{"paper_id":"25207108-1496-43db-af8b-85defbe84ca0","body_text":"Manuscript accepted for publication\n1 \nProvisionally accepted for publication \nNARRATIVE REVIEW  \nMenstrual blood VEGF, IL-6, TGF and nerve fiber as markers of adenomyosis: a literature\nreview\nMenstrual blood VEGF, IL-6, TGF , nerve fiber in adenomyosis \nY\nohanes Iddo Adventa *, Anita Rachmawati, Dian Tjahyadi \n1 Division of Fertility and Reproductive Endocrinology, Department of Obstetrics and Gynaecology,\nFaculty of Medicine, Dr. Hasan Sadikin General Hospital Padjadjaran University, Bandung,\nIndonesia.\n*\n Corresponding author: Yohanes Iddo Adventa, M.D., Department of Obstetrics and \nGynecology, Faculty of Medicine, Dr. Hasan Sadikin General Hospital Padjadjaran University,\nJalan Soekarno Hatta, Pekanbaru, Riau 28565, Indonesia.\nEmail: yohanesiddo@gmail.com. \nORCID: 0009-0007-5169-5657. \nDo\ni: 10.36129/jog.2025.226 \nABS\nTRACT \nB\nackground: Adenomyosis is a benign uterine disease characterized by the presence of\nendometrial glands and stroma in the myometrium. It lacks classic physical or laboratory\nexamination findings, which hinders clinical diagnosis. Although unlikely to replace hysterectomy,\ntransvaginal ultrasound, or MRI, menstrual blood based-biomarker testing is expected to aid in \nearly adenomyosis detection and consequently earlier initiation of clinical management strategies.\nObjective: This literature review aims to review and summarize the expression of VEGF, IL-6,\nTGF, and menstrual blood nerve fiber as biomarkers of adenomyosis.Method: We searched for\nliterature using four database sources, published in English within the last 10 years using the \nfollowing keywords: \"adenomyosis\" AND \"VEGF\" AND \"IL-6\" AND \"TGF\" AND \"Nerve fiber\". Data\nwas extracted independently by the authors and then selected based on specified inclusion and \nexclusion criteria. Results: Expression of VEGF, IL-6, TGF, and endomyometrial nerve fibers in \npatients with adenomyosis were significantly increased in patients with adenomyosis. Conclusion:\nMost research results point to the expression of VEGF, IL-6, TGF, and endomyometrial nerve fibers\nas potential biomarkers for adenomyosis. However, future research with better methodology still\nneeds to be conducted before routine clinical implementation.\nK\neywords: Adenomyosis; VEGF; IL-6; TGF; Endomyometrial nerve fiber. \n\nManuscript accepted for publication\n \n 2 \nBackground \nAdenomyosis is a benign uterine disease marked by endometrial glands and stroma embedded in \nthe myometrium, which surrounded by smooth muscle hyperplasia [1,2]. The true prevalence of \nadenomyosis is unknown, as a definitive diagnosis requires histopathological examination via \nhysterectomy. Current estimates of prevalence range from 8.8–61.5% in patients undergoing \nconsecutive hysterectomies over the past 50 years. Another study conducted involving 985 women \nundergoing transvaginal ultrasound in the UK found that the prevalence of adenomyosis was \n20.9%. It is also reported to coexist in a number of other gynaecological conditions: leiomyoma, \npelvic organ prolapse, and abnormal uterine bleeding Differences in histopathologic criteria for \ndiagnosis, different numbers of histologic tissue samples for each hysterectomy, and providers' \nlevel of awareness contribute to this broad estimation [1]. \nDiagnosis of adenomyosis typically begins with clinical suspicion and is confirmed through \ntransvaginal ultrasound and pelvic MRI. Around one-third of patients with adenomyosis are \nasymptomatic, while others may experience heavy menstrual bleeding (most common symptom), \ninfertility, or pelvic pain. It also lacks any classic physical examination findings or laboratory studies \nthat would identify it as a possible diagnosis. Furthermore, sonographic assessment of \nadenomyosis is hindered by low reproducibility [3,4]. Therefore, the diagnosis of adenomyosis can \nbe challenging and ambiguous as it requires a combination of clinical evaluation, imaging, and \nhistopathological examination, much like other uterine conditions [5–7]. Meanwhile, prompt \ndiagnosis of adenomyosis is critical as delays may result in disease progression, increased \nmorbidity, and impaired fertility.  \nMenstrual blood based-biomarker testing could enable earlier detection of adenomyosis compared \nto current diagnostic methods, enabling prompt initiation of clinical management strategies and \nfertility treatments. While unlikely to replace hysterectomy as the gold standard or imaging tools \nsuch as transvaginal ultrasound and MRI, biomarkers could still be used as adjunct in clinical \ndecision-making [5,8,9]. With an understanding of molecular and clinical pathogenesis of \nadenomyosis, numerous potential biomarkers can be used to detect adenomyosis. This narrative \nreview aims to examine the current evidence four adenomyosis biomarkers that have great \npotential which are not yet used routinely in clinical practice, namely VEGF, IL-6, TGF, and \nendometrial nerve fibers. These biomarkers are expected to be applied in the future in clinical \npractice. \n \nMaterials and Methods \nWe searched the literature using four database sources: PubMed, Cochrane, Medline, and \nScienceDirect that published in English between 2014 and 2024 using the following keywords: \n\"adenomyosis\" AND \"VEGF\" AND \"IL-6\" AND \"TGF\" AND \"Nerve fiber\". Additionally, snowballing \nand hand searching were also done. The authors independently extracted data, starting with an \ninitial screening of titles and abstracts (Figure 1). If the eligibility of an article could not be \ndetermined from the title and abstract alone, they reviewed the full text to make a final \nassessment. The studies obtained were then selected based on the specified inclusion and \nexclusion criteria. The inclusion criteria of our studies were: (1) Studies investigating the basic and \nclinical molecular pathogenesis of adenomyosis use human specimens, (2) Expression VEGF, IL6, \nTGF, and endometrium blood nerve in adenomyosis. The exclusion criteria for this study include: \ninaccessible full text forms, narrative text, or research design. Study selection and data extraction \nwas done by all authors, with discrepancies being resolved through discussion. \n \n \n\nManuscript accepted for publication\n \n 3 \nResults \nA total of 16 articles met the research criteria and were used in this literature review study as the \nmain findings, consisting of 6 articles discussing VEGF (Table 1), 3 articles discussing IL-6 (Table \n2), 5 articles discussing TGF (Table 3), and 3 articles discussing endomyometrial nerve fiber (Table \n4). \n \nDiscussion \nPathogenesis of Adenomyosis \nThere are several theories regarding the pathogenesis of adenomyosis (Figure 2). According to the \nmost popular theory, adenomyosis arises from the invagination of the basalis endometrium into the \nmyometrium, triggered by the myometrium's contractions, which cause trauma to the endometrial-\nmyometrial junction zone (JZ), a structure that highly specialized hormone-responsive, located in \nthe inner third of the myometrium. Persistent peristaltic myometrial contractions may induce \nconstant microtrauma to the JZ, leading to inflammation, which in turn promotes local increases in \noestrogen production and the recruitment of inflammatory mediators. Recent studies have also \ndiscovered that physiopathological mechanisms, including abnormalities in sex steroid hormones, \ninflammation, fibrosis, and neuroangiogenesis, may be associated to the pathogenesis of \nadenomyosis [10–13]. \n \nAngiogenesis is a mechanism of forming new capillaries from pre-existing blood vessels, which \nnaturally occurs during the proliferative phase. Oestrogen plays an important role in this event \nthrough increasing cell mobilization and microvascular integration. Numerous studies have shown \nthat increased neoangiogenesis is present in adenomyosis, as indicated by abnormalities and \nhigher microvessel density in both ectopic and eutopic endometrium. Vascular endothelial growth \nfactor (VEGF), a potent mitogen for endothelial cells, is highly secreted by endometrial epithelial, \nstromal, and perivascular cells in adenomyosis and plays a key role in angiogenesis mechanism. \nWhile VEGF is crucial for regenerating the endometrial lining after menstruation, its levels may be \nexcessive in patients with adenomyosis [14,15]. \n \nAdditionally, two growth factors, follistatin and activin A (both part of the TGF-β family), are involved \nin new blood vessel formation. In adenomyosis, these factors act as proangiogenic agents by \npromoting the formation of new capillaries and expanding the surface area of existing ones \ncompared to controls. Specifically, Activin A enhances VEGF production by endometrial stromal \ncells, altering vascularization and cause formation of new capillary. Furthermore, the mRNA \nexpression levels of follistatin and activin type II receptors are elevated in adenomyotic nodules \n[11]. \n \nThe increasing expression of oestrogen and TNF also trigger adenomyotic tissues to produce \nelevated levels of neurogenic factors, like nerve growth factors (NGF), which control the secretion \nof inflammatory factors, leading to mast cell growth and degranulation, producing inflammatory \nmediators, including IL-1b, IFNa, IFNc, IL-6, TNFa, TNF-B, TGF-B.28,30 Additionally, NGF \npromotes neuronal survival, plasticity, growth, and differentiation of catecholamine production in a \nmanner that depends on the dose. Zhang et al. reported finding nerve fibers in the functional layer \nof the endometrium in women with adenomyosis who experienced pain symptoms. These nerve \n\nManuscript accepted for publication\n \n 4 \nfibers were absent in women with asymptomatic adenomyosis. NGF may be related to these \nfindings [11]. \n \nMenstrual blood-based biomarker  \nSeveral biomarkers have been investigated in research for diagnosing adenomyosis, but none \nhave been implemented in clinical practice. Menstruation is the process of shedding the functional \nlayer of the uterine lining following the luteal phase of the ovarian cycle. Endometrium is a \nmulticellular and dynamic uterine tissue that is highly responsive to sex steroid hormones [16]. \nMenstrual blood offers a promising non-invasive diagnostic tool because layers of the \nendometrium are shed during menstruation and returned to the pelvic cavity during menstruation, \nsimplifying and accelerating the diagnostic process [17]. Some of these biomarkers can be found \nin menstrual blood, including VEGF. VEGF protein is expressed in normal endometrial stromal \ncells, with levels rising in response to oestrogen and progesterone, which are elevated in \nadenomyosis [18]. Sex hormones that regulate the menstrual cycle also induce the secretion of \nvarious cytokines (such as interleukin and TGF) in the uterine endometrium, which are essential for \nangiogenesis, the proliferation of natural killer (NK) and T cells, decidualization, and implantation \n[19]. Thus, these cytokines can thus be found in menstrual blood. Additionally, nerve fibers can be \ndetected in menstrual blood, both under physiological and pathological conditions. In pathological \nconditions like adenomyosis, where endometrial tissue infiltrates the muscular layer of the uterus, \nnerve fibers can also be released during menstruation [20]. While still under research, evidence for \nmenstrual blood biomarkers may one day be as robust as that for biomarkers used in cervical \ncancer [21]. \n \nStudy by Burghaus et al. also revealed there are other potential biomarkers for adenomyosis. \nBurghaus et al. found compared to 5 other blood-based biomarkers (HGF.aAB, Prokineticin-1, \nNSE, S100-A12, DNASE2.aAB), sFRP-4 was the best performing univariate biomarker with a \nsensitivity of 56.4% for comparison versus “all symptom controls”. For comparison versus \n“pathology-free symptom control”, S100-A12 was the best performing univariate biomarker with a \nsensitivity of 74.6% [8]. \n \nVEGF as Biomarker of Adenomyosis \nIn adenomyosis, tissue injury and repair result in the accumulation of myofibroblasts in the affected \nmyometrium, causing myometrial hypertrophy. VEGF plays a significant role in stimulating the \ngrowth of new blood vessels, supplying oxygen and nutrients to the proliferating tissue. In \nadenomyosis, Additionally, repetitive tissue injury causes local vascular disruption and blood \nextravasation, leading to platelet aggregation, the formation of clots, and consequent hypoxia. In \nresponse to hypoxic stimuli, hypoxia-inducible factor-1alpha (HIF-1α), a main mediator of cellular \nadaptation to hypoxia, is activated [18,22]. \n \nMacrophages also recruited to the wounding site, secrete chemotactic factors and several growth \nfactors, including VEGF. This factor is important for cell migration and proliferation, which mediates \ntissue repair and is enhanced by activation of platelets releasing a series of cell growth factors and \nangiogenic factors, such as PDGF and VEGF. VEGF plays a crucial role in regenerating the \nendometrial layer after menstruation; however, it is overexpressed in patients with adenomyosis. \nConsequently, an increase in VEGF expression is anticipated in the myometrium of adenomyosis \npatients [18,22]. \n\nManuscript accepted for publication\n \n 5 \n \nWhile studies utilizing immunochemistry (IHC) and RT-PCR have demonstrated increased VEGF \nexpression in adenomyotic lesions, inconsistencies remain. For instance, Harmsen et al. reported \nno difference in myometrial VEGF levels between patients with adenomyosis and control. The \nstudy also found that IHC score of VEGF was highest in the myometrium, followed by endometrial \nglands, and lowest in the endometrial stroma. While their study was the first to utilize multiplex \nIHC, the limited number of sample is a clear limitation. The samples were also only analysed \nbased on areas of interest, which may not be representative [23]. In contrast to the result by \nHarmsen, Kwack et al [24], Liu et al [25], and Yalaza et al [26] all also found VEGF expression \nlevels to be elevated in adenomyotic and myometrial lesions compared with eutopic endometrium, \nwhether from normal subjects or those with adenomyosis. \n \nWang et al, also reported similar findings, with notably higher levels of VEGF in the endometrial \nglandular epithelial cells of adenomyotic lesions. Additionally, the study found that the \nimmunoreactivity of GRIM-19, a novel protein which regulates apoptosis and the formation of new \nblood vessels, was markedly reduced in the adenomyosis group. In adenomyosis, deficiency in \nexpression of GRIM-19 results in decreased apoptosis and increased angiogenesis [27]. Orazov et \nal. also added that VEGF levels were significantly higher in ectopic endometrial epithelial cell and \nin the myometrial smooth muscle cells and stromal cells. VEGF levels were also reported to be \nhigher than those found in abnormal uterine bleeding. These findings suggest that the \nneovascularization process, which is promoted by VEGF, plays a significant role in the \ndevelopment of pelvic pain associated with adenomyosis [28]. Future studies should further study \nthe role of VEGF in the pathophysiology of adenomyosis, along with the role of novel proteins, \nsuch as GRIM-19. Utilization of advanced techniques such as multiplex IHC is also promising. \nHowever, retrospective design of the studies may introduce selection bias and should be \naddressed in subsequent studies. \n \nIL-6 as Biomarker of Adenomyosis \nIL-6 is a growth regulator of human endometrial stromal cells. When bound to its receptor, it \nactivates JAK2, leading to the phosphorylation and nuclear localization of signal transducer and \nactivation of transcription 3 (STAT3). This signalling pathway is crucial for the growth and \nprogression of various human cancers, including endometrial carcinoma. Hyperactivation of this \nsignalling pathway may enhance the invasive behaviour of endometrial cells in adenomyosis. \nExosomes, a subtype of extracellular vesicles, function as carriers for transferring molecules such \nas DNA, RNA, proteins, and lipids from parental cells to recipient cells. Thus, endometrial cell-\nderived exosomes could facilitate communication between the endometrium and myometrium via \nIL-6 signalling, playing a role in the development of adenomyosis [22,29]. \n \nJiang et al found that IL-6 expressions were enhanced in adenomyosis myometrium cells that were \nexposed to exosomes. Western blotting also revealed that endometrial cell exosomes are \nsignificantly increased the protein expression of IL-6, p-JAK2, JAK2, p-STAT3, STAT3, which \ninfluenced the effect of endometrial cell exosomes on AM cells. Reflecting on this, exosome \ninhibitors may be a future therapeutic modality in adenomyosis. IL-6 may also be directly targeted \nin future treatment of adenomyosis. Adenomyotic myometrium cells exposed to tocilizumab, an IL-\n6 inhibitor, were also observed to display apoptotic characteristics and significant reduction in \nsurvivability during the MTT assay [22]. However, there are still questions to be answered with \n\nManuscript accepted for publication\n \n 6 \nregards to the precise mechanisms of tocilizumab and its dynamics on immune cells in \nadenomyosis.  \nStudy by Kim et al in patients undergoing IVF revealed higher baseline IL-6 levels in infertile \nadenomyosis patients with clinical pregnancy rate being significantly lower in those with higher IL-6 \nlevels [30]. It would be interesting to explore the prognostic role of IL-6 in pregnancy and fertility \namong patients with adenomyosis.  \nJiang et al also reported RT-PCR results that showed IL-6 mRNA expression levels in ectopic and \neutopic were significantly higher than in control group. Jiang et al also found a significant positive \ncorrelation between IL-6 mRNA expression and TLR-1,4,5, and 9 in eutopic tissue. In EC, IL-6 \nmRNA expression was positively correlated with TLR-1, 2, 4, 5, 6, and 9; but did not show any \nsignificant correlation with other TLRs. These findings suggest that TLRs might potentially play a \nrole in the inflammatory development of adenomyosis through the NK-κB-mediated signalling \npathway [31,32]. \nTGF as Biomarker of Adenomyosis \nThe Epithelial–mesenchymal transition (EMT) is a physiological process where epithelial cells gain \nthe motile and invasive properties of mesenchymal cells. During embryonic development, EMT is \nan expected and coordinated process which involves interactions among various cells and tissues \n[33]. However, microenvironmental changes and abnormal stimuli may improperly activate the \nEMT process, contributing to the pathogenesis of adenomyosis. Transforming growth factor (TGF)-\nβ1 and TGF-β2 may play an important role in the induction and regulation of EMT. The \nupregulation of these factors in the endometrium of patients with adenomyosis indicate a \ndysfunction during the secretory phase [34,35]. \nResearch conducted by Juárez-Barber et al. supported this notion as they reported significantly \nincreased TGF-β2 expression in adenomyosis when evaluated by IHC [34], with Cai et al. and Liu \net al. reporting comparable results [25,36]. Furthermore, the experiment by Cai et al. found a \nnegative correlation between the level of eIF3e staining and TGF-β1. According to recent research, \ndecreased expression of eIF3e is associated with the epithelial–mesenchymal transition (EMT) \nprocess. The phenomena of EMT may be a widespread occurrence in disease progression and \nrequires an active and ongoing TGF-β signaling pathway, which may also be a future therapeutic \ntarget with antibodies or small molecule inhibitors [36]. \nResults from the experiment by Cheong et al. suggested that TGFβ1 influences collagen \nproduction by inducing CTGF, a protein classified within the CCN family of matricellular proteins. It \nis a key regulator of tissue remodeling and fibrosis where impairment causes excessive \nextracellular matrix (ECM) synthesis which is implicated in various fibrotic conditions [37]. Elevated \nlevels of CTGF may promote the development and fibrotic advancement of adenomyosis, which \nconsequently lead to dysmenorrhea [38]. \n \nEndomyometrial Nerve Fiber as Biomarker of Adenomyosis \nRecent research have identified fine and unmyelinated sensory nerve fibers in the functional layer \nof the eutopic endometrium in women with endometriosis. These nerve fibers have subsequently \nbeen observed in the peritoneal endometrioses. Study by Yadav et al. reported that 10 out of 73 \npatients (13.7%) in the adenomyosis group had nerve fibers, as indicated by positive PGP 9.5 \nstaining. However, the percentage of women with endomyometrial nerve fibers is significantly \nhigher in the endometriosis group [39]. \n \n\nManuscript accepted for publication\n \n 7 \nResearch by Takeuchi et al. in adenomyosis patients found significantly lower density of nerve \nfibers and lower NGF immunoreactivity in those receiving dienogest [40]. Dienogest, a novel \nprogestin derived from 19-norsteroid, is highly selective for progesterone receptors and exhibits \nantiproliferative, immunologic, and antiangiogenic effects on endometrial tissue. It also significantly \nreduces chronic pelvic pain and menorrhagia in patients with adenomyosis [41]. Furthermore, \nLertvikool et al reported significantly increased number of nerve fibers identified by PGP9.5 \nstaining in the myometrium of adenomyosis patients experiencing moderate to severe pain when \ncompared to those with less pain. NGF and its receptors are crucial in mediating both \nneuropathological and non-neuropathological pain by promoting the growth, survival, and \nmaintenance of sensory neurons. Studies in a mouse model have also shown that NGF-beta is a \nkey factor in the pathogenic mechanisms of adenomyosis [42]. These findings shed a light on the \npossible mechanism on how dienogest may reduce pain in adenomyosis. \n \nClinical Implications \nThere are three primary ways in which measuring a biomarker in clinical care can enhance health: \nit can help the patients in understanding their disease, which enhances their quality of life and \nmental health; it can motivate patients to adopt healthier behaviours, such as better diet, increased \nexercise, or improved adherence to prescribed treatments; and it can assist clinicians in making \nbetter clinical decisions, such as determining appropriate treatments, which leads to better patient \nhealth. However, biomarker measurements can also have negative health outcomes through these \nsame mechanisms (for example causing depressed mood from unfavourable news). Furthermore, \nthese biomarkers may also have the potential to provide gynaecologic and obstetric prognostic \nvalue in the holistic management of adenomyosis. Therefore, before ordering a biomarker test, \nclinicians should have a clear expectation that, on average, the test will lead to improved health \nthrough one or more of these mechanisms. \n \nConclusions \nMost of the research results point to the possibility of VEGF, IL-6, TGF, and endomyometrial nerve \nfibers as potential biomarkers for adenomyosis. In summary, we found these expressions were \nsignificantly increased in patients with adenomyosis compared to the control group (without \nadenomyosis). VEGF and endomyometrial nerve fibers may play an important role in pain in \nadenomyosis [43,44]. However, more evidence backed by better research methodology is still \nnecessary before routine clinical application, such as by employing an experimental design and \nblinding. This would also better resolve the conflicting findings seen between authors \n \nCompliance with Ethical Standards: This study did not involve any human or animal \nparticipants. All studies used in the drafting of this article has been properly cited. \n \nAuthors contribution: A.R.: Conceptualization. Y.I.A.: Data curation, Formal Analysis, Funding \nacquisition, Investigation. D.T.: Methodology. Y .I.A.: Project administration, Resources, Software. \nA.R., D.T.: Supervision, Validation. Y.I.A.: Visualization, Writing – original draft, Writing – review & \nediting. All authors have read and agreed to the published version of the manuscript. \n \nFunding: None. \n\nManuscript accepted for publication\n \n 8 \n \nStudy registration: N/A. \n \nDisclosure of Interests: The authors declared no conflict of interests. \n \nEthical Approval: N/A. \n \nInformed consent: N/A. \n \nData sharing: N/A. \n \nReferences \n1. Upson K, Missmer SA. Epidemiology of Adenomyosis. Semin Reprod Med. 2020 May;38(2-\n03):89-107. doi: 10.1055/s-0040-1718920. \n2. Taran FA, Stewart EA, Brucker S. 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DAMPs/PAMPs \ninduce monocytic TLR activation and tolerance in COVID-19 patients; nucleic acid binding \nscavengers can counteract such TLR agonists. Biomaterials [Internet]. 2022 Apr;283:121393. \nAvailable from: https://linkinghub.elsevier.com/retrieve/pii/S0142961222000321 \n33.  Nistico P, Bissell MJ, Radisky DC. Epithelial-Mesenchymal Transition: General Principles \nand Pathological Relevance with Special Emphasis on the Role of Matrix Metalloproteinases. Cold \nSpring Harb Perspect Biol [Internet]. 2012 Feb 1;4(2):a011908–a011908. Available from: \nhttp://cshperspectives.cshlp.org/lookup/doi/10.1101/cshperspect.a011908 \n34.  Juárez-Barber E, Francés-Herrero E, Corachán A, Vidal C, Giles J, Alamá P, et al. \nEstablishment of Adenomyosis Organoids as a Preclinical Model to Study Infertility. J Pers Med \n[Internet]. 2022 Feb 4;12(2):219. Available from: https://www.mdpi.com/2075-4426/12/2/219 \n35.  Hwang JS, Lai TH, Ahmed M, Pham TM, Elashkar O, Bahar E, et al. 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Reprod Biomed Online \n[Internet]. 2021 Mar;42(3):651–60. Available from: \nhttps://linkinghub.elsevier.com/retrieve/pii/S1472648320305873 \n\nManuscript accepted for publication\n \n 15 \n39.  Yadav G, Rao M, Gothwal M, Singh P, Kathuria P , Sharma PP . Detection of nerve fibers in \nthe eutopic endometrium of women with endometriosis, uterine fibroids and adenomyosis. Obstet \nGynecol Sci [Internet]. 2021 Sep 15;64(5):454–61. Available from: \nhttp://ogscience.org/journal/view.php?doi=10.5468/ogs.21114 \n40.  Takeuchi A, Koga K, Miyashita M, Makabe T, Sue F, Harada M, et al. Dienogest reduces \nproliferation, NGF expression and nerve fiber density in human adenomyosis. Eur J Obstet \nGynecol Reprod Biol [Internet]. 2016 Dec;207:157–61. Available from: \nhttps://linkinghub.elsevier.com/retrieve/pii/S0301211516310119 \n41.  Ali MK, Hussein RS, Abdallah KS, Mohamed AA. The use of dienogest in treatment of \nsymptomatic adenomyosis: A systematic review and meta-analysis. J Gynecol Obstet Hum Reprod \n[Internet]. 2024 Sep;53(7):102795. Available from: \nhttps://linkinghub.elsevier.com/retrieve/pii/S2468784724000734 \n42.  Lertvikool S, Sukprasert M, Pansrikaew P , Rattanasiri S, Weerakiet S. Comparative study of \nnerve fiber density between adenomyosis patients with moderate to severe pain and mild pain. J \nMed Assoc Thail. 2014;97(8):791–7.  \n43.  Pletcher MJ, Pignone M. Evaluating the Clinical Utility of a Biomarker. Circulation [Internet]. \n2011 Mar 15;123(10):1116–24. Available from: \nhttps://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.110.943860 \n44.  Califf RM. Biomarker definitions and their applications. Exp Biol Med [Internet]. 2018 Feb \n6;243(3):213–21. Available from: http://journals.sagepub.com/doi/10.1177/1535370217750088 \n  \n\nManuscript accepted for publication\n \n 16 \n \nTable 1 Summary of Studies Discussing VEGF as Adenomyosis Marker  \nAuthor Year Study Design Sample Size Results \nHarmsen \net al23 \n2022 Retrospective \nmatched \ncase-control \nstudy \n19 specimen diagnosed \nwith adenomyosis and \n19 specimen controls \nwith unrelated \npathology \nThere was no difference in \nthe intensity of VEGF \nstaining between \nadenomyosis and control \npatients  \nKwack et \nal24 \n2022 Retrospective \nstudy \nA uterine sample was \ntaken from 22 \npremenopausal \npatients with focal \nuterine adenomyosis. \nSamples were collected \nfrom three specific \nareas: the \nadenomyosis lesion, \nthe unaffected \nmyometrium, and the \nendometrial tissue just \nbeneath the unaffected \nmyometrium \n VEGF expression was \nsignificantly higher in \nadenomyotic lesions and \nthe myometrium compared \nto the eutopic endometrium \n \nYalaza et \nal26 \n2020 Retrospective \nstudy  \n90 paraffin-embedded \narchival tissues that \ncategorized into three \ngroups: Group I \n(ectopic endometrial \ntissues of adenomyosis \npatients), (n = 35); \nGroup II (eutopic \nendometrial tissues of \nadenomyosis patients), \n(n = 35); Control Group \n(endometrial tissues of \nindividuals without \nadenomyosis), (n = 20) \nThere was significant \ndifference in the level of \nVEGF gene expression \nbetween Group I–Group II \n(p = 0.036) and Group I–\nControl Group (p = 0.001), \nand there was no \nsignificant difference \nbetween Group II and \nControl Group (p = 0.275) \nWang et \nal27 \n2016 Retrospective \nstudy \n30 ectopic and eutopic \nendometrial tissues of \nadenomyosis patients \nand 10 endometrial \ntissues of patients \nwithout adenomyosis \nas control \nThe staining levels of \nVEGF in the ectopic and \neutopic endometrial of \npatients with adenomyosis \nwere significantly higher \nthan in the controls \n\nManuscript accepted for publication\n \n 17 \nOrazov \net al28 \n2016 Retrospective \nstudy \n Uterus specimens from \n30 patients with diffuse \nadenomyosis \naccompanied by severe \npelvic pain syndrome \nand 30 biopsies of \nadenomyosis patients \nwith a painless \nsyndrome  \nVEGF expression in \nperivascular compartment \ncells was found to be \nhigher in adenomyosis \npatients with the painful \nform compared to those \nwith the painless form  \nLiu et al25 2016 Cross \nsectional \nstudy \nEndometrial tissue \nspecimens from 34 \nwomen with \nadenomyosis \n(excluding \nendometriosis) and 20 \nwomen without \nadenomyosis (controls) \nIHC result show that \nstaining of VEGF, were \nhighly significantly \nincreased in ectopic \nendometrium from \nadenomyosis patients \ncompared to controls \nVEGF: vascular endothelial growth factor; IHC: immunohistochemistry. \n  \n\nManuscript accepted for publication\n \n 18 \nTable 2 Summary of studies Discussing IL-6 as Adenomyosis Marker  \nAuthor Year Study Design Sample Size Results \nJiang et \nal22 \n2023 Retrospective \nstudy \nBiopsy specimens from \n10 adenomyosis \npatients \nIL-6 expressions were \ndetected and enhanced in \nadenomyosis myometrium \ncells that were exposed to \nexosomes \nKim et \nal30 \n2019 Retrospective \ncohort study \nBlood samples of 59 \ninfertile women with \nadenomyosis  \nSerum IL-6 levels on the \nday of hCG injection were \nmarkedly higher in infertile \nwomen with adenomyosis \ncompared to those without \nadenomyosis who were \nundergoing IVF at the \nsame time (P=0.01). \n(P=0.01) \nJiang et \nal31 \n2017 Retrospective \nstudy \nEutopic endometrial \n(EU) and Ectopic \nendometrial (EC) \nsamples were derived \nfrom 30 adenomyosis \npatients, and \nendometrium samples \nwithout adenomyosis \n(CE) from 30 healthy \npatients as controls \nRT-PCR analysis showed \nthat IL-6 mRNA expression \nlevels in EC and EU were \nsignificantly higher than in \nCE, with EC showing \nsignificantly higher \nexpression than EU (P < \n0.01) \nIL-6: interleukin-6; hCG: human chorionic gonadotropin; IVF: in-vitro fertilization; RT-PCR: reverse \ntranscription-polymerase chain reaction; mRNA: messenger ribonucleic acid. \n  \n\nManuscript accepted for publication\n \n 19 \nTable 3 Summary of studies Discussing TGF as Adenomyosis Marker \nAuthor Year Study Design Sample Size Results \nJuárez-\nBarber, \net al34 \n2022 Retrospective \nstudy \n Human endometrial \nbiopsy specimens from \nadenomyosis women (n \n= 6) and healthy \nwomen (n = 6) \nAdenomyosis organoids \n(self-organized in vitro in \n3D structures) showed \nthere was higher \nexpression of TGF-β2 \nCheong \net al37 \n2019 Experimental \ndesign \nEndometrium samples \nat secretory phase of \nmenstrual \ncycle from 25 patients \nwith adenomyosis \n \nExpression of TGF-β1 in \nthe stroma of adenomyotic \nendometrium induce \ncollagen production in \nendometrium-derived \nfibroblasts \nCai et \nal36 \n2019 Experimental \ndesign \nEctopic endometrial \ntissue samples from 40 \npremenopausal women \nwith adenomyosis (28 \nwith diffuse \nadenomyosis, 12 with \nfocal adenomyosis) and \nendometrial samples \nfrom 40 women without \nendometriosis, \nadenomyosis, uterine \nfibroids \nExpression of TGF-β1 was \nsignificantly elevated in \nadenomyosis group \ncompared to control  \nKishi et \nal20 \n2017 Retrospective \nstudy \nBiopsy specimens from \n18 adenomyosis \npatients (8 cases occur \nat the inner \nmyometrium and 10 \ncases occur at outer \nmyometrium) \nA significant staining of \nTGF-β were found only at \nthe smooth muscle cells of \nsubtype II adenomyosis \n(occur at outer \nmyometrium) \n \nLiu et \nal25 \n2016 Cross \nsectional \nstudy \nEndometrial tissue \nspecimens from 34 \nwomen with \nadenomyosis \n(excluding \nendometriosis) and 20 \nwomen without \nadenomyosis (controls) \nAdenomyotic lesions had a \nsignificantly increased \nstaining for TGF-\nβ1 \ncompared to control (P \n<0.001) \nTGF: tumor growth factor.  \n\nManuscript accepted for publication\n \n 20 \nTable 4 Summary of studies Discussing Endomyometrial Nerve Fiber as Adenomyosis Marker \nAuthor Year Study \nDesign \nSample Size Results \nYadav et \nal39 \n2021 Prospectiv\ne study \nEndometrial tissue \nspecimens of 190 patients \nwith endometriosis, \nadenomyosis, or uterine \nfibroids (73 patients had \nadenomyosis) and 30 \npatients without \nendometriosis, \nadenomyosis, uterine \nfibroids \nThere were 10/73 (13.7%) \npatients in the \nadenomyosis group who \nhad endomyometrial nerve \nfibers and a significant \ndifference was observed in \nthe presence of nerve \nfibers among these groups \n(endometriosis, \nadenomyosis, or uterine \nfibroid, P<0.001) \nTakeuchi \net al40 \n2016 Experiment\nal Design \nAdenomyosis tissue \nsamples from 12 patients \ndivided into 6 patients who \nreceived dienogest and 6 \npatients who did not \nreceive hormonal \ntreatment for ≥3 months as \nthe control group \nThe density of nerve fibers \nin adenomyosis lesions \nwas significantly reduced in \nthe dienogest group \ncompared to the control \ngroup \nLertvikool \net al42 \n2014 Cross \nsectional \nstudy \nUterine samples from 23 \nreproductive age women \nwith adenomyosis that \ndivided into two groups, \nVAS ≥5 (moderated and \nsevere pain) and VAS <5 \n(less pain) \nNerve fibers density were \nsignificantly higher in \nadenomyosis patients with \nmoderate and severe pain \ncompared to less pain \ngroup \nVAS: visual analog scale. \n \n \n \n \n \n \n \n \n \n\n \n 21 \nFigure 1. Study Selection Process. \n \n \n \n \n \n \n \n \n \n \nManuscript accepted for publication\n\n \n 22 \n \nFigure 2. Overview of pathogenesis of Adenomyosis. \n \n \n \n \nManuscript accepted for publication","source_license":"CC0","license_restricted":false}