Adenomyosis and Adolescence: A Challenging Diagnosis and Complex Management

Adenomyosis is a chronic, hormone-related disease characterized by the presence of the endometrial glands and stroma within the myometrium. This condition can manifest in various features, focal or diffuse adenomyosis or as an adenomyoma, and it may involve different uterine walls (posterior, anterior, and/or lateral walls). The disease can also be classified into different degrees, as mild, moderate and severe, which can be associated with more intense symptoms, although this correlation is not always directly proportional. In fact, adenomyosis can be asymptomatic in about a third of cases or it can significantly impact patients' quality of life through painful symptoms, such as dysmenorrhea and dyspareunia, abnormal uterine bleeding-particularly heavy menstrual bleeding-and potential effects on fertility. Historically, adenomyosis has been considered a disease primarily affecting premenopausal women over the age of 40, often multiparous, because the diagnosis was traditionally based on surgical reports from hysterectomies performed after the completion of reproductive desire. Data on the presence of adenomyosis in adolescent patients remain limited. However, in recent years, advancements in noninvasive diagnostic tools and increased awareness of this pathology have enabled earlier diagnoses. The disease appears to have an early onset during adolescence, with a tendency to progress in terms of extent and severity over time. Adenomyosis often coexists with endometriosis, which also has an early onset. Therefore, it is important, when diagnosing adenomyosis, to also screen for concomitant endometriosis, especially deep endometriosis in the posterior compartment. The aim of this narrative review is to investigate the prevalence of different types and degrees of adenomyosis in younger patients, assess the associated symptoms, and describe the most appropriate diagnostic procedures for effective therapeutic management and follow-up, with the goal of improving the quality of life for these young women.

Automatic diagnosis for adenomyosis in ultrasound images by deep neural networks

OBJECTIVE

To present a new noninvasive technique for automatic diagnosis of adenomyosis, using a novel end-to-end unified network framework based on transformer networks.

STUDY DESIGN

This is a prospective descriptive study conducted at a university hospital.1654 patients were recruited to the study according to adenomyosis diagnosed by transvaginal ultrasound (TVS). For adenomyosis characteristics and ultrasound images, automatic identification of adenomyosis were performed based on deep learning methods. We called this unique technique A2DNet: Adenomyosis Auto Diagnosis Network.

RESULTS

The A2DNet exhibits excellent performance in diagnosis of adenomyosis, achieving an accuracy of 92.33%, a precision of 96.06%, a recall of 91.71% and an F1 score of 93.80% in the test group. The confusion matrix of experimental results show that the A2DNet can achieve a correct diagnosis rate of 92% or more for both normal and adenomyosis samples, which demonstrate the superiority of the A2DNet comparing with the state-of-the-arts.

CONCLUSION

The A2DNet is a safe and effective technique to aid in automatic diagnosis of adenomyosis. The technique which is nondestructive and non-invasive, is new and unique due to the advantages of artificial intelligence.

Distribution of endometriosis phenotypes according to patients' age in adult women with surgical evaluation

STUDY QUESTION

What is the distribution of endometriosis phenotypes according to age in adult women undergoing surgery?

SUMMARY ANSWER

The phenotype of endometriosis did not significantly vary after 24 years old.

WHAT IS KNOWN ALREADY

The phenotypic evolution of endometriosis over time remains unclear. While adolescents can exhibit any type of endometriosis lesions, ovarian endometriosis (OMA) and/or deep-infiltrating endometriosis (DIE) tend to increase with age in young adults. In adulthood, understanding the evolution of lesions is crucial for disease management, but the literature on this subject is limited. This study aims to examine the distribution of endometriosis phenotypes in relation to age among adult patients requiring surgical treatment.

STUDY DESIGN, SIZE, DURATION

This observational cohort study included patients aged between ≥18 and ≤42 years, who underwent surgery for benign gynecological conditions at our institution between January 2004 and December 2022. A standardized questionnaire was completed for each patient during a face-to-face interview conducted by the surgeon in the month preceding surgery. Women with histologically proven endometriosis were included.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The distribution of endometriosis phenotypes (isolated superficial (SUP) endometriosis, OMA ± SUP, DIE ± SUP/OMA) was compared between young adults (≤24 years) and adults (>24 years) and among adults (25-28 years, 29-33 years, 34-38 years, 39 to ≤42 years) using univariate and multivariate analysis. The distribution of different subtypes of DIE (uterosacral ligament(s), vagina, bladder, intestine, and ureter), OMA size, and intensity of pain symptoms were also examined.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 1311 adult women with histologically proven endometriosis were included. In women aged 24 years or younger (n = 116), the distribution of endometriosis phenotypes differed significantly from women older than 24 years (n = 1195): The frequency of the DIE ± SUP/OMA phenotype was lower (41.4% versus 56.1%, respectively), while the rate of isolated superficial lesions was higher (from 32.0% versus 25.9%) (P = 0.001). In the group of women aged >24 years, a significantly higher proportion of vaginal DIE lesions (P = 0.012) and a lower proportion of uterosacral ligament DIE lesions (P = 0.004) were found compared to women aged ≤24 years. No significant differences were observed in terms of endometrioma size. Between the ages of 25 and 42 years, there were no significant changes in the distribution of endometriosis phenotypes after univariate and multivariate analysis. The distribution of subtype of DIE lesions did not significantly change with age between 25 and 42 years. Concerning pain symptom scores, there was a significant decrease with age for dysmenorrhea and dyspareunia.

LIMITATIONS, REASONS FOR CAUTION

Inclusion of only surgical patients may have introduced a selection bias. Women referred to our center may have suffered from particularly severe clinical forms of endometriosis.

WIDER IMPLICATIONS OF THE FINDINGS

This study highlights that endometriosis presentation did not change with age in adult women. Further research on endometriosis phenotype evolution is necessary to assist practitioners in clinical decisions and treatment strategies.

STUDY FUNDING/COMPETING INTERESTS

None declared.

TRIAL REGISTRATION NUMBER

N/A.

MR Diffusion Kurtosis Imaging (DKI) of the Normal Human Uterus in Vivo During the Menstrual Cycle

BACKGROUND

The uterus undergoes dynamic changes throughout the menstrual cycle. Diffusion kurtosis imaging (DKI) is based on the non-Gaussian distribution of water molecules and can perhaps represent the changes of uterine microstructure.

PURPOSE

To investigate the temporal changes in DKI-parameters of the normal uterine corpus and cervix during the menstrual cycle.

STUDY TYPE

Prospective.

POPULATION

21 healthy female volunteers (26.64 ± 4.72 years) with regular menstrual cycles (28 ± 7 days).

FIELD STRENGTH/SEQUENCE

Readout segmentation of long variable echo-trains (RESOLVE)-based DKI and fast spin-echo T2-weighted sequences at 3.0T.

ASSESSMENT

Each volunteer was scanned during the menstrual phase, ovulatory phase, and luteal phase. Regions of interest (ROI) were manually delineated in the endometrium, junctional zone, and myometrium of the uterine body, and in the mucosal layer, fibrous stroma layer, and loose stroma layer of the cervix. The mean Kapp (diffusion kurtosis coefficient), Dapp (diffusion coefficient), and ADC (apparent diffusion coefficient) values were measured in the ROI.

STATISTICAL TESTS

ANOVA with Bonferroni or Tamhane correction. Intraclass correlation coefficient (ICC) for assessing agreement. P < 0.05 was considered statistically significant.

RESULTS

During the menstrual cycle, the highest Kapp (0.848 ± 0.184) and lowest Dapp (1.263 ± 0.283 *10-3 mm2/sec) values were found in the endometrium during the menstrual phase. The Dapp values for the myometrium were significantly higher than those of the endometrium and the junctional zone in every phase. Meanwhile, the Dapp values for the three zonal structures of the cervix during ovulation were significantly higher than those during the luteal phase. However, there was no significant difference in the ADC values of the loose stroma between ovulation and the luteal phase (P = 0.568). The reproducibility of DKI parameters was good (ICC, 0.857-0.944).

DATA CONCLUSION

DKI can show dynamic changes of the normal uterus during the menstrual cycle.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 2.

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.

Evaluation of junctional zone differential and ratio as possible markers of clinical efficacy in uterine artery embolisation of adenomyosis

BACKGROUND

Uterine artery embolisation is a recommended method of adenomyosis treatment with good clinical results. Changes in uterine volume and maximal junctional zone thickness (JZmax) after embolisation are thoroughly analyzed in the literature. In contrast changes in other suggested morphological diagnostic markers of adenomyosis (junctional zone differential / JZdiff-and junctional zone ratio / JZratio) are rarely evaluated. This single-centre retrospective study aimed to analyse the changes in morphological parameters used for the MR imaging diagnosis of adenomyosis (including JZdiff and JZratio) after UAE. Clinical effectiveness and safety were also analysed.

MATERIALS AND METHODS

Patients who underwent UAE for pure adenomyosis from Jan 2008 to Dec 2021 were evaluated. Adenomyosis was diagnosed based on JZmax, JZdiff, and JZratio measured on MR imaging. To assess clinical efficacy, the numerical-analog-quality-of-life (QoL) score was routinely obtained from patients at our centre. MRI morphological data were analysed. Statistical analysis was conducted using Wilcoxon signed-rank test, uni- and multivariate regression models, Pearson product-moment correlation, and Kruskal-Wallis tests.

RESULTS

From our database of 801 patients who underwent UAE between Jan 2008 to Dec 2021, preprocedural MR images were available in 577 cases and, 15 patients had pure adenomyosis (15/577, 2.6%). Uterine volume, JZmax, and JZdiff decreased significantly after UAE; QoL score increased significantly. A significant correlation was found between QoL change vs. JZmax and JZdiff change. Permanent amenorrhoea and elective hysterectomy 5 years after UAE were both 7.1%.

CONCLUSION

Change of JZdiff after UAE in adenomyosis is a potential marker of clinical success. UAE is a clinically safe and effective treatment for adenomyosis.

[Classification of Uterine Adenomyosis: A Pictorial Essay]

MRI is a crucial tool for diagnosing adenomyosis and identifying its related pathologies. To accurately diagnose adenomyosis, it is necessary to recognize both the typical MRI findings and atypical features of the condition. Recently, a standardized classification system has been developed to facilitate precise presurgical diagnosis of adenomyosis and to determine the appropriate treatment method. Differentiating between various subtypes based on MRI-based classification and identifying different MRI phenotypes can aid in categorizing patients with adenomyosis into specific treatment groups and monitoring their response to therapy.

The "freeze-all" strategy seems to improve the chances of birth in adenomyosis-affected women

OBJECTIVE

To compare assisted reproductive technologies (ARTs) outcomes between fresh vs. freeze-all strategies in infertile women affected by adenomyosis.

DESIGN

A single-center observational study.

SETTINGS

University hospital-based research center.

PATIENTS

Adenomyosis-affected women undergoing blastocyst embryo transfer after in vitro fertilization and intracytoplasmic sperm injection between January 1, 2018, and November 31, 2021. The diagnosis of adenomyosis was based on imaging criteria (i.e., transvaginal ultrasound and/or magnetic resonance imaging).

INTERVENTION(S)

Women who underwent a freeze-all strategy were compared with those who underwent a fresh embryo transfer (ET) strategy.

MAIN OUTCOME MEASURE(S)

Cumulative live birth rate (LBR).

RESULTS

A total of 306 women were included in the analysis: 111 in the fresh ET group and 195 in the freeze-all group. The adenomyosis phenotype (internal diffuse adenomyosis, external focal adenomyosis, and adenomyoma) was not significantly different between the two groups. The cumulative LBR (86 [44.1%] vs. 34 [30.6%], respectively), and the cumulative ongoing pregnancy rate (88 [45.1%] vs. 36 [32.4%], respectively) were significantly higher in the freeze-all group compared with the fresh ET group. After multivariate logistic regression analysis, the freeze-all strategy in women with adenomyosis was associated with significantly higher odds of live birth compared with fresh ET (odds ratio = 1.80; 95% confidence interval = 1.02-3.16).

CONCLUSION

The freeze-all strategy in women afflicted with adenomyosis undergoing ART was associated with significantly higher cumulative LBRs. Our preliminary results suggest that the freeze-all strategy is an attractive option that increases ART success rates. Additional studies, with a randomized design, should be conducted to further test whether the freeze-all strategy enhances the pregnancy rate in adenomyosis-affected women.

Effect of aging on the human myometrium at single-cell resolution

Age-associated myometrial dysfunction can prompt complications during pregnancy and labor, which is one of the factors contributing to the 7.8-fold increase in maternal mortality in women over 40. Using single-cell/single-nucleus RNA sequencing and spatial transcriptomics, we have constructed a cellular atlas of the aging myometrium from 186,120 cells across twenty perimenopausal and postmenopausal women. We identify 23 myometrial cell subpopulations, including contractile and venous capillary cells as well as immune-modulated fibroblasts. Myometrial aging leads to fewer contractile capillary cells, a reduced level of ion channel expression in smooth muscle cells, and impaired gene expression in endothelial, smooth muscle, fibroblast, perivascular, and immune cells. We observe altered myometrial cell-to-cell communication as an aging hallmark, which associated with the loss of 25 signaling pathways, including those related to angiogenesis, tissue repair, contractility, immunity, and nervous system regulation. These insights may contribute to a better understanding of the complications faced by older individuals during pregnancy and labor.

Differences in the incidence of obstetric complications depending on the extent and location of adenomyosis lesions

OBJECTIVES

Although adenomyosis is reportedly associated with adverse pregnancy outcomes, clinical factors related to the high risk of obstetric complications are unclear. This study aimed to elucidate the characteristics of adenomyosis lesions associated with the increased incidence of obstetric complications based on imaging findings.

METHODS

This was a retrospective, observational cohort study conducted in a tertiary perinatal care center. Eighty-eight singleton pregnant women with adenomyosis were included in the study. Based on magnetic resonance imaging or ultrasonography before and/or during pregnancy, patients were classified according to three types of image characteristics: the extent of adenomyosis lesion (focal type or diffuse type), location of the lesion (extrinsic type, intrinsic type, or indeterminate type), the positional relationship between the lesion and the placenta (placenta distant from adenomyosis or placenta over adenomyosis), and the incidence of obstetric complications were examined.

RESULTS

Patients with diffuse type adenomyosis are significantly more likely to have spontaneous second-trimester miscarriage (diffuse type vs. focal type: 16.7 vs. 0%, p < .01), preterm premature rupture of membranes (19.4 vs. 1.9%, p < .01), and preeclampsia (25.0 vs. 7.7%, p = .02), as compared to those with focal type adenomyosis. In a comparison of the three location types, the incidence of placental malposition was higher in patients with the extrinsic type adenomyosis (extrinsic type vs. intrinsic type vs. indeterminate type: 20.0 vs. 6.7 vs. 2.3%, p = .03). Comparisons between the types of the placenta over or distant from adenomyosis lesion displayed no significant differences in the frequencies of obstetric complications.

CONCLUSIONS

We demonstrated that the frequency of obstetric complications related to adenomyosis varies depending on the extent and location of the lesion; patients with diffuse type adenomyosis have an increased risk of spontaneous second-trimester miscarriage, preterm premature rupture of membranes, and preeclampsia, while patients with extrinsic type adenomyosis have an increased risk of placental malposition. Imaging evaluation of adenomyosis prior to conception or early in pregnancy may be useful for the obstetrical risk assessment among patients with adenomyosis.

US, MRI, CT Performance and Interpretation of Uterine Masses

Uterine masses are commonly encountered as incidental findings during cross-sectional imaging or when individuals present with symptoms such as pain and bleeding. The World Health Organization categorizes tumors of the uterine corpus into 5 distinct groups: endometrial epithelial tumors and their precursors, tumor-like growths, mesenchymal uterine tumors, tumors with a combination of epithelial and mesenchymal elements, and various other types of tumors. The primary imaging method for assessing uterine abnormalities is transvaginal ultrasound. However, magnetic resonance imaging (MRI) can be employed to enhance the visualization of soft tissues, enabling a more detailed characterization of uterine masses. This article aims to outline the imaging features of both benign and malignant uterine masses using ultrasound, MRI, and computed tomography.

Association of normalization of postoperative carbohydrate antigen 125 levels with treatment failure following uterine artery embolization for adenomyosis

OBJECTIVE

To investigate the association between carbohydrate antigen 125 (CA125) level and adenomyosis treatment failure (TF) after uterine artery embolization (UAE).

METHODS

We evaluated 224 patients with symptomatic adenomyosis who underwent UAE between January 2016 and December 2020. Improvements in dysmenorrhea and menorrhagia were assessed on the basis of symptom relief criteria. The factors associated with TF were investigated using a multivariate logistic regression model. Patients were analyzed for preoperative CA125 levels, postoperative CA125 levels, and the normalization of postoperative CA125 levels. Long-term symptom relief and quality of life after UAE were compared between the groups.

RESULTS

During the 24-month follow-up, 50 patients (22.3%) experienced TF. Compared to patients in the non-TF group, those in the TF group had significantly higher preoperative and postoperative CA125 levels (p < 0.05). Multivariate analysis revealed that failure to normalize postoperative CA125 levels was independently associated with an increased risk of TF (34.7% vs. 8.5%, p < 0.001; hazard ratio 3.953, 95% confidence interval 1.567-9.973, p = 0.004). After a 3-month follow-up period, patients who normalized their CA125 levels were more likely to achieve complete necrosis on magnetic resonance imaging than those who did not (82.1% vs. 56.8%, p < 0.001). Normalization of postoperative CA125 levels was significantly associated with fewer symptoms and better quality of life 12 months after UAE (p < 0.05).

CONCLUSIONS

Following UAE, normalization of postoperative CA125 levels, rather than absolute values, was the strongest predictive marker of TF.

Pregnancy is associated with reduced progression of symptomatic adenomyosis: a retrospective pilot study

BACKGROUND

Adenomyosis is a common gynecological disease in women of reproductive age and causes various symptoms such as dysmenorrhea and heavy menstrual bleeding. However, the influence of pregnancy on the progression of adenomyosis remains unclear. The insight into whether the size of adenomyosis is increased, decreased, or unchanged during pregnancy is also undetermined. The current study aimed to evaluate the influence of pregnancy in patients with symptomatic adenomyosis.

METHODS

This study retrospectively enrolled patients diagnosed with adenomyosis by magnetic resonance imaging between 2015 and 2022 at The University of Tokyo Hospital. Uterine size changes were evaluated by two imaging examinations. In the pregnancy group, the patients did not receive any hormonal and surgical treatments, except cesarean section, but experienced pregnancy and delivery between the first and second imaging examinations. In the control group (nonpregnancy group), the patients experienced neither hormonal and surgical treatments nor pregnancy from at least 1 year before the first imaging to the second imaging. The enlargement rate of the uterine size per year (percentage) was calculated by the uterine volume changes (cm3) divided by the interval (years) between two imaging examinations. The enlargement rate of the uterine size per year was compared between the pregnancy group and the control group.

RESULTS

Thirteen and 11 patients with symptomatic adenomyosis were included in the pregnancy group and in the control group, respectively. The pregnancy group had a lower enlargement rate per year than the control group (mean ± SE: -7.4% ± 3.6% vs. 48.0% ± 18.5%, P < 0.001), indicating that the size of the uterus with adenomyosis did not change in the pregnancy group.

CONCLUSIONS

Pregnancy is associated with reduced progression of symptomatic adenomyosis.

Adenomyosis at a Glance: An Integrated Review of Transvaginal Ultrasound and MR Imaging Findings

Adenomyosis is a benign uterine disorder increasingly recognized in premenopausal women. Given its significant clinical burden, an accurate noninvasive diagnosis is paramount. Both transvaginal ultrasound (TVUS) and magnetic resonance (MR) provide an adequate assessment of adenomyosis, the former being recommended for first-line imaging evaluation and the latter being mainly used as a problem-solving technique. In this article, the authors review the TVUS and MR imaging findings of adenomyosis while referring to their histopathological background. Whereas direct signs correlate directly to ectopic endometrial tissue and are highly specific to adenomyosis, indirect signs result from myometrial hypertrophy and increase diagnostic sensitivity. Potential pitfalls, differential diagnoses, and frequently associated estrogen-dependent conditions are also discussed.

Placenta Accreta Spectrum: The Role of Interventional Radiology in Multidisciplinary Management

Placenta accreta spectrum is increasing in prevalence and poses significant risks to obstetric patients. This article defines characteristics, diagnosis, management, and outcomes of placenta accreta spectrum, highlighting interventional radiology's role in its management as part of a multidisciplinary approach.

Adenomyosis: An Updated Review on Diagnosis and Classification

Adenomyosis is a commonly diagnosed benign condition characterized by the presence of ectopic endometrial glands within the underlying myometrium. The most common presenting signs and symptoms are abnormal uterine bleeding, chronic pelvic pain, and infertility. The clinical relevance of this condition is evident in both medical and surgical care. Histopathology and imaging studies are used for the diagnosis and classification of adenomyosis, which are hallmarks of the advancement of our ability to diagnose adenomyosis. Importantly, the diagnosis and classification of adenomyosis lacks standardization due to the nature of imaging techniques, features of adenomyosis, and the clinical spectrum of adenomyosis. We reviewed the literature to summarize the available classification systems for adenomyosis and highlight the different imaging approaches and histologic criteria used in diagnosis. Despite the high prevalence of the disease, there is no clear consensus on one classification system. We provide a review of some of the classification systems available and discuss their strengths and limitations.

Prevalence of adenomyosis in women with subfertility: systematic review and meta-analysis

OBJECTIVE

To determine the prevalence of adenomyosis in women with subfertility.

METHODS

A systematic search was conducted in MEDLINE, EMBASE, CINAHL Plus, Google Scholar, PsycINFO and Web of Science Core Collection from database inception to October 2022. The included studies evaluated the prevalence of adenomyosis in women with subfertility, with or without endometriosis and/or uterine fibroids. Secondary analyses were conducted to identify variation in the prevalence of isolated adenomyosis according to geographical location, diagnostic modality, diagnostic criteria, type of ultrasound, ultrasound features of adenomyosis and the use of assisted reproductive technology.

RESULTS

Among 21 longitudinal studies evaluating 25 600 women, the overall pooled prevalence of isolated adenomyosis was 10% (95% CI, 6-15%) (I2  = 99.1%; tau2  = 0.12). The pooled prevalence was 1% (95% CI, 0-4%) for adenomyosis with concurrent fibroids (eight studies; I2  = 95.8%; tau2  = 0.03), 6% (95% CI, 3-11%) for adenomyosis with concurrent endometriosis (18 studies; I2  = 98.6%; tau2  = 0.12) and 7% (95% CI, 2-13%) for adenomyosis with concurrent endometriosis and/or fibroids (nine studies; I2  = 98.3%; tau2  = 0.09). The prevalence of isolated adenomyosis varied substantially according to geographical location, with Australia exhibiting the highest pooled prevalence of adenomyosis (19% (95% CI, 12-27%)), which was significantly higher compared with that in Asia (5% (95% CI, 1-12%)). The pooled prevalence of isolated adenomyosis diagnosed using a combination of direct and indirect ultrasound features was 11% (95% CI, 7-16%), whereas it was 0.45% (95% CI, 0-1%) in the study in which only an indirect feature was used as the diagnostic criterion.

CONCLUSION

One in 10 women with subfertility have a diagnosis of isolated adenomyosis. The prevalence of adenomyosis varies according to the presence of concurrent endometriosis and/or fibroids. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

A Study on the Prediction of Reproductive Outcomes in Frozen Embryo Transfer Cycles by Calculating the Volume of Uterine Junctional Zone with Three-Dimensional Ultrasound

PURPOSE

To prospectively study the influence of the volume of the uterine junctional zone (JZ) as a novel predictor of reproductive outcomes in frozen embryo transfer cycles.

METHODS

Among the first 30 patients, intra- and interobserver repeatability was evaluated and expressed as a coefficient of repeatability. The same classification system was used to evaluate the JZ of 142 infertility patients undergoing in vitro fertilization (IVF). Ultrasonography was performed on the day before transplantation. The three-dimensional (3D) volume images were then analyzed to obtain the volume of the endometrium (EV), the average thickness of the JZ on the coronal plane, and the volume of the JZ (JZV). The JZV was then divided by the EV. These parameters were compared with the outcomes of clinical pregnancy.

RESULTS

The 3D image showed that the JZ achieved a good intra- and interobserver consistency (k = 0.862, k = 0.694). The total pregnancy rate was 47%. There was a highly significant difference between pregnant and non-pregnant women with respect to age (p < 0.001), JZV (p = 0.003), and JZV/EV (p < 0.001) on the day before transplantation. Age and JZV/EV were independent factors for predicting the success of IVF transplantation (p = 0.010, p = 0.016). The area under the ROC curve of JZV/EV in predicting clinical pregnancy was 0.688, the cut-off value was 0.54, the sensitivity was 83.8%, and the specificity was 50.0%.

CONCLUSION

Age and JZV/EV are independent factors for predicting the success of frozen embryo transfer cycles in IVF. A smaller JZV/EV was more beneficial for clinical pregnancy.

Magnetic resonance imaging thicknesses and apparent diffusion coefficient values of the endometrium and junction zone in women of reproductive age

BACKGROUND

The endometrium and uterine junction zone often change throughout the menstrual cycle. Some pathological conditions may appear normal in uterine imaging, which will lead to missed diagnosis and misdiagnosis.

PURPOSE

To evaluate the changes in the thickness and apparent diffusion coefficient (ADC) values of the endometrium and uterine junction zone throughout the menstrual cycle in magnetic resonance imaging (MRI) of women of reproductive age.

MATERIAL AND METHODS

Data were collected from 40 healthy women of reproductive age with regular menstrual cycles from January 2017 to April 2018. They underwent four total MRI sessions during the menstrual, proliferation, and early and late secretive phases. The main MRI sequences were T2-weighted (T2W) volume isotropic turbo spin echo acquisition (VISTA) spectral attenuated inversion recovery (SPAIR) and diffusion-weighted imaging (b = 0, 600, 800, 1000 s/mm²), which were used to measure the thicknesses and ADC values of endometrium and uterine junction zone.

RESULTS

First, the endometrium was thinnest during the menstrual phase and thickest in the late secretive phase. Second, the uterine junction zone was thinnest in the late secretive phase and thickest in the menstrual phase. Third, the ADC values of the endometrium were lowest in the menstrual phase and peaked in the early secretive phase. Finally, the ADC values of the uterine junction zone were lowest in the menstrual phase and peaked in the late secretive phase.

CONCLUSION

The endometrium and uterine junction zone showed cyclic changes. Radiologists should consider these changes in the thickness and ADC values when analyzing MRI images of the uterus.

MRI of Adenomyosis: Where Are We Today?

Purpose of Review: The purpose of this review is to (i) summarize the current literature regarding the role of magnetic resonance imaging (MRI) in diagnosing adenomyosis, (ii) examine how to integrate MRI phenotypes with clinical symptomatology and histological findings, (iii) review recent advances including proposed MRI classifications, (iv) discuss challenges and pitfalls of diagnosing adenomyosis, and (v) outline the future role of MRI in promoting a better understanding of the pathogenesis, diagnosis, and treatment options for patients with uterine adenomyosis. Recent Findings: Recent advances and the widespread use of MRI have provided new insights into adenomyosis and the range of imaging phenotypes encountered in this disorder. Summary: Direct and indirect MRI features allow for accurate non-invasive diagnosis of adenomyosis. Adenomyosis is a complex and poorly understood disorder with variable MRI phenotypes that may be correlated with different pathogeneses, clinical presentations, and patient outcomes. MRI is useful for the assessment of the extent of findings, to evaluate for concomitant gynecological conditions, and potentially can help with the selection and implementation of therapeutic options. Nevertheless, important gaps in knowledge remain. This is in part due to the lack of standardized criteria for reporting resulting in heterogeneous and conflicting data in the literature. Thus, there is an urgent need for a unified MRI reporting system incorporating standardized terminology for diagnosing adenomyosis and defining the various phenotypes.

[Radiologic Evaluation of Uterine Lesions Using a Pattern Recognition Approach]

It is important to distinguish uterine lesions from other lesions occurring in the pelvic cavity for the proper management. The primary radiological evaluation of uterine lesions is performed using transvaginal ultrasonography, and if the lesion is too large or shows atypical benign imaging findings, magnetic resonance imaging should be performed. Analyzing radiological findings of uterine lesions through a pattern recognition approach can help establish the accurate diagnosis and treatment plan. In this pictorial assay, we describe imaging characteristics of various lesions arising from the uterus and evaluate them based on the pattern recognition approach.

Predictive value of preoperative MRI using the #ENZIAN classification score in patients with deep infiltrating endometriosis

PURPOSE

The aim of this study is to investigate the correlation between the magnetic resonance imaging (MRI) and intraoperative findings of deep infiltrating endometriosis using the #ENZIAN score.

METHODS

This retrospective study included 64 patients who underwent surgery for deep infiltrating endometriosis between January 2017 and August 2020. Preoperative abdominopelvic MRI assessment was evaluated and scored using the #ENZIAN classification. Operative scores were considered the gold standard, and the sensitivity, specificity, and positive and negative predictive values (PPV and NPV) of MRI for each category were calculated.

RESULTS

MRI has higher sensitivity and specificity in showing the lesions of the compartments O (ovarian lesions), A (rectovaginal septum and posterior vaginal fornix), and B (uterosacral ligaments and parametrium) (100-100%, 100-100%, and 97-100%, respectively, p < 0.001) compared to the other compartments. The lowest sensitivity, specificity, accuracy, and PPV of the MRI was found in compartment P (14%, 76%, 70%, and 7%, respectively).

CONCLUSION

We demonstrated that the #ENZIAN classification in MRI reports has significant sensitivity and specificity in compartments A, B (uterosacral ligaments and parametrium), and O. Furthermore, the determination of peritoneal lesions via MRI is inadequate.

Transcervical radiofrequency ablation of focal adenomyosis: pilot results

Objective: Adenomyosis is a common gynecological disease, which occurs in women in reproductive age and is characterized by the presence of endometrial glands and stroma within the myometrium. Abnormal uterine bleeding, pelvic pain as well as infertility can be associated with adenomyosis. There are two main types of adenomyosis: diffuse and focal. Previously, adenomyosis was diagnosed only upon histopathological examination after hysterectomy and/or adenomyomectomy. However, the development of imagining techniques such as transvaginal ultrasound and magnetic resonance imaging enables the diagnosis of adenomyosis (diffuse and focal) without any surgical intervention. When medical therapy is contraindicated or ineffective, or if patients have a fertility desire, a surgical treatment may be necessary.Methods: In this study, a total of 13 patients with 16 areas of focal adenomyosis were treated. All patients provided their informed consent to undergo transcervical adenomyosis ablation treatment with the Sonata System, aware that the safety and effectiveness of transcervical radiofrequency (RF) ablation for the treatment of adenomyosis has not been established. Follow-up was performed six months after Sonata treatment.Results: The positive results relating to the improvement of symptoms and reduction of adenomyosis lesion size were observed in our study.Conclusion: Transcervical RF ablation with the Sonata System may be a promising therapeutic alternative method to conventional procedures such as hysterectomy for the treatment of focal adenomyosis, disease which has limited therapeutic approach, and may enable a minimally invasive, uterine preserving option.

Diagnostic Role of Transvaginal Sonography and Magnetic Resonance Imaging in Adenomyosis of the Uterus and its Correlation with Histopathology

Background and Objective

The prevalence of adenomyosis of the uterus varies from 5% to 70%, and there is no clear consensus on its imaging diagnostic criteria. The objective of this study was to evaluate the role of transvaginal sonography (TVS), combined TVS and color Doppler (TVS-CD), and magnetic resonance imaging (MRI) in the diagnosis of adenomyosis.

Materials and Methods

This was a tertiary care hospital-based prospective study, in which 365 clinically suspected cases of adenomyosis were enrolled. All three types of imaging (TVS, TVS-CD, and MRI) were done in 233/365 patients, followed by hysterectomy in 50. Imaging features were correlated with the histopathological examination (HPE), which was taken as the gold standard for the diagnosis. The diagnostic performance of each imaging modality was assessed.

Results

Among patients who underwent hysterectomy, 36/50 (72%) had adenomyosis on HPE, with or without associated benign gynecological abnormalities. Sensitivity, specificity, positive predictive value (PPV), negative PV (NPV), and diagnostic accuracy (DA) of MRI were higher than that of TVS-CD (91.67% vs. 77.78%, 85.71% vs. 78.57%, 94.29% vs. 90.32%, 80% vs. 57.89%, and 90% vs. 78%, respectively). TVS alone had lower diagnostic performance (specificity: 64.29%, PPV 84.85%, NPV 52.94%, and DA74%) than TVS-CD, but equal sensitivity (77.78%). Heterogeneous myometrium was the most sensitive (80.56%), while myometrial cyst was the most specific (92.86%) TVS feature. The maximum junctional zone thickness ≥12 mm was the most sensitive (97.22%), while the hyperintense myometrial focus was the most specific (100%) MRI feature.

Conclusion

TVS-CD should be used as an initial diagnostic imaging modality in clinically suspected cases of adenomyosis; however, MRI due to better diagnostic efficacy should be the imaging modality of choice before subjecting such patients to hysterectomy.

Impact of Adenomyosis on Infertile Patients-Therapy Options and Reproductive Outcomes

Adenomyosis is associated with a negative impact on reproductive outcomes. Although adenomyosis is detected more frequently in women of late reproductive age, its impact on pregnancy rates is important because, in today's world, family planning has shifted towards the late reproductive phase of life for many women. Although the diagnostic indications for imaging studies are well-known, we lack strict diagnostic criteria and classification systems concerning the extent of the disease. Selecting the optimal evidence-based treatment option for adenomyosis is difficult because of the paucity of evidence concerning the association between fertility and the degree and composition of adenomyosis. Furthermore, the treatment of infertility might interfere with the treatment of adenomyosis due to the presence of pain. The aim of this review is to analyze the association between adenomyosis and infertility, and describe treatment options to enhance reproductive outcomes. The following aspects will be addressed in detail: (a) prevalence and causes of adenomyosis, (b) diagnostic tools with imaging techniques, (c) clinical symptoms, (d) proposed pathomechanism of adenomyosis and infertility, and (e) different treatment approaches (pharmacological, surgical, others) and their impact on reproductive outcomes.

Uterine junctional zone and adenomyosis: comparison of MRI, transvaginal ultrasound and histology

The uterine junctional zone is the subendometrial area in the myometrium that contributes to peristalsis and aids in spermatozoa and blastocyst transport. Alterations in the appearance of the junctional zone on transvaginal sonography (TVS) or magnetic resonance imaging (MRI) are associated with adenomyosis. The lack of standardization of description of its appearance and ill-defined boundaries on both histology and imaging hamper understanding of the junctional zone and limit its role in the diagnosis of adenomyosis. The objectives of this review were to investigate the accordance in definition of the junctional zone across different diagnostic approaches and to examine how imaging findings can be linked to histological findings in the context of diagnosis of adenomyosis. A comprehensive literature review was conducted of articles describing the appearance on imaging and the histological structure of the uterine junctional zone. Our review suggests that the junctional zone is distinguished from the middle and outer myometrium by gradual changes in smooth-muscle cell density, extracellular space, connective tissue, water content and vascular properties. However, while the signal intensity from the junctional zone to the middle myometrium changes abruptly on MRI, the histopathological changes are gradual and its border may be difficult or impossible to distinguish on two-dimensional TVS. Moreover, the thickness of the junctional zone measured on MRI is larger than that measured on TVS. Thus, these two imaging modalities reflect this zone differently. Although a thickened junctional zone is often used to diagnose adenomyosis on MRI, the presence of adenomyosis can be described more accurately as interruptions of the junctional zone by endometrial tissue, which leads to direct signs on imaging such as subendometrial lines and buds on two- and three-dimensional TVS or bright foci on MRI. The histopathological criteria for diagnosis are based on enlargement of the uterus with severe adenomyosis, and might not reflect its early stages. Clinicians should be aware that findings on MRI cannot be extrapolated readily to ultrasound. An understanding of this is necessary when investigating the uterine junctional zone as a functional unit and the association between visualization of direct features of adenomyosis in the junctional zone and clinical symptoms. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Cyclic changes in T2* relaxometry of human uterus during the menstrual cycle using BOLD MR imaging

PURPOSE

To evaluate dynamic changes of T2* values within the endometrium, junctional zone and myometrium during the menstrual cycle using blood oxygen level-dependent (BOLD) magnetic resonance imaging.

METHOD

Volunteers underwent MRI scans on menstrual phase, ovulatory phase and luteal phase, including T2-weighted imaging and BOLD MR imaging. Multi-gradient-recalled echo (MGRE) sequence was used to obtain BOLD MR images. T2* values of different uterine layers, including endometrium, junctional zone and myometrium, on sagittal images were analyzed quantitatively.

RESULTS

Twenty-four subjects calculated T2* values successfully. The T2* values of each zonal structure during menstruation were significantly lower than those during ovulatory phase (P < 0.05) and luteal phase (P < 0.001). The T2* value of junctional zone was significantly lower than that of the myometrium over all three menstrual phases (P = 0.000, menstrual; P = 0.000, ovulatory; P = 0.001, luteal). The mean T2* value in endometrium during the ovulatory phase was the highest of the uterine zones over menstrual cycle. During menstrual phase, there was no statistical difference between endometrium and junctional zone (P > 0.05). Conversely, the comparison of the T2* values between endometrium and myometrium, junctional zone and myometrium both showed significant difference (P = 0.000). The mean T2* values within endometrium during ovulatory phase and luteal phase were significantly higher than those within junctional zone and myometrium (P < 0.05).

CONCLUSIONS

Cyclic changes of T2* values in each zonal structure of the uterus were revealed during the menstrual cycle by means of BOLD technique, which may be potentially beneficial in investigating dysmenorrhea, guiding assisted reproductive technologies and monitoring hypoxia in gynecological tumors.

Cracking the enigma of adenomyosis: an update on its pathogenesis and pathophysiology

In brief

Traditionally viewed as enigmatic and elusive, adenomyosis is a fairly common gynecological disease but is under-recognized and under-researched. This review summarizes the latest development on the pathogenesis and pathophysiology of adenomyosis, which have important implications for imaging diagnosis of the disease and for the development of non-hormonal therapeutics.

Abstract

Traditionally considered as an enigmatic disease, adenomyosis is a uterine disease that affects many women of reproductive age and is a contributing factor for pelvic pain, heavy menstrual bleeding (HMB), and subfertility. In this review, the new development in the pathogenesis and pathophysiology of adenomyosis has been summarized, along with their clinical implications. After reviewing the progress in our understanding of the pathogenesis and describing the prevailing theories, in conjunction with their deficiencies, a new hypothesis, called endometrial-myometrial interface disruption (EMID), which is backed by extensive epidemiologic data and demonstrated by a mouse model, is reviewed, along with recent data implicating the role of Schwann cells in the EMI area in the genesis of adenomyosis. Additionally, the natural history of adenomyotic lesions is elaborated and underscores that, in essence, adenomyotic lesions are fundamentally wounds undergoing repeated tissue injury and repair (ReTIAR), which progress to fibrosis through epithelial-mesenchymal transition, fibroblast-to-myofibroblast transdifferentiation, and smooth muscle metaplasia. Increasing lesional fibrosis propagates into the neighboring EMI and endometrium. The increased endometrial fibrosis, with ensuing greater tissue stiffness, results in attenuated prostaglandin E2, hypoxia signaling and glycolysis, impairing endometrial repair and causing HMB. Compared with adenomyosis-associated HMB, the mechanisms underlying adenomyosis-associated pain are less understood but presumably involve increased uterine contractility, hyperinnervation, increased lesional production of pain mediators, and central sensitization. Viewed through the prism of ReTIAR, a new imaging technique can be used to diagnose adenomyosis more accurately and informatively and possibly help to choose the best treatment modality.

Consensus on revised definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis: results of modified Delphi procedure

OBJECTIVES

To evaluate whether the Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis need to be better defined and, if deemed necessary, to reach consensus on the updated definitions.

METHODS

A modified Delphi procedure was performed among European gynecologists with expertise in ultrasound diagnosis of adenomyosis. To identify MUSA features that might need revision, 15 two-dimensional (2D) video recordings (four recordings also included three-dimensional (3D) still images) of transvaginal ultrasound (TVS) examinations of the uterus were presented in the first Delphi round (online questionnaire). Experts were asked to confirm or refute the presence of each of the nine MUSA features of adenomyosis (described in the original MUSA consensus statement) in each of the 15 videoclips and to provide comments. In the second Delphi round (online questionnaire), the results of the first round and suggestions for revision of MUSA features were shared with the experts before they were asked to assess a new set of 2D and 3D still images of TVS examinations and to provide feedback on the proposed revisions. A third Delphi round (virtual group meeting) was conducted to discuss and reach final consensus on revised definitions of MUSA features. Consensus was predefined as at least 66.7% agreement between experts.

RESULTS

Of 18 invited experts, 16 agreed to participate in the Delphi procedure. Eleven experts completed and four experts partly finished the first round. The experts identified a need for more detailed definitions of some MUSA features. They recommended use of 3D ultrasound to optimize visualization of the junctional zone. Fifteen experts participated in the second round and reached consensus on the presence or absence of ultrasound features of adenomyosis in most of the still images. Consensus was reached for all revised definitions except those for subendometrial lines and buds and interrupted junctional zone. Thirteen experts joined the online meeting, in which they discussed and agreed on final revisions of the MUSA definitions. There was consensus on the need to distinguish between direct features of adenomyosis, i.e. features indicating presence of ectopic endometrial tissue in the myometrium, and indirect features, i.e. features reflecting changes in the myometrium secondary to presence of endometrial tissue in the myometrium. Myometrial cysts, hyperechogenic islands and echogenic subendometrial lines and buds were classified unanimously as direct features of adenomyosis. Globular uterus, asymmetrical myometrial thickening, fan-shaped shadowing, translesional vascularity, irregular junctional zone and interrupted junctional zone were classified as indirect features of adenomyosis.

CONCLUSION

Consensus between gynecologists with expertise in ultrasound diagnosis of adenomyosis was achieved regarding revised definitions of the MUSA features of adenomyosis and on the classification of MUSA features as direct or indirect signs of adenomyosis. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Is there a relationship between adenomyosis and nabothian cyst?

Purpose

The aim of this study was to investigate whether there is a relationship between adenomyosis and nabothian cyst (NC) in a large patient series.

Material and methods

The patient's data were scanned retrospectively and patients with a junctional zone thickness of 12 mm and above on magnetic resonance imaging were accepted as group adenomyosis (group A). Patients with a junctional zone thickness of less than 12 mm were not admitted as adenomyosis (control group). Both groups were compared for NC.

Results

In group A, 176 (69.8%) patients had NC (n = 250), while in the control group (n = 202), 57 (28.2%) patients had NC. NC was significantly higher in group A than in the control group (p < 0.001).

Conclusions

The aetiology of NC is still unclear. According to our results, similar factors may affect adenomyosis and NC aetiopathogenesis.

Characterization of Uterine Peristaltic Waves by Ultrasound Strain Analysis

Uterine peristalsis (UP) is a wavelike uterine motion that plays an important role in the generation of intrauterine streams for menstrual emptying and to support embryo implantation. Our understanding of uterine mechanical behavior is hampered by a lack of quantitative analysis. Here, we propose a spatiotemporal analysis of UP by ultrasound speckle tracking and dedicated strain analysis. We aim at characterizing UP propagating around the endometrial cavity through the anterior and posterior walls of the uterus. To this end, velocity and coordination features are proposed in this study. We investigated a total of 11 healthy volunteers during their natural menstrual cycle and 81 patients undergoing in vitro fertilization (IVF) treatment. They all received multiple 4-min 2-D transvaginal ultrasound scans. Significant differences in propagation velocity were found among different phases of the menstrual cycle, which are in line with the expected uterine behavior. A significant difference in coordination was found between the group of women with successful (pregnancy at 11 weeks) and unsuccessful IVF. This result suggests that the ability to generate coordinated UP represents an important factor for IVF success. The proposed UP quantification may represent a valuable clinical tool for improved understanding of UP and improved decision-making in the context of IVF procedures.

Prevalence of adenomyosis in women undergoing hysterectomy for abnormal uterine bleeding, pelvic pain or uterine prolapse – A retrospective cohort study

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.

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In patients with bleeding disorders and dysmenorrhea we found the highest rate of adenomyosis (59.3%).

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81,1% of patients with adenomyosis reported symptoms.

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In 58.9% of patients with adenomyosis we found additional fibroids.

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In 42 postmenopausal patients we found adenomyosis in 23.8% of cases.

MRI and Adenomyosis: What Can Radiologists Evaluate?

Uterine adenomyosis is a common benign condition defined by the presence of heterotopic endometrial glands and stroma within the myometrium. Adenomyosis is often related to infertility and other adverse pregnancy outcomes. Modern imaging techniques allow the non-invasive diagnosis of adenomyosis and, in this framework, Magnetic Resonance Imaging (MRI) has assumed a central role due to its high diagnostic accuracy in the detection of adenomyosis. Currently, there is still a lack of international consensus on adenomyosis diagnostic criteria and classification, despite the fact that an agreed reporting system would promote treatment outcomes and research. This review aims to emphasize the important contribution of MRI to the diagnosis of adenomyosis and to highlight how, thanks to the great tissue differentiation provided by MRI, it is possible to identify the main direct (cystic component) and indirect (junctional zone features) signs of adenomyosis and to distinguish its various subtypes according to different MRI-based classifications. We also explored the main MRI criteria to identify the most common pitfalls and differential diagnoses of adenomyosis, whose features should be considered to avoid misdiagnosis.

Uterine Artery Embolization for Symptomatic Adenomyosis: Proceedings from a Society of Interventional Radiology Foundation Research Consensus Panel

Adenomyosis poses an important diagnostic and therapeutic challenge in women's health because of a variety of clinical/imaging presentations and frequent coexistence with other benign gynecologic conditions. In recent years, uterine artery embolization (UAE) for the treatment of adenomyosis has shown encouraging and favorable outcomes and long-term symptom improvement. To expand the current understanding of adenomyosis pathophysiology, imaging diagnostic criteria, and treatment outcomes, the Society of Interventional Radiology Foundation gathered a multidisciplinary Research Consensus Panel with experts from diverse backgrounds. The topics addressed were centered around the following: (i) the clinical presentation and imaging findings to diagnose adenomyosis; (ii) the currently available medical, interventional, and surgical treatment options; and (iii) existing literature for and experiences with UAE in symptomatic disease. The panel acknowledged that before the pursuit of a clinical trial, it would be necessary to first evaluate the imaging criteria for adenomyosis and correlate them with pathology and symptoms to establish a noninvasive imaging classification system. Second priority was given to the development of a quality of life questionnaire to assess patient outcomes following treatment. The third priority was the performance of a prospective clinical trial comparing UAE with medical therapy, which would help establish UAE in the treatment algorithm and societal guidelines for symptomatic adenomyosis.

Women with combined adenomyosis and endometriosis on MRI have worse IVF/ICSI outcomes compared to adenomyosis and endometriosis alone: A matched retrospective cohort study

STUDY OBJECTIVES

To assess the effect of adenomyosis, endometriosis and combined adenomyosis and endometriosis, diagnosed on MRI, on IVF/ICSI outcomes versus male subfertility controls.

STUDY DESIGN

This single-centre matched retrospective cohort study was carried out at Catharina Hospital in Eindhoven, The Netherlands. The study group consisted of infertile women undergoing their first, fresh embryo transfer during IVF/ICSI, with adenomyosis only (N = 36), endometriosis only (N = 61), and combined adenomyosis and endometriosis (N = 93) based on MRI. The control group consisted of IVF/ICSI patients undergoing treatment due to male subfertility (N = 889). 1:2 case-control matching based on age during IVF/ICSI, parity and number of embryos transferred was performed. Odds ratios were calculated for biochemical pregnancy, ongoing pregnancy and live birth rate versus matched male subfertility controls, and were corrected for embryo quality.

RESULTS

Only the combined adenomyosis and endometriosis group showed a significantly reduced OR for biochemical pregnancy (p = 0.004, OR 0.453 (95% CI :(0.284-0.791)), ongoing pregnancy (p = 0.001, OR 0.302 (95% CI: (0.167-0.608)) and live birth (p = 0.001, OR 0.309 (95% CI: (0.168-0.644)) compared to matched male subfertility controls.

CONCLUSIONS

The lower (ongoing) pregnancy and live birth rates in the combined adenomyosis and endometriosis women can be attributed to more severe disease in these women, ultimately resulting in increased chances for failed implantation and miscarriage. This highlights the importance of screening for adenomyosis in endometriosis patients, and identifies these women target for additional (hormonal) treatment prior to IVF/ICSI.

Adenomyosis and infertility

PURPOSE

Adenomyosis is a poorly understood entity with no unified treatment protocol. It has been thought to only affect the quality of life of older women, but growing evidence is highlighting the increased frequency of adenomyosis in younger patients and its possible effects on fertility outcomes. This can have a great impact on how clinicians screen, diagnose, and treat this condition. The aim of this review is to explore the relationship between adenomyosis and infertility.

METHODS

A literature search of the keywords "adenomyosis", "infertility", "pregnancy" and "fertility" was conducted using the PubMed and Medline search engines. The articles selected were observational, systematic reviews, meta-analyses, and randomized controlled trials. The search was limited to English, abstracts were screened, and articles were selected.

RESULTS

The literature reports lower clinical pregnancy rates, lower live birth rates, higher miscarriage rates, and higher odds of adverse obstetric outcomes in patients with adenomyosis. Treatment seems to be associated with higher pregnancy rates and live births rates.

CONCLUSION

An association between adenomyosis and infertility seems to exist, and treatment could lead to improved fertility outcomes.

Integrative metabolomic profiling reveals aberrations in myometrium associated with adenomyosis: a pilot study

BACKGROUND

Uterine adenomyosis is a common gynecologic disease in premenopausal women, the pathological mechanism of which remains largely unknown. The aim of this study was to identify metabolic biomarkers significantly altered in the myometrium of adenomyosis patients.

METHODS

The comprehensive metabolomic profiles of 17 myometrium specimens from adenomyosis patients and 25 control specimens were analyzed using untargeted approach by combination of gas chromatography-mass spectrometry and high performance liquid chromatography-mass spectrometry. Metabolic data were filtered using orthogonal partial least square-discriminant analysis and univariate statistics.

RESULTS

We firstly demonstrated that the myometrial metabolome of women with adenomyosis is distinct from that of women without adenomyosis. A total of 106 metabolites, mainly including nucleosides, lipids (including acylcarnitines), amino acids, organic acids and carbohydrates, were found to be differentially expressed in myometrium of uteri with adenomyosis compared to the control subjects. Functional inferences of these perturbed metabolites indicated that inflammation, oxidative stress, cell proliferation and apoptosis, and energy metabolism appeared to be involved in the progress of adenomyosis.

CONCLUSION

This study firstly described the integrated metabolic signatures of the adenomyosis uterus, which provided novel insights for the pathogenesis study of this disease.

The role of three-dimensional MRI in the differentiation between angular pregnancy and interstitial pregnancy

Background

In clinical practice it is an ongoing challenge to distinguish between angular pregnancy and interstitial pregnancy. With the three-dimensional (3D) magnetic resonance imaging (MRI) being increasingly used, it is worth exploring its role in differentiating angular pregnancy from interstitial pregnancy. This study aims to investigate how 3D MRI can help reveal the differences between these two special pregnancies in the early diagnosis.

Methods

We reviewed and analyzed the 3D MRI images of 50 patients with interstitial pregnancy and 55 patients with angular pregnancy retrospectively. Imaging features were identified to compare these two special pregnancies, and the ROC (Receiver Operating Characteristic) analysis was conducted to assess the diagnostic performance.

Results

The significant differences of the 3D MRI imaging features between interstitial pregnancy and angular pregnancy were found in the outline of uterus cavity (p < 0.001), involvement of junctional zone (p < 0.001), the signal of surroundings (p = 0.005), the relationship with round ligament (p = 0.042), and the overlying myometrial thickness (p = 0.041). Furthermore, the multivariate logistic regression analysis identified a series of significant indicators for angular pregnancy, including the junctional zone involvement, being-surrounded by hyper/iso-intensity on 3D images, and the asymmetric outline of uterus cavity. Combining these three imaging features, the AUC (Area under the Curve) of ROC curve was 0.87 in distinguishing interstitial pregnancy from angular pregnancy.

Conclusions

This study suggests that 3D MRI can help distinguish angular pregnancy from interstitial pregnancy in clinical practice, with the advantages that conventional MRI or ultrasound does not have. Through the significant image features, 3D MRI plays an important role in improving the timing of diagnosis, avoiding unnecessary interventions, and preventing hemorrhage in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04470-z.

Endometriosis increases the rate of spontaneous early miscarriage in women who have adenomyosis lesions

RESEARCH QUESTION

In women with radiologically diagnosed adenomyosis, is the presence of endometriosis associated with a higher rate of miscarriage?

DESIGN

An observational cohort study of women who received medical care for benign gynaecological conditions between May 2005 and May 2018. Women who had adenomyosis lesions visualized by uterine magnetic resonance imaging (MRI) were included. Women who had never been pregnant were excluded. Women with adenomyosis identified by MRI but who did not have endometriosis lesions (control group) were compared with women with adenomyosis and endometriosis lesions (study group). Primary outcome was rate of a previous history of early miscarriage.

RESULTS

A total of 214 pregnancies in the study group and 53 pregnancies in the control group were analysed. The rate of a previous miscarriage was significantly higher among women with adenomyosis and endometriosis lesions compared with women in the control group (61/214 [28.5%] versus 6/53 [11.3%], respectively, P = 0.009). A multivariable generalized estimating equation logistic regression model, adjusted for adenomyosis and endometriosis phenotypes, found that the association between endometriosis and adenomyosis significantly increased the risk of miscarriage (OR 3.2, 95% CI 1.1 to 9.65). The risk was significantly higher with deep infiltrating endometriosis (OR 4.37, 95% CI 1.32 to 14.53).

CONCLUSIONS

Women affected by endometriosis had a significantly higher rate of previous spontaneous miscarriage than women without endometriosis with adenomyosis lesions identified by MRI. Mechanistic studies are needed to establish the complex link between the presence of endometriosis and adenomyosis and the rate of spontaneous miscarriage.

Characterization of patients that can continue conservative treatment for adenomyosis

Background

Historically, hysterectomy has been the radical treatment for adenomyosis. Although, some patients may not want to have their uterus removed, patients often have to no choice but to request hysterectomy during conservative treatment. The factors necessitating these hysterectomies remain unknown. The purpose of this study was to determine which patients can continue conservative treatment for adenomyosis.

Methods

We selected women diagnosed with adenomyosis and provided with conservative treatment at the Kindai University Hospital and Osaka Red Cross Hospital in Osaka Japan from 2008 to 2017. Age at diagnosis, parity, uterine size, subtype of adenomyosis, type of conservative treatment, and timing of hysterectomy for cases with difficulty continuing conservative treatment were examined retrospectively.

Results

A total of 885 patients were diagnosed with adenomyosis, and 124 started conservative treatment. Conservative treatment was continued in 96 patients (77.4%) and hysterectomy was required in 28 patients (22.6%). The cumulative hysterectomy rate was 32.4%, and all women had hysterectomy within 63 months. In the classification tree, 82% (23/28) of women aged 46 years or younger were able to continue conservative treatment when parity was zero or one. In those with parity two and over, 95% (20/21) of those aged 39 years and older had hysterectomy.

Conclusions

Patients who continue conservative treatment for approximately 5 years are more likely to have successful preservation of the uterus. Multiparity and higher age at diagnosis are factors that contribute to hysterectomy after conservative treatment. Parity and age at diagnosis may be stratifying factors in future clinical trials of hormone therapy.

Classifying Adenomyosis: Progress and Challenges

Classically, the diagnosis of adenomyosis relied on histological examination of uteri following hysterectomy and classifications focused on the depth of endometrial invasion within the myometrium. There remain uncertainties around the cut-off point for the histological diagnosis. Imaging-based diagnosis enables recognition of the condition in women not undergoing surgery and facilitates the assessment of the extent of adenomyosis within the whole uterus, as well as of affections of the uterovesical pouch and of the pouch of Douglas. In this article, we explore the diagnostic uncertainties, the need to produce a classification of the condition and the challenges towards that goal. A distinction should be drawn between disease mapping and a classification that may link histological or image-based features with clinical characteristics, or with pathophysiology. An agreed system for reporting adenomyotic lesions may enable comparisons of research studies and thus contribute towards an informed classification. To this aim, we outline the features of the condition and explore the characteristics that are considered when producing a taxonomy. These include the latest proposal for subdivision of adenomyosis into an internal and an external variant. We also explore the uncertainties linked to classifying involvement of the uterovesical pouch, the pouch of Douglas and lesions in the outer myometrium. The limitations of currently available evidence suggest that agreement on a hypothesis to underpin a classification is unlikely at present. Therefore, current efforts will probably remain focused on disease mapping.

Magnetic Resonance Imaging of Uterine Cervix: A Pictorial Essay

Uterine cervix is the lower constricted part of uterus which is best evaluated by magnetic resonance imaging (MRI) due to its higher soft tissue and contrast resolution. The cervical cancer is a common gynecological cancer causing much morbidity and mortality especially in developing countries. Cervical carcinomas mainly occurs in reproductive age group with prognosis mainly depending on the extent of disease at the time of diagnosis, hence it is important to identify these cancerous lesions early and stage them accurately for optimal treatment. In this article, we will review the following: (1) the normal MRI anatomy of uterine cervix; (2) MRI protocol and techniques in evaluation of cervical lesions; (3) imaging of spectrum of various congenital abnormalities and pathologies affecting uterine cervix which ranges from congenital abnormalities to various benign lesions of cervix like nabothian cysts, tunnel cysts, cervicitis, cervical fibroid, and, lastly, endometriosis which usually coexists with adenomyosis; the malignant lesions include carcinoma cervix, adenoma malignum or direct extension from carcinoma endometrium or from carcinoma of vagina; (4) Accurately stage carcinoma of cervix using FIGO classification (2018); and (5) posttreatment evaluation of cervical cancers. MRI is the most reliable imaging modality in evaluation of various cervical lesions, identification of cervical tumors, staging of the cervical malignancy, and stratifying patients for surgery and radiation therapy. It also plays an important role in detection of local disease recurrence.

The Role of Abnormal Uterine Junction Zone in the Occurrence and Development of Adenomyosis

Adenomyosis is a benign disease with a malignant behavior, bothering a lot of women at reproductive age who suffer from increased menstruation, prolonged menstruation, progressive dysmenorrhea, and infertility. At present, there is no effective treatment for adenomyosis. It seriously affects the life quality of these patients. However, the pathogenesis of adenomyosis is not yet clear. Recently, uterus junctional zone, defined as the inner 1/3 of myometrium between endometrium and myometrium, has gained broad attention. As is reported, the structure and function disorder of uterus junctional zone may play an important part in the occurrence and development of adenomyosis. In this issue, the present study generally reviews the role of uterine junction zone and the related mechanisms involved in adenomyosis, such as the local micro-damage, the formation of inflammatory and hypoxic microenvironment, changes of cytokines, and abnormalities of miRNA as well as signal pathways. It will provide new insights and potential therapeutic target strategies for clinical strategies in the management of adenomyosis.

Multiparametric magnetic resonance imaging facilitates the selection of patients prior to fertility-sparing management of endometrial cancer

PURPOSE

To compare the diagnostic performance of biparametric magnetic resonance imaging (bpMRI) versus multiparametric MRI (mpMRI) for the staging of well-differentiated endometrioid endometrial cancer (EC) in potential candidates for fertility-sparing management.

METHODS

This multi-center retrospective study included 48 potential candidates for fertility-sparing management (age <46 years, grade 1 endometroid EC) who did not wish to undergo fertility-sparing management and thus underwent definitive surgery. Two readers (R1, R2) independently reviewed bpMRI (T1, T2, and diffusion-weighted imaging) and mpMRI (bpMRI and dynamic contrast-enhanced imaging, DCE) during two separate sessions spaced one month apart for the presence of myometrial invasion (MI), cervical stromal involvement (CSI), malignant adnexal disease (mAD), and pelvic lymphadenopathy (pLNM). Each reader also recorded maximum tumor diameter, tumor volume, and tumor-to-uterine volume ratio (TVR) on T2-weighted imaging. The diagnostic performance of bpMRI and mpMRI was determined for each reader with surgical pathology serving as a gold standard.

RESULTS

The area under the receiver operating curve (AUC) for bpMRI versus mpMRI was 0.76/0.78 (R1/R2) versus 0.84/0.83 for MI, 0.79/0.76 versus 0.99/0.80 for CSI, 0.84/0.84 versus 0.84/0.80 for mAD, and 0.82/0.82 for pLMN. The sensitivity and specificity of MRI for detecting tumor spread beyond the endometrium were 71%/77% and 71%/65% for bpMRI (R1/R2) vs. 84%/90% and 71%/65% for mpMRI (R1/R2), respectively. The AUC of maximum tumor diameter, tumor volume, and TVR for MI was 0.71/0.61, 0.73/0.75, and 0.75/0.77 for R1/R2, respectively.

CONCLUSION

MRI had moderate diagnostic performance across potential candidates for fertility-sparing treatment of EC. mpMRI outperformed bpMRI for detecting EC spreading beyond the endometrium.

Effects of localisation of uterine adenomyosis on outcome of in vitro fertilisation/intracytoplasmic sperm injection fresh and frozen-thawed embryo transfer cycles: a multicentre retrospective cohort study

BACKGROUND

Uterine adenomyosis is a benign disease, common among women in their 40 and 50 s, characterised by ectopic endometrial tissue in the uterine myometrial layer. Adenomyosis causes infertility and has a negative effect on the outcomes of in vitro fertilisation (IVF)/intracytoplasmic sperm injection (ICSI) embryo transfer (ET) cycles. It has also been reported to have different characteristics depending on the adenomyotic lesion localisation. The effect of its localisation on IVF/ICSI-ET outcomes is unclear. This study aimed to investigate whether adenomyotic lesion localisation, assessed using magnetic resonance imaging (MRI), was associated with outcomes of IVF/ICSI-ET cycles.

METHODS

This multicentre, joint, retrospective cohort study analysed the medical records of 67 infertile patients with adenomyosis who underwent IVF/ICSI with fresh and frozen-thawed ET at five participating facilities from January 2012 to December 2016 and for whom MRI data were available. Fifteen patients were excluded; therefore, the MRI data of 52 patients were evaluated by two radiologists. We assessed the localisation of and classified adenomyotic lesions into advanced (invades the full thickness of the uterine myometrium), extrinsic (localised on the serosal side), and intrinsic (localised on the endometrial side) subtypes.

RESULTS

There were 40 advanced, nine extrinsic, and three intrinsic cases, and the outcomes of 100, 27, and nine ET cycles, respectively, were analysed. Pregnancy loss/clinical pregnancy and live birth rates of the advanced, extrinsic, and intrinsic groups were 64 % (16/25) and 9 % (9/100), 33.3 % (3/9) and 22.2 % (6/27), and 50 % (1/2) and 11.1 % (1/9), respectively. A logistic regression analysis adjusted for age, prior miscarriage, and body mass index showed that the extrinsic group had fewer pregnancy losses (odds ratio 0.06; 95 % confidence interval [CI]: 0.00-0.54, p = 0.026) and more live births (odds ratio 6.05; 95 % CI: 1.41-29.65, p = 0.018) than the advanced group.

CONCLUSIONS

Adenomyotic lesions exert different effects on IVF/ICSI-ET outcomes. Thus, MRI assessments of adenomyosis in infertile patients are beneficial. Establishment of treatment plans based on adenomyotic lesion localisation should be considered.

Upregulated microRNA let-7a accelerates apoptosis and inhibits proliferation in uterine junctional zone smooth muscle cells in adenomyosis under conditions of a normal activated hippo-YAP1 axis

BACKGROUND

Let-7a is a small non-coding RNA that has been found to take part in cell proliferation and apoptosis. The hippo-YAP1 axis, known as a tumour suppressor pathway, also plays an important role in cell proliferation and apoptosis. YAP1, TAZ, and phospho-YAP1 play key roles in actions of the hippo-YAP1 axis. Adenomyosis (ADS) is a proliferative disease leading to a large uterus in patients with prolonged illness. Abnormal proliferation of smooth muscle cells (SMCs) in the uterine endometrial-myometrial junctional zone (JZ) is an important reason for developing ADS. This study aimed to explore the expression levels of let-7a and components of the hippo-YAP1 axis in SMCs in the uterine endometrial-myometrial JZ in ADS and to explore the roles of let-7a and the hippo-YAP1 axis of JZ SMC proliferation and apoptosis in ADS.

METHODS

We collected JZ tissues for the primary culture of SMCs from 25 women diagnosed with ADS and 27 women without ADS. We used quantitative real-time polymerase chain reaction and western blotting to measure the mRNA and protein expression levels of let-7a, YAP1, TAZ, and phospho-YAP1 in ADS JZ SMCs. A CCK-8 assay and flow cytometry analysis of apoptosis were utilized to test the proliferation and apoptosis of JZ SMCs. The let-7a overexpression lentiviral vector GV280 was used to increase the expression level of let-7a. We added verteporfin to block the phosphorylation of components of the hippo-YAP1 axis.

RESULTS

We found that the let-7a level was decreased, while the YAP1 and TAZ levels were increased in ADS JZ SMCs. Upregulated let-7a affected the expression levels of components of the hippo-YAP1 axis, accelerated apoptosis, and inhibited proliferation in JZ SMCs. Furthermore, accumulated YAP1 led to increasing proliferation of JZ SMCs after verteporfin treatment to block the phosphorylation of components of the hippo-YAP1 axis. If components of the hippo-YAP1 axis were unphosphorylated, upregulated let-7a could not inhibit the proliferation of ADS JZ SMCs. Upregulated let-7a could not activate the hippo-YAP1 axis in verteporfin treatment.

CONCLUSIONS

Our findings suggest that the let-7a and hippo-YAP1 axis may act as important regulators of JZ SMCs proliferation, and upregulated let-7a may be an effective method to treat ADS.

Magnetic Resonance Imaging in endometriosis-associated pain

INTRODUCTION

Endometriosis affects 10%-15% of women in reproductive age and may cause no-cyclic chronic pelvic pain, dysmenorrhea, dyspareunia, urinary tract symptoms, and it is frequently associated with infertility. The peak of incidence is between 24 and 29 years old and the clinical diagnosis of endometriosis is generally delayed by 6-7 years. Laparoscopy with surgical biopsies is the "gold standard" for the diagnosis of endometriosis, with histological verification of endometrial ectopic glands and/or stroma. However, nowadays two different non-invasive modalities are routinely used for a presumptive diagnosis: Transvaginal Ultrasound (TVUS) and Magnetic Resonance Imaging (MRI).

EVIDENCE ACQUISITION

A structured search using PubMed was performed starting from October 2020 and including all relevant original and review articles published since 2000. The search used the following key word combinations: "Endometriosis MRI" AND "DIE and MRI" (45); "MRI endometriosis and Pelvic Pain" OR "Endometriosis and MRI technical development" (296). Ultimately, 87 articles were deemed relevant and used as the literature basis of this review.

EVIDENCE SYNTHESIS

TVUS represents the first imaging approach for endometriosis showing a good diagnostic performance but it is highly operator dependent. MRI is a second level examination often used in complex cases indeterminate after TVUS and in pre-operative planning. MRI is considered the best imaging technique for mapping endometriosis since it provides a more reliable map of deep infiltrating endometriosis than physical examination and transvaginal ultrasound. We have analyzed and described the main forms of endometriosis: adnexal endometriosis, adenomyosis, peritoneal implants and deep infiltrating endometriosis, showing their appearance in the two imaging modalities.

CONCLUSIONS

Endometriosis is one of the most common gynecologic disorders correlated to chronic pelvic pain whose treatment is still today complex and controversial. In this context, MRI has become an important additional non-invasive tool to investigate cases of chronic pelvic pain related to deep infiltrating endometriosis (DIE) with or without neural involvement.

Adenomyosis is associated with specific proton nuclear magnetic resonance (1H-NMR) serum metabolic profiles

OBJECTIVE

To determine whether the adenomyosis phenotype affects the proton nuclear magnetic resonance (¹H-NMR)-based serum metabolic profile of patients.

DESIGN

Cohort study.

SETTING

University hospital-based research center.

PATIENTS

Seventy-seven patients who underwent laparoscopy for a benign gynecologic condition.

INTERVENTIONS

Pelvic magnetic resonance imaging and collection of a venous peripheral blood sample were performed during the preoperative workup. The women were allocated to the adenomyosis group (n = 32), or the control group (n = 45). The adenomyosis group was further subdivided into two groups: diffuse adenomyosis of the inner myometrium (n = 14) and focal adenomyosis of the outer myometrium (n = 18). Other adenomyosis phenotypes were excluded.

MAIN OUTCOME MEASURES

Metabolomic profiling based on ¹H-NMR spectroscopy in combination with statistical approaches.

RESULTS

The serum metabolic profiles of the patients with adenomyosis indicated lower concentrations of 3-hydroxybutyrate, glutamate, and serine compared with controls. Conversely, the concentrations of proline, choline, citrate, 2-hydroxybutyrate, and creatinine were higher in the adenomyosis group. The focal adenomyosis of the outer myometrium and the diffuse adenomyosis phenotypes also each exhibited a specific metabolic profile.

CONCLUSION

Serum metabolic changes were detected in women with features of adenomyosis compared with their disease-free counterparts, and a number of specific metabolic pathways appear to be engaged according to the adenomyosis phenotype. The metabolites with altered levels are particularly involved in immune activation as well as cell proliferation and cell migration. Nevertheless, this study did find evidence of a correlation between metabolite levels and symptoms thought to be related to adenomyosis. Further studies are required to determine the clinical significance of these differences in metabolic profiles.