Comparison of the treatment efficacies of HIFU, HIFU combined with GnRH-a, and HIFU combined with GnRH-a and LNG-IUS for adenomyosis: A systematic review and meta-analysis

Clinical application of a novel hysteroscopic LNG-IUS non-suture fixation at the uterine fundus

Objective

This study aimed to explore the feasibility and clinical effects of a novel hysteroscopic levonorgestrel-releasing intrauterine system (LNG-IUS) non-suture fixation at the uterine fundus.

Methods

From October 2023 to July 2024, a prospective study involving a novel hysteroscopic LNG-IUS non-suture fixation at the uterine fundus was conducted at Obstetrics and Gynecology Hospital, Fudan University. The patient's clinical symptoms, surgical time, surgical complications, postoperative LNG-IUS expulsion, and other follow-up information were recorded.

Results

A total of 31 patients were included in this study. The average uterine depth is 9.17 ± 0.67 cm. Among them, 10 cases had a history of LNG-IUS expulsion. The average surgical time is 13.0 ± 4.1 min, and the average intraoperative blood loss is 5.3 ± 3.6 mL. All patients did not experience complications such as uterine perforation, massive bleeding, fluid overload, or postoperative infection. The average follow-up time after surgery was 6.0 ± 1.8 months, and no LNG-IUS expulsion occurred. The pain assessment and mean menstrual flow postoperation were less than preoperation, and the endometrial thickness and mean uterine volume postoperation were lower than preoperation, with statistically significant differences. For patients with dysmenorrhea, the postoperative relief rate was 96.3% (26/27), and for those with excessive menstruation, the postoperative effective rate reached 96.2% (25/26). The main adverse reaction was irregular vaginal bleeding, with an incidence rate of 61.3% (19/31).

Conclusion

Hysteroscopic LNG-IUS non-suture fixation at the uterine fundus is a safe and effective technique, particularly suitable for patients with dysmenorrhea, excessive menstruation, or a large uterine cavity who have previously experienced LNG-IUS expulsion. This procedure is simple and minimally invasive, has a short surgical time, has minimal bleeding, and provides rapid recovery; therefore, it is worthy of clinical application.

Innovative application of high-intensity focused ultrasound combined with endometrial thermal balloon ablation in the treatment of adenomyosis: A cohort study

OBJECTIVE

To evaluate the efficacy of high-intensity focused ultrasound (HIFU) combined with endometrial thermal balloon ablation (TBEA) for treating adenomyosis-related hypermenorrhagia.

METHODS

This retrospective cohort study included 120 patients diagnosed with adenomyosis-related hypermenorrhagia. Patients were divided into three groups: the HIFU combined with TBEA group (HIFU + TBEA, 34 cases), the HIFU combined with gonadotropin-releasing hormone agonist and intrauterine levonorgestrel intrauterine system (HIFU + GnRH-a + LNG-IUS, 51 cases) group and the HIFU (35 cases) group. Efficacy and safety were assessed using the pictorial blood loss assessment chart (PBAC), dysmenorrhea scores evaluated by the Numerical Rating Scale (NRS), quality of life measured by the Uterine Fibroid Symptom and Quality of Life scale (UFS-QOL), reintervention rates, success rates, satisfaction, and adverse effects at pretreatment and 1, 3, 6, 9, and 12 months posttreatment.

RESULTS

The HIFU + TBEA group showed significantly greater reductions in PBAC scores at 6, 9, and 12 months compared to the HIFU + GnRH-a + LNG-IUS group, and consistently lower scores than the HIFU group at all follow-up points. No significant differences in NRS scores or reintervention rates were observed between groups. Additionally, the HIFU + TBEA group reported higher UFS-QOL scores at 6 and 12 months posttreatment and greater satisfaction at 12 months posttreatment. Its success rate exceeded that of the HIFU group but was comparable to the HIFU + GnRH-a + LNG-IUS group. Serious adverse reactions were rare across all groups.

CONCLUSION

HIFU combined with TBEA demonstrates good efficacy and safety, providing an effective long-term treatment option for adenomyosis-related hypermenorrhagia in patients without fertility needs.

SYNOPSIS

Evaluating HIFU + TBEA as an effective long-term treatment for adenomyosis-related hypermenorrhagia in patients without fertility needs.

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.

Combining Medication With High-Intensity-Focused Ultrasound for Adenomyosis: A Network Meta-Analysis of Randomized Controlled Trials

This network meta-analysis aims to identify the best possible combination therapy for individuals suffering from adenomyosis. To identify pertinent research for the network meta-analysis, a comprehensive search was conducted across multiple databases, including PubMed, Embase, Cochrane Library, Web of Science, CNKI, WanFang, and VIP, spanning from their commencement to February 21, 2024. The study's focus was on evaluating outcomes including visual analog scale (VAS) scores for dysmenorrhea, measurements of uterine and lesion volumes, menstrual blood loss, and the rate of disease recurrence. The findings from both direct and indirect comparisons, which were quantitatively assessed using weighted mean differences or relative risk along with their respective 95% confidence intervals, were graphically depicted in forest plots. Additionally, the ranking probability was illustrated, which indicated the likelihood of various high-intensity-focused ultrasound (HIFU) combination therapies being the most effective across each measured outcome. In the final analysis, this network meta-analysis encompassed a total of 31 articles. The results showed that HIFU combined with gonadotropin-releasing hormone agonist (GnRH-a) and progestin was more effective to decrease VAS score for dysmenorrhea than other combined therapies. HIFU combined with progestin was superior to other combined therapies in decreasing uterine volume, lesion size, and recurrence rate. HIFU combined with mifepristone was more effective to reduce menstrual volume compared to other combined therapies. The analysis suggests that regimens incorporating HIFU along with GnRH-a and progestin, or HIFU combined with progestin or HIFU combined with mifepristone might offer superior benefits in the clinical management of adenomyosis. These combined treatment approaches could potentially be more effective options for patients suffering from this condition.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

An Updated Review of Thermal Ablation Technology for Uterine Fibroids and Adenomyosis: Focusing on Protecting Fertility

There is a growing trend towards minimally invasive or noninvasive alternatives for gynecological disorders due to their rapid alleviation of symptom, expedited recovery, and minimal risks of postoperative complications. Thermal ablation technology has been commonly advocated as a minimally invasive therapeutic methods in recent years, including microwave ablation, radiofrequency ablation, and high-intensity focused ultrasound. The increasing application scenarios require updated and systematic research, and more evidence to promote their appropriate use. The objective of this review is to summarize the latest views of ablation from a prospective of fertility protection, endeavor to clarify the clinical value of thermal ablation technology in protecting fertility by assessing parameters such as ablation rates, alleviation of disease symptoms, re-intervention rates and post-treatment pregnancy rates. We review the clinical studies of ablation for uterine fibroids and adenomyosis treatment in the past 10 years, summarize the limitation and the prospects of its development in the treatment process, so as to provide clinicians with advice on the best practice. In the management of uterine fibroids and adenomyosis, thermal ablation technology offers improved fertility preservation and minimizes normal tissue injury compared to traditional surgical approaches for patients pursuing reproductive goals. In the future, thermal ablation technology will play a significantly enhanced role in preserving fertility for individuals requiring treatment for uterine fibroids and adenomyosis, guided by indications. But further research is still needed in the form of more extensive randomized prospective trials to provide stronger evidence supporting this perspective.

Ultrasound-Guided High-Intensity Focused Ultrasound of Uterine Fibroids and Adenomyosis: An 11-Year Experience from a Single Center in Hong Kong

Introduction: This study evaluated the efficacy and safety of ultrasound-guided high-intensity focused ultrasound (HIFU) in treating symptomatic uterine fibroids and adenomyosis. Methods: HIFU treatments performed in premenopausal women with symptomatic uterine fibroids and adenomyosis were analyzed retrospectively. Lesion volume reduction, change in symptoms of menstrual pain, and quality of life were examined. Major and minor complications, together with re-intervention rates, were evaluated. Results: Eighty-one HIFU treatments were performed in seventy-nine premenopausal women. The follow-up period was up to 95 months. A total of 65 women underwent treatment for uterine fibroids and 14 were treated for adenomyosis. For patients with uterine fibroids, the baseline fibroid volume median was 190.1 cm3 (18.5-1729.4 cm3). Fibroid volume was reduced by 50.1% (-26.2-97.8, p < 0.0001) at 6 months and 66.9% (-33.7-98.3, p < 0.0001) at 12 months after treatment. The modified Uterine Fibroid Symptom and Quality of Life (UFS-QOL) scores had decreased by 43.5% (0-62.5%, p < 0.0001) at 6 months and 50% (0-73%, p < 0.0001) at 12 months after treatment. In the adenomyosis arm, the median baseline uterine volume was 97.7 cm3 (43.7-367.4 m3). Uterine volume was reduced by 19.6% (range: 1.2-42.0, p = 0.28) at 6 months and 41.9% (18.9-69.2, p = 0.04) at 12 months after treatment. UFS-QOL scores were reduced by 38.1% (6-66.7%, p < 0.0001) at 6 months and 40% (0-70%, p < 0.0001) at 12s month after treatment. Fourteen (21.5%) patients with uterine fibroid and five (35.7%) patients with adenomyosis required subsequent interventions. Conclusions: HIFU provides symptomatic relief to most patients with uterine fibroids and adenomyosis. It is a promising uterus-sparing treatment for patients with these conditions.

Alternative treatments of adenomyosis - an update in procedural management and clinical outcomes

PURPOSE OF REVIEW

Adenomyosis is a common cause of abnormal uterine bleeding (AUB), dysmenorrhea, and pelvic pain. Definitive diagnosis and treatment have historically been by uterine histopathology at time of hysterectomy; however, advances in imaging have supported earlier diagnosis and subsequent conservative treatment. This review aims to update the evidence supporting the uterine-sparing, procedural management options with a focus on clinical outcomes.

RECENT FINDINGS

Uterine artery embolization (UAE), radiofrequency ablation (RFA), high-intensity focused ultrasound (HIFU), percutaneous microwave ablation (PMWA), and adenomyomectomy are minimally invasive interventions proven to be effective in reducing AUB and dysmenorrhea due to adenomyosis. Symptom improvement is associated with a decrease in uterine volume. Studies support the use of alternative treatment options given the overall low rates of symptom recurrence and reintervention. Combination therapy may be more effective than monotherapy.

SUMMARY

This review provides the current evidence for use of alternative treatment options for adenomyosis. Access to ablative therapies in the USA is limited and primarily off label, given lack of FDA approval. High-quality prospective and randomized controlled trials are needed in order to further delineate treatment comparisons, efficacy, safety, and ideal patient selection for these treatments. More data are needed to assess safety and utility in those desiring future fertility.

Analysis of related factors influencing postoperative recurrence of adenomyosis treated with HIFU

OBJECTIVE

To analyze the efficacy of high-intensity focused ultrasound (HIFU) for adenomyosis and postoperative recurrence and its influencing factors.

METHODS

Clinical and follow-up data of 308 patients with adenomyosis who were treated with HIFU in Haifu Center, Affiliated Hospital of Chengdu University of Traditional Chinese Medicine from September 2017 to January 2022 were retrospectively analyzed. The recurrence of adenomyosis and the efficacy of HIFU at 6 months after surgery were followed up. To explore factors influencing postoperative prognosis and recurrence, the following variables were analyzed: patients' age, course of disease, gravidity and parity, size of the uterus, duration of HIFU, duration of irradiation, treatment intensity, dysmenorrhea score, time of follow-up, combined treatment of traditional Chinese medicine (TCM), western medicine adjuvant treatment, lesion location and type, and menorrhagia.

RESULTS

Among the 308 patients, 238 (77%) were followed up from 6 to 36 months, with an average follow-up time of 15.24 ± 9.97 months. The other 70 (23%) were lost to follow-up. At 6-month after surgery, efficacy rates of dysmenorrhea and menorrhagia management were 86.7% and 89.3%, respectively. Postoperative recurrence rates were 4.8% (1-12 months), 9.0% (12-24 months), and 17.0% (24-36 months) for dysmenorrhea; and 6.3% (1-12 months), 2.4% (12-24 months), and 12.2% (24-36 months) for menorrhagia. Multivariate logistic regression analyses showed that parity (P = 0.043, OR = 1.773, 95% CI 1.018-3.087), uterine size (P = 0.019, OR = 1.004, 95% CI 1.001-1.007), combined treatment of TCM (P = 0.047, OR = 1.846, 95% CI 1.008-3.381), diffuse lesion type (P = 0.013, OR = 0.464, 95% CI 0.254-0.848) and ablation rate (P = 0.015, OR = 0.481, 95%CI 0.267-0.868) were prognostic factors (P < 0.05). Age, course of disease, gravidity, duration of HIFU, duration of irradiation, treatment intensity, preoperative dysmenorrhea score, time of follow-up, western medicine adjuvant therapy, lesion location, and preoperative menstrual volume had no effect on prognosis (P > 0.05).

CONCLUSION

HIFU can effectively relieve dysmenorrhea and reduce menstrual volume in patients with adenomyosis. Parity, uterine size, lesion type (diffuse), and ablation rate are risk factors for symptom recurrence after HIFU, while the combination of TCM therapy is a protective factor for relapse. We, therefore, recommend TCM in the adjuvant setting after HIFU according to patient condition.

Intrauterine adhesion

Intrauterine adhesions (IUA) occurred in the reproductive-age women are a big economic and health problem, resulting in severe impairment of social, psychological and physical function of the female genital organs. IUA-related symptoms or signs are varied greatly from free of symptoms or ambiguous symptoms (an incidental finding during the intervention) to ceased menstruation and loss of fecundability. The underlying pathophysiology is not completely understood, but intrauterine damage with broken basal layers of the endometrium formatting scar tissues or fibrosis in the endometrium with subsequently causing partial or complete occlusion of the uterine cavity may be a well-accepted hypothesis. Previously, infection is the most common cause to develop IUA, but now, intrauterine surgery may be a critical cause contributing to the majority of cases of IUA. In the current review, update information about the etiology, epidemiology, pathophysiology, sequelae and prevention of IUA will be renewed. We emphasize the importance of awareness of IUA, and primary prevention should be considered in the routine clinical practice if intrauterine surgery has been applied, based on uncertainty of ideal treatment for the established IUA and unpredictable outcomes after IUA treatment. So far, evidence supports that hyaluronic acid with/without other strategy is the most valuable and effective method to reduce the formation and re-formation of IUA as well as to achieve the best fertility outcome.

Efficacy of etonogestrel subcutaneous implants versus the levonorgestrel-releasing intrauterine system in the conservative treatment of adenomyosis

To evaluate the clinical efficacy of etonogestrel subcutaneous implant (ENG-SCI) with that of the levonorgestrel-releasing intrauterine system (LNG-IUD) for adenomyosis treatment. A prospective randomized cohort study was conducted including 108 patients (50 patients in ENG-SCI group and 58 in the LNG-IUD group) with adenomyosis from January 2019 to July 2021. After 3 months of treatment, both ENG-SCI group and LNG-IUD group showed significant improvement in patients' visual analog scale, pictorial blood loss assessment chart (PBAC), and uterine volume (P ＜ 0.05). The uterine volume of patients in LNG-IUD group decreased more significantly than that in the ENG-SCI group since 3 months of treatment. The PBAC score in the LNG-IUD group improved better than that in the ENG-SCI group since 6 months of treatment (P ＜ 0.05). No significant difference in the occurrence rate of ideal vaginal bleeding patterns and the hemoglobin levels between the two groups was observed. The ENG-SCI group had a higher probability of weight gain and progesterone-related side effects (P ＜ 0.05). Both ENG-SCI and LNG-IUD were effective in treatment of adenomyosis. However, LNG-IUD had a more significant effect in treating adenomyosis-related dysmenorrhea, excessive menstrual flow, anemia, and uterine enlargement, with relatively fewer side effects.

High-intensity focused ultrasound in adenomyosis treatment: Insights on safety, efficacy, and reproductive prospects

The management of adenomyosis has undergone significant evolution, moving from traditional surgical interventions like hysterectomy to more conservative methods aimed at preserving fertility. Essential roles have been played by uterine-sparing surgeries and uterine artery embolization. Despite these advancements, there is a growing interest in less invasive alternatives. This review delves into the potential of high-intensity focused ultrasound (HIFU). HIFU employs focused ultrasound waves for precise ablation of adenomyotic lesions. The review conducts a thorough analysis of HIFU principles, safety, efficacy, and its possible synergies with other therapies. HIFU seems to be effective for adenomyosis treatment, demonstrating a favorable adverse effect profile and suitability for fertility preservation. Combining HIFU with hormonal treatment appears to enhance long-term symptom control, presenting a promising and comprehensive approach for managing adenomyosis. The goal of this article is to develop a comprehensive understanding of HIFU's role in contemporary adenomyosis management and to explore areas requiring further research.