Adenomyosis and Abnormal Uterine Bleeding (AUB-A)—Pathogenesis, diagnosis, and management

Differences in the Sonographic Features of Adenomyosis and Concurrent Endometriosis Compared to Isolated Adenomyosis: A MUSA Criteria Analysis

OBJECTIVE

To examine whether the co-occurrence of endometriosis affects the sonographic features of adenomyosis based on the revised Morphological Uterus Sonographic Assessment (MUSA) criteria.

METHODS

This prospective cohort study utilized data from a tertiary referral center collected between 2010 and 2022. Non-pregnant women aged 20-53 years who presented with symptoms potentially related to adenomyosis and underwent pelvic ultrasound scans were included. Diagnoses were based on the revised MUSA criteria, which distinguish between direct features (endometrial cysts, hyperechogenic islands, echogenic sub-endometrial lines, and buds) and indirect features (globular shape of the uterus, asymmetrical uterine wall thickening, irregular junctional zone, fan-shaped shadowing, translesional vascularity, and interrupted junctional zone). Patients were categorized into 2 groups: 1) concurrent adenomyosis and endometriosis and 2) isolated adenomyosis. Demographic and clinical characteristics were retrospectively collected.

RESULTS

Ninety-four patients were diagnosed with adenomyosis. Of these, 24 (27%) had concurrent endometriosis, while 70 had isolated adenomyosis. The most frequent sonographic features were globular uterine configuration (52%), myometrial cysts (44%), and asymmetrical myometrial thickening (33%). The isolated adenomyosis group had a higher proportion of direct features (29%) and both direct and indirect features (33%) compared to the concurrent group, which predominantly exhibited indirect features (71%) (P < .05). Direct features of myometrial cysts were significantly more frequent in the isolated adenomyosis group (51%) compared to the concurrent group (21%, P = .01).

CONCLUSIONS

Utilizing the revised MUSA criteria revealed significant differences in the sonographic features of adenomyosis in symptomatic patients with concurrent endometriosis compared to isolated adenomyosis. This highlights the necessity for standardized diagnostic methods and enhances understanding of the complex relationship between adenomyosis and endometriosis, underscoring the importance of accurate diagnosis in clinical practice.

Effect of adenomyosis on placenta-related obstetric complications

RESEARCH QUESTION

What is the relationship between sonographic diagnosis of isolated adenomyosis and placenta-associated obstetric outcomes?

DESIGN

In this 12-year retrospective cohort study (2010-2022), patients presenting with adenomyosis-related symptoms were assessed via ultrasound. The study included 59 women diagnosed with adenomyosis and 62 controls, leading to 203 births (90 in the adenomyosis group and 113 in the control group). Patients with endometriosis, uterine fibroids and anomalies, and those using assisted reproductive technology were excluded. The primary outcome focused on a composite of placenta-associated adverse outcomes, including preterm birth, small-for-gestational-age fetuses, hypertensive disorders of pregnancy, placental abruption and post-partum haemorrhage.

RESULTS

No clinically significant differences in demographic characteristics were noted between the two groups. However, the adenomyosis group showed a significantly higher rate of adverse placental function outcomes (27%) compared with the control group (11%, P = 0.005). Adjusted analyses for maternal age, parity and aspirin usage revealed increased risk of hypertensive disorders (adjusted OR 5.91, 95% CI 1.50-30.0; P = 0.017) and adverse placental function outcomes (adjusted OR 3.44, 95% CI 1.53-8.09; P = 0.003) in the adenomyosis group.

CONCLUSION

Adenomyosis is significantly associated with increased risk of adverse placental function outcomes and hypertensive disorders of pregnancy. These findings suggest that adenomyosis may have a distinct impact on pregnancy, underscoring the need for further research to elucidate specific sonographic characteristics of adenomyosis and their effects on placental function.

Value of serum muscular creatinine phosphokinase levels in patients with adenomyosis as a non-invasive diagnostic marker

OBJECTIVE

In the present study, we aimed to compare serum CK-MM levels in patients with and without adenomyosis and to investigate whether CK-MM level can be a non-invasive marker for myometrial damage due to adenomyosis.

MATERIALS AND METHODS

Our study was a prospective case-control study in a tertiary center and consisted of 40 patients with a clinical/ultrasonographic diagnosis of adenomyosis and 40 patients without a clinical/ultrasonographic diagnosis of adenomyosis as the control group based on recently published morphological uterus sonographic assessment (MUSA) criteria. Individuals of similar age who signed a voluntary consent form were included in our study. Demographic, clinical, and laboratory findings of the patients in both groups were recorded. Blood serum samples were used for the determination of serum CK-MM levels of the participants in our study. The samples were analyzed by using the human CK-MM enzyme-linked immunosorbent assay (ELISA) kit.

RESULTS

In our study, the mean serum CK-MM level was 16.2 ± 21.7 (ng/dL) in patients with adenomyosis and 2.6 ± 2.2 (ng/dL) in patients without adenomyosis. Serum CK-MM level was statistically significantly higher in the patient group with adenomyosis than in the control group (p < 0.001). The CK-MM threshold value of 3.43 ng/mL, with a sensitivity of 82.5% and specificity of 85%, has been found to be a valuable distinguishing level in patients with and without adenomyosis.

CONCLUSION

In this study, we demonstrated that serum CK-MM can be used as a non-invasive diagnostic method in patients with adenomyosis. As the number of studies around this subject in the literature is insufficient, larger studies are needed to use CK-MM as a diagnostic marker in adenomyosis.

Efficacy and uterine bleeding patterns in initiating goserelin therapy during different menstrual phases in patients with adenomyosis: a prospective cohort study

OBJECTIVE

We carried out this study to explore the possibility of initiating goserelin therapy during the non-menstrual period in patients diagnosed with adenomyosis.

METHODS

115 premenopausal adenomyosis patients were enrolled and divided into three groups based on their menstrual cycle phase during the initial outpatient visit: menstrual, follicular, and luteal. Each received a 3.6 mg subcutaneous dose of goserelin monthly for three months. The endpoints encompassed alterations in uterine volume, dysmenorrhea Numerical Rating Scale (NRS) score, CA125 level, hemoglobin (HGB) after a 12-week treatment course, and the occurrence and duration of uterine hemorrhage during the first treatment cycle.

RESULTS

Analysis revealed that the timing of goserelin therapy initiation in the menstrual cycle did not significantly impact its effectiveness in reducing uterine size, alleviating pain, lowering CA125 levels, or improving hemoglobin concentrations. However, patients starting treatment during the luteal phase experienced increased uterine bleeding (reference: menstrual period, OR = 4.33, 95% CI 1.23-15.25, p = .023).

CONCLUSIONS

The results suggested non-inferiority of goserelin therapy initiated during the non-menstrual period, but the uterine bleeding rate was higher in the luteal phase group. Therefore, goserelin treatment for outpatient adenomyosis patients should not be limited to starting during the menstrual period; it can also be initiated outside the menstrual period, providing more convenience for patients as most consultations occur outside the menstrual period. However, the use of goserelin during the luteal phase should be avoided to reduce the risk of exacerbated bleeding, especially in anemic patients with heavy menstrual bleeding. This study highlights the importance of individualizing treatment initiation based on the patient's health profile to optimize therapeutic outcomes and minimize adverse effects.

TRIAL REGISTRATION

ChiCTR2200059548.

Factors associated with dysmenorrhoea and menorrhagia improvement in patients with adenomyosis after uterine artery embolisation

BACKGROUND

This study examined the improvement of dysmenorrhoea and menorrhagia after uterine artery embolisation (UAE) in women with symptomatic adenomyosis and identified factors that could predict the improvement of dysmenorrhoea and menorrhagia.

METHODS

This retrospective study included women with adenomyosis who underwent bilateral UAE between December 2014 and December 2016. The percentage of the volume of the absence of contrast enhancement on T1-weighted images was evaluated 5-7 days after UAE. A receiver operating characteristic (ROC) analysis was used to determine a cut-off point and predict the improvement of dysmenorrhoea and menorrhagia.

RESULTS

Forty-eight patients were included. At 24 and 36 months after UAE, the improvement rates for dysmenorrhoea and menorrhagia were 60.4% (29/48) and 85.7% (30/35), and the recurrence rates were 19.4% (7/36) and 9.1% (3/33), respectively. Only the percentage of the volume of the absence of contrast enhancement on T1-weighted images was associated with the improvement of dysmenorrhoea (p = 0.001, OR = 1.051; 95% CI: 1.02-1.08) and menorrhagia (p = 0.006, OR = 1.077; 95% CI: 1.021-1.136). When the cut-off value of the ROC analysis was 73.1%, sensitivity, specificity, positive predictive value, and negative predictive value for the improvement of dysmenorrhoea were 58.6%, 94.7%, 94.4%, and 60%, while they were 58.9%, 80%, 100%, 100%, and 45.5% for the improvement of dysmenorrhoea.

CONCLUSION

Bilateral UAE for symptomatic adenomyosis led to good improvement of dysmenorrhoea and menorrhagia. The percentage of the volume of the absence of contrast enhancement on T1-weighted images of the uterus in postoperative magnetic resonance imaging might be associated with the improvement of dysmenorrhoea and menorrhagia.

Management of Abnormal Uterine Bleeding Among Reproductive Age Group Women: A Cross-Sectional Study

Background: Abnormal uterine bleeding (AUB) is a common gynecological complaint affecting women of reproductive age. This study aimed to explore the management of AUB using the FIGO PALM-COEIN classification system. Methods: A cross-sectional study was conducted at King Abdullah bin Abdulaziz University Hospital, reviewing 500 medical records of women aged 20-50 years with AUB. Data on demographics, clinical characteristics, PALM-COEIN classification, and treatment modalities were collected and analyzed. Results: The majority of participants were aged 20-29 years (43%) and overweight or obese (64.2%). Ovulatory dysfunction (31.6%) was the most common identifiable cause of AUB, followed by leiomyoma (16.8%). Hormonal treatments, particularly combined oral contraceptive pills, were associated with improved outcomes (OR = 2.15, p < 0.001) and reduced anemia prevalence (p = 0.042). Age (OR = 0.95, p = 0.015) and BMI (OR = 1.10, p = 0.005) were significant predictors of treatment response. The presence of leiomyoma decreased the odds of treatment success (OR = 0.55, p = 0.007), while ovulatory dysfunction increased the likelihood of response (OR = 1.75, p = 0.003). Conclusions: The study highlights the complex nature of AUB and the effectiveness of hormonal treatments in its management. Findings emphasize the need for individualized treatment approaches based on the underlying etiology and patient characteristics. Future research should focus on long-term outcomes and optimizing management strategies for complex cases.

Application of the Morphological Uterine Scoring Assessment in Ultrasound for Abnormal Uterine Bleeding

Abnormal uterine bleeding (AUB) is a common gynecological condition that disrupts women's health due to irregularities in menstrual frequency, duration, and volume, often resulting in a significant impact on daily life and productivity. Accurate diagnosis of AUB is critical but complicated by its varied etiologies and presentations. Recent advancements in imaging techniques, particularly the Morphological Uterus Sonographic Assessment (MUSA), have enhanced the diagnostic precision of uterine pathologies such as fibroids and adenomyosis. MUSA combines gray-scale sonography, color Doppler, and three-dimensional ultrasound to evaluate uterine abnormalities with standardized terminology, ensuring diagnostic consistency. This study aimed to assess the efficacy of MUSA in diagnosing and managing AUB. A descriptive observational study was conducted on 50 patients at Dr. D. Y. Patil Medical College and Hospital, focusing on pre- and post-menopausal women with clinically symptomatic AUB. Patients underwent detailed ultrasonography, including both transabdominal and transvaginal scans, to evaluate uterine structures and correlate findings with histopathology. Results showed that 62% of patients had adenomyosis, while 38% had fibroids. MUSA effectively differentiated between the two conditions based on key ultrasound characteristics such as serosal contour, junctional zone, myometrial wall symmetry, and echogenicity. Adenomyosis cases showed significantly higher rates of heterogeneous echogenicity and asymmetrical myometrial walls compared to fibroids. Statistical analyses revealed high diagnostic sensitivity and specificity for both conditions, with an overall accuracy of 88.9% for adenomyosis and 94.1% for fibroids. The findings confirm the utility of MUSA in improving diagnostic accuracy and informing management strategies for AUB, particularly in complex cases. The study highlights MUSA as an indispensable tool for clinicians, facilitating enhanced patient outcomes through precise evaluation and treatment of uterine pathologies.

The suture fixation of the levonorgestrel-releasing intrauterine device with hysteroscope for the treatment of adenomyosis in patients at high risk of device expulsion-a prospective observational study

BACKGROUND

This study aimed to investigate the safety and efficacy of suture fixation of the levonorgestrel-releasing intrauterine device (LNG-IUD) by hysteroscope for the treatment of adenomyosis in patients at high risk of device expulsion, to provide a viable treatment option for these patients.

METHODS

Twenty-one patients with large symptomatic adenomyosis were sewed and fixed with the LNG-IUD in the uterus by hysteroscopy to prevent the device expulsion.

RESULTS

In this prospective case series, all 21 patients were successfully sewed and fixed with the LNG-IUD in the uterus by hysteroscopy. The amount of menstruation was significantly decreased and dysmenorrhea was significantly relieved in 3, 6, and 12 months after surgery compared with before surgery. Only one patient underwent a laparoscopic hysterectomy due to dysmenorrhea which was not alleviated one month later. Serious IUD complications including expulsion and perforation were not observed. There was no development of new side effects than LNG-IUD insertion.

CONCLUSION

Our findings indicate that suture fixation of the LNG-IUD by hysteroscope is a safe, effective, and minimally invasive surgical procedure to prevent the device expulsion. It is a good solution for the treatment of large symptomatic adenomyosis and has shown to be effective in managing symptoms related to adenomyosis.

FIGO PALM-COEIN Classification of Abnormal Uterine Bleeding in Saudi Women

Background

Abnormal uterine bleeding (AUB) is a significant concern in women's health. However, there is limited research on its prevalence and characteristics in Saudi Arabia.

Objectives

To determine the prevalence of AUB in a gynecology outpatient setting in Saudi Arabia and to categorize the cases of AUB according to the FIGO classification.

Methods

This retrospective study included all Saudi female patients who presented to the Obstetrics and Gynecology clinic at King Khalid University Hospital, Riyadh, Saudi Arabia, over a 2-year period, except those who were pregnant. Data regarding demographics, BMI, clinical symptoms, laboratory tests, ultrasound results, and histopathology findings was collected. Cases of AUB were classified using the FIGO PALM-COEIN system.

Results

A total of 2724 patients were included, of which 44.6% had AUB. The most common presentations of AUB were irregular cycles (59.3%) and heavy bleeding (12.8%), and the most affected group was the reproductive age group (19-39 years). Obesity was identified as a significant risk factor. AUB-O (ovulatory disorder; functional cause) was the most prevalent (23%), followed by AUB-L (leiomyomas, 18%; structural cause) and AUB-P (polyps, 8.8%). Specific AUB patterns correlated with ultrasonographic findings, with heavy bleeding associated with polyps, adenomyosis, and leiomyomas. AUB patients had lower hemoglobin levels, indicating potential health impacts.

Conclusions

The study found that nearly half of all women presenting with gynecological complaints in Riyadh, Saudi Arabia, have AUB. According to the FIGO classification, functional causes of AUB were more prevalent than structural causes. Further research is necessary to explore underlying causes of AUB and its long-term health implications.

Progression of adenomyosis: Rate and associated factors

OBJECTIVE

To evaluate the rate of disease progression and the factors associated with such progression in patients with an ultrasound diagnosis of adenomyosis.

METHODS

This was a single center, prospective, observational, cohort study performed at a tertiary referral center. Patients who obtained an ultrasound diagnosis of adenomyosis from May 2022 to August 2022 were recruited. Demographic, clinical and ultrasound data were recorded at the first visit (T0) and after 12 months (T1) for enrolled patients and compared between T0 and T1. The study population was divided in two groups according to progression (increase in uterine volume >20%) or stability/regression (decrease or increase in uterine volume ≤20%) of adenomyosis at T1. Primary study outcome was the rate of adenomyosis progression, while secondary study outcome was the association of adenomyosis progression with demographic and clinical factors. Post hoc subgroups analyses for primary and secondary study outcomes were performed based on hormonal therapy (untreated and treated).

RESULTS

A total of 221 patients were enrolled in the study, with no significant difference in terms of baseline data among the two study groups and no patients were lost to follow-up. The overall rate of adenomyosis progression was 21.3% (47/221 patients). The rate was 30.77% in hormonally untreated women, and 18.34% in hormonally treated women. Progression was associated with the presence of focal adenomyosis of the outer myometrium (P = 0.037), moderate to severe dysmenorrhea (P = 0.001), chronic pelvic pain (P = 0.05), dyschezia (P = 0.05), and worsening of chronic pelvic pain (P = 0.04) at T1.

CONCLUSION

Adenomyosis showed a rate of disease progression of 21.3% at the 12-month follow-up (30.77% in hormonally untreated women, and 18.34% in hormonally treated women). The presence and/or worsening of painful symptoms, such as severe dysmenorrhea, dyschezia and chronic pelvic pain, as well as the presence focal adenomyosis of the outer myometrium, might help identify patients at higher risk of disease progression and tailor their follow-up.

Prevalence and risk factors for chronic endometritis in patients with adenomyosis and infertility: a retrospective cohort study

BACKGROUND

To explore the incidence of chronic endometritis (CE) in patients with infertility and different forms of adenomyosis and analyze potential high-risk factors for infection.

METHODS

This retrospective cohort study included 154 patients with infertility in the Liuzhou Maternity and Child Healthcare Hospital. Among them, 77 patients with adenomyosis were divided into four subgroups based on magnetic resonance imaging (MRI): internal, exterior, intramural, and full-thickness. Meanwhile, 77 patients did not have adenomyosis. Hysteroscopy and endometrial biopsy were performed in the proliferative phase. The main outcome measures were the morphology of the endometrium, syndecan-1 (CD138) immunohistochemical staining, clinical characteristics, and prevalence of CE in the adenomyosis subgroups.

RESULTS

In comparison to the non-adenomyosis group, the adenomyosis group had significantly higher body mass index (BMI) and CA125 levels. The menstrual cycle in the adenomyosis group was significantly shorter, and menarche was significantly earlier. In comparison to the non-adenomyosis group, the adenomyosis group had a significantly higher diagnostic rate of CE (75.3% vs. 46.8% according to hysteroscopy and 74.0% vs. 33.8% according to histopathology, both with p < .050). The incidence of CE was significantly lower in patients with internal adenomyosis when compared with the other three subgroups. Increased BMI contributed to a higher risk of CE.

CONCLUSIONS

The prevalence of CE was significantly higher in patients with adenomyosis and infertility. The differences in the incidence of CE are closely associated with the classification of adenomyosis. When patients with infertility are diagnosed with adenomyosis, it is recommended to identify the subtype and screen for endometritis.

Effectiveness of high-intensity focused ultrasound combined with gonadotropin-releasing hormone agonist or combined with levonorgestrel-releasing intrauterine system for adenomyosis: A systematic review and meta-analysis

Gonadotropin-Releasing Hormone Agonist (GnRH-a) and levonorgestrel releasing intrauterine system (LNG-IUS) are conventional conservative treatments for adenomyosis, and high-intensity focused ultrasound (HIFU) is a novel ablation technique. This study aimed to investigate the effectiveness of HIFU combined with GnRH-a or LNG-IUS for adenomyosis patients. In this systematic review and meta-analysis, Pubmed, Embase, Cochrane Library and Scopus databases were searched up to December 2021. Published studies comparing HIFU plus GnRH-a with HIFU plus LNG-IUS in adenomyosis patients were assessed for eligibility by two independent authors. Risk of bias tool was utilized for risk evaluation. We selected treatment effective rate of dysmenorrhea (pain during menstruation) as the primary outcome; effective rate of menorrhagia severity and reduction rate of adenomyotic lesion as the secondary outcomes. Adverse effects were assessed. Four studies with a total 729 patients were enrolled in the meta-analysis. HIFU plus LNG-IUS showed lower dysmenorrhea [within 6 months: risk ratio (RR) 0.88, 95% confidence interval (CI) 0.83-0.93, p < 0.00001; over 1 year: RR 0.73, 95% CI 0.65-0.82, p < 0.00001] and less menorrhagia severity (RR 0.63, 95% CI 0.60-0.66, p < 0.00001) than HIFU plus GnRH-a. Both groups demonstrated equal efficacy in adenomyotic lesion reduction rate (RR 1.03, 95% CI 0.97-1.09, p = 0.30). Adverse effects happened equally in both groups. Combination therapy of HIFU and LNG-IUS revealed better effectiveness in treating dysmenorrhea and menorrhagia than that of HIFU and GnRH-a. However, interpreting the conclusion should be approached with caution as a result of significant heterogeneity.

Impact of government-issued financial incentive to medical facilities on management of secondary dysmenorrhea

AIM

In April 2020, the Japanese government introduced a Specific Medical Fee for managing secondary dysmenorrhea (SD). This initiative provided financial incentives to medical facilities that provide appropriate management of SD with hormonal therapies. We aimed to assess how this policy affects the management processes and outcomes of patients with SD.

METHODS

Using a large Japanese administrative claims database, we identified outpatient visits of patients diagnosed with SD from April 2018 to March 2022. We used an interrupted time-series analysis and defined before April 2020 as the pre-introduction period and after April 2020 as the post-introduction period. Outcomes were the monthly proportions of outpatient visits due to SD and hormonal therapy among women in the database and the proportions of outpatient visits for hormonal therapy and continuous outpatient visits among patients with SD.

RESULTS

We identified 815 477 outpatient visits of patients diagnosed with SD during the pre-introduction period and 920 183 outpatient visits during the post-introduction period. There were significant upward slope changes after the introduction of financial incentives in the outpatient visits due to SD (+0.29% yearly; 95% confidence interval, +0.20% to +0.38%) and hormonal therapies (+0.038% yearly; 95% confidence interval, +0.030% to +0.045%) among the women in the database. Similarly, a significant level change was observed after the introduction of continuous outpatient visits among patients with SD (+2.68% monthly; 95% confidence interval, +0.87% to +4.49%).

CONCLUSIONS

Government-issued financial incentives were associated with an increase in the number of patients diagnosed with SD, hormonal therapies, and continuous outpatient visits.

Associations between race and ethnicity and perioperative outcomes among women undergoing hysterectomy for adenomyosis

OBJECTIVE

To study racial and ethnic disparities among women undergoing hysterectomy performed for adenomyosis across the United States.

DESIGN

A cohort study.

SETTING

Data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2012-2020.

PATIENTS

Patients with an adenomyosis diagnosis.

INTERVENTION

Hysterectomy for adenomyosis.

MAIN OUTCOME MEASURES

Patients were identified using the International Classification of Diseases 9th and 10th editions codes 617.0 and N80.0 (endometriosis of the uterus). Hysterectomies were classified on the basis of the Current Procedural Terminology codes. We compared baseline and surgical characteristics and 30-day postoperative complications across the different racial and ethnic groups. Postoperative complications were classified into minor and major complications according to the Clavien-Dindo classification system.

RESULTS

A total of 12,599 women underwent hysterectomy for adenomyosis during the study period: 8,822 (70.0%) non-Hispanic White, 1,597 (12.7%) Hispanic, 1,378 (10.9%) non-Hispanic Black or African American, 614 (4.9%) Asian, 97 (0.8%) Native Hawaiian or Pacific Islander, and 91 (0.7%) American Indian or Alaska Native. Postoperative complications occurred in 8.8% of cases (n = 1,104), including major complications in 3.1% (n = 385). After adjusting for confounders, non-Hispanic Black race and ethnicity were independently associated with an increased risk of major complications (adjusted odds ratio 1.54, 95% confidence interval [CI] {1.16-2.04}). Laparotomy was performed in 13.7% (n = 1,725) of cases. Compared with non-Hispanic White race and ethnicity, the adjusted odd ratios for undergoing laparoscopy were 0.58 (95% CI 0.50-0.67) for Hispanic, 0.56 (95% CI 0.48-0.65) for non-Hispanic Black or African American, 0.33 (95% CI 0.27-0.40) for Asian, and 0.26 (95% CI 0.17-0.41) for Native Hawaiian or Pacific Islander race and ethnicity.

CONCLUSION

Among women undergoing hysterectomy for postoperatively diagnosed adenomyosis, non-Hispanic Black or African American race and ethnicity were associated with an increased risk of major postoperative complications. Compared with non-Hispanic White race and ethnicity, Hispanic ethnicity, non-Hispanic Black or African American, Asian, Native Hawaiian, or Pacific Islander race and ethnicity were less likely to undergo minimally invasive surgery.

The timing of adenomyosis diagnosis and its impact on pregnancy outcomes: a national population-based study

OBJECTIVE

Adenomyosis impacts pregnancy outcomes, although there is a lack of consensus regarding the actual effects. It is likely, however, that the severity of adenomyosis or ultrasound findings or timing of diagnosis can have different effects on adverse pregnancy outcomes (APOs).

METHODS

In this study, we aimed to investigate the impact of the timing of adenomyosis diagnosis on pregnancy outcomes. Singleton pregnant women who delivered between 2017 and 2022 were analyzed based on the timing of adenomyosis diagnosis, using a national database. The final cohort was classified into three groups: 1) group 1, without adenomyosis; 2) group 2, those diagnosed with adenomyosis before pregnancy; and 3) group 3, those diagnosed with adenomyosis during pregnancy.

RESULTS

A total of 1,226,475 cases were ultimately included in this study. Women with a diagnosis of adenomyosis had a significantly higher risk of APOs including hypertensive disorder during pregnancy (HDP), gestational diabetes mellitus (GDM), postpartum hemorrhage, placental abruption, preterm birth, and delivery of a small-for-gestational-age infant even after adjusting for covariates. In particular, concerning HDP, the risk was highest in group 3 (group 2: adjusted odds ratio [aOR], 1.15 vs. group 3: aOR, 1.36). However, the highest GDM risk was in group 2 (GDM; group 2: aOR, 1.24 vs. group 3: aOR, 1.04).

CONCLUSION

The increased risk of APO differed depending on the timing of adenomyosis diagnosis. Therefore, efforts for more careful monitoring and prevention of APOs may be necessary when such women become pregnant.

The myometrial-cervical ratio: Can a simple sonographic measurement improve diagnosis of adenomyosis in a regional setting?

Introduction

Adenomyosis is histologically defined by the presence of endometrial glands and stroma in the myometrium. Ultrasound findings of adenomyosis are being redefined to better diagnose adenomyosis pre-operatively.

Methods

A single-centre retrospective study was performed at a regional hospital. The myometrial-cervical ratio was calculated on pre-operative ultrasounds, and histopathology reviewed for each case. Logistic regression was used to estimate the association between the myometrial-cervical ratio and adenomyosis confirmed on histopathology, and the area under the receiver operating characteristic curve was calculated. Comparisons were performed based on the presence of fibroids on ultrasound.

Results

Complete data were available for 136 benign hysterectomies between 1 January 2015 and 31 December 2020. When the myometrial-cervical ratio was treated as a continuous variable in a logistic regression of adenomyosis on histopathology, there was no statistical evidence (χ2(1) < 0.01, p = 0.98) of an association. When cases including fibroids in the myometrial-cervical ratio were excluded, there was a non-significant association between myometrial-cervical ratio and adenomyosis on histopathology (odds ratio = 3.435, 95% confidence interval = 0.964, 12.235; χ2(1) = 3.62, p = 0.057); area under the receiver operating characteristic = 0.637 (95% confidence interval = 0.504, 0.770). The optimal myometrial-cervical ratio cutpoint was 1.875 (95% confidence interval = 1.698, 2.051), which achieved 71.43% sensitivity and 60.00% specificity. There was strong statistical evidence (χ2(1) = 9.02, p = 0.003) that the myometrial-cervical ratio outperformed standard pre-operative ultrasound identification of adenomyosis.

Conclusion

While accuracy remains suboptimal, the myometrial-cervical ratio outperformed standard ultrasound diagnostic features of adenomyosis in a regional setting. The myometrial-cervical ratio may offer a simple imaging measurement for adenomyosis in inexperienced hands when fibroids are absent.

Value of contrast-enhanced ultrasonography in microwave ablation treatment of symptomatic focal uterine adenomyosis

PURPOSE

This study evaluated the value of contrast-enhanced ultrasonography (CEUS) in the ultrasound-guided microwave ablation (MWA) treatment of symptomatic focal uterine adenomyosis.

METHODS

This retrospective study was conducted between March 2020 and January 2023, enrolling 52 patients with symptomatic focal uterine adenomyosis who had undergone MWA. All patients were examined with CEUS before and after MWA. The non-perfused volume (NPV) was compared between CEUS and dynamic contrast-enhanced magnetic resonance imaging (DCEMRI) following ablation. Therapeutic efficacy and safety were evaluated at 3-, 6-, and 12-month follow-ups. Additionally, this study explored the correlations between pre-treatment CEUS features and a volume reduction ratio indicating sufficient ablation, defined as 50% or more at the 3-month follow-up.

RESULTS

No significant differences in NPV were noted between CEUS and DCE-MRI immediately after MWA and during follow-up (all P>0.05). At the 3-month follow-up, the median VRRs for the uterus and adenomyosis were 33.2% and 63.9%, respectively. Sufficient ablation was achieved in 69.2% (36/52) of adenomyosis cases, while partial ablation was observed in the remaining 30.8% (16/52). The identification of non-enhancing areas on pre-treatment CEUS was associated with sufficient ablation (P=0.016). At the 12-month follow-up, significant decreases were observed in both the uterine and adenomyosis volumes (all P<0.001). Dysmenorrhea and menorrhagia were significantly alleviated at 12 months, and no major complications were encountered.

CONCLUSION

CEUS can be used to evaluate the ablation zone of focal adenomyosis that has been treated with MWA, similarly to DCE-MRI. The identification of non-enhancing areas on pretreatment CEUS indicates satisfactory treatment outcomes.

Adenomyosis and obstetric complications: A retrospective case-control study

OBJECTIVE

Adenomyosis is a uterine pathology affecting an increasing number of women of childbearing age. Its diagnosis is based upon histology or imaging [ultrasound or magnetic resonance imaging (MRI)]. Several studies have investigated the impact of adenomyosis on obstetric complications, with its diagnosis based on clinical symptoms, ultrasound or composite criteria. The aim of this study was to identify potential obstetric complications related to adenomyosis in women with an MRI-confirmed diagnosis.

METHODS

A single centre retrospective case-control study was undertaken in pregnant patients with an MRI-confirmed diagnosis of adenomyosis between January 2013 and December 2017 at the University Hospitals of Strasbourg. Controls were matched in a 4:1 ratio for age, parity and body mass index. Multivariate analysis was performed to identify obstetric complications.

RESULTS

In total, 291 women with an MRI-confirmed diagnosis of adenomyosis were identified during the study period. Of these, 89 patients achieved pregnancy after 24 weeks of gestation. The mean age of patients was 30.8 years. The adenomyosis group and the control group were comparable for matching criteria. Adenomyosis was found to be associated with increased risk of caesarean section [odds ratio (OR) 1.1, 95 % confidence interval (CI) 1.0-1.2; p = 0.03], intrauterine growth restriction (OR 1.3, 95 % CI 1.1-1.4; p < 0.001), postpartum haemorrhage (OR 1.2, 95 % CI 1.1- 1.4; p < 0.01), pre-eclampsia (OR 1.3, 95 % CI 1.0-1.6; p = 0.004) and previous spontaneous miscarriage (OR 2.09, 95 % CI 1.36-3.33; p < 0.001). Premature rupture of membranes, preterm delivery, severe intrauterine growth restriction and the risk of placenta praevia were not significantly higher in the adenomyosis group compared with the control group on multivariate analysis.

CONCLUSION

This study demonstrates increased risk of several obstetric complications (caesarean section, intrauterine growth restriction, postpartum haemorrhage, pre-eclampsia, history of spontaneous miscarriage) in women with adenomyosis. To the authors' knowledge, this is the first study to use MRI as the sole criterion for diagnosis. These results could be complemented by larger-scale prospective studies in order to manage these patients more effectively during pregnancy.

Expression of high-mobility group box-1 in eutopic/ectopic endometrium and correlations with inflammation-related factors in adenomyosis

OBJECTIVE

To investigate the expression of HMGB1 and toll-like receptor 4 (TLR4) in adenomyosis eutopic/ectopic endometrium.

METHODS

Twenty patients with adenomyosis and 20 controls, all undergoing laparoscopy, were recruited from September 2015 to July 2016. Samples were collected from the endometrium without adenomyosis (CE), the eutopic endometrium with adenomyosis (EuE), and the ectopic endometrium with adenomyosis (EE). The mRNA and protein expression of HMGB1 and TLR4, and interleukin-6 (IL-6) and interleukin-8 (IL-8) RNA expression levels were measured.

RESULTS

The average age of the adenomyosis women was 43.4 ± 5.3 years; their BMI was 23.3 ± 2.3 kg/m2. The control group included women aged 38.8 ± 9.8 years, with BMI 22.2 ± 3.4 kg/m2. The mRNA expression levels of HMGB1, TLR4, IL-6, and IL-8 in the EE and EuE groups were higher than those in the CE group (p < .01), and those in the EE group were higher than those in the EuE group (p < .01). The protein expression levels of HMGB1 and TLR4 in the EE and EuE groups were higher than those in the CE group (p < .01); they were higher in the EE group than the ones in the EuE group (p < .01). HMGB1 mRNA was significantly positively correlated with TLR4 in EuE and EC patients (r = 0.538 and r = 0.916, p < .01), as well as with IL-6 (r = 0.470 and r = 0.976, p < .01) and IL-8 (r = 0.574 and r = 0.650, p < .01).

CONCLUSIONS

The overexpression of HMGB1 and TLR4 in EuE and EE is positively correlated with IL-6 and IL-8 expression. The HMGB1 signaling-mediated immune-inflammatory system might be involved in the development of adenomyosis.

Abnormal Uterine Bleeding in Reproductive Age Women: Role of Imaging in the Diagnosis and Management

Abnormal uterine bleeding (AUB) is defined by the International Federation of Gynecology and Obstetrics as bleeding from the uterine corpus that is abnormal in regularity, volume, frequency, or duration and occurs in the absence of pregnancy. AUB is a common condition that affects about a third of women in their lifetime. Abnormal bleeding in duration, quantity, or timing consists of 2 categories, predictable cyclical heavy menstrual bleeding (HMB) and irregular non-cyclical intermenstrual bleeding (IMB). The most common causes of HMB include fibroids and adenomyosis and IMB is commonly caused by ovulatory dysfunction such as in polycystic ovaries, endometrial polyp, or an IUD. A pelvic ultrasound is the initial and often only imaging modality needed in the imaging evaluation of abnormal uterine bleeding and can accurately identify the common causes of abnormal uterine bleeding in the reproductive age group.

Clinical efficacy and safety of trimonthly administration of goserelin acetate 10.8 mg in premenopausal Chinese females with symptomatic adenomyosis: a prospective cohort study

OBJECTIVE

This prospective cohort study aimed to compare the clinical efficacy and safety of goserelin 10.8 mg administered trimonthly with goserelin 3.6 mg administered monthly in premenopausal females with symptomatic adenomyosis.

METHODS

We recruited 139 premenopausal females with adenomyosis who complained of dysmenorrhea and/or menorrhagia. The first group (n = 70) received a single subcutaneous injection of goserelin 10.8 mg, and the second group (n = 69) received monthly subcutaneous goserelin 3.6 mg administered for 3 months. Follow-up was performed at the outpatient department after 12 weeks.

RESULTS

Ultimately, 130 patients completed the study, including 68 and 62 patients in the goserelin 10.8 mg (n = 70) and 3.6 mg (n = 69) groups, respectively. We observed a significant decrease in the dysmenorrhea (NRS) score, uterine volume, and cancer antigen 125 (CA125) levels, and a significant increase in hemoglobin (HGB) levels in both treatment groups. There was no significant difference between the two groups. The sum of the adverse event scores was slightly higher in the goserelin 3.6 mg than in the 10.8 mg group.

CONCLUSIONS

The clinical efficacy of trimonthly administration of goserelin 10.8 mg was equivalent to monthly 3.6 mg dosing and was non-inferior regarding safety and tolerability. Hence, it can be a more cost-effective and convenient alternative treatment option in premenopausal females with symptomatic adenomyosis.

TRIAL REGISTRATION

ChiCTR2200059548.

Endometrial cell‑derived exosomes facilitate the development of adenomyosis via the IL‑6/JAK2/STAT3 pathway

Interleukin (IL)-6 upregulation is involved in the pathogenesis of adenomyosis, but the underlying mechanism remains to be elucidated. Exosomes mediate intercellular communication, therefore the present study investigated whether endometrial cell-derived exosomes mediated the crosstalk between the endometrium and the myometrium via IL-6 signaling. Primary adenomyotic myometrial (AM) cells and eutopic endometrial cells were isolated from patients with adenomyosis. Exosomes were obtained from endometrial cells and incubated with AM cells in the presence or absence of tocilizumab (an IL-6 inhibitor). MTT, flow cytometry and wound-healing assays were performed to examine AM cell proliferation, apoptosis, cell cycle distribution and migration. Western blotting and reverse transcription-quantitative PCR were conducted to determine the expression of the IL-6/Janus kinase 2 (JAK2)/STAT3 pathway proteins. Incubation with endometrial cell exosomes suppressed cell apoptosis of AM cells compared with controls, accompanied by increases in IL-6 production and JAK2/STAT3 phosphorylation. Endometrial cell exosomes promoted cell proliferation, increased the percentage of S-phase cells and enhanced the migration of AM cells. These effects were completely reversed by tocilizumab, along with substantial decreases in IL-6 production and JAK2/STAT3 phosphorylation. Endometrial cell-derived exosomes promote cell proliferation, migration and cell cycle transition of AM cells through IL-6/JAK2/STAT3 activation, facilitating the development of adenomyosis by mediating the crosstalk between the endometrium and the myometrium, and IL-6 targeted therapy could be a complementary approach against adenomyosis.

Compare the Efficacy of Dienogest and the Levonorgestrel Intrauterine System in Women with Adenomyosis

PURPOSE

The goal of this study was to examine the efficacy and safety of the levonorgestrel intrauterine system (LNG-IUS) versus dienogest (DNG) in female subjects with symptomatic uterine adenomyosis.

METHODS

This study enrolled 117 women with symptomatic adenomyosis who visited our hospital from May 1, 2019, to June 30, 2022. Participants were randomized to either the LNG-IUS group (n = 48) or the DNG group (n = 79) in an as-controlled clinical trial for 36 months. Visual analog scale (VAS) scores, uterine volume, endometrial thickness, serum carcinoma antigen 125 level, estradiol, follicle-stimulating hormone, luteinizing hormone, and side effects were assessed to compare the efficacy of LNG-IUS and DNG.

FINDINGS

The VAS pain score was significantly decreased in both groups after 3 months of treatment. Three months later, patients receiving DNG reported significantly lower VAS scores compared with those treated with LNG- IUS (P < 0.05). Compared with LNG-IUS, DNG effectively controlled uterine volume growth after 12 months of treatment but neither significantly reduced uterine volume. During the treatment period, endometrial thickness in both groups was maintained at 0.4 to 0.7 cm.

IMPLICATIONS

Both DNG and LNG-IUS significantly improved adenomyosis-associated pain after 3 months of treatment. Compared with LNG-IUS, DNG was shown to continuously relieve the symptoms of pain and effectively control the growth of uterine volume.

Ultrasound-guided percutaneous microwave ablation for adenomyosis with abnormal uterine bleeding: clinical outcome and associated factors

OBJECTIVE

To investigate the factors affecting the efficacy of ultrasound (US)-guided percutaneous microwave ablation (PMWA) for adenomyosis with abnormal uterine bleeding (AUB-A).

METHODS

Baseline data of patients with AUB-A who underwent US-guided PMWA treatment between October 2020 and October 2021, including demography characteristics, laboratory and imaging examination results were retrospectively analyzed. 3D reconstruction of magnetic resonance imaging (MRI) was applied to quantitatively assess the local treatment responses, including ratio of non-perfusion volume to adenomyosis volume (NPVr), ablation rate of the endometrial-myometrial junction (EMJ), and surface area (SA) of the ablated part of the EMJ. Patients were followed up at 3, 6, and 12 months after treatment, and divided into two groups: group with complete relief (CR), and group with partial relief (PR) or no relief (NR). Data were compared between them.

RESULTS

Thirty-one patients were analyzed with a mean age of 38.7 ± 6.8 years (range: 24-48): 48.4% (15/31), 63.3% (19/30), and 65.5% (19/29) achieved CR at 3, 6, and 12 months, respectively. In univariate analysis, compared with the PR/NR group, serum CA125 levels were significantly lower in CR group at 3 months, while ablation rates of EMJ and SA of the ablated part of the EMJ were significantly higher at the three time points. Other baseline characteristics and NPVr did not differ between the two groups.

CONCLUSION

Baseline CA125 and ablation rate of the EMJ and SA of the ablated part of the EMJ are associated with the outcome of AUB-A patients after US-guided PMWA treatment.

Effects of localization of uterine adenomyosis on clinical features and pregnancy outcome

The purpose of this study was to implore the association among clinical features, long-term fertility outcomes and the anatomical location of adenomyosis identified by ultrasound. We collected data of non-pregnant patients between 20 and 40 years old who had undergone surgical exploration for benign gynecological conditions at our institution between January 2010 and December 2017. A total of 158 women met the inclusion criteria and were allocated into three groups according to the ultrasound-determined adenomyosis anatomical location: anterior (Group A), posterior (Group B), both posterior and anterior (Group C). 44.3% (70/158) adenomyosis was located at the posterior side. History of miscarriage and parity were significantly higher in Group C (p = 0.036 and 0.001 respectively). Group C also had a higher concurrence rate of ovarian endometrioma (OEM) (80.4%, p = 0.002), pelvic adhesion (80.4%, P = 0.003) and the revised American Fertility Society (rAFS) Score (median64, range2-100, P < 0.001), while a significantly lower rate of concurrent peritoneal endometriosis (P = 0.01). Group B showed a relative higher rate of coexistent heavy menstrual bleeding (28.6%, p = 0.04) and oviduct obstruction (24.3%, P = 0.038). Group A had a higher proportion of coexistent leiomyoma (53.1%, P = 0.002). There were no significant differences between group A, B, and C in terms of pain symptoms, endometrial polyps, operation time, and endometriosis fertility index score and other basic characters (p > 0.05). During the follow-up, 59.2% (61/103) patients had clinical pregnancies, and 26.2% (16/61) of them experienced pregnancy loss. Total in vitro fertilization and embryo transfer pregnancy rate was 64.6% (42/65) and spontaneous pregnancy rate was 50.0% (19/38). The Kaplan-Meier curves demonstrated significant lower cumulative pregnancy rate in Group C than Group A and Group B (p = 0.01). Severe obstetric complications such as placenta previa, placenta accreta, preeclampsia, and preterm birth were only found in women with adenomyosis located in the posterior side. In conclusion, types of adenomyosis based on sonographic location had different clinical features and pregnancy outcome. Patients with adenomyosis lesion in both anterior and posterior sides had higher combination of OEM, pelvic adhesion and rAFS score.

Pregnancy is associated with reduced progression of symptomatic adenomyosis: a retrospective pilot study

BACKGROUND

Adenomyosis is a common gynecological disease in women of reproductive age and causes various symptoms such as dysmenorrhea and heavy menstrual bleeding. However, the influence of pregnancy on the progression of adenomyosis remains unclear. The insight into whether the size of adenomyosis is increased, decreased, or unchanged during pregnancy is also undetermined. The current study aimed to evaluate the influence of pregnancy in patients with symptomatic adenomyosis.

METHODS

This study retrospectively enrolled patients diagnosed with adenomyosis by magnetic resonance imaging between 2015 and 2022 at The University of Tokyo Hospital. Uterine size changes were evaluated by two imaging examinations. In the pregnancy group, the patients did not receive any hormonal and surgical treatments, except cesarean section, but experienced pregnancy and delivery between the first and second imaging examinations. In the control group (nonpregnancy group), the patients experienced neither hormonal and surgical treatments nor pregnancy from at least 1 year before the first imaging to the second imaging. The enlargement rate of the uterine size per year (percentage) was calculated by the uterine volume changes (cm3) divided by the interval (years) between two imaging examinations. The enlargement rate of the uterine size per year was compared between the pregnancy group and the control group.

RESULTS

Thirteen and 11 patients with symptomatic adenomyosis were included in the pregnancy group and in the control group, respectively. The pregnancy group had a lower enlargement rate per year than the control group (mean ± SE: -7.4% ± 3.6% vs. 48.0% ± 18.5%, P < 0.001), indicating that the size of the uterus with adenomyosis did not change in the pregnancy group.

CONCLUSIONS

Pregnancy is associated with reduced progression of symptomatic adenomyosis.

Exosomes: potential diagnostic markers and drug carriers for adenomyosis

Adenomyosis is a common benign gynecological disorder and an important factor leading to infertility in fertile women. Adenomyosis can cause deep lesions and is persistent and refractory in nature due to its tumor-like biological characteristics, such as the ability to implant, adhere, and invade. The pathogenesis of adenomyosis is currently unclear. Therefore, new therapeutic approaches are urgently required. Exosomes are nanoscale vesicles secreted by cells that carry proteins, genetic materials and other biologically active components. Exosomes play an important role in maintaining tissue homeostasis and regulating immune responses and metabolism. A growing body of work has shown that exosomes and their contents are key to the development and progression of adenomyosis. This review discusses the current research progress, future prospects and challenges in this emerging therapeutic tool by providing an overview of the changes in the adenomyosis uterine microenvironment and the biogenesis and functions of exosomes, with particular emphasis on the role of exosomes and their contents in the regulation of cell migration, proliferation, fibrosis formation, neovascularization, and inflammatory responses in adenomyosis.

Therapeutic options for the management of abnormal uterine bleeding

Just as the investigation of abnormal uterine bleeding (AUB) is approached systematically using the two FIGO systems for AUB in the reproductive years, treatment options can be considered similarly. Therapeutic options fall into two categories-medical and surgical-and while medical management is typically regarded as first-line therapy, there are several exceptions defined by the presenting cause or causes, mainly when infertility is a concurrent issue. In the early 1990s, up to 60% of women underwent a hysterectomy for the symptom of heavy menstrual bleeding (HMB), but this figure has decreased. The number of women undergoing a hysterectomy for benign disorders continues to decline, along with an increase in hysterectomies performed using minimally invasive techniques. Discussions about therapeutic options are tailored to the individual patient, and we include the risks and benefits of each option, including no management, to enable the patient to make an informed choice. The different types of treatment options and the factors affecting decision-making are considered in this article.

Prevalence of adenomyosis in women with subfertility: systematic review and meta-analysis

OBJECTIVE

To determine the prevalence of adenomyosis in women with subfertility.

METHODS

A systematic search was conducted in MEDLINE, EMBASE, CINAHL Plus, Google Scholar, PsycINFO and Web of Science Core Collection from database inception to October 2022. The included studies evaluated the prevalence of adenomyosis in women with subfertility, with or without endometriosis and/or uterine fibroids. Secondary analyses were conducted to identify variation in the prevalence of isolated adenomyosis according to geographical location, diagnostic modality, diagnostic criteria, type of ultrasound, ultrasound features of adenomyosis and the use of assisted reproductive technology.

RESULTS

Among 21 longitudinal studies evaluating 25 600 women, the overall pooled prevalence of isolated adenomyosis was 10% (95% CI, 6-15%) (I2  = 99.1%; tau2  = 0.12). The pooled prevalence was 1% (95% CI, 0-4%) for adenomyosis with concurrent fibroids (eight studies; I2  = 95.8%; tau2  = 0.03), 6% (95% CI, 3-11%) for adenomyosis with concurrent endometriosis (18 studies; I2  = 98.6%; tau2  = 0.12) and 7% (95% CI, 2-13%) for adenomyosis with concurrent endometriosis and/or fibroids (nine studies; I2  = 98.3%; tau2  = 0.09). The prevalence of isolated adenomyosis varied substantially according to geographical location, with Australia exhibiting the highest pooled prevalence of adenomyosis (19% (95% CI, 12-27%)), which was significantly higher compared with that in Asia (5% (95% CI, 1-12%)). The pooled prevalence of isolated adenomyosis diagnosed using a combination of direct and indirect ultrasound features was 11% (95% CI, 7-16%), whereas it was 0.45% (95% CI, 0-1%) in the study in which only an indirect feature was used as the diagnostic criterion.

CONCLUSION

One in 10 women with subfertility have a diagnosis of isolated adenomyosis. The prevalence of adenomyosis varies according to the presence of concurrent endometriosis and/or fibroids. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Risk of Recurrence and Reintervention After Uterine-Sparing Interventions for Symptomatic Adenomyosis: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the risk of recurrence and reintervention after uterine-sparing treatment options for symptomatic adenomyosis, including adenomyomectomy, uterine artery embolization (UAE), and image-guided thermal ablation.

DATA SOURCES

We searched electronic databases such as Web of Science, MEDLINE, Cochrane Library, EMBASE, ClinicalTrials.gov, and Google Scholar from January 2000 to January 2022. The search was conducted using the following search terms: "adenomyosis," "recurrence," "reintervention," "relapse," and "recur."

METHODS OF STUDY SELECTION

All studies that described the risk of recurrence or reintervention after uterine-sparing interventions for symptomatic adenomyosis were reviewed and screened according to the eligibility criteria. Recurrence was defined as the reappearance of symptoms (painful menses or heavy menstrual bleeding) after significant or complete remission, or the reappearance of adenomyotic lesions confirmed by ultrasonography or magnetic resonance imaging.

TABULATION, INTEGRATION, AND RESULTS

The outcome measures were presented as the frequency with percentage and pooled with 95% CI. A total of 42 studies (single-arm retrospective and prospective studies) that represented 5,877 patients were included. The recurrence rates after adenomyomectomy, UAE, and image-guided thermal ablation were 12.6% (95% CI 8.9-16.4%), 29.5% (95% CI 17.4-41.5%), and 10.0% (95% CI 5.6-14.4%), respectively. The reintervention rates were 2.6% (95% CI 0.9-4.3%), 12.8% (95% CI 7.2-18.4%), and 8.2% (95% CI 4.6-11.9%) after adenomyomectomy, UAE, and image-guided thermal ablation, respectively. Subgroup analysis and sensitivity analysis were performed, and the heterogeneity was reduced in several analyses.

CONCLUSION

Uterine-sparing techniques were successful in treating adenomyosis with low reintervention rates. Uterine artery embolization had higher recurrence and reintervention rates than other techniques; however, patients treated with UAE had larger uteri and larger adenomyosis, indicating that selection bias may influence these results. More randomized controlled trials with a larger population are needed in the future.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021261289.

The immunohistochemical expression of GPER and classical sex hormone receptors differs in adenomyosis and eutopic endometrium

G protein-coupled estrogen receptor (GPER) has been found to be an important key regulator in the homeostasis of sex hormone-dependent human cells. The aim of this study was to compare the expression of GPER, estrogen receptor alpha (ER-α), estrogen receptor beta (ER-β) and progesterone receptor (PR) in adenomyosis, eutopic endometrium from the same patients, and eutopic endometrium from patients without adenomyosis. Immunohistochemical analysis of GPER, ER-α, ER-β and PR was performed to assess the expression levels on samples of hysterectomies using tissue microarrays. 73 adenomyotic tissue probes and corresponding eutopic endometrial specimens, as well as 48 samples of eutopic endometrial control specimens from patients without adenomyosis were included in this study. Mean age of the women with adenomyosis was 51.7 (SD ± 11.1) and 65.8% were premenopausal. We found a higher nuclear stromal expression of GPER in eutopic endometrium of patients with adenomyosis in comparison to control endometrium (p < 0.001). Comparing adenomyosis to eutopic endometrium of patients with adenomyosis and to control, there was a lower expression of nuclear GPER in epithelial cells (p < 0.001 and p = 0.048, respectively). Lower epithelial nuclear ER-α in adenomyosis and higher epithelial nuclear ER-β in eutopic endometrium of patients with adenomyosis was found in comparison to control endometrium (p = 0.008 and p = 0.017, respectively). This study showed a significant difference in the immunohistochemical expression of GPER in adenomyosis compared to eutopic endometrium of the same patients and to endometrium of control group. GPER in adenomyosis may be a potential therapeutic target for selective agonists and antagonists.

Abnormal Uterine Bleeding

Abnormal uterine bleeding is a common problem in premenopausal women and refers to uterine bleeding that is abnormal in frequency, duration, volume, and/or regularity. Etiologies can be classified using the PALM-COIEN system. Patients should receive a comprehensive history and physical with special attention to menstrual, sexual, and family history. Physical examination needs to include a pelvic examination with speculum and bimanual components. All patients need to have a pregnancy test and CBC with platelets. Treatments vary by etiology. Medical treatments include levonorgestrel intrauterine devices, oral contraceptive pills, and tranexamic acid. Surgical treatment options include endometrial ablation and hysterectomy.

Heterogeneity of clinical symptoms and therapeutic strategies for different subtypes of adenomyosis: An initial single-center study in China

OBJECTIVE

To investigate the relationship between the magnetic resonance imaging (MRI) classification of different clinical symptoms and corresponding therapeutic efficacy in adenomyosis patients.

METHODS

From January 2015 to October 2020, a total of 468 patients diagnosed with adenomyosis through MRI examination at Peking University Third Hospital were included in this retrospective cohort study. Totals of 184 (39.3%), 208 (44.4%), 17 (3.6%), and 59 (12.6%) patients were categorized into Subtypes I (intrinsic), II (extrinsic), III (intramural), and IV (penetrating), respectively. Clinical information such as age, dysmenorrhea, menorrhagia, infertility, assisted reproduction, and drug treatment and its efficacy were analyzed. By comparing the clinical information of different adenomyosis subtypes, we intend to provide better fertility guidance and find better treatment strategies for these patients.

RESULTS

The proportion of dysmenorrhea increased in intrinsic, extrinsic, intramural, and penetrating subtypes (74.5% vs 82.7% vs 94.1% vs 94.9%, respectively, P = 0.002). The proportion of menorrhagia in the intrinsic subtype (53.3%) was significantly higher than that in the extrinsic (28.4%) and intramural (29.4%) subtypes (P < 0.001). The effective rate of progesterone in the intrinsic subtype was significantly lower than that in the extrinsic subtype (52.0% vs 86.5%, P < 0.001). The infertility rates of adenomyosis patients with different subtypes were relatively high (17.6%-41.3%), and that of the extrinsic subtype was the highest among all the subtype groups (41.3%, P < 0.001).

CONCLUSIONS

Significant differences in age, dysmenorrhea, menorrhagia, and infertility were found among patients with different subtypes of adenomyosis. A novel classification of adenomyosis was proposed to provide a theoretical basis for the treatment of adenomyosis patients with infertility.

Uterine rupture after high-intensity focused ultrasound ablation of adenomyosis: a case report and literature review

AIM

High-intensity focused ultrasound (HIFU) is a non-invasive treatment of adenomyosis. Uterine rupture during pregnancy is a rare adverse event after HIFU treatment, because HIFU treatment results in tissue coagulative necrosis.

METHODS

We reported a case of uterine rupture in a 34-year-old woman. The woman had HIFU treatment for adenomyosis eight months before unplanned pregnancy. She was closely monitored during the pregnancy and the antenatal course was uneventful. At the gestational age of 38 weeks and 2 days, an emergency lower segment cesarean section was performed because of inexplainable abdominal pain. After delivery of the fetus, a 2 × 2 cm serous membrane rupture was observed in the HIFU treatment area.

CONCLUSION

Uterine rupture during pregnancy after HIFU is a rare adverse event, however, attention is required during the whole pregnancy in case of unexpected uterine rupture.

Comparison of pregnancy outcomes in infertile patients with different types of adenomyosis treated with high-intensity focused ultrasound

OBJECTIVE

This study assessed the improvement of symptoms and pregnancy outcomes in infertile patients with various types of adenomyosis who were treated with high-intensity focused ultrasound (HIFU).

MATERIALS AND METHODS

Between October 2017 and January 2022, 129 infertile patients with adenomyosis who wished to conceive were treated with HIFU. Based on the relationship between the adenomyotic lesion, the endometrium, and the subserosa of the uterus on magnetic resonance imaging, the adenomyotic lesions were divided into internal, external, intramural, and full-thickness types. Menstruation pain score, menstruation blood volume score, anti-Müllerian hormone (AMH) levels, reproductive results, pregnancy and delivery complications, and other clinical variables were compared among these four groups.

RESULTS

Patients with external adenomyosis had the greatest menstrual distress, whereas patients with internal adenomyosis had the greatest menstrual blood volume. Dysmenorrhea and heavy menstruation were significantly improved after HIFU treatment in all groups. AMH levels were not significantly different before and six months after HIFU. Of the 129 patients, 50 (38.7%) became pregnant after HIFU, and patients with internal adenomyosis had the highest pregnancy rate. Patients with adenomyotic lesions located in the posterior wall of the uterus had a higher pregnancy rate than those with lesions located in the fundus of the uterus.

CONCLUSIONS

The classification of adenomyosis is closely related to distinctions in clinical symptoms and pregnancy outcomes. Infertile patients with different types of adenomyosis could be effectively treated with HIFU. HIFU can be considered as an option for infertile patients with adenomyosis who want to maintain their fertility.

Expression deregulation of matrix metalloproteinases and vasoconstriction related genes in Pakistani females with abnormal uterine bleeding

BACKGROUND

Abnormal uterine bleeding (AUB) is irregular menstrual bleeding which has great impact on female health and life style. Various genetic factors are involved in etiology and pathology of AUB. Present study was designed to explore the association of PTGFR, MMP9, MMP2, TGFB3 and VEGFB with AUB.

METHODS

Blood samples of 212 females with AUB were collected along with age-matched healthy control. Expression variation of targeted genes was evaluated using qPCR. Present study cohort was divided into different groups based on demographic parameters and all targeted genes were correlated with study demographics.

RESULTS

Expression of targeted genes was significantly (P < 0.001) downregulated in females with AUB compared to control. Reduced (P < 0.01) expression of targeted genes was observed in all age groups (21-30, 31-40, 41-50 year) of AUB patients compared to respective control. Expression of VEGFB increased (P < 0.05) in AUB females with > 9 days bleeding compared to AUB patient had < 9 days bleeding. AUB women with miscarriage history showed upregulation in MMP2, TGFB3 (P < 0.05), and downregulation in MMP9 and VEGFB (P < 0.05) expression compared to AUB group with no miscarriage history. Expression of MMP2 increased (P < 0.05) in AUB females with > 60 kg body weigh compared to AUB patient with < 60 kg weight.

CONCLUSION

Present study open a new window for diagnosis of AUB at early stages and suggested a possible involvement of PTGFR, MMP9, MMP2, TGFB3 and VEGFB as candidate biomarkers in AUB.

Adenomyosis-Associated Ischemic Stroke: Pathophysiology, Detection and Management

Female-specific risk factors for stroke have gradually received attention. The relationship between ischemic stroke and adenomyosis, a benign uterine disorder commonly present in parous women, is underrecognized. We aimed to provide an overview of the epidemiology, pathophysiological mechanisms, clinical characteristics, diagnostic considerations, and potential therapeutic strategies of adenomyosis-associated ischemic stroke. We shared our experience with the diagnosis and management of a patient, and summarized current findings and knowledge gaps of this disease based on previous literature. The relevant studies were searched in English and Chinese databases up to April 2022 using the keywords "ischemic stroke", "cerebral infarction" and "adenomyosis". Then, we provided a narrative review of the retrieved articles. Finally, the data of 32 cases were analyzed. We found that increased levels of carbohydrate antigen 125 and D-dimer and decreased level of hemoglobin are biomarkers of adenomyosis-associated ischemic stroke. In addition, hypercoagulability might be a key mechanism leading to thromboembolism in the cerebrovascular system. Additional studies are needed to find optimal prevention strategies for the disease. A better understanding of this "rare" pathogenesis of ischemic stroke may inform a more precise diagnosis and effective prevention strategy in middle-aged women with embolic stroke of undetermined source.

Exploration the global single-cell ecological landscape of adenomyosis-related cell clusters by single-cell RNA sequencing

Background: Adenomyosis (AM) is a common benign uterine disease that threatens the normal life of patients. Cells associated with microenvironmental immune ecology are crucial in AM, although they are not as well understood at the cellular level.

Methods: Single-cell sequencing (scRNA-seq) data were used to construct an AM global single-cell map, to further identify relevant cell clusters and infer chromosomal copy number variation (CNV) in AM samples. The biological functions of cell clusters were explored and cellular evolutionary processes were inferred by enrichment analysis and pseudotime analysis. In addition, a gene regulatory network (GRN) analysis was constructed to explore the regulatory role of transcription factors in AM progression.

Results: We obtained the expression profiles of 42260 cells and identified 10 cell clusters. By comparing the differences in cell components between AM patients and controls, we found that significant abundance of endometrial cells (EC), epithelial cells (Ep), endothelial cells (En), and smooth muscle cells (SMC) in AM patients. Cell clusters with high CNV levels possessing tumour-like features existed in the ectopic endometrium samples. Moreover, the Ep clusters were significantly involved in leukocyte transendothelial cell migration and apoptosis, suggesting an association with cell apoptosis and migration. En clusters were mainly involved in pathways in cancer and apoptosis, indicating that En has certain malignant features.

Conclusion: This study identified cell clusters with immune-related features, investigated the changes in the immune ecology of the microenvironment of these cells during AM, and provided a new strategy for the treatment of AM.

Factors influencing treatment decisions in HIFU treatment of adenomyosis: A retrospective study

Objective

To explore the influencing factors of decision-making in patients with adenomyosis, who are receiving high-intensity focused ultrasound (HIFU) treatment.

Methods

A total of 776 patients with adenomyosis were enrolled into HIFU group (241 cases) and hysterectomy group (535 cases) according to the treatment methods. The general data, clinical symptoms, marital and childbearing history, and economic status were compared between the two groups, and factors with P < 0.05 were introduced into multivariate logistic regression analysis to determine the determinants of patients choosing HIFU.

Results

The average age of the patients in the HIFU group was 39.1 ± 5.2 years, which was lower than that in the hysterectomy group, which was 45.1 ± 3.9 years (P < 0.05). The basic medical insurance for urban workers in the HIFU group was more than the hysterectomy group (P < 0.05). 95.9% of the hysterectomy group had no desire to have children, compared to 60.6% of the HIFU group, the difference was significant (P < 0.05). The treatment costs of HIFU group were significantly lower than that of hysterectomy group (P < 0.05). The main symptoms of the two groups were dysmenorrhea, menorrhagia, and secondary anemia. The results of multivariate logistic regression analysis showed that 31–40 years old, fertility desire, dysmenorrhea, menorrhagia, anemia and dizziness and fatigue were the influencing factors for the decision-making of HIFU for patients with adenomyosis.

Conclusion

31–40 years old, fertility desire, dysmenorrhea, menorrhagia, anemia and dizziness and fatigue were the influencing factors for patients to choose HIFU treatment. HIFU therapy has emerged as a new option for patients with adenomyosis as an alternative to hysterectomy.

Chronic Pelvic Pain: A Comprehensive Review

Chronic pelvic pain (CPP) is explained as a complaint of cyclic or non-cyclic pelvic pain lasting for at least six months with or without dysmenorrhea, dyspareunia, dysuria, and dyschezia. The etiology of symptoms can be categorized according to organ system involvement. Gynecological causes typically involve endometriosis-related pain, pelvic congestion syndrome, pelvic inflammatory disease, adenomyosis, hydrosalpinx, etc. Endometriosis-related pain is seldom non-cyclic and may present due to recurrent bleeding in endometriotic implants. Engorgement of veins leads to inadequate venous washout and presents chronic pelvic pain in pelvic congestion syndrome. The pressure effect of benign lesions of the uterus and cervix may lead to cyclic pain, as in uterine fibroids. Often presentation of diseases like hydrosalpinx may not present until it has overdistended or may at times present as acute pelvic pain if it undergoes torsion. Long-standing untreated pelvic inflammatory diseases in sexually active females is another cause of pelvic pain. The complaint of CPP is also shared due to the involvement of the gastrointestinal system in conditions like irritable bowel syndrome, inflammatory bowel diseases, long-standing abdominal hernias, colorectal cancer, etc. Alteration of the gut biome and dysregulated brain-gut associations lead to typical manifestations of chronic lower back pain and pelvic pain in irritable bowel syndrome. Colorectal tumors, when in the advanced stage, may spread to nearby tissues creating fistulas and affecting nearby nerves, causing pelvic, perineal, and sacral pain. Abdominal hernias with small bowel prolapse are always related to pelvic pain symptoms. Infections in the urinary tract like urethral syndrome, chronic prostatitis, and chronic recurrent cystitis present with CPP and voiding problems. Musculoskeletal etiologies, though varying in degrees, are responsible for isolated complaints of CPP. Examples include pelvic girdle pain, levator syndrome, coccygodynia, and pelvic floor prolapse.

Mechanism Study of Cinnamomi Ramulus and Paris polyphylla Sm. Drug Pair in the Treatment of Adenomyosis by Network Pharmacology and Experimental Validation

Objective. To explore the molecular mechanism of the Cinnamomi ramulus and Paris polyphylla Sm. (C-P) drug pair in the treatment of adenomyosis (AM) based on network pharmacology and animal experiments. Methods. Via a network pharmacology strategy, a drug-component-target-disease network (D-C-T-D) and protein–protein interaction (PPI) network were constructed to explore the core components and key targets of C-P drug pair therapy for AM, and the core components and key targets were verified by molecular docking. Based on the results of network pharmacology, animal experiments were performed for further verification. The therapeutic effect of the C-P drug pair on uterine ectopic lesions was evaluated in a constructed AM rat model. Results. A total of 30 components and 45 corresponding targets of C-P in the treatment of AM were obtained through network pharmacology. In the D-C-T-D network and PPI network, 5 core components and 10 key targets were identified. Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis showed that the PI3K signaling pathway was the most significantly enriched nontumor pathway. Molecular docking showed that most of the core components and key targets docked completely. Animal experiments showed that the C-P drug pair significantly ameliorated the pathological changes of endometriotic lesions in AM model rats and inhibited PI3K and Akt gene expression, and PI3K and Akt protein phosphorylation. In addition, treatment with the C-P drug pair promoted AM cell apoptosis; upregulated the protein expression of Bax, Caspase-3, and cleaved Caspase-9; and restrained Bcl-2 expression. Conclusions. We propose that the pharmacological mechanism of the C-P drug pair in the treatment of AM is related to inhibition of the PI3K/Akt pathway and promotion of apoptosis in AM ectopic lesions.

Ultrasound-guided microwave ablation for symptomatic adenomyosis: More areas of concern for more uniform and promising outcomes

Adenomyosis is a common gynecological disease in reproductive women, which causes serious dysmenorrhea, menorrhagia, anemia, and infertility, and has a serious impact on the physical and mental health of women. Considering that the efficacy of the traditional medication and surgical treatment is not ideal, an increasing number of patients are searching for more effective and less invasive therapies. Ultrasound (US)-guided microwave ablation (MWA) has emerged as a new effective and minimally invasive alternative treatment for symptomatic adenomyosis, and it is widely being used in clinical settings. Several studies have proven that it is an efficient and safe treatment modality for symptomatic adenomyosis, but a significant variance in clinical outcomes reported in previous studies was also observed. Herein, we have analyzed the potential causes of this problem from the aspects of the diagnosis of adenomyosis, symptom evaluation before ablation, steps of US-guided ablation treatment, and outcome evaluation after ablation. Simultaneously, the clinical problems existing in the ablation treatment of adenomyosis are discussed, and the directions of future research are pointed out.

A clinical scoring system for the diagnosis of adenomyosis

Objective

To develop a scoring system using clinical evaluation methods to predict the presence of adenomyosis.

Materials and Methods

A cohort of 232 patients who underwent hysterectomy for benign gynecologic disorders was prospectively enrolled. A detailed anamnesis was obtained and physical/pelvic examinations with trans-vaginal ultrasound imaging were performed one day before the hysterectomy. The diagnosis of adenomyosis was based on histopathologic examination. Findings were compared between patients with (n=55) and without (n=166) adenomyosis. Factors associated with adenomyosis were assessed with regression analysis and odds ratios (OR) were calculated. The variables found to be significant were chosen for the scoring system. Receiver operating characteristic analysis was carried out to find the cut-off values for these variables.

Results

Number of parity, dyspareunia and dysmenorrhea visual analogue scale (VAS) scores, age of menarche, presence of uterine tenderness and detection of heterogeneous myometrium and myometrial cysts during ultrasonography were found to be the significant parameters. OR for the presence of myometrial heterogeneity, myometrial cysts, uterine tenderness were 27.2, 3.6 and 9.3 respectively. Cut-off values were calculated; 3 for parity (OR=2.8), 13-years for menarche (OR=1.6), 2 for dyspareunia VAS scores (OR=1.9) and 4 for dysmenorrhea VAS scores (OR=1.2). The total sum of maximum OR that a patient can obtain was calculated as 47.6 and this value was assumed to predict the presence of adenomyosis 100%. The multiplication of the sum of the OR in a patient by 2.1 (100/47.2) was found to have a predictive ability for the presence of adenomyosis.

Conclusion

A scoring system is developed to predict adenomyosis non-invasively based on clinical evaluation.

Uterine Artery Embolization for Symptomatic Adenomyosis: Proceedings from a Society of Interventional Radiology Foundation Research Consensus Panel

Adenomyosis poses an important diagnostic and therapeutic challenge in women's health because of a variety of clinical/imaging presentations and frequent coexistence with other benign gynecologic conditions. In recent years, uterine artery embolization (UAE) for the treatment of adenomyosis has shown encouraging and favorable outcomes and long-term symptom improvement. To expand the current understanding of adenomyosis pathophysiology, imaging diagnostic criteria, and treatment outcomes, the Society of Interventional Radiology Foundation gathered a multidisciplinary Research Consensus Panel with experts from diverse backgrounds. The topics addressed were centered around the following: (i) the clinical presentation and imaging findings to diagnose adenomyosis; (ii) the currently available medical, interventional, and surgical treatment options; and (iii) existing literature for and experiences with UAE in symptomatic disease. The panel acknowledged that before the pursuit of a clinical trial, it would be necessary to first evaluate the imaging criteria for adenomyosis and correlate them with pathology and symptoms to establish a noninvasive imaging classification system. Second priority was given to the development of a quality of life questionnaire to assess patient outcomes following treatment. The third priority was the performance of a prospective clinical trial comparing UAE with medical therapy, which would help establish UAE in the treatment algorithm and societal guidelines for symptomatic adenomyosis.

Uterine bleeding: how understanding endometrial physiology underpins menstrual health

Menstruation is a physiological process that is typically uncomplicated. However, up to one third of women globally will be affected by abnormal uterine bleeding (AUB) at some point in their reproductive years. Menstruation (that is, endometrial shedding) is a fine balance between proliferation, decidualization, inflammation, hypoxia, apoptosis, haemostasis, vasoconstriction and, finally, repair and regeneration. An imbalance in any one of these processes can lead to the abnormal endometrial phenotype of AUB. Poor menstrual health has a negative impact on a person's physical, mental, social, emotional and financial well-being. On a global scale, iron deficiency and iron deficiency anaemia are closely linked with AUB, and are often under-reported and under-recognized. The International Federation of Gynecology and Obstetrics have produced standardized terminology and a classification system for the causes of AUB. This standardization will facilitate future research endeavours, diagnosis and clinical management. In a field where no new medications have been developed for over 20 years, emerging technologies are paving the way for a deeper understanding of the biology of the endometrium in health and disease, as well as opening up novel diagnostic and management avenues.

The use of the myometrial-cervical ratio in the ultrasound diagnosis of adenomyosis - A validation study

BACKGROUND

Adenomyosis is a benign disorder defined by ectopic endometrial glands within the uterine myometrium. A study by Mooney et al reported the myometrial-cervical ratio (MCR), a novel ultrasound measurement that was found to improve the preoperative diagnosis of adenomyosis.

AIMS

To validate the association between sonographic MCR and adenomyosis confirmed on histopathology in an independent patient group.

MATERIALS AND METHODS

Single-centre retrospective cohort study including women who underwent hysterectomy between 1 January 2016 and 31 December 2018 for a benign, non-obstetric indication with an ultrasound at the study centre prior to surgery. Clinical details and histopathology were extracted. Ultrasound images were reviewed by a gynaecology ultrasound subspecialist blinded to histological findings.

RESULTS

Eight hundred eighty-seven patients underwent hysterectomy in the study period for eligible indications; 317 had an ultrasound at the study centre and were included. There was no statistically significant association between the MCR and adenomyosis on histology when all patients were included; however, increased MCR was associated with adenomyosis when those with fibroids on ultrasound were excluded. The area under the receiver operating characteristic for this model was 0.614 (95% CI: 0.53 to 0.69). The optimal MCR cut-point in this subgroup was 1.79, which achieved 55.6% sensitivity and 62.8% specificity, with 58.5% correctly classified. There was no significant difference in MCR compared to traditional ultrasound markers of adenomyosis.

CONCLUSIONS

In a population undergoing hysterectomy for benign and non-obstetric indications, the MCR applied to preoperative ultrasound was only weakly associated with a histological diagnosis of adenomyosis.