Adenomyosis: An Updated Review on Diagnosis and Classification

Nomogram to predict cumulative live birth rate following in vitro fertilization/intracytoplasmic sperm injection cycles in patients with endometriosis

BACKGROUND

The success of in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) in endometriosis patients varies widely, and predicting the likelihood of achieving a live birth remains a clinical challenge. This study aims to develop a predictive nomogram for assessing the cumulative live birth (CLB) rate following IVF/ICSI cycles among patients with endometriosis.

METHOD

A retrospective cohort study was conducted to analyze the clinical data of 1457 patients with endometriosis after IVF/ICSI treatment from January 2017 to August 2022. The patients were divided into a training set (70%) and a validation set (30%) using a random number table. Univariate analysis and multifactorial logistic regression analysis were employed to identify relevant predictive factors affecting CLB rate. A predictive model was then established based on the identified factors.

RESULTS

Univariate analysis and multifactorial logistic regression analysis revealed that patients with concurrent adenomyosis had a decreased CLB rate (OR = 0.51, 95% CI: 0.31-0.82). As the duration of infertility increased, the CLB rate decreased (OR = 0.93, 95% CI: 0.88-0.99). Higher numbers of fertilized oocytes and high-quality embryos were associated with an increased likelihood of CLB. A nomogram predictive model for CLB rate, based on age, concurrent adenomyosis, duration of infertility, number of fertilization, and number of high-quality embryos, was developed. The area under the curve (AUC) for the training set and validation set was 0.823 (95% CI: 0.798-0.849) and 0.773 (95% CI: 0.729-0.818), respectively. The stratified analysis demonstrated the applicability of the model in the validation cohort.

CONCLUSION

This predictive nomogram for CLB rate in patients with endometriosis provides valuable and precise information for personalized decision-making, which could be a visual and easily applied tool for IVF/ICSI counselling.

Molecular mechanism of aberrant decidualization in adenomyosis leading to reduced endometrial receptivity

Patients with adenomyosis not only experience a decrease in quality of life as a result of dysmenorrhea and severe monthly flow but they are also rendered infertile. Pregnancy rates are still low among women with adenomyosis, even with assisted reproduction. According to the current study, endometrial receptivity is primarily responsible for the lower conception rate among patients with adenomyosis. Decidualization of endometrial stromal cells is the fundamental requirement for endometrial receptivity and the maintenance of a normal pregnancy, even though endometrial receptivity is made up of a variety of cells, including immune cells, endometrial epithelial cells, and endometrial stromal cells. Our overview reveals that endometriosis deficiencies are present in patients with adenomyosis. These flaws may be linked to aberrant pathways in endometrial stromal cells, such as PI3K/Akt, JAK2/STAT3, and hedgehog. Correcting the abnormal expression of molecules in endometrial stromal cells in the endometrium of patients with adenomyosis may become the focus of research to improve endometrial receptivity and increase the pregnancy rate.

Unmasking cerebral infarction: hemianopia and heavy menstrual bleeding in a patient with adenomyosis and vascular abnormalities

BACKGROUND

Adenomyosis, typically associated with heavy menstrual bleeding and pelvic pain, is rarely linked to neurological complications. This case presents a rare instance of ischemic stroke in a young patient with adenomyosis and vascular abnormalities, underscoring the role of anemia, hypercoagulability, and vascular factors as potential contributors to cerebral infarction.

CASE PRESENTATION

We describe a 41-year-old female with a history of adenomyosis who presented with right-sided hemianopia and dizziness following severe menstrual bleeding. Imaging revealed multiple acute cerebral infarctions and diffuse narrowing of the left internal carotid artery, suggesting an underlying vascular pathology. Thrombelastography revealed a hypercoagulable state, raising questions about the contributions of systemic and vascular factors in the context of adenomyosis.

CONCLUSION

This case highlights the need for a multidisciplinary approach in young patients with atypical risk factors. The findings underscore the importance of considering gynecological, vascular, and coagulation abnormalities in the evaluation of cerebrovascular events, offering new insights into diagnostic and therapeutic strategies.

Effects of pretreatment strategies on fertility outcomes in patients with adenomyosis

Adenomyosis is a commonly encountered pathology in women of reproductive age and frequently coexists with infertility. The effect of adenomyosis on fertility, particularly on in vitro fertilisation and intracytoplasmic sperm injection outcomes, is not well understood. Various pretreatment modalities have been used to improve pregnancy rates and live birth outcomes; however, because of a lack of high-quality evidence, there is no clear consensus on the best pretreatment option. This review was conducted through a PubMed search aiming to highlight the relationship between pretreatment and fertility in women with adenomyosis. Medical, ablative surgical, and non-surgical therapies were reviewed. According to the current literature, gonadotropin-releasing hormone agonist therapy and placement of a levonorgestrel intrauterine system are two suitable medical pretreatment strategies that can improve the clinical pregnancy rates of patients with adenomyosis. Surgical ablation of adenomyosis can also be beneficial, although surgical management can be challenging. Non-surgical thermal techniques, including high-intensity focused ultrasound ablation, percutaneous microwave ablation, and radiofrequency ablation, are much less invasive techniques that have shown effectiveness in improving fertility. Although evidence remains limited, all these procedures have demonstrated a favourable safety profile. Further studies are needed to better develop these techniques and demonstrate their effectiveness.

Research Advances in Adenomyosis-Related Signaling Pathways and Promising Targets

Adenomyosis is a benign gynecological condition characterized by the proliferation of the endometrial stroma and glands into the myometrium, uterine volume enlargement, and peripheral smooth muscle hypertrophy. The typical clinical symptoms include chronic pelvic pain, abnormal uterine bleeding, and subfertility, all of which significantly impact quality of life. There are no effective prevention or treatment strategies for adenomyosis, partly due to a limited understanding of the pathological mechanisms underlying the initiation and progression of the disease. Given that signaling pathways play a crucial role in the development of adenomyosis, a better understanding of these signaling pathways is essential for identifying therapeutic targets and advancing drug development. The occurrence and progression of adenomyosis are closely linked to various underlying pathophysiological mechanisms, including proliferation, migration, invasion, fibrosis, angiogenesis, inflammation, oxidative stress, immune response, and epigenetic changes. This review summarizes the signaling pathways and targets associated with the pathogenesis of adenomyosis, including CXCL/CXCR, NLRP3, NF-κB, TGF-β/smad, VEGF, Hippo/YAP, PI3K/Akt/mTOR, JAK/STAT, and other relevant pathways. In addition, it identifies promising future targets for the development of adenomyosis treatment, such as m6A, GSK3β, sphks, etc.

Association between adenomyosis volume and adverse perinatal outcomes: multicenter cohort study

OBJECTIVE

To assess the association between adenomyosis volume, as a reflection of its severity, and the risk of adverse perinatal outcomes.

METHODS

This multicenter retrospective cohort study was conducted at a comprehensive tertiary care institution and a tertiary maternal and child healthcare hospital, which are the main types of hospital providing maternal medical care in China. The study included pregnant women without adenomyosis (non-AD cohort) who delivered between 1 January 2021 and 31 December 2021, and women with pregnancy complicated by adenomyosis (AD cohort) who delivered between 1 January 2020 and 31 December 2022. Adenomyosis was diagnosed and measured using transvaginal or transabdominal ultrasound up to 14 weeks of gestation. The adenomyosis volume (V) was calculated based on the sonographic measurement of three dimensions, using the formula V = (length × width × thickness) × 4/3π. Univariate and multivariate logistic regression analyses were conducted to assess the association between adenomyosis and the risk of pregnancy complications. We also performed a sensitivity analysis among 226 pregnancies complicated by adenomyosis that had volume measurements available and 10 507 pregnancies without adenomyosis, using as a threshold for severe adenomyosis the 3rd quartile of adenomyosis volume.

RESULTS

The study group included 10 507 pregnant women in the non-AD cohort and 321 in the AD cohort. Pregnancies complicated by adenomyosis had an increased risk of preterm birth < 37 weeks of gestation (adjusted odds ratio (aOR), 2.39 (95% CI, 1.65-3.48)), spontaneous preterm birth < 37 weeks of gestation (aOR, 2.57 (95% CI, 1.54-4.28)), placenta previa (aOR, 2.57 (95% CI, 1.41-4.67)), cervical incompetence (aOR, 9.70 (95% CI, 4.00-23.55)) and abnormal fetal presentation (aOR, 2.04 (95% CI, 1.39-3.00)), and there was also a non-significant trend toward increased risk of pre-eclampsia (aOR, 1.64 (95% CI, 0.94-2.85)). Sensitivity analysis revealed there was a greater risk in pregnancies with severe (≥ 757.5 cm3) vs mild adenomyosis of preterm birth < 37 weeks of gestation (aOR, 5.50 (95% CI, 2.80-10.82) vs aOR, 1.73 (95% CI, 0.98-3.05)), pre-eclampsia (aOR, 4.94 (95% CI, 2.11-11.58) vs aOR, 1.03 (95% CI, 0.41-2.58)), placenta previa (aOR, 6.37 (95% CI, 2.39-17.04) vs aOR, 1.58 (95% CI, 0.60-4.19)) and cervical incompetence (aOR, 12.79 (95% CI, 2.87-56.93) vs aOR, 4.97 (95% CI, 1.25-19.77)) compared to pregnancies without adenomyosis. The risk of spontaneous preterm birth < 37 weeks and the risk of abnormal fetal presentation was similar between the two subgroups.

CONCLUSION

Pregnancies complicated by adenomyosis, particularly those with severe adenomyosis, have an increased risk of pregnancy complications, including preterm birth, spontaneous preterm birth, placenta previa, cervical incompetence and abnormal fetal presentation. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

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.

Unraveling Cystic Adenomyosis: Diagnostic Odyssey and Surgical Resolution in a Multiparous Woman

Cystic adenomyosis, a rare variant of adenomyosis, poses diagnostic challenges due to its resemblance to other uterine pathologies. We present the case of a 37-year-old multiparous woman with a history of cesarean sections, who presented with heavy menstrual bleeding and progressive pelvic pain. Despite initial medical management, symptoms persisted, prompting further investigation. Ultrasonography initially suggested fibroid degeneration or a neoplastic change, later confirmed by magnetic resonance imaging which showed degenerative changes in fibroid. However, worsening symptoms and failed medical management led to surgical intervention. The patient underwent a total abdominal hysterectomy, revealing cystic spaces filled with altered blood within the myometrium. Histopathological analysis postsurgery confirmed the diagnosis of cystic adenomyosis. This case highlights the diagnostic challenges and therapeutic considerations in managing cystic adenomyosis in multiparous women.

Advances in Adenomyosis Treatment: High-Intensity Focused Ultrasound, Percutaneous Microwave Therapy, and Radiofrequency Ablation

Background/Objectives: Adenomyosis is a debilitating gynecologic condition that affects both multiparous older women and nulliparous younger women, inducing a variety of symptoms such as dysmenorrhea, menorrhagia, and infertility. Thermal ablation techniques are new procedures that have been proposed for the treatment of adenomyosis. They include high-intensity focused ultrasound (HIFU), percutaneous microwave ablation (PMWA), and radiofrequency ablation (RFA). Because thermal ablation techniques are minimally invasive or noninvasive, fertility is not impaired while symptoms improve. In addition, hospital stays and financial costs are generally reduced, increasing the interest in these alternative management options. Methods: In this narrative review, we conducted a thorough literature search of PubMed/Medline from the database inception to September 2022. In our search, we focused on noninvasive treatment methods such as HIFU ablation, RFA ablation, and PMWA as well as adenomyosis-specific terms and noninvasive techniques (ultrasonography, ultrasound, or magnetic resonance imaging). The queries were a combination of MeSH terms and keywords. The search was limited to the English language. Abstracts were screened according to their content, and relevant articles were selected. Results: Overall, the results showed that the above-mentioned ablation techniques are effective and safe in providing adenomyosis treatment. Lesion size and uterus volume are reduced, leading to considerable symptom alleviation with all three methods. Positive results concerning safety and fertility preservation have been described as well. Conclusions: Nonetheless, more research is required in this field to compare the efficacy and safety of different ablation techniques with traditional therapies. Such research will help improve these procedures and their associated decision-making processes.

The Impact of Adenomyosis on Pregnancy

Adenomyosis is characterized by ectopic proliferation of endometrial tissue within the myometrium. Histologically, this condition is marked by the presence of islands of benign endometrial glands surrounded by stromal cells. The myometrium appears thinner, and cross-sectional analysis often reveals signs of recent or chronic hemorrhage. The ectopic endometrial tissue may respond to ovarian hormonal stimulation, exhibiting proliferative or secretory changes during the menstrual cycle, potentially leading to bleeding, uterine swelling, and pain. Adenomyosis can appear as either a diffuse or focal condition. It is crucial to understand that adenomyosis involves the infiltration of the endometrium into the myometrium, rather than its displacement. The surgical management of adenomyosis is contingent upon its anatomical extent. The high incidence of the disease and the myths that develop around it increase the need to study its characteristics and its association with pregnancy and potential obstetric complications. These complications often require quick decisions, appropriate diagnosis, and proper counseling. Therefore, knowing the possible risks associated with adenomyosis is key to decision making. Pregnancy has a positive effect on adenomyosis and its painful symptoms. This improvement is not only due to the inhibition of ovulation, which inhibits the bleeding of adenomyotic tissue, but also to the metabolic, hormonal, immunological, and angiogenic changes associated with pregnancy. Adenomyosis affects pregnancy through disturbances of the endocrine system and the body's immune response at both local and systemic levels. It leads to bleeding from the adenomyotic tissue, molecular and functional abnormalities of the ectopic endometrium, abnormal placentation, and destruction of the adenomyotic tissue due to changes in the hormonal environment that characterizes pregnancy. Some of the obstetric complications that occur in women with adenomyosis in pregnancy include miscarriage, preterm delivery, placenta previa, low birth weight for gestational age, obstetric hemorrhage, and the need for cesarean section. These complications are an understudied field and remain unknown to the majority of obstetricians. These pathological conditions pose challenges to both the typical progression of pregnancy and the smooth conduct of labor in affected women. Further multicenter studies are imperative to validate the most suitable method for concluding labor following surgical intervention for adenomyosis.

Cytotoxic T Lymphocytes, Tc17 Cells, Th1 Cells, and ThGM Cells are Increased in the Blood and Ectopic Endometrium of Patients With Adenomyosis

PROBLEM

Adenomyosis (AM) is associated with immune response and inflammation. However, the role of T cell subsets in AM development has not been thoroughly understood.

METHOD OF STUDY

Patients with focal or diffuse AM were recruited. Serum cytokines were quantified by enzyme-linked immunosorbent assay (ELISA). Different T cell subsets in the blood and ectopic endometrium were determined by flow cytometry.

RESULTS

Serum interleukin-6 (IL-6) and macrophage-colony-stimulating factor (GM-CSF) were increased in patients with focal or diffuse AM before focused ultrasound ablation surgery (FUAS), but not after FUAS. Compared with the healthy control, the frequencies of CD8+ interferon-gamma (IFN-γ)-expressing cytotoxic T lymphocytes (CTLs), interleukin-17A (IL-17A)-expressing Tc17 cells, CD4+ T helper 1 (Th1) cells, and GM-CSF-expressing T helper (ThGM) cells were up-regulated in the blood of patients with AM, especially those with diffuse AM. However, these changes were eradicated after FUAS. Meanwhile, the frequencies of these T cell subsets were positively correlated with the CA-125 level. Furthermore, these T cell subsets were also increased in ectopic endometrium.

CONCLUSIONS

Our study delineates for the first time the presence of CTLs, Tc17 cells, Th1, and ThGM cells in the blood and ectopic endometrium in AM. The results imply that T cell response might impact AM development.

Bioengineering approaches for the endometrial research and application

The endometrium undergoes a series of precise monthly changes under the regulation of dynamic levels of ovarian hormones that are characterized by repeated shedding and subsequent regeneration without scarring. This provides the potential for wound healing during endometrial injuries. Bioengineering materials highlight the faithful replication of constitutive cells and the extracellular matrix that simulates the physical and biomechanical properties of the endometrium to a larger extent. Significant progress has been made in this field, and functional endometrial tissue bioengineering allows an in-depth investigation of regulatory factors for endometrial and myometrial defects in vitro and provides highly therapeutic methods to alleviate obstetric and gynecological complications. However, much remains to be learned about the latest progress in the application of bioengineering technologies to the human endometrium. Here, we summarize the existing developments in biomaterials and bioengineering models for endometrial regeneration and improving the female reproductive potential.

Associations between race and ethnicity and perioperative outcomes among women undergoing hysterectomy for adenomyosis

OBJECTIVE

To study racial and ethnic disparities among women undergoing hysterectomy performed for adenomyosis across the United States.

DESIGN

A cohort study.

SETTING

Data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2012-2020.

PATIENTS

Patients with an adenomyosis diagnosis.

INTERVENTION

Hysterectomy for adenomyosis.

MAIN OUTCOME MEASURES

Patients were identified using the International Classification of Diseases 9th and 10th editions codes 617.0 and N80.0 (endometriosis of the uterus). Hysterectomies were classified on the basis of the Current Procedural Terminology codes. We compared baseline and surgical characteristics and 30-day postoperative complications across the different racial and ethnic groups. Postoperative complications were classified into minor and major complications according to the Clavien-Dindo classification system.

RESULTS

A total of 12,599 women underwent hysterectomy for adenomyosis during the study period: 8,822 (70.0%) non-Hispanic White, 1,597 (12.7%) Hispanic, 1,378 (10.9%) non-Hispanic Black or African American, 614 (4.9%) Asian, 97 (0.8%) Native Hawaiian or Pacific Islander, and 91 (0.7%) American Indian or Alaska Native. Postoperative complications occurred in 8.8% of cases (n = 1,104), including major complications in 3.1% (n = 385). After adjusting for confounders, non-Hispanic Black race and ethnicity were independently associated with an increased risk of major complications (adjusted odds ratio 1.54, 95% confidence interval [CI] {1.16-2.04}). Laparotomy was performed in 13.7% (n = 1,725) of cases. Compared with non-Hispanic White race and ethnicity, the adjusted odd ratios for undergoing laparoscopy were 0.58 (95% CI 0.50-0.67) for Hispanic, 0.56 (95% CI 0.48-0.65) for non-Hispanic Black or African American, 0.33 (95% CI 0.27-0.40) for Asian, and 0.26 (95% CI 0.17-0.41) for Native Hawaiian or Pacific Islander race and ethnicity.

CONCLUSION

Among women undergoing hysterectomy for postoperatively diagnosed adenomyosis, non-Hispanic Black or African American race and ethnicity were associated with an increased risk of major postoperative complications. Compared with non-Hispanic White race and ethnicity, Hispanic ethnicity, non-Hispanic Black or African American, Asian, Native Hawaiian, or Pacific Islander race and ethnicity were less likely to undergo minimally invasive surgery.

The Impact of Conservative Surgical Treatment of Adenomyosis on Fertility and Perinatal Outcomes

Adenomyosis is a benign condition commonly encountered in patients with infertility. While the definitive surgical management is hysterectomy, conservative surgical management is gaining attention in patients desiring future fertility. This review explores whether the surgical treatment of adenomyosis affects fertility outcomes for patients trying to conceive. The PubMed and Medline databases were searched using the keywords: "adenomyosis", "surgery", "radiofrequency", "infertility", "pregnancy", "sterility", "conception", "miscarriage", and "endometrial receptivity". Abstracts were screened, and relevant articles were selected for review. This review reveals that surgery appears to improve fertility outcomes with or without medical therapy; however, the risk of uterine rupture remains high and the best technique to reduce this risk is still not known. More studies are needed to formulate the best surgical approach for preserving fertility in treating adenomyosis and to establish standardized guidelines.

The role of progestin subdermal implant in the management of adenomyosis: a systematic review

PURPOSE

The long-acting reversible contraception progestin subdermal implant (ENG implant) may be effective to improve endometriosis-related symptoms. Since adenomyosis is a histopathological form of endometriosis, we aimed to evaluate the effectiveness of ENG implant in adenomyosis management.

MATERIALS AND METHODS

Electronic search in Medline, Scopus, Embase databases and Google Scholar using combinations of the following keywords: Progestin; subdermal implant; Implanon; Nexplanon; Adenomyosis; Endometriosis.

RESULTS

Out of 889 articles in the initial database, 5 prospective observational studies were eligible for inclusion in our literature review. Our review involving 152 participants found a significant reduction in pelvic pain and dysmenorrhoea (baseline median VAS score ranged from 10 to 7.62 before implantation vs VAS score ranged from 1.81 to 0.1 after implantation) as well as an increase in the levels of haemoglobin after implantation of the device (from 86 g/L to 129 g/L after implantation). Moreover, the improvement may be sustained throughout the long-term follow-up visits (until 36 months). The most common adverse events were changes in bleeding patterns which were tolerable in most cases.

CONCLUSION

ENG implant may be a relevant and promising medical option in the management of adenomyosis. Nevertheless, randomised controlled trials and prospective studies with larger cohorts are needed to confirm the potential role of ENG implant in the management of adenomyosis.

Innovative Ultrasound Criteria for the Diagnosis of Adenomyosis and Correlation with Symptoms: A Retrospective Re-Evaluation

The 2022 Delphi revision of the MUSA (Morphological Uterus Sonographic Assessment) criteria for the ultrasound diagnosis of adenomyosis divides the ultrasound signs for diagnosis into direct and indirect ones, considering the presence of at least one direct sign as a mandatory criterion. This study aimed to reclassify the patients referred to the Pelvic Pain specialist outpatient clinic of the Gynecological Clinic of Udine according to the new criteria, evaluating the number of overdiagnoses and the possible correlation between the direct and indirect signs and the patients' symptoms. 62 patients affected by adenomyosis were retrospectively recruited. The patients were then re-evaluated by ultrasound and clinically. At least one direct sign of adenomyosis was found in 52 patients, while 16% of the population examined did not present any. There was no statistically significant difference between patients presenting direct signs and those presenting none for the symptoms considered. According to the new criteria, 16% of the patients examined were not affected by adenomyosis; applying the new consensus to symptomatic patients could increase false negatives. In a population of symptomatic patients, the diagnosis of adenomyosis is still highly probable even without direct ultrasound signs, given the clinical symptoms and having ruled out other causes of such symptoms.