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Tsikouras P, Kritsotaki N, Nikolettos K, Kotanidou S, Oikonomou E, Bothou A, Andreou S, Nalmpanti T, Chalkia K, Spanakis V, Tsikouras N, Chalil M, Machairiotis N, Iatrakis G, Nikolettos N. The Impact of Adenomyosis on Pregnancy. Biomedicines 2024; 12:1925. [PMID: 39200389 PMCID: PMC11351718 DOI: 10.3390/biomedicines12081925] [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: 07/16/2024] [Revised: 07/27/2024] [Accepted: 08/20/2024] [Indexed: 09/02/2024] Open
Abstract
Adenomyosis is characterized by ectopic proliferation of endometrial tissue within the myometrium. Histologically, this condition is marked by the presence of islands of benign endometrial glands surrounded by stromal cells. The myometrium appears thinner, and cross-sectional analysis often reveals signs of recent or chronic hemorrhage. The ectopic endometrial tissue may respond to ovarian hormonal stimulation, exhibiting proliferative or secretory changes during the menstrual cycle, potentially leading to bleeding, uterine swelling, and pain. Adenomyosis can appear as either a diffuse or focal condition. It is crucial to understand that adenomyosis involves the infiltration of the endometrium into the myometrium, rather than its displacement. The surgical management of adenomyosis is contingent upon its anatomical extent. The high incidence of the disease and the myths that develop around it increase the need to study its characteristics and its association with pregnancy and potential obstetric complications. These complications often require quick decisions, appropriate diagnosis, and proper counseling. Therefore, knowing the possible risks associated with adenomyosis is key to decision making. Pregnancy has a positive effect on adenomyosis and its painful symptoms. This improvement is not only due to the inhibition of ovulation, which inhibits the bleeding of adenomyotic tissue, but also to the metabolic, hormonal, immunological, and angiogenic changes associated with pregnancy. Adenomyosis affects pregnancy through disturbances of the endocrine system and the body's immune response at both local and systemic levels. It leads to bleeding from the adenomyotic tissue, molecular and functional abnormalities of the ectopic endometrium, abnormal placentation, and destruction of the adenomyotic tissue due to changes in the hormonal environment that characterizes pregnancy. Some of the obstetric complications that occur in women with adenomyosis in pregnancy include miscarriage, preterm delivery, placenta previa, low birth weight for gestational age, obstetric hemorrhage, and the need for cesarean section. These complications are an understudied field and remain unknown to the majority of obstetricians. These pathological conditions pose challenges to both the typical progression of pregnancy and the smooth conduct of labor in affected women. Further multicenter studies are imperative to validate the most suitable method for concluding labor following surgical intervention for adenomyosis.
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Affiliation(s)
- Panagiotis Tsikouras
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (N.K.); (K.N.); (S.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (M.C.); (N.N.)
| | - Nektaria Kritsotaki
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (N.K.); (K.N.); (S.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (M.C.); (N.N.)
| | - Konstantinos Nikolettos
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (N.K.); (K.N.); (S.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (M.C.); (N.N.)
| | - Sonia Kotanidou
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (N.K.); (K.N.); (S.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (M.C.); (N.N.)
| | - Efthymios Oikonomou
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (N.K.); (K.N.); (S.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (M.C.); (N.N.)
| | - Anastasia Bothou
- Department of Midwifery, School of Health Sciences, University of West Attica (UNIWA), 12243 Athens, Greece; (A.B.); (G.I.)
| | - Sotiris Andreou
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (N.K.); (K.N.); (S.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (M.C.); (N.N.)
| | - Theopi Nalmpanti
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (N.K.); (K.N.); (S.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (M.C.); (N.N.)
| | - Kyriaki Chalkia
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (N.K.); (K.N.); (S.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (M.C.); (N.N.)
| | - Vlasios Spanakis
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (N.K.); (K.N.); (S.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (M.C.); (N.N.)
| | - Nikolaos Tsikouras
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (N.K.); (K.N.); (S.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (M.C.); (N.N.)
| | - Melda Chalil
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (N.K.); (K.N.); (S.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (M.C.); (N.N.)
| | - Nikolaos Machairiotis
- Third Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Attikon Hospital, Rimini 1, 12462 Athens, Greece;
| | - George Iatrakis
- Department of Midwifery, School of Health Sciences, University of West Attica (UNIWA), 12243 Athens, Greece; (A.B.); (G.I.)
| | - Nikolaos Nikolettos
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece; (N.K.); (K.N.); (S.K.); (E.O.); (S.A.); (T.N.); (K.C.); (V.S.); (N.T.); (M.C.); (N.N.)
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Habiba M, Guo SW, Benagiano G. Adenomyosis and Abnormal Uterine Bleeding: Review of the Evidence. Biomolecules 2024; 14:616. [PMID: 38927019 PMCID: PMC11201750 DOI: 10.3390/biom14060616] [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: 04/09/2024] [Revised: 05/15/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Thomas Cullen described bleeding abnormalities and dysmenorrhea as the "expected" presentations of adenomyomas. Adenomyosis is included within the FIGO classification of structural causes of abnormal uterine bleeding (AUB). Nevertheless, this long-standing association has been questioned by some authors who reported a high incidence of adenomyosis in uteri removed for indications other than AUB or dysmenorrhea. Here, we examine evidence for the link between adenomyosis and AUB. METHODS A comprehensive Medline literature review of all publications to October 2023. RESULTS Sixty-three articles were identified and included in the review. Despite a large body of studies, the available literature does not provide conclusive evidence of a link between adenomyosis and AUB. This is because of unsuitable study design, or poor characterization of the study population or of the inclusion or exclusion criteria. Additional challenges arise because of the lack of agreed criteria for diagnosing adenomyosis and the often absence of detailed assessment of menstrual blood loss. Adenomyosis often coexists with other conditions that have also been linked to similar symptoms, and many cases of adenomyosis are asymptomatic. CONCLUSION Most of the existing literature and studies that addressed treatment outcome of adenomyosis started from the premise that a link between the condition and AUB had been proven. Yet, published information shows that aspects such a relationship is still uncertain. Further research is needed to address the relation between AUB and adenomyosis burden (or subtypes), distribution, and concomitant pathology.
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Affiliation(s)
- Marwan Habiba
- Department of Health Sciences, University of Leicester, Leicester LE1 7RH, UK
- Women and Perinatal Services, Leicester Royal Infirmary, Leicester LE1 5WW, UK
| | - Sun-Wei Guo
- Research Institute, Shanghai Obstetrics and Gynecology Hospital, Fudan University, Shanghai 200011, China;
| | - Giuseppe Benagiano
- Faculty of Medicine and Surgery, “Sapienza” University of Rome, 00161 Rome, Italy;
- Geneva Foundation for Medical Education and Research, 1202 Geneva, Switzerland
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Krentel H, De Wilde RL. Prevalence of adenomyosis in women undergoing hysterectomy for abnormal uterine bleeding, pelvic pain or uterine prolapse – A retrospective cohort study. Ann Med Surg (Lond) 2022; 78:103809. [PMID: 35734686 PMCID: PMC9206934 DOI: 10.1016/j.amsu.2022.103809] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 05/13/2022] [Accepted: 05/14/2022] [Indexed: 12/02/2022] Open
Abstract
Background Adenomyosis can cause symptoms like dysmenorrhea, dyspareunia, pelvic pain and bleeding disorders and is related to subfertility and obstetrical complications. The disease is probably underestimated and underdiagnosed because of difficulties in reliable clinical examination and imaging results. The age-related prevalence of adenomyosis still remains unclear. In this retrospective analysis we describe the rate of adenomyosis in two independent cohorts of patients undergoing hysterectomy for benign diseases (2011–2013 and 2015–2018) and its correlation to presurgical symptoms respectively indications for hysterectomy. Materials and methods All surgeries have been performed in the same department of minimally invasive gynecological surgery by a total of two experienced surgeons following a surgical internal standard for the indication bleeding disorder, dysmenorrhea. We analyzed the overall rate of patients with adenomyosis in both cohorts and related the histological presence of adenomyosis to presurgical symptoms. We also analyzed a subgroup of postmenopausal patients with uterine prolapse. Results In 307 patients we detected 42.0% of cases with histologically proven adenomyosis. In the group of patients with bleeding disorders and dysmenorrhea as indication for surgery we found the highest rate of adenomyosis (59.3%, cohort 1). 81,1% patients with adenomyosis (cohort 1) reported symptoms. In the subgroup of 42 postmenopausal patients, we found 23.8% of cases with adenomyosis. Conclusion Our data shows that a positive anamnesis regarding the symptoms bleeding disorders and dysmenorrhea is suspicious for adenomyosis. In hysterectomy specimen adenomyosis can be found in more than 40%. The role of adenomyosis-related symptoms requires further investigation, especially in adolescent and postmenopausal patients. In 307 patients undergoing hysterectomy we detected 42.0% of cases with adenomyosis. In patients with bleeding disorders and dysmenorrhea we found the highest rate of adenomyosis (59.3%). 81,1% of patients with adenomyosis reported symptoms. In 58.9% of patients with adenomyosis we found additional fibroids. In 42 postmenopausal patients we found adenomyosis in 23.8% of cases.
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Affiliation(s)
- Harald Krentel
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, Bethesda Hospital Duisburg, Academic Teaching Hospital, Duisburg, Germany
- Corresponding author. Bethesda Hospital Duisburg, Heerstrasse 219, 47053, Duisburg, Germany.
| | - Rudy Leon De Wilde
- Clinic of Gynecology, Obstetrics and Gynecological Oncology, University Hospital for Gynecology, Pius-Hospital Oldenburg, Medical Campus University of Oldenburg, Germany
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