Transvaginal sonography in the diagnosis of adenomyosis: which findings are most accurate?

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

BACKGROUND

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

OBJECTIVE

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

RESULTS AND CONCLUSION

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

US, MRI, CT Performance and Interpretation of Uterine Masses

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

Accuracy of ultrasound signs on two-dimensional transvaginal ultrasound in prediction of adenomyosis: prospective multicenter study

OBJECTIVE

Two-dimensional (2D) transvaginal ultrasound (TVS) is an accessible and cost-effective diagnostic tool for the detection of adenomyosis. Different ultrasound features related to adenomyosis have been described, but the predictive value of each ultrasound sign and their combinations requires further investigation. We aimed to analyze the accuracy of 2D-TVS and describe possible combinations of ultrasound signs with a high predictive value in the diagnosis of adenomyosis.

METHODS

This was a prospective multicenter study of patients scheduled for laparoscopic hysterectomy who had been examined using standardized 2D-TVS at nine expert centers specializing in the diagnosis and treatment of endometriosis. 2D-TVS examination included nine typical adenomyosis ultrasound features, comprising heterogeneous myometrium, myometrial linear striations, myometrial cysts, subendometrial microcysts, asymmetrical myometrial thickening, uterine enlargement, the 'question mark sign', thickening of the junctional zone and hyperechoic myometrial spots, in order to predict or exclude the presence of adenomyosis. Ultrasound examination results were compared with histology after hysterectomy. The diagnostic reliability of the nine ultrasound signs and their combinations, and the influence of concurrent fibroids on the accuracy of the results, were analyzed.

RESULTS

A total of 202 patients were enrolled into the study. Histopathological examination revealed adenomyosis in 130 patients (64.4%). The accuracy of prediction of adenomyosis by 2D-TVS examination using all signs was 63.4% (positive predictive value, 71.5%; negative predictive value, 48.6%; sensitivity, 71.5%; specificity, 48.6%). Heterogeneous myometrium, myometrial cysts, subendometrial microcysts and hyperechoic myometrial spots showed the highest accuracy (55.7-62.1%) as individual ultrasound signs for the prediction of adenomyosis. The combination of the most accurate ultrasound signs (subendometrial microcysts, myometrial cysts and heterogeneous myometrium) improved the specificity of prediction (86.1%) when compared with that of these three single markers (35.2-81.7%). Uterine enlargement and asymmetry showed both low sensitivity (60.8% and 52.3%, respectively) and specificity (41.7% and 49.3%, respectively) as individual sonographic signs.

CONCLUSIONS

Heterogeneous myometrium, myometrial cysts, subendometrial microcysts and hyperechoic myometrial spots showed the highest accuracy for the detection of adenomyosis in this study, while uterine enlargement and asymmetry led to high false-positive and false-negative results. A combination of ultrasound features including the most accurate signs increases specificity. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

The role of the junctional zone in the management of adenomyosis with infertility

The junctional zone (JZ) is an important structure in the myometrium that maintains uterine fertility. Changes in the junctional zone are closely related to infertility and adenomyosis (ADS). As an increasing number of young women are affected by ADS, the disease is no longer considered typical of women over 40. With these changes, an increasing number of patients refuse hysterectomy and desire fertility preservation treatment. At the same time, ADS is a crucial factor causing female infertility. Therefore, the treatment of ADS-related infertility and preservation of reproductive function is one of the other major challenges facing clinicians. For these young patients, preserving fertility and even promoting reproduction has become a new challenge. Therefore, we searched and summarized these studies on PubMed and Google Scholar using keywords such as "adenomyosis", "junctional zone", and "infertility" to explore infertility causes, diagnosis, and treatment of ADS patients who wish to preserve their uterus or fertility and become pregnant, focusing on the junctional zone, to obtain a full appreciation of the new perspective on this disease.

The Present and the Future of Medical Therapies for Adenomyosis: A Narrative Review

Uterine Adenomyosis is a benign condition characterized by the presence of endometrium-like epithelial and stromal tissue in the myometrium. Several medical treatments have been proposed, but still, no guidelines directing the management of adenomyosis are available. While a hysterectomy is typically regarded as the definitive treatment for adenomyosis, the scarcity of high-quality data leaves patients desiring fertility with limited conservative options. Based on the available data, the levonorgestrel-IUD appears to offer the most favorable outcomes. Other treatments, including GnRH antagonists, dienogest, prolactin, and oxytocin modulators, show promise; however, further data are required to establish their efficacy definitively. Furthermore, there are many emerging therapies that have been developed that seem worthy of consideration in the near future. The aim of this narrative review was to explore the current medical treatments available for adenomyosis and to provide a glimpse of future therapies under assessment. For this scope, we performed a literature search on PubMed and Medline from incept to September 2022 using the keywords: "medical treatment", "non-steroidal anti-inflammatory", "progesterone intrauterine device", "dienogest", "combined oral contraceptives", "gonadotropin releasing hormone agonist", "gonadotropin releasing hormone antagonist", "danazol", "aromatase inhibitors", "ulipristal acetate", "anti-platelet therapy", "dopamine", "oxytocin antagonists", "STAT3", "KRAS", "MAPK", "micro-RNA", "mifepristone", "valproic acid", "levo-tetrahydropalamatine", and "andrographolide". The search was limited to articles in English, with subsequent screening of abstracts. Abstracts were screened to select relevant studies.

Adenomyosis in Pregnancy-Should It Be Managed in High-Risk Obstetric Units?

BACKGROUND

Uterine adenomyosis is an increasingly frequent disorder. Our study aimed to demonstrate the presence of obstetric complications in the population affected by this condition to demonstrate the need for follow-up in high-risk obstetric units.

MATERIAL AND METHODS

The data for the study were obtained from TriNetX, LLC, between 2010 and 2020. The outcomes analyzed were intrauterine growth restriction (IUGR), preterm delivery, cesarean delivery, hypertension, abruption placentae, and spontaneous abortion. Seven thousand six hundred and eight patients were included in the cohort of pregnant patients with adenomyosis, and 566,153 women in the cohort of pregnant patients without any history of endometriosis.

RESULTS

Upon calculating the total risk of presenting any of these problems during pregnancy, we obtained an OR = 1.521, implying that a pregnancy with adenomyosis was 52.1% more likely to present some complication. We found: IUGR OR = 1.257 (95% CI: 1.064-1.485) (p = 0.007); preterm delivery OR = 1.422 (95% CI: 1.264-1.600) (p = 0.0001); cesarean delivery OR = 1.099 (95% CI: 1.002-1.205) (p = 0.046); hypertensive disorders OR = 1.177 (95% CI: 1.076-1.288) (p = 0.0001); abruption placentae OR = 1.197 (95% CI: 1.008-1.422) (p = 0.040), and spontaneous abortion OR = 1.529 (95% CI: 1.360-1.718) (p = 0.0001).

CONCLUSION

We conclude that the review carried out and the data we obtained on increased risk provide sufficient evidence to recommend that patients with adenomyosis should be managed in obstetric high-risk units.

The Asian Society of Endometriosis and Adenomyosis guidelines for managing adenomyosis

This is the first guidelines for adenomyosis from the Asian Society of Endometriosis and Adenomyosis.

Cardiometabolic profiles in women with adenomyosis

The aim of this study was to investigate the reproductive profiles, metabolic parameters and cardiometabolic risk assessed by surrogate indexes in women with adenomyosis. Ninety-six premenopausal women who were diagnosed with adenomyosis by transvaginal ultrasound and 97 age-body mass index (BMI) matched controls with normal ultrasound during routine examination were included. Women with adenomyosis were more likely to have higher gravidity and had more abortions than women without adenomyosis. Regarding the individual metabolic syndrome components, the adenomyosis group was more likely to have higher prevalence of hypertension, low HDL-C and central obesity. No significant difference was found between the groups in terms of visceral adiposity index, lipid accumulation product and fatty liver index. Only higher blood pressure (BP) remained statistically significant after adjustment for confounding factors in multivariate analysis. Women with adenomyosis had remarkably high risk of hypertension. It may be advisable to monitor their BP closely.Impact StatementWhat is already known on this subject? The only anthropometric characteristic assessed in women in relation to adenomyosis is body mass index (BMI). A case-control study showed that women who are obese are more likely to have adenomyosis. The gravidity, number of spontaneous abortions and previous uterine surgeries such as dilatation and curettage (D&C) and caesarean section were found significantly associated with adenomyosis.What do the results of this study add? A remarkable finding of our study was the increased incidence of higher systolic BP in women with adenomyosis. No difference was observed in adiposity indices between women with and without adenomyosis. Higher prevalence of central obesity and lower HDL-C levels were seen in women with adenomyosis.What are the implications of these findings for clinical practice and/or further research? The study identifies that adenomyosis is associated with an increased risk of hypertension, and women with adenomyosis may be monitored closely for blood pressure changes. Our report also provides novel information about the metabolic risk profiles associated with adenomyosis.

Sonographic Assessment of Uterine Biometry for the Diagnosis of Diffuse Adenomyosis in a Tertiary Outpatient Clinic

Background: to compare several uterine biometric parameters at transvaginal ultrasound (TVUS) between adenomyosis and non-adenomyosis uteri and evaluate their role for the diagnosis of diffuse adenomyosis. Methods: prospective observational study conducted between the 1 February 2022 and the 30 April 2022. In this case, 56 patients with TVUS diagnosis of adenomyosis were included. A 1:1 ratio age and parity-matched group of non-adenomyosis patients was selected. We compared sonographic uterine biometric parameters (longitudinal (LD), anteroposterior (APD) and transverse (TD) diameters, volume, simple and complex diameter ratios) and investigated their diagnostic performance. Results: all sonographic parameters were significantly different between the study groups, except for TD/(LD+APD). Optimal cut-off values of APD and LD/APD showed the best sensitivity and specificity. APD diameter equal or superior to 39.5 mm (95% CI, 36.2–42.8) had sensitivity of 0.70 (95% CI, 0.57–0.80), specificity of 0.71 (95% CI, 0.59–0.82) and accuracy of 0.75 (95% CI, 0.66–0.84). LD/APD equal or inferior to 2.05 (95% CI, 1.96–2.13) showed sensitivity and specificity of 0.70 (95% CI, 0.57–0.80) each and accuracy of 0.72 (95% CI, 0.62–0.81). Conclusions: several biometric uterine parameters at TVUS in fertile-aged women were statistically different between adenomyosis and non-adenomyosis uteri, though their optimal cut-off values showed low accuracy in diagnosing adenomyosis.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Adenomyosis and infertility

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association between the occurrence of adenomyosis and the clinical outcomes of vaginal repair of cesarean section scar defects: an observational study

Background

To examine the correlation between the occurrence of adenomyosis and the outcome of vaginal repair of cesarean section scar defects (CSDs).

Methods

A total of 278 women with CSD were enrolled in this retrospective observational cohort study at the Shanghai First Maternity & Infant Hospital between January 2013 and August 2017. Patients were divided into two groups according to preoperative magnetic resonance imaging (MRI) findings: the adenomyosis group and the non-adenomyosis group. They all underwent vaginal excision and suturing of CSDs and were required to undergo examinations 3 and 6 months after surgery. Preoperative and postoperative clinical information was collected. Optimal healing was defined as a duration of menstruation of no more than 7 days and a thickness of the residual myometrium (TRM) of no less than 5.8 mm after vaginal repair.

Results

Before vaginal repair, for patients in the adenomyosis group, the mean duration of menstruation was longer and TRM was significantly thinner than those in patients in the non-adenomyosis group (p < 0.05). The TRM and duration of menstruation 3 and 6 months after surgery were significantly improved in both groups (p < 0.05). There were more patients with optimal healing in the non-adenomyosis group than in the adenomyosis group (44.7% vs. 30.0%; p < 0.05). Furthermore, 59.3% (32/54) of the women tried to conceive after vaginal repair. The pregnancy rates of women with and without adenomyosis were 66.7% (8/12) and 61.9% (26/42), respectively. The duration of menstruation decreased significantly from 13.4 ± 3.3 days before vaginal repair to 7.6 ± 2.3 days after vaginal repair in 25 patients (p < 0.001). The TRM increased significantly from 2.3 ± 0.8 mm before vaginal repair to 7.6 ± 2.9 mm after vaginal repair (p < 0.001).

Conclusions

Vaginal repair reduced postmenstrual spotting and may have improved fertility in patients with CSDs. Patients with adenomyosis are more likely to have suboptimal menstruation and suboptimal healing of CSDs. Adenomyosis might be an adverse factor in the repair of uterine incisions.

Imaging of Endometriosis: The Role of Ultrasound and Magnetic Resonance

Endometriosis is a chronic gynecological disease characterized by the growth of functional ectopic endometrial glands and stroma outside the uterus. It causes pelvic pain, dysmenorrhea, dyspareunia, or infertility. Diagnosis requires a combination of clinical history, non-invasive and invasive techniques. The aim of the present review was to evaluate the contribution of imaging techniques, mainly transvaginal sonography and magnetic resonance imaging to diagnose different locations and for the most appropriate treatment planning. Endometriosis requires a multidisciplinary teamwork to manage these patients clinically and surgically.

A Comparison of Shear Wave Elastography between Normal Myometrium, Uterine Fibroids, and Adenomyosis: A Cross-Sectional Study

Background

The differential diagnosis between uterine fibroid and adenomyosis is sometimes difficult; a precise diagnosis is required in women with infertility because of the different choice of treatments. Ultrasound elastography (UE) is a novel technique to evaluate the elasticity or the stiffness of the tissue of interest. The present study aims to compare UE shear wave velocity (SWV) among normal uterine myometrium, uterine fibroid, and adenomyosis, and assess the accuracy of shear wave elastography in the diagnosis of adenomyosis.

Materials and Methods

This cross-sectional study recruited 25 subjects for each group (control, adenomyosis, and fibroid) from April 2019 to April 2020. Transvaginal UE using an Aplio 500 (Toshiba Medical Systems, Japan) with ultrasound mapping for point of tissue biopsy was performed for all subjects. The diagnosis was confirmed by histology. Masson’s trichrome staining for collagen was performed and quantified

Results

The mean ± standard deviation (SD) for SWV was 3.44 ± 0.95 m/seconds (control group), 4.63 ± 1.45 m/seconds (adenomyosis group), and 4.53 ± 1.07 m/seconds (fibroid group). The mean SWV differed when comparing normal myometrium and adenomyosis after adjustments for age and endometrial pathology (P=0.019). The cut-off point of SWV at 3.465 m/seconds could differentiate adenomyosis from the normal uterus with an 80% sensitivity, 80% specificity, and an area under the curve (AUC) of 0.80 (95% confidence interval [CI]: 0.68-0.93) (P<0.001). No significant difference in SWV between the adenomyosis and fibroid groups was detected.

Conclusion

Shear wave elastography could be an alternative tool to distinguish between normal myometrium and adenomyosis; however, it could not differentiate adenomyosis from uterine fibroid or uterine fibroid from normal myometrium.

Diagnostic Accuracy of Transvaginal Ultrasound and Magnetic Resonance Imaging for Adenomyosis: Systematic Review and Meta-Analysis and Review of Sonographic Diagnostic Criteria

We aim to first systematically review and perform a meta-analysis of the diagnostic accuracy of transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI) and, second, to evaluate the accuracy of various sonographic diagnostic criteria for adenomyosis. A search of PubMed and Embase yielded 32 eligible studies. In diagnosing adenomyosis, the diagnostic performance of TVUS was found to be high and comparable to the performance of MRI. Of the eight sonographic criteria, only five were assessable. The best individual criterion was echogenic subendometrial lines and buds. Limited data exist for the various sonographic criteria, and further studies are required to compare their performance.

Adenomyosis: An update regarding its diagnosis and clinical features

Adenomyosis is a common gynecologic disease characterized by invasion of endometrial glands and stroma within the myometrium. Clinically, it can result in abnormal uterine bleeding, pelvic pain, and infertility. Adenomyosis has historically been diagnosed by histology of hysterectomy specimens. As a result of the development of imaging techniques, the diagnosis is nowadays possible by means of transvaginal pelvic ultrasound or pelvic magnetic resonance imaging. The use of pelvic imaging has demonstrated the existence of different forms of adenomyosis, notably allowing distinction between lesions of the external myometrium and those of the internal myometrium. The epidemiological and clinical characteristics may depend on the anatomical location of the adenomyosis lesions. In order to provide the best management for women with adenomyosis, the objective of this review is to provide an update regarding the diagnosis of adenomyosis and its clinical features according to the different adenomyosis phenotypes.

Ultrasound Findings of Adenomyosis in Adolescents: Type and Grade of the Disease

STUDY OBJECTIVE

To evaluate the ultrasound features, types, and degrees of adenomyosis among adolescents and to correlate these findings with clinical symptoms DESIGN: A retrospective observational study.

SETTING

Gynecological ultrasound units from January 2014 to June 2020.

PATIENTS

A total of 43 adolescents (aged 12-20 years) who were diagnosed as having adenomyosis at a pelvic ultrasound examination.

INTERVENTIONS

Ultrasound features and location and type of adenomyosis within the uterus were evaluated on stored 2-dimensional images and videos and 3-dimensional volumes. Adenomyosis was classified as mild, moderate, and severe according to the extension of the disease in the uterus as described in our previous published classification.

MEASUREMENTS AND MAIN RESULTS

Adenomyotic features recorded among our population were myometrial hyperechoic areas, uterine wall asymmetry, intramyometrial cystic areas, and some types of junctional zone alterations. The posterior uterine wall (58%) and the outer myometrial layer (93%) were mostly affected. In 44% of adolescents (19/43) with adenomyosis, at least 1 location of pelvic endometriosis was documented. Dysmenorrhea was the most commonly reported symptoms (88%), and it was associated with adenomyosis of the outer myometrium, myometrial hyperechoic areas, uterine wall asymmetry, and intramyometrial cystic areas. Adolescents with dyspareunia showed diffuse adenomyosis (9/9 patients) including both the inner and outer myometrium (7/9 patients) and in the posterior wall (7/9 patients). Heavy menstrual bleeding was associated with diffuse adenomyosis (18/23 patients) mostly of the outer myometrium (22/23 patients). Scoring system showed predominantly mild disease and no severe adenomyosis was found. Adolescents with diffuse adenomyosis were significantly older and showed a high percentage of heavy menstrual bleeding compared with those with the focal disease of the inner myometrium.

CONCLUSION

This study shows that adenomyosis is not only a pathology of adult life, but it involves young patients mostly in a mild-to-moderate form and is associated with typical painful symptoms. In adolescents, the diagnosis of adenomyosis is feasible through a noninvasive way with ultrasound and a proper management can be set.

Sonographic Signs of Adenomyosis in Women with Endometriosis Are Associated with Infertility

We compared the prevalence of ultrasound signs of adenomyosis in women with endometriosis who underwent surgery to those who were managed conservatively. This was a retrospective study of women evaluated at a tertiary endometriosis referral center who underwent 2D/3D transvaginal ultrasound. Adenomyosis diagnosis was based on the presence of at least three sonographic signs. The study group subsequently underwent laparoscopic surgery while the control group continued conservative management. Statistical analysis compared the two groups for demographics, symptoms, clinical data, and sonographic findings. The study and control groups included 244 and 158 women, respectively. The presence of any, 3+, or 5+ sonographic signs of adenomyosis was significantly more prevalent in the study group (OR = 1.93–2.7, p < 0.004, 95% CI; 1.24–4.09). After controlling for age, for all findings but linear striations, the OR for having a specific feature was higher in the study group. Women in the study group with ≥ 5 sonographic signs of adenomyosis had more than twice the risk of experiencing infertility (OR = 2.31, p = 0.012, 95% CI; 1.20–4.45). Sonographic signs of adenomyosis are more prevalent in women with symptomatic endometriosis who underwent surgery compared with those who continued conservative management. Women with 5+ findings have a significantly increased risk of infertility. Adenomyosis on ultrasound should be considered in the management decisions regarding these patients.

Sonographic and clinical features of adenomyosis in women in "early" (18-35) and "advanced" (>35) reproductive ages

BACKGROUND

Adenomyosis has been considered for a long time a condition of advanced reproductive age. Recently, imaging techniques have allowed its diagnosis in young women. The aim of our study was to compare adenomyosis in early (18-35) and advanced (>35) reproductive age (ERA vs. ARA).

METHODS

Between May 2019 and October 2020, 928 consecutive women underwent transvaginal ultrasounds (TV-US) in our Department. We enrolled 134 women of reproductive age (18-55) presenting at least 2 US features of adenomyosis, according to the MUSA consensus. We compared the two reproductive age groups (ERA and ARA) about both clinical and US features of adenomyosis.

RESULTS

Severe dysmenorrhea was more frequent in the ERA group (78.7% vs. 54.8%), while menorrhagia was more frequent in the ARA group (64.4% vs. 37.7%). At US, the ARA group had a higher frequency of altered junctional zone (67.1% vs. 39.3%), diffuse (76.7% vs. 39.3%) and severe adenomyosis (24.7% vs. 9.8%), and adenomyoma (16.4% vs. 1.6%).

CONCLUSIONS

Adenomyosis may occur in young women, who present different clinical and sonographic features compared to older women. Young patients have a higher prevalence of severe dysmenorrhea and focal and mild adenomyosis at US, while older women present more frequently menorrhagia, and altered junctional zone, diffuse and severe adenomyosis at US. Early diagnosis in young women suffering from adenomyosis may help to interrupt the mechanisms that drive the development of adenomyosis, starting immediately the right treatment.

Magnetic Resonance Imaging in endometriosis-associated pain

INTRODUCTION

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

Diagnosing adenomyosis: an integrated clinical and imaging approach

BACKGROUND

Adenomyosis is a benign uterine disorder where endometrial glands and stroma are pathologically demonstrated within the uterine myometrium. The pathogenesis involves sex steroid hormone abnormalities, inflammation, fibrosis and neuroangiogenesis, even though the proposed mechanisms are not fully understood. For many years, adenomyosis has been considered a histopathological diagnosis made after hysterectomy, classically performed in perimenopausal women with abnormal uterine bleeding (AUB) or pelvic pain. Until recently, adenomyosis was a clinically neglected condition. Nowadays, adenomyosis may also be diagnosed by non-invasive techniques, because of imaging advancements. Thus, a new epidemiological scenario has developed with an increasing number of women of reproductive age with ultrasound (US) or magnetic resonance imaging (MRI) diagnosis of adenomyosis. This condition is associated with a wide variety of symptoms (pelvic pain, AUB and/or infertility), but it is also recognised that some women are asymptomatic. Furthermore, adenomyosis often coexists with other gynecological comorbidities, such as endometriosis and uterine fibroids, and the diagnostic criteria are still not universally agreed. Therefore, the diagnostic process for adenomyosis is challenging.

OBJECTIVE AND RATIONALE

We present a comprehensive review on the diagnostic criteria of adenomyosis, including clinical signs and symptoms, ultrasound and MRI features and histopathological aspects of adenomyotic lesions. We also briefly summarise the relevant theories on adenomyosis pathogenesis, in order to provide the pathophysiological background to understand the different phenotypes and clinical presentation. The review highlights the controversies of multiple existing criteria, summarising all of the available evidences on adenomyosis diagnosis. The review aims also to underline the future perspective for diagnosis, stressing the importance of an integrated clinical and imaging approach, in order to identify this gynecological disease, so often underdiagnosed.

SEARCH METHODS

PubMed and Google Scholar were searched for all original and review articles related to diagnosis of adenomyosis published in English until October 2018.

OUTCOMES

The challenge in diagnosing adenomyosis starts with the controversies in the available pathogenic theories. The difficulties in understanding the way the disease arises and progresses have an impact also on the specific diagnostic criteria to use for a correct identification. Currently, the diagnosis of adenomyosis may be performed by non-invasive methods and the clinical signs and symptoms, despite their heterogeneity and poor specificity, may guide the clinician for a suspicion of the disease. Imaging techniques, including 2D and 3D US as well as MRI, allow the proper identification of the different phenotypes of adenomyosis (diffuse and/or focal). From a histological point of view, if the diagnosis of diffuse adenomyosis is straightforward, in more limited disease, the diagnosis has poor inter-observer reproducibility, leading to extreme variations in the prevalence of disease. Therefore, an integrated non-invasive diagnostic approach, considering risk factors profile, clinical symptoms, clinical examination and imaging, is proposed to adequately identify and characterise adenomyosis.

WIDER IMPLICATIONS

The development of the diagnostic tools allows the physicians to make an accurate diagnosis of adenomyosis by means of non-invasive techniques, representing a major breakthrough, in the light of the clinical consequences of this disease. Furthermore, this technological improvement will open a new epidemiological scenario, identifying different groups of women, with a dissimilar clinical and/or imaging phenotypes of adenomyosis, and this should be object of future research.

Question Mark Sign and Transvaginal Ultrasound Uterine Tenderness for the Diagnosis of Adenomyosis: A Prospective Validation

OBJECTIVES

To evaluate the diagnostic accuracy of the classic ultrasound (US) signs of adenomyosis, the question mark sign and transvaginal ultrasound (TVUS) uterine tenderness, in the diagnosis of adenomyosis.

METHODS

This was a prospective study including 78 patients waiting for hysterectomy for uterine benign diseases and undergoing preoperative US examinations to evaluate all criteria for US diagnosis of adenomyosis as reported by the consensus statement of the Morphological Uterus Sonographic Assessment group. A US diagnosis of adenomyosis was made in the presence of 2 or more Morphological Uterus Sonographic Assessment features. Moreover, the question mark sign and TVUS uterine tenderness were evaluated. Ultrasound features were compared with the histologic examination, which was considered the reference standard for the diagnosis of adenomyosis. The Cohen κ coefficient was used to measure the accordance between US and histologic results. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of each US feature were calculated.

RESULTS

The prevalence of adenomyosis in the sample was 33.3%. The sensitivity, specificity, PPV, NPV, and accuracy of TVUS in the diagnosis of adenomyosis were 77%, 96%, 91%, 89%, and 90%, respectively. Myometrial heterogeneity was the most frequently encountered feature (100%) but showed low specificity (7%). The question mark sign and TVUS uterine tenderness showed sensitivity, specificity, PPV, NPV, and accuracy of 41%, 96%, 83%, 77%, and 69% and 69%, 65%, 66%, 81%, and 67%.

CONCLUSIONS

The question mark sign and TVUS uterine tenderness are useful tools for the diagnosis of adenomyosis.

Accuracy of findings in the diagnosis of uterine adenomyosis on ultrasound

PURPOSE

MRI is the current imaging gold standard to diagnose adenomyosis, but access is often limited by high costs and availability. Transvaginal ultrasound provides a cost-effective, accurate and readily available alternative. The objective of our study was to determine the diagnostic accuracy of commonly described sonographic findings in predicting uterine adenomyosis.

METHODS

This retrospective study evaluated 649 MRI studies performed to investigate adenomyosis with a preceding transvaginal ultrasound within 12 months between 2013 and 2018. Two blinded reviewers assessed the presence or absence of six sonographic features: bulky uterus, heterogeneous myometrium, streaky myometrium, myometrial cysts, endometrial-myometrial interface ill-definition, and echogenic linear striations. The sensitivity, specificity, positive and negative predictive values of these features were calculated individually and in combination when compared to MRI as the standard of reference.

RESULTS

Adenomyosis was found in 315 (48.5%) cases on MRI. Ultrasound had a high specificity of 91.8% (95% CI 88.4 to 94.6%) but was less sensitive (36.8% (95% CI 31.5 to 42.4%)) for detecting adenomyosis. Comorbid fibroids or focal adenomyosis did not affect diagnostic accuracy. All six variables were significantly more common in patients with adenomyosis compared to those without. Individually, 'bulky uterus' and 'heterogenous myometrium' each demonstrated a mean sensitivity and specificity > 50%. The best dual combined variables were 'bulky uterus' + 'ill definition of the endometrial-myometrial interface' (sensitivity 39%, specificity 91%). The best triple combined variables were 'bulky uterus', 'heterogeneous myometrium' + 'ill definition of the endometrial-myometrial interface' (sensitivity 38%, specificity 93%).

CONCLUSION

Transvaginal ultrasound is highly specific for diagnosing uterine adenomyosis, providing a cost-effective and readily available alternative to MRI.

The prevalence of adenomyosis in an infertile population: a cross-sectional study

RESEARCH QUESTION

Adenomyosis has been reported in a high proportion (24.4%) of infertile women, but this may be over-representative. What is the exact prevalence of adenomyosis in an infertility clinic population?

DESIGN

In this cross-sectional study, 320 infertile women ≤41 years of age attending the infertility clinic of a university teaching hospital were screened by two-dimensional transvaginal ultrasound (2D-TVS) to look for the sonographic markers of adenomyosis, with subsequent magnetic resonance imaging (MRI) if suspected. Additionally, the adenomyosis subtype (I-IV) was determined from MRI geography (Kishi classification). Comparisons between women with and without adenomyosis were carried out.

RESULTS

Adenomyosis was found by 2D-TVS in 24 cases (7.5%) and confirmed by MRI in 21 (6.6%). The mean age of the group was 29.2 ± 4.7 years. The most frequently observed sonographic finding (58.3% of cases) was asymmetrical myometrial thickening. The majority of MRI-confirmed cases (85.7%) had diffuse adenomyosis. A significantly higher prevalence was found in women ≥40 compared with women <40 years old (40.0% versus 4.9%, respectively; P < 0.0001). Adenomyotic women had significantly higher mean age (32.7 ± 3.0 versus 28.6 ± 4.4 years; P < 0.00001), body mass index (31.3 ± 2.7 versus 28.7 ± 3.3 kg/m²; P < 0.0001), suffered more dysmenorrhoea (38% versus 17%; P = 0.02) and had more ovarian endometriomas (19% versus 6%; P = 0.03) than those without adenomyosis.

CONCLUSION

The observed prevalence of adenomyosis detected de novo by 2D-TVS in a population of young infertile women (7.5%) should alert gynaecologists and ultrasonographers to look for the features of adenomyosis when scanning such patients.

Imaging for Adenomyosis: Making the Diagnosis by Sonography

OBJECTIVE

To demonstrate a systematic approach for ultrasound diagnosis of adenomyosis.

DESIGN

Stepwise demonstration of the ultrasound features of adenomyosis with narrated video footage.

SETTING

In 2015, the International Morphological Uterus Sonographic Assessment group published a consensus on which terminology to use when describing myometrial lesions seen on ultrasonography [12]. However, 2-dimensional (2D) and 3-dimensional (3D) ultrasound features of adenomyosis are demonstrated most optimally using video clips.

INTERVENTIONS

A systematic description, including pictograms of individual features of adenomyosis, is correlated to the typical findings of adenomyosis in 2D and 3D ultrasound images and video clips.

CONCLUSION

A structured, systematic description of individual 2D and 3D ultrasound features is important for a correct diagnosis of adenomyosis [3-5].

New Sonographic Classification of Adenomyosis: Do Type and Degree of Adenomyosis Correlate to Severity of Symptoms?

STUDY OBJECTIVE

To correlate the type and degree of adenomyosis, scored through a new system based on the features of transvaginal sonography, to patients' symptoms and fertility.

DESIGN

This is a multicenter, observational, prospective study.

SETTING

Two endometriosis tertiary referral centers (University of Rome "Tor Vergata" and University of Siena).

PATIENTS

A total of 108 patients with ultrasonographic signs of adenomyosis.

INTERVENTIONS

A new ultrasonographic scoring system designed to assess the severity and the extent of uterine adenomyosis was used to stage the disease in correlation with the clinical symptoms. Menstrual uterine bleeding was assessed by a pictorial blood loss analysis chart, painful symptoms were evaluated using a visual analog scale, and infertility factors were considered.

MEASUREMENTS AND MAIN RESULTS

A total of 108 patients with ultrasonographic signs of adenomyosis (mean age ± standard deviation, 37.7 ± 7.7 years) were classified according to the proposed scoring system. Women with ultrasound diagnosis of diffuse adenomyosis were older (p = .04) and had heavier menstrual bleeding (p = .04) than women with focal disease; however, no statistically significant differences were found regarding the presence and severity of dyspareunia and dysmenorrhea. Higher values of menstrual bleeding were found for severe diffuse adenomyosis, with the highest values being found in those with adenomyomas. In patients trying to conceive, the presence of ultrasound findings of focal disease was associated with a higher percentage of infertility than in those with diffuse disease, and the focal involvement of the junctional zone showed a higher percentage of at least 1 miscarriage than in those with diffuse adenomyosis.

CONCLUSION

The ultrasonographic evaluation of the type and extension of adenomyosis in the myometrium seems to be important in correlation to the severity of symptoms and infertility.

Ultrasound Imaging in Endometriosis

Ultrasound examination is an indisputable imaging method in the diagnosis of endometriosis, as the first step in the detection, as the fundamental tool in planning the management, and as the best diagnostic instrument during surveillance of affected women. The aim of this article is to provide an update on the role of ultrasound in the detection, in the planning of medical and surgical treatment, and in the surveillance of patients with endometriosis.

Management of uterine adenomyosis: current trends and uterine artery embolization as a potential alternative to hysterectomy

Adenomyosis is a challenging clinical condition that is commonly being diagnosed in women of reproductive age. To date, many aspects of the disease have not been fully understood, making management increasingly difficult. Over time, minimally invasive diagnostic and treatment methods have developed as more women desire uterine preservation for future fertility or to avoid major surgery. Several uterine-sparing treatment options are now available, including medication, hysteroscopic resection or ablation, conservative surgical methods, and high-intensity focused ultrasound each with its own risks and benefits. Uterine artery embolization is an established treatment option for uterine fibroids and has recently gained ground as a safe and cost-effective method for treatment of uterine adenomyosis with promising results. In this review, we discuss current trends in the management of uterine adenomyosis with a special focus on uterine artery embolization as an alternative to hysterectomy.

Inter-rater agreement in the diagnosis of adenomyosis by 2- and 3-dimensional transvaginal ultrasonography

OBJECTIVES

To assess the inter-rater agreement of 2-dimensional (2D) and 3-dimensional (3D) transvaginal ultrasonography (TVUS) in the diagnosis of adenomyosis.

METHODS

This prospective study included premenopausal women (n = 96) with heavy menstrual bleeding, menstrual pain, or both who were scheduled for hysterectomy or transcervical resection of the endometrium. All women underwent real-time 2D TVUS and subsequently offline 3D TVUS, which was blinded to 2D TVUS, by a single expert rater and a single nonexpert rater for the diagnosis of adenomyosis based on standardized pattern recognition and junctional zone measurements. Three-dimensional TVUS was done on a computer with 3D volumes recorded during 2D TVUS by both raters. The expert rater reported the image quality of all 3D volumes (n = 192). Inter-rater agreement (Cohen's κ) was assessed for both techniques, and the improvement over time was assessed for 2D TVUS.

RESULTS

Diagnosis of adenomyosis showed good (κ = 0.69) and poor (κ = 0.21) inter-rater agreement with 2D and 3D TVUS, respectively (P < .05). The agreement with 2D TVUS improved over time. The agreement with 3D TVUS was slightly better for expert-recorded 3D volumes (κ = 0.40), which also had better image quality (P < .05). The most reproducible 2D and 3D features were anechoic lacunae (κ = 0.52) and junctional zone irregularity (κ = 0.27), respectively.

CONCLUSIONS

Standardized pattern recognition during real-time 2D TVUS may result in good agreement between expert and nonexpert raters for the diagnosis of adenomyosis. Offline 3D TVUS is less reproducible, and junctional zone measurements do not improve the inter-rater agreement. The low inter-rater agreement may be related to a lack of experience and low image quality of nonexpert-recorded 3D volumes.

Ulipristal acetate therapy increases ultrasound features of adenomyosis: a good treatment given in an erroneous diagnosis of uterine fibroids

Ulipristal acetate (UPA) is used for medical treatment of uterine fibroids. The aim of this study was to describe the effects on painful symptoms and the sonographic uterine modifications in patients with adenomyosis erroneously treated with UPA. This is an observational study on six women affected by adenomyosis and treated with three months of UPA (5 mg/24h). The baseline ultrasonography (US) was not performed at out center nor was the diagnosis of fibroids. The patients came to our attention after the treatment with UPA, prescribed by an external physician. During our post-treatment scan we found aspects of adenomyosis, while no fibroids were detected. Symptoms, myometrial and endometrial ultrasound features were evaluated. All patients reported an increase in pelvic pain. At US evaluation intramyometrial cystic areas were found in all six cases (100%). All patients showed an enhancement of adenomyosis features.The intra-myometrial cysts appeared enlarged and the vascularization enhanced when compared to the images of the pretreatment scan. In patients with adenomyosis treated with UPA due to an erroneous diagnosis of uterine fibroids we observed a worsening of the US features of adenomyosis and of the painful symptoms.

The Association of Sonographic Evidence of Adenomyosis with Severe Endometriosis and Gene Expression in Eutopic Endometrium

STUDY OBJECTIVE

To examine the presence of sonographic evidence of adenomyosis (SEOA) in patients undergoing laparoscopic surgery for the investigation of endometriosis and to assess if there is an association between SEOA and endometriosis severity. Using gene expression analysis, we also aimed to determine if gene expression in eutopic endometria differed in patients with and without adenomyosis.

DESIGN

A prospective study (Canadian Task Force classification II-2).

SETTING

A tertiary medical center.

PATIENTS

Reproductive-age women who underwent laparoscopic surgery after presenting to a pelvic pain-focused gynecology clinic.

INTERVENTIONS

Endometrial tissue, detailed patient questionnaires, pathology, and surgical notes were collected. Sonographic data from tertiary ultrasounds performed up to 12 months before surgery were retrospectively added (n = 234, researchers blinded to surgical and pathological findings). Gene array data from endometrial biopsies (n = 41) were used to analyze differential gene expression; patients were divided into 2 groups according to the presence or absence of SEOA.

MEASUREMENTS AND MAIN RESULTS

Of the 588 patients recruited, 234 (40%) had an available pelvic scan and were included in this study. The average age of the included women was 30.6 years, with 35% having SEOA. Patients with SEOA were 5.4 years older (p = .02). There was no significant difference in the rates of endometriosis between groups; however, patients with SEOA were more likely to have stage IV endometriosis (41% vs 9.8%, p <.001). Patients with SEOA were also more likely to have other markers of severe endometriosis such as endometriomas and deep infiltrating endometriosis (p <.001). No significant difference was observed in endometrial gene expression between adenomyosis cases and controls after adjusting for menstrual c`ycle phases and the presence/absence of endometriosis.

CONCLUSION

Sonographic features of adenomyosis may be included as a component of the clinical assessment when attempting to predict the presence of severe endometriosis. No differences in gene expression were observed. Further research is needed to characterize uterine adenomyosis and to explore molecular pathways involved in its pathogenesis.

Ultrasound diagnosis of endometriosis and adenomyosis: State of the art

Transvaginal ultrasonography has become the primary test in the diagnosis of pelvic endometriosis and adenomyosis. A review of the literature on the diagnostic accuracy of ultrasonography in pelvic endometriosis and adenomyosis, as well as a comparison with magnetic resonance imaging, will be presented. Criteria for diagnosis of an endometrioma according to robust prospective data together with guidelines as to adequate reporting of the location of deep infiltrating endometriosis will be given. The sonographic features of adenomyosis including the differential diagnosis between focal adenomyosis and a uterine fibroid are reviewed. The available data in the literature on ultrasound diagnosis of pelvic endometriosis and adenomyosis, their clinical relevance, and their limitations are discussed.

From Clinical Symptoms to MR Imaging: Diagnostic Steps in Adenomyosis

Adenomyosis or endometriosis genitalis interna is a frequent benign disease of women in fertile age. It causes symptoms like bleeding disorders and dysmenorrhea and seems to have a negative effect on fertility. Adenomyosis can be part of a complex genital and extragenital endometriosis but also can be found as a solitary uterine disease. While peritoneal endometriosis can be easily diagnosed by laparoscopy with subsequent biopsy, the determination of adenomyosis is difficult. In the following literature review, the diagnostic methods clinical history and symptoms, gynecological examination, 2D and 3D transvaginal ultrasound, MRI, hysteroscopy, and laparoscopy will be discussed step by step in order to evaluate their predictive value in the diagnosis of adenomyosis.

Sonographic Signs of Adenomyosis Are Prevalent in Women Undergoing Surgery for Endometriosis and May Suggest a Higher Risk of Infertility

Objectives

To determine the prevalence of ultrasound features suggestive of adenomyosis in women undergoing surgery for endometriosis compared with a control group of healthy women without endometriosis.

Methods

Retrospective case-control study comparing women with intractable pain or infertility, who underwent transvaginal ultrasound and subsequent laparoscopic surgery, with a control group of healthy women without a previous history of endometriosis. A diagnosis of adenomyosis on TVUS was made based on asymmetrical myometrial thickening, linear striations, myometrial cysts, hyperechoic islands, irregular endometrial-myometrial junction, parallel shadowing, and localized adenomyomas and analyzed for one sign and for three or more signs.

Results

The study and control groups included 94 and 60 women, respectively. In the study group, women were younger and had more dysmenorrhea and infertility symptoms. The presence of any sonographic feature of adenomyosis, as well as three or more signs, was found to be more prevalent in the study group, which persisted after controlling for age, for all features but linear striations. Women in the study group who had five or more sonographic features of adenomyosis had more than a threefold risk of suffering from infertility (OR = 3.19, p = 0.015, 95% CI; 1.25–8.17). There was no association with disease severity at surgery.

Conclusions

Sonographic features of adenomyosis are more prevalent in women undergoing surgery for endometriosis compared to healthy controls. Women with more than five features had an increased risk of infertility.

The impact of adenomyosis on the outcome of IVF-embryo transfer

Our study examined the impact of adenomyosis on the chance of clinical pregnancy after IVF and embryo transfer (IVF-ET). This was a prospective multicentre study from April 2013 to October 2015. We included 375 women with history of infertility who attended for a 3D scan prior to IVF-ET. A total of 150/375 (40.0%, 95% confidence interval [CI] 35.2-45.0) women had clinical pregnancy. Women with any feature of adenomyosis had a lower clinical pregnancy rate (21/72 [29.2%, 95% CI 18.6-39.6] versus 129/303 [42.6%, 95% CI 37.1-48.2], P = 0.044, relative risk (RR) 0.68 [95% CI 0.47-1.00]). Logistic regression selected an adenomyosis score of 4 or higher as an independent predictor of clinical pregnancy (odds ratio [OR] 0.35 [95% CI 0.15-0.82]). Estimated probability of clinical pregnancy decreased from 42.7% (95% CI 37.1-48.3) for women with no adenomyosis features to 22.9% (95% CI 13.4-32.6) for those with four and 13.0% (95% CI 2.2-23.9) for those with all seven. Women with adenomyosis have lower clinical pregnancy rate after IVF-ET. Condition severity expressed as a number of morphological features on ultrasound scan increases the magnitude of the effect.

Interobserver Agreement in the Study of 2D and 3D Sonographic Criteria for Adenomyosis

Objective

To study the degree of interobserver agreement for already known two-dimensional (2D) and three-dimensional (3D) sonography criteria of adenomyosis.

Methods

Fifty cases (25 adenomyosis cases, 25 non-adenomyosis cases) were studied by four expert observers and a less-experienced researcher. Each sonographic adenomyosis criterion was separately studied. Interobserver agreement was analysed by the kappa index with 95% confidence interval (CI).

Results

The degree of agreement about diagnosing adenomyosis was high or very high in all pair-wise comparisons (kappa values of 0.58–0–92). The agreement on identifying intra-myometrial cysts (kappa values of 0.46–0.79) and evaluating the junctional zone (JZ) by 3D-transvaginal ultrasound (3D-TVS) (kappa index of 0.46–0.88) was good. The agreements reached when evaluating the other criteria varied, but good agreement was generally reached.

Conclusions

Both the 2D-TVS and 3D-TVS criteria employed in diagnosing adenomyosis were reproducible parameters in adenomyosis diagnostics. The results were reproducible, even by a less experienced observer.

Assessment of the uterus with three-dimensional ultrasound in women undergoing ART

BACKGROUND

A detailed assessment of the uterus forms a pivotal part of the ART treatment process. The emergence of three-dimensional ultrasound (3D US) has provided clinicians with a highly powerful tool in this respect. Assessments with 3D US range from the reconstruction of anatomical planes elusive to conventional US, to the objective measurement of anatomical volumes and vascularization parameters. However, despite the ever increasing number of publications emerging in the literature, the question of which aspects of 3D US are of most clinical value remains a topic of debate.

OBJECTIVE AND RATIONALE

The objective of this review is to dissect which aspects of the 3D US assessment of the uterus are supported by a strong level of evidence to date, and should therefore be incorporated into current routine clinical practice.

SEARCH METHODS

We conducted a systematic search of the PubMed database up to May 2016, using a combination of text words and Medical Subject Headings (MeSH) pertaining to the 3D US assessment of the uterus. All articles published in the English language were screened to ascertain relevance to women of reproductive age; further citations were retrieved through manual reference list searching.

OUTCOMES

A multitude of predominantly observational studies were identified, which concerned a vast variety of 3D US uterine assessments. All articles unequivocally praised the non-invasive, cost-effective, highly acceptable and objective nature of 3D US. Studies regarding the value of assessing the endometrial volume and vascularization prior to embryo transfer appeared conflicting and inconsistent. Studies regarding the imaging of uterine pathology and identification of intratubal and intrauterine devices consistently reported high rates of diagnostic accuracy. A recent RCT did not show an improvement in clinical outcomes when comparing 3D versus 2D US during embryo transfer. However, preliminary studies suggested that 3D US is superior in determining the site of implantation, particularly in ambiguous cases such as interstitial and angular pregnancies. Finally, pilot studies have suggested that the further integration of 3D and possibly 4D US with surgical interventions of the uterus may be a promising prospect.

WIDER IMPLICATIONS

3D US may prove to be an invaluable tool in the assessment of the uterus within the context of ART. Currently, the aim should be to highlight the aspects of 3D US that are most evidence-based and valuable for patients, and to incorporate these into routine clinical practice.

Long-Term Vaginal Danazol Treatment in Fertile Age Women with Adenomyosis

Background

The aim of the study was to evaluate the clinical efficacy of long-term vaginal danazol treatment in fertile age women with adenomyosis on pain symptoms and abnormal uterine bleeding (AUB).

Methods

A retrospective study on 66 young women with dysmenorrhea and/or dyspareunia, AUB and 2D-ultrasound diagnosis of adenomyosis was conducted at University Hospital of Siena (Italy). Women included were treated with a daily low-dose vaginal danazol (200 mg) for 6 months, followed by 2 different schedules: group A) continuous treatment for further 18 months (n = 30); group B) cyclic intermittent treatment with 3 months’ therapy followed by 3 months’ interval for further 18 months (n = 36). A visual analog scale (VAS) for pain symptoms, a pictorial blood-loss assessment chart (PBAC) for uterine bleeding, 2D-ultrasound signs of adenomyosis and quality-of-life measures were assessed at baseline and after both vaginal progestin regimens.

Results

The pain symptoms, PBAC score and uterine volume were significantly reduced (p<0.0001) after 6 months, and the reduction persisted in both group of patients until the end. Mental and physical index score values increased (p<0.0001) in both groups at the end of treatment, with significantly higher mental index scores in intermittent than in continuous treatment (p<0.0001), associated with some drop-out (10%).

Conclusions

A long-term treatment with vaginal danazol is effective to control pain and AUB in women with adenomyosis. The 6 months’ treatment followed by a cyclic 3 months’ treatment for further 18 months has the best compliance in symptomatic patients with adenomyosis.

Transvaginal Ultrasound for the Diagnosis of Abnormal Uterine Bleeding

Transvaginal ultrasound is the first-line imaging test for the evaluation of abnormal uterine bleeding in both premenopausal and postmenopausal women. Transvaginal ultrasound can be used to diagnose structural causes of abnormal bleeding such as polyps, adenomyosis, leiomyomas, hyperplasia, and malignancy, and can also be beneficial in making the diagnosis of ovulatory dysfunction. Traditional 2-dimensional imaging is often enhanced by the addition of 3-dimension imaging with coronal reconstruction and saline infusion sonohysterography. In this article we discuss specific ultrasound findings and technical considerations useful in the diagnosis of abnormal uterine bleeding.

Current and Future Medical Treatment of Adenomyosis

Adenomyosis is a benign gynecological disorder associated with abnormal uterine bleeding, dysmenorrhea, dyspareunia and infertility, requiring a life-long management plan through medical or surgical treatment. The choice depends on woman's age, reproductive status and clinical symptoms. However, until now no drug labelled for adenomyosis is available; thus, the present review will focus on medical treatments currently used for adenomyosis and those in development.

Adenomyosis may be considered a sex steroid hormone-related disorder associated with an intense inflammatory process. The use of gonadotropin-releasing hormone agonists (GnRH-a) for treating adenomyosis is described blocking the hypothalamic-pituitary-gonadal axis; however, it has long been associated with frequent and intolerable hypoestrogenic side effects. An antiproliferative effect of progestins suggests their use for treating adenomyosis, reducing bleeding and pain. Continuous oral norethisterone acetate or medroxyprogesterone acetate may help to inducing regression of adenomyosis, relief pain and reduce bleeding. The use of vaginal danazol has therapeutic effect on adenomyosis combining progestogenic and anti-inflammatory activity. The intrauterine device releasing levonorgestrel (Lng-IUD) is widely assessed in menorrhagia, and has been shown to be extremely effective in resolving pain and bleeding symptoms associated with adenomyosis. Recent data show a therapeutic effect of dienogest on adenomyosis symptoms.

New drugs are under development for the treatment of adenomyosis, such as aromatase inhibitors (AIs) and selective estrogen receptor modulators (SERMs), that produce a hypoestrogenic environment reducing pain, but are correlated with some adverse effects and a recurrence of symptoms after discontinuation of treatment. Selective progesterone receptor modulators (SPRMs) may reduce adenomyosis-associated pelvic pain, by inhibiting endometrial proliferation and suppressing adenomyotic lesion growth, as shown in animal models; however, the long-term effect with SPRMs needs further determination.