Large Anechogenic "Holes" in The Uterus: The Utility of Contextual Combination of Ultrasound and Hysteros

BOHR International Journal on Gynaecology
2022, Vol. 1, No. 1, pp. 25–27

https://doi.org/10.54646/bijg.005
www.bohrpub.com
Large Anechogenic “Holes” in the Uterus: The Utility of Contextual

Combination of Ultrasound and Hysteroscopy
Paola Algeri1,∗ , Maria Donata Spazzini2 , Nina Pinna3 , Marta Seca4 , Tiziana Tomaselli2 ,
Riccardo Campanile Garruto2 and Antonella Villa2
1 Department of Obstetrics and Gynaecology, Bolognini Hospital, ASST Bergamo est, Seriate, Bergamo
2 Department of Obstetrics and Gynaecology, Treviglio Hospital, ASST Bergamo ovest, Treviglio, Bergamo
3 Department of Oncology, San Carlo Clinic, Paderno Dugnano, Milan
4 Department of Obstetrics and Gynaecology, San Gerardo Hospital, University of Milano-Bicocca, Monza,
Monza e Brianza
∗ Corresponding author: [email protected]
Abstract. Cystic adenomyosis is a rare occurrence, especially in young patients. We report a challenging case of a
44-year-old African patient, in which the ultrasound described a large bilobate anechogenic cyst in the myometrium.
The combination of ultrasound, contextual hysteroscopy, and subsequent magnetic resonance imaging helped to
clarify the case, reducing the risk of complications for the patient, potentially due to misdiagnosis.
Keywords: Hysteroscopy, cystic adenomyosis, ultrasound, sonohysteroscopys.
INTRODUCTION In these patients, even if there is no need for fertility

sparing, difficulties may be related to other potential risks,
Uterine adenomyosis is characterized by the presence which we discussed in our case report. In particular, the
of heterotopic endometrial glands and stroma at about possible risk of uterine perforation following invasive pro-
2.5 mm in depth in the myometrium, or more than cedures or the risk of adverse obstetrical outcomes, such
one microscopic field at 10 times magnification from as rupture of the uterus, in the case of pregnancy are
the endometrium–myometrium junction, and a variable remarkable.
degree of adjacent myometrial hyperplasia [1].
This condition is related to dysmenorrhea and pelvic
pain that can worsen the quality of life of patients. CASE PRESENTATION
A correct diagnosis was important to define the appro-
priate therapy. However, even if some peculiar sono- A 44-year-old African woman had three vaginal deliveries,
graphic characteristics are reported, the diagnosis is not one voluntary termination of pregnancy, and one abortion
always guaranteed. The combination of ultrasound and a year earlier in Senegal. After this spontaneous miscar-
magnetic resonance imaging (MRI) could be useful to riage, which did not require hysterosuction, the patient
better define this condition [2]. chose a long-acting contraceptive and was administered
In the case of cystic adenomyosis, a rare type of quarterly intramuscular progesterone for three times con-
adenomyosis, diagnosis and management are extremely secutively. During this period, she was not subjected to
difficult [3]. any gynecological checks because she was in good health
Cystic adenomyosis is usually described in young without any gynecological problems.
patients, in whom the need to reduce symptoms is linked Just before the fourth progesterone-depo administration,
to the need for fertility sparing [4–8]. However, elderly the patient showed up in the emergency room complaining
patients may also be suffering from cystic adenomyosis. of irregular vaginal bleeding lasting two months. The
25
26 Paola Algeri et al.
Figure 1. Transvaginal view of the uterus in subsequent sections, which showed the bilobate anechogenic myometrial cyst (marked with
an asterisk).
Figure 2. Magnetic resonance image, which confirmed the diag- Figure 3. Laparoscopic surgical view, which confirmed the cystic
nosis of cystic adenomyosis (marked with an arrow). consistency of the uterine neoformation at instrument touch.
beta-HCG was negative. The gynecological examination ultrasonographic changes that may have occurred follow-
was regular. ing the discontinuation of progesterone therapy.
On ultrasound examination, she presented a non-
univocal image, described as a big anechogenic and non-
vascularized formation with subtle contours within the
uterus (Figure 1). Adnexa was regular. Accordingly, she CONCLUSION
was referred for hysteroscopy.
At hysteroscopy, the cavity was larger than normal but Although cystic adenomyosis is more common in young
without irregularities. The uterine fundus was distorted by patients, it can be difficult to diagnose and manage in the
a kind of “diverticulum.” Due to the difficulties in defining elderly [4–8].
the picture, a second gynecologist performed a concomi- We presented our case, which demonstrated a non-
tant transabdominal ultrasound to guide hysteroscopy. univocal ultrasound image but with the potential for seri-
At the uterine fundus, a bilobate anechogenic formation ous harm in the event of a misdiagnosis.
was detected, and the suspicion of cystic adenomyosis We hypothesized that the ultrasound picture could be
has been raised. A biopsy of the endometrium was per- correlated with a decidualization of the cystic adenomy-
formed under ultrasound guidance. Histological examina- oma due to the prolonged progesterone therapy, although
tion described a secretive endometrium. we cannot confirm this hypothesis. However, we would
Since the effect of slow-release progesterone was almost like to underline that, in cases of hormonal therapy, the
over, the patient required sterilization. While waiting for imaging could present atypical changes.
the laparoscopic surgery, an MRI was prescribed. The Moreover, in our case, only the combination of con-
MRI confirmed the presence of a cystic formation of the textual hysteroscopy under ultrasound guidance could
myometrium measuring 35 × 26 × 47 mm, which reduced determine whether the adenomyosis was in continuity
the muscular wall of the uterine fundus (Figure 2). with the cavity. This combination of contextual procedures
Laparoscopy, performed for tubal sterilization, con- is not yet reported in literature with this intent. However,
firmed the presence of an enlarged uterus of cystic consis- in our case, it allowed a better definition and reduced the
tency (Figure 3). The hypothesis to perform a hysterectomy risk of uterine perforation.
was dismissed, with the patient preferring a less invasive A correct definition of uterine structure is actually nec-
surgery with maintenance of body image, also considering essary in cases of large myometrial cysts, particularly in
that the patient was young, sexually active, and asymp- cases of invasive procedures such as hysterosuction, hys-
tomatic. teroscopy, or even a simple endometrial biopsy.
The post-surgery course was regular. The patient We also used ultrasound and MRI to confirm the diag-
was also scheduled for a follow-up to assess any nosis afterward, as already suggested [2, 3].
Giant Cystic Adenomyosis of the Uterus 27
In consideration of the patient’s request, we performed REFERENCES

tubal sterilization; we chose not to associate hysterec-
tomy or cyst removal. We really didn’t get histological [1] Reinhold C, McCarthy S, Bret PM, et al. (1996). Diffuse adenomyosis:
confirmation of our imaging diagnosis. Laparoscopic ster- comparison of endovaginal US and MR imaging with histopathologic
correlation. Radiology, (199), 151–158.
ilization, on the other hand, allowed for a less invasive
[2] Bordonné C, Puntonet J, Maitrot-Mantelet L, et al. (2021). Imaging
surgery while maintaining body image and postponing the for evaluation of endometriosis and adenomyosis. Minerva Obstet
risk of uterine rupture due to a thin uterine wall in the case Gynecol. 73(3):290–303.
of pregnancy. [3] Marc Bazot, Emile Daraï. (2018). Role of transvaginal sonography and
In conclusion, the combination of ultrasound and magnetic resonance imaging in the diagnosis of uterine adenomyosis.
contextual hysteroscopy helped to avoid potential com- Fertil Steril 109(3):389–397.
[4] Alka Kriplani, Reeta Mahey, Nutan Agarwal, et al. (2011). Laparo-
plications related to invasive procedures or accidental
scopic management of juvanile cystic adenomyoma: four cases.
pregnancies in this challenging case of cystic adenomyosis J Minim Invasive Gynecol. 18(3):343–8.
with a large bilobate myometrial cyst. [5] Akihiro Takeda, Kotaro Sakai, Takashi Mitsui, et al. (2007). Laparo-
scopic management of juvenile cystic adenomyoma of the uterus:
report of two cases and review of the literature. J Minim Invasive
CONFLICT OF INTEREST Gynecol. 14(3):370–4.
[6] Maryjo Marques Branquinho, Andreia Leitão Marques, Helena Barros
The authors declare that the research was conducted in the Leite, et al. (2012). Juvenile cystic adenomyoma. BMJ Case Rep. 19;
absence of any commercial or financial relationships that 2012:bcr2012007006.
could be construed as a potential conflict of interest. [7] Ivo Brosens, Stephan Gordts, Marwan Habiba, et al. (2015). Uterine
cystic adenomyosis: a disease of younger women. J Pediatr Adolesc
Gynecol. 28(6):420–6.
AUTHOR CONTRIBUTIONS [8] Yohan Kerbage 1, Sarah Dericquebourg 2, Pierre Collinet, et al.
(2022). Cystic adenomyoma surgery. J Gynecol Obstet Hum Reprod.
All authors contributed to the study. Material prepara- 51(3):102313.
tion and data collection were performed by Maria Donata
Spazzini, Tiziana Tommaselli, Stefano Campanile Garruto,
and Antonella Villa. The first draft of the manuscript was
written by Paola Algeri, and all authors commented on
previous versions of the manuscript. Nina Pinna and Marta
Seca revised the language and edited the paper. All authors
read and approved the final manuscript.

Large Anechogenic "Holes" in The Uterus: The Utility of Contextual Combination of Ultrasound and Hysteros

Uploaded by

Copyright:

Available Formats

Large Anechogenic "Holes" in The Uterus: The Utility of Contextual Combination of Ultrasound and Hysteros

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Large Anechogenic "Holes" in The Uterus: The Utility of Contextual Combination of Ultrasound and Hysteros

Uploaded by

Copyright:

Available Formats

BOHR International Journal on Gynaecology

2022, Vol. 1, No. 1, pp. 25–27

Large Anechogenic “Holes” in the Uterus: The Utility of Contextual

INTRODUCTION In these patients, even if there is no need for fertility

In consideration of the patient’s request, we performed REFERENCES

You might also like