Pathologic findings from the Maryland Women's Health Study: practice patterns in the diagnosis of adenomyosis

MRI of Adenomyosis: Where Are We Today?

Purpose of Review: The purpose of this review is to (i) summarize the current literature regarding the role of magnetic resonance imaging (MRI) in diagnosing adenomyosis, (ii) examine how to integrate MRI phenotypes with clinical symptomatology and histological findings, (iii) review recent advances including proposed MRI classifications, (iv) discuss challenges and pitfalls of diagnosing adenomyosis, and (v) outline the future role of MRI in promoting a better understanding of the pathogenesis, diagnosis, and treatment options for patients with uterine adenomyosis. Recent Findings: Recent advances and the widespread use of MRI have provided new insights into adenomyosis and the range of imaging phenotypes encountered in this disorder. Summary: Direct and indirect MRI features allow for accurate non-invasive diagnosis of adenomyosis. Adenomyosis is a complex and poorly understood disorder with variable MRI phenotypes that may be correlated with different pathogeneses, clinical presentations, and patient outcomes. MRI is useful for the assessment of the extent of findings, to evaluate for concomitant gynecological conditions, and potentially can help with the selection and implementation of therapeutic options. Nevertheless, important gaps in knowledge remain. This is in part due to the lack of standardized criteria for reporting resulting in heterogeneous and conflicting data in the literature. Thus, there is an urgent need for a unified MRI reporting system incorporating standardized terminology for diagnosing adenomyosis and defining the various phenotypes.

In Search of an Imaging Classification of Adenomyosis: A Role for Elastography?

Adenomyosis is a complex and poorly understood gynecological disease. It used to be diagnosed exclusively by histology after hysterectomy; today its diagnosis is carried out increasingly by imaging techniques, including transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI). However, the lack of a consensus on a classification system hampers relating imaging findings with disease severity or with the histopathological features of the disease, making it difficult to properly inform patients and clinicians regarding prognosis and appropriate management, as well as to compare different studies. Capitalizing on our grasp of key features of lesional natural history, here we propose adding elastographic findings into a new imaging classification of adenomyosis, incorporating affected area, pattern, the stiffest value of adenomyotic lesions as well as the neighboring tissues, and other pathologies. We argue that the tissue stiffness as measured by elastography, which has a wider dynamic detection range, quantitates a fundamental biologic property that directs cell function and fate in tissues, and correlates with the extent of lesional fibrosis, a proxy for lesional "age" known to correlate with vascularity and hormonal receptor activity. With this new addition, we believe that the resulting classification system could better inform patients and clinicians regarding prognosis and the most appropriate treatment modality, thus filling a void.

Unveiling the Pathogenesis of Adenomyosis through Animal Models

Background: Adenomyosis is a common gynecological disorder traditionally viewed as “elusive”. Several excellent review papers have been published fairly recently on its pathogenesis, and several theories have been proposed. However, the falsifiability, explanatory power, and predictivity of these theories are often overlooked. Since adenomyosis can occur spontaneously in rodents and many other species, the animal models may help us unveil the pathogenesis of adenomyosis. This review critically tallies experimentally induced models published so far, with a particular focus on their relevance to epidemiological findings, their possible mechanisms of action, and their explanatory and predictive power. Methods: PubMed was exhaustively searched using the phrase “adenomyosis and animal model”, “adenomyosis and experimental model”, “adenomyosis and mouse”, and “adenomyosis and rat”, and the resultant papers were retrieved, carefully read, and the resultant information distilled. All the retrieved papers were then reviewed in a narrative manner. Results: Among all published animal models of adenomyosis, the mouse model of adenomyosis induced by endometrial–myometrial interface disruption (EMID) seems to satisfy the requirements of falsifiability and has the predictive capability and also Hill’s causality criteria. Other theories only partially satisfy Hill’s criteria of causality. In particular, animal models of adenomyosis induced by hyperestrogenism, hyperprolactinemia, or long-term exposure to progestogens without much epidemiological documentation and adenomyosis is usually not the exclusive uterine pathology consequent to those induction procedures. Regardless, uterine disruption appears to be a necessary but not sufficient condition for causing adenomyosis. Conclusions: EMID is, however, unlikely the sole cause for adenomyosis. Future studies, including animal studies, are warranted to understand how and why in utero and/or prenatal exposure to elevated levels of estrogen or estrogenic compounds increases the risk of developing adenomyosis in adulthood, to elucidate whether prolactin plays any role in its pathogenesis, and to identify sufficient condition(s) that cause adenomyosis.

Classifications of Adenomyosis and Correlation of Phenotypes in Imaging and Histopathology to Clinical Outcomes: a Review

Purpose of Review

To provide an update on published classification and reporting systems for adenomyosis. There is an urgent need to standardize reporting of various phenotypes of adenomyosis into a validated and globally recognized system. This can be used to examine the nature and severity of adenomyosis symptoms and inform the design, evaluation, and implementation of appropriate treatment options.

Recent Findings

In recent years, several new proposals for adenomyosis classification have emerged. Most are MRI-based and include features such as uterine size, junctional zone thickness, size and location of the lesions, and distribution patterns. To date, none of those proposals has been validated. Only one recent classification based on transvaginal ultrasound was validated for interobserver congruence and correlated to clinical findings. However, the differentiation of diffuse and focal adenomyosis still lacks consensus. In addition, only a few authors advocated imaging-based definitions.

Summary

There is a need for one or a combination of a classification and reporting system for adenomyosis. To date, there is no widely accepted and validated system.

Novel microarchitecture of human endometrial glands: implications in endometrial regeneration and pathologies

BACKGROUND

Human endometrium remains a poorly understood tissue of the female reproductive tract. The superficial endometrial functionalis, the site of embryo implantation, is repeatedly shed with menstruation, and the stem cell-rich deeper basalis is postulated to be responsible for the regeneration of the functionalis. Two recent manuscripts have demonstrated the 3D architecture of endometrial glands. These manuscripts have challenged and replaced the prevailing concept that these glands end in blind pouches in the basalis layer that contain stem cells in crypts, as in the intestinal mucosa, providing a new paradigm for endometrial glandular anatomy. This necessitates re-evaluation of the available evidence on human endometrial regeneration in both health and disease in the context of this previously unknown endometrial glandular arrangement.

OBJECTIVE AND RATIONALE

The aim of this review is to determine if the recently discovered glandular arrangement provides plausible explanations for previously unanswered questions related to human endometrial biology. Specifically, it will focus on re-appraising the theories related to endometrial regeneration, location of stem/progenitor cells and endometrial pathologies in the context of this recently unravelled endometrial glandular organization.

SEARCH METHODS

An extensive literature search was conducted from inception to April 2021 using multiple databases, including PubMed/Web of Science/EMBASE/Scopus, to select studies using keywords applied to endometrial glandular anatomy and regeneration, and the references included in selected publications were also screened. All relevant publications were included.

OUTCOMES

The human endometrial glands have a unique and complex architecture; branched basalis glands proceed in a horizontal course adjacent to the myometrium, as opposed to the non-branching, vertically coiled functionalis glands, which run parallel to each other as is observed in intestinal crypts. This complex network of mycelium-like, interconnected basalis glands is demonstrated to contain endometrial epithelial stem cells giving rise to single, non-branching functionalis glands. Several previous studies that have tried to confirm the existence of epithelial stem cells have used methodologies that prevent sampling of the stem cell-rich basalis. More recent findings have provided insight into the efficient regeneration of the human endometrium, which is preferentially evolved in humans and menstruating upper-order primates.

WIDER IMPLICATIONS

The unique physiological organization of the human endometrial glandular element, its relevance to stem cell activity and scarless endometrial regeneration will inform reproductive biologists and clinicians to direct their future research to determine disease-specific alterations in glandular anatomy in a variety of endometrial pathological conditions.

Classifying Adenomyosis: Progress and Challenges

Classically, the diagnosis of adenomyosis relied on histological examination of uteri following hysterectomy and classifications focused on the depth of endometrial invasion within the myometrium. There remain uncertainties around the cut-off point for the histological diagnosis. Imaging-based diagnosis enables recognition of the condition in women not undergoing surgery and facilitates the assessment of the extent of adenomyosis within the whole uterus, as well as of affections of the uterovesical pouch and of the pouch of Douglas. In this article, we explore the diagnostic uncertainties, the need to produce a classification of the condition and the challenges towards that goal. A distinction should be drawn between disease mapping and a classification that may link histological or image-based features with clinical characteristics, or with pathophysiology. An agreed system for reporting adenomyotic lesions may enable comparisons of research studies and thus contribute towards an informed classification. To this aim, we outline the features of the condition and explore the characteristics that are considered when producing a taxonomy. These include the latest proposal for subdivision of adenomyosis into an internal and an external variant. We also explore the uncertainties linked to classifying involvement of the uterovesical pouch, the pouch of Douglas and lesions in the outer myometrium. The limitations of currently available evidence suggest that agreement on a hypothesis to underpin a classification is unlikely at present. Therefore, current efforts will probably remain focused on disease mapping.

[Endometriosis and adenomyosis]

Diffuse adenomyosis, focal adenomyosis, ovarian endometrioma, superficial endometriosis and deep infiltrating adenomyosis are all defined by the presence of an endometrioid tissue in an ectopic location that is at distance from the endometrium. Although frequently associated, these lesions represent different clinico-pathological entities that the pathologist should recognized. Herein, we review the clinical and pathological features of these entities, as well as related current physiopathological understandings and differential diagnoses that could be raised by some morphological variants. The statistical association between endometriosis and several ovarian tumors, mainly endometrioid and clear cell carcinomas and seromucinous borderline tumors is well established and we present some molecular and morphological features that support this transformation potential.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diagnosing adenomyosis: an integrated clinical and imaging approach

BACKGROUND

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

OBJECTIVE AND RATIONALE

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

SEARCH METHODS

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

OUTCOMES

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

WIDER IMPLICATIONS

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

Epidemiology of Adenomyosis

Adenomyosis, characterized by the presence of endometrial glands and stroma within the myometrium, can have a substantial impact on the quality of women's lives. Despite this, the epidemiologic research on this condition lags considerably behind that of other noncancerous reproductive health conditions. The lack of progress and knowledge is due in part to the challenges in designing valid epidemiologic studies, since the diagnosis of adenomyosis historically has been limited to the examination of uterine specimens from hysterectomy. This review describes the available data on the frequency of this condition and the epidemiologic investigation thus far into the risk factors for disease-highlighting the methodologic and inference challenges primarily around study sample selection. We conclude with providing recommendations for approaches to future epidemiologic study that capitalize on the advancements in imaging technology to detect adenomyosis and provide a fuller picture of the occurrence and risk factors for disease.

Pathology and Pathogenesis of Adenomyosis

Adenomyosis represents a unique pathophysiological condition in which normal-appearing endometrial mucosa resides within myometrium and is thus protected from menstrual shedding. The resulting ectopic presence of endometrial tissue composed of glands and stroma is thought to affect normal contractile function and peristalsis of uterine smooth muscle, causing menometrorrhagia, infertility, and adverse obstetric outcomes. Since the first description of adenomyosis more than 150 years ago, pathologists have studied this lesion by examining tissue specimens, and have proposed multiple explanations to account for its pathogenesis. However, as compared with endometriosis, progress of adenomyosis research has been, at best, incremental mainly due to the lack of standardized protocols in sampling tissue and a lack of consensus diagnostic criteria in pathology practice. Despite these limitations, recent advances in revealing the detailed anatomy and biology of eutopic endometrium offer an unprecedented opportunity to study this common but relatively understudied disorder. Here, we briefly summarize the pathological aspects of adenomyosis from an historical background, and discuss conventional morphology and recent tissue-based molecular studies with a special emphasis on elucidating its tissue of origin from a pathologist's perspective. We also discuss unmet needs in pathology studies that would be important for advancing adenomyosis research.

Role of Hormones in Common Benign Uterine Lesions: Endometrial Polyps, Leiomyomas, and Adenomyosis

Leiomyoma, adenomyosis, and endometrial polyps are benign uterine disorders which seem to develop in the context of hormonal imbalances, due to steroid hormones, estrogen and progesterone, in association with various factors ranging from genetic factors to modifiable lifestyle factors. A growing body of evidence suggests that those hormones and their receptors are key modulators in the genesis and the growth of those pathologic entities. Further studies are required to understand their involvement in the pathogenesis of those lesions and their link to other factors such as extracellular matrix components, growth factors, chemokines, cytokines, and tissue repair mechanisms.

Adenomyotic glands are highly related to endometrial glands

RESEARCH QUESTION

How closely related are adenomyotic and endometrial glands?

DESIGN

In this study, the mRNA and protein database www.proteinatlas.org was searched for proteins expressed predominantly in the endometrial glands. Specificity was tested with tissue microarrays. Biopsy specimens of endometrial, adenomyotic tissue, or both, were collected after surgery from 21 women without endometriosis, 20 women with endometriosis, 18 women with adenomyosis together with endometriosis and 12 women with adenomyosis alone. Tissue expression was analysed by immunohistochemistry.

RESULTS

Two proteins were identified: calcyphosine (CAPS), and msh homeobox 1 (MSX1). A high abundance and good specificity in endometrial glands were found. Both proteins, CAPS and MSX1, showed a high specificity for endometrium and are both localized in the luminal cells and epithelial cells of the glandular and adenomyotic glands. No significant differences were found between CAPS- and MSX1-positive endometrial glands between cases with and without endometriosis. Also, no cycle-specific different expression was found. Furthermore, a close relationship between the adenomyotic glands and the endometrial glands for CAPS (range 63.0-98.3%) and for MSX1 (range 87.1-99.3%) could be demonstrated. Only 11.2% and 6.8% negative glands for CAPS and MSX1 were identified in all tissues from all patients, respectively; none were negative for both proteins.

CONCLUSIONS

Taken together, our results show that the protein expression pattern of adenomyosis is nearly identical to those of the endometrium with and without endometriosis, thus suggesting endometrial glands as the main source for adenomyotic glands.

Classification and Reporting Systems for Adenomyosis

OBJECTIVE

To conduct a review of the available histologic and image-based classification systems to determine which of these systems, if any, provide clinical utility for prognosis or the selection of appropriate therapeutic interventions.

DATA SOURCES

PubMed in addition to the bibliographies of identified publications.

METHODS OF STUDY SELECTION

One investigator searched PubMed using Medical Subject Headings terms that included "Adenomyosis," "Classification," "Ultrasound Classification," "MRI Classification," and "Diagnosis," TABULATION, INTEGRATION AND RESULTS: Search results were tabulated in a Microsoft Excel workbook that facilitated the identification of duplicate entries. Publications were allocated into separate categories that included histopathologic, ultrasound, and MRI classifications. Identified systems associated with clinical outcomes were separately tabulated. Abstracts of 1669 articles were reviewed and 278 were identified for review of full text. Twenty-five were considered potentially relevant from the PubMed review and an additional 17 were found in bibliographies. In the 42 full-text articles that were reviewed in detail, 9 histologic classifications were identified, 4 of which were accompanied by an attempt at clinical correlation, 1 of which described a correlation with the outcome of medical, procedural, or surgical intervention. There were 9 image-based reporting or classification systems, 2 using transvaginal ultrasound and 7 using MRI, 3 of which included correlations with intervention outcomes, although these were surrogate (imaging) and not clinical outcomes.

CONCLUSION

There is inconsistency in histopathologic definitions, and there is no uniformly accepted or validated system of image-based reporting or classification that can inform clinical decision making. There exists a need for harmonized classification systems for both ultrasound and MRI that agree with the histopathologic features of the disorder.

Clinical Manifestations Of Adenomyosis Patients With Or Without Pain Symptoms

Purpose

Our study aims to investigate the distribution of pain symptoms and the association between pain symptoms and clinical parameters in patients with adenomyosis.

Patients and methods

The clinical and pathological data of 291 patients diagnosed with adenomyosis in the Obstetrics and Gynecology Department of Peking Union Medical College Hospital from March 2012 to September 2015 were collected, and analyzed in regard to the pain symptoms.

Results

The median age at disease onset was 34 years. 71.8% of the patients had pain symptoms (pain group) and 28.2% had no pain symptoms (painless group). Patients with symptoms accompanied by dysmenorrhea accounted for 68%, among which 30.3% were mild, 36.9% were moderate, and 32.8% severe, while 56.1% presented with progressive pain. Through comparison, significant differences were identified between the pain and painless groups with regard to age at diagnosis (P=0.009), age at onset of disease (P=0.008), and level of pre-surgical CA125 (P<0.001), as well as proportion of patients with rectal irritation (P=0.008), elevated CA125 level (P<0.001), thickened myometrial layer (P<0.001) and concurrent endometriosis (P=0.001). In the multivariable analysis, an elevated level of pre-surgical CA125 (P<0.001) and thickened posterior myometrial layer (P=0.023) were both independent risk factors for the morbidity of pain symptoms. Similar results except for the difference in rectal irritation were noticed when we made further comparison between the dysmenorrhea and non-dysmenorrhea groups in adenomyosis patients.

Conclusion

Our research analyzes the clinical features related to pain symptoms in patients with adenomyosis, which may provide clues for the possible presurgical diagnosis of adenomyosis, as well as references for pain management of adenomyosis.

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

STUDY OBJECTIVE

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

DESIGN

This is a multicenter, observational, prospective study.

SETTING

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

PATIENTS

A total of 108 patients with ultrasonographic signs of adenomyosis.

INTERVENTIONS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSION

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

Adenomyosis As a Confounder to Accurate Endometrial Cancer Staging

The coexistence of endometrial adenocarcinoma and adenomyosis in the same uterus is a common phenomenon. In many of such affected patients foci of adenomyosis could also be colonized by adenocarcinoma. The various permutations arising from these scenarios pose preoperative imaging and postoperative pathologic staging challenges. This article aims to raise awareness of these staging issues and lists some of the relevant practical approaches. Adenomyosis reduces the accuracy of magnetic resonance imaging in assessing the depth of invasion as it reduces the contrast between the endometrial cancer adenomyosis-involved myometrium. The article also offers an alternate argument for staging cancers where myoinvasion is found deep in the myometrium, arising from cancer-positive adenomyotic foci when the surface tumor is either limited to the endometrium or to the inner half of myometrium.

Gonadotrophin-releasing hormone agonist combined with high-intensity focused ultrasound ablation for adenomyosis: a clinical study

OBJECTIVES

This study was to investigate the clinical efficacy of a gonadotrophin-releasing hormone agonist (GnRH-a) combined with high-intensity focused ultrasound (HIFU) ablation treatment for adenomyosis.

DESIGN

A non-randomized prospective study.

SETTING

Gynaecological Minimally Invasive Centre in a single hospital.

POPULATION

Patients with adenomyosis.

METHODS

Seventy-nine patients with adenomyosis were enrolled, including 55 patients in the control group treated with only HIFU and 24 patients in the study group treated with GnRH-a combined with HIFU. All the patients follow up 6 months after the HIFU procedure. The related parameters in the two groups were assessed before and 3 months as well as 6 months after treatment including serum levels of tumor marker and cytokine, volumes of uterine, adenomyotic lesion, and menstrual blood, as well as dysmenorrheal scores.

MAIN OUTCOME MEASURES

Differences between the group treated with HIFU alone and the group treated with GnRH-a combined with HIFU.

RESULTS

Before HIFU treatment, no significant difference was observed in serum levels of CA125, CA19-9, and interleukin-6 (IL-6), the volumes of uterine, adenomyotic lesion, and menstrual blood, as well as dysmenorrhea scores between the two groups. (P > 0.05). The serum CA125 levels significantly decreased in both groups after HIFU, but the serum CA125 levels in the study group were still significantly lower than those in the control group (P < 0.05). The volume of uterine and adenomyotic lesion significantly decreased in both groups after HIFU procedure, and decreased even more in the study group 3 and 6 months after treatment (P < 0.05). Dysmenorrhea scores and menstruation volumes significantly decreased in both groups after HIFU treatment. Moreover in the study group were significantly lower than those in the control group after 3 and 6 months (P < 0.05). No significant difference was observed in the rate of adverse effects between the two groups.

CONCLUSIONS

The short-term follow-up results indicate that the combination of GnRH-a and HIFU treatment significantly decreased serum CA125 levels, volumes of uterine, adenomyotic lesion and menstrual blood, as well as dysmenorrhea scores, and improved the clinical outcomes compared with the HIFU ablation alone in patients with adenomyosis. However, the further follow-up is needed to explore the long-term effects.

TWEETABLE ABSTRACT

A combination of GnRH-a with HIFU in the treatment of adenomyosis significantly decreased serum CA125 levels, uterine and adenomyotic lesion volumes, dysmenorrhea scores, and menstrual blood volumes.

Use of Uterine Characteristics to Improve Fertility-Sparing Diagnosis of Adenomyosis

Objective: To describe patient demographics, determine accuracy of clinical diagnosis, and evaluate reliability of laparoscopic uterine characteristics in the diagnosis of adenomyosis. Materials and Methods: Enrollment included 117 patients undergoing laparoscopic hysterectomy for benign indications. Intraoperatively, the attending surgeon predicted uterine weight; evaluated the presence of fibroids; and commented on the uterus' shape, color, and consistency while probing it with a blunt instrument. A prediction was also made about whether final pathology would reveal adenomyosis. Standardized video recordings were obtained at the start of the case. Each video was viewed retrospectively twice by three expert surgeons in a blinded fashion. Uterine characteristics were reported again with a prediction of whether or not there would be a pathologic diagnosis of adenomyosis. These data were used to calculate inter-and intrarater reliability of diagnosis. Results: Women with adenomyosis were more likely to complain of midline pain as opposed to lateral or diffuse pain (p = 0.048) with no difference in the timing of the pain (p = 0.404), compared to patients without adenomyosis. Uterine tenderness on examination was not an accurate predictor of adenomyosis (p = 0.566). Preoperative diagnosis of adenomyosis by clinicians was poor, with an accuracy rate of 51.7%. None of the intraoperative uterine characteristics were significant for predicting adenomyosis on final pathology, nor was any combination of the features (p = 0.546). Retrospective video reviews failed to reveal any uterine characteristics that generated consistent inter- or intrarater reliability (Krippendorff's α < 0.7) in making the diagnosis of adenomyosis. Conclusions: Clinical and video diagnosis of adenomyosis have low accuracy with no uterine characteristics consistently or reliably predicting adenomyosis on final pathology. (J GYNECOL SURG 34:183).

The Investigation and Management of Adenomyosis in Women Who Wish to Improve or Preserve Fertility

The management of adenomyosis remains a great challenge to practicing gynaecologists. Until recently, hysterectomy has been the only definitive treatment in women who have completed child bearing. A number of nonsurgical and minimally invasive, fertility-sparing surgical treatment options have recently been developed. This review focuses on three aspects of management, namely, (1) newly introduced nonsurgical treatments; (2) management strategies of reproductive failures associated with adenomyosis; and (3) surgical approaches to the management of cystic adenomyoma.

Pain is an Independent Risk Factor for Failed Global Endometrial Ablation

STUDY OBJECTIVE

To determine whether pain, as part of an indication for global endometrial ablation, is an independent risk factor for failure.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Academic-affiliated community hospital.

PATIENTS

Women undergoing global endometrial ablation with radiofrequency ablation (RFA), hydrothermablation (HTA), or uterine balloon ablation (UBA) between January 2003 and December 2015.

INTERVENTIONS

Procedure failure was defined as subsequent hysterectomy after the index ablation.

MEASUREMENTS AND MAIN RESULTS

A total of 5818 women who underwent an endometrial ablation were identified, including 3706 with RFA (63.7%), 1786 with HTA (30.7%), and 326 with UBA (5.6%). Of the 5818 ablations, 437 (7.5%) involved pain (i.e., pelvic pain, dysmenorrhea, dyspareunia, lower abdominal pain, endometriosis, or adenomyosis) before ablation, along with abnormal uterine bleeding. Pain as part of the preoperative diagnoses before endometrial ablation was a significant risk factor for subsequent hysterectomy compared with all other diagnoses (19.2% vs 13.5%; p = .001). Consistent with previous studies, women who underwent ablation at an older age were less likely to fail, which held true even when one of the indications for ablation was related to pain (odds ratio, 0.96/year; 95% confidence interval, 0.95-0.97). When the pathology reports of women who underwent a hysterectomy were examined, women in the pain group had lower rates of adenomyosis than women without pain (38.1% vs 50.1%; p = .04). However, there was a trend toward a higher rate of endometriosis on pathology reports (14.3% vs 8.7%; p = .09) and even higher rates of visualized endometriosis identified by operative reports in women who had pain before their ablation (42.9% vs 15.8%; p < .001). Patients who had pain before their ablation were less likely to have myomas/polyps (p = .01).

CONCLUSION

Pelvic pain before global endometrial ablation is an independent risk factor for failure.

The Effect of Adenomyosis in Myometrial Invasion and Overall Survival in Endometrial Cancer

Aim

The aim of this study was to evaluate whether adenomyosis had an effect on myometrial tumor invasion, stage of the disease, and survival in endometrial cancer.

Methods

Endometrial cancer patients encountered between 2007 and 2016 were identified from pathology records. Patients who underwent suboptimal surgical or medical treatment or with insufficient clinical or surgical data were excluded. Patients diagnosed as having concurrent adenomyosis constituted the study group. Control group patients were randomly selected in a paired design according to the tumor grades in the study group, and for each tumor grade, 4 times as many as patients were included. Tumor stage, histologic type and grade, myometrial invasion, lymphovascular space invasion, presence and location of the adenomyosis in myometrial wall, distance from endometrial line, tumor in adenomyosis, adjuvant treatment, and relapse were primary outcomes.

Age, body mass index, medical comorbidities, and type of operation were also recorded. Univariate and multivariate Cox proportional hazards regression models were performed for overall survival.

Results

Of those 1242 endometrial cancer patients, 80 with concurrent adenomyosis were identified and compared with 320 patients without adenomyosis following a paired selection based on tumor grade. Higher rates of myometrial invasion, lymphovascular space invasion, tumor diameter, and adjuvant treatments were found in the nonadenomyosis group compared with adenomyosis group (P ≤ 0.001). In patients with adenomyosis, rates of early-stage disease and overall survival were significantly higher compared with the control group (P = 0.001 and 0.01, respectively).

Conclusions

Our results showed that adenomyosis is significantly associated with lower stage in endometrial cancer that may suggest a possible limiting effect on endometrial cancer spread. In addition, despite similar rates in disease-free survival and endometrial cancer–related death, overall survival rate was significantly higher in the presence of adenomyosis and might be considered as a good prognostic factor for endometrial cancer.

MRI for adenomyosis: a pictorial review

Adenomyosis is defined as the presence of ectopic endometrial glands and stroma within the myometrium. It is a disease of the inner myometrium and results from infiltration of the basal endometrium into the underlying myometrium. Transvaginal ultrasonography (TVUS) and magnetic resonance imaging (MRI) are the main radiologic tools for this condition. A thickness of the junctional zone of at least 12 mm is the most frequent MRI criterion in establishing the presence of adenomyosis. Adenomyosis can appear as a diffuse or focal form. Adenomyosis is often associated with hormone-dependent lesions such as leiomyoma, deep pelvic endometriosis and endometrial hyperplasia/polyps. Herein, we illustrate the MRI findings of adenomyosis and associated conditions, focusing on their imaging pitfalls.

TEACHING POINTS

• Adenomyosis is defined as the presence of ectopic endometrium within the myometrium. • MRI is an accurate tool for the diagnosis of adenomyosis and associated conditions. • Adenomyosis can be diffuse or focal. • The most established MRI finding is thickening of junctional zone exceeding 12 mm. • High-signal intensity myometrial foci on T2- or T1-weighted images are also characteristic.

A comparison of the cost-utility of ultrasound-guided high-intensity focused ultrasound and hysterectomy for adenomyosis: a retrospective study

OBJECTIVE

To evaluate cost-effectiveness of ultrasound-guided high-intensity focused ultrasound (USgHIFU) and open hysterectomy for adenomyosis.

DESIGN

A retrospective analysis.

SETTING

Gynaecological department in a single centre in China.

POPULATION

Patients with symptomatic adenomyosis.

MAIN OUTCOME MEASURES

Cost difference between patients with adenomyosis treated with USgHIFU and open hysterectomy.

METHODS

Three hundred and sixty-eight patients with adenomyosis were retrospectively reviewed. Among them, 302 patients were treated with USgHIFU and 66 patients with open hysterectomy. All of them had 1-, 3-, 6- and 12-month follow ups. The patients' quality of life (QOL) was evaluated and the utility scores were obtained from a rating scale to conduct a cost-utility analysis (CUA).

RESULTS

No significant differences were found at any follow-up time point in the QOL between the two groups (P > 0.05). After treatment, the QOL scores significantly increased in both groups (P < 0.05): the quality adjusted life year (QALY) for patients treated with USgHIFU was USUS$5256.48, whereas it was USUS$7510.03 for patients treated with open hysterectomy. Both incremental cost and sensitivity analysis showed that USgHIFU was less costly than open hysterectomy.

CONCLUSIONS

The QOL of patients with adenomyosis can be significantly improved by either USgHIFU or open hysterectomy, but USgHIFU is less costly.

TWEETABLE ABSTRACT

USgHIFU can safely be used to treat patients with adenomyosis and significantly improved the quality of life of patients after treatment. The cost of USgHIFU is less than that of surgical treatment.

Coexistence of adenomyosis uteri and endometrial cancer is associated with an improved prognosis compared with endometrial cancer only

The present study aimed to identify differences in protein expression in cases of endometrioid endometrial cancer (EEC) with and without coexisting adenomyosis uteri (AM), and to evaluate the histopathological and prognostic distinctions. The total cohort included 22 patients in Group A (patients with concomitant AM and EEC) and 35 patients in Group B (patients affected only by EEC). Evaluation of the following factors was performed: Tumour grade, International Federation of Gynaecology and Obstetrics (FIGO) stage, survival, and expression of estrogen receptor β (ERβ), glycodelin and inhibin βB. Group A (AM and EEC) was associated with a lower tumour grade (G1, 90.9 vs. 45.7%; P=0.001) and a lower FIGO stage (FIGO stage I, 100 vs. 80%; P=0.002) compared with Group B (EEC only). In the survival analysis, Group A was associated with a significantly higher 5-year survival rate (95 vs. 82%; P=0.024) than Group B. In addition, the expression of ERβ in Group A was significantly higher (P<0.001), whereas the expression of glycodelin is significantly lower (P=0.028), compared with Group B. The results of the present study indicate that the presence of AM in cases of EEC may be a positive prognostic factor.

Late-onset endometrial ablation failure

Endometrial ablation, first reported in the 19th century, has gained wide acceptance in the gynecologic community as an important tool for the management of abnormal uterine bleeding when medical management has been unsuccessful or contraindicated. The introduction of global endometrial ablation (GEA) devices beginning in 1997 has provided unsurpassed safety addressing many of the concerns associated with their resectoscopic predecessors. As of this writing the GEA market has surpassed a half-million devices in the United States per annum and has an expected compound annual growth rate (CAGR) projected to be 5.5% from 2016 to 2024.

While the short term safety and efficacy of these devices has been reported in numerous clinical trials we only recently are becoming aware of the high incidence of late-onset endometrial ablation failures (LOEAFs) associated with these procedures. Currently, about a quarter of women who undergo a GEA procedure will eventually require a hysterectomy while an unknown number have less than satisfactory results. In order to reduce these suboptimal outcomes physicians must better understand the etiology and risk factors that predispose a patient toward the development of LOEAF as well as current knowledge of patient and procedure selection for EA as well as treatment options for these delayed complications.

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Over 500,000 endometrial ablations (EAs) are performed in the U. S. each year.

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Late-onset endometrial ablation failures (LOEAFs) are the most common complication of EA.

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25% of women who undergo EA will require hysterectomy within 5 years.

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Reducing the incidence of LOEAFs requires improved patient selection for EA.

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Ultrasound-guided reoperative hysteroscopic surgery (UGRHS) reduces the need hysterectomy following LOEAF.

Coexistence of adenomyosis and endometrioid endometrial cancer: Role in surgical guidance and prognosis estimation

The aim of the current study was to diagnose the concomitant presence of adenomyosis (AM) in endometrioid endometrial cancer (EEC) in order to evaluate its value as an oncological prognostic marker. A retrospective analysis of 289 patients diagnosed with EEC who underwent total hysterectomy, bilateral salpingo-oophorectomy and pelvic-lymphadenectomy was conducted. The total cohort included 37 patients in Group A (those with concomitant AM and EEC) and 252 patients in Group B (those affected only by EEC). The following factors were evaluated: Presence or absence of AM, tumor grade, depth of myometrial invasion, tumor size, lymphovascular space involvement, lymph node status, peritoneal cytology, concomitant detection of endometrial atypical-hyperplasia or polypoid endometrial features and tumor stage according to the International Federation of Gynecology and Obstetrics (FIGO) classification. Uterine examination of different sections of uterine cervix, corpus, myomas and cervical or endometrial polyps was performed. The diagnosis of AM was confirmed when the distance between the lower border of the endometrium and the foci of the endometrial glands and stroma was >2.5 mm. Parametric and nonparametric statistical tests were performed when possible; continuous variables were analyzed using a Student's t-test, and categorical variables were analyzed by the χ² test or Fisher's exact test. The association between FIGO stage and group was determined to be significant: 83.8% of Group A patients were categorized as FIGO stage I, vs. 68.7% of Group B patients. In addition, Group A was associated with lower grades in FIGO stage, myometrial invasion, lymphovascular space involvement, lymph node involvement and tumor size. The findings suggest that the intraoperative evaluation of the presence of AM in patients with EEC may aid surgeons in estimating oncological risk and in selecting the most appropriate surgical treatment.

Adenomyosis: a life-cycle approach

The life-cycle approach to endometriosis highlighted unexpected features of the condition; the same approach was therefore applied to gain insight into the clinical features of adenomyosis and to draw a comparison with endometriosis. This is possible today thanks to new imaging techniques enabling non-invasive diagnosis of adenomyosis. The specificity and sensitivity of magnetic resonance imaging and transvaginal ultrasound remain uncertain. Unlike endometriosis, little information is available on the presence of classic adenomyosis in adolescents, except for rare cystic forms that may not represent the true disease. Adenomyosis is most likely to affect adult women, although most reported incidences are still based on post-hysterectomy studies, and are affected by diligence in histopathologic diagnosis and the adopted cut-off point. The traditionally accepted associations of adult adenomyosis, such as multiparity, a link to infertility and its effect on pregnancy are uncertain. Active adenomyosis has been found in pre- and peri-menopausal women and in postmenopausal women receiving tamoxifen. In conclusion, major diagnostic limitations and the systematic bias of hysterectomy make it difficult to draw firm conclusions from existing evidence. In addition, no information is available on the natural history of adenomyosis and no study has systematically evaluated its existence in adolescents.

Patterns of myoinvasion in endometrial adenocarcinoma: recognition and implications

Endometrial endometrioid adenocarcinoma (EEC) is the most common malignancy of the female genital tract, partly attributable to chronic estrogen exposure secondary to increased obesity rates. Tumor stage, which in most cases is based on depth of invasion (DOI), is of critical importance in determining if additional treatment is needed. However, the array of invasive morphologies within the spectrum of ECC can make the determination of DOI difficult. Several morphologic patterns of invasion have been described, including diffusely infiltrating irregular glands, "broad front" (or pushing border), adenoma malignum, adenomyosis-like, and microcystic, elongated, and fragmented glands. EEC may often contain a mixture of invasive patterns, which can further complicate evaluation of these common tumors. Recognition of these patterns may lead to more accurate staging, but perhaps more importantly, some patterns may be associated with adverse prognostic features. The purpose of this review is to highlight the various invasive patterns of EEC and note their unique pitfalls and prognostic implications in an effort to improve staging accuracy and treatment and follow-up for the thousands of women affected by this disease each year.

Does the presence of adenomyosis and lymphovascular space invasion affect lymph node status in patients with endometrioid adenocarcinoma of the endometrium?

OBJECTIVE

We sought to determine the prevalence of adenomyosis and assess its effect on lymph node status in endometrioid adenocarcinoma of the endometrium (EAC).

STUDY DESIGN

Hysterectomy specimens from a single institution were reviewed for the presence of adenomyosis, lymphovascular space invasion (LVSI), tumor grade, histology, and lymph node status. Standard statistical analysis was used to compare variables.

RESULTS

Adenomyosis was present in 42% of total and 66% of malignant hysterectomy specimens (P = .009). Adenomyosis was most commonly associated with EAC histology (P = .023). LVSI was found to be an independent predictor of lymph node metastasis in EAC patients without adenomyosis, but not in those with coexisting adenomyosis (odds ratio, 58.7; P = .03; and odds ratio, 4.98; P = .15; respectively).

CONCLUSION

Adenomyosis was associated with a lower risk of lymph node metastasis in EAC patients with LVSI. Further studies are needed to investigate the role of adenomyosis in lymphatic tumor infiltration.

Adenomyosis: Not such an elusive diagnosis any longer

Adenomyosis has been an elusive diagnosis until recently due to the need for a histological confirmation of diagnosis post-hysterectomy. This commentary focuses on the role of non-invasive imaging techniques that have become available for use in the diagnosis of adenomyosis in women with an intact uterus. These include magnetic resonance imaging (MRI) and transvaginal ultrasound (TVS). With improvements in imaging modalities it has now become feasible to establish a diagnosis of adenomyosis without hysterectomy, to exclude additional pathology and to institute conservative symptomatic treatment and monitoring.

Diagnosis, laparoscopic management, and histopathologic findings of juvenile cystic adenomyoma: a review of nine cases. Fertil Steril. 2010;94:862-868. [PMID: 19539912 DOI: 10.1016/j.fertnstert.2009.05.010]

OBJECTIVE

To define diagnostic criteria for juvenile cystic adenomyoma (JCA), describe the histologic features of the condition and evaluate laparoscopic excision for treating associated dysmenorrhea and pelvic pain.

DESIGN

Prospective long-term follow-up study.

SETTING

University-affiliated hospital.

PATIENT(S)

Nine consecutive patients with JCA.

INTERVENTION(S)

Patients meeting the diagnostic criteria for JCA underwent laparoscopic enucleation of the lesion. The severity of dysmenorrhea was evaluated before surgery and every 6 months after surgery. Five patients underwent second-look laparoscopy (SLL) 6 months after surgery.

MAIN OUTCOME MEASURE(S)

Relief of dysmenorrhea as measured by a visual analog scale, postoperative healing at SLL, and subsequent pregnancy when desired by the patient.

RESULT(S)

Laparoscopic enucleation of the cystic adenomyoma resulted in a statistically and clinically significant reduction in dysmenorrhea and improved chronic pelvic pain. Neither cystic adenomyoma nor severe dysmenorrhea recurred during the follow-up period. Adhesions were minimal at SLL. Two of the three patients who desired pregnancy conceived after surgery. The histologic findings of the JCA lesion and adenomyosis were similar, and the endometrial glands and stroma infiltrating the surrounding myometrium in all patients were consistent with the appearance of adenomyosis.

CONCLUSION(S)

We defined the diagnostic criteria for JCA, and demonstrated significant improvement of dysmenorrhea after laparoscopic excision of the lesion.

Vascular endothelial growth factor gene polymorphisms are associated with the risk of developing adenomyosis

Vascular endothelial growth factor (VEGF), a major mediator of angiogenesis and vascular permeability, may play a key role in the development of adenomyosis. The aim of this study was to investigate whether these four VEGF polymorphisms (-2578C/A, -1154G/A, -460C/T, and +936C/T) were associated with the risk of adenomyosis development. Genotypes were determined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay in 174 adenomyosis patients and 199 frequency-matched control women. There were significant differences between patients and control group in allele frequencies and genotype distributions of the -2578C/A polymorphisms (P = 0.010 and 0.044, respectively). Compared with the C/C genotype, the A/A + C/A genotype could significantly modify the risk of developing adenomyosis [odds ratio (OR) = 0.64, 95% confidence interval (CI) = 0.42-0.97]. For the -1154G/A polymorphism, the allele frequencies and genotype distributions in patient group were significant different from those of the controls (P = 0.001 and 0.007, respectively). Compared with the G/G genotype, the A/A + G/A genotype could significantly decrease the risk of developing adenomyosis (OR = 0.51, 95% CI = 0.33-0.80). However, the genotype distributions and allele frequencies of the -460C/T and +936C/T polymorphisms did not significantly differ between controls and patients (all P value > 0.05). The haplotype analysis suggested that the TGA (VEGF -460/-1154/-2578) and CGA haplotypes exhibited a significant decrease in the risk of developing adenomyosis compared with the haplotype of TGC (OR = 0.64, 95% CI = 0.41-1.00; OR = 0.44, 95% CI = 0.21-0.93, respectively). The study indicated that the -2578A or -1154A allele of VEGF gene could significantly decrease the risk of adenomyosis and might be potentially protective factors for adenomyosis development.

Endometrioid adenocarcinoma arising in adenomyosis: elucidation by periodic magnetic resonance imaging evaluations

There are several case reports of adenocarcinomas developing within adenomyosis. However, there is no report demonstrating the natural course from adenomyosis to adenocarcinoma. We report a patient (a 41-year-old Japanese woman) who was observed every 6 months after being diagnosed with adenomyosis at our University Hospital. Although she went through menopause at age 51, she occasionally complained subsequently of abnormal genital bleeding. Eleven years after the initial diagnosis, endometrial cytology revealed the presence of malignant cells. Pelvic magnetic resonance imaging (MRI) demonstrated replacement of the adenomyotic lesion by a poorly demarcated lesion, compared to the findings on prior MRI. Consequently, we performed a modified radical hysterectomy and pelvic lymph node dissection, under a presumptive diagnosis of adenocarcinoma arising in adenomyosis. Histological diagnosis revealed an endometrioid adenocarcinoma (G3) transformed from adenomyotic epithelium, which was classified, according to the International Federation of Gynecology and Obstetrics, as stage Ic, pT1cN0M0. In this patient, periodic MRI evaluations, in conjunction with pathological examination, identified the transformation from adenomyosis to adenocarcinoma.

Polymorphisms in the matrix metalloproteinase-2 and tissue inhibitor of metalloproteinase-2 and the risk of human adenomyosis

The matrix metalloproteinases (MMPs) and tissue inhibitor of metalloproteinases (TIMPs) may contribute to the development of adenomyosis. The aim of the present study was to investigate whether three single nucleotide polymorphisms (SNPs) in the promoter regions of MMP-2 (-1306C/T and -735C/T) and TIMP-2 (-418G/C) genes were related to the risk of adenomyosis development. Genotypes were determined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) assay in 180 adenomyosis patients and 324 frequency-matched control women in a Chinese population. There were significant differences in allele frequencies and genotype distributions of the MMP-2 -1306C/T polymorphism between patients and control women (P = 0.01 and 0.04, respectively). The frequency of C allele in patients (92.2%) was significantly higher than in the controls (87.0%) (P = 0.01). Compared with the C/T+T/T genotypes, the C/C genotype could significantly increase the risk of adenomyosis development, with an odds ratio of 1.83 (95% CI = 1.13-2.96). However, no statistically significant difference was found in allele frequencies and genotype distributions of MMP-2 -735C/T and TIMP-2 -418G/C SNPs between the two groups (all P values > 0.05). Two polymorphisms of MMP-2 displayed linkage disequilibrium (D' = 0.74). The haplotype analysis suggested no significant association of four haplotypes with the risk of adenomyosis development. Our results indicated an association of MMP-2 -1306C/T polymorphism with the risk of adenomyosis, suggesting a potential role in adenomyosis development in North Chinese women.