Insoluble Dilemma of Adenomyosis: Diagnosis, Management, and Treatment  - Errico Zupi, MD

Individualizing the management and the treatment of adenomyosis is mandatory.

Key Points

Information for the presentation: Errico Zupi, MD is an associate professor in the Department of Obstetrics and Gynecology, University of Rome, Rome, Italy. He was the previous editor of the Journal of American Association of Gynecologic Laparoscopist. His speech in Endofound 2020 is on the topic "Insoluble dilemma of adenomyosis: Diagnosis, Management, and Treatment.

Importance:

• The frequency of "diagnosed adenomyosis" has increased in women who attend infertility clinics in recent years. In the past multiparty, short menstrual cycles and 35-50 years of age were the risk factors of the disease. But in recent years nulliparity and younger ages less than 30 years also gained importance.
• For these young patients who need to preserve their fertility, the selection of IVF treatment, or the uterus-sparing conservative surgery depends on their situation.

Highlights:

• Adequate preoperative definition of adenomyosis in gynecology clinics and to increase pregnancy achievement in the long-term is crucial.
• Research on the surgical and medical management and obstetric complications will help to scrutinize the role of adenomyosis on infertility and postpartum complications.

Remarks:

• Preoperative diagnosis of adenomyosis is difficult because the pathologic definition is mandatory. But it will be easy to define it preoperatively if the ultrasonographic image is recognized and the clinic is well-known by the clinician.  
• Uterus-sparing surgery is useful in women with adenomyosis who experienced IVF treatment failures especially before the age of 39. There are no clear benefits of the surgery on fertility outcomes in women who are more than 40.
• The risk of uterine rupture due to pregnancy after removal of adenomyosis is four times more when compared the surgery for the myomectomy.
• Global endometrial ablation by hysteroscopy has proved successful in the treatment of excessive bleeding in women with adenomyosis.
• Obstetric complications related to adenomyosis are PPROM (preterm premature rupture of membranes), preterm delivery, and postpartum hemorrhages.
• Selecting medical and/or surgical therapy should be by individualizing the treatment, together with the patient.

Lay Summary

The prevalence of adenomyosis has been reported to range from 1% to 70% in different studies. This large range can be explained by the lack of standard diagnostic criteria by imaging modalities or pathological analyses. Sixty-five% of the women with adenomyosis have clinical symptoms of abnormal uterine bleeding and dysmenorrhea. Additionally, there is an increasing diagnosis of adenomyosis among young women who consult infertility clinics. The FIGO group declared adenomyosis as a disease that is responsible for abnormal uterine bleeding in the 2018 meeting. The importance of this disease is that it can be seen 40-70% with endometriosis and 35-55% with leiomyomas, and also causes clinically different uterine bleeding.

In terms of medical treatment and classical drug therapy, Dr. Errico Zupi said "We use progestins as MPA/orally that have side effects like acne, and edema and NETA/vaginally that is progressively better with a longer duration of use. The third option is to put intracavitary IUD covered with progestin. After cessation of the medical therapy abnormal uterine bleeding and enlargement of the adenomyosis could determine clinically".

When we come to the surgical treatment of adenomyosis, which used to be a hysterectomy before the diagnostic frequency is increased among younger women; "In the case of pregnancy desire, we should consider uterus-sparing conservative surgery". Removal of adenomyosis consists of the radical excision of the adenomyosis and reconstruction of the uterus, which resulted in a dramatic reduction of symptoms. The rupture due to the enlargement of the uterus during pregnancy is four times higher compared to pregnancies followed by the removal of leiomyomas. Another surgical approach to adenomyosis with excessive uterine bleeding is hysteroscopic ablation of the endometrium.", Dr. Zuppi added.

Uterine artery embolization, a way to treat some uterine leiomyomas, could be effective in adenomyosis as well, as a non-surgical treatment. It could be considered as an alternative treatment option especially for symptomatic women of childbearing age in the presence of a large uterus with diffuse adenomyosis. Nevertheless, it is not suggested for patients who desire pregnancy in the long-term. MR-guided high-focus ultrasound surgery is another option that is mostly accepted by the patient but there are not enough data to be considered in the final conclusion.

Clinically a number of complications such as preterm premature rupture of membranes, premature delivery, malpresentation, preeclampsia, and postpartum hemorrhage are possible obstetrical outcomes of adenomyosis. The pathophysiology of postpartum hemorrhage by which adenomyosis predisposes will be published from the study group of Dr.Zupi in the coming months. This study that is in progress, will consider four different possible roles of adenomyosis, namely, Junctional zone modification, neoangiogenesis, coagulative modulators, and myometrial contraction.

Research Source: https://www.endofound.org/insoluble-dilemma-of-adenomyosis-diagnosis-management-and-treatment-errico-zupi-md?pop=mc