Minimally invasive treatment of adenomyosis

Prediction of Ablation Rate for High-Intensity Focused Ultrasound Therapy of Adenomyosis in MR Images Based on Multi-model Fusion

This study aimed to develop a model based on radiomics and deep learning features to predict the ablation rate in patients with adenomyosis undergoing high-intensity focused ultrasound (HIFU) therapy. A total of 119 patients with adenomyosis who received HIFU therapy were retrospectively analyzed. Participants were included in the training and testing queues in a 7:3 ratio. Radiomics features were extracted from T2-weighted imaging (T2WI) images, and VGG-19 was used to extract advanced deep features. An ensemble model based on multi-model fusion for predicting the efficacy of HIFU in adenomyosis was proposed, which consists of four base classifiers and was evaluated using accuracy, precision, recall, F-score, and area under the receiver operating characteristic curve (AUC). The predictive performance of the combined model combining radiomics and deep learning features outperformed the radiomics and deep learning feature models alone, with accuracy of 0.848 and 0.814 in training and test sets, and AUC of 0.916 and 0.861, respectively. Compared with the base classifiers that make up the multi-model fusion model, the fusion model also exhibited better prediction performance. The fusion model incorporating both radiomics and deep learning features had certain predictive value for the ablation rate of adenomyosis under HIFU therapy and could help select patients with adenomyosis who would benefit from HIFU therapy.

Alternative treatments of adenomyosis - an update in procedural management and clinical outcomes

PURPOSE OF REVIEW

Adenomyosis is a common cause of abnormal uterine bleeding (AUB), dysmenorrhea, and pelvic pain. Definitive diagnosis and treatment have historically been by uterine histopathology at time of hysterectomy; however, advances in imaging have supported earlier diagnosis and subsequent conservative treatment. This review aims to update the evidence supporting the uterine-sparing, procedural management options with a focus on clinical outcomes.

RECENT FINDINGS

Uterine artery embolization (UAE), radiofrequency ablation (RFA), high-intensity focused ultrasound (HIFU), percutaneous microwave ablation (PMWA), and adenomyomectomy are minimally invasive interventions proven to be effective in reducing AUB and dysmenorrhea due to adenomyosis. Symptom improvement is associated with a decrease in uterine volume. Studies support the use of alternative treatment options given the overall low rates of symptom recurrence and reintervention. Combination therapy may be more effective than monotherapy.

SUMMARY

This review provides the current evidence for use of alternative treatment options for adenomyosis. Access to ablative therapies in the USA is limited and primarily off label, given lack of FDA approval. High-quality prospective and randomized controlled trials are needed in order to further delineate treatment comparisons, efficacy, safety, and ideal patient selection for these treatments. More data are needed to assess safety and utility in those desiring future fertility.

Conservative surgical treatment for adenomyosis: New options for looking beyond uterus removal

Adenomyosis is a common benign uterine disorders and patients may present dysmenorrhea, dyspareunia, abnormal uterine bleeding (AUB) and infertility. The treatment is very complex, including medical, surgical or radiological approaches. Hormonal drugs represent the first line therapy of adenomyosis, highly effective on symptoms and uterine volume reduction. Radiological procedures (UAE and HIFU), RFA and hysteroscopy may be proposed in those cases in which medical therapy is ineffective. Considering surgical treatment, hysterectomy remains the only existing definitive treatment but in the last decades the desire of uterus preservation is becoming more and more diffuse. On the other hand, surgical conservative treatments of adenomyosis are very effective in ameliorating AUB and pelvic pain and in reducing uterine volume, with some post-operative risks and obstetrics complications. Cytoreductive surgery for adenomyosis may be very complex, therefore it should be performed by experienced surgeons in dedicated centers, above all in case of concomitant endometriosis.

Long-term efficacy and safety of levonorgestrel releasing intrauterine system in the treatment of adenomyosis: evidence mapping

PURPOSE

To summarize evidence on levonorgestrel releasing intrauterine system (LNG-IUS) in the treatment of adenomyosis (AM) and to identify potential research gaps.

METHODS

Search was conducted in MEDLINE, The Cochrane Library, EMBASE, CBM, CNKI, and Wanfang. We included studies investigating patients with AM treated with LNG-IUS combined with conservative therapy.

RESULTS

Thirty-nine studies compared LNG-IUS with other conservative therapeutic drugs. The most common comparison was GnRH-a + LNG-IUS vs. LNG-IUS alone, followed by LNG-IUS vs. mifepristone, expected treatment, and GnRH-a. GnRH-a + LNG-IUS was more beneficial in reducing the intensity of dysmenorrhea than LNG-IUS alone at the 6-month follow-up in patients with an enlarged uterus and moderate to severe dysmenorrhea. Large and well-designed studies are needed to confirm the efficacy of LNG-IUS and GnRH-a on reducing uterine volume at 6-month follow-up. Thirty-two studies investigated LNG-IUS as the postoperative management. The most common comparison was surgical excision + LNG-IUS vs. surgical excision. Results showed VAS scores were lower in the surgical excision + LNG-IUS group than in the surgical excision group at the 1-year follow-up. Evidence on endometrial thickness, quality of life, adverse events and beneficial effect at 3 and 5 years are needed.

CONCLUSIONS

Combined GnRH-a and LNG-IUS treatment was more efficacious than LNG-IUS alone for patients with an enlarged uterus and moderate to severe dysmenorrhea. Moreover, LNG-IUS seemed to show potential long-term benefits in postoperative therapy, warranting further meta-analysis for confirmation.

Intrauterine chilled saline instillation reduces endometrial impairment on MRI after ultrasound-guided percutaneous microwave ablation of uterine adenomyosis

OBJECTIVE

To investigate whether intrauterine chilled saline can reduce endometrial impairment during US-guided percutaneous microwave ablation (PMWA) of adenomyosis.

METHODS

An open-label, randomized trial was conducted with sixty symptomatic adenomyosis patients who were randomly assigned (1:1) to receive PMWA treatment assisted by intrauterine saline instillation (study group) or traditional PMWA treatment alone (control group). The primary endpoint was endometrial perfusion impairment grade on post-ablation contrast-enhanced MRI. The secondary endpoints were endometrial dehydration grade, ablation rate, and intra-ablation discomfort.

RESULTS

The baseline characteristics of the two groups were similar. The incidence rates of endometrial perfusion impairment on MRI in the study and control groups were 6.7% (2/30) and 46.7% (14/30), respectively (p < 0.001). There were 28 (93.3%), 2 (6.7%), 0, and 0 patients in the study group and 16 (53.3%), 7 (23.3%), 5 (16.7%), and 2 (6.7%) in the control group (p < 0.001) who had grade 0, 1, 2, and 3 perfusion impairment, respectively. Additionally, there were 27 (90%), 3 (10%), and 0 patients in the study group and 19 (63.3%), 10 (33.3%), and 1 (3.3%) in the control group who had grade 0, 1, and 2 endometrial dehydration (p = 0.01). The ablation rates achieved in the study and control groups were 93.3 ± 17% (range: 69.2-139.6%) and 99.7 ± 15.7% (range: 71.5-129.8%), and they were not significantly different (p = 0.14). No significant difference was found in the intra-ablation discomfort.

CONCLUSION

Intrauterine chilled saline can effectively reduce endometrial impairment after PMWA treatment for adenomyosis.

CRITICAL RELEVANCE STATEMENT

This trial demonstrated that the instillation of intrauterine chilled saline reduced endometrial impairment on MRI during PMWA of adenomyosis. This approach allows more precise and safe ablation in clinical practice.

KEY POINTS

Endometrial impairment occurs in the PMWA treatment of adenomyosis. Intrauterine chilled saline can reduce endometrial impairment during PMWA for adenomyosis. An intrauterine catheter is a practical endometrial protecting method during thermal ablation.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR2100053582. Registered 24 November 2021, www.chictr.org.cn/showproj.html?proj=141090 .

Optimized treatment parameter by computer simulation for high-intensity focused ultrasound treatment of uterine adenomyosis: Short-term and long-term results

This study aimed to investigate the efficacy and safety of using optimized parameters obtained by computer simulation for ultrasound-guided high-intensity focused ultrasound (HIFU) treatment of uterine adenomyosis in comparison with conventional parameters. We retrospectively assessed a single-institution, prospective study that was registered at Clinical Research Information Service (CRiS) of Republic of Korea (KCT0003586). Sixty-six female participants (median age: 44 years) with focal uterine adenomyosis were prospectively enrolled. All participants were treated with a HIFU system by using treatment parameters either for treating uterine fibroids (Group A, first 20 participants) or obtained via computer simulation (Group B, later 46 participants). To assess the treatment efficacy of HIFU, qualitative indices, including the clinically effective dysmenorrhea improvement index (DII), were evaluated up to 3 years after treatment, whereas quantitative indices, such as the nonperfused volume ratio and adenomyosis volume shrinkage ratio (AVSR), on MRI were evaluated up to 3 months after treatment. Quantitative/qualitative indices were compared between Groups A and B by using generalized linear mixed effect model. A safety assessment was also performed. Results showed that clinically effective DII was more frequently observed in Group B than in Group A (odds ratio, 3.69; P = 0.025), and AVSR were higher in Group B than in Group A (least-squares means, 21.61; P = 0.001). However, two participants in Group B developed skin burns at the buttock and sciatic nerve pain and required treatment. In conclusion, parameters obtained by computer simulation were more effective than the conventional parameters for treating uterine adenomyosis by using HIFU in terms of clinically effective DII and AVSR. However, care should be taken because of the risk of adverse events.

Comparing magnetic resonance imaging and ultrasound in the clinical evaluation of fibroids prior to uterine artery embolization

PURPOSE

Uterine artery embolization has become established as a frontline treatment for uterine leiomyomata. In planning embolization, preprocedural imaging can further characterize pathology and anatomy, but it may also reveal coexisting diagnoses that have the potential to change clinical management. The purpose of this study is to compare the diagnostic outcomes of ultrasound and MRI performed for patients prior to undergoing embolization.

METHODS

The study cohort consisted of 199 patients who underwent uterine artery embolization at a single academic institution between 2013 and 2018. Prior to embolization, all patients had an MRI confirming a leiomyomata diagnosis. Additionally, 118 patients underwent transvaginal ultrasound within five years prior to MRI. MRI findings were analyzed and, when applicable, compared to prior ultrasound impressions to assess for the incidence of new findings. The diagnoses of interest were adenomyosis, hydrosalpinx, predominantly infarcted leiomyomata, and large intracavitary leiomyomata. Data were collected from retrospective chart review and included demographics, symptomology, and imaging reports.

RESULTS

199 patients ultimately underwent embolization for treatment of MRI-confirmed leiomyomata. Of 118 patients who also had an ultrasound within five years prior to their MRI, 26 (22.0%) received a second gynecologic diagnosis based on MRI findings that was not previously seen on ultrasound. Of 81 patients who only had an MRI before embolization, 19 (23.5%) received a second gynecologic diagnosis not previously documented. The most common coexisting pathology was adenomyosis, presenting in 34 (17.1%) patients with leiomyomata, followed by large intracavitary leiomyomata (8, 4.0%), infarcted leiomyomata (7, 3.5%), and hydrosalpinx (6, 3.0%),.

CONCLUSIONS

When considering uterine artery embolization for the treatment of symptomatic leiomyomata, preprocedural MRI is superior to ultrasound in detecting coexisting pathologies, including adenomyosis and hydrosalpinx. It can also better characterize leiomyomata, including identifying lesions as intracavitary or infarcted. These findings have the potential to alter clinical management or contraindicate embolization entirely.

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.

Efficacy and safety of percutaneous microwave ablation for adenomyosis in the posterior uterine wall

OBJECTIVE

To evaluate the efficacy and safety of percutaneous microwave ablation (PMWA) for treating adenomyosis in the posterior uterine wall.

METHODS

Thirty-six patients with symptomatic adenomyosis in the posterior uterine wall who had been subjected to PMWA were retrospectively enrolled in this study. 20 patients who had no ideal transabdominal puncture path due to the retroverted or retroflexed uterine position were treated with PMWA combined with Yu's uteropexy (Group 1). The other 16 patients were treated with PMWA only (Group 2). The non-perfused volume (NPV) ratio, symptomatic relief rate, recurrence rate, changes in clinical symptom scores, economic cost, and complications were compared.

RESULTS

The mean NPV ratio for the 36 patients was 90.2±18.3%, and the percentage of patients who obtained complete relief of dysmenorrhea and menorrhagia was 81.3% (26/32), and 69.6% (16/23) respectively. The recurrence rate was 11.1% (4/36). No major complication was observed. Minor complications included lower abdominal pain, fever, vaginal discharge, nausea, and/or vomiting after ablation, with incidences of 55.6%, 41.7%, 47.2%, and 19.4% respectively. Subgroup analysis showed no significant difference in the median value of NPV ratio, symptomatic relief rate of dysmenorrhea and menorrhagia, changes in clinical symptom scores, recurrence rate and economic cost between the two groups (all p > 0.05).

CONCLUSION

PMWA is an effective and safe treatment for adenomyosis in the posterior uterine wall.

ADVANCES IN KNOWLEDGE

This study focused on the ultrasound-guided PMWA treatment for adenomyosis in the posterior uterine wall. Yu's uteropexy, a new ancillary technique allowing safe PMWA for deep posterior uterine wall lesions in retroverted uterus, expanded the indications of PMWA for symptomatic adenomyosis.

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.

In vivo self-assembled shape-memory polyurethane for minimally invasive delivery and therapy

Advanced elastomers are highly in demand for the fabrication of medical devices for minimally invasive surgery (MIS). Herein, a shape memory and self-healing polyurethane (PCLUSe) composed of semi-crystalline poly(ε-caprolactone) (PCL) segments and interchangeable and antioxidative diselenide bonds was designed and synthesized. The excellent shape memory of PCLUSe contributed to the smooth MIS operation, leading to less surgical wounds than in the case of sternotomy. The diselenide bonds of PCLUSe contributed to the rapid self-healing under 405 nm irradiation within 60 s, and the alleviation of tissue oxidation post injury. After being delivered through a 10 mm diameter trocar onto a beating canine heart by MIS, two shape-recovered PCLUSe films self-assembled (self-healing) into a larger single patch (20 × 10 × 0.2 mm3) under the trigger of laser irradiation in situ, which could efficiently overcome the limited-size problem within MIS and meet a larger treatment area. The diselenide bonds in the PCLUSe cardiac patches protected the myocardium under oxidative stress post myocardial infarction (MI), and significantly maintained the cardiac functions.

Evaluation and Medical Management of Chronic Pelvic Pain

Chronic pelvic pain (CPP) is a challenging condition affecting an estimated 15% of females in the United States. Multiorgan system dysfunction results in the complex clinical pain presentation. Similar to other chronic pain syndromes, CPP is influenced by biopsychosocial factors and requires a multimodal approach for optimal pain management. This review summarizes the clinical evaluation and medical management of CPP with a comprehensive approach.

Pregnancy Outcomes after Uterus-sparing Operative Treatment for Adenomyosis: A Systematic Review and Meta-analysis

OBJECTIVE

A meta-analysis was conducted to evaluate the overall pregnancy outcomes after uterus-sparing operative treatment in patients with adenomyosis (AD).

DATA SOURCES

We searched PubMed, Web of Science, Cochrane Library, and Embase for literature from January 2000 to January 2022.

METHODS OF STUDY SELECTION

We included all studies reporting reproductive outcomes of uterine-sparing surgery for patients with AD with fertility requirements. Surgical treatment was classified as complete excision or incomplete removal of AD and nonexcisional techniques for induction of necrosis in AD. The latter included physically removing the tissue where pathology is present or disrupting the blood flow to the affected area, involving high-intensity focused ultrasound, microwave ablation, radiofrequency ablation, and uterine artery embolization. Two independent researchers performed study selection according to the screening criteria.

TABULATION, INTEGRATION, AND RESULTS

A total of 13 studies with 1319 patients with AD were included in this study, comprising 795 women wishing fertility. Pooled estimates of pregnancy, miscarriage, and live-birth rates after excisional treatment for women attempting to conceive were 40% (95% confidence interval [CI], 29-52), 21% (95% CI, 16-27), and 70% (95% CI, 64-76), respectively, and corresponding rates after nonexcisional treatment were 51% (95% CI, 42-60), 22% (95% CI, 13-34), and 71% (95% CI, 57-83), respectively. The differences were not statistically significant.

CONCLUSION

Excisional treatment could be a treatment consideration for patients with symptomatic AD and infertility for several years or repeated failure of assisted reproductive technology. Nonexcisional techniques may be considered probably for AD-related infertility.

Interventional Radiology in Obstetrics and Gynecology: Updates in Women's Health

Interventional radiology has had an expanding role in women's health over the past few decades, with recent accelerated growth and development. Interventional radiology is fundamental in the treatment of multiple conditions that affect women, including pelvic venous disease, uterine fibroids, and adenomyosis, and in postpartum management. Patient workup, classification, and treatment techniques have continued to evolve as interventional radiology has become more prevalent in the treatment of patients affected by these conditions. The authors provide a review of the pathophysiology of, patient workup for, and treatment of pelvic venous disease and uterine artery embolization for various disease processes. The authors also highlight updates from the past 5-10 years in diagnosis, classification, and treatment strategies. ^© RSNA, 2023 Quiz questions for this article are available in the supplemental material.

The Asian Society of Endometriosis and Adenomyosis guidelines for managing adenomyosis

This is the first guidelines for adenomyosis from the Asian Society of Endometriosis and Adenomyosis.

Clinical efficacy of myometrial and endometrial microwave ablation in the treatment of patients with adenomyosis who had anemia

OBJECTIVE

This study evaluated the clinical efficacy of myometrial and endometrial microwave ablation (MEWA) for treating adenomyosis in patients with anemia.

METHODS

This retrospective study enrolled 64 patients with adenomyosis who had anemia treated with either MEWA (MEWA group) or myometrial microwave ablation (MMWA group) between May 2019 and May 2021. The uterine volumes, uterine-volume reduction rates, hemoglobin (Hb) levels, cancer antigen 125 (CA125) levels, dysmenorrhea visual analog scale (VAS) scores, uterine fibroblast symptoms and health-related quality of life (UFS-QOL) scores, menstrual flow scores (MFS) before and 3, 6, and 12 months post-treatment, and adverse events and complications in both groups were collected to assess clinical efficacy.

RESULTS

No statistically significant preoperative differences were observed in any measured factors. Postoperatively, there was a significant reduction in uterine volume and CA125 level, an increase in Hb level, and improvement in the UFS-QOL, dysmenorrhea VAS score, and MFS. No differences were observed in postoperative uterine volume, CA125 level, overall response rate, and adverse event rate during the follow-up period until 12 months postoperatively. However, the MEWA group showed a better uterine-volume reduction rate 6 months postoperatively and improvement in Hb level, USF-QOL score, dysmenorrhea VAS score, and MFS postoperatively.

CONCLUSION

MEWA and MMWA demonstrated high clinical efficacy in treating adenomyosis and anemia. However, MEWA is a more effective therapy that successfully improves anemia, resulting in improved quality of life.

Doppler Imaging Assessment of Changes of Blood Flow in Adenomyosis After Higher-Dose Oxytocin: A Randomized Controlled Trial

OBJECTIVES

To assess the changes of blood flow in adenomyosis (AM) after higher-dose oxytocin (OT) in different doses, and to evaluate the safety for patients.

METHODS

A total of 124 patients with AM were randomly divided into 4 groups with continuous intravenous infusion of OT as 0.06, 0.12, 0.24 and 0.36 U/min, respectively. The changes of arteries of AM before and after intravenous infusion of OT were observed by color Doppler ultrasound. The changes of blood flow volume of the artery of AM before and after intravenous infusion of OT were compared among the 4 groups, and the vital signs and adverse drug reactions were monitored during intravenous drip.

RESULTS

During the trial, no severe adverse reactions occurred and the vital signs of all the patients were stable. Among the 4 groups, it was found that there was a significant difference in the change of blood flow volume of blood artery in AM lesions between 0.06 U/min OT group and the other three groups after intravenous drip of OT (P < .05), but there was no significant difference in blood flow volume among the three groups (P > .05), and the difference of adverse drug reactions was statistically significant with the increase of OT dose (P < .05).

CONCLUSION

OT can effectively reduce the blood flow volume of AM lesions, and continuous intravenous infusion of 0.12 U/min OT is an appropriate dose that can not only minimize the blood flow volume but also reduce the incidence of adverse drug reactions.

A review of high-intensity focused ultrasound as a novel and non-invasive interventional radiology technique

High-intensity focused ultrasound (HIFU) is a non-invasive interventional radiology technology, which has been generally accepted in clinical practice for the treatment of benign and malignant tumors. HIFU can cause targeted tissue coagulative necrosis and protein denaturation by thermal or non-thermal effects, guided by diagnostic ultrasound or magnetic resonance imaging, without destruction of the normal adjacent tissue, under sedation or general anesthesia. HIFU has become an important alternative to standard treatments of solid tumors, including surgery, radiation, and medications. The aim of this review is to describe the development, principle, devices, and clinical applications of HIFU.

[Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynecologists and Obstetricians (CNGOF)]

OBJECTIVE

To provide French guidelines for the management of women with abnormal uterine bleeding (AUB).

DESIGN

A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, or medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The last guidelines from the Collège national des gynécologues et obstétriciens français (CNGOF) on the management of women with AUB was published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescent; idiopathic AUB; endometrial hyperplasia and polyps; fibroids type 0 to 2; fibroids type 3 and more; adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 present a strong agreement and 17 a weak agreement. Fourteen questions did not find any response in the literature. We preferred to abstain from recommending instead of providing expert advice.

CONCLUSIONS

The 36 recommendations made it possible to specify the diagnostic and therapeutic strategies of various clinical situations managed by the practitioner, from the simplest to the most complex.

Sanders A, Sobel M. Current diagnosis and management of adenomyosis in Canada: A survey of Canadian gynaecologists

Objective:

The purpose of this study was to understand how Canadian Obstetricians/Gynaecologists (OBGYNs) diagnose and manage adenomyosis.

Methods:

This cross-sectional study was performed via an online survey distributed to 262 OBGYNs at three Canadian universities (University of Toronto, University of Calgary, and McMaster University).

Results:

A total of 137 responses were obtained out of 262 OBGYNs (52.3%) with a completion rate of 98%. Adenomyosis was a diagnosis in 6%–10% of patients seen by OBGYNs. The most common clinical symptoms included heavy menstrual bleeding (HMB) (82.8%) and dysmenorrhea (91.0%). Most participants (83%) used transvaginal ultrasound (TVUS) as first-line imaging for diagnosis of adenomyosis. Many respondents (35.8%) indicated that adenomyosis was not associated with infertility or recurrent miscarriage. Treatment considerations for all patients with adenomyosis included levonorgestrel intra-uterine system (LNG-IUS) (91.8%), hysterectomy (88.8%), expectant management (85.1%), combined hormonal contraceptives (CHC) (83.6%), tranexamic acid (81.3%), gonadotropin releasing hormone (GnRH) agonists (64.2%), depo-provera (64.2%), dienogest (57.5%), and norethisterone acetate (NETA) (40.3%). Treatments for adenomyosis in patients wishing to conceive included expectant management (85.1%), tranexamic acid (79.1%), CHC (44.8%), LNG-IUS (32.8%), and GnRH agonists (35.8%). Excision of adenomyosis would only be offered by 24% of respondents. Uterine artery embolization (UAE) would not be used in the treatment of adenomyosis by 44% of respondents. Finally, 82.8% of respondents would use improvement of clinical symptoms to follow treatment success.

Conclusion:

Practice varies across Canada despite recent emerging evidence in the diagnosis and management of adenomyosis, highlighting the need for a clinical practice guideline on adenomyosis.

Implementation of an enhanced recovery after surgery program in the treatment of uterine fibroids with focused ultrasound ablation surgery

BACKGROUND

Enhanced recovery after surgery (ERAS) can reduce the length of hospital stay, incidence of surgery-related complications, and postoperative pain. We aimed to demonstrate the implementation of an ERAS pathway in the treatment of uterine fibroids with focused ultrasound ablation surgery (FUAS).

MATERIALS AND METHODS

A retrospective data analysis was performed on clinical outcomes encompassing the following three phases: before ERAS (pre-ERAS), during adjustment of ERAS (interim-ERAS), and after the introduction of an ERAS program (post-ERAS). The purpose of describing the interim-ERAS was to provide references for the formulation of the program during the course of FUAS by describing the adjustment processes. Data from patients admitted to the hospital from September 2019 to December 2019 and April 2020 to November 2020 and who met the criteria for FUAS in the treatment of their uterine fibroids were examined. Length of stay, cost of surgery, postoperative pain score, utilization of postoperative analgesics, and incidence of postoperative adverse events were compared across the abovementioned three phases.

RESULTS

Compared with the pre-phase, the cost of treatment and length of stay were reduced after the implementation of ERAS. The use of analgesics before leaving the operating room, as well as the incidence of postoperative nausea and vomiting, were also reduced.

CONCLUSION

The implementation of an ERAS protocol might benefit patients with uterine fibroids treated with FUAS in terms of requiring a shorter hospitalization period, lower costs, and reduced opioid use.

A novel technique for myometrial defect closure after robot-assisted laparoscopic adenomyomectomy: A retrospective cohort study

OBJECTIVE

To introduce our novel technique for myometrial defect closure after adenomyomectomy.

MATERIALS AND METHODS

A retrospective cohort study. A total of 40 patients with adenomyosis who visited our clinic between October 2012 and January 2018 were recruited. Of those 34 patients were eligible for analysis.

RESULTS

The mean thickness of the affected uterine wall before surgery was 4.02 cm ± 1.11, dropping to 2.37 cm ± 0.84 postoperatively. This led to a mean drop of 41% in the thickness of the affected wall, which was found to be significant using a paired t-test (p < 0.0001). The mean preoperative pain score was 8.68 ± 1.12, while the postoperative mean was 0.06 ± 0.34. The mean preoperative CA 125 was 121.73 ± 117.29, dropping to 6.95 ± 2.60 postoperatively. This was found to be significantly lower using both the Wilcoxon Signed Rank and Sign tests (p = 0.0156).

CONCLUSION

Myometrial defect closure in a layer-by-layer fashion after robot-assisted laparoscopic adenomyomectomy is a reproducible technique. This uterine conserving method was effective in reducing our patients' pain. It may be the solution to maintaining adequate myometrial wall thickness, uterine layer alignment, and endometrial integrity.

Minimally invasive adenomyomectomy via a laparoscopic-assisted approach compared to a laparoscopic or laparotomic approach

OBJECTIVE

The present study assessed the safety and benefits of laparoscopic-assisted adenomyomectomy compared to laparoscopic or laparotomic adenomyomectomy.

MATERIALS AND METHODS

This study was a retrospective comparative study. A total of 277 patients underwent adenomyomectomy between January 2016 and January 2019 at the Department of Obstetrics and Gynaecology, Ulsan University Hospital, including 25 with laparoscopic-assisted adenomyomectomy, 82 with laparoscopic adenomyomectomy, and 170 with laparotomic adenomyomectomy. Laparoscopic-assisted adenomyomectomy consisted of a laparoscopic uterine artery procedure to reduce blood loss and a minimal incisional for laparotomic adenomyomectomy. An additional laparoscopic surgery was performed for possible pelvic pathology.

RESULTS

Data on patient demographics, surgical indications, operative times, estimated blood loss (EBL), short-term complications, and postoperative hospital stays were compared. The laparoscopic-assisted surgery (LAS) and laparotomic groups were comparable in average EBL (208.0 ± 128.8 vs. 193.6 ± 193.0 ml, p = 0.11), weight of removed mass (85.5 ± 71.7 vs. 108.2 ± 91.9 g, p = 0.39), and postoperative hospital days (HDs) (4.5 ± 1.0 vs. 4.7 ± 0.8 days, p = 0.27). These values were lower in the laparoscopic group (EBL 119.5 ± 79.6 ml, mass weight 39.3 ± 25.9 g, HD 3.6 ± 0.8 days). Additional procedures, including myomectomy and combined severe endometriosis surgery, were more frequently performed in the LAS group than the laparotomic group. The mean operating time was longer in the LAS group (179.8 ± 36.6 min) than the other groups (laparoscopy 99.9 ± 40.6 min, p < 0.00; laparotomy 133.0 ± 41.1 min, p < 0.00). The three groups did not differ significantly in transfusion rates, hemoglobin changes, or perioperative complications. However, febrile morbidity was lower in the laparoscopic group than the LAS and laparotomic groups.

CONCLUSION

LAS adenomyomectomy allows for maximal debulking of adenomyosis via extracorporeal and intracorporeal procedures while retaining the advantages of the laparoscopic approach. Additional pelvic surgery for benign uterine and adnexal pathology may easily be performed with this approach.

[Diffusion-weighted magnetic resonance imaging instead of contrast-enhanced imaging for evaluating immediate therapeutic efficacy of high-intensity focused ultrasound ablation of adenomyosis]

OBJECTIVE

To explore the feasibility of diffusion-weighted magnetic resonance imaging (DWI) instead of contrast-enhanced (CE) imaging for evaluation of the immediate therapeutic efficacy of high-intensity focused ultrasound (HIFU) ablation for treatment of adenomyosis.

METHODS

We retrospectively analyzed the data of 29 patients aged 40.5 ± 5.4 years under going HIFU treatment for adenomyosis in our hospital between December, 2017 and July, 2020. The patients received MRI examination both before and within 24 h after the operation. Two observers analyzed the morphology of the ablation area on DWI and classified the lesions into type 1 (spot-like or no obvious signal intensity changes), type 2 (patchy signal intensity changes) and type 3 (ring-like signal intensity changes). The inter- and intra-observer reliability of morphological assessment was assessed using kappa test. The volume of necrotic tissues following the ablation was measured with both DWI and CE imaging, and the consistency of the measurements and the inter- and intra-observer reliability of DWI-based measurements were evaluated using Bland-Altman plot tests.

RESULTS

The median volume of necrotic tissues was 36.9 cm3 (range 16.4-65.5 cm3) following ablation of the 29 lesions. DWI findings identified 24-25 (82.8%-86.2%) lesions with type 2 or 3 signal changes following the ablation with measurable necrotic tissue volume. On DW images, the Kappa value of intra- and inter-observer reliability for morphological classification of the ablation area reached 0.798 (P=0.000) and 0.933 (P= 0.000), respectively. Bland-Altman plots showed a good consistency of the necrotic volumes measured by CE and at DWI with a strong inter- and intra-observer reliability of DWI-based volume measurements (with only one point outside the range of 95% limits of agreement). The remaining 4 or 5 lesions, which presented with type 1 signal changes following ablation, were all small in size (the largest was only 18.61 cm3) and showed poor therapeutic responses to the ablation.

CONCLUSION

DWI-based morphological assessment and necrotic tissue volume measurement can replace CE imaging for assessment of the immediate therapeutic efficacy of HIFU ablation for treatment of adenomyosis.

Efficacy of High-Intensity Focused Ultrasound Combined With GnRH-a for Adenomyosis: A Systematic Review and Meta-Analysis

Objective: High-intensity focused ultrasound (HIFU) is an innovative non-invasive technology used for adenomyosis. Gonadotropin-releasing hormone agonist (GnRH-a) is a hormone commonly used for adenomyosis. We investigated and assessed the efficacy of HIFU combined with GnRH-a for adenomyosis. Methods: For this systematic review and meta-analysis, we searched Pubmed, Cochrane Library, Web of Science, Embase, CNKI, WanFang, and VIP databases for relevant articles published in Chinese or English that compared HIFU combined with GnRH-a vs. HIFU alone in patients with adenomyosis. The last literature search was completed on January 31, 2021. Two reviewers independently assessed study eligibility and assessed risk of bias. Another two reviewers extracted the data. The RevMan5.3 software was used for the data analysis. Changes in volume of the uterine and adenomyotic lesion were defined as the primary outcomes. The secondary outcomes were visual analog scale (VAS) scores for dysmenorrhea, menstrual volume scores, serum CA125 levels, and recurrence rate. This study is registered with PROSPERO (CRD42021234301). Results: Three hundred and ninety potentially relevant articles were screened. Nine studies with data for 766 patients were finally included. Compared with the HIFU alone group, the HIFU combined with GnRH-a group had a higher rate of uterine volume reduction (MD 7.51, 95% CI 5.84-9.17, p < 0.00001), smaller adenomyotic lesion volume (MD 4.11, 95% CI 2.93-5.30, p < 0.00001), lower VAS score for dysmenorrhea (MD 1.27, 95% CI 0.54-2.01, p = 0.0007) and menstrual volume score (MD 0.88, 95% CI 0.73-1.04, p < 0.00001), and lower CA125 level (SMD 0.31, 95% CI 0.05-0.56, p = 0.02) after the procedure. The recurrence rate in the HIFU combined with GnRH-a group was lower than that in the HIFU alone group (RR 0.28, 95% CI 0.10-0.82, p = 0.02). Conclusions: Compared with HIFU treatment alone, HIFU combined with GnRH-a for the treatment of adenomyosis has greater efficacy in decreasing the volumes of the uterine and adenomyotic lesions and alleviating symptoms. However, since the number of the included studies was too small and most of them were written in Chinese, this conclusion needs to be referenced with caution. And the long-term evidence of its efficacy is still insufficient. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/ identifier [CRD42021234].

Clinical evaluation of HIFU combined with GnRH-a and LNG-IUS for adenomyosis patients who failed to respond to drug therapies: two-year follow-up results

OBJECTIVE

To investigate the clinical effect of high intensity focused ultrasound (HIFU) ablation combined with gonadotropin-releasing hormone agonist (GnRH-a) and levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of adenomyosis patients who failed to respond to drug therapies.

STUDY DESIGN

A total of 47 patients with adenomyosis who had failed to respond to drug therapies and had no fertility desires were treated with HIFU combined with GnRH-a and LNG-IUS. The score of dysmenorrhea and menstrual volume were measured at pre and 6-, 12-, 18-, 24-month post-HIFU.

RESULTS

All patients completed HIFU ablation without major postoperative complications. Compared with the symptom scores before the HIFU treatment, the score of dysmenorrhea and menstrual volume decreased significantly at 6, 12, 18 and 24 months after HIFU treatment (p < 0.05), but no significant difference was observed between 6, 12, 18 and 24 months after HIFU (p > 0.05). The clinical success rate was 100%, 100%, 95.7% and 93.6% respectively at 6, 12, 18 and 24 months after the combined treatment.

CONCLUSION

The combined therapeutic regimen of HIFU, GnRH-a and LNS-IUS is safe and effective, which can be an alternative treatment option for patients with adenomyosis who failed to respond to drug therapies to avoid adenomyomectomy or hysterectomy.

Uterine Artery Embolization with Small-Sized Particles for the Treatment of Symptomatic Adenomyosis: A 42-Month Clinical Follow-Up

Purpose

To assess the long-term outcome of performing uterine artery embolization (UAE) using small particles in women with symptomatic adenomyosis (AD).

Methods

Twenty-seven consecutive women (median age 42 years, range 29–53 years) with AD, in eight cases AD combined with fibroids, who underwent UAE between February 2015 and January 2019, were retrospectively analyzed. The embolization was performed using small-sized polyvinyl alcohol particles (100 μm and 300 μm). The patients completed the Uterine Fibroid Symptom and Quality of Life questionnaire at baseline and at a 42-month follow-up (range 24–71). The junction zone (JZ) thickness and uterine volume were also calculated at baseline and at a three-month follow-up.

Results

The total symptom severity score (SSS) decreased from a median of 59 (range 34–78) at baseline to a median of 9 (range 3–47) at the end of this study; the health-related quality of life score (HRQOL) increased from a median of 38 (range 23–49) at baseline to a median of 84 (range 46–97) at 42 months. Twenty of the 27 patients were asymptomatic. The clinical response of the remaining seven women was little improvement in their symptoms, and one of the seven women underwent a hysterectomy at 35 months. Twenty-six of the 27 (96%) patients had a preserved uterus at the 42-month follow-up. There was no difference after UAE in SSS, HRQOL, junction zone (JZ) thickness, and uterus volume between patients with pure AD and those with AD combined with fibroids (p = 0.729, 0.710, 0.973, and > 0.99). There was no difference in the JZ thickness and uterus volume at baseline between the asymptomatic women and the women with an insufficient response (p = 0.854 and 0.253), and there were no major complications afterwards.

Conclusion

From the long-term follow-ups, it could be seen that UAE using small particles is safe and effective in treating AD, especially in preserving the uterus. There is no relationship between the clinical outcomes and the initial presence of AD, with or without fibroids, and the JZ thickness at baseline does not seem to be a predictor for the long-term outcome of UAE.

The suture fixation of levonorgestrel-releasing intrauterine device using the hysteroscopic cold-knife surgery system: an original method in treatment of adenomyosis

OBJECTIVE

To introduce an effective approach using the hysteroscopic cold-knife surgery system (HCSS) for suture fixation of the levonorgestrel-releasing intrauterine device (LNG-IUD) in patients with adenomyosis.

DESIGN

Video description of the surgical procedures to demonstrate the detailed technique. The study was reviewed and approved by the institutional review board of Hangzhou Women's Hospital.

SETTING

Maternity hospital.

PATIENT(S)

A 39-year-old woman diagnosed with adenomyosis had endured 7 years of severe dysmenorrhea and 4 years of heavy menstrual bleeding. She had a past medical history that was significant for expulsion of an LNG-IUD. Transvaginal ultrasonography revealed that her uterus was enlarged by adenomyosis. She insisted on preserving fertility potential.

INTERVENTION(S)

We proceeded with the HCSS and the uterine cavity was found enlarged significantly. In consideration of the patient's strong desire for maintaining fertility options, the fixation of the LNG-IUD on the intrauterine posterior wall with an Ethibond suture was performed successfully through an endoscopic needle driver and a knot-pushing device. Proficient endoscopic suturing is the key to the technique. Informed consent was obtained from the patient.

MAIN OUTCOME MEASURE(S)

Feasibility and value of using the HCSS to fix an LNG-IUD for treatment of adenomyosis.

RESULT(S)

The LNG-IUD was fixed successfully by the HCSS with an Ethibond suture on the posterior wall of the uterus within 30 minutes, and the intraoperative blood loss was 2 mL. The patient was discharged 24 hours postoperatively without any adverse perioperative complications. At the one-year follow-up, the patient reported obvious relief of her dysmenorrhea and menorrhagia and no more experience with expulsion. Ultrasound demonstrated normal position of the IUD at 1, 3, 6, and 12 months postoperatively.

CONCLUSION(S)

Hysteroscopy presents a clear visual field to locate and fix the IUD. In patients with adenomyosis suffering from dysmenorrhea or excessive menstrual blood loss, suture fixation of the LNG-IUD using the HCSS can be a minimally invasive and effective alternative for treating adenomyosis, especially in patients who have previously expelled an LNG-IUD, preventing the risk of expulsion.

Ultrasound-guided transvaginal radiofrequency ablation combined with levonorgestrel-releasing intrauterine system for symptomatic uterine adenomyosis treatment

OBJECTIVE

To evaluate the clinical outcomes of transvaginal ultrasound-guided radiofrequency ablation (RFA) combined with a levonorgestrel-releasing intrauterine system (LNG-IUS) for the treatment of symptomatic uterine adenomyosis.

METHODS

Patients with symptomatic uterine adenomyosis treated with ultrasound-guided RFA in combined with an LNG-IUS from January 2013 to January 2016 and followed up for 3 years after treatment were selected. Assessment endpoints included the uterine volume reduction rate, dysmenorrheal score, symptom severity score and adverse events.

RESULTS

Among the 72 patients, 64 completed the 3-year follow-up evaluations after treatment. No LNG-IUS expulsion was reported. Dysmenorrhea and symptom severity scores statistically significantly declined after the combined treatment of RFA and LNG-IUS was administered. The uterine volume significantly decreased, and the average reduction rate was 55%.

CONCLUSION

Ultrasound-guided RFA combined with an LNG-IUS might be a simple, safe and effective alternative for the treatment of symptomatic adenomyosis.

Uterine Artery Embolization for Adenomyosis

Adenomyosis is a benign gynecologic condition of the uterus similar to uterine leiomyoma (fibroids), but with different pathophysiology and prevalence. The treatment algorithms for symptomatic adenomyosis are not as established as for uterine fibroids and other gynecologic conditions. Uterine artery embolization (UAE) is a well-recognized treatment for symptomatic uterine fibroids. This minimally invasive therapy has been likewise effective for symptomatic adenomyosis but with nuances in UAE protocol and outcomes. There is also less quality evidence to garner support for generalized use of the procedure for symptomatic adenomyosis. Many factors contribute to this lack of data, and efforts to clarify the utility of UAE in adenomyosis will need to address a classification system and standardization of technique.

Successful pregnancy outcome in refractory adenomyosis treated with two sessions of uterine artery embolization: A case report and brief review

INTRODUCTION

Adenomyosis associated abnormal uterine bleeding (AUB-A) often remains non-responsive to medical management. Uterine sparing treatment in young patients presenting with refractory AUB-A poses a challenge.

CASE REPORT

A 28-years-old woman presenting with AUB-A with failed medical therapy did not improve with uterine artery embolization (UAE). She underwent a second session of UAE with smaller embolic particles to which she responded. The reported case is interesting as patient conceived spontaneously despite transiently diminished post-UAE ovarian reserves, indicating spontaneous recovery of ovarian function.

CONCLUSION

UAE is a promising option for young patients, though UAE for adenomyosis may require smaller embolic particles to be effective which may diminish ovarian reserves due to non-target effects, however recovery is possible in young patients..

Hysteroscopy and female infertility: a fresh look to a busy corner

Hysteroscopy has evolved from the traditional art of examining the uterine cavity for diagnostic purposes to an invaluable modality to concomitantly diagnose and (see and) treat a multitude of intrauterine pathologies, especially in the field and clinics specialising in female reproduction. This article reviews the literature on the most common cervical, endometrial, uterine and tubal pathologies such as chronic endometritis, endometrial polyps, adenomyosis, endometriosis, endometrial atrophy, adhesions, endometrial hyperplasia, cancer, and uterine malformations. The aim is to determine the efficiency of hysteroscopy compared with other available techniques as a diagnostic and treatment tool and its association with the success of in vitro fertilisation procedures. Although hysteroscopy requires an experienced operator for optimal results and is still an invasive procedure, it has the unique advantage of combining great diagnostic and treatment opportunities before and after ART procedures. In conclusion, hysteroscopy should be recommended as a first-line procedure in all cases with female infertility, and a special effort should be made for its implementation in the development of new high-tech procedures for identification and treatment infertility-associated conditions.

Adenomyosis: diagnostics and treatment

Background

Adenomyosis is a frequent additional condition in patients with endometriosis and should be included in diagnostic and treatment concepts.

Objective

Description of diagnostic and therapeutic approaches in patients with adenomyosis in relation to patient age, family planning status, peritoneal and/or deep endometriosis and symptoms.

Methods

The current literature on adenomyosis including case reports was analyzed. Due to the lack of evidenced-based approaches the most probable trends in diagnostics and treatment are discussed.

Results

Adenomyosis plays an important role in fertile patients with dysmenorrhea, dyspareunia and pelvic pain, with or without additional peritoneal or deep endometriosis. It has a negative impact on fertility and can cause a variety of symptoms. The disease can be diagnosed by a skilled examiner and treatment concepts exist.

Conclusion

Adenomyosis can be diagnosed by a combination of clinical history, gynecological examination, transvaginal ultrasound and magnetic resonance imaging. Various medical and surgical treatment approaches are available to reduce symptoms and to increase fertility. The course of action depends on the family planning status of the patient.

High-intensity focused ultrasound (HIFU) combined with gonadotropin-releasing hormone analogs (GnRHa) and levonorgestrel-releasing intrauterine system (LNG-IUS) for adenomyosis: a case series with long-term follow up

Objective: This research was conducted to assess the long-term outcomes of a combination treatment of High-intensity focused ultrasound (HIFU) ablation, gonadotropin-releasing hormone analogs (GnRHa) and Levonorgestrel-releasing intrauterine system (LNG-IUS) for women with adenomyosis (AD).Methods: One hundred and forty-two patients with AD were enrolled and treated with HIFU conservative treatment in combination with adjuvant therapy of GnRHa and LNG-IUS. All the cases were followed up to 5 years after treatment. The volumes of uteri, AD lesions, and menstrual blood, and dysmenorrhea scores were measured. Also, the incidences of recurrence and complications were recorded.Results: Both the uterine and lesion volumes significantly decreased after treatment. The uterine volume gradually reduced after treatment, reaching the lowest level of 122.07 ± 44.12 cm³ at 12 months after treatment, with an average reduction rate of 45%, and then increased slightly, maintaining a reduction rate of about 35% compared with the baseline level. Similar decreases in AD lesion volumes, dysmenorrhea scores, and menstrual flow were also demonstrated. Hemoglobin levels increased. Moreover, the long-term recurrence rates were low, with 5.68% and 7.91% in dysmenorrhea and menorrhagia, respectively. No serious complications or adverse events were reported.Conclusions: HIFU ablation, in combination with GnRHa and LNG-LUS, might be a safe and effective alternative in the treatment for women with adenomyosis.

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.

Is High-intensity Focused Ultrasound Effective for the Treatment of Adenomyosis? A Systematic Review and Meta-analysis

STUDY OBJECTIVE

To systematically review the literature regarding the efficacy of high-intensity focused ultrasound (HIFU) in reducing adenomyotic lesions, patients' pain and bleeding symptoms, and the impact on patients' quality of life.

DATA SOURCE

A search was performed through PubMed/MEDLINE and Cochrane databases.

METHODS OF STUDY SELECTION

All available studies published in the English language in the last 10 years that evaluated the effects of HIFU for adenomyosis.

TABULATION, INTEGRATION, AND RESULTS

A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A meta-analysis was performed on data from homogeneous studies. Pooled results from the meta-analysis showed that after HIFU treatment for adenomyosis, a large effect was observed in reducing the uterine volume at 12 months (standard mean difference [SMD] = 0.85), a significant reduction in dysmenorrhea at 3 months (SMD = 1.83) and 12 months (SMD = 2.37), and a significant improvement in quality of life at 6 months (SMD = 3.0) and 12 months (SMD = 2.75). Adverse reactions after HIFU were reported in 55.9% of patients.

CONCLUSION

This review suggests a potential benefit for HIFU in the treatment of adenomyosis-related symptoms; however, findings of the meta-analysis were based on fewer, nonuniform studies, which did not equally account for each specific symptom/parameter across the board. Results showed there appears to be a potential of HIFU in the treatment of adenomyosis-related symptoms. To date, there are no comparative and randomized clinical trials comparing the HIFU technique with other conservative treatment options. As yet, there are insufficient data regarding fertility and pregnancy outcomes.

Management of uterine adenomyosis: current trends and uterine artery embolization as a potential alternative to hysterectomy

Adenomyosis is a challenging clinical condition that is commonly being diagnosed in women of reproductive age. To date, many aspects of the disease have not been fully understood, making management increasingly difficult. Over time, minimally invasive diagnostic and treatment methods have developed as more women desire uterine preservation for future fertility or to avoid major surgery. Several uterine-sparing treatment options are now available, including medication, hysteroscopic resection or ablation, conservative surgical methods, and high-intensity focused ultrasound each with its own risks and benefits. Uterine artery embolization is an established treatment option for uterine fibroids and has recently gained ground as a safe and cost-effective method for treatment of uterine adenomyosis with promising results. In this review, we discuss current trends in the management of uterine adenomyosis with a special focus on uterine artery embolization as an alternative to hysterectomy.

[The second generation endometrial ablation (NovaSure) improves efficacy of levonorgestrel-releasing intrauterine system in management of adenomyosis]

OBJECTIVE

To determine the efficacy of second generation endometrial ablation (NovaSure) combined with levonorgestrel-releasing intrauterine system (Mirena) in the treatment of adenomyosis.

METHODS

Clinical data of patients with adenomyosis admitted in Women's Hospital, Zhejiang University School of Medicine from January 2015 to December 2018 were retrospectively analyzed. Among 66 patients, 44 received Mirena placement only (control group) and 22 received Mirena placement and NovaSure treatment (study group). The menstruation blood loss, dysmenorrhea score, uterine size, expulsion rate of Mirena and the patients' satisfaction rate were assessed in two groups.

RESULTS

There was a significant reduction in menstruation blood loss (P<0.05) and significant improvement in dysmenorrhea (P<0.05) after the treatment in both groups. The patients in study group had more marked improvement in menstruation blood loss than those in control group (P<0.05). The patients' satisfaction was higher and the expulsion rate of Mirena was lower in study group than that in control group (all P<0.05). The score of dysmenorrhea and the size of uterine had no significant difference between two groups (all P>0.05).

CONCLUSIONS

NovaSure can improve the efficacy of Mirena in treatment of adenomyosis.

Combined therapeutic effects of HIFU, GnRH-a and LNG-IUS for the treatment of severe adenomyosis

OBJECTIVE

To evaluate the combined efficacy of high-intensity focused ultrasound (HIFU), gonadotropin-releasing hormone agonist (GnRH-a) and the levonorgestrel-releasing intrauterine system (LNG-IUS) for the treatment of severe adenomyosis.

METHOD

Four hundred and sixty-six patients with adenomyosis admitted to the Department of Gynecology of Shanghai First Maternity and Infant Hospital underwent HIFU treatment, and then were consecutively administered with GnRH-a 1 d, 1 month and 3 months after HIFU treatment. The uterine size was then measured with ultrasound or MRI 2-4 weeks after three cycles of GnRH-a injection. The LNG-IUS was then inserted when the uterine length less than 9 cm. The visual analog scale (VAS), verbal rating scale (VRS), menstrual volume score, uterus volume, MRI, serum levels of hemoglobin and CA125 were measured at pre and 3-, 6-, 12-month post-HIFU.

RESULTS

Dysmenorrhea and menorrhagia significantly relieved after combined treatment with HIFU, GnRH-a and the LNS-IUS. The uterine volume shrank and returned to its normal size. The serum CA-125 level was reduced to the normal level after the combined treatment.

CONCLUSIONS

The combined therapeutic regimen of HIFU, GnRH-a and LNS-IUS is safe, effective and efficient for curing severe adenomyosis.

Recent advances in understanding and managing adenomyosis

Adenomyosis is a benign uterine disorder in which endometrial glands and stroma are pathologically demonstrated in the uterine myometrium and it is considered a specific entity in the PALM-COEIN FIGO (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified - International Federation of Gynecology and Obstetrics) classification of causes of abnormal uterine bleeding (AUB). Although it has always been considered the classic condition of multiparous women over 40 years old who have pain and heavy menstrual bleeding, diagnosed at hysterectomy, the epidemiological scenario has completely changed. Adenomyosis is increasingly identified in young women with pain, AUB, infertility, or no symptoms by using imaging techniques such as transvaginal ultrasound and magnetic resonance. However, there is no agreement on the definition and classification of adenomyotic lesions from both the histopathology and the imaging point of view, and the diagnosis remains difficult and unclear. A uniform and shared reporting system needs to be implemented in order to improve our understanding on imaging features, their relationship with pathogenic theories, and their importance in terms of clinical symptoms and response to treatment. In fact, adenomyosis pathogenesis remains elusive and not a single theory can explain all of the different phenotypes of the disease. Furthermore, adenomyosis often coexists with other gynecological conditions, such as endometriosis and uterine fibroids, increasing the heterogeneity of available data. Treatment requires a lifelong management plan as the disease has a negative impact on quality of life in terms of menstrual symptoms, fertility, and pregnancy outcome and has a high risk of miscarriage and obstetric complications.

Endometriosis treatment with shock waves: A novel approach

Endometriosis affects 10-15% of women. When medication is unsatisfactory, not well tolerated or unwanted, surgery remains the sole option. There is a need for a less invasive treatment. We suggest the application of shock wave therapy (SWT) to endometriotic nodules (including deep infiltrating endometriosis), endometriomas and adenomyosis. We hypothesize pain relief via an antiinflammatory effect, an antioxidant effect and neural pathways modulation, as well as a direct effect on the lesions by the energy thus delivered. Questions to be answered before a clinical application is tested include route of administration (external versus internal transducers), dose regimen, optimal duration of treatment and type of shock waves used (focalised versus radial).