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Endometriosis and Adenomyosis: Modern Concepts on Clinical Outcomes, Treatment and Management

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Obstetrics & Gynecology".

Deadline for manuscript submissions: closed (10 October 2024) | Viewed by 12496

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Prof. Dr. Errico Zupi

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Department of Molecular and Developmental Medicine, Obstetrics and Gynecological Clinic, University of Siena, 53100 Siena, Italy
Interests: endometriosis; adenomyosis; laparoscopic surgery; transvaginal ultrasound; hysteroscopy; pelvic anatomy

Special Issue Information

Dear Colleagues,

Endometriosis is a chronic benign disease which affects 10% of women worldwide. Adenomyosis affects 5–70% of women and is frequently associated with endometriosis. Both reduce the quality of life of patients by causing painful symptoms, abnormal uterine bleeding, and subfertility.

Nowadays, treatment includes several medical and surgical options. The choice of the most appropriate therapy is tailored to the patient according to age, painful symptoms, and desire of pregnancy.

In the last 10 years, researchers have investigated new medical therapies and experimented with new surgical techniques to achieve the best outcome in terms of control of symptoms, fertility, and quality of life.

Research is proceeding quickly. New findings and modern concepts in the near future can aid specialized and dedicated physicians in the management of endometriosis and adenomyosis.

The topics of this Special Issue will include (but are not limited to):

New medical treatments for endometriosis and adenomyosis;
Novel surgical approaches to endometriosis and adenomyosis;
Investigation of accepted treatments which could modify the outcome and the clinical management of endometriosis and adenomyosis patients.

Therefore, researchers in the field of endometriosis and adenomyosis are encouraged to submit original articles and reviews related to this Special Issue. Communications, systematic reviews, and meta-analyses are also welcome.

Prof. Dr. Errico Zupi
Guest Editor

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Keywords

endometriosis
adenomyosis
management
outcome
surgical treatment
medical treatment
modern concepts

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Published Papers (9 papers)

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Research

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15 pages, 3218 KiB

Open AccessArticle

Relationship Between Ultrasound Diagnosis, Symptoms and Pain Scale Score on Examination in Patients with Uterosacral Ligament Endometriosis

by Shae Maple, Eva Bezak, K. Jane Chalmers and Nayana Parange

J. Clin. Med. 2024, 13(22), 6901; https://doi.org/10.3390/jcm13226901 (registering DOI) - 16 Nov 2024

Abstract

Background/Objectives: This study investigated patient pain descriptors for transvaginal ultrasound (TVS) diagnostic evaluation of endometriosis for uterosacral ligaments (USLs), including correlation between USL thickness and site-specific tenderness (SST). It further investigated if SST could positively assist diagnosing endometriosis on TVS. Methods: TVS images and SST pain descriptors were collected from 42 patients. SST was evaluated by applying sonopalpation during TVS. The images were presented to six observers for diagnosis based on established USL criteria. Following this, they were given the SST pain scores and asked to reevaluate their diagnosis to assess if the pain scores impacted their decision. Results: An independent t-test showed that the patients with an endometriosis history had higher pain scores overall (7.2 ± 0.59) compared to the patients with no history (0.34 ± 0.12), t (40) = 8.8673. Spearman’s correlation showed a strong correlation to the pain scale score for clinical symptoms (r = 0.74), endometriosis diagnosis (r = 0.78), USL thickness (r = 0.74), and when USL nodules were identified (r = 0.70). Paired t-tests showed that the observers demonstrated a higher ability to correctly identify endometriosis with the pain scale information (33 ± 8.83) as opposed to not having this information (29.67 ± 6.31), which was a statistically significant change of 3.33, t (5) = 2.7735. Conclusions: Patients with an endometriosis history have significantly higher pain scores on TVS compared to patients with no endometriosis history. A strong correlation was shown between SST pain scores and patient symptoms, USL thickness, and USL nodules. Inclusion of SST alongside TVS imaging shows promise, with these results demonstrating a higher ability to diagnose endometriosis with additional SST pain scale information. Full article

(This article belongs to the Special Issue Endometriosis and Adenomyosis: Modern Concepts on Clinical Outcomes, Treatment and Management)

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Figure 1
Flowchart summarizing the methodology process and the inclusion criteria of eligible patients and observers in the study. TVS, transvaginal ultrasound, DE, Deep Endometriosis, IDEA, International Deep Endometriosis Analysis, SST, site-specific tenderness. Full article ">Figure 2
Whisker plots demonstrating the Spearman’s correlation coefficient results for endometriosis characteristics versus pain scale. These graphs show the spread of endometriosis characteristics with patient SST pain scores on TVS (where X = mean score) with statistical significance (where all p < 0.0005), as represented in <a href="#jcm-13-06901-t003" class="html-table">Table 3</a>. (A) Correlation of endometriosis diagnosis (surgically or clinically by referring gynecologist) and pain; (B) correlation of patient clinical symptoms (chronic pelvic pain, dysmenorrhea, and dyspareunia) and pain; (C) correlation of USL thickness and pain; and (D) correlation of USL nodules (endometriosis identified including a focal USL nodule and endometriosis identified with no USL nodule seen) and pain. Full article ">Figure 3
Graph representation of relationship of diagnostic scores of professional observers before and after using pain scale across the six observers, as shown in <a href="#jcm-13-06901-t004" class="html-table">Table 4</a>. Full article ">Figure 4
Ultrasound images correlating patient TVS and SST. (A) Endometriomas/medialized ovaries to USLs: Transverse TVS image shows there are bilateral endometriomas and medialization of both ovaries adherent to the USLs (right and left as labeled) at the torus uterinus. A focal endometriotic nodule (arrows) can be seen between the right and left USLs. This patient has confirmed endometriosis associated with long-standing pelvic pain. Correlating SST at this location was described as “sharp” with a total 13/15 pain score. (B) Thickened USL and nodule: USL DE in a woman with severe pelvic pain and dyspareunia who was confirmed to have extensive endometriosis in laparoscopy. Sagittal TVS image shows an irregular and thickened left USL (labeled with caliper measuring 6.5 mm) with adherence of the left ovary (labeled). There is an associated focal endometriotic nodule (arrows) adherent to the adjacent structures. Calipers demonstrate a 6.5 mm thickness of the left USL measured at the thickest point. Correlating SST at this location was described as “sharp” with a total 12/15 pain score. (C) Rectosigmoid DE adherent to USL: Sagittal TVS image demonstrating extensive deep infiltrative endometriosis. Endometriosis plaque deposits (circled) can be seen at the level of the rectosigmoid bowel, tethered to the inferior margin of the left ovary (labeled). The left ovary is medialized, with an endometrioma adherent to the torus uterinus, extending to the right USL. Correlating SST at this location was described as “sharp” with a total 10/15 pain score. Full article ">

13 pages, 874 KiB

Open AccessArticle

Conservative Management of Bowel Endometriosis: Cross-Sectional Analysis for Assessing Clinical Outcomes and Quality-of-Life

by Marcello Ceccaroni, Silvia Baggio, Tommaso Capezzuoli, Mara Albanese, Paride Mainardi, Carlotta Zorzi, Giovanni Foti and Fabio Barra

J. Clin. Med. 2024, 13(21), 6574; https://doi.org/10.3390/jcm13216574 - 1 Nov 2024

Viewed by 412

Abstract

Background/Objectives: Bowel endometriosis (BE) is characterized by the presence of endometrial-like tissue within the muscular layer of the bowel wall. When BE does not result in the severe obstruction to fecal transit and in the absence of (sub)occlusive symptoms, the decision to perform surgery can be challenging, as intestinal procedures are associated with higher complication rates and long-term bowel dysfunction. This cross-sectional study aims to evaluate the quality of life (QoL) in patients with BE who avoided surgery, as well as to investigate the impact of the characteristics of BE nodules on the QoL and intestinal function. Methods: A retrospective cross-sectional analysis was conducted involving 580 patients with BE who did not undergo surgery but were treated conservatively with medical therapy or expectant management between January 2017 and August 2022. The diagnosis of BE was established through transvaginal ultrasound and confirmed via double contrast barium enema. After at least one year of follow-up, the QoL and intestinal function were assessed using the Endometriosis Health Profile-5 (EHP-5) questionnaire and the Bowel Endometriosis Symptom (BENS) score, while pain symptoms were quantified with the Visual Analog Scale (VAS 0–10). Statistical analyses were performed to explore potential associations between the QoL and the characteristics of BE nodules (size, location, and evidence of stenosis), as well as the type and duration of medical therapy. Results: Patients with BE reported a satisfactory overall QoL, with a mean EHP-5 score of 105.42 ± 99.98 points and a VAS score below three across all pain domains. They did not demonstrate significant impairment in bowel function, as indicated by a mean BENS score of 4.89 ± 5.28 points. Notably, patients receiving medical therapy exhibited a better QoL compared to those not receiving treatment (p < 0.05), with the exception of postmenopausal patients, who reported the highest QoL overall (p < 0.05). Among the characteristics of BE, nodule location significantly impacted the QoL and symptom intensity, with low (rectal or rectosigmoid) nodules less tolerated compared to sigmoid nodules, particularly regarding non-menstrual pelvic pain (NMPP), dyschezia, and psychological impact on daily life (p < 0.05). Conclusions: Women can effectively manage BE conservatively in the absence of (sub)occlusive symptoms, even when large nodules are present, causing significant radiological stenosis. The characteristics of BE nodules do not significantly affect the QoL or symptom intensity; however, the location of BE nodules is a crucial factor negatively influencing these outcomes. Medical therapy may confer a beneficial impact on patients of reproductive age with BE, but its use should be carefully considered for those approaching menopause, weighing the risks and benefits. Full article

(This article belongs to the Special Issue Endometriosis and Adenomyosis: Modern Concepts on Clinical Outcomes, Treatment and Management)

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11 pages, 665 KiB

Open AccessArticle

Women with Endometriosis—Who Is at Risk for Complications Associated with Pregnancy and Childbirth? A Retrospective Case–Control Study

by Teresa Mira Gruber, Laura Ortlieb, Wolfgang Henrich and Sylvia Mechsner

J. Clin. Med. 2024, 13(2), 414; https://doi.org/10.3390/jcm13020414 - 11 Jan 2024

Viewed by 1398

Abstract

Women with endometriosis (EM), particularly the manifestations of adenomyosis (AM) and deep infiltrating endometriosis (DIE), suffer from pain and sterility. DIE also appears with several specific obstetric complications. To determine the risk profile, we designed a retrospective case–control study. Primary outcomes were defined as the risk of preterm birth and caesarean delivery (CD). Primiparous singleton pregnancies in women with DIE were compared with controls without EM. We matched for mode of conception and maternal age. A total of 41 women diagnosed with DIE and 164 controls were recruited. A total of 92.7% of the cases were also diagnosed with AM. Preterm birth occurred in 12.2% of cases and in 6.7% of controls. The difference was not statistically significant (OR: 1.932; 95% CI: 0.632–5.907). The rate of CD was similar in both groups. Remarkably, placental implantation disorders in the form of placenta praevia were eight times more frequent in women with DIE (9.8%) than in controls (1.2%, OR: 8.757; 95% CI: 1.545–49.614). Neonatal outcome was similar in both groups. Four out of fourteen cases reported abdominal wall endometriosis after CD. Women with DIE/AM and with placenta praevia are at risk of bleeding complications. After CD, they can develop abdominal wall EM. We therefore suggest evaluating the birth mode in each woman with DIE/AM. Full article

(This article belongs to the Special Issue Endometriosis and Adenomyosis: Modern Concepts on Clinical Outcomes, Treatment and Management)

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Review

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18 pages, 611 KiB

Open AccessReview

Novel Minimally Invasive Surgical Approaches to Endometriosis and Adenomyosis: A Comprehensive Review

by Flávia Ribeiro and Hélder Ferreira

J. Clin. Med. 2024, 13(22), 6844; https://doi.org/10.3390/jcm13226844 - 14 Nov 2024

Viewed by 200

Abstract

Endometriosis and adenomyosis are chronic gynecological conditions that significantly impact women’s quality of life, leading to symptoms such as pelvic pain, dysmenorrhea, and infertility. Despite ongoing research, a definitive cure for these conditions remains elusive, and treatment often focuses on managing symptoms. Minimally invasive surgery is considered the gold standard for surgical management, but novel surgical techniques are continuously being developed to enhance outcomes. These innovations aim to reduce disease recurrence, improve fertility rates, and provide better long-term symptom relief. In addition, techniques like robot-assisted laparoscopy (RAS) have revolutionized the treatment of complex cases, such as deep infiltrating endometriosis (DIE), offering improved precision and effectiveness. This review explores the latest advancements in surgical approaches, their clinical efficacy, and future directions, emphasizing the need for individualized multidisciplinary care to optimize patient outcomes. Full article

(This article belongs to the Special Issue Endometriosis and Adenomyosis: Modern Concepts on Clinical Outcomes, Treatment and Management)

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15 pages, 7931 KiB

Open AccessReview

Adenomyosis: An Update Concerning Diagnosis, Treatment, and Fertility

by Aikaterini Selntigia, Pietro Molinaro, Silvio Tartaglia, Antonio Pellicer, Daniela Galliano and Mauro Cozzolino

J. Clin. Med. 2024, 13(17), 5224; https://doi.org/10.3390/jcm13175224 - 3 Sep 2024

Viewed by 2511

Abstract

This review article aims to summarize current tools used in the diagnosis of adenomyosis with relative pharmacological and surgical treatment and to clarify the relative association between adenomyosis and infertility, considering the importance of an accurate diagnosis of this heterogeneous disease. Among different reported concepts, direction invagination of gland cells from the basalis endometrium deep into the myometrium is the most widely accepted opinion on the development of adenomyosis. Adenomyosis has been increasingly identified in young women with pain, AUB, infertility, or no symptoms by using imaging techniques such as transvaginal ultrasound and magnetic resonance. Furthermore, adenomyosis often coexists with other gynecological conditions, such as endometriosis and uterine fibroids, increasing the heterogeneity of available data. However, there is no agreement on the definition and classification of adenomyotic lesions from both the histopathology and the imaging points of view, and diagnosis remains difficult and unclear. A standard, universally accepted classification system needs to be implemented to improve our understanding and inform precise diagnosis of the type of adenomyosis. This could be the key to designing RCT studies and evaluating the impact of adenomyosis on quality of life in terms of menstrual symptoms, fertility, and pregnancy outcome, given the high risk of miscarriage and obstetric complications. Full article

(This article belongs to the Special Issue Endometriosis and Adenomyosis: Modern Concepts on Clinical Outcomes, Treatment and Management)

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13 pages, 542 KiB

Open AccessReview

Endometriosis and Adenomyosis: Modern Concepts of Their Clinical Outcomes, Treatment, and Management

by Jessica Ottolina, Roberta Villanacci, Sara D’Alessandro, Xuemin He, Giorgia Grisafi, Stefano Maria Ferrari and Massimo Candiani

J. Clin. Med. 2024, 13(14), 3996; https://doi.org/10.3390/jcm13143996 - 9 Jul 2024

Cited by 1 | Viewed by 1981

Abstract

Endometriosis and adenomyosis are complex gynecological conditions characterized by diverse clinical presentations, including superficial peritoneal endometriosis (SPE), ovarian endometrioma (OMA), and deep infiltrating endometriosis (DIE). The hallmark features of these pathologies involve the manifestation of pain symptoms and infertility, and approximately 30% of patients are asymptomatic. Despite ongoing research, definitive treatments for these conditions remain elusive, and clinical management primarily revolves around medical or surgical interventions. Recent advancements in our understanding of the efficacy of various treatment modalities, including medical therapy and surgical interventions, have provided clinicians with valuable insights into pain relief and fertility preservation. This review aims to provide an updated overview of the latest literature on clinical outcomes, treatment options, and management strategies for different types of endometriosis. By synthesizing the newest available data, this review seeks to inform clinicians and guide decision making based on factors such as patients’ symptom severity, childbearing desire, and overall health. Full article

(This article belongs to the Special Issue Endometriosis and Adenomyosis: Modern Concepts on Clinical Outcomes, Treatment and Management)

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15 pages, 305 KiB

Open AccessReview

Artificial Intelligence in the Management of Women with Endometriosis and Adenomyosis: Can Machines Ever Be Worse Than Humans?

by Giulia Emily Cetera, Alberto Eugenio Tozzi, Valentina Chiappa, Isabella Castiglioni, Camilla Erminia Maria Merli and Paolo Vercellini

J. Clin. Med. 2024, 13(10), 2950; https://doi.org/10.3390/jcm13102950 - 16 May 2024

Cited by 1 | Viewed by 1637

Abstract

Artificial intelligence (AI) is experiencing advances and integration in all medical specializations, and this creates excitement but also concerns. This narrative review aims to critically assess the state of the art of AI in the field of endometriosis and adenomyosis. By enabling automation, AI may speed up some routine tasks, decreasing gynecologists’ risk of burnout, as well as enabling them to spend more time interacting with their patients, increasing their efficiency and patients’ perception of being taken care of. Surgery may also benefit from AI, especially through its integration with robotic surgery systems. This may improve the detection of anatomical structures and enhance surgical outcomes by combining intra-operative findings with pre-operative imaging. Not only that, but AI promises to improve the quality of care by facilitating clinical research. Through the introduction of decision-support tools, it can enhance diagnostic assessment; it can also predict treatment effectiveness and side effects, as well as reproductive prognosis and cancer risk. However, concerns exist regarding the fact that good quality data used in tool development and compliance with data sharing guidelines are crucial. Also, professionals are worried AI may render certain specialists obsolete. This said, AI is more likely to become a well-liked team member rather than a usurper. Full article

(This article belongs to the Special Issue Endometriosis and Adenomyosis: Modern Concepts on Clinical Outcomes, Treatment and Management)

18 pages, 3287 KiB

Open AccessReview

Deep Infiltrating Endometriosis in Adolescence: Early Diagnosis and Possible Prevention of Disease Progression

by Francesco Giuseppe Martire, Matteo Giorgi, Claudia D’Abate, Irene Colombi, Alessandro Ginetti, Alberto Cannoni, Francesco Fedele, Caterina Exacoustos, Gabriele Centini, Errico Zupi and Lucia Lazzeri

J. Clin. Med. 2024, 13(2), 550; https://doi.org/10.3390/jcm13020550 - 18 Jan 2024

Cited by 12 | Viewed by 2478

Abstract

Endometriosis has a prevalence of 10% worldwide in premenopausal women. Probably, endometriosis begins early in the life of young girls, and it is commonly diagnosed later in life. The prevalence of deep infiltrating endometriosis (DIE) in adolescence is currently unknown due to diagnostic limits and underestimation of clinical symptoms. Dysmenorrhea is a common symptom in adolescents affected by DIE, often accompanied by dyspareunia and chronic acyclic pelvic pain. Ultrasonography—either performed transabdominal, transvaginal or transrectal—should be considered the first-line imaging technique despite the potential for missed diagnosis due to early-stage disease. Magnetic resonance imaging should be preferred in the case of virgo patients or when ultrasonographic exam is not accepted. Diagnostic laparoscopy is deemed acceptable in the case of suspected DIE not responding to conventional hormonal therapy. An early medical and/or surgical treatment may reduce disease progression with an immediate improvement in quality of life and fertility, but at the same time, painful symptoms may persist or even recur due to the surgery itself. The aim of this narrative review is to report the prevalence of DIE in adolescents, describe the pathogenetic theories and discuss the management in adolescent women, including the challenging road to diagnosis and the treatment alternatives. Full article

(This article belongs to the Special Issue Endometriosis and Adenomyosis: Modern Concepts on Clinical Outcomes, Treatment and Management)

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Other

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12 pages, 3039 KiB

Open AccessSystematic Review

The Role of Different Medical Therapies in the Management of Adenomyosis: A Systematic Review and Meta-Analysis

by Giulia Galati, Gianfilippo Ruggiero, Alice Grobberio, Oriana Capri, Daniela Pietrangeli, Nadia Recine, Michele Vignali and Ludovico Muzii

J. Clin. Med. 2024, 13(11), 3302; https://doi.org/10.3390/jcm13113302 - 4 Jun 2024

Viewed by 1082

Abstract

Background/Objectives: Adenomyosis is a benign condition characterized by the presence of endometrial tissue within the myometrium. Despite surgery being a valuable approach, medical options are considered as the first-line approach and have been investigated in the treatment of adenomyosis, although strong evidence in favor of these is still lacking. This study aims to gather all available data and determine the effectiveness of the aforementioned medical options in patients with associated pain and not currently seeking pregnancy, both in comparison to placebo and to one another. Methods: For this study, PubMed and EMBASE were used as data sources, searched up to January 2024. A systematic review and meta-analysis were performed in accordance to guidelines from the Cochrane Collaboration. The primary outcomes investigated were changes in dysmenorrhea, quantified by means of VAS scores, HMB in terms of number of bleeding days, and changes in uterine volume determined at ultrasound. Twelve eligible studies were selected. Results: The results highlighted that dienogest yields a reduction in dysmenorrhea that is significantly superior to that of the rest of the medical treatments investigated (p-value of <0.0002). On the other hand, GnRH agonists seem to play a more prominent role in reducing uterine volume (p-value of 0.003). While it was not possible to determine which medical treatment better decreased the number of bleeding days, it was observed that COC performed significantly worse than the other treatments studied (p-value of 0.02). Conclusions: While this meta-analysis provides valuable insights in the comparative efficacy of different treatments, the paucity of relevant studies on the topic might impact the reliability of some of the conclusions drawn. Full article

(This article belongs to the Special Issue Endometriosis and Adenomyosis: Modern Concepts on Clinical Outcomes, Treatment and Management)

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