Type and Location of Adenomyosis in Women with Recurrent Pregnancy Loss: A Transvaginal Ultrasonographic Assessment.

The current knowledge on adenomyosis as a risk factor for RPL is very scant. Overall 120 women were included in this retrospective observational study. They were divided in three groups each of which consisted of 40 subjects: Group 1: women with RPL who were diagnosed to have adenomyosis on transvaginal ultrasound (TVS); Group 2: patients with RPL without ultrasonographic findings of adenomyosis; Group 3: patients with ultrasound diagnosis of adenomyosis without RPL and at least one live birth pregnancy. The copresence of endometriosis was also investigated. Among women with RPL, patients with adenomyosis (Group 1) had higher number of pregnancy losses (p = 0.03) and lower age at first pregnancy loss (p = 0.03) than women without adenomyosis (Group 2). Moreover, they had more frequently primary RPL (p = 0.008). Adenomyosis of the inner myometrium was found more frequently (p = 0.04) in patients of Group 1 than in patients of Group 3 in which adenomyosis was mainly in the outer myometrium (p= 0.02). No differences were found in the severity of adenomyosis between these two groups of women. TVS findings for endometriosis were observed more frequently in women with adenomyosis without RPL (Group 3) than in the other two groups of patients. Adenomyosis can be a factor involved in RPL. Differences in adenomyosis localization are associated with different risks for RPL. Patients with RPL should be investigated for the presence of adenomyosis and also for the type and localization of the disease in the different myometrial layers.

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

OBJECTIVE: To study racial and ethnic disparities among women undergoing hysterectomy performed for adenomyosis across the United States. DESIGN: A cohort study. SETTING: Data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2012-2020. PATIENTS: Patients with an adenomyosis diagnosis. INTERVENTION: Hysterectomy for adenomyosis. MAIN OUTCOME MEASURES: Patients were identified using the International Classification of Diseases 9th and 10th editions codes 617.0 and N80.0 (endometriosis of the uterus). Hysterectomies were classified on the basis of the Current Procedural Terminology codes. We compared baseline and surgical characteristics and 30-day postoperative complications across the different racial and ethnic groups. Postoperative complications were classified into minor and major complications according to the Clavien-Dindo classification system. RESULTS: A total of 12,599 women underwent hysterectomy for adenomyosis during the study period: 8,822 (70.0%) non-Hispanic White, 1,597 (12.7%) Hispanic, 1,378 (10.9%) non-Hispanic Black or African American, 614 (4.9%) Asian, 97 (0.8%) Native Hawaiian or Pacific Islander, and 91 (0.7%) American Indian or Alaska Native. Postoperative complications occurred in 8.8% of cases (n = 1,104), including major complications in 3.1% (n = 385). After adjusting for confounders, non-Hispanic Black race and ethnicity were independently associated with an increased risk of major complications (adjusted odds ratio 1.54, 95% confidence interval [CI] {1.16-2.04}). Laparotomy was performed in 13.7% (n = 1,725) of cases. Compared with non-Hispanic White race and ethnicity, the adjusted odd ratios for undergoing laparoscopy were 0.58 (95% CI 0.50-0.67) for Hispanic, 0.56 (95% CI 0.48-0.65) for non-Hispanic Black or African American, 0.33 (95% CI 0.27-0.40) for Asian, and 0.26 (95% CI 0.17-0.41) for Native Hawaiian or Pacific Islander race and ethnicity. CONCLUSION: Among women undergoing hysterectomy for postoperatively diagnosed adenomyosis, non-Hispanic Black or African American race and ethnicity were associated with an increased risk of major postoperative complications. Compared with non-Hispanic White race and ethnicity, Hispanic ethnicity, non-Hispanic Black or African American, Asian, Native Hawaiian, or Pacific Islander race and ethnicity were less likely to undergo minimally invasive surgery.

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

INTRODUCTION: Studies that use standardized ultrasonographic criteria to diagnose adenomyosis in subfertile women are needed. These would improve the understanding of the disease burden and enable further studies on its impact on fertility and assisted reproductive treatment (ART) outcome. The aim of this study was to determine the prevalence of different features of adenomyosis in women scheduled for their first ART, diagnosed at two (2D) and three-dimensional (3D) transvaginal ultrasonography (TVUS) using the revised Morphological Uterus Sonographic Assessment (MUSA) group definitions. MATERIAL AND METHODS: This was a prospective, observational cross-sectional study of subfertile women aged 25 to ≤39 years, that were referred to a university hospital for their first ART between December 2018 and May 2021. Of 1224 eligible women, 1160 women fulfilled the inclusion criteria and consented to participate in the study. All women underwent a systematic 2D and 3D TVUS examination. The primary outcome was the presence of direct and indirect features of adenomyosis, as proposed by the MUSA group. Secondary outcomes were to describe the ultrasonographic characteristics of the different features, as well as any difference in the diagnostics at 2D or 3D TVUS and any association with clinical characteristics such as endometriosis. RESULTS: At least one direct or indirect feature of adenomyosis was observed in 272 (23.4%, 95% confidence interval [CI] 21.0-25.9) women. Direct features that are pathognomonic for the disease were observed in 111 (9.6%, 95% CI, 7.9-11.3) women. Direct features were visible only at 3D TVUS in 56 (4.8%, 95% CI 3.6-6.1) women, that is, 56/111 (50.5%) of women with at least one direct adenomyosis feature. Direct features were more common in women with endometriosis (OR 2.8, 95% CI 1.8-4.3). CONCLUSIONS: We found than one in 10 women scheduled for ART had direct features of adenomyosis at ultrasound examination. The present study suggests that the use of 3D TVUS is an important complement to 2D in the diagnostics of adenomyosis. Our results may further improve the counseling of women scheduled for ART and enables future studies on the impact of different features of adenomyosis on subfertility, ART results and obstetric outcomes.

Uterine peristalsis in women affected by adenomyosis: A step towards functional assessment.

OBJECTIVE: The non-pregnant uterus shows an intrinsic contractility pattern, actively involved in early reproductive processes. Uterine contractility is characterized by endometrial waves that originate from the junctional zone and varies throughout the menstrual cycle due to fluctuations in the concentrations of hormones. The aim of this study was to compare the uterine contractility patterns in the periovulatory phase in a group of patients with isolated adenomyosis and a group of healthy women using transvaginal ultrasound (TVUS). METHODS: From March 2019 to March 2021, we enrolled consecutive nulliparous patients in the periovulatory phase of the menstrual cycle, divided in patients with isolated adenomyosis (group A, n = 18) and healthy patients in the control group (group B, n = 18). Patients who met the inclusion criteria underwent TVUS for the study of uterine contractility: the uterus was scanned on sagittal plane for 3 min and all the movies were recorded. Then, static images and video were evaluated offline and the uterine contractility patterns were defined. RESULTS: The patients belonging to the study group had a higher incidence of painful symptoms (dysmenorrhea, 6.11 ± 2.81 vs 1.39 ± 2.17; chronic pelvic pain, 2.56 ± 3.01 vs 0.39 ± 1.04) and a larger uterine volume (137.48 ± 117.69 vs 74.50 ± 27.58 cm3; P = 0.04). Regarding the uterine contractility, a statistically significant difference was observed about the retrograde patterns (group A, 27.8% vs group B, 72.2%, P < 0.01) and opposing (group A, 38.9% vs, group B, 5.6%, P = 0.02). CONCLUSION: The study confirms the presence of altered uterine peristalsis in the periovulatory phase in patients with adenomyosis. The abnormal uterine peristalsis could lead to both structural and functional changes, which are the basis of the clinical manifestations of adenomyosis and the perpetuation of the anatomical damage.

Pregnancy outcomes with donor oocyte embryos in patients diagnosed with adenomyosis using the Morphological Uterus Sonographic Assessment criteria.

OBJECTIVE: To use the Morphological Uterus Sonographic Assessment (MUSA) criteria to evaluate the impact of adenomyosis on the live birth rate after donor egg embryo transfer. DESIGN: Retrospective cohort study. SETTING: Tertiary fertility care center. PATIENT(S): A total of 100 patients who received 223 donor embryo transfers from January 2014-2020. All patients underwent ultrasound before their first transfer. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Our study was powered (80%) to assess the primary outcome of live birth rate; the secondary outcomes included the clinical pregnancy, biochemical pregnancy, and miscarriage rates. RESULT(S): Only 22 of 100 patients were diagnosed with adenomyosis on the original ultrasound report. When the MUSA criteria were applied, 76 patients had at least 1 possible ultrasonographic feature of adenomyosis; all 76 patients had an interrupted junctional zone. The second most common feature of adenomyosis was a globular and/or enlarged uterus (89.4%). Adjusted modeling demonstrated that a single ultrasound feature, 2 or more features, specific features, or the location of features did not affect the live birth outcome. A per-centimeter increase in the diameter of focal lesions was significantly associated with a decrease in the odds of live birth by the factor of 0.91. CONCLUSION(S): To our knowledge, our study is the first to characterize adenomyosis using the MUSA criteria in the donor oocyte population. Overall, our data were reassuring in that the ultrasonographic features of adenomyosis may not impact reproductive outcomes. However, we identified that the location and size of focal lesions may be important and should be studied further.

Doppler Imaging Assessment of Changes of Blood Flow in Adenomyosis After Higher-Dose Oxytocin: A Randomized Controlled Trial.

OBJECTIVES: To assess the changes of blood flow in adenomyosis (AM) after higher-dose oxytocin (OT) in different doses, and to evaluate the safety for patients. METHODS: A total of 124 patients with AM were randomly divided into 4 groups with continuous intravenous infusion of OT as 0.06, 0.12, 0.24 and 0.36 U/min, respectively. The changes of arteries of AM before and after intravenous infusion of OT were observed by color Doppler ultrasound. The changes of blood flow volume of the artery of AM before and after intravenous infusion of OT were compared among the 4 groups, and the vital signs and adverse drug reactions were monitored during intravenous drip. RESULTS: During the trial, no severe adverse reactions occurred and the vital signs of all the patients were stable. Among the 4 groups, it was found that there was a significant difference in the change of blood flow volume of blood artery in AM lesions between 0.06 U/min OT group and the other three groups after intravenous drip of OT (P < .05), but there was no significant difference in blood flow volume among the three groups (P > .05), and the difference of adverse drug reactions was statistically significant with the increase of OT dose (P < .05). CONCLUSION: OT can effectively reduce the blood flow volume of AM lesions, and continuous intravenous infusion of 0.12 U/min OT is an appropriate dose that can not only minimize the blood flow volume but also reduce the incidence of adverse drug reactions.

Assessment of Quality of Life, Sexual Quality of Life, and Pain Symptoms in Deep Infiltrating Endometriosis Patients With or Without Associated Adenomyosis and the Influence of a Flexible Extended Combined Oral Contraceptive Regimen: Results of a Prospective, Observational Study.

BACKGROUND: The quality of life of women with deep infiltrating endometriosis (DIE) is impaired and may improve with combined oral contraceptives (COCs). AIM: To compare the overall and sexual quality of life of patients diagnosed with DIE with or without associated adenomyosis (AD) with that of healthy controls and determine the influence of a COC containing 2 mg dienogest/30 µg ethinyl estradiol on these aspects. METHODS: We enrolled 42 women diagnosed with DIE; 31 diagnosed with DIE + AD by transvaginal ultrasound, and 39 non-AD/DIE controls. All patients were interviewed regarding pain symptoms (dysmenorrhea, dyspareunia, dyschezia, and dysuria), heavy menstrual bleeding using the Pictorial Blood Loss Assessment Chart, quality of life using the Short Form-36 questionnaire (SF-36), and sexual quality of life using the Sexual Quality of Life-Female questionnaire (SQOL-F) and the Brief Profile of Female Sexual Function (B-PFSF) before starting COCs and after 12 months of treatment. OUTCOMES: There was significant improvement in overall and sexual quality of life after treatment in DIE and DIE + AD patients. RESULTS: Non-AD/DIE controls showed significantly higher scores in the B-PFSF, the SQOL-F and the SF-36 questionnaires (P < .05) at baseline versus the other groups. DIE + AD patients showed poorer quality of sexual life and greater intensity in pain symptoms compared with DIE patients. After 12 months of treatment, there was a significant improvement in overall and sexual quality of life in the DIE and DIE + AD groups, with improvement in sexual quality of life being slightly greater in DIE + AD patients compared with DIE patients. Pain symptoms also decreased in both groups. CLINICAL IMPLICATIONS: Patients with DIE + AD showed greater impairment in overall and sexual quality of life compared with patients with isolated DIE which seems to improve with a COC containing 2 mg dienogest/30 µg ethinyl estradiol. STRENGTHS & LIMITATIONS: Strengths include the long-term follow up, assessment of the impact of two associated conditions, and administration of the same COC in all patients. Limitations include the relatively small sample size, and the fact that we did not assess the effectiveness of a flexible extended COC regimen containing 2 mg dienogest/30 µg ethinyl estradiol since the groups were different at baseline. CONCLUSION: Patients diagnosed with DIE with or without AD have a decreased quality of life which may improve with a COC containing 2 mg dienogest/30 µg ethinyl estradiol. Further research is needed to confirm our results. Alcalde AM, Martínez-Zamora MÁ, Gracia M, et al. Assessment of Quality of Life, Sexual Quality of Life, and Pain Symptoms in Deep Infiltrating Endometriosis Patients With or Without Associated Adenomyosis and the Influence of a Flexible Extended Combined Oral Contraceptive Regimen: Results of a Prospective, Observational Study. J Sex Med 2022;19:311-318.

Consensus on revised definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis: results of modified Delphi procedure.

OBJECTIVES: To evaluate whether the Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis need to be better defined and, if deemed necessary, to reach consensus on the updated definitions. METHODS: A modified Delphi procedure was performed among European gynecologists with expertise in ultrasound diagnosis of adenomyosis. To identify MUSA features that might need revision, 15 two-dimensional (2D) video recordings (four recordings also included three-dimensional (3D) still images) of transvaginal ultrasound (TVS) examinations of the uterus were presented in the first Delphi round (online questionnaire). Experts were asked to confirm or refute the presence of each of the nine MUSA features of adenomyosis (described in the original MUSA consensus statement) in each of the 15 videoclips and to provide comments. In the second Delphi round (online questionnaire), the results of the first round and suggestions for revision of MUSA features were shared with the experts before they were asked to assess a new set of 2D and 3D still images of TVS examinations and to provide feedback on the proposed revisions. A third Delphi round (virtual group meeting) was conducted to discuss and reach final consensus on revised definitions of MUSA features. Consensus was predefined as at least 66.7% agreement between experts. RESULTS: Of 18 invited experts, 16 agreed to participate in the Delphi procedure. Eleven experts completed and four experts partly finished the first round. The experts identified a need for more detailed definitions of some MUSA features. They recommended use of 3D ultrasound to optimize visualization of the junctional zone. Fifteen experts participated in the second round and reached consensus on the presence or absence of ultrasound features of adenomyosis in most of the still images. Consensus was reached for all revised definitions except those for subendometrial lines and buds and interrupted junctional zone. Thirteen experts joined the online meeting, in which they discussed and agreed on final revisions of the MUSA definitions. There was consensus on the need to distinguish between direct features of adenomyosis, i.e. features indicating presence of ectopic endometrial tissue in the myometrium, and indirect features, i.e. features reflecting changes in the myometrium secondary to presence of endometrial tissue in the myometrium. Myometrial cysts, hyperechogenic islands and echogenic subendometrial lines and buds were classified unanimously as direct features of adenomyosis. Globular uterus, asymmetrical myometrial thickening, fan-shaped shadowing, translesional vascularity, irregular junctional zone and interrupted junctional zone were classified as indirect features of adenomyosis. CONCLUSION: Consensus between gynecologists with expertise in ultrasound diagnosis of adenomyosis was achieved regarding revised definitions of the MUSA features of adenomyosis and on the classification of MUSA features as direct or indirect signs of adenomyosis. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Assessment of Sexual Quality of Life and Satisfaction in Couple Relationships Among Women With Deep Infiltrating Endometriosis and Adenomyosis.

Adenomyosis and endometriosis are similar gynecological diseases that decrease sexual quality of life and, in the case of endometriosis, satisfaction in couple relationships. This study aimed to assess sexual quality of life and couple satisfaction in women diagnosed with adenomyosis (AD) or deep infiltrating endometriosis (DIE). The study population included three groups of couples: one composed of 58 couples in which the woman was diagnosed with AD by transvaginal ultrasound (AD group), a second group comprising 55 couples in which the woman was diagnosed with isolated DIE by transvaginal ultrasound (DIE group), and a third group composed of 60 couples in which the women did not have AD or endometriosis (non-AD/DIE group). All women completed the Sexual Quality of Life-Female (SQOL-F) questionnaire, and all the couples completed the Dyadic Adjustment Scale (DAS). Sexual quality of life was significantly worse in women with AD or DIE compared with non-AD/DIE controls. Dyadic adjustment was significantly worse in the AD and DIE groups compared with the non-AD/DIE group. AD and DIE may impair quality of sexual life and couple relationships. Clinicians should be aware of this issue when treating women with AD or DIE.

The Value of Adenomyosis Type in Clinical Assessment: A Single-center Experience of 755 Nodular and Diffuse Adenomyosis Cases.

BACKGROUND: To investigate the incidence of nodular and diffuse adenomyosis, concomitant pathologies and also to compare the demographic and clinic differences among patients with adenomyosis and their surgery indications. METHODS: This retrospective study was conducted in Tepecik Research Hospital, Izmir, Turkey between 2014 and 2016. Patients were divided into two groups of nodular and diffuse adenomyosis. The following variables were evaluated for both groups: age, gravidity, parity, menopausal status, indication for hysterectomy, ultrasonographic parameters, gynecological symptoms (abnormal uterine bleeding [AUB], pelvic pain and pelvic pressure, postmenopausal vaginal bleeding), preoperative and postoperative histopathological assessment, and coexisting pathologies. RESULTS: Of the total 3457 cases of hysterectomies, 755 (95% CI: 20.4-23.1) were confirmed with adenomyosis. There were 217 (95% CI: 23.9-30.0) postmenopausal women. Adenomyosis was most commonly detected in patients in the age of 40 to 50 (57.6%). The most common symptoms were AUB (n: 336) (95% CI: 40.9-48.0), pelvic pain or pressure (n:139) (18.4%), and postmenopausal vaginal bleeding (n: 119) (95% CI: 13.1-18,4). Seventy-four (95% CI: 7.9-11.9) of the patients had nodular and 681(95% CI: 88.0-92.3) had diffuse adenomyosis. Demographic data, age, parity, gravidity, endometrial thickness, and menopausal status were similar between the groups. AUB was more frequently detected in nodular adenomyosis (56.8%). Myoma uteri was the main hysterectomy indication in both groups. In addition, treatment-resistant AUB for nodular adenomyosis and endometrial pathologies for diffuse adenomyosis were the most frequent indications for hysterectomy after myoma uteri. CONCLUSION: The most common form of adenomyosis was the diffuse form. Endometrial pathologies were more frequently associated with diffuse adenomyosis. Asymptomatic and incidental adenomyosis were more common with the diffuse form. AUB was more frequently detected with nodular adenomyosis.

Assessment of quality of sexual life in women with adenomyosis.

This study aimed to assess the impact of adenomyosis (AD) on different domains of sexual life. The study population included three groups: one composed of 68 women diagnosed with AD by transvaginal ultrasound, a second group comprised by 65 women diagnosed with isolated deep infiltrating endometriosis by transvaginal ultrasound and a third group including 70 women without AD or/and endometriosis. All participants completed the Brief Profile of Female Sexual Function (B-PFSF), the Female Sexual Distress Scale (FSDS), and the Sexual Quality of Life-Female (SQOL-F) questionnaire. Compared with non-AD/DIE controls, women with AD present significantly lower scores of the B-PFSF and the SQOL-F questionnaires and higher FSDS questionnaire scores (p < .0001). There were no differences between the groups of AD and deep infiltrating endometriosis. Clinicians should be aware that the quality of sexual life may be affected in patients with AD. Early diagnosis and multidisciplinary management would contribute to preventing impairment of sexual quality of life in these patients.

Which imaging method is better for the differentiation of adenomyosis and uterine fibroids?

OBJECTIVE: The paper compares shear wave elastography (SWE), strain elastography (SE) and magnetic resonance imaging apparent diffusion coefficient (MRI ADC) values, to evaluate their efficacy for differentiating between adenomyosis (AM) and uterine fibroids (UF). METHODS: Patients who were scheduled for hysterectomy for AM or UFs, with a preliminary diagnosis, were additionally evaluated before surgery by transabdominal and transvaginal ultrasound elastography. SE of patients were evaluated by transvaginal ultrasound, and SWE of patients and control subjects were evaluated by transabdominal ultrasound. Then, the patients with a definitive histopathological diagnosis as AM or UFs were evaluated retrospectively and compared to the control group without myometrial pathology. In addition, MRI images of patients with UFs and AM were examined for ADC values. RESULTS: The results of 98 patients in the UF group, 37 patients in the AM group, and 40 volunteers with a healthy myometrium in the control group were compared. There were no statistically significant differences in age and body mass index between the groups (P > 0.05). Uterine size was significantly higher in the UF and AM group than the control group (P < 0.001). A statistically significant difference was found between strain ratio (mean), strain ratio (max), and ADC values between the UF and AM groups (P < 0.001 for all three). There was a statistically significant difference in elastography scores distribution between the groups (P < 0.001). There was a statistically significant difference between the UF and control (P < 0.001) and between the UF and AM (P < 0.001) groups in terms of SWE (kilopascal (kPa)) averages (P < 0.001). We found that none of these discrimination methods were statistically superior to each other in differentiating the UFs from the AM. CONCLUSION: In the differentiation of myometrial pathologies in gynecological imaging, both SE and SWE are cheaper, provide faster results, are non-invasive and easy to apply, and hence are as promising as the more expensive MRI ADC. Our study is the first to use both modalities of elastography and MRI ADC values together, compare these methods with each other and confirm the results pathologically.

Drug Development in Endometriosis and Adenomyosis: It Takes More Than Just Good Science.

The pipelines of pharmaceutical companies are filled with thousands of promising new compounds for a plethora of indications. Yet, a close review of the drugs that have recently been in clinical trials quickly reveals that only a handful of drugs under evaluation in women with endometriosis can be genuinely qualified as truly innovative and breakthrough drugs. Why is there such an industry-wide lukewarm interest in drug research and development for endometriosis/adenomyosis? Why are pharmaceutical companies so reluctant to initiate programs or invest in academic research in endometriosis/adenomyosis? It is evident that a substantial part of the novel druggable targets originate from research in academia. However, only the pharmaceutical industry has the resources and expertise to bring drugs to patients. In other words, we are fully dependent on the pharmaceutical industry to bring new therapeutics to the market. The aim of this editorial is to make scientists from academia aware of the enormous complexity of the drug development process, the drivers that propel pharmaceutical companies to initiate new programs and to prioritize their portfolios, the value of intellectual property rights, and also about the importance of scientific rigor, predictive translational models, and biomarkers. At the same time, the pharmaceutical industry must be made aware of the enormous opportunity at hand, as the current patient population with endometriosis/adenomyosis is just the tip of the iceberg. We hope that the insights presented here will enable the endometriosis/adenomyosis research community to find ways to valorize their knowledge and attract the interest of the industry.

Accuracy and Reproducibility of Sonoelastography for the Assessment of Fibroids and Adenomyosis, with Magnetic Resonance Imaging as Reference Standard.

The aims of this prospective diagnostic evaluation study were (i) to estimate the inter-observer agreement and reproducibility of real-time sonoelastography and real-time gray-scale ultrasound in the measurement of uterine and fibroid volumes; (ii) to evaluate the agreement between real-time gray-scale ultrasound, sonoelastography and magnetic resonance imaging with respect to these outcomes; and (iii) to evaluate the diagnostic accuracy of sonoelastography in the diagnosis of uterine pathology on stored sonoelastography and gray-scale cine loops. Women without a history of uterine pathology and with the diagnosis intrauterine fibroids or adenomyosis were included. All participants underwent gray-scale ultrasound, sonoelastography and magnetic resonance imaging. Compression sonoelastography was found to have high inter-observer and inter-method agreement for the measurement of uterine and fibroid volumes. The addition of sonoelastography to gray-scale ultrasound seems to be useful in the differentiation between fibroids, adenomyosis and normal uteri as reflected by an increase in accuracy and diagnostic agreement.

Drug therapy for adenomyosis: a prospective, nonrandomized, parallel-controlled study.

Objective To provide novel insights into the clinical treatment of adenomyosis. Methods Two hundred patients with adenomyosis were enrolled in this prospective, nonrandomized, parallel-controlled study with a 1-year follow-up in our hospital. Group 1 was treated with 3.75 mg leuprorelin acetate (LA) (n = 40), Group 2 was treated with 1.88 mg LA (n = 40), Group 3 underwent Mirena implantation (n = 40), Group 4 underwent Mirena implantation after treatment with 3.75 mg LA (n = 40), Group 5 underwent Mirena implantation after treatment with 1.88 mg LA (n = 20), and Group 6 received San-Jie-Zhen-Tong capsules alone (n = 20). Uterine volume, pain, cancer antigen 125 level, ovary function, adverse effects, and Mirena expulsion were evaluated. Results The uterine volume and pain scores were lower in the groups treated with 1.88 than 3.75 mg LA, but the lower dose was associated with significantly fewer hot flashes and sweating. The 1-year Mirena expulsion rate was higher in Group 3 than in Groups 4 and 5 (10.00% vs. 3.33%, respectively). Costs were significantly higher in Groups 1 and 4 than in Groups 2 and 5. Conclusion Administration of 1.88 mg LA may be an alternative therapy for Asian patients with adenomyosis. The combination of LA and Mirena could enhance the therapeutic effect. Registration number: ChiCTR-IPR-15005971.

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

OBJECTIVE: To evaluate cost-effectiveness of ultrasound-guided high-intensity focused ultrasound (USgHIFU) and open hysterectomy for adenomyosis. DESIGN: A retrospective analysis. SETTING: Gynaecological department in a single centre in China. POPULATION: Patients with symptomatic adenomyosis. MAIN OUTCOME MEASURES: Cost difference between patients with adenomyosis treated with USgHIFU and open hysterectomy. METHODS: Three hundred and sixty-eight patients with adenomyosis were retrospectively reviewed. Among them, 302 patients were treated with USgHIFU and 66 patients with open hysterectomy. All of them had 1-, 3-, 6- and 12-month follow ups. The patients' quality of life (QOL) was evaluated and the utility scores were obtained from a rating scale to conduct a cost-utility analysis (CUA). RESULTS: No significant differences were found at any follow-up time point in the QOL between the two groups (P > 0.05). After treatment, the QOL scores significantly increased in both groups (P < 0.05): the quality adjusted life year (QALY) for patients treated with USgHIFU was USUS$5256.48, whereas it was USUS$7510.03 for patients treated with open hysterectomy. Both incremental cost and sensitivity analysis showed that USgHIFU was less costly than open hysterectomy. CONCLUSIONS: The QOL of patients with adenomyosis can be significantly improved by either USgHIFU or open hysterectomy, but USgHIFU is less costly. TWEETABLE ABSTRACT: USgHIFU can safely be used to treat patients with adenomyosis and significantly improved the quality of life of patients after treatment. The cost of USgHIFU is less than that of surgical treatment.

Preoperative assessment of factors associated with difficulty in performing total laparoscopic hysterectomy.

AIM: Our objective was to determine the preoperative factors associated with difficulty in total laparoscopic hysterectomy (TLH). METHODS: This retrospective clinical study included 157 patients who underwent TLH for leiomyoma or adenomyosis between 2009 and 2013. All patients underwent magnetic resonance imaging (MRI) before surgery. We categorized patients as 'difficult' if the operation time was > 243 min, if total blood loss was > 500 mL, or if conversion to laparotomy was necessary. Preoperative information, including MRI findings, was compared between the difficult and 'other' patients. Stepwise logistic regression analysis was used to control for covariates that were significant on univariate analysis (P < 0.05). RESULTS: The presence of an endometrioma, a previous cesarean section (CS), a wide uterus, and a high body mass index were independent risk factors for being a difficult patient. For adenomyosis patients, the presence of an endometrioma, a prior CS, subtype II adenomyosis, and high body mass index were independent risk factors for being a difficult patient. For leiomyoma patients, the presence of an endometrioma, a prior CS, and having at least seven leiomyomas were independent risk factors for being a difficult patient. All laparotomy conversion patients had multiple risk factors. CONCLUSION: We have elucidated the factors associated with difficult TLH patients using patients' background and preoperative MRI findings. Awareness of these predictive factors may enable surgeons to prepare for the operation, minimize complications, or choose another more appropriate route of hysterectomy than TLH.

Terms, definitions and measurements to describe sonographic features of myometrium and uterine masses: a consensus opinion from the Morphological Uterus Sonographic Assessment (MUSA) group.

The MUSA (Morphological Uterus Sonographic Assessment) statement is a consensus statement on terms, definitions and measurements that may be used to describe and report the sonographic features of the myometrium using gray-scale sonography, color/power Doppler and three-dimensional ultrasound imaging. The terms and definitions described may form the basis for prospective studies to predict the risk of different myometrial pathologies, based on their ultrasound appearance, and thus should be relevant for the clinician in daily practice and for clinical research. The sonographic features and use of terminology for describing the two most common myometrial lesions (fibroids and adenomyosis) and uterine smooth muscle tumors are presented.

Real-time elastography for assessment of uterine disorders.

OBJECTIVES: Sonoelastography is an ultrasound-imaging technique that measures tissue strain. The aim of this study was to define, in a systematic manner, specific sonoelastographic characteristics of the myometrium, fibroids and adenomyosis, to evaluate the feasibility of sonoelastography in patients with suspected gynecological pathology and to compare the results with histology and/or magnetic resonance imaging (MRI)-based diagnoses. METHODS: We performed a prospective observational cohort study between 2009 and 2011. Two-hundred and eighteen women with suspected gynecological pathology underwent routine transvaginal ultrasound and additional real-time sonographic elastography. Sixty-nine of the 218 women underwent MRI and/or histological examination and were included in the final analysis. Acquisition of elastographic images was standardized. We analyzed the elastographic characteristics of myometrium, fibroids and adenomyosis. An independent observer, unaware of clinical, histological or MRI findings, evaluated the recorded elastographic images and cineloops. These elastographic-based diagnoses were compared with histology and/or MRI diagnoses. RESULTS: With elastography, the uterus was well delineated from the surrounding bowel. The myometrium was uniform in color in 49% of the cases, with a main color of purple or dark blue, indicating stiffer tissue. Fibroids and adenomyosis had different elastographic characteristics and different color patterns. In general, fibroids were darker and adenomyosis was brighter than adjacent myometrium. The agreement between elastography-based diagnosis of fibroids and adenomyosis with MRI-based diagnosis was excellent; with histology-based diagnosis, agreement was substantial for fibroids and adenomyosis. CONCLUSIONS: Elastography is able to identify clear discriminating characteristics of the uterus, fibroids and adenomyosis, and elastography-based diagnoses are in excellent agreement with those of MRI. Agreement between elastography-based diagnosis of adenomyosis and histology is substantial but not optimal.