Use of natural language processing to uncover racial bias in obstetrical documentation

Natural Language Processing (NLP), a form of Artificial Intelligence, allows free-text based clinical documentation to be integrated in ways that facilitate data analysis, data interpretation and formation of individualized medical and obstetrical care. In this cross-sectional study, we identified all births during the study period carrying the radiology-confirmed diagnosis of fibroid uterus in pregnancy (defined as size of largest diameter of >5 cm) by using an NLP platform and compared it to non-NLP derived data using ICD10 codes of the same diagnosis. We then compared the two sets of data and stratified documentation gaps by race. Using fibroid uterus in pregnancy as a marker, we found that Black patients were more likely to have the diagnosis entered late into the patient's chart or had missing documentation of the diagnosis. With appropriate algorithm definitions, cross referencing and thorough validation steps, NLP can contribute to identifying areas of documentation gaps and improve quality of care.

Validation of a Simulation Model for Robotic Myomectomy

STUDY OBJECTIVE

Several simulation models have been evaluated for gynecologic procedures such as hysterectomy, but there are limited published data for myomectomy. This study aimed to assess the validity of a low-cost robotic myomectomy model for surgical simulation training.

DESIGN

Prospective cohort simulation study.

SETTING

Surgical simulation laboratory.

PARTICIPANTS

Twelve obstetrics and gynecology residents and 4 fellowship-trained minimally invasive gynecologic surgeons were recruited for a 3:1 novice-to-expert ratio.

INTERVENTIONS

A robotic myomectomy simulation model was constructed using <$5 worth of materials: a foam cylinder, felt, a stress ball, bandage wrap, and multipurpose sealing wrap. Participants performed a simulation task involving 2 steps: fibroid enucleation and hysterotomy repair. Video-recorded performances were timed and scored by 2 blinded reviewers using the validated Global Evaluative Assessment of Robotic Skills (GEARS) scale (5-25 points) and a modified GEARS scale (5-40 points), which adds 3 novel domains specific to robotic myomectomy. Performance was also scored using predefined task errors. Participants completed a post-task questionnaire assessing the model's realism and utility.

MEASUREMENTS AND MAIN RESULTS

Median task completion time was shorter for experts than novices (9.7 vs 24.6 min, p = .001). Experts scored higher than novices on both the GEARS scale (median 23 vs 12, p = .004) and modified GEARS scale (36 vs 20, p = .004). Experts made fewer task errors than novices (median 15.5 vs 37.5, p = .034). For interrater reliability of scoring, the intraclass correlation coefficient was calculated to be 0.91 for the GEARS assessment, 0.93 for the modified GEARS assessment, and 0.60 for task errors. Using the contrasting groups method, the passing mark for the simulation task was set to a minimum modified GEARS score of 28 and a maximum of 28 errors. Most participants agreed that the model was realistic (62.5%) and useful for training (93.8%).

CONCLUSION

We have demonstrated evidence supporting the validity of a low-cost robotic myomectomy model. This simulation model and the performance assessments developed in this study provide further educational tools for robotic myomectomy training.

MRI, clinical, and radiomic models for differentiation of uterine leiomyosarcoma and leiomyoma

PURPOSE

To assess the predictive ability of conventional MRI features and MRI texture features in differentiating uterine leiomyoma (LM) from uterine leiomyosarcoma (LMS).

METHODS

This single-center, IRB-approved, HIPAA-compliant retrospective study included 108 patients (69 LM, 39 LMS) who had pathology, preoperative MRI, and clinical data available at our tertiary academic institution. Two radiologists independently evaluated 14 features on preoperative MRI. Texture features based on 3D segmentation were extracted from T2W-weighted MRI (T2WI) using commercially available texture software (TexRAD™, Feedback Medical Ltd., Great Britain). MRI conventional features, and clinical and MRI texture features were compared between LM and LMS groups. Dataset was randomly divided into training (86 cases) and testing (22 cases) cohorts (8:2 ratio); training cohort was further subdivided into training and validation sets using ten-fold cross-validation. Optimal radiomics model was selected out of 90 different machine learning pipelines and five models containing different combinations of MRI, clinical, and radiomics variables.

RESULTS

12/14 MRI conventional features and 2/2 clinical features were significantly different between LM and LMS groups. MRI conventional features had moderate to excellent inter-reader agreement for all but two features. Models combining MRI conventional and clinical features (AUC 0.956) and MRI conventional, clinical, and radiomics features (AUC 0.989) had better performance compared to models containing MRI conventional features alone (AUC 0.846 and 0.890) or radiomics features alone (0.929).

CONCLUSION

While multiple MRI and clinical features differed between LM and LMS groups, the model combining MRI, clinical, and radiomic features had the best predictive ability but was only marginally better than a model utilizing conventional MRI and clinical data alone.

Determination of Whole Blood Loss From Minimally Invasive Myomectomy Using a Standardized Formula: A Pilot Study

STUDY OBJECTIVE

To determine the median perioperative blood loss (PBL) during minimally invasive surgical (MIS) myomectomy.

DESIGN

Prospective pilot study.

SETTING

Large academic teaching hospital.

PATIENTS

Thirty-one patients underwent laparoscopic or robotic myomectomy and completed a postoperative complete blood count (CBC) from November 2020 to August 2022. Patients had to have at least one fibroid greater than or equal to 3 cm on preoperative imaging.

INTERVENTIONS

A CBC was collected preoperatively within 7 days of surgery. Estimated blood loss (EBL) was determined by the surgeon intraoperatively. A repeat CBC was drawn between postoperative days 2 through 4. PBL was calculated using the equation PBL = (patient weight in kg × 65 cc/kg) × (preoperative hematocrit - postoperative hematocrit)/preoperative hematocrit.

MEASUREMENTS AND MAIN RESULTS

Median PBL (536.3 cc [270.0, 909.3]) was greater than median EBL (200.0 cc [75.0, 500.0]). PBL ranged from a net gain of 191.5 cc to net loss of 2362.5 cc. Median size of the largest fibroid on preoperative imaging was 8.8 cm (6.6, 11.5), and median weight of fibroids removed was 321 g (115, 519). About half of patients (51.6%) had one fibroid removed, and 48.4% had 2 or more fibroids removed. Five patients were converted to laparotomy, 4 from robotic approaches. Two patients required a blood transfusion.

CONCLUSION

Calculated PBL was greater than intraoperative EBL. This suggests there is continued blood loss post myometrial bed closure. Blood loss should be evaluated both during and after myomectomy, as intraoperative EBL underestimates total PBL.

Psychosocial Stress and MicroRNA Expression Profiles in Myometrial Tissue of Women Undergoing Surgical Treatment for Uterine Fibroids

Uterine leiomyomas (fibroids) are the most common non-cancerous tumors affecting women. Psychosocial stress is associated with fibroid risk and severity. The relationship between psychosocial stress and fibroid pathogenesis may involve alterations in microRNAs (miRNAs) although this has yet to be examined. We investigated associations between two psychosocial stress measures, a composite measure of recent stressful life events and perceived social status, with expression levels of 401 miRNAs in myometrium (n = 20) and fibroids (n = 44; 20 with paired fibroid and myometrium samples) among pre-menopausal women who underwent surgery for fibroid treatment. We used linear regressions to identify psychosocial stressors associated with miRNAs, adjusting for covariates (age, body mass index, race/ethnicity, and oral contraceptive use). The association between psychosocial stressors and miRNAs was considered statistically significant at an FDR p < 0.10 and showed a monotonic response (nominal p-trend < 0.05). In the myometrium, 21 miRNAs were significantly associated with a composite measure of recent stressful events, and two miRNAs were associated with perceived social status. No fibroid miRNAs were associated with either stress measure. Pathway analyses revealed miRNA-mRNA targets were significantly enriched (FDR p < 0.05) in pathways relevant to cancer/tumor development. Of the 74 differentially expressed miRNAs between myometrium and fibroids, miR-27a-5p and miR-301b were also associated with stress exposure. Our pilot analysis suggests that psychosocial stress is associated with myometrial miRNA expression and, thus, may have a role in the pathogenesis of fibroids from healthy myometrium.

I saw the Venetian blind sign

The Venetian blind sign is a radiologic sign seen on pelvic ultrasound. It is classically associated with adenomyosis and, less commonly, uterine fibroids. It appears as alternating vertical stripes of hyperechoic and hypoechoic bands, resembling the horizontal slatted window blinds for which it is named.

A randomized controlled trial of rectal versus intramuscular diclofenac for post-operative analgesia after open myomectomy

AIM

To determine the efficacy and safety of rectal versus intramuscularly administered Diclofenac in reducing post-operative pain in the first 24 h after open-myomectomy.

METHODS

A single blind, placebo controlled randomized trial consisting of 90 consenting women that had open-abdominal-myomectomy. They were randomized into two-groups (rectal-group and intramuscular-group) of 45 women (1:1 ratio). Rectal-group received 75 mg of Diclofenac suppository 12 hourly for 24 h and placebo (3 ml of intramuscular injection-water) 12hourly for 24 h while intramuscular-group received intramuscular Diclofenac 75 mg 12 hourly for 24 h and placebo (Anusol suppository) 12 hourly for 24 h. Both groups received intramuscular Pentazocine 30 mg 6 hourly for 24 h as primary analgesic after myomectomy. Pain was assessed using a Ten-Point Visual-Analogue-Scale. Participants' satisfaction of the mode of the pain relief was assessed using the Likert-scale after 24 h. The primary outcome was the pain score using the visual-analogue-scale. The secondary outcome-measures were participants' satisfaction after 24 h of administration of the drugs, the need and frequency of rescue-analgesia and maternal-side-effects.

RESULT

The baseline socio-demographic characteristics were similar in both groups. There was no statistically significant difference between both groups in pain assessment at 1 h post-myomectomy (p-value > 0.05). However, the pain assessments at 6, 12, 18 and 24 h post-myomectomy were statistically significant with more pain in intramuscular-group when compared to rectal-group. Majority of participants in rectal-group were both very satisfied (35.6 %) and satisfied (55.6 %) when compared to intramuscular-group (11.1 %) and (31,1%) respectively (p-value < 0.05). Also majority of the participants in intramuscular-group were dissatisfied (17.8 %) with none of the participant showing any form of dissatisfaction (p-value < 0.05). Majority of the participant in rectal-group had no drug side effects when compared with intramuscular-group. Epigastric discomfort was commoner in rectal-group while drowsiness was commoner in intramuscular-group.

CONCLUSION

Rectal Diclofenac with intramuscular Pentazocine is significantly associated with better effectiveness in pain reduction and maternal satisfaction when compared with intramuscular Diclofenac and intramuscular Pentazocine following open-myomectomy. While epigastric discomfort was the commonest side-effect in rectal-group, drowsiness was commoner in intramuscular-group.

TRIAL REGISTRATION

Pan-African-clinical-trial-registry (PACTR); PACTR202206556144219.

New Surgical Approach to Treat Fibroids and Solid Tumors - Thermal and Nonthermal Ablation

There is a trend toward more minimally invasive treatment for symptomatic uterine fibroids. They are image-guided ablation surgery with focused ultrasound, microwave, and radiofrequency ablations that are becoming tested and used in some medical centers or hospitals. Nevertheless, these image-guided ablation surgeries involve thermal ablation to the fibroids, which might lead to thermal injury to the surrounding tissues, for example, nerve injury, vessel injury, and skin burn due to heat diffusion. A new technology - irreversible electroporation (IRE) - is a new paradigm for treating solid tumors. This nonthermal ablation process does not induce high temperatures when treating cancers or solid tumors. The IRE treatment may soon be used for treating fibroids or other solid tumors. In a few clinical trials, IRE is currently used in experimental studies for treating gynecological cancers. This paper will present the minimally invasive thermal ablation treatments for fibroids, introduce this new nonthermal IRE ablation in treating gynecological cancer, and propose its future uses in uterine fibroids.

A uterine fibroid presenting as an incarcerated epigastric hernia: a case report and review of the literature

BACKGROUND

Uterine fibroids incarcerated in abdominal wall hernias during pregnancy are rare, with only six cases reported in umbilical hernias. This case report presents the first reported case of an incarcerated uterine fibroid in an epigastric hernia.

CASE PRESENTATION

A 31-year-old primigravid Caucasian woman at 28 weeks gestational age presented with sudden onset abdominal pain and vomiting. Physical examination revealed an incarcerated epigastric hernia containing a non-reducible firm mass. Ultrasound showed a healthy fetus, and during surgery, a subserosal and sessile fibroid originating from the anterior uterine wall was found in the hernia sac. It was easily reduced, and the hernia was repaired with no complications. The patient proceeded to deliver a healthy baby boy by cesarean section at full term.

CONCLUSION

Uterine fibroids incarcerated in abdominal wall hernias during pregnancy are rare and affect mostly primigravid women in the third trimester. Abdominal ultrasound may facilitate the diagnosis, and pedunculated fibroids may be resected while sessile fibroids should be simply reduced. Clinicians should consider incarcerated fibroid as a differential diagnosis in pregnant women with irreducible ventral abdominal wall hernias. This case report aims to contribute to the literature and optimize the management of abdominal wall hernias in pregnant women.

Short-term outcomes of uterine artery embolization for urgent or emergent abnormal uterine bleeding

PURPOSE

To evaluate the outcomes of uterine artery embolization (UAE) for patients with urgent or emergent abnormal uterine bleeding (AUB).

MATERIALS AND METHODS

Retrospective review of all patients from 1/2009-12/2020 who were treated urgently or emergently with UAE for AUB. Urgent and emergent cases were defined as those requiring inpatient admissions. Demographic data were collected for each patient including hospitalizations related to bleeding and length of stay (LOS) for each hospitalization. Hemostatic interventions other than UAE were collected. Hematologic data were collected before and after UAE including hemoglobin, hematocrit, and transfusion products. Data specific to the UAE procedure included complication rates, 30-day readmission, 30-day mortality, embolic agent, site of embolization, radiation dose, and procedure time.

RESULTS

52 patients (median age: 39) underwent 54 urgent or emergent UAE procedures. The most common indications for UAE were malignancy (28.8%), post-partum hemorrhage (21.2%), fibroids (15.4%), vascular anomalies (15.4%), and post-operative bleeding (9.6%). There were no procedure-related complications. Following UAE, 44 patients (84.6%) achieved clinical success and required no additional intervention. Packed red blood cell transfusion decreased from a mean of 5.7 to 1.7 units (p < 0.0001). Fresh frozen plasma transfusion decreased from a mean of 1.8 to 0.48 units (p = 0.012). 50% of patients received a transfusion prior to UAE, while only 15.4% were transfused post-procedure (p = 0.0001).

CONCLUSIONS

Emergent or urgent UAE is a safe and effective procedure to control AUB hemorrhage secondary to a variety of etiologies.

Fumarase Deficiency and Its Effect on Infertility: A Case Series

Background

Fumarase deficiency is an autosomal recessive condition characterized by severe neurologic abnormalities due to homozygous mutations in the fumarate hydratase (FH) gene. Heterozygous carriers of FH mutations have increased risk of developing uterine fibroids that can be associated with hereditary leiomyomatosis and renal cell cancer (HLRCC). The association between FH mutations and infertility remains uncertain. The objective of our study was to characterize the infertility diagnoses, treatments, and outcomes in women presenting to a fertility center who were found to be carriers of fumarase deficiency based on the presence of heterozygous FH mutations.

Case Presentation

A retrospective case series was conducted including 10 women presenting to an academic fertility center who were found to be FH carriers based on genetic carrier screening. Of the 9 women who were engaged in further workup, 2 had imaging results consistent with uterine fibroids. One woman underwent hysteroscopic myomectomy prior to two courses of ovulation induction with timed intercourse (OI/TIC) followed by one successful cycle of IVF. Of the remaining patients, only 1 woman successfully delivered after a cycle of ovulation induction with intrauterine insemination (OI/IUI). Other patients pursuing OI/IUI, OI/TIC, or monitored natural cycles had unsuccessful experiences.

Conclusion

Patients with infertility who are offered genetic testing should be screened for FH mutations, as the carriers are at risk of developing HLRCC-associated uterine fibroids, which can influence fertility and pregnancy. Additional research is needed to investigate the impacts of FH mutations on infertility.

Laparoscopic myomectomy complications: META analysis on RCTs and review of large cohort studies

Complications of myomectomy are generally rare and highly dependent on the surgeons' skills and selection of patients. Haemorrhage, direct injury, post-operative pain and fever present as intra and peri-operative complications, while adhesions are considered late complications. 21 RCTs and 15 meta-analyses have been conducted to date, with the last comprehensive meta-analysis being published in 2009. The main disadvantage of the previous meta-analysis included incomplete selection of studies, inclusion of studies with small sample sizes, and major heterogeneity of methods used between studies. The aim of this meta-analysis comparing laparoscopic myomectomy (LMy) to open conservative myomectomy is to provide an updated review of the type, frequency and severity of complications. These results can direct teaching efforts and guidelines and give updated advice to gynaecologists. A literature search was conducted on PubMed and Google scholar for RCTs on this topic. 276 studies were identified and 19 RCTs ultimately met the criteria for inclusion in the meta-analysis and subsequent heterogeneity assessment. The results showed that laparoscopic myomectomy has a more favourable outcome with regards to several complications when compared with laparotomy. Laparoscopic myomectomy is significantly associated with lower Hg drop (WMD = -0.48, 95% CI [-0.89, -0.07], p = 0.02179); lower incidence of post-operative fever (RR = 0.43, 95% CI [0.29, 0.64], p < 0.001); lower levels of pain at 48Hrs post-op (WMD = -0.88, 95% CI [-1.63, -0.014], p = 0.02020) and decreased analgesia requests (RR = 0.49, 95% CI [0.37, 0.64], p < 0.0001). Prophylaxis use was associated with less adhesions (RR = 0.064, 95% CI [0.44, 0.92], p = 0.01), although not enough data was available to draw conclusions regarding specific prophylactic agents. No differences were found between LMy and laparotomy for blood loss (WMD = -13.6494, 95% CI [-44.48, 17.18], p = 0.38553) or pain at 24Hrs post-op (WMD = -0.19, 95% CI [-0.55, 0.18], p = 0.32136). These findings support previously published meta-analyses. Given the right indications of the surgery and training of the surgeon, LMy seems to be most preferable to laparotomy in achieving a better clinical result with fewer complications.

Beyond the learning curve: improving outcomes in Robotic myomectomy compared to laparoscopic myomectomy

Uterine myomas are benign tumours frequently seen in women of reproductive age. Myomectomy remains a viable option for treating this condition in women who wish to preserve their uterus. We undertook this study to compare the peri-operative surgical outcomes of Robotic myomectomy (RM) with laparoscopic myomectomy (LM) in Indian patients of uterine myomas after the initial learning curve of RM was achieved. A retrospective chart review was performed for the patients who underwent RM or LM for the treatment of uterine myomas. A total of 177 patients, 116 in the RM group and 61 in the LM group, were included in the study. The mean age in the RM and LM group was 34.31 ± 5.40 years and 33.54 ± 4.96 years, respectively (p = 0.355). The mean total operative time was marginally more in RM group (127.37 ± 110.67 vs. 120.66 ± 44.27, p = 0.650) but the difference was not statistically significant. Patients in the RM group had significantly less blood loss (115.43 ± 79.43 vs. 340.98 ± 453.9 ml, p = < 0.0001), hospital stay (1.28 ± 0.49 vs. 1.92 ± 1.05 days, p = < 0.0001), requirement of blood transfusion (93.97 vs. 81.97%, p = 0.031) and requirement of intravenous (IV) analgesia (41.38 vs. 34.43%, p = 0.019) as compared to the patients in the LM group. The Robotic myomectomy significantly reduces blood loss, the duration of hospital stay, and requirement of blood transfusions and IV analgesia as compared to the laparoscopic myomectomy.

Beta blockers reduce uterine fibroid incidence in hypertensive women

OBJECTIVE

Is prior beta blocker (BB) use associated with reduced odds of the clinical incidence of leiomyomas?

WHAT IS KNOWN ALREADY

In-vitro and in-vivo evidence has supported the role of beta receptor blockade in reducing leiomyoma cell proliferation and growth. However, no population-based study to date has investigated this potential association.

STUDY DESIGN, SIZE, DURATION

A nested case-control study was conducted in a population of women aged 18-65 with arterial hypertension (n = 699,966). Cases (n = 18,918) with a leiomyoma diagnosis were matched to controls (n = 681,048) with no such diagnosis at a 1:36 ratio by age and region of origin within the United States.

PARTICIPANTS/MATERIALS, SETTING, METHODS

This population was assembled from the Truven Health MarketScan® Research Database, which includes health insurance claims from January 1st, 2012 to December 31st, 2017. Prior use of BB wasdetermined fromoutpatient drug claims and leiomyoma development was indicated by a first-time diagnosis code. We conducted a conditional logistic regression to determine the odds of uterine fibroid development in women with prior use of BB compared to women with no such history. We then conducted subset analyses, stratifying the women by age group and by type of BB.

RESULTS

Women on a BB experienced 15% reduced odds of developing clinically recognized leiomyoma compared to non-users (OR 0.85, 95% CI 0.76-0.94). This association was significant for the 30-39 age group (OR 0.61, 95% CI 0.40-0.93) but no other age group. Of the BBs, propranolol (OR 0.58, 95% CI 0.36-95) demonstrated a significant association with reduced leiomyoma incidence and metoprolol (OR 0.82, 95% CI 0.70-0.97) was associated with lower uterine fibroid incidence after adjustment for comorbidities.

CONCLUSIONS

Hypertensive women with prior BB use experienced reduced odds of developing clinically recognized leiomyoma compared to non-users. A key predisposing risk factor for uterine leiomyoma is elevated blood pressure. Thus, the results of this analysis may have clinical relevance to women with hypertension, as the use of this drug may introduce a dual benefit of managing hypertension as well as curbing an increased risk of leiomyomas.

Towards a clinical consensus on the management of pregnancy and birth after laparoscopic and open myomectomy: A survey of obstetricians and gynaecologists

OBJECTIVES

The primary aim was to assess if a clinical consensus regarding the management of pregnancy post myomectomy existed amongst consultant obstetricians and gynaecologists. Secondary objectives were to evaluate factors which influence the clinician's decision making in this group of women.

STUDY DESIGN

Electronic survey sent to all consultants working in the North Central and East London deanery, Kent Surrey and Sussex deanery and Imperial NHS Trust to assess opinions on mode of birth post myomectomy, intervals advised to pregnancy post myomectomy, factors influencing the management of delivery in the scarred uterus post myomectomy, opinions on induction of labour and questions relating to operative notes.

RESULTS

209 consultant responses received between 07/03/2022-07/05/2022 (44% response rate); 77% (161/209) practicing obstetricians and gynaecologists, 10% (21/109) pure gynaecologists and 13% (27/209) pure obstetricians. The majority would support a vaginal birth after open myomectomy (75%) and laparoscopic myomectomy (79%). No consensus was found as to the optimal time interval between myomectomy and pregnancy. Higher frequency of performing myomectomy and a greater level of experience were significantly associated with a shorter interval to pregnancy advised. The most important operative factors influencing decision to support trial of labour post myomectomy were breach of uterine cavity; location of fibroids removed and number of incisions on the uterus. 77% believe women should be given a choice regarding mode of delivery post myomectomy in a similar way to previous LSCS. 82.8% would support enrolment of patients into a prospective trial to investigate delivery post myomectomy.

CONCLUSIONS

We present a comprehensive survey of clinician opinions on pregnancy post myomectomy demonstrating that the majority of consultant obstetricians and gynaecologists sampled would support vaginal birth post myomectomy; counselling patients in a similar way to VBAC; a standardised myomectomy operation note and enrolment of patients in a future prospective trial. Wide variation in opinion regarding interval to pregnancy post myomectomy has been highlighted. We believe this information will facilitate counselling discussions and empower women with subsequent pregnancies after myomectomy to make an informed decision on mode of birth post myomectomy.

Laparoscopic subtotal hysterectomy followed by in-bag transvaginal corpus uteri morcellation and extraction: A case series

OBJECTIVES

Laparoscopic subtotal hysterectomy (LSH) is a possible treatment for patients with benign uterine disease. Once the hysterectomy has been completed, morcellation and extraction of the corpus uteri is a crucial step of the procedure. We here present a case series to evaluate the feasibility of the in-bag transvaginal specimen retrieval following LSH.

STUDY DESIGN

We report a case series of consecutive patients who underwent LSH followed by in-bag transvaginal specimen retrieval. LSH was accomplished in a standard fashion. Once the uterus was detached from the cervix, a 2 cm posterior colpotomy was performed laparoscopically with a monopolar hook under direct view to insert a specimen retrieval bag into the abdomen. The corpus uteri was placed into the bag and transvaginal contained manual morcellation was performed. The colpotomy was then sutured transvaginally. Baseline patients' characteristics and surgical data were collected. Postoperative complications, same-hospital readmissions, and reoperations were registered if occurred within 30 days from surgery.

RESULTS

Patients' median age and BMI were 45,5 and 22,7, respectively. Median operative time was 71.5 min (range 34-143) and uterus weight ranged from 60 g to 470 g (median 210 g). The estimated blood loss was 100 mL (median) and no blood transfusion was required. No conversions to open surgery, nor intraoperative complications occurred. Median hospital stay was 2 days (1-3) and no postoperative complications within 30 days from surgery were recorded.

CONCLUSIONS

LSH followed by in-bag transvaginal specimen extraction is a promising technique and might be considered a reliable and safe option to further reduce the invasiveness of the procedure.

Racial disparities in uterine fibroids and endometriosis: a systematic review and application of social, structural, and political context

IMPORTANCE

Uterine fibroids and endometriosis are 2 of the leading causes of morbidity among reproductive-aged women. There are significant racial disparities in disease prevalence, incidence, age of onset, and treatment profile in fibroids. The data on endometriosis are less clear.

OBJECTIVE

To conduct a systematic review of racial disparities in prevalence of uterine fibroids and endometriosis in the United States and summarize the literature on these 2 highly prevalent benign gynecologic conditions using a framework that explicitly incorporates and acknowledges the social, structural, and political contexts as a root cause of racial disparities between Black and White women.

EVIDENCE REVIEW

A systematic review regarding racial disparities in prevalence of fibroids and endometriosis was conducted separately. Two separate searches were conducted in PubMed to identify relevant original research manuscripts and prior systematic reviews regarding racial disparities in uterine fibroids and endometriosis using standardized search terms. In addition, we conducted a structured literature search to provide social, structural, and political context of the disparities.

FINDINGS

A systematic review of the literature indicated that the prevalence of uterine fibroids was consistently higher in Black than in White women with the magnitude of the difference varying depending on population and case definition. Prevalence of endometriosis varied considerably depending on the base population and case definition, but was the same or lower among Black vs. White women. As a result of the social, structural, and political context in the United States, Black women disproportionately experience a range of exposures across the life course that may contribute to their increased uterine fibroid incidence, prevalence, and severity of uterine fibroids. However, data suggest no racial difference in the incidence of endometriosis. Nevertheless, Black women with fibroids or endometriosis experience worse clinical and surgical outcomes than their White counterparts.

CONCLUSION AND RELEVANCE

Racial disparities in uterine fibroids and endometriosis can be linked with differential exposures to suspected etiologic agents, lack of adequate access to health care, including highly skilled gynecologic surgeons, and bias and discrimination within the health care system. Eliminating these racial disparities will require solutions that address root causes of health disparities through policy, education and programs to ensure that all patients receive culturally- and structurally-competent care.

Abnormal Uterine Bleeding

Abnormal uterine bleeding is a common problem in premenopausal women and refers to uterine bleeding that is abnormal in frequency, duration, volume, and/or regularity. Etiologies can be classified using the PALM-COIEN system. Patients should receive a comprehensive history and physical with special attention to menstrual, sexual, and family history. Physical examination needs to include a pelvic examination with speculum and bimanual components. All patients need to have a pregnancy test and CBC with platelets. Treatments vary by etiology. Medical treatments include levonorgestrel intrauterine devices, oral contraceptive pills, and tranexamic acid. Surgical treatment options include endometrial ablation and hysterectomy.

Structural Gynecological Disease: Fibroids, Endometriosis, Ovarian Cysts

Fibroids, endometriosis, and ovarian cysts are common conditions. Fibroids can be asymptomatic or present with heavy menstrual bleeding, pelvic pressure, and pain. Endometriosis is a common cause of cyclical pelvic pain. Ovarian cysts are generally diagnosed incidentally. Transvaginal ultrasound is the performed imaging modality for all structural gynecological disease. Symptomatic management is recommended for each condition. Fibroids can be managed medically or surgically depending on the patient's symptoms and desire for future fertility. Nonsteroidal anti-inflammatory drugs are the first-line therapy for endometriosis followed by oral contraceptives and surgical management. Ovarian cysts can be managed expectantly.

Fruit and vegetable consumption, pesticide residue intake from consumption of fruits and vegetables, and risk of uterine fibroids

OBJECTIVE

To examine the association between consumption of fruits and vegetables and pesticide residue intake from consumption of fruits and vegetables and risk of ultrasound- or hysterectomy-confirmed fibroids. Only a few studies have evaluated the association of fruit and vegetable intake with uterine fibroids, with inconsistent results. No studies have examined pesticide exposure through fruits and vegetables with fibroid risk.

DESIGN

Prospective cohort study. Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs).

SETTING

Not applicable.

PATIENT(S)

A total of 81,782 premenopausal participants from the Nurses' Health Study II cohort were followed from 1991 to 2009 for fruit and vegetable analysis, and 49,927 participants were followed from 1999 to 2009 for pesticide residue burden analysis. Their diet was assessed every 4 years with a food frequency questionnaire. Fruits and vegetables were classified into high- or low-pesticide residues using a validated method based on surveillance data from the US Department of Agriculture.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Cases of ultrasound- or hysterectomy-confirmed fibroids were identified from self-reports to validated questionnaires.

RESULT(S)

From 1991 to 2009, 9,706 incident cases of ultrasound- or hysterectomy-confirmed fibroids were reported, and 4,195 incident cases were identified from 1999 to 2009. No association was observed between total fruit and vegetable consumption and uterine fibroid risk. Participants with the highest intake of total fruits (≥4/day) were 10% less likely to develop uterine fibroids compared with participants who consumed <1/day (95% CI = 0.80-1.01). No associations were observed with any other fruit or vegetable groups. An inverse association was observed between intake of high-pesticide-residue fruits and vegetables and fibroid risk (HR for 5th vs. 1st quintile = 0.87; 95% CI = 0.77-0.99), while no association with low-pesticide-residue fruits and vegetables was observed (HR for 5th vs. 1st quintile = 1.08; 95% CI = 0.95-1.23).

CONCLUSION(S)

Our findings suggest that pesticide residues on fruits and vegetables are not associated with a higher risk of uterine fibroids. Furthermore, our results suggest that intake of fruits may be associated with a lower risk of fibroids. Future research in this area should focus on dietary exposures across the life course as well as assessment of class-specific pesticides.

Intraoperative Laparoscopic Ultrasound Increases Fibroid Detection During Laparoscopic Myomectomy

Objective

To assess the utility of intraoperative laparoscopic ultrasound in detecting additional fibroids during laparoscopic myomectomy (LM).

Methods

Forty-two patients were enrolled in this prospective cohort study. All cases were performed by the same surgeon at a university affiliated hospital between April 1, 2019 and February 29, 2020. Following routine laparoscopic myomectomy, the laparoscopic ultrasound was then introduced, and ultrasonography was performed directly on the uterus. Any additional fibroids discovered were enucleated.

Results

Using the laparoscopic ultrasound, an additional 54 fibroids among 27 (64%) of the 42 patients were found, with a median of 2 additional fibroids per patient (interquartile range [IQR] 1,3). Median fibroid size detected by laparoscopic ultrasound was 1.5 centimeters (IQR 1-3) and the most common types were FIGO grades 3 and 2 (43% and 33% respectively). The median surgical time was longer among patients in whom additional fibroids were found (170 minutes (IQR 137-219) vs 150 minutes (IQR 120-193), p = .044). When ≥ 2 fibroids were removed by usual methods, the laparoscopic ultrasound found additional fibroids 80% of the time, compared to 25% when < 2 fibroids were removed by usual methods (p < .001).

Conclusion

Intraoperative laparoscopic ultrasonography is a useful tool in detecting additional fibroids that would have otherwise been missed. It is particularly helpful in identifying smaller intramural fibroids and in patients with multiple fibroids. By detecting additional fibroids, laparoscopic ultrasonography can help maximize the effectiveness of laparoscopic myomectomy and help decrease the rates of residual fibroids.

Route of myomectomy and fertility: a prospective cohort study

OBJECTIVE

To assess prospectively the association between the myomectomy route and fertility.

DESIGN

Prospective cohort study.

SETTING

The Comparing Treatments Options for Uterine Fibroids (COMPARE-UF) Study is a multisite national registry of eight clinic centers across the United States.

PATIENT(S)

Reproductive-aged women undergoing surgery for symptomatic uterine fibroids.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

We used life-table methods to estimate cumulative probabilities and 95% confidence intervals (CI) of pregnancy and live birth by the myomectomy route during 12, 24, and 36 months of follow-up (2015-2019). We also conducted 12-month interval-based analyses that used logistic regression to estimate odds ratios and 95% CIs for associations of interest. In all analyses, we used propensity score weighting to adjust for differences across surgical routes.

RESULT(S)

Among 1,095 women who underwent myomectomy (abdominal = 388, hysteroscopic = 273, and laparoscopic = 434), 202 reported pregnancy and 91 reported live birth during 36 months of follow-up. There was little difference in the 12-month probability of pregnancy or live birth by route of myomectomy overall or among women intending pregnancy. In interval-based analyses, adjusted ORs for pregnancy were 1.28 (95% CI, 0.76-2.14) for hysteroscopic myomectomy and 1.19 (95% CI, 0.76-1.85) for laparoscopic myomectomy compared with abdominal myomectomy. Among women intending pregnancy, adjusted ORs were 1.27 (95% CI, 0.72-2.23) for hysteroscopic myomectomy and 1.26 (95% CI, 0.77-2.04) for laparoscopic myomectomy compared with abdominal myomectomy. Associations were slightly stronger but less precise for live birth.

CONCLUSION(S)

The probability of conception or live birth did not differ appreciably by the myomectomy route among women observed for 36 months postoperatively. CLINICAL TRIALS REGISTRATION NUMBER: (NCT02260752, clinicaltrials.gov).

Preoperative Uterine Artery Embolization in Women Undergoing Uterus-Preserving Myomectomy for Extensive Fibroid Disease: A Retrospective Analysis

OBJECTIVES

The aim of this study was to determine if a long versus short interval between preoperative uterine artery embolization (PUAE) and subsequent myomectomy impact perioperative blood loss and the complication rate in cases of enlarged multi-fibroid uterus.

DESIGN

In cases of an enlarged multi-fibroid uterus, operative myomectomy can lead to heavy blood loss and consequently increases the risk for transfusion and hysterectomy. PUAE can possibly contribute to a reduction of these risks. Our study was designed to determine if a long versus short interval between PUAE and subsequent surgery impacts perioperative blood loss and complication rate.

PARTICIPANTS AND METHODS

PUAE was performed 24 h before the planned myoma enucleation in 21 patients between January 2011 and March 2016 (group 1) or 19 days before the operation in 23 patients from March 2016 to May 2018 (group 2). A comparison was made to a historical sample of 57 patients with large myomas (>10 cm) without PUAE (group 3). Perioperative blood loss, need for postoperative blood transfusion, and postoperative complications were recorded. Subjective improvement of myoma-related symptoms was assessed for each group by a questionnaire.

RESULTS

PUAE was carried out successfully without complications in all patients. Conversion to hysterectomy was not needed in any of the PUAE patients but was necessary in one of the control patients. In the three groups' comparison, there was a significant lower risk for high blood loss (≥500 mL) in group 1 and a lower but not significant lower risk in group 2 compared to group 3 without an embolization preoperatively. Also, a significant lower risk for postoperative blood transfusion for group 1 (OR 0.02; 0.001-0.328; p = 0.01) and 2 (OR 0.02; 0.001-0.277; p = 0.01) compared to group 3 was observed. The postoperative complication risk was lower in group 2 (model 1: OR 0.12; 0.016-0.848; p = 0.03; model 2 OR 0.07; 0.009-0.588; p = 0.01) compared to group 3. In the context of the postoperative questionnaire, 10 of 11 patients in group 1, 12 of 12 patients in group 2, and 31 of 36 patients from the control group reported an improvement of their complaints.

CONCLUSION

PUAE is beneficial for uterus-preserving removal of myomas from patients with a substantially enlarged uterus. There is a significant reduction of high blood loss (≥500 mL), need for postoperative blood transfusion, and postoperative complications in patients with extensive fibroid disease after PUAE compared to no intervention before myoma enucleation.

Factors influencing intraoperative blood loss and hemoglobin drop during laparoscopic myomectomy: a tailored approach is possible?

A retrospective study was conducted on patients subjected to laparoscopic myomectomy at our institution from January 2017 to December 2018 to identify predictive factors of blood loss. Two multiple regression models were run to predict intraoperative blood loss and haemoglobin drop. Predictors of an increased intraoperative blood loss and haemoglobin drop were the presence of three-four fibroids at ultrasound (+47 ml, p = .01; +0.58 g/dl, p = .05) and increased operative time (r = 0.57, p = .01; r = 0.01, p < .01), while predictors of a reduced intraoperative blood loss and haemoglobin drop were epinephrine injection (-50 ml, p < .01; -0.42 g/dl, p < .01), FIGO7 (-87 ml, p < .01; -0.85, p = .01), and FIGO6 (-35 ml, p < .01; -0.44, p = .02) fibroids at the ultrasound. Preoperative ultrasound evaluation is crucial in identifying patients at higher risk for blood loss, which could benefit from optimising haemoglobin values. The injection of diluted epinephrine could be proposed in selected high-risk patients. In the clinical practice, a tailored approach based on fibroids' ultrasonographic characteristics should be implemented to optimise preoperative Hb values and evaluate the use of diluted epinephrine in selected cases, reducing blood loss and the potential related complications.Impact statementWhat is already known on this subject? Laparoscopic myomectomy is the conservative surgical treatment of choice for symptomatic uterine fibroids. Still, it could represent a challenging procedure even for an experienced surgeon, with the risk of excessive blood loss, need of transfusions, prolonged operative time, and prolonged hospital stay. The knowledge of the predictive factors of blood loss is essential for patient preparation and surgical planning to reduce intraoperative and postoperative complications.What do the results of this study add? The results of the present study focus on the importance of presurgical evaluation to identify predictive factors of intraoperative blood loss and Hb drop such as the number of fibroids and the FIGO classification (at preoperative ultrasound), as well as intraoperative factors like operative time and the intramyometrial injection of diluted epinephrine.What are the implications of these findings for clinical practice and/or further research? A tailored approach based on the ultrasonographic characteristics of fibroids should be implemented to optimise preoperative haemoblobin levels.

Hysteroscopic myomectomy: The guidelines of the International Society for Gynecologic Endoscopy (ISGE)

OBJECTIVE

With this publication, the International Society for Gynecologic Endoscopy (ISGE) aims to provide the clinicians with the recommendations arising from the best evidence currently available on hysteroscopic myomectomy (HM).

STUDY DESIGN

The ISGE Task Force for HM defined key clinical questions, which led the search of Medline/PubMed and the Cochrane Database. We selected and analyzed relevant English-language articles, published from January 2005 to June 2021, including original works, reviews and the guidelines previously published by the European Society for Gynecological Endoscopy (ESGE) and the American Association of Gynecologic Laparoscopists (AAGL), in which bibliographies were also checked in order to identify additional references, using the medical subject heading (MeSH) term "Uterine Myomectomy" (MeSH Unique ID: D063186) in combination with ''Myoma" (MeSH Unique ID: D009214) and ''Hysteroscopy" (MeSH Unique ID: D015907). We developed the recommendations through multiple cycles of literature analysis and expert discussion.

RESULTS

The ISGE Task Force did develop 10 grade 1A-C and 4 grade 2A-C recommendations. For planning HM, evaluation of the uterus with saline infusion sonohysterography (SIS) or combined assessment by transvaginal ultrasound (TVUS) and diagnostic hysteroscopy is recommended (Grade 1A). The use of STEPW (Size, Topography, Extension of the base, Penetration and lateral Wall position) classification system of submucosal leiomyoma (LM) is recommended to predict the complex surgeries, incomplete removal of the LM, long operative time, fluid overload and other major complications (grade 1B). For type 0 LMs, in addition to resectoscopy (slicing technique), morcellation is recommended, being faster and having a shorter learning curve with respect to resectoscopy (grade 1C). For type 1-2 LMs, slicing technique is currently recommended (grade 1C). A fluid deficit of 1000 mL also in case of bipolar myomectomy with saline solution, in healthy women of reproductive age, contains low risk for major complications. Lower thresholds (750 mL) for fluid deficit should be considered in the elderly and in women with cardiovascular, renal or other co-morbidities (Grade 1B).

CONCLUSION

HM is the most effective conservative minimally invasive gynecologic intervention for submucous LM. The set of 14 ISGE recommendations can significantly contribute to the success of HM and the safety of patients for whom the choice of appropriate surgical technique, as well as the surgeon's awareness and measures to prevent complications are of the utmost importance.

Uterine leiomyomas revisited with review of literature

Uterine leiomyomas, more commonly known as fibroids, are the most common neoplasms of the uterus. These tumors have a profound effect on health care and cost worldwide. Depending on the race, uterine leiomyomas can be seen in 70-80% of all women. Although majority of the women with uterine leiomyomas remain asymptomatic, approximately 30% can present with symptoms. Diagnosing typical leiomyomas on imaging is straightforward. However, when large, located extrauterine and especially with degeneration, the diagnosis can be challenging on imaging. In this article, apart from reviewing the demographics and management of patients with leiomyomas, we describe in detail the imaging appearance of various atypical leiomyomas, uncommon locations outside the uterus and their important differential diagnosis that can have a profound effect on patient management.

Appraisal of national and international uterine fibroid management guidelines: a systematic review

BACKGROUND

Guidelines standardise high-quality evidence-based management strategies for clinicians. Uterine fibroids are a highly prevalent condition and may exert significant morbidity.

OBJECTIVES

To appraise national and international uterine fibroid guidelines using the validated AGREE-II instrument.

SELECTION STRATEGY

Database search of PubMed and EMBASE from inception to October 2020 for all published English-language uterine fibroid clinical practice guidelines.

DATA COLLECTION AND ANALYSIS

In all, 939 abstracts were screened for eligibility by two reviewers independently. Three reviewers used the AGREE-II instrument to assess guideline quality in six domains. Recommendations were mapped to allow a narrative synthesis regarding areas of consensus and disagreement.

MAIN RESULTS

Eight national guidelines (AAGL, SOGC 2014, ACOG, ACR, SOGC 2019, CNGOF, ASRM and SOGC 2015) and one international guideline (RANZOG) were appraised. The highest scoring guideline was RANZOG 2001(score 56.5%). None of the guidelines met the a priori criteria for being high-quality overall (score ≥66%). There were 166 recommendations across guidelines. There were several areas of disagreement and uncertainty. There were only three areas of consensus. Supporting evidence was not evident for many recommendations; 27.7% of recommendations were based on expert opinion only.

CONCLUSIONS

There is a need for high-quality guidelines on fibroids given their heterogeneity across individuals and the large range of treatment modalities available. There are also areas of controversy in the management of fibroids (e.g. Ulipristal acetate, power morcellation), which should also be addressed in any guidelines. Future guidelines should be methodologically robust to allow high-quality decision-making regarding fibroid treatments.

TWEETABLE ABSTRACT

Current national fibroid guidelines have deficiencies in quality when appraised using the validated AGREE instrument.

Urinary concentrations of phenols, parabens, and triclocarban in relation to uterine leiomyomata incidence and growth

OBJECTIVE

To examine the association of urinary concentrations of phenols, parabens, and triclocarban with incidence and growth of uterine leiomyomata (UL; fibroids).

DESIGN

Case-cohort study, nested within the Study of Environment, Lifestyle, and Fibroids, a prospective cohort study.

SETTING

Clinic visits at baseline and every 20 months for 60 months.

PATIENT(S)

754 Black women aged 23-35 years residing in the Detroit, Michigan area (enrolled during 2010-2012).

INTERVENTION

None.

MAIN OUTCOME MEASURE(S)

At each study visit, women underwent transvaginal ultrasound for measurement of UL incidence and growth and provided urine specimens in which we quantified concentrations of seven phenols, four parabens, and triclocarban. We used Cox proportional hazards regression to estimate hazard ratios and 95% confidence intervals (CIs) characterizing the relation of urinary biomarker concentrations with UL incidence during the 60 months of follow-up. In a subset of UL detected and measured at multiple time points, we used linear regression to assess the associations between biomarker concentrations and UL growth.

RESULT(S)

Urinary biomarker concentrations were generally inversely associated with UL incidence, but the associations were weak and nonmonotonic. For example, hazard ratios comparing concentrations ≥90th with <50th percentile were 0.77 (95% CI: 0.46, 1.27) for bisphenol A, 0.72 (95% CI: 0.40, 1.28) for bisphenol S, and 0.76 (95% CI: 0.43, 1.33) for methylparaben. Biomarker concentrations were not strongly associated with UL growth.

CONCLUSION(S)

In this study of reproductive-aged Black women, urinary phenols, parabens, and triclocarban biomarkers were neither strongly nor consistently associated with UL incidence and growth.

Uterine Fibroids and Pregnancy: How Do They Affect Each Other?

The present narrative review is aimed to rekindle discussion regarding whether and how uterine leiomyoma and pregnancy may impact each other. Although fibroids are hormone-dependent lesions, their growth during pregnancy seems to have a nonlinear trend. Besides placental estrogens and progesterone, an array of endocrine and paracrine factors affect fibroid blood supply, growth rate, and risk of degeneration along the gestational and puerperal periods. According to current evidence, the presence of leiomyomas might increase the risk of some adverse pregnancy outcomes. Although a causative relation between fibroids and spontaneous abortion is questionable, the presence of multiple submucosal lesions in certain populations, such as infertile women, may increase the risk of pregnancy loss. Slightly increased risks of placenta previa, placental abruption and fetal malpresentation may occur, mainly due to the mechanical influence of multiple and large fibroids. Cesarean section and preterm birth rates are also probably increased in the presence of fibroids. The risk associations are based on meta-analyses of cohort studies (level of evidence 2a), retrospective cohort studies (2b), case-control (3a), and cross-sectional studies (3b), but with a predominantly low risk of bias. For evaluating the growth pattern of leiomyomas and their real influence on obstetric outcomes, future studies should enroll women with fibroids diagnosed prior to pregnancy and follow them prospectively throughout the gestation and puerperium.

The Large Uterus Classification System: a prospective observational study

Objective

To investigate the Large Uterus Classification System (LUCS) ability to predict surgical outcomes and complications in total laparoscopic hysterectomies (TLHs) for large uteri.

Design

Prospective observational study.

Setting

Two referral centres.

Population or sample

Three hundred and ninety‐two women who underwent TLH for a large uterus (uterine fundus at or over the transverse umbilical line).

Methods

Between 2004 and 2019, the intraoperative LUCS was estimated in all patients. The LUCS considers the uterine and adnexal vascular pedicles displacement. Type 1 is without vascular pedicles displacement. Type 2 has the cephalad displacement of adnexal vascular pedicles. The uterine vessels displacement regardless of adnexal pedicles defines Type 3.

Main outcome measures

Patients’ characteristics with perioperative outcomes were prospectively collected and compared between the three types of large uteri.

Results

Two hundred and fifty‐one (64%), 82 (20.9%) and 59 (15.1%) women had Type 1, Type 2 and Type 3 uteri, respectively. Women with Type 1 uteri had a lower uterine weight, shorter operative time, less blood loss and lower complication rates than women with Types 2 and 3. The conversion rate to laparotomy in Type 1 was similar to that in Type 2 (odds ratio [OR] 0.98; 95% CI 0.32–3.56) but lower than Type 3 (OR 0.35; 95% CI 0.14–0.97); in Type 2 it was lower than Type 3, although without the conventional statistical significance (OR 0.36; 95% CI 0.13–1.13; P = 0.07). Multivariable analysis showed that the uterine Type (1 versus 2–3) was independently associated with the total complications rate (OR 2.00; 95% CI 1.09–3.68; P = 0.02).

Conclusions

The LUCS appears associated with surgical outcomes and complications, potentially stratifying the surgical risk and guiding the surgical technique in TLHs for large uteri.

Tweetable abstract

The Large Uterus Classification System may predict outcomes in total laparoscopic hysterectomy of large uteri.

The Large Uterus Classification System may predict outcomes in total laparoscopic hysterectomy of large uteri.

An analysis of the surgical outcomes of laparoendoscopic single-site myomectomy and multi-port laparoscopic myomectomy

Background

This study sought to compare the surgical results of patients undergoing a laparoendoscopic single-site myomectomy (LESS-M) and a conventional laparoscopic myomectomy (CLM) at our hospital.

Methods

The basic data of 233 patients undergoing LESS-M and 233 patients undergoing CLM at the Obstetrics and Gynecology Hospital Affiliated to Fudan University were collected from January 2018 to January 2020, and the results of the operations were compared by evaluating a number of factors, including operation time, intraoperative bleeding, postoperative fever, and postoperative maximum body temperature.

Results

The operation times of the LESS-M and CLM groups were 83.9±33.4 and 75.2±26.7 min, respectively; the difference between the groups was statistically significant. The surgical blood loss of the LESS-M group was 86.1±76.9 mL, and that of the CLM group was 83.8±79.9 mL (P>0.05). When the diameter of a fibroid was ≥8 cm, a fibroid was located in the posterior wall or the number of fibroids was ≥4, the operation time of the CLM group was shorter than that of the LESS-M group. When the diameter of a fibroid was ≥8 cm, the blood loss of the CLM group was less than that of the LESS-M group.

Conclusions

LESS-M is safe and feasible. If the diameter of a fibroid is ≥8 cm, the fibroid is located in the posterior wall, or the number of fibroids is ≥4, the utility of single-port surgery should be carefully considered.

Efficacy of ulipristal acetate in women with fibroid induced menorrhagia: A systematic review and meta-analysis

AIM

To evaluate the efficacy of UPA in women with fibroid induced menorrhagia.

METHODS

Embase, MEDLINE, CAB Abstracts, Cochrane Central Register of Controlled Trials, PsychInfo were searched up to 18th May 2020 and updated on 7th February 2021. Randomised controlled trials evaluating the efficacy of UPA in women with fibroid induced menorrhagia were included in the study.

RESULTS

Two authors independently reviewed and extracted the study data. Statistical heterogeneity was quantified using I² statistics. Publication bias and data asymmetry was assessed by funnel plots. A meta-analysis was conducted where appropriate. Six studies were eligible for inclusion. UPA (5 mg and 10 mg) achieved statistically significant amenorrhoeic outcome when compared to placebo (p<0.00001). Increased adverse events (AE) profile was observed in the higher UPA dose, however, did not reach statistical significance.

CONCLUSIONS

This review demonstrates the efficacy of UPA in achieving amenorrhoea in women with fibroid induced menorrhagia. However, the favourable dose of UPA remains inconclusive when AE profile is taken into account. Evidence remains obscure regarding liver damage and further research is warranted to attain a conclusive outcome.

Post-Market Safety of Laparoscopic Ultrasound-Guided Radiofrequency Ablation

Background and Objectives

Postoperative safety outcomes with laparoscopic intra-abdominal ultrasound-guided radiofrequency ablation, as performed by gynecologic surgeons new to the procedure, were evaluated and compared to the premarket, pivotal study. Post-procedure feedback from surgeons was reported.

Methods

This was a post-market, prospective, single-arm analysis with 4 to 8 weeks follow-up among surgeons (n = 29) with varying levels of laparoscopic surgery experience participating in the ongoing, multinational Treatment Results of Uterine Sparing Technologies randomized clinical trial. Patients were premenopausal adult women (n = 110) desiring uterine-conserving treatment for symptomatic fibroids. During run-in, surgeons received proctored training. Following training, and after performing ≥ 2 procedures, surgeons provided self-assessment and feedback using a standardized form.

Results

Surgeons performed 105 procedures with 100 per-protocol patients. The average number of proctored cases per surgeon was 2.48. No acute (≤ 48 hours) serious adverse events occurred (0/101, 0.0%) compared with 2 acute serious adverse events in the premarket study (2/137, 1.46%). Both studies reported 1 near-term (∼30 days) serious adverse event (< 1% for both). In this study, the near-term complication was fever of unknown origin requiring hospitalization related to uterine entry/manipulation. This was categorized as probably device-related; the patient was treated with antibiotics and discharged. Twenty-six surgeons completed the evaluation form; none reported experiencing problems with the procedure.

Conclusion

Minimally invasive gynecologic surgeons can learn laparoscopic intraabdominal ultrasound-guided radiofrequency ablation and perform it safely (in terms of acute and near-term serious adverse events) after ≥ 2 proctored cases. There were no significant differences in safety outcomes compared to the premarket, pivotal study.

Developing a visual aid to improve women's knowledge of hysterectomy

BACKGROUND

Female reproductive anatomy and physiology, compounded by low health literacy, can result in limited patient understanding of gynecologic procedures, complicating the already challenging patient decision-making process.

OBJECTIVE

Describe a process of developing an effective visual aid that accurately communicates the risks, benefits, and possible outcomes of hysterectomy surgical approaches.

PATIENT INVOLVEMENT

None.

METHODS

This qualitative study was performed in a private practice and an academic institution with a total of 8 female non-clinical employees in the English-speaking group and 9 non-employees in the Spanish-speaking group. A 5-minute video focusing on the hysterectomy procedure was developed and shown to focus group participants. A discussion led by a sociologist obtained feedback regarding understanding and perceptions of video content to validate the tool, which was analyzed to extract themes that could guide refinements.

RESULTS

Focus group participants wanted more information on post-hysterectomy quality of life and desired a longer video that included more general information about hysterectomies. All participants felt the video would be a valuable aid if watched prior to undergoing a hysterectomy and would be an effective tool for improving patient communication.

DISCUSSION

While there was strong support for the video-based patient education program, participants found some elements confusing (e.g., type and magnitude of risk, scope of aftercare) and expressed interest in more in-depth information. Our development process would have been enhanced by involving patients before the initial version of the video was created, holding more and more diverse focus groups and ensuring that translation was both accurate and culturally appropriate.

PRACTICAL VALUE

This study offers lessons learned in the process of developing a video-based visual aid for improving women's knowledge of hysterectomy and may inform other efforts to help patients understand complex medical pathology and procedures.

Cervical elongation caused by big cervical fibroid resembling malignant cervical prolapse? Management via vaginal surgery

INTRODUCTION

Cervical elongation could lead to cervical elongation thus worsen the descent of uterine prolapse. In certain cases, this hypertrophic and hyperplastic mass could have fragile surface with some bleeding and necrotic, resembling cervical cancer. As case of cervical elongation due to cervical fibroid is quite rare, such cases are valuable to be reported. We present two cases of cervical fibroid with cervical elongation resembling cervical malignancy.

PRESENTATION OF CASE

First case was A 59-year-old lady with intractable vaginal mass since one day before admission. Bleeding from the mass was positive. We found a bulky vaginal mass exceeding hymenal ring, 14 × 7 × 6 cm sized, with some necrotic and discharge, foul smelling, and some bleeding area. Ultrasound evaluation revealed a cervical fibroid with differential diagnosis cervical malignancy. The second case was Mrs 53-year-old with vaginal mass since last year. For the last 7 months the mass has been bigger and could not be inserted into vagina, with some bleeding. We found globular vaginal mass 12 × 9 × 6 cm exceeding hymenal ring, with some necrotic and reddish surface, foul smelling, discharge, and some blood. Ultrasound evaluation revealed cervical mass on anterior lip with elongated cervices. Both cases have been menopaused. As the clinical presentation resembling malignancy, we did biopsy. The biopsy results were no evidence of malignancy, then we did Manchester fothergill, and colporaphy as needed.

DISCUSSION

Length between internal to external cervical ostium ≥ 5 cm correlated to cervical elongation. Growing cervical mass could drag the cervix, predisposing to cervical elongation and prolapse. Cervical fibroids protruded through vagina was usually pedunculated. But in our cases, the fibroids were not pedunculated but manifested as a bulky mass on the cervical tissue with some bleeding and necrotics, mimicking cervical malignancy. The most important initial management besides ultrasound evaluation was mass biopsy.

CONCLUSION

In such cervical fibroids with cervical elongation resembling cervical malignancy, biopsy is compulsory to determine the diagnosis and to lead the management.

The effect of pelvic pathology on uterine vein diameters

BACKGROUND

Transvaginal ultrasound (TVS) is a sensitive tool for detecting various conditions that contribute to pelvic pain. TVS can be also used to assess blood flow and measure the size of pelvic veins. Pelvic venous congestion (PVC) is characterised by enlargement of the pelvic veins and has been recognised as a cause of chronic pelvic pain. The reference ranges for uterine venous diameter in women with normal pelvic organs have been established, but there is no information regarding the potential effect of pelvic pathology on the uterine venous diameters. The aim of this study was to examine the size of uterine venous plexus in women with evidence of pelvic abnormalities on TVS and to determine whether the reference ranges need to be adjusted in the presence of pelvic pathology. A prospective, observational study was conducted in our gynaecological outpatient clinic. Morphological characteristics of all pelvic abnormalities detected on TVS and their sizes were recorded. The uterine veins were identified and their diameters were measured in all cases. The primary outcome measure was the uterine venous diameter. Regression analyses were performed to determine factors affecting the uterine venous size in women with pelvic pathology.

RESULTS

A total of 1500 women were included into the study, 1014 (67%) of whom were diagnosed with pelvic abnormalities. Women with pelvic pathology had significantly larger uterine venous diameters than women with normal pelvic organs (p < 0.01). Multivariable analysis showed that pre-menopausal status, high parity, presence of fibroids (p < 0.001) and Black ethnicity were all associated with significantly larger uterine vein diameters. Based on these findings modified reference ranges for uterine venous diameters have been designed which could be used for the diagnosis of PVC in women with uterine fibroids.

CONCLUSIONS

Our findings show that of all pelvic pathology detected on TVS, only fibroids are significantly associated with uterine venous enlargement. Factors known to be associated with enlarged veins in women with normal pelvic organs, namely parity and menopausal status, also apply in patients with pelvic pathology. Future studies of uterine venous circulation should take into account the presence and size of uterine fibroids when assessing women for the signs of PVC.

Brominated flame retardants and organochlorine pesticides and incidence of uterine leiomyomata: A prospective ultrasound study

Uterine leiomyomata (UL) are hormone-responsive benign neoplasms. Brominated flame retardants and organochlorine pesticides (OCPs) can disrupt hormones involved in UL etiology.

METHODS

The Study of Environmental, Lifestyle, and Fibroids is a Detroit-area prospective cohort of 1693 Black women 23-35 years of age. At baseline and approximately every 20 months for 5 years, women completed questionnaires and underwent transvaginal ultrasounds. Using a case-cohort study design, we selected 729 UL-free participants at baseline and analyzed baseline plasma samples for polybrominated diphenyl ethers (PBDEs), a polybrominated biphenyl ether (PBB-153), and OCPs. We used Cox proportional hazard models to estimate hazard ratios (HRs) and 95% confidence intervals (CIs).

RESULTS

Compared with total PBDE plasma concentrations <50th percentile, adjusted HRs for the 50th-74th, 75th-89th, and ≥90th percentiles were 1.00 (95% CI = 0.68, 1.47), 1.04 (95% CI = 0.63, 1.68), and 0.85 (95% CI = 0.48, 1.50), respectively. HRs for PBB-153 plasma concentrations were generally similar to total PBDE plasma concentrations. Compared with total OCP plasma concentrations <50th percentile, HRs for the 50th-74th, 75th-89th, and ≥90th percentiles were 0.86 (95% CI = 0.57, 1.29), 0.73 (95% CI = 0.43, 1.22), and 0.58 (95% CI = 0.32, 1.04), respectively. HRs for individual PBDEs and OCPs were similar to their respective totals.

CONCLUSION

We found little support for an association between brominated flame retardant plasma concentrations and UL incidence, and some evidence of lower UL incidence with the highest OCP plasma concentrations.

Medical Therapy for Fibroids: What Next for Ulipristal Acetate?

Ulipristal acetate (UPA) was introduced as a novel progesterone receptor modulator as effective therapy for symptomatic fibroids. Randomised clinical trials established its effectiveness in the management of heavy menstrual bleeding due to uterine leiomyomas. The trials did not find any significant evidence of clinical harm to the participants. Recently, however, there have been reports of liver injury necessitating liver transplant in women who have had UPA treatment. This has led to the suspension of UPA as one of the medical therapies in the treatment for uterine fibroids while the European Medicines Agency (EMA) conducts a review of liver injury risk with its use. The European Medicine Agency safety committee has advised that women should stop taking 5 mg UPA and that no new patients should commence treatment with the medicine until the ongoing review is completed. In this article, we review the rise of UPA as one of the emerging medical therapies for symptomatic uterine fibroids and the subsequent reports of adverse events leading to the suspension of its use.

Specificity of the lactate dehydrogenase isoenzyme index as a preoperative screen for uterine sarcoma before myomectomy

OBJECTIVE

To evaluate the applicability of the Uterine mass Magna Graecia (UMG) risk index (elevation defined by a lactate dehydrogenase isoenzyme index >29) in women undergoing surgery for benign fibroids and to determine whether other factors were associated with an elevated index. An elevated UMG index has been reported to be associated with an increased risk of uterine sarcoma in Italian women.

DESIGN

Retrospective cohort study.

SETTING

University fibroid center.

PATIENTS

All women presenting from July 1, 2013, through June 30, 2019, with fibroids who had lactate dehydrogenase isoenzymes collected and surgery performed.

INTERVENTIONS

Calculation of UMG index.

MAIN OUTCOME MEASURE

Applicability of UMG index.

RESULTS

Of 272 patients initially identified, 179 met inclusion criteria, 163 with UMG index ≤29 and 16 with UMG index >29. There were no cases of uterine sarcoma. Race, age, and presence of endometriosis, adenomyosis, or degenerating fibroids were not predictors of elevated UMG index. Body mass index (BMI) was positively associated with elevated UMG index. Specificity of UMG index to exclude uterine sarcoma was 91.1% (163/179) and higher in non-obese (BMI<30; 95.1%) than obese women (85.5%).

CONCLUSION

A previously reported UMG index cutoff of 29 had a specificity of 91.1% (higher with normal BMI and lower when obese) in our patient population. Although lower than previously reported, the index could be a useful initial method of preoperative screening of women with symptomatic fibroids. Higher BMI appears to be associated with elevated UMG indices, increasing the false-positive rate in obese women.

Female pelvic medicine & reconstructive surgery (FPMRS) challenges on behalf of the collaborative research in pelvic surgery consortium (CoRPS): managing complicated cases series 7: can fibroids worsen incontinence?

This case presents the work-up and management of a patient with a fibroid uterus and urinary incontinence. Five international experts also provide their evaluation and approach to this case. According to the literature, there is uncertainty surrounding the relationship between fibroids and urinary incontinence. The experts emphasize patient counseling and a staged approach.

Exposure to organophosphate esters, phthalates, and alternative plasticizers in association with uterine fibroids

Exposure to endocrine disrupting chemicals is suggested to be responsible for the development or progression of uterine fibroids. However, little is known about risks related to emerging chemicals, such as organophosphate esters (OPEs) and alternative plasticizers (APs). A case-control study was conducted to investigate whether exposures to OPEs, APs, and phthalates, were associated with uterine fibroids in women of reproductive age. For this purpose, the cases (n = 32) and the matching controls (n = 79) were chosen based on the results of gynecologic ultrasonography among premenopausal adult women in Korea and measured for metabolites of several OPEs, APs, and major phthalates. Logistic regression models were employed to assess the associations between chemical exposure and disease status. Factor analysis was conducted for multiple chemical exposure assessments as a secondary analysis. Among OPE metabolites, diphenyl phosphate (DPHP), 2-ethylhexyl phenyl phosphate (EHPHP), and 1-hydroxy-2-propyl bis(1-chloro-2-propyl) phosphate (BCIPHIPP) were detected in >80% of the subjects. Among APs, metabolites of di-isononyl phthalate (DINP) and di(2-propylheptyl) phthalate (DPrHpP) were detected in >75% of the urine samples. The odds ratios (ORs) of uterine fibroids were significantly higher among the women with higher exposures to tris(1,3-dichloro-2-propyl) phosphate (TDCIPP) and tris(2-butoxyethyl) phosphate (TBOEP), di(2-ethylhexyl) terephthalate (DEHTP), DPrHpP, and di-(iso-nonyl)-cyclohexane-1,2-dicarboxylate (DINCH). In addition, urinary concentrations of mono(2-ethyl-5-oxohexyl) phthalate (MEOHP), a sum of five di(2-ethylhexyl) phthalate metabolites (∑5DEHP), and mono(4-methyl-7-hydroxyoctyl) phthalate (OH-MINP) were significantly higher in the cases. In factor analysis, a factor heavily loaded with DPrHpP and DEHP was significantly associated with uterine fibroids, supporting the observation from the single chemical regression model. We found for the first time that several metabolites of OPEs and APs are associated with increased risks of uterine fibroids among pre-menopausal women. Further epidemiological and mechanistic studies are warranted to validate the associations observed in the present study.

Clinical, Imaging and Procedural Risk Factors for Intrauterine Infective Complications After Uterine Fibroid Embolisation: A Retrospective Case Control Study

Introduction

This was a retrospective case–control study at a single tertiary centre investigating all UFE procedures between January 2013 and December 2018 for symptomatic fibroids. The aim was to determine the clinical, imaging and procedural risk factors which impact upon the risk of post-uterine fibroid embolisation (UFE) intrauterine infection. Cases were patients which developed intrauterine infection post-procedure, and controls were the background UFE population without infection.

Methods

Clinical demographics, presenting symptoms, uterine and fibroid characteristics on imaging and procedural variants were analysed. A p value of less than 0.05 was considered statistically significant. The main outcome measures were presence of infection and requirement of emergency hysterectomy.

Results

333 technically successful UFE procedures were performed in 330 patients. Infection occurred after 25 procedures (7.5%). 3 of these patients progressed to overwhelming sepsis and required emergency hysterectomy. Clinical obesity (BMI > 30) (OR 1.53 [1.18–1.99]) and uterine volume > 1000cm3 (2.94 [1.15–7.54]) were found to increase the risk of infection

Conclusions

UFE is generally safe in patients with symptomatic fibroids. Obese patients (BMI > 30) and those with large volume uteri (> 1000cm³) are at slight increased risk of developing infection and require appropriate pre-procedural counselling, as well as careful post-UFE follow-up. BMI and uterine volume may be useful to assess before the procedure to help to determine post-UFE infection risk.

Electronic supplementary material

The online version of this article (10.1007/s00270-020-02622-2) contains supplementary material, which is available to authorised users.

Randomized trial of a patient education tool about leiomyoma

OBJECTIVE

Uterine leiomyomata are a frequent indication for women seeking gynecologic care [1]. The objective of our study was to assess whether patient knowledge about leiomyomata, anxiety, or satisfaction with counseling differed in patients who received multimedia counseling versus standard counseling.

METHODS

Women with leiomyomata who presented to the gynecology clinic at a single institution were randomized to standard counseling or multimedia counseling using the drawMD OB/GYN iPad™ application. Participants completed a pre-counseling questionnaire, received the designated method of counseling, and completed a post-counseling questionnaire. Outcomes of the study included assessment of patient knowledge, satisfaction, and anxiety.

RESULTS

Seventy-two participants were randomized. There was no significant difference in post-counseling anxiety between the groups (p = 0.86). For both groups, anxiety significantly improved after counseling. Both groups were satisfied with the counseling they received, however, there was no difference between groups. Participants in both groups significantly improved their knowledge about fibroids post-counseling.

CONCLUSION

Counseling of patients with leiomyomata improves patient satisfaction and knowledge. The addition of a multimedia tool may or may not enhance patient counseling.

PRACTICE IMPLICATIONS

This is the first prospective, randomized controlled trial evaluating the impact of a multimedia tool on patient education and counseling for patients with leiomyomata.

Quality of Life after Laparoscopic and Open Abdominal Myomectomy

STUDY OBJECTIVE

To evaluate the baseline and postoperative changes in quality of life and symptom-severity scores in women undergoing laparoscopic or open abdominal myomectomy for symptomatic myomas.

DESIGN

Prospective cohort study of patients choosing myomectomy for symptomatic uterine myomas.

SETTING

Academic medical center.

PATIENTS

A total of 143 women enrolled in the study. Of these, 80 women completed both a preoperative questionnaire and at least 1 postoperative questionnaire between 6 and 27 months after surgery.

INTERVENTIONS

A total of 52 women had open abdominal myomectomy, and 28 had laparoscopic myomectomy between October 2014 and September 2017.

MEASUREMENTS AND MAIN RESULTS

The results of the Uterine Fibroid Symptom and Health-Related Quality-of-Life Questionnaire were compared before and after laparoscopic or open myomectomy. Women undergoing open abdominal myomectomy had larger and more numerous myomas than women undergoing laparoscopic myomectomy. Baseline quality-of-life scores were less adversely affected for women having laparoscopic myomectomy (mean [standard deviation], 57 [24] laparoscopic vs 43 [19] open abdominal, p = .01). However, baseline symptom-severity scores were statistically similar (49 [22] for laparoscopic and 57 [20] for open abdominal, p = .08) approaches. Six to 12 months after surgery, both open abdominal and laparoscopic surgeries provided excellent and similar improvements in symptom-severity and quality of life (postoperative symptoms severity scores, mean [standard deviation], 20 [14] laparoscopic vs 13 [11] open abdominal, p = .24 and quality-of-life scores, mean [standard deviation], 91 [16] laparoscopic vs 88 [17] open abdominal, p = .49). These improvements were sustained for women who returned questionnaires up to 27 months of follow-up.

CONCLUSION

Women with symptomatic myomas have a compromised quality of life, and they experience a similarly dramatic improvement in quality of life and decrease in symptom-severity after both laparoscopic and open abdominal myomectomies.

Suspension of ulipristal acetate for uterine fibroids during ongoing EMA's review of liver injury risk: Unfortunate timing during the Covid-19 pandemic!

Objective

EMA decided that with ulipristal acetate (UPA) treatment for uterine fibroids, should be discontinued due to the associated risk of hepatic failure, We analyzed whether the risk of recurrent symptoms due to fibroids may lead to an increased risk of Covid -19 infection and death, that would exceed the former risk of hepatic failure and transplantation.

Study design, size, duration

We used a Markov model to generate probabilities.

Participants/materials, setting, methods

There are currently about 36,250 treated patients in Europe. We estimated bleeding probabilities, while using or discontinuing UPA, which may induce a need of medical or surgical management in symptomatic patients, and increase the risk of acquiring a Covid-19 infection, and die from it. We also estimated the risk of suffering a hepatic failure and hepatic transplantation.

Main results and the role of chance

Based on our assumptions, ceasing UPA during a Covid 19 pandemic may be associated with a fatality ratio between 4 and 18, due to the Pandemic, whereas pursuing UPA would be associated with a fatality rate due to the pandemic between 1–2, and an added fatality rate due to hepatic impairment of 1. The added risk of stopping UPA may range between 2 and 15 additional deaths.

Our calculations suggest that the decision to stop UPA in the middle of the Covid- 19 pandemic may be untimely, since it may result in an increased risk of Covid-19 infection, due to the recurrence of symptoms and the need for medical and surgical treatment.

Wider implications of the findings

A decision, like the one EMA took need to be taken in a wider health context of a population, than simply analyzing its role as regulating agent for medications.

Hormone therapy for intramural myoma-related infertility from ulipristal acetate to GnRH antagonist: a review

Uterine fibroids may cause infertility, depending on their size and location according to the International Federation of Gynecology and Obstetrics classification. In this review, infertility relating to intramural myomas is evaluated. The mechanisms linking uterine fibroids and infertility are numerous: uterine cavity distortion (fibroids types 0, 1, 2, 2-5); impaired endometrial and myometrial blood supply; increased uterine contractility; hormonal, paracrine and molecular changes; impaired endometrial receptivity in gene expression (decrease in homeobox 10 [HOXA-10] expression); and thicker capsule. The negative effect of intramural myoma is related to myoma size and proximity of the uterine cavity. Therefore, a medical approach could be proposed to reduce the size of the myoma and push it back deep into the myometrium. The relevant medical treatments, including selective progesterone receptor modulator and gonadotrophin releasing hormone antagonist are reviewed. Even if the mystery surrounding intramural myomas remains, the development of new algorithms for intramural myoma-related infertility, and evaluation of the place of medical treatment as a primary approach are urgently needed. An algorithm, taking into account the mechanisms linking uterine fibroids and infertility, is proposed.

Accuracy of findings in the diagnosis of uterine adenomyosis on ultrasound

PURPOSE

MRI is the current imaging gold standard to diagnose adenomyosis, but access is often limited by high costs and availability. Transvaginal ultrasound provides a cost-effective, accurate and readily available alternative. The objective of our study was to determine the diagnostic accuracy of commonly described sonographic findings in predicting uterine adenomyosis.

METHODS

This retrospective study evaluated 649 MRI studies performed to investigate adenomyosis with a preceding transvaginal ultrasound within 12 months between 2013 and 2018. Two blinded reviewers assessed the presence or absence of six sonographic features: bulky uterus, heterogeneous myometrium, streaky myometrium, myometrial cysts, endometrial-myometrial interface ill-definition, and echogenic linear striations. The sensitivity, specificity, positive and negative predictive values of these features were calculated individually and in combination when compared to MRI as the standard of reference.

RESULTS

Adenomyosis was found in 315 (48.5%) cases on MRI. Ultrasound had a high specificity of 91.8% (95% CI 88.4 to 94.6%) but was less sensitive (36.8% (95% CI 31.5 to 42.4%)) for detecting adenomyosis. Comorbid fibroids or focal adenomyosis did not affect diagnostic accuracy. All six variables were significantly more common in patients with adenomyosis compared to those without. Individually, 'bulky uterus' and 'heterogenous myometrium' each demonstrated a mean sensitivity and specificity > 50%. The best dual combined variables were 'bulky uterus' + 'ill definition of the endometrial-myometrial interface' (sensitivity 39%, specificity 91%). The best triple combined variables were 'bulky uterus', 'heterogeneous myometrium' + 'ill definition of the endometrial-myometrial interface' (sensitivity 38%, specificity 93%).

CONCLUSION

Transvaginal ultrasound is highly specific for diagnosing uterine adenomyosis, providing a cost-effective and readily available alternative to MRI.