MR imaging of diffuse adenomyosis changes after GnRH analog therapy

MRI of Adenomyosis: Where Are We Today?

Purpose of Review: The purpose of this review is to (i) summarize the current literature regarding the role of magnetic resonance imaging (MRI) in diagnosing adenomyosis, (ii) examine how to integrate MRI phenotypes with clinical symptomatology and histological findings, (iii) review recent advances including proposed MRI classifications, (iv) discuss challenges and pitfalls of diagnosing adenomyosis, and (v) outline the future role of MRI in promoting a better understanding of the pathogenesis, diagnosis, and treatment options for patients with uterine adenomyosis. Recent Findings: Recent advances and the widespread use of MRI have provided new insights into adenomyosis and the range of imaging phenotypes encountered in this disorder. Summary: Direct and indirect MRI features allow for accurate non-invasive diagnosis of adenomyosis. Adenomyosis is a complex and poorly understood disorder with variable MRI phenotypes that may be correlated with different pathogeneses, clinical presentations, and patient outcomes. MRI is useful for the assessment of the extent of findings, to evaluate for concomitant gynecological conditions, and potentially can help with the selection and implementation of therapeutic options. Nevertheless, important gaps in knowledge remain. This is in part due to the lack of standardized criteria for reporting resulting in heterogeneous and conflicting data in the literature. Thus, there is an urgent need for a unified MRI reporting system incorporating standardized terminology for diagnosing adenomyosis and defining the various phenotypes.

Conservative Management of Uterine Adenomyosis: Medical vs. Surgical Approach

Uterine adenomyosis is a commonly encountered estrogen-dependent disease in reproductive-age women, causing heavy menstrual bleeding, intense pelvic pain, and infertility. Although adenomyosis was previously considered a disease of multiparous women, it is becoming increasingly evident that it also affects younger nulliparous women and may compromise their fertility potential. It is clear that hysterectomy, the standard approach to definitively manage the disease, is not an option for patients wishing to preserve their fertility, so there is an urgent need to develop novel conservative strategies. We searched the current literature for available methods for conservative management of adenomyosis, including both pharmacological and surgical approaches. There is no existing drug that can cure adenomyosis at present, but some off-label treatment options may be used to tackle disease symptoms and improve fertility outcomes. Adenomyosis in patients wishing to conceive can be 'treated' by conservative surgery, though these procedures require highly experienced surgeons and pose a considerable risk of uterine rupture during subsequent pregnancies. While currently available options for conservative management of adenomyosis do have some capacity for alleviating symptoms and enhancing patient fertility perspectives, more effective new options are needed, with gonadotropin-releasing hormone antagonists showing encouraging results in preliminary studies.

Adenomyosis and infertility: the role of the junctional zone

OBJECTIVE

Adenomyosis is a benign uterine disorder characterized by the invasion of the endometrium within the myometrium, starting from the junctional zone (JZ), the inner hormone dependent layer of the myometrium that plays an important role in sperm transport, implantation and placentation. The resulting histological abnormalities and functional defects may represent the pathogenic substrate for infertility and pregnancy complications. The objective of this paper is to review the literature to evaluate the correlation between inner myometrium alterations and infertility and to assess the role of JZ in the origin of adverse obstetric outcomes of both spontaneous and in vitro fertilization (IVF) pregnancies.

METHODS

we searched Pubmed for all original and review articles in the English language from January1962 until December 2019, using the MeSH terms of 'adenomyosis', 'junctional zone', combined with 'infertility', 'obstetrical outcomes', 'spontaneous conception', 'in vitro fertilization' and 'classification'. The review was divided into three sections to assess this pathogenic correlation, evaluating also the importance of classification of the disease.

RESULTS AND CONCLUSIONS

Absent or incomplete remodeling of the JZ can affect uterine peristalsis, alter vascular plasticity of the spiral arteries and activate inflammatory pathways, all related to adverse obstetric outcomes. Despite these observations, there is still limited evidence whether adenomyosis is a cause of infertility. However, it is reasonable to screen patients for adenomyosis, to consider pregnant women with diffuse adenomyosis at high risk of adverse obstetric outcomes, and to evaluate the importance of a noninvasive validated classification in the management of women with adenomyosis.

Objective measures of adenomyosis on MRI and their diagnostic accuracy-a systematic review & meta-analysis

INTRODUCTION

Magnetic resonance imaging (MRI) diagnosis of adenomyosis is considered the most accurate non-invasive technique, but remains subjective, with no consensus on which diagnostic parameters are most accurate. We aimed to systematically review the literature on how adenomyosis can be objectively quantified on MRI in a scoping manner, to review the diagnostic performance of these characteristics compared with histopathological diagnosis, and to summarize correlations between measures of adenomyosis on MRI and clinical outcomes.

MATERIAL AND METHODS

We searched databases Pubmed, Embase, and Cochrane for relevant literature up to April 2020 according to PRISMA guidelines. We included studies that objectively assessed adenomyosis on MRI, and separately assessed studies investigating the diagnostic performance of MRI vs histopathology for inclusion in a meta-analysis. The QUADAS-2 tool was used for risk of bias, with many studies showing an unclear or high risk of bias.

RESULTS

Eighty studies were included, of which 14 assessed the diagnostic performance of individual MRI parameters, with four included in the meta-analysis of diagnostic accuracy. Common MRI parameters were: junctional zone (JZ) characteristics, such as maximum JZ thickness-pooled sensitivity 71.6% (95% CI 46.0%-88.2%), specificity 85.5% (52.3%-97.0%); JZ differential-pooled sensitivity 58.9% (95% CI 44.3%-72.1%), specificity 83.2% (95% CI 71.3%-90.8%); and JZ to myometrial ratio-pooled sensitivity 63.3% (95% CI 51.9%-73.4%), specificity 79.4% (95% CI 42.0%-95.4%); adenomyosis lesion size, uterine morphology (pooled sensitivity 42.9% (95% CI 15.9%-74.9%), specificity 87.7%, (95% CI 37.9-98.8) and changes in signal intensity-eg, presence of myometrium cysts; pooled 59.6% (95% CI 41.6%-75.4%) and specificity of 96.1% (95% CI 80.7%-99.3%). Other MRI parameters have been used for adenomyosis diagnosis, but their diagnostic performance is unknown. Few studies attempted to correlate adenomyosis MRI phenotype to clinical outcomes.

CONCLUSIONS

A wide range of objective parameters for adenomyosis exist on MRI; however, in many cases their individual diagnostic performance remains uncertain. JZ characteristics remain the most widely used and investigated with acceptable diagnostic accuracy. Specific research is needed into how these objective measures of adenomyosis can be correlated to clinical outcomes.

Gonadotropin-releasing hormone analogs: Mechanisms of action and clinical applications in female reproduction

Extra-hypothalamic GnRH and extra-pituitary GnRH receptors exist in multiple human reproductive tissues, including the ovary, endometrium and myometrium. Recently, new analogs (agonists and antagonists) and modes of GnRH have been developed for clinical application during controlled ovarian hyperstimulation for assisted reproductive technology (ART). Additionally, the analogs and upstream regulators of GnRH suppress gonadotropin secretion and regulate the functions of the reproductive axis. GnRH signaling is primarily involved in the direct control of female reproduction. The cellular mechanisms and action of the GnRH/GnRH receptor system have been clinically applied for the treatment of reproductive disorders and have widely been introduced in ART. New GnRH analogs, such as long-acting GnRH analogs and oral nonpeptide GnRH antagonists, are being continuously developed for clinical application. The identification of the upstream regulators of GnRH, such as kisspeptin and neurokinin B, provides promising potential to develop these upstream regulator-related analogs to control the hypothalamus-pituitary-ovarian axis.

Fertility, pregnancy and neonatal outcomes of patients with adenomyosis: a systematic review and meta-analysis

This study aimed to investigate the association of adenomyosis with fertility, pregnancy and neonatal outcomes. An electronic search was conducted using the MEDLINE, PubMed and Cochrane databases up to April 2020. Seventeen observational studies were included. Adenomyosis was significantly associated with a lower clinical pregnancy rate (odds ratio [OR] 0.69; 95% confidence interval [CI] 0.51-0.94) and higher miscarriage rate (OR 2.17; 95% CI 1.25-3.79) after treatment with assisted reproductive technology (ART). The lower clinical pregnancy rate was more significant in the subgroup of patients with short down-regulation protocols. Similar associations were recorded after age adjustment. Adenomyosis was also significantly associated with an increased risk of pre-eclampsia, preterm delivery, Caesarean section, fetal malpresentation, small for gestational age infancy and post-partum haemorrhage, which was confirmed after correction for age and mode of conception. In conclusion, adenomyosis is associated with negative effects on fertility after ART. The potentially protective role of the ultra-long down-regulation protocols needs further evaluation in randomized controlled studies. Adenomyosis is also associated (independently of the mode of conception) with adverse pregnancy and neonatal outcomes. Proper counselling prior to ART and close monitoring of pregnancy in patients with adenomyosis should be recommended.

Quercetin Inhibits Adenomyosis by Attenuating Cell Proliferation, Migration and Invasion of Ectopic Endometrial Stromal Cells

Purpose

To evaluate the effects of quercetin on proliferation, invasion and migration of endometrial stromal cells (ESCs) from adenomyosis patients.

Methods

Primary ectopic ESCs (EESCs) and eutopic ESCs (EuESCs) were obtained and purified from patients undergoing total hysterectomy for adenomyosis and identified by immunocytochemistry staining. The cytotoxicity and inhibition rate were determined by CCK-8 assay to obtain the IC₅₀ value. Cell proliferative, migratory, and invasive abilities were detected by BrdU, wound scratch, transwell assays, respectively. Western blot analysis was employed to explore the effects of quercetin on the expression of MMP-2, MMP-9, Ezrin and Fascin proteins in cells.

Results

Both EESCs and EuESCs were characterized with strongly positive staining for vimentin and almost negative for cytokeratin. Quercetin inhibited the viability of EESCs and EuESCs in a dose- and time-dependent manner, with an IC₅₀ = 33.00 μM for EuESCs and IC₅₀ = 74.88 μM for EESCs at 72 h. Thus, the final concentrations and action time of quercetin in EuESCs (0, 20, 40, and 80 μM for 72 h) and EESCs (0, 40, 80, and 160 μM for 72 h) were selected. BrdU assay showed that quercetin dose-dependently suppressed the proliferation of EESCs and EuESCs, while the inhibition rate in EESCs was higher. Similarly, administration of quercetin in EESCs and EuESCs significantly decreased the motility and invasiveness in a dose-dependent fashion, with stronger inhibitory effects on EESCs. Finally, Western blot analysis demonstrated that invasion- and migration-related proteins (MMP-2, MMP-9, Erzin, and Fascin) were significantly downregulated with the quercetin concentration increasing. Moreover, the decreased level of these proteins in EESCs under quercetin exposure was greater than that in EuESCs.

Conclusion

Quercetin can inhibit the proliferation of EESCs in adenomyosis and reduce their mobility and invasiveness. These inhibitory effects may be related to the downregulation of MMP-2, MMP-9, Fascin, and Erzin proteins.

The importance of the junctional zone of the endometrium in human reproduction

Junctional zone endometrium (JZE) thickness and contractility seem to determine gamete and embryo transportation and implantation. Proper function depends on concentration levels, mode and timing of oestrogen and progesterone production. Most probably, the remodelling of spiral arteries, and the development of endometrium and decidua are also highly dependent on JZE activity. Fibroids that are adjacent to JZE affect JZE contractility contributing to abnormal or failed implantation. Disruption of the JZE continuity provokes adenomyosis, a condition that causes chronic inflammation and fibrosis, which negatively affects the normal function of JZE. Imaging by magnetic resonance imaging and three-dimensional sonography can diagnose JZE abnormal appearance, alterations in thickening and contractility frequency, usually in the advanced stage of the disease. Failures of assisted reproduction, and adverse early pregnancy outcomes have also been associated with abnormal JZE. Altered uterine contractions due to JZE changes are strongly associated with poor reproductive outcome and early pregnancy loss. Endometriosis and adenomyosis prevalently co-exist, with clear relation and negative effects on the JZE. The presence of endometriosis should alert to the possibility of coexisting adenomyosis. Co-existence of endometriosis may mask the extent of the negative impact of adenomyosis in infertility.

Minimally invasive treatment of adenomyosis

The aim of the present review is to give a comprehensive overview of minimal invasive treatment options and suggest a minimally invasive approach in women with adenomyosis (AD). A review of relevant literature on medical and surgical treatment options is performed. Surgical options include endometrial ablation, hysteroscopic endometrial and adenomyoma resection, laparoscopic resection of AD, high-intensity focused ultrasonography (HIFU), and uterine artery embolization (UAE). This review summarizes treatment strategies for the management of AD and highlights the present lack of knowledge, which makes suggestions of evidence-based treatment difficult.

Quercetin alleviates generalized hyperalgesia in mice with induced adenomyosis

Adenomyosis is a common gynecologic disorder characterized by the presence of endometrial glands and stroma within the myometrium. The present study investigated the effect of quercetin in neonatal Imprinting Control Region mice with tamoxifen-induced adenomyosis. The body weight and hotplate response latency of all mice was examined at 4, 8, 12 and 16 weeks after birth. The mice dosed with tamoxifen were divided into four groups: high- or low-quercetin group, valproic acid (VPA) group and untreated group. The group of mice that were neonatally administrated with the solvent only (no tamoxifen), received no treatment and served as a blank control group. After 3 weeks of drug treatment, the potential ability of quercetin to improve the generalized hyperalgesia in mice with induced adenomyosis was evaluated by determining the body weight, pain modulation, examining the myometrial infiltration by histology examination of the uterus and detecting the expression of transient receptor potential cation channel subfamily V member 1 (Trpv-1), phospho (p)-p38 mitogen activated protein kinase p-extracellular signal-regulated kinase (p-ERK) in DRG neurons via immunohistochemistry. The results demonstrated that treatment with quercetin improved the generalized hyperalgesia by extending the hotplate response latency, reduced myometrial infiltration and decreased the expression levels Trpv-1, p-p38 and p-ERK in dorsal root ganglion neurons. The results indicated that quercetin decreases the incidence of hyperalgesia in mice with tamoxifen-induced adenomyosis, and the potential mechanism is through reduced central sensitization, which may be a promising treatment for adenomyosis.

Fifteen cases clinical analysis of wedge-shaped resection of uterus treating adenomyosis-CONSORT

To investigate the improvement of dysmenorrhea and menorrhagia after wedge-shaped resection of uterus. The clinical data of 15 patients who experienced wedge-shaped resection of uterus for adenomyosis were retrospectively analyzed from September 2012 to October 2013. We use the amount of the completed soaked napkins to measure the menstrual blood volume, and the visual analog scale to evaluate the degree of dysmenorrhea. We used the 2 index to evaluate the improvement of dysmenorrhea and menorrhagia after operation. All operations were successful, no serious complication occurred. Before the operation, all 15 patients used more than 25 pieces of completed soaked napkins, after the operation, 13 patients had significantly decreased menstrual flow, the average amount of completed soaked napkins was 3.6. Meanwhile, 2 patients had no menstrual after surgery. Before the operation, among the 10 patients with severe dysmenorrhea, 9 patients had significant relief on pain, they only experienced slight pain after surgery, only 1 patient still experienced moderate pain. Two patients with slight pain had no pain after operation. Among the 3 patients with moderate pain, 2 patients experienced slight pain and 1 patient felt no pain after operation. The wedge-shaped resection of uterus is a safe and effective procedure to significantly reduce menorrhagia and alleviate the extent of dysmenorrhea, which is a promising alternative for patient who suffered from dysmenorrhea and menorrhagia for adenomyosis.

Regression of Adenomyosis on Magnetic Resonance Imaging after a Course of Hormonal Suppression in Adolescents: A Case Series

STUDY OBJECTIVE

To demonstrate that adenomyosis is a rare cause of dysmenorrhea or chronic pelvic pain (CPP) in the adolescent population that can be identified with magnetic resonance imaging (MRI) and to report resolution of adenomyosis by MRI after a course of hormonal suppression in 4 adolescents.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective case series of 4 adolescents with adenomyosis on pelvic MRI at Texas Children's Hospital.

INTERVENTIONS

Continuous oral contraceptive (COC) therapy or leuprolide acetate.

MAIN OUTCOME MEASURES

Lesions on pelvic MRI after treatment.

METHODS

We reviewed medical records of 4 adolescents with CPP and adenomyosis on T2-weighted pelvic MRI. All patients had initial diagnostic pelvic MRI and then definitive hormonal intervention. Repeat imaging was obtained after a symptom-free interval.

RESULTS

Patient ages ranged from 12 to 16 years. One patient had resolution of symptoms with COC therapy. MRI performed 3 years later showed no adenomyosis. Three patients failed COC therapy. All were symptomatically improved after therapy with a gonadotropin-releasing hormone agonist. Follow-up MRI performed at intervals between 6 months and 3 years showed resolution of adenomyosis.

CONCLUSION

MRI can raise suspicion for the diagnosis of adenomyosis in adolescents with refractory CPP. Subsequent MRI can show regression of lesions after symptom resolution with hormonal therapy.

Comparative analysis of changes in MR imaging of pre and post intrauterine progesterone implants in adenomyosis cases

BACKGROUND

Magnetic Resonance Imaging (MRI) plays an important role in the evaluation and management of adenomyosis. In this study, we first diagnosed the adenomyosis on MRI and then we analyzed the MRI changes in the uterus in pre and post intrauterine progesterone implants cases.

METHOD

All the patients with clinical diagnosis of menorrhagia or dysmenorrhea were screened by Ultrasonography (USG) of the pelvis. Patients with heterogeneous echo texture of the uterus were then evaluated by the MRI of the pelvis. All patients with MRI findings suggestive of adenomyosis formed the study group.

RESULT

On MRI study 60 patients were diagnosed as adenomyosis, 68.33% had diffuse adenomyosis and 31.66% had focal adenomyosis. 83% of diagnosed adenomyosis cases had high intensity signal foci which were seen in 75% cases of diffuse adenomyosis and 100% cases of focal adenomyosis. 50 diagnosed adenomyosis cases were then reviewed after 03 months, 06 months and 12 months to see for any change in the MRI findings in the post intrauterine implant cases. On follow up MRI after post progesterone intrauterine implant, 50% of the cases showed reduction in the high intensity signals, 10% of the cases showed mild reduction in the junctional zone thickness with no significant change in the uterine size.

CONCLUSIONS

It is inferred that MR imaging is not only helpful in diagnosing but also helpful in monitoring the effects of hormonal therapy in adenomyosis.

Efficacy of dienogest in the treatment of symptomatic adenomyosis: a pilot study

Adenomyosis is a common disorder in premenopausal women that causes dysmenorrhea, pelvic pain and menorrhagia. Considering that adenomyosis is an estrogen-dependent disease, the medical treatment is based on this hormone. Effective and well-tolerated medical treatments for symptomatic adenomyosis are needed. Dienogest, an oral progestin, has been extensively investigated in the treatment of endometriosis. In this report, we present the results on the efficacy and safety of dienogest in the treatment of symptomatic adenomyosis. Seventeen patients with symptomatic adenomyosis were included in this study, of which 15 continued dienogest for up to 24 weeks. Dienogest significantly reduced adenomyosis-associated pelvic pain as well as serum CA-125 and CA19-9 levels. It also demonstrated a modest suppression of estradiol (>50 pg/ mL), which is consistent with the findings of other reports. During treatment, five patients experienced worsening anemia because of metrorrhagia, which is the most frequent adverse effect associated with dienogest. This report suggests that dienogest is an effective and well-tolerated therapy for symptomatic adenomyosis.

Noninvasive treatment of focal adenomyosis with MR-guided focused ultrasound in two patients

Adenomyosis is a common benign gynecological disorder presenting with dysmenorrhea, menorrhagia, and pressure symptoms. Magnetic resonance imaging–guided focused ultrasound surgery (MRgFUS) utilizes precisely focused USG waves to generate and maintain high temperatures within the targeted tissue to achieve protein denaturation and coagulative necrosis. The heat generated is monitored using MRI images acquired in real-time in three planes. We present two cases of focal adenomyosis treated with MRgFUS showing good symptomatic relief at 3 and 6 months follow-up.

Infertility and adenomyosis

Classically, the diagnosis of adenomyosis has only been possible on a hysterectomy specimen, usually in women in their late fourth and fifth decades, and, therefore, evaluating any relationship with infertility was simply not possible. As a consequence, to this day, no epidemiologic data exists linking adenomyosis to a state of subfertility. Today, new imaging techniques have enabled a noninvasive diagnosis at a much earlier time and a number of single-case or small series reports have appeared showing that medical, surgical, or combined treatment can restore fertility in women with adenomyosis, an indirect proof of an association. At the functional level, several anomalies found in the so-called junctional zone, or inner myometrium, in adenomyosis patients have been shown to be associated with poor reproductive performance, mainly through perturbed uterine peristalsis. Additional evidence for an association comes from experimental data: in baboons, adenomyosis is associated with lifelong primary infertility, as well as to endometriosis. Finally, indirect proof comes from studies of the eutopic and ectopic endometrium in women with adenomyosis proving the existence of an altered endometrial function and receptivity. In conclusion, sufficient indirect proof exists linking adenomyosis to infertility to warrant systematic clinical studies.

Feasibility of MRI-guided high intensity focused ultrasound treatment for adenomyosis

PURPOSE

To test the feasibility of MRI-guided high intensity focused ultrasound ablation for adenomyosis.

MATERIALS AND METHODS

Patients with symptomatic adenomyosis were treated with MRI-guided high intensity focused ultrasound (MRIgHIFU). Under conscious sedation, MRIgHIFU was performed by a clinical MRI-compatible focused ultrasound tumour therapeutic system (JM15100, Haifu® Technology Co. Ltd., Chongqing, China) which is combined with a 1.5 T MRI system (Magnetom Symphony, Siemens Healthcare, Erlangen, Germany). MRI was used to calculate the volume of the uterus and lesion. Non-perfused volume of the targeted lesions was evaluated immediately after MRIgHIFU. Patient symptoms were assessed using symptom severity score (SSS) and uterine fibroids symptoms and quality of life questionnaire (UFS-QOL).

RESULTS

Ten patients with mean age of 40.3±4 years with an average lesion size of 56.9±12.7 mm in diameter were treated. Non-perfused volume and the percentage of non-perfused volume obtained from contrast-enhanced T1 Magnetic resonance images immediately post-treatment were 66.6±49.4 cm3 and 62.5±21.6%, respectively. The mean SSS and UFS-QOL showed significant improvements of 25%, 16% and 25% at 3, 6 and 12 months follow up, respectively, to pre-treatment scores. No serious complications were observed.

CONCLUSION

Based on the results from this study, MRIgHIFU treatment appears to be a safe and feasible modality to ablate adenomyosis lesion and alleviate its symptoms.

Appearance of abdominal wall endometriosis on MR imaging

OBJECTIVE

Abdominal wall endometriosis (AWE) is defined as endometrial tissue that is superficial to the peritoneum. AWE is often difficult to diagnose, mimicking a broad spectrum of diseases. The aim of this study was to describe the appearance of AWE on magnetic resonance (MR) imaging.

METHODS

We present ten patients with AWE (12 lesions) in which MR imaging was used for diagnosis. MR imaging included T2-weighted imaging and T1-weighted imaging with fat suppression. To assess the value of diffusion-weighted imaging (DWI) in endometriosis, four patients underwent additional DWI. The apparent diffusion coefficient (ADC) was calculated using b values of 50, 400, 800 and 1,200 s/mm(2).

RESULTS

In most cases, the lesion was located ventral or dorsal to the aponeurosis of the rectus oblique muscle (n = 6) or in the rectus abdominis (n = 5). MR of AWE lesions showed isointense or slightly hyperintense signal compared with muscle on T2-weighted images and showed isointense or slightly hyperintense signal compared with muscle on T1-weighted images with foci of high signal intensity, indicative of haemorrhage. The mean ADC value of AWE was 0.93 x 10(-3)/mm(2)/s.

CONCLUSION

MR imaging seems to be useful in determining the location and depth of infiltration in surrounding tissue preoperatively.

Adenomyosis: New Knowledge is Generating New Treatment Strategies

In the early days, all mucosal invasions of abdominal organs were considered to be one pathological condition of uncertain origin, termed adenomyoma. It was only in the 1920s that endometriosis and adenomyosis were clearly separated and it took approximately 80 years to put forward a new theory reunifying their pathogenesis. Today, identification of adenomyosis is carried out exclusively through vaginal ultrasonography and MRI. These techniques have made a careful evaluation of a distinct anatomical structure and the inner myometrial layers underlying the endometrium, termed the junctional zone, possible. Adenomyosis is characterized by a homogeneous thickening of this portion of the myometrium. When this hyperplasia is associated to an alteration of spiral arterioles' angiogenesis, then both adenomyosis and endometriosis may develop. Evidence is being accumulated that pre-eclampsia, fetal growth restriction and premature delivery may be linked, together representing a new, major obstetrical syndrome characterized by a modified uterine environment around the time of nidation. A dozen different medical or surgical techniques are utilized for the treatment of adenomyosis and novel approaches are being tested. These include use of inhibitors of angiogenesis that have been shown to cause reduced neo-angiogenesis, a significant modification of gene expression and a decrease in the percentage of active lesions. Encouraging results have also been obtained with the levonorgestrel-releasing intrauterine system.

Early results of magnetic resonance-guided focused ultrasound surgery of adenomyosis: analysis of 20 cases

STUDY OBJECTIVE

To evaluate the thermal ablative effects of magnetic resonance-(MR) guided focused ultrasound surgery (MRgFUS) on adenomyosis and to assess improvement in clinical parameters.

DESIGN

Twenty patients with adenomyosis were treated with MRgFUS. Extensive adenomyosis (6 cases) was treated with 2 applications. Uterine volume was evaluated by MR imaging before and immediately after MRgFUS. Ablation of adenomyosis and the architecture of nonperfused areas were evaluated immediately after MRgFUS. Improvement in patient symptoms was assessed through the symptom severity score questionnaire (Canadian Task Force classification II-3).

SETTING

Department of gynecology at a Japanese general hospital.

PATIENTS

Premenopausal women at least 18 years of age with symptomatic adenomyosis.

INTERVENTIONS

Thermal ablation by MRgFUS.

MEASUREMENTS AND MAIN RESULTS

We classified the nonperfused lesions on contrast-enhanced MR images immediately after MRgFUS into 3 types: lesions with round margins (type R), serrated margins (type S), and honeycomb architecture (type H). Type R was the most common (16/20 patients). Most adenomyosis lesions could be sufficiently ablated close to the serosal surface or to the endometrium by MRgFUS. The mean uterine volume 6 months after therapy was decreased by 12.7%. Symptom severity score improved significantly during 6 months of follow-up. No serious complications were observed.

CONCLUSION

These early results indicate the safe and effective ablation of adenomyosis tissue by MRgFUS. The procedure also resulted in the improvement in clinical symptoms during the 6 months of follow-up.

The role of magnetic resonance imaging in minimal access surgery

PURPOSE OF REVIEW

Magnetic resonance imaging is commonly used for gynaecological malignancies, but also is increasingly used for the investigation of benign gynaecological complaints. This review summarizes the current evidence regarding its use as an adjunct to minimal access surgery for endometriosis, adenomyosis, adhesions and fibroids.

RECENT FINDINGS

Magnetic resonance imaging appears to be equal in efficacy to ultrasound for the diagnosis of both fibroids and endometriosis, and perhaps superior for the diagnosis of adenomyosis. It is extremely useful for the preoperative investigation of severe endometriosis, especially recto-vaginal disease. Milder endometriosis is, however, still difficult to diagnose by either ultrasound or magnetic resonance imaging. Magnetic resonance imaging can also be helpful for the detection of adhesions, pelvic collections, congenital defects and fibroids. It is also useful following fibroid embolization.

SUMMARY

Currently, it is not cost-effective to use magnetic resonance imaging as the modality of first choice when investigating pelvic pain and or menstrual disorders. If preoperative patients are carefully selected, however, it can substantially reduce surgical morbidity by using it to diagnose severe endometriosis and adhesions which may lead to cost savings overall.

Spectrum of MR features in adenomyosis

Magnetic resonance (MR) imaging is a highly accurate non-invasive technique for the diagnosis of adenomyosis. Typical MR features include either diffuse or focal thickening of the junctional zone or an ill-defined area of low signal intensity in the myometrium on T2-weighted MR images. Occasionally, the islands of ectopic endometrial tissue can be identified as punctate foci of high signal intensity. Less commonly, adenomyosis can present as a well-circumscribed form known as adenomyoma, adenomyotic cyst characterized by the presence of haemorrhagic cyst, or adenomyomatous polyp protruding into the uterine cavity. The MR appearances of adenomyosis may occasionally fluctuate in response to hormonal stimulation and treatment. MR imaging is helpful not only in monitoring the treatment effect of hormonal therapy, but also in predicting therapeutic effect. In cases of endometrial cancer in the uterus with adenomyosis, evaluation of myometrial invasion may become difficult. Rarely, endometrial cancer may arise directly from adenomyosis resulting from malignant transformation of endometrial glands, creating diagnostic challenges. Differential diagnosis of adenomyosis on MR imaging include physiological myometrial contraction and almost all myometrial lesions, and they should be carefully differentiated from adenomyosis by identifying typical clinical and MR features in these lesions. Precise knowledge of the spectrum of MR features in adenomyosis greatly helps in determining an accurate diagnosis and appropriate management of the patients.

Transvaginal ultrasound for diagnosis of adenomyosis: a review

The objective of this chapter is to relate the image findings of transvaginal ultrasound (TVS) to structural changes of adenomyosis; in order to clarify the present clinical diagnostic approach in the diagnosis of adenomyosis, the performance of TVS is evaluated in comparison to other diagnostic modalities. A Medline search of papers in English on the use of TVS and needle biopsy for the diagnosis of adenomyosis was carried out. It was found that TVS is highly observer-dependent, but in the hands of experienced investigators it has an adequate diagnostic accuracy in clinically suspected cases. The diagnostic accuracy of TVS is at an intermediate level but is in line with that of magnetic resonance imaging (MRI) in unselected patients without myomas undergoing surgery. TVS is a sufficiently accurate tool for diagnosis of adenomyosis in clinically suspected cases, but not in unselected premenopausal women with myomas. Resectoscopic hysteroscopic biopsy has not been sufficiently evaluated but could be a useful diagnostic tool, whereas needle biopsy is not. In conclusion, in clinically suspected adenomyosis cases TVS should be favoured as the primary diagnostic tool. Substantial experience and specific training is required for TVS to be a useful diagnostic tool in adenomyosis. MRI may be considered when TVS is inconclusive. Clinicians should above all be observant of image findings of adenomyosis in patients with no wish to preserve fertility.

New interventional techniques for adenomyosis

This chapter demonstrates that new interventional techniques have been introduced over recent years in order to find an adequate non-invasive therapy for adenomyosis. There is no evidence-based medicine to guide us in the treatment of adenomyosis with minimally invasive therapy. In fact, most data regarding adenomyosis and these evolving therapies comes from the inadvertent treatment of adenomyosis in studies designed to treat uterine leiomyomas. Essentially, all data are from case reports or small case series. The problem is compounded by the fact that there is no agreed imaging definition of adenomyosis, and so therapies that do not excise the uterus have no 'gold standard' for comparison. Nonetheless, there are some reports suggesting that there may be efficacy in techniques such as medicated intrauterine devices, uterine artery embolization, and MRI-guided focused ultrasound surgery. Larger studies specifically treating adenomyosis are clearly required. As with every new approach, the widespread success of these techniques will depend on the general adoption of adequate diagnostic solutions and improvements in the technical parameters of these new regimens. Since the techniques presented in this chapter are new, they have not yet undergone the necessary thorough scientific scrutiny and discussion that is needed for their general acceptance. In the past, adenomyosis was mainly a 'post-factum' pathological diagnosis after extensive surgery. Based on the evidence presented in this chapter it seems that adenomyosis has become an entity that might be treatable by new, minimally invasive or non-invasive treatments.

[Adenomyosis: update on a frequent but difficult diagnosis]

Adenomyosis is a frequent entity, with difficult diagnosis, often obtained by pathological analysis performed after hysterectomy. This condition can cause abnormal uterine bleeding and dysmenorrhea, frequent reasons for consultation and hysterectomy. The development of ultrasonographic and magnetic resonance imaging techniques allow preoperative diagnosis. They also permit the use of hysteroscopic techniques for conservative uterine surgery, and have brought diagnosis and management of this disease to the front of the scene. This article reviews the pathological description of the disease, its epidemiology, clinical presentations, useful and necessary explorations, etiopathogeny and available therapies.

MRI of Adenomyosis: Changes with Uterine Artery Embolization

OBJECTIVE

Our objective was to describe the MRI features of patients with pure or dominant adenomyosis treated with uterine artery embolization (UAE) and to correlate imaging features with symptoms.

SUBJECTS AND METHODS

Nineteen patients with symptomatic pure or dominant adenomyosis on MRI were referred for UAE. All 19 patients had repeat MRI 4 months after UAE. The MR images obtained before and after UAE were evaluated for maximal junctional zone thickness, junctional zone-myometrial ratio, uterine volume, and the presence of avascular regions. Patients were asked to complete a questionnaire about their symptoms before and 3 and 12 months after UAE.

RESULTS

Uterine volume decreased significantly after UAE (p < 0.01). The mean uterine volume reduction was 25.1%. Junctional zone thickness decreased significantly (p < 0.001). The junctional zone-myometrial ratio did not decrease significantly (p = 0.526). Fourteen (73.7%) of the 19 patients showed devascularized change within the adenomyotic region. Eighteen patients completed a questionnaire at 3 months. Sixteen (88.9%) of the 18 reported an improvement in symptoms, whereas the two remaining patients (11.1%) reported no change (p < 0.001). Of the 16 patients with clinical improvement, 11 had devascularized areas after UAE and five did not. Eleven of the 18 patients who completed a questionnaire 3 months after UAE also completed a questionnaire 12 months after UAE. Ten of these 11 patients still reported continued improvement, and one patient reported a worsening of symptoms.

CONCLUSION

UAE in patients with pure or dominant adenomyosis results in decreased uterine volume and regions of devascularization. Most patients reported an improvement in clinical symptoms within 3 months after UAE. Some patients reported benefit for at least 1 year; however, the long-term durability of symptomatic relief remains unknown.

MR Imaging Findings of Adenomyosis: Correlation with Histopathologic Features and Diagnostic Pitfalls

Adenomyosis is a nonneoplastic condition, characterized by benign invasion of ectopic endometrium into the myometrium with hyperplasia of adjacent smooth muscle. The common symptoms include dysmenorrhea, menorrhagia, and abnormal uterine bleeding, but these do not allow diagnosis. Therefore, imaging plays an important role because establishment of the correct preoperative diagnosis is critical to avoid unnecessary intervention. Magnetic resonance (MR) imaging is a highly accurate noninvasive modality for diagnosis of adenomyosis, differentiation of adenomyosis from other gynecologic disorders, and planning of appropriate treatment. Although the typical MR imaging findings are well established, adenomyosis actually varies widely in terms of histopathologic features (adenomyosis with sparse glands), growth patterns (polypoid adenomyoma, adenomyotic cyst, and miniature uterus), responses to hormonal activity (tamoxifen, decidual changes), and responses to treatment (gonadotropin-releasing hormone agonist). The MR imaging findings of adenomyosis occasionally mimic those of uterine malignancy or ovarian cancer. Furthermore, malignancy occasionally develops in otherwise benign adenomyosis. Pitfalls in diagnosis of adenomyosis include myometrial contractions, leiomyoma, adenomatoid tumor, metastases, endometrial carcinoma, and endometrial stromal sarcoma. Knowledge of the various appearances of adenomyosis and the possible pitfalls in differential diagnosis help guide the determination of appropriate treatment options.

Expression of Apoptosis-Related Proteins in Adenomyotic Uteri Treated with Danazol and GnRH Agonists

The biologic properties of adenomyosis and the effects of therapeutic agents on adenomyosis were evaluated with immunohistochemistry, terminal deoxy-nucleotidyl transferase-mediated dUTP-biotin nick end-labeling (TUNEL) method, transmission electron microscopy, and analysis of genomic abnormality. In the adenomyotic endometrium, estrogen receptor (ER) expression was more intense than in the eutopic endometrium during the secretory phase, and bcl-2 was constantly expressed throughout the menstrual cycle. The expression of ER and bcl-2 was weaker in the adenomyotic endometrium treated with danazol than in that treated with gonadotro-pin-releasing hormone agonist (GnRHa), whereas bcl-2 phosphorylated on serine-87 was more intensely expressed in danazol-treated adenomyotic endometrium than in the GnRHa-treated one. The number of TUNEL-positive cells increased in the adenomyotic endometrium treated with danazol or GnRHa. Ultrastructurally, most of the adenomyotic endometrial cells treated with danazol underwent postapoptotic necrosis and formed a cluster of dead cells. In contrast, cells treated with GnRHa underwent typical apoptosis and were sparsely distributed in the adenomyotic endometrium. Analysis of several cancer-related genes showed no microsatellite instability or loss of heterozygosity in adenomyotic tissues. Therefore, we conclude that the occurrence of adenomyosis is correlated to bcl-2 expression regulated by estrogen and ER rather than genetic mutation.

MR Imaging of Disorders Associated with Female Infertility: Use in Diagnosis, Treatment, and Management

Magnetic resonance (MR) imaging has extended the usefulness of imaging in evaluation of pelvic disorders associated with female infertility. The causes of female infertility include ovulatory disorders (ie, pituitary adenoma and polycystic ovarian syndrome), disorders of the fallopian tubes (ie, hydrosalpinx and pelvic inflammatory disease), uterine disorders (ie, müllerian duct anomaly, adenomyosis, and leiomyoma), and pelvic endometriosis. Although laparoscopy, hysteroscopy, hysterosalpingography, and transvaginal ultrasonography are the most effective techniques for evaluation of pelvic disorders related to female infertility, MR imaging is used in a variety of clinical settings in diagnosis, treatment, and management. The applications of MR imaging include evaluation of the functioning uterus and ovaries, visualization of pituitary adenomas, differentiation of müllerian duct anomalies, and accurate noninvasive diagnosis of adenomyosis, leiomyoma, and endometriosis. In addition, MR imaging helps predict the outcome of conservative treatment for adenomyosis, leiomyoma, and endometriosis and may lead to selection of better treatment plans and management. Finally, MR imaging may serve as an adjunct to diagnostic laparoscopy and hysterosalpingography in patients with hydrosalpinx, peritubal adhesions, or pelvic adhesions related to endometriosis.

Benign myometrial conditions: leiomyomas and adenomyosis

Leiomyomas and adenomyosis are common benign myometrial conditions. Although their symptoms overlap, traditional treatment of these two entities differs; thus, making the correct diagnosis is critical. Specifically, uterine-conserving therapy is well established for many women with symptomatic leiomyomas, whereas hysterectomy is the treatment for debilitating adenomyosis. Magnetic resonance imaging (MRI) is the most accurate modality for identifying leiomyomas and adenomyosis. T2-weighted sequences often are diagnostic. For leiomyomas, MRI reliably identifies their number, size, and location. These features help triage patients to appropriate therapy. For adenomyosis, MRI establishes the diagnosis in cases of equivocal or nondiagnostic ultrasounds. MRI also has been used to confirm an ultrasound diagnosis of adenomyosis when curative surgery is being considered. Intravenous gadolinium chelates are not necessary to make the diagnosis of either adenomyosis or leiomyomas, but it provides useful information about vascularity of lesions, a factor that may impact the type of treatment undertaken.