Guideline No. 437: Diagnosis and Management of Adenomyosis

Predicting high-intensity focused ultrasound efficacy in adenomyosis treatment based on magnetic resonance (MR) radiomics and clinical-imaging features

AIMS

To develop a model predicting high-intensity focused ultrasound (HIFU) efficacy in adenomyosis treatment using enhanced T1WI and T2WI-FS radiomics combined with clinical imaging features.

MATERIALS AND METHODS

The study included 137 adenomyosis patients treated with HIFU from September 2021 to December 2023. Based on nonperfused volume ratio (NPVR), participants were divided into two groups: NPVR < 50% (n=77) and NPVR ≥ 50% (n=60). Patients were randomly split into training and test sets (7:3 ratio). Radiomics features were extracted from enhanced T1WI and T2WI-FS sequences, while clinical imaging features were selected using univariate analysis and binary logistic regression. Logistic regression models were built for radiomics, clinical imaging, and combined data. Model performance was assessed using ROC curves, Delong's test, and calibration curves.

RESULTS

AUCs for the radiomics, clinical-imaging, and combined models in the training set were 0.831, 0.664, and 0.845, respectively, and 0.829, 0.597, and 0.831 in the test set. The combined model outperformed the clinical-imaging model (training p=0.001, test p=0.01) and the radiomics model (training p=0.012, test p=0.032). However, no significant difference was found between the combined and radiomics models (p>0.05). Calibration curves and decision curve analysis confirmed the combined model's accuracy and clinical applicability.

CONCLUSION

A model incorporating clinical-imaging features with T1WI and T2WI-FS radiomics effectively predicts HIFU success in adenomyosis treatment, offering valuable guidance for clinical decision-making.

The First Lugano Workshop on the role of adenomyosis in ART

Adenomyosis is an important clinical condition with uncertain prevalence, and clinical focus on adenomyosis in patients undergoing assisted reproductive technology (ART) has increased during recent years. Recognizing the limited clinical knowledge on the impact of adenomyosis on ART outcomes, the First Lugano Adenomyosis Workshop was a symposium involving experts in the field of adenomyosis, covering basic research, imaging, surgery and infertility to highlight current advances and future research areas over a wide range of topics related to adenomyosis. Adenomyosis is characterized by altered oestrogen and progesterone signalling pathways. Although the criteria of the Morphological Uterus Sonographic Assessment (MUSA) Consortium apply to patients with infertility, the presence of direct signs and localization in the different myometrial layers, particularly the inner myometrium, need more focus. In addition to the MUSA criteria, clinical symptoms and the magnitude of uterine enlargement should also be considered. Whilst pre-treatment with gonadotrophin-releasing hormone agonist with or without an aromatase inhibitor in frozen embryo transfer cycles seems promising, many issues related to therapy remain unanswered. During the Workshop, therapeutic progress over the past decades as well as novel insights were presented and discussed. The role of this opinion paper is to stimulate discussion and spark further interest in adenomyosis and the role of adenomyosis in infertility.

Assessment of ovarian reserve function in patients with adenomyosis and ovarian endometriosis by three-dimensional transvaginal ultrasound and Anti-Müllerian hormone

We evaluated the impact of adenomyosis and ovarian endometriosis on ovarian reserve function through transvaginal three-dimensional ultrasound and anti-mullerian hormone testing. A total of 150 female patients who were admitted to our hospital from January 2023 to May 2024 were selected; 58 cases had adenomyosis (adenomyosis group), 36 had ovarian endometriosis (ovarian endometriosis group), and 56 were healthy (healthy group). There were no statistically significant differences in clinical baseline data among the three groups (all P > 0.05). However, significant overall differences were found in anti-Mullerian hormone levels, antral follicle count, ovarian volume, vascularization index, flow index, and vascularization flow index among the three groups (F values were 90.34, 146.50, 92.61, 63.87, 59.50, 49.36 respectively; all P < 0.001); compared to the healthy group, these indicators were all decreased in the adenomyosis group and ovarian endometriosis group (all P < 0.05). Pearson correlation analysis revealed that serum anti-mullerian hormone levels were positively correlated with antral follicle count, ovarian volume, vascularization index, flow index, and vascularization flow index (r = 0.80, 0.73, 0.50, 0.48, 0.45, respectively; all P < 0.01). These data suggest that adenomyosis and ovarian endometriosis can lead to a decline in ovarian reserve function in women of reproductive age compared to their peers. Also, antral follicle count and ovarian volume are the optimal indicators for evaluating ovarian reserve function in these patients.

Effect of Gonadotropin-Releasing Hormone Agonist Pre-Treatment on Outcomes of Fresh and Frozen Embryo Transfers in Women With Adenomyosis: A Retrospective Cohort Study With Literature Review

OBJECTIVES

To investigate the effect of gonadotropin-releasing hormone agonist (GnRHa) pre-treatment on the clinical outcomes of fresh and frozen embryo transfers (ETs and FETs, respectively) in infertile patients with adenomyosis.

DESIGN

Retrospective cohort study with literature review.

SETTING

Peking University First Hospital.

POPULATION

We analysed 413 cycles of 369 women with adenomyosis who underwent ETs or FETs.

METHODS

We performed logistic regression analysis and meta-analysis to assess the association of GnRHa pre-treatment with the clinical outcomes of ETs and FETs.

MAIN OUTCOME MEASURES

The live birth rate (LBR) was compared between patients with and without GnRHa pre-treatment.

RESULTS

The LBR was higher in the GnRHa pre-treatment group than in the non-GnRHa pre-treatment group in ETs (41.27% vs. 24.32%, p = 0.034) and FETs (40.36% vs. 20.75%, p = 0.008). The odds of achieving a live birth of women with GnRHa pre-treatment were 2.65 times higher than that of those without (95% CI: 1.19-5.92, p = 0.017) after adjusting for confounders in ETs. Similarly, the adjusted odds ratio (OR) was 2.43 (95% CI: 1.10-5.40, p = 0.029) in FETs. For the meta-analysis, eight studies met the inclusion criteria; however, only six reported the adjusted ORs. Combination of these six adjusted ORs with our results revealed that the GnRHa pre-treatment group had higher LBRs than the non-GnRHa pre-treatment group (ET: OR 1.71, 95% CI: 1.30-2.26, FET: OR 2.61, 95% CI: 1.52-4.49).

CONCLUSIONS

In women with adenomyosis, GnRHa pre-treatment may be beneficial for LBRs following both ETs and FETs.

Medical treatment before in-vitro fertilization in patients with adenomyosis: a systematic review and meta-analysis

The objective of this study is to evaluate if medical treatment before assisted reproductive technology (ART) improves the results in infertile patients with adenomyosis. A literature search was performed with EMBASE, PubMed, and Cochrane. The primary outcome was clinical pregnancy rate (CPR). Secondary outcomes were live birth rate (LBR) per cycle and miscarriage rate (MR) after ART with or without medical pretreatment. Additionally, a comparison was made between women undergoing medical pretreatment before frozen embryo transfer (FET) and those who underwent FET alone, including any type of endometrial preparation. Ten studies were included. The present meta-analysis supports the use of long-term GnRH agonist therapy in patients with adenomyosis, which enhances the CPR (odds ratio (OR) 1.49, 95% CI 1.15 to 1.92) in IVF/ICSI with fresh ET, while the comparison in women undergoing FET cycles did not reach statistical significance (OR 1.34 95% CI 0.70-2.55). Pretreatment with GnRH agonist did not demonstrate a benefit on the LBR and MR per cycle in IVF/ICSI with fresh ET in comparison to standard ovarian stimulation protocols. Similar results were observed in the setting of FET, failing to indicate a superiority of GnRH agonist pretreatment over standard FET protocols for LBR and MR. In conclusion, GnRH agonist pretreatment before ART carries a potential benefit in improving outcomes in terms of higher CPR, but there is no significant impact on LBR and MR. Pretreatment with GnRH agonists could be adopted as a possible alternative ART protocol in selected patients with adenomyosis and infertility.

Evaluation of the therapeutic efficacy of high-intensity focused ultrasound ablation combined with different drugs in the treatment of adenomyosis

OBJECTIVES

To observe the therapeutic efficacy of high-intensity focused ultrasound (HIFU) combined with different pharmacological treatments for adenomyosis.

MATERIALS AND METHODS

A total of 126 patients with adenomyosis who underwent HIFU combined with pharmacological treatment were retrospectively reviewed. Patients were treated with either dienogest (DNG) (Group A, N = 38) or GnRH-a (Group B, N = 88) for three months after HIFU, and received levonorgestrel-releasing intrauterine systems (LNG-IUS) at the end of the third month. Visual Analog Scale (VAS) and Pictorial Blood Loss Assessment Chart (PBAC) scores were used for evaluating symptom improvement.

RESULTS

After propensity score matching (1:2), 38 patients were included in Group A and 76 in Group B. All patients showed significant improvement in VAS and PBAC scores after HIFU, but the PBAC score of Group A was significantly higher than that of patients in Group B at 18 months [11.50 (1.00, 29.50) vs. 0.00 (0.00, 16.50), p < 0.01] and 24 months [4.00 (0.25, 27.75) vs. 0.00 (0.00, 12.75), p = 0.04] after HIFU. Furthermore, patients in Group B had a greater uterine volume reduction at 24 months after HIFU than that of patients in Group A [51.00 (27.00, 62.00) vs. 30.00 (17.00, 42.75, p = 0.02)]. However, the adverse effects in Group A were lower than those in Group B [7 (15.79) vs. 35 (46.05), p < 0.01]. No significant difference was observed in the recurrence rate between the two groups.

CONCLUSIONS

HIFU combined with DNG and LNG-IUS is a safe and effective treatment for patients with adenomyosis.

Comparison of the effectiveness of levonorgestrel intrauterine system and dienogest in the management of adenomyosis: A systematic review and meta-analysis

BACKGROUND

Adenomyosis is a gynaecological lesion that impairs female fertility and contributes to reduced quality of life. There are several surgical and medical options for the management of this lesion; however, women who wish to conceive opt for medical therapies such as the levonorgestrel intrauterine device (LNG-IUS) and dienogest, which have various outcomes. To date, there is no consensus regarding which is more effective.

OBJECTIVES

To compare the effectiveness of LNG-IUS and dienogest for the management of adenomyosis, and explore the risk of occurrence of known side effects for both treatments.

DESIGN

Systematic review and meta-analysis exploring the effectiveness of LNG-IUS and dienogest for the management of adenomyosis.

METHODS

A literature search was conducted using PICO guidelines and EMBASE, PubMed/MEDLINE, Scopus and Web of Science databases. Only clinical trials were collected and analysed.

RESULTS

Of the 792 studies that were initially identified, six were eligible for inclusion in this study. The studies included a total of 707 women; of these, 270 were treated with LNG-IUS, 354 were treated with dienogest, and 83 were controls. All the studies were from Asia (Bangladesh n = 1, China n = 2, India n = 1, Japan n = 1, South Korea n = 1). Dienogest was found to reduce pelvic pain significantly, evidenced by a lower visual analogue scale score, compared with LNG-IUS. Also, dienogest led to a significant reduction in uterine volume compared with LNG-IUS. However, subjects in the LNG-IUS group had significantly higher levels of haemoglobin than those in the dienogest group. Nonetheless, the occurrence of side effects such as weight gain, breast tenderness/distension, headache, insomnia/sleep disorder, depression/mood disorder, skin disorder/acne, and coital discomfort/reduced libido were comparable in both treatment groups.

CONCLUSION

Dienogest may be more effective than LNG-IUS for the management of adenomyosis, as it shows a superior effect in the reduction of pelvic pain and uterine volume. As only six studies were included in the present meta-analysis due to the paucity of data in the literature, it is recommended that well-designed randomized controlled trials comparing the effectiveness of dienogest with LNG-IUS should be conducted.

From Diagnosis to Fertility: Optimizing Treatment of Adenomyosis for Reproductive Health

Adenomyosis is a benign gynecologic disorder that had previously not been well studied or understood. However, it is now become a more common diagnosis with long-standing implications especially for fertility. In this literature review, the pathophysiology and diagnosis along with management options for uterine preservation and fertility along with more definitive options are reviewed. While there is a better understanding of adenomyosis, there is still more research that is needed to fully elucidate the best ways of management for patients especially in those seeking fertility.

Adenomyosis-A Call for Awareness, Early Detection, and Effective Treatment Strategies: A Narrative Review

OBJECTIVE

To provide a brief summary of the high incidence, symptomatology, different types, and diagnosis of adenomyosis and to explore various aspects of the disease, with the primary aim of raising awareness among gynecologists for appropriate and early detection.

BACKGROUND

Adenomyosis, a benign gynecological condition characterized by the infiltration of endometrial tissue into the myometrium, poses significant challenges to women's reproductive health.

METHODS

A narrative review was conducted by searching PubMed, Scopus, and Cochrane databases and offering a non-systematic summary and critical analysis of current knowledge on the impact of adenomyosis on women's health. Articles published in the English language up to May 2023, including original scientific papers, clinical trials, meta-analyses, and reviews focusing on various aspects of adenomyosis, were included in the synthesis of this review.

CONCLUSIONS

Approximately 20% of women are affected by adenomyosis, which manifests with various subtypes, distinct epidemiological profiles, symptomatology, and treatment responses. Despite its clinical significance, adenomyosis remains understudied, resulting in a significant disparity in research and the literature compared to other gynecological conditions. The severity of adenomyosis is compounded when coexisting with endometriosis, particularly deep-infiltrating endometriosis (DIE), leading to exacerbated fertility issues and severe symptomatology. The wide range of symptoms, including adverse pregnancy outcomes such as pre-eclampsia, highlights its wider impact and emphasizes the need for increased awareness of the condition. Adenomyosis is frequently associated with treatment failure in endometriosis, contributing to dienogest resistance, elevated discontinuation rates, and persistent pain post-endometriosis surgery. Additionally, the lack of specific treatments tailored to adenomyosis poses a considerable challenge in clinical management.

A new treatment for Robert's uterus with adenomyosis: a case report and review of the literature

PURPOSE

To provide a method for the differential diagnosis of Robert's uterus with adenomyosis, a rare uterine malformation, and determine the best course of treatment.

METHODS

A patient who had Robert's uterus with adenomyosis was admitted to our hospital in December 2022. We analyzed and summarized her case .

RESULTS

Our patient complained of progressively worsening primary dysmenorrhea over the course of 3 years and lower abdominal pain lasting for 2 days. Her carbohydrate antigen 125 (CA125) level was 372.10 U/mL. Examinations conducted by several hospitals indicated that she had a single-horned uterus and a residual horned uterus, and our hospital's examination identified Robert's uterus. This malformation was corrected by open abdominal surgery. For the procedure, pelvic adhesions were first isolated, after which the closed uterine cavity and adenomyosis were resected. Subsequently, the left ovarian endometriosis cyst was resected and right tubal ligation was performed. After surgery, three injections of gonadotropin-releasing hormone A (GnRH-A) were administered, which lowered the patient's CA125 level to 14 U/mL and normalized her condition.

CONCLUSION

We pioneered a new therapeutic approach for the treatment of Robert's uterus with adenomyosis. Some valuable references are provided for clinical practice.

A systematic review and Bayesian analysis of the adverse effects of dienogest

BACKGROUND AND OBJECTIVE

Endometriosis and adenomyosis are two common diseases that impair women's health, and dienogest is one of the pharmacologic treatments which is the first-line therapeutic option for patients with pelvic pain and individuals who have no desire for immediate pregnancy. The goal of this study was to summarize the current evidence of adverse events associated with dienogest as well as the prevalence of these adverse events during treatment with dienogest.

METHODS

Several databases (PubMed, Embase, Cochrane Central and Clinicaltrials.gov, etc.) and the US FDA Adverse Event Reporting System (FAERS) Public Dashboard were searched on May 31, 2023, using the topic words alongside free words of dienogest and "adverse reaction". Studies were incorporated into this research if they reported or assessed safety issues or adverse reactions of dienogest during the period of endometriosis treatment or adenomyosis therapy. The extracted information comprised trial design, dienogest and control group demographics, as well as reported side effects.

RESULTS

This systematic review comprehended 39 publications in total. The mean age of patients in the included studies was 34.43 years. The follow-up duration varied from 3 to 60 months. Most adverse reactions were common and not serious, and the most common adverse reactions during dienogest medication were abnormal uterine bleeding (55%, 95% CI 37-73%), amenorrhea (17%, 95% CI 2-42%) and swelling (13%, 95% CI 3-28%). Uncommon adverse reactions included dysmenorrhea (0.2%, n = 1), dyspepsia (0.4%, n = 1), and (lower) abdominal pain (1%, 95% CI 0-3%), urticaria (1%, 95% CI 0-3%) and peritonitis (1%, n = 1). Serious adverse reactions including decreased lumbar spine Bone Mineral Density (BMD), depression, peritonitis and so on have been reported. Heterogeneity assessment revealed that patient number and study design are influencing factors to adverse reaction prevalence. Moreover, abdominal pain, diarrhea, nausea and vomiting, back pain and anemia are side effects reported both in the FAERS database and in the systematic review.

CONCLUSIONS

Dienogest's most frequent side effects were not severe. Dienogest is generally safe for treating endometriosis and adenomyosis. Nevertheless, people should be aware of serious adverse reactions, such as decreased lumbar spine BMD and hemorrhagic shock.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

CRITICAL RELEVANCE STATEMENT

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

KEY POINTS

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

TRIAL REGISTRATION

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

MRI-Based Radiomics as a Promising Noninvasive Diagnostic Technique for Adenomyosis

Background: MRI diagnostics are important for adenomyosis, especially in cases with inconclusive ultrasound. This study assessed the potential of MRI-based radiomics as a novel tool for differentiating between uteri with and without adenomyosis. Methods: This retrospective proof-of-principle single-center study included nine patients with and six patients without adenomyosis. All patients had preoperative T2w MR images and histological findings served as the reference standard. The uterus of each patient was segmented in 3D using dedicated software, and 884 radiomics features were extracted. After dimension reduction and feature selection, the diagnostic yield of individual and combined features implemented in the machine learning models were assessed by means of receiver operating characteristics analyses. Results: Eleven relevant radiomics features were identified. The diagnostic performance of individual features in differentiating adenomyosis from the control group was high, with areas under the curve (AUCs) ranging from 0.78 to 0.98. The performance of ML models incorporating several features was excellent, with AUC scores of 1 and an area under the precision-recall curve of 0.4. Conclusions: The set of radiomics features derived from routine T2w MRI enabled accurate differentiation of uteri with adenomyosis. Radiomics could enhance diagnosis and furthermore serve as an imaging biomarker to aid in personalizing therapies and monitoring treatment responses.

Efficacy of etonogestrel subcutaneous implants versus the levonorgestrel-releasing intrauterine system in the conservative treatment of adenomyosis

To evaluate the clinical efficacy of etonogestrel subcutaneous implant (ENG-SCI) with that of the levonorgestrel-releasing intrauterine system (LNG-IUD) for adenomyosis treatment. A prospective randomized cohort study was conducted including 108 patients (50 patients in ENG-SCI group and 58 in the LNG-IUD group) with adenomyosis from January 2019 to July 2021. After 3 months of treatment, both ENG-SCI group and LNG-IUD group showed significant improvement in patients' visual analog scale, pictorial blood loss assessment chart (PBAC), and uterine volume (P ＜ 0.05). The uterine volume of patients in LNG-IUD group decreased more significantly than that in the ENG-SCI group since 3 months of treatment. The PBAC score in the LNG-IUD group improved better than that in the ENG-SCI group since 6 months of treatment (P ＜ 0.05). No significant difference in the occurrence rate of ideal vaginal bleeding patterns and the hemoglobin levels between the two groups was observed. The ENG-SCI group had a higher probability of weight gain and progesterone-related side effects (P ＜ 0.05). Both ENG-SCI and LNG-IUD were effective in treatment of adenomyosis. However, LNG-IUD had a more significant effect in treating adenomyosis-related dysmenorrhea, excessive menstrual flow, anemia, and uterine enlargement, with relatively fewer side effects.

Treatment of adenomyosis, abdominal wall endometriosis and uterine leiomyoma with interventional radiology: A review of current evidences

Interventional radiology shows promises in the field of women's health, particularly in pelvic interventions. This review article discusses the latest advancements in interventional radiology techniques for pelvic conditions affecting women including adenomyosis, abdominal wall endometriosis and uterine leiomyoma. Extraperitoneal endometriosis involving the abdominal wall may be treated by percutaneous thermal ablation, such as cryoablation, whereas uterine leiomyoma and adenomyosis can be managed either using percutaneous thermal ablation or using uterine artery embolization. Continued research and development in interventional radiology will further enhance the minimally-invasive interventions available for women's health, improving outcomes and quality of life for this large patient population of women.