Ultrasound-guided transvaginal radiofrequency ablation combined with levonorgestrel-releasing intrauterine system for symptomatic uterine adenomyosis treatment

Adenomyosis is a heterogenous gynecologic condition. Patients with adenomyosis can have a range of clinical presentations. The most common presentation of adenomyosis is heavy menstrual bleeding and dysmenorrhea; however, patients can also be asymptomatic. Currently, there are no standard diagnostic imaging criteria, and choosing the optimal treatment for patients is challenging. Women with adenomyosis often have other associated gynecologic conditions such as endometriosis or leiomyomas, therefore making the diagnosis and evaluating response to treatment challenging. The objective of this review was to highlight current clinical information regarding the epidemiology, risk factors, pathogenesis, clinical manifestations, diagnosis, imaging findings, and treatment of adenomyosis. Several studies support the theory that adenomyosis results from invasion of the endometrium into the myometrium, causing alterations in the junctional zone. These changes are commonly seen on imaging studies such as transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI). The second most common theory is that adenomyosis results from embryologic-misplaced pluripotent mullerian remnants. Traditionally, adenomyosis was only diagnosed after hysterectomy; however, studies have shown that a diagnosis can be made with biopsies at hysteroscopy and laparoscopy. Noninvasive imaging can be used to help guide the differential diagnosis. The most common findings on 2-dimensional/3-dimensional TVUS and MRI are reviewed. Two-dimensional TVUS and MRI have a respectable sensitivity and specificity; however, recent studies indicate that 3-dimensional TVUS is superior to 2-dimensional TVUS for the diagnosis of adenomyosis and may allow for the diagnosis of early-stage disease. Management options for adenomyosis, both medical and surgical, are reviewed. Currently, the only definitive management option for patients is hysterectomy.

Uterine adenomyosis was initially thought to be found only in parous women, and final diagnosis was made at histology after hysterectomy. With better imaging techniques and with women attending clinics at older ages, adenomyosis is diagnosed with increasing frequency in women attending infertility clinics. A dozen conservative interventions have been advocated, with variable reports of their impact on fertility. This presents a dilemma for clinicians managing such patients. Hence, this systematic review of adenomyosis was performed to determine (i) the prevalence in a subfertile population, (ii) the accuracy of diagnostic tests, (iii) the efficacy of fertility sparing treatment options and (iv) the reproductive and obstetric/perinatal outcomes in women with adenomyosis.

The complex pathogenesis and variable presentation of adenomyosis make it one of the most difficult of the FIGO PALM-COIEN abnormal uterine bleeding group to diagnose and treat. Basic clinical parameters such as prevalence are difficult to accurately assess because histological confirmation is usually employed; however, because of the access to and accuracy and utilization of transvaginal ultrasound and other advanced imaging techniques such as MRI, noninvasive diagnosis is recognized to be highly accurate. The clinical symptoms of pain, abnormal uterine bleeding, and subfertility are the primary presentations of adenomyosis with increasing data supporting a substantial role of this disease in reducing fecundity and interfering with assisted reproductive interventions. Treatments have been aimed at managing symptoms and improving fertility options. Management by hysterectomy is not always desired by women, and with many women having children in their fourth and even fifth decades, it is often not reasonable to consider this radical option.