Hormonal contraceptives and endometriosis/adenomyosis

Ultrasound and single-port laparoscopic-guided microwave ablation of abdominal wall endometriosis lesions: A single-center observational study

INTRODUCTION

Raising the temperature of abdominal wall endometriosis lesions contributes to an effective ablation; however, providing sufficient protection to the surrounding tissues remains a challenge. In this study, we aimed to combine ultrasound and single-port laparoscopic images to not only achieve complete ablation of abdominal wall endometriosis lesions but also protect surrounding tissues from damage. The adverse events and complications were Common Terminology Criteria for Adverse Events grade 1 or Society of Interventional Radiology classification grade A.

MATERIAL AND METHODS

This historical study included 30 patients with abdominal wall endometriosis who underwent ultrasound and single-port laparoscopic-guided microwave ablation at the Ultrasonography and Gynecology Department of the Wuhan Central Hospital between October 2017 and February 2022. Ultrasonography and magnetic resonance imaging were used to evaluate the number, size, and depth of the lesions. Pain levels were assessed using a visual analog scale. Subsequently, ultrasound and single-port laparoscopic-guided microwave ablation of the lesions was performed, and patients were followed up to monitor the lesion volume and pain.

RESULTS

One patient experienced an intra-abdominal wall burn that was detected by single-port laparoscopy, and ablation was stopped immediately. No other complications were recorded. Following surgery, the lesion volume decreased and was lower than the preoperative lesion volume at 1 year postoperatively (1.6 ± 1.3 vs. 4.0 ± 3.6 cm3; p < 0.05). Visual analog scale scores revealed that, compared with preoperative levels, pain was reduced significantly at all postoperative time points (p < 0.01). The recurrence rate was 16.7% (5/30).

CONCLUSIONS

The addition of single-port laparoscopy to ultrasound-guided microwave ablation may allow greater protection of the surrounding tissues, particularly in cases involving deep lesions, and may, therefore, represent a promising clinical treatment strategy.

Is high-intensity focused ultrasound a magical solution to endometriosis? A systematic review

Background

Endometriosis presents a significant challenge in gynecological endocrinology, affecting approximately 1 in 10 women of reproductive age. Abdominal wall endometriosis (AWE) and rectosigmoid deep infiltrating endometriosis (DIE) pose unique clinical complexities. High-intensity focused ultrasound (HIFU) has emerged as a novel alternative for treating these conditions, offering a noninvasive option with potential therapeutic benefits.

Methods

A systematic review was conducted following PRISMA guidelines to investigate the safety and efficacy of HIFU therapy for AWE and rectosigmoid DIE. The literature search encompassed databases from inception to January 20, 2024. Eligible studies included observational studies, case reports, and clinical trials evaluating HIFU treatment for endometriosis. Data extraction and risk of bias assessment were performed following established protocols.

Results

Fourteen studies were included, comprising 330 patients with AWE and 28 patients with rectosigmoid DIE. HIFU treatment demonstrated significant efficacy, with many patients experiencing complete remission, and clinical effectiveness. Reductions in lesion volume posttreatment were consistent across studies. However, safety concerns were noted, including pain at the treatment site, hematuria, and skin burns. Adverse effects underscored the importance of careful patient selection and monitoring during HIFU therapy.

Conclusion

HIFU therapy shows promise as a noninvasive approach for managing AWE and rectosigmoid DIE. While efficacy outcomes are encouraging, safety considerations warrant attention. Further research, particularly randomized controlled trials with larger sample sizes, is needed to validate findings and optimize treatment protocols.

Safety and efficacy of microwave ablation for abdominal wall endometriosis: A retrospective study

Objectives

This retrospective study aimed to evaluate the safety and feasibility of ultrasound-guided microwave ablation in the treatment of abdominal wall endometriosis (AWE).

Background

AWE is a rare form of endometriosis that often results in cyclic abdominal pain. The current treatment algorithm for AWE is not well established. Microwave ablation technology is a promising new thermal ablation technique for treating AWE.

Methods

This was a retrospective study of nine women with pathologically proven endometriosis of the abdominal wall. All patients were treated with ultrasound-guided microwave ablation. Grey-scale and color Doppler flow ultrasonography, contrast-enhanced ultrasonography, and MRI were used to observe the lesions before and after treatment. The complications, pain relief, AWE lesion volume, and volume reduction rate were recorded 12 months after treatment to evaluate the treatment efficacy. Complications were classified according to the Common Terminology Criteria for Adverse Events and the Society of Interventional Radiology classification system.

Results

Contrast-enhanced ultrasound showed that all lesions underwent successful treatment with microwave ablation. The average initial nodule volume was 7.11 ± 5.75 cm³, which decreased significantly to 1.85 ± 1.02 cm³ at the 12-month follow-up with a mean volume reduction rate of 68.77 ± 12.50%. Periodic abdominal incision pain disappeared at 1 month after treatment in all nine patients. The adverse events and complications were Common Terminology Criteria for Adverse Events grade 1 or Society of Interventional Radiology classification grade A.

Conclusions

Ultrasound-guided microwave ablation is a safe and effective technique for the treatment of AWE, and further study is warranted.

Pharmaceuticals targeting signaling pathways of endometriosis as potential new medical treatment: A review

Endometriosis (EM) is defined as endometrial tissues found outside the uterus. Growth and development of endometriotic cells in ectopic sites can be promoted via multiple pathways, including MAPK/MEK/ERK, PI3K/Akt/mTOR, NF-κB, Rho/ROCK, reactive oxidative stress, tumor necrosis factor, transforming growth factor-β, Wnt/β-catenin, vascular endothelial growth factor, estrogen, and cytokines. The underlying pathophysiological mechanisms include proliferation, apoptosis, autophagy, migration, invasion, fibrosis, angiogenesis, oxidative stress, inflammation, and immune escape. Current medical treatments for EM are mainly hormonal and symptomatic, and thus the development of new, effective, and safe pharmaceuticals targeting specific molecular and signaling pathways is needed. Here, we systematically reviewed the literature focused on pharmaceuticals that specifically target the molecular and signaling pathways involved in the pathophysiology of EM. Potential drug targets, their upstream and downstream molecules with key aberrant signaling, and the regulatory mechanisms promoting the growth and development of endometriotic cells and tissues were discussed. Hormonal pharmaceuticals, including melatonin, exerts proapoptotic via regulating matrix metallopeptidase activity while nonhormonal pharmaceutical sorafenib exerts antiproliferative effect via MAPK/ERK pathway and antiangiogenesis activity via VEGF/VEGFR pathway. N-acetyl cysteine, curcumin, and ginsenoside exert antioxidant and anti-inflammatory effects via radical scavenging activity. Natural products have high efficacy with minimal side effects; for example, resveratrol and epigallocatechin gallate have multiple targets and provide synergistic efficacy to resolve the complexity of the pathophysiology of EM, showing promising efficacy in treating EM. Although new medical treatments are currently being developed, more detailed pharmacological studies and large sample size clinical trials are needed to confirm the efficacy and safety of these treatments in the near future.

Ultrasound-guided high-intensity focused ultrasound treatment for abdominal wall endometriosis: a retrospective study

OBJECTIVE

To evaluate the safety and efficacy of ultrasound-guided high-intensity focused ultrasound (USgHIFU) for treating abdominal wall endometrioses (AWE).

DESIGN

A retrospective study.

SETTING

Department of Obstetrics and Gynaecology in China.

POPULATION

Patients with abdominal wall endometriosis.

METHODS

From August 2010 to April 2014, 32 patients with AWE were treated with USgHIFU in our hospital. USgHIFU treatment was performed with the Model JC-200 High Intensity Focused Ultrasound Tumor Therapeutic System. The symptom relief and the adverse effects were evaluated after USgHIFU ablation.

MAIN OUTCOME MEASURES

USgHIFU as a new treatment option for patients with AWE.

RESULTS

Contrast-enhanced ultrasound showed that all lesions were successfully ablated with USgHIFU. The follow-up results showed that the average volume of AWE lesions at 6 months after USgHIFU was significantly smaller than that before treatment (2.80 ± 0.12 versus 1.33 ± 0.31 cm³ ). The pain scores at 6 months after treatment were significantly lower than those before treatment (6.80 ± 2.64 versus 1.80 ± 0.3). The non-perfused volume (indicative of successful ablation) was measured in all patients immediately after treatment, ranging from 0.9 to 2.1 cm³ (median: 1.6 cm³ ), and the fractional ablation ranged from 87% to 100% (median: 94%). Local oedema was observed in these patients, lasting for 1-3 days only. No severe complications occurred during the follow-up period.

CONCLUSIONS

Based on our study, USgHIFU ablation is a safe and effective method for treating AWE.

TWEETABLE ABSTRACT

As a non-invasive treatment technique, HIFU could be used to treat abdominal wall endometriosis.

Abdominal wall endometriosis treatment by ultrasound-guided high-intensity focused ultrasound ablation: a case report

Abdominal wall endometriosis (AWE) occurs in about 0.1% of people with endometriosis, and is often diagnosed postoperatively. Surgical resection is generally used to treat AWE. We successfully treated AWE with ultrasound-guided high-intensity focused ultrasound therapy (USgHIFU). A 37-year-old Korean female presented with a palpable subcutaneous nodule associated with cyclic pain and swelling during menstruation. She was recommended surgical excision three months ago. She had a history of laparoscopic surgery for endometriosis 4 years ago and was interested in less invasive methods of treatment. The 0.9 cm painful nodule was observed as a low-echoic shadow in transabdominal ultrasonography and as an iso-signal in T1 MRI images. USgHIFU treatment was performed under light sedation and completed when the hyperechoic area covered the entire lesion. HIFU treatment was effective without any postoperative complications such as blisters or skin burns. The lesion showed changes in hyper-intensity signal on T1 MRI images. Physical examination showed absence of pain or tenderness and three months later, the painful nodule shrunk, and the menstrual cyclic pain associated with the nodule disappeared. In conclusion, USgHIFU may represent an effective therapy for AWE.

Current and Future Medical Treatment of Adenomyosis

Adenomyosis is a benign gynecological disorder associated with abnormal uterine bleeding, dysmenorrhea, dyspareunia and infertility, requiring a life-long management plan through medical or surgical treatment. The choice depends on woman's age, reproductive status and clinical symptoms. However, until now no drug labelled for adenomyosis is available; thus, the present review will focus on medical treatments currently used for adenomyosis and those in development.

Adenomyosis may be considered a sex steroid hormone-related disorder associated with an intense inflammatory process. The use of gonadotropin-releasing hormone agonists (GnRH-a) for treating adenomyosis is described blocking the hypothalamic-pituitary-gonadal axis; however, it has long been associated with frequent and intolerable hypoestrogenic side effects. An antiproliferative effect of progestins suggests their use for treating adenomyosis, reducing bleeding and pain. Continuous oral norethisterone acetate or medroxyprogesterone acetate may help to inducing regression of adenomyosis, relief pain and reduce bleeding. The use of vaginal danazol has therapeutic effect on adenomyosis combining progestogenic and anti-inflammatory activity. The intrauterine device releasing levonorgestrel (Lng-IUD) is widely assessed in menorrhagia, and has been shown to be extremely effective in resolving pain and bleeding symptoms associated with adenomyosis. Recent data show a therapeutic effect of dienogest on adenomyosis symptoms.

New drugs are under development for the treatment of adenomyosis, such as aromatase inhibitors (AIs) and selective estrogen receptor modulators (SERMs), that produce a hypoestrogenic environment reducing pain, but are correlated with some adverse effects and a recurrence of symptoms after discontinuation of treatment. Selective progesterone receptor modulators (SPRMs) may reduce adenomyosis-associated pelvic pain, by inhibiting endometrial proliferation and suppressing adenomyotic lesion growth, as shown in animal models; however, the long-term effect with SPRMs needs further determination.

β-Catenin activation contributes to the pathogenesis of adenomyosis through epithelial-mesenchymal transition

Adenomyosis is defined by the presence of endometrial glands and stroma within the myometrium. Despite its frequent occurrence, the precise aetiology and physiopathology of adenomyosis is still unknown. WNT/β-catenin signalling molecules are important and should be tightly regulated for uterine function. To investigate the role of β-catenin signalling in adenomyosis, the expression of β-catenin was examined. Nuclear and cytoplasmic β-catenin expression was significantly higher in epithelial cells of human adenomyosis compared to control endometrium. To determine whether constitutive activation of β-catenin in the murine uterus leads to development of adenomyosis, mice that expressed a dominant stabilized β-catenin in the uterus were used by crossing PR-Cre mice with Ctnnb1(f(ex3)/+) mice. Uteri of PR(cre) (/+) Ctnnb1(f(ex3)/+) mice displayed an abnormal irregular structure and highly active proliferation in the myometrium, and subsequently developed adenomyosis. Interestingly, the expression of E-cadherin was repressed in epithelial cells of PR(cre) (/+) Ctnnb1(f(ex3)/+) mice compared to control mice. Repression of E-cadherin is one of the hallmarks of epithelial-mesenchymal transition (EMT). The expression of SNAIL and ZEB1 was observed in some epithelial cells of the uterus in PR(cre) (/+) Ctnnb1(f(ex3)/+) mice but not in control mice. Vimentin and COUP-TFII, mesenchymal cell markers, were expressed in some epithelial cells of PR(cre) (/+) Ctnnb1(f(ex3)/+) mice. In human adenomyosis, the expression of E-cadherin was decreased in epithelial cells compared to control endometrium, while CD10, an endometrial stromal marker, was expressed in some epithelial cells of human adenomyosis. These results suggest that abnormal activation of β-catenin contributes to adenomyosis development through the induction of EMT.

Application of Mini-abdominoplasty after Conservative Excision of Extensive Cesarean Scar Endometriosis

Endometriosis is defined as the presence of functioning endometrial tissue outside the uterine cavity, and the standard treatment is extensive surgical excision. Cesarean scar endometriosis is a type of cutaneous endometriosis arising on or near a Cesarean section scar. A 44-year-old woman presented with a 9×6 cm sized dark-brown, stony-hard, irregular, lower abdominal mass of four years duration. The patient had a history of two Cesarean deliveries, 14 and 16 years ago. Suspecting endometriosis, we excised the tumor conservatively rather than extensively to prevent incisional hernia considering the benign nature of the tumor and the low possibility of recurrence because the patient's age was near menopause, along with simultaneous bilateral salpingo-oophorectomy that was performed in this case. On reconstruction, mini-abdominoplasty was adopted to avoid possible wound complications and cosmetic deformities. The patient was satisfied with the cosmetic results, and neither recurrence nor functional problems occurred during the 1-year follow-up period. Plastic surgeons should keep in mind the possibility of cutaneous endometriosis in an abdominal mass of a female of reproductive age with a previous history of pelvic or intra-abdominal surgery. An optimal result from oncological, functional, and cosmetic standpoints can be achieved with conservative excision followed by mini-abdominoplasty of extensive Cesarean scar endometriosis.

Adenomyosis: a challenge in clinical gynecology

Adenomyosis is a prevalent, benign gynecologic condition in which endometrial tissue invades the myometrium, causing myometrial inflammation and hypertrophy. Although some women with adenomyosis are asymptomatic, the condition often causes menorrhagia and dysmenorrhea. This article provides women's health providers with a review of causes and risk factors for developing adenomyosis, clinical presentations of women with the condition, diagnostic modalities and criteria, and medical and surgical treatment options.