adenomyosis is a common gynecological condition that is characterized by ingrowths of the endometrial cells into the myometrium . adenomyosis and leiomyoma are benign conditions that are often responsible for uterine enlargement , menorrhagia , anemia , and infertility . adenomyosis or internal endometriosis may occur as a result of increased overgrowth of the endometrium with invasion of the underlying myometrium or the displacement of the endometrium during pregnancy , delivery , endometrial curettage , cesarean section , myomectomy , or metroplasty . because of its similarities to leiomyoma , it can be difficult in some cases to accurately diagnose adenomyosis by ultrasound . most gynecologists will consider conservative medical treatment more often for adenomyosis only , while surgical options will be chosen frequently for leiomyoma or combined adenomyosis and leiomyoma , especially in large uteri . the three most common methods of clinical diagnosis of adenomyosis are magnetic resonance imaging ( mri ) , transabdominal ultrasonography ( tas ) , and transvaginal ultrasonography ( tvs ) . there is limited diagnostic capacity with tas , while tvs is a more feasible option . moreover , tvs is also much more cost effective than mri and is generally more readily available in the office to most practicing gynecologists . the aim of this retrospective study was to determine the accuracy , sensitivity , specificity , positive predictive value ( ppv ) , and negative predictive value ( npv ) of tvs in the diagnosis of adenomyosis and leiomyoma confirmed by postsurgical histopathological findings . the importance of an accurate noninvasive diagnostic method like ultrasound for adenomyosis , leiomyoma , or combined is an ongoing need in the gynecological community . this was an institutional review board ( irb ) approved retrospective consecutive case series study . from november 2006 to may 2012 , patients underwent surgery for the treatment of adenomyosis , leiomyoma , or combined adenomyosis and leiomyoma . diagnostic criteria of uterine adenomyosis include two of the five sonographic features on tvs : ( 1 ) no distinction of the endometrial - myometrial junction ; ( 2 ) asymmetry of the anterior and posterior myometrium ; ( 3 ) subendometrial myometrial striations ; ( 4 ) myometrial cysts and fibrosis ; and ( 5 ) heterogeneous myometrial echotexture . diagnostic criteria of uterine leiomyoma include two of the five sonographic features on tvs : ( 1 ) clear demarcation of the tumor margin ; ( 2 ) whorly appearance of the tumor content ; ( 3 ) the presence of blood vessels ( by color doppler ) surrounding the tumor ; ( 4 ) irregularities of the uterine surface ( subserous and intramural tumors ) ; and ( 5 ) irregularities of the endometrial surface ( submucous tumors type 1 and 2 ) . symptomatic patients diagnosed with adenomyosis and leiomyoma via tvs underwent myomectomy with excision of the surrounding myometrium which presumably contained adenomyosis . following surgery , a histopathological examination was performed by the hospital pathologists . student 's t - tests were used for parametric continuous variables ; and the chi - square or fisher 's exact test , where suitable , was used for categorical variables . sensitivity , specificity , npv , ppv , positive and negative likelihood ratios , and accuracy were determined for ultrasound findings as they corresponded to the final histopathological diagnosis . from november 2006 to may 2012 , 163 patients underwent surgery for the treatment of adenomyosis , leiomyoma , or combined adenomyosis and leiomyoma . one hundred and twenty - three patients were diagnosed with adenomyosis , and 134 patients were diagnosed with leiomyoma . twenty - nine patients were diagnosed with adenomyosis only , 40 patients were diagnosed with leiomyoma only , and 94 patients were diagnosed with combined adenomyosis and leiomyoma , as illustrated in figure 1 . patient diagnosis groups one hundred and thirty patients diagnosed with adenomyosis or combined adenomyosis and leiomyoma via tvs underwent hysterectomy . the mean age was 43.7 years with a standard deviation ( sd ) of 6.7 years and median of 43 years . there was no significant difference in the mean age , weight , height , gravidity , and parity of the patient diagnosis groups . patient characteristics for 163 females who underwent hysterectomy or myomectomy between 2006 and 2012 of the 123 patients ( 75.46% ) who were positively diagnosed with adenomyosis , 93 of the patients ( 75.61% ppv ) diagnoses were confirmed by the histopathological findings . histopathological reports found 23 ( 57.50% npv ) confirmed negative diagnoses and 17 ( 42.50% ) positive findings . the sensitivity of tvs in the diagnosis of adenomyosis was 84.55% ( 95% ci 76.4 - 90.7 , p < 0.0001 ) and the specificity was 43.40% ( 95% ci 29.8 - 57.7 , p = 0.41 ) . table 2 shows the sensitivities , specificities , ppvs , npvs , and accuracy for each of the initial tvs diagnoses . this could be explained by the difficulty to diagnose adenomyosis in patients with other intrauterine abnormalities or conditions . patients positively diagnosed with adenomyosis via tvs are 1.49 ( 95% ci 1.16 - 1.92 , p < 0.002 ) times more likely to have the condition . conversely , patients negatively diagnosed with adenomyosis via tvs are 2.81 ( 95% ci 1.65 - 4.79 , p = 0.0002 ) times less likely to have the condition . number of patients , positive and negative predictive values , sensitivity , specificity , and accuracy of transvaginal ultrasound for initial diagnosis with histopathological correlation ( n=107 ) one hundred and thirty - four patients ( 82.21% ) were diagnosed with leiomyoma and 29 patients ( 17.79% ) were negative for leiomyoma upon the initial tvs . of the 134 patients diagnosed with leiomyoma , 133 ( 99.25% ppv ) had a confirmed diagnosis represented in their postsurgical pathology report and one patient 's ( 0.75% ) pathology report did not confirm the diagnosis . of the 29 patients whose tvs diagnosis was negative for leiomyoma , 24 ( 82.76% ) patients histopathological findings were also negative , and five patients ( 17.24% ) had a positive histopathological diagnosis . the corresponding sensitivity and specificity of tvs as a diagnostic test for leiomyoma was 96.38% ( 95% ci 91.75 - 98.81 ) and 96.00% ( 95% ci 79.65 - 99.90 ) , respectively . patients with a positive diagnosis of leiomyoma via tvs are 24.09 times ( 95% ci 35.30 - 164.45 , p = 0.001 ) more likely to have leiomyoma . patients with a negative diagnosis of leiomyoma via tvs are 26.53 times ( 95% ci 11.16 - 62.89 , p < 0.0001 ) less likely to have leiomyoma . for the statistical calculations of adenomyosis and leiomyoma as coexisting conditions , analyses were performed excluding the patients who were diagnosed with a singular condition . these patients were classified as  negative  solely for the purpose of calculations regarding the combined condition . of the 94 patients ( 57.67% ) that were positively diagnosed with combined adenomyosis and leiomyoma , 70 ( 74.47% ppv ) had histopathological confirmation of both conditions and 24 patients ( 25.53% ) did not have evidence of both conditions in their post - surgical pathology report . sixty - nine ( 42.33% ) patients had a negative tvs diagnosis for combined adenomyosis and leiomyoma , and 49 ( 71.01% npv ) had histopathological confirmation of the negative diagnosis . however , 20 patients ( 28.99% ) had a positive histopathological diagnosis for both adenomyosis and leiomyoma . the sensitivity and specificity of tvs in the diagnosis of combined adenomyosis and leiomyoma was 77.78 ( 95% ci 67.79 - 85.87 ) and 67.12% ( 95% ci 55.13 - 77.67 ) , respectively . patients who obtained a positive tvs diagnosis are 2.37 times ( 95% ci 1.67 - 3.34 , p < 0.0001 ) more likely to be diagnosed with combined adenomyosis and leiomyoma . alternatively , patients who are negatively diagnosed with adenomyosis and leiomyoma via tvs are 3.02 times ( 95% ci 1.99 - 4.59 , p < 0.0001 ) less likely to be diagnosed with combined adenomyosis and leiomyoma . adenomyosis is a gynecological disorder that is characterized by the overgrowth of the endometrium into the underlying myometrium . the difficulty in diagnosing adenomyosis clinically is due to the lack of strong positive pathognomonic signs and/or clinical findings . the explanation for this wide range of values , as described by azziz , is the result of differences in the histological criteria for the diagnosis of adenomyosis , the care of which the pathologic specimens are handled , and the number of blocks of sampling specimens taken . various measures of accuracy were calculated for the diagnosis of adenomyosis , leiomyoma , and combined adenomyosis and leiomyoma . table 3 shows a comparison of sensitivity , specificity , ppv , and npv of this study with several previous studies that investigated the diagnosis of adenomyosis . it is important to note that the mean number of patients included in the 13 previous studies in table 3 is 76.8 patients ; however , this study utilized 163 patients in the analyses . along with differences in inclusion criteria , ultrasound equipment , and/or the differences in the criteria to diagnose adenomyosis , the larger sample size could contribute to the difference in results . the sensitivity and specificity of tvs for the diagnosis of adenomyosis in this study was 84.55 and 43.40% , respectively . the associated p value for the specificity was not significant , suggesting tvs as a diagnostic tool is sensitive , but not specific in the diagnosis of adenomyosis . the sensitivity in this study is similar to those previously reported in table 3 , but the specificity is the lowest of those reported . this could be due to the difficulty in diagnosing adenomyosis in the presence of other uterine abnormalities and conditions , especially uterine leiomyomata that may distort the uterus . patients that were diagnosed with multiple intrauterine conditions were not excluded from this study , since the principle inclusion criteria was patients who underwent hysterectomy or myomectomy and a preoperative tvs . sensitivity , specificity , positive and negative predictive values of tvs for the diagnosis of adenomyosis from previous series compared with this series the sensitivity of tvs for the diagnosis of leiomyoma was 96.38% and the specificity was 96.00% , which is similar to that of a previous study . the sensitivity for the diagnosis of combined adenomyosis and leiomyoma was 77.78% , and the specificity was 67.12% . it was accurate , sensitive , and specific in the diagnosis of leiomyoma and combined adenomyosis and leiomyoma . tvs was both accurate and sensitive in the diagnosis of adenomyosis , but not specific . moreover , tvs is cost effective and readily available in the office to the majority of practicing gynecologists . this study demonstrated that tvs is a valuable noninvasive method that should be utilized in the diagnosis of leiomyoma and combined adenomyosis and leiomyoma .
objective : to evaluate the accuracy , sensitivity , specificity , positive predictive value ( ppv ) , and negative predictive value ( npv ) of the diagnosis of adenomyosis , leiomyoma , or combined adenomyosis and leiomyoma by the use of transvaginal ultrasonography ( tvs ) compared to the histopathological findings.subjects and methods : this is a retrospective study of patients with a preoperative tvs diagnosis of adenomyosis , leiomyoma , or combined . 
 patients diagnosed with adenomyosis or combined adenomyosis and leiomyoma via tvs underwent hysterectomy . 
 symptomatic patients diagnosed with adenomyosis and leiomyoma via tvs underwent myomectomy with excision of the surrounding myometrium which contained possible adenomyosis . following surgery , a histopathological examination was performed by the hospital pathologists . 
 the microscopic diagnosis of the specimen was recorded.results:tvs diagnosis of adenomyosis was sensitive but not specific . 
 tvs was sensitive , specific , and accurate in the diagnosis of leiomyoma and combined adenomyosis and leiomyoma.conclusion:this study demonstrated that tvs is a valuable noninvasive method that should be utilized in the diagnosis of leiomyoma and combined adenomyosis and leiomyoma . 
 tvs is sensitive , but is not specific in the diagnosis of adenomyosis only .