could the uterine junctional zone be used to identify early stage endometriosis in women

Although the correlation between endometriosis, junctional zone (JZ) hyperplasia and adenomyosis is still debated, the correlation among JZ and different etiological and clinical aspects is, today, well recognized. Starting from that, clinicians must consider in their own practice all the potential modifications of the JZ because the described could be correlated with reproductive or obstetrics disorders [1]. The accurate and analytical evaluation, case by case, of the JZ is one of the most crucial points in the flowchart of infertile patients and also endometriotic patients. An accurate evaluation of JZ and its potential modifications can provide important information for patients with endometriosis and/or infertility or chronic pelvic pain. We know that adenomyosis is a common gynecologic disease characterized by the migration of endometrial glands and stroma from the basal layer of endometrium into the myometrium, and could be associated with smooth muscle hyperplasia. The first author that mentioned adenomyosis and its histopathological features was Rokitansky in 1860 describing the invasion of stroma and endometrial glands inside the myometrium with different levels of invasion up to the serosa [2]. A common pathogenesis for adenomyosis and endometriosis has been hypothesized, and it is argued that endometrial stroma being in direct contact with the underlying myometrium allows communication and interaction, thus facilitating endometrial invagination or invasion of a structurally weakened myometrium during periods of regeneration, healing and re-epithelization. Dislocation of basal endometrium may also result in endometriosis through retrograde menstruation [3]. Pelvic endometriosis and uterine adenomyosis are variants of the same disease, which involves the dislocation of basal endometrium and results from a dysfunction and disease primarily at the level of the JZ [4]. Pelvic endometriosis, especially in its severe stages, is also strongly associated with JZ thickening [5–8]. Therefore, the evaluation of JZ and its alterations by non invasive imaging are very important, especially in patients with endometriosis. Adenomyosis is also defined as the chronic disruption of the boundary between the basal layer of the endometrium and the myometrium, known as the JZ, with the hallmark pathologic finding of endometrial glands and stroma within the myometrium [9]. Both parts of the JZ (endometrium and subendometrial myometrium) have a common embryological origin from the paramesonephric ducts and show cyclical changes during the menstrual cycle, whereas the outer myometrium is of nonparamesonephric mesenchymal origin [10]. The etiology of adenomyosis is not known, but there are recent interesting theories that consider adenomyosis as an expression of pathological endomyometrial JZ, trying to explain, in this Could the uterine junctional zone be used to identify early-stage endometriosis in women

Transvaginal ultrasound evaluation of the pelvis and symptoms after laparoscopic partial cystectomy for bladder endometriosis

Objective: To evaluate transvaginal sonography (TVS) findings after laparoscopic partial cystectomy for bladder endometriosis and to correlate postsurgical ultrasound findings with symptoms. Material and Methods: A retrospective study including women who underwent laparoscopic partial cystectomy for bladder endometriosis. Within 12 months after surgery, TVS examination was conducted in all patients to evaluate the bladder morphology, and the presence of any postsurgical sonographic findings of the pelvis. Painful symptoms were assessed using a visual analogue scale. Results: A total of 40 women were included. At the follow-up visit, 25 patients were receiving medical treatment while 15 had declined post-surgical therapy and had tried to conceive. The presence of bladder deep-infiltrating endometriosis (DIE) was found in nine (22.5%), fibrotic thickening of the bladder wall was found in 15 (37.5%), and normal bladder morphology was observed in 16 (40%). There was a correlation between anterior adenomyosis and bladder DIE, and fibrotic thickening of the bladder. Patients with TVS signs of bladder DIE and anterior adenomyosis suffered more dysmenorrhea and dysuria than patients with normal bladder. Conclusion: Post-operative TVS can detect the alteration of pelvis and could explain the causes of the persistence of symptoms. (J Turk Ger Gynecol Assoc 2022; 23: 145-53

Complications during pregnancy and delivery in women with untreated rectovaginal deep infiltrating endometriosis

5noreservedObjective To study outcomes and complications during pregnancy and at delivery in women with a posterior deep infiltrating endometriosis (DIE) nodule persisting after surgery and diagnosed at transvaginal sonography (TVS) in comparison with a control group of women without endometriosis. Design Multicenter observational and cohort study. Setting University hospital. Patient(s) Women (n = 200) with a posterior DIE nodule equal or more than 2 cm centimeters in size who desired a pregnancy and a control group of women (n = 300) with no previous recorded diagnosis of endometriosis who delivered in our clinic during the same time period. Intervention(s) Patient data collected from medical charts and by phone interviews. Main Outcome Measure(s) Evaluation of complications during pregnancy and delivery. Result(s) Of the 101 women with a posterior DIE nodule, 52 become pregnant among whom 25 used assisted reproductive technology. Of these 52 pregnancies, 11 ended in an early abortion, and 41 delivered a baby; 13 (31.7%) had a premature delivery, 7 (17.8%) a placenta praevia, and 28 (68.2%) had a cesarean delivery. When compared with the control group, the women with endometriosis had a higher risk of pregnancy complicated by preterm birth, placenta previa, placental abruption, and hypertension. Cesarean delivery and complications during surgery (hysterectomy, hemoperitoneum, and bladder injuries) were statistically significantly more frequent in women with endometriosis than in controls. Conclusion(s) Women with an incomplete removal of posterior DIE have a high complications rate during pregnancy and delivery. © 2016 American Society for Reproductive MedicinemixedExacoustos, C.; Lauriola, I.; Lazzeri, L.; De Felice, G.; Zupi, E.Exacoustos, C.; Lauriola, I.; Lazzeri, L.; De Felice, G.; Zupi, E

Review: the destiny of myoma. Ultrasound diagnosis of uterine myomas

Myomas represent a large part of benign gynecological pathology, widely spread in fertile female population. First step to diagnose fibroids is ultrasound (US) that can be 2-dimensional (2D), 3-dimensional (3D), Color Doppler (CD) and sonohysterography (SHG). This review develops according to MUSA's sonographic features (Morphological Uterus Sonographic Assessment). One of the main topic of interest for ultrasonographer today is endo/myometrial junctional zone (JZ), because it may be useful to discern a diagnosis of myoma and adenomyosis. Another important aspect of ultrasound is the analysis of vascularization in front of a uterine lesion. Indeed, vascular pattern can be used to make differential diagnosis between myoma-adenomyosis and leiomyosarcomas. Myomas should be described accurately according to sonographic guidelines. Sonographic features correlated with symptoms should guide an appropriate surgical or medical treatment

Recurrence of endometriomas after laparoscopic removal: Sonographic and clinical follow-up and indication for second surgery

This study involved patients who, after laparoscopic surgery, had recurrence of endometriomas detected by sonography. The aim of this study was to evaluate the role of transvaginal sonography (TVS) in the management of recurrent endometriomas and to establish ultrasonographic criteria that would direct the therapy toward additional surgery versus medical or expectant management

A sonographic classification of adenomyosis: interobserver reproducibility in the evaluation of type and degree of the myometrial involvement

Objective: To study the interobserver reproducibility of our new ultrasonographic mapping system to define the type and extension of uterine adenomyosis. Design: Interobserver study involving two observers with different medical backgrounds and gynecological ultrasound experience. Setting: University hospital. Patients: Seventy consecutive women who underwent transvaginal ultrasound for suspected endometriosis, pelvic pain, heavy menstrual bleeding, and infertility. Intervention: Two operators (observers A and B), who were blinded, independently reviewed the ultrasound videos offline, assessing the type of adenomyosis and the severity of the disease. Diagnosis of adenomyosis was made when typical ultrasonographic features of the disease were observed at the examination. Adenomyosis was defined as diffuse, focal, and adenomyoma according to the ultrasonographic characteristics. The severity of adenomyosis was described using a new schematic scoring system that describes the extension of the disease considering all possible ultrasound adenomyosis features. Main Outcome Measures: Reproducibility of the new mapping system for adenomyosis and rate agreement between two operators. Results: Multiple rate agreements to classify the different features and the score of adenomyosis (diffuse, focal adenomyoma, and focal or diffuse alteration of junctional zone) ranged from substantial to almost perfect (Cohen κ = 0.658 – 1) except for adenomyoma score 4 (one or more adenomyomas with the largest diameter >40 mm) in which interobserver agreement was moderate (κ = 0.479). Conclusion: Our new scoring system for uterine adenomyosis is reproducible and could be useful in clinical practice. The standardization of the transvaginal approach and of the sonographer training represent a crucial point for a correct diagnosis of myometrial disease

Isolated Ovarian Endometrioma: A History Between Myth and Reality

Study Objective: To assess the association between ovarian endometriomas detectable at transvaginal ultrasound (TVS) and other specific extraovarian lesions including adhesions, deep infiltrating endometriosis (DIE), and adenomyosis. Design: Retrospective observational study (Canadian Task Force classification II-2). Setting: Two university hospitals. Patients: Two hundred fifty-five symptomatic women with at least 1 ovarian endometrioma found on ultrasound after presentation with pain or irregular menstruation. Interventions: Patients underwent TVS followed by either medical or surgical treatment. Measurements and Main Results: Two hundred fifty-five women, aged 20 to 40 years, underwent TVS and were found to have at least 1 endometrioma with a diameter > 20 mm. Associated sonographic signs of pelvic endometriosis (adhesions, DIE, and adenomyosis) were recorded, and a subgroup of patients (n = 50) underwent laparoscopic surgery within 3 months of TVS. Mean endometrioma diameter was 40.0 ± 18.1 mm, and bilateral endometriomas were observed in 65 patients (25.5%). TVS showed posterior rectal DIE in 55 patients (21.5%) and a thickening of at least 1 uterosacral ligament in 93 patients (36.4%). One hundred eighty-six patients (73%) had adhesions, and 134 patients (53%) showed signs of myometrial adenomyosis on TVS. Thirty-eight patients (15%) exhibited only a single isolated endometrioma with a mobile ovary and no other signs of pelvic endometriosis/adenomyosis at TVS. Conclusion: Ovarian endometriomas are indicators for pelvic endometriosis and are rarely isolated. Particularly, left endometriomas were found to be associated with rectal DIE and left uterosacral ligament localization and bilateral endometriomas correlated with adhesions and pouch of Douglas obliteration, whereas no correlation was found between endometrioma size and DIE. Determining appropriate management, whether clinical or surgical, is critical for ovarian endometriomas and concomitant adhesions, endometriosis, and adenomyosis in patients desiring future fertility

Preoperative and Postoperative Clinical and Transvaginal Ultrasound Findings of Adenomyosis in Patients With Deep Infiltrating Endometriosis

Deep infiltrating endometriosis (DIE) represents the most complex form of endometriosis and its treatment is still challenging. The coexistence of DIE with other appearances of endometriosis stimulates new studies to improve the preoperative diagnosis. Adenomyosis is a clinical form that shares several symptoms with DIE. The present study investigated the possible presence of adenomyosis in a group of women with DIE and its impact on pre- and postoperative symptoms