Ultrasound techniques for diagnosing deep infiltrating endometriosis (DIE) currently lack a quantitative method to assess microstructural heterogeneity in relation to diagnosis and clinical symptoms. This study evaluates Shannon entropy-based radiomics for differentiating DIE lesions from adjacent tissue and correlating these features with pain severity.

In this retrospective cohort study (2020-2024), fertile women with histologically confirmed parametrial endometriosis and high-quality ultrasound images were evaluated. Pain was measured using a 10-cm visual analog scale. Two 25 mm² regions of interest (ROIs) were defined: one within the DIE nodule and one in the adjacent perilesional tissue. Each ROI was analyzed with the Shannon entropy algorithm to assess tissue heterogeneity.

In this study, 148/663 women (22.3%) were diagnosed with parametrial DIE, of whom 52 underwent surgery and were included in the study. DIE was localized in 92.3% in the posterior, in 5.8% in both posterior and anterior, and in 2% in the anterior parametrium. Primary symptoms were menstrual pain (88%) and pain at intercourse (63%). ROI entropy of DIE lesion was lower than that of the perilesional ROI (p = 0.05). The area-under-the-curve (AUC) of Shannon entropy for endometriotic vs. adjacent tissue was 91.36% (95% CI: 84.5%-98.21%). The ROI entropy of the DIE lesion exhibited an inverse correlation with menstrual pain (rho -0.46, CI 95% -0.74/-0.12, p = 0.025), and that of perilesional tissue with chronic pelvic pain (rho -0.41, 95% CI -0.73/- 0.04; p = 0.072).

Entropy analysis distinguishes DIE lesion from perilesional tissue and significantly correlates with menstrual pain.

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

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.

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).

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.

To explore the associations between adenomyosis patterns on transvaginal sonography (TVS) and surgical outcomes.

A retrospective cohort study.

Peking Union Medical College Hospital, Beijing, China.

The medical records of 322 patients diagnosed with adenomyosis who underwent open or laparoscopic fertility-sparing surgeries from March 1 to December 31, 2018, were reviewed. Patients were divided into localized (221 patients) and diffuse (101 patients) adenomyosis groups on the basis of TVS findings.

Detailed epidemiological information, imaging evaluations, surgical reports, and pathological findings were retrospectively collected.

The median postsurgical follow-up period was 52.8 months (range 6-88 months), with 24 patients (7.4%) lost to follow-up by July 1, 2019. The localized and diffuse adenomyosis groups had similar symptom relief and recurrent uterine lesions. Among the 104 patients who attempted pregnancy, 75 patients (72.1%) conceived, with 35 miscarriages (46.7%) and 59 live births (78.7%). For the whole cohort and the localized adenomyosis and diffuse adenomyosis groups, the cumulative 5-year conception rates were 75%, 83% and 60%, respectively; the cumulative 5-year live birth rates were 63%, 79% and 37%, respectively. The adenomyosis patterns found during sonography were the only independent risk factors related to clinical pregnancy and live birth in the Cox regression model. Patients with diffuse adenomyosis had significantly lower rates of conception (HR 0.5, 95% CI 0.3-1.0) and live birth (HR 0.4, 95% CI 0.2-0.8).

Adenomyosis patterns (localized versus diffuse) in pretreatment TVS could predict obstetrical outcomes, irrespective of surgical type and uterine size.

The clinical trial registry name is the Cooperative Adenomyosis Network (CAN); the registration number is NCT03230994 (https://clinicaltrials.gov). This study started on June 30, 2017, and was completed on December 30, 2020.

Does definitive occlusion of uterine arteries have a short- or long-term impact on ovarian reserve markers in reproductive-age women undergoing laparoscopic myomectomy?

Preventive definitive uterine artery occlusion (UAO) during laparoscopic myomectomy reduces intraoperative blood loss but does not impact serum AMH levels after short- and long-term follow-up in reproductive-age women.

Uterine leiomyomas are the most common benign tumours in women of reproductive age. For symptomatic women willing to retain their uterus, especially for a future pregnancy, the current gold standard is surgical myomectomy for subserous/intramural leiomyoma. Temporary or definitive occlusion of uterine arteries can be performed to control bleeding during surgery but its impact on ovarian reserve markers is still unclear. A single randomized trial with a 1-year follow-up demonstrated that temporary bilateral UAO during laparoscopic myomectomy slightly decreased AMH levels at postoperative day 2 but has no significant impact at 3, 6, and 12 months after surgery.

We conducted a randomized controlled trial with a 2-year follow-up evaluating the effect of definitive occlusion of uterine arteries on ovarian reserve markers via sequential measures of AMH levels and AFC by ultrasound assessment. The study included 58 women with symptomatic leiomyoma type FIGO 3 to 6 scheduled for laparoscopic myomectomy between July 2015 and October 2021. Patient allocation was disclosed to the surgeon just before starting the procedure; women were blinded to group allocation throughout the study.

Patients were randomized in two groups: the UAO group (laparoscopic myomectomy with preventive occlusion of uterine arteries) (n = 29 women) and the no-UAO group (laparoscopic myomectomy without occlusion of uterine arteries but with intra-myometrial injection of vasoconstrictive agents) (N = 29 women). Serum AMH levels and AFC were evaluated at baseline (T0) and followed at 1 month (T1), 3 months (T3), 6 months (T6), 12 months (T12), and 24 months (T24) after surgery. Intraoperative blood loss, evolution of uterine bleeding and pain symptoms, and leiomyoma recurrence were also evaluated as secondary outcomes. Pregnancies and live births were monitored.

Women in both groups did not differ in their baseline characteristics in terms of age, body mass index, ethnicity, parity, wish to become pregnant, hormonal treatment, leiomyoma number and size, baseline haemoglobin levels, uterine bleeding symptoms, baseline serum AMH levels, and AFC. The mean operative time was similar between both groups. Mean blood loss during surgery was on average 138 (±104) ml in the UAO group versus 436 (±498) ml in controls (P < 0.001). In the UAO group, 0% had an intraoperative blood loss >500 ml versus 32.1% in the no-UAO group (P < 0.01). Regarding clinical symptoms, most patients in both groups had decreased menstrual flow at the last follow-up visit (24 months) compared to baseline and improvement of dysmenorrhea followed the same trend with a reduction in pain levels in both groups. The risk of leiomyoma recurrence was similar between both groups. Serum AMH levels did not differ between the groups at any time (T1, T3, T6, T12, and T24) and non-inferiority of preventive occlusion was demonstrated with a non-inferiority margin of [-3.5 pmol/l]. Differences between means and 95% CI (in parentheses) were as follows: at T1 -0.11 (-2.14 to 2.40), at T3 -0.25 (-2.36 to 2.21), at T6 0.81 (-2.69 to 3.84), at T12 -0.95 (-3.15 to 1.33), and at T24 1.18 (-1.95 to 3.82). AFC did not differ between the groups at any time, however, non-inferiority of preventive occlusion could not be demonstrated, presumably due to a large variability in this measurement.

Our sample size was calculated to detect a clinically relevant difference of at least two-thirds of the SD in serum AMH levels, but we cannot exclude that a larger sample size might have revealed a smaller impact on serum AMH.

Preventive UAO during laparoscopic myomectomy does not compromise ovarian reserve markers and can be used safely to improve perioperative bleeding control in women of reproductive age. Incorporating UAO as a preventive measure during laparoscopic myomectomy may enhance the safety of the procedure.

Funded by the Department of Paediatrics, Gynecology and Obstetrics of the Geneva University Hospitals. There are no competing interests to declare.

NCT02563392.

9 July 2015.

July 2015.

A departmental audit identified a case of adenomyosis which had not been reported, highlighting the need to assess whether the current service provision is adequate in identifying patients with (possible) adenomyosis and how improvements in this part of the service could be made.

To assess whether sonographers are effectively identifying and reporting adenomyosis on transvaginal ultrasound.

A scoping review and retrospective service evaluation was undertaken which included (n = 79) adult female premenopausal patients with symptoms of adenomyosis who had undergone a transvaginal ultrasound scan during the first quarter of 2023. Patients were identified using the CRIS statistic module according to pre-defined inclusion and exclusion criteria. All data were anonymised and collated to include the patient age, referral information (symptoms), scan report and sonographer. The scan report and archived images were evaluated using the sonographic signs identified by the Morphological Uterus Sonographic Assessment group (Harmsen et al., 2022) and then compared to the original report.

In total, 21.5% (n = 17) of patients had signs of adenomyosis on image review, but only 23.5% (n = 4) of these were reported as such. The majority (n = 8) of unidentified cases were reported as having a 'heterogeneous myometrium'. Inter-rater agreement ranged from 50% to 100%.

Most ultrasonic diagnoses of adenomyosis were not identified in our service which is likely due to a lack of internationally agreed criteria for ultrasound diagnosis of adenomyosis preventing adequate reporting.

In Europe, endometrial carcinoma was found to be the fourth most common tumor in the female population in 2022. The depth of myometrial invasion is a well-established and crucial prognostic risk factor in endometrial cancer patients and is important for choosing the most appropriate management for the patient. However, while the preoperative assessment of tumor invasion carried out using radiological imaging is very important, it is a subjective examination and its accuracy is based on the experience of the operator. In this scenario we proposed a radiomic-based model to predict myometrial invasion for ultrasound images. We collected clinical data and qualitative ultrasound indicators of 77 consecutive patients affected by endometrial carcinoma. After a pre-processing phase of ultrasound images, a pre-trained Inception-V3 convolutional neural network (CNN) was used as features extractor. Then, a binary classification model and a multiclass model were trained, after a double step of feature selection; the first selection stage performed feature filtering based on a nonparametric test, the second stage selected features by evaluating not only the relationship with the outcome of interest, but also the relationship with other predictive features. For the multiclass prediction model, a cascade approach has been developed. The two proposed models were validated in 100 ten-fold cross-validation rounds. In addition, to assess the effect of the potential added value of using this tool in clinical practice, we compared the operator's performance with and without the developed automated support. The binary and multiclass model reached optimal classification performances with a mean AUC value equals to 90.76 (88.63-92.89 IC95%). When the operator was assisted by the radiomic-based decision-making system increased by 10% points in terms of precision. The multiclass model showed the per-classes recall were 93.33%, 71.88% and 90.00%, for focal infiltration, infiltration less than 50%, and infiltration greater than 50% class, respectively. The performances of the operator when assisted by the radiomic-based decision-making system were statistically superior both in terms of overall accuracy and per-class recall of intermediate class (rising to 82.82% and 71.88% compared to 71.88% and 56.25%, respectively). The proposed models have the potential to standardize examinations that rely on subjective evaluations, such as ultrasound. They can represent a valid support tool for the clinicians for an accurate estimate of the deep myometrial infiltration already in the diagnosis phase with an easily accessible, low-cost examination that causes no discomfort for the patient such as ultrasound.

To assess the effects of relugolix combination therapy in women with uterine fibroids (UFs) and concomitant ultrasound-diagnosed adenomyosis.

This post hoc analysis used pooled data from completers of the pivotal LIBERTY studies. The subgroup of women with adenomyosis and UFs was compared with the overall study population on selected efficacy and safety endpoints.

Premenopausal women (aged 18-50 years) with diagnosed UFs (confirmed by ultrasonography) and heavy menstrual bleeding (assessed by the alkaline hematin method).

Once-daily relugolix combination therapy (40 mg relugolix, 1 mg estradiol, and 0.5 mg of norethindrone acetate) or placebo for 24 weeks, or delayed relugolix combination therapy (40 mg of relugolix monotherapy for 12 weeks, followed by relugolix combination therapy for 12 weeks).

Endpoints included the percentage of women with concomitant adenomyosis, the proportion of treatment responders (achieved or maintained a menstrual blood loss <80 mL and ≥50% reduction in menstrual blood loss volume from baseline over the last 35 days of treatment), the proportion of women achieving or maintaining amenorrhea over the last 35 days of treatment, and the change from baseline to week 24 in uterine volume and adverse events.

A total of 111 women (18.2%) had a baseline diagnosis of concomitant adenomyosis (37 in the relugolix combination therapy group, 45 in the delayed relugolix combination therapy group, 29 in the placebo group) and were included in this analysis. Of women with adenomyosis, 83.8% in the relugolix combination therapy group were treatment responders compared with 27.6% in the placebo group. Amenorrhea was achieved in 64.9% of women with adenomyosis treated with relugolix combination therapy and in 6.9% of women treated with placebo. The least square mean uterine volume of women with adenomyosis decreased by 22.2% and 5.8% in the relugolix combination therapy and placebo groups, respectively. Results for the above outcomes in the relugolix combination therapy population were similar to the delayed relugolix combination therapy group.

Efficacy outcomes in women with adenomyosis and UFs were comparable with those in women from the overall LIBERTY study population.

The primary objective of this study was to assess if uterine adenomyosis impacts live birth rate per euploid embryo transfer. The secondary objectives included addressing obstetric and perinatal outcomes in the study group.

This was a multicenter and retrospective cohort study in which 228 patients diagnosed with adenomyosis undergoing single euploid embryo transfer between 2016 and June 2023 were included and matched on 1:1 ratio to control patients without ultrasonographic diagnostic criteria for adenomyosis.

A significant higher live birth rate per embryo transfer was observed in controls compared to women with adenomyosis: 107/228 (46.9%) versus 56/228 (24.6%), respectively (odds ratio (OR) = 2.71, 95% confidence interval [CI]: 1.73-4.13, p < 0.001). When dividing adenomyotic patients regarding the nature of the disease, a higher live birth rate per transfer was described in diffuse adenomyosis compared to focal adenomyosis: 47/166 (28.3%) versus 9/62 (15%), respectively (OR = 2.32, 95% CI: 1.03-5.78, p = 0.034). Described differences were constant even when correcting for multiple variables. There was no statistically significant difference in childbirth delivery method (vaginal vs. cesarean section) between the adenomyosis and control groups. Mean gestational age at the time of delivery, newborn size and weight, and incidences of low birth weight, preterm birth, and admission to the neonatal intensive care unit did not differ between the two groups. In addition, in vitro fertilization (IVF) and perinatal outcomes were similar in patients with diffuse compared with focal adenomyosis.

Adenomyosis, especially focal adenomyosis, affects clinical but may not affect perinatal outcomes after single euploid embryo transfer.

This study aims to describe the clinical and imaging characteristics of uterine sarcomas and the role of imaging modalities in assessing them.

This retrospective study enrolled all patients diagnosed with uterine sarcoma at Tu Du Hospital, Vietnam between January 2020 and December 2023. The findings of ultrasound (US) and magnetic resonance imaging (MRI) were compared to histology as the reference.

Among 78 patients, 46.2% of cases were menopause. Abnormal vaginal bleeding was the most common symptom. Three common types of uterine sarcoma were leiomyosarcoma (50.0%), low-grade endometrial stromal sarcoma (23.1%), and carcinosarcoma (19.2%). Some imaging features of uterine sarcomas were found including nontypical lesion of fibroid (89.7%), solitary mass (84.6%), inhomogeneous structure (76.9%), invisible endometrium (67.9%), moderate-rich vascularization on Doppler signal (57.7%), irregular border of tumor (48.7%), classification of FIGO 0 (44.9%), cystic area within tumor (42.3%), acoustic shadowing (34.6%), "cooked" appearance (9.0%), and calcification image in tumor (6.4%). The sensitivity of standard US, consultant US, and MRI was 56.4%, 88.4%, and 87.5%, respectively.

Besides clinical presentations, uterine sarcomas present some specific features on US. Consultant US and MRI could be added to standard US to increase the accuracy and help in surgical decision making where applicable.

Adenomyosis, characterized by ectopic endometrial tissue within the myometrium, causes chronic pelvic pain, heavy bleeding, and reduced fertility. Nowadays, diagnosis relies heavily on imaging, primarily transvaginal ultrasound, supplemented by MRI. While hysterectomy remains a definitive treatment, the rise in younger patients desiring fertility necessitates uterine-sparing approaches. This review aimed to evaluate these approaches in relation to their impact on fertility and obstetrical outcomes.

Research highlights the association between adenomyosis and increased risk for pregnancy loss, preterm birth, and pre-eclampsia. Minimally invasive thermal ablation therapies and hysteroscopic techniques, including adenomyomectomy, offer promising fertility-sparing options, although long-term data on fertility outcomes and potential complications like uterine rupture remain limited. Advances in laparoscopic and laparotomy-based cytoreductive surgeries are also explored, but large-scale studies comparing efficacy and safety are lacking.

This review examines recent advancements in understanding and managing adenomyosis, focusing on fertility-sparing interventions. Studies show varying success rates for these interventions, highlighting the need for larger, well-designed trials with standardized diagnostic criteria, to assess long-term fertility outcomes, and refine patient selection for optimal results. A consistent challenge across all approaches is the potential for uterine rupture and placenta accreta spectrum, demanding careful patient selection and close monitoring.

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.

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

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

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

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

Endometriosis is currently considered a systemic inflammatory disease and different non-invasive inflammatory markers, such as cell-free DNA (cfDNA), have recently been evaluated. Hormonal treatments are frequently prescribed as first-line treatments to improve symptoms, reduce lesions and improve the quality of life of patients with endometriosis. The most frequently used hormonal treatments are estroprogestins and progestins due to their effectiveness and well-tolerated clinical profile. However, the impact these hormonal treatments may have on these markers has yet to be determined. The aim of this study was to assess whether cfDNA levels are modified under the two main first-line hormonal treatments in patients with deep endometriosis (DE).

Ninety patients diagnosed with DE were analyzed in this prospective, observational study. Forty-five received daily oral treatment with dienogest 2 mg, and 45 with 2 mg dienogest/30 μg ethinylestradiol. Plasma cfDNA levels were evaluated by fluorescent assay prior to initiation of treatment and at 6 and 12 months of treatment.

An increase in cfDNA levels was observed during the follow-up at 6 and 12 months. However, these higher levels were only statistically significant at 12 months of treatment. The increase of cfDNA levels was similar with both treatments.

Higher cfDNA levels were observed in DE patients at 12 months of oral hormonal treatment showing similar results with dienogest or dienogest/ethinylestradiol. This increase could be explained by apoptosis of the endometriosis foci due to the treatment.

To date, there are no clear guidelines available on the treatment of adenomyosis-associated pelvic pain (AAPP); however, numerous hormonal treatments (HTs) are currently being used off-label. We conducted a systematic review and network metanalysis with the aim of assessing the efficacy and safety of HTs to reduce AAPP and ranking the available options.

MEDLINE, LILACS, EMBASE, Scielo.br, PROSPERO, Cochrane Library, conference proceedings, and international registries were searched with no time, region, or language restrictions. Randomized controlled trials that analyzed AAPP in women undergoing HTs were deemed suitable.

Six studies (563 women affected by adenomyosis) were included. At 3 months, women who received a placebo or a levonorgestrel-based intrauterine system (LNG-IUS) experienced more AAPP than those who received dienogest [mean difference of visual analog scale (VAS) pain scores (MD) 4.10 (95% CI 0.49 to 7.71); high evidence; MD 3.05 (95% CI 0.45 to 5.65); high evidence]. At 6 months, women who received dienogest experienced significantly less AAPP compared to those who received combined oral contraceptives [MD -2.85 (95% CI -5.30 to -0.39); moderate evidence], while the prevalence of AAPP was higher among those who received a LNG-IUS than those who received dienogest [MD 1.79 (95% CI 0.06 to 3.53); low evidence].

Dienogest seems to be the most effective HT for AAPP. However, although rare, it is also related to more adverse effects compared to other HTs.

https://www.crd.york.ac.uk/prospero/, identifier CRD42024535472.

Endometriosis, a prevalent gynecological condition affecting 10-15% of reproductive-age women, involves the growth of endometrial-like tissue outside the uterine cavity. This chronic inflammatory disease can significantly impact fertility by disrupting ovulation, tubal transport, and implantation. Clinical manifestations vary widely, ranging from asymptomatic cases to severe pelvic pain, dysmenorrhea, and dyspareunia. Accurate diagnosis remains challenging, often requiring a combination of patient history, clinical examination, and imaging studies. This paper will discuss the clinical approach to endometriosis during a first-line gynecological appointment, focusing on patient history, including detailed assessment of menstrual, pelvic, and bowel symptoms, and clinical examination; thorough gynecological examination, including abdominal and pelvic palpation, speculum examination, and bimanual examination; imaging evaluation (particularly of the role of ultrasound in identifying and characterizing endometriotic lesions, including the use of the #ENZIAN classification for deep infiltrating endometriosis and evaluation of fertility impact); and discussion of the Endometriosis Fertility Index (EFI) as a tool for assessing fertility potential. This comprehensive approach aims to guide clinicians in identifying and managing endometriosis effectively, improving patient outcomes and optimizing fertility management strategies. Methods: A literature search for suitable articles published from January 1974 to 2024 in the English language was performed using PubMed. Results: Endometriosis is associated with infertility rates ranging from 20% to 68%, with mechanisms including pelvic adhesions, chronic inflammation, and immune dysregulation. The revised American Society for Reproductive Medicine (rASRM) classification and #ENZIAN classification were identified as essential tools for staging and characterizing the disease. Transvaginal ultrasound (TVS) demonstrated high diagnostic accuracy for deep infiltrating endometriosis, with a sensitivity of up to 96% and specificity of 99%. EFI emerged as a valuable predictor of natural conception post-surgery. Additionally, the review underscores the frequent co-occurrence of adenomyosis in women with endometriosis, which may further compromise fertility. Despite advancements in imaging techniques and classification systems, the variability in symptom presentation and disease progression continues to challenge early diagnosis and effective management. Conclusions: Endometriosis is a prevalent gynecological condition affecting women of reproductive age and is associated with infertility. This paper describes the diagnostic approach to endometriosis during a first-line gynecological appointment, focusing on clinical history, physical examination, and the role of imaging, particularly ultrasound, in identifying and characterizing endometriosis lesions. The adoption of standardized classification systems such as #ENZIAN and EFI enhances disease staging and fertility prognosis, allowing for tailored treatment strategies. Despite improvements in non-invasive diagnostic methods, challenges persist in correlating symptom severity with disease extent, necessitating continued research into biomarkers and novel imaging techniques. Additionally, the frequent coexistence of adenomyosis further complicates fertility outcomes, underscoring the need for comprehensive management strategies. Further research is needed to enhance early detection strategies and optimize fertility preservation techniques for affected women.

We aimed to evaluate the successful long-term use of dienogest for the management of pelvic pain and bleeding control in perimenopausal women with symptomatic adenomyosis using real-world data. All women aged ≥ 40 years with adenomyosis who complained of dysmenorrhea and/or menorrhagia and received dienogest between September 2018 and December 2021 were retrospectively recruited. The primary outcome was successful long-term use of dienogest for pelvic pain and/or bleeding control. A total of 87 women were analyzed. Overall, forty-nine (56%) patients had excellent pain control, but 17 (20%) eventually underwent hysterectomy, while 21 (24%) received dienogest for over 24 months (mean 33.5 ± 8.5 months). According to subgroup analysis by age (≥ 45 vs. <45), older women easily discontinued dienogest due to side effects (51% vs. 30%, p = 0.047) but less frequently changed to surgery (11% vs. 30%, p = 0.012) than younger women. Older age, higher CA-125 value, and larger uterine size before treatment were linked to poorer long-term responses to dienogest. As risk factor, uterine volume > 352.7 cm3 reflects easier treatment failure (sensitivity = 65.4%, specificity = 66.7%, area = 0.68, p = 0.032). In perimenopausal women with symptomatic adenomyosis, nearly half of the treated patients benefitted from dienogest. Our informative findings can assist clinicians in pre-treatment counseling and identifying factors correlated with treatment effectiveness.

Background: Long-COVID is characterized by the persistency of COVID-19 symptoms beyond 12 weeks, and it is probably consequent to immune dysregulation induced by SARS-CoV-2 infection. Immune dysregulation is associated with and probably involved in the pathogenesis of chronic gynecological conditions like endometriosis and adenomyosis. This study evaluated whether the presence of endometriosis or adenomyosis increases the risk of long-COVID, i.e., the persistence of COVID-19 symptoms beyond 12 weeks since infection. Methods: This retrospective observational study was performed at the outpatient service for endometriosis and chronic pelvic pain, at a university hospital. The diagnosis of endometriosis/adenomyosis was primarily based on clinical symptoms and ultrasonography assessment. Data regarding infection, vaccination, symptoms associated with SARS-CoV-2 infection, and their persistence for a minimum of 12 weeks were collected. Results: This study included 247 women, 149 controls without and 98 cases with endometriosis/adenomyosis. Among these, 194 (116 controls and 78 cases) had suffered from SARS-CoV-2 infection. Rates of infection and vaccination were similar in the two groups. The distribution of the SARS-CoV-2 vaccine was uniform across the two cohorts. COVID-19 patients with endometriosis or adenomyosis exhibited a higher prevalence (p < 0.001) of dyspnea and chest pain. The prevalence of long-COVID beyond 12 weeks was higher in cases than controls (42% vs. 12%; p < 0.001) with chest pain (p < 0.001) and ageusia (p < 0.05), forming the most representative symptoms. Conclusions: Symptoms of long-COVID are more frequent in women with than without endometriosis/adenomyosis.

Postmenopausal bleeding (PMB) with a diffusely enlarged uterus necessitates Magnetic Resonance Imaging (MRI) to reach an accurate diagnosis. Adenomyosis, especially extensive glandular variant, is an extremely rare cause reported in a postmenopausal woman. We present a challenging case of an 81-year-old woman with PMB where preoperative MRI suggested possible invasive endometrial neoplasm. However, final histopathological evidence of the hysterectomy specimen suggested Adenomyosis with extensive glandular proliferation. The patient was a multiparous lady with controlled diabetes and hypertension (controlled on medications) and a Body Mass Index of 36 kg/m2. Bimanual examination suggested a diffusely enlarged uterus corresponding to 8-10 weeks gestation. Transvaginal ultrasound (TVUS) and Contrast Enhanced (CE) MRI were performed that reported multiple cystic areas with myometrial thinning at the fundal region- suspected infiltrating endometrial neoplasm. A hysteroscopic guided endometrial biopsy was suggestive of endometrial hyperplasia. In view of concerning MRI findings, a total abdominal hysterectomy and bilateral Salpingo-oophorectomy was performed. Histopathological examination revealed Adenomyosis with extensive glandular proliferation co-existing with endometrial hyperplasia and no atypia. This case highlights an important variant of Adenomyosis that potentially mimics an invasive uterine neoplasm. There is a dearth of uniform reporting standards for Adenomyosis and rarity of this condition in postmenopausal woman posing a significant preoperative diagnostic challenge.

Alterations in the microbiome composition have been identified in common gynecologic pathologies such as endometriosis carving a new frontier in diagnosis and treatment. We aimed to examine the existing literature on perturbations in the reproductive tract microbiome of individuals with adenomyosis informing future therapeutic targets. To examine the association between the reproductive tract microbiome composition among individuals with adenomyosis when compared to controls that can lead to new research evaluating novel mechanisms of action and treatment modalities. A systematic literature search identified studies that compared differences in microbiome composition using culture-independent microbiome analysis between individuals with adenomyosis when compared to controls. Five observational cross-sectional studies characterizing the lower and upper reproductive tract in humans were included. The diagnostic criteria of adenomyosis included surgical and imaging-based criteria. All studies used a 16S rRNA sequencing method. All individuals were recruited from either China or Thailand. An association between adenomyosis and alterations in the microbiome composition included relative deficiencies in Lactobacillus and relative enrichment of anaerobic and gram-negative bacteria when compared to control participants. Comparative studies suggest that there are significant perturbations in the microbiota composition of individuals with adenomyosis when compared with controls. Limiting conclusions include relative small sample sizes, a homogeneous population, and scant clinical phenotypic data. This systematic review identified significant alterations in the bacterial composition of adenomyosis cases that can be leveraged to design mechanistic studies and future innovative approaches to diagnose and manage this pathology. Trial registration: PROSPERO (CRD42023494563). Registered December 28, 2023.

The objective of this study is to evaluate if medical treatment before assisted reproductive technology (ART) improves the results in infertile patients with adenomyosis. A literature search was performed with EMBASE, PubMed, and Cochrane. The primary outcome was clinical pregnancy rate (CPR). Secondary outcomes were live birth rate (LBR) per cycle and miscarriage rate (MR) after ART with or without medical pretreatment. Additionally, a comparison was made between women undergoing medical pretreatment before frozen embryo transfer (FET) and those who underwent FET alone, including any type of endometrial preparation. Ten studies were included. The present meta-analysis supports the use of long-term GnRH agonist therapy in patients with adenomyosis, which enhances the CPR (odds ratio (OR) 1.49, 95% CI 1.15 to 1.92) in IVF/ICSI with fresh ET, while the comparison in women undergoing FET cycles did not reach statistical significance (OR 1.34 95% CI 0.70-2.55). Pretreatment with GnRH agonist did not demonstrate a benefit on the LBR and MR per cycle in IVF/ICSI with fresh ET in comparison to standard ovarian stimulation protocols. Similar results were observed in the setting of FET, failing to indicate a superiority of GnRH agonist pretreatment over standard FET protocols for LBR and MR. In conclusion, GnRH agonist pretreatment before ART carries a potential benefit in improving outcomes in terms of higher CPR, but there is no significant impact on LBR and MR. Pretreatment with GnRH agonists could be adopted as a possible alternative ART protocol in selected patients with adenomyosis and infertility.

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

What is the relationship between sonographic diagnosis of isolated adenomyosis and placenta-associated obstetric outcomes?

In this 12-year retrospective cohort study (2010-2022), patients presenting with adenomyosis-related symptoms were assessed via ultrasound. The study included 59 women diagnosed with adenomyosis and 62 controls, leading to 203 births (90 in the adenomyosis group and 113 in the control group). Patients with endometriosis, uterine fibroids and anomalies, and those using assisted reproductive technology were excluded. The primary outcome focused on a composite of placenta-associated adverse outcomes, including preterm birth, small-for-gestational-age fetuses, hypertensive disorders of pregnancy, placental abruption and post-partum haemorrhage.

No clinically significant differences in demographic characteristics were noted between the two groups. However, the adenomyosis group showed a significantly higher rate of adverse placental function outcomes (27%) compared with the control group (11%, P = 0.005). Adjusted analyses for maternal age, parity and aspirin usage revealed increased risk of hypertensive disorders (adjusted OR 5.91, 95% CI 1.50-30.0; P = 0.017) and adverse placental function outcomes (adjusted OR 3.44, 95% CI 1.53-8.09; P = 0.003) in the adenomyosis group.

Adenomyosis is significantly associated with increased risk of adverse placental function outcomes and hypertensive disorders of pregnancy. These findings suggest that adenomyosis may have a distinct impact on pregnancy, underscoring the need for further research to elucidate specific sonographic characteristics of adenomyosis and their effects on placental function.

Adhesions between the uterus, bladder and anterior abdominal wall are associated with clinical sequelae, including chronic pelvic pain and dyspareunia, and can also yield complications during surgery. The transvaginal sonographic (TVS) sliding bladder sign is a minimally invasive diagnostic tool to evaluate the presence of vesicouterine adhesions. This study aimed to determine the predictive value and intra- and interobserver variation of the TVS sliding bladder sign in the assessment of vesicouterine adhesions.

This was a prospective observational double-blind diagnostic accuracy study conducted at the Amsterdam University Medical Center. Patients scheduled for gynecological laparoscopic surgery for a benign disorder between January 2020 and December 2022 were included consecutively. All patients underwent preoperative TVS, including a dynamic sliding bladder sign examination in our outpatient clinic. Videoclips of the TVS scans were stored for offline assessment and used as an index test. The recordings of both TVS and laparoscopy were evaluated for diagnostic characteristics of vesicouterine adhesions by independent assessors, who were blinded to the clinical situation in addition to the laparoscopic findings when assessing recordings of TVS and vice versa. The presence of adhesions on laparoscopy was used as the reference standard. The positive predictive value (PPV), negative predictive value (NPV), specificity and sensitivity of the sliding bladder sign were calculated. In addition, inter- and intraobserver variability of the sliding bladder sign on TVS were assessed.

Of 116 included women, 57 had a negative sliding bladder sign on TVS, while on laparoscopy, 51 women had mild and 28 had severe vesicouterine adhesions. A negative sliding bladder sign had a PPV of 94.7% (95% CI, 88.9-100%) for the presence of any vesicouterine adhesions, and a positive sliding bladder sign had a specificity of 91.9% (95% CI, 83.1-100%). For severe adhesions, the negative sliding bladder sign had a sensitivity of 89.3% (95% CI, 77.8-100%) and a positive sliding bladder sign had a NPV of 94.9% (95% CI, 89.3-100%). When using Cohen's kappa coefficient, inter- and intraobserver agreement between assessors was good.

Sliding bladder sign evaluation using TVS is a reliable diagnostic tool for the prediction of vesicouterine adhesions on laparoscopy. A negative sliding bladder sign indicates the presence of vesicouterine adhesions, while a positive sliding bladder sign makes the presence of severe adhesions unlikely. Establishing vesicouterine adhesions by TVS may optimize preoperative planning, and can be used for future studies to evaluate the relationship between symptomatology and vesicouterine adhesions and, subsequently, the effect of adhesion-prevention interventions. © 2024 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

In the present study, we aimed to compare serum CK-MM levels in patients with and without adenomyosis and to investigate whether CK-MM level can be a non-invasive marker for myometrial damage due to adenomyosis.

Our study was a prospective case-control study in a tertiary center and consisted of 40 patients with a clinical/ultrasonographic diagnosis of adenomyosis and 40 patients without a clinical/ultrasonographic diagnosis of adenomyosis as the control group based on recently published morphological uterus sonographic assessment (MUSA) criteria. Individuals of similar age who signed a voluntary consent form were included in our study. Demographic, clinical, and laboratory findings of the patients in both groups were recorded. Blood serum samples were used for the determination of serum CK-MM levels of the participants in our study. The samples were analyzed by using the human CK-MM enzyme-linked immunosorbent assay (ELISA) kit.

In our study, the mean serum CK-MM level was 16.2 ± 21.7 (ng/dL) in patients with adenomyosis and 2.6 ± 2.2 (ng/dL) in patients without adenomyosis. Serum CK-MM level was statistically significantly higher in the patient group with adenomyosis than in the control group (p < 0.001). The CK-MM threshold value of 3.43 ng/mL, with a sensitivity of 82.5% and specificity of 85%, has been found to be a valuable distinguishing level in patients with and without adenomyosis.

In this study, we demonstrated that serum CK-MM can be used as a non-invasive diagnostic method in patients with adenomyosis. As the number of studies around this subject in the literature is insufficient, larger studies are needed to use CK-MM as a diagnostic marker in adenomyosis.

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.

To establish the expert opinions and consensus recommendations from the Taiwanese Endometriosis Society on managing adenomyosis.

This study employed a two-round modified Delphi method incorporating a national panel of expert gynecologists to form the consensus on managing adenomyosis. The first round of the Delphi procedure involved an expert panel from the board members to evaluate the relevance of each item. In the subsequent round of votes, gynecologists affiliated with the Taiwan Endometriosis Society participated and used a 5-point Likert scale to cast votes and approve each statement. The rating scales for each item of the key recommendations were analyzed for the distribution of degrees of agreement.

The consensus for managing adenomyosis was developed, encompassing various aspects including imaging diagnosis, hormonal treatment, surgical treatment, noninvasive/minimally invasive treatment, infertility concerns, and obstetric considerations. In the first round of voting, all 25 recommendations received approval from the board members, advancing them to the second round. During the second round of voting, the majority of recommendations received either a "strongly agree" or "agree" response. There was divergence regarding the similarity of effectiveness in alleviating adenomyosis-related pain by either laparotomic or laparoscopic approaches (55% strongly agree or agree vs. 21% disagree or strongly disagree).

The Taiwan Endometriosis Society expert panel has established a set of consensus guidelines for the management of adenomyosis. There are diverging opinions among experts regarding the optimal surgical approaches for resection of adenomyosis.

Differential diagnosis between benign uterine smooth muscle tumors and malignant counterpart is challenging.

To evaluate the accuracy of a clinical and ultrasound based algorithm in predicting mesenchymal uterine malignancies, including smooth muscle tumors of uncertain malignant potential.

We report the 12-month follow-up of an observational, prospective, single-center study that included women with at least 1 myometrial lesion ≥3 cm on ultrasound examination. These patients were classified according to a 3-class diagnostic algorithm, using symptoms and ultrasound features. "White" patients underwent annual telephone follow-up for 2 years, "Green" patients underwent a clinical and ultrasound follow-up at 6, 12, and 24 months and "Orange" patients underwent surgery. We further developed a risk class system to stratify the malignancy risk.

Two thousand two hundred sixty-eight women were included and target lesion was classified as benign in 2158 (95.1%), as other malignancies in 58 (2.6%) an as mesenchymal uterine malignancies in 52 (2.3%) patients. At multivariable analysis, age (odds ratio 1.05 [95% confidence interval 1.03-1.07]), tumor diameter >8 cm (odds ratio 5.92 [95% confidence interval 2.87-12.24]), irregular margins (odds ratio 2.34 [95% confidence interval 1.09-4.98]), color score=4 (odds ratio 2.73 [95% confidence interval 1.28-5.82]), were identified as independent risk factors for malignancies, whereas acoustic shadow resulted in an independent protective factor (odds ratio 0.39 [95% confidence interval 0.19-0.82[). The model, which included age as a continuous variable and lesion diameter as a dichotomized variable (cut-off 81 mm), provided the best area under the curve (0.87 [95% confidence interval 0.82-0.91]). A risk class system was developed, and patients were classified as low-risk (predictive model value <0.39%: 0/606 malignancies, risk 0%), intermediate risk (predictive model value 0.40%-2.2%: 9/1093 malignancies, risk 0.8%), high risk (predictive model value ≥2.3%: 43/566 malignancies, risk 7.6%).

The preoperative 3-class diagnostic algorithm and risk class system can stratify women according to risk of malignancy. Our findings, if confirmed in a multicenter study, will permit differentiation between benign and mesenchymal uterine malignancies allowing a personalized clinical approach.

Evidence suggests that aberrant uterine contractility in nonpregnant women with endometriosis and adenomyosis contributes to symptoms and potentially heralds their pathogenesis. However, uterine peristalsis remains understudied, inconsistently measured, and poorly understood.

To summarize evidence on uterine contractility across the menstrual cycle phases in women with endometriosis and adenomyosis.

PubMed/MEDLINE, Embase, and Scopus databases searched up to May 2, 2024.

Observational studies compared quantitative measures of uterine contractility using magnetic resonance imaging, ultrasound, electrophysiology, or direct intrauterine pressure recording across different menstrual cycle phases between women with endometriosis/adenomyosis and controls on the basis of predefined problem/population, intervention, comparison, and outcome criteria. Study quality was assessed using the Newcastle-Ottawa Scale. Pooled estimates for primary (risk ratios with 95% confidence intervals [CIs]) and secondary (mean difference [MD] with 95% CIs) outcomes were calculated using random-effects models.

Pooled risk of retrograde menstruation uterine contraction pattern in cases vs. controls; pooled MD in continuous measures of uterine contractility (frequency, amplitude, and velocity of contractions) across all the menstrual cycle phases in cases vs. controls.

Nine studies met the inclusion criteria; most were studies that evaluated women with endometriosis. An increased risk of retrograde uterine contractions during menstruation was observed in women with endometriosis compared with that in controls (risk ratio, 8.63; 95% CI, 3.24-22.95; I2, 0). The pooled MDs in contraction frequency between cases and controls were 0.82 (95% CI, 0.13-1.52; I2, 18.61%) in the menstrual phase and 0.52 (95% CI, 0.22-0.83; I2, 27.18%) in the luteal phase. Results for the follicular and periovulatory phases were more heterogeneous. Higher contraction amplitudes in women with endometriosis or adenomyosis were reported across all menstrual cycle phases. Because of the paucity of data, especially for adenomyosis, evidence certainty was graded as low for most comparisons.

The approximately ninefold increased risk of retrograde pattern during menstruation in endometriosis supports the potential role of retrograde menstruation in its etiopathogenesis. Abnormal uterine contractility, likely not limited to the menstrual phase, may be a mechanical factor contributing to development of endometriosis and related symptoms, including menstrual pain and infertility, with limited, mostly concordant evidence for adenomyosis.

PROSPERO ID CRD42024512273-accepted on February 23, 2024.

Are there correlations between the biological expression of steroid receptors and the extent of fibrosis in adenomyotic lesions, and the treatment effectiveness of the levonorgestrel-releasing intrauterine system (LNG-IUS) on alleviation of adenomyosis-associated dysmenorrhoea.

In this retrospective cohort study, 125 women with adenomyosis who underwent hysterectomy were screened. Tissue samples were collected from 41 patients who had undergone LNG-IUS treatment prior to surgery, and these patients were further categorized into the treatment effective group (n = 18) and the treatment failure group (n = 23) according to their self-reported relief from dysmenorrhoea after 6 months of treatment. Oestrogen receptor-α (ER-α) and progesterone receptor expression, and the extent of fibrosis in the adenomyotic lesions were measured using immunohistochemistry and Masson's trichrome staining, respectively.

Patients in the treatment failure group demonstrated lower expression of ER-α and progesterone receptors, and more pronounced fibrosis in the stroma of adenomyotic lesions compared with patients in the treatment effective group. In the glandular epithelium of lesions, ER-α expression was reduced significantly in the treatment failure group, whereas no notable difference in the expression of progesterone receptors was observed. Notably, the staining intensity of ER-α in the stroma of lesions was found to have the strongest positive correlation with the degree of symptom alleviation for dysmenorrhoea (r = 0.703, P < 0.001), with an area under the curve of 0.894 for prediction.

The reduced expression of steroid receptors in adenomyotic lesions, especially ER-α in the stroma, was associated with increased likelihood of treatment failure of LNG-IUS for alleviation of dysmenorrhoea.

We carried out this study to explore the possibility of initiating goserelin therapy during the non-menstrual period in patients diagnosed with adenomyosis.

115 premenopausal adenomyosis patients were enrolled and divided into three groups based on their menstrual cycle phase during the initial outpatient visit: menstrual, follicular, and luteal. Each received a 3.6 mg subcutaneous dose of goserelin monthly for three months. The endpoints encompassed alterations in uterine volume, dysmenorrhea Numerical Rating Scale (NRS) score, CA125 level, hemoglobin (HGB) after a 12-week treatment course, and the occurrence and duration of uterine hemorrhage during the first treatment cycle.

Analysis revealed that the timing of goserelin therapy initiation in the menstrual cycle did not significantly impact its effectiveness in reducing uterine size, alleviating pain, lowering CA125 levels, or improving hemoglobin concentrations. However, patients starting treatment during the luteal phase experienced increased uterine bleeding (reference: menstrual period, OR = 4.33, 95% CI 1.23-15.25, p = .023).

The results suggested non-inferiority of goserelin therapy initiated during the non-menstrual period, but the uterine bleeding rate was higher in the luteal phase group. Therefore, goserelin treatment for outpatient adenomyosis patients should not be limited to starting during the menstrual period; it can also be initiated outside the menstrual period, providing more convenience for patients as most consultations occur outside the menstrual period. However, the use of goserelin during the luteal phase should be avoided to reduce the risk of exacerbated bleeding, especially in anemic patients with heavy menstrual bleeding. This study highlights the importance of individualizing treatment initiation based on the patient's health profile to optimize therapeutic outcomes and minimize adverse effects.

ChiCTR2200059548.

To assess the diagnostic performance and inter-observer agreement of a PREoperative sarcoma scoring based on ultrasound (PRESS-US) in differentiating uterine leiomyosarcoma (uLMS) from leiomyoma (LM).

We conducted a retrospective evaluation of patients who underwent surgery and received standardized ultrasound examinations due to the presence of uterine myoma-like masses. Histological diagnosis was used as the reference standard. The masses were analyzed using morphological uterus sonographic assessment criteria, and the diagnostic accuracy of PRESS-US was evaluated using ROC curve analysis. Kappa (κ) statistics were used to assess the inter-observer agreement between a less experienced and an expert radiologist.

Among the 646 patients, 632 (97.8%) were diagnosed with LM, and 14 (2.2%) had uLMS. The malignancy rates for low-risk and high-risk patients were 0.35% and 13.48%, respectively. The optimal PRESS-US cutoff was 17.5, resulting in an AUC of 89.7% (95% CI, 0.79-1.00), with a sensitivity of 85.7% and a specificity of 87.8%. The inter-observer agreement between a less experienced and an expert radiologist was excellent (κ = 0.811, P < 0.001).

PRESS-US provides effective risk stratification for uLMS for radiologists with different levels of experience, with high reliability. Subgrouping high-risk patients helps in better risk stratification.

Evaluating menstrual blood loss (MBL) in primary healthcare is challenging. Our study aimed to assess MBL using two methods: self-perception and pictograms (Pictorial Blood Assessment Chart-PBAC and Menstrual Pictogram superabsorbent polymer-c version-MP) in women undergoing transvaginal ultrasound (TVS).

We enrolled 221 premenopausal women with spontaneous menstruation, no hormonal therapy, and no ongoing pregnancy. They were divided into four age groups (12-20, 21-30, 31-40, and 41-55 years). Women self-reported normal (NMB) or heavy menstrual bleeding (HMB) and filled out PBAC and MP. A PBAC score ≥ 150 and MP score ≥ 80 ml indicated HMB. TVS was conducted on all patients, recording any pelvic pathologies. We compared self-perception with pictograms across the cohort, age groups, and ultrasound findings.

Of the cohort, 50.2% reported normal periods and 49.8% heavy periods. No significant differences were found between self-perception and pictograms in identifying NMB and HMB across all groups. However, significant differences were observed between PBAC and MP scores for NMB (56.1% vs 41.2%, p = 0.001) and HMB (43.9% vs 58.8%, p = 0.001), particularly in the 31-40 age group. Significant differences in PBAC and MP scores were noted between age groups 12-20 and 41-55, and 31-40 and 41-55. No significant differences were found between self-perception and pictograms regarding ultrasound findings like adenomyosis, fibroids, endometrial pathology, and uterine congenital malformations.

Self-perception could be a reliable method for describing MBL across all age groups and ultrasound findings. Given the complexity and potential errors in using pictograms, clinicians should consider relying on self-perception for assessing menstrual cycle quantity.

Background/Objectives: Endometriosis and inflammatory bowel disease (IBD) share some epidemiological, clinical and pathogenetic features. A differential diagnosis between pelvic endometriosis and IBD may be challenging, even for expert clinicians. In the present review, we aimed to summarize the currently available data regarding the relationship between endometriosis and IBD and their possible association. Methods: The PubMed and Scopus database were considered, by searching the following terms: "Crohn's Disease", "Ulcerative Colitis", "Endometriosis", "Adenomyosis", and "Inflammatory Bowel Disease", individually or combined. Full-text papers published in English with no date restriction were considered. Results: Few studies have researched the possible association between endometriosis and IBD. Both conditions are characterized by chronic recurrent symptoms, which may be shared (abdominal pain, fatigue, infertility, menstrual irregularities, diarrhea, constipation). Deep infiltrating endometriosis (DIE) can cause bowel symptoms. In a large Danish study, a 50% increased risk of IBD was observed in women with endometriosis. A missed diagnosis of endometriosis and an increased risk of endometriosis has been reported in IBD. Current evidence does not support an association between endometriosis and IBD characteristics. However, IBD may be associated with DIE, characterized by pelvic symptoms (dyschezia, dyspareunia). Preliminary observations suggest an increased IBD risk in patients with endometriosis treated with hormonal therapy. Conclusions: Current findings suggest that a careful search is needed for concomitant endometriosis in subgroups of patients with IBD showing compatible symptoms and vice versa. A multidisciplinary approach including dedicated gastroenterologists and gynecologists is required for a proper search for IBD and endometriosis in subgroups of patients. This approach may avoid diagnostic delays or overtreatments for these conditions.

Abnormal uterine bleeding (AUB) is a common gynecological condition that disrupts women's health due to irregularities in menstrual frequency, duration, and volume, often resulting in a significant impact on daily life and productivity. Accurate diagnosis of AUB is critical but complicated by its varied etiologies and presentations. Recent advancements in imaging techniques, particularly the Morphological Uterus Sonographic Assessment (MUSA), have enhanced the diagnostic precision of uterine pathologies such as fibroids and adenomyosis. MUSA combines gray-scale sonography, color Doppler, and three-dimensional ultrasound to evaluate uterine abnormalities with standardized terminology, ensuring diagnostic consistency. This study aimed to assess the efficacy of MUSA in diagnosing and managing AUB. A descriptive observational study was conducted on 50 patients at Dr. D. Y. Patil Medical College and Hospital, focusing on pre- and post-menopausal women with clinically symptomatic AUB. Patients underwent detailed ultrasonography, including both transabdominal and transvaginal scans, to evaluate uterine structures and correlate findings with histopathology. Results showed that 62% of patients had adenomyosis, while 38% had fibroids. MUSA effectively differentiated between the two conditions based on key ultrasound characteristics such as serosal contour, junctional zone, myometrial wall symmetry, and echogenicity. Adenomyosis cases showed significantly higher rates of heterogeneous echogenicity and asymmetrical myometrial walls compared to fibroids. Statistical analyses revealed high diagnostic sensitivity and specificity for both conditions, with an overall accuracy of 88.9% for adenomyosis and 94.1% for fibroids. The findings confirm the utility of MUSA in improving diagnostic accuracy and informing management strategies for AUB, particularly in complex cases. The study highlights MUSA as an indispensable tool for clinicians, facilitating enhanced patient outcomes through precise evaluation and treatment of uterine pathologies.

To describe the clinical and ultrasonographic features of uterine perivascular epithelioid cell tumor (PEComa) using standardized terminology.

This was a retrospective analysis of patients with uterine PEComa diagnosed and confirmed by pathology and immunohistochemistry at West China Second University Hospital, Sichuan University, Sichuan, China, between January 2010 and September 2023. The Morphological Uterus Sonographic Assessment (MUSA) consensus and the International Endometrial Tumor Analysis (IETA) consensus were utilized for the standardized description of the sonographic characteristics of uterine PEComa. We summarized the clinical and ultrasound features of uterine PEComa in cases from our center and those found in a review of the literature conducted using PubMed from 1 January 2013 to 30 September 2023 (inclusive).

Five patients, aged 33-57 (median, 52) years, with a total of six uterine PEComa lesions were included in our cohort. All cases had complete ultrasonographic and pathological images. None of the patients had a history of tuberous sclerosis complex. Two patients had malignant PEComa (one patient had two lesions) and three had benign PEComa, originating from the cervix, myometrium or uterine cavity. Patients presented with symptoms including increased vaginal discharge, vaginal bleeding and pelvic or abdominal pain. The three patients with benign PEComa underwent total hysterectomy and bilateral adnexectomy, tumor excision and conservative management, respectively, while both malignant cases underwent total hysterectomy and bilateral adnexectomy followed by chemotherapy. Regular follow-up (from 6 to 24 months) revealed recurrence in one case. Two lesions were misdiagnosed as uterine fibroids, two as cervical cancer, one as metastatic cervical cancer (with myometrial invasion) and one was indeterminate. Ultrasound examination showed that most lesions displayed regular round or ovoid shape (66.7%), uniform echoes (66.7%) and hypoechogenicity (66.7%), with one (16.7%) malignant PEComa showing cystic areas and one (16.7%) benign PEComa showing punctate calcifications. All lesions lacked shadowing and the majority showed moderate to abundant vascularity (color score of 3-4, 83.3%). The color score was 2-4 in the periphery in 100% of cases and internally in 83.3% of cases. The three benign PEComas showed similar characteristics in vascular distribution, with scattered internal vessels and peripheral vessels exhibiting a circular pattern. The literature search identified 11 articles describing the ultrasonographic appearance of 18 cases of uterine PEComa, with similar characteristics to those in our cohort.

The sonographic features of uterine PEComa include a uniform or non-uniform hypoechogenic mass, typically round or ovoid with regular margins, occasionally containing cystic areas or calcifications, lacking shadowing and often showing moderate to abundant vascularity. Although the preoperative ultrasound diagnosis of uterine PEComa remains challenging, particularly given the non-specific nature of the sonographic characteristics described here, dispersed intratumoral vessels and a peripheral circular vascular distribution may serve as diagnostic clues for uterine PEComa, but more cases are needed for confirmation. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Internal cervical os (ICO) stiffness is related to menstrual pain, a key symptom of endometriosis. The study evaluated whether women with endometriosis have a stiffer ICO than unaffected women.

A retrospective cross-sectional analysis was conducted using prospectively collected data from women with and without endometriosis, spanning from June 2020 to September 2022. Endometriosis was diagnosed through clinical and ultrasound evaluations, with histological confirmation in a subset of participants. Strain elastography (SE) was employed to measure tissue elasticity in four cervical regions of interest: the ICO and the anterior, posterior, and middle cervical compartments (ACC, PCC, and MCC, respectively). Tissue elasticity was quantified using a color-based scoring system ranging from 0.1 (blue, indicating less elasticity) to 3.0 (red, indicating greater elasticity).

Overall, 287 women were included, with 157 diagnosed with endometriosis and 130 controls. On SE, women with endometriosis exhibited a lower color score (mean±standard deviation), indicating lower elasticity, for the ICO (0.56±0.28 vs. 0.70±0.26, P=0.001) and PCC (0.69±0.30 vs. 0.80±0.27, P=0.002). Additionally, they had a lower ICO/MCC ratio (0.45±0.28 vs. 0.60±0.32, P=0.001) and ICO/ACC ratio (0.68±0.42 vs. 0.85±0.39, P=0.001). Multiple logistic regression analysis revealed that endometriosis was associated with the ICO color score (odds ratio, 0.053; 95% confidence interval, 0.014 to 0.202; R2=0.358; P=0.001), even after adjusting for confounding factors like the presence of myomas (P=0.040) and the use of hormonal therapy (P=0.001). The results were corroborated in women with histologically confirmed endometriosis (n=71).

The findings suggest a potential relationship between a stiffer ICO and endometriosis.

Imaging fibroid vascularity may predict fibroid growth and aid to determine most appropriate therapy. Microvascular (MV) flow imaging is relatively new and is able to detect slow flow in small vessels. Data on feasibility, reproducibility, and reliability of MV-flow imaging in fibroids is lacking. The purpose of our study was to determine the reproducibility of MV-flow imaging and to explore this technique for clinical practice for assessing blood flow in fibroids.

Thirty patients with one or multiple fibroids (diameter 1.5-12.0 cm) were prospectively included. Transvaginal ultrasound scanning was performed in B-mode, 2D MV-Flow™, 2D and 3D power Doppler mode (HERA W10, Samsung) by two experienced gynecologists at a tertiary care clinic from February to December 2021. The primary outcome was intra- and interobserver agreement of the vascular index (VI) and color score (CS). The following parameters: '2D MV-flow VI', '3DPD VI', '2D MV-flow CS' and '2DPD CS' were measured offline in the center, pseudocapsule, and entire fibroid. Secondary offline outcomes for exploring 2D MV-flow for clinical practice, included (1) ability to discern vascular structures, (2) assessing the degree of vascularity via CS and calculating a VI, and (3) determining penetration depth of the ultrasound signal in both power Doppler and MV-flow imaging.

All scans of the 30 included patients were of sufficient quality to analyze. Inter- and intra-observer correlations of all studied parameters were good to excellent, both for 2D MV-flow and 2D power Doppler (intercorrelation coefficient 0.992-0.996). Using 2D MV-flow different vascular structures were visible in detail, in contrary to using 2D and 3D power Doppler. In significantly more fibroids central flow could be visualized using 2D MV-flow (63%) than with 2D power Doppler (13%, p = 0.001). Finally, penetration of the ultrasound signal was deeper using 2D MV-flow (3.92 cm) than with 2D power Doppler (2.95 cm, p = 0.001).

Using 2D MV-flow imaging for determining vascularity is highly reproducible. It has potential added value for clinical practice as it depicts detailed vascular structures and the degree of vascularity, especially in the center of the fibroid.

Adenomyosis is a chronic, hormone-related disease characterized by the presence of the endometrial glands and stroma within the myometrium. This condition can manifest in various features, focal or diffuse adenomyosis or as an adenomyoma, and it may involve different uterine walls (posterior, anterior, and/or lateral walls). The disease can also be classified into different degrees, as mild, moderate and severe, which can be associated with more intense symptoms, although this correlation is not always directly proportional. In fact, adenomyosis can be asymptomatic in about a third of cases or it can significantly impact patients' quality of life through painful symptoms, such as dysmenorrhea and dyspareunia, abnormal uterine bleeding-particularly heavy menstrual bleeding-and potential effects on fertility. Historically, adenomyosis has been considered a disease primarily affecting premenopausal women over the age of 40, often multiparous, because the diagnosis was traditionally based on surgical reports from hysterectomies performed after the completion of reproductive desire. Data on the presence of adenomyosis in adolescent patients remain limited. However, in recent years, advancements in noninvasive diagnostic tools and increased awareness of this pathology have enabled earlier diagnoses. The disease appears to have an early onset during adolescence, with a tendency to progress in terms of extent and severity over time. Adenomyosis often coexists with endometriosis, which also has an early onset. Therefore, it is important, when diagnosing adenomyosis, to also screen for concomitant endometriosis, especially deep endometriosis in the posterior compartment. The aim of this narrative review is to investigate the prevalence of different types and degrees of adenomyosis in younger patients, assess the associated symptoms, and describe the most appropriate diagnostic procedures for effective therapeutic management and follow-up, with the goal of improving the quality of life for these young women.