Adenomyosis: Epidemiology, Risk Factors, Clinical Phenotype and Surgical and Interventional Alternatives to Hysterectomy

Guideline No. 345: Primary Dysmenorrhea

OBJECTIVE

This guideline reviews the investigation and treatment of primary dysmenorrhea.

TARGET POPULATION

Individuals experiencing menstrual pain for which no underlying cause has been identified.

BENEFITS, HARMS, AND COSTS

Primary dysmenorrhea is common and frequently undertreated, despite effective therapy being widely available at a minimal cost. Treatment of primary dysmenorrhea has the potential to improve quality of life and decrease time away from school or work.

EVIDENCE

Published clinical trials, randomized controlled trials, observational studies, population studies, and systematic review articles indexed in PubMed and the Cochrane database were identified using search the terms "dysmenorrhea" and "menstrual pain." This search builds on the previous review (January 2005 to March 2016), including new literature between March 2016 and December 2024.

VALIDATION METHODS

The author rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

Primary care providers, pediatricians, and obstetrician/gynaecologists.

SOCIAL MEDIA ABSTRACT

Although menstrual pain is commonly experienced by women and adolescents, it is often undertreated or unfairly dismissed. If left untreated, persistent menstrual pain may develop into a chronic pain syndrome. Treatment includes non-steroidal anti-inflammatory drugs and hormonal contraceptives and can be provided without the need for pelvic examinations; treatment should not be delayed pending a definitive diagnosis. Effective treatments are available and do not require a pelvic examination or invasive procedures.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Using artificial intelligence to semi-automate trustworthiness assessment of randomized controlled trials: a case study

BACKGROUND AND OBJECTIVE

Randomized controlled trials (RCTs) are the cornerstone of evidence-based medicine. Unfortunately, not all RCTs are based on real data. This serious breach of research integrity compromises the reliability of systematic reviews and meta-analyses, leading to misinformed clinical guidelines and posing a risk to both individual and public health. While methods to detect problematic RCTs have been proposed, they are time-consuming and labor-intensive. The use of artificial intelligence large language models (LLMs) has the potential to accelerate the data collection needed to assess the trustworthiness of published RCTs.

METHODS

We present a case study using ChatGPT powered by OpenAI's GPT-4o to assess an RCT paper. The case study focuses on applying the trustworthiness in randomised controlled trials (TRACT checklist) and automating data table extraction to accelerate statistical analysis targeting the trustworthiness of the data. We provide a detailed step-by-step outline of the process, along with considerations for potential improvements.

RESULTS

ChatGPT completed all tasks by processing the PDF of the selected publication and responding to specific prompts. ChatGPT addressed items in the TRACT checklist effectively, demonstrating an ability to provide precise "yes" or "no" answers while quickly synthesizing information from both the paper and relevant online resources. A comparison of results generated by ChatGPT and the human assessor showed an 84% level of agreement of (16/19) TRACT items. This substantially accelerated the qualitative assessment process. Additionally, ChatGPT was able to extract efficiently the data tables as Microsoft Excel worksheets and reorganize the data, with three out of four extracted tables achieving an accuracy score of 100%, facilitating subsequent analysis and data verification.

CONCLUSION

ChatGPT demonstrates potential in semiautomating the trustworthiness assessment of RCTs, though in our experience this required repeated prompting from the user. Further testing and refinement will involve applying ChatGPT to collections of RCT papers to improve the accuracy of data capture and lessen the role of the user. The ultimate aim is a completely automated process for large volumes of papers that seems plausible given our initial experience.

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

Background

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

Methods

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

Results

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

Conclusion

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

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

BACKGROUND

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

CASE PRESENTATION

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

CONCLUSIONS

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

Endometriosis and adenomyosis research priorities in India and Sri Lanka: a call for regional collaboration

Endometriosis and adenomyosis are major gynaecological conditions affecting women of reproductive age-group, particularly in low- and middle-income countries. This Health Policy outlined research priorities for India and Sri Lanka, derived from a structured debate during the 'Future Directions in Endometriosis and Adenomyosis Research' workshop. Researchers from both countries emphasise the need for nationally representative data, improved diagnostic tools, and comprehensive care models. Shared priorities include developing patient registries and improving healthcare access. India focuses on multidisciplinary care centres, advanced diagnostic research, and public education, while Sri Lanka highlights integrating traditional medicine and assessing economic impacts. Both countries prioritise non-invasive diagnostics to address diagnostic delays and healthcare limitations. Establishing patient registries and consortiums for large-scale studies could inform healthcare strategies. Collaborative research among Asian countries could generate tailored regional solutions. Coupled with a strong political will, and adequate funding, the initiative can potentially improve diagnosis, treatment, and quality of life for affected women.

Anti-angiogenic therapy as potential treatment for adenomyosis

Adenomyosis is characterized by abnormal uterine bleeding, dysmenorrhea and subfertility. Increased expression of angiogenesis markers in adenomyosis presents a treatment opportunity and was studied in an adenomyosis mouse model. Mice were administered tamoxifen (1 mg/kg) on neonatal days 2-5. At six weeks of age, mice received oral treatment with axitinib 3 mg/kg ('dose I/AX3', n = 34), axitinib 25 mg/kg ('dose II/AX25' n = 34), or with vehicle-only ('placebo', n = 34). The prevalence and severity of adenomyosis were assessed. An adenomyosis severity index was calculated by multiplying mean grade/mouse by the percentage affected surface area. Angiogenesis-related gene expression was evaluated using real-time quantitative PCR. 101 mice completed adenomyosis induction and could be analyzed. The prevalence of adenomyosis was 30/33 (90.0%) in dose I, 29/34 (85.3%) in dose II, and 30/34 (88.2%) in placebo treated mice (p = 0.78). High grade (2/3) adenomyosis was significantly less prevalent in mice treated with axitinib dose II (n = 19, 55.9%) than in the placebo group (n = 27, 79.4%, p < 0.05). The adenomyosis severity index was reduced by 48% in the axitinib-treated groups (dose I, p < 0.05). The expression of angiogenic growth factors was reduced in the dose I and II axitinib-treated groups compared to the placebo-treated group. Following these promising first results, further research should focus on commonality among different angiostatic drugs, potential side effects, as well as the method and timing of application.

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

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

Ovarian adenomyoma: a case report

INTRODUCTION

Ovarian adenomyoma is a rare gynecological tumor with a high misdiagnosis rate, leading many patients to undergo unnecessary surgeries that may affect fertility. Menstrual abdominal pain is the most common symptom, and auxiliary examinations often cannot clarify its nature. It often relies on intraoperative diagnosis, and surgical resection can achieve good therapeutic effects.

CASE PRESENTATION

A 50-year-old woman presented with lower abdominal pain during her menstrual period for the past two months. She had a previous medical history of uterine adenomyomectomy, ovarian cystectomy, and a cesarean section. Ultrasound revealed a 5.7 × 3.8 × 4.3 cm mass on the posterior wall of the uterus, a 9.9 × 5.6 × 8.2 cm hypoechoic mass in the right posterior part of the uterus, and a 2.8 × 2.2 × 2.7 cm anechoic mass in the left ovary. CA125 (Carbohydrate antigen 125) 191.80U/ml (0-30). MRI (magnetic resonance imaging) imaging confirmed a 7.9 × 6.2 × 7.2 cm fibroid on the right posterior wall of the uterus. Consider partial degeneration of multiple uterine fibroids and benign cystic degeneration in the lower left abdomen. Surgical resection was performed smoothly, and the diagnosis was confirmed by postoperative pathology.

CONCLUSION

Ovarian adenomyoma is a rare benign gynecologic tumour with a high rate of misdiagnosis. When a patient presents with recent lower abdominal pain or dysmenorrhea, a history of endometriosis or myomectomy, and MRI findings showing irregular bleeding patterns in a pelvic mass, the possibility of extrauterine adenomyosis should be considered. Minimally invasive treatment options, such as single-port laparoscopy or vaginal dissection, may offer advantages, but caution should be exercised due to the potential for malignant tumors. Preserving fertility is something worth exploring. We hope to provide warnings to more gynaecologists and reduce misdiagnosis and unnecessary treatment.

Effects of pretreatment strategies on fertility outcomes in patients with adenomyosis

Adenomyosis is a commonly encountered pathology in women of reproductive age and frequently coexists with infertility. The effect of adenomyosis on fertility, particularly on in vitro fertilisation and intracytoplasmic sperm injection outcomes, is not well understood. Various pretreatment modalities have been used to improve pregnancy rates and live birth outcomes; however, because of a lack of high-quality evidence, there is no clear consensus on the best pretreatment option. This review was conducted through a PubMed search aiming to highlight the relationship between pretreatment and fertility in women with adenomyosis. Medical, ablative surgical, and non-surgical therapies were reviewed. According to the current literature, gonadotropin-releasing hormone agonist therapy and placement of a levonorgestrel intrauterine system are two suitable medical pretreatment strategies that can improve the clinical pregnancy rates of patients with adenomyosis. Surgical ablation of adenomyosis can also be beneficial, although surgical management can be challenging. Non-surgical thermal techniques, including high-intensity focused ultrasound ablation, percutaneous microwave ablation, and radiofrequency ablation, are much less invasive techniques that have shown effectiveness in improving fertility. Although evidence remains limited, all these procedures have demonstrated a favourable safety profile. Further studies are needed to better develop these techniques and demonstrate their effectiveness.

Prevalence, incidence, and treatment trends of adenomyosis in South Korean women for 15 years: A national population-based study

OBJECTIVE

Adenomyosis is associated with female infertility worldwide. With improvements in imaging methods, such as pelvic magnetic resonance imaging, the diagnosis and treatment of adenomyosis have changed. This study aimed to evaluate the overall prevalence, incidence, and treatment trends of adenomyosis in South Korea using data from the Korean National Health Insurance Service Database (NHIS).

METHODS

Data were collected from the Korean NHIS, a population-based complete enumeration database. A total of 678 641 women aged 11-55 years diagnosed with adenomyosis (N80.0 ICD-10 code) from the database from 2002 to 2016 were enrolled. After applying a one-year look-back method, 629 592 patients were analyzed to estimate the prevalence, incidence, and treatment trends of adenomyosis.

RESULTS

The overall prevalence during the study period was 3.86 per 1000 people. The prevalence of adenomyosis has increased from 1.42 per 1000 individuals in 2002 to 7.50 per 1000 individuals in 2016. The crude annual incidence rate of adenomyosis was 1.62 per 1000 people in 2003, which increased to 4.12 per 1000 people in 2016. In addition, the proportion of uterus-preserving surgeries in adenomyosis treatments has increased from 7.51% to 21.29% over 15 years.

CONCLUSION

The prevalence and incidence of adenomyosis in South Korea increased between 2002 and 2016. Furthermore, the proportion of uterus-preserving surgeries and progestin prescriptions for adenomyosis treatment has increased. We expect that our findings will raise awareness of the necessity for fertility preservation through earlier diagnosis and proper management of patients with adenomyosis.

Retrospective study of the factors involved in the development of adenomyosis and the in vitro link between adenomyosis and breast cancer

Background and aims

Adenomyosis is a heterogeneous disease, which differs from patient to patient. The objective of our study was to evaluate the risk factors that influence the occurrence of adenomyosis, more precisely to highlight aspects that may be used in practice. In addition, the in vitro impact of levonorgestrel (a possible predisposing factor in the occurrence of adenomyosis) on MDA-MB-231 cells was evaluated, trying to obtain a link between adenomyosis and mammary cancer.

Methods

Clinical and demographic data of patients diagnosed with adenomyosis hospitalized between January and September 2023 in the Obstetrics-Gynecology Clinic were analyzed. For the in vitro assays, the MTT and LDH method was used to investigate the effect on cell viability and the potential cytotoxic effect of LG on MDA-MB-23 cells.

Results

Out of a total of 99 hysterectomies performed, the diagnosis of adenomyosis was confirmed by ultrasound in 28 cases. Among our patients, we could observe that most of cases of adenomyosis developed in women between 40 and 45 years old. Multiple pregnancies can influence the development of this uterine pathology, along with a history of uterine surgery and abortions. It was also found that treatment with sex hormones can increase the risk of adenomyosis. Our in vitro study has showed that LG stimulates the proliferation of MDA-MB-231 cells depending on the dose and time.

Conclusions

Personal history along with progestin treatment may influence myometrial lesions, leading to diffuse or focal adenomyosis. Moreover, in vitro, LG has been shown to stimulate the proliferation of breast cancer cells.

'Fish in a Net' and 'Swiss cheese' pattern 2 cases of unusual adenomyosis with different β-HCG level

Myometrial hypertrophy and hyperplasia, which usually on magnetic resonance imaging (MRI) typically reveal an enlarged uterus with ill-defined areas of low signal intensity and a diminished junctional zone, along with small foci of hyperintensity due to ectopic endometrium, are found in uterine adenomyosis. Those are caused by the presence of ectopic endometrial glands and stroma within the uterine myometrium. However, our case reports highlight the importance of recognizing atypical presentations, such as extensive mass-like hyperintense signals resembling a "Fish in a Net" and Swiss cheese pattern on T2-weighted imaging. Recognizing this pattern could aid in preventing misdiagnosis and guiding appropriate management strategies. Furthermore, there is a possibility that the same diagnosis (adenomyosis) could present a different β-human choriogonadotropin hormone (β-HCG) serum level.

Comparison of ultra-long gonadotropin releasing hormone agonist versus standard downregulation in women with adenomyosis undergoing frozen-thawed embryo transfer: a randomized clinical trial

BACKGROUND

Adenomyosis can lead to infertility and failure of in vitro fertilization. Limited evidence suggests that the use of long-term treatment with gonadotropin-releasing hormone (GnRH) agonists followed by frozen-thawed embryo transfer (FET) may be the preferred approach for women with adenomyosis.

OBJECTIVE

The aim of this randomized controlled trial is to compare the efficacy of an ultra-long GnRH agonist with standard downregulation in women with adenomyosis undergoing FET.

MATERIALS AND METHODS

This randomized controlled trial enrolled 72 women with adenomyosis diagnosed by sonographic criteria who underwent FET cycles at the Avicenna Infertility Center. These women were randomly assigned to two equal groups: one received GnRH agonist treatment for three months before the FET cycle and the other served as the standard downregulation group. Results were reported as chemical and clinical pregnancy rates.

RESULTS

The two groups were similar in age, body mass index, anti-Müllerian hormone levels, number of previous pregnancies and miscarriages, presence of uterine myomas, and endometriosis. However, the total dose of estradiol used until embryo transfer was significantly higher in the ultra-long GnRH agonist group than in the standard group (96.14 mg vs. 80.52 mg, p-value = 0.004). Nevertheless, chemical and clinical pregnancy rates did not differ significantly between the two groups.

CONCLUSIONS

Ultra-long GnRH agonist downregulation did not improve the chemical and clinical pregnancy rate in the FET cycle in women with adenomyosis compared with standard GnRH agonist downregulation in the other words, ultra-long GnRH agonist downregulation is not superior to standard protocol. In women with adenomyosis (without history of endometriosis), downregulation of standard GnRH agonists prior to frozen-thawed embryo transfer may be the preferred embryo transfer protocol to gain higher clinical/chemical pregnancy rate.

TRIAL REGISTRATION

Clinical trial registry: IRCT20160717028967N9, available at: https://irct.behdasht.gov.ir/trial/36103 .

Comparison of the effectiveness of levonorgestrel intrauterine system and dienogest in the management of adenomyosis: A systematic review and meta-analysis

BACKGROUND

Adenomyosis is a gynaecological lesion that impairs female fertility and contributes to reduced quality of life. There are several surgical and medical options for the management of this lesion; however, women who wish to conceive opt for medical therapies such as the levonorgestrel intrauterine device (LNG-IUS) and dienogest, which have various outcomes. To date, there is no consensus regarding which is more effective.

OBJECTIVES

To compare the effectiveness of LNG-IUS and dienogest for the management of adenomyosis, and explore the risk of occurrence of known side effects for both treatments.

DESIGN

Systematic review and meta-analysis exploring the effectiveness of LNG-IUS and dienogest for the management of adenomyosis.

METHODS

A literature search was conducted using PICO guidelines and EMBASE, PubMed/MEDLINE, Scopus and Web of Science databases. Only clinical trials were collected and analysed.

RESULTS

Of the 792 studies that were initially identified, six were eligible for inclusion in this study. The studies included a total of 707 women; of these, 270 were treated with LNG-IUS, 354 were treated with dienogest, and 83 were controls. All the studies were from Asia (Bangladesh n = 1, China n = 2, India n = 1, Japan n = 1, South Korea n = 1). Dienogest was found to reduce pelvic pain significantly, evidenced by a lower visual analogue scale score, compared with LNG-IUS. Also, dienogest led to a significant reduction in uterine volume compared with LNG-IUS. However, subjects in the LNG-IUS group had significantly higher levels of haemoglobin than those in the dienogest group. Nonetheless, the occurrence of side effects such as weight gain, breast tenderness/distension, headache, insomnia/sleep disorder, depression/mood disorder, skin disorder/acne, and coital discomfort/reduced libido were comparable in both treatment groups.

CONCLUSION

Dienogest may be more effective than LNG-IUS for the management of adenomyosis, as it shows a superior effect in the reduction of pelvic pain and uterine volume. As only six studies were included in the present meta-analysis due to the paucity of data in the literature, it is recommended that well-designed randomized controlled trials comparing the effectiveness of dienogest with LNG-IUS should be conducted.

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

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

Adenomyosis and fertility-sparing surgery: A literature appraisal

Adenomyosis is an intricate pathological condition that negatively impacts the uterus. It is closely related to the more well-known endometriosis, with which it shares parallels in terms of diagnosis, therapy, and both microscopic and macroscopic features. The purpose of this narrative review is to give a clear univocal definition and outlook on the different, patient-adapted, surgical treatments. MEDLINE and PubMed searches on these topics were conducted from 1990 to 2022 using a mix of selected keywords. Papers and articles were identified and included in this narrative review after authors' revision and evaluation. From the literature analysis, authors reported the following surgical techniques: laparoscopic double/triple-flap method, laparotomic wedge resection of the uterine wall, laparotomic transverse H-incision of the uterine wall, laparotomic wedge-shaped excision, and laparotomic complete debulking excision by asymmetric dissection technique. Each of these techniques has strengths and weaknesses, but the literature data on the pregnancy rate are somewhat limited. The only certain information is the risk of uterine rupture up to 6.0% after surgical treatment for uterine adenomyosis. Over the years, the surgical approach continued to reach a positive result by minimally invasive treatment, with less hospitalization, less postoperative pain, and less blood loss. Over the years, the gynecological surgeon has gained the skills, training and increasingly sophisticated surgical techniques to target effective therapy. That's why a hysterectomy is no longer the only surgical resource to treat adenomyosis, but in patients who wish to preserve the fertility, there is a wide variety of surgical alternatives.

Association of Uterine Tissue Innervation and Peripheral Nerve Density with Adenomyosis Related Pain. A Systematic Review

Adenomyosis is associated with dysmenorrhea and chronic pelvic pain; however, the triggering mechanisms of painful stimuli and the role of uterine nerve fibers in the manifestation of pain remain poorly understood. The objective of this study was to systematically review the role of uterine nerve fibers' presence and density in the occurrence of pain in patients with adenomyosis. An electronic search was performed using the Embase, PubMed/Medline, and Cochrane databases. We included all studies from inception to November 2023. A total of ten studies that compared uterine biopsies samples of women with and without adenomyosis were included. The biomarker antiprotein gene product 9.5 was decreased or absent in the endometrium of most included women with adenomyosis. None of the included studies observed a difference in neurofilament (NF) staining between the adenomyosis and non-adenomyosis groups. Studies that assessed nerve growth factor (NGF) staining were heterogeneous in design. One study reported no difference in immunohistochemistry staining in any endometrial layer between the adenomyosis and non-adenomyosis groups, while another reported increased staining in the adenomyosis functional endometrial layer, and a third study reported overexpression of NGF, synaptophysin (SYN), and microtubule-associated protein 2 mRNA in focal adenomyosis alone. Preliminary data from poor-quality studies suggest an increase in the uterine density of nerve fibers in patients with adenomyosis. Well-designed studies are essential to assess the cause-and-effect relationship between uterine nerve fibers and pain in patients with adenomyosis.

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.

Chitinase-3-like protein 1, matrix metalloproteinase-9, and monocyte chemoattractant protein-1 as potential biomarkers and treatment targets of adenomyosis

OBJECTIVE

This study aimed to investigate the levels of chitinase-3-like protein-1 (CHI3L1), matrix metalloproteinase-9 (MMP-9), and monocyte chemoattractant protein-1 (MCP-1) in adenomyosis, as compared to normal myometrial tissue. These biomarkers may be useful for determining potential treatment targets.

METHODS

This was a correlative, analytical, and observational study with a cross-sectional design. Participants with a diagnosis of moderate-to-severe adenomyosis, as determined through transvaginal ultrasonography and histological examination, and who underwent laparotomy or laparoscopic surgery for the treatment of adenomyosis, were enrolled in the study. Unlike other studies that recruited healthy women as controls, our study used adenomyotic and healthy nonadenomyotic myometria obtained from the same individual. The levels of CHI3L1, MMP-9, and MCP-1 in the biopsy samples were determined using enzyme-linked immunoassay kits, according to the manufacturer's protocol.

RESULTS

A highly significant increase in the levels of CHI3L1, MMP-9, and MCP-1 was found in adenomyotic tissues compared to non-adenomyotic tissues (P<0.001). A significant positive correlation was found between CHI3L1 and MMP-9 levels (r=0.463; P=0.008), CHI3L1 and MCP-1 levels (r=0.594; P<0.001), and MCP-1 and MMP-9 levels (r=0.680; P<0.001) in adenomyotic tissues.

CONCLUSION

CHI3L1 may play a role in the pathogenesis of adenomyosis via the regulation of the MCP-1 and MMP-9 pathways. Therefore, these molecules may serve as biomarkers and potential therapeutic targets for adenomyosis.

Long-term efficacy and safety of levonorgestrel releasing intrauterine system in the treatment of adenomyosis: evidence mapping

PURPOSE

To summarize evidence on levonorgestrel releasing intrauterine system (LNG-IUS) in the treatment of adenomyosis (AM) and to identify potential research gaps.

METHODS

Search was conducted in MEDLINE, The Cochrane Library, EMBASE, CBM, CNKI, and Wanfang. We included studies investigating patients with AM treated with LNG-IUS combined with conservative therapy.

RESULTS

Thirty-nine studies compared LNG-IUS with other conservative therapeutic drugs. The most common comparison was GnRH-a + LNG-IUS vs. LNG-IUS alone, followed by LNG-IUS vs. mifepristone, expected treatment, and GnRH-a. GnRH-a + LNG-IUS was more beneficial in reducing the intensity of dysmenorrhea than LNG-IUS alone at the 6-month follow-up in patients with an enlarged uterus and moderate to severe dysmenorrhea. Large and well-designed studies are needed to confirm the efficacy of LNG-IUS and GnRH-a on reducing uterine volume at 6-month follow-up. Thirty-two studies investigated LNG-IUS as the postoperative management. The most common comparison was surgical excision + LNG-IUS vs. surgical excision. Results showed VAS scores were lower in the surgical excision + LNG-IUS group than in the surgical excision group at the 1-year follow-up. Evidence on endometrial thickness, quality of life, adverse events and beneficial effect at 3 and 5 years are needed.

CONCLUSIONS

Combined GnRH-a and LNG-IUS treatment was more efficacious than LNG-IUS alone for patients with an enlarged uterus and moderate to severe dysmenorrhea. Moreover, LNG-IUS seemed to show potential long-term benefits in postoperative therapy, warranting further meta-analysis for confirmation.

Prevalence of adenomyosis features in women scheduled for assisted reproductive treatment, using the Morphological Uterus Sonographic Assessment group definitions

INTRODUCTION

Studies that use standardized ultrasonographic criteria to diagnose adenomyosis in subfertile women are needed. These would improve the understanding of the disease burden and enable further studies on its impact on fertility and assisted reproductive treatment (ART) outcome. The aim of this study was to determine the prevalence of different features of adenomyosis in women scheduled for their first ART, diagnosed at two (2D) and three-dimensional (3D) transvaginal ultrasonography (TVUS) using the revised Morphological Uterus Sonographic Assessment (MUSA) group definitions.

MATERIAL AND METHODS

This was a prospective, observational cross-sectional study of subfertile women aged 25 to ≤39 years, that were referred to a university hospital for their first ART between December 2018 and May 2021. Of 1224 eligible women, 1160 women fulfilled the inclusion criteria and consented to participate in the study. All women underwent a systematic 2D and 3D TVUS examination. The primary outcome was the presence of direct and indirect features of adenomyosis, as proposed by the MUSA group. Secondary outcomes were to describe the ultrasonographic characteristics of the different features, as well as any difference in the diagnostics at 2D or 3D TVUS and any association with clinical characteristics such as endometriosis.

RESULTS

At least one direct or indirect feature of adenomyosis was observed in 272 (23.4%, 95% confidence interval [CI] 21.0-25.9) women. Direct features that are pathognomonic for the disease were observed in 111 (9.6%, 95% CI, 7.9-11.3) women. Direct features were visible only at 3D TVUS in 56 (4.8%, 95% CI 3.6-6.1) women, that is, 56/111 (50.5%) of women with at least one direct adenomyosis feature. Direct features were more common in women with endometriosis (OR 2.8, 95% CI 1.8-4.3).

CONCLUSIONS

We found than one in 10 women scheduled for ART had direct features of adenomyosis at ultrasound examination. The present study suggests that the use of 3D TVUS is an important complement to 2D in the diagnostics of adenomyosis. Our results may further improve the counseling of women scheduled for ART and enables future studies on the impact of different features of adenomyosis on subfertility, ART results and obstetric outcomes.

Associations between race and ethnicity and perioperative outcomes among women undergoing hysterectomy for adenomyosis

OBJECTIVE

To study racial and ethnic disparities among women undergoing hysterectomy performed for adenomyosis across the United States.

DESIGN

A cohort study.

SETTING

Data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2012-2020.

PATIENTS

Patients with an adenomyosis diagnosis.

INTERVENTION

Hysterectomy for adenomyosis.

MAIN OUTCOME MEASURES

Patients were identified using the International Classification of Diseases 9th and 10th editions codes 617.0 and N80.0 (endometriosis of the uterus). Hysterectomies were classified on the basis of the Current Procedural Terminology codes. We compared baseline and surgical characteristics and 30-day postoperative complications across the different racial and ethnic groups. Postoperative complications were classified into minor and major complications according to the Clavien-Dindo classification system.

RESULTS

A total of 12,599 women underwent hysterectomy for adenomyosis during the study period: 8,822 (70.0%) non-Hispanic White, 1,597 (12.7%) Hispanic, 1,378 (10.9%) non-Hispanic Black or African American, 614 (4.9%) Asian, 97 (0.8%) Native Hawaiian or Pacific Islander, and 91 (0.7%) American Indian or Alaska Native. Postoperative complications occurred in 8.8% of cases (n = 1,104), including major complications in 3.1% (n = 385). After adjusting for confounders, non-Hispanic Black race and ethnicity were independently associated with an increased risk of major complications (adjusted odds ratio 1.54, 95% confidence interval [CI] {1.16-2.04}). Laparotomy was performed in 13.7% (n = 1,725) of cases. Compared with non-Hispanic White race and ethnicity, the adjusted odd ratios for undergoing laparoscopy were 0.58 (95% CI 0.50-0.67) for Hispanic, 0.56 (95% CI 0.48-0.65) for non-Hispanic Black or African American, 0.33 (95% CI 0.27-0.40) for Asian, and 0.26 (95% CI 0.17-0.41) for Native Hawaiian or Pacific Islander race and ethnicity.

CONCLUSION

Among women undergoing hysterectomy for postoperatively diagnosed adenomyosis, non-Hispanic Black or African American race and ethnicity were associated with an increased risk of major postoperative complications. Compared with non-Hispanic White race and ethnicity, Hispanic ethnicity, non-Hispanic Black or African American, Asian, Native Hawaiian, or Pacific Islander race and ethnicity were less likely to undergo minimally invasive surgery.

Whether surgical procedure can improve the prognosis of endometrial cancer arising in adenomyosis (EC-AIA)? A systematic review and meta-analysis

PURPOSE

Endometrial cancer arising in adenomyosis (EC-AIA) is frequently detected accidentally following a general hysterectomy for adenomyosis. Whether supplemental lymphadenectomy in patients with EC-AIA can improve the survival outcome remains inconclusive. Herein, the authors summarized the data of patients with EC-AIA and further explored the impact of lymphadenectomy on the prognosis of these patients.

METHODS

Five electronic databases, namely MEDLINE, Web of Science, PubMed, Embase, and the Cochrane Library were employed for searching articles from inception to May 2023.

RESULTS

In total, 38 eligible studies enrolling 56 patients were included. Of these, 44 patients had a traceable prognosis. Kaplan-Meier curves demonstrated that patients who had undergone lymphadenectomy had a better progression-free survival (PFS) compared with those who had not undergone lymphadenectomy ( P =0.016), but there was no difference in overall survival. Univariable ( P =0.025, HR=0.25, 95% CI=0.08-0.84) and multivariable ( P =0.042, HR=0.13, 95% CI=0.020-0.930) Cox regression analyses revealed that lymphadenectomy was an independent protective factor for PFS.

CONCLUSION

For patients diagnosed with EC-AIA following hysterectomy for benign disease, further supplementary lymphadenectomy is recommended to improve PFS.

The Impact of Conservative Surgical Treatment of Adenomyosis on Fertility and Perinatal Outcomes

Adenomyosis is a benign condition commonly encountered in patients with infertility. While the definitive surgical management is hysterectomy, conservative surgical management is gaining attention in patients desiring future fertility. This review explores whether the surgical treatment of adenomyosis affects fertility outcomes for patients trying to conceive. The PubMed and Medline databases were searched using the keywords: "adenomyosis", "surgery", "radiofrequency", "infertility", "pregnancy", "sterility", "conception", "miscarriage", and "endometrial receptivity". Abstracts were screened, and relevant articles were selected for review. This review reveals that surgery appears to improve fertility outcomes with or without medical therapy; however, the risk of uterine rupture remains high and the best technique to reduce this risk is still not known. More studies are needed to formulate the best surgical approach for preserving fertility in treating adenomyosis and to establish standardized guidelines.

High-intensity Focused Ultrasound is a Better Choice for Women with Fertility Desire: A Systematic Review and Meta-analysis of the Comparison between High-intensity Focused Ultrasound and Laparoscopic Treatment of Uterine Fibroids

High-intensity focused ultrasound (HIFU) is commonly used to treat uterine fibroids and adenomyosis, but there is no evidence using metadata to compare fertility outcomes between conventional laparoscopic procedures and HIFU. The purpose of this study analysis is that evidence-based fertility outcomes may provide better treatment options for clinicians and patients considering fertility. The literature on fertility data for HIFU surgery versus laparoscopic myomectomy was searched in seven English language databases from January 1, 2010, to November 23, 2022. A total of 1375 articles were received in the literature, 14 of which were selected. We found that women who underwent HIFU surgery had higher rates of spontaneous pregnancy, higher rates of spontaneous delivery, and higher rates of full-term delivery but may have higher rates of miscarriage or postpartum complications than women who underwent laparoscopic myomectomy. Looking forward to future studies, it is hoped that the literature will examine endometrial differences in women who undergo HIFU and laparoscopic myomectomy to demonstrate the ability of endometrial repair. The location of fibroids in the sample should also be counted to allow for attribution statistics on the cause of miscarriage.

Extracellular vesicle-encapsulated miR-25-3p promotes epithelial-mesenchymal transition and migration of endometrial epithelial cells by inducing macrophage polarization

The pathogenesis of adenomyosis is closely related to the epithelial-mesenchymal transition and macrophages. MicroRNAs have been extensively investigated in relation to the epithelial-mesenchymal transition in a range of malignancies. However, there is a paucity of research on extracellular vesicles derived from the eutopic endometrium of adenomyosis and their encapsulated microRNAs. In this study, we investigated the role of microRNA-25-3p derived from extracellular vesicles in inducing macrophage polarization and promoting the epithelial-mesenchymal transition in endometrial epithelial cells of patients with adenomyosis and controls. We obtained eutopic endometrial samples and isolated extracellular vesicles from the culture supernatant of primary endometrial cells. Real-time quantitative PCR analysis demonstrated that microRNA-25-3p was highly expressed in extracellular vesicles, as well as in macrophages stimulated by extracellular vesicles from eutopic endometrium of adenomyosis; and macrophages transfected with microRNA-25-3p exhibited elevated levels of M2 markers, while displaying reduced levels of M1 markers. After co-culture with the above polarized macrophages, endometrial epithelial cells expressed higher levels of N-cadherin and Vimentin, and lower protein levels of E-cadherin and Cytokeratin 7. It was revealed that microRNA-25-3p encapsulated in extracellular vesicles from eutopic endometrial cells could induce macrophage polarization toward M2, and the polarized macrophages promote epithelial-mesenchymal transition in epithelial cells. However, in vitro experiments revealed no significant disparity in the migratory capacity of endometrial epithelial cells between the adenomyosis group and the control group. Furthermore, it was observed that microRNA-25-3p-stimulated polarized macrophages also facilitated the epithelial-mesenchymal transition and migration of endometrial epithelial cells within the control group. Thus, the significance of microRNA-25-3p-induced polarized macrophages in promoting the development of adenomyosis is unclear, and macrophage infiltration alone may be adequate for this process. We emphasize the specificity of the local eutopic endometrial microenvironment and postulate its potential significance in the pathogenesis of adenomyosis.

Reduced fertility in an adenomyosis mouse model is associated with an altered immune profile in the uterus during the implantation period

STUDY QUESTION

Does a reduction in fertility and/or systemic immune cell change occur during the early implantation period in a mouse model of adenomyosis?

SUMMARY ANSWER

A reduction in fertility was observed in mice with adenomyosis, coinciding with local and systemic immune changes observed during the implantation period.

WHAT IS KNOWN ALREADY

Adenomyosis is a pathology responsible for impaired fertility in humans, with a still unclear pathophysiology. One hypothesis is that changes in immune cells observed in adenomyosis-affected uteri may alter fertility, notably the physiological immune environment necessary for successful implantation and a healthy pregnancy.

STUDY DESIGN, SIZE, DURATION

Randomly selected CD-1 female neonatal pups were orally dosed by administration of tamoxifen to induce adenomyosis (TAM group), while others received solvent only (control group). From 6 weeks of life, CD-1 mice of both groups were mated to study impaired fertility and related local and/or systemic immune cell changes during the early implantation period.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

To evaluate fertility and pregnancy outcomes, ultrasound imaging was performed at E (embryonic day) 7.5 and E11.5 to count the number of gestational sacs and the number of resorptions in eight mice of the TAM group and 16 mice of the control group. The mice were sacrificed at E18.5, and morphometric, functional (quantitative reverse transcription PCR; RT-qPCR), and histological analyses were performed on the placentas. To identify local and/or systemic immune changes during the early implantation period, 8 mice of the TAM group and 12 mice of the control group were sacrificed at E4.5. Uterine horns and spleens were collected for flow cytometry and RT-qPCR analyses to study the immune cell populations. To investigate the profile of the cytokines secreted during the early implantation period at the systemic level, supernatants from stimulated spleen cells were analyzed by multiplex immunoassay analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

By ultrasound imaging, we observed a lower number of implantation sites (P < 0.005) and a higher number of resorptions (P < 0.001) in the TAM group, leading to smaller litters (average number of fetuses per litter: 1.00 [0.00; 5.25] in the TAM group versus 12.00 [9.50; 13.75] in the control group (P < 0.001). Histological and morphometric analyses of the placentas at E18.5 showed a higher junctional/labyrinthine area ratio in the TAM group (P = 0.005). The expression levels of genes that play a role in vascularization and placental growth (Vegf (P < 0.001), Plgf (P < 0.005), Pecam (P < 0.0001), and Igf2 (P = 0.002)) were reduced in the TAM group. In the TAM group, the percentages of macrophages, natural killer (NK) cells, and dendritic cells (DC) were significantly decreased in the uterus around the implantation period. However, the number of M1 macrophages was increased. Both macrophages and DC had an increased activation profile (higher expression of MCHII, P = 0.012; CD80, P = 0.015; CCR7, P = 0.043 for macrophages, and higher expression of CD206, P = 0.018; CXCR4, P = 0.010; CCR7, P = 0.006, MCHII, P = 0.010; and CD80, P = 0.012 for DC). In spleen, an increase in the activation of macrophages (CCR7, P = 0.002; MCHII, P = 0.001; and CD80, P = 0.034) and DC was observed in the TAM group (CCR7, P = 0.001; MCHII, P = 0.001; Ly6C, P = 0.015). In the uteri and the spleen, we observed increased percentages of CD4+ T lymphocytes (P = 0.0237 and P = 0.0136, respectively) in the TAM group and, in the uteri, an increased number of regulatory T cells (P = 0.036) compared with the controls.

LARGE SCALE DATA

Not applicable.

LIMITATIONS, REASONS FOR CAUTION

This study is limited by the use of an animal model and the lack of intervention.

WIDER IMPLICATIONS OF THE FINDINGS

These data support involvement of innate and adaptive immune cells in the implantation failure and the increased rate of resorption observed in the mouse model of adenomyosis. This substantiates the need for additional research in this domain, with the goal of addressing fertility challenges in women affected by this condition.

STUDY FUNDING/COMPETING INTEREST(S)

None.

Adenomyoma recurrence 7 years after laparoscopic supracervical hysterectomy: A case report and literature review

RATIONALE

Adenomyosis, a gynecological condition characterized by endometrial tissue within the uterine myometrium, often leads to menstrual pain and heavy bleeding, significantly affecting the quality of life. The primary treatment for adenomyosis and leiomyomas is hysterectomy. However, in rare instances, these conditions can recur in the cervical stump following a hysterectomy.Here, we present a case of cervical adenomyoma development after a prior laparoscopic supracervical hysterectomy.

PATIENT CONCERNS

A 47-year-old woman sought medical attention due to increased vaginal bleeding.

DIAGNOSES

She had undergone a laparoscopic supracervical hysterectomy 7 years earlier to address uterine myoma and adenomyosis. Just 1 month posthysterectomy, a pelvic ultrasound revealed the presence of a cervical stump measuring approximately 4.0 × 4.0 cm. Subsequent follow-up ultrasounds documented the gradual growth of the cervical mass. Two years ago, a recurrent myoma was identified, and the patient experienced intermittent vaginal bleeding. Over 7 years, the cervical mass increased from 4 to 7 cm. Preadmission pelvic ultrasonography confirmed the existence of cervical adenomyoma measuring 7 × 6 cm.

INTERVENTIONS

Consequently, the patient underwent a laparoscopic trachelectomy. Intraoperatively, an enlarged cervix, approximately 7 × 6 cm in size, containing adenomyoma was observed. A gross examination of the specimen indicated hypertrophic muscle tissue and hemorrhagic foci. Subsequent histopathological examination confirmed the presence of adenomyoma.

OUTCOMES

Remarkably, the patient exhibited no recurrence over the subsequent 8 months.

LESSONS

The case presented here highlights the potential occurrence of cervical adenomyoma following a supracervical hysterectomy. Management options include hormone therapy and surgical excision. Furthermore, annual follow-up comprising ultrasound and pap smear evaluations is recommended for patients with supracervical hysterectomies to detect and address possible recurrences.

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.

Magnetic resonance imaging presentation of diffuse and focal adenomyosis before and after pregnancy

RESEARCH QUESTION

Is there a change in magnetic resonance imaging (MRI) criteria of diffuse and focal phenotypes of adenomyosis before and after pregnancy?

DESIGN

A retrospective, monocentric, observational study in a single academic tertiary referral centre for endometriosis diagnosis and management. Women were followed for symptomatic adenomyosis, and without a prior history of surgery who give birth after 24+0 weeks. For each patient, pelvic MRI pre- and post-pregnancy was performed by two experienced radiologists with the same image acquisition protocol. Diffuse and focal adenomyosis MRI presentation were analysed before and after pregnancy.

RESULTS

Between January 2010 and September 2020, of the 139 patients analysed, 96 (69.1%) had adenomyosis at MRI distributed as follow: 22 (15.8%) presented diffuse adenomyosis, 55 (39.6%) focal adenomyosis and 19 (13.7%) both phenotypes. The frequency of isolated diffuse adenomyosis on MRI was significantly lower before versus after pregnancy (n = 22 [15.8%] versus n = 41 [29.5%], P = 0.01). The frequency of isolated focal adenomyosis was significantly higher before pregnancy than after pregnancy (n = 55 [39.6%] versus n = 34 [24.5%], P = 0.01). The mean volume of all focal adenomyosis lesions on MRI decreased significantly after pregnancy, from 6.7 ± 2.5 mm3 to 6.4 ± 2.3 mm3, P = 0.01.

CONCLUSION

The current data indicate that, based on MRI, there is an increase in diffuse adenomyosis and a decrease in focal adenomyosis after pregnancy.

Prevalence of adenomyosis in women with subfertility: systematic review and meta-analysis

OBJECTIVE

To determine the prevalence of adenomyosis in women with subfertility.

METHODS

A systematic search was conducted in MEDLINE, EMBASE, CINAHL Plus, Google Scholar, PsycINFO and Web of Science Core Collection from database inception to October 2022. The included studies evaluated the prevalence of adenomyosis in women with subfertility, with or without endometriosis and/or uterine fibroids. Secondary analyses were conducted to identify variation in the prevalence of isolated adenomyosis according to geographical location, diagnostic modality, diagnostic criteria, type of ultrasound, ultrasound features of adenomyosis and the use of assisted reproductive technology.

RESULTS

Among 21 longitudinal studies evaluating 25 600 women, the overall pooled prevalence of isolated adenomyosis was 10% (95% CI, 6-15%) (I2  = 99.1%; tau2  = 0.12). The pooled prevalence was 1% (95% CI, 0-4%) for adenomyosis with concurrent fibroids (eight studies; I2  = 95.8%; tau2  = 0.03), 6% (95% CI, 3-11%) for adenomyosis with concurrent endometriosis (18 studies; I2  = 98.6%; tau2  = 0.12) and 7% (95% CI, 2-13%) for adenomyosis with concurrent endometriosis and/or fibroids (nine studies; I2  = 98.3%; tau2  = 0.09). The prevalence of isolated adenomyosis varied substantially according to geographical location, with Australia exhibiting the highest pooled prevalence of adenomyosis (19% (95% CI, 12-27%)), which was significantly higher compared with that in Asia (5% (95% CI, 1-12%)). The pooled prevalence of isolated adenomyosis diagnosed using a combination of direct and indirect ultrasound features was 11% (95% CI, 7-16%), whereas it was 0.45% (95% CI, 0-1%) in the study in which only an indirect feature was used as the diagnostic criterion.

CONCLUSION

One in 10 women with subfertility have a diagnosis of isolated adenomyosis. The prevalence of adenomyosis varies according to the presence of concurrent endometriosis and/or fibroids. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Diagnosis and Treatment of Adenomyosis with Office Hysteroscopy-A Narrative Review of Literature

INTRODUCTION

Adenomyosis is a common chronic disease in women of reproductive age, characterised by the presence of ectopic endometrial tissue within myometrium. Even though adenomyosis presents with chronic pelvic pain, menorrhagia or abnormal uterine bleeding, dysmenorrhoea, and dyspareunia and is often recognised after hysterectomies. However, the development of ultrasonography and magnetic resonance imaging has improved the pre-operative diagnosis of the disease. Hysteroscopy provides information in real time from the uterine cavity and the offers the possibility of obtaining direct biopsies.

MATERIAL AND METHODS

The literature was searched via Pubmed and Embase with the following headings: diagnosis of adenomyosis or adenomyoma and office hysteroscopy, hysteroscopy findings of adenomyosis or adenomyoma, treatment of adenomyosis or adenomyoma with office hysteroscopy.

RESULTS

The literature showed that hysteroscopy can identify superficial adenomyosis. There are a variety of hysteroscopic images that can be connected with the disease. New equipment like the spirotome has been used to access deeper layers of myometrium and obtain biopsies under direct vision from the adenomyotic areas. Different methods of treatment have been also described, like enucleation of focal superficial adenomyoma, coagulation, evacuation of cystic adenomyosis when the lesion is smaller than 1.5 cm, and resection of adenomyotic nodules in case of bigger lesions (>1.5 cm). Diffuse superficial adenomyosis is also managed by resection.

CONCLUSIONS

Hysteroscopy has revolutionised the approach to adenomyosis. It is a useful tool in assessing mainly superficial adenomyosis. The role of hysteroscopy in surgical management of adenomyosis need to be confirmed with further studies.

Total or Subtotal Hysterectomy for the Treatment of Endometriosis: A Review

OBJECTIVE

The purpose of the review was to evaluate and compare outcomes after total or subtotal hysterectomy in women with endometriosis or adenomyosis.

METHODS

We searched four electronic databases: Medline (PubMed), Scopus, Embase, and Web of Science (WoS). The first aim of the study was to compare outcomes after total and subtotal hysterectomy in women with endometriosis, and the second aim was to compare the two procedures in women with adenomyosis. Publications that reported short- and long-term outcomes after total and subtotal hysterectomy were included in the review. The search was not subject to any limitation in terms of time or method.

RESULTS

After screening 4948 records, we included 35 studies published from 1988 to 2021; the studies were based on various methodologies. With regard to the first aim of the review, we found 32 eligible studies and divided these into the following four categories: postoperative short- and long-term outcomes, recurrence of endometriosis, quality of life and sexual function, and patient satisfaction after total or subtotal hysterectomy in women with endometriosis. Five investigations were deemed eligible for the second aim of the review. No differences were seen in terms of postoperative short- and long-term outcomes after subtotal or total hysterectomy in women with endometriosis or adenomyosis.

CONCLUSIONS

Preservation or removal of the cervix in women with endometriosis or adenomyosis appears to have no effect on short- or long-term outcomes, recurrence of endometriosis, quality of life and sexual function, or patient satisfaction. Nevertheless, we lack randomized blinded controlled trials on these aspects. Such trials will be needed to enhance our comprehension of both surgical approaches.

Modern view on the diagnostics and treatment of adenomyosis

Adenomyosis is identified by the enlargement of the uterus secondary to such areas of the endometrium as the endometrial glands and stroma located deep in the myometrium, which causes its hyperplasia and hypertrophy. The most common signs of the development of adenomyosis in a patient are copious menstrual bleeding and dysmenorrhea. However, it should be borne in mind that in some patients, the disease may be asymptomatic. Despite the wide abundance of imaging and other diagnostic methods for diagnosing adenomyosis, there are currently no standard verified diagnostic criteria for pathologists. In addition, women with adenomyosis often have other concomitant gynaecological diseases, such as endometriosis or leiomyomas, which makes it difficult to diagnose and choose the optimal treatment for patients. Therefore, the purpose of this study was to highlight up-to-date and relevant information for the practitioner about the epidemiology, clinical manifestations, diagnostics and treatment options for adenomyosis. Sources from four databases (PubMed, Web of Science, Elsevier and Google Scholar) were used to search for data. As a result of a literature review, it was established that the "gold" standard for the diagnostics of adenomyosis is histological research methods, in particular, biopsy performed during hysteroscopy or laparoscopy, whereas imaging methods (transvaginal sonography, magnetic resonance imaging) are more often used for differential diagnostics of adenomyosis with other diseases. In addition, magnetic resonance imaging allows for a better differential diagnostics between adenomyosis and myomatosis and helps to recognise the disease at an early stage. Regarding treatment, there is currently no particular therapy and algorithms for the treatment of adenomyosis, which is primarily due to the lack of precise criteria for the diagnostics of the disease. However, the most effective therapeutic methods at the present stage are the use of aromatase inhibitors and gonadotropin-releasing hormone antagonists, whilst minimally invasive techniques, in particular, endometrial ablation and uterine artery embolisation, are becoming increasingly popular amongst surgical techniques.

Sonographic features of adenomyosis correlated with clinical symptoms and intraoperative findings: a case-control study

PURPOSE

Adenomyosis is a common disease of females during their reproductive age. As of today, histologic examination of the uterus after hysterectomy constitutes the gold standard for diagnosis. The aim of this study was to determine the validity of sonographic, hysteroscopic, and laparoscopic criteria for the diagnosis of the disease.

METHODS

This study included data collected from 50 women in the reproductive age of 18-45 years, who underwent a laparoscopic hysterectomy in the gynecology department of the Saarland University Hospital in Homburg between 2017 and 2018. The patients with adenomyosis were compared with a healthy control group.

RESULTS

We collected data of anamnesis, sonographic criteria, hysteroscopic criteria and laparoscopic criteria and compared it with the postoperative histological results. A total 25 patients were diagnosed with adenomyosis postoperatively. For each of these; at least three sonographic diagnostical criteria for adenomyosis were found compared with a maximum of two for the control group.

CONCLUSION

This study demonstrated an association between pre- and intraoperative signs of adenomyosis. In this way, it shows a high diagnostic accuracy of the sonographic examination as a pre-operative diagnostic method of the adenomyosis.

Uterine artery embolisation: fertility, adenomyosis and size - what is the evidence?

BACKGROUND

Uterine artery embolisation is well established as a treatment for symptomatic fibroids, however, there remain some uncertainties. We have carried out a focused literature review on three particularly challenging aspects - post-procedure fertility, symptomatic adenomyosis and large volume fibroids and uteri, to enable operators to utilise evidence-based guidance in patient selection, consent, and management.

REVIEW

Literature searches were performed of the PubMed/Medline, Google scholar, EMBASE and Cochrane databases. The outcomes of our analysis of studies which recorded fertility rates in women desiring pregnancy following UAE for symptomatic fibroids found an overall mean pregnancy rate of 39.4%, live birth rate of 69.2% and miscarriage rate of 22%. The major confounding factor was patient age with many studies including women over 40 years who already have lower fertility compared to younger cohorts. Miscarriage rates and pregnancy rates in the studies analysed were comparable to the age matched population. Treatment of pure adenomyosis and adenomyosis with co-existing uterine fibroids with UAE has been shown to produce symptomatic improvement with better outcomes in those with combined disease. Although the effectiveness is not as high as it is in pure fibroid disease, UAE provides a viable and safe alternative for patients seeking symptom relief and uterine preservation. Our analysis of studies assessing the outcomes of UAE in patients with large volume uteri and giant fibroids (> 10 cm) demonstrate no significant difference in major complication rates demonstrating that fibroid size should not be a contraindication to UAE.

CONCLUSION

Our findings suggest uterine artery embolisation can be offered to women desiring pregnancy with fertility and miscarriage rates comparable to that of the age-matched general population. It is also an effective therapeutic option for symptomatic adenomyosis as well as for the treatment of large fibroids > 10 cm in diameter. Caution is advised in those with uterine volumes greater than 1000cm³. It is however clear that the quality of evidence needs to be improved on with an emphasis on well-designed randomised controlled trials addressing all three areas and the consistent use of validated quality of life questionnaires for outcome assessment to enable effective comparison of outcomes in different studies.

Impact of Adenomyosis on Infertile Patients-Therapy Options and Reproductive Outcomes

Adenomyosis is associated with a negative impact on reproductive outcomes. Although adenomyosis is detected more frequently in women of late reproductive age, its impact on pregnancy rates is important because, in today's world, family planning has shifted towards the late reproductive phase of life for many women. Although the diagnostic indications for imaging studies are well-known, we lack strict diagnostic criteria and classification systems concerning the extent of the disease. Selecting the optimal evidence-based treatment option for adenomyosis is difficult because of the paucity of evidence concerning the association between fertility and the degree and composition of adenomyosis. Furthermore, the treatment of infertility might interfere with the treatment of adenomyosis due to the presence of pain. The aim of this review is to analyze the association between adenomyosis and infertility, and describe treatment options to enhance reproductive outcomes. The following aspects will be addressed in detail: (a) prevalence and causes of adenomyosis, (b) diagnostic tools with imaging techniques, (c) clinical symptoms, (d) proposed pathomechanism of adenomyosis and infertility, and (e) different treatment approaches (pharmacological, surgical, others) and their impact on reproductive outcomes.

Strategies for modelling endometrial diseases

Each month during a woman's reproductive years, the endometrium undergoes vast changes to prepare for a potential pregnancy. Diseases of the endometrium arise for numerous reasons, many of which remain unknown. These endometrial diseases, including endometriosis, adenomyosis, endometrial cancer and Asherman syndrome, affect many women, with an overall lack of efficient or permanent treatment solutions. The challenge lies in understanding the complexity of the endometrium and the extensive changes, orchestrated by ovarian hormones, that occur in multiple cell types over the period of the menstrual cycle. Appropriate model systems that closely mimic the architecture and function of the endometrium and its diseases are needed. The emergence of organoid technology using human cells is enabling a revolution in modelling the endometrium in vitro. The goal of this Review is to provide a focused reference for new models to study the diseases of the endometrium. We provide perspectives on the power of new and emerging models, from organoids to microfluidics, which have opened up a new frontier for studying endometrial diseases.

The Effect of Uterine Adenomyosis on IVF Outcomes: a Systematic Review and Meta-analysis

To investigate the impact of uterine adenomyosis on in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) clinical outcomes and also to evaluate the impact of gonadotropin-releasing hormone agonist (GnRHa) and surgical treatments. Infertile women with adenomyosis undergoing conventional IVF or ICSI were compared with women without adenomyosis. Fertility outcomes were evaluated in two patients with adenomyosis untreated and treated surgically or medically therapy. The review protocol was registered in PROSPERO (CRD42020214586). We consider the live birth rate (LBR) as the primary outcome. The analysis showed that women with adenomyosis had lower LBR (OR 0.59, 95% CI 0.37-0.92, p = 0.02), clinical pregnancy rate (OR 0.66, 95% CI 0.48-0.90), and ongoing pregnancy rate (OR 0.43, 95% CI 0.21-0.88) compared to those without adenomyosis, and miscarriage rate was higher in women with adenomyosis (OR 2.11, 95% CI 1.33-3.33). Surgical treatment increases natural conception in women with adenomyosis although the paucity of data (only two studies), and conversely, treatment with GnRHa does not increase the IVF outcomes. Women with adenomyosis have decreased IVF clinical outcomes. Pretreatment with the use of long-term GnRHa could not be beneficial, even though only three studies were included in the meta-analysis. The major part of the studies has not divided focal and diffuse adenomyosis, and this represents a relevant source of bias: studies conducted with standardized diagnostic criteria for adenomyosis are still needed to determine if the different clinical presentations of such condition could compromise IVF outcomes.

Pathogenesis of Human Adenomyosis: Current Understanding and Its Association with Infertility

The aim of this review article was to summarize our current understanding on the etiologies and pathogenesis of human adenomyosis and to clarify the relative association between adenomyosis and infertility. The exact pathogenesis of adenomyosis is still elusive. Among different reported concepts, direction invagination of gland cells from the basalis endometrium deep into myometrium is the most widely accepted opinion on the development of adenomyosis. According to this concept, endometrial epithelial cells and changed fibroblasts, abnormally found in the myometrium in response to repeated tissue injury and/or disruption at the endometrium-myometrium interface (EMI), elicit hyperplasia and hypertrophy of the surrounding smooth muscle cells. In this review, a comprehensive review was performed with a literature search using PubMed for all publications in English and Japanese (abstract in English), related to adenomyosis and infertility, from inception to April 2021. As an estrogen-regulated factor, hepatocyte growth factor (HGF) exhibits multiple functions in endometriosis, a disease commonly believed to arise from the functionalis endometrium. As a mechanistic basis of gland invagination, we investigated the role of HGF, either alone or in combination with estrogen, in the occurrence of epithelial-mesenchymal transition (EMT) in adenomyosis. Aside from microtrauma at the EMI, metaplasia of displaced Müllerian remnants, differentiation of endometrial stem/progenitor cells within the myometrium and somatic mutation of some target genes have been put forward to explain how adenomyosis develops. In addition, the possible role of microRNAs in adenomyosis is also discussed. Besides our knowledge on the conventional classification (focal and diffuse), two recently proposed classifications (intrinsic and extrinsic) of adenomyosis and the biological differences between them have been described. Although the mechanistic basis is unclear, the influence of adenomyosis on fertility outcome is important, especially considering the recent tendency to delay pregnancy among women. Besides other proposed mechanisms, a recent transmission election microscopic (TEM) study indicated that microvilli damage and an axonemal alteration in the apical endometria of human adenomyosis, in response to endometrial inflammation, may be involved in negative fertility outcomes. We present a critical analysis of the literature data concerning the mechanistic basis of infertility in women with adenomyosis and its impact on fertility outcome.

Transvaginal Ultrasound Combined with Strain-Ratio Elastography for the Concomitant Diagnosis of Uterine Fibroids and Adenomyosis: A Pilot Study

Uterine fibroids (UFs) and adenomyosis (AM) represent two benign uterine conditions that can affect fertility and are most frequently commonly responsible for abnormal uterine bleeding and chronic pelvic pain. Their differential diagnosis still represents a challenge, and several authors advise the addition of elastography to transvaginal ultrasound (TVUS) for a more accurate imagistic recognition. Through this study, we aimed to assess the diagnostic accuracy of TVUS combined with strain-ratio elastography (SRE) in concomitant AM and UFs. We conducted a study on 17 patients diagnosed with concomitant UFs and AM undergoing hysterectomy and 46 healthy patients. TVUS combined with SRE was conducted in each patient, focusing on identifying rigidity patterns of the lesions. Significantly higher mean SR and maximum SR values were identified among both AM and UF lesions as opposed to controls (p < 0.01), with the highest tissue stiffness being encountered among AM lesions, which allows for the differentiation of UF (p < 0.01) and concomitant identification of both lesions. These results are reflected by higher cut-off values obtained for AM, both for mean SR (5.42 vs. 2.85) and maximum SR (5.80 vs. 3.30). TVUS combined with SRE showed good diagnostic performance in identifying coexisting UFs and AM within the same uterine specimen. Future studies on wider populations are required to validate our findings.

A clinical scoring system for the diagnosis of adenomyosis

Objective

To develop a scoring system using clinical evaluation methods to predict the presence of adenomyosis.

Materials and Methods

A cohort of 232 patients who underwent hysterectomy for benign gynecologic disorders was prospectively enrolled. A detailed anamnesis was obtained and physical/pelvic examinations with trans-vaginal ultrasound imaging were performed one day before the hysterectomy. The diagnosis of adenomyosis was based on histopathologic examination. Findings were compared between patients with (n=55) and without (n=166) adenomyosis. Factors associated with adenomyosis were assessed with regression analysis and odds ratios (OR) were calculated. The variables found to be significant were chosen for the scoring system. Receiver operating characteristic analysis was carried out to find the cut-off values for these variables.

Results

Number of parity, dyspareunia and dysmenorrhea visual analogue scale (VAS) scores, age of menarche, presence of uterine tenderness and detection of heterogeneous myometrium and myometrial cysts during ultrasonography were found to be the significant parameters. OR for the presence of myometrial heterogeneity, myometrial cysts, uterine tenderness were 27.2, 3.6 and 9.3 respectively. Cut-off values were calculated; 3 for parity (OR=2.8), 13-years for menarche (OR=1.6), 2 for dyspareunia VAS scores (OR=1.9) and 4 for dysmenorrhea VAS scores (OR=1.2). The total sum of maximum OR that a patient can obtain was calculated as 47.6 and this value was assumed to predict the presence of adenomyosis 100%. The multiplication of the sum of the OR in a patient by 2.1 (100/47.2) was found to have a predictive ability for the presence of adenomyosis.

Conclusion

A scoring system is developed to predict adenomyosis non-invasively based on clinical evaluation.

Berberine attenuates hyperalgesia in mice with adenomyosis

PURPOSE

Adenomyosis is a common gynecological disease, but its pathogenesis and treatment options are not yet completely clear. This study aimed to investigate the analgesic effect of berberine on tamoxifen-induced neonatal mouse adenomyosis and its curative effects on the disease.

METHODS

The mouse adenomyosis model was established in neonatal female mice via oral administration of tamoxifen suspended solution. Adenomyosis mice were given berberine by intraperitoneal injection with the dosage of 5, 10, and 20 mg/kg body weight, respectively, at 17 weeks after birth. The pain sensation of the mice was evaluated by hotplate and tail-flick tests. The mRNA levels of gene expression were detected by RT-qPCR. The protein expression was analyzed by ELISA and Western blot.

RESULTS

Berberine reduced the uterine weight, suppressed the myometrial infiltration of ectopic endometrium, improved the hotplate and tail-flick latency of the adenomyosis mice. Mechanistically, berberine downregulated the expression of genes related to pain and inflammation, such as TRPV1, COX-2, VEGF and OTR, impaired the inflammatory response at the DRG site, and inhibited the expression of TLR4 in DRG and uterine tissues.

CONCLUSIONS

Berberine attenuates hyperalgesia and exhibits analgesic and therapeutic effects on adenomyosis mice.

The Potential Relationship Between Environmental Endocrine Disruptor Exposure and the Development of Endometriosis and Adenomyosis

Women with endometriosis, the growth of endometrial glands and stroma outside the uterus, commonly also exhibit adenomyosis, the growth of endometrial tissues within the uterine muscle. Each disease is associated with functional alterations in the eutopic endometrium frequently leading to pain, reduced fertility, and an increased risk of adverse pregnancy outcomes. Although the precise etiology of either disease is poorly understood, evidence suggests that the presence of endometriosis may be a contributing factor to the subsequent development of adenomyosis as a consequence of an altered, systemic inflammatory response. Herein, we will discuss the potential role of exposure to environmental toxicants with endocrine disrupting capabilities in the pathogenesis of both endometriosis and adenomyosis. Numerous epidemiology and experimental studies support a role for environmental endocrine disrupting chemicals (EDCs) in the development of endometriosis; however, only a few studies have examined the potential relationship between toxicant exposures and the risk of adenomyosis. Nevertheless, since women with endometriosis are also frequently found to have adenomyosis, discussion of EDC exposure and development of each of these diseases is relevant. We will discuss the potential mechanisms by which EDCs may act to promote the co-development of endometriosis and adenomyosis. Understanding the disease-promoting mechanisms of environmental toxicants related to endometriosis and adenomyosis is paramount to designing more effective treatment(s) and preventative strategies.

Evaluation of pharmacological interventions in the management of adenomyosis: a systematic review

PURPOSE

Medical management of adenomyosis largely revolves around symptom management, with very few drugs having received regulatory approval for the disease. However, the level of evidence supporting the use of pharmacological interventions is low, making it difficult to establish their efficacy in the treatment of adenomyosis. Hence, the aim of our systematic review is to identify the strength of evidence currently available and evaluate the effectiveness of different medical interventions in the management of adenomyosis.

METHODS

The search was performed in MEDLINE, Embase, Cochrane Library, CENTRAL and ClinicalTrials.gov. Articles published between 1 January 2010 and 30 November 2020 were considered. Randomized controlled trials and observational studies that assessed the efficacy of medical interventions in patients with adenomyosis were included. The quality of the data was analyzed using RevMan 5.3 software.

RESULTS

LNG-IUS (levonorgestrel intrauterine system), dienogest and gonadotropin-releasing hormone (GnRH) analogues were effective in reducing pain, uterine volume and menstrual bleeding. However, these data were largely obtained in the non-trial setting and were fraught with issues that included patient selection, short duration of therapy, small sample size, and limited long-term safety and effectiveness data.

CONCLUSIONS

Although LNG-IUS, dienogest and GnRH analogues have better evidence for effectiveness in adenomyosis, the need of the hour is to thoroughly evaluate other novel molecules for adenomyosis using well-designed randomized controlled trials.

The effect of adenomyosis on endometrial cancer: a university hospital-based cohort study

Endometrial cancer (EC) can coexist with gynaecological diseases including adenomyosis which can be defined as the location of endometrial cells within the myometrium. Our aim was to clarify the impact of adenomyosis on the clinical and survival outcomes of EC. We included the patients who underwent an operation for EC and had concurrent adenomyosis in this retrospective cohort study. All clinicodemographical and tumour characteristics with survival outcomes of the patients were analysed comparatively. A total of 763 patients who met the eligibility criteria were included. Of those, 591 patients in the non-adenomyosis group and 172 patients in the adenomyosis group were examined. Disease-specific survival (DSS) was significantly prolonged while progression-free survival (PFS) was not affected by the presence of adenomyosis (p = .004 vs. p = .161). However, adenomyosis did not remain as an independent prognostic factor for EC in multivariate analysis (p = .341). These patients with coexistent adenomyosis and EC have better clinicopathological characteristics and less advanced tumour. Although adenomyosis is associated with prolonged DSS, it has no prognostic importance for survival outcomes of the patients with EC.IMPACT STATEMENTWhat is already known on this subject? Endometrial cancer (EC) can coexist with other gynaecological diseases including uterine adenomyosis. Adenomyosis is typically diagnosed by the pathological evaluation of the uterus following hysterectomy, although diagnosis is possible with imaging methods However, the coexistence of adenomyosis and EC is controversial in the literature.What do the results of this study add? To the best of our knowledge, our study is the largest study performed at a single university hospital. All potential confounding factors including clinicodemographical characteristics of the patients, examination of histopathology slides by the experienced gynaecological pathologists, evaluation of all included factors that may affect the survival outcomes of EC by multivariate analysis were examined. Although adenomyosis is associated with prolonged disease-specific survival (DSS), it has no prognostic importance for survival outcomes of the patients with EC.What are the implications of these findings for clinical practice and/or further research? Women having coexistent adenomyosis and EC should be informed about the impact of adenomyosis on the survival outcomes of EC.

Barriers to self-management of patients with adenomyosis: A qualitative study

Aim

This study aims to explore the barriers to self‐management of patients with adenomyosis.

Design

Phenomenological qualitative methodology.

Methods

Totally, 18 patients with diagnosis of adenomyosis participated in this study. We used purposive sampling for recruitment until data saturation. A qualitative research was conducted using in‐depth interviews, which were tape recorded and transcribed verbatim. Colaizzi's method was used to analyse the contents of interviews.

Results

This study presented important information about the barriers to self‐management of patients with adenomyosis in China. Four themes were identified: “lack of disease knowledge,” “challenges and dilemmas of daily life,” “multidimensional negative emotions” and “personalized supporting requirements.”

Conclusion

The study provided new insights into the barriers to self‐management of patients with adenomyosis, including physical, psychological, daily life and self‐image problems, and the patients need emotional and social support, which recommended that professionals should provide authoritative health education and multiple support.