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Wu HM, Tsai TC, Liu SM, Pai AHY, Chen LH. The Current Understanding of Molecular Mechanisms in Adenomyosis-Associated Infertility and the Treatment Strategy for Assisted Reproductive Technology. Int J Mol Sci 2024; 25:8937. [PMID: 39201621 PMCID: PMC11354813 DOI: 10.3390/ijms25168937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Revised: 08/14/2024] [Accepted: 08/14/2024] [Indexed: 09/02/2024] Open
Abstract
Adenomyosis, endometriosis of the uterus, is associated with an increased likelihood of abnormal endometrial molecular expressions thought to impair implantation and early embryo development, resulting in disrupted fertility, including the local effects of sex steroid and pituitary hormones, immune responses, inflammatory factors, and neuroangiogenic mediators. In the recent literature, all of the proposed pathogenetic mechanisms of adenomyosis reduce endometrial receptivity and alter the adhesion molecule expression necessary for embryo implantation. The evidence so far has shown that adenomyosis causes lower pregnancy and live birth rates, higher miscarriage rates, as well as adverse obstetric and neonatal outcomes. Both pharmaceutical and surgical treatments for adenomyosis seem to have a positive impact on reproductive outcomes, leading to improved pregnancy and live birth rates. In addition, adenomyosis has negative impacts on reproductive outcomes in patients undergoing assisted reproductive technology. This association appears less significant after patients follow a long gonadotropin-releasing hormone agonist (GnRHa) protocol, which improves implantation rates. The pre-treatment of GnRHa can also be beneficial before engaging in natural conception attempts. This review aims to discover adenomyosis-associated infertility and to provide patient-specific treatment options.
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Affiliation(s)
- Hsien-Ming Wu
- Department of Obstetrics and Gynecology, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (H.-M.W.); (T.-C.T.); (S.-M.L.); (A.H.-Y.P.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
| | - Tian-Chi Tsai
- Department of Obstetrics and Gynecology, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (H.-M.W.); (T.-C.T.); (S.-M.L.); (A.H.-Y.P.)
| | - Shang-Min Liu
- Department of Obstetrics and Gynecology, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (H.-M.W.); (T.-C.T.); (S.-M.L.); (A.H.-Y.P.)
| | - Angel Hsin-Yu Pai
- Department of Obstetrics and Gynecology, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (H.-M.W.); (T.-C.T.); (S.-M.L.); (A.H.-Y.P.)
| | - Liang-Hsuan Chen
- Department of Obstetrics and Gynecology, Linkou Medical Center, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan; (H.-M.W.); (T.-C.T.); (S.-M.L.); (A.H.-Y.P.)
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 333, Taiwan
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Valdés‐Bango M, Gracia M, Rubio E, Vergara A, Casals‐Pascual C, Ros C, Rius M, Martínez‐Zamora MÁ, Mension E, Quintas L, Carmona F. Comparative analysis of endometrial, vaginal, and gut microbiota in patients with and without adenomyosis. Acta Obstet Gynecol Scand 2024; 103:1271-1282. [PMID: 38661227 PMCID: PMC11168268 DOI: 10.1111/aogs.14847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/30/2024] [Accepted: 04/02/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION Alterations in microbiota composition have been implicated in a variety of human diseases. Patients with adenomyosis present immune dysregulation leading to a persistent chronic inflammatory response. In this context, the hypothesis that alterations in the microbiota may be involved in the pathogenesis of adenomyosis, by affecting the epigenetic, immunologic, and biochemical functions of the host, has recently been postulated. The aim of the present study was to compare the microbiota composition in the vagina, endometrium, and gut of individuals with and without adenomyosis. MATERIAL AND METHODS Cross-sectional study including 38 adenomyosis patients and 46 controls, performed between September 2021 and October 2022 in a university hospital-based research center. The diagnosis of adenomyosis was based on sonographic criteria. Fecal, vaginal, and endometrial samples were collected. Study of the microbiota using 16S rRNA gene sequencing. RESULTS Patients with adenomyosis exhibited a significant reduction in the gut microbial alpha diversity compared with healthy controls (Chao1 p = 0.012, Fisher p = 0.005, Observed species p = 0.005). Beta-diversity analysis showed significant differences in the compositions of both gut and vaginal microbiota between adenomyosis patients and the control group (Adonis p-value = 0.001; R2 = 0.03 and Adonis p-value = 0.034; R2 = 0.04 respectively). Specific bacterial taxa were found to be either overrepresented (Rhodospirillales, Ruminococcus gauvreauii group, Ruminococcaceae, and Actinomyces) or underrepresented in the gut and endometrial microbiota of adenomyosis patients compared with controls. Distinct microbiota profiles were identified among patients with internal and external adenomyosis phenotypes. CONCLUSIONS The study revealed reduced gut microbiota diversity in adenomyosis patients, accompanied by distinct compositions in gut and vaginal microbiota compared with controls. Overrepresented or underrepresented bacterial taxa were noted in the gut and endometrial microbiota of adenomyosis patients, with variations in microbiota profiles among those with internal and external adenomyosis phenotypes. These findings suggest a potential association between microbiota and adenomyosis, indicating the need for further research to comprehensively understand the implications of these differences.
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Affiliation(s)
- Marta Valdés‐Bango
- Endometriosis Unit, Gynecology Department, Institute Clinic of Gynecology, Obstetrics and Neonatology (ICGON), Hospital Clinic of BarcelonaUniversitat de BarcelonaBarcelonaSpain
| | - Meritxell Gracia
- Endometriosis Unit, Gynecology Department, Institute Clinic of Gynecology, Obstetrics and Neonatology (ICGON), Hospital Clinic of BarcelonaUniversitat de BarcelonaBarcelonaSpain
| | - Elisa Rubio
- Department of Clinical Microbiology, Hospital Clinic of BarcelonaUniversitat de BarcelonaBarcelonaSpain
| | - Andrea Vergara
- Department of Clinical Microbiology, Hospital Clinic of BarcelonaUniversitat de BarcelonaBarcelonaSpain
- Barcelona Institute for Global Health (ISGlobal)BarcelonaSpain
- CIBER Enfermedades Infecciosas (CIBERINFEC)Instituto Salud Carlos IIIMadridSpain
| | - Climent Casals‐Pascual
- Department of Clinical Microbiology, Hospital Clinic of BarcelonaUniversitat de BarcelonaBarcelonaSpain
- Barcelona Institute for Global Health (ISGlobal)BarcelonaSpain
- CIBER Enfermedades Infecciosas (CIBERINFEC)Instituto Salud Carlos IIIMadridSpain
| | - Cristina Ros
- Endometriosis Unit, Gynecology Department, Institute Clinic of Gynecology, Obstetrics and Neonatology (ICGON), Hospital Clinic of BarcelonaUniversitat de BarcelonaBarcelonaSpain
| | - Mariona Rius
- Endometriosis Unit, Gynecology Department, Institute Clinic of Gynecology, Obstetrics and Neonatology (ICGON), Hospital Clinic of BarcelonaUniversitat de BarcelonaBarcelonaSpain
| | - Maria Ángeles Martínez‐Zamora
- Endometriosis Unit, Gynecology Department, Institute Clinic of Gynecology, Obstetrics and Neonatology (ICGON), Hospital Clinic of BarcelonaUniversitat de BarcelonaBarcelonaSpain
| | - Eduard Mension
- Endometriosis Unit, Gynecology Department, Institute Clinic of Gynecology, Obstetrics and Neonatology (ICGON), Hospital Clinic of BarcelonaUniversitat de BarcelonaBarcelonaSpain
| | - Lara Quintas
- Endometriosis Unit, Gynecology Department, Institute Clinic of Gynecology, Obstetrics and Neonatology (ICGON), Hospital Clinic of BarcelonaUniversitat de BarcelonaBarcelonaSpain
| | - Francisco Carmona
- Endometriosis Unit, Gynecology Department, Institute Clinic of Gynecology, Obstetrics and Neonatology (ICGON), Hospital Clinic of BarcelonaUniversitat de BarcelonaBarcelonaSpain
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Shenoy-Bhangle AS, Pires-Franco IV, Ray LJ, Cao J, Kilcoyne A, Horvat N, Chamie LP. Imaging of Urinary Bladder and Ureteral Endometriosis with Emphasis on Diagnosis and Technique. Acad Radiol 2023:S1076-6332(23)00608-6. [PMID: 37996365 DOI: 10.1016/j.acra.2023.10.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 10/27/2023] [Accepted: 10/28/2023] [Indexed: 11/25/2023]
Abstract
Endometriosis is a chronic inflammatory gynecological condition affecting 10-15% of women in the reproductive age group. The urinary tract is the second most common extragenital organ system affected by endometriosis, and the urinary bladder and ureter are the two most common sites involved. Involvement of the urinary bladder can cause chronic debilitating symptoms, whereas ureteral involvement may lead to asymptomatic loss of renal function. Both conditions are frequently unsuspected, leading to a delay in diagnosis. Therefore, it is important to recognize this entity early, for which knowledge of imaging appearances and techniques is helpful. In this review article, we describe (a) endometriosis background, pathogenesis, definitions and clinical symptoms, (b) imaging appearance, with emphasis on ultrasound and MRI findings of urinary bladder and ureteric endometriosis, (c) ultrasound technique and MRI sequences useful for making the correct diagnosis, (d) overview of the treatment options and key imaging findings that are important to the surgeon for surgical planning, and (e) a structured reporting template useful for multidisciplinary patient management.
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Affiliation(s)
- Anuradha S Shenoy-Bhangle
- Harvard Medical School, Massachusetts General Hospital, MassGeneral Brigham Radiology, 55 Fruit Street, WHT-2- 270, Boston, Massachusetts, 02114, USA (A.S.S.B.).
| | | | - Lauren J Ray
- Massachusetts General Hospital, Department of Pathology, 55 Fruit Street, Boston, Massachusetts, 02114, USA (L.J.R.)
| | - Jinjin Cao
- Massachusetts General Hospital, 55 Fruit Street, WHT-2-207, Boston, Massachusetts, 02114, USA (J.C.)
| | - Aoife Kilcoyne
- Massachusetts General Hospital, MassGeneral Brigham Radiology, 55 Fruit Street, WHT-2- 270, Boston, Massachusetts, 02114, USA (A.K.)
| | - Natally Horvat
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, New York, 10065, USA (N.H.)
| | - Luciana Pardini Chamie
- Chamie Imagem da Mulher, Casa do Ator street. 1117, 72 suite, São Paulo, 04546-004, Brazil (L.P.C.)
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Liu X, Ding D, Shen M, Yan D, Guo SW. Shorter Anogenital Distance in Women with Ovarian Endometriomas and Adenomyosis, but Not Uterine Leiomyomas. Biomedicines 2023; 11:2618. [PMID: 37892992 PMCID: PMC10603971 DOI: 10.3390/biomedicines11102618] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/29/2023] Open
Abstract
We investigated whether anogenital distance (AGD) is associated with adenomyosis, endometriosis and uterine leiomyomas (UL, also called uterine fibroids). We recruited 81 women with UL, 105 with ovarian endometrioma (OE), 116 with adenomyosis, 28 with both adenomyosis and UL, and 100 control subjects with other acquired gynecological conditions but not endometriosis, adenomyosis, UL, or polycystic ovarian syndrome. Measurements from the anterior clitoral surface to the center of the anus (AGDAC), from the tip of the clitoris to the center of the anus (AGDACt), and from the posterior fourchette to the center of the anus (AGDAF) were made in all subjects. Multiple regression was performed to estimate the association between AGDs and presence of OE, adenomyosis, and UL while controlling for possible confounding factors. We found that, compared with controls, women with OE and adenomyosis, but not UL, had significantly shorter AGDAF, but not AGDAC. However, the amount of variance that could be explained by the disease status is rather moderate, suggesting that factors other than disease status, bodyweight and height were also responsible for AGD. Thus, prenatal exposure to reduced levels of androgen may increase the risk of developing endometriosis and adenomyosis. However, other factors may also contribute to the pathogenesis of endometriosis and adenomyosis.
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Affiliation(s)
- Xishi Liu
- Department of Gynecology, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China; (X.L.); (D.D.); (M.S.); (D.Y.)
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai 200011, China
| | - Ding Ding
- Department of Gynecology, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China; (X.L.); (D.D.); (M.S.); (D.Y.)
| | - Minhong Shen
- Department of Gynecology, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China; (X.L.); (D.D.); (M.S.); (D.Y.)
| | - Dingmin Yan
- Department of Gynecology, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China; (X.L.); (D.D.); (M.S.); (D.Y.)
| | - Sun-Wei Guo
- Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai 200011, China
- Research Institute, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China
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Shi J, Wu Y, Li X, Gu Z, Zhang C, Yan H, Dai Y, Leng J. Effects of localization of uterine adenomyosis on clinical features and pregnancy outcome. Sci Rep 2023; 13:14714. [PMID: 37679426 PMCID: PMC10485030 DOI: 10.1038/s41598-023-40816-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/17/2023] [Indexed: 09/09/2023] Open
Abstract
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.
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Affiliation(s)
- Jinghua Shi
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, National Clinical Research Center for Obstetric and Gynecologic Diseases, Shuaifuyuan No. 1, Dongcheng District, Beijing, China
| | - Yushi Wu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, National Clinical Research Center for Obstetric and Gynecologic Diseases, Shuaifuyuan No. 1, Dongcheng District, Beijing, China
| | - Xiaoyan Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, National Clinical Research Center for Obstetric and Gynecologic Diseases, Shuaifuyuan No. 1, Dongcheng District, Beijing, China
| | - Zhiyue Gu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, National Clinical Research Center for Obstetric and Gynecologic Diseases, Shuaifuyuan No. 1, Dongcheng District, Beijing, China
| | - Chenyu Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, National Clinical Research Center for Obstetric and Gynecologic Diseases, Shuaifuyuan No. 1, Dongcheng District, Beijing, China
| | - Hailan Yan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, National Clinical Research Center for Obstetric and Gynecologic Diseases, Shuaifuyuan No. 1, Dongcheng District, Beijing, China
| | - Yi Dai
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, National Clinical Research Center for Obstetric and Gynecologic Diseases, Shuaifuyuan No. 1, Dongcheng District, Beijing, China
| | - Jinhua Leng
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Science, National Clinical Research Center for Obstetric and Gynecologic Diseases, Shuaifuyuan No. 1, Dongcheng District, Beijing, China.
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Marcellin L, Legay L, Santulli P, Millischer AE, Bordonne C, Maitrot Mantelet L, Maignien C, Bourdon M, Gaudet Chardonnet A, Borghese B, Goffinet F, Chapron C. Magnetic resonance imaging presentation of diffuse and focal adenomyosis before and after pregnancy. Reprod Biomed Online 2023; 47:121-128. [PMID: 37137789 DOI: 10.1016/j.rbmo.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 02/05/2023] [Accepted: 02/20/2023] [Indexed: 02/26/2023]
Abstract
RESEARCH QUESTION Is there a change in magnetic resonance imaging (MRI) criteria of diffuse and focal phenotypes of adenomyosis before and after pregnancy? DESIGN A retrospective, monocentric, observational study in a single academic tertiary referral centre for endometriosis diagnosis and management. Women were followed for symptomatic adenomyosis, and without a prior history of surgery who give birth after 24+0 weeks. For each patient, pelvic MRI pre- and post-pregnancy was performed by two experienced radiologists with the same image acquisition protocol. Diffuse and focal adenomyosis MRI presentation were analysed before and after pregnancy. RESULTS Between January 2010 and September 2020, of the 139 patients analysed, 96 (69.1%) had adenomyosis at MRI distributed as follow: 22 (15.8%) presented diffuse adenomyosis, 55 (39.6%) focal adenomyosis and 19 (13.7%) both phenotypes. The frequency of isolated diffuse adenomyosis on MRI was significantly lower before versus after pregnancy (n = 22 [15.8%] versus n = 41 [29.5%], P = 0.01). The frequency of isolated focal adenomyosis was significantly higher before pregnancy than after pregnancy (n = 55 [39.6%] versus n = 34 [24.5%], P = 0.01). The mean volume of all focal adenomyosis lesions on MRI decreased significantly after pregnancy, from 6.7 ± 2.5 mm3 to 6.4 ± 2.3 mm3, P = 0.01. CONCLUSION The current data indicate that, based on MRI, there is an increase in diffuse adenomyosis and a decrease in focal adenomyosis after pregnancy.
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Affiliation(s)
- Louis Marcellin
- Université de Paris, Faculté de Médecine, Paris, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Service de Chirurgie Gynécologie Obstétrique II et Médecine de la Reproduction, Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France; Oxidative Stress, Cellular Proliferation and Inflammation Team, Department of Development, Reproduction and Cancer, INSERM U1016, Paris, France.
| | | | - Pietro Santulli
- Université de Paris, Faculté de Médecine, Paris, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Service de Chirurgie Gynécologie Obstétrique II et Médecine de la Reproduction, Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France; Genomics, Epigenetics and Physiopathology of Reproduction Team, Department of Development, Reproduction and Cancer, INSERM U1016, Paris, France
| | - Anne Elodie Millischer
- Centre de Radiologie IMPC Bachaumont Pole Femme-Mère-Enfant, 75002 Paris, France; Institut de la Femme et de l'Endométriose (IFEEN), 75003 Paris, France
| | - Corinne Bordonne
- Centre de Radiologie IMPC Bachaumont Pole Femme-Mère-Enfant, 75002 Paris, France; Institut de la Femme et de l'Endométriose (IFEEN), 75003 Paris, France
| | - Lorraine Maitrot Mantelet
- Université de Paris, Faculté de Médecine, Paris, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Service de Chirurgie Gynécologie Obstétrique II et Médecine de la Reproduction, Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - Chloé Maignien
- Université de Paris, Faculté de Médecine, Paris, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Service de Chirurgie Gynécologie Obstétrique II et Médecine de la Reproduction, Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - Mathilde Bourdon
- Université de Paris, Faculté de Médecine, Paris, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Service de Chirurgie Gynécologie Obstétrique II et Médecine de la Reproduction, Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - Antoine Gaudet Chardonnet
- Université de Paris, Faculté de Médecine, Paris, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Service de Chirurgie Gynécologie Obstétrique II et Médecine de la Reproduction, Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France
| | - Bruno Borghese
- Université de Paris, Faculté de Médecine, Paris, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Service de Chirurgie Gynécologie Obstétrique II et Médecine de la Reproduction, Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France; Genomics, Epigenetics and Physiopathology of Reproduction Team, Department of Development, Reproduction and Cancer, INSERM U1016, Paris, France
| | - François Goffinet
- Université de Paris, Faculté de Médecine, Paris, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Maternité Port-Royal, Paris, France
| | - Charles Chapron
- Université de Paris, Faculté de Médecine, Paris, France; Assistance Publique - Hôpitaux de Paris (AP-HP), Paris, France; Service de Chirurgie Gynécologie Obstétrique II et Médecine de la Reproduction, Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France; Oxidative Stress, Cellular Proliferation and Inflammation Team, Department of Development, Reproduction and Cancer, INSERM U1016, Paris, France; Genomics, Epigenetics and Physiopathology of Reproduction Team, Department of Development, Reproduction and Cancer, INSERM U1016, Paris, France
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7
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Guo SW. Cracking the enigma of adenomyosis: an update on its pathogenesis and pathophysiology. Reproduction 2022; 164:R101-R121. [PMID: 36099328 DOI: 10.1530/rep-22-0224] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/12/2022] [Indexed: 11/08/2022]
Abstract
In brief Traditionally viewed as enigmatic and elusive, adenomyosis is a fairly common gynecological disease but is under-recognized and under-researched. This review summarizes the latest development on the pathogenesis and pathophysiology of adenomyosis, which have important implications for imaging diagnosis of the disease and for the development of non-hormonal therapeutics. Abstract Traditionally considered as an enigmatic disease, adenomyosis is a uterine disease that affects many women of reproductive age and is a contributing factor for pelvic pain, heavy menstrual bleeding (HMB), and subfertility. In this review, the new development in the pathogenesis and pathophysiology of adenomyosis has been summarized, along with their clinical implications. After reviewing the progress in our understanding of the pathogenesis and describing the prevailing theories, in conjunction with their deficiencies, a new hypothesis, called endometrial-myometrial interface disruption (EMID), which is backed by extensive epidemiologic data and demonstrated by a mouse model, is reviewed, along with recent data implicating the role of Schwann cells in the EMI area in the genesis of adenomyosis. Additionally, the natural history of adenomyotic lesions is elaborated and underscores that, in essence, adenomyotic lesions are fundamentally wounds undergoing repeated tissue injury and repair (ReTIAR), which progress to fibrosis through epithelial-mesenchymal transition, fibroblast-to-myofibroblast transdifferentiation, and smooth muscle metaplasia. Increasing lesional fibrosis propagates into the neighboring EMI and endometrium. The increased endometrial fibrosis, with ensuing greater tissue stiffness, results in attenuated prostaglandin E2, hypoxia signaling and glycolysis, impairing endometrial repair and causing HMB. Compared with adenomyosis-associated HMB, the mechanisms underlying adenomyosis-associated pain are less understood but presumably involve increased uterine contractility, hyperinnervation, increased lesional production of pain mediators, and central sensitization. Viewed through the prism of ReTIAR, a new imaging technique can be used to diagnose adenomyosis more accurately and informatively and possibly help to choose the best treatment modality.
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Affiliation(s)
- Sun-Wei Guo
- Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Fudan University, Shanghai, China
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8
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Classification of Uterine Adenomyosis. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2022. [DOI: 10.1007/s13669-022-00337-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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9
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Unveiling the Pathogenesis of Adenomyosis through Animal Models. J Clin Med 2022; 11:jcm11061744. [PMID: 35330066 PMCID: PMC8953406 DOI: 10.3390/jcm11061744] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 03/09/2022] [Accepted: 03/15/2022] [Indexed: 02/08/2023] Open
Abstract
Background: Adenomyosis is a common gynecological disorder traditionally viewed as “elusive”. Several excellent review papers have been published fairly recently on its pathogenesis, and several theories have been proposed. However, the falsifiability, explanatory power, and predictivity of these theories are often overlooked. Since adenomyosis can occur spontaneously in rodents and many other species, the animal models may help us unveil the pathogenesis of adenomyosis. This review critically tallies experimentally induced models published so far, with a particular focus on their relevance to epidemiological findings, their possible mechanisms of action, and their explanatory and predictive power. Methods: PubMed was exhaustively searched using the phrase “adenomyosis and animal model”, “adenomyosis and experimental model”, “adenomyosis and mouse”, and “adenomyosis and rat”, and the resultant papers were retrieved, carefully read, and the resultant information distilled. All the retrieved papers were then reviewed in a narrative manner. Results: Among all published animal models of adenomyosis, the mouse model of adenomyosis induced by endometrial–myometrial interface disruption (EMID) seems to satisfy the requirements of falsifiability and has the predictive capability and also Hill’s causality criteria. Other theories only partially satisfy Hill’s criteria of causality. In particular, animal models of adenomyosis induced by hyperestrogenism, hyperprolactinemia, or long-term exposure to progestogens without much epidemiological documentation and adenomyosis is usually not the exclusive uterine pathology consequent to those induction procedures. Regardless, uterine disruption appears to be a necessary but not sufficient condition for causing adenomyosis. Conclusions: EMID is, however, unlikely the sole cause for adenomyosis. Future studies, including animal studies, are warranted to understand how and why in utero and/or prenatal exposure to elevated levels of estrogen or estrogenic compounds increases the risk of developing adenomyosis in adulthood, to elucidate whether prolactin plays any role in its pathogenesis, and to identify sufficient condition(s) that cause adenomyosis.
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Classifications of Adenomyosis and Correlation of Phenotypes in Imaging and Histopathology to Clinical Outcomes: a Review. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2022. [DOI: 10.1007/s13669-021-00320-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Abstract
Purpose of Review
To provide an update on published classification and reporting systems for adenomyosis. There is an urgent need to standardize reporting of various phenotypes of adenomyosis into a validated and globally recognized system. This can be used to examine the nature and severity of adenomyosis symptoms and inform the design, evaluation, and implementation of appropriate treatment options.
Recent Findings
In recent years, several new proposals for adenomyosis classification have emerged. Most are MRI-based and include features such as uterine size, junctional zone thickness, size and location of the lesions, and distribution patterns. To date, none of those proposals has been validated. Only one recent classification based on transvaginal ultrasound was validated for interobserver congruence and correlated to clinical findings. However, the differentiation of diffuse and focal adenomyosis still lacks consensus. In addition, only a few authors advocated imaging-based definitions.
Summary
There is a need for one or a combination of a classification and reporting system for adenomyosis. To date, there is no widely accepted and validated system.
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Sun M, Xu P, Zou G, Wang J, Zhu L, Zhang X. Extrinsic Adenomyosis Is Associated With Postoperative Recurrence of Ovarian Endometrioma. Front Med (Lausanne) 2022; 8:815628. [PMID: 35096905 PMCID: PMC8793806 DOI: 10.3389/fmed.2021.815628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/13/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To determine whether endometrioma recurrence is closely related to the presence of extrinsic adenomyosis, which was demonstrated by magnetic resonance imaging (MRI). Design: Observational crosssectional study involving patients with the recurrence of ovarian endometrioma (OMA). Correlations of endometrioma recurrence and adenomyosis subtypes shown by MRI were analyzed. Method: Between January 2018 and December 2020, a total of 233 patients with recurrence of OMA after ovarian cystectomy were administered for surgery at our institution. All patients were divided into subtype II (Group A), subtype I+IV (Group B), and nonadenomyosis (Group C) groups at preoperative MRI imaging. The correlations of endometrioma recurrence with clinical features, imaging appearance, and surgical findings were retrospectively analyzed. Results: We found 112 (48.07%) patients of endometrioma recurrence combined with subtype II adenomyosis, 8 (3.43%) subtype I adenomyosis, 47 (20.17%) subtype IV adenomyosis, 66 (28.32%) nonadenomyosis. The mean time of OMA recurrence (44.28 ± 8.37, vs. 63.96 ± 10.28, vs. 69.36 ± 9.34 mon), rate of pain symptoms (85.71, vs. 69.10, vs. 18.18%), and primary infertility (31.25, vs. 14.55, vs. 10.77%) were higher in Group A. Uterine volume (257.37± 42.61, vs. 203.14 ± 33.52, vs. 100.85 ± 26.67 cm3), and mean OMA size (4.97 ± 2.25, vs. 4.36 ± 2.38, vs. 4.46 ± 2.70 cm) were significantly larger in Group A. The rate of DIE (83.93, vs. 45.45, vs. 40.91%), the number of DIE (3.6 ± 1.8 vs. 2.3 ± 1.5 vs. 2.2 ± 1.3), the mean total revised American Society for Reproductive Medicine score (rASRM, 103.14 ± 23.89 vs. 74.23 ± 16.72 vs. 36.51 ± 14.23) were significantly higher in Group A. After a multiple logistic regression analysis, extrinsic adenomyosis (OR 2.5, 95% CI 1.2-3.4), DIE lesions (OR 2.1, 95% CI 1.4-2.8), and primary infertility (OR 1.8, 95% CI 1.3-4.3) were significantly associated with early recurrence (in 3-year) of OMA. Conclusions: Extrinsic adenomyosis was associated with postoperative recurrence of OMA. In addition, a pathogenic link between extrinsic adenomyosis and pelvic endometriosis needs to be clarified.
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Affiliation(s)
- Man Sun
- The Department of Gynecology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ping Xu
- The Department of Gynecology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Gen Zou
- The Department of Gynecology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jianzhang Wang
- The Department of Gynecology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Libo Zhu
- The Department of Gynecology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xinmei Zhang
- The Department of Gynecology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Bourdon M, Santulli P, Marcellin L, Maignien C, Maitrot-Mantelet L, Chapron C. [Adenomyosis pathophysiology: An unresolved enigma]. ACTA ACUST UNITED AC 2021; 50:182-188. [PMID: 34656788 DOI: 10.1016/j.gofs.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Indexed: 11/25/2022]
Abstract
Adenomyosis is a chronic benign uterine disease characterized by the presence of endometrial glands and stroma within the myometrium. It is a heterogeneous disease, presenting various clinical forms, depending on the location of the ectopic lesions within the myometrium. Adenomyosis can be responsible for several symptoms such as dysmenorrhea, abnormal uterine bleeding and/or infertility. Its pathophysiology is a real conundrum and several theories have been proposed: development of adenomyosis lesion could initiate de novo from Mullerian rests or from stem cells. Moreover, multiple factors could be involved in initiating lesions, including specific hormonal, immune and/or genetic changes. The objective of this review is to provide an update on adenomyosis pathophysiology, in particular on the various theories proposed concerning the invasion of the myometrium by endometrial cells and the inducing mechanisms, and to study the link between the physiopathology, the symptoms and the medical treatments.
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Affiliation(s)
- M Bourdon
- Université de Paris, faculté de santé, faculté de médecine Paris Centre, Paris, France; Assistance publique-Hôpitaux de Paris (AP-HP), hôpital universitaire Paris Centre (HUPC), centre hospitalier universitaire (CHU) Cochin, département de gynécologie obstétrique II et médecine de la reproduction, Paris, France; Département 3I « infection, immunité et inflammation », Cochin Institute, INSERM U1016, Paris, France.
| | - P Santulli
- Université de Paris, faculté de santé, faculté de médecine Paris Centre, Paris, France; Assistance publique-Hôpitaux de Paris (AP-HP), hôpital universitaire Paris Centre (HUPC), centre hospitalier universitaire (CHU) Cochin, département de gynécologie obstétrique II et médecine de la reproduction, Paris, France; Département 3I « infection, immunité et inflammation », Cochin Institute, INSERM U1016, Paris, France
| | - L Marcellin
- Université de Paris, faculté de santé, faculté de médecine Paris Centre, Paris, France; Assistance publique-Hôpitaux de Paris (AP-HP), hôpital universitaire Paris Centre (HUPC), centre hospitalier universitaire (CHU) Cochin, département de gynécologie obstétrique II et médecine de la reproduction, Paris, France; Département 3I « infection, immunité et inflammation », Cochin Institute, INSERM U1016, Paris, France
| | - C Maignien
- Assistance publique-Hôpitaux de Paris (AP-HP), hôpital universitaire Paris Centre (HUPC), centre hospitalier universitaire (CHU) Cochin, département de gynécologie obstétrique II et médecine de la reproduction, Paris, France
| | - L Maitrot-Mantelet
- Assistance publique-Hôpitaux de Paris (AP-HP), hôpital universitaire Paris Centre (HUPC), centre hospitalier universitaire (CHU) Cochin, département de gynécologie obstétrique II et médecine de la reproduction, Paris, France
| | - C Chapron
- Université de Paris, faculté de santé, faculté de médecine Paris Centre, Paris, France; Assistance publique-Hôpitaux de Paris (AP-HP), hôpital universitaire Paris Centre (HUPC), centre hospitalier universitaire (CHU) Cochin, département de gynécologie obstétrique II et médecine de la reproduction, Paris, France; Département 3I « infection, immunité et inflammation », Cochin Institute, INSERM U1016, Paris, France
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Bourdon M, Santulli P, Marcellin L, Maignien C, Maitrot-Mantelet L, Bordonne C, Plu Bureau G, Chapron C. Adenomyosis: An update regarding its diagnosis and clinical features. J Gynecol Obstet Hum Reprod 2021; 50:102228. [PMID: 34520877 DOI: 10.1016/j.jogoh.2021.102228] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/29/2021] [Accepted: 09/08/2021] [Indexed: 11/28/2022]
Abstract
Adenomyosis is a common gynecologic disease characterized by invasion of endometrial glands and stroma within the myometrium. Clinically, it can result in abnormal uterine bleeding, pelvic pain, and infertility. Adenomyosis has historically been diagnosed by histology of hysterectomy specimens. As a result of the development of imaging techniques, the diagnosis is nowadays possible by means of transvaginal pelvic ultrasound or pelvic magnetic resonance imaging. The use of pelvic imaging has demonstrated the existence of different forms of adenomyosis, notably allowing distinction between lesions of the external myometrium and those of the internal myometrium. The epidemiological and clinical characteristics may depend on the anatomical location of the adenomyosis lesions. In order to provide the best management for women with adenomyosis, the objective of this review is to provide an update regarding the diagnosis of adenomyosis and its clinical features according to the different adenomyosis phenotypes.
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Affiliation(s)
- Mathilde Bourdon
- Université de Paris, Faculté de médecine, Paris, France; Département de Gynécologie Obstétrique II et médecine de la reproduction, Hôpital Cochin (UHC), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), Paris, France; Département 3I "Infection, Immunité et inflammation", Cochin Institute, INSERM U1016, Paris, France.
| | - Pietro Santulli
- Université de Paris, Faculté de médecine, Paris, France; Département de Gynécologie Obstétrique II et médecine de la reproduction, Hôpital Cochin (UHC), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), Paris, France; Département 3I "Infection, Immunité et inflammation", Cochin Institute, INSERM U1016, Paris, France
| | - Louis Marcellin
- Université de Paris, Faculté de médecine, Paris, France; Département de Gynécologie Obstétrique II et médecine de la reproduction, Hôpital Cochin (UHC), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), Paris, France; Département 3I "Infection, Immunité et inflammation", Cochin Institute, INSERM U1016, Paris, France
| | - Chloé Maignien
- Département de Gynécologie Obstétrique II et médecine de la reproduction, Hôpital Cochin (UHC), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), Paris, France
| | - Lorraine Maitrot-Mantelet
- Département de Gynécologie Obstétrique II et médecine de la reproduction, Hôpital Cochin (UHC), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), Paris, France
| | - Corinne Bordonne
- Département de radiologie, Hôpital Hôtel Dieu, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), Paris, France
| | - Geneviève Plu Bureau
- Université de Paris, Faculté de médecine, Paris, France; Département de Gynécologie Obstétrique II et médecine de la reproduction, Hôpital Cochin (UHC), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), Paris, France
| | - Charles Chapron
- Université de Paris, Faculté de médecine, Paris, France; Département de Gynécologie Obstétrique II et médecine de la reproduction, Hôpital Cochin (UHC), Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital universitaire Paris Centre (HUPC), Paris, France; Département 3I "Infection, Immunité et inflammation", Cochin Institute, INSERM U1016, Paris, France
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Just PA, Moret S, Borghese B, Chapron C. [Endometriosis and adenomyosis]. Ann Pathol 2021; 41:521-534. [PMID: 34183193 DOI: 10.1016/j.annpat.2021.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 03/10/2021] [Accepted: 03/22/2021] [Indexed: 10/21/2022]
Abstract
Diffuse adenomyosis, focal adenomyosis, ovarian endometrioma, superficial endometriosis and deep infiltrating adenomyosis are all defined by the presence of an endometrioid tissue in an ectopic location that is at distance from the endometrium. Although frequently associated, these lesions represent different clinico-pathological entities that the pathologist should recognized. Herein, we review the clinical and pathological features of these entities, as well as related current physiopathological understandings and differential diagnoses that could be raised by some morphological variants. The statistical association between endometriosis and several ovarian tumors, mainly endometrioid and clear cell carcinomas and seromucinous borderline tumors is well established and we present some molecular and morphological features that support this transformation potential.
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Affiliation(s)
- Pierre-Alexandre Just
- Université de Paris, service de pathologie, AP-HP, hôpital Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France.
| | - Sandrine Moret
- Université de Paris, service de pathologie, AP-HP, hôpital Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Bruno Borghese
- Université de Paris, service de gynécologie obstétrique 2 et médecine de la reproduction, AP-HP, hôpital Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
| | - Charles Chapron
- Université de Paris, service de gynécologie obstétrique 2 et médecine de la reproduction, AP-HP, hôpital Cochin, 27, rue du Faubourg-Saint-Jacques, 75014 Paris, France
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15
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Adenomyosis is associated with specific proton nuclear magnetic resonance ( 1H-NMR) serum metabolic profiles. Fertil Steril 2021; 116:243-254. [PMID: 33849709 DOI: 10.1016/j.fertnstert.2021.02.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To determine whether the adenomyosis phenotype affects the proton nuclear magnetic resonance (1H-NMR)-based serum metabolic profile of patients. DESIGN Cohort study. SETTING University hospital-based research center. PATIENTS Seventy-seven patients who underwent laparoscopy for a benign gynecologic condition. INTERVENTIONS Pelvic magnetic resonance imaging and collection of a venous peripheral blood sample were performed during the preoperative workup. The women were allocated to the adenomyosis group (n = 32), or the control group (n = 45). The adenomyosis group was further subdivided into two groups: diffuse adenomyosis of the inner myometrium (n = 14) and focal adenomyosis of the outer myometrium (n = 18). Other adenomyosis phenotypes were excluded. MAIN OUTCOME MEASURES Metabolomic profiling based on 1H-NMR spectroscopy in combination with statistical approaches. RESULTS The serum metabolic profiles of the patients with adenomyosis indicated lower concentrations of 3-hydroxybutyrate, glutamate, and serine compared with controls. Conversely, the concentrations of proline, choline, citrate, 2-hydroxybutyrate, and creatinine were higher in the adenomyosis group. The focal adenomyosis of the outer myometrium and the diffuse adenomyosis phenotypes also each exhibited a specific metabolic profile. CONCLUSION Serum metabolic changes were detected in women with features of adenomyosis compared with their disease-free counterparts, and a number of specific metabolic pathways appear to be engaged according to the adenomyosis phenotype. The metabolites with altered levels are particularly involved in immune activation as well as cell proliferation and cell migration. Nevertheless, this study did find evidence of a correlation between metabolite levels and symptoms thought to be related to adenomyosis. Further studies are required to determine the clinical significance of these differences in metabolic profiles.
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Rees CO, Nederend J, Mischi M, van Vliet HAAM, Schoot BC. Objective measures of adenomyosis on MRI and their diagnostic accuracy-a systematic review & meta-analysis. Acta Obstet Gynecol Scand 2021; 100:1377-1391. [PMID: 33682087 DOI: 10.1111/aogs.14139] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 02/15/2021] [Accepted: 03/02/2021] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Magnetic resonance imaging (MRI) diagnosis of adenomyosis is considered the most accurate non-invasive technique, but remains subjective, with no consensus on which diagnostic parameters are most accurate. We aimed to systematically review the literature on how adenomyosis can be objectively quantified on MRI in a scoping manner, to review the diagnostic performance of these characteristics compared with histopathological diagnosis, and to summarize correlations between measures of adenomyosis on MRI and clinical outcomes. MATERIAL AND METHODS We searched databases Pubmed, Embase, and Cochrane for relevant literature up to April 2020 according to PRISMA guidelines. We included studies that objectively assessed adenomyosis on MRI, and separately assessed studies investigating the diagnostic performance of MRI vs histopathology for inclusion in a meta-analysis. The QUADAS-2 tool was used for risk of bias, with many studies showing an unclear or high risk of bias. RESULTS Eighty studies were included, of which 14 assessed the diagnostic performance of individual MRI parameters, with four included in the meta-analysis of diagnostic accuracy. Common MRI parameters were: junctional zone (JZ) characteristics, such as maximum JZ thickness-pooled sensitivity 71.6% (95% CI 46.0%-88.2%), specificity 85.5% (52.3%-97.0%); JZ differential-pooled sensitivity 58.9% (95% CI 44.3%-72.1%), specificity 83.2% (95% CI 71.3%-90.8%); and JZ to myometrial ratio-pooled sensitivity 63.3% (95% CI 51.9%-73.4%), specificity 79.4% (95% CI 42.0%-95.4%); adenomyosis lesion size, uterine morphology (pooled sensitivity 42.9% (95% CI 15.9%-74.9%), specificity 87.7%, (95% CI 37.9-98.8) and changes in signal intensity-eg, presence of myometrium cysts; pooled 59.6% (95% CI 41.6%-75.4%) and specificity of 96.1% (95% CI 80.7%-99.3%). Other MRI parameters have been used for adenomyosis diagnosis, but their diagnostic performance is unknown. Few studies attempted to correlate adenomyosis MRI phenotype to clinical outcomes. CONCLUSIONS A wide range of objective parameters for adenomyosis exist on MRI; however, in many cases their individual diagnostic performance remains uncertain. JZ characteristics remain the most widely used and investigated with acceptable diagnostic accuracy. Specific research is needed into how these objective measures of adenomyosis can be correlated to clinical outcomes.
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Affiliation(s)
- Connie O Rees
- Department of Gynecology and Obstetrics, Catharina Hospital, Eindhoven, the Netherlands.,Department of Reproductive Medicine, Ghent University Hospital, Ghent, Belgium
| | - Joost Nederend
- Department of Radiology, Catharina Hospital, Eindhoven, the Netherlands
| | - Massimo Mischi
- Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | | | - Benedictus C Schoot
- Department of Gynecology and Obstetrics, Catharina Hospital, Eindhoven, the Netherlands.,Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands.,Department of Reproductive Medicine, Ghent University Hospital, Ghent, Belgium
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A Detailed Study in Adenomyosis and Endometriosis: Evaluation of the Rate of Coexistence Between Uterine Adenomyosis and DIE According to Imaging and Histopathology Findings. Reprod Sci 2021; 28:2387-2397. [PMID: 33725313 DOI: 10.1007/s43032-021-00527-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 03/01/2021] [Indexed: 01/11/2023]
Abstract
The current study was designed to evaluate the relationship between adenomyosis and its subtypes with endometriotic lesions (ovarian endometrioma (OMAs) and posterior deep infiltrative endometriosis (DIE)), to examine the probability of existence of a common cause of these mysterious diseases, and to evaluate the accuracy, sensitivity, and specificity of both transvaginal ultrasonography (TVS) and MRI in diagnosis of adenomyotic uterus. In this retrospective cross-sectional study, we selected 154 women with coexistence of endometriosis and adenomyosis according to their imaging, intraoperative, or pathological findings who were nominated for laparoscopic surgery. Eighty-six patients with just DIE resection without LH (laparoscopic hysterectomy) (group 1), and 68 patients with LH + DIE resection (group 2). The accuracy, sensitivity, and specificity of ultrasonographic and MRI findings for diagnosing adenomyosis were 72.1%, 77.6%, 40.0% and 49.2%, 41.5%, 90.0% respectively. So, TVS is a more sensitive diagnostic tool for diagnosing adenomyosis. However, MRI was more specific than TVS in the diagnosis of diffuse adenomyosis especially with simultaneous presence of uterine leiomyoma. Regarding the association of different types of adenomyosis (focal and diffuse) with different endometriosis lesions (OMA and posterior compartment DIE), we just found diffuse type of adenomyosis more frequent in the absence of rectal and rectovaginal septum (RVS) DIE (p ≤ 0.05). In addition to the questionable different nature of rectal and RVS DIE lesion, there is no relationship between adenomyosis subtypes and endometriotic lesions.
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Abstract
To summarize and update our current knowledge regarding adenomyosis diagnosis, prevalence, and symptoms. Systematic review of PubMed between January 1972 and April 2020. Search strategy included: "adenomyosis [MeSH Terms] AND (endometriosis[MeSH Term OR prevalence study [MeSH Terms] OR dysmenorrhea[Text Word] OR prevalence[Text Word] OR young adults [Text Word] OR adolesce* [Text Word] OR symptoms[Text Word] OR imaging diagnosis [Text Word] OR pathology[Text Word]. Articles published in English that addressed adenomyosis and discussed prevalence, diagnosis, and symptoms were included. Included articles described: pathology diagnosis, imaging, biopsy diagnosis, prevalence and age of onset, symptoms, and concomitant endometriosis. Sixteen articles were included in the qualitative analysis. The studies are heterogeneous when diagnosing adenomyosis with differing criteria, protocols, and patient populations. Prevalence estimates range from 20% to 88.8% in symptomatic women (average 30-35%) with most diagnosed between 32-38 years old. The correlation between imaging and pathology continues to evolve. As imaging advances, newer studies report younger symptomatic women are being diagnosed with adenomyosis based on both magnetic resonance imaging (MRI) and/or transvaginal ultrasound (TVUS). High rates of concomitant endometriosis create challenges when discerning the etiology of pelvic pain. Symptoms that are historically attributed to endometriosis may actually be caused by adenomyosis. Adenomyosis remains a challenge to identify, assess and research because of the lack of standardized diagnostic criteria, especially in women who wish to retain their uterus. As noninvasive diagnostics such as imaging and myometrial biopsies continue to improve, younger women with variable symptoms will likely create criteria for diagnosis with adenomyosis. The priority should be to create standardized histopathological and imaging diagnoses to gain deeper understandings of adenomyosis.
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Affiliation(s)
- Keith Isaacson
- Department of OB/GYN Harvard Medical School, Department of MIGS and Infertility, Newton, Massachusetts
| | - Megan Loring
- Department of MIGS and Infertility, Newton Wellesley Hospital, Department of MIGS and Infertility, Newton, Massachusetts
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Rousset P, Bischoff E, Charlot M, Grangeon F, Dubernard G, Paparel P, Lega JC, Golfier F. Bladder endometriosis: Preoperative MRI analysis with assessment of extension to ureteral orifices. Diagn Interv Imaging 2020; 102:255-263. [PMID: 33339775 DOI: 10.1016/j.diii.2020.11.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE The purpose of this study was to retrospectively evaluate the performance of magnetic resonance imaging (MRI) in locating endometriosis implants within the bladder wall with assessment of ureteral orifice extension using surgical findings as standard of reference. MATERIALS AND METHODS MRI examinations of 39 consecutive women (mean age: 31.2±5.5 [SD] years; age range: 22-42years) operated in 3 university hospitals for bladder endometriosis over a 6-year period were reviewed by 2 independent readers. Interobserver agreement was assessed using Kappa tests. Results of consensus reading were used to calculate sensitivity, specificity and accuracy of MRI for the diagnosis, location and extent of endometriosis implants using surgical findings as the standard of reference. RESULTS Mean bladder repletion volume was 134±110 [SD] mL (range: 21-479mL). The mean largest endometriosis implant diameter was 30±7 [SD] mm (range: 19-41mm). On MR images, 34/39 (87%) endometriosis implants were present in the two anterior thirds of the dome (k=0.45), 31/39 (79%) extended or were present in the posterior third pouch (k=0.92) and 25/39 (64%) extended into the bladder base (k=0.84) with sensitivities of 100% (31/31; 95% confidence interval [CI]: 89-100%), 100% (30/30; 95% CI: 88-100%) and 90% (19/21; 95% CI: 69-98%), respectively, specificities of 83% (5/6, 95% CI: 36-100), 88% (7/8, 95% CI: 47-100%), 87% (13/15; 95% CI: 52-96), respectively and accuracies of 97% (36/37, 95% CI: 86-100%), 97% (37/38; 95% CI: 86-100%), and 89% (32/36; 95% CI: 74-97%), respectively. In 9 (9/25; 36%) patients with bladder base involvement, a zero distance was reported between endometriosis implants and ureteral orifices, all but one presenting with low-to-moderate bladder volumes. In the two patients who needed ureteral resection-reimplantation, ureteral dilation was associated with a zero distance. External adenomyosis was reported in 26/39 (66%) patients (k=0.94). CONCLUSION A dedicated preoperative MRI work-up for bladder endometriosis helps accurately depict and locate endometriosis implants. Adequate bladder filling is needed to improve appropriate estimate of the distance between endometriosis implants and ureteral orifices to better predict requirement of ureteral resection-reimplantation.
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Affiliation(s)
- Pascal Rousset
- Lyon 1 Claude-Bernard University, EMR 3738, Hospices Civils de Lyon, Lyon Sud University Hospital, Department of Radiology, 69495 Pierre-Bénite, France.
| | - Elodie Bischoff
- Hospices Civils de Lyon, Lyon Sud University Hospital, Department of Radiology, 69495 Pierre-Bénite, France
| | - Mathilde Charlot
- Hospices Civils de Lyon, Lyon Sud University Hospital, Department of Radiology, 69495 Pierre-Bénite, France
| | - Flavia Grangeon
- Lyon 1 Claude-Bernard University, EMR 3738, Hospices Civils de Lyon, Lyon Sud University Hospital, Department of Radiology, 69495 Pierre-Bénite, France
| | - Gil Dubernard
- Lyon 1 Claude-Bernard University, LabTAU, Hospices Civils de Lyon, Croix-Rousse Hospital, Obstetrics and Gynaecology Department, 69004 Lyon, France
| | - Philippe Paparel
- Lyon 1 Claude-Bernard University, Hospices Civils de Lyon, Lyon Sud University Hospital, Urology Department, 69495 Pierre-Bénite, France
| | - Jean-Christophe Lega
- Lyon 1 Claude-Bernard University, UMR CNRS 5558, Hospices Civils de Lyon, Lyon Sud University Hospital, Internal and Vascular Medicine Department, 69495 Pierre-Bénite, France
| | - François Golfier
- Lyon 1 Claude-Bernard University, EMR 3738, Hospices Civils de Lyon, Lyon Sud University Hospital, Gynecological Oncological, and Obstetrics Department, 69495 Pierre-Bénite, France
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Abdalla Ribeiro HS, da Costa Porto BT, Bassoi L, Ninomiya GY, Tomasi MC, Cervantes GV, Ribeiro PA. Effect of nodule size on symptoms and the choice of surgical technique in patients with bladder endometriosis. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2020. [DOI: 10.1177/2284026520977996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: In this study, we evaluated the relationships between symptoms of bladder endometriosis (EDT), lesion size, and the subsequent surgical technique used to excise the lesion. Methods: This is retrospective observational study of patients who underwent surgery in the Gynecological Endoscopy and Endometriosis Section at Hospital da Santa Casa of São Paulo, Brazil. A sample population of 39 women diagnosed with bladder EDT was included from 463 women presenting with deep pelvic EDT between January 2010 and March 2017. Clinical evaluations and surgical treatments for each EDT were performed. Results: Of the 39 women, 43.58% had dysmenorrhea or dyspareunia and 2.56% had hematuria. Furthermore, 21.10% presented with dysuria and endometriotic nodules on the bladder ( p < 0.04). The nodules had reached the muscle layer in 97.30% of patients, and a further 2.60% had reached the mucosal layer. In addition to bladder involvement, other pelvic regions were affected, including the left (15.8%) and right (13.2%) round ligament, left (68.4%) and right (65.8%) uterosacral ligament, retrocervical region (84.20%), and ureter (45.71%). Conclusion: The patients’ pain symptoms were found to be associated with bladder endometriosis and nodule size. Partial cystectomy with complete lesion excision might be an effective treatment option to relieve these symptoms. A study with a larger sample population is needed to confirm these findings.
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Affiliation(s)
- Helizabet Salomão Abdalla Ribeiro
- Gynecological Endoscopy and Endometriosis Clinic, Faculdade de Ciências Médicas da Santa Casa de Misericordia de São Paulo, São Paulo, Brazil
| | - Beatriz Taliberti da Costa Porto
- Gynecological Endoscopy and Endometriosis Clinic, Faculdade de Ciências Médicas da Santa Casa de Misericordia de São Paulo, São Paulo, Brazil
| | - Luisa Bassoi
- Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
| | | | - Mariana C Tomasi
- Gynecological Endoscopy and Endometriosis Clinic, Faculdade de Ciências Médicas da Santa Casa de Misericordia de São Paulo, São Paulo, Brazil
| | - Graziele V Cervantes
- Gynecological Endoscopy and Endometriosis Clinic, Faculdade de Ciências Médicas da Santa Casa de Misericordia de São Paulo, São Paulo, Brazil
| | - Paulo Ayroza Ribeiro
- Gynecology and Obstetrics, Faculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, Brazil
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21
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Chapron C, Vannuccini S, Santulli P, Abrão MS, Carmona F, Fraser IS, Gordts S, Guo SW, Just PA, Noël JC, Pistofidis G, Van den Bosch T, Petraglia F. Diagnosing adenomyosis: an integrated clinical and imaging approach. Hum Reprod Update 2020; 26:392-411. [PMID: 32097456 DOI: 10.1093/humupd/dmz049] [Citation(s) in RCA: 181] [Impact Index Per Article: 45.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 11/20/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Adenomyosis is a benign uterine disorder where endometrial glands and stroma are pathologically demonstrated within the uterine myometrium. The pathogenesis involves sex steroid hormone abnormalities, inflammation, fibrosis and neuroangiogenesis, even though the proposed mechanisms are not fully understood. For many years, adenomyosis has been considered a histopathological diagnosis made after hysterectomy, classically performed in perimenopausal women with abnormal uterine bleeding (AUB) or pelvic pain. Until recently, adenomyosis was a clinically neglected condition. Nowadays, adenomyosis may also be diagnosed by non-invasive techniques, because of imaging advancements. Thus, a new epidemiological scenario has developed with an increasing number of women of reproductive age with ultrasound (US) or magnetic resonance imaging (MRI) diagnosis of adenomyosis. This condition is associated with a wide variety of symptoms (pelvic pain, AUB and/or infertility), but it is also recognised that some women are asymptomatic. Furthermore, adenomyosis often coexists with other gynecological comorbidities, such as endometriosis and uterine fibroids, and the diagnostic criteria are still not universally agreed. Therefore, the diagnostic process for adenomyosis is challenging. OBJECTIVE AND RATIONALE We present a comprehensive review on the diagnostic criteria of adenomyosis, including clinical signs and symptoms, ultrasound and MRI features and histopathological aspects of adenomyotic lesions. We also briefly summarise the relevant theories on adenomyosis pathogenesis, in order to provide the pathophysiological background to understand the different phenotypes and clinical presentation. The review highlights the controversies of multiple existing criteria, summarising all of the available evidences on adenomyosis diagnosis. The review aims also to underline the future perspective for diagnosis, stressing the importance of an integrated clinical and imaging approach, in order to identify this gynecological disease, so often underdiagnosed. SEARCH METHODS PubMed and Google Scholar were searched for all original and review articles related to diagnosis of adenomyosis published in English until October 2018. OUTCOMES The challenge in diagnosing adenomyosis starts with the controversies in the available pathogenic theories. The difficulties in understanding the way the disease arises and progresses have an impact also on the specific diagnostic criteria to use for a correct identification. Currently, the diagnosis of adenomyosis may be performed by non-invasive methods and the clinical signs and symptoms, despite their heterogeneity and poor specificity, may guide the clinician for a suspicion of the disease. Imaging techniques, including 2D and 3D US as well as MRI, allow the proper identification of the different phenotypes of adenomyosis (diffuse and/or focal). From a histological point of view, if the diagnosis of diffuse adenomyosis is straightforward, in more limited disease, the diagnosis has poor inter-observer reproducibility, leading to extreme variations in the prevalence of disease. Therefore, an integrated non-invasive diagnostic approach, considering risk factors profile, clinical symptoms, clinical examination and imaging, is proposed to adequately identify and characterise adenomyosis. WIDER IMPLICATIONS The development of the diagnostic tools allows the physicians to make an accurate diagnosis of adenomyosis by means of non-invasive techniques, representing a major breakthrough, in the light of the clinical consequences of this disease. Furthermore, this technological improvement will open a new epidemiological scenario, identifying different groups of women, with a dissimilar clinical and/or imaging phenotypes of adenomyosis, and this should be object of future research.
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Affiliation(s)
- Charles Chapron
- Department of Gynecology Obstetrics II and Reproductive Medicine, Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France.,Department "Development, Reproduction and Cancer", Institut Cochin, INSERM U1016 (Doctor Vaiman), Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Department "Development, Reproduction and Cancer", Institut Cochin, INSERM U1016 (Professor Batteux), Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Silvia Vannuccini
- Department of Gynecology Obstetrics II and Reproductive Medicine, Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France.,Department of Obstetrics and Gynecology, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy.,Department of Neuroscience, Psychology, Pharmacology and Child Health (NEUROFARBA), University of Florence, Florence, Italy.,Department of Molecular and Developmental Medicine, University of Siena, viale Mario Bracci, 16, 53100, Siena, Italy
| | - Pietro Santulli
- Department of Gynecology Obstetrics II and Reproductive Medicine, Université Paris Descartes, Sorbonne Paris Cité, Faculté de Médecine, Assistance Publique - Hôpitaux de Paris (AP-HP), Hôpital Universitaire Paris Centre (HUPC), Centre Hospitalier Universitaire (CHU) Cochin, Paris, France.,Department "Development, Reproduction and Cancer", Institut Cochin, INSERM U1016 (Doctor Vaiman), Université Paris Descartes, Sorbonne Paris Cité, Paris, France.,Department "Development, Reproduction and Cancer", Institut Cochin, INSERM U1016 (Professor Batteux), Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Mauricio S Abrão
- Endometriosis Section, Gynecologic Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil.,Gynecologic Division, BP-A Beneficencia Portuguesa de Sao Paulo, Sao Paulo, Brazil
| | - Francisco Carmona
- Department of Gynecology, Institut Clinic of Gynecology, Obstetrics and Neonatology, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Ian S Fraser
- School of Women's and Children's Health, Royal Hospital for Women, University of New South Wales, Randwick, NSW, Australia
| | - Stephan Gordts
- Leuven Institute for Fertility & Embryology, Schipvaartstraat 4, 3000 Leuven, Belgium
| | - Sun-Wei Guo
- Department of Biochemistry, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai, China
| | - Pierre-Alexandre Just
- Faculté de Médecine, Hôpitaux Universitaires Paris Centre (AP-HP), Hôpital Cochin, Service de pathologie, CAncer Research for PErsonalized Medicine (CARPEM), Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Jean-Christophe Noël
- Department of Pathology, Erasme University Hospital/Curepath, Free University of Brussels (ULB), Brussels, Belgium
| | - George Pistofidis
- Department of Gynecologic Endoscopy, Lefkos Stavros Hospital, Athens, Greece
| | - Thierry Van den Bosch
- Department of Obstetrics and Gynecology, University Hospitals KU Leuven, Leuven, Belgium
| | - Felice Petraglia
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Largo Brambilla 3, 50134, Florence, Italy
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22
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Guo SW. Cancer-associated mutations in endometriosis: shedding light on the pathogenesis and pathophysiology. Hum Reprod Update 2020; 26:423-449. [PMID: 32154564 DOI: 10.1093/humupd/dmz047] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/22/2019] [Accepted: 11/19/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Endometriosis is a benign gynaecological disease. Thus, it came as a complete surprise when it was reported recently that the majority of deep endometriosis lesions harbour somatic mutations and a sizeable portion of them contain known cancer-associated mutations (CAMs). Four more studies have since been published, all demonstrating the existence of CAMs in different subtypes of endometriosis. While the field is still evolving, the confirmation of CAMs has raised many questions that were previously overlooked. OBJECTIVE AND RATIONALE A comprehensive overview of CAMs in endometriosis has been produced. In addition, with the recently emerged understanding of the natural history of endometriotic lesions as well as CAMs in normal and apparently healthy tissues, this review attempts to address the following questions: Why has there been such a wild discrepancy in reported mutation frequencies? Why does ectopic endometrium have a higher mutation rate than that of eutopic endometrium? Would the presence of CAMs in endometriotic lesions increase the risk of cancer to the bearers? Why do endometriotic epithelial cells have much higher mutation frequencies than their stromal counterpart? What clinical implications, if any, do the CAMs have for the bearers? Do these CAMs tell us anything about the pathogenesis and/or pathophysiology of endometriosis? SEARCH METHODS The PubMed database was searched, from its inception to September 2019, for all papers in English using the term 'endometriosis and CAM', 'endometriosis and cancer-driver mutation', 'somatic mutations', 'fibrosis', 'fibrosis and epigenetic', 'CAMs and tumorigenesis', 'somatic mutation and normal tissues', 'oestrogen receptor and fibrosis', 'oxidative stress and fibrosis', 'ARID1A mutation', and 'Kirsten rat sarcoma mutation and therapeutics'. All retrieved papers were read and, when relevant, incorporated into the review results. OUTCOMES Seven papers that identified CAMs in endometriosis using various sequencing methods were retrieved, and their results were somewhat different. Yet, it is apparent that those using microdissection techniques and more accurate sequencing methods found more CAMs, echoing recent discoveries that apparently healthy tissues also harbour CAMs as a result of the replicative aging process. Hence endometriotic lesions, irrespective of subtype, if left intact, would generate CAMs as part of replicative aging, oxidative stress and perhaps other factors yet to be identified and, in some rare cases, develop cancer. The published data still are unable to paint a clear picture on pathogenesis of endometriosis. However, since endometriotic epithelial cells have a higher turnover than their stromal counterpart due to cyclic bleeding, and since the endometriotic stromal component can be formed by refresh influx of mesenchymal cells through epithelial-mesenchymal transition, endothelial-mesenchymal transition, mesothelial-mesenchymal transition and other processes as well as recruitment of bone-marrow-derived stem cells and outflow due to smooth muscle metaplasia, endometriotic epithelial cells have much higher mutation frequencies than their stromal counterpart. The epithelial and stromal cellular components develop in a dependent and co-evolving manner. Genes involved in CAMs are likely to be active players in lesional fibrogenesis, and hyperestrogenism and oxidative stress are likely drivers of both CAMs and fibrogenesis. Finally, endometriotic lesions harbouring CAMs would conceivably be more refractory to medical treatment, due, in no small part, to their high fibrotic content and reduced vascularity and cellularity. WIDER IMPLICATIONS The accumulating data on CAMs in endometriosis have shed new light on the pathogenesis and pathophysiology of endometriosis. They also suggest new challenges in management. The distinct yet co-evolving developmental trajectories of endometriotic stroma and epithelium underscore the importance of the lesional microenvironment and ever-changing cellular identity. Mutational profiling of normal endometrium from women of different ages and reproductive history is needed in order to gain a deeper understanding of the pathogenesis. Moreover, one area that has conspicuously received scant attention is the epigenetic landscape of ectopic, eutopic and normal endometrium.
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Affiliation(s)
- Sun-Wei Guo
- Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China.,Shanghai Key Laboratory of Female Reproductive Endocrine-Related Diseases, Shanghai 200011, China
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23
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Abstract
Adenomyosis, characterized by the presence of endometrial glands and stroma within the myometrium, can have a substantial impact on the quality of women's lives. Despite this, the epidemiologic research on this condition lags considerably behind that of other noncancerous reproductive health conditions. The lack of progress and knowledge is due in part to the challenges in designing valid epidemiologic studies, since the diagnosis of adenomyosis historically has been limited to the examination of uterine specimens from hysterectomy. This review describes the available data on the frequency of this condition and the epidemiologic investigation thus far into the risk factors for disease-highlighting the methodologic and inference challenges primarily around study sample selection. We conclude with providing recommendations for approaches to future epidemiologic study that capitalize on the advancements in imaging technology to detect adenomyosis and provide a fuller picture of the occurrence and risk factors for disease.
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Affiliation(s)
- Kristen Upson
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, Michigan
| | - Stacey A Missmer
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, Michigan.,Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, Grand Rapids, Michigan.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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24
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Loring M, Chen TY, Isaacson KB. A Systematic Review of Adenomyosis: It Is Time to Reassess What We Thought We Knew about the Disease. J Minim Invasive Gynecol 2020; 28:644-655. [PMID: 33371949 DOI: 10.1016/j.jmig.2020.10.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To summarize and update our current knowledge regarding adenomyosis diagnosis, prevalence, and symptoms. DATA SOURCES Systematic review of PubMed between January 1972 and April 2020. Search strategy included: "adenomyosis [MeSH Terms] AND (endometriosis[MeSH Term OR prevalence study [MeSH Terms] OR dysmenorrhea[text word] OR prevalence[Text Word] OR young adults [Text Word] OR adolesce* [Text Word] OR symptoms[Text Word] OR imaging diagnosis [Text Word] OR pathology[Text Word]. METHODS OF STUDY SELECTION Articles published in English that addressed adenomyosis and discussed prevalence, diagnosis, and symptoms were included. The included articles described pathology diagnosis, imaging, biopsy diagnosis, prevalence and age of onset, symptoms, and concomitant endometriosis. TABULATION, INTEGRATION, AND RESULTS Sixteen articles were included in the qualitative analysis. The studies are heterogeneous when diagnosing adenomyosis with differing criteria, protocols, and patient populations. The prevalence estimates range from 20% to 88.8% in women who are symptomatic (average 30%-35%), with most diagnosed between the ages of 32 years and 38 years. The correlation between imaging and pathology continues to evolve. As imaging advances, newer studies report that younger women who are symptomatic are being diagnosed with adenomyosis on the basis of both magnetic resonance imaging and/or transvaginal ultrasound. High rates of concomitant endometriosis create challenges when discerning the etiology of pelvic pain. Symptoms that are historically attributed to endometriosis may actually be caused by adenomyosis. CONCLUSION Adenomyosis remains a challenge to identify, assess, and research because of the lack of standardized diagnostic criteria, especially in women who wish to retain their uterus. As noninvasive diagnostics such as imaging and myometrial biopsies continue to improve, younger women with variable symptoms will likely create criteria for diagnosis with adenomyosis. The priority should be to create standardized histopathologic and imaging diagnoses to gain a deeper understanding of adenomyosis.
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Affiliation(s)
- Megan Loring
- Center for Minimally Invasive Gynecologic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts (all authors).
| | - Tammy Y Chen
- Center for Minimally Invasive Gynecologic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts (all authors)
| | - Keith B Isaacson
- Center for Minimally Invasive Gynecologic Surgery, Newton-Wellesley Hospital, Newton, Massachusetts (all authors)
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25
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Focal adenomyosis of the outer myometrium and deep infiltrating endometriosis severity. Fertil Steril 2020; 114:818-827. [PMID: 32741618 DOI: 10.1016/j.fertnstert.2020.05.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Revised: 04/28/2020] [Accepted: 05/02/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To determine whether the presence of focal adenomyosis of the outer myometrium (FAOM) at preoperative magnetic resonance imaging is associated with the severity of deep infiltrating endometriosis. DESIGN Observational cross-sectional study involving 255 symptomatic deep infiltrating endometriosis patients. Comparisons were performed according to the presence of FAOM. SETTING University hospital. PATIENT(S) Women with a preoperative magnetic resonance imaging and complete surgical exeresis of endometriotic lesions with histologically documented deep infiltrating endometriosis. INTERVENTION(S) Surgical management for deep infiltrating endometriosis. MAIN OUTCOME MEASURE(S) The presence of multiple deep infiltrating endometriosis lesions, the mean number and location of deep infiltrating endometriosis lesions, and the mean total revised American Society for Reproductive Medicine scores. RESULT(S) The prevalence of FAOM at preoperative magnetic resonance imaging in the 255 patients with deep infiltrating endometriosis was 56.5%. The mean number of deep infiltrating endometriosis lesions was significantly higher in the FAOM(+) group than in the FAOM(-) group: 3.5 ± 2.1 vs. 2.2 ± 1.5. The mean total revised American Society for Reproductive Medicine score was higher in case of FOAM coexisting with deep infiltrating endometriosis. After adjusting for confounding factors, the presence of FAOM was significantly associated with multiple deep lesions. CONCLUSION(S) FAOM was significantly associated with greater deep infiltrating endometriosis severity. This needs to be integrated into the management strategy. Furthermore, a pathogenic link between deep infiltrating endometriosis and FAOM cannot be excluded.
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26
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Mason BR, Chatterjee D, Menias CO, Thaker PH, Siegel CL, Yano M. Encyclopedia of endometriosis: a pictorial rad-path review. Abdom Radiol (NY) 2020; 45:1587-1607. [PMID: 31919647 DOI: 10.1007/s00261-019-02381-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endometriosis affects approximately 10% of reproductive age women and represents a significant cause of pelvic pain and infertility. Unfortunately, the diagnosis of endometriosis is often delayed by years. Endometriosis may manifest as cystic lesions in the ovaries known as endometriomas. Superficial endometriosis is typically detected by laparoscopy along the pelvic peritoneum as these lesions tend to be difficult to detect by imaging. Deep infiltrative endometriosis may be detected by ultrasound, CT or MRI in classic locations within the pelvis, such as the posterior cul-de-sac and uterosacral ligaments. Endometriosis may also involve the thorax, gastrointestinal and urinary tracts, and locations such as the abdominal wall and abdominal organs. We present MRI and CT case examples, together with corresponding laparoscopic and histopathology images to enhance radiologists' understanding of this disease.
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Affiliation(s)
- Brandon R Mason
- Department of Radiology, Stillwater Medical Center, Stillwater, OK, USA
| | - Deyali Chatterjee
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Premal H Thaker
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO, USA
| | - Cary Lynn Siegel
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd., Campus Box 8131, St. Louis, MO, 63110, USA
| | - Motoyo Yano
- Department of Radiology, Mayo Clinic, Phoenix, AZ, USA.
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27
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Diagnosing Deep Endometriosis Using Transvaginal Elastosonography. Reprod Sci 2020; 27:1411-1422. [PMID: 32333226 DOI: 10.1007/s43032-019-00108-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/28/2019] [Indexed: 12/17/2022]
Abstract
Transvaginal ultrasound (TVUS) and MRI are currently two mainstream imaging techniques used to diagnose deep endometriosis (DE) with comparable accuracy, but there is still ample room for improvement. As endometriotic lesions progress to fibrosis concomitant with the increase in tissue stiffness, transvaginal elastosonography (TVESG) is well-suited for diagnosing DE. To test the hypothesis that lesional stiffness as measured by TVESG correlates with the extent of lesional fibrosis, the markers of progression, hormonal receptor expression, and vascularity, we recruited 30 patients suspected to have DE who went through pelvic examination, TVUS and/or MRI, and TVESG and were ultimately diagnosed by histology. Their lesional tissue samples were subjected to immunohistochemistry analysis of markers for epithelial-mesenchymal transition (EMT), fibroblast-to-myofibroblast transdifferentiation (FMT), estrogen and progesterone receptors (ERβ and PR), microvessel density (MVD), and vascularity, as well as quantification of lesional fibrosis. We found that pelvic examination, TVUS, and MRI detected 83.3%, 66.7%, and 83.3% of all DE cases, respectively, while TVESG detected them all. The lesions missed by pelvic exam, TVUS and MRI were significantly smaller than those detected but nonetheless had higher lesional stiffness. Lesional stiffness correlated closely and positively with the extent of lesional fibrosis, negatively with the markers of EMT, MVD, vascularity, and PR expression, but positively with the marker for FMT and ERβ. Thus, through the additional use of information on differential stiffness between DE lesions and their surrounding tissues, TVESG improves diagnostic accuracy, provides a ballpark estimate on the developmental stage of the lesions, and may help clinicians choose the best treatment modality.
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28
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The Pathogenesis of Adenomyosis vis-à-vis Endometriosis. J Clin Med 2020; 9:jcm9020485. [PMID: 32050720 PMCID: PMC7073526 DOI: 10.3390/jcm9020485] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 01/31/2020] [Accepted: 02/04/2020] [Indexed: 12/13/2022] Open
Abstract
Adenomyosis is used to be called endometriosis interna, and deep endometriosis is now called adenomyosis externa. Thus, there is a question as to whether adenomyosis is simply endometriosis of the uterus, either from the perspective of pathogenesis or pathophysiology. In this manuscript, a comprehensive review was performed with a literature search using PubMed for all publications in English, related to adenomyosis and endometriosis, from inception to June 20, 2019. In addition, two prevailing theories, i.e., invagination—based on tissue injury and repair (TIAR) hypothesis—and metaplasia, on adenomyosis pathogenesis, are briefly overviewed and then critically scrutinized. Both theories have apparent limitations, i.e., difficulty in falsification, explaining existing data, and making useful predictions. Based on the current understanding of wound healing, a new hypothesis, called endometrial-myometrial interface disruption (EMID), is proposed to account for adenomyosis resulting from iatrogenic trauma to EMI. The EMID hypothesis not only highlights the more salient feature, i.e., hypoxia, at the wounding site, but also incorporates epithelial mesenchymal transition, recruitment of bone-marrow-derived stem cells, and enhanced survival and dissemination of endometrial cells dispersed and displaced due to iatrogenic procedures. More importantly, the EMID hypothesis predicts that the risk of adenomyosis can be reduced if certain perioperative interventions are performed. Consequently, from a pathogenic standpoint, adenomyosis is not simply endometriosis of the uterus, and, as such, may call for interventional procedures that are somewhat different from those for endometriosis to achieve the best results.
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29
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Marcellin L, Leconte M, Gaujoux S, Santulli P, Borghese B, Chapron C, Dousset B. Associated ileocaecal location is a marker for greater severity of low rectal endometriosis. BJOG 2019; 126:1600-1608. [DOI: 10.1111/1471-0528.15901] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2019] [Indexed: 12/23/2022]
Affiliation(s)
- L Marcellin
- Département de Gynécologie Obsétrique II et Médecine de la Reproduction (Professeur Chapron) Assistance Publique‐Hôpitaux de Paris (AP‐HP) Centre Hospitalier Universitaire (CHU) Cochin Hôpital Universitaire Paris Centre (HUPC) Paris France
- Université Paris Descartes Sorbonne Paris Cité Paris France
| | - M Leconte
- Université Paris Descartes Sorbonne Paris Cité Paris France
- Service de Chirurgie Digestive Hépato‐biliaire et Endocrinienne Assistance, Publique‐Hôpitaux de Paris (AP‐HP) Centre Hospitalier Universitaire (CHU) Cochin Hôpital Universitaire, Paris Centre (HUPC) Paris France
| | - S Gaujoux
- Université Paris Descartes Sorbonne Paris Cité Paris France
- Service de Chirurgie Digestive Hépato‐biliaire et Endocrinienne Assistance, Publique‐Hôpitaux de Paris (AP‐HP) Centre Hospitalier Universitaire (CHU) Cochin Hôpital Universitaire, Paris Centre (HUPC) Paris France
| | - P Santulli
- Département de Gynécologie Obsétrique II et Médecine de la Reproduction (Professeur Chapron) Assistance Publique‐Hôpitaux de Paris (AP‐HP) Centre Hospitalier Universitaire (CHU) Cochin Hôpital Universitaire Paris Centre (HUPC) Paris France
- Université Paris Descartes Sorbonne Paris Cité Paris France
| | - B Borghese
- Département de Gynécologie Obsétrique II et Médecine de la Reproduction (Professeur Chapron) Assistance Publique‐Hôpitaux de Paris (AP‐HP) Centre Hospitalier Universitaire (CHU) Cochin Hôpital Universitaire Paris Centre (HUPC) Paris France
- Université Paris Descartes Sorbonne Paris Cité Paris France
| | - C Chapron
- Département de Gynécologie Obsétrique II et Médecine de la Reproduction (Professeur Chapron) Assistance Publique‐Hôpitaux de Paris (AP‐HP) Centre Hospitalier Universitaire (CHU) Cochin Hôpital Universitaire Paris Centre (HUPC) Paris France
- Université Paris Descartes Sorbonne Paris Cité Paris France
| | - B Dousset
- Université Paris Descartes Sorbonne Paris Cité Paris France
- Service de Chirurgie Digestive Hépato‐biliaire et Endocrinienne Assistance, Publique‐Hôpitaux de Paris (AP‐HP) Centre Hospitalier Universitaire (CHU) Cochin Hôpital Universitaire, Paris Centre (HUPC) Paris France
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Munro MG. Uterine polyps, adenomyosis, leiomyomas, and endometrial receptivity. Fertil Steril 2019; 111:629-640. [PMID: 30929720 DOI: 10.1016/j.fertnstert.2019.02.008] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 02/05/2019] [Indexed: 01/02/2023]
Abstract
Endometrial polyps, adenomyosis, and leiomyomas are commonly encountered abnormalities frequently found in both fertile women and those with infertility. The clinician is frequently challenged to determine which of these entities, when found, is likely to impair fertility, and which are "innocent bystanders" unrelated to the problem at hand. Although removing an endometrial polyp may be seen as a relatively benign and safe intervention, myomectomy, and in particular adenomyomectomy, can be substantive surgical procedures, associated with their own potential for disrupting fertility. One of the mechanisms thought to be involved when these entities are contributing to infertility is an adverse impact on endometrial receptivity. Indeed polyps, adenomyosis, and leiomyomas have all been associated with an increased likelihood of abnormal endometrial molecular expressions thought to impair implantation and early embryo development. This review is designed to examine the relationship of these common entities to endometrial receptivity and to identify evidence gaps that should be considered when strategizing research initiatives. It is apparent that we have the tools necessary to fill these gaps, but it will be necessary to approach the issue in a strategic and coordinated fashion. It is likely that we will have to recognize the limitations of imaging alone and look to the evidence-based addition of molecular analysis to provide the individualized phenotyping of disease necessary for patient-specific treatment decisions.
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Affiliation(s)
- Malcolm G Munro
- Department of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA, Los Angeles, California; Department of Obstetrics and Gynecology, Kaiser-Permanente, Los Angeles Medical Center, Los Angeles, California.
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Abstract
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.
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Affiliation(s)
- Silvia Vannuccini
- Department of Neuroscience, Psychology, Pharmacology and Child Health (NEUROFARBA), University of Florence, Florence, Largo Brambilla 3, 50134, Italy.,Department of Molecular and Developmental Medicine, University of Siena, Siena, viale Mario Bracci 16, 53100, Italy.,Obstetrics and Gynecology, Department of Maternity and Child Health, University Hospital Florence, Careggi University Hospital, Florence, Largo Brambilla 3, 50134, Italy
| | - Felice Petraglia
- Obstetrics and Gynecology, Department of Maternity and Child Health, University Hospital Florence, Careggi University Hospital, Florence, Largo Brambilla 3, 50134, Italy.,Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Florence, Largo Brambilla 3, 50134, Italy
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Koninckx PR, Ussia A, Zupi E, Gomel V. Association of Endometriosis and Adenomyosis: Vast Literature but Scant Conclusive Data. J Minim Invasive Gynecol 2018; 25:745-748. [DOI: 10.1016/j.jmig.2018.03.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 03/17/2018] [Indexed: 12/21/2022]
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