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Biopsy diagnosis and conservative surgical treatment of adenomyosis
Biopsy Diagnosisand ConservativeTreatmenlof Adenomyosis Wood et al
Biopsy Diagnosis and Conservative Surgical Treatment of Adenomyosis Carl Wood, Peter Maher, and David Hill Abstract
Study Objective. To diagnose adenomyosis by vaginal ultrasound and percutaneous or transcervical myometrial biopsy, and use the results to choose treatment and assess prognosis. Design. Evaluation of 31 consecutive women referred by other physicians. Setting. A private gynecologic practice. Patients. The women had menstrual symptoms that had not responded to medical treatment or uterine curettage. Interventions. Myometrial diagnosis was made by percutaneous ultrasound-guided needle biopsy, by transcervical electrosurgical loop biopsy at the time of endometrial resection, or by needle biopsy at the time of laparoscopy or laparotomy. Endometrial resection was performed in 15 patients, laparoscopic myometrial reduction in 7, and excision of adenomyotic myometrium or localized adenomyoma in 8. Measurements and Main Results. Cure was defined as relief of menorrhagia and dysmenorrhea. Endometrial resection cured menorrhagia in 12 of 15 patients but dysmenorrhea in only 3 of 8; myometrial excision cured 7 of 8, and myometrial reduction 4 of 7 women. Conclusions. Vaginal ultrasound combined with transabdominal or transcervical myometrial biopsy established the diagnosis of adenomyosis in all patients. Endornetrial resection and myometrial reduction or excision reduced the need for hysterectomy to 30% in these women.
The application of vaginal ultrasound and percut a n e o u s or t r a n s c e r v i c a l m y o m e t r i a l b i o p s y m a y improve the diagnosis of adenomyosis. L 2 Conservative surgery, e n d o m e t r i a l resection, m y o m e t r i a l reduction by electrocoagulation, excision of localized areas of adenomyosis, or wedge resection of extensive areas of m y o m e t r i u m may enable palliative or
curative treatment without hysterectomy. We attempted to diagnose adenomyosis combining vaginal ultrasound and percutaneous or transcervical myometrial biopsy in 31 women, and used this
i n f o r m a t i o n to assist in c h o o s i n g t r e a t m e n t and assessing prognosis.
From the Department of Obstetrics and Gynaecology, Monash University (Carl Wood) and the Melbourne Gynoscopy Centre, Melbourne, Australia (all authors). Address reprint requests to Carl Wood, Department of Obstetrics and Gynaecology,Monash University,Melbourne, Australia.
313
August 1994, Vol. 1, No. 4, Part 1
The Journal of the American Association of Gynecologic Laparoscopists
Materials and Methods
Patients Thirty-one patients were referred to a private practice for treatment of menstrual symptoms that had not responded to medical treatment or uterine curettage. Thirteen were referred for possible hysterectomy. Clinical review confirmed that the symptoms were causing severe restriction of normal activities, medical treatments had been unsuccessful, and all but one woman preferred to avoid hysterectomy. This one patient underwent hysterectomy, leaving 30 patients possibly suitable for more conservative surgery. The patients ranged in age from 33 to 53 years (mode 41 yrs). Parity varied from none to five; five women were infertile. Twenty-nine complained of dysmenorrhea and menorrhagia, one of dysmenorrhea alone, and one of menorrhagia alone. All were receiving therapy with at least two of the following drugs: oral c o n t r a c e p t i v e s , p r o g e s t o g e n s , antiprostaglandins, and danazol. They all had undergone at least one previous uterine curretage. The severity of bleeding was documented before and after surgery according to pad and tampon use, occurrence of a n e m i a , and p a t i e n t s ' subjective response to blood loss. Pain was documented by the use of analgesic drugs and its interference with normal activities. A pain-scoring system was not used.
Diagnostic Procedures Transabdominal and transvaginal ultrasound examinations were performed using an Acuson XP10 (Mountainview, CA) with the addition of color Doppler. Abnormal areas were identified by mottling of the myometrium, thickening of the myometrium, loss of definition of the myoendometrial junction, and localized changes in vascularity using color Doppler. Vaginal ultrasound suggested the possibility of adenomyosis in 25 patients. Color Doppler demonstrated altered blood flow in the m o t t l e d areas of the myometrium in all of the eight women in whom it was used. The diagnosis was made in one of three ways: by percutaneous ultrasound-guided needle myometrial biopsy as an outpatient procedure (10 patients); by transcervical electrosurgical loop myometrial biopsy at the time of endometrial resection under general anesthesia (9/15 patients); or by needle biopsy of the myometrium at the time of laparoscopy or laparotomy (12 patients).
314
For the outpatient procedure, when the uterus and associated abnormalities were visualized, 1% mepivacaine 5 ml was injected into the skin and anterior abdominal wall above the symphysis pubis. A Bard Biopty-cut biopsy needle, 18 gauge (1.2 mm), sampling n o t c h 17 mm, and l e n g t h 16 cm, was attached to the firing gun (Radiplast AB, Uppsala, Sweden). The needle was inserted under the skin close to the outer uterine wall by means of a guidance system attached to the abdominal ultrasound transducer. The gun was fired and the biopsy needle passed 2 cm into the uterine wall. ~Two or three cores were obtained from the most abnormal areas seen on ultrasound. The material was placed in fixative and examined by a specialist in gynecologic pathology. Operative biopsy was done at laparoscopy using the biopsy needle and gun, the suspicious areas being determined either by previous ultrasound or laparoscopic detection of thickened, nodular, or firmer areas of myometrium. Vasopressin was not administered, and bleeding always stopped quickly. At laparotomy, excisional biopsy tissue was taken from suspicious areas. Frozen section was not used.
Surgical Procedures E n d o m e t r i a l resection was p e r f o r m e d in 15 patients, and 2 also had laparoscopic myometrial reduction. Adenomyosis was not localized, and menorrhagia was the major complaint at the time of presentation in all patients. The technique described previously2 was modified so that 0.5 to 1 cm of myometrium was removed by a cutting loop to enable suitable h i s t o l o g y and possible r e d u c t i o n of diseased myometrium. This did not produce excessive bleeding. Patients having endometrial resection were warned that the success could be reduced because of the presence of adenomyosis.2 Adenomyoisis or adenomyoma was localized by preoperative high-resolution ultrasound, or by the laparoscopic or laparotomy appearance of myometrial thickening, nodularity, altered vascularity, or increased resistance to needle penetration. Laparoscopic myometrial reduction was performed in five patients with infertility and two with localized areas of adenomyosis less than 4 cm. It was performed by deep electrocoagulation using a Corson needle electrode and 50 W monopolar coagulation at 1 to 3 cm depth at about 1-cm intervals until blanching s p r e a d for 1 cm b e y o n d the n e e d l e point. Superficial blanching of the abnormal myometrial
Biopsy Diagnosis and Conservative Treatment of Adenomyosis Wood et al
area was thereby achieved. This was assisted by the preliminary injection of vasopressin 1:50 dilution into the myometrium. Adenomyotic myometrium or a localized adenomyoma was excised by laparotomy in eight patients. Attempted laparoscopic excision of a 7-cm adenomyoma failed because of the inability to control bleeding, the junction between the adenomyoma and normal myometrium being indistinct. The women were followed every 3 months for 2 years with office visits and two further vaginal ultrasound examinations.
Results Cure was defined as the relief of menorrhagia and dysmenorrhea whereby no further treatment was required. Vaginal ultrasound showed persistence of adenomyosis in three of the women who were cured of symptoms. Endometrial resection cured 10 of 15 patients, myometrial excision 7 of 8, and myometrial reduction 4 of 7, for an overall cure rate of 70% (Table 1). Endometrial resection cured menorrhagia in 12 of 15 patients, but dysmenorrhea in only 3 of 8. Nine patients required hysterectomy after the initial surgery. The reason was the persistence of pain in all nine women, and associated bleeding in three. All underwent laparovaginal hysterectomies without complications.3 Laparoscopy and hysteroscopy were performed in five of the seven women who had undergone myometrial reduction, either to check fertility status or because of the persistence of menstrual symptoms. TABLE 1. Results of Conservative Surgery for Adenomyosis: 2-Year Follow-Up
Surgical Procedure Endometrial resection Myometrial or adenomyoma excision Myometrial reduction Totals
No. of Patients
No. With Relief of Symptoms
No. With Hysterectomy
15
10
5
8
7
1
7 30
4 21 (70%)
3 9 (30%)
315
One patient had visible scar tissue on the uterus and omental adhesions, but experienced no related symptoms.
Discussion Vaginal ultrasound in combination with transabdominal or transcervical myometrial biopsy enabled the diagnosis of adenomyosis in all patients. False positive results may occur with vaginal ultrasound 1 and false negative results with myometrial biopsy, although we have not seen the latter. Patients with negative biopsy results but whose ultrasound findings were suggestive of adenomyosis were not included in the current study as the diagnosis of adenomyosis was not made. Hysterectomy in three such patients confirmed that adenomyosis was not present (i.e., the biopsy was more accurate than ultrasound). Color Doppler may improve the specificity of ultrasound diagnosis, as vascular changes occur in areas of adenomyosis. In one study, magnetic resonance imaging (MRI) was more reliable than vaginal ultrasound, with the latter misdiagnosing a myoma in 4 of 11 patients.4 A myoma may be difficult to distinguish from an adenomyoma but not, in our experience, from adenomyosis. With a suspected or proved preoperative diagnosis of adenomyosis, the surgeon can discuss with the patient alternative treatments, such as endometrial resection, myometrial reduction by electrocoagulation or laser, myometrial excision, or hysterectomy. Until larger numbers of patients with adenomyosis have been treated by endometrial resection, myometrial reduction, and myometrial excision, the success rates of these procedures cannot be accurately estimated. It was reported that the success rate of endometrial resection is reduced in women with adenomyosis.5 In our study, it was more successful providing long-term relief of menorrhagia (12/15) than of dysmenorrhea (3/8), and women with severe dysmenorrhea should be warned of the possibility of a poor outcome. Because the procedure is so simple compared with hysterectomy, however, many patients wish to try it before agreeing to hysterectomy. A major limitation of myometrial reduction by electrocoagulation is the possibility that large areas of necrotic myometrium could release toxic substances into the circulation. In our hands the coagulated areas have been limited to 3 x 3 cm without side effects.
August 1994, Vol. 1, No. 4, Part 1
The Journal of the American Association of Gynecologic Laparoscopists
This procedure is simple, and the risk of bleeding and adhesions may be less than with excisional surgery, as mild a d h e s i o n s were f o u n d in only one of five patients having subsequent laparoscopy. Three of the seven patients undergoing myometrial reduction had a successful pregnancy. The operation may warrant further study in patients wishing to conceive, however, particularly those with small areas of adenomyosis. Scarring from electrocoagulation of large areas of the myometrium may result in the risk of uterine rupture in a subsequent pregnancy. Excisional surgery for adenomyoma is simple, as the diseased area is readily identified. The border between normal and adenomyotic myometrium may be difficult to determine, although ultrasound and MRI may show differences, and consistency, nodularity or thickening, and vascularity of the myometrium may be indicative. Because no capsule exists around adenomyosis, bleeding may be difficult to control. P r e o p e r a t i v e a d m i n i s t r a t i o n of danzol or gonadotropin-releasing hormone analogs may reduce blood flow and bleeding at the time of surgery. Such drugs also may obscure the appearance of the diseased areas, but localized nodules would still be visible and could be identified after preoperative drug therapy. Despite the one failure in the present study, laparoscopic excisional surgery of adenomyomas may be possible providing hemostasis is satisfactory and the myometrial defect is sutured. Laparoscopic or vaginal hysterectomy is available to patients with adenomyosis, either as an elective or secondary operation, as the uterus is nearly always less than 16 cm in length. Vaginal ultrasound and myometrial biopsy are important initial investigations in developing new strategies for t r e a t i n g these women, however, and improvements in conservative surgical procedures may further reduce the need for hysterectomy.
316
Summary Thirty-one women with dysmenorrhea and meno r r h a g i a r e f r a c t o r y to medical t r e a t m e n t were referred for surgical treatment. Adenomyosis was suggested preoperatively by vaginal ultrasound in 25 patients. The histologic diagnosis was made by percutaneous preoperative outpatient myometrial biopsy in 10 patients, by transcervical myometrial biopsy in 9, and by needle biopsy at laparoscopy or laparotomy in 12. Conservative surgery was endometrial resection (15), myometrial reduction by electrocoagulation (7), and myometrial or adenomyoma excision (8). Twoyear follow-up demonstrated cure of the symptoms in 10, 7, and 4 women , respectively (70% overall). Subsequent h y s t e r e c t o m y was r e q u i r e d in nine women, thus these conservative procedures reduced the overall need for hysterectomy to 30%. References
1. Wood C, Hurley VA, Fortune DW, et al: Percutaneous ultrasound guided needle uterine biopsy. Med J Aust 158:458-460, 1993 2. Wood C: Indication for endometrial resection. Med J Aust 156(3):157-160, 1992 3. Wood C, Maher P, Hill D, et al: Laparovaginal hysterectomy, Aust NZ J Obstet Gynaeco134(1):81-84, 1994 4. Arnold LL, Asher SA, Schruefer J J, et al: Transvaginal ultrasound vs magnetic resonance imaging in the diagnosis of adenomyosis. Abstracts of the American Fertility Society meeting October 11-14, 1993, Montreal, Canada 5. Loffer F: Laser ablation of the endometrium. Obstet Gynecol Clin North Am 15:77-89, 1988
Biopsy Diagnosis and Conservative Surgical Treatment of Adenomyosis Carl Wood, Peter Maher, and David Hill Abstract
Study Objective. To diagnose adenomyosis by vaginal ultrasound and percutaneous or transcervical myometrial biopsy, and use the results to choose treatment and assess prognosis. Design. Evaluation of 31 consecutive women referred by other physicians. Setting. A private gynecologic practice. Patients. The women had menstrual symptoms that had not responded to medical treatment or uterine curettage. Interventions. Myometrial diagnosis was made by percutaneous ultrasound-guided needle biopsy, by transcervical electrosurgical loop biopsy at the time of endometrial resection, or by needle biopsy at the time of laparoscopy or laparotomy. Endometrial resection was performed in 15 patients, laparoscopic myometrial reduction in 7, and excision of adenomyotic myometrium or localized adenomyoma in 8. Measurements and Main Results. Cure was defined as relief of menorrhagia and dysmenorrhea. Endometrial resection cured menorrhagia in 12 of 15 patients but dysmenorrhea in only 3 of 8; myometrial excision cured 7 of 8, and myometrial reduction 4 of 7 women. Conclusions. Vaginal ultrasound combined with transabdominal or transcervical myometrial biopsy established the diagnosis of adenomyosis in all patients. Endornetrial resection and myometrial reduction or excision reduced the need for hysterectomy to 30% in these women.
The application of vaginal ultrasound and percut a n e o u s or t r a n s c e r v i c a l m y o m e t r i a l b i o p s y m a y improve the diagnosis of adenomyosis. L 2 Conservative surgery, e n d o m e t r i a l resection, m y o m e t r i a l reduction by electrocoagulation, excision of localized areas of adenomyosis, or wedge resection of extensive areas of m y o m e t r i u m may enable palliative or
curative treatment without hysterectomy. We attempted to diagnose adenomyosis combining vaginal ultrasound and percutaneous or transcervical myometrial biopsy in 31 women, and used this
i n f o r m a t i o n to assist in c h o o s i n g t r e a t m e n t and assessing prognosis.
From the Department of Obstetrics and Gynaecology, Monash University (Carl Wood) and the Melbourne Gynoscopy Centre, Melbourne, Australia (all authors). Address reprint requests to Carl Wood, Department of Obstetrics and Gynaecology,Monash University,Melbourne, Australia.
313
August 1994, Vol. 1, No. 4, Part 1
The Journal of the American Association of Gynecologic Laparoscopists
Materials and Methods
Patients Thirty-one patients were referred to a private practice for treatment of menstrual symptoms that had not responded to medical treatment or uterine curettage. Thirteen were referred for possible hysterectomy. Clinical review confirmed that the symptoms were causing severe restriction of normal activities, medical treatments had been unsuccessful, and all but one woman preferred to avoid hysterectomy. This one patient underwent hysterectomy, leaving 30 patients possibly suitable for more conservative surgery. The patients ranged in age from 33 to 53 years (mode 41 yrs). Parity varied from none to five; five women were infertile. Twenty-nine complained of dysmenorrhea and menorrhagia, one of dysmenorrhea alone, and one of menorrhagia alone. All were receiving therapy with at least two of the following drugs: oral c o n t r a c e p t i v e s , p r o g e s t o g e n s , antiprostaglandins, and danazol. They all had undergone at least one previous uterine curretage. The severity of bleeding was documented before and after surgery according to pad and tampon use, occurrence of a n e m i a , and p a t i e n t s ' subjective response to blood loss. Pain was documented by the use of analgesic drugs and its interference with normal activities. A pain-scoring system was not used.
Diagnostic Procedures Transabdominal and transvaginal ultrasound examinations were performed using an Acuson XP10 (Mountainview, CA) with the addition of color Doppler. Abnormal areas were identified by mottling of the myometrium, thickening of the myometrium, loss of definition of the myoendometrial junction, and localized changes in vascularity using color Doppler. Vaginal ultrasound suggested the possibility of adenomyosis in 25 patients. Color Doppler demonstrated altered blood flow in the m o t t l e d areas of the myometrium in all of the eight women in whom it was used. The diagnosis was made in one of three ways: by percutaneous ultrasound-guided needle myometrial biopsy as an outpatient procedure (10 patients); by transcervical electrosurgical loop myometrial biopsy at the time of endometrial resection under general anesthesia (9/15 patients); or by needle biopsy of the myometrium at the time of laparoscopy or laparotomy (12 patients).
314
For the outpatient procedure, when the uterus and associated abnormalities were visualized, 1% mepivacaine 5 ml was injected into the skin and anterior abdominal wall above the symphysis pubis. A Bard Biopty-cut biopsy needle, 18 gauge (1.2 mm), sampling n o t c h 17 mm, and l e n g t h 16 cm, was attached to the firing gun (Radiplast AB, Uppsala, Sweden). The needle was inserted under the skin close to the outer uterine wall by means of a guidance system attached to the abdominal ultrasound transducer. The gun was fired and the biopsy needle passed 2 cm into the uterine wall. ~Two or three cores were obtained from the most abnormal areas seen on ultrasound. The material was placed in fixative and examined by a specialist in gynecologic pathology. Operative biopsy was done at laparoscopy using the biopsy needle and gun, the suspicious areas being determined either by previous ultrasound or laparoscopic detection of thickened, nodular, or firmer areas of myometrium. Vasopressin was not administered, and bleeding always stopped quickly. At laparotomy, excisional biopsy tissue was taken from suspicious areas. Frozen section was not used.
Surgical Procedures E n d o m e t r i a l resection was p e r f o r m e d in 15 patients, and 2 also had laparoscopic myometrial reduction. Adenomyosis was not localized, and menorrhagia was the major complaint at the time of presentation in all patients. The technique described previously2 was modified so that 0.5 to 1 cm of myometrium was removed by a cutting loop to enable suitable h i s t o l o g y and possible r e d u c t i o n of diseased myometrium. This did not produce excessive bleeding. Patients having endometrial resection were warned that the success could be reduced because of the presence of adenomyosis.2 Adenomyoisis or adenomyoma was localized by preoperative high-resolution ultrasound, or by the laparoscopic or laparotomy appearance of myometrial thickening, nodularity, altered vascularity, or increased resistance to needle penetration. Laparoscopic myometrial reduction was performed in five patients with infertility and two with localized areas of adenomyosis less than 4 cm. It was performed by deep electrocoagulation using a Corson needle electrode and 50 W monopolar coagulation at 1 to 3 cm depth at about 1-cm intervals until blanching s p r e a d for 1 cm b e y o n d the n e e d l e point. Superficial blanching of the abnormal myometrial
Biopsy Diagnosis and Conservative Treatment of Adenomyosis Wood et al
area was thereby achieved. This was assisted by the preliminary injection of vasopressin 1:50 dilution into the myometrium. Adenomyotic myometrium or a localized adenomyoma was excised by laparotomy in eight patients. Attempted laparoscopic excision of a 7-cm adenomyoma failed because of the inability to control bleeding, the junction between the adenomyoma and normal myometrium being indistinct. The women were followed every 3 months for 2 years with office visits and two further vaginal ultrasound examinations.
Results Cure was defined as the relief of menorrhagia and dysmenorrhea whereby no further treatment was required. Vaginal ultrasound showed persistence of adenomyosis in three of the women who were cured of symptoms. Endometrial resection cured 10 of 15 patients, myometrial excision 7 of 8, and myometrial reduction 4 of 7, for an overall cure rate of 70% (Table 1). Endometrial resection cured menorrhagia in 12 of 15 patients, but dysmenorrhea in only 3 of 8. Nine patients required hysterectomy after the initial surgery. The reason was the persistence of pain in all nine women, and associated bleeding in three. All underwent laparovaginal hysterectomies without complications.3 Laparoscopy and hysteroscopy were performed in five of the seven women who had undergone myometrial reduction, either to check fertility status or because of the persistence of menstrual symptoms. TABLE 1. Results of Conservative Surgery for Adenomyosis: 2-Year Follow-Up
Surgical Procedure Endometrial resection Myometrial or adenomyoma excision Myometrial reduction Totals
No. of Patients
No. With Relief of Symptoms
No. With Hysterectomy
15
10
5
8
7
1
7 30
4 21 (70%)
3 9 (30%)
315
One patient had visible scar tissue on the uterus and omental adhesions, but experienced no related symptoms.
Discussion Vaginal ultrasound in combination with transabdominal or transcervical myometrial biopsy enabled the diagnosis of adenomyosis in all patients. False positive results may occur with vaginal ultrasound 1 and false negative results with myometrial biopsy, although we have not seen the latter. Patients with negative biopsy results but whose ultrasound findings were suggestive of adenomyosis were not included in the current study as the diagnosis of adenomyosis was not made. Hysterectomy in three such patients confirmed that adenomyosis was not present (i.e., the biopsy was more accurate than ultrasound). Color Doppler may improve the specificity of ultrasound diagnosis, as vascular changes occur in areas of adenomyosis. In one study, magnetic resonance imaging (MRI) was more reliable than vaginal ultrasound, with the latter misdiagnosing a myoma in 4 of 11 patients.4 A myoma may be difficult to distinguish from an adenomyoma but not, in our experience, from adenomyosis. With a suspected or proved preoperative diagnosis of adenomyosis, the surgeon can discuss with the patient alternative treatments, such as endometrial resection, myometrial reduction by electrocoagulation or laser, myometrial excision, or hysterectomy. Until larger numbers of patients with adenomyosis have been treated by endometrial resection, myometrial reduction, and myometrial excision, the success rates of these procedures cannot be accurately estimated. It was reported that the success rate of endometrial resection is reduced in women with adenomyosis.5 In our study, it was more successful providing long-term relief of menorrhagia (12/15) than of dysmenorrhea (3/8), and women with severe dysmenorrhea should be warned of the possibility of a poor outcome. Because the procedure is so simple compared with hysterectomy, however, many patients wish to try it before agreeing to hysterectomy. A major limitation of myometrial reduction by electrocoagulation is the possibility that large areas of necrotic myometrium could release toxic substances into the circulation. In our hands the coagulated areas have been limited to 3 x 3 cm without side effects.
August 1994, Vol. 1, No. 4, Part 1
The Journal of the American Association of Gynecologic Laparoscopists
This procedure is simple, and the risk of bleeding and adhesions may be less than with excisional surgery, as mild a d h e s i o n s were f o u n d in only one of five patients having subsequent laparoscopy. Three of the seven patients undergoing myometrial reduction had a successful pregnancy. The operation may warrant further study in patients wishing to conceive, however, particularly those with small areas of adenomyosis. Scarring from electrocoagulation of large areas of the myometrium may result in the risk of uterine rupture in a subsequent pregnancy. Excisional surgery for adenomyoma is simple, as the diseased area is readily identified. The border between normal and adenomyotic myometrium may be difficult to determine, although ultrasound and MRI may show differences, and consistency, nodularity or thickening, and vascularity of the myometrium may be indicative. Because no capsule exists around adenomyosis, bleeding may be difficult to control. P r e o p e r a t i v e a d m i n i s t r a t i o n of danzol or gonadotropin-releasing hormone analogs may reduce blood flow and bleeding at the time of surgery. Such drugs also may obscure the appearance of the diseased areas, but localized nodules would still be visible and could be identified after preoperative drug therapy. Despite the one failure in the present study, laparoscopic excisional surgery of adenomyomas may be possible providing hemostasis is satisfactory and the myometrial defect is sutured. Laparoscopic or vaginal hysterectomy is available to patients with adenomyosis, either as an elective or secondary operation, as the uterus is nearly always less than 16 cm in length. Vaginal ultrasound and myometrial biopsy are important initial investigations in developing new strategies for t r e a t i n g these women, however, and improvements in conservative surgical procedures may further reduce the need for hysterectomy.
316
Summary Thirty-one women with dysmenorrhea and meno r r h a g i a r e f r a c t o r y to medical t r e a t m e n t were referred for surgical treatment. Adenomyosis was suggested preoperatively by vaginal ultrasound in 25 patients. The histologic diagnosis was made by percutaneous preoperative outpatient myometrial biopsy in 10 patients, by transcervical myometrial biopsy in 9, and by needle biopsy at laparoscopy or laparotomy in 12. Conservative surgery was endometrial resection (15), myometrial reduction by electrocoagulation (7), and myometrial or adenomyoma excision (8). Twoyear follow-up demonstrated cure of the symptoms in 10, 7, and 4 women , respectively (70% overall). Subsequent h y s t e r e c t o m y was r e q u i r e d in nine women, thus these conservative procedures reduced the overall need for hysterectomy to 30%. References
1. Wood C, Hurley VA, Fortune DW, et al: Percutaneous ultrasound guided needle uterine biopsy. Med J Aust 158:458-460, 1993 2. Wood C: Indication for endometrial resection. Med J Aust 156(3):157-160, 1992 3. Wood C, Maher P, Hill D, et al: Laparovaginal hysterectomy, Aust NZ J Obstet Gynaeco134(1):81-84, 1994 4. Arnold LL, Asher SA, Schruefer J J, et al: Transvaginal ultrasound vs magnetic resonance imaging in the diagnosis of adenomyosis. Abstracts of the American Fertility Society meeting October 11-14, 1993, Montreal, Canada 5. Loffer F: Laser ablation of the endometrium. Obstet Gynecol Clin North Am 15:77-89, 1988