A Detailed Study in Adenomyosis and Endometriosis: Evaluation of the Rate of Coexistence Between Uterine Adenomyosis and DIE According to Imaging and Histopathology Findings

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.

Patterns of health service use before and after diagnosis of endometriosis: a data linkage prospective cohort study

STUDY QUESTION

What are the patterns of health service use (HSU) before and after endometriosis diagnosis?

SUMMARY ANSWER

Women with endometriosis had higher rates of visits to general practitioners (GPs), specialists, and diagnostic imaging before and after diagnosis compared to those without the condition; however, after diagnosis, their visits to GPs and specialists other than obstetricians/gynaecologists decreased compared to before, while visits to obstetricians/gynaecologists and use of diagnostic imaging increased.

WHAT IS KNOWN ALREADY

Women with endometriosis have higher rates of healthcare use compared to those without the condition; however, no longitudinal study has examined patterns of HSU over a prolonged period before and after diagnosis.

STUDY DESIGN, SIZE, DURATION

The Australian Longitudinal Study on Women's Health linked to a national administrative health record. A total of 30 473 women, born in 1973-1978 and 1989-1995, from two cohorts with data collected from 1996 to 2021, as online or postal questionnaires.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women with endometriosis were identified using the self-report surveys and their administrative health records. A control group of women without endometriosis was randomly selected and age-matched with women with endometriosis. The final sample included 9545 women from the 1973-1978 cohort (1909 cases, 7636 controls) and 7510 from the 1989-1995 cohort (1502 cases, 6008 controls). Women's HSU was assessed using the Medicare Benefits Schedule database. A random intercept zero-inflated negative binomial model was used to compare outcomes between cases and controls, addressing skewed data, over-dispersion, and excess zeros.

MAIN RESULTS AND THE ROLE OF CHANCE

In both cohorts, women with endometriosis had a higher level of HSU, both before and after diagnosis, compared with those without the condition. For the 1973-1978 cohort, women with endometriosis had a higher rate of visits to GPs before and after diagnosis (adjusted incidence rate ratio: 1.19, 95% CI 1.14, 1.23 and 1.24, 95% CI 1.19, 1.30, respectively), specialists other than obstetricians/gynaecologists (1.50, 95% CI 1.40, 1.61, and 1.36, 95% CI 1.27, 1.46), and for diagnostic imaging (1.15, 95% CI 1.10, 1.21, and 1.20, 95% CI 1.15, 1.26). The average number of these visits remained consistent in the early years, peaked around 3 years before diagnosis, and then partly declined post-diagnosis, to later stabilize at a higher level than those without the condition. Following the diagnosis, women with endometriosis had a higher number of visits to obstetricians/gynaecologists (1.11, 95% CI 1.05, 1.17) than their matched controls, with a marked increase in the first 6 years post-diagnosis, but gradually returned to same levels as the control group. After diagnosis, women with endometriosis had a lower rate of visits to GPs (0.95, 95% CI 0.93, 0.98) and specialists other than obstetricians/gynaecologists (0.88, 95% CI 0.82, 0.93) compared to before their diagnosis, while they had a higher rate of visits to obstetricians/gynaecologists (1.09, 95% CI 1.01, 1.18) and diagnostic imaging (1.07, 95% CI 1.01, 1.14). Similar patterns of HSU were observed in the 1989-1995 cohort, regardless of whether surgically confirmed or clinically suspected cases of endometriosis were used, though the evidence for changes in specific HSU before and after diagnosis was weaker.

LIMITATIONS, REASONS FOR CAUTION

Approximately half of the women with endometriosis were clinically suspected cases without laparoscopic confirmation, which may result in an overestimation of prevalence and introduce the risk of misdiagnosis, potentially influencing clinical management and research findings.

WIDER IMPLICATIONS OF THE FINDINGS

The continued high level of HSU among women with endometriosis, even over a decade after diagnosis, suggests that they have substantially greater healthcare needs than other women. The distinct patterns of the use of healthcare in the years before and after endometriosis diagnosis can support efforts to improve diagnosis, management, and treatment outcomes for patients and to reduce healthcare costs.

STUDY FUNDING/COMPETING INTEREST(S)

The Australian Longitudinal Study on Women's Health is funded by the Australian Government Department of Health and Aged Care. G.D.M. and G.M. are Australian National Health and Medical Research Council Leadership Fellows (GNT2009577 and GNT1177194). D.G.G. was funded by MRFF EndoAIMM (RFEHP100126). Funding sources had no role in the study design, data analysis, interpretation, or manuscript writing. The authors have no conflict of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

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.

A stacked machine learning-based classification model for endometriosis and adenomyosis: a retrospective cohort study utilizing peripheral blood and coagulation markers

Introduction

Endometriosis (EMs) and adenomyosis (AD) are common gynecological diseases that impact women's health, and they share symptoms such as dysmenorrhea, chronic pain, and infertility, which adversely affect women's quality of life. Current diagnostic approaches for EMs and AD involve invasive surgical procedures, and thus, methods of noninvasive differentiation between EMs and AD are needed. This retrospective cohort study introduces a novel, noninvasive classification methodology employing a stacked ensemble machine learning (ML) model that utilizes peripheral blood and coagulation markers to distinguish between EMs and AD.

Methods

The study included a total of 558 patients (329 with EMs and 229 with AD), in whom key hematological and coagulation markers were analyzed to identify distinctive profiles. Feature selection was conducted through ML (logistic regression, support vector machine, and K-nearest neighbors) to determine significant hematological markers.

Results

Red cell distribution width, mean corpuscular hemoglobin concentration, activated partial thromboplastin time, international normalized ratio, and antithrombin III were proved to be the key distinguishing indexes for disease differentiation. Among all the ML classification models developed, the stacked ensemble model demonstrated superior performance (area under the curve = 0.803, 95% credibility interval = 0.701-0.904). Our findings demonstrate the effectiveness of the stacked ensemble ML model for classifying EMs and AD.

Discussion

Integrating biomarkers into this multi-algorithm framework offers a novel approach to noninvasive diagnosis. These results advocate for the application of stacked ensemble ML utilizing cost-effective and readily available peripheral blood and coagulation indicators for the early, rapid, and noninvasive differential diagnosis of EMs and AD, offering a potentially transformative approach for clinical decision-making and personalized treatment strategies.

Assessment of the Ferroptosis Regulators: Glutathione Peroxidase 4, Acyl-Coenzyme A Synthetase Long-Chain Family Member 4, and Transferrin Receptor 1 in Patient-Derived Endometriosis Tissue

Ferroptosis, an iron-dependent form of non-apoptotic cell death, plays a pivotal role in various diseases and is gaining considerable attention in the realm of endometriosis. Considering the classical pathomechanism theories, we hypothesized that ferroptosis, potentially driven by increased iron content at ectopic sites, may contribute to the progression of endometriosis. This retrospective case-control study provides a comprehensive immunohistochemical assessment of the expression and tissue distribution of established ferroptosis markers: GPX4, ACSL4, and TfR1 in endometriosis patients. The case group consisted of 38 women with laparoscopically and histologically confirmed endometriosis and the control group consisted of 18 women with other gynecological conditions. Our study revealed a significant downregulation of GPX4 in stromal cells of endometriosis patients (M = 59.7% ± 42.4 versus 90.0% ± 17.5 in the control group, t (54) = -2.90, p = 0.005). This finding aligned with slightly, but not significantly, higher iron levels detected in the blood of endometriosis patients, using hemoglobin as an indirect predictor (Hb 12.8 (12.2-13.5) g/dL versus 12.5 (12.2-13.4) g/dL in the control group; t (54) = -0.897, p = 0.374). Interestingly, there was no concurrent upregulation of TfR1 (M = 0.7 ± 1.2 versus 0.2 ± 0.4 for EM, t (54) = 2.552, p = 0.014), responsible for iron uptake into cells. Our empirical findings provide support for the involvement of ferroptosis in the context of endometriosis. However, variances in expression patterns within stromal and epithelial cellular subsets call for further in-depth investigations.

Imaging and molecular features of adenomyosis after menopause

OBJECTIVES

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

STUDY DESIGN

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

The Impact of Endometriosis on Pregnancy

Despite the increased frequency of endometriosis, it remains one of the most enigmatic disorders regarding its effects on pregnancy. Endometriosis adversely affects both natural and assisted conception. Impaired folliculogenesis, which causes follicular dysfunction and low egg quality, as well as luteal phase problems, reduced fertilization, and abnormal embryogenesis, are some of the mechanisms advocated to explain reproductive dysfunction. There is a rising need for a comprehensive study of the potential negative consequences of this condition on pregnancy outcomes, including the postpartum period, as more women with a medical history of endometriosis become pregnant. Obstetrical complications (small for gestational age [SGA], cesarean section [CS], miscarriage, hemorrhage, low placental adhesion, and preterm delivery) are statistically elevated in women with endometriosis. Furthermore, ruptured ovarian endometrioma, appendicitis, intestinal perforation, and hemoperitoneum have been described in pregnancy. Obstetricians are largely unfamiliar with these complications, as they have not been thoroughly investigated. The development and pathogenesis of endometriosis is an important field of study and has not yet been fully elucidated. Finding these mechanisms is crucial for the development of new and more effective strategies to treat this condition. Endometriosis can have an impact on obstetric and neonatal outcomes of pregnancy, in addition to its potential effects on conception. To date, no additional monitoring is recommended for pregnancies with a history of endometriosis. However, more studies are urgently needed to assess the need for the tailored pregnancy monitoring of women with endometriosis.

How to Manage Endometriosis in Adolescence: The Endometriosis Treatment Italian Club Approach

The evaluation of endometriosis in an adolescent girl is a challenging topic. The initial stage of the disease and the limited diagnostic instrument appropriate for the youth age and for its typical features can reduce the ability of the gynecologist. At the same time, missing a prompt diagnosis can delay the beginning of specific and punctual management of endometriosis, which could avoid a postponed diagnosis from 6 to 12 years, typical of adolescent girls complaining of dysmenorrhea. This article aimed to answer all the potential questions around the diagnosis and management of endometriosis in adolescents starting from a clinical case looking at the possible solution that is easily reproducible in the clinical practice.

The role of levonorgestrel-releasing intrauterine system for recurrence prevention after conservative surgery among patients with coexistent ovarian endometrioma and diffuse adenomyosis: A retrospective case control study with long-term follow up

BACKGROUND

When ovarian endometrioma coexist with adenomyosis, the risk of postoperative recurrence increased. How is the effect of levonorgestrel-releasing intrauterine system (LNG-IUS) on symptomatic recurrence for those patients was unknown.

METHODS

This study retrospectively analyzed 119 women with coexistent endometrioma and diffuse adenomyosis who received laparoscopic excision of pelvic endometriosis from January 2009 to April 2013. Women were categorized into two groups: intervention group with LNG-IUS and control group with expectant observation after surgery. Data were compared in terms of preoperative history, laboratory and intraoperative findings, and clinical outcomes during follow-up, including pain regression, changes in uterine volume and recurrence.

RESULTS

During a median 79 months (range, 6-107) of follow-up, patients with LNG-IUS experienced a significantly lower symptomatic recurrence of either ovarian endometrioma or dysmenorrhea (11.1% vs. 31.1%, p = 0.013), compared with women under expectant observation by Kaplan-Meier survival analysis (χ² = 5.448, p = 0.020) and Cox univariate assessment (hazard ratio of 0.336, 95% confidence interval 0.128-0.885, p = 0.027). Patients treated with LNG-IUS demonstrated a more prominent reduction in uterine volume (-14.1 ± 20.9 vs. 8.7 ± 48.8, p = 0.003) and higher percentage of complete pain remission (95.6% vs. 86.5%). For multivariate analysis, use of LNG-IUS (aHR 0.159, 95%CI 0.033-0.760, p = 0.021) and severity of dysmenorrhea (aHR 4.238, 95%CI 1.191-15.082, p = 0.026) were two independent factors associated with overall recurrence.

CONCLUSION

Postoperative insertion of LNG-IUS may prevent recurrence in symptomatic women with comorbidity of ovarian endometrioma and diffuse adenomyosis.

Transvaginal ultrasound versus magnetic resonance imaging for diagnosing adenomyosis: A systematic review and head-to-head meta-analysis

BACKGROUND

Transvaginal ultrasound (TVS) and magnetic resonance imaging (MRI) are used for the clinical diagnosis of adenomyosis.

OBJECTIVES

To compare the diagnostic accuracy of TVS and MRI for the diagnosis of adenomyosis.

SEARCH STRATEGY

A search of studies was performed in five databases comparing TVS and MRI for the diagnosis of adenomyosis from January 1990 to May 2022.

SELECTION CRITERIA

Studies were eligible if they reported on the use of TVS and MRI in the same set of patients. The reference standard must be pathology (hysterectomy).

DATA COLLECTION AND ANALYSIS

The quality of studies was assessed using the QUADAS-2 tool. Pooled sensitivity and specificity of both techniques were estimated and compared.

MAIN RESULTS

Six studies comprising 595 women were included. The risk of bias of patient selection was high in three studies. The risk of bias for index tests and reference test was low. Pooled estimated sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio for TVS were 75%, 81%, 3.9, and 0.31, respectively. These figures for MRI were 69%, 80%, 3.5, and 0.39, respectively. No statistically significant differences were found (p = 0.7509). Heterogeneity was high.

CONCLUSIONS

MRI and TVS have similar performances for the diagnosis of adenomyosis.

Value of Transabdominal Combined Transvaginal Color Doppler Ultrasonography in the Distinguish between Uterine Adenomyoma and Uterine Fibroids

Objective. To investigate the value of transabdominal combined transvaginal color Doppler ultrasonography in the diagnosis of uterine adenomyoma. Methods. A total of 80 patients with suspected uterine adenomyoma in our hospital from January 2019 to December 2021 were selected as the study subjects. All of them were examined by transabdominal color Doppler ultrasound (TA-CDUS) and transvaginal color Doppler ultrasound (TV-CDUS), and the postoperative pathological examination results were taken as the gold standard to analyze the diagnostic efficacy of different examination methods for uterine adenomyoma. Results. By postoperative pathological biopsy, 46 cases (57.50%) were diagnosed as positive and 34 cases (42.50%) were diagnosed as negative, including 29 cases of uterine adenomyoma and 5 other cases. The sensitivity, accuracy, and negative predictive value of TA-CDUS combined with TV-CDUS in the diagnosis of adenomyoma were higher than those of TA-CDUS ( $P<0.05$ ), and the Kappa value between TA-CDUS and pathological diagnosis was 0.923, which was higher than the 0.615 between TV-CDUS and pathological diagnosis. TA-CDUS combined with TV-CDUS showed that there were significant differences in the distribution of Adier blood flow grades between patients with uterine adenomyoma and uterine fibroids ( $P<0.05$ ), and the Adier blood flow grades of patients with uterine adenomyoma were mainly grade 0 and grade I; and the resistance index (RI), peak systolic velocity (Vs), and pulsatile index (PI) in patients with uterine adenomyoma were higher than those in patients with uterine fibroids ( $P<0.05$ ). Conclusion. Compared with TA-CDUS, TA-CDUS combined with TV-CDUS is more sensitive and accurate in the diagnosis of uterine adenomyoma and has a good consistency with pathological diagnosis results. Attention should be paid to the blood flow parameter values in the differential diagnosis of uterine fibroids.