The influence of uterine abnormalities on uterine peristalsis in the non-pregnant uterus:A systematic review

Uterine peristalsis is the rhythmic wave-like motion of the subendometrial layer of the uterus. These contractions change throughout the menstrual cycle in terms of direction, frequency and amplitude, and can be analysed with various methods. Not much is known about uterine peristalsis in patients with uterine abnormalities. To that end, we decided to systematically review the available studies for evidence on the influence of uterine abnormalities, including leiomyomas, endometriosis, adenomyosis and congenital uterine anomalies, on uterine peristalsis. After a systematic search of relevant databases, sixteen eligible studies were included in this review; eight case-control studies and eight controlled prospective cohort studies. The sample sizes ranged from twelve to 205 participants. Various methods of analysing uterine contractions were used, including transvaginal ultrasound, hysterosalpingo-radionuclide scintigraphy, cine MRI and intrauterine pressure measurement. Studies varied in their design, uterine contraction measurement method and patient groups. Generally however, uterine abnormalities do seem to have an influence on uterine peristalsis. Compared to healthy controls, the specific phase of the menstrual cycle (namely the periovulatory and luteal phases) seems to play a major role in the observed effect on uterine contractions. The included studies were difficult to compare directly due to heterogeneity however, and sample sizes were relatively small. Despite these limitations, it can be concluded that uterine abnormalities likely have a menstrual phase-dependent effect on uterine peristalsis and contraction features. These aberrant contractions potentially play a role in the relationship between (benign) uterine abnormalities and infertility, along with other associated symptoms (i.e., dysmenorrhea, abnormal uterine bleeding). It is not yet possible to make a definite conclusion on the nature of this effect however. Further research is needed on objective measurement tools, treatment and clinical consequences of abnormal uterine peristalsis in patients with uterine abnormalities

Prediction of adenomyosis diagnosis based on MRI

ObjectiveDevelopment of a multivariate prediction model based on MRI and clinical parameters for histological adenomyosis diagnosis.Materials and methodsThis single centre retrospective cohort study took place in the gynaecological department of a referral hospital. In all, 296 women undergoing hysterectomy with preoperative pelvic MRI between 2007–2022 were included. MRI scans were retrospectively assessed for adenomyosis markers (junctional zone [JZ] parameters, high signal intensity [HSI] foci in a blinded fashion. A multivariate regression model for histopathological adenomyosis diagnosis was developed based on MRI and clinical variables from univariate analysis with p < 0.1 and factors deemed clinically relevant.Results131/296 women (44.3%) had histopathological adenomyosis. Patients had comparable age at hysterectomy, BMI and clinical symptoms, p > 0.05. Adenomyosis patients more often had: undergone a curettage (22.1% vs. 8.9%, p = 0.002), a higher mean JZ thickness (9.40 vs. 8.35 mm, p < .001), maximal JZ thickness (16.00 vs. 13.40 mm, p < .001), mean JZ/myometrium ratio (0.56 vs. 0.49, p = .040), and JZ differential (8.60 vs. 8.15 mm, p = .003). Presence of HSI foci was the strongest predictor for adenomyosis (39.7% vs. 8.9%, p < .001). Based on the parameters age and BMI, history of curettage, dysmenorrhoea, abnormal uterine bleeding (AUB), mean JZ, JZ differential ≥ 5 mm, JZ/myometrium ratio > 40, and presence of HSI foci, a predictive model was created with a good area under the curve (AUC) of .776.ConclusionsThis is the first study to create a diagnostic tool based on MRI and clinical parameters for adenomyosis diagnosis. After sufficient external validation, this model could function as a useful clinical decision-making tool in women with suspected adenomyosis

Removal of endometrial polyps: hysteroscopic morcellation versus bipolar resectoscopy, a randomized trial

Study Objectives: To compare hysteroscopic morcellation with bipolar resectoscopy for removal of endometrial polyps, in terms of procedure time, peri- and postoperative adverse events, tissue availability, and short-term effectiveness. Design: Multicenter, open label, randomized controlled trial (Canadian Task Force classification I). Setting: Day surgery setting of a teaching and a university hospital. Patients: Women with larger (≥1 cm) endometrial polyps. Interventions: Hysteroscopic morcellation with the TRUCLEAR 8.0 Tissue Removal System or bipolar resectoscopy with a rigid 8.5-mm bipolar resectoscope. Measurements and Main Results: Eighty-four women were included in the intention-to-treat analysis. Median operating time was 4.0 min (range: 2.5-7.1) and 6.0 min (range: 3.8-11.7) in the hysteroscopic morcellation and resectoscopy groups, respectively. Operating time was reduced by 38% (95% confidence interval: 5%-60%; p = .028) in the hysteroscopic morcellation group. Procedure time, which was defined as the sum of the installation and operating time, tended to be less for the hysteroscopic morcellation group (median 9.5 min [range: 7.6-12.2] vs 12.2 min [range: 8.8-16.0]; p = .072). Perforation occurred at dilation or hysteroscope (re)introduction in 3 patients of the resectoscopy group, resulting in procedure discontinuation or prolongation of hospital stay. Perforation occurred at dilation in 1 patient in the hysteroscopic morcellation group; however, the procedure was successfully completed. Postoperatively, 2 patients of the hysteroscopic morcellation group were diagnosed with a urinary tract infection. Tissue was available for pathology analysis in all patients, except for 2 patients in the resectoscopy group in whom the procedure was discontinued due to perforation. Conclusion: Hysteroscopic morcellation is a fast, effective, and safe alternative to bipolar resectoscopy for removal of endometrial polyps

Ovarian cancer prognosis in women with endometriosis: a retrospective nationwide cohort study of 32,419 women

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Women with combined adenomyosis and endometriosis on MRI have worse IVF/ICSI outcomes compared to adenomyosis and endometriosis alone:A matched retrospective cohort study

Study objectivesTo assess the effect of adenomyosis, endometriosis and combined adenomyosis and endometriosis, diagnosed on MRI, on IVF/ICSI outcomes versus male subfertility controls.Study DesignThis single-centre matched retrospective cohort study was carried out at Catharina Hospital in Eindhoven, The Netherlands. The study group consisted of infertile women undergoing their first, fresh embryo transfer during IVF/ICSI, with adenomyosis only (N = 36), endometriosis only (N = 61), and combined adenomyosis and endometriosis (N = 93) based on MRI. The control group consisted of IVF/ICSI patients undergoing treatment due to male subfertility (N = 889). 1:2 case-control matching based on age during IVF/ICSI, parity and number of embryos transferred was performed. Odds ratios were calculated for biochemical pregnancy, ongoing pregnancy and live birth rate versus matched male subfertility controls, and were corrected for embryo quality.ResultsOnly the combined adenomyosis and endometriosis group showed a significantly reduced OR for biochemical pregnancy (p = 0.004, OR 0.453 (95% CI :(0.284–0.791)), ongoing pregnancy (p = 0.001, OR 0.302 (95% CI: (0.167–0.608)) and live birth (p = 0.001, OR 0.309 (95% CI: (0.168–0.644)) compared to matched male subfertility controls.ConclusionsThe lower (ongoing) pregnancy and live birth rates in the combined adenomyosis and endometriosis women can be attributed to more severe disease in these women, ultimately resulting in increased chances for failed implantation and miscarriage. This highlights the importance of screening for adenomyosis in endometriosis patients, and identifies these women target for additional (hormonal) treatment prior to IVF/ICSI

The ADENO study:ADenomyosis and its Effect on Neonatal and Obstetric outcomes: a retrospective population-based study

Background: Adenomyosis is a benign gynecologic condition arising from the uterine junctional zone. Recent studies suggest a relationship between adenomyosis and adverse obstetrical outcomes, but evidence remains conflicting. There is no large-scale study investigating obstetrical outcomes in women with adenomyosis using the gold standard of histopathologic diagnosis.Objective: This study aimed to investigate the prevalence of adverse obstetrical and neonatal outcomes in women with histopathologic adenomyosis and that of the general (Dutch) population.Study design: This retrospective population-based study used 2 Dutch national databases (Perined, the perinatal registry, and the nationwide pathology databank [Pathologisch Anatomisch Landelijk Geautomiseerd Archief], from 1995 to 2018) to compare obstetrical outcomes in women before histopathologic adenomyosis diagnosis to the general Dutch population without registered histopathologic adenomyosis. The adjusted odds ratios (95% confidence interval) were calculated for adverse obstetrical outcomes. The outcomes were adjusted for maternal age, parity, ethnicity, year of registered birth, induction of labor, hypertensive disorders in previous pregnancies, multiple gestation, and low socioeconomic status.Results: The pregnancy outcomes of 7925 women with histopathologic adenomyosis were compared with that of 4,615,803 women without registered adenomyosis. When adjusted for confounders, women with adenomyosis had adjusted odds ratios of 1.37 (95% confidence interval, 1.25-1.50) for hypertensive disorders, 1.37 (95% confidence interval, 1.25-1.51) for preeclampsia, 1.15 (95% confidence interval, 1.07-1.25) for small-for-gestational-age infants, 1.54 (95% confidence interval, 1.41-1.68) for emergency cesarean delivery, 1.24 (95% confidence interval, 1.12-1.37) for failure to progress, 1.29 (95% confidence interval, 1.10-1.48) for placental retention, and 1.23 (95% confidence interval, 1.10-1.38) for postpartum hemorrhage. No increased risk of HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, placental abruption, or operative vaginal delivery or need for oxytocin stimulation was found.Conclusion: Women with a histopathologic diagnosis of adenomyosis showed an increased prevalence of hypertensive disorders of pregnancy and small-for-gestational-age infants, failure to progress in labor, and placental retention compared with the general population in previous pregnancies. This suggests that uterine (contractile) function in labor and during pregnancy is impaired in women with adenomyosis.<br/

Association between sex hormone-binding globulin levels and activated protein C resistance in explaining the risk of thrombosis in users of oral contraceptives containing different progestogens \ud

BACKGROUND: Epidemiological studies have shown that both the estrogen dose and progestogen type of oral contraceptives contribute to the increased risk of thrombosis in oral contraceptive users. Thrombin generation-based activated protein C (APC) sensitivity is a global test for the net prothrombotic effect of oral contraceptives and predicts the thrombotic risk. Our objective was to test the usefulness of sex hormone-binding globulin (SHBG) as a marker for the thrombotic risk of an oral contraceptive. METHODS: We measured SHBG and APC resistance in 156 healthy users of various types of oral contraceptives. RESULTS: Users of oral contraceptives with a moderately increased risk of thrombosis (gestodene and desogestrel pills) had higher SHBG levels than users of low-risk oral contraceptives containing levonorgestrel. Similarly, for higher doses of estrogen in oral contraceptives we found higher SHBG levels. Women using oral contraceptives with the highest thrombotic risk (cyproterone acetate pills) rendered the highest SHBG levels. Users of oral contraceptives containing gestodene, desogestrel or cyproterone acetate were more resistant to APC than users of levonorgestrel pills. SHBG levels were positively associated with the increased APC resistance. CONCLUSIONS: Our findings support the hypothesis that the effect of an oral contraceptive on SHBG levels might be a marker for the thrombotic risk. \u

Uterine contractile activity in healthy women throughout the menstrual cycle measured using a novel quantitative two-dimensional transvaginal ultrasound speckle tracking method

Research question: To explore normal uterine contractile function across the menstrual cycle using a novel quantitative ultrasound method. Design: This multicentre prospective observational study took place in three European centres from 2014 to 2022. Uterine contraction frequency (contractions/minute), amplitude, direction (cervix-to-fundus, C2F; fundus-to-cervix; F2C), velocity and coordination were investigated. Features were extracted from transvaginal ultrasound recordings (TVUS) using speckle tracking. Premenopausal women ≥18 years of age, with normal, natural menstrual cycles were included. A normal cycle was defined as: regular (duration 28 ± 2 days), no dysmenorrhoea, no menometrorrhagia. Four-minute TVUS were performed during the menstrual phase, mid-follicular, late follicular phase, early luteal phase and/or late luteal phase. Of the 96 recordings available from 64 women, 70 were suitable for inclusion in the analysis. Results: Contraction frequency (for the posterior wall) and velocity (for the anterior uterine wall in the F2C direction) were highest in the late follicular phase and lowest in the menstrual and late luteal phases (1.61 versus 1.31 and 1.35 contractions/min, P &lt; 0.001 and 0.81 versus 0.67 and 0.62 mm/s, P &lt; 0.001, respectively). No significant difference was found for contraction amplitude. Contraction coordination (simultaneous contraction of the anterior and posterior walls in the same direction) was least coordinated in the mid-follicular phase (P = 0.002). Conclusions: This is the first study to objectively measure uterine contraction features in healthy women during the natural menstrual cycle on TVUS. Likewise, it introduces contraction coordination as a specific feature of uterine peristalsis. Differences in uterine contractility across the menstrual cycle are confirmed, with highest activity seen in the late follicular phase, and lowest in the late luteal phase.</p