According to consistent epidemiological data, the slope of the incidence curve of endometriosis rises rapidly and sharply around the age of 25 years. The delay in diagnosis is generally reported to be between 5 and 8 years in adult women, but it appears to be over 10 years in adolescents. If this is true, the actual onset of endometriosis in many young women would be chronologically placed in the early postmenarchal years. Ovulation and menstruation are inflammatory events that, when occurring repeatedly for years, may theoretically favour the early development of endometriosis and adenomyosis. Moreover, repeated acute dysmenorrhoea episodes after menarche may not only be an indicator of ensuing endometriosis or adenomyosis, but may also promote the transition from acute to chronic pelvic pain through central sensitization mechanisms, as well as the onset of chronic overlapping pain conditions. Therefore, secondary prevention aimed at reducing suffering, limiting lesion progression, and preserving future reproductive potential should be focused on the age group that could benefit most from the intervention, i.e. severely symptomatic adolescents. Early-onset endometriosis and adenomyosis should be promptly suspected even when physical and ultrasound findings are negative, and long-term ovulatory suppression may be established until conception seeking. As nowadays this could mean using hormonal therapies for several years, drug safety evaluation is crucial. In adolescents without recognized major contraindications to oestrogens, the use of very low-dose combined oral contraceptives is associated with a marginal increase in the individual absolute risk of thromboembolic events. Oral contraceptives containing oestradiol instead of ethinyl oestradiol may further limit such risk. Oral, subcutaneous, and intramuscular progestogens do not increase the thromboembolic risk, but may interfere with attainment of peak bone mass in young women. Levonorgestrel-releasing intra-uterine devices may be a safe alternative for adolescents, as amenorrhoea is frequently induced without suppression of the ovarian activity. With regard to oncological risk, the net effect of long-term oestrogen–progestogen combinations use is a small reduction in overall cancer risk. Whether surgery should be considered the first-line approach in young women with chronic pelvic pain symptoms seems questionable. Especially when large endometriomas or infiltrating lesions are not detected at pelvic imaging, laparoscopy should be reserved to adolescents who refuse hormonal treatments or in whom first-line medications are not effective, not tolerated, or contraindicated. Diagnostic and therapeutic algorithms, including self-reported outcome measures, for young individuals with a clinical suspicion of early-onset endometriosis or adenomyosis are proposed.

To analyze the ultrasonographic imaging features of accessory cavitated uterine malformations (ACUM) and discuss the practical value of ultrasonography in diagnosing this disease.

This study presents a unifying concept of the pathophysiology of endometriosis and adenomyosis. In particular, a physiological model is proposed that provides a comprehensive explanation of the local production of estrogen at the level of ectopic endometrial lesions and the endometrium of women affected with the disease.In women suffering from endometriosis and adenomyosis and in normal controls, a critical analysis of uterine morphology and function was performed using immunohistochemistry, MRI, hysterosalpingoscintigraphy, videohysterosonography, molecular biology as well as clinical aspects. The relevant molecular biologic aspects were compared to those of tissue injury and repair (TIAR) mechanisms reported in literature.Circumstantial evidence suggests that endometriosis and adenomyosis are caused by trauma. In the spontaneously developing disease, chronic uterine peristaltic activity or phases of hyperperistalsis induce, at the endometrial-myometrial interface near the fundo-cornual raphe, microtraumatizations with the activation of the mechanism of 'tissue injury and repair' (TIAR). This results in the local production of estrogen. With ongoing peristaltic activity, such sites might increase and the increasingly produced estrogens interfere in a paracrine fashion with the ovarian control over uterine peristaltic activity, resulting in permanent hyperperistalsis and a self-perpetuation of the disease process. Overt auto-traumatization of the uterus with dislocation of fragments of basal endometrium into the peritoneal cavity and infiltration of basal endometrium into the depth of the myometrial wall ensues. In most cases of endometriosis/adenomyosis, a causal event early in the reproductive period of life must be postulated leading rapidly to uterine hyperperistalsis. In late premenopausal adenomyosis, such an event might not have occurred. However, as indicated by the high prevalence of the disease, it appears to be unavoidable that, with time, chronic normoperistalsis throughout the reproductive period of life leads to the same extent of microtraumatization. With the activation of the TIAR mechanism followed by infiltrative growth and chronic inflammation, endometriosis/adenomyosis of the younger woman and premenopausal adenomyosis share in principle the same pathophysiology. In conclusion, endometriosis and adenomyosis result from the physiological mechanism of 'tissue injury and repair' (TIAR) involving local estrogen production in an estrogen-sensitive environment normally controlled by the ovary.

Adenomyosis is a common disorder of the uterus, and is associated with an enlarged uterus, heavy menstrual bleeding (HMB), pelvic pain, and infertility. It is characterized by endometrial epithelial cells and stromal fibroblasts abnormally found in the myometrium where they elicit hyperplasia and hypertrophy of surrounding smooth muscle cells. While both the mechanistic processes and the pathogenesis of adenomyosis are uncertain, several theories have been put forward addressing how this disease develops. These include intrinsic or induced (1) microtrauma of the endometrial-myometrial interface; (2) enhanced invasion of endometrium into myometrium; (3) metaplasia of stem cells in myometrium; (4) infiltration of endometrial cells in retrograde menstrual effluent into the uterine wall from the serosal side; (5) induction of adenomyotic lesions by aberrant local steroid and pituitary hormones; and (6) abnormal uterine development in response to genetic and epigenetic modifications. Dysmenorrhea, HMB, and infertility are likely results of inflammation, neurogenesis, angiogenesis, and contractile abnormalities in the endometrial and myometrial components. Elucidating mechanisms underlying the pathogenesis of adenomyosis raise possibilities to develop targeted therapies to ameliorate symptoms beyond the current agents that are largely ineffective. Herein, we address these possible etiologies and data that support underlying mechanisms.Thieme. All rights reserved.

Adenomyosis is a common estrogen-dependent disease, characterized by the invasion of endometrial glands and stroma into the myometrium. It often results in dysmenorrhea, menorrhagia, and infertility, significantly impacting patients’ quality of life. Currently, the etiology and pathogenesis of adenomyosis remain unclear, and existing treatments have limitations. Therefore, further research on the mechanism and treatment of adenomyosis is urgently needed. Studies indicate that adenomyosis involves dysregulation of multiple signaling pathways, including VEGF, Wnt, PI3K, MAPK, NF-κB, cGAS-STING, TGF-β, Hedgehog, and Hippo pathways, which regulate processes such as estrogen and progesterone imbalance, angiogenesis, proliferation and invasion, and the processes of inflammation and fibrosis. This review summarizes the relevant signaling pathways involved in adenomyosis and discusses recent progress in targeted pathway therapies. Additionally, emerging therapeutic strategies such as multi-target combination therapy, epigenetic regulation, and natural products are emphasized as viable avenues for adenomyosis treatment in the future.

Adenomyosis is challenging to diagnose with transvaginal ultrasound (TVUS) and requires operator expertise to recognize its sonographic features; however, little is known about the learning curve for trainees. This study aimed to assess the learning curve of inexperienced residents in diagnosing adenomyosis and identifying its key ultrasound signs using the learning curve–cumulative summation test (LC‐CUSUM) method.

Purpose of Review: The purpose of this review is to (i) summarize the current literature regarding the role of magnetic resonance imaging (MRI) in diagnosing adenomyosis, (ii) examine how to integrate MRI phenotypes with clinical symptomatology and histological findings, (iii) review recent advances including proposed MRI classifications, (iv) discuss challenges and pitfalls of diagnosing adenomyosis, and (v) outline the future role of MRI in promoting a better understanding of the pathogenesis, diagnosis, and treatment options for patients with uterine adenomyosis. Recent Findings: Recent advances and the widespread use of MRI have provided new insights into adenomyosis and the range of imaging phenotypes encountered in this disorder. Summary: Direct and indirect MRI features allow for accurate non-invasive diagnosis of adenomyosis. Adenomyosis is a complex and poorly understood disorder with variable MRI phenotypes that may be correlated with different pathogeneses, clinical presentations, and patient outcomes. MRI is useful for the assessment of the extent of findings, to evaluate for concomitant gynecological conditions, and potentially can help with the selection and implementation of therapeutic options. Nevertheless, important gaps in knowledge remain. This is in part due to the lack of standardized criteria for reporting resulting in heterogeneous and conflicting data in the literature. Thus, there is an urgent need for a unified MRI reporting system incorporating standardized terminology for diagnosing adenomyosis and defining the various phenotypes.

To determine whether there is a correlation between stiffness measured by strain elastography and the severity of dysmenorrhea and to determine the value of elastography in evaluating severe dysmenorrhea in patients with adenomyosis.

Adenomyosis is a gynecological condition characterized by the invasion of endometrial tissue into the myometrium, causing symptoms such as dysmenorrhea, menorrhagia, and chronic pelvic pain. Its diagnosis remains challenging due to overlapping features with other uterine disorders, and the variability in symptom presentation makes management complex. This study aims to evaluate the utility of shear wave elastography (SWE) in predicting clinical symptoms of adenomyosis and to explore the potential of machine learning (ML) models in enhancing diagnostic precision and predicting patient outcomes.

To present a new noninvasive technique for automatic diagnosis of adenomyosis, using a novel end-to-end unified network framework based on transformer networks.This is a prospective descriptive study conducted at a university hospital.1654 patients were recruited to the study according to adenomyosis diagnosed by transvaginal ultrasound (TVS). For adenomyosis characteristics and ultrasound images, automatic identification of adenomyosis were performed based on deep learning methods. We called this unique technique ADNet: Adenomyosis Auto Diagnosis Network.The ADNet exhibits excellent performance in diagnosis of adenomyosis, achieving an accuracy of 92.33%, a precision of 96.06%, a recall of 91.71% and an F1 score of 93.80% in the test group. The confusion matrix of experimental results show that the ADNet can achieve a correct diagnosis rate of 92% or more for both normal and adenomyosis samples, which demonstrate the superiority of the ADNet comparing with the state-of-the-arts.The ADNet is a safe and effective technique to aid in automatic diagnosis of adenomyosis. The technique which is nondestructive and non-invasive, is new and unique due to the advantages of artificial intelligence.Copyright © 2024. Published by Elsevier B.V.

Background/Objectives: The aim of this study is to assess the inter- and intra-observer reproducibility of the identification of direct and indirect ultrasonographic features of adenomyosis as defined by the revised Morphological Uterus Sonographic Assessment (MUSA) consensus (2022). Methods: A cohort of 74 women, aged 18 to 45, were recruited from the recurrent miscarriage and general gynaecology clinic at a university-based fertility centre. All the participants underwent 2D and 3D transvaginal Ultrasound scan (TVS) examination in the late follicular and early luteal phase. Conventional grey scale and power Doppler image volumes were acquired and stored. Subsequently, the stored 3D ultrasound images were independently re-evaluated offline by the two observers for the direct and indirect features of adenomyosis as outlined by the revised MUSA group. The intra- and the inter-observer reproducibility was estimated using Cohen’s Kappa coefficient. Results: The intra- and interobserver reproducibility (K −0.27, 95% CI 0.06–0.48 and K 0.13, 95% CI −0.10–0.37, respectively) for at least one direct feature of adenomyosis was only modest. Amongst the individual direct features, the interobserver variability of identifying myometrial cysts was fair (K 0.21, 95% CI −0.00–0.42), whereas the intra-observer variability was moderate (K 0.44, 95% CI 0.26–0.63). While hyperechogenic islands identification achieved a fair level of intra- (K 0.31, 95% CI 0.09–0.53) and interobserver (K 0.24, 95% CI 0.01–0.47) agreement, the reproducibility of reporting sub-endometrial lines/buds was fair for the intra-observer (K 0.22, 95% CI −0.02 0.47) and poor for the interobserver (K 0.00, 95% CI −0.20–0.19). The interobserver agreement for indirect features varied from poor to moderate, while the intra-observer agreement ranged between poor to good. Conclusions: The reporting of adenomyosis using direct features suggested by the revised MUSA group consensus showed only modest interobserver and intra-observer agreement. The definitions of ultrasound features for adenomyosis need further refining to enhance the reliability of diagnosis criteria of adenomyosis.

This case report highlights the diagnostic dilemma and therapeutic challenges encountered while managing adolescent girls with progressive dysmenorrhoea and management of Robert's uterus. Two girls aged 20 years and 13 years presented with severe progressive dysmenorrhoea. In the first case, laparoscopy revealed juvenile cystic adenomyoma (JCA) of 3 cm × 3 cm on the left side anteroinferior to the round ligament. Laparoscopic resection of the lesion was done, and histopathology revealed features of adenomyosis. In the second case, there was a globular enlargement of the right half of the uterine body with round ligament and adnexa attached to the lesion (Robert's uterus). In view of severe symptoms, complete resection of the lesion and partial resection of hemi-uterus was done, followed by myometrial defect closure. Both cases were initially diagnosed as JCA, and the final diagnosis was made on laparoscopy. Both girls had complete symptomatic relief from the next menstrual cycle and have been under follow-up for 24 months and 18 months, respectively. Due to the rarity of conditions, Robert's uterus and JCA are usually misdiagnosed with each other or with other Mullerian anomalies such as a non-communicating unicornuate uterus. Radiologists and clinicians should be aware of these different pathologies causing similar symptoms. Understanding the pathology, early diagnosis, timely referral and correct surgical procedure are emphasised to improve reproductive outcomes.Copyright: © 2023 Journal of Human Reproductive Sciences.

Mullerian uterine anomalies are structural defects of the female reproductive system. An accessory cavitated uterine malformation (ACUM) is a rare congenital Mullerian anomaly where an accessory cavity with normal lining of endometrium is seen within the myometrium of a normally functioning uterus. We report a case of a late-adolescence (18–21 years) girl who came with complaints of severe progressive dysmenorrhoea and chronic pelvic pain for 2 years. Ultrasound misdiagnosed it as a non-communicating rudimentary horn. On laparoscopy, a definite diagnosis of ACUM was made, followed by laparoscopic excision. The defect was sutured. Postoperatively, the patient is on regular follow-up and is asymptomatic at present.

Understanding nonsteroidal antiinflammatory drug (NSAID) use and impact on common rheumatic and arthritic conditions is critical to reconciling their appropriate use with their potentially serious adverse effects. NSAIDs have a profound impact on the treatment of connective tissue disorders because of their ability to address the underlying cause with specific benefits of decreasing stiffness and inflammation, and improving mobility. NSAID use is twice as common as opioid use, and inappropriate use of NSAIDs is widespread. NSAID use should be monitored and the impact understood to mitigate the risks. NSAID discontinuation should be evidence based and individualized to specific requirements.Published by Elsevier Inc.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used to manage mild to moderate pain. While limited use is appropriate for many patients, there are safety concerns with use in certain patient populations or with long-term use of these agents. Topical NSAIDs may provide analgesic benefits while decreasing the overall risks of adverse effects. This article will review safety information for both oral and topical NSAIDs.Copyright © 2024 by National Association of Orthopaedic Nurses.

Non-steroidal anti-inflammatory drugs (NSAIDs) have well-known adverse effects, and numerous studies have shown inappropriate behaviors regarding their use. The primary aim of this study was to analyze the knowledge, attitudes, and behaviors regarding the use of NSAIDs simultaneously in one of the largest and most populated areas of Italy, Naples.

Non-relaxing pelvic floor dysfunction (NR-PFD) is a poorly understood and underdiagnosed cause of voiding dysfunction in patients without clear anatomic or neurologic obstruction. Symptoms may include pelvic pain, urinary complaints, defecatory dysfunction, and sexual issues, but their variability makes NR-PFD challenging to recognize and manage. This review focuses on the urologic manifestations of NR-PFD and outlines current diagnostic and treatment strategies.Video urodynamics and surface EMG, alongside focused physical examination, are key tools for diagnosing NR-PFD. Pelvic floor physical therapy remains the first-line treatment, with strong evidence supporting its efficacy across sexes. Adjunctive options, including biofeedback, trigger point injections, botulinum toxin, and sacral neuromodulation, can benefit patients with refractory symptoms. Cognitive behavioral therapy and integrative modalities are also increasingly utilized. NR-PFD is an underrecognized cause of functional bladder outlet obstruction and complex LUTS. Management should be individualized and multidisciplinary. Future studies are needed to standardize diagnostic criteria and refine treatment algorithms.© 2025. The Author(s).

To develop evidence- and consensus-based clinical practice guidelines for management of high-tone pelvic floor dysfunction (HTPFD). High-tone pelvic floor dysfunction is a neuromuscular disorder of the pelvic floor characterized by non-relaxing pelvic floor muscles, resulting in lower urinary tract and defecatory symptoms, sexual dysfunction, and pelvic pain. Despite affecting 80% of women with chronic pelvic pain, there are no uniformly accepted guidelines to direct the management of these patients.A Delphi method of consensus development was used, comprising three survey rounds administered anonymously via web-based platform (Qualtrics XM) to national experts in the field of HTPFD recruited through targeted invitation between September and December 2021. Eleven experts participated with backgrounds in urology, urogynecology, minimally invasive gynecology, and pelvic floor physical therapy (PFPT) participated. Panelists were asked to rate their agreement with rated evidence-based statements regarding HTPFD treatment. Statements reaching consensus were used to generate a consensus treatment algorithm.A total of 31 statements were reviewed by group members at the first Delphi round with 10 statements reaching consensus. 28 statements were reposed in the second round with 17 reaching consensus. The putative algorithm met clinical consensus in the third round. There was universal agreement for PFPT as first-line treatment for HTPFD. If satisfactory symptom improvement is reached with PFPT, the patient can be discharged with a home exercise program. If no improvement after PFPT, second-line options include trigger or tender point injections, vaginal muscle relaxants, and cognitive behavioral therapy, all of which can also be used in conjunction with PFPT. Onabotulinumtoxin A injections should be used as third line with symptom assessment after 2-4 weeks. There was universal agreement that sacral neuromodulation is fourth-line intervention. The largest identified barrier to care for these patients is access to PFPT. For patients who cannot access PFPT, experts recommend at-home, guided pelvic floor relaxation, self-massage with vaginal wands, and virtual PFPT visits.A stepwise approach to the treatment of HTPFD is recommended, with patients often necessitating multiple lines of treatment either sequentially or in conjunction. However, PFPT should be offered first line.Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.

Cystic adenomyosis is a rare type of adenomyosis that often occurs in adolescents or women of childbearing age. Due to the few reports of this case, its clinical characteristics have not been clearly established.

High intensity focused ultrasound (HIFU) is an effective and safe non-invasive treatment method, widely used in the treatment of uterine fibroids and adenomyosis in the field of gynecology. The side effects in HIFU is low in incidence and mild. HIFU can significantly alleviate the symptoms of patients, reduce lesion volumes, improve quality of life, and has good cost-effectiveness. HIFU can accurately ablate the uterine fibroids and adenomyosis lesions, without destroying normal myometrium and endometrium, and thus HIFU is a promising alternative to myomectomy in uterine fibroids patients with fertility desire. Several studies have shown that in terms of ovarian endocrine function protection, HIFU treatment is superior to uterine artery embolization, and similar to myomectomy. Existing limited researches show that patients with uterine fibroids have a favorable pregnancy rate and live birth rate, as well as a lower natural abortion rate after HIFU treatment. Pregnancy rate after HIFU treatment for uterine fibroids is not lower than myomectomy, and higher than uterine artery embolization. HIFU may have significant advantages in shortening pregnancy interval compared with myomectomy. However, the proportion of cesarean section delivery after HIFU treatment is relatively high, and gestational uterine rupture after HIFU treatment exist in literature. Higher quality clinical data is needed to confirm the pregnancy outcomes and safety after HIFU treatment in future.© 2024. The Author(s).

Adenomyosis is a common uterine disease second only to uterine leiomyoma. Its management often requires medical treatment. However, practically no drug has ever been developed exclusively for adenomyosis. Development of non‐hormonal drugs for adenomyosis so far has been unsuccessful. In this review, challenges in the development of non‐hormonal drugs for adenomyosis are spelled out, an overview of current knowledge on the pathophysiology of adenomyosis is provided, and some promising avenues for drug development are outlined.