Therapeutic options for adenomyosis: a review

Changes of serum CA125 and PGE2 before and after high-intensity focused ultrasound combined with GnRH-a in treatment of patients with adenomyosis

This study aimed to investigate the changes of serum carbohydrate antigen 125 (CA125) and prostaglandin E2 (PGE2) in patients with adenomyosis before and after treatment with high-intensity focused ultrasound (HIFU) combined with gonadotropin-releasing hormone agonist (GnRH-a). One hundred and sixty-five patients with adenomyosis who received HIFU combined with GnRH-a were selected as case group. Sixty-five healthy women who underwent physical examination at the same time were taken as normal control group. At the end of follow-up 6 months after treatment, the case group were divided into effective subgroup and ineffective subgroup according to clinical efficacy. Changes of serum CA125 and PGE2 were analyzed. Serum CA125 and PGE2 levels in the case group were higher than those in the normal control group before treatment (both P < 0.001). Serum CA125 and PGE2 levels in the case group 6 months after treatment were lower than those before treatment (both P < 0.001). There was no difference in serum CA125 and PGE2 levels between effective subgroup and ineffective subgroup before treatment (P = 0.351, 0.284, respectively). Serum CA125 and PGE2 levels in the effective subgroup were lower than those in the ineffective subgroup 6 months after treatment (both P < 0.001). Serum CA125 and PGE2 may be involved in the development of adenomyosis, and their expression levels may be related to the prognosis of patients. Levels of serum CA125 and PGE2 in patients with adenomyosis decrease after treatment with HIFU combined with GnRH-a. The detection of serum CA125 and PGE2 may be used as an index to diagnose adenomyosis and evaluate the therapeutic effect of HIFU combined with GnRH-a.

Laparoscopic adenomyomectomy combined with levonorgestrel-releasing intrauterine system is effective for long-term management of adenomyosis

BACKGROUD

Laparoscopic adenomyomectomy combined with intraoperative placement of levonorgestrel-releasing intrauterine device (LNG-IUS) is a novel conservative surgical procedure for adenomyosis. Our study aimed to compare the efficacy of surgery with or without intraoperative placement of LNG-IUS treatment in adenomyosis.

METHODS

We retrospectively reviewed the medical records of adenomyosis patients who received laparoscopic adenomyomectomy from January 2014 to April 2020, finally including 70 patients undergoing surgery-LNG-IUS as group A and 69 patients undegoing surgery only as group B. Risk factors for three-year relapse were analyzed using Cox's multivariate proportional hazard analysis.

RESULTS

Visual analog scale and Mansfield-Voda-Jorgensen Menstrual Bleeding Scale scores of group A at 3, 6, 12, 24, and 36 months were significantly lower than those of group B at the corresponding points (P < .001 for both scales). Individuals in both groups showed statistically significant symptom relief. The recurrence rate in group A was significantly lower than that in group B at 36 months after the surgery (2.94% vs. 32.84%, P < .001). A cox proportional hazard model showed that relapse was significantly associated with coexisting ovarian endometriosis (adjusted hazard ratio [aHR], 2.94; 95% confidence interval [CI], 1.33-7.02, P = .015). Patients who received surgery-LNG-IUS had a lower risk of recurrence than those with surgery-alone (aHR, 0.07; 95% CI, 0.016-0.31, P < .001).

CONCLUSIONS

Conservative surgery with intraoperative placement of LNG-IUS is effective and well-accepted for long-term therapy with a lower recurrence rate for adenomyosis. Coexistent ovarian endometriosis is a major factor for adenomyosis relapse.

Association of normalization of postoperative carbohydrate antigen 125 levels with treatment failure following uterine artery embolization for adenomyosis

OBJECTIVE

To investigate the association between carbohydrate antigen 125 (CA125) level and adenomyosis treatment failure (TF) after uterine artery embolization (UAE).

METHODS

We evaluated 224 patients with symptomatic adenomyosis who underwent UAE between January 2016 and December 2020. Improvements in dysmenorrhea and menorrhagia were assessed on the basis of symptom relief criteria. The factors associated with TF were investigated using a multivariate logistic regression model. Patients were analyzed for preoperative CA125 levels, postoperative CA125 levels, and the normalization of postoperative CA125 levels. Long-term symptom relief and quality of life after UAE were compared between the groups.

RESULTS

During the 24-month follow-up, 50 patients (22.3%) experienced TF. Compared to patients in the non-TF group, those in the TF group had significantly higher preoperative and postoperative CA125 levels (p < 0.05). Multivariate analysis revealed that failure to normalize postoperative CA125 levels was independently associated with an increased risk of TF (34.7% vs. 8.5%, p < 0.001; hazard ratio 3.953, 95% confidence interval 1.567-9.973, p = 0.004). After a 3-month follow-up period, patients who normalized their CA125 levels were more likely to achieve complete necrosis on magnetic resonance imaging than those who did not (82.1% vs. 56.8%, p < 0.001). Normalization of postoperative CA125 levels was significantly associated with fewer symptoms and better quality of life 12 months after UAE (p < 0.05).

CONCLUSIONS

Following UAE, normalization of postoperative CA125 levels, rather than absolute values, was the strongest predictive marker of TF.

Recurrent embolic stroke associated with adenomyosis: A single case report and literature review

INTRODUCTION

Uterine adenomyosis is a benign disorder in which endometrial glands and stroma are present within the myometrium. There have been several case reports of cerebral infarction associated with adenomyosis, but their clinical characteristics, optimal treatment, and prognosis have not been systematically reviewed.

METHODS

A case of cerebral infarction with adenomyosis is reported, and a comprehensive systematic literature search using the PubMed database was conducted.

RESULTS

A 42-year-old woman, previously diagnosed with adenomyosis, developed multiple cerebral infarctions during menstruation. Her CA125 level was 293 U/mL, and treatment with edoxaban 30 mg was started. Seven days after hospital discharge, she had her subsequent menstrual period and then developed a recurrent stroke. Her CA125 level was 743 U/mL on readmission. A hysterectomy was performed, and the patient has had no further stroke recurrence. A systematic review identified 19 cases with cerebral infarction associated with adenomyosis, including the present case. The patients' clinical characteristics included young age (44.7 ± 6.2 years), stroke development during menstruation (85%), multiple infarctions affecting ≥ 3 vessel territories (39%), and high levels of CA125 and D-dimer (810.6 ± 888.4 U/mL, and 10.3 ± 18.6 μg/mL, respectively). Antithrombotic therapy was given to 14 patients, but recurrent stroke occurred in 5 (36%) patients. Hysterectomy was conducted in 5 and 4 patients with initial and recurrent stokes, respectively, and there were no further recurrences thereafter.

CONCLUSION

Cerebral infarction associated with adenomyosis has specific clinical characteristics. Antithrombotic therapy was insufficient, and hysterectomy should particularly be considered in cases of recurrent stroke.

Protective Effects of Resveratrol Against Adenomyosis in a Mouse Model

Adenomyosis is a uterine condition in which endometrial glands and stroma are commonly pathologically observed in the myometrium. In this study, we sought to determine the effect of resveratrol on the progression of adenomyosis. Adenomyosis was induced in mice given tamoxifen neonatally. All mice were subjected to body weight measurement and hotplate testing every four weeks beginning four weeks after birth. All mice with adenomyosis were randomly separated into 3 groups at 16 weeks: untreated, low-dose resveratrol (25 mg/kg), and high-dose resveratrol (50 mg/kg). After 3 weeks of treatment, final hotplate test and body weight measurement were performed, and the uterine horn blood samples were collected. Adenomyosis in mice caused body weight loss and uterine weight gain, reduced hotplate latency, and progression of endometrial fibrosis. The underlying biological process could be coupled with the overexpression of many cells' proliferation and immune-regulation-related genes. Resveratrol treatment could slow the progression of adenomyosis by enhancing hotplate latency, lowering endometrial fibrosis, and restoring cell proliferation- and immune-regulation-associated gene expression levels in endometrium and plasma. However, resveratrol treatment also reduced the body weight and uterine weight. In conclusion, Resveratrol might be a potential compound for treating patients with adenomyosis.

Uterine disorders and iron deficiency anemia

Abnormal uterine bleeding (AUB) is a clinical entity which can lead to iron deficiency anemia. Classification according to the acronym PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy, and hyperplasia; coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not otherwise classified) provides a structured approach to establish the cause of AUB. The goal of this review is to discuss the different mechanisms and the relationship between uterine disorders and AUB. Heavy menstrual bleeding, a subgroup of AUB, is more closely related to the presence of uterine fibroids. The relationship between heavy menstrual bleeding and uterine fibroids remains poorly characterized, particularly the understanding of endometrial function in women with structural myometrial features such as leiomyomas. A number of theories have been proposed in the literature and are discussed in this review. Uterine adenomyosis is also a frequent cause of AUB, and its pathogenesis is still far from being fully elucidated. The mechanisms contributing to its development are multifactorial. Many theories lean toward invasion of the myometrium by endometrial cells. Both clinical and basic studies favor the theory of direct invasion, although de novo development of adenomyosis from Müllerian rests or stem cells has not been ruled out. Development of adenomyotic lesions involves repeated tissue injury and repair. In addition, this review describes the other causes of AUB such as endometrial polyps, cesarean scar defects, and uterine vascular abnormalities. Endometrial polyps are often asymptomatic, but approximately 68% of women have concomitant AUB. Histologic alterations in the lower uterine segment in patients who had undergone cesarean sections were identified and may explain the cause of AUB.

Microbubble contrast agent SonoVue combined with oxytocin improves the efficiency of high-intensity focused ultrasound ablation for adenomyosis

BACKGROUND

To investigate the combined enhancing effects of microbubble-contrast SonoVue and oxytocin on high-intensity focused ultrasound (HIFU) ablation of adenomyosis.

METHODS

330 patients with adenomyosis were randomly assigned to SonoVue and oxytocin group (group A, n = 82), oxytocin (group B, n = 85), SonoVue (group C, n = 81), or the control (group D, n = 82) for HIFU ablation. In group A, oxytocin was dripped 0.32 IU/min, and HIFU ablation was started one minute after SonoVue injection. In group B, oxytocin was dripped 0.32 IU/min during ablation. In group C, HIFU ablation was started one minute after SonoVue injection. In group D, neither oxytocin nor SonoVue was applied. The clinical data, treatment results, and complications were analyzed.

RESULTS

All participants underwent HIFU treatment safely, and the mean energy efficiency factor (EEF) in the four groups was 4.7 ± 0.9J/mm³, 8.5 ± 0.6J/mm³, 8.9 ± 0.7J/mm³, and 12.6 ± 1.8J/mm³, respectively, with the mean ablation time (AT) of 633.7 ± 55.1 s, 874.2 ± 65.6 s, 936.3 ± 85.2 s, and 1103.2 ± 96.2 s, respectively. The non-perfused volume ratios (NPVR) were 90.4 ± 8.8%, 88.7 ± 9.1%, 89.4 ± 7.2%, 80.5 ± 7.9%, respectively. In addition, EEF and AT were the shortest in group A (p < 0.05). NPVR was significantly higher in group A than in the control group D (p < 0.05). The incidence rates of adverse events were not significantly different in the four groups (p > 0.05).

CONCLUSIONS

Compared to the control group, oxytocin combined with SonoVue in HIFU for adenomyosis can significantly decrease the energy and time needed for the ablation and safely enhance the treatment efficiency by improving the cavitation and heating of HIFU ablation and increasing the non-perfused volume ratio.

The Role of Stem Cells and Their Derived Extracellular Vesicles in Restoring Female and Male Fertility

Infertility is a globally recognized issue caused by different reproductive disorders. To date, various therapeutic approaches to restore fertility have been attempted including etiology-specific medication, hormonal therapies, surgical excisions, and assisted reproductive technologies. Although these approaches produce results, however, fertility restoration is not achieved in all cases. Advances in using stem cell (SC) therapy hold a great promise for treating infertile patients due to their abilities to self-renew, differentiate, and produce different paracrine factors to regenerate the damaged or injured cells and replenish the affected germ cells. Furthermore, SCs secrete extracellular vesicles (EVs) containing biologically active molecules including nucleic acids, lipids, and proteins. EVs are involved in various physiological and pathological processes and show promising non-cellular therapeutic uses to combat infertility. Several studies have indicated that SCs and/or their derived EVs transplantation plays a crucial role in the regeneration of different segments of the reproductive system, oocyte production, and initiation of sperm production. However, available evidence triggers the need to testify the efficacy of SC transplantation or EVs injection in resolving the infertility issues of the human population. In this review, we highlight the recent literature covering the issues of infertility in females and males, with a special focus on the possible treatments by stem cells or their derived EVs.

A Case of Elastography-Assisted Laparoscopic Fertility Preservation for Severe Deep Endometriosis Causing Ureteral Stenosis and Subtype II Adenomyosis

Adenomyosis is commonly treated by total hysterectomy. Adenomyomectomy is considered for women of reproductive age who wish to preserve their fertility. However, a high recurrence rate following adenomyomectomy has been reported because complete removal of the lesion is difficult, and uterine rupture during pregnancy remains a complication. We previously reported that laparoscopic adenomyomectomy using a cold knife prevented thermal damage to the myometrium and elastography to avoid residual lesions. Here, we report the case of a patient who underwent complete resection of a subtype II adenomyosis and resection of deep endometriosis (DE) with the closure of the pouch of Douglas. The patient was 31 years old, had severe dysmenorrhea, and had left ureteral stenosis and subtype II adenomyosis associated with the closure of the pouch of Douglas by the DE. After resection of the DE posterior wall adenomyosis, residual lesions were confirmed by laparoscopic real-time elastography. Eight weeks after surgery, postoperative transvaginal ultrasound showed that the myometrium had shrunk from 28 to 22.7 mm, and the hydronephrosis had disappeared, although a stent remained necessary. In this study, we report the complete resection of subtype II adenomyosis and DE, combined with elastography to visualize the lesions during resection.

A Feasible Technique in Laparoscopic Excision for Juvenile Cystic Adenomyosis: A Case Report, Literature Review, and Surgical Video

Background: Juvenile cystic adenomyosis (JCA) is a rare uterine lesion. We present the case of a young woman who was diagnosed with JCA and subsequently managed with laparoscopic cyst removal with sharp and blunt dissection. Moreover, we provide a literature review and a surgical video. Case: A 22-year-old nulliparous woman presented with severe dysmenorrhea and was assessed using contrast-enhanced abdominal computed tomography, transvaginal ultrasonography and pelvic magnetic resonance imaging, and diagnosed with a cystic lesion on the left side of the myometrium. She underwent laparoscopic cyst excision and uterine reconstruction. Histology was suggestive of JCA. The dysmenorrhea resolved postoperatively. Conclusion: Surgical resection is the first choice of treatment for cystic adenomyosis, and a laparoscopic approach using scissor forceps is effective.

Long-term durability of uterine artery embolisation for treatment of symptomatic adenomyosis

BACKGROUND

Failing conservative therapies, uterine artery embolisation (UAE) has been proposed as a uterine-sparing option for treatment of symptomatic adenomyosis. UAE appears effective at short-term; however long-term durability is less well established.

AIMS

To evaluate the long-term clinical efficacy of UAE for treatment of adenomyosis.

MATERIALS AND METHODS

One hundred and four women with initial clinical success following UAE for adenomyosis (results previously published) were further followed with a two-part online survey. Part one inquired about menopause, symptom recurrence, need for further intervention and overall satisfaction. Part two comprised the Uterine Fibroid Symptom and health-related Quality of Life (UFS-QOL) questionnaire. Maintenance of clinical success was defined as remaining 'happy' or 'very happy' with overall outcome, no recurrence of symptoms, or need for further intervention.

RESULTS

Of those women with initial success, 91/104 (88%) participated in this long-term study at mean 52 months following UAE. Maintenance of clinical success was demonstrated in 82/91 (90%) women. For the remaining 9/91 (10%) women, mean time to failure was 31 months. There were 53/91 (58%) women who reached menopause at mean age of 51.5 years, occurring at mean 30 months post-UAE. UFS-QOL demonstrated significant decrease in symptom severity from 58.9 to 20.0 (P < 0.001); and significant increase in QOL from 40.3 to 86.3 (P < 0.001).

CONCLUSIONS

Long-term durability of UAE for treatment of adenomyosis was demonstrated, with cumulative success rate of 80% at mean 52 months. UAE did not appear to bring forward menopause. UAE should be considered as an alternative to hysterectomy to treat adenomyosis.

Animal Models of Adenomyosis

Adenomyosis is a nonmalignant uterine disorder in which endometrial tissue exists within and grows into the myometrium. Animal models have generated limited insight into the still-unclear pathogenesis of adenomyosis, provided a platform for preclinical screening of many drugs and compounds with potential as therapeutics, and elucidated mechanisms underlying the pain and fertility issues that occur in many women with the disease. Spontaneous adenomyosis has been studied in nonhuman primates, primarily in the form of case reports. Adenomyosis is routinely experimentally induced in mice through methods such as neonatal tamoxifen exposure, pituitary engraftment, and human tissue xenotransplantation. Several studies have also reported hormonal or environmental toxicant exposures that give rise to murine adenomyosis, and genetically engineered models have been created that recapitulate the human-like condition, most notably involving alteration of β-catenin expression. This review describes the animal models for adenomyosis and their contributions to our understanding of the factors underpinning the development of symptoms. Animal models represent a unique opportunity for understanding the molecular basis of adenomyosis and developing efficacious treatment options for affected women. Herein, we assess their different potentials and limitations with regard to identification of new therapeutic interventions and reflect on future directions for research and drug validation.

Significance of changes in inflammatory parameters following uterine artery embolization in pre-menopausal females

The purpose of the present study was to describe the course of changes in laboratory inflammatory markers following bilateral uterine artery embolization (UAE) as a treatment for leiomyomas and adenomyosis. The body temperature was measured and blood samples were collected to determine white blood cell (WBC) count and C-reactive protein (CRP) levels in 270 patients on the day prior to UAE and for up to 4 days post-embolization. Aside from a single case with a non-inflammatory complication, none of the other cases had any complications. Post-UAE leukocytosis with a mean maximum value of 10.8±3.5x10⁹/l (range, 5.9-18.6x10⁹/l) was observed one-year post-intervention. The mean leukocyte numbers were indicated to be higher on day 3 post-UAE. The CRP level was also increased post-UAE, with a mean maximum value of 7.75±3.5 mg/dl. Maximum levels were reached in 8 patients on the 2nd and in 11 patients on the 3rd post-operative day. The maximum pain score was ~5.5 and reached its lowest level at the end of the 12th week post-intervention. The present study did not consider an association between the embolic material used or uterus size with the level of treatment success. No complications were observed post-UAE; however, a significant increase in the WBC count was observed within the first 3 days, indicating mild leukocytosis.

The effect of transcervical endometrial resection on clinical symptoms related to intrinsic adenomyosis and junctional zone changes

Objectives

To assess the effect of transcervical endometrial resection on clinical symptoms related to histopathological findings of the junctional zone.

Study design

This prospective study took place at a university hospital. Premenopausal women suffering from abnormal uterine bleeding and/or pelvic pain and scheduled for transcervical endometrial resection were enrolled (n = 112). Histopathological findings of the endomyometrial biopsies were categorized as follows: Adenomyosis of the inner myometrium (intrinsic adenomyosis): ≥ 2 mm myometrial invasion without contact to the basal endometrium, serrated junctional zone: > 3 mm myometrial invasion with contact to the basal endometrium and linear junctional zone: No or marginal myometrial invasion (≤ 3 mm) with contact to the basal endometrium. All study participants received a baseline and two follow-up questionnaires (6 and 18 months after surgery) regarding symptom severity, health-related quality of life and pelvic pain. Data regarding reintervention surgery was obtained from the National Database Patoweb. The rate of reintervention surgery and the improvement in symptom severity, health-related quality of life and pelvic pain were correlated to histopathological findings.

Results

Twenty-four patients had intrinsic adenomyosis, 31 had serrated junctional zone and 57 had linear junctional zone. Fifteen patients (13%) underwent reintervention surgery; three (20%) within 6 months, nine (60%) between 6–18 months and three (20%) > 18 months after transcervical endometrial resection. Reintervention surgery was more common in women with intrinsic adenomyosis compared to women without (33% (95% CI: 16–55) vs 8% (95% CI: 3–16)) (p-value: < .05). Nine patients (38%) with intrinsic adenomyosis were asymptomatic based on low symptom severity score, high health-related quality of life and no pelvic pain at 18 months follow-up. Patients with linear junctional zone had a higher improvement in symptom severity and health-related quality of life than patients with intrinsic adenomyosis or serrated junctional zone at 6 months follow-up after surgery (p-value < .05). However, there was no significant difference in pelvic pain reduction.

Conclusion

The effect of transcervical endometrial resection may depend upon the degree of junctional zone changes, and patients with intrinsic adenomyosis are more likely to undergo reintervention surgery than patients with either linear or serrated junctional zone. However, intrinsic adenomyosis may also be successfully treated with endometrial resection.

Uterine artery embolisation in women with symptomatic adenomyosis

Adenomyosis is frequently called the "forgotten" diagnosis, because of its non-characteristic clinical appearance. Similar to fibroid symptoms, adenomyosis may be the cause of disabling symptoms such as heavy menstrual bleeding, in particular pain (abdominal-, pelvic-, low back- and menstrual pain), with or without bulk related symptoms and fertility issues in premenopausal women. The current literature demonstrates durable symptom improvement in patients with adenomyosis following uterine artery embolisation. It is no longer justified to withhold women the option of uterine artery embolisation for symptomatic adenomyosis with or without fibroids.

Intrauterine cystic adenomyosis: Report of two cases

BACKGROUND

Cystic adenomyosis is a special type of adenomyosis. Its clinical manifestations lack specificity. Pelvic ultrasound and nuclear magnetic resonance imaging can help clarify the diagnosis. Because cystic uterine adenomyosis is rare in clinical work, it can be easily misdiagnosed or its diagnosis can be missed. Early surgical treatment and postoperative drug treatment can alleviate dysmenorrhea, menorrhagia, anemia, and other symptoms.

CASE SUMMARY

Two cases complained about abnormal vaginal bleeding and were diagnosed with intrauterine cystic adenomyosis by gynecological ultrasound and pathological examination. The clinical manifestations included dysmenorrhea, hypermenorrhea, and a history of cesarean section. Both cases underwent a surgery, and chocolate-like liquid was released from the cystic mass in the uterus and the manifestations were relieved.

CONCLUSION

Intrauterine cystic adenomyosis could be diagnosed by pathological examination and treated by hysterectomy or hystscopy to release the liquid inside.

Experience of Symptoms and Disease Impact in Patients with Adenomyosis

BACKGROUND

Adenomyosis is a poorly understood, benign disease of the uterus.

OBJECTIVE

In this study, patient interviews were conducted to characterize the symptoms and impact of adenomyosis.

METHODS

This was a cross-sectional study in which women with adenomyosis were recruited from five US clinics and a health-related social network forum. Participants (aged 18-55 years) were pre-menopausal with a history of regular menstrual cycles. Participants were interviewed about their experiences with adenomyosis, symptoms and impacts on day-to-day activities (concept elicitation), and subsequently about the occurrence, relative severity, and impact of symptoms (card-sorting exercise).

RESULTS

In total, 31 women were interviewed. Mean duration since onset of first adenomyosis symptom was 5.7 years; 41.9% reported severe/very severe adenomyosis. Over 50 symptoms and 30 impacts of adenomyosis were reported in the concept elicitation; 87% of symptoms were reported after 7 interviews and 78% of impacts after 5 interviews, indicating a condition with a significant symptom burden and a consistent presentation. The most common symptoms were heavy menstrual bleeding (87%), cramps (84%), and blood clots during menstrual bleeding (84%). The most common impacts were burdensome self-care hygiene (71%), and fatigue/low energy (71%). In the card-sorting exercise, the most commonly endorsed symptoms were pain during menstruation/menstrual cramps and heavy menstrual bleeding (both frequently rated as severe). The symptom with the highest impact was heavy menstrual bleeding.

CONCLUSION

Initiatives to understand women's experiences with adenomyosis may improve management of the condition. This study provides a first step in understanding their experience and new information on the symptom profile of adenomyosis.

Treatment options and reproductive outcome for adenomyosis-associated infertility

PURPOSE

Adenomyosis is a benign gynecological disease mostly diagnosed in the forth and fifth decades. The recent improvement of the diagnostic tools and a better understanding of the pathology allowed clinicians to postulate a possible relationship between adenomyosis and infertility and to diagnose it in younger asymptomatic women during infertility work-up. Purpose of this article is to review the different theories regarding the possible correlation between adenomyosis and infertility and to discuss the treatment options and the final reproductive outcome after the treatment.

MATERIALS AND METHODS

We search Pubmed for articles published in the English language with the use of the following MeSH search terms: "adenomyosis" combined with "treatment" and "fertility outcome" with the restriction to the human species. A manual search of review articles and cross-references completed the search. All selected articles were assessed for study design, patients characteristic, diagnosis of adenomyosis, type of treatment, post-treatment rates of conception, full-term pregnancy and completeness of information of the data sets.

RESULTS

Limited data are available concerning the efficacy of the different treatment options of adenomyosis on fertility outcome and the only ones published are retrospective evaluations or small case series.

CONCLUSIONS

Adenomyosis represents a common gynecological disorder with a negative impact on fertility. However, it remains challenging to establish if adenomyosis is the only cause of the infertility or not, because patients, in both case and control groups, may be affected by concomitant endometriosis. Further studies are required to determine the reason of implantation failure in women with adenomyosis and the impact of adenomyosis on infertile women with or without endometriosis.

Adenomyosis and urinary system symptoms

OBJECTIVE

This study aims to investigate the presence and incidence of overactive bladder (OAB) syndrome in patients diagnosed with adenomyosis and to evaluate the impacts of urinary symptoms on the quality of life of the patients.

MATERIALS AND METHODS

A total of 108 individuals including 50 patients with adenomyosis and 58 controls who were admitted to the Obstetrics and Gynecology Department of Bursa, Cekirge State Hospital and Derince Training and Research Hospital between April 2015 and December 2015 were included. The Urogenital Distress Inventory (UDI-6) and Incontinence Impact Questionnaire (IIQ-7) were used to evaluate symptoms.

RESULTS

Irritative urinary symptoms such as nocturia and frequency were seen more frequently in the adenomyosis group (p = 0.001 and p = 0.035). Overactive bladder symptoms were more common in the adenomyosis group (p = 0.0001).

CONCLUSION

Our study showed that symptoms of urinary tract symptoms are common in patients with adenomyosis, which adversely affect the quality of life.

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.

The Role of Hysteroscopy in the Diagnosis and Treatment of Adenomyosis

Uterine adenomyosis is a common gynecologic disorder in women of reproductive age, characterized by the presence of ectopic endometrial glands and stroma within the myometrium. Dysmenorrhea, abnormal uterine bleeding, chronic pelvic pain, and deep dyspareunia are common symptoms of this pathological condition. However, adenomyosis is often an incidental finding in specimens obtained from hysterectomy or uterine biopsies. The recent evolution of diagnostic imaging techniques, such as transvaginal sonography, hysterosalpingography, and magnetic resonance imaging, has contributed to improving accuracy in the identification of this pathology. Hysteroscopy offers the advantage of direct visualization of the uterine cavity while giving the option of collecting histological biopsy samples under visual control. Hysteroscopy is not a first-line treatment approach for adenomyosis and it represents a viable option only in selected cases of focal or diffuse “superficial” forms. During office hysteroscopy, it is possible to enucleate superficial focal adenomyomas or to evacuate cystic haemorrhagic lesions of less than 1.5 cm in diameter. Instead, resectoscopic treatment is indicated in cases of superficial adenomyotic nodules > 1.5 cm in size and for diffuse superficial adenomyosis. Finally, endometrial ablation may be performed with the additional removal of the underlying myometrium.

Single- and Multiple-Day Dosing Studies to Investigate High-Dose Pharmacokinetics of Epelsiban and Its Metabolite, GSK2395448, in Healthy Female Volunteers

Open-label single- and double-blind repeat-dose studies in healthy female volunteers were conducted to investigate the pharmacokinetics (PK) and safety/tolerability of epelsiban total daily doses ranging from 600 to 900 mg. In 1 study (n = 12), epelsiban was dosed at 300 or 450 mg twice daily (every 12 hours) for a single day. In the repeat-dose double-blind study, epelsiban and placebo were administered to 31 subjects as 200 mg 3 times daily, 300 mg 3 times daily (TID), or 450 mg twice daily (BID) for 14 days. After both single and 14 daily repeat doses, the PK profiles for epelsiban and its metabolite, GSK2395448, remained linear at all administered doses. The exposures at a given total daily dose were also similar between BID and TID dosing regimens. Exposure (AUC_0-τ ), based on dosing intervals, for both epelsiban and GSK2395448 was similar. However, compared with morning dosing, C_max was lower after evening dosing, possibly because of a food effect. The highest accumulation of epelsiban and GSK2395448 exposures (AUC_0-τ ) was approximately 34% for each after repeat dosing, consistent with the short half-life. At total daily doses of 600 and 900 mg, epelsiban was generally well tolerated, and there were no significant safety concerns identified.

Pitfalls of Sonographic Imaging of Uterine Leiomyoma

Leiomyomas are the most common uterine tumor and the most common cause of uterine enlargement in the nonpregnant patient. Sonography is the imaging modality of choice for the initial diagnosis and imaging workup of uterine leiomyomas and is also extremely helpful in determining the etiology of a broad range of pelvic symptoms in the female patient. Although the classic sonographic appearance of uterine leiomyomas is well established and easily recognizable, other pelvic masses may occasionally be confused with uterine leiomyomas, and the ability to distinguish between these entities is crucial in optimizing appropriate patient care. This article will review pelvic abnormalities that can be confused on ultrasound with uterine leiomyomas and potential methods that can be used to avoid these pitfalls.

Leonurine Attenuates Hyperalgesia in Mice with Induced Adenomyosis

Background

Adenomyosis, defined as the invasion of endometrial glands and stroma into the myometrium, is a common gynecological disorder. In the present study we report on the effect of leonurine on ICR mice with adenomyosis induced by neonatal tamoxifen.

Material/Method

After being treated with tamoxifen for 4, 8, and 12 weeks, we assessed body weight and pain modulation in mice in hotplate tests. The mice were divided into 5 groups: a low-dose leonurine treatment group, a high-dose leonurine treatment group, a valproic acid (VPA) treatment group, a vehicle only treatment group, and a blank control group. We evaluated body weight, pain modulation in hotplate tests, and the depth of myometrial infiltration. Immunoreactivity staining of progesterone receptor (PR), nuclear factor-κB phosphorylated-p65 (p-p65), cyclooxygenase-2 (COX-2), and oxytocin receptor (OTR) was evaluated by immunohistochemistry.

Results

The measurement of the body weight, myometrial infiltration, and pain modulation showed that neonatal tamoxifen treatment led to adenomyosis. Leonurine treatment appeared to decrease hyperalgesia and myometrial infiltration. Immunoreactivity staining showed decreased p-p65, COX-2, and OTR protein expressions.

Conclusions

Our results indicate that leonurine attenuates hyperalgesia in mice with induced adenomyosis via down-regulating expressions of p-P65, COX-2, and OTR, and could be beneficial for treating adenomyosis.

Outcomes in Adenomyosis Treated with Uterine Artery Embolization Are Associated with Lesion Vascularity: A Long-Term Follow-Up Study of 252 Cases

Purpose

To study the therapeutic effects of uterine artery embolization (UAE) on adenomyosis and to investigate the association between uterine blood supply and artery embolization treatment outcomes.

Methods

Using digital subtraction angiography (DSA) imaging data, we retrospectively evaluated the vascular features of 252 adenomyosis patients treated with UAE. The cases were classified based on the equality of uterine blood supply (equal and unequal subgroups) and the degree of vascularity at the adenomyosis lesion site (hypervascular, isovascular and hypovascular subgroups). Patients were followed-up for 5 years after UAE. Improvements in dysmenorrhea and menorrhagia were evaluated based on the relief of the patients’ symptoms. The improvement rates among the different subgroups were analyzed and compared.

Results

The improvement rates of dysmenorrhea and menorrhagia were 74.0% and 70.9%, respectively, at the short-term (12-month) follow-up and 70.4% and 68.8%, respectively, at the long-term (5-year) follow-up. No statistically significant differences were observed in the improvement rates for dysmenorrhea or menorrhagia between the equal and unequal blood supply subgroups at either the short- or long-term follow-up. The improvement rates for dysmenorrhea among the hypervascular, isovascular and hypovascular subgroups were 86.5%, 71.8% and 58.8%, respectively, at the short-term follow-up (p = 0.002) and 83.6%, 67.3% and 52.8%, respectively, at the long-term follow-up (p = 0.005). The improvement rates for menorrhagia in the hypervascular, isovascular and hypovascular subgroups were 81.0%, 68.3% and 60.7%, respectively, at the short-term follow-up (p = 0.024) and 79.4%, 61.4% and 62.2%, respectively, at the long-term follow-up (p = 0.052).

Conclusion

UAE is effective in treating patients with adenomyosis in both the short and long term. The outcomes of patients with adenomyosis were significantly correlated with lesion vascularity.

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.

Laparoscopic Radiofrequency Thermal Ablation for Uterine Adenomyosis

BACKGROUND AND OBJECTIVES

Symptomatic uterine adenomyosis, unresponsive to medical therapy, is a challenging condition for patients who desire to preserve their uterus. This study was an evaluation of the feasibility and efficacy of laparoscopic radiofrequency thermal ablation of symptomatic nodular uterine adenomyosis.

METHODS

Fifteen women with symptomatic nodular adenomyosis, who had no plans for pregnancy but declined hysterectomy, underwent radiofrequency thermal ablation. Ultrasonography was performed at baseline and at postoperative follow-ups at 3, 6, 9, and 12 months. The impact of uterine adenomyosis-related symptoms was assessed according to the visual analog scale.

RESULTS

The median number of nodular lesions treated per patient was 1 (range, 1-2). The median baseline volume of the adenomyosis area was 60 cm(3) (range, 18-128). The median reduction in volume was 32, 49.4, 59.6, and 65.4% at 3, 6, 9, and 12 months, respectively. A significant progressive improvement in the symptoms score was observed at the 4 follow-ups.

CONCLUSION

In this study, laparoscopic radiofrequency thermal ablation reduced uterine adenomyosis-related symptoms and volume, with significant relief of symptoms.

Medical treatment for adenomyosis and/or adenomyoma

Uterine adenomyosis and/or adenomyoma is characterized by the presence of heterotopic endometrial glands and stroma within the myometrium, >2.5 mm in depth in the myometrium or more than one microscopic field at 10 times magnification from the endometrium-myometrium junction, and a variable degree of adjacent myometrial hyperplasia, causing globular and cystic enlargement of the myometrium, with some cysts filled with extravasated, hemolyzed red blood cells, and siderophages. Hysterectomy is a "gold standard" and definitive therapy for uterine adenomyosis, and many cases of adenomyosis have been diagnosed by pathological review retrospectively. As such, the diagnosis of adenomyosis is difficult, and this subsequently results in difficulty in the management of these patients, especially those who are symptomatic but have a strong desire to preserve their uterus. In our previous review, we found that the use of uterine-sparing surgery in the management of uterine adenomyosis and/or adenomyoma is still controversial, although some data support its feasibility. Conservative treatment is still needed in the group of patients that requires preservation of fertility and improvement of quality of life. However, studies focusing on the topic of medical treatment for adenomyosis are rare. In this article, current knowledge regarding the use of medical therapy for uterine adenomyosis, partly based on the understanding of endometriosis, is reviewed.

Surgical Management of Abnormal Uterine Bleeding in Fertile Age Women

Abnormal uterine bleeding is a common gynecological disease and represents one of the most frequent reasons for hospital admission to a specialist unit, often requiring further surgical treatment. Following the so-called PALM-COEIN system we will attempt to further clarify the surgical treatments available today. The first group (PALM) is characterized by structural lesions, which may be more appropriately treated by means of surgical management. Although hysterectomy remains the definitive and decisive choice, there are many alternative techniques available. These minimally invasive procedures offer the opportunity for a more conservative approach. Precise and accurate counseling facilitates better patient selection, based on the patient's desires, age and disease type, allowing treatment to be individually tailored to each woman.

Adenomyosis: Epidemiology, Risk Factors, Clinical Phenotype and Surgical and Interventional Alternatives to Hysterectomy

Adenomyosis is an important clinical challenge in gynecology and healthcare economics; in its fully developed form, hysterectomy is often used to treat it in premenopausal and perimenopausal women. Symptoms of adenomyosis typically include menorrhagia, pelvic pain and dysmenorrhea. Moreover, adenomyosis and leiomyomas commonly coexist in the same uterus, and differentiating the symptoms for each pathological process can be problematic. Although it has been recognized for over a century, reliable epidemiological studies on this condition are limited, because only postoperative diagnoses were possible in the past. Minimally invasive surgical techniques (endometrial ablation/resection, myometrial excision/reduction, myometrial electrocoagulation, uterine artery ligation) have had limited success in the treatment of adenomyosis, and the reported data for these procedures have been obtained from case reports or small case series with only short follow-up times. However, newer techniques including uterine artery embolization (UAE) and magnetic resonance imaging guided focused ultrasound (MRgFUS) show promise in treating adenomyosis. The data is strongest for UAE; these studies have the largest patient cohorts. However, none of the UAE studies were randomized or controlled. Thus, despite the clinical importance of adenomyosis, there is little evidence on which to base treatment decisions. The objective of this review is to summarize the epidemiology, risk factors, clinical phenotype and to evaluate the accrued experience with surgical and interventional alternatives to hysterectomy.

Value of magnetic resonance imaging in diagnosis of adenomyosis and myomas of the uterus

STUDY OBJECTIVE

To estimate the diagnostic performance of magnetic resonance imaging (MRI) in detection of myomas and adenomyosis of the uterus.

DESIGN

Prospective cohort observational study (Canadian Task Force classification II-2).

SETTING

Department of obstetrics and gynecology, tertiary academic hospital.

PATIENTS

One hundred fifty-three consecutive women with an enlarged uterus accompanied by gynecologic symptoms and/or with an asymptomatic pelvic mass.

INTERVENTION

Total abdominal hysterectomy. All patients underwent MRI before the operation.

MEASUREMENTS AND MAIN RESULTS

The sensitivity, specificity, positive, and negative predictive value of MRI for the diagnosis of uterine pathology was calculated using histologic findings as the standard criterion for final diagnosis. Receiver operating characteristics curves were constructed to describe the diagnostic performance of MRI. In the diagnosis of myomas, MRI demonstrated sensitivity of 94.1%, specificity of 68.7%, PPV of 95.7%, and NPV of 61.1%. In the diagnosis of adenomyosis, MRI demonstrated sensitivity of 46.1%, specificity of 99.1%, PPV of 92.3%, and NPV of 88.5%. The area under the curve (AUC) for the diagnostic performance of MRI in the detection of myomas and adenomyosis was 0.81 and 0.73, respectively. Uterine sarcoma was diagnosed in 5 patients; in these cases, MRI demonstrated sensitivity of 60.0%, specificity of 99.2%, PPV of 75.0%, and NPV of 98.4%. The AUC for MRI in the diagnosis of uterine sarcomas was 0.80.

CONCLUSIONS

MRI exhibits a high AUC for the diagnosis of both adenomyosis and myomas. The PPV of MRI in the diagnosis of adenomyosis and myomas of the uterus is high as well. MRI seems to be a useful technique in everyday clinical practice in the diagnostic approach of these common conditions, enabling clinicians to select the most appropriate management.

An update on adenomyosis

Adenomyosis is a common benign uterine pathology that is defined by the presence of islands of ectopic endometrial tissue within the myometrium. It is asymptomatic in one third of cases, but when there are clinical signs they remain non-specific. It can often be misdiagnosed on sonography as it may be taken to be multiple uterine leiomyomata or endometrial thickening, both of which have a different prognosis and treatment. Adenomyosis is often associated with hormone-dependent pelvic lesions (myoma, endometriosis, or endometrial hyperplasia). It is less commonly connected to infertility or obstetrical complications and indeed any direct relationship remains controversial. The purpose of imaging is to make the diagnosis, to determine the extent of spread (focal or diffuse, superficial or deep adenomyosis, adenomyoma), and to check whether there is any associated disease, in particular endometriosis. The aim of this article is to provide assistance in recognising adenomyosis on imaging and to identify the pathologies that are commonly associated with it in order to guide the therapeutic management of symptomatic patients. Pelvic ultrasonography is the first line investigation. Sonohysterography can assist with diagnosis in some cases (pseudothickening of the endometrium seen on sonography). MRI may be used in addition to sonography to back up the diagnosis and to look for any associated disease.

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.

Norethindrone acetate in the medical management of adenomyosis

The role of norethindrone acetate (NA) in the management of adenomyosis was evaluated with a retrospective chart review of 28 premenopausal women between 27–49 years of age presenting with moderate to severe pelvic pain and bleeding. Bleeding and dysmenorrhea scores were analyzed using paired T-tests. There was significant improvement of both dysmenorrhea and bleeding after treatment. Age showed no correlation with dysmenorrhea or bleeding. Low dose NA could be considered an effective, well-tolerated and inexpensive medical alternative to surgery for treating symptomatic adenomyosis. Large multicentric studies may help validate our findings.

Providing holistic care for women with chronic pelvic pain

Chronic pelvic pain (CPP) is one of the most common pain conditions affecting women and can have a significant impact on quality of life. Assessment of women with CPP is best approached in a comprehensive, systematic manner that includes exploration of physiological and psychological causes. A range of treatment options that draw from conventional medicine and complementary and alternative modalities should be offered. The women's health nurse plays a pivotal role in all aspects of care.

Adenomyosis: a challenge in clinical gynecology

Adenomyosis is a prevalent, benign gynecologic condition in which endometrial tissue invades the myometrium, causing myometrial inflammation and hypertrophy. Although some women with adenomyosis are asymptomatic, the condition often causes menorrhagia and dysmenorrhea. This article provides women's health providers with a review of causes and risk factors for developing adenomyosis, clinical presentations of women with the condition, diagnostic modalities and criteria, and medical and surgical treatment options.

Long-term follow-up of uterine artery embolization for symptomatic adenomyosis

INTRODUCTION

Long-term results of uterine artery embolization (UAE) for adenomyosis are largely unknown. We assess long-term outcome of UAE in 40 women with adenomyosis.

MATERIALS AND METHODS

Between March 1999 and October 2006, 40 consecutive women with adenomyosis (22 in combination with fibroids) were treated with UAE. Changes in junction zone thickness were assessed with magnetic resonance imaging (MRI) at baseline and again at 3 months. After a mean clinical follow-up of 65 months (median 58 [range 38-129]), women filled out the uterine fibroid symptom and quality of life (UFS-QoL) questionnaire, which had additional questions on the long-term evolution of baseline symptoms and adverse events.

RESULTS

During follow-up, 7 of 40 women (18%) underwent hysterectomy. Among these 7 women, the junction zones were significantly thicker, both at baseline (mean 23 vs. 16 mm, P = 0.028) and at 3-month follow-up (mean 15 vs. 9 mm, P = 0.034). Of 33 women with preserved uterus, 29 were asymptomatic. Four patients had symptom severity scores of 50 to 85 and overall QoL scores of 60 to 66, indicating substantial clinical symptoms. There was no relation between clinical outcome and the initial presence of fibroids in addition to adenomyosis.

CONCLUSION

In women with therapy-resistant adenomyosis, UAE resulted in long-term preservation of the uterus in the majority. Most patients with preserved uterus were asymptomatic. The only predictor for hysterectomy during follow-up was initial thickness of the junction zone. The presence or absence of fibroids in addition to adenomyosis had no relation with the need for hysterectomy or clinical outcome.