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

Differences in the Sonographic Features of Adenomyosis and Concurrent Endometriosis Compared to Isolated Adenomyosis: A MUSA Criteria Analysis

OBJECTIVE

To examine whether the co-occurrence of endometriosis affects the sonographic features of adenomyosis based on the revised Morphological Uterus Sonographic Assessment (MUSA) criteria.

METHODS

This prospective cohort study utilized data from a tertiary referral center collected between 2010 and 2022. Non-pregnant women aged 20-53 years who presented with symptoms potentially related to adenomyosis and underwent pelvic ultrasound scans were included. Diagnoses were based on the revised MUSA criteria, which distinguish between direct features (endometrial cysts, hyperechogenic islands, echogenic sub-endometrial lines, and buds) and indirect features (globular shape of the uterus, asymmetrical uterine wall thickening, irregular junctional zone, fan-shaped shadowing, translesional vascularity, and interrupted junctional zone). Patients were categorized into 2 groups: 1) concurrent adenomyosis and endometriosis and 2) isolated adenomyosis. Demographic and clinical characteristics were retrospectively collected.

RESULTS

Ninety-four patients were diagnosed with adenomyosis. Of these, 24 (27%) had concurrent endometriosis, while 70 had isolated adenomyosis. The most frequent sonographic features were globular uterine configuration (52%), myometrial cysts (44%), and asymmetrical myometrial thickening (33%). The isolated adenomyosis group had a higher proportion of direct features (29%) and both direct and indirect features (33%) compared to the concurrent group, which predominantly exhibited indirect features (71%) (P < .05). Direct features of myometrial cysts were significantly more frequent in the isolated adenomyosis group (51%) compared to the concurrent group (21%, P = .01).

CONCLUSIONS

Utilizing the revised MUSA criteria revealed significant differences in the sonographic features of adenomyosis in symptomatic patients with concurrent endometriosis compared to isolated adenomyosis. This highlights the necessity for standardized diagnostic methods and enhances understanding of the complex relationship between adenomyosis and endometriosis, underscoring the importance of accurate diagnosis in clinical practice.

Diagnosing adenomyosis using transvaginal ultrasound in current practice: A scoping review and service evaluation

Background

A departmental audit identified a case of adenomyosis which had not been reported, highlighting the need to assess whether the current service provision is adequate in identifying patients with (possible) adenomyosis and how improvements in this part of the service could be made.

Aim

To assess whether sonographers are effectively identifying and reporting adenomyosis on transvaginal ultrasound.

Methodology

A scoping review and retrospective service evaluation was undertaken which included (n = 79) adult female premenopausal patients with symptoms of adenomyosis who had undergone a transvaginal ultrasound scan during the first quarter of 2023. Patients were identified using the CRIS statistic module according to pre-defined inclusion and exclusion criteria. All data were anonymised and collated to include the patient age, referral information (symptoms), scan report and sonographer. The scan report and archived images were evaluated using the sonographic signs identified by the Morphological Uterus Sonographic Assessment group (Harmsen et al., 2022) and then compared to the original report.

Results

In total, 21.5% (n = 17) of patients had signs of adenomyosis on image review, but only 23.5% (n = 4) of these were reported as such. The majority (n = 8) of unidentified cases were reported as having a 'heterogeneous myometrium'. Inter-rater agreement ranged from 50% to 100%.

Conclusion

Most ultrasonic diagnoses of adenomyosis were not identified in our service which is likely due to a lack of internationally agreed criteria for ultrasound diagnosis of adenomyosis preventing adequate reporting.

Adenomyosis, especially in its focal nature, hampers implantation and live birth rate after single euploid embryo transfer

OBJECTIVE

The primary objective of this study was to assess if uterine adenomyosis impacts live birth rate per euploid embryo transfer. The secondary objectives included addressing obstetric and perinatal outcomes in the study group.

METHODS

This was a multicenter and retrospective cohort study in which 228 patients diagnosed with adenomyosis undergoing single euploid embryo transfer between 2016 and June 2023 were included and matched on 1:1 ratio to control patients without ultrasonographic diagnostic criteria for adenomyosis.

RESULTS

A significant higher live birth rate per embryo transfer was observed in controls compared to women with adenomyosis: 107/228 (46.9%) versus 56/228 (24.6%), respectively (odds ratio (OR) = 2.71, 95% confidence interval [CI]: 1.73-4.13, p < 0.001). When dividing adenomyotic patients regarding the nature of the disease, a higher live birth rate per transfer was described in diffuse adenomyosis compared to focal adenomyosis: 47/166 (28.3%) versus 9/62 (15%), respectively (OR = 2.32, 95% CI: 1.03-5.78, p = 0.034). Described differences were constant even when correcting for multiple variables. There was no statistically significant difference in childbirth delivery method (vaginal vs. cesarean section) between the adenomyosis and control groups. Mean gestational age at the time of delivery, newborn size and weight, and incidences of low birth weight, preterm birth, and admission to the neonatal intensive care unit did not differ between the two groups. In addition, in vitro fertilization (IVF) and perinatal outcomes were similar in patients with diffuse compared with focal adenomyosis.

CONCLUSION

Adenomyosis, especially focal adenomyosis, affects clinical but may not affect perinatal outcomes after single euploid embryo transfer.

Feasibility study of the application of magnetic resonance elastography to diagnose uterine adenomyosis

OBJECTIVE

Magnetic resonance elastography (MRE), a novel imaging technique that allows in vivo measurement of tissue mechanical properties, was used to test the prediction that the stiffness of the uterus may be increased due to fibrotic changes in patients with adenomyosis.

DESIGN

A feasibility study in which a 3-dimensional (3D) MRE imaging protocol was developed to measure the stiffness of the tissues of the uterus.

SUBJECTS

Four patients with suspected adenomyosis and heavy menstrual bleeding diagnosed via transvaginal ultrasound and clinical history and 1 healthy control were recruited. Two patients underwent hysterectomy, and histologic analysis of the tissue samples was performed.

MAIN OUTCOME MEASURES

The stiffness of the whole uterus was obtained by region of interest analysis of the 3D MRE images for the 4 patients and 1 healthy control. In addition, for the 2 patients who underwent hysterectomy, the uterine tissue samples were assessed to determine histologic presence of adenomyosis via hematoxylin and eosin staining, cellular/molecular measures of tissue stiffness (collagen [picrosirius red], α-smooth muscle actin, and e-cadherin), and whether a relationship existed between in vivo assessment of the uterus via 3D MRE and in vitro uterine tissue histology.

RESULTS

3D MRE was successfully used to acquire elastograms for 4 patients with adenomyosis (diffuse, n = 3; focal, n = 1) and 1 healthy control. Calculated global uterine stiffness was higher in women with adenomyosis (2.93 kPa; range, 2.34-3.39 kPa) than in the healthy control (2.04 kPa). Regions of high stiffness on the 3D elastograms reflected adenomyotic changes visualized via conventional magnetic resonance imaging and were correlated with histologic and immunohistochemical markers of tissue stiffness.

CONCLUSION

3D MRE has the potential to provide non-invasive characterization of changes in the mechanical properties of uterine tissue that is not possible using conventional magnetic resonance imaging or transvaginal ultrasound. Further studies are needed to confirm the efficacy of the 3D MRE protocol for diagnosing adenomyosis.

Imaging Spectrum of Typical and Atypical Adenomyosis

Adenomyosis, characterized by heterotopic endometrial tissue within the myometrium, is a common yet poorly understood condition affecting patients of childbearing age. Although typical features of adenomyosis are extensively discussed in the literature, there is no consensus on its imaging classification. The Morphological Uterus Sonographic Assessment (MUSA) consensus statement is a valuable tool for identifying and describing typical adenomyosis imaging features at US. However, for MRI, there is still no standardized consensus for descriptors and subtypes. The diverse atypical manifestations of adenomyosis are a diagnostic challenge. Familiarity with these manifestations is essential for accurate diagnosis, avoiding misdiagnosis, and ensuring optimal clinical management. The authors examine the imaging appearances of typical and atypical adenomyosis at US and MRI, encompassing focal adenomyosis, diffuse adenomyosis, adenomyomas (solid and cystic types), polypoid adenomyomas, adenomyosis during pregnancy, and malignant transformation. The discussion includes clinical, surgical, and pathologic aspects in the differential diagnosis, with consideration of uterine contractions, deep endometriosis with myometrial infiltration, leiomyomas, and accessory cavitated uterine masses. Practical tips are provided to assist radiologists in distinguishing adenomyosis from other conditions. ©RSNA, 2025 Supplemental material is available for this article.

Updates on adenomyosis and fertility

PURPOSE OF REVIEW

Adenomyosis, characterized by ectopic endometrial tissue within the myometrium, causes chronic pelvic pain, heavy bleeding, and reduced fertility. Nowadays, diagnosis relies heavily on imaging, primarily transvaginal ultrasound, supplemented by MRI. While hysterectomy remains a definitive treatment, the rise in younger patients desiring fertility necessitates uterine-sparing approaches. This review aimed to evaluate these approaches in relation to their impact on fertility and obstetrical outcomes.

RECENT FINDINGS

Research highlights the association between adenomyosis and increased risk for pregnancy loss, preterm birth, and pre-eclampsia. Minimally invasive thermal ablation therapies and hysteroscopic techniques, including adenomyomectomy, offer promising fertility-sparing options, although long-term data on fertility outcomes and potential complications like uterine rupture remain limited. Advances in laparoscopic and laparotomy-based cytoreductive surgeries are also explored, but large-scale studies comparing efficacy and safety are lacking.

SUMMARY

This review examines recent advancements in understanding and managing adenomyosis, focusing on fertility-sparing interventions. Studies show varying success rates for these interventions, highlighting the need for larger, well-designed trials with standardized diagnostic criteria, to assess long-term fertility outcomes, and refine patient selection for optimal results. A consistent challenge across all approaches is the potential for uterine rupture and placenta accreta spectrum, demanding careful patient selection and close monitoring.

Adenomyosis: the missed disease

Adenomyosis, a menstruation-related uterine disorder, refers to the presence of endometrial stroma and glands within the myometrium and is typically observed in reproductive-age women. The pathogenesis explaining the migration, persistence, proliferation and differentiation of ectopic endometrial cells includes a genetic and epigenetic background, an oestrogen/progesterone receptor imbalance and an inflammatory reaction driven by local immune dysfunction, along with fibrosis and neuroangiogenesis within the myometrium. In the past, it was thought that adenomyosis almost exclusively affected multiparous women after 40 years of age and the diagnosis was generally confirmed upon hysterectomy. Nowadays, using imaging techniques such as transvaginal ultrasonography and magnetic resonance imaging, adenomyosis is increasingly identified in young women with dysmenorrhoea, dyspareunia, abnormal uterine bleeding and heavy menstrual bleeding, and also in infertile patients. Furthermore, adenomyosis often coexists with other gynaecological conditions, such as endometriosis and uterine fibroids. Despite the improvement of non-invasive diagnostic tools, the awareness of the condition is still poor and the diagnosis is often missed, due also to a heterogeneity in clinical presentation and imaging criteria. In addition, medical and surgical management do not follow shared recommendations, even though adenomyosis requires a lifelong management plan, including pain and bleeding control, fertility preservation and pregnancy complications.

Primary versus secondary recurrent pregnancy losses: Clinical findings and live birth rate after comprehensive work-up and personalized management

INTRODUCTION

Recurrent pregnancy loss (RPL), defined as two or more consecutive pregnancy losses before 24 weeks of gestation, affects up to 1%-2% of couples. Aim of this retrospective cohort study was to report the main causes and pregnancy outcomes of a cohort of women with RPL and the efficacy of a personalized work-up and treatment in terms of live birth rate.

MATERIAL AND METHODS

Women with primary (pRPL) and secondary (sRPL) RPL underwent a complete work-up and personalized therapeutic management. Data related to clinical findings and subsequent pregnancy outcomes were collected. A retrospective comparison between clinical findings and pregnancy outcomes of pRPL vs sRPL was performed by Mann-Whitney U or Chi-square test.

RESULTS

Main findings after diagnostic work-up in pRPL (n = 157) vs sRPL (n = 138) couples were hormonal and metabolic factors (75% vs. 90%, p < 0.01), autoimmunity (52% vs. 59%, p = 0.2), acquired uterine/endometrial factors (43% vs. 34%, p = 0.2), vaginal and/or cervical infections (19% vs. 49%; p < 0.0001), congenital Mullerian anomalies (15% vs. 9%; p = 0.1), inherited thrombophilias (13% vs. 21%; p = 0.1), female karyotype abnormalities (2% vs. 2%; p = 0.9), sperm infections (27% vs. 22%; p = 0.1), abnormal semen analysis (17% vs. 14%; p = 0.1), male karyotype abnormalities (2% vs. 0%; p = 0.1). Higher pregnancy and fetal loss rate was observed in pRPL compared with sRPL (85% vs. 56%, p < 0.0001and 9% vs. 0%, p < 0.01, respectively). Higher live birth rate was found in pRLP vs sRPL women (76% vs. 56%, p < 0.001). Increased live birth rate was observed among pRPL women aged <40 years (OR 2.76; CI 1.36-5.64, p < 0.01) and/or with an AMH >1 ng/mL (OR 3.96; CI 1.34-12.52, p < 0.05). Among sRPL women, the age < 40 years was significantly associated to higher live birth rate (OR 3.23; 1.55-6.94, p < 0.01).

CONCLUSIONS

RPL is a heterogeneous multifactorial syndrome. A customized management can lead to a good pregnancy outcome in more than a half of cases. Age <40 and AMH >1 ng/mL are the major positive predictors of live birth rate in RPL women.

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.

Risk factors for uterine adenomyosis diagnosed by MRI in women of reproductive age

Background

Adenomyosis is a condition characterized by the presence of endometrial glands and stroma within the myometrium. It can manifest as either focal or diffuse. While histopathological examination of the uterus following hysterectomy remains the gold standard for definitive diagnosis, non-invasive imaging techniques, particularly magnetic resonance imaging (MRI), are crucial for diagnosis. This study aimed to investigate the risk factors and associated pathologies in women with MRI-confirmed adenomyosis.

Methods

In this case-control study, 50 women of reproductive age with MRI-confirmed adenomyosis were recruited as the case group, and fifty other women who underwent pelvic MRI due to various indications that were not diagnosed as adenomyosis were included as the control group. Pelvic MRI with and without intravenous contrast was done for all patients. Factors such as age, smoking, number of pregnancies, history of uterine surgery, endometriosis, ovarian cyst, and coexisting leiomyoma were searched and recorded in both groups, and their relationship with uterine adenomyosis was statistically analyzed. The software used was IBM-SPSS v.26. A Significance level of less than 5% was considered.

Results

No significant difference was found in terms of age (P = 0.891), smoking (P = 0.999), coexisting leiomyoma (P = 0.687), and ovarian cysts (P = 1.00) between case and control groups. The prevalence of endometriosis (P < 0.0001), history of uterine surgery (P = 0.002), and number of pregnancies (P = 0.012) were significantly higher in the case group.

Conclusion

The study findings suggest significant associations between endometriosis, number of pregnancies, and history of uterine surgery with adenomyosis. Therefore, managing these risk factors appropriately can substantially reduce the occurrence of adenomyosis.

Sequential therapy of dienogest following relugolix for adenomyosis and impact on symptoms and serum CA125 levels: a case series

BACKGROUND

Adenomyosis, characterized by endometrial tissue within the uterine muscle, often presents with severe pelvic pain and menorrhagia. This case series demonstrates the efficacy of sequential therapy involving relugolix followed by dienogest in managing adenomyosis.

CASE PRESENTATION

In five patients with adenomyosis, the gonadotropin-releasing hormone antagonist relugolix initially mitigated symptoms and reduced the levels of serum CA125, a marker associated with disease activity. After six months of relugolix, patients were transitioned to dienogest. This sequential approach maintained symptom relief and further stabilized CA125 levels.

CONCLUSIONS

Our findings demonstrate that sequential therapy provides effective symptom management and long-term disease control. Further, CA125 remains a valuable biomarker for monitoring therapeutic success.

Treatment-related changes in adenomyosis: a primer for radiologists

Adenomyosis is a common, estrogen-dependent condition where endometrial tissue grows within the myometrium, often accompanied by smooth muscle hypertrophy. Initially thought to represent a condition primarily seen in multiparas with menorrhagia, and dysmenorrhea, adenomyosis is now increasingly recognized in younger patients and those with infertility and subfertility. As a result, conservative treatments aimed at preserving the uterus and improving reproductive outcomes have gained attention to treat adenomyosis. While research has largely focused on managing abnormal uterine bleeding and dysmenorrhea, there is limited evidence on the treatment of infertility associated with adenomyosis, particularly in terms of imaging follow-up. This paper reviews the emerging literature, highlighting key imaging findings before and after uterus-preserving treatments for adenomyosis, to better inform management and decision-making.

Evaluation of Long-COVID Syndrome in a Cohort of Patients with Endometriosis or Adenomyosis

Background: Long-COVID is characterized by the persistency of COVID-19 symptoms beyond 12 weeks, and it is probably consequent to immune dysregulation induced by SARS-CoV-2 infection. Immune dysregulation is associated with and probably involved in the pathogenesis of chronic gynecological conditions like endometriosis and adenomyosis. This study evaluated whether the presence of endometriosis or adenomyosis increases the risk of long-COVID, i.e., the persistence of COVID-19 symptoms beyond 12 weeks since infection. Methods: This retrospective observational study was performed at the outpatient service for endometriosis and chronic pelvic pain, at a university hospital. The diagnosis of endometriosis/adenomyosis was primarily based on clinical symptoms and ultrasonography assessment. Data regarding infection, vaccination, symptoms associated with SARS-CoV-2 infection, and their persistence for a minimum of 12 weeks were collected. Results: This study included 247 women, 149 controls without and 98 cases with endometriosis/adenomyosis. Among these, 194 (116 controls and 78 cases) had suffered from SARS-CoV-2 infection. Rates of infection and vaccination were similar in the two groups. The distribution of the SARS-CoV-2 vaccine was uniform across the two cohorts. COVID-19 patients with endometriosis or adenomyosis exhibited a higher prevalence (p < 0.001) of dyspnea and chest pain. The prevalence of long-COVID beyond 12 weeks was higher in cases than controls (42% vs. 12%; p < 0.001) with chest pain (p < 0.001) and ageusia (p < 0.05), forming the most representative symptoms. Conclusions: Symptoms of long-COVID are more frequent in women with than without endometriosis/adenomyosis.

Uterine smooth muscle tumours with uncertain malignant potential: reproductive and clinical outcomes in patients undergoing fertility-sparing management

STUDY QUESTION

Can patients with uterine smooth muscle tumours of uncertain malignant potential (STUMP) be effectively and safely managed with fertility-sparing treatment?

SUMMARY ANSWER

This multicentre retrospective study demonstrates that fertility-sparing management for patients diagnosed with STUMP is both feasible and safe.

WHAT IS KNOWN ALREADY

Few studies, involving a limited number of patients, have investigated fertility-sparing management for STUMP in women with future pregnancy aspirations.

STUDY DESIGN SIZE DURATION

This multicentre retrospective study was conducted in collaboration with 13 Italian institutions specializing in gynaecologic oncology. The primary objective was to evaluate the reproductive outcomes of the included patients, while the secondary objective was to analyse their clinical outcomes.

PARTICIPANTS/MATERIALS SETTING METHODS

A total of 106 patients with a histological diagnosis of STUMP who underwent fertility-sparing treatment for uterine tumours were included. Patient data were collected from 13 referral centres across Italy, and reproductive and clinical outcomes were documented during follow-up. The median (range) length of follow-up was 48 (7-191) months.

MAIN RESULTS AND THE ROLE OF CHANCE

Of the 106 patients, 47 (44.3%) patients actively tried to conceive after fertility-sparing surgery, and 27 of them (57.4%) achieved a pregnancy. Among the patients trying to conceive, 12 (25.5%) women had more than one pregnancy after surgery for STUMP. At follow-up, 23 (21.7%) out of the 106 women had a recurrence of uterine disease. Furthermore, a higher rate of recurrence was observed among patients who became pregnant (17 out of 27 women (63.0%)) compared with those who did not (6 out of 79 women (7.6%); P < 0.001). Only two cases (1.9%) of malignant relapse were recorded, and one patient with a leiomyosarcoma recurrence died.

LIMITATIONS REASONS FOR CAUTION

The primary limitation of this study is the inherent biases associated with its retrospective design.

WIDER IMPLICATIONS OF THE FINDINGS

This multicentre retrospective study represents the largest case series to date examining the reproductive and clinical outcomes of patients undergoing conservative treatment for STUMP. The findings suggest that patients can be counselled on the feasibility and safety of fertility-sparing management, which should be considered by clinicians as both safe and effective.

STUDY FUNDING/COMPETING INTERESTS

No funding was received, and there are no competing interests.

TRIAL REGISTRATION NUMBER

N/A.

Adenomyosis: A potential cause of surgical failure in treating dyspareunia in rectovaginal septum endometriosis

OBJECTIVE

Dyspareunia can severely impact the quality of life of patients with endometriosis. This symptom is often linked to a specific form of deep infiltrating endometriosis, such as rectovaginal septum endometriosis. Despite the radicality of surgery, persistence and recurrence of symptoms post-surgery are not uncommon. The aim of the present study was to determine whether adenomyosis contributes to the failure of surgical interventions for dyspareunia in these patients.

METHODS

A retrospective single-cohort study was conducted at the at tertiary care gynecologic center of the University Federico II of Naples, using medical records from January 2020 to July 2023. The study included patients who underwent surgery for dyspareunia associated with rectovaginal endometriosis and had a definitive histologic diagnosis. Pain and sexual quality of life were assessed using the visual analog scale (VAS) and the sexual quality of life-female (SQoL-F) questionnaire, both before and 6 months after surgery. Patients with isolated rectovaginal endometriosis were compared to those with concurrent adenomyosis.

RESULTS

A total of 94 patients were included: thirty-five in group A (endometriosis with adenomyosis) and 59 in group B (isolated rectovaginal endometriosis). Histology confirmed deep infiltrating endometriosis (DIE) in all patients. Clinical characteristics such as age, BMI, abnormal uterine bleeding, and infertility, showed no significant differences between the groups. Multiparity was more common in group A (20%) compared to group B (5.1%) (P < 0.001). Pain VAS scores decreased significantly in both groups: from 7.11 to 5.40 in group A and from 7.34 to 3.31 in group B (both P < 0.001). Sexual quality of life (SQoL) scores improved significantly: from 42 to 57 in group A and from 41 to 66 in group B (both P < 0.001). Patients in group B showed a more significant improvement. Adjusted linear regression showed no significant association between parity and the severity of dyspareunia or sexual quality of life.

CONCLUSION

Adenomyosis appears to reduce the effectiveness of surgical treatment for dyspareunia in patients with rectovaginal septum endometriosis. Comprehensive preoperative screening for adenomyosis is recommended to improve surgical outcomes and provide appropriate counseling. Future research should further explore the impact of adenomyosis on dyspareunia and the potential benefits of adjunctive medical therapies.

Grading Sonographic Severity of Adenomyosis: A Pilot Study Assessing Feasibility and Interobserver Reliability

OBJECTIVES

The reported prevalence of adenomyosis ranges widely due to different study populations, diagnostic tests and criteria. Categorizing the severity of disease may prove important. This study aims to develop a semi-quantifiable sonographic method to grade the severity of adenomyosis and assess the feasibility and interobserver reliability of this method.

METHODS

Cross-sectional pilot study performed at a gynecology outpatient clinic, included 35 premenopausal women with adenomyosis, not taking hormonal medication. Diagnosis required ≥1 direct sonographic feature of adenomyosis. Two-dimensional (2D) grayscale video clips and 3-dimensional (3D) volumes of the uterus of the first 5 patients were evaluated using 6 offline methods to assess feasibility. Feasible methods were analyzed for interobserver (n = 3) reliability (Fleiss kappa or intraclass correlation) and compared with current ultrasound methods (Cohen's weighted kappa and Spearman's rank correlation). Current methods include real-time estimation (mild/moderate/severe) and counting the individual sonographic features.

RESULTS

"eXtended Imaging virtual organ computer-aided analysis (XI VOCAL) counting" (counting affected slices of 20 parallel slices in the 3D volume), "Multiplanar and 3D rendering (MPR) estimation" (grading volume by eyeballing in multiplanar render mode), and "2D-clip estimation" (grading volume in 2D-clips) emerged as feasible methods. "XI VOCAL counting" and "2D-clip estimation" demonstrated good interobserver reliability, whereas "MPR estimation" had poor reliability. Comparison with real-time estimation showed moderate reliability with all methods. "XI VOCAL counting" and "MPR estimation" correlated positively with the number of sonographic features.

CONCLUSION

"XI VOCAL counting" demonstrated to be feasible with good interobserver reliability to assess the severity of adenomyosis in an objective, systematic, and semi-quantifiable fashion and should be validated with large-scale studies for future use. Future studies should also explore the association between sonographic severity and symptoms of adenomyosis.

The clinical efficacy and influencing factors of uterine artery embolization in the treatment of different types of uterine adenomyosis

Uterine adenomyosis, a common benign tumor disease in gynecology, mainly manifested as chronic pelvic pain, menstrual disorders, dysmenorrhea, etc., has a great impact on patients' daily life and work. Compared with traditional surgery and drug therapy, uterine artery embolization (UAE), as a new treatment with less trauma, faster recovery and uterine preservation, can relieve pain while preserving normal physiological and reproductive functions of the uterus, which is favored by the majority of patients. In this study, the patients were divided into two groups based on magnetic resonance imaging (MRI) test. Their serum CA125 level was detected, and the degree of symptom relief and health index were evaluated, aiming to explore the clinical efficacy and influencing factors of UAE in the treatment of adenomyosis. The results showed that before UAE, CA125 level in group B was significantly higher than that in group A, and 2 days after UAE, CA125 level in both groups was lower than before treatment, indicating that the serum CA125 level may be related to the type of adenomyosis, but UAE has a good therapeutic effect on both focal and diffuse adenomyosis. 3 months after interventional treatment, the patients had significantly reduced symptoms with dramatically improved health status and the VAS pain score was significantly reduced, indicating that UAE can significantly improve the clinical symptoms of patients with adenomyosis. Uterine artery embolization was performed in both groups. No serious complications occurred during the operation, and the technical success rate reached 100%. In summary, UAE, as a minimally invasive treatment, has obvious and significant clinical effects in the treatment of adenomyosis, and is an important alternative treatment for adenomyosis.

Early-Life Exposures and Odds of Adenomyosis: A Population-Based Case-Control Study

BACKGROUND

Adenomyosis can confer life-altering symptoms such as pelvic pain. Yet, the epidemiologic study of this uterine condition lags other gynaecologic conditions. This includes the investigation of intrauterine exposures that could disrupt foetal development and contribute to the presence of adenomyosis in adulthood.

OBJECTIVE

We investigated nine early-life factors and the odds of adenomyosis using data from a population-based case-control study of enrollees of an integrated healthcare system in Washington State ages 18-59.

METHODS

Cases (n = 386) had incident, pathology-confirmed adenomyosis diagnosed between 2001 and 2006. Two control groups were employed: hysterectomy controls (n = 233) and randomly selected age-matched enrollees with an intact uterus ('population controls', n = 323). The primary study activity was a structured in-person interview; participants were also mailed a family history questionnaire that included questions on early-life factors. We conducted logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) for the associations between early-life factors and adenomyosis.

RESULTS

Comparing cases to population controls, our data suggested an 80% increased odds of adenomyosis with younger maternal age at participant's birth (≤ 19 vs. ages 25-29) (aOR 1.81, 95% CI 0.94, 3.50) and a 50% increased odds of adenomyosis for participants who were the fourth or later live birth (vs. firstborn) (aOR 1.51, 95% CI 0.88, 2.59). Among never-smoking participants, our data suggested a 50% increased odds of adenomyosis with intrauterine exposure to cigarette smoking (aOR 1.50, 95% CI 0.92, 2.46). In analyses using hysterectomy controls, these associations were attenuated.

CONCLUSIONS

These data suggested that several intrauterine exposures were associated with increased odds of adenomyosis in adulthood. The intrauterine period may be a susceptible window for subsequent development of adenomyosis and warrants further investigation.

Women's experiences of living with adenomyosis and perceptions of the diagnostic journey: a scoping review

OBJECTIVES

Uterine adenomyosis is a common gynaecological disease that can be debilitating. It is poorly understood and may be overlooked in clinical settings. A research gap exists as there are currently no published scoping reviews on perceptions and experiences early in the illness course. As part of a professional doctorate thesis, the aim of this review is to systematically retrieve and describe available literature, exploring the impact of living with adenomyosis and perceptions of the diagnostic journey.

DESIGN

A scoping review is conducted using JBI methodology.

DATA SOURCES

Medline, CINAHL Plus, Web of Science, Google Scholar, Cochrane library, JBI and PROSPERO databases, EThOS online and Google. Searches were made from database inception to July 2023.

ELIGIBILITY CRITERIA

The characteristics of the evidence sourced were deliberately broad. Studies exploring the experiences and perceptions of women diagnosed with adenomyosis were considered.

DATA EXTRACTION AND SYNTHESIS

Titles and abstracts were initially screened. Subsequently, eligibility was clarified through methods section inspection, and the remaining studies were read in depth. A manual hand-search of references of selected studies was conducted. Prespecified data were extracted, charted and categorised into themes.

RESULTS

Six eligible studies were found, with themes describing impact and burdens, as well as several categories of unsupported needs. No studies specifically focused on perceptions of the diagnostic journey, but some eligible studies made minor reference to this and are included.

CONCLUSIONS

This review highlights the profound impact of adenomyosis and is the first to explore the lived experiences and the diagnostic journey. Understanding the burdens of disease in terms of perceptions and lived experience in combination with the experiences of diagnostic interactions is vital to improving diagnostic pathways. Education with improved multidisciplinary collaboration and further qualitative and case study research will be crucial to achieve this goal.

REGISTRATION

A priori protocol was registered (https://doi.org/10.17605/OSF.IO/2UDYN) and published (https://doi.org/10.1136/bmjopen-2023-075316).

How Reproducible Are the Ultrasound Features of Adenomyosis Defined by the Revised MUSA Consensus?

Background/Objectives: The aim of this study is to assess the inter- and intra-observer reproducibility of the identification of direct and indirect ultrasonographic features of adenomyosis as defined by the revised Morphological Uterus Sonographic Assessment (MUSA) consensus (2022). Methods: A cohort of 74 women, aged 18 to 45, were recruited from the recurrent miscarriage and general gynaecology clinic at a university-based fertility centre. All the participants underwent 2D and 3D transvaginal Ultrasound scan (TVS) examination in the late follicular and early luteal phase. Conventional grey scale and power Doppler image volumes were acquired and stored. Subsequently, the stored 3D ultrasound images were independently re-evaluated offline by the two observers for the direct and indirect features of adenomyosis as outlined by the revised MUSA group. The intra- and the inter-observer reproducibility was estimated using Cohen's Kappa coefficient. Results: The intra- and interobserver reproducibility (K -0.27, 95% CI 0.06-0.48 and K 0.13, 95% CI -0.10-0.37, respectively) for at least one direct feature of adenomyosis was only modest. Amongst the individual direct features, the interobserver variability of identifying myometrial cysts was fair (K 0.21, 95% CI -0.00-0.42), whereas the intra-observer variability was moderate (K 0.44, 95% CI 0.26-0.63). While hyperechogenic islands identification achieved a fair level of intra- (K 0.31, 95% CI 0.09-0.53) and interobserver (K 0.24, 95% CI 0.01-0.47) agreement, the reproducibility of reporting sub-endometrial lines/buds was fair for the intra-observer (K 0.22, 95% CI -0.02 0.47) and poor for the interobserver (K 0.00, 95% CI -0.20-0.19). The interobserver agreement for indirect features varied from poor to moderate, while the intra-observer agreement ranged between poor to good. Conclusions: The reporting of adenomyosis using direct features suggested by the revised MUSA group consensus showed only modest interobserver and intra-observer agreement. The definitions of ultrasound features for adenomyosis need further refining to enhance the reliability of diagnosis criteria of adenomyosis.

Adenomyosis Patterns on Transvaginal Sonography Could Predict the Obstetrical Outcomes of Fertility-sparing Surgeries: A Retrospective Cohort Study

STUDY OBJECTIVE

To explore the associations between adenomyosis patterns on transvaginal sonography (TVS) and surgical outcomes.

DESIGN

A retrospective cohort study.

SETTING

Peking Union Medical College Hospital, Beijing, China.

PATIENTS

The medical records of 322 patients diagnosed with adenomyosis who underwent open or laparoscopic fertility-sparing surgeries from March 1 to December 31, 2018, were reviewed. Patients were divided into localized (221 patients) and diffuse (101 patients) adenomyosis groups on the basis of TVS findings.

INTERVENTIONS

Detailed epidemiological information, imaging evaluations, surgical reports, and pathological findings were retrospectively collected.

MEASUREMENTS AND MAIN RESULTS

The median postsurgical follow-up period was 52.8 months (range 6-88 months), with 24 patients (7.4%) lost to follow-up by July 1, 2019. The localized and diffuse adenomyosis groups had similar symptom relief and recurrent uterine lesions. Among the 104 patients who attempted pregnancy, 75 patients (72.1%) conceived, with 35 miscarriages (46.7%) and 59 live births (78.7%). For the whole cohort and the localized adenomyosis and diffuse adenomyosis groups, the cumulative 5-year conception rates were 75%, 83% and 60%, respectively; the cumulative 5-year live birth rates were 63%, 79% and 37%, respectively. The adenomyosis patterns found during sonography were the only independent risk factors related to clinical pregnancy and live birth in the Cox regression model. Patients with diffuse adenomyosis had significantly lower rates of conception (HR 0.5, 95% CI 0.3-1.0) and live birth (HR 0.4, 95% CI 0.2-0.8).

CONCLUSION

Adenomyosis patterns (localized versus diffuse) in pretreatment TVS could predict obstetrical outcomes, irrespective of surgical type and uterine size.

CLINICAL REGISTRY

The clinical trial registry name is the Cooperative Adenomyosis Network (CAN); the registration number is NCT03230994 (https://clinicaltrials.gov). This study started on June 30, 2017, and was completed on December 30, 2020.

Effect of adenomyosis on placenta-related obstetric complications

RESEARCH QUESTION

What is the relationship between sonographic diagnosis of isolated adenomyosis and placenta-associated obstetric outcomes?

DESIGN

In this 12-year retrospective cohort study (2010-2022), patients presenting with adenomyosis-related symptoms were assessed via ultrasound. The study included 59 women diagnosed with adenomyosis and 62 controls, leading to 203 births (90 in the adenomyosis group and 113 in the control group). Patients with endometriosis, uterine fibroids and anomalies, and those using assisted reproductive technology were excluded. The primary outcome focused on a composite of placenta-associated adverse outcomes, including preterm birth, small-for-gestational-age fetuses, hypertensive disorders of pregnancy, placental abruption and post-partum haemorrhage.

RESULTS

No clinically significant differences in demographic characteristics were noted between the two groups. However, the adenomyosis group showed a significantly higher rate of adverse placental function outcomes (27%) compared with the control group (11%, P = 0.005). Adjusted analyses for maternal age, parity and aspirin usage revealed increased risk of hypertensive disorders (adjusted OR 5.91, 95% CI 1.50-30.0; P = 0.017) and adverse placental function outcomes (adjusted OR 3.44, 95% CI 1.53-8.09; P = 0.003) in the adenomyosis group.

CONCLUSION

Adenomyosis is significantly associated with increased risk of adverse placental function outcomes and hypertensive disorders of pregnancy. These findings suggest that adenomyosis may have a distinct impact on pregnancy, underscoring the need for further research to elucidate specific sonographic characteristics of adenomyosis and their effects on placental function.

The First Lugano Workshop on the role of adenomyosis in ART

Adenomyosis is an important clinical condition with uncertain prevalence, and clinical focus on adenomyosis in patients undergoing assisted reproductive technology (ART) has increased during recent years. Recognizing the limited clinical knowledge on the impact of adenomyosis on ART outcomes, the First Lugano Adenomyosis Workshop was a symposium involving experts in the field of adenomyosis, covering basic research, imaging, surgery and infertility to highlight current advances and future research areas over a wide range of topics related to adenomyosis. Adenomyosis is characterized by altered oestrogen and progesterone signalling pathways. Although the criteria of the Morphological Uterus Sonographic Assessment (MUSA) Consortium apply to patients with infertility, the presence of direct signs and localization in the different myometrial layers, particularly the inner myometrium, need more focus. In addition to the MUSA criteria, clinical symptoms and the magnitude of uterine enlargement should also be considered. Whilst pre-treatment with gonadotrophin-releasing hormone agonist with or without an aromatase inhibitor in frozen embryo transfer cycles seems promising, many issues related to therapy remain unanswered. During the Workshop, therapeutic progress over the past decades as well as novel insights were presented and discussed. The role of this opinion paper is to stimulate discussion and spark further interest in adenomyosis and the role of adenomyosis in 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.

Untangling the independent effect of endometriosis, adenomyosis, and ART-related factors on maternal, placental, fetal, and neonatal adverse outcomes: results from a systematic review and meta-analysis

BACKGROUND

Women with endometriosis may constitute a group at a particularly increased risk of pregnancy-related complications. Furthermore, women selected for assisted reproductive technology (ART) are exposed to additional endocrinological and embryological factors that have been associated with adverse pregnancy outcomes.

OBJECTIVE AND RATIONALE

This study aimed to investigate the independent effect of endometriosis, adenomyosis, and various ART-related factors on adverse maternal, placental, fetal, and neonatal outcomes.

SEARCH METHODS

Published randomized controlled trials, cohort studies, and case-control studies were considered eligible. PubMed, MEDLINE, ClinicalTrials.gov, Embase, and Scopus were systematically searched up to 1 March 2024. This systematic review and meta-analysis was performed in line with the PRISMA and the MOOSE reporting guidelines. To thoroughly investigate the association between endometriosis/adenomyosis and adverse pregnancy outcomes, sub-analyses were conducted, whenever possible, according to: the method of conception (i.e. ART and non-ART conception), the endometriosis stage/phenotype, the coexistence of endometriosis and adenomyosis, any pre-pregnancy surgical treatment of endometriosis, and the form of adenomyosis. The odds ratio (OR) with 95% CI was used as effect measure. The quality of evidence was assessed using the GRADE approach.

OUTCOMES

We showed a higher risk of placenta previa in women with endometriosis compared to controls (34 studies, OR 2.84; 95% CI: 2.47, 3.26; I2 = 83%, moderate quality). The association was observed regardless of the method of conception and was particularly strong in the most severe forms of endometriosis (i.e. rASRM stage III-IV endometriosis and deep endometriosis (DE)) (OR 6.61; 95% CI: 2.08, 20.98; I2 = 66% and OR 14.54; 95% CI: 3.67, 57.67; I2 = 54%, respectively). We also showed an association, regardless of the method of conception, between endometriosis and: (i) preterm birth (PTB) (43 studies, OR 1.43; 95% CI: 1.32, 1.56; I2 = 89%, low quality) and (ii) cesarean section (29 studies, OR 1.52; 95% CI: 1.41, 1.63; I2 = 93%, low quality). The most severe forms of endometriosis were strongly associated with PTB. Two outcomes were associated with adenomyosis both in the main analysis and in the sub-analysis that included only ART pregnancies: (i) miscarriage (14 studies, OR 1.83; 95% CI: 1.53, 2.18; I2 = 72%, low quality) and (ii) pre-eclampsia (7 studies, OR 1.70; 95% CI: 1.16, 2.48; I2 = 77%, low quality). Regarding ART-related factors, the following associations were observed in the main analysis and confirmed in all sub-analyses conducted by pooling only risk estimates adjusted for covariates: (i) blastocyst stage embryo transfer (ET) and monozygotic twinning (28 studies, OR 2.05; 95% CI, 1.72, 2.45; I2 = 72%, low quality), (ii) frozen embryo transfer (FET) and (reduced risk of) small for gestational age (21 studies, OR 0.59; 95% CI, 0.57, 0.61; P < 0.00001; I2 = 17%, very low quality) and (increased risk of) large for gestational age (16 studies, OR 1.70; 95% CI, 1.60, 1.80; P < 0.00001; I2 = 55%, very low quality), (iii) artificial cycle (AC)-FET and pre-eclampsia (12 studies, OR 2.14; 95% CI: 1.91-2.39; I2 = 9%, low quality), PTB (21 studies, OR 1.24; 95% CI 1.15, 1.34; P < 0.0001; I2 = 50%, low quality), cesarean section (15 studies, OR 1.59; 95% CI 1.49, 1.70; P < 0.00001; I2 = 67%, very low quality) and post-partum hemorrhage (6 studies, OR 2.43; 95% CI 2.11, 2.81; P < 0.00001; I2 = 15%, very low quality).

WIDER IMPLICATIONS

Severe endometriosis (i.e. rASRM stage III-IV endometriosis, DE) constitutes a considerable risk factor for placenta previa and PTB. Herein, we recommend against superimposing on this condition other exposure factors that have a strong association with the same obstetric adverse outcome or with different outcomes which, if coexisting, could determine the onset of an ominous obstetric syndrome. Specifically, we strongly discourage the use of AC regimens for FET in ovulatory women with rASRM stage III-IV endometriosis or DE. We also recommend single ET at the blastocyst stage in this high-risk population.

REGISTRATION NUMBER

CRD42023401428.

New MUSA classification of adenomyosis: correlation of symptoms and clinical severity with direct and indirect features

Introduction

To correlate the direct and indirect morphological uterus sonographic assessment (MUSA) features of adenomyosis with clinical symptoms severity.

Material and methods

This observational prospective study was conducted at a tertiary care institute from April 2023 to March 2024, involving 254 women aged 18 to 45 years with a regular menstrual cycle and ultrasound-confirmed diagnosis of adenomyosis. Detailed clinicodemographic data were collected, including symptoms such as painful menses, heavy menstrual bleeding (HMB), chronic pelvic pain (CPP), and bowel/bladder symptoms. Severity of symptoms was graded using a visual analogue scale and pictorial blood loss analysis chart. All participants underwent a 2D transvaginal ultrasound during the secretory phase, performed by blinded sonographers. Diagnosis of adenomyosis was based on the presence of direct or indirect MUSA features.

Results

The study's primary findings showed that 94.4% of participants had at least one direct feature, with myometrial cysts being the most common (83.75%). Statistical analysis revealed significant associations between clinical symptoms and specific MUSA features. Heavy menstrual bleeding was linked with asymmetrical myometrial thickening, interrupted junctional zone, and globular uterus. Chronic pelvic pain was significantly associated with myometrial cysts, and dysmenorrhoea was linked with myometrial cysts and hyperechogenic islands. On stepwise logistic regression, HMB was found to be significantly associated with asymmetrical myometrial thickening, interrupted JZ, and globular uterus with odds ratios (OR) of 2.84, 2.01, and 4.03, respectively. Chronic pelvic pain was significantly associated with myometrial cyst (OR = 3.07), as was dysmenorrhoea (OR = 1.13).

Conclusions

The findings of the study highlight that few sonographic direct and indirect signs of adenomyosis are linearly associated with the severity of disease symptoms.

Evaluation of menstrual blood loss (MBL) by self-perception and pictorial methods and correlation to uterine myometrial pathology

PURPOSE

Evaluating menstrual blood loss (MBL) in primary healthcare is challenging. Our study aimed to assess MBL using two methods: self-perception and pictograms (Pictorial Blood Assessment Chart-PBAC and Menstrual Pictogram superabsorbent polymer-c version-MP) in women undergoing transvaginal ultrasound (TVS).

METHODS

We enrolled 221 premenopausal women with spontaneous menstruation, no hormonal therapy, and no ongoing pregnancy. They were divided into four age groups (12-20, 21-30, 31-40, and 41-55 years). Women self-reported normal (NMB) or heavy menstrual bleeding (HMB) and filled out PBAC and MP. A PBAC score ≥ 150 and MP score ≥ 80 ml indicated HMB. TVS was conducted on all patients, recording any pelvic pathologies. We compared self-perception with pictograms across the cohort, age groups, and ultrasound findings.

RESULTS

Of the cohort, 50.2% reported normal periods and 49.8% heavy periods. No significant differences were found between self-perception and pictograms in identifying NMB and HMB across all groups. However, significant differences were observed between PBAC and MP scores for NMB (56.1% vs 41.2%, p = 0.001) and HMB (43.9% vs 58.8%, p = 0.001), particularly in the 31-40 age group. Significant differences in PBAC and MP scores were noted between age groups 12-20 and 41-55, and 31-40 and 41-55. No significant differences were found between self-perception and pictograms regarding ultrasound findings like adenomyosis, fibroids, endometrial pathology, and uterine congenital malformations.

CONCLUSION

Self-perception could be a reliable method for describing MBL across all age groups and ultrasound findings. Given the complexity and potential errors in using pictograms, clinicians should consider relying on self-perception for assessing menstrual cycle quantity.

Inflammatory Bowel Disease and Endometriosis: Diagnosis and Clinical Characteristics

Background/Objectives: Endometriosis and inflammatory bowel disease (IBD) share some epidemiological, clinical and pathogenetic features. A differential diagnosis between pelvic endometriosis and IBD may be challenging, even for expert clinicians. In the present review, we aimed to summarize the currently available data regarding the relationship between endometriosis and IBD and their possible association. Methods: The PubMed and Scopus database were considered, by searching the following terms: "Crohn's Disease", "Ulcerative Colitis", "Endometriosis", "Adenomyosis", and "Inflammatory Bowel Disease", individually or combined. Full-text papers published in English with no date restriction were considered. Results: Few studies have researched the possible association between endometriosis and IBD. Both conditions are characterized by chronic recurrent symptoms, which may be shared (abdominal pain, fatigue, infertility, menstrual irregularities, diarrhea, constipation). Deep infiltrating endometriosis (DIE) can cause bowel symptoms. In a large Danish study, a 50% increased risk of IBD was observed in women with endometriosis. A missed diagnosis of endometriosis and an increased risk of endometriosis has been reported in IBD. Current evidence does not support an association between endometriosis and IBD characteristics. However, IBD may be associated with DIE, characterized by pelvic symptoms (dyschezia, dyspareunia). Preliminary observations suggest an increased IBD risk in patients with endometriosis treated with hormonal therapy. Conclusions: Current findings suggest that a careful search is needed for concomitant endometriosis in subgroups of patients with IBD showing compatible symptoms and vice versa. A multidisciplinary approach including dedicated gastroenterologists and gynecologists is required for a proper search for IBD and endometriosis in subgroups of patients. This approach may avoid diagnostic delays or overtreatments for these conditions.

The effect of unicornuate uterus on reproductive outcomes in infertile patients

OBJECTIVE

Unicornuate uterus, which is a rare congenital anomaly, has been associated with obstetric and perinatal complications. The aim of this study is to evaluate the reproductive outcomes of patients with unicornuate uterus, and also to compare them with outcomes of infertile patients without a Müllerian anomaly.

METHODS

Retrospective analyses of the data of 18-40 year old infertile patients with unicornuate uterus diagnosed in between January 2012 and December 2022, and a control group with the same number of patients, with age and infertility durations matched were performed. Demographic data, cycle parameters and reproductive outcomes of the unicornuate uterus and control groups were compared.

RESULTS

A total of 75 patients with unicornuate uterus and a control group of 75 infertile patients without a Müllerian anomaly were included in the study. Totally, 116 and 91 pregnancies were achieved at unicornuate uterus and the control groups, respectively. Ectopic pregnancy rates (10.3 % vs 2.2 %, OR = 5.53, 95 %CI [1.17-26.21]) and malpresentation rates (29 % vs 0 %, OR = 1.40, 95 %CI [1.12-1.76]) were significantly higher and newborn birth weights in singleton pregnancies were significantly lower in the unicornuate group (3000 g vs 3455 g, p = 0.005). No significant difference was found in other obstetric parameters.

CONCLUSION

Unicornuate uterus constitutes a small portion of all congenital uterine anomalies. Although increased ectopic pregnancy and malpresentation rates with diminished birth weights were found in the unicornuate group in our study, live birth rates and preterm deliveries did not differ significantly between the two groups. However, patients should be counseled on this issue both during the reproductive treatment process and during pregnancy, and should be followed closely.

Correlation of adenomyosis features to live birth rates after the first IVF/ICSI treatment, when using the revised Morphological Uterus Sonographic Assessment group definitions

INTRODUCTION

Data regarding the impact of adenomyosis on the outcomes after in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) treatment are conflicting. Standardized diagnostic criteria are prerequisites for studying a potential association between adenomyosis and IVF/ICSI treatment outcomes. This study aims to examine the cumulative live birth rate (CLBR) after the first IVF/ICSI treatment in women with or without direct or indirect features of adenomyosis, using the revised Morphological Uterus Sonographic Assessment (MUSA) group definitions.

MATERIAL AND METHODS

This was a prospective cohort study of 1037 women aged 25-≤39 years, undergoing their first IVF/ICSI treatment between January 2019 and October 2022. The presence of MUSA features of adenomyosis was assessed prior to treatment start.

RESULTS

The CLBR after the first IVF/ICSI treatment was 424/1037 (40.9%, 95% CI, 37.9-43.8) in the total cohort. Women with direct features of adenomyosis had lower CLBR, 25/102 (24.5%; 95% CI, 17.5-31.5) than women without, 399/935 (42.7%; 95% CI, 39.5-45.8), p < 0.001. The adjusted relative risk (aRR) for live birth for women with direct features of adenomyosis compared to women without was 0.62 (95% CI, 0.43-0.88), p = 0.007. Direct features were associated with a higher risk of miscarriage after frozen embryo transfer, aRR 2.88 (95% CI, 1.49-5.57), p = 0.002. Women with indirect features had a lower CLBR [50/188 (26.6%, 95% CI, 20.3-32.9)] than women without [399/935, (42.7%, 95% CI, 39.5-45.8)], aRR 0.58 (95% CI, 0.45-0.75), p < 0.001. For features located in the inner myometrium, the aRR for live birth was 0.29 (95% CI 0.11-0.74), p = 0.010 and for the outer myometrium 2.61 (95% CI 1.42-4.8), p = 0.002. An interrupted junctional zone was the single feature that impacted CLBR the most.

CONCLUSIONS

The presence of direct or indirect MUSA features of adenomyosis correlates to reduced live birth rates in women undergoing their first IVF/ICSI treatment. Features located in the inner myometrium, particularly an interrupted junctional zone, reduced the chance of live birth the most, whereas location in the outer myometrium was associated with higher chances of live birth. Systematic ultrasound examinations should be considered for women scheduled for IVF/ICSI treatment, for adequate counseling on the chances of successful treatment.

Automatic diagnosis for adenomyosis in ultrasound images by deep neural networks

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Potential anatomical determinants of retrograde menstruation: a comprehensive narrative review

A century ago, Sampson identified three uterine anatomical structures that may determine the amount of retrograde menstruation and the likelihood of the development of endometriosis: the cervix, the intramural portion of the fallopian tubes, and the myometrium. Critical appraisal was undertaken of data published over the last 40 years on the potential effect of the characteristics of these three anatomical variables on the risk of endometriosis. There is some evidence to support the pathogenic role of the diameter of the cervical canal, stenosis of internal or external orifices, and stiffness of cervical tissue. One study showed a significant association between the morphology of the intramural tubal tract and the frequency of endometriosis. A large body of evidence points to abnormalities of the myometrial structure as the anatomical aberration most consistently associated with endometriosis. These abnormalities have largely been interpreted as signs of early-onset adenomyosis, which may precede endometriosis and even lead to its development by increasing the amount of retrograde menstruation. Future research should aim to verify whether a positive relationship exists between the substantially increased number of ovulatory menses occurring in the decade following menarche, the development of anatomical myometrial abnormalities, changes in the amount of retrograde menstruation over time, and the risk of endometriosis.

Progression of adenomyosis: Rate and associated factors

OBJECTIVE

To evaluate the rate of disease progression and the factors associated with such progression in patients with an ultrasound diagnosis of adenomyosis.

METHODS

This was a single center, prospective, observational, cohort study performed at a tertiary referral center. Patients who obtained an ultrasound diagnosis of adenomyosis from May 2022 to August 2022 were recruited. Demographic, clinical and ultrasound data were recorded at the first visit (T0) and after 12 months (T1) for enrolled patients and compared between T0 and T1. The study population was divided in two groups according to progression (increase in uterine volume >20%) or stability/regression (decrease or increase in uterine volume ≤20%) of adenomyosis at T1. Primary study outcome was the rate of adenomyosis progression, while secondary study outcome was the association of adenomyosis progression with demographic and clinical factors. Post hoc subgroups analyses for primary and secondary study outcomes were performed based on hormonal therapy (untreated and treated).

RESULTS

A total of 221 patients were enrolled in the study, with no significant difference in terms of baseline data among the two study groups and no patients were lost to follow-up. The overall rate of adenomyosis progression was 21.3% (47/221 patients). The rate was 30.77% in hormonally untreated women, and 18.34% in hormonally treated women. Progression was associated with the presence of focal adenomyosis of the outer myometrium (P = 0.037), moderate to severe dysmenorrhea (P = 0.001), chronic pelvic pain (P = 0.05), dyschezia (P = 0.05), and worsening of chronic pelvic pain (P = 0.04) at T1.

CONCLUSION

Adenomyosis showed a rate of disease progression of 21.3% at the 12-month follow-up (30.77% in hormonally untreated women, and 18.34% in hormonally treated women). The presence and/or worsening of painful symptoms, such as severe dysmenorrhea, dyschezia and chronic pelvic pain, as well as the presence focal adenomyosis of the outer myometrium, might help identify patients at higher risk of disease progression and tailor their follow-up.

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

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

Prevalence of Septate Uterus in a Large Population of Women of Reproductive Age: Comparison of ASRM 2016 and 2021, ESHRE/ESGE, and CUME Diagnostic Criteria: A Prospective Study

In this study, we aimed to assess and compare the prevalence of septate uterus using the diagnostic criteria of the ESHRE-ESGE, ASRM 2016, ASRM 2021, and CUME classifications. This prospective observational study included 977 women of reproductive age. Each participant underwent a transvaginal ultrasound, and a 3D volume of the uterus was obtained for further analysis. Offline assessment of the uterine coronal plane was conducted to measure uterine wall thickness, fundal indentation length, and indentation angle. The diagnosis of a septate uterus was determined according to the criteria of the ESHRE-ESGE, ASRM, and CUME classifications. The prevalence of septate uterus was then calculated and compared across these classifications. The ESHRE-ESGE classification identified 132 women (13.5%) with a septate uterus. The 2016 ASRM classification identified nine women (0.9%), with an additional nine women falling into a grey zone. The 2021 ASRM classification identified fourteen women (1.4%), with eleven women in the grey zone. The CUME classification identified 23 women (2.4%). The prevalence of septate uterus was significantly higher when using the ESHRE-ESGE criteria compared to the 2016 ASRM [relative risk (RR): 7.33 (95% CI: 4.52-11.90)], the 2021 ASRM [RR: 5.28 (95% CI: 3.47-8.02)], and the CUME [RR: 5.94 (95% CI: 3.72-8.86)] (p < 0.001). Our findings indicate that the ESHRE-ESGE criteria result in a significantly higher prevalence of septate uterus compared to the ASRM and CUME criteria. The ASRM 2016 criteria may underdiagnose more than half of the cases.

Pain with orgasm in endometriosis: potential etiologic factors and clinical correlates

BACKGROUND

Pelvic pain worsened by orgasm is a poorly understood symptom in patients with endometriosis.

AIM

To assess the prevalence of pelvic pain worsened by orgasm in patients with endometriosis and explore its association with potential etiologic factors, including pelvic floor myalgia, uterine tenderness and adenomyosis, and central nervous system sensitization.

METHODS

An analysis was done of a prospective data registry based at a tertiary referral center for endometriosis. Eligible participants were patients aged 18 to 50 years who were referred between January 1, 2018, and December 31, 2019, diagnosed with endometriosis, and subsequently underwent surgery at the center. Clinical features were compared between participants reporting worsening pelvic pain with orgasm and those without worsening pain with orgasm, including patient-reported variables, physical examination findings, and anatomic phenotyping at the time of surgery. Pelvic floor myalgia and uterine tenderness were assessed by palpation on pelvic examination, adenomyosis by ultrasound, and central nervous system sensitization via the Central Sensitization Inventory (range, 0-100).

OUTCOMES

Outcomes included pelvic or lower abdominal pain in the last 3 months that worsened with orgasm (yes/no).

RESULTS

Among 358 participants with endometriosis, 14% (49/358) reported pain worsened by orgasm while 86% (309/358) did not. Pain with orgasm was significantly associated with pelvic floor myalgia (55% [27/49] vs 35% [109/309]; Cohen's h = 0.40, P = .01) and higher scores on the Central Sensitization Inventory (mean ± SD, 53.3 ± 17.0 vs 42.7 ± 18.2; Cohen's d = 0.60, P < .001) but not with uterine tenderness or adenomyosis. Other clinical features associated with pain with orgasm were poorer sexual health (higher scores: deep dyspareunia, Cohen's h = 0.60; superficial dyspareunia, Cohen's h = 0.34; and Female Sexual Distress Scale-Revised, Cohen's d = 0.68; all P < .05) and poorer mental health (higher scores: Patient Health Questionnaire-9, 12.9 ± 6.7 vs 9.1 ± 6.3, Cohen's d = 0.59, P < .001; Generalized Anxiety Disorder-7, 9.4 ± 5.6 vs 6.8 ± 5.5, Cohen's d = 0.48, P = .002). Anatomic findings at the time of surgery did not significantly differ between the groups.

CLINICAL IMPLICATIONS

Interventions targeting pelvic floor myalgia and central nervous system sensitization may help alleviate pain worsened by orgasm in patients with endometriosis.

STRENGTHS AND LIMITATIONS

A strength is that pain worsened by orgasm was differentiated from dyspareunia. However, pain with orgasm was assessed by only a binary question (yes/no). Also, the study is limited to a single center, and there were limited data on sexual function.

CONCLUSION

Pelvic pain exacerbated by orgasm in people with endometriosis may be related to concurrent pelvic floor myalgia and central sensitization.

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.

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.

From Diagnosis to Fertility: Optimizing Treatment of Adenomyosis for Reproductive Health

Adenomyosis is a benign gynecologic disorder that had previously not been well studied or understood. However, it is now become a more common diagnosis with long-standing implications especially for fertility. In this literature review, the pathophysiology and diagnosis along with management options for uterine preservation and fertility along with more definitive options are reviewed. While there is a better understanding of adenomyosis, there is still more research that is needed to fully elucidate the best ways of management for patients especially in those seeking fertility.

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.

The importance of the 'uterine factor' in recurrent pregnancy loss: a retrospective cohort study on women screened through 3D transvaginal ultrasound

STUDY QUESTION

What is the prevalence of congenital and acquired anomalies of the uterus in women with recurrent pregnancy loss (RPL) of unknown etiology examined using 3D transvaginal ultrasound (US)?

SUMMARY ANSWER

Depending on the adopted diagnostic criteria, the prevalence of partial septate uterus varies between 7% and 14% and a T-shaped uterus is 3% or 4%, while adenomyosis is 23%, at least one of type 0, type 1 or type 2 myoma is 4%, and at least one endometrial polyp is 4%.

WHAT IS KNOWN ALREADY

ESHRE and the Royal College of Obstetricians and Gynaecologists guidelines on RPL recommend the adoption of the 3D transvaginal US to evaluate the 'uterine factor'. Nevertheless, there are no published studies reporting the prevalence of both congenital and acquired uterine anomalies as assessed by 3D transvaginal US and diagnosed according to the criteria proposed by the most authoritative panels of experts in a cohort of women with RPL.

STUDY DESIGN, SIZE, DURATION

This was a retrospective cohort study including 442 women with at least two previous first-trimester spontaneous pregnancy losses (i.e. non-viable intrauterine pregnancies), who referred to the obstetrics and gynecology unit of two university hospitals between July 2020 and July 2023.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Records of eligible women were reviewed. Women could be included in the study if: they were between 25 and 42 years old; they had no relevant comorbidities; they were not affected by infertility, and they had never undergone ART; they and their partner tested negative to a comprehensive RPL diagnostic work-up; and they had never undergone metroplasty, myomectomy, minimally invasive treatments for uterine fibroids or adenomyomectomy. Expert sonographers independently re-analyzed the stored 2- and 3D transvaginal US images of all included patients. Congenital uterine anomalies (CUAs) were reported according to the American Society for Reproductive Medicine (ASRM) 2021, the ESHRE/European Society for Gynaecological Endoscopy (ESGE) and the Congenital Uterine Malformation by Experts (CUME) criteria. Acquired uterine anomalies were reported according to the International Federation of Gynecology and Obstetrics (FIGO) and the Morphological Uterus Sonographic Assessment (MUSA) criteria.

MAIN RESULTS AND THE ROLE OF CHANCE

The partial septate uterus was diagnosed in 60 (14%; 95% CI: 11-17%), 29 (7%; 95% CI: 5-9%), and 47 (11%; 95% CI: 8-14%) subjects, according to the ESHRE/ESGE, the ASRM 2021, and the CUME criteria, respectively. The T-shaped uterus was diagnosed in 19 women (4%; 95% CI: 3-7%) according to the ESHRE/ESGE criteria and in 13 women (3%; 95% CI: 2-5%) according to the CUME criteria. The borderline T-shaped uterus (diagnosed when two out of three CUME criteria for T-shaped uterus were met) was observed in 16 women (4%; 95% CI: 2-6%). At least one of FIGO type 0, type 1, or type 2 myoma was detected in 4% of included subjects (95% CI: 3-6%). Adenomyosis was detected in 100 women (23%; 95% CI: 19-27%) and was significantly more prevalent in women with primary RPL and in those with three or more pregnancy losses. At least one endometrial polyp was detected in 4% of enrolled women (95% CI: 3-7%).

LIMITATIONS, REASONS FOR CAUTION

The absence of a control group prevented us from investigating the presence of an association between both congenital and acquired uterine anomalies and RPL. Second, the presence as well as the absence of both congenital and acquired uterine anomalies detected by 3D US was not confirmed by hysteroscopy. Finally, the results of the present study inevitably suffer from the intrinsic limitations of the adopted classification systems.

WIDER IMPLICATIONS OF THE FINDINGS

The prevalence of CUAs in women with RPL varies depending on the classification system used. For reasons of clarity, the US reports should always state the name of the uterine anomaly as well as the adopted classification and diagnostic criteria. Adenomyosis seems to be associated with more severe forms of RPL. The prevalence rates estimated by our study as well as the replicability of the adopted diagnostic criteria provide a basis for the design and sample size calculation of prospective studies.

STUDY FUNDING/COMPETING INTEREST(S)

No specific funding was used. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

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.

Evaluating the development of endometriosis and adenomyosis lesions over time: An ultrasound study of symptomatic women

INTRODUCTION

There is a gap in knowledge regarding development of endometriosis and adenomyosis lesions visible at transvaginal ultrasound. The objectives were to evaluate if women with symptoms suggestive of endometriosis or adenomyosis but normal ultrasound examination develop endometriosis or adenomyosis lesions visible at ultrasound over time and if alterations of symptoms over time are associated with ultrasound findings at follow-up.

MATERIAL AND METHODS

This was a prospective cohort study of 100 symptomatic women with normal initial ultrasound examination during 2014-2017 who underwent follow-up ultrasound examination in 2022. Symptoms suggestive of endometriosis were assessed using visual analog scale at both examinations and minimal clinically important difference of 10 mm was considered as a significant alteration. An examiner with expertise in advanced ultrasound examination of endometriosis performed transvaginal ultrasound examinations in accordance with the consensus protocol by the International Deep Endometriosis Analysis group.

RESULTS

At follow-up ultrasound examination of 100 women, 13 (13% [95% CI 7.1-21.2]) had visible endometriosis or adenomyosis lesions, 8 (8% [95% CI 3.5-15.2]) had endometriosis lesions, and 6 (6% [95% CI 2.2-12.6]) had adenomyosis. At follow-up, women with endometriosis or adenomyosis lesions reported lower intensity of dysmenorrhea and chronic pelvic pain compared to women without lesions (48 mm [IQR 16-79] vs. 73 mm [IQR 46-85] and 45 mm [IQR 26-57] vs. 57 mm [IQR 36-75], p = 0.087 and p = 0.026, respectively). None of the women with endometriosis or adenomyosis lesions reported increased intensity of dysmenorrhea at follow-up, compared to 32/86 women (37%) without lesions (p = 0.008). Increased intensity of chronic pelvic pain tended to be less common in women with lesions compared to those without (3/13 [23%] vs. 35/86 [41%], p = 0.223).

CONCLUSIONS

Our findings suggest that in symptomatic women, endometriosis and adenomyosis lesions visible at ultrasound may develop over time. However, majority of women remain having normal ultrasound examinations despite symptoms. Exacerbation of dysmenorrhea or chronic pelvic pain during follow-up was not associated with the development of endometriosis or adenomyosis lesions visible at ultrasound, suggesting that even women with less severe symptoms might benefit from a follow-up ultrasound when indicated.

Adenomyosis among patients undergoing postpartum hysterectomy for uncontrollable uterine bleeding: A multicenter, observational, retrospective, cohort study on histologically-based prevalence and clinical characteristics

OBJECTIVE

To assess the prevalence of adenomyosis at pathologic examination, and its association with obstetric complications, peripartum maternal clinical characteristics and neonatal birth weight in patients undergoing postpartum hysterectomy due to postpartum hemorrhage (PPH).

METHODS

A multicenter, observational, retrospective, cohort study was carried out including all women who underwent postpartum hysterectomy due to PPH at gestational week 23+0 or later, between January 2010 and May 2023. Patients were categorized into two groups based on the presence of adenomyosis at pathologic examination, and were compared for obstetric complications, peripartum maternal clinical characteristics, and neonatal birth weight.

RESULTS

The histologically-based prevalence of adenomyosis in patients undergoing postpartum hysterectomy due to PPH was 39.4%. Adenomyosis was associated with a longer hospitalization time (regression coefficient: 4.43 days, 95% CI: 0.34-8.52, P = 0.034) and a higher risk of hypertensive disorders (OR: 5.82, 95% CI: 1.38-24.46, P = 0.016), threatened preterm labor (OR: 3.34, 95% CI: 1.08-10.31, P = 0.036), urgent/emergency C-section (OR: 24.15, 95% CI: 2.60-223.96, P = 0.005), postpartum maternal complications (OR: 4.96, 95% CI: 1.48-16.67, P = 0.012), maternal intensive care unit admission (OR: 3.56, 95% CI: 1.05-12.05, P = 0.041), and low birth weight neonates (OR: 3.8, 95% CI: 1.32-11.02, P = 0.013).

CONCLUSION

In patients undergoing postpartum hysterectomy due to PPH, adenomyosis is a highly prevalent condition among, and is associated with adverse obstetric, maternal, and neonatal outcomes.