective study. In women who opted for expectant management, demographic data including age, gravidity and parity were recorded. Indications for scan, site of cysts, dimensions and the outcomes of expectant management were also recorded. RESULTS: Two hundred and eighty-nine women were diagnosed with a total of 323 dermoid cysts by a single expert ultrasound operator. 93/289 (32.2%; 95% CI, 26.8-37.6%) women with 105/323 (32.5%; 95% CI, 27.4-37.6%) ovarian dermoid cysts were managed expectantly for longer than 3 months. The mean age at diagnosis was 33.8 (range, 13-79) years and the median duration of follow up was 12.6 (interquartile range, 7.6-29.3) months. The mean growth rate of dermoid cysts during follow up was 1.67 mm/year. There were no demographic or morphological features that could be used to predict the growth rate of dermoid cysts. After a period of expectant management, 24/93 (25.8%; 95% CI, 16.9-34.7%) women had surgical intervention. The risk of surgical intervention was significantly increased in younger women, those of parity > or = 2 and in women with bilateral cysts or larger-diameter cysts, and reduced in women with a past history of ovarian cyst. CONCLUSIONS: The success rate of expectant management of dermoid cysts is high and this approach should be considered as a viable alternative to surgical management.

The natural history of fibroids.

OBJECTIVES: Fibroids are common, hormone-dependent, benign uterine tumors. They can cause significant morbidity and the symptoms depend largely on their size. The aim of this study was to describe the natural history of fibroids and identify factors that may influence their growth. METHODS: This was a retrospective longitudinal study of premenopausal women who were diagnosed with uterine fibroids on ultrasound examination. All women underwent at least two transvaginal ultrasound scans, which were all performed by a single operator. Fibroids were measured in three perpendicular planes and the mean diameter was calculated. The size and position of every individual fibroid was assessed and recorded on a computerized database. The volume of each fibroid was calculated using the formula for a sphere. RESULTS: A total of 122 women were included in the study. Their median age at the initial examination was 40 (range, 27-45) years. Seventy-two (59.0%) were nulliparous and 74 (60.7%) had multiple fibroids. The median interval between the initial and final examination was 21.5 (range, 8-90) months. The median fibroid volume increased by 35.2% per year. Small fibroids (< 20 mm mean diameter) grew significantly faster than larger fibroids (P = 0.007). The median increase in size was significantly higher in cases of intramural fibroids (53.2 (interquartile range (IQR), 11.2-217)%) than in subserous fibroids (25.1 (IQR, 1.1-87.1)%) and submucous fibroids (22.8 (IQR, - 11.7 to 48.3)%) (P = 0.012). Multivariate analysis retained only fibroid size at presentation as an independent predictor of fibroid growth. CONCLUSION: The growth of fibroids in premenopausal women is influenced by the tumor's size at presentation.