The Asian Society of Endometriosis and Adenomyosis guidelines for managing adenomyosis

Effect of Gonadotropin-Releasing Hormone Agonist Pre-Treatment on Outcomes of Fresh and Frozen Embryo Transfers in Women With Adenomyosis: A Retrospective Cohort Study With Literature Review

OBJECTIVES

To investigate the effect of gonadotropin-releasing hormone agonist (GnRHa) pre-treatment on the clinical outcomes of fresh and frozen embryo transfers (ETs and FETs, respectively) in infertile patients with adenomyosis.

DESIGN

Retrospective cohort study with literature review.

SETTING

Peking University First Hospital.

POPULATION

We analysed 413 cycles of 369 women with adenomyosis who underwent ETs or FETs.

METHODS

We performed logistic regression analysis and meta-analysis to assess the association of GnRHa pre-treatment with the clinical outcomes of ETs and FETs.

MAIN OUTCOME MEASURES

The live birth rate (LBR) was compared between patients with and without GnRHa pre-treatment.

RESULTS

The LBR was higher in the GnRHa pre-treatment group than in the non-GnRHa pre-treatment group in ETs (41.27% vs. 24.32%, p = 0.034) and FETs (40.36% vs. 20.75%, p = 0.008). The odds of achieving a live birth of women with GnRHa pre-treatment were 2.65 times higher than that of those without (95% CI: 1.19-5.92, p = 0.017) after adjusting for confounders in ETs. Similarly, the adjusted odds ratio (OR) was 2.43 (95% CI: 1.10-5.40, p = 0.029) in FETs. For the meta-analysis, eight studies met the inclusion criteria; however, only six reported the adjusted ORs. Combination of these six adjusted ORs with our results revealed that the GnRHa pre-treatment group had higher LBRs than the non-GnRHa pre-treatment group (ET: OR 1.71, 95% CI: 1.30-2.26, FET: OR 2.61, 95% CI: 1.52-4.49).

CONCLUSIONS

In women with adenomyosis, GnRHa pre-treatment may be beneficial for LBRs following both ETs and FETs.

Endometriosis Severity and Risk of Preeclampsia: A Combined Mendelian Randomization and Observational Study

Purpose

Endometriosis has been hypothesized to increase the risk of preeclampsia (PE) and eclampsia, although the exact mechanism of this relationship is not clear. This study aimed to further explore the potential association between endometriosis and PE/eclampsia through Mendelian randomization (MR) and confirm these findings in a retrospective cohort study.

Methods

A two-sample MR study was performed using genetic variants associated with endometriosis from the Finnish database, with outcome data for PE and eclampsia from the UK Biobank. Subgroup analyses were conducted based on endometriosis severity (American society of reproductive Medicine (ASRM) stages I-II and III-IV) and anatomical location (uterus, ovary, deep infiltrating endometriosis). Additionally, a retrospective cohort study was conducted to further assess the association, adjusting for confounding factors such as age, Body Mass Index (BMI), dysmenorrhea, history of uterine surgery, and adenomyosis. Multivariate logistic regression was used to analyze the risk of PE/eclampsia based on endometriosis severity.

Results

MR using the Inverse Variance Weighted method found a meaningful association between advanced endometriosis (ASRM stages III-IV) and PE/eclampsia (p = 0.008), while no significant associations were observed for lower stages or endometriosis in the uterus and ovary. In the retrospective cohort, the initial association between the revised American Fertility Society (r-AFS) score and PE/eclampsia (OR: 1.02, 95% CI: 1.01-1.03, p < 0.001) weakened after adjusting for confounders. Significant risk factors identified included age (OR: 1.20, 95% CI: 1.10-1.30, p < 0.001), dysmenorrhea (OR: 2.72, 95% CI: 1.31-5.76, p = 0.008) and adenomyosis showing the strongest association (OR: 9.96, 95% CI: 5.00-20.06, p < 0.001).

Conclusion

The findings suggest a potential relationship between advanced endometriosis and the risk of PE/eclampsia. However, other clinical factors such as age, dysmenorrhea, and adenomyosis appear to contribute more significantly to the risk. Further studies are needed to confirm these findings and clarify the underlying mechanisms.

The present adenomyosis treatment status in Luzhou, China: a small scope observational cross-sectional survey

OBJECTIVE

To evaluate the current treatment status and management deficiencies of adenomyosis in Luzhou, China.

MATERIALS AND METHODS

A small-scale observational cross-sectional study of patients whose imaging suggests adenomyosis from July 2018 to February 2022 at a teaching hospital in Luzhou, China. All participants (1542 patients) completed a questionnaire of 14 items, including basic information, symptoms, treatment options, outcomes, and costs. The patients' treatment options and the hysterectomy rate were evaluated.

RESULTS

The treatment options of hormone agents included combined oral contraceptive pills (COCs), gonadotropin-releasing hormone analogues (GnRH-a), levonorgestrel-releasing intrauterine system (LNG-IUS), and dienogest for 2.07, 46.04, 63.49, and 4.67% of patients, respectively. The treatment options under uterus-sparing surgery included adenomyectomy and high-intensity focused ultrasound (HIFU) treatment, presenting in 3.76 and 33.27% of patients, respectively. Finally, 458 (29.70%) patients chose a hysterectomy. The hysterectomy rate between the hormone and uterus-sparing surgery sequential hormone groups (surgery group) was not significantly different (14.8 vs. 12.7%, χ2 = 0.344, P > 0.05). However, for the focal type and patients with > 24 months delayed treatment interval, the hysterectomy rate of the hormone group was significantly higher than that of the surgery group (8.5% vs. 1.3%, χ2 = 11.722, P < 0.01 and 26.7% vs. 18.5%, χ2 = 4.906, P < 0.05, respectively).

CONCLUSIONS

There were treatment delays and treatment selection bias in managing adenomyosis in Luzhou, China. Popular science education and early individualized hormone therapy are needed. Uterine-sparing surgery should be carefully selected.

Dienogest treatment of symptomatic adenomyosis: An in-depth meta-analysis

BACKGROUND

Adenomyosis is a common gynecological disease and a major contributor to dysmenorrhea that substantially reduces the quality of life of the affected. Dienogest has emerged as a promising drug for treating adenomyosis. A few systematic reviews and meta-analyses on this topic have been published recently. However, these meta-analyses were typically based on 2-7 studies, even though numerical data could have been extracted and more studies have been published. Moreover, it is unclear whether there is any characteristic of the patients that is associated with more pronounced improvement after treatment, or which patient subgroup, if any, would benefit most from the dienogest treatment.

OBJECTIVES

To evaluate the efficacy of dienogest in alleviating dysmenorrhea associated with adenomyosis and identifying study/patient characteristics that contribute to a better therapeutic response.

DESIGN

An in-depth meta-analysis incorporating more recent published studies.

METHODS

An in-depth meta-analysis of 14 studies published up to March 2024, involving 637 patients was conducted, using the visual analog scale (VAS) scores on dysmenorrhea severity as the primary outcome measure. Subgroup analyses and multivariable regression were performed to explore potential factors influencing the treatment effect.

RESULTS

Dienogest significantly improved dysmenorrhea, with a mean reduction in VAS scores of 6 on a 10-point scale. Subgroup analyses indicated that dienogest was effective across varying severities of dysmenorrhea and different treatment durations. Notably, patients with higher baseline VAS scores and longer treatment durations experienced greater reductions in VAS scores.

CONCLUSION

Dienogest substantially alleviates dysmenorrhea in women with adenomyosis, particularly among those with severe baseline dysmenorrhea and extended treatment periods. However, variability in patient responses and the potential for adverse effects underscores the importance of individualized treatment strategies. Further large-scale, long-term comparative studies and randomized clinical trials are warranted to optimize treatment outcomes and better understand patient-specific factors.

Medical treatment before in-vitro fertilization in patients with adenomyosis: a systematic review and meta-analysis

The objective of this study is to evaluate if medical treatment before assisted reproductive technology (ART) improves the results in infertile patients with adenomyosis. A literature search was performed with EMBASE, PubMed, and Cochrane. The primary outcome was clinical pregnancy rate (CPR). Secondary outcomes were live birth rate (LBR) per cycle and miscarriage rate (MR) after ART with or without medical pretreatment. Additionally, a comparison was made between women undergoing medical pretreatment before frozen embryo transfer (FET) and those who underwent FET alone, including any type of endometrial preparation. Ten studies were included. The present meta-analysis supports the use of long-term GnRH agonist therapy in patients with adenomyosis, which enhances the CPR (odds ratio (OR) 1.49, 95% CI 1.15 to 1.92) in IVF/ICSI with fresh ET, while the comparison in women undergoing FET cycles did not reach statistical significance (OR 1.34 95% CI 0.70-2.55). Pretreatment with GnRH agonist did not demonstrate a benefit on the LBR and MR per cycle in IVF/ICSI with fresh ET in comparison to standard ovarian stimulation protocols. Similar results were observed in the setting of FET, failing to indicate a superiority of GnRH agonist pretreatment over standard FET protocols for LBR and MR. In conclusion, GnRH agonist pretreatment before ART carries a potential benefit in improving outcomes in terms of higher CPR, but there is no significant impact on LBR and MR. Pretreatment with GnRH agonists could be adopted as a possible alternative ART protocol in selected patients with adenomyosis and infertility.

Expert Consensus on the Management of Adenomyosis: A Modified Delphi Method Approach by the Taiwan Endometriosis Society

Objectives

To establish the expert opinions and consensus recommendations from the Taiwanese Endometriosis Society on managing adenomyosis.

Materials and Methods

This study employed a two-round modified Delphi method incorporating a national panel of expert gynecologists to form the consensus on managing adenomyosis. The first round of the Delphi procedure involved an expert panel from the board members to evaluate the relevance of each item. In the subsequent round of votes, gynecologists affiliated with the Taiwan Endometriosis Society participated and used a 5-point Likert scale to cast votes and approve each statement. The rating scales for each item of the key recommendations were analyzed for the distribution of degrees of agreement.

Results

The consensus for managing adenomyosis was developed, encompassing various aspects including imaging diagnosis, hormonal treatment, surgical treatment, noninvasive/minimally invasive treatment, infertility concerns, and obstetric considerations. In the first round of voting, all 25 recommendations received approval from the board members, advancing them to the second round. During the second round of voting, the majority of recommendations received either a "strongly agree" or "agree" response. There was divergence regarding the similarity of effectiveness in alleviating adenomyosis-related pain by either laparotomic or laparoscopic approaches (55% strongly agree or agree vs. 21% disagree or strongly disagree).

Conclusion

The Taiwan Endometriosis Society expert panel has established a set of consensus guidelines for the management of adenomyosis. There are diverging opinions among experts regarding the optimal surgical approaches for resection of adenomyosis.

Impact of surgery on reproductive outcomes in women with deep endometriosis and proven presurgical infertility: Facts and controversies

In women with proven infertility and deep endometriosis (DE), optimal management is controversial. To date, there is no clear evidence on the association between infertility and different stages of rASRM, nor is there clear guidance from leading scientific societies for surgical treatment of DE patients. A comprehensive literature search was conducted on the main databases for English-language trials describing the effectiveness of surgery for DE in patients with proven infertility; 16 studies were deemed eligible for inclusion in this systematic review (CRD42024498888). Quantitative analysis was not possible because of the heterogeneity of the data. A descriptive summary of the results according to location of pathology, surgical technique used, and whether assisted reproductive technology (ART) was needed or not was provided. A total of 947 infertile women were identified, 486 of whom became pregnant, with an average pregnancy rate of 51.3%. Our review suggests that surgery can be of valuable help in improving reproductive outcomes by improving the results of ART. It has not been possible to reach robust conclusions on the outcomes of surgery based on the location of DE because of the heterogeneity of evidence available to date. Overall, although some data encourage first-line surgical management, further investigation is needed to determine its effective application before or after ART failure.

Adenomyosis-A Call for Awareness, Early Detection, and Effective Treatment Strategies: A Narrative Review

OBJECTIVE

To provide a brief summary of the high incidence, symptomatology, different types, and diagnosis of adenomyosis and to explore various aspects of the disease, with the primary aim of raising awareness among gynecologists for appropriate and early detection.

BACKGROUND

Adenomyosis, a benign gynecological condition characterized by the infiltration of endometrial tissue into the myometrium, poses significant challenges to women's reproductive health.

METHODS

A narrative review was conducted by searching PubMed, Scopus, and Cochrane databases and offering a non-systematic summary and critical analysis of current knowledge on the impact of adenomyosis on women's health. Articles published in the English language up to May 2023, including original scientific papers, clinical trials, meta-analyses, and reviews focusing on various aspects of adenomyosis, were included in the synthesis of this review.

CONCLUSIONS

Approximately 20% of women are affected by adenomyosis, which manifests with various subtypes, distinct epidemiological profiles, symptomatology, and treatment responses. Despite its clinical significance, adenomyosis remains understudied, resulting in a significant disparity in research and the literature compared to other gynecological conditions. The severity of adenomyosis is compounded when coexisting with endometriosis, particularly deep-infiltrating endometriosis (DIE), leading to exacerbated fertility issues and severe symptomatology. The wide range of symptoms, including adverse pregnancy outcomes such as pre-eclampsia, highlights its wider impact and emphasizes the need for increased awareness of the condition. Adenomyosis is frequently associated with treatment failure in endometriosis, contributing to dienogest resistance, elevated discontinuation rates, and persistent pain post-endometriosis surgery. Additionally, the lack of specific treatments tailored to adenomyosis poses a considerable challenge in clinical management.

Postmenopausal giant uterine adenomyoma with adipose metaplasia: A case report and literature review

RATIONALE

Uterine adenomyomas (UAs) are common benign tumors, usually not exceeding 280 g or the weight of the uterus at 12 weeks gestation. Postmenopausal giant UAs of diameter larger than 20 cm are rare, as well as steatosis, but curable by surgical excision. Few cases of postmenopausal giant UAs have been reported.

PATIENT CONCERNS

Herein, we report a case of a 70-year-old female patient who presented with a giant pelvic tumor of about 20 cm × 18 cm × 20 cm with postmenopausal vaginal bleeding, and whose radiographic manifestations did not exclude the possibility of uterine malignancy.

DIAGNOSES

Histopathology confirms an adenomyoma with partial adipose metaplasia.

INTERVENTIONS

We did an open laparotomy of hysterectomy, bi-adnexectomy, and pelvic adhesion release for the patient.

OUTCOMES

Pathology revealed adenomyoma with adipose metaplasia. The patient recovered well and was discharged on postoperative day 7 with satisfactory follow-up.

Meclizine improves endometrial repair and reduces simulated menstrual bleeding in mice with induced adenomyosis

BACKGROUND

Adenomyosis is one of the structural causes of abnormal uterine bleeding, which often presents as heavy menstrual bleeding. Mostly because of the poor understanding of its pathophysiology, medical management of adenomyosis-induced heavy menstrual bleeding is still a challenge. We have previously reported that glycolysis is crucial to endometrial repair following menstruation and that suppressed glycolysis can cause heavy menstrual bleeding.

OBJECTIVE

This study aimed to test the hypothesis that meclizine, a drug with an excellent safety profile, alleviates heavy menstrual bleeding in mice with induced adenomyosis using a simulated menstruation model.

STUDY DESIGN

Adenomyosis was induced in 36 female C57BL/6 mice using endometrial-myometrial interface disruption. Three months after induction, the mice were randomly divided into the following 3 groups: low-dose meclizine, high-dose meclizine, and controls. Treatment with meclizine or vehicle started shortly before the simulated menstruation procedure and ended before progesterone withdrawal. The amount of blood loss was quantified and uterine tissue was harvested for histologic evaluation of the grade of endometrial repair. We performed immunohistochemistry analysis of 4 proteins critically involved in glycolysis: Glut1 (glucose transporter 1), Hk2 (hexokinase 2), Pfkfb3 (6-phosphofructo-2-kinase/fructose-2,6-biphosphatase 3), and Pkm2 (pyruvate kinase M2). The extent of tissue fibrosis in both ectopic and eutopic endometria was evaluated using Masson trichrome staining.

RESULTS

In mice with induced adenomyosis, meclizine accelerated endometrial repair in a dose-dependent manner and reduced the amount of menstrual bleeding. Meclizine administration raised endometrial immunoexpression of Hk2 and Pfkfb3 but not of Glut1 or Pkm2. The extent of endometrial fibrosis was reduced following the meclizine administration. Remarkably, these favorable changes were accompanied by the suppression of lesional progression, as evidenced by the dose-dependent reduction in the extent of fibrosis (a surrogate for lesional progression).

CONCLUSION

These encouraging results, taken together, suggest that glycolysis may be a promising therapeutic target and that meclizine may hold therapeutic potential as a nonhormonal treatment for adenomyosis-induced heavy menstrual bleeding without exacerbating the disease.

MRI-Based Radiomics as a Promising Noninvasive Diagnostic Technique for Adenomyosis

Background: MRI diagnostics are important for adenomyosis, especially in cases with inconclusive ultrasound. This study assessed the potential of MRI-based radiomics as a novel tool for differentiating between uteri with and without adenomyosis. Methods: This retrospective proof-of-principle single-center study included nine patients with and six patients without adenomyosis. All patients had preoperative T2w MR images and histological findings served as the reference standard. The uterus of each patient was segmented in 3D using dedicated software, and 884 radiomics features were extracted. After dimension reduction and feature selection, the diagnostic yield of individual and combined features implemented in the machine learning models were assessed by means of receiver operating characteristics analyses. Results: Eleven relevant radiomics features were identified. The diagnostic performance of individual features in differentiating adenomyosis from the control group was high, with areas under the curve (AUCs) ranging from 0.78 to 0.98. The performance of ML models incorporating several features was excellent, with AUC scores of 1 and an area under the precision-recall curve of 0.4. Conclusions: The set of radiomics features derived from routine T2w MRI enabled accurate differentiation of uteri with adenomyosis. Radiomics could enhance diagnosis and furthermore serve as an imaging biomarker to aid in personalizing therapies and monitoring treatment responses.

Systematic review and meta-analysis of reproductive outcomes after high-intensity focused ultrasound (HIFU) treatment of adenomyosis

High-intensity focused ultrasound (HIFU) has emerged as a promising uterus-sparing and possibly fertility-sparing treatment modality for women with adenomyosis, especially those who desire to conceive. We conducted this systematic review and performed a meta-analysis on clinical studies aimed to improve reproduction in women with adenomyosis. After extensive search of PubMed and CNKI, we identified 10 studies published in English and Chinese involving a total of 557 patients with adenomyosis who desired to conceive after HIFU treatment. We found a pooled estimate of pregnancy rate of 53.4% and of the live birth rate of 35.2%, and there was a substantial heterogeneity among these studies. While there is a potential for HIFU treatment to improve fertility for patients with adenomyosis who desired to conceive, such evidence is very weak as of now. Comparative studies with much higher methodological rigor, preferably randomized clinical trials, are badly needed to further illuminate this issue.