Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses: a consensus opinion from the Morphological Uterus Sonographic Assessment (MUSA) group

Tailoring the Diagnostic Pathway for Medical and Surgical Treatment of Uterine Fibroids: A Narrative Review

Uterine leiomyomas are the most common benign uterine tumors in women and are often asymptomatic, with clinical manifestation occurring in 20-25% of cases. The diagnostic pathway begins with clinical suspicion and includes an ultrasound examination, diagnostic hysteroscopy, and, when deemed necessary, magnetic resonance imaging. The decision-making process should consider the impairment of quality of life due to symptoms, reproductive desire, suspicion of malignancy, and, of course, the woman's preferences. Despite the absence of a definitive cure, the management of fibroid-related symptoms can benefit from various medical therapies, ranging from symptomatic treatments to the latest hormonal drugs aimed at reducing the clinical impact of fibroids on women's well-being. When medical therapy is not a definitive solution for a patient, it can be used as a bridge to prepare the patient for surgery. Surgical approaches continue to play a crucial role in the treatment of fibroids, as the gynecologist has the opportunity to choose from various surgical options and tailor the intervention to the patient's needs. This review aims to summarize the clinical pathway necessary for the diagnostic assessment of a patient with uterine fibromatosis, presenting all available treatment options to address the needs of different types of women.

Adenomyosis: An Update Concerning Diagnosis, Treatment, and Fertility

This review article aims to summarize current tools used in the diagnosis of adenomyosis with relative pharmacological and surgical treatment and to clarify the relative association between adenomyosis and infertility, considering the importance of an accurate diagnosis of this heterogeneous disease. Among different reported concepts, direction invagination of gland cells from the basalis endometrium deep into the myometrium is the most widely accepted opinion on the development of adenomyosis. Adenomyosis has been increasingly identified in young women with pain, AUB, infertility, or no symptoms by using imaging techniques such as transvaginal ultrasound and magnetic resonance. Furthermore, adenomyosis often coexists with other gynecological conditions, such as endometriosis and uterine fibroids, increasing the heterogeneity of available data. However, there is no agreement on the definition and classification of adenomyotic lesions from both the histopathology and the imaging points of view, and diagnosis remains difficult and unclear. A standard, universally accepted classification system needs to be implemented to improve our understanding and inform precise diagnosis of the type of adenomyosis. This could be the key to designing RCT studies and evaluating the impact of adenomyosis on quality of life in terms of menstrual symptoms, fertility, and pregnancy outcome, given the high risk of miscarriage and obstetric complications.

Transvaginal radiofrequency ablation: a therapeutic option for managing symptomatic uterine fibroids in women with reproductive desires

Objective

To evaluate whether transvaginal radiofrequency (RF) ablation of fibroids is a technique that can be offered to women with reproductive desires.

Design

Unicentric, prospective, observational study.

Setting

University Hospital.

Patients

Twenty-seven individuals who desired to become mothers after undergoing RF ablation for symptomatic fibroids.

Interventions

Transvaginal RF ablation for symptomatic fibroids with a maximum total volume of 145 cm3.

Main Outcome Measures

The reduction in the size of the fibroids, improvement of symptoms, and reproductive outcomes during the 24 months after the ablation. For patients who achieved pregnancy, we assessed the type of conception, course of gestation, type of delivery, neonatal outcomes, and occurrence of both maternal and fetal complications.

Results

A statistically significant reduction in symptoms related to the fibroids 6 months after the ablation was demonstrated through the implementation of the Symptom Severity Scale. No patient required hospitalization after the procedure, and on average from the third day after intervention, they resumed their work activities without the need for analgesics. Among those patients who attempted pregnancy during the 24-month follow-up period, 73.68 % (14/19) achieved motherhood. There were no cases of uterine rupture, premature birth, or intrauterine fetal death.

Conclusions

Radiofrequency ablation for fibroids seems to be a promising, safe, and low-complexity alternative that does not appear to interfere with the development of a normal term gestation.

The association between sonographic features and clinical symptoms of adenomyosis

PURPOSE

To investigate the association of sonographic features and clinical symptoms of adenomyosis.

METHODS

This was a prospective observational study. Only reproductive age women who underwent standardized transvaginal ultrasound examination were included. The diagnosis of adenomyosis was based on sonographic features proposed by Morphological Uterus Sonographic Assessment (MUSA) group. Pictorial blood loss assessment chart (PBAC) and numerical rating scale (NRS) were respectively used for the evaluation of menstrual bleeding and pain.

RESULTS

Fifty-three women were recruited. Adenomyosis group consisted of 33 (62.3%) representative cases, whereas control group consisted of 20 (37.7%). Women with adenomyosis experienced significantly heavier menstrual bleeding (p = 0.008) and more painful menstrual periods (p = 0.003). Significant positive correlation between the number of sonographic adenomyosis features and both PBAC (r = 0.613, p < 0.001) and NRS scores (r = 0.402, p = 0.022) was found. PBAC score was significantly higher if either fan-shaped shadowing (r = 0.548, p = 0.001), interrupted junctional zone (JZ) (r = 0.548, p = 0.001) or globular uterus (r = 0.445, p = 0.011) was detected. Interrupted JZ (r = 0.440, p = 0.012) was associated with higher NRS score. Significant positive correlation between PBAC score and adenomyosis spread in uterine layers (r = 0.495, p = 0.004) was established.

CONCLUSION

Certain sonographic features of adenomyosis and assessment of its involvement in uterine layers may predict the severity of adenomyosis symptoms.

Prediction of adenomyosis according to revised definitions of morphological uterus sonographic assessment features

Objectives

This study aimed to predict the diagnosis of adenomyosis by revised definitions of morphological uterus sonographic assessment (MUSA) features in individuals who had hysterectomy.

Methods

This was retrospective cohort research conducted at a tertiary facility. Between January 2022 and January 2023, 196 individuals who had hysterectomy were analyzed in the research. The revised definitions of MUSA features of the adenomyosis approach were used to record the direct and indirect results of the sonography. The cases were classified as Group 1 (adenomyosis; n = 40, 20.4%) and Group 2 (control; n = 156, 79.6%) according to histopathology reports.

Results

Hyperechogenic islands and echogenic subendometrial buds and lines were the most predictive direct features (p = 0.02). Globular uterus and irregular junctional zone were the most predictive indirect features (p = 0.04; p = 0.03, respectively). Among all indirect features, the globular uterus was the most predictive (p = 0.02). Total feature >4 was determined as the significant cutoff value to predict adenomyosis (p < 0.001).

Conclusion

This study shows that combinations with a total number of features >4 can be practically used in the evaluation of adenomyosis using the revised definitions of MUSA features.

Type and Location of Adenomyosis in Women with Recurrent Pregnancy Loss: A Transvaginal Ultrasonographic Assessment

The current knowledge on adenomyosis as a risk factor for RPL is very scant. Overall 120 women were included in this retrospective observational study. They were divided in three groups each of which consisted of 40 subjects: Group 1: women with RPL who were diagnosed to have adenomyosis on transvaginal ultrasound (TVS); Group 2: patients with RPL without ultrasonographic findings of adenomyosis; Group 3: patients with ultrasound diagnosis of adenomyosis without RPL and at least one live birth pregnancy. The copresence of endometriosis was also investigated. Among women with RPL, patients with adenomyosis (Group 1) had higher number of pregnancy losses (p = 0.03) and lower age at first pregnancy loss (p = 0.03) than women without adenomyosis (Group 2). Moreover, they had more frequently primary RPL (p = 0.008). Adenomyosis of the inner myometrium was found more frequently (p = 0.04) in patients of Group 1 than in patients of Group 3 in which adenomyosis was mainly in the outer myometrium (p= 0.02). No differences were found in the severity of adenomyosis between these two groups of women. TVS findings for endometriosis were observed more frequently in women with adenomyosis without RPL (Group 3) than in the other two groups of patients. Adenomyosis can be a factor involved in RPL. Differences in adenomyosis localization are associated with different risks for RPL. Patients with RPL should be investigated for the presence of adenomyosis and also for the type and localization of the disease in the different myometrial layers.

Preterm birth and uterine fibroid necrosis: The clinical presentation illustrated in a case series

OBJECTIVE

Uterine fibroids increase the risk of preterm birth. The current study highlights uterine fibroid necrosis as a possible cause of (extreme) preterm birth.

STUDY DESIGN

Retrospective cohort study in one Dutch academic hospital. Cases were selected from the 526 participants of the MyoFert study (Netherlands Trial Register, NL7990), which included patients who presented between 2004 and 2018 and were between the age of 18 and 45 years at the time of diagnosis of uterine fibroids. Of these participants, 414 women became pregnant. A retrospective chart review of the first pregnancies was performed. The main outcomes were (imminent) preterm birth and signs of fibroid necrosis on ultrasound. In women with signs of fibroid necrosis, the following data were collected systematically: fibroid characteristics, clinical presentation, pregnancy outcome, and postpartum period.

RESULTS

In total, 66 women had a preterm birth (16 %, 66/414), of which 25 pregnancies ended between 16 and <24 weeks (38 %, 25/66) and 41 pregnancies ended between 24 and <37 weeks of gestation (62 %, 41/66). Of all women with preterm birth and available ultrasound images, 15 % (7/48) had fibroid necrosis at the time of labour. These seven patients, supplemented with three patients with fibroid necrosis during their first pregnancy and at least one episode of imminent preterm birth, are described in more detail. In these ten patients, the fibroids increased substantially in size during the first and second trimester, leading to severe abdominal pain in all patients and hospital admission in seven patients. Ultrasound examination of the fibroids showed heterogenic changes and focal transonic areas in the fibroid, which are characteristics that indicate fibroid necrosis. In four patients, myomectomy was performed and necrosis was confirmed histologically.

CONCLUSION

Fibroid necrosis during pregnancy is likely associated with (imminent) preterm birth. Clinicians are advised to structurally evaluate the myometrium in pregnancy, specifically in women presenting with abdominal pain in the second trimester.

Adenomyosis and fertility-sparing surgery: A literature appraisal

Adenomyosis is an intricate pathological condition that negatively impacts the uterus. It is closely related to the more well-known endometriosis, with which it shares parallels in terms of diagnosis, therapy, and both microscopic and macroscopic features. The purpose of this narrative review is to give a clear univocal definition and outlook on the different, patient-adapted, surgical treatments. MEDLINE and PubMed searches on these topics were conducted from 1990 to 2022 using a mix of selected keywords. Papers and articles were identified and included in this narrative review after authors' revision and evaluation. From the literature analysis, authors reported the following surgical techniques: laparoscopic double/triple-flap method, laparotomic wedge resection of the uterine wall, laparotomic transverse H-incision of the uterine wall, laparotomic wedge-shaped excision, and laparotomic complete debulking excision by asymmetric dissection technique. Each of these techniques has strengths and weaknesses, but the literature data on the pregnancy rate are somewhat limited. The only certain information is the risk of uterine rupture up to 6.0% after surgical treatment for uterine adenomyosis. Over the years, the surgical approach continued to reach a positive result by minimally invasive treatment, with less hospitalization, less postoperative pain, and less blood loss. Over the years, the gynecological surgeon has gained the skills, training and increasingly sophisticated surgical techniques to target effective therapy. That's why a hysterectomy is no longer the only surgical resource to treat adenomyosis, but in patients who wish to preserve the fertility, there is a wide variety of surgical alternatives.

Ultrasound Elastography in Benign Gynecology: A Scoping Review

OBJECTIVE

To perform a scoping review of the literature in which ultrasound elastography (UE) has been used in benign gynecology and identify avenues for its use in future research and clinical implementations.

METHODS

A structured search of EMBASE, Medline and Cochrane databases was conducted (last search date April 15th, 2022). Eligible studies included adult participants with female pelvic anatomy. English language papers focusing on the utility of ultrasound elastography applied to benign gynecology were included. Narrative reviews, conference abstracts, and letters to the editor were excluded. Two independent reviewers screened titles and abstracts for inclusion, a third reviewer was consulted in cases of disagreement. Study quality was assessed by a checklist for study implementation and elastography technique. Extracted data included elastography technology, gynecologic application, opportunities for clinical implementation, and strengths and limitations.

RESULTS

The search returned 2026 studies. A total of 40 studies, published between 2013 and 2022, were retained for data extraction. Studies most frequently used shear wave elastography as the method of UE (n = 23), followed by strain elastography (n = 13) and acoustic radiation force impulse (n = 4). Most common clinical applications for UE were the diagnosis of adenomyosis and uterine fibroids (27.5%), assessment of pelvic floor muscle function (22.5%), and describing the elastic properties of polycystic ovaries (17.5%) and the uterine cervix (15.0%). Limitations of the technology were identified as the lack of published reference values for gynecologic organs and difficulties in assessing tissues deep to the transducer.

CONCLUSION

Future research is needed to validate the use of ultrasound elastography in gynecology under both normal and pathologic conditions.

Endometriosis and Adenomyosis: Modern Concepts of Their Clinical Outcomes, Treatment, and Management

Endometriosis and adenomyosis are complex gynecological conditions characterized by diverse clinical presentations, including superficial peritoneal endometriosis (SPE), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE). The hallmark features of these pathologies involve the manifestation of pain symptoms and infertility, and approximately 30% of patients are asymptomatic. Despite ongoing research, definitive treatments for these conditions remain elusive, and clinical management primarily revolves around medical or surgical interventions. Recent advancements in our understanding of the efficacy of various treatment modalities, including medical therapy and surgical interventions, have provided clinicians with valuable insights into pain relief and fertility preservation. This review aims to provide an updated overview of the latest literature on clinical outcomes, treatment options, and management strategies for different types of endometriosis. By synthesizing the newest available data, this review seeks to inform clinicians and guide decision making based on factors such as patients' symptom severity, childbearing desire, and overall health.

Ultrasound Appearance of Intravascular Uterine Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP): A Case Report

A 43-year-old patient with a history of uterine fibromatosis was referred to our hospital for menometrorrhagia and pelvic pain. At the pelvic ultrasound, a highly-vascularized myometrial lesion in volumetric increase was described. An elongated, solid, hypoechoic, painless, and highly vascularized left parauterine mass was identified. On histological examination, a uterine smooth muscle tumor of uncertain malignant potential (STUMP) with intravascular invasion of the left uterine vein was diagnosed. The adnexa and peritoneum were free of disease. On a retrospective evaluation of the ultrasound images, we noticed that the intravascular lesion showed sonographic features comparable to the original mass. Moreover, the Color Doppler (CD) analysis revealed an interrupted blood flow within the left uterine vein. In this case, the ultrasound proved to be an accurate diagnostic tool. When inhomogeneous uterine masses are suspected, and a parauterine/paraadnexal mass surrounded by irregular vessels are identified, the sonographer should take into account a risk of intravascular invasion. The patency of uterine and ovarian vessels should be accurately evaluated, to guide a tailored patient surgical approach.

Comparative analysis of endometrial, vaginal, and gut microbiota in patients with and without adenomyosis

INTRODUCTION

Alterations in microbiota composition have been implicated in a variety of human diseases. Patients with adenomyosis present immune dysregulation leading to a persistent chronic inflammatory response. In this context, the hypothesis that alterations in the microbiota may be involved in the pathogenesis of adenomyosis, by affecting the epigenetic, immunologic, and biochemical functions of the host, has recently been postulated. The aim of the present study was to compare the microbiota composition in the vagina, endometrium, and gut of individuals with and without adenomyosis.

MATERIAL AND METHODS

Cross-sectional study including 38 adenomyosis patients and 46 controls, performed between September 2021 and October 2022 in a university hospital-based research center. The diagnosis of adenomyosis was based on sonographic criteria. Fecal, vaginal, and endometrial samples were collected. Study of the microbiota using 16S rRNA gene sequencing.

RESULTS

Patients with adenomyosis exhibited a significant reduction in the gut microbial alpha diversity compared with healthy controls (Chao1 p = 0.012, Fisher p = 0.005, Observed species p = 0.005). Beta-diversity analysis showed significant differences in the compositions of both gut and vaginal microbiota between adenomyosis patients and the control group (Adonis p-value = 0.001; R2 = 0.03 and Adonis p-value = 0.034; R2 = 0.04 respectively). Specific bacterial taxa were found to be either overrepresented (Rhodospirillales, Ruminococcus gauvreauii group, Ruminococcaceae, and Actinomyces) or underrepresented in the gut and endometrial microbiota of adenomyosis patients compared with controls. Distinct microbiota profiles were identified among patients with internal and external adenomyosis phenotypes.

CONCLUSIONS

The study revealed reduced gut microbiota diversity in adenomyosis patients, accompanied by distinct compositions in gut and vaginal microbiota compared with controls. Overrepresented or underrepresented bacterial taxa were noted in the gut and endometrial microbiota of adenomyosis patients, with variations in microbiota profiles among those with internal and external adenomyosis phenotypes. These findings suggest a potential association between microbiota and adenomyosis, indicating the need for further research to comprehensively understand the implications of these differences.

Ultrasonographic characterization of parametrial endometriosis: a prospective study

OBJECTIVE

To study the ultrasonographic diagnostic accuracy and characteristics of parametrial endometriosis comprehensively.

DESIGN

This prospective study enrolled patients with suspected deep endometriosis (DE) scheduled for laparoscopic surgical treatment. Preoperative ultrasonographic examinations were performed following the International Deep Endometriosis Analysis criteria. This study aimed to evaluate the presence of parametrial endometriosis and its ultrasonographic characteristics, using surgical diagnosis as the reference standard. Additionally, indirect signs of DE and concomitant DE nodules associated with parametrial involvement were identified, assessing their predictive significance in the anterior, lateral, and posterior parametrial areas.

SETTING

Referral institution for endometriosis.

PATIENTS

Patients with suspected DE scheduled for surgical treatment.

INTERVENTIONS

Standardized preoperative ultrasonographic examination.

MAIN OUTCOME MEASURES

The diagnostic accuracy of transvaginal ultrasound in identifying parametrial endometriosis, including sensitivity and specificity, and the ultrasonographic characteristics of parametrial nodules, prevalence in distinct parametrial areas, and associations with indirect DE signs and concomitant DE nodules.

RESULTS

Surgical confirmation of parametrial nodules was observed in 105 of 545 patients (left, 18.5; right, 17.0%). Transvaginal ultrasound demonstrated a sensitivity of 77.1% (95% confidence interval, 68.0%-84.8%) and specificity of 99.1% (95% confidence interval, 67.7%-99.8%). Parametrial nodules typically exhibited characteristics such as a mild hypoechoic appearance (83.6%), starry morphology (74.7%), irregular margins (70.2%), and low vascularization. The posterior parametrial region was the most common location (52.2%), followed by the lateral (41.0%) and anterior (6.8%) parametrial regions. Concomitant DE nodules in the rectum (63.5%) and infiltrating the rectovaginal septum (56.5%) were significantly more prevalent in patients with parametrial involvement. Indirect DE signs, such as the ovaries fixed to the uterine wall (71.8%) and the absence of a posterior sliding sign (51.8%), were also more common in women with parametrial nodules. Hydronephrosis, although relatively uncommon in patients with parametrial involvement (8.2%), was largely detected in lateral parametrial nodules (70.0%).

CONCLUSIONS

This study represents a systematic ultrasonographic characterization of parametrial endometriosis. Specifically, it comprehensively assesses the diagnostic accuracy of transvaginal ultrasound in identifying parametrial involvement within a sizable cohort of patients with preoperative suspicion of DE.

CLINICAL TRIAL REGISTRATION NUMBER

NCT06017531.

Clinical and ultrasound characteristics of deep endometriosis affecting sacral plexus

OBJECTIVE

To describe the sonomorphological changes and appearance of deep endometriosis (DE) affecting the nervous tissue of the sacral plexus (SP).

METHODS

This was a retrospective study of symptomatic patients who underwent radical resection of histologically confirmed DE affecting the SP and who had undergone preoperative transvaginal sonography (TVS) between 2019 and 2023. Lesions were described based on the terms and definitions of the International Deep Endometriosis Analysis (IDEA), International Ovarian Tumor Analysis (IOTA) and Morphological Uterus Sonographic Assessment (MUSA) groups. A diagnosis of DE affecting the SP on TVS was made when the sonographic criteria of DE were visualized in conjunction with fibers of the SP and the presence of related symptoms corresponding to sacral radiculopathy. Clinical symptoms, ultrasound features and histological confirmation were analyzed for each patient included.

RESULTS

Twenty-seven patients with DE infiltrating the SP were identified in two contributing tertiary referral centers. Median age was 37 (range, 29-45) years and all patients were symptomatic and presented one or more of the following neurological symptoms: dysesthesia in the ipsilateral lower extremity (n = 17); paresthesia in the ipsilateral lower extremity (n = 10); chronic pelvic pain radiating in the ipsilateral lower extremity (n = 9); chronic pain radiating in the pudendal region (n = 8); and motor weakness in the ipsilateral lower extremities (n = 3). All DE lesions affecting the SP were purely solid tumors in the posterior parametrium in direct contact with, or infiltrating, the S1, S2, S3 and/or S4 roots of the SP. The median of the largest diameter recorded for each of the DE nodules was 35 (range, 18-50) mm. Echogenicity was non-uniform in 23 (85%) of the DE nodules, with all but one of these nodules containing hyperechogenic areas. The shape of the lesions was irregular in 24 (89%) cases. Only one lesion exhibited a lobulated form, with all other irregular lesions showing a spiculated appearance. An acoustic shadow was produced in 20 (74%) of the nodules, all of which were internal. On color or power Doppler examination, 21 (78%) of the nodules showed no signal (color score of 1). The remaining six (22%) lesions showed a minimal color content (color score of 2). According to pattern recognition, most DE nodules were purely solid, non-uniform, hypoechogenic nodules containing hyperechogenic areas, with internal shadows and irregular spiculated contours, and were poorly vascularized on color/power Doppler examination.

CONCLUSION

The ultrasound finding of a parametrial, unilateral, solid, non-uniform, hypoechogenic nodule with hyperechogenic areas and possible internal shadowing, as well as irregular spiculated contours, demonstrating poor vascularization on Doppler examination in proximity to or involving the structures of the SP, indicates DE affecting the SP. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Imaging and molecular features of adenomyosis after menopause

OBJECTIVES

To explore the imaging features and the molecular characterization of adenomyosis after menopause.

STUDY DESIGN

An observational cross-sectional study was performed in a group of postmenopausal patients undergoing a transvaginal ultrasound (TVUS) (n = 468). Among those presenting the US criteria for adenomyosis, also confirmed by magnetic resonance imaging (MRI), previous menstrual symptoms, gynecological and obstetric history were reviewed. In a subgroup undergoing hysterectomy, uterine specimens were analyzed by histology and expression of genes implicated in the epithelial-mesenchymal transition, inflammation and fibrosis, including the sphingosine-1-phosphate (S1P) pathway, was evaluated and compared to matched non-menopausal adenomyosis specimens.

MAIN OUTCOME MEASURES

Direct and indirect US features of adenomyosis according to Morphological Uterus Sonographic Assessment at TVUS. Molecular characterization of postmenopausal versus pre-menopausal adenomyosis samples.

RESULTS

According to TVUS and MRI, adenomyosis was identified in 49 patients (10.4 %). On US, diffuse adenomyosis was the most common phenotype, whereas internal adenomyosis with diffuse pattern and asymmetric type was the most prevalent on MRI. Molecular analysis showed that adenomyosis lesions express markers of epithelial-mesenchymal transition, inflammation and fibrosis also in postmenopausal women. By comparing the results with those from pre-menopausal samples, the expression of α smooth muscle actin (αSMA), a marker of fibrosis, was significantly greater after menopause, and altered S1P catabolism and signaling were observed.

CONCLUSIONS

Adenomyosis may be identified in postmenopausal women by imaging, either TVUS or MRI, and fibrosis is one of the key features on molecular analysis.

Clinical signs and diagnosis of fibroids from adolescence to menopause

The aim of this review was to provide an updated assessment of the present diagnostic tools and clinical symptoms and signs to evaluate uterine fibroids (UFs) on the basis of current guidelines, recent scientific evidence, and a PubMed and Google Scholar search for peer-reviewed original and review articles related to clinical signs and diagnosis of UFs. Approximately 50%-75% of UFs are considered nonclinically relevant. When present, the most common symptoms are abnormal uterine bleeding, pelvic pain and/or bulk symptoms, and reproductive failure. Transvaginal ultrasound is recommended as the initial diagnostic modality because of its accessibility and high sensitivity, although magnetic resonance imaging appears to be the most accurate diagnostic tool to date in certain cases. Other emerging techniques, such as saline infusion sonohysterography, elastography, and contrast-enhanced ultrasonography, may contribute to improving diagnostic accuracy in selected cases. Moreover, artificial intelligence has begun to demonstrate its ability as a complementary tool to improve the efficiency of UF diagnosis. Therefore, it is critical to standardize descriptions of transvaginal ultrasound images according to updated classifications and to individualize the use of the different complementary diagnostic tools available to achieve precise uterine mapping that can lead to targeted therapeutic approaches according to the clinical context of each patient.

Establishment and validation of a nomogram model for predicting adverse pregnancy outcomes of pregnant women with adenomyosis

PURPOSE

To establish a reliable nomogram model to predict the risk of major adverse pregnancy outcomes in pregnant women with adenomyosis, and to provide a reference tool for the hierarchical management and the prenatal examination of pregnant women.

METHODS

We collected the clinical data of pregnant women with adenomyosis who were treated in the First Affiliated Hospital of Chongqing Medical University, the Women and Children's Hospital of Chongqing Medical University, and Yubei District People's Hospital of Chongqing from January 2014 to June 2020. They were divided into the training cohort and the validation cohort, respectively. In the training cohort, we screened out risk factors associated with major adverse pregnancy outcomes and established a model, which was subsequently validated.

RESULTS

In the training cohort, we found that previous parity, natural conception or not, type of adenomyosis, with or without endometriosis, history of infertility or adverse pregnancy outcomes, and history of uterine body surgery were associated with major adverse pregnancy outcomes of pregnant women with adenomyosis, and based on these factors, a nomogram model was constructed. The calibration curves of the model were well fitted in both the training and validation cohorts. The receiver-operating characteristic curve (ROC curve) showed that the area under the curve (AUC) was 0.873 and 0.851 in the training and validation cohorts, respectively. The optimal risk threshold of the model was 0.22, and this threshold can be applied to risk stratification of pregnant women.

CONCLUSION

The nomogram model established in this study can reliably predict the risk of major APO in pregnant women with AD.

Prevalence of sonographic signs in women with uterine sarcoma: a systematic review and meta-analysis

OBJECTIVE

To assess the prevalence of sonographic signs in women with uterine sarcoma.

MATERIALS AND METHODS

A systematic review and meta-analysis were performed. Five electronic databases were searched from inception to June 2022 for all studies allowing calculation of the prevalence of sonographic signs in women with uterine sarcoma. Pooled prevalence with 95% confidence intervals was calculated for each sonographic sign and was a priori defined as "very high" when it was ≥ 80%, "high" when it ranged from 80% to 70%, and less relevant when it was ≤ 70%.

RESULTS

6 studies with 317 sarcoma patients were included. The pooled prevalence was: · 25.0% (95%CI:15.4-37.9%) for absence of visibility of the myometrium. · 80.5% (95%CI:74.8-85.2%) for solid component. · 78.3% (95%CI:59.3-89.9%) for inhomogeneous echogenicity of solid component. · 47.9% (95%CI:41.1-54.8%) for cystic areas. · 80.7% (95%CI:68.3-89.0%) for irregular walls of cystic areas. · 72.3% (95%CI:16.7-97.2%) for anechoic cystic areas. · 54.8% (95%CI:34.0-74.1%) for absence of shadowing. · 73.5% (95%CI:43.3-90.9%) for absence of calcifications. · 48.7% (95%CI:18.6-79.8%) for color score 3 or 4. · 47.3% (95%CI:37.0-57.8%) for irregular tumor borders. · 45.4% (95%CI:27.6-64.3%) for endometrial cavity not visualizable. · 10.9% (95%CI:3.5-29.1%) for free pelvic fluid. · 6.4% (95%CI:1.1-30.2%) for ascites. · 21.2% (95%CI:2.1-76.8%) for intracavitary process. · 81.5% (95%CI:56.1-93.8%) for singular lesion..

CONCLUSION

Solid component, irregular walls of cystic areas, and singular lesions are signs with very high prevalence, while inhomogeneous echogenicity of solid component, anechoic cystic areas, and absence of calcifications are signs with high prevalence. The remaining signs were less relevant.

Accessory cavitated uterine malformation (ACUM): A scoping review

INTRODUCTION

Accessory cavitated uterine malformation (ACUM) is a relatively recent term used to describe a noncommunicating, accessory uterine cavity. ACUM have been published under different terms ranging from juvenile cystic adenomyosis to "uterus-like mass". The objective of this study was to systematically identify all cases of ACUM and definitions described in the literature, regardless of label, and identify morphological, epidemiological, and clinical characteristics as well as management, while also highlighting knowledge gaps.

MATERIAL AND METHODS

A systematic literature search of three databases was performed, reviewing all records of cystic myometrial lesions. Cases that fitted common definitions for ACUM were included and clinical and imaging characteristics were documented in detail. This work was registered to PROSPERO and reporting followed PRISMA guidelines for scoping reviews.

RESULTS

A total of 53 articles were included, comprising 115 cases that met the minimal criteria for ACUM. The median age at onset of symptoms was 17 years, presenting with dysmenorrhea soon after menarche. A total of 19 women were parous. On ultrasound, ACUM appears as unilocular myometrial cysts, usually with ground-glass content. Hemorrhagic content is also observed on magnetic resonance imaging (MRI), with high signal intensity on both T2 and T1-weighted images. Ninety-five (83%) cases were managed surgically, with a trend towards primary nonsurgical options. Although no adverse outcomes were reported, long-term follow-up on subsequent fertility and pregnancy was rare.

CONCLUSIONS

Despite its increasing recognition as a clinical entity, ACUM often remains underdiagnosed as it shares similarities with other myometrial masses. We propose a unified terminology and definition for ACUM based on the data in this review. ACUM presents as a cavitated lesion, surrounded by a myometrial mantle, in continuity with the anterolateral uterine wall and located beneath the insertion of the round ligament and the interstitial portion of the fallopian tube. In contrast to other uterine abnormalities, a normal uterine cavity is visualized. Future studies are needed, using a clear definition for ACUM, and prospectively investigating management strategies, including long-term follow-up of patient-reported symptoms, fertility, and pregnancy outcomes.

Prevalence of adenomyosis features in women scheduled for assisted reproductive treatment, using the Morphological Uterus Sonographic Assessment group definitions

INTRODUCTION

Studies that use standardized ultrasonographic criteria to diagnose adenomyosis in subfertile women are needed. These would improve the understanding of the disease burden and enable further studies on its impact on fertility and assisted reproductive treatment (ART) outcome. The aim of this study was to determine the prevalence of different features of adenomyosis in women scheduled for their first ART, diagnosed at two (2D) and three-dimensional (3D) transvaginal ultrasonography (TVUS) using the revised Morphological Uterus Sonographic Assessment (MUSA) group definitions.

MATERIAL AND METHODS

This was a prospective, observational cross-sectional study of subfertile women aged 25 to ≤39 years, that were referred to a university hospital for their first ART between December 2018 and May 2021. Of 1224 eligible women, 1160 women fulfilled the inclusion criteria and consented to participate in the study. All women underwent a systematic 2D and 3D TVUS examination. The primary outcome was the presence of direct and indirect features of adenomyosis, as proposed by the MUSA group. Secondary outcomes were to describe the ultrasonographic characteristics of the different features, as well as any difference in the diagnostics at 2D or 3D TVUS and any association with clinical characteristics such as endometriosis.

RESULTS

At least one direct or indirect feature of adenomyosis was observed in 272 (23.4%, 95% confidence interval [CI] 21.0-25.9) women. Direct features that are pathognomonic for the disease were observed in 111 (9.6%, 95% CI, 7.9-11.3) women. Direct features were visible only at 3D TVUS in 56 (4.8%, 95% CI 3.6-6.1) women, that is, 56/111 (50.5%) of women with at least one direct adenomyosis feature. Direct features were more common in women with endometriosis (OR 2.8, 95% CI 1.8-4.3).

CONCLUSIONS

We found than one in 10 women scheduled for ART had direct features of adenomyosis at ultrasound examination. The present study suggests that the use of 3D TVUS is an important complement to 2D in the diagnostics of adenomyosis. Our results may further improve the counseling of women scheduled for ART and enables future studies on the impact of different features of adenomyosis on subfertility, ART results and obstetric outcomes.

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.

Can Laparoscopic Surgery Reduce Fatigue in Women with Endometriosis?-A Pilot Study

Background: Fatigue is mentioned as one of the most significant symptoms of endometriosis. The impact of laparoscopic endometriosis surgeries on fatigue remains unknown. The aim of this study was to investigate, for the first time, the effect of laparoscopic surgery in endometriosis patients, with the complete removal of endometriotic lesions, on the severity of fatigue. Methods: This is a single-center prospective pilot study including 58 participants. Participants were recruited at the Tertiary Endometriosis Referral Center of the Medical University of Vienna between February 2020 and November 2021. Thirty patients with histologically proven endometriosis were compared to a control group of 28 patients who underwent a laparoscopy for benign gynecologic conditions other than endometriosis. All participants were interviewed using the Fatigue Severity Scale before their surgery and 6 months afterward. Relationships between variables were established using regression analysis and associations were quantified as odds ratios. Results: Fatigue was significantly more severe preoperatively in patients with endometriosis when compared to controls ((odds ratio (OR): 1.82; 95% confidence interval (CI): 1.24-2.67, p < 0.01). Six months postoperatively, the fatigue severity score of endometriosis patients decreased significantly (p < 0.01). In multivariate analysis, fatigue was significantly associated with endometriosis (OR: 4.50, CI: 1.14-17.8, p < 0.05), when adjusted for abdominal pain and menstrual bleeding. Fatigue in patients with endometriosis was not associated with disease stage or the presence of deep endometriosis. Conclusions: Fatigue is a frequent and bothersome symptom in patients with endometriosis. Within our study, we demonstrated for the first time that fatigue responds to surgical treatment. The management of fatigue is crucial to improving patients' quality of life.

Adenomyosis diagnosis among adolescents and young women with dysmenorrhoea and heavy menstrual bleeding

RESEARCH QUESTION

What is the prevalence of adenomyosis at ultrasonography among adolescents and young women reporting dysmenorrhoea and/or heavy menstrual bleeding (HMB)?

DESIGN

This observational cohort study involved adolescents and young women referred for dysmenorrhoea and/or HMB to the Adolescent Medicine Unit at Careggi University Hospital, Italy. Patients with endometriosis and bleeding disorders were excluded. Transvaginal ultrasonography or transrectal sonography using a transvaginal probe was performed. The myometrium was described according to the Morphological Uterus Sonographic Assessment criteria. Details of baseline characteristics, clinical data and symptoms were collected. The presence of sonographic features of adenomyosis and the association between imaging findings and clinical symptoms were evaluated.

RESULTS

The cohort included 95 patients aged between 13 and 25 years, referred for dysmenorrhoea (88.4%), HMB (23.2%) or both (13.7%). According to the MUSA criteria the sonographic diagnosis of adenomyosis was made in 27.4% of patients, with the diffuse type the most prevalent. Uterine wall asymmetry, hyperechoic intramyometrial islands, translesional vascularity and an interrupted junctional zone were the most common features. Patients with imaging findings of adenomyosis had significantly higher rates of HMB than those with a normal myometrial appearance (38.5% versus 17.4%, P = 0.030). In addition, the coexistence of dysmenorrhoea and HMB was significantly associated with adenomyosis (odds ratio 5.68, 95% confidence interval 1.65-19.5).

CONCLUSIONS

Adenomyosis may be diagnosed among teenagers and young women referred with dysmenorrhoea and/or HMB. The clinical presentation is relevant for the diagnosis, with HMB alone and HMB plus dysmenorrhoea significantly associated with the sonographic identification of adenomyosis.

Uterine peristalsis in women affected by adenomyosis: A step towards functional assessment

OBJECTIVE

The non-pregnant uterus shows an intrinsic contractility pattern, actively involved in early reproductive processes. Uterine contractility is characterized by endometrial waves that originate from the junctional zone and varies throughout the menstrual cycle due to fluctuations in the concentrations of hormones. The aim of this study was to compare the uterine contractility patterns in the periovulatory phase in a group of patients with isolated adenomyosis and a group of healthy women using transvaginal ultrasound (TVUS).

METHODS

From March 2019 to March 2021, we enrolled consecutive nulliparous patients in the periovulatory phase of the menstrual cycle, divided in patients with isolated adenomyosis (group A, n = 18) and healthy patients in the control group (group B, n = 18). Patients who met the inclusion criteria underwent TVUS for the study of uterine contractility: the uterus was scanned on sagittal plane for 3 min and all the movies were recorded. Then, static images and video were evaluated offline and the uterine contractility patterns were defined.

RESULTS

The patients belonging to the study group had a higher incidence of painful symptoms (dysmenorrhea, 6.11 ± 2.81 vs 1.39 ± 2.17; chronic pelvic pain, 2.56 ± 3.01 vs 0.39 ± 1.04) and a larger uterine volume (137.48 ± 117.69 vs 74.50 ± 27.58 cm3; P = 0.04). Regarding the uterine contractility, a statistically significant difference was observed about the retrograde patterns (group A, 27.8% vs group B, 72.2%, P < 0.01) and opposing (group A, 38.9% vs, group B, 5.6%, P = 0.02).

CONCLUSION

The study confirms the presence of altered uterine peristalsis in the periovulatory phase in patients with adenomyosis. The abnormal uterine peristalsis could lead to both structural and functional changes, which are the basis of the clinical manifestations of adenomyosis and the perpetuation of the anatomical damage.

Ultrasound features using MUSA terms and definitions in uterine sarcoma and leiomyoma: cohort study

OBJECTIVES

Timely and accurate preoperative diagnosis of uterine sarcoma will increase patient survival. The primary aim of this study was to describe the ultrasound features of uterine sarcoma compared with those of uterine leiomyoma based on the terms and definitions of the Morphological Uterus Sonographic Assessment (MUSA) group. A secondary aim was to assess the interobserver agreement for reporting on ultrasound features according to MUSA terminology.

METHODS

This was a retrospective cohort study of patients with uterine sarcoma or uterine leiomyoma treated in a single tertiary center during the periods 1997-2019 and 2016-2019, respectively. Demographic characteristics, presenting symptoms and surgical outcomes were extracted from patients' files. Ultrasound images were re-evaluated independently by two sonologists using MUSA terms and definitions. Descriptive statistics were calculated and interobserver agreement was assessed using Cohen's κ (with squared weights) or intraclass correlation coefficient, as appropriate.

RESULTS

A total of 107 patients were included, of whom 16 had a uterine sarcoma and 91 had a uterine leiomyoma. Abnormal uterine bleeding was the most frequent presenting symptom (69/107 (64%)). Compared with leiomyoma cases, patients with uterine sarcoma were older (median age, 65 (interquartile range (IQR), 60-70) years vs 48 (IQR, 43-52) years) and more likely to be postmenopausal (13/16 (81%) vs 15/91 (16%)). In the uterine sarcoma cohort, leiomyosarcoma was the most frequent histological type (6/16 (38%)), followed by adenosarcoma (4/16 (25%)). On ultrasound evaluation, according to Observers 1 and 2, the tumor border was irregular in most sarcomas (11/16 (69%) and 13/16 (81%) cases, respectively), but regular in most leiomyomas (65/91 (71%) and 82/91 (90%) cases, respectively). Lesion echogenicity was classified as non-uniform in 68/91 (75%) and 51/91 (56%) leiomyomas by Observers 1 and 2, respectively, and 15/16 (94%) uterine sarcomas by both observers. More than 60% of the uterine sarcomas showed acoustic shadows (11/16 (69%) and 10/16 (63%) cases by Observers 1 and 2, respectively), whereas calcifications were reported in a small minority (0/16 (0%) and 2/16 (13%) cases by Observers 1 and 2, respectively). In uterine sarcomas, intralesional vascularity was reported as moderate to abundant in 13/16 (81%) cases by Observer 1 and 15/16 (94%) cases by Observer 2, while circumferential vascularity was scored as moderate to abundant in 6/16 (38%) by both observers. Interobserver agreement for the presence of cystic areas, calcifications, acoustic shadow, central necrosis, color score (overall, intralesional and circumferential) and maximum diameter of the lesion was moderate. The agreement for shape of lesion, tumor border and echogenicity was fair.

CONCLUSIONS

A postmenopausal patient presenting with abnormal uterine bleeding and a new or growing mesenchymal mass with irregular tumor borders, moderate-to-abundant intralesional vascularity, cystic areas and an absence of calcifications on ultrasonography is at a higher risk of having a uterine sarcoma. Interobserver agreement for most MUSA terms and definitions is moderate. Future studies should validate the abovementioned clinical and ultrasound findings on uterine mesenchymal tumors in a prospective multicenter fashion. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Clinical and ultrasonographic characteristics of pregnancy-related enhanced myometrial vascularity: prospective cohort study

OBJECTIVE

To assess the ultrasonographic, epidemiological, clinical and evolutive characteristics of enhanced myometrial vascularity (EMV) following a first-trimester termination of pregnancy (TOP) or management of non-viable pregnancy.

METHODS

This prospective study included women who underwent follow-up ultrasound examination 5-6 weeks after a first-trimester TOP or after management of a first-trimester non-viable pregnancy at the University Hospital Polyclinic San Martino of Genoa between March 2021 and March 2022. EMV was characterized using two- and three-dimensional ultrasound and Virtual Organ Computer-aided Analysis. Ultrasonographic diagnosis of EMV was made when an unusual, tortuous myometrial vessel structure, with high-velocity blood flow, protruding towards the endometrium was observed, while an abnormal junctional zone, absent endometrial midline and heterogeneous endometrium supported the diagnosis. Patients with EMV underwent expectant management with planned ultrasonographic follow-up every 2 weeks until resolution.

RESULTS

During the study period, 305 women underwent TOP, of whom 132 attended the initial follow-up 5-6 weeks later, at which 52 were diagnosed with EMV. Ninety-six women were managed for a non-viable pregnancy, of whom 32 presented for follow-up, at which six had a diagnosis of EMV. Thus, overall, 164 of 401 women were included in the study and EMV was identified in 58 (35%) of these. The prevalence of EMV 5-6 weeks after a TOP was therefore between 52/305 (17%) and 52/132 (39%), and that after management of a non-viable pregnancy was between 6/96 (6%) and 6/32 (19%). Bleeding/pelvic pain was present in half (29/58) of the women with EMV, and serum human chorionic gonadotropin was detectable in 29% (17/58) at the first follow-up examination. At ultrasound assessment, all cases with EMV presented abundant tortuous myometrial vessels with high-velocity flow projecting from the myometrium towards the endometrium, along with non-uniform heterogeneous endometrium in 97% of cases, which often (67% of these) contained cystic areas, absence of the endometrial midline in 98% of cases and an abnormal junctional zone in 97% of cases (64% interrupted, 33% irregular). Most (67%) women with EMV were parous and 90% of them had undergone TOP rather than management for a non-viable pregnancy. Medical management of the TOP or non-viable pregnancy was more frequent in women with than those without EMV (93% vs 77%, P = 0.023). Multiple regression analysis showed the risk of EMV to be increased following TOP vs non-viable pregnancy (odds ratio (OR), 3.67 (95% CI, 1.16-11.56), P = 0.026) and in parous compared with nulliparous women (OR, 2.95 (95% CI, 1.45-6.01), P = 0.002). All women with EMV underwent expectant management. Eleven women did not return for subsequent follow-up examinations and did not present to our outpatient or emergency facilities, so were lost to further follow-up. Spontaneous resolution of the lesion was observed within 7-16 weeks after the procedure in 96% (45/47) of the remaining cases. Two women chose to undergo surgery for pelvic discomfort, and histology showed the presence of neovessels mixed with retained chorionic villi.

CONCLUSIONS

EMV is a transient and common finding 5-6 weeks following first-trimester TOP or management of non-viable pregnancy. TOP and being parous are risk factors for EMV. Expectant management of EMV is appropriate, because, in almost all cases, this resolves spontaneously, without complications, within 2-4 months. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Early GnRH-agonist therapy does not negatively impact the endometrial repair process or live birth rate

Study objective

To investigate whether different timings of GnRH-a downregulation affected assisted reproductive outcomes in infertile women with moderate-to-severe intrauterine adhesions (IUAs) accompanied by adenomyosis.

Design

A retrospective case series.

Setting

An assisted reproductive technology center.

Patients

The study reviewed 123 infertile women with moderate-to-severe IUAs accompanied by adenomyosis undergoing their first frozen-thawed embryo transfer (FET) cycles between January 2019 and December 2021.

Measurements and main results

The majority of patients had moderate IUA (n=116, 94.31%). The average Basal uterine volume was 73.58 ± 36.50 cm3. The mean interval from operation to the first downregulation was 21.07 ± 18.02 days (range, 1-79 days). The mean duration of hormone replacement therapy (HRT) was 16.93 ± 6.29 days. The average endometrial thickness on the day before transfer was 10.83 ± 1.75 mm. A total of 70 women achieved clinical pregnancy (56.91%). Perinatal outcomes included live birth (n=47, 67.14%), early miscarriage (n=18, 25.71%), and late miscarriage (n=5, 7.14%). The time interval between uterine operation and the first downregulation was not a significant variable affecting live birth. Maternal age was the only risk factor associated with live birth (OR:0.89; 95% CI: 0.79-0.99, P=0.041).

Conclusions

The earlier initiation of GnRH-a to suppress adenomyosis prior to endometrial preparation for frozen embryo transfer did not negatively impact repair of the endometrium after resection.

Abnormal Uterine Bleeding: A Pictorial Review on Differential Diagnosis and Not-So-Common Cases of Interventional Radiology Management

Abnormal uterine bleeding (AUB) poses a multifaceted challenge in women's health, necessitating an integrated approach that addresses its diverse etiologies and clinical presentations. The International Federation of Gynecology and Obstetrics PALM-COEIN classification system provides a systematic approach to the diagnosis of AUB in non-pregnant women, based on clinical and imaging-based categorization of causes into structural (Polyps, Adenomyosis, Leiomyomas and Malignancy; PALM), and non-structural causes (Coagulopathies, Ovulatory disorders, primary Endometrial disorders, Iatrogenic and Not otherwise classified; COEIN). On the other hand, placental disorders, uterine rupture, ectopic pregnancy and retained products of conceptions are the main causes of uterine bleeding during pregnancy and in the peripartum period. Ultrasound is usually the first-line imaging technique for the differential diagnosis of causes of AUB. Computed Tomography may be useful if ultrasound findings are unclear, especially in emergency settings. Magnetic resonance imaging, when indicated, is an excellent second-line diagnostic tool for a better non-invasive characterization of the underlying cause of AUB. This pictorial review aims to illustrate the main causes of AUB from the point of view of diagnostic imaging and to show not-so-common cases that can be treated by means of interventional radiology.

Diagnostic accuracy of MRI in the differential diagnosis between uterine leiomyomas and sarcomas: A systematic review and meta-analysis

BACKGROUND

Differential diagnosis between uterine leiomyomas and sarcomas is challenging. Magnetic resonance imaging (MRI) represents the second-line diagnostic method after ultrasound for the assessment of uterine masses.

OBJECTIVES

To assess the accuracy of MRI in the differential diagnosis between uterine leiomyomas and sarcomas.

SEARCH STRATEGY

A systematic review and meta-analysis was performed searching five electronic databases from their inception to June 2023.

SELECTION CRITERIA

All peer-reviewed observational or randomized clinical trials that reported an unbiased postoperative histologic diagnosis of uterine leiomyoma or uterine sarcoma, which also comprehended a preoperative MRI evaluation of the uterine mass.

DATA COLLECTION AND ANALYSIS

Sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and area under the curve on summary receiver operating characteristic of MRI in differentiating uterine leiomyomas and sarcomas were calculated as individual and pooled estimates, with 95% confidence intervals (CI).

RESULTS

Eight studies with 2495 women (2253 with uterine leiomyomas and 179 with uterine sarcomas), were included. MRI showed pooled sensitivity of 0.90 (95% CI 0.84-0.94), specificity of 0.96 (95% CI 0.96-0.97), positive likelihood ratio of 13.55 (95% CI 6.20-29.61), negative likelihood ratio of 0.08 (95% CI 0.02-0.32), diagnostic odds ratio of 175.13 (95% CI 46.53-659.09), and area under the curve of 0.9759.

CONCLUSIONS

MRI has a high diagnostic accuracy in the differential diagnosis between uterine leiomyomas and sarcomas.

Society of Radiologists in Ultrasound Consensus on Routine Pelvic US for Endometriosis

Endometriosis is a prevalent and potentially debilitating condition that mostly affects individuals of reproductive age, and often has a substantial diagnostic delay. US is usually the first-line imaging modality used when patients report chronic pelvic pain or have issues of infertility, both common symptoms of endometriosis. Other than the visualization of an endometrioma, sonologists frequently do not appreciate endometriosis on routine transvaginal US images. Given a substantial body of literature describing techniques to depict endometriosis at US, the Society of Radiologists in Ultrasound convened a multidisciplinary panel of experts to make recommendations aimed at improving the screening process for endometriosis. The panel was composed of experts in the imaging and management of endometriosis, including radiologists, sonographers, gynecologists, reproductive endocrinologists, and minimally invasive gynecologic surgeons. A comprehensive literature review combined with a modified Delphi technique achieved a consensus. This statement defines the targeted screening population, describes techniques for augmenting pelvic US, establishes direct and indirect observations for endometriosis at US, creates an observational grading and reporting system, and makes recommendations for additional imaging and patient management. The panel recommends transvaginal US of the posterior compartment, observation of the relative positioning of the uterus and ovaries, and the uterine sliding sign maneuver to improve the detection of endometriosis. These additional techniques can be performed in 5 minutes or less and could ultimately decrease the delay of an endometriosis diagnosis in at-risk patients.

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.

Defining a Uterine Extraction Score based on a Volume/Access Ratio in Total Hysterectomy: a retrospective cohort study

Background

Regardless of the technique used, extraction of the uterus is a crucial step in hysterectomy. There is currently no scoring system to predict its feasibility.

Objectives

Our main objective was to determine a predictive score of uterine extraction feasibility to optimise surgical planning of total hysterectomy. As secondary objectives, we examined the correlation between uterine volume predicted by preoperative ultrasound and the final weight of the surgical specimen and analysed the impact of the uterine extraction modality on operative and hospitalisation times.

Materials and Methods

We defined a Uterine Extraction Score (UES) based on the ratio between uterine sizes and vaginal access. This score was retrospectively applied to a cohort of 178 patients who were hysterectomised for benign conditions between January 2019 and December 2022.

Main outcome measures

The UES allows identification of three groups of decreasing feasibility of vaginal extraction, symbolised by traffic light colours: green - vaginal extraction without morcellation, orange -vaginal extraction with morcellation, red - abdominal morcellation by mini-laparotomy or primary laparotomy.

Results

The results show that the UES--predicted, and the observed routes of extraction concord in 92% of cases. There is a strong correlation between estimated volume and final uterine weight. Uterine morcellation lengthens the operative time and the hospital stay.

Conclusions

The UES seems to be a reliable tool to predict the route of uterine extraction in total hysterectomy.

What is new?

The development of a new scoring system empowers surgeons with decisive information to enhance perioperative outcomes.

Hysteroscopic diode laser myolysis: from a case series to literature review of incisionless myolysis techniques for managing heavy menstrual bleeding in premenopausal women

PURPOSE

This case series examined the safety and effectiveness of hysteroscopic myolysis using laser-induced interstitial thermo-therapy (LITT) for treating heavy menstrual bleeding (HMB) in premenopausal women with FIGO type 1 or 2 uterine fibroids, not planning for future fertility. Additionally, a comprehensive review of innovative, minimally invasive, incisionless myolysis techniques was conducted.

METHODS

Women with HMB, sonographically diagnosed with a single FIGO type 1 or 2 fibroid, underwent hysteroscopic myolysis using the Leonardo® diode laser. Effectiveness was assessed via transvaginal ultrasound measurement of myoma size, volume and vascularization pre and post-procedure. Moreover, we also evaluated any improvements in symptoms using the Pictorial Blood Loss Assessment Chart (PBAC score) scores.

RESULTS

The procedure resulted in significant HMB reductions and noticeable fibroid size, volume, and vascularization decrease in all three patients, with no reported complications. The literature review revealed both advantages and limitations of the minimally invasive, incisionless myolysis techniques.

CONCLUSIONS

Hysteroscopic laser myolysis is a safe and effective therapeutic intervention for patients experiencing HMB, diagnosed with FIGO type 1 or 2 fibroids, and not planning for future fertility. The procedure resulted in significant reductions in menstrual blood loss and fibroid size. Despite the promising results, it is essential to note the limitations of this report, including its case series design, a small number of patients, and a short follow-up period. Further research is necessary to confirm these results.

Extrauterine adenomyoma: A case report and systematic review of the literature

OBJECTIVE

To describe a case of extrauterine adenomyoma (EA) and review all the cases of EA in the literature.

METHODS

Pubmed/MEDLINE, Embase, and Google Scholar from 1807 to December 2022. All studies reporting the histologic diagnosis of an EA. We collected the following data: patient's age, size and location of adenomyoma, presence of endometriosis and adenomyosis, past gynecologic treatment, symptoms, diagnostic imaging, surgical intervention, alternative/adjuvant treatment, associated malignancy, and follow up.

RESULTS

Sixty-seven studies with 85 patients were included. Pain was the most frequent symptom (69.5%). Among diagnostic examinations, ultrasonography was used in 60 out of 81 reported cases, with several radiologic features described. EA was located inside the pelvis in 77.6% of patients. Adnexa were the most frequent site of the disease (24, 28.2%). History of endometriosis or adenomyosis was described in 35 patients (35, 41.2%). Uterine tissue morcellation was reported in 6 of the 85 patients (7.1%). Associated malignancy was detected in 9 out of 85 patients with available data (10.6%). There were two recurrences of disease.

CONCLUSION

Specific imaging features of EA are yet to be described in the literature. History of endometriosis and adenomyosis or uterine tissue morcellation may be suggestive of EA. Histologic examination can give a definitive diagnosis and exclude malignant transformation.

Reproducibility of #Enzian classification by transvaginal ultrasound and its correlation with symptoms

Background

The #Enzian classification represents a system to describe endometriotic lesions during surgery. Its use is well established in correlating ultrasound and surgical findings.

Objectives

To describe interobserver reproducibility of ultrasound use and symptom correlation with compartments involved using #Enzian classification.

Materials and Methods

Two experienced operators performed transvaginal sonography (TVS) in 52 patients affected by pelvic endometriosis. A rate agreement was determined. A further 200 women with endometriotic TVS signs, with no previous surgery and not taking any hormonal therapy, were staged by one of three different operators according to the #Enzian (compartments A, B, C, O, T, FA, FB, FI, FU, FO). Statistical analysis compared all the compartments, as single or associated, with single or combined symptoms (dysmenorrhea, dyspareunia, heavy menstrual bleeding - HMB, bowel symptoms).

Main outcome measures

Evaluation of the reproducibility of #Enzian classification in assessing pelvic endometriosis among different operators using TVS, and of possible associations between symptoms and specific #Enzian compartments.

Results

Excellent agreement between the two operators in evaluating almost all the compartments (k >0.8) was observed. Dysmenorrhea did not correlate with any specific compartment. We observed a significant association between dyspareunia and B compartment (p=0.02). HMB is associated with FA (p=0.02). Bowel symptoms were associated with B (p=0.02). Combining more symptoms, we observed more significant associations with different compartments.

Conclusions

#ENZIAN classification is reproducible in the evaluation of pelvic endometriosis. Some symptoms are correlated to specific ultrasound signs of the disease.

What is new?

An accurate evaluation of symptoms could guide TVS examination to detect specific endometriotic lesions and establish the best management for the patients.

Correlation between endometriosis and migraine features: Results from a prospective case-control study

BACKGROUND

Endometriosis and migraine frequently coexist, but only a limited number of studies have focused on their mutual association. The aim of our study was to investigate, in untreated women with comorbid endometriosis/adenomyosis and migraine, the correlation between headache features and endometriotic subtypes and their possible relationship with pain severity and disease disability.

METHODS

Fifty women affected by endometriosis/adenomyosis and migraine matched (1:2) with 100 patients with endometriosis alone and 100 patients with only migraine were recruited and underwent pelvic ultrasound imaging and neurological examination.

RESULTS

Severe adenomyosis, posterior and anterior deep infiltrating endometriosis (p = 0.027, p = 0.0031 and p = 0.029, respectively) occurred more frequently in women with migraine. Dysmenorrhea was the most commonly reported symptom in women with endometriosis and migraine and the mean VAS scores of all typical endometriotic symptoms were significantly higher in the presence of comorbidity. Women with both migraine and endometriosis reported significant higher pain intensity (p = 0.004), higher monthly migraine days (p = 0.042) and increased HIT 6-scores (p = 0.01), compared with those without endometriosis.

CONCLUSIONS

Our results demonstrated that the co-occurrence of migraine in untreated women with endometriosis is associated with more severe gynecological infiltrations and correlated with increased pain intensity and disease disability.Trial Registration: Protocol number 119/21.

Developing a Predictive Model for Minimal or Mild Endometriosis as a Clinical Screening Tool in Infertile Women: Uterosacral Tenderness as a Key Predictor

STUDY OBJECTIVE

To develop a noninvasive predictive model based on patients with infertility for identifying minimal or mild endometriosis.

DESIGN

A retrospective cohort study.

SETTING

This study was conducted at a tertiary referral center.

PATIENTS

A total of consecutive 1365 patients with infertility who underwent laparoscopy between January 2013 and August 2020 were divided into a training set (n = 910) for developing the predictive model and a validation set (n = 455) to confirm the model's prediction efficiency. The patients were randomly assigned in a 2:1 ratio.

INTERVENTIONS

Sensitivities, specificities, area under the curve, the Hosmer-Lemeshow goodness of fit test, Net Reclassification Improvement index, and Integrated Discrimination Improvement index were evaluated in the training set to select the optimum model. In the validation set, the model's discriminations, calibrations, and clinical use were tested for validation.

MEASUREMENTS AND MAIN RESULTS

In the training set, there were 587 patients with minimal or mild endometriosis and 323 patients without endometriosis. The combination of clinical parameters in the model was evaluated for both statistical and clinical significance. The best-performing model ultimately included body mass index, dysmenorrhea, dyspareunia, uterosacral tenderness, and serum cancer antigen 125 (CA-125). The nomogram based on this model demonstrated sensitivities of 87.7% and 93.3%, specificities of 68.6% and 66.4%, and area under the curve of 0.84 (95% confidence interval 0.81-0.87) and 0.85 (95% confidence interval 0.80-0.89) for the training and validation sets, respectively. Calibration curves and decision curve analyses also indicated that the model had good calibration and clinical value. Uterosacral tenderness emerged as the most valuable predictor.

CONCLUSION

This study successfully developed a predictive model with high accuracy in identifying infertile women with minimal or mild endometriosis based on clinical characteristics, signs, and cost-effective blood tests. This model would assist clinicians in screening infertile women for minimal or mild endometriosis, thereby facilitating early diagnosis and treatment.

Impact of adenomyosis on in vitro fertilization outcomes in women undergoing donor oocyte transfers: a prospective observational study

OBJECTIVE

To prospectively examine the association between adenomyosis type, location, and severity with reproductive outcomes in patients undergoing single embryo transfer (SET) with embryos derived from donor oocytes.

DESIGN

A prospective observational cohort study.

SETTING

University-affiliated in vitro fertilization center.

PATIENTS

Patients with infertility with (n = 114) and without (n = 114) adenomyosis who received their first donor oocyte transfer between January 2019 and January 2023 were included in this study.

INTERVENTIONS

Adenomyosis was confirmed with the presence of at least one direct feature visualized by 2- or 3-dimensional transvaginal ultrasound and classified according to type (diffuse or focal), localization (inner or outer myometrium and/or junctional zone [JZ]), and uterine extension (mild, moderate, or severe). After an artificial or natural endometrial preparation cycle, patients underwent SET in the blastocyst stage.

MAIN OUTCOME MEASURES

The primary outcome was the implantation rate. The secondary outcomes were the clinical pregnancy, live birth, and miscarriage rates after SET.

RESULTS

The presence of adenomyosis did not significantly affect the implantation, clinical pregnancy, or live birth rates. However, women with adenomyosis had a significantly higher miscarriage rate than those without adenomyosis (35.4% vs. 18.1%, respectively). The multivariate analysis assessed possible risk factors for each clinical outcome considered in the study and showed that adenomyosis affected the risk of miscarriage. Specifically, transvaginal sonography detection of adenomyosis in the JZ was associated with over threefold higher relative risk of miscarriage (relative risk [RR], 3.28; 95% confidence interval [CI], 1.38-7.78). Conversely, adenomyosis features detected exclusively in the outer myometrium were associated with a higher ongoing pregnancy rate (RR, 0.30; 95% CI, 0.13-0.72). Diffuse adenomyosis in the JZ and severe adenomyosis increased the relative risk of miscarriage two-fold (RR, 2.29; 95% CI, 1.22-4.30 and RR, 2.20; 95% CI, 1.19-4.04, respectively).

CONCLUSIONS

This study demonstrated that although adenomyosis did not significantly reduce the odds of implantation, the direct signs of adenomyosis in the JZ and disease severity are significant risk factors for miscarriage in patients receiving donor oocyte transfers. This study highlights the importance of thorough ultrasound examination and detailed adenomyosis classification in the assessment and management of patients with infertility.

Clinical characteristics and outcomes of women with adenomyosis pain during pregnancy: a retrospective study

OBJECTIVES

Adenomyosis is associated with unfavorable perinatal outcomes, and recent case reports show that some women with adenomyosis experience pain at the adenomyosis lesion during pregnancy and have detrimental perinatal outcomes. This study aimed to clarify the clinical characteristics of this pain and perinatal outcomes associated with this phenomenon.

METHODS

This was a single-center retrospective analysis of pregnant women with adenomyosis. The incidence of pain onset at adenomyosis lesions, defined as persistent pain at the adenomyosis site with administration of analgesics for pain relief, and its association with perinatal outcomes were analyzed.

RESULTS

Among 91 singleton pregnancies with adenomyosis, 12 pregnancies (13.2 %) presented with pain. One pregnancy resulted in second-trimester miscarriage, and 5 of the 11 pregnancies (45 %) developed preeclampsia, which resulted in preterm delivery, and 3 of the 12 pregnancies (25 %) achieved term delivery. The incidence of preeclampsia and preterm delivery was higher in those who experienced pain than in those without (45 % [5/11] vs. 15 % [11/74]; p<0.05, and 73 % [8/11] vs. 34 % [25/74]; p<0.05, respectively). Among women with pain, the maximum C-reactive protein level was significantly higher in women who developed preeclampsia than in those who did not (5.45 vs. 0.12 mg/dL, p<0.05).

CONCLUSIONS

Our study revealed that adenomyosis can cause pain in over one of eight pregnancies with adenomyosis, which may be associated with the increased incidence of preeclampsia resulting in preterm delivery. Women with pain, especially those with high C-reactive protein levels, may be at high risk for future development of preeclampsia and consequent preterm delivery.

Management of Uterine Fibroids and Sarcomas: The Palermo Position Paper

BACKGROUND

Uterine fibroids are benign monoclonal tumors originating from the smooth muscle cells of the myometrium, constituting the most prevalent pathology within the female genital tract. Uterine sarcomas, although rare, still represent a diagnostic challenge and should be managed in centers with adequate expertise in gynecological oncology.

OBJECTIVES

This article is aimed to summarize and discuss cutting-edge elements about the diagnosis and management of uterine fibroids and sarcomas.

METHODS

This paper is a report of the lectures presented in an expert meeting about uterine fibroids and sarcomas held in Palermo in February 2023.

OUTCOME

Overall, the combination of novel molecular pathways may help combine biomarkers and expert ultrasound for the differential diagnosis of uterine fibroids and sarcomas. On the one hand, molecular and cellular maps of uterine fibroids and matched myometrium may enhance our understanding of tumor development compared to histologic analysis and whole tissue transcriptomics, and support the development of minimally invasive treatment strategies; on the other hand, ultrasound imaging allows in most of the cases a proper mapping the fibroids and to differentiate between benign and malignant lesions, which need appropriate management.

CONCLUSIONS AND OUTLOOK

The choice of uterine fibroid management, including pharmacological approaches, surgical treatment, or other strategies, such as high-intensity focused ultrasound (HIFU), should be carefully considered, taking into account the characteristics of the patient and reproductive prognosis.

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.

Uterine smooth muscle tumors: a multicenter, retrospective, comparative study of clinical and ultrasound features

OBJECTIVE

To evaluate a wide range of clinical and ultrasound characteristics of different uterine smooth muscle tumors to identify features capable of discriminating between these types.

METHODS

This was a retrospective, multicenter study that included 285 patients diagnosed with uterine smooth muscle tumors (50 leiomyosarcomas, 35 smooth muscle tumors of uncertain malignant potential, and 200 leiomyomas). The patients were divided into three groups based on the histological type of their tumors, and the groups were compared according to the variables collected.

RESULTS

Leiomyosarcomas were more common in older and post-menopausal women. Compared with leiomyomas, smooth muscle tumors of uncertain malignant potential and leiomyosarcomas had similar ultrasound features such as absence of normal myometrium, multilocular appearance, hyper-echogenicity in case of uniform echogenicity, absence of posterior shadows, echogenic areas, and hyperechoic rim. Leiomyosarcomas were larger, had more cystic areas, and were associated with a higher prevalence of pelvic free fluid. Smooth muscle tumors of uncertain malignant potential were characterized by a higher frequency of International Federation of Gynecology and Obstetrics (FIGO) type 6-7, the absence of internal shadows, and, in the case of cystic area, the presence of a regular internal wall. Tumor outline varied among the three histological types. A color score of 1 was typical of leiomyoma, a color score 2 was mainly observed in leiomyomas and smooth muscle tumors of uncertain malignant potential, a color score 3 did not differ among the tumors, while a color of score 4 was related to leiomyosarcomas. When combining color scores 3 and 4, leiomyosarcomas and smooth muscle tumors of uncertain malignant potential showed a high percentage of both circumferential and intra-lesional vascularization. A cooked appearance was not statistically different among the tumors.

CONCLUSIONS

Based on our findings, specific ultrasonographic features as well as age and menopausal status are associated with different uterine smooth muscle tumor types. Integration of these data can help the pre-operative assessment of these lesions for proper management.

Diagnostic accuracy of the IDEA protocol for non invasive diagnosis of rectosigmoid DE - a prospective cohort study

OBJECTIVES

 To test the accuracy of TVS applying the IDEA approach for suspected rectosigmoid DE and to determine the frequency of other pelvic diseases mimicking DE in patients undergoing surgery.

MATERIALS UND METHODS

 Prospective single center observational study including consecutive women undergoing TVS for clinically suspected rectosigmoid DE followed by conservative or surgical therapy. TVS findings were compared with those obtained by laparoscopy and confirmed histologically.

RESULTS

 Of the 671 included patients, 128 women opted for medical therapy, and 6 patients decided for surgery but did not give consent to participate in the study. 537 women were enrolled in the final analysis. 279 (52 %) exhibited surgically confirmed rectosigmoid DE. The sensitivity and specificity, positive and negative predictive value (PPV, NPV), positive and negative likelihood ratio (LR+/-) and accuracy of TVS for diagnosing DE in the rectosigmoid were 93.5 %, 94.6 %, 94.9 %, 93.1 %, 17.24, 0.07, 94.04 %. 12 women who were clinically suspected for DE and mimicked sonographic signs fulfilling the IDEA criteria did exhibit other pathologies. Diagnoses were as follows: vaginal Gartner duct cyst (3/291;1.0 %), anorectal abscess (3/291; 1.0 %), rectal cancer (2/291;0.7 %), hydrosalpinx (2/291;0.7 %), metastatic endometrial cancer (1/291;0.35 %) and Crohn's disease (1/291;0.35 %).

CONCLUSION

 TVS for diagnosing colorectal DE applying the IDEA criteria is highly accurate for presurgical diagnosis. However, additional pelvic pathologies are encountered in 4-5 % of women attending for suspected rectosigmoid DE. These need to be taken into account when investigating patients for suspected DE.

The myometrial-cervical ratio: Can a simple sonographic measurement improve diagnosis of adenomyosis in a regional setting?

Introduction

Adenomyosis is histologically defined by the presence of endometrial glands and stroma in the myometrium. Ultrasound findings of adenomyosis are being redefined to better diagnose adenomyosis pre-operatively.

Methods

A single-centre retrospective study was performed at a regional hospital. The myometrial-cervical ratio was calculated on pre-operative ultrasounds, and histopathology reviewed for each case. Logistic regression was used to estimate the association between the myometrial-cervical ratio and adenomyosis confirmed on histopathology, and the area under the receiver operating characteristic curve was calculated. Comparisons were performed based on the presence of fibroids on ultrasound.

Results

Complete data were available for 136 benign hysterectomies between 1 January 2015 and 31 December 2020. When the myometrial-cervical ratio was treated as a continuous variable in a logistic regression of adenomyosis on histopathology, there was no statistical evidence (χ2(1) < 0.01, p = 0.98) of an association. When cases including fibroids in the myometrial-cervical ratio were excluded, there was a non-significant association between myometrial-cervical ratio and adenomyosis on histopathology (odds ratio = 3.435, 95% confidence interval = 0.964, 12.235; χ2(1) = 3.62, p = 0.057); area under the receiver operating characteristic = 0.637 (95% confidence interval = 0.504, 0.770). The optimal myometrial-cervical ratio cutpoint was 1.875 (95% confidence interval = 1.698, 2.051), which achieved 71.43% sensitivity and 60.00% specificity. There was strong statistical evidence (χ2(1) = 9.02, p = 0.003) that the myometrial-cervical ratio outperformed standard pre-operative ultrasound identification of adenomyosis.

Conclusion

While accuracy remains suboptimal, the myometrial-cervical ratio outperformed standard ultrasound diagnostic features of adenomyosis in a regional setting. The myometrial-cervical ratio may offer a simple imaging measurement for adenomyosis in inexperienced hands when fibroids are absent.

Dysregulated expression of GATA2 and GATA6 transcription factors in adenomyosis: implications for impaired endometrial receptivity

OBJECTIVE

To study the effect of adenomyosis on the localized expression of the GATA binding proteins 2 and 6 (GATA2 and GATA6) zinc-finger transcription factors that are involved in proliferation of hematopoietic and endocrine cell lineages, cell differentiation, and organogenesis, potentially leading to impaired endometrial implantation.

DESIGN

Laboratory based experimental study.

SETTING

Academic hospital and laboratory.

PATIENTS

Human endometrial stromal cells (HESCs) of reproductive age patients, 18-45 years of age, with adenomyosis were compared with patients with no pathology and leiomyomatous uteri as controls (n = 4 in each group, respectively). Additionally, midsecretory phase endometrial sections were obtained from patients with adenomyosis and control patients with leiomyoma (n = 8 in each group, respectively).

INTERVENTIONS

GATA2 and GATA6 immunohistochemistry and H-SCORE were performed on the midsecretory phase endometrial sections from adenomyosis and leiomyoma control patients (n = 8 each, respectively). Control and adenomyosis patient HESC cultures were treated with placebo or 10-8 M estradiol (E2), or decidualization media (EMC) containing 10-8 M E2, 10-7 M medroxyprogesterone acetate, and 5 × 10-5 M cAMP for 6 and 10 days. Additionally, control HESC cultures (n = 4) were transfected with scrambled small interfering RNA (siRNA) (control) or GATA2-specific siRNAs for 6 days while adenomyosis HESC cultures (n = 4) were transfected with human GATA2 expression vectors to silence or induce GATA2 overexpression.

MAIN OUTCOME MEASURES

Immunohistochemistry was performed to obtain GATA2 and GATA6 H-SCORES in adenomyosis vs. control patient endometrial tissue. Expression of GATA2, GATA6, insulin-like growth factor-binding protein 1 (IGFBP1), prolactin (PRL), progesterone receptor (PGR), estrogen receptor 1 (ESR1), leukemia inhibitory factor (LIF), and Interleukin receptor 11 (IL11R) messenger RNA (mRNA) levels were analyzed using by qPCR with normalization to ACTB. Silencing and overexpression experiments also had the corresponding mRNA levels of the above factors analyzed. Western blot analysis was performed on isolated proteins from transfection experiments.

RESULTS

Immunohistochemistry revealed an overall fourfold lower GATA2 and fourfold higher GATA6 H-SCORE level in the endometrial stromal cells of patients with adenomyosis vs. controls. Decidual induction with EMC resulted in significantly lower GATA2, PGR, PRL and IGFBP1 mRNA levels in HESC cultures from patients with adenomyosis patient vs. controls. Leukemia inhibitory factor and IL11R mRNA levels were also significantly dysregulated in adenomyosis HESCs compared with controls. . Silencing of GATA2 expression in control HESCs induced an adenomyosis-like state with significant reductions in GATA2, increases in GATA6 and accompanying aberrations in PGR, PRL, ESR1 and LIF levels. Conversely, GATA2 overexpression via vector in adenomyosis HESCs caused partial restoration of the defective decidual response with significant increases in GATA2, PGR, PRL and LIF expression.

CONCLUSION

In-vivo and in-vitro experiment results demonstrate that there is an overall inverse relationship between endometrial GATA2 and GATA6 levels in patients with adenomyosis who have diminished GATA2 levels and concurrently elevated GATA6 levels. Additionally, lower GATA2 and higher GATA6 levels, together with aberrant levels of important receptors and implantation factors, such as ESR1, PGR, IGFBP1, PRL, LIF, and IL11R mRNA in HESCs from patients with adenomyosis or GATA2-silenced control HESCs, support impaired decidualization. These effects were partially restored with GATA2 overexpression in adenomyosis HESCs, demonstrating a potential therapeutic target.

Adenomyosis and endometriosis in adolescents and young women with pelvic pain: prevalence and risk factors

BACKGROUND

The aim of this study was to evaluate the prevalence of ultrasound diagnosis of adenomyosis and endometriosis in young women complaining of pelvic pain and to find the symptoms and clinical characteristics associated with these diseases in young women.

METHODS

Cross-sectional study, including 100 young women (14-24 years) with a history of chronic pelvic pain. Women were asked detailed medical hystory and pain symptoms scores (Visual Analogue Scale) and underwent gynecological examination and ultrasound evaluation.

RESULTS

The prevalence of endometriosis and adenomyosis in young women amounted to 25.0% and 46.0%, respectively. A significant correlation was found between ovarian endometriosis and adenomyosis. Dysmenorrhea and dyspareunia were risk factors for adenomyosis. Dyschezia, dyspareunia, chronic pelvic pain, presence of sonographic soft markers suggestive of pelvic adhesions, being a worker and having a previous surgery were risk factors for endometriosis. Young women (20-24 years) had a higher incidence of both adenomyosis and endometriosis than adolescents (14-19 years).

CONCLUSIONS

Our outcomes strengthen the hypothesis of a progressive and common course of the natural history of endometriosis, which initially may manifest with symptoms, then with signs of pelvic adhesions and finally as adenomyosis, ovarian endometriomas or deep infiltrating endometriosis.

Role of ultrasonography in the evaluation of disease severity and treatment efficacy in adenomyosis

BACKGROUND

Adenomyosis is a benign disorder characterized by the presence of ectopic endometrial glands and stroma within the myometrium. The main clinical manifestations of adenomyosis are dysmenorrhea, menorrhagia, and infertility, which affect patients' quality of life. Recently, with advancements in imaging techniques, magnetic resonance imaging, and ultrasonography have become the main diagnostic tools for adenomyosis. In addition to the diagnosis and differential diagnosis of adenomyosis, ultrasonography can also be used to evaluate the severity of adenomyosis. The emergence of new techniques, such as elastography and contrast-enhanced ultrasonography (CEUS), has significantly improved the accuracy of ultrasound-based diagnosis of adenomyosis. These two imaging tools can also be used for the differential diagnosis of adenomyosis and the evaluation of treatment efficacy after medication or ablation procedure.

OBJECTIVE

we review the efficacy of ultrasonography as a diagnostic tool for adenomyosis. We also aim to introduce the potential of ultrasound imaging in the evaluation of the severity of this disease, as well as the application of elastography and contrast-enhanced ultrasonography (CEUS) in its diagnosis.

RESULTS AND CONCLUSION

Our findings reveal the potential value of ultrasonography combined with elastography and/or CEUS as medication guidance and efficacy evaluation tools in the long-term management of adenomyosis.

Role of ultrasonography in the diagnosis of endometriosis in infertile women: Ovarian endometrioma, deep endometriosis, and superficial endometriosis

Endometriosis is a complex chronic inflammatory process characterised by the presence of endometrial-like glandular tissue outside the uterine cavity, typically within the pelvic structures. This condition affects up to 10-15 % of women and those assigned female at birth, and can result in chronic pelvic pain and in/subfertility. Treatment goals include medical, surgical options and alternative therapies. Transvaginal ultrasound (TVUS) is the currently recommended first line investigation for endometriosis with magnetic resonance imaging (MRI) reserved for those with equivocal ultrasound findings. In this paper, we aim to outline the commonly seen sonographic appearances of endometriosis divided into anterior, middle and posterior pelvic compartments. Limitations to ultrasound imaging include high operator dependence and patient factors. New imaging techniques and research into the utility of artificial intelligence (AI) into the detection of endometriosis is currently underway, with possibility of reduced diagnostic delay and better patient outcomes.