Adenomyosis pathogenesis: insights from next-generation sequencing

Efficacy of focused ultrasound ablation surgery in patients with adenomyosis and coexisting pelvic adhesions

OBJECTIVE

The objective of this study was to assess the efficacy of focused ultrasound ablation surgery (FUAS) in treating patients with adenomyosis and coexisting pelvic adhesions.

MATERIALS AND METHODS

A total of 396 patients diagnosed with adenomyosis and who underwent FUAS between January 2014 and December 2022 were enrolled. Pelvic adhesions were evaluated using magnetic resonance imaging (MRI), and the patients were categorized into either adhesive group or non-adhesive group. The aim was to investigate the comparative efficacy between the two groups.

RESULTS

Among the 396 patients, pelvic adhesions were detected in 123 (31.06%) women. Compared to the non-adhesive group, patients in the adhesive group exhibited a higher preoperative dysmenorrhea score (7 vs. 6, p  < 0.001), a lower short-term clinical success rate (74.80% vs. 84.62%, p = 0.025), and a higher long-term cumulative recurrence rate (log-rank p = 0.009). The adhesive group exhibited a high incidence of anal discomfort during the procedure compared to the non-adhesive group (18.70% vs. 7.69%, p = 0.002). Additionally, patients with severe adhesion demonstrated a lower ratio of non-perfused volume ratio (NPVR) (38.81% vs. 46.58%, p = 0.009). Multivariate binary logistic regression analysis revealed that pelvic adhesion independently increased the risk of dysmenorrhea (OR = 4.730, 95%CI: 2.026-11.044, p < 0.001), while severe pelvic adhesion was identified as an independent risk factor for NPVR (OR = 2.226, 95%CI: 1.181-4.196, p = 0.013).

CONCLUSION

The preoperative assessment of pelvic adhesions plays a crucial role in predicting intraoperative adverse events of FUAS in patients with adenomyosis, as well as determining both short-term and long-term efficacy, thereby providing valuable guidance for the development of comprehensive treatment.

The inconsistent pathogenesis of endometriosis and adenomyosis: insights from endometrial metabolome and microbiome

Endometriosis (EM) and adenomyosis (AM) are interrelated gynecological disorders characterized by the aberrant presence of endometrial tissue and are frequently linked with chronic pelvic pain and infertility, yet their pathogenetic mechanisms remain largely unclear. In this cross-sectional study, we analyzed endometrial samples from 244 participants, split into 91 EM patients, 56 AM patients, and 97 healthy controls (HC). We conducted untargeted liquid chromatography-mass spectrometry (LC-MS) and 5R 16S rRNA sequencing to examine endometrial metabolome and microbiome profiles. Additionally, we integrated transcriptomic analysis using nine transcriptomic data sets to investigate the biological basis of these conditions. Metabolomic profiling and 16S rRNA sequencing revealed distinct metabolic and microbial signatures. Specific pathways, including linoleic acid and glycerophospholipid metabolism, show significant alterations in both conditions. Notably, four metabolites, including phosphatidylcholine 40:8 [PC(40:8)], exhibited marked changes in both EM and AM, suggesting shared pathological features. Furthermore, taxonomic analysis identified unique bacterial species associated with each condition, particularly those belonging to the phylum Proteobacteria, which correlated with altered metabolic signatures. Machine learning models demonstrated high predictive accuracy for differentiating between AM, EM, and HC based on metabolic and microbial signatures. Integrative analysis with transcriptomic data highlighted distinct pathways related to immune response and signaling transduction for each condition. Our study provides fresh insights into the pathogenesis of AM and EM through a multi-omic approach, suggesting potential inconsistencies in the underlying pathogenetic mechanisms.

IMPORTANCE

Existing research highlighted a connection between endometriosis (EM) and adenomyosis (AM), underscoring their overlapping symptoms and potential shared pathophysiological mechanisms. Although the role of microbiota in inflammatory conditions has been acknowledged, comprehensive investigations into the endometrial microbiota in cases of EM and AM have been limited. Previous studies identified distinct microbial communities associated with these conditions; however, they were constrained by small sample sizes and a lack of integrated analyses of microbiota and metabolomics. Furthermore, the ongoing debate over whether EM and AM should be classified as separate diseases or related phenotypes emphasizes the necessity for further exploration of their molecular interactions. Our study uncovers distinct microbial and metabolic signatures associated with each condition, revealing both shared and unique pathways that may contribute to their pathogenesis. Furthermore, the integration of transcriptomic data offers valuable insights into the complex interactions underlying these disorders.

Integrated multi-omics analysis and experimental verification reveal the involvement of the PI3K/Akt signaling pathway in myometrial fibrosis of adenomyosis

Adenomyosis (AM) is characterized as a chronic and progressive disorder with limited therapeutic strategies available. Myometrial fibrosis is a prominent pathological feature of AM, yet the underlying molecular mechanisms remain elusive. The present study conducted a comparative analysis using proteomics and metabolomics to investigate myometrial fibrosis and its underlying mechanisms. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) was utilized to analyze adenomyotic and normal myometrial tissues from ten AM patients who underwent hysterectomy with myometrial fibrosis confirmed by Masson staining. This analysis established comprehensive proteomic and metabolomic profiles of AM patients and revealed widespread alterations in the proteome and metabolome within normal and fibrotic myometrium. Key proteins and signaling pathways linked to myometrial fibrogenesis were identified based on proteomic data. The integrated analysis showed significant associations between proteomic and metabolomic data and highlighted the critical role of the PI3K/AKT signaling pathway. Immunohistochemistry and Spearman's correlation analysis suggested a relationship between myometrial fibrosis and the metaplasia of myometrial stromal cells into myofibroblasts. Subsequent experiments identified crucial proteins and signaling pathways involved in myometrial fibrosis, indicating an association with the activation of the PI3K/AKT signaling pathway in myofibroblasts. Notably, PI3K/AKT inhibitors may contribute to the effective alleviation of myometrial fibrosis. This study is the first to demonstrate that myometrial fibrosis represents a critical pathological mechanism in AM through multi-omics methods and to elucidate the crucial role of the PI3K/AKT signaling pathway in this process. These findings provide valuable insights into the pathophysiology of AM and suggest antifibrotic treatment as a promising therapeutic strategy.

Adenomyosis: the missed disease

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

Endometriosis and adenomyosis unveiled through single-cell glasses

Single-cell technologies are expanding our understanding of endometriosis and adenomyosis, which are sister disorders of the uterine endometrium that contain similar complements of lesion cell types but in different locations-outside and inside the uterus, respectively. Both diseases cause significant morbidity and impaired quality of life among those affected, and current therapies mitigate most of the symptoms although with highly variable efficacy, duration of effect, and frequent intolerable side effects. Thus, there is a pressing need for transformative approaches and to develop individualized therapies for the variety of presentations of endometriosis and adenomyosis symptoms and the heterogeneity of lesion types, both histologically and architecturally. Single-cell technologies are transforming the understanding of human physiology and pathophysiology in the reproductive system and beyond. This manuscript reviews the clinical characteristics of endometriosis and adenomyosis and the recent studies focused on eutopic endometrium and ectopic lesions at single-cell resolution, the myriad of cell types and subtypes, cell-cell communications, signaling pathways, applications for novel drug discovery and therapeutic approaches, and challenges and opportunities that accompany this type of research. Key take-home messages from the studies reviewed herein include the following: We conclude the review with an eye to the future-what Alice might see beyond the single-cell looking glass that connects endometrium and endometrial disorders with the trillions of cells of other tissues and organs in health and disease throughout the human body and the opportunities for novel diagnostic modalities and drug discovery for endometriosis, adenomyosis, and related uterine and inflammatory conditions.

Adenomyosis associated with endometrial cancer: Possible correlation with pathological, immunohistochemical and molecular characteristics

BACKGROUND/OBJECTIVE

Adenomyosis is a benign uterine disorder characterized by an inflammatory and hyperestrogenic state. Its association with endometrial cancer (EC) remains controversial. This study aimed to investigate the correlation between adenomyosis and the pathological, immunohistochemical (IHC), and molecular features of EC.

METHODS

This retrospective cohort study analyzed 172 patients with EC who underwent surgical staging. Patients were stratified into two groups based on the presence of adenomyosis. The primary endpoint was the prevalence of FIGO stage ≥IB disease. Secondary endpoints included tumor histotype, grade, lymphovascular invasion, IHC markers, and molecular alterations. Logistic regression was performed to identify independent predictors of adverse pathological features.

RESULTS

Adenomyosis was identified in 37.2 % of EC patients. These patients were younger, less likely to be postmenopausal, and exhibited significantly lower rates of FIGO stage ≥IB disease, deep myometrial invasion, lymphovascular invasion, and extrauterine spread. Multivariate analysis confirmed adenomyosis as an independent protective factor against FIGO stage ≥IB disease. This protective effect could be attributed to the altered myometrial microenvironment in adenomyosis, characterized by inflammation, smooth muscle hyperplasia, and fibrosis, which appears to limit tumor invasiveness. No significant differences were observed in IHC or molecular profiles, although a trend toward higher prevalence of KRAS mutations was observed in patients with adenomyosis.

CONCLUSION

Adenomyosis was associated with a lower prevalence of FIGO stage ≥IB disease, deep myometrial invasion, lymphovascular invasion, and extrauterine spread. These findings suggest that structural changes in the myometrial microenvironment may play a role in limiting tumor invasiveness and spread, warranting further investigation.

Regulation on mitophagy in adenomyosis by Guizhi Fuling Wan

ETHNOPHARMACOLOGICAL RELEVANCE

Guizhi Fuling Wan (GZFLW), a canonical herbal formulation originating from Synopsis of the Golden Chamber, has been widely utilized in managing pain-associated disorders. While its therapeutic efficacy in adenomyosis (AM) characterized by severe dysmenorrhea is well-documented, the underlying pharmacological mechanisms remain elusive. Emerging evidence suggests that hypoxic mitochondrial damage in endometrial tissue constitutes a pathological hallmark of AM, wherein mitophagy regulation through the PINK1/Parkin signaling pathway plays a pivotal role in mitochondrial quality control. Although certain phytomedicines have demonstrated mitophagy-modulating properties under hypoxic conditions, the specific regulatory effects of GZFLW on this process in AM pathogenesis warrant systematic investigation.

AIM OF THE STUDY

To elucidate the mitophagy-modulating mechanism of GZFLW in AM through integrated in vivo and in vitro approaches.

MATERIALS AND METHODS

An allogeneic pituitary transplantation-induced AM mouse model was established. Pharmacodynamic assessment included hotplate testing and serum cancer antigen 125 (CA125) quantification, while blood urea nitrogen (BUN) and alanine aminotransferase (ALT) levels were monitored for hepatorenal toxicity screening. Histopathological characterization employed hematoxylin-eosin (H&E) staining and transmission electron microscopy (TEM) for ultrastructural analysis. Protein expression of PINK1/Parkin pathway components (PINK1, Parkin, OPTIN, NDP52, P62) were determined by Western blot. Primary endometrial stromal cells (ESCs) isolated from clinical AM specimens underwent functional assessment via transwell migration/invasion assays, complemented by flow cytometric quantification of mitochondrial membrane potential (MMP) and reactive oxygen species (ROS). Molecular docking simulations evaluated ligand-receptor interactions between GZFLW bioactive constituents and PINK1/Parkin proteins. This study protocol was approved by the Medical Ethics Committee of China Three Gorges University (No. 2022CA002).

RESULTS

Histopathological validation confirmed successful AM model establishment. ELISA revealed significantly elevated CA125 levels in AM mice versus controls (P < 0.05), with notable reductions in GZFLW-treated groups (GET: P < 0.05, GZFLW-L: P < 0.01). No intergroup differences emerged in ALT/BUN levels, indicating absence of hepatorenal toxicity. Post-modeling pain threshold depression (P < 0.05 vs control) was attenuated by GZFLW treatment (P < 0.05). TEM analysis demonstrated mitochondrial pathology in AM endometrium, including structural deformation, reduced mitochondrial quantity, and autophagosome accumulation, all ameliorated by GZFLW-L intervention. Western blot showed upregulated PINK1 (P < 0.01), Parkin, OPTIN, and NDP52 (P < 0.05) in AM group, with subsequent downregulation following GZFLW-L administration (P < 0.05). In vitro, AM ESCs exhibited MMP depolarization (P < 0.05), reversed by GZFLW treatment alongside suppressed migratory/invasive capacity (P < 0.01, P < 0.05), ROS reduction (P < 0.05), and attenuated PINK1/Parkin pathway activation. Molecular docking confirmed strong binding affinities (binding energy < -5.0 kcal/mol) between GZFLW phytoconstituents and PINK1/Parkin targets.

CONCLUSION

This investigation reveals that GZFLW exerts its therapeutic effects on AM via targeted modulation of the PINK1/Parkin-mediated mitophagy axis, supporting its potential as a mitochondria-targeted therapeutic strategy for AM management.

Clinical efficacy of etonogestrel implants on relieving dysmenorrhea in endometriosis and adenomyosis women for up to 3 years

Background

Dysmenorrhea and menstrual disorders caused by endometriosis (EM) and adenomyosis (AM) have significantly affected the quality of life of a large number of women. As a highly effective clinical contraceptive measure, etonogestrel implants have been previously reported to relieve dysmenorrhea. However, the dysmenorrhea treatment and menstrual regulation effects of etonogestrel implants in AM and EM patients have not been systematically studied.

Methods

This retrospective study followed up 100 patients with etonogestrel implants from May 2015 to October 2016, including 44 patients with EM and 56 patients with AM. The VAS scores of dysmenorrhea, menstrual volume, and related adverse events were measured at 12, 24, and 36 months after etonogestrel implantation in these patients.

Results

In 100 EM and AM patients, dysmenorrhea significantly improved, with moderate and severe cases decreasing from 50 to 16 and 0% at 36 months. Amenorrhea increased over time, and frequent bleeding declined. Adverse reactions included weight gain (21%), acne (13%), and decreased sexual desire (10%). Serum CA125 levels dropped, confirming therapeutic efficacy.

Conclusion

Etonogestrel implantation significantly alleviated dysmenorrhea symptoms in AM and EM patients.

miR-21 regulates autophagy and apoptosis of ectopic endometrial stromal cells of adenomyosis via PI3K/ AKT/ mTOR pathway

Adenomyosis (AM) is a common and challenging disease in gynecological clinics, which adversely affects women's physical and mental health. Despite the growing number of studies, the mechanisms associated with the growth of the lesion are poorly understood. Studies show that abnormal proliferation, apoptosis, and migration in ectopic endometrial stromal cells (EESc) of AM may contribute to the development and progression of AM. Understanding the underlying molecular mechanisms can significantly contribute to diagnosing and treating AM. In the present study, EESc was isolated and cultured from the ectopic endometrium of patients with AM. These cells were treated with a PI3K/AKT activator (740 Y-P) and an inhibitor (LY294002), while the expression of microRNA-21 (miR-21) was interfered with. The effects of miR-21 on the apoptosis and autophagy of EESc, as well as the associated mechanisms, were investigated from multiple perspectives. Here, we found that 740 Y-P could significantly promote proliferation, inhibit apoptosis of EESc, and increase the expression of mTOR and p-mTOR proteins in EESc. Moreover, activating miR-21 enhanced the pro-migration effect of 740 Y-P and reversed the pro-apoptotic effect of LY294002, reducing the apoptosis rate and increasing the migration ability of EESc. Our investigation revealed that miR-21 can inhibit apoptosis and autophagy and promote migration of EESc. This effect is likely mediated via the PI3K/AKT/mTOR pathway.

Decoding driver and phenotypic genes in cancer: Unveiling the essence behind the phenomenon

Gray hair, widely regarded as a hallmark of aging. While gray hair is associated with aging, reversing this trait through gene targeting does not alter the fundamental biological processes of aging. Similarly, certain oncogenes (such as CXCR4, MMP-related genes, etc.) can serve as markers of tumor behavior, such as malignancy or prognosis, but targeting these genes alone may not lead to tumor regression. We pioneered the name of this class of genes as "phenotypic genes". Historically, cancer genetics research has focused on tumor driver genes, while genes influencing cancer phenotypes have been relatively overlooked. This review explores the critical distinction between driver genes and phenotypic genes in cancer, using the MAPK and PI3K/AKT/mTOR pathways as key examples. We also discuss current research techniques for identifying driver and phenotypic genes, such as whole-genome sequencing (WGS), RNA sequencing (RNA-seq), RNA interference (RNAi), CRISPR-Cas9, and other genomic screening methods, alongside the concept of synthetic lethality in driver genes. The development of these technologies will help develop personalized treatment strategies and precision medicine based on the characteristics of relevant genes. By addressing the gap in discussions on phenotypic genes, this review significantly contributes to clarifying the roles of driver and phenotypic genes, aiming at advancing the field of targeted cancer therapy.

Could Transcervical Radiofrequency Ablation Become a Therapy Option for Focal Adenomyosis?

BACKGROUND/AIM

Adenomyosis is a common gynecological disease characterized by the presence of ectopic endometrial tissue (endometrial stroma and glands) within the myometrium. It is classified into two main types: diffuse and focal. The aim of this study was to present the outcomes of patients with focal adenomyosis following treatment with transcervical radiofrequency ablation.

PATIENTS AND METHODS

This was a retrospective analysis of patients treated with the Sonata® System. A total of 574 cases were analyzed, all performed at two centers in Germany: Academic Hospital Cologne Weyertal and Hospital Böblingen.

RESULTS

Thirty patients with focal adenomyosis were treated with transcervical radiofrequency ablation. All surgeries were performed without any complications. The mean surgery's time was 30.7 minutes, while the mean ablation time was 8.5 minutes. At the time of this report, 27 patients had returned for follow-up. 89% of patients reported improvement in their symptoms. No patient reported a worsening of their symptoms. The procedure reduced the average focal lesion size from 4.4 cm to 2.8 cm. No postoperative complications were observed. All patients reported satisfaction with the procedure.

CONCLUSION

Transcervical radiofrequency ablation appears to be an effective approach for treating adenomyosis. The Sonata® System, in particular, offers notable advantages, making it a potentially valuable alternative to conventional procedures like hysterectomy and tissue excision. This minimally invasive approach preserves the uterus, providing a less invasive and more patient-centered treatment option for adenomyosis.

Steps towards the clinical application of endometrial and menstrual fluid mesenchymal stem cells for the treatment of gynecological disorders

INTRODUCTION

The human endometrium is a highly regenerative tissue that contains mesenchymal stem/stromal cells (MSCs). These MSCs are sourced via office-based biopsies and menstrual fluid, providing a less invasive and readily available option for cell-based therapies. This review provides an update on endometrial-derived MSCs as a treatment option for gynecological diseases.

AREAS COVERED

This narrative review covers the characterization and therapeutic mechanisms of endometrium biopsy-derived MSCs (eMSCs) and menstrual fluid-derived mesenchymal stromal cells (MenSCs), highlighting similarities and differences. It also covers studies of their application in preclinical animal models and in clinical trials as potential cell-based therapies for gynecological diseases.

EXPERT OPINION

eMSCs and MenSCs from a homologous tissue source have the potential to promote regenerative activity as a treatment for gynecological diseases. Both eMSCs and MenSCs demonstrate therapeutic benefits through their paracrine activity in tissue regeneration, immunomodulation, angiogenesis, and mitigating fibrosis. Further research is essential to establish standardized isolation and characterization protocols, particularly for heterogeneous MenSCs, and to fully understand their mechanisms of action. Implementing SUSD2 magnetic bead sorting for purifying eMSCs from endometrial tissues and menstrual fluid is crucial for their use in future cell-based therapies. Optimization of production, storage, and delivery methods will maximize their therapeutic effectiveness.

Impaired fertility and perinatal outcomes in adenomyosis: insights from a novel murine model and uterine gene profile alterations during implantations

BACKGROUND

Adenomyosis is a uterine disorder closely linked to infertility and adverse pregnancy outcomes. Despite its clinical significance, the mechanisms by which adenomyosis impairs embryo implantation and perinatal outcomes remain incompletely defined. Previous studies have indicated that alterations in the uterine microenvironment may contribute to these reproductive challenges.

OBJECTIVE

To investigate the effects of adenomyosis on fertility and perinatal outcomes using a novel murine model and to identify molecular pathways involved in implantation failure and pregnancy loss.

STUDY DESIGN

A mechanically induced adenomyosis model was established in female Bagg Albino/c mice through endometrial-myometrial interface disruption to closely simulate the clinical condition observed in humans. Mice were randomly assigned to either the adenomyosis group or a sham-operated control group. Reproductive outcomes were systematically assessed at multiple gestational time points, focusing on embryo implantation site distribution, implantation rates, pregnancy loss, fetal growth parameters, and postnatal uterine recovery. In parallel, uterine tissues collected from implantation sites and interimplantation regions at 4.5 days postcoitus were subjected to RNA sequencing. Differential gene expression analyses were performed, and enriched pathways were identified using Gene Ontology and Kyoto Encyclopedia of Genes and Genomes enrichment tools.

RESULTS

Mice in the adenomyosis group demonstrated significant disruptions in the uterine microenvironment compared to controls. Notably, the adenomyosis group exhibited irregular distribution of implantation sites with reduced interembryo distances, leading to compromised spatial organization of the developing conceptuses. Although the total number of embryos at early gestation did not differ significantly between groups, a marked increase in pregnancy loss was observed during mid-gestation, accompanied by a reduction in the size of surviving embryos. Histological evaluation revealed extensive architectural disruptions in the uterine muscle layers and increased local inflammatory responses in adenomyotic uteri. RNA sequencing further revealed that adenomyosis was associated with the dysregulation of multiple genes involved in immune modulation, apoptotic regulation, and metabolic processes. In particular, significant enrichment of the phosphoinositide 3-kinase-Akt pathway, mitogen-activated protein kinase, and tumor necrosis factor signaling pathways was observed, suggesting that variation in these cascades may underlie the impaired uterine receptivity and embryo development seen in adenomyosis.

CONCLUSION

Our findings indicate that adenomyosis exerts a adverse effect on fertility and perinatal outcomes by disrupting the uterine environment and interfering with critical molecular pathways essential for proper embryo implantation and development. The results of this study not only enhance our understanding of adenomyosis pathophysiology but also pinpoint potential molecular targets-such as the phosphoinositide 3-kinase-Akt pathway, mitogen-activated protein kinase, and tumor necrosis factor pathways-for therapeutic intervention. These insights offer promising targets for developing treatments aimed at reversing the adverse reproductive impacts associated with adenomyosis.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cine-MRI for Quantifying Uterine Peristalsis: A Systematic Review and Meta-Analysis

Background: Uterine contractility, also known as uterine peristalsis (UP), is a critical determinant of fertility, affecting sperm transport and embryo implantation. Increased uterine peristaltic activity has been associated with reduced pregnancy rates. However, data are heterogeneous and uterine contractility has not been widely translated into clinical practice. Cine-MRI, although limited by cost and heterogeneity in data reporting, has emerged as a promising tool to assess uterine dynamics and increase our knowledge of UP in physiological and pathological conditions. Objective: This systematic review and meta-analysis aimed to describe patterns of UP in physiological and pathological uterine conditions, including endometriosis and fibroids, using cine-MRI. Methods: A systematic literature search of the Medline, Embase, Cochrane and CENTRAL databases and Google Scholar was conducted up to May 2024, including studies evaluating UP by cine-MRI. Clinical studies evaluating uterine contractility were included, excluding those affected by therapeutic interventions or unrelated pathologies. This meta-analysis pooled data from studies comparing uterine contractility in patients with endometriosis. Results: In the 13 included studies (365 women), uterine contractility varied significantly according to menstrual cycle phases and pathological conditions. This meta-analysis showed that women with endometriosis had higher uterine contractility in the luteal phase (0.74; 95% CI: 0.27-1.21) but not in the periovulatory phase (SMD 0.8; 95% CI: -3.78-5.37). Conclusions: Cine-MRI is a promising diagnostic tool for the analysis of UP. Endometriosis is associated with impaired UP, which may be a cause of the decreased implantation rate and infertility in endometriosis. However, further research is needed to consolidate the effect of UP on implantation and fertility and to develop standardised and cost-effective tools to assess uterine contractility and tailor infertility treatment.

BCL6 (B-cell lymphoma 6) expression in adenomyosis, leiomyomas and normal myometrium

Adenomyosis and leiomyomas are common benign uterine disorders characterized by abnormal cellular proliferation. The BCL6 protein, a transcriptional repressor implicated in cell proliferation and oncogenesis, has been linked to the pathogenesis of endometriosis. This study investigates BCL6 expression in adenomyosis, leiomyomas, and normal myometrium using immunohistochemistry and deep learning neural networks. We analyzed paraffin blocks from total hysterectomies performed between 2009 and 2017, confirming diagnoses through pathological review. Immunohistochemistry was conducted using an automated system, and BCL6 expression was quantified using Fiji-ImageJ software. A supervised deep learning neural network was employed to classify samples based on DAB staining. Our results show that BCL6 expression is significantly higher in leiomyomas compared to adenomyosis and normal myometrium. No significant difference in BCL6 expression was observed between adenomyosis and controls. The deep learning neural network accurately classified samples with a high degree of precision, supporting the immunohistochemical findings. These findings suggest that BCL6 plays a role in the pathogenesis of leiomyomas, potentially contributing to abnormal smooth muscle cell proliferation. The study highlights the utility of automated immunohistochemistry and deep learning techniques in quantifying protein expression and classifying uterine pathologies. Future studies should investigate the expression of BCL6 in adenomyosis and endometriosis to further elucidate its role in uterine disorders.

Mapping Human Uterine Disorders Through Single-Cell Transcriptomics

Disruptions in uterine tissue function contribute to disorders such as endometriosis, adenomyosis, endometrial cancer, and fibroids, which all significantly impact health and fertility. Advances in transcriptomics, particularly single-cell RNA sequencing, have revolutionized uterine biological research by revealing the cellular heterogeneity and molecular mechanisms underlying disease states. Single-cell RNA sequencing and spatial transcriptomics have mapped endometrial and myometrial cellular landscapes, which helped to identify critical cell types, signaling pathways, and phase-specific dynamics. Said transcriptomic technologies also identified stromal and immune cell dysfunctions, such as fibroblast-to-myofibroblast transitions and impaired macrophage activity, which drive fibrosis, chronic inflammation, and lesion persistence in endometriosis. For endometrial cancer, scRNA-seq uncovered tumor microenvironmental complexities, identifying cancer-associated fibroblast subtypes and immune cell profiles contributing to progression and therapeutic resistance. Similarly, studies on adenomyosis highlighted disrupted signaling pathways, including Wnt and VEGF, and novel progenitor cell populations linked to tissue invasion and neuroinflammation, while single-cell approaches characterized smooth muscle and fibroblast subpopulations in uterine fibroids, elucidating their roles in extracellular matrix remodeling and signaling pathways like ERK and mTOR. Despite challenges such as scalability and reproducibility, single-cell transcriptomic approaches may have potential applications in biomarker discovery, therapeutic target identification, and personalized medicine in gynecological disorders.

Endometrial stromal cell signaling and microRNA exosome content in women with adenomyosis

Adenomyosis is a chronic, estrogen-driven disorder characterized by the presence of endometrial glands and stroma within the myometrium. Despite its significant impact on reproductive health and quality of life, the pathogenesis of the disease remains unclear. Both the glandular and stromal compartments of eutopic endometrium from women with adenomyosis show alterations compared to healthy subjects. However, the molecular mechanisms driving crosstalk between stromal cells and epithelial glands, along with paracrine signaling underlying lesion development and progression, are still poorly understood. Exosomes, small cell-derived carriers and microRNAs, namely non-coding RNA molecules, are crucial to intercellular communication within the endometrium and may elucidate interactions between the two compartments that contribute to adenomyotic lesion formation. To our knowledge, this is the first foundational study to comprehensively isolate and characterize stroma-derived exosomes from women with adenomyosis. Exosome isolation by means of differential ultracentrifugation was validated in 22 samples, including 11 healthy subjects and 11 women with adenomyosis, using nanoparticle tracking analysis, transmission electron microscopy, and flow cytometry. Profiling of microRNA in secreted exosomes revealed 10 microRNAs with significantly altered expression in adenomyosis subjects during the menstrual phase compared to controls. Thorough investigations into menstruation-specific molecular mechanisms, as well as predicted target genes and enriched pathways of exosomal microRNAs, offer promising insights into the pathogenesis of adenomyosis, shedding light on the potential mechanisms underlying stromal cell signaling and adenomyotic lesion establishment. This work does, however, have certain drawbacks, including modest sample size and limited representation due to a lack of readily available endometrial biopsies in the menstrual phase. Having done the groundwork in this study, future research should seek to validate these findings in larger cohorts and apply functional assays. Indeed, our findings can serve as a resource to elucidate the role of menstruation-specific stroma-derived microRNA-mediated signaling and its potential impact on adenomyosis development.

Emerging bioengineering breakthroughs in precision diagnosis and therapy for endometriosis and adenomyosis

Endometriosis and adenomyosis are debilitating gynecological conditions that severely affect the quality of life of women. Traditional diagnostic and treatment methods, including laparoscopic surgery and hormonal therapy, face significant limitations such as incomplete lesion detection, high recurrence rates, and adverse side effects. Emerging bioengineering technologies offer promising solutions for precise diagnosis and therapy of these diseases. Advances in biomarker detection through electrochemical immunosensors, including specific molecular markers like cytokines and growth factors, have improved their early diagnosis. Innovative imaging techniques, such as near-infrared fluorescence imaging, magnetic resonance imaging, and photoacoustic imaging, enhance lesion visualization and surgical precision. In therapeutic applications, bioengineered drug delivery systems enable targeted therapy by modifying drug carriers with ligands targeting highly expressed receptors in endometriotic lesions. Such strategies could improve drug accumulation at target sites and reduce damage to healthy tissues. Integrating external energy (including lasers, focused ultrasound, and magnetic fields) with nanoplatforms offers key benefits for treating endometriosis and adenomyosis, allowing precise delivery of energy-responsive molecules to lesions and minimizing damage to healthy tissues. Additionally, novel approaches, such as immunotherapy, gene therapy, ferroptosis induction, and synthetic lethal activation, offer new avenues for effective treatment of endometriosis and adenomyosis. Significantly, this paper discusses the advantages of precision diagnosis and treatment of endometriosis in preserving the fertility of women of reproductive age. This review highlights the potential of bioengineering breakthroughs to transform the diagnosis and management of endometriosis and adenomyosis, emphasizing their role in advancing precision medicine and improving women's health.

The First Lugano Workshop on the role of adenomyosis in ART

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

Recurrence rates and associated risk factors after conservative surgery for adenomyosis: a retrospective study

BACKGROUND

Conservative surgery for adenomyosis has been shown to be effective. However, risk factors for postoperative recurrence have yet to be clarified. In this study, we aimed to determine the recurrence rate after conservative surgery for adenomyosis and identify the risk factors for recurrence.

METHODS

This retrospective study was conducted in a tertiary hospital. Patients who underwent conservative surgery for adenomyosis between January 2013 and April 2023 were identified. Eligible patients were assigned to either the recurrent or non-recurrent group. Continuous and categorical variables were compared between the two groups using the Mann-Whitney U test or chi-squared test. Risk factors for recurrence were identified by Cox proportional risk analysis.

RESULTS

Data for 133 eligible patients who underwent conservative surgery for adenomyosis were analyzed. The mean follow-up duration was 52 months. The recurrence rate after conservative surgery was 39.1% (52/133). Cox proportional risk analysis identified adenomyosis involving the posterior uterine wall (hazard ratio [HR] 6.505, P = 0.018), two or more adenomyotic lesions (HR 6.310, P = 0.030), laparotomy (HR 2.490, P = 0.029), and concomitant endometriosis (HR 2.313, P = 0.036) to be risk factors for recurrence after conservative surgery. Postoperative combined progestogen therapy (HR 0.126, P < 0.001) or treatment with a gonadotropin-releasing hormone agonist (GnRHa) (HR 0.237, P = 0.004) prevented recurrence of adenomyosis.

CONCLUSION

Adenomyosis continues to have a relatively high long-term recurrence rate after conservative surgery. Patients with adenomyosis involving the posterior wall of the uterus, those with two or more adenomyotic lesions, and those with concomitant endometriosis are at high risk for recurrence after conservative surgery. Postoperative progestogen or GnRHa therapy may reduce the risk of recurrence of adenomyosis. Considering the retrospective nature of this study and its small sample size, larger prospective studies are needed to confirm its findings.

Insights into Reproductive Immunology and Placental Pathology

The formation of a daughter organism as a result of the fusion of an egg and a sperm cell, followed by the implantation of the embryo, the formation of the placenta, and the further growth of the embryo and then fetus until delivery, poses particular challenges for the immune system [...].

Adenomyosis Localized in Both the Anterior and Posterior Myometrium Is Associated with Deep Rectal Endometriosis: A Retrospective Study

BACKGROUND

Endometriosis and adenomyosis are two closely related, estrogen-dependent, benign gynecological diseases. The available evidence on their common pathogenesis and association is limited and often does not address the heterogeneity of both entities. The aim of our study is to investigate the association between different types and localizations of adenomyosis and endometriosis phenotypes, using magnetic resonance imaging (MRI) and laparoscopic findings.

METHODS

We performed a retrospective observational study involving premenopausal women over 18 years old who underwent laparoscopic surgery for endometriosis and were pre-operatively diagnosed with adenomyosis through MRI examination at the Cantonal Hospital of Schaffhausen, Switzerland between 2011 and 2022.

RESULTS

Of 130 patients with adenomyosis, 23 (17.7%) women had adenomyosis only in the anterior wall (group 1), 38 (29.2%) only in the posterior wall (group 2), and 69 (53.1%) in both the anterior and posterior wall (group 3). Women in group 1 experienced significantly more dysuria compared to the two other groups (p = 0.018), while the prevalence of other pain symptoms (dysmenorrhea, dyspareunia, dyschesia) was comparable between the groups. Women in group 3 had significantly thicker anterior and posterior myometrium compared to groups 1 and 2 (p < 0.001). Co-existence of deep rectal endometriosis was more frequent in women from group 3 compared to groups 1 and 2 (p = 0.039) and in women with adenomyosis in the outer (extrinsic) compared to adenomyosis in the inner myometrium (intrinsic) (p < 0.001).

CONCLUSIONS

This study provides evidence of an association between the localization of adenomyosis and the distribution of concomitant endometriosis. Specifically, adenomyosis localized in both the anterior and posterior wall appears to be more proliferative compared to adenomyosis found only in the anterior or posterior wall. This is indicated by its association with higher uterine volume, thicker posterior junctional zone, and greater myometrial thickness and with a higher co-existence with deep rectal endometriosis. These findings support an association between the development of specific subtypes of both entities, which represents a valuable resource for the identification of future targets for the treatment and clinical management of adenomyosis and endometriosis.

Eutopic and Ectopic Endometrial Interleukin-17 and Interleukin-17 Receptor Expression at the Endometrial-Myometrial Interface in Women with Adenomyosis: Possible Pathophysiology Implications

Adenomyosis involves the infiltration of endometrial glands and stroma deep into the uterine tissue, causing disruption to the endometrial-myometrial interface (EMI). The role of interleukin-17 (IL-17) has been extensively studied in endometriosis, but its involvement in adenomyosis remains unclear. This study aimed to investigate the expression of IL-17 in eutopic and ectopic endometrium (adenomyosis) of individuals with adenomyosis at the level of EMI. Paired tissues of eutopic endometrium and adenomyoma were collected from 16 premenopausal women undergoing hysterectomy due to adenomyosis. The IL-17 system was demonstrated in paired tissue samples at the level of EMI by the immunochemistry study. Gene expression levels of IL-17A and IL-17 receptor (IL-17R) were assessed through quantitative real-time reverse transcription polymerase chain reaction (RT-PCR). Comparative gene transcript amounts were calculated using the delta-delta Ct method. By immunohistochemical staining, CD4, IL-17A, and IL-17R proteins were detected in both eutopic endometrium and adenomyosis at the level of EMI. IL-17A and IL-17R were expressed mainly in the glandular cells, and the expression of both IL-17A and IL-17R was found to be stronger in adenomyosis than in endometrium. 3-Diaminobenzidine (DAB) staining revealed greater IL-17A expression in adenomyosis compared to eutopic endometrium. Quantitative RT-PCR showed 7.28-fold change of IL-17A and 1.99-fold change of IL-17R, and the fold change level of both IL-17A and IL-17R is significantly higher in adenomyosis (IL-17A: p = 0.047, IL-17R: p = 0.027) versus eutopic endometrium. We found significantly higher IL-17 levels in adenomyosis compared to eutopic endometrium at the level of EMI. The results showed that the IL-17 system may play a role in adenomyosis.

Effect of High-Intensity Focused Ultrasound on Different Types of Adenomyosis Based on Magnetic Resonance Imaging Classification

OBJECTIVE

We aimed to analyze the effect of high-intensity focused ultrasound (HIFU) on different types of adenomyosis (AM) based on magnetic resonance imaging (MRI) classification.

METHODS

A total of 206 AM patients who underwent HIFU between January 2017 and December 2021 were included in this retrospective study. The size and location of AM were evaluated based on T2-weighted imaging (T2WI) of MRI. Patients were divided into internal (subtype I), external (subtype II), intramural (subtype III), and full-thickness (subtype IV) AM groups. All patients underwent an MRI examination before and one day after HIFU. After ultrasound-guided HIFU ablation, the parameters of ultrasonic energy input during HIFU treatment among different groups were recorded and compared. The adverse reactions and complications among different groups were compared.

RESULTS

The lesion volume in the subtype IV group was significantly larger than the subtype II and III groups (P < .05). The HIFU irradiation time, treatment time, and total energy input in the subtype IV group were significantly higher than the subtype I and III groups (P < .05). The number of cases of abdominal pain and vaginal fluid in the treatment area in the subtype IV group was significantly higher than in the subtype II group.

CONCLUSION

Although HIFU has different treatment strategies and parameters for different subtypes of AM, it can achieve a satisfactory ablation rate, which is safe and effective.

Blockage of the NLRP3 inflammasome by MCC950 inhibits migration and invasion in adenomyosis

RESEARCH QUESTION

Does the NOD-like receptor protein 3 (NLRP3) inflammasome have an effect in adenomyosis?

DESIGN

Fresh-frozen endometrial tissues and paraffin specimens were obtained from endometrial tissues from patients with adenomyosis and controls. Western blot, quantitative real-time polymerase chain reaction (qRT-PCR) and immunohistochemistry (IHC) were applied to assess expression of the NLRP3 inflammasome components. Primary eutopic endometrial stromal cells were isolated from the uteri of patients with adenomyosis. After NLRP3 was knocked down using small interfering RNA, proliferation, invasion and epithelial-mesenchymal transition (EMT) were evaluated using EdU, CCK8, transwell assays and western blot. Importantly, a mouse model of adenomyosis was established to evaluate the effects of the NLRP3 inhibitor MCC950 on the formation of adenomyosis.

RESULTS

Expression of the NLRP3 inflammasome components was elevated in the ectopic or eutopic endometrium of patients with adenomyosis. NLRP3 knockdown inhibited migration, invasion and EMT in endometrial cells and primary endometrial cells (P < 0.0001). MCC950, which blocks the NLRP3 inflammasome, reduced migration and invasion of endometrial cells (P < 0.01) and primary endometrial cells (P < 0.0001) considerably. Importantly, in the mouse model of adenomyosis, MCC950 had a mitigating effect on the severity of adenomyosis (P < 0.01).

CONCLUSIONS

NLRP3 was found to enhance migration, invasion and EMT of human endometrial cells in adenomyosis. Notably, the NLRP3 inhibitor MCC950 reduced migration and invasion of endometrial cells effectively. Furthermore, in the mouse model of adenomyosis, MCC950 exhibited a therapeutic effect by alleviating the severity of adenomyosis.

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

Introduction

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

Methods

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

Results

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

Discussion

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

Evaluation of the therapeutic efficacy of high-intensity focused ultrasound ablation combined with different drugs in the treatment of adenomyosis

OBJECTIVES

To observe the therapeutic efficacy of high-intensity focused ultrasound (HIFU) combined with different pharmacological treatments for adenomyosis.

MATERIALS AND METHODS

A total of 126 patients with adenomyosis who underwent HIFU combined with pharmacological treatment were retrospectively reviewed. Patients were treated with either dienogest (DNG) (Group A, N = 38) or GnRH-a (Group B, N = 88) for three months after HIFU, and received levonorgestrel-releasing intrauterine systems (LNG-IUS) at the end of the third month. Visual Analog Scale (VAS) and Pictorial Blood Loss Assessment Chart (PBAC) scores were used for evaluating symptom improvement.

RESULTS

After propensity score matching (1:2), 38 patients were included in Group A and 76 in Group B. All patients showed significant improvement in VAS and PBAC scores after HIFU, but the PBAC score of Group A was significantly higher than that of patients in Group B at 18 months [11.50 (1.00, 29.50) vs. 0.00 (0.00, 16.50), p < 0.01] and 24 months [4.00 (0.25, 27.75) vs. 0.00 (0.00, 12.75), p = 0.04] after HIFU. Furthermore, patients in Group B had a greater uterine volume reduction at 24 months after HIFU than that of patients in Group A [51.00 (27.00, 62.00) vs. 30.00 (17.00, 42.75, p = 0.02)]. However, the adverse effects in Group A were lower than those in Group B [7 (15.79) vs. 35 (46.05), p < 0.01]. No significant difference was observed in the recurrence rate between the two groups.

CONCLUSIONS

HIFU combined with DNG and LNG-IUS is a safe and effective treatment for patients with adenomyosis.

Adenomyosis: An Update Concerning Diagnosis, Treatment, and Fertility

This review article aims to summarize current tools used in the diagnosis of adenomyosis with relative pharmacological and surgical treatment and to clarify the relative association between adenomyosis and infertility, considering the importance of an accurate diagnosis of this heterogeneous disease. Among different reported concepts, direction invagination of gland cells from the basalis endometrium deep into the myometrium is the most widely accepted opinion on the development of adenomyosis. Adenomyosis has been increasingly identified in young women with pain, AUB, infertility, or no symptoms by using imaging techniques such as transvaginal ultrasound and magnetic resonance. Furthermore, adenomyosis often coexists with other gynecological conditions, such as endometriosis and uterine fibroids, increasing the heterogeneity of available data. However, there is no agreement on the definition and classification of adenomyotic lesions from both the histopathology and the imaging points of view, and diagnosis remains difficult and unclear. A standard, universally accepted classification system needs to be implemented to improve our understanding and inform precise diagnosis of the type of adenomyosis. This could be the key to designing RCT studies and evaluating the impact of adenomyosis on quality of life in terms of menstrual symptoms, fertility, and pregnancy outcome, given the high risk of miscarriage and obstetric complications.

The Impact of Adenomyosis on Pregnancy

Adenomyosis is characterized by ectopic proliferation of endometrial tissue within the myometrium. Histologically, this condition is marked by the presence of islands of benign endometrial glands surrounded by stromal cells. The myometrium appears thinner, and cross-sectional analysis often reveals signs of recent or chronic hemorrhage. The ectopic endometrial tissue may respond to ovarian hormonal stimulation, exhibiting proliferative or secretory changes during the menstrual cycle, potentially leading to bleeding, uterine swelling, and pain. Adenomyosis can appear as either a diffuse or focal condition. It is crucial to understand that adenomyosis involves the infiltration of the endometrium into the myometrium, rather than its displacement. The surgical management of adenomyosis is contingent upon its anatomical extent. The high incidence of the disease and the myths that develop around it increase the need to study its characteristics and its association with pregnancy and potential obstetric complications. These complications often require quick decisions, appropriate diagnosis, and proper counseling. Therefore, knowing the possible risks associated with adenomyosis is key to decision making. Pregnancy has a positive effect on adenomyosis and its painful symptoms. This improvement is not only due to the inhibition of ovulation, which inhibits the bleeding of adenomyotic tissue, but also to the metabolic, hormonal, immunological, and angiogenic changes associated with pregnancy. Adenomyosis affects pregnancy through disturbances of the endocrine system and the body's immune response at both local and systemic levels. It leads to bleeding from the adenomyotic tissue, molecular and functional abnormalities of the ectopic endometrium, abnormal placentation, and destruction of the adenomyotic tissue due to changes in the hormonal environment that characterizes pregnancy. Some of the obstetric complications that occur in women with adenomyosis in pregnancy include miscarriage, preterm delivery, placenta previa, low birth weight for gestational age, obstetric hemorrhage, and the need for cesarean section. These complications are an understudied field and remain unknown to the majority of obstetricians. These pathological conditions pose challenges to both the typical progression of pregnancy and the smooth conduct of labor in affected women. Further multicenter studies are imperative to validate the most suitable method for concluding labor following surgical intervention for adenomyosis.

Surface-Conjugated Galactose on Electrospun Polycaprolactone Nanofibers: An Innovative Scaffold for Uterine Tissue Engineering

The uterus, a vital organ in the female reproductive system, nurtures and supports developing embryos until maturity. This study focuses on addressing uterine related problems by creating a nanofibrous scaffold to regenerate uterine myometrial tissue, closely resembling the native extracellular matrix (ECM) for enhanced efficacy. To achieve this, we utilized polycaprolactone (PCL) as a biomaterial and employed an electrospinning technique to generate PCL nanofibers in both random and aligned orientations. Due to the inherent hydrophobic nature of PCL nanofibers, a two-step wet chemistry surface modification technique is used, involving the conjugation of galactose onto them. Galactose, a lectin-binding sugar, was chosen to enhance the scaffold's hydrophilicity, thereby improving cell adhesion and fostering l-selectin-based interactions between the scaffold and uterine cells. These interactions, in turn, activated uterine fibroblasts, leading to ECM remodeling. The optimized electrospinning process successfully generated random and aligned nanofibers. Subsequent surface modification was carried out, and the modified scaffold was subjected to various physicochemical characterization, such as the ninhydrin assay, enzyme-linked lectin assay techniques that revealed successful galactose conjugation, and mechanical characterization to assess any changes in material bulk properties resulting from the modification. The tensile strength of random galactose-modified PCL fibers reached 0.041 ± 0.01 MPa, outperforming random unmodified PCL fibers (0.026 ± 0.01 MPa), aligned unmodified PCL fibers (0.011 ± 0.001 MPa), and aligned modified PCL fibers (0.016 ± 0.002 MPa). Cytocompatibility studies with human uterine fibroblast cells showed enhanced viability and proliferation on the modified scaffolds. Initial pilot studies were attempted in the current study involving subcutaneous implantation in the dorsal area of Wistar rats to assess biocompatibility and tissue response before proceeding to intrauterine implantation indicated that the modification did not induce adverse inflammation in vivo. In conclusion, our study introduces a surface-modified PCL nanofibrous material for myometrial tissue engineering, offering promise in addressing myometrial damage and advancing uterine health and reproductive well-being.

Overview of crosstalk between stromal and epithelial cells in the pathogenesis of adenomyosis and shared features with deep endometriotic nodules

Since the first description of adenomyosis more than 150 years ago, multiple hypotheses have attempted to explain its pathogenesis. Indeed, research over recent years has greatly enhanced our knowledge of the underlying causes. This has opened up avenues for the development of strategies for both disease prevention and treatment of its main symptoms, such as pelvic pain, heavy menstrual bleeding, and infertility. However, the current means are still largely ineffective, so it is vital that we shed light on the pathways involved. Dysregulated mechanisms and aberrant protein expression have been identified as contributing factors in interactions between endometrial epithelial and stromal cells, ultimately leading to the growth of adenomyotic lesions. These include collective cell migration, epithelial-to-mesenchymal transition, hormonal influence, and signaling from non-coding RNAs and extracellular vesicles. We provide a concise summary of the latest insights into the crosstalk between glands and stroma in ectopic adenomyotic lesion formation. While there is an abundance of literature on similarities between adenomyosis and deep endometriosis, there are insufficient data on the cytochemical, molecular, and pathogenetic mechanisms of these two disorders. However, various shared features, including alterations of cell adhesion molecules, abnormal hormone regulation, and the presence of cancer-driving mutations and epigenetic modifications, have been identified. Nevertheless, the pathogenic mechanisms that contribute to the cause and development of these enigmatic diseases have not been fully elucidated yet.

Endometriosis and Adenomyosis: Modern Concepts of Their Clinical Outcomes, Treatment, and Management

Endometriosis and adenomyosis are complex gynecological conditions characterized by diverse clinical presentations, including superficial peritoneal endometriosis (SPE), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE). The hallmark features of these pathologies involve the manifestation of pain symptoms and infertility, and approximately 30% of patients are asymptomatic. Despite ongoing research, definitive treatments for these conditions remain elusive, and clinical management primarily revolves around medical or surgical interventions. Recent advancements in our understanding of the efficacy of various treatment modalities, including medical therapy and surgical interventions, have provided clinicians with valuable insights into pain relief and fertility preservation. This review aims to provide an updated overview of the latest literature on clinical outcomes, treatment options, and management strategies for different types of endometriosis. By synthesizing the newest available data, this review seeks to inform clinicians and guide decision making based on factors such as patients' symptom severity, childbearing desire, and overall health.

Efficacy of hysteroscopic levonorgestrel‑releasing intrauterine device fixation in the treatment of adenomyosis: A cohort study

The present study aimed to investigate the efficacy of hysteroscopic levonorgestrel-releasing intrauterine device (LNG-IUD) fixation surgery in the treatment of adenomyosis through a cohort study. The cohort study was performed at the Affiliated Jinhua Hospital of Wenzhou Medical University (Jinhua, China). A total of 31 women with adenomyosis were initially recruited from June 2020 to June 2022 and divided into an experimental group and a control group. The experimental group underwent hysteroscopic LNG-IUD fixation surgery and the control group underwent conventional implantation of the levonorgestrel-releasing intrauterine system. The assessed efficacy outcomes included the time of LNG-IUD expulsion, postoperative vaginal bleeding time, dysmenorrhea, and the menstrual blood loss score (MBLS). A total of 31 participants completed the research. The LNG-IUD expulsion rate was 6.25 and 60% (P<0.05) in the experimental and control group, respectively. The LNG-IUD in place time was 20.50 months (Q1, 15.75; Q3, 24.00) in the experimental group and 10.00 months (Q1, 6.50; Q3, 15.00) in the control group (P<0.05); the time of vaginal bleeding after surgery in the experimental and control groups were 12.50 days (9.25, 16.25) and 120.00 days (75.00, 120.00), respectively (P<0.05). Multiple-factor Cox regression analysis revealed that the LNG-IUD expulsion in patients with adenomyosis is associated with the hysteroscopic LNG-IUD fixation surgery [hazard ratio (HR), 1954.09], uterine cavity depth (HR, 16.63), MBLS (HR, 1.14), history of gonadotropin-releasing hormone agonist treatment in the previous 6 months (HR, 2.10), history of vaginal delivery (HR, 1.79) and history of cervical laceration (HR, 3.69). In conclusion, hysteroscopic LNG-IUD fixation reduces the rate of LNG-IUD expulsion, prolongs the time of LNG-IUD in the uterine cavity, reduces the time of postoperative vaginal bleeding, relieves the symptoms of dysmenorrhea and reduces the menstrual volume in the patients with adenomyosis. The present trial was retrospectively registered in the Chinese Clinical Trial Registry on 28th December 2023 (registration no. ChiCTR2300079233).

Long noncoding RNA BMPR1B-AS1 stability regulated by IGF2BP2 affects the decidualization in endometriosis patients through the SMAD1/5/9 pathway

Endometriosis (EMs)-related infertility commonly has decreased endometrial receptivity and normal decidualization is the basis for establishing and maintaining endometrial receptivity. However, the potential molecular regulatory mechanisms of impaired endometrial decidualization in patients with EMs have not been fully clarified. We confirmed the existence of reduced endometrial receptivity in patients with EMs by scanning electron microscopy and quantitative real-time PCR. Here we identified an lncRNA, named BMPR1B-AS1, which is significantly downregulated in eutopic endometrium in EMs patients and plays an essential role in decidual formation. Furthermore, RNA pull-down, mass spectrometry, RNA immunoprecipitation, and rescue analyses revealed that BMPR1B-AS1 positively regulates decidual formation through interaction with the RNA-binding protein insulin-like growth factor 2 mRNA-binding protein 2 (IGF2BP2). Downregulation of IGF2BP2 led to a decreased stability of BMPR1B-AS1 and inhibition of activation of the SMAD1/5/9 pathway, an inhibitory effect which diminished decidualization in human endometrial stromal cells (hESCs) decidualization. In conclusion, our identified a novel regulatory mechanism in which the IGF2BP2-BMPR1B-AS1-SMAD1/5/9 axis plays a key role in the regulation of decidualization, providing insights into the potential link between abnormal decidualization and infertility in patients with EMs, which will be of clinical significance for the management and treatment of infertility in patients with EMs.

The pathogenesis of endometriosis and adenomyosis: insights from single-cell RNA sequencing†

Endometriosis and adenomyosis are two similar gynecological diseases that are characterized by ectopic implantation and the growth of the endometrial tissue. Previous studies have reported that they share a common pathophysiology in some respects, such as a similar cellular composition and resistance to the progestogen of lesions, but their underlying mechanisms remain elusive. Emerging single-cell ribonucleic acid sequencing (scRNA-seq) technologies allow for the dissection of single-cell transcriptome mapping to reveal the etiology of diseases at the level of the individual cell. In this review, we summarized the published findings in research on scRNA-seq regarding the cellular components and molecular profiles of diverse lesions. They show that epithelial cell clusters may be the vital progenitors of endometriosis and adenomyosis. Subclusters of stromal cells, such as endometrial mesenchymal stem cells and fibroblasts, are also involved in the occurrence of endometriosis and adenomyosis, respectively. Moreover, CD8+ T cells, natural killer cells, and macrophages exhibit a deficiency in clearing the ectopic endometrial cells in the immune microenvironment of endometriosis. It seems that the immune responses are activated in adenomyosis. Understanding the immune characteristics of adenomyosis still needs further exploration. Finally, we discuss the application of findings from scRNA-seq for clinical diagnosis and treatment. This review provides fresh insights into the pathogenesis of endometriosis and adenomyosis as well as the therapeutic targets at the cellular level.

Early GnRH-agonist therapy does not negatively impact the endometrial repair process or live birth rate

Study objective

To investigate whether different timings of GnRH-a downregulation affected assisted reproductive outcomes in infertile women with moderate-to-severe intrauterine adhesions (IUAs) accompanied by adenomyosis.

Design

A retrospective case series.

Setting

An assisted reproductive technology center.

Patients

The study reviewed 123 infertile women with moderate-to-severe IUAs accompanied by adenomyosis undergoing their first frozen-thawed embryo transfer (FET) cycles between January 2019 and December 2021.

Measurements and main results

The majority of patients had moderate IUA (n=116, 94.31%). The average Basal uterine volume was 73.58 ± 36.50 cm3. The mean interval from operation to the first downregulation was 21.07 ± 18.02 days (range, 1-79 days). The mean duration of hormone replacement therapy (HRT) was 16.93 ± 6.29 days. The average endometrial thickness on the day before transfer was 10.83 ± 1.75 mm. A total of 70 women achieved clinical pregnancy (56.91%). Perinatal outcomes included live birth (n=47, 67.14%), early miscarriage (n=18, 25.71%), and late miscarriage (n=5, 7.14%). The time interval between uterine operation and the first downregulation was not a significant variable affecting live birth. Maternal age was the only risk factor associated with live birth (OR:0.89; 95% CI: 0.79-0.99, P=0.041).

Conclusions

The earlier initiation of GnRH-a to suppress adenomyosis prior to endometrial preparation for frozen embryo transfer did not negatively impact repair of the endometrium after resection.

[Estrogen, estrogen receptor and miR-21 in adenomyosis: their pathogenic roles and regulatory interactions]

OBJECTIVE

To explore the pathogenic roles of miR-21, estrogen (E2), and estrogen receptor (ER) in adenomyosis.

METHODS

We examined the expression levels of miR-21 in specimens of adenomyotic tissue and benign cervical lesions using qRT-PCR. In primary cultures of cells isolated from the adenomyosis lesions, the effect of ICI82780 (an ER inhibitor) on miR-21 expression levels prior to E2 activation or after E2 deprivation were examined with qRT-PCR. We further assessed the effects of a miR-21 mimic or an inhibitor on proliferation, apoptosis, migration and autophagy of the cells.

RESULTS

The expression level of miR-21 was significantly higher in adenomyosis tissues than in normal myometrium (P < 0.05). In the cells isolated from adenomyosis lesions, miR-21 expression level was significantly higher in E2 activation group than in ER inhibition + E2 activation group and the control group (P < 0.05); miR-21 expression level was significantly lower in cells in E2 deprivation+ER inhibition group than in E2 deprivation group and the control group (P < 0.05). The adenomyosis cells transfected with miR-21 inhibitor showed inhibited proliferation and migration, expansion of mitochondrial endoplasmic reticulum, increased lysosomes, presence of autophagosomes, and increased cell apoptosis, while transfection of the cells with the miR-21 mimic produced the opposite effects.

CONCLUSION

MiR-21 plays an important role in promoting proliferation, migration, and antiapoptosis in adenomyosis cells by altering the cell ultrastructure, which may contribute to early pathogenesis of the disease. In addition to binding with E2, ER can also regulate miR-21 through other pathways to participate in the pathogenesis of adenomyosis, thus having a stronger regulatory effect on miR-21 than E2.

The research advances in Kirsten rat sarcoma viral oncogene homolog (KRAS)-related cancer during 2013 to 2022: a scientometric analysis

Introduction

Cancer represents a significant global public health concern. In recent years, the incidence of cancer has been on the rise worldwide due to various factors, including diet, environment, and an aging population. Simultaneously, advancements in tumor molecular biology and genomics have led to a shift from systemic chemotherapy focused on disease sites and morphopathology towards precise targeted therapy for driver gene mutations. Therefore, we propose a comprehensive review aimed at exploring the research hotspots and directions in the field of Kirsten rat sarcoma viral oncogene homolog (KRAS)-mutant cancers over the past decade, providing valuable insights for cancer treatment strategies. Specifically, we aim to present an intellectual landscape using data obtained from the Web of Science (WoS) regarding KRAS mutation.

Methods

Bibliometrix, VOSviewer, CiteSpace, and HistCite were employed to conduct scientometric analyses on national publications, influential authors, highly cited articles, frequent keywords, etc.

Results

A total of 16,609 publications met the screening criteria and exhibited a consistent annual growth trend overall. Among 102 countries/regions, the United States occupied the vast majority share of the published volume. The journal Oncotarget had the highest circulation among all scientific publications. Moreover, the most seminal articles in this field primarily focus on biology and targeted therapies, with overcoming drug resistance being identified as a future research direction.

Conclusion

The findings of the thematic analysis indicate that KRAS mutation in lung cancer, the prognosis following B-Raf proto-oncogene, serine/threonine kinase (BRAF) or rat sarcoma (RAS) mutations, and anti-epidermal growth factor receptor (EGFR)-related lung cancer are the significant hotspots in the given field. Considering the significant advancements made in direct targeting drugs like sotorasib, it is anticipated that interest in cancers associated with KRAS mutations will remain steadfast.

mtDNA regulates cGAS-STING signaling pathway in adenomyosis

In various hyperproliferative disorders, damaged mitochondria can release mitochondrial DNA (mtDNA) into the cytoplasm, activating the cGAS-STING signaling pathway and subsequent immune imbalances. Our previous research has demonstrated that hypoxia plays a role in the development of adenomyosis (AM) by inducing mitochondrial dysfunction. However, the precise involvement of the cGAS-STING signaling pathway and mtDNA in AM remains unclear. Therefore, this study aims to investigate the relationship between mtDNA secretion, changes in the cGAS-STING signaling pathway, and the abnormal cellular proliferation observed in AM. We found the cGAS, STING, TBK1, p-TBK1, IRF3, and p-IRF3 proteins levels were significantly elevated in the tissues of patients with AM compared to the control group. Additionally, there was an increase in the expression of the pro-inflammatory cytokines IL-6 and IFN-α in the AM tissues. Hypoxia-induced an increase in the proliferation and migration abilities of endometrial stromal cells (ESCs), accompanied by the activation of the cGAS-STING signaling pathway and elevated levels of IFN-α. Furthermore, hypoxia promoted the leakage of mtDNA into the cytoplasm in AM ESCs, and the deletion of mtDNA reduced the activation of the cGAS-STING pathway. Moreover, knockdown of the STING gene inhibited the expression of TBK1, p-TBK1, IRF3, and p-IRF3 and suppressed the secretion of the inflammatory cytokines IL-6 and IFN-α. Furthermore, the migration and invasion abilities of AM ESCs were significantly diminished after STING knockdown. These findings provide valuable insights into the role of mtDNA release and the cGAS-STING signaling pathway in the pathogenesis of AM.

The adenomyosis/endometriosis IVF patient - call for clinical focus

Endometriosis and adenomyosis are distinct clinical conditions that carry the same pathophysiological features. In recent years the clinical focus on assisted reproductive technology patients with either condition (E/A) has increased, in the recognition that this subgroup of patients might need special attention to obtain reproductive success. Endometriosis and adenomyosis are characterized by a disruption of progesterone and oestrogen signalling pathways, resulting in local oestrogen dominance and progesterone resistance at the receptor level. Recent scientific evidence suggests that the endometrial progesterone receptor resistance encountered in E/A patients can be overcome by a freeze-all policy, followed by down-regulating circulating oestradiol concentrations prior to frozen embryo transfer (FET), in combination with an increase in exogenous luteal phase progesterone supplementation in hormonal replacement therapy (HRT) FET cycles. Specifically, for adenomyosis patients who do not respond to gonadotrophin-releasing hormone agonist down-regulation in terms of a decrease in circulating oestradiol concentrations, a small case series has suggested that the addition of an aromatase inhibitor for 21 days prior to HRT-FET is a valid option. Endometriosis and adenomyosis are hormonally active diseases, which need to be treated by controlling local hyperoestrogenism and progesterone resistance. Based on physiology and recent preliminary clinical data, the authors of this opinion paper wish to stimulate discussion and spark interest in research in E/A patients.

Impact of adenomyosis on in vitro fertilization outcomes in women undergoing donor oocyte transfers: a prospective observational study

OBJECTIVE

To prospectively examine the association between adenomyosis type, location, and severity with reproductive outcomes in patients undergoing single embryo transfer (SET) with embryos derived from donor oocytes.

DESIGN

A prospective observational cohort study.

SETTING

University-affiliated in vitro fertilization center.

PATIENTS

Patients with infertility with (n = 114) and without (n = 114) adenomyosis who received their first donor oocyte transfer between January 2019 and January 2023 were included in this study.

INTERVENTIONS

Adenomyosis was confirmed with the presence of at least one direct feature visualized by 2- or 3-dimensional transvaginal ultrasound and classified according to type (diffuse or focal), localization (inner or outer myometrium and/or junctional zone [JZ]), and uterine extension (mild, moderate, or severe). After an artificial or natural endometrial preparation cycle, patients underwent SET in the blastocyst stage.

MAIN OUTCOME MEASURES

The primary outcome was the implantation rate. The secondary outcomes were the clinical pregnancy, live birth, and miscarriage rates after SET.

RESULTS

The presence of adenomyosis did not significantly affect the implantation, clinical pregnancy, or live birth rates. However, women with adenomyosis had a significantly higher miscarriage rate than those without adenomyosis (35.4% vs. 18.1%, respectively). The multivariate analysis assessed possible risk factors for each clinical outcome considered in the study and showed that adenomyosis affected the risk of miscarriage. Specifically, transvaginal sonography detection of adenomyosis in the JZ was associated with over threefold higher relative risk of miscarriage (relative risk [RR], 3.28; 95% confidence interval [CI], 1.38-7.78). Conversely, adenomyosis features detected exclusively in the outer myometrium were associated with a higher ongoing pregnancy rate (RR, 0.30; 95% CI, 0.13-0.72). Diffuse adenomyosis in the JZ and severe adenomyosis increased the relative risk of miscarriage two-fold (RR, 2.29; 95% CI, 1.22-4.30 and RR, 2.20; 95% CI, 1.19-4.04, respectively).

CONCLUSIONS

This study demonstrated that although adenomyosis did not significantly reduce the odds of implantation, the direct signs of adenomyosis in the JZ and disease severity are significant risk factors for miscarriage in patients receiving donor oocyte transfers. This study highlights the importance of thorough ultrasound examination and detailed adenomyosis classification in the assessment and management of patients with infertility.

A method for isolating and culturing ectopic epithelial and stromal cells to study human adenomyosis

PURPOSE

Although adenomyosis is a common and benign gynecological disease, the specific pathogenesis of this condition is yet to be fully elucidated. It is difficult to culture primary cells of the ectopic endometrial epithelia and stroma from human adenomyosis lesions. Most of the previous of studies on adenomyosis were based on primary eutopic endometrium cells. However, as yet, no efficient protocols have been developed for the isolation, culture or purification of primary ectopic epithelial and stromal cells from human adenomyosis lesions. Therefore, the present study aimed to develop an efficient protocol for the isolation and culture of primary ectopic epithelial and stromal cells from human adenomyosis lesions.

METHODS

In the present study, we aimed to obtain ectopic endometrium tissue from human adenomyosis foci and use a simple and operable type I collagenase digestion method for primary culture. Cells were isolated by sterile cell strainer filtration and flow cytometry was performed to identify, purify, and evaluate the viability of isolated ectopic endometrial cells.

RESULTS

Using our method, we successfully isolated and cultured highly purified and active ectopic endometrial epithelial and stromal cells from human adenomyosis foci. Ep-CAM was expressed in ectopic epithelial cells of human adenomyosis with a purity of 93.74% and a viability of 80.58%. In addition, CD10 were robustly expressed by ectopic stromal cells in human adenomyosis. Cellular purity and viability were determined to be 96.37 and 93.49%, respectively.

CONCLUSION

Our method provides a new experimental model for studying the molecular pathogenesis of human adenomyosis.

Correlation between the Systemic Immunoinflammatory Index and Platelet-Lymphocyte Ratio in Patients with Adenomyosis

Background

The chronic inflammatory immune response is a significant factor in the pathogenesis of benign gynecological diseases. The systemic immunoinflammatory index (SII) and the platelet-to-lymphocyte ratio (PLR) are commonly available biomarkers of inflammation. However, evidence of the relationship between SII and PLR in patients with adenomyosis is limited. This study aimed to investigate the relationship between SII and PLR in patients with adenomyosis.

Methods

This cross-sectional study included 483 patients with adenomyosis who were first diagnosed at our institution between January 2019 and December 2021. Basic patient clinical information and inflammatory factors were collected for univariate analysis, smoothed curve fitting, and multivariate segmented linear regression.

Results

The results of the univariate analysis showed a significant positive correlation between PLR levels and SII (P < 0.001). In addition, a nonlinear relationship between PLR and SII was tested using a smoothed curve fit after adjusting for potential confounders. Multiple segmented linear regression models showed a significant relationship between SII and PLR in both SII < 1,326.47 (β 0.14, 95% CI: 0.12, 0.16; P < 0.0001) and >1,326.47 (β 0.02, 95% CI: -0.01, 0.05; P = 0.2461).

Conclusions

In conclusion, this study showed a nonlinear relationship between SII and PLR in patients with uterine adenomyosis. An increase in serum PLR levels correlates with an increase in SII before SII levels reach an inflection point.

Magnetic Resonance Imaging-Based Classifications for Symptom of Adenomyosis

OBJECTIVES

The aim of the study was to identify an optimal magnetic resonance imaging (MRI)-based classification for the severity of adenomyosis and explore the factors associated with disease severity (dysmenorrhea or menorrhagia).

DESIGN

and Participants: Several classifications based on MRI have been proposed, and their phenotypes are reported to be associated with the severity of adenomyosis. However, a consensus classification based on MRI findings has not yet been reached. Our study was designed to retrospectively analyze data from a cohort of patients in the Affiliated Nanchong Central Hospital of North Sichuan Medical College from June 2017 to December 2021 before focused ultrasound ablation surgery (FUAS), identify the optimal classification of adenomyosis severity from different classification criteria, and explore factors associated with the presence of symptoms.

METHODS

The proportions of disease severity among different classification groups were compared to obtain the one generating the most considerable χ2 value, which was identified as the optimal classification for informing disease severity. A logistic regression model was constructed to explore factors associated with disease severity.

RESULTS

Classification of Kobayashi H (classification 4) concerning the affected areas and size (volumes of lesions) was recognized as the optimal one, which identified dysmenorrhea (χ2 = 18.550, p value = 0.002) and menorrhagia (χ2 = 15.060, p value = 0.010) secondary to adenomyosis. For volumes of the uterine wall <2/3, the dysmenorrhea rate in subtype 4 was higher than that in subtype 1 (χ2 = 4.114, p value = 0.043), and the dysmenorrhea rate in subtype 5 was higher than that in subtype 2 (χ2 = 4.357, p value = 0.037). Age (odds ratio [OR] = 0.899, 95% confidence interval [CI] = 0.810∼0.997, p value = 0.044) and external phenotype (OR = 3.588, 95% CI = 1.018∼12.643, p value = 0.047) were associated with dysmenorrhea. Concerning volumes of the uterine wall ≥2/3, the menorrhagia rate in subtype 3 remarkably increased compared with that in subtype 6 (χ2 = 9.776, p value = 0.002), and internal phenotype was identified as an independent factor associated with menorrhagia (OR = 1.706, 95% CI = 1.131∼2.573, p value = 0.011).

LIMITATIONS

Patients in our study were all included before FUAS, which limited our result interpretation for the general patient population.

CONCLUSIONS

MRI-based classification 4 is identified as an optimal classification for informing the severity of adenomyosis. The phenotype of classification is the main characteristic associated with disease severity.

CA125-Associated Activated Partial Thromboplastin Time and Thrombin Time Decrease in Patients with Adenomyosis

Objective

Adenomyosis patients are in a hypercoagulable state, and studies have shown that carbohydrate antigen125 (CA125) may relate to the hypercoagulability and thrombosis of patients with adenomyosis, but there is still a lack of clarity regarding the changes in CA125-related coagulation indicators. This study was to explore the changes and influencing factors of CA125-related coagulation parameters in patients with adenomyosis.

Methods

Retrospective observational study conducted on 200 patients with adenomyosis (AM group), 240 patients with uterine leiomyoma (LM group) and 81 patients with cervical intraepithelial neoplasia (CIN)-III (control group), of which the coagulation parameters were detected by clinical blood sample collection and statistical method analysis and informed consent was obtained.

Results

The level of CA125 in the AM group was significantly higher than that in the LM group and control group. However, thrombin time (TT) shortened in the AM group when compared with the LM and control group. Activated partial thromboplastin time (APTT) in the AM group was shorter than in the control group. Multivariate logistic regression analysis found that adenomyosis was associated with CA125 level (OR=323.860, 95% CI 90.424-1159.924, P<0.001), APTT (OR=1.295, 95% CI 1.050-1.598, P=0.016), TT (OR=0.642, 95% CI 0.439-0.938, P=0.022), menorrhagia (OR=7.363, 95% CI 2.544-21.315, P<0.001), dysmenorrhea (OR=22.590, 95% CI 8.185-62.347, P<0.001). Correlation analysis revealed that APTT (r= -0.207) and TT (r = -0.174) were negatively correlated with the level of CA125.

Conclusion

The shortening of CA125-related APTT and TT indicates that it is meaningful to detect coagulation parameters of patients with elevated CA125 levels early, dysmenorrhea and menorrhagia, and maybe further discover the hypercoagulability and prevent the occurrence of thrombus in adenomyosis.

Paradoxical role of phosphorylated STAT3 in normal fertility and the pathogenesis of adenomyosis and endometriosis†

Signal transducer and activator of transcription 3 (STAT3), when phosphorylated at tyrosine 705, plays an important role in endometrial stromal cell decidualization and the receptivity of the endometrial epithelium during embryo implantation. However, the function of phosphorylated STAT3 (p-STAT3) in normal uterine receptivity is distinct from that in adenomyosis and endometriosis. In normal pregnancy, STAT3 phosphorylation in the endometrial epithelium determines the success of embryo implantation by regulating uterine receptivity. Additionally, p-STAT3 promotes cellular proliferation and differentiation during endometrial decidualization, which is crucial for embryonic development. In contrast, excessive STAT3 phosphorylation occurs in adenomyosis and endometriosis, which may lead to disease progression. Therefore, achieving a delicate balance in STAT3 activation is crucial. This review aimed to focus on the current understanding and knowledge gaps regarding the control of p-STAT3 activity in normal and pathological endometrial processes. This topic is important because precise control of p-STAT3 production could alleviate the symptoms of adenomyosis and endometriosis, improve endometrial receptivity, and potentially mitigate infertility without compromising normal fertility processes.

Proposal for targeted, neo-evolutionary-oriented secondary prevention of early-onset endometriosis and adenomyosis. Part II: medical interventions

According to consistent epidemiological data, the slope of the incidence curve of endometriosis rises rapidly and sharply around the age of 25 years. The delay in diagnosis is generally reported to be between 5 and 8 years in adult women, but it appears to be over 10 years in adolescents. If this is true, the actual onset of endometriosis in many young women would be chronologically placed in the early postmenarchal years. Ovulation and menstruation are inflammatory events that, when occurring repeatedly for years, may theoretically favour the early development of endometriosis and adenomyosis. Moreover, repeated acute dysmenorrhoea episodes after menarche may not only be an indicator of ensuing endometriosis or adenomyosis, but may also promote the transition from acute to chronic pelvic pain through central sensitization mechanisms, as well as the onset of chronic overlapping pain conditions. Therefore, secondary prevention aimed at reducing suffering, limiting lesion progression, and preserving future reproductive potential should be focused on the age group that could benefit most from the intervention, i.e. severely symptomatic adolescents. Early-onset endometriosis and adenomyosis should be promptly suspected even when physical and ultrasound findings are negative, and long-term ovulatory suppression may be established until conception seeking. As nowadays this could mean using hormonal therapies for several years, drug safety evaluation is crucial. In adolescents without recognized major contraindications to oestrogens, the use of very low-dose combined oral contraceptives is associated with a marginal increase in the individual absolute risk of thromboembolic events. Oral contraceptives containing oestradiol instead of ethinyl oestradiol may further limit such risk. Oral, subcutaneous, and intramuscular progestogens do not increase the thromboembolic risk, but may interfere with attainment of peak bone mass in young women. Levonorgestrel-releasing intra-uterine devices may be a safe alternative for adolescents, as amenorrhoea is frequently induced without suppression of the ovarian activity. With regard to oncological risk, the net effect of long-term oestrogen-progestogen combinations use is a small reduction in overall cancer risk. Whether surgery should be considered the first-line approach in young women with chronic pelvic pain symptoms seems questionable. Especially when large endometriomas or infiltrating lesions are not detected at pelvic imaging, laparoscopy should be reserved to adolescents who refuse hormonal treatments or in whom first-line medications are not effective, not tolerated, or contraindicated. Diagnostic and therapeutic algorithms, including self-reported outcome measures, for young individuals with a clinical suspicion of early-onset endometriosis or adenomyosis are proposed.

Proposal for targeted, neo-evolutionary-oriented, secondary prevention of early-onset endometriosis and adenomyosis. Part I: pathogenic aspects

The potential for repeated ovulation and menstruation is thought to have provided a Darwinian advantage during the Palaeolithic. Reproductive conditions remained relatively stable until the pre-industrial era, characterized by late menarche, very young age at first birth, multiple pregnancies, and prolonged periods of lactational amenorrhoea. For hundreds of thousands of years, menstruators experienced few ovulatory cycles, even though they were genetically adapted to ovulate and menstruate every month. In the post-industrial era, the age at menarche gradually declined, the age at first birth progressively increased, and breastfeeding became optional and often of short duration. This created a mismatch between genetic adaptation and socio-environmental evolution, so that what was initially a probable reproductive advantage subsequently contributed to increased susceptibility to diseases associated with lifetime oestrogen exposure, such as ovarian, endometrial and breast cancer and, hypothetically, also those associated with the number of ovulatory menstruations, such as endometriosis and adenomyosis. The incidence of endometriosis shows a steep and progressive increase around the age of 25 years, but given the consistently reported delay in diagnosis, the actual incidence curve should be shifted to the left, supporting the possibility that the disease has its roots in adolescence. This raises the question of whether, from an evolutionary point of view, anovulation and amenorrhoea should not still be considered the physiological state, especially in the postmenarchal period. However, an increase in the frequency of endometriosis in recent decades has not been demonstrated, although this deserves further epidemiological investigation. In addition, as endometriosis occurs in a minority of individuals exposed to retrograde menstruation, other important pathogenic factors should be scrutinised. Research should be resumed to explore in more detail the transtubal reflux of not only blood, but also endometrial cells, and whether they are systematically present in the peritoneal fluid after menstruation. If repetitive ovulatory menstruation during the early reproductive years is shown to increase the risk of endometriosis and adenomyosis development and progression in susceptible individuals, hormonal interventions could be used as secondary prevention in symptomatic adolescents.