Dysmenorrhea: Evaluation with Cine-Mode-Display MR Imaging—Initial Experience

Embracing the Versatility of Botulinum Neurotoxins in Conventional and New Therapeutic Applications

Botulinum neurotoxins (BoNTs) have been used for almost half a century in the treatment of excessive muscle contractility. BoNTs are routinely used to treat movement disorders such as cervical dystonia, spastic conditions, blepharospasm, and hyperhidrosis, as well as for cosmetic purposes. In addition to the conventional indications, the use of BoNTs to reduce pain has gained increased recognition, giving rise to an increasing number of indications in disorders associated with chronic pain. Furthermore, BoNT-derived formulations are benefiting a much wider range of patients suffering from overactive bladder, erectile dysfunction, arthropathy, neuropathic pain, and cancer. BoNTs are categorised into seven toxinotypes, two of which are in clinical use, and each toxinotype is divided into multiple subtypes. With the development of bioinformatic tools, new BoNT-like toxins have been identified in non-Clostridial organisms. In addition to the expanding indications of existing formulations, the rich variety of toxinotypes or subtypes in the wild-type BoNTs associated with new BoNT-like toxins expand the BoNT superfamily, forming the basis on which to develop new BoNT-based therapeutics as well as research tools. An overview of the diversity of the BoNT family along with their conventional therapeutic uses is presented in this review followed by the engineering and formulation opportunities opening avenues in therapy.

Uterine fibroid cell cytoskeletal organization is affected by altered G protein-coupled estrogen receptor-1 and phosphatidylinositol 3-kinase signaling

OBJECTIVE

To determine whether cyclic strain affects fibroid cell cytoskeletal organization, proliferation, and collagen synthesis differently than myometrial cells.

DESIGN

A basic science study using primary cultures of patient-matched myometrial and fibroid cells.

SETTING

Academic laboratory.

PATIENT(S)

Premenopausal women undergoing myomectomy or hysterectomy for the treatment of symptomatic uterine fibroids.

INTERVENTION(S)

Application of uniaxial strain patterns mimicking periovulation, menses, or dysmenorrhea using the Flexcell tension system or static control. Secondarily, inhibition of G protein-coupled estrogen receptor-1 and phosphatidylinositol 3-kinase.

MAIN OUTCOME MEASURE(S)

Cell alignment, cell number, and collagen content.

RESULT(S)

Menses-strained cells demonstrated the most variation in cell alignment, cell proliferation, and procollagen content between myometrial and fibroid cells. Procollagen content decreased in myometrial cells with increasing strain amplitude and decreasing frequency. G protein-coupled estrogen receptor-1 inhibition decreases cellular alignment in the presence of strain.

CONCLUSION(S)

Mechanotransduction affecting cytoskeletal arrangement through the G protein-coupled estrogen receptor-1-phosphatidylinositol 3-kinase pathway is altered in fibroid cells. These results highlight the importance of incorporating mechanical stimulation into the in vitro study of fibroid pathology.

Uterine botulinum toxin injections in severe dysmenorrhea, dyspareunia and chronic pelvic pain: Results on quality of life, pain level and medical consumption

OBJECTIVE

To evaluate quality of life (Qol), pain level and medical consumption before and after uterine botulinum toxin (BT) injections in severe dysmenorrhea, dyspareunia and chronic pelvic pain.

METHODS

This was a before and after study using the database of a pilot study (Open-label non comparative study, on 30 patients, with severe dysmenorrhoea in therapeutic failure) assessing efficacy and cost of uterine injection of BT in women with chronic pelvic pain after failure of conventional treatment (hormonal and analgesics) (CT). Main clinical outcome: Patient Global Impression of Improvement (PGI-I), EuroQol health-related QoL (EQ-5D-5L), EuroQol-visual analogue scale (EQ-VAS), Female Sexual Function Index (FSFI), utility measure of health-related quality of life (also called health state preference values), cost and of health care consumption were collected prospectively and analysed in the two phases (before and after). The two timepoints were 12 months before uterine BT injection, when the patient had been receiving CT, and 12 months after uterine BT injection.

RESULTS

Median visual analogue scale scores were significantly improved by BT regarding the patients' main source of pain (31.6 vs 80.55; p < 0.00001). We also noted a significant reduction in the proportion of patients who reported dyspareunia [15 (75%) vs 3 (15%) patients, p = 0.001] and pain during menstruation (p < 0.0001). The PGI-I scale showed a significant increase in the proportion of patients who were satisfied with their treatment after receiving the BT injection. The injection of BT was frequently associated with increase in QoL and a reduction in health care consumption, and cost: 714.82 €+/- €336.43 (BT) versus 1104.16 €+/- €227.37 (CT), which could result in substantial savings approximately (389,34€) per patient.

CONCLUSION

This study revealed the clinical effectiveness of BT injections on dysmenorrhea, chronic pelvic pain as well as reduction of cost and health care consumption, in our population, which is innovative since no standard of treatment exists in this domain.

Angle of Uterine Flexion and Adenomyosis

The aim of this study was to assess the prevalence of adenomyosis in symptomatic women in relation to the angle of flexion of the uterus. A total of 120 patients referring to our Chronic Pelvic Pain Center were prospectively enrolled. Each woman scored menstrual pain, intermenstrual pain, and dyspareunia on a 10 cm visual analogue scale and underwent a clinical examination and transvaginal ultrasound. MUSA criteria were used for the diagnosis of adenomyosis. The angle of flexion of the uterus on the cervix was categorized as <150° (75% of cases), between 150° and 210° (6.7% of cases) and >210° (18.3% of cases). Adenomyosis was diagnosed in 76/120 women (63.3%). In women with adenomyosis, the VAS of intermenstrual pain was higher than in women without adenomyosis (4.04 ± 3.79 vs. 2.57 ± 3.34; p < 0.034). The angle of uterine flexion >210° was more prevalent in women with than without adenomyosis (25.0% vs. 6.8%; p < 0.015). The odds ratio of suffering from adenomyosis markedly increased in the presence of an angle of uterine flexion >210° (OR 5.8 95% CI 1.19, 28.3; p > 0.029). The data indicate that the ultrasound-estimated angle of uterine flexion >210° is related to a higher prevalence of adenomyosis.

Prediction of pain intensity with uterine morphological features and brain microstructural and functional properties in women with primary dysmenorrhea

Primary dysmenorrhea (PDM), defined as painful menstrual cramps of uterine origin, could cause brain structural and functional changes after long-term menstrual pain. Here, we aimed to investigate the predictive value of uterine morphological features and microstructural/functional properties of the brain extracted from periovulatory phases for the intensity of menstrual pain as rated by women with PDM during their subsequent menstrual period. Forty-five women with PDM were recruited and classified into the high and mild pain intensity groups. Pelvic MRI was employed to extract the uterine texture features. White matter diffusion properties, grey matter and functional connectivity features were extracted as brain features. Multivariate logistic regression models with iteration optimization were built for classifying different pain intensity groups. Texture features from myometrium and uterine junction zone had outstanding prediction performance with an area under the receiver operating characteristic (AUC) of 0.96 (P < 0.05, permutation test), and diffusion properties along the thalamic fiber bundles were the most discriminative features with AUC of 0.95. Applying features from uterus and brain together, we could gain better prediction performance. Our results indicated that accumulated differences in menstrual pain were associated not only with uterine structure but also diffusion properties of thalamic-related fiber tracts, suggesting that treatment options of PDM patients may be expanded from only being able to manage pain in the uterus focusing on the functional/structural modifications of the pain processing system.

Treatment of acute dysmenorrhoea and pelvic pain syndrome of uterine origin with myometrial botulinum toxin injections under hysteroscopy: A pilot study

BACKGROUND

Acute dysmenorrhoea in women which has been shown to be anatomically negative for endometriosis is a very common condition. It is frequently associated with Chronic Pelvic Pain (CPP) from uterine origin, including painful uterine contractions and deep dyspareunia. We call this association Painful Uterine Syndrome (PUS).

SEARCH STRATEGY

In these women in failure of the usual treatments, we proposed a new treatment, with Uterine Toxin Botulinic injections (BTX) under hysteroscopy, as a compassionate option, among women in severe pain and therapeutic failure. Indeed, increased uterine contractility has been confirmed using cine magnetic resonance imaging in patients with acute dysmenorrhea and PUS. These findings, associated with the hypothesis of a possible uterine sensitization on the same model as irritable bowel syndrome (IBS) or painful bladder syndrome (PBS), led to the application of botulinum toxin (BTX) injections under hysteroscopy of the uterine myometrium in this indication.

MATERIAL AND METHODS

In 2018, we conducted an open-label non comparative study, on 30 patients, with severe dysmenorrhea and PUS in therapeutic failure situation. All women had failure of usual treatments, with painkillers, anti-inflammatory drugs, contraceptive pill, menstrual suppressant therapy and a negative MRI and laparoscopy. The BTX units (200 IU of Incobotulinum-toxin A) were evenly distributed in the anterior and posterior myometrial wall under hysteroscopic control. Patients were reviewed between 8 and 12 weeks after BTX injections and then, at 6 months.

MAIN RESULTS

Median VAS scores were significantly improved at 8-12 weeks follow up for dysmenorrhoea, deep dyspareunia, and pelvic pain outside of menstruation. Quality of life scores all improved dramatically. No major side effect has been reported in this pilot study. At 6 months, 12 patients (40 %), were given new injections for pain reccurence. But 14 patients (47 %), were still improved and did not require repeat injection at that time. 4 patients, were improvement was not significant, did not ask for repat BTX injections. These patients were all positive for Pelvic Sensitization criteria.

CONCLUSIONS

Uterine BTX injection could be a very interesting therapeutic option in women with acute dysmenorrheoa and PUS in therapeutic failure. Only long-term randomised studies will be able to confirm that BTX injections are useful as a treatment for this condition. The randomised long-term study, Uteroxine, will shortly release its results.

Impact of uterine contractility on quality of life of women undergoing uterine fibroid embolization

Background

Although changes in uterine contractility pattern after uterine fibroid embolization (UFE) has already been assessed by cine magnetic resonance imaging (MRI), their impact on quality of life outcomes has not been evaluated. The purpose of this study was to evaluate the impact of uterine contractility on the quality of life of women undergoing UFE measured by the Uterine Fibroid Symptom and Quality of Life questionnaire (UFS-QOL).

Results

A total of 26 patients were included. MRI scans were acquired 30–7 days before and 6 months after UFE for all patients. The UFS-QOL was applied in person on first MRI exam day and 1 year after UFE and the outcomes were analyzed according to the groups of evolution pattern of uterine contractility: Group A: Unchanged Uterine Contractility Pattern, 38%; Group B: Favorable Modified Uterine Contractility Pattern, 50%; and Group C: Loss of Uterine Contractility, 11%. All UFE patients presented a reduction in the mean score for symptoms and increase in mean scores on quality of life. All patients in this cohort presented a reduction in mean symptom score and increase in the mean score of quality of life subscales. Group A had more relevant complaints regarding their sense of self-confidence; Group B presented worse sexual function scores before UFE, which improved after UFE compared to Group A.

Conclusions

Significant improvement in symptoms, quality of life, and uterine contractility was observed after UFE in women of reproductive age with symptomatic fibroids. Functional uterine contractility seems to have a positive impact on quality of life and sexual function in this population.

Level of evidence

Level 3, Non-randomized controlled cohort/follow-up study.

Evaluation of Uterine Contractility by Magnetic Resonance Imaging in Women Undergoing Embolization of Uterine Fibroids

PURPOSE

To assess uterine contractility using ultrafast magnetic resonance imaging (cine MRI) before and after uterine fibroid embolization (UFE).

MATERIALS AND METHODS

This is a prospective study of uterine contractility in 26 patients (age 30-41 years) undergoing UFE for symptomatic uterine fibroids. Cine MRI was performed before and 6 months after UFE. Two radiologists evaluated uterine contractility and classified it as absent, ordered, or disordered. Patients were then grouped into three distinct patterns of progression: unchanged contractility (group A), modified contractility (B), and loss of contractility (C). These findings were then confronted with factors that might have interfered with uterine contractility pattern (uterine volume, location of dominant fibroid, fibroid/myometrium index, and fibroid necrosis pattern).

RESULTS

Of the 26 patients, 8 (30.7%) had no contractility before the procedure, while 18 (69.2%) exhibited some form of contractility (11 [61%] ordered, 7 [39%] disordered). All 8 patients who had no contractility at baseline exhibited contractility after UFE (5 ordered, 3 disordered). Of the 11 who had ordered contractility at baseline, 9 remained ordered and 2 lost contractility after UFE. Of the 7 with disordered contractility at baseline, 1 remained disordered, 5 progressed to ordered contractility, and 1 lost contractility. Overall, 10 patients (38%) had no change in contractility after UFE (group A), 13 (50%) had a positive change (group B), and 3 (11%) lost contractility (group C). The potential interference factors assessed had no statistically significant effect in any group.

CONCLUSION

In women of reproductive age with symptomatic fibroids, uterine contractility improved significantly after UFE.

LEVEL OF EVIDENCE

Level 3-non-randomized controlled cohort/follow-up study.

Cine MRI during spontaneous cramps in women with menstrual pain

BACKGROUND

The lack of noninvasive methods to study dysmenorrhea has resulted in poor understanding of the mechanisms underlying pain, insufficient diagnostic tests, and limited treatment options. To address this knowledge gap, we have developed a magnetic resonance imaging-based strategy for continuously monitoring the uterus in relationship to participants' spontaneous pain perception.

OBJECTIVE

The study objective was to evaluate whether magnetic resonance imaging can detect real-time changes in myometrial activity during cramping episodes in women with dysmenorrhea, with a handheld squeeze bulb for pain reporting.

STUDY DESIGN

Sixteen women with dysmenorrhea and 10 healthy control women both on and off their menses were evaluated with magnetic resonance imaging while not taking analgesic medication. Continuous magnetic resonance imaging was acquired using half-Fourier acquisition single-shot turbo spin echo sequence along with simultaneous reporting of pain severity with a squeeze bulb. Pearson's coefficient was used to compare results between reviewers. Proportional differences between women with dysmenorrhea and controls on/off menses were evaluated with a Fisher exact test. The temporal relationships between signal changes were evaluated with Monte Carlo simulations.

RESULTS

Spontaneous progressive decreases in myometrial signal intensity were more frequently observed in women on their menses than in the absence of pain in the same women off their menses or participants without dysmenorrhea (P < .01). Women without reductions in myometrial signal intensity on their menses either had a history of endometriosis or were not in pain. Observations of myometrial events were consistently reported between 2 raters blinded to menstrual pain or day status (r = 0.97, P < .001). Episodes of cramping occurred either immediately before or 32-70 seconds after myometrial signal change onset (P < .05).

CONCLUSION

Transient decreases in myometrial uterine T2-weighted signal intensity can be reliably measured in women with menstrual pain. The directionality of signal change and temporal relationship to pain onset suggest that cramping pain may be caused by a combination of uterine pressure and hemodynamic dysfunction.

Functional magnetic resonance imaging for clinical evaluation of uterine contractility

Uterine contractility out of the gestational phase, during the menstrual cycle and the habitual functional variations of the organ, this is one of the responsible mechanisms for reproduction and fertility, due to its direct action in the mechanisms conducting the spermatozoa to the ovule and in the decidual implantation. Pathologies such as uterine leiomyoma, endometriosis, adenomyosis, polycystic ovarian syndrome, as well as the use of intrauterine devices and oral contraceptives, may alter a functionality of uterine contractility. Thus, magnetic resonance imaging with ultrafast sequences provides a dynamic evaluation (cine-MRI) and thus the correlation of uterine contractility quality in patients with current infertility or pathologies.

Enlarged uterine corpus volume in women with endometriosis: Assessment using three-dimensional reconstruction of pelvic magnetic resonance images

AIM

To assess and compare the uterine volume and endometrium length between women with and without endometriosis, using pelvic magnetic resonance imaging scans.

METHODS

In this case-control study, a total of 75 nulligravid women (aged 20-45 years) with regular menstrual cycles whose uterus were free of any surgically confirmed lesions were enrolled. The endometriosis group underwent surgery for endometrioma (n = 39), and the control group underwent surgery for non-endometrioma ovarian cysts (n = 36). The primary outcome was uterine corpus volume, which was assessed using three-dimensional reconstructions of preoperative pelvic magnetic resonance imaging scans.

RESULTS

The mean uterine volume was significantly larger in the endometriosis group than in the control group (mean ± standard deviation, 50.9 ± 14.4 cm³ vs 41.7 ± 14.3 cm³ ; P < 0.01). The longitudinal length and transverse diameter of the corpus and the longitudinal length of the endometrium were also significantly greater in the endometriosis group (all, P < 0.01).

CONCLUSIONS

An increase in uterine volume and endometrium length was observed in women with endometriosis.

Effects of low-dose combined drospirenone-ethinylestradiol on perimenstrual symptoms experienced by women with endometriosis

OBJECTIVE

To determine the effectiveness of a 24/4-day regimen of a low-dose combination drospirenone-ethinylestradiol oral contraceptive in alleviating perimenstrual symptoms among Japanese women with endometriosis.

METHODS

The present prospective, non-randomized study enrolled women diagnosed with endometriosis radiographically or surgically at the Kyoto Prefectural University of Medicine hospital, Japan, between December 1, 2010 and August 31, 2013. Patients received treatment with oral drospirenone-ethinylestradiol for six treatment cycles. Dysmenorrhea, chronic pelvic pain, and dyspareunia severity were assessed using visual analog scale scores after three and six treatment cycles, and changes in perimenstrual symptoms were assessed using the menstrual distress questionnaire (MDQ) scores.

RESULTS

In total, 46 patients were recruited for the study. Dysmenorrhea, chronic pelvic pain, and dyspareunia were all significantly reduced after both three and six treatment cycles in comparison with baseline (P<0.001 for all comparisons). After six treatment cycles, significant reductions were observed for all menstrual MDQ measures and for the premenstrual water retention and negative-effect MDQ measures (all P<0.05).

CONCLUSIONS

Combination drospirenone-ethinylestradiol was effective in the treatment of dysmenorrhea, chronic pelvic pain, dyspareunia, and somatic/psychological symptoms in Japanese women with endometriosis.

Uterine anatomy and function on cine magnetic resonance imaging

The female reproductive organ undergoes dynamic morphological changes under the influence of hormonal stimuli, and particularly those mediated by estrogen and progesterone. The uterus changes both its morphological appearance and its functional movements in function of these influences. Functionally, the uterus is known to exert two kinds of inherent contractility: sustained uterine contractions and uterine peristalsis. The former is focal and consists of the sporadic bulging of the myometrium, while the latter is rhythmic and manifests itself as the subtle stripping movement in the subendometrial myometrium. The mechanisms underlying these uterine movements, their relationship and their correlation to age, pharmaceutical administration, and a variety of gynecologic and obstetrical problems remain under discussion. Cine MR imaging may offer the potential to directly observe the changes undergone by the uterus in relation to important functions such as fertility and menstrual problems.

[An Examination for Uterine Dynamic Study with Phase-sensitive Inversion-recovery]

The depth of myometrial invasion in patients with endometrial carcinoma is recognized as an important factor that closely correlates with prognosis. Preoperative assessment of myometrial invasion is essential for planning surgery. To enhance the contrast between myometrium and endometrium including myometrial invasion with endometrial carcinoma, we optimized the sequence parameter with phase-sensitive inversion-recovery (PSIR) in gadolinium dynamic study of uterine corpus. On a 1.5-T magnetic resonance imaging (MRI), images were acquired by three-dimensional (3D) T1 -turbo field echo (TFE) with PSIR sequence and gadolinium-diethylenetriamine pentaacetic acid( Gd-DTPA) diluted phantom (0-5 mmol/L) and myometrium model (manganese chloride tetrahydrate+agar). We calculated the null point and the contrast-to-noise ratio (CNR) at multiple TFE inversion delay times, 200 ms-maximum in each combination; flip angles (FAs), 5-35 degrees; TFE factor, 20-40; and shot interval (SI), 500-1000 ms. We assumed that dynamic scanning time was 30 seconds when the sensitivity encoding factor was 2, namely, in this study, the scanning time was 1 minute with no sensitivity encoding. In addition, we compared CNR between optimized PSIR sequence ande-Thrive. We recognized a successful CNR of the 3D PSIR parameter was TFE inversion delay times, 335 ms; FA, 25 degrees; TFE factor, 20; and SI, 500 ms. In each gadolinium-DTPA diluted phantom, the average CNR of the optimized PSIR sequence was approximately 1.7 times (maximum: 3 times) higher than e-Thrive. Optimizing sequence parameter of PSIR is applicable in gadolinium dynamic study of uterine corpus.

Evaluation of uterine peristalsis using cine MRI on the coronal plane in comparison with the sagittal plane

BACKGROUND

Uterine peristalsis is supposed to be closely related to the early stages of reproduction. Sperms are preferentially transported from the uterine cervix to the side of the tube with the dominant follicle. However, with respect to magnetic resonance imaging (MRI), uterine peristalsis has only been evaluated at the sagittal plane of cine MRI.

PURPOSE

To evaluate and compare uterine peristalsis both on sagittal and coronal planes using cine MRI.

MATERIAL AND METHODS

Internal ethics committee approval was obtained, and subjects provided informed written consent. Thirty-one women underwent MRI scans in the periovulatory phase of the menstrual cycle. Cine MR images obtained by fast advanced spin echo sequence at 3-T field strength magnet (Toshiba Medical Systems) were visually evaluated by two independent radiologists. The frequency and the direction of peristalsis, and the presence of outer myometrium conduction of signal intensities (OMC), were evaluated. The laterality of the dominant follicle was determined on axial images and compared with the peristaltic direction in fundus.

RESULTS

The subjects in which peristaltic directions were more clearly recognized were significantly frequent in coronal planes than in sagittal planes (P < 0.05). There was no significant difference in the peristaltic frequency between the sagittal and the coronal plane. However, the OMC was more recognized in the coronal plane than in the sagittal plane (P < 0.05). Peristaltic waves conducted toward the possible ovulation side were observed in only three of the 10 subjects.

CONCLUSION

OMC of uterine peristalsis was better demonstrated in the coronal plane compared to the sagittal plane.

Magnetic resonance imaging relaxation times of female reproductive organs

BACKGROUND

Relaxation time of female reproductive organs affects the tissue contrast of magnetic resonance image (MRI), and is used for quantitative analysis.

PURPOSE

To evaluate the relaxation times of normal female reproductive organs in the luteal phase of the menstrual cycle.

MATERIAL AND METHODS

On a 1.5-T MRI, relaxation times were measured in pelvic tissues (endometrium, junctional zone, myometrium, follicle, and stroma) of 32 female healthy volunteers (33.5 ± 6.8 years). The Look-Locker sequence was used to measure T1 relaxation times. Furthermore, a multiple spin-echo method with 32 different echo times was used to measure T2 relaxation times. The images were obtained in the luteal phase of each volunteer's menstrual cycle.

RESULTS

The measured relaxation times (means ± standard deviations) were as follows: endometrium (T1, 1703 ± 147 ms; T2, 214 ± 35 ms), junctional zone (T1, 1168 ± 63 ms; T2, 72 ± 12 ms), myometrium (T1, 1314 ± 103 ms; T2, 138 ± 20 ms), follicle (T1, 2267 ± 49 ms; T2, 603 ± 68 ms), and stroma (T1, 1481 ± 129 ms; T2, 126 ± 29 ms).

CONCLUSION

Reliable MRI measurements of T1 and T2 relaxation times of normal female reproductive organs in the luteal phase of the menstrual cycle are useful as references to recognize the normal value.

An in vivo mouse model of primary dysmenorrhea

Primary dysmenorrhea (PD) is a common gynecological disorder. Hitherto, animal models which recapitulate clinical features of PD have not been fully established. We aimed to examine whether a pain model in mice could mimic the clinic features of PD. After pretreated with estradiol benzoate (1 mg/kg/day) intraperitoneally (i.p.) for 3 consecutive days, non-pregnant female Imprinting Control Region mice (6–8 weeks old) was injected with 0.4 U of oxytocin to induce the stretching or writhing response which was recorded for a time period of 30 min. During the writhing period, the uterine artery blood flow alterations were examined by Doppler ultrasound detection. After writhing test, the uterine morphological changes were observed by hematoxylin and eosin (H&E) staining histopathology. In addition, enzyme-linked immunosorbent assay kit was used to measure the levels of prostaglandins F_2α/prostaglandins E₂ (PGF_2α/PGE₂) and TXB₂ (a metabolite of TXA₂)/6-keto-PGF_1α (a metabolite of PGI₂) in the uterine tissue homogenates and plasma, respectively. Western blot analyses were performed to determine the expressions of oxytocin receptor (OTR), beta2-adrenergic receptor (beta2-AR), and cyclooxygenase-2 (COX-2) in uterine, which are responsible for the uterine contraction. The writhing response only occurred in the estrogen pretreated female mice. The area of uterine myometrium significantly decreased along with the increased thickness in the oxytocin-induced estrogen pretreated mice model. The uterine artery blood flow velocity dropped, while the pulsatility index and resistance index slightly increased after the injection of oxytocin. The PGF_2α/PGE₂ level significantly increased and the plasma TXB₂/6-keto-PGF_1α level significantly enhanced. Compared with the control group, the uterine histopathology demonstrated moderate to severe edema of endometrium lamina propria. In consistent with the uterine morphological changes, a significant reduction of beta2-AR and a significant increase of OTR and COX-2 in the uterine tissue were observed. The writhing response was caused by the abnormal contraction of uterus. The uterine spasm and ischemia changes of oxytocin-induced estrogen pretreated female mice model were similar to the pathology of human PD. We reported an in vivo mice model, which can be used to study PD and for clinical therapeutic evaluations.

Diffusion tensor imaging (DTI) of the normal human uterus in vivo at 3 tesla: comparison of DTI parameters in the different uterine layers

PURPOSE

To investigate the differences in the fiber architecture and related diffusion tensor imaging (DTI) parameters among different uterine layers of the normal human uterus in vivo at 3 Tesla (T).

MATERIALS AND METHODS

DTI of the uterus was performed for nine healthy women of reproductive age on a 3T scanner. A volume of interest (VOI) was drawn for the outer myometrium (OM), junctional zone (JZ), and endometrium (EM). Apparent diffusion coefficient (ADC), fractional anisotropy (FA), and maximum fiber length were compared using paired Student's t-tests. Fibers were classified into four groups and were visually evaluated.

RESULTS

ADC (×10(-3) mm(2) /s) was highest for OM (1.12), followed by EM (0.97) and JZ (0.83) (OM versus JZ, P < 0.0001; JZ versus EM, P = 0.0001; OM versus EM, P = 0.0057). FA was highest for JZ (0.297), followed by OM (0.257) and EM (0.186) (OM versus JZ, P = 0.0002; JZ versus EM, P < 0.0001; OM versus EM, P < 0.0001). Fibers were longest in OM (42.0 mm), followed by JZ (34.2 mm) and EM (20.0 mm). Circularly oriented fibers were observed in 69% in OM and in 70% in JZ.

CONCLUSION

DTI of the uterus in vivo revealed layer-wise differences in the microstructure of the uterus.

Uterine morphology and peristalsis in women with polycystic ovary syndrome

BACKGROUND

Polycystic ovary syndrome (PCOS) is associated with chronic oligo-anovulation and high circulating sex hormone levels. Women with PCOS have an increased risk of developing endometrial cancer. In anovulatory women with PCOS a positive relationship between endometrial thickness and endometrial hyperplasia has been observed. Uterine peristalsis, which has been suggested to be of importance for female fertility, has not previously been studied in PCOS.

PURPOSE

To assess whether women with PCOS have altered endometrial thickness, uterine wall morphology, and peristalsis.

MATERIAL AND METHODS

In this prospective case-control study 55 women with PCOS (mean age, 29.5 years ± 4.5 SD) and 28 controls (27.6 ± 3.2) were examined using magnetic resonance imaging (MRI), assessing thickness of endometrium, junctional zone (JZ), and myometrium, and evaluating the occurrence, frequency (waves/min), strength (amplitude), pattern, and direction of peristalsis. Uterine morphology was also assessed by transvaginal ultrasonography (TVUS).

RESULTS

The endometrium was thinner in PCOS with oligo-amenorrhea compared to controls, also after adjustments for age and BMI (adjusted P = 0.043). There was no difference in thickness of the JZ or the myometrium in cases versus controls. Uterine peristalsis was less commonly observed in women with PCOS than in controls (adjusted P = 0.014).

CONCLUSION

There were no differences in myometrial morphology between PCOS and controls, but the endometrium was thinner in PCOS with oligo-amenorrhea. Based on cine MRI, uterine peristalsis was less common in PCOS than in controls.

Skin adhesive low-level light therapy for dysmenorrhoea: a randomized, double-blind, placebo-controlled, pilot trial

PURPOSE

The cause of dysmenorrhoea is an abnormal function of smooth muscles in the uterus due to long-term deficient blood supply into smooth muscle tissue. The purpose of this study was to evaluate the effectiveness of skin adhesive low-level light therapy (LLLT) in participants with dysmenorrhoea.

METHODS

Thirty-one women were included in this randomized, double-blind, placebo-controlled, pilot trial. Twenty-one women were treated with active LLLT and ten women were treated with placebo one. The therapy was performed in a laboratory room for 20 min a day over a period of 5 days prior to the expected onset of menstruation. The outcome was measured using a visual analog scale (VAS) for each participant's dysmenorrhoeal pain severity. VAS of each subject was measured every month for 6 months.

RESULTS

In the active LLLT group, 16 women reported successful results during their first menstrual cycle just after active LLLT and 5 women had successful results from the second menstrual cycle after active LLLT. The pain reduction rate was 83 % in the active LLLT group, whereas there was only a slight and temporary reduction in pain in the placebo LLLT group. Changes of VAS within 6 months of LLLT showed statistical significance (p = 0.001) over placebo control.

CONCLUSIONS

Our study suggests that skin adhesive LLLT on acupuncture points might be an effective, simple and safe non-pharmacological treatment for dysmenorrhoea.

Three-dimensional power Doppler assessment of uterine vascularization in women with primary dysmenorrhea

OBJECTIVE

The aim of this study was to assess myometrial vascularization with 3-dimensional (3D) power Doppler angiography (PDA) in women with different grades of primary dysmenorrhea at the moment of maximum menstrual pain in an effort to improve the pathophysiologic knowledge of one of the most common gynecologic conditions.

METHODS

This was a cross-sectional study involving 70 voluntary women that studied or worked at the Clinica Universitaria de Navarra between January 2006 and January 2008. All women underwent transvaginal sonographic 3D PDA on the day of maximum pain after the onset of menstruation or during the first 24 to 48 hours of the new cycle if no pain was present. Three groups were defined according to a visual analog scale: no pain to mild dysmenorrhea, moderate dysmenorrhea, and severe dysmenorrhea. Vascularity assessment was done on the basis of 3D vascularity indices: the vascularization index (VI), flow index (FI), and vascularization-flow index (VFI).

RESULTS

The mean VI and VFI for the inner 5 mm of the myometrium and the total myometrium were significantly higher in the women with severe dysmenorrhea than in those with no pain to mild dysmenorrhea (P < .05). The VI, FI, and VFI in the women with moderate dysmenorrhea did not differ significantly from those in the women with severe dysmenorrhea.

CONCLUSIONS

This study evaluated the use of 3D PDA for assessing uterine and specifically myometrial vascularization. Our data indicate that women with severe dysmenorrhea have increased myometrial vascularization during the early menstrual phase compared with women without pain.

Intrauterine devices and uterine peristalsis: evaluation with MRI

Intrauterine devices (IUDs) have been viewed as an effective form of contraception. However, the mechanism by which IUDs disturb fertility remains controversial. This study aimed to evaluate the effects of IUDs on uterine contractility using cine MR. Eleven healthy female volunteers of reproductive age bearing IUDs and 12 women not bearing IUDs were evaluated during the periovulatory phase. MR images were obtained with a 1.5-T magnet, acquiring 60 serial images every 3 s via half-Fourier acquisition single-shot turbo spin echo to be displayed on cine mode. Assessments were based on (a) the presence of peristaltic waves, (b) the frequency and direction of peristaltic waves and (c) the extent of peristaltic waves. Static images were evaluated for thickness of the junctional zone (JZ) and myometrium. A fundo-cervical (FC)-directed peristaltic wave was identified in 4 of 11 IUD-bearing subjects and in only 1 of 12 subjects from the control group. FC waves extended through more than half of the thickness of the myometrium. Peristaltic frequency in IUD users (5.0/3 min) was less than that of the control group (6.5/3 min). The JZ and myometrium were significantly thicker in IUD users. FC-directed waves were more often observed in IUD-bearing subjects, which might explain the inhibition of active sperm transport.

Functional MR imaging of the female pelvis

Recent developments in MR techniques have magnified the roles and potential of MRI in the female pelvis. This article reviews the techniques and clinical applications of functional MRI (fMRI) of the female pelvis, including cine MRI, diffusion-weighted MRI (DWI), and dynamic contrast-enhanced (DCE)-MRI. Cine MRI is a useful tool for evaluating uterine contractility, including sustained contraction and peristalsis, in a variety of conditions and gynecologic disorders, and for evaluating pelvic-floor weakness. DWI can demonstrate abnormal signals in pathologic foci based on differences in molecular diffusion. It also enables the quantitative evaluation of the apparent diffusion coefficient (ADC), which may be useful for distinguishing malignant from benign tissues and monitoring therapeutic outcome. DCE-MRI has the potential to improve tumor detection and local staging, and can also provide quantitative information about perfusion of the tumor, which may be useful for both monitoring therapeutic effects and predicting therapeutic outcome. Understanding the roles played by functional MR techniques in the female pelvic region is beneficial not only for determining clinical applications, but also for developing further investigations with MRI.

Uterine Contractility Evaluated on Cine Magnetic Resonance Imaging

The inherent contractility of the uterus has attracted concern of researchers and exhibits two known patterns of contraction. One is focal and sporadic bulging of the myometrium, and the other is rhythmic and subtle stripping movement in the subendometrial myometrium, known as uterine peristalsis. Recent development in the ultrafast magnetic resonance imaging (MRI) techniques has enabled us to observe these uterine contractions directly and noninvasively. Although the mechanisms and relationship of these two kinds of myometrial contractions and their relations to age, pharmaceutical administration such as oral contraceptives (OCs), and a variety of gynecologic and obstetrical problems are still under debate, cine MRI can be applied for directly monitoring changes of the uterus related to important uterine functions such as fertility and menstrual problems.

MRI of the female pelvis at 3T compared to 1.5T: Evaluation on high-resolution T2-weighted and HASTE images

PURPOSE

To evaluate the feasibility of MRI of the female pelvis using high-resolution T2-weighted imaging (T2WI) and the half-Fourier acquisition single-shot turbo spin-echo (HASTE) technique at 3 Tesla (T) compared to 1.5T, while focusing on the uterine body and cervical anatomy.

MATERIALS AND METHODS

A total of 19 healthy women underwent pelvic MR scans on 3T and 1.5T scanners. Axial and sagittal T2W (voxel size of 0.6 x 0.8 x 2 mm) and sagittal HASTE images were obtained. The images were evaluated qualitatively for overall image quality, contrast in the uterine zonal appearance and cervical structure, image inhomogeneity, and artifacts. A quantitative evaluation was performed regarding zonal contrast and image inhomogeneity.

RESULTS

On T2WI, the image contrast in the uterine cervix and vagina were significantly higher at 3T than at 1.5T, although there was no significant difference in the overall image quality or contrast in the uterine zonal appearance. Image inhomogeneity was more prominent at 3T, and motion artifact was more severe at 1.5T.

CONCLUSION

Our results suggest that MRI of the female pelvis at 3T may potentially provide excellent images of the uterine cervix on high-resolution T2WI. New techniques to reduce inhomogeneity are thus called for.

Cine MR imaging of uterine peristalsis in patients with endometriosis

Endometriosis is one of the most important causes of infertility; however the precise mechanism by which it affects female fertility is unclear. The objective of this study was to study the functional aspects of the uterus by evaluating uterine contractility in patients with endometrial cysts of the ovary. The study population was recruited from two institutes and consisted of 26 women (periovulatory (10), luteal (13), and menstrual phase (3); age range: 19-51 years) with untreated endometriosis; the control group consisted of 12 healthy women (age range: 22-41 years). Cine MR imaging obtained by a 1.5T magnet was visually evaluated at 12x faster than real speed, focusing on the presence of uterine peristalsis, the direction and frequency of peristalsis, and the presence of sustained uterine contractions. Uterine peristalsis was identifiable in 3/10, 3/13, and 3/3 of the endometriosis patients in each menstrual cycle, respectively, and in 11/12, 3/12, and 5/12 of their control subjects. Peristaltic detection rate and frequency were significantly less for the endometriosis group than for the controls in the periovulatory phase only (p<0.05). Sustained contractions were recognized in 19/36 control subjects and in 13/26 endometriosis patients, but the difference was not significant. Uterine peristalsis appears to be suppressed during the periovulatory phase in patients with endometriosis, which may have an adverse effect on sperm transport.

MR Imaging of Benign Uterine Disease

MR provides excellent depiction of the female pelvic anatomy and has become the imaging modality of choice for the accurate diagnosis of numerous benign gynecologic conditions. Detection and characterization of leiomyomata and adenomyosis is performed routinely at many centers, and MR plays an important role in stratifying patients into appropriate treatment options. MR imaging is also uniquely well suited to the evaluation of gynecologic conditions that occur during pregnancy and in the postpartum period. This article describes MR protocols and the typical findings of various benign conditions of the uterine corpus and cervix, including congenital anomalies, leiomyomas, adenomyosis, and complications related to pregnancy.

Magnetic Resonance Imaging of Morphological and Functional Changes of the Uterus Induced by Sacral Surface Electrical Stimulation

The purpose of this study is to examine the morphological and kinematical changes of the uterus induced by electrical stimulation applied to the skin just above the second and fourth posterior sacral foramens (sacral surface electrical stimulation [ssES]) in 26 healthy subjects. Out of them, eight subjects who had severe pain subjectively during every menstruation received ssES just in menstruation. Morphological and functional changes of the uterus were examined by using T2-weighted magnetic resonance (MR) imaging and T1-weighted MR cinematography, respectively. Cyclic electrical stimulation for 15 min with 5 sec ON and 5 sec OFF was applied just before MR scanning. A decrease in thickness of the muscular layer of the uterus was observed in every subject after ssES for 15 min and was significant as compared with the thickness before ssES. Periodic uterine movement during menstruation was observed in the subjects with severe menstrual pain in MR cine and the power spectrum analysis of the movement showed a marked decrease in peak power and frequency after ssES treatment. We conclude that ssES causes a reduction of static muscle tension of the uterus in all menstrual cycle periods and suppression of uterine peristalsis during menstruation in the subjects with severe menstrual pain. Possible neural mechanisms for these static and dynamic effects of ssES on the uterus at spinal level are discussed.