Adenomyosis: Not such an elusive diagnosis any longer

Diagnosing adenomyosis: an integrated clinical and imaging approach

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.

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

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

Transmembrane G protein-coupled receptor 30 gene polymorphisms and uterine adenomyosis in Korean women

To compare the genetic distributions of 14G protein-coupled receptor 30 (GPR30) single-nucleotide polymorphisms (SNPs) between women with and without uterine adenomyosis. The study population comprised 69 Korean women. Uterine tissues from the adenomyosis and non-adenomyosis groups were used for DNA extraction. Pre-designed PCR/Sanger or Sequencing Primer and TaqMan^® SNP Genotyping Assays were used for the SNP genotyping of the GPR30 gene. Immunohistochemical staining was performed to confirm the GPR30 expression. Differences in genotype and allele frequencies between the two groups were calculated using Fisher's exact test. The rs3802141 CT genotype was more common in the control group (p = .02), and the rs4266553 CC genotype was more common in the adenomyosis group (p = .02). The C allele of the SNP rs4266553 was more common in the adenomyosis group (p = .02). GPR30 expression was confirmed in 69 individuals in both groups. GPR30 gene polymorphism is presumed to affect the risk of adenomyosis with limited sample size. Further large-scale study is needed to explain the genetic influence of GPR30 gene polymorphism.

A comparison of the cost-utility of ultrasound-guided high-intensity focused ultrasound and hysterectomy for adenomyosis: a retrospective study

OBJECTIVE

To evaluate cost-effectiveness of ultrasound-guided high-intensity focused ultrasound (USgHIFU) and open hysterectomy for adenomyosis.

DESIGN

A retrospective analysis.

SETTING

Gynaecological department in a single centre in China.

POPULATION

Patients with symptomatic adenomyosis.

MAIN OUTCOME MEASURES

Cost difference between patients with adenomyosis treated with USgHIFU and open hysterectomy.

METHODS

Three hundred and sixty-eight patients with adenomyosis were retrospectively reviewed. Among them, 302 patients were treated with USgHIFU and 66 patients with open hysterectomy. All of them had 1-, 3-, 6- and 12-month follow ups. The patients' quality of life (QOL) was evaluated and the utility scores were obtained from a rating scale to conduct a cost-utility analysis (CUA).

RESULTS

No significant differences were found at any follow-up time point in the QOL between the two groups (P > 0.05). After treatment, the QOL scores significantly increased in both groups (P < 0.05): the quality adjusted life year (QALY) for patients treated with USgHIFU was USUS$5256.48, whereas it was USUS$7510.03 for patients treated with open hysterectomy. Both incremental cost and sensitivity analysis showed that USgHIFU was less costly than open hysterectomy.

CONCLUSIONS

The QOL of patients with adenomyosis can be significantly improved by either USgHIFU or open hysterectomy, but USgHIFU is less costly.

TWEETABLE ABSTRACT

USgHIFU can safely be used to treat patients with adenomyosis and significantly improved the quality of life of patients after treatment. The cost of USgHIFU is less than that of surgical treatment.

MRI, US or real-time virtual sonography in the evaluation of adenomyosis?

PURPOSE

Real-time virtual sonography (RVS) allows displaying and synchronizing real-time US and multiplanar reconstruction of MRI images. The purpose of this study was to evaluate the feasibility and ability of RVS to assess adenomyosis since literature shows US itself has a reduced diagnostic accuracy compared to MRI.

MATERIALS AND METHODS

This study was conducted over a 4-month period (March-June 2015). We enrolled in the study 52 women with clinical symptoms of dysmenorrhea, methrorragia and infertility. Every patient underwent an endovaginal US examination, followed by a 3T MRI exam and a RVS exam (Hitachi HI Vision Ascendus). The MRI image dataset acquired at the time of the examination was loaded into the fusion system and displayed together with the US images. Both sets of images were then manually synchronized and images were registered using multiple plane MR imaging. Radiologist was asked to report all three examinations separately.

RESULTS

On a total of 52 patients, on standard endovaginal US, adenomyosis was detected in 27 cases: of these, 21 presented diffuse adenomyosis, and 6 cases focal form of adenomyosis. MRI detected adenomyosis in 30 cases: 22 of these appeared as diffuse form and 8 as focal form, such as adenomyoma and adenomyotic cyst, thus resulting in 3 misdiagnosed cases on US. RVS confirmed all 22 cases of diffuse adenomyosis and all 8 cases of focal adenomyosis.

CONCLUSIONS

Thanks to information from both US and MRI, fusion imaging allows better identification of adenomyosis and could improve the performance of ultrasound operator thus to implement the contribution of TVUS in daily practice.

Adenomyosis: a challenge in clinical gynecology

Adenomyosis is a prevalent, benign gynecologic condition in which endometrial tissue invades the myometrium, causing myometrial inflammation and hypertrophy. Although some women with adenomyosis are asymptomatic, the condition often causes menorrhagia and dysmenorrhea. This article provides women's health providers with a review of causes and risk factors for developing adenomyosis, clinical presentations of women with the condition, diagnostic modalities and criteria, and medical and surgical treatment options.

Is adenomyosis the neglected phenotype of an endomyometrial dysfunction syndrome?

Since the dissociation between adenomyoma and endometriosis in the 1920s and the laparoscopic progress in the diagnosis and surgery of endometriosis, the literature has been greatly focused on the disease endometriosis. The study of adenomyosis, on the other hand, has been neglected as the diagnosis remained based on hysterectomy specimens. However, since the introduction of magnetic resonance and sonographic imaging techniques in the 1980s, the myometrial junctional zone has been identified as a third uterine zone and interest in adenomyosis was renewed. This has also been the start for the interest in the role of the myometrial junctional zone dysfunction and adenomyosis in reproductive and obstetrical disorders.

Diagnostic accuracy of transvaginal sonography for the diagnosis of adenomyosis: systematic review and metaanalysis

OBJECTIVE

The purpose of this study was to critically appraise the diagnostic accuracy of transvaginal sonography for diagnosing adenomyosis.

STUDY DESIGN

Computerized databases were used to identify relevant reports published between 1966 and 2007 reporting data on the accuracy of transvaginal sonography for diagnosing adenomyosis in women having hysterectomy. The presence or absence of adenomyosis was confirmed by histopathologic analysis of hysterectomy specimens. The total analysis included 14 trials with 1895 aggregate participants. Two authors independently assessed methodological quality and constructed tables for the assessment of diagnostic measures.

RESULTS

Transvaginal ultrasound predicted adenomyosis with a likelihood ratio of 4.67 (95% confidence interval [CI], 3.13-6.17). The overall prevalence of adenomyosis was 27.9% (95% CI, 25.5-30.3). The probability of adenomyosis with an abnormal transvaginal ultrasound was 66.2% (95% CI, 61.6- 70.6). The probability of adenomyosis with a normal transvaginal ultrasound was 9.1% (95% CI, 7.3-11.1).

CONCLUSION

Transvaginal sonography appears to be an accurate diagnostic test for adenomyosis.

A pilot study on the off-label use of valproic acid to treat adenomyosis

Following on the heels of the discovery that endometriosis is an epigenetic disease, we conducted a pilot study on the off-label use of valproic acid to treat adenomyosis. We found that by the end of the 3-month treatment, all three recruited patients reported complete disappearance of dysmenorrhea, with an average of one-third reduction in uterus size.