{"paper_id":"31400ace-00fd-4365-a48e-6f35209f92fe","body_text":"Der Gynäkologe\nLeitthema\nGynäkologe2020·53:683–688\nhttps://doi.org/10.1007/s00129-020-04655-7\nPublishedonline:15September2020\n©TheAuthor(s)2020\nRedaktion\nL.Kiesel,Münster\nW.Janni,Ulm\nHarald Krentel1 ·R u d yL e o nD eW i l d e2\n1 ClinicofGynecology,Obstetrics,GynecologicalO ncologyandSenology,BethesdaHospitalDuisburg,\nAcademicTeachingHospital,Duisburg,Germany\n2 ClinicofGynecology,ObstetricsandGynecologicalOncology,UniversityHospitalforGynecology,Pius-\nHospitalOldenburg,MedicalCampusUniversityofOldenburg,Oldenburg,Germany\nAdenomyosis: diagnostics\nand treatment\nAdenomyosis can cause dysmen-\norrhea, dyspareunia, bleeding\ndisordersandpelvicpainandhas\nanegativeimpactonfertility. The\nbenignuterinediseasecanbefound\ninalmost50%ofpatientswithdeep\nendometriosis,butalsocanappear\nwithoutadditionalendometriosis.\nAdenomyosisisstillunderestimated\nandunderdiagnosedandanexactin-\ncidence,especiallyrelatedtopatient\nage,isstillnotknown. Thismight\nberelatedtothedifficultiesindiag-\nnosingadenomyosis, althoughthe\ndiagnostictoolshaveahighaccuracy\ninthehandsoftheskilledexaminer.\nConsideringadenomyosisallowsthe\nindividualizationofmedicinaland\nsurgicaltreatmentinsymptomatic\nand/orinfertilepatients.\nThe uterus is the central organ of the\nfemale pelvis and plays anindispensable\nrole in reproduction. Adenomyosis is\na benign disease of this important or-\ng a na n dk n o w l e d g ea b o u tt h ei m p a c to f\nadenomyosis on symptomatology and\nfertilityanditsrelationtoadditionalperi-\ntoneal or deep endometriosis has been\nincreasing over the years. Although\nthe exact incidence of adenomyosis re-\nmainsunclear,thediseaseseemstoaffect\nwomenfromadolescencetomenopause.\nMany patients with adenomyosis are\nsymptomatic and report dysmenorrhea,\ndyspareunia, central pelvic pain and\nbleeding disorders. The negative impact\nof adenomyosis on fertility is still un-\nder discussion but several publications\nhave shown reduced pregnancy and\nbirth rates and higher abortion rates in\npatients with adenomyosis undergoing\nreproductive treatment [1]. A risk for\nobstetric complications in patients with\nadenomyosis has recently been reported\nregarding premature birth, premature\nrupture of membranes, uterine rupture,\npostpartum hemorrhage, placentation\nfailure and intrauterine fetal growth\nreduction [2]. It has been reported\nin various publications that medicinal\nand surgical treatment of adenomyosis\nmay improve fertility [3]a n dr e d u c e s\nsymptoms, although a standard for the\ntreatment of infertile women with ade-\nnomyosis has not yet been established\n[4]. Hence it is of importance to con-\nsider adenomyosis as a possible factor\nin the diagnosis and treatment of all pa-\ntientswithendometriosis,corresponding\nsymptoms or infertility. The identifica-\ntionofpatients withadenomyosisallows\nindividualized treatment approaches in\nrelation to family planning status.\nFromanamnesistotransvaginal\nultrasound—Thediagnosis\nAs always, the clinical diagnosis starts\nwith a detailed anamnesis. The clinical\nsymptoms can lead to the suspicion of\nadenomyosisasmostofthepatientshave\ntypical symptoms, such as dysmenor-\nrhea, bleeding disorders, chronic pelvic\npain and dyspareunia. Adenomyosis\nmight also be the reason for persistent\nsymptoms after surgical interventions\nfor peritoneal and deep endometrio-\nsis [5]. The gynecological examination\nmay reveal a dolorous enlarged uterus\nand an additional palpable deep en-\ndometriosis of the retrocervical area\n[6]. Almost 50% of patients with deep\nendometriosis also have an involvement\nof the uterus. The most important di-\nagnostic tool in the daily gynecological\npractice is the transvaginal ultrasound\n[7]. Several typical ultrasound signs\nhave been described in the literature:\nmyometrial cysts, subendometrial mi-\ncrocysts, question mark sign, heteroge-\nneous myometrium, uterine asymmetry,\nhyperechoic myometrial lesions, suben-\ndometrial thickening, disruption of the\njunctional zone, subendometrial linear\nstriaeanduterineenlargement(\n. Fig. 1).\n»The most important\ndiagnostic tool in daily\ngynecological practice is\ntransvaginalultrasound\nAlthough the meaning of the particu-\nlar signs is not yet clear and a score\nsystem does not yet exist, the overall\naccuracy of 2D transvaginal ultrasound\nin the diagnosis of adenomyosis is high\nwith a pooled sensitivity of 83.8% and\napooledspecificityof63.9%[ 8]. The10-\nyear meta-analysis [8]describedthe fea-\nture heterogeneous myometrium as the\nsign with the highest pooled sensitivity,\nwhile globular uterine enlargement was\nthe most specific sign. The combination\nwith the feature question mark sign in-\ncreased the accuracy. A similar review\nshowed comparable results pointing out\nthe high heterogeneity between the in-\ncludedstudiesandthemissingconsensus\ninadenomyosisclassification[ 9]. Differ-\nentpublications showedahighvariation\nDer Gynäkologe 10 · 2020 683\n\nLeitthema\nFig. 18Transvaginalultrasoundimageoftheuterusshowingasuben-\ndometrialmicrocystinadenomyosis(size4mm)withassociatedlinearstriae.\n(Withpermission©H.Krentel,allrightsreserved)\nFig. 28Transvaginalultrasoundimageoftheuterusshowingasuben-\ndometrialmicrocystinadenomyosis.Theadditionalcoloreddopplersonog-\nraphyhelpstodistinguishbloodvessels( blueand red color)frommicrocysts\nwithnocolorsignal.(Withpermission©H.Krentel,allrightsreserved)\nFig. 38Nativetissuesampleafterhysterec-\ntomyshowingmyometrialtissuewithsuben-\ndometriallayerincludingmicrocystsinadeno-\nmyosis(3mm).(Withpermission©H.Krentel,\nallrightsreserved)\nin the most useful ultrasound features,\nvaryingbetweenlinearstriation,myome-\ntrial cysts, question mark sign, hetero-\ngeneous myometrium and asymmetri-\ncal myometrial thickening. Additional\nsonographic techniquescanhelptocon-\nfirm the diagnosis of adenomyosis. In\nthe examination of the junctional zone\nand its typical irregularities in adeno-\nmyosis, the 3D transvaginal ultrasound\nseems to be superior to 2D sonography.\nDoppler sonography can be used to dis-\ntinguishadenomyosis(centralflow)from\nfibroids (circular flow) by its typical flow\ncharacteristics and to differentiate small\nmyometrial blood vessels from micro-\ncysts ([10]; . Fig. 2 and 3).\nIn combination with the clinical his-\ntory and gynecological examination,\ntransvaginal ultrasound isapotentdiag-\nnostictoolinthehandsoftheexperienced\nexaminer. The consensus statement of\nthe morphological uterus sonographic\nassessment (MUSA) group on sono-\ngraphic uterine features and the use\nof terminology summarized the actual\nstatus quo[11]. Specializedtraining and\nas t a n d a r du l t r a s o u n de x a m i n a t i o ni n\nall patients with typical symptoms may\nhelp to detect adenomyosis.\n»Magneticresonanceimaging\nisapotentialdiagnostictoolwith\nhighaccuracy\nInordertodetectfocalanddiffuseadeno-\nmyosis and to presurgically localize and\nmeasuretheaffecteduterinetissue,mag-\nneticresonance(MR)imagingisapoten-\ntial diagnostic tool with high accuracy.\nThe most important diagnostic sign in\nMR imaging seems to be the irregular-\nity of the junctional zone (JZ), followed\nby focal or diffuse thickening of the JZ,\na JZ(max) to myometrial thickness ratio\n>40%,areasofmyometrial lowsignalin-\ntensity and high signal intensity spots in\ntheT2-weightedtechniquearethetypical\nfindings [12, 13] .B a z o te ta l .c o m p a r e d\ntransvaginal ultrasound with MR imag-\ning and reported no difference in accu-\nracy. In patients with additional uterine\nmyomasthesensitivitywashigherinMR\nimaging [12].\nSurgical diagnosis and\nhistologicalproof\nThenon-invasivediagnosticstepscanbe\ncombinedwithoperativediagnosticpro-\ncedures,suchasdiagnostichysteroscopy\nand bipolar mini-resectoscopy. These\ntechniques allow the retrieval of biopsy\nsamples and thus the histological proof\nof the presence of adenomyosis and can\nbe easily performed during surgery for\nendometriosis and infertility (. Fig. 4).\nIn diagnostic hysteroscopy the uterine\ncavity and the endometrial layer can be\ninspected. Typical signs in adenomyosis\naretinyopeningsintheendometrialsur-\nface, irregular endometrium, hypervas-\ncularization, strawberry pattern, fibrous\ncystic appearance of intrauterine lesions\nand cystic hemorrhagic lesions [14]. Si-\nmultaneouslysubendometrialadenomy-\notic tissue resection and histopathologic\nexaminationcanbeperformed. Thediag-\nnosticspecificitycanbeincreasedbythe\ncombination of transvaginal ultrasound\nand endomyometrial biopsy [15].\n»Diagnostic findings can\nchangein relationtopatient\nage,hormonaltreatmentand\nmenstrualcycle\nLaparoscopic signs of adenomyosis can\nbe uterine enlargement, a pillowy resis-\nt a n c eo ft h eu t e r i n ew a l l ,t h eb l u es i g n\nandcysticsubseroushemorrhagiclesions\n684 Der Gynäkologe 10 · 2020\n\n(. Fig. 5). Laparoscopy-guided myome-\ntrial biopsy techniques have been de-\nscribed as an accuratetool for obtaining\na definitive diagnosis in patients with a\nclinical suspicion of adenomyosis [16].\nThehistologic proof canbehelpful in\ntherapeutic decisions, especiallyincases\nof adenomyosis-related infertility. The\naccuracy of percutaneous, transvaginal,\nhysteroscopicandlaparoscopicsampling\ntechniques varies in relation to exam-\ninerexperienceandqualityofultrasound\ndetection [17]. All diagnostic findings\nin adenomyosis can change in relation\nto patient age, hormonal treatment and\nmenstrual cycle. In conclusion the di-\nagnosis or exclusion of adenomyosis by\ntheexperiencedgynecologist ispossible.\nThe individual combination of different\ndiagnostic tools including imaging tech-\nniques and minimally invasive surgical\napproachesprovideahighaccuracyinthe\ndiagnosis of adenomyosis and in some\ncases even histological certainty.\nSurgicaltreatmentwhenfamily\nplanningiscompleted\nAdenomyosis can be treated by medici-\nnaland/orsurgicalapproachesincluding\nreproductive techniques. The decision\non how to treat adenomyosis individ-\nually depends on the following factors:\ntype of symptoms, family planning sta-\ntus, additional peritoneal and/or deep\nendometriosis and age. In patients\nwith completed family planning ade-\nnomyosis can be definitively treated by\nlaparoscopic total hysterectomy or la-\nparoscopic subtotal hysterectomy when\nthe uterine cervixis freeof adenomyosis\nor retrocervical deep endometriosis.\nThe laparoscopic approach allows the\ninspection of the complete pelvis and\nthus the simultaneous resection of ad-\nditional endometriosis. In cases of\nsubtotal hysterectomy, laparoscopic in\nbag morcellation of the uterine cor-\npus should be performed in order to\navoid iatrogenic new onset intraperi-\ntoneal or retroperitoneal adenomyosis,\nendometriosis, metastatic myomatosis,\nsarcoma or late onset malignant trans-\nformation of uterine tissue. Abdominal,\nlaparoscopic or hysteroscopic adenomy-\nomectomyinfocalorcysticadenomyosis\nAbstract · Zusammenfassung\nGynäkologe2020·53:683–688 https://doi.org/10.1007/s00129-020-04655-7\n©TheAuthor(s)2020\nH. Krentel · R. L. De Wilde\nAdenomyosis: diagnosticsandtreatment\nAbstract\nBackground.A denomy osisisafr equent\nadditional condition in patientswith\nendometriosisandshouldbeincludedin\ndiagnosticandtreatmentconcepts.\nObjective.Descriptionofdiagnosticand\ntherapeuticapproachesinpatientswith\nadenomyosisinrelationtopatientage,family\nplanningstatus,peritonealand/ordeep\nendometriosisandsymptoms.\nMethods. The current literature on\nadenomyosisincludingcasereports was\nanalyzed.Duetothelackofevidenced-based\napproachesthemostprobabletrends in\ndiagnosticsandtreatmentarediscussed.\nResults.Adenomyosisplaysanimportant\nroleinfertilepatientswithdysmenorrhea,\ndyspareuniaandpelvicpain,withorwithout\nadditionalperitonealordeependometriosis.\nIthasanegativeimpactonfertilityandcan\ncauseavarietyofsymptoms.The disease\ncanbediagnosedbyaskilledexaminerand\ntreatmentconceptsexist.\nConclusion.Adenomyosiscanbediagnosed\nby a combinationof clinicalhistory,\ngynecologicalexamination,transvaginal\nultrasoundandmagneticresonanceimaging.\nVariousmedicaland surgicaltreatment\napproachesareavailabletoreducesymptoms\nandtoincreasefertility.Thecourseofaction\ndependsonthefamilyplanningstatusofthe\npatient.\nKeywords\nEndometriosis·Infertility·Dyspareunia·\nDysmenorrhea·Transvaginalultrasound\nAdenomyose: DiagnostikundTherapie\nZusammenfassung\nHintergrund.D i eA d e n o m y o s ei s te i n e\nhäufig auftretendeBegleiterkrankung\nbeiPatientinnenmitEndometriose und\nsollteinDiagnostikundtherapeutischen\nBehandlungskonzeptemiteinbezogen\nwerden.\nZiel.Beschreibungderdiagnostischenund\ntherapeutischenAnsätzebei Patienten\nmit Adenomyose in Bezug auf Alter,\nFamilienplanungsstatus,Peritoneal-und/oder\ntiefeEndometrioseundSymptome.\nMethoden. Die aktuelleLiteraturzur\nAdenomyoseeinschließlichderFallberichte\nwurde analysiert.Aufgrund mangelnder\nevidenzbasierterAnsätzewerden die\nwichtigstenEntwicklungeninDiagnostikund\nTherapiediskutiert.\nErgebnisse.D ieA d enom y osespielteine\nbedeutendeRollebeifruchtbarenPatien-\ntinnenmitDysmenorrhö,Dyspareunieund\nBeckenschmerzen,mitoderohnezusätzliche\nPeritoneal-odertiefe Endometriose.Sie\nwirktsichnegativaufdieFruchtbarkeitaus\nundkanneineVielzahlvonSymptomen\nverursachen.DieErkrankungkannvoneinem\nqualifiziertenUntersucherdiagnostiziert\nw er d en.F ürd ieT her apiestehend iv er se\nBehandlungskonzeptezurVerfügung.\nSchlussfolgerung.DieAdenomyosekann\ndurch eine Kombinationaus klinischer\nAnamnese,gynäkologischerUntersuchung,\ntransvaginalemUltraschallundMagnetre-\nsonanztomographie(MRT) diagnostiziert\nwerden.ZurLinderungderSymptomeund\nzur Erhöhung der Fruchtbarkeitstehen\nverschiedenemedizinischeundchirurgische\nBehandlungsansätzezurVerfügung.Das\nweitereVorgehen richtetsichnachdem\nFamilienplanungsstatusderPatientin.\nSchlüsselwörter\nEndometriose·Infertilität·Dyspareunie·\nDysmenorrhö·TransvaginalerUltraschall\nandcytoreductivesurgicalproceduresin\ndiffuse adenomyosis can reduce symp-\ntoms in patients who wish to preserve\nthe uterus. Focal subendometrial or in-\ntramural cystic adenomyotic lesions and\nintracavitary polypoidadenomyomacan\nbe treated by hysteroresectoscopy. New\ninstrumentswithasmallerdiameteralso\nprovide a minimally invasive approach\nin very young nulliparous women. The\nhysteroscopic resection of adenomyotic\nl e s i o n si m p r o v e ss y m p t o m s .L a r g e ri n -\ntramural cystic lesions should be treated\nby laparoscopic resection and uterine\nsuturing (\n. Fig. 6;[ 18]). The influence\nof these procedures on patient fertility\nshould by further investigated.\nDer Gynäkologe 10 · 2020 685\n\nLeitthema\nFig. 48Bipolarmini-hysteroresectoscopic\nbiopsytechnique.(Withpermission©H.Krentel,\nallrightsreserved)\nEndometrial ablation offers a less in-\nvasive treatment option in patients who\nwanttopreservetheuterus;however,the\nefficacyincontrollingbleedingdecreases\nover time [19].\nMedicaltreatmentoptions\nAnother treatment option is the use\nof a levonorgestrel intrauterine device\n(LNG-IUD), gestagens or combined\noral contraceptives. In the subgroup of\npatients with ongoing family planning\nthe medical treatment can only be an\noption as a pretreatment before repro-\nductive procedures or as a prophylactic\ntreatment in very young women with\nadenomyosis and a pregnancy wish in\nthe future. In these cases a long-term\ntreatment with low complication rates\nandtheaimtopreventaworseningofthe\nuterine situation is required. All med-\nical therapeutic possibilities in patients\nwith adenomyosis have been recently\nreviewed by various authors [20, 21].\nThe suppressive hormonal treatments\nwith high dose progestins, oral con-\ntraceptives, LNG-IUDs, gonadotropin-\nreleasing hormone (GnRH) agonists,\naromatase inhibitors, selective estrogen\nreceptor modulator (SERM) and selec-\ntive progesterone receptor modulator\n( S P R M )a r ea b l et or e d u c es y m p t o m s\nby reduction of adenomyosis; however,\neach of these treatments is related to\nspecific side effects. Currently, all med-\nical approaches represent an off-label\nuse as no medical solution is licensed in\nthe specific treatment of adenomyosis.\nDienogestisabletoreduceadenomyosis-\nrelatedpelvicpainanddysmenorrheabut\niscombined with ahigh risk of irregular\nuterine bleeding as the most common\nadverse reaction. Therefore, patients\ntreated with dienogest have a certain\nrisk of treatment discontinuation espe-\ncially when they are of young age, have\nanemia before treatment and/or have\nmildly supressed or unsuppressed estra-\ndiol after starting dienogest treatment\n[22]. Also, progestins such as norethis-\nterone acetate or medroxyprogesteron\nacetate can reduce pain in patients with\nadenomyosis but are related to side ef-\nfects,suchasacne,edemaandreduction\nof libido causing high discontinuation\nrates. Combined oral contraceptives\nrepresent another evidence-based ther-\napeutic option. The data show a pain\nreduction but also bleeding disorders\nas the main adverse effect. The LNG-\nIUD seems to be the most effective\noption in reducing pain and menstrual\nblood loss [23]. The LNG-IUDs can be\nused in women with completed family\nplanninginsteadofh ysterectom y ,andas\namaintenancetherapyafteradenomyosis\nsurgery. In a retrospective analysis of\ntreatment with LNG-IUD in patients\nwith a large uterine adenomyosis and\nheavy menstrual bleeding, 10% under-\nwent premature LNG-IUD removal and\n16.7% underwent subsequent hysterec-\ntomy[24]. Theincidenceofspontaneous\nexpulsion of the IUD is higher in pa-\ntients with adenomyosis and/or uterine\nfibroids than in women with a normal\nuterus and seems to depend on the\ninsertion technique and the placement\ntiming. The role of LNG-releasing in-\ntrauterine systems in the treatment of\nadolescent or very young women with\nadenomyosis, especially the use of low-\ndose IUDs should be investigated. The\nuse of LNG-IUDs prior to assisted re-\nproduction also has been described but\nhas not yet been scientifically evaluated.\nAnother medical treatment option is\nthe use of GnRH agonists or antago-\nnists. Theapplicationcanbepresurgical,\npostsurgical, prior to assisted repro-\nd u c t i v et e c h n i q u e so ra sa ni n d i v i d u a l\napproachinstead of other medicaltreat-\nments. The presurgical treatment can\nreduce complications and bleeding in\nadenomyosis surgery. The combina-\ntion of GnRH agonist application with\nconservative surgery seems to result\nin longer symptom control and better\nreproductive outcomes in symptomatic\nandsubfertilepatientswithadenomyosis\ncompared with GnRH treatment alone.\nIn infertile women with adenomyosis\nthe treatment with GnRH agonists is\nindicated before fertility treatment in\norder to increase pregnancy and birth\nrates and decrease abortion rates [25].\nThe efficacy of GnRH agonists in ado-\nlescents with refractory chronic pelvic\npain, failed therapy with combined oral\ncontraceptives and positive MR imaging\nfor adenomyosis has been reported. The\ntreatment improved symptoms and re-\npeated MR imaging showed regression\nof thelesions [26]. Asestrogen,estrogen\nreceptors and aromatase play a role in\nthe pathogenesis of adenomyosis, the\ntherapeutic use of aromatase inhibitors\nis an additional option. The reduction\nof adenomyosis volume and symptoms\nhas been shown; however only a few\npublications exist and further investiga-\ntions are needed. Selective progesterone\nreceptor modulators, selective estrogen\nreceptor modulators, valproic acid and\nantiplatelet treatment represent another\ngroup oftreatment options, whichneeds\ntobeinvestigatedbeforeusedinthedaily\nroutine. So far, the medical treatment of\nadenomyosis especially in patients with\nongoing family planningisanindividual\nrecommendation, while the situation in\npatients with completedfamily planning\nis based on a large number of publi-\ncations, especially regarding the use of\nLNG-IUDs.\nSurgicalorcombinedtreatment\noptions in patients with\nongoingfamilyplanning\nPatients with adenomyosis and infertil-\nityhavevarious treatment options; how-\never none of these options is evidence\nbased.Onewaycouldbethedirectrepro-\nductive approach with or without med-\nical pretreatment. Another way could\nbe the combination with uterus-sparing\nsurgery, such as adenomyectomy or cy-\ntoreduction. Thequestions areifsurgery\nhasanadditional benefitfor infertile pa-\n686 Der Gynäkologe 10 · 2020\n\nFig. 58Laparoscopicviewofsubserouscysticadenomyosis.(Withpermis-\nsion,©H.Krentel,allrightsreserved)\nFig. 68Transvaginalultrasoundimageofanintramuralcysticadenomyosis\ninpatientwithongoingfamilyplanning.(Withpermission©H.Krentel,all\nrightsreserved)\ntientswithadenomyosisandwhatwould\nbe the right moment for surgery? In\na recent literature review these options\nincludingmedicalandsurgicalmethods,\nhighlightingtreatmentstrategies,butalso\nthelackofknowledgeandthedifficulties\ninsuggestingevidence-basedtreatments,\nhas been discussed [27]. An important\nfactorinthepatientselectionforsurgery\nis the patients age, which should be less\nthan 39 years [28]. Additional surgery\nm i g h tb ea no p t i o ni ns y m p t o m a t i cp a -\ntients, who are not able to undergo re-\nproductive procedures, patients with in-\nfertility despite in vitro fertilization and\nintracytoplasmic sperm injection (IVF/\nICSI)andasalastresortinextremecases\nof diffuse adenomyosis. Surgery might\nbe helpful in matters of fertility but the\neffect of surgery needs to be proven in\nthe future [3].\n»Importantinpatientselection\nforsurgeryisthatpatientsshould\nbelessthan39yearsold\nInarecentreviewanoverallclinicalpreg-\nnancy rate of 18.2% after surgical treat-\nmentofadenomyosiswasdescribed. The\nadditional postoperative treatment with\nGnRH agonists increased the rate up to\n40%[29]. Therisksofsurgicalprocedures\nin adenomyosis should not be underes-\ntimated. Thesurgerycanbedifficultand\nthe loss of organs due to severe intra-\noperative bleeding has been described.\nAdenomyosis surgery can cause uterine\nrupture,postsurgicalintrauterineandin-\ntra-abdominal adhesions and irregular\nplacentation. Inordertominimizecom-\nplications adenomyosis surgery should\nbecarriedoutinspecializedcenterswith\nexperienced gynecological surgeons.\nNew minimally invasive\ntreatmentoptions\nHigh-intensityfocusedultrasound(HIFU)\nand radiofrequency ablation are alter-\nnative treatment methods for focal and\ndiffuse adenomyosis. Both techniques\nprovide symptom relief and a low rate\nof major and minor complications in\npatients whowish topreservethe uterus\nor to conceive in the future. In recent\npublications patients undergoing HIFU\nfor adenomyosis showed high concep-\ntion and live birth rates after treatment\n[30] ;h o w e v e r ,t h er o l eo fH I F Ui np a -\ntients who wish to conceive should be\nfurther investigated. The transcervical\nradiofrequencyablationforsymptomatic\nadenomyosis has also been reported to\nbe a safe and effective method. Also,\nuterine artery embolization can reduce\nsymptoms and improve the quality of\nlife in patients with symptomatic ade-\nnomyosis. The impact of uterine artery\nembolization on fertility and pregnancy\nrequires further evaluation. The litera-\nturedescribesawiderangeoftherapeutic\noptions, but none of them are evidence\nbasedandinrelationtoeffectiveness,fer-\ntility outcome, reliability andsideeffects\nmanyquestionsstillremainunanswered.\nProspectiverandomizedtrialsareneeded\ninordertoshowifmedicinal,surgicalor\nreproductive treatment alone or a com-\nbination is the best way to improve\nfertility in patients with adenomyosis.\nPatientswithadenomyosisneedanindi-\nvidual approach with detailed diagnosis\nof the extent of the disease and an ac-\ncurate planning of the medicinal and/or\nsurgical treatment.\nRecommendations fordaily\npractice\n4 A d e n o m y o s i si saf r e q u e n tb e n i g n\nuterine disease,\n4 Dysmenorrhea, dyspareunia, pelvic\npain and bleeding disorders are\ntypical symptoms,\n4 Adenomyosis has a negative impact\non fertility,\n4 Adenomyosis can be diagnosed by\na combination of clinical history,\ngynecological examination and\ntransvaginal 2Dultrasound,\n4 MR imaging can be useful as an\nadditional diagnostictool,\n4 The treatment approachdependson\nthe patient’s family planning and the\ntypeandlocalization of thedisease,\n4 Medicinal treatment and surgical\nresection ofadenomyosis can reduce\nsymptoms,\n4 Adenomyosis surgery should only be\nperformedinspecializedcenters.\nDer Gynäkologe 10 · 2020 687\n\nLeitthema\nCorrespondingaddress\nDr.HaraldKrentel\nClinic of Gynecology,\nObstetrics,Gynecological\nOncologyand Senology,\nBethesdaHospitalDuisburg,\nAcademicTeachingHospital\nDuisburg,Germany\nh.krentel@bethesda.de\nCompliance with ethical\nguidelines\nConflict of interest.H.KrentelandR.L.DeWilde\ndeclarethattheyhavenocompetinginterests.\nEthical standards. Forthisarticlenostudieswith\nhumanparticipantsoranimalswereperformedby\nanyoftheauthors.Allstudiesperformedwerein\naccordancewiththeethic alstandardsindicatedin\neachcase.\nOpen Access.ThisarticleislicensedunderaCreative\nCommonsAttribution4.0InternationalLicense,which\npermitsuse,sharing,adaptation,distributionandre-\nproductioninanymediumorformat,aslongasyou\ngiveappropriatecredittotheoriginalauthor(s)and\nthesource,providealinktotheCreativeCommonsli-\ncence,andindicateifchangesweremade.Theimages\norotherthirdpartymaterialinthisarticleareincluded\ninthearticle’sCreativeCommonslicence,unlessin-\ndicatedotherwiseinacreditlinetothematerial.If\nmaterialisnotincludedinthearticle’sCreativeCom-\nmonslicenceandyourintendeduseisnotpermitted\nbystatutoryregulationorexceedsthepermitteduse,\nyouwillneedtoobtainpermissiondirectlyfromthe\ncopyrightholder.Toviewacopyofthislicence,visit\nhttp://creativecommons.org/licenses/by/4.0/.\nReferences\n1. 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