Adenomyosis Facts and Questionsbr\n13th World Congress on Endometriosis, 2017br\nMay 1720, 2017, Vancouver, CANbr\nExtended Abstractsbr

about regulation of endometriosis can be applied for adenomyosis as well should be validated, followed by adeno- myosis specific factors and pathways.

1. MacFarlane LA, Murphy PR. MicroRNA. Biogenesis, func tion and role in cancer. Curr Genomics 2010; 11: 537– 61. 2. Adammek M, Greve B, Kässens N, Schneider C, Brüg- ge mann K, et al. MicroRNA miR-145 inhibits proliferation, invasiveness, and stem cell phenotype of an in vitro endo- metriosis model by targeting multiple cytoskeletal ele- ments and pluripotency factors. Fertil Steril 2013; 99: 1346–55. 3. Saare M, Rekker K, Laisk-Podar T, Rahmioglu N, Zon- der van K, et al. Challenges in endometriosis miRNA stud- ies - From tissue heterogeneity to disease specific miR- NAs. Biochim Biophys Acta 2017; 1863: 2282–92. 4. Kästingschäfer CS, Schäfer SD, Kiesel L, Götte M. miR- 142-3p is a novel regulator of cell viability and proinflam- matory signalling in endometrial stroma cells. Repro- ductive BioMedicine Online 2015; 30: 553–6. 5. Eggers JC, Martino V, Reinbold R, Schafer SD, Kiesel L, et al. microRNA miR-200b affects proliferation, invasiveness and stemness of endometriotic cells by targeting ZEB1, ZEB2 and KLF4. Reprod Biomed Online 2016; 32: 434–45. 6. Guo Y, Lang X, Lu Z, Wang J, Li T, et al. MiR-10b Directly Targets ZEB1 and PIK3CA to curb adenomyotic epithelial cell invasiveness via upregulation of E-Cadherin and inhi- bition of akt phosphorylation. Cell Physiol Biochem 2015; 35: 2169–80. 7. Herndon CN, Aghajanova L, Balayan S, Erikson D, Bar- ragan F, et al. Global transcriptome abnormalities of the eutopic endometrium from women with adenomyosis. Reproductive Sciences 2016; 23: 1289–303. 8. Chen H, Fan Y, Xu W, Chen J, Xu C, et al. miR-10b In- hibits apoptosis and promotes proliferation and invasion of endometrial cancer cells via targeting HOXB3. Cancer Biother Radiopharm 2016; 31: 225–31. 9. Furuya M, Masuda H, Hara K, Uchida H, Sato K, et al. ZEB1 expression is a potential indicator of invasive endo- metriosis. Acta Obstet Gynecol Scand 2017; 96: 1128–35. Correspondence to: Prof. Dr. med. Ludwig Kiesel Department of Gynaecology and Obstetrics University Hospital Münster Albert-Schweitzer-Campus 1, 48149 Münster Germany e-mail: [email protected] T able 1. Dysregulation of miRNAs in endometriosis. Mod. from [6, 7]. Downregulated miRNAs [6] (sign. Microarray and qRT­PCR) Upregulated miRNAs [6] (sign. Microarray and qRT­ PCR) Downregulated miRNAs [7] miR-10b miR-143 miR-9-1 miR-371b-5p miR-513a miR-139 miR-92b-5p miR-466 miR-149 miR-30c miR-197 miR-326 miR-339 Figure 1. miR-10 b in endometriosis after Guo et al 2015. Mod. from [5], open access (CC BY-NC). „ Relevancy to Practice – miRNAs can be future targets for individualized therapies. – miRNAs may be valid candidates for biomarkers in diagnosis of endometriosis and adenomyosis. – Adenomyosis and endometriosis have different pathophysiologi- cal characteristics and need to be evaluated separately. – Standardized research is needed for endometriosis and adenomy- osis, providing opportunities for researchers. J Reproduktionsmed Endokrinol_Online 2018; 15 (5–6) Extended Abstracts 255 Adenomyosis – Possible Cause for Infertility in Women with Endometriosis? K. Bühler1, K. J. Neis1, F. Neis2 1 Centre of Excellence for Endometriosis of the University Hospitals of Saarland – Frauenärzte am Staden, Saarbrücken; 2 Department of Obstetrics and Gynaecology, University of Tübingen „ Abstract Adenomyosis is a heterogeneous and poorly understood gynaecologic disease. Most frequently the major symptoms are troublesome, heavy menstrual bleeding, dysmenorrhoea and sometimes a tender uterus. Since more women are tending to delay their first pregnancy till their late thirties or early forties, adenomyosis has become more relevant in the context of subfertility. In order to be able to answer the question referred, a literature re- search was performed. As possible causes for infertility in women with adenomyosis can be seen: intrauterine abnormalities, intensified uterine peristalsis and altered endome- trial milieu. But, there is a lack of suf- ficient data to show doubtless evidence that adenomyosis alone is the cause of subfertility. To improve fertility, surgi- cal treatment or/and reproductive medi- cine ± GnRH analogues pre-treatment are recommended. It is necessary to provide a complete removal of all ad- enomyosis or to induce a reduction of the inflammatory process by a GnRH agonist ( ultra-)long pre-treatment be- fore fertility enhancing procedures are started. „ Introduction Adenomyosis is a heterogeneous gy- naecologic disease. It is a poorly un- derstood and so often called enigmatic and/or elusive due to the difficulties in diagnosis and the lack of agreement con- cerning the definition. Most frequently the major symptoms are troublesome, heavy menstrual bleeding, excruciating dysmenorrhoea and sometimes a tender uterus. But sometimes it can also be asymptomatic. Adenomyosis is a benign disease of the uterus characterised by an invasion of ectopic endometrial glands and stroma within the myometrium producing a diffusely enlarged uterus which micro- scopically exhibits ectopic, non-neo- plastic, endometrial glands and stroma surrounded by the hypertrophic and hy- perplastic myometrium [1]. A first sci- entific description of adenomyosis was done by C. Rokitansky in his publica- tion: “Über Uterusdrüsen-Neubildung” in 1860 [2]. Adenomyosis is seen mostly in women at their late 4 th or 5 th life decade and so during long time the problem adenomy- osis and fertility seemed not to be exist- ent! Since more women are tending to delay their first pregnancy till their late thirties or early forties, adenomyosis has become more relevant in the context of subfertility. It is a welcome figure that in Germany in 2016 the number of new- borns re-approached the level reached in 1996 but on the other side the number of mothers at the age of 40 years and more increased since 2011 of 13.4% up to nearly 40,000 women [3]. When looking at ART treatment we have to realise that in 2016 every 5th woman treated by IVF was at the age of ≥ 40 years and 3.2% even at the age of ≥ 44 years [4]. These figures explain very well that adeno- myosis has become an increasing prob- lem in fertility treatment although the incidence peak is about 5–10 years later compared to endometriosis [5]. Never - theless, endometriosis and adenomyosis often occur together in about 27% to 49% and is significantly associated with deep infiltrating endometriosis, parity, dysmenorrhea intensity and women’s age [6]. „ Methods In order to be able to answer the question referred, a literature research was per - formed looking to the following items: – adenomyosis – fertility – endometriosis – surgery in patients with adenomyosis ± endometriosis – medical treatment in patients with adenomyosis ± endometriosis. „ Adenomyosis in Patients with Fertility Disturbances In animal studies it is quite easier to examine the association between ad- enomyosis and fertility. In a population of captive baboons endometriosis was strongly associated with the presence of adenomyosis with an OR of 31.5. Adeno- myosis was associated with the presence of lifelong infertility (OR = 20.6), even if cases with coexisting endometriosis were excluded (OR = 20.1) [7]. In human, long time, the only way to be certain of adenomyosis is to examine the uterine tissue under the microscope after surgery. Only with the possibility to diag- nose adenomyosis at the “living object” by ultrasound – US – and/or magnetic resonance imaging – MRI – the ques- tion of impact on fertility has emerged. But there are conflicting results reported in the literature. One group reported in women with infertility and symptoms of dysmenorrhoea or menorrhagia that in 54% adenomyosis could be detected by MRI. But finally, only 26 women were included in the study [8]. Puente et al. [9] diagnosed adenomyosis in women before starting an ART treatment or after recurrent pregnancy loss by 3D-US. They found signs for adenomyosis in 24.4%, significantly more often in women aged ≥ 40, in 29.7% as compared to women < 40 years, 22%. The prevalence was also significantly higher in those cases of recurrent pregnancy loss, 38.2 %, and previous ART failure, 34.7%. Patients with fibroids showed also adenomyosis in 18%. Among the patients with endo- metriosis, 35.1% were also diagnosed with adenomyosis. This is in contrast to the group of Bazot et al. which reported the coincidence of pelvic endometriosis and adenomyosis only in 27% (44/163 – diagnostic by MRI) [10]. In a further study the same group demonstrated in women with dysmenorrhea, nonmen- strual pelvic pain, dyspareunia, and pain on defecation treated with laparoscopic J Reproduktionsmed Endokrinol_Online 2018; 15 (5–6) Extended Abstracts 256 colorectal resection only 4 women of 22 – 18.2% – who wanted to conceive showed also adenomyosis. 45.5% of the women got pregnant after the surgery, but none of them with adenomyosis [11]. Kunz et al. looked in 227 infertile women about the prevalence of adenomyosis, diagnosed by MRI, and endometriosis and its impact on fertility. In 28% of the women without endometriosis signs of adenomyosis were found in 28% of the women and when in them there was an andrological reason of the infertili- ty only in 9%. But in 160 women with proven endometriosis 79% showed also adenomyosis and in 30 women of them, younger than 36 years and with fertile partners even in 90% adenomyosis could be detected with MRI [12]. These differ- ences are due to the different definitions applied. As possible causes for infertility in wom- en with adenomyosis can be seen: Intrauterine abnormalities: distortion of the uterine cavity, obstruc- tion of tubal ostium, interference with sperm & embryo Uterine peristalsis: dysfunctional uterine hyperperistalsis, increased intrauterine pressure, junc- tional zone hyperactivity → contractions (→ ectopic pregnancies ↑), disturbed uterotubal sperm transport Altered endometrial milieu: higher macrophage density, more proin- flammatory cytokines, such as TNF-α or IL-1, reduction of progesterone receptor expression Very often, a reduced endometrial re- ceptivity is discussed also. So, Huang et al. discussed if an abnormal expres- sion of oxytocin receptors in the uterine junctional zone may result in abnormal uterine contractile activity and reduces so fertility [13]. The group of the Instituto Valenciano de Infertilidad evaluated the endometrial receptivity in patients with adenomyo- sis by two aspects: endometrial gene expression and the model of oocyte donation (OD) [14]. Endometrial sam- ples were collected from six women in whom ade nomyosis had been diagnosed by MRI and transvaginal US. There is a similar endometrial gene expression pattern in both the adenomyosis group and controls, and nonparametric tests revealed 34 dysregulated genes in ad- enomyosis patients but none belonged to the group of window of implantation genes. Pregnancy rates in OD did not differ among the three groups, control, women with endometrioma, women with adenomyosis. However, miscar - riage was significantly higher in the ad- enomyosis group vs. the endometriosis and control groups and so, term preg- nancy rate was also significantly lower in the adenomyosis group compared with others (Fig. 1). „ T reatment Options in Patients with Adenomyo­ sis and Infertility Surgical treatment to improve fertility Limited data are available concerning the efficacy of the different treatment options of adenomyosis on fertility outcome and mostly the data are retro- spective evaluations or small case series [15]. As different surgical techniques are described: adenomyomectomy with unilateral salpingectomy, microsurgical adenomyomectomy, adenomyomectomy using double or triple-flap method, or e. g. adenomyomectomy with continu- ous horizontal mattress technique. Rocha et al. reported in a recent review [16] a pooled clinical pregnancy rate after sur - gical resection of adenomyosis of 38.8%, mostly achieved by ART, and a miscar - riage rate and live birth rate of 17.9% and 30.4% respectively (Fig. 2). Reproductive medicine to im­ prove fertility Once again, mostly retrospective stud- ies are available. In the pooled analysis from Rocha et al. [16] the overall preg- nancy rate was 36.1%, live birth/ongoing pregnancy rate 29.9% and miscarriage rate 25.9%. There is a significant differ - ence in the outcome of IVF/ICSI treat- ment cycles depending of the type of GnRH analogue used (Fig. 3). If the long agonist regimen was applied pregnancy and live birth rates were significantly increased and the miscarriage rate sig- nificantly lower. This was also showed by a meta-analysis [17]. There was no difference in ART outcome in women with adenomyosis compared to women without adenomyosis when the long down regulation protocol was used but with the short protocol the results were significantly lower. And also looking at miscarriage rates there was no difference with the long downregulation but with the short protocol when adenomyosis was present. Obviously, the myometrial thickness can serve as a marker for the ART treatment outcome. If in transvaginal US a myo- metrial thickening of more than 2.50 cm was seen at the day of hCG triggering the implantation, clinical pregnancy, and live Figure 1. Cumulative pregnancy (CPR) and term pregnancy (TPR) rates after embryo transfer with donated oocytes of women without adenomyosis. Mod. from [14]. *significant difference J Reproduktionsmed Endokrinol_Online 2018; 15 (5–6) Extended Abstracts 257 birth rates were significantly lower in the IVF-ET treatment with the short protocol [18]. Also, if frozen embryo transfer (FET) was performed long downregulation with GnRH agonist showed a beneficial effect: significantly higher ongoing preg- nancy/live birth rates [19, 20]. It seems that GnRH-a treatment decreases the size and demarcation of adenomyotic lesions, as demonstrated by MRI [21], and treat- ment has a positive effect on endometrial implantations markers [22]. „ Conclusion Adenomyosis represents a chronically inflammatory process yielding particu- larly in early pregnancy loss. Concern- ing a possibly reduced implantation the present evidence is too poor and more studies are needed to reach a definitive conclusion. Only if adenomyosis and pelvic endometriosis occur together a clear fertility reduction is established. So, there is a lack of sufficient data to show doubtless evidence that adeno- myosis alone is the cause of subfertility. It seems that adenomyosis is the reason for higher miscarriage rates and reduced fertility is more due to often concomitant endometriosis. But in both pathologies it is necessary in order to ameliorate fer - tility to provide a complete removal of all adenomyosis and/or endometriotic foci or to induce a reduction of the in- flammatory process by a GnRH agonist (ultra-)long pre-treatment before fertility enhancing procedures are started.

1. Bird CC, McElin TW, Manalo-Estrella P . The elusive ad- enomyosis of the uterus. Am J Obstet Gynecol 1972; 112: 583–93. 2. Rokitansky C. Über Uterusdrüsen-Neubildungen in Uterus- und Ovarial-Sarcomen. Zeitschrift der Kaiserlich Koenigl Gesellschaft der Aerzte zu Wien 1860; 37: 577–81. 3. DeStatis. Continued increase in births in 2016. https:// www.destatis.de/EN/PressServices/Press/pr/2018/03/ PE18_115_122.html. pressrelease no. 165. (last seen July 26, 2018). 4. Blumenauer V, Czeromin U, Fehr D, Fiedler K, Gnoth C, Krüssel JS, Kupka MS, Ott A, Tandler-Schneider A. D.I.R Annual 2016 – The German IVF-Registry. J Reproduktions- med Endokrinol 2017; 14: 272–305. 5. Templeman C, Marshall SF, Ursin G, Horn-Ross PL, Clarke CA, et al. Adenomyosis and endometriosis in the California Teachers Study. Fertil Steril 2008, 90: 415–24. 6. Di Donato N, Montanari G, Benfenati A, Leonardi D, Bertoldo V, et al. Prevalence of adenomyosis in women undergoing surgery for endometriosis. 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Adenomyosis and infertility: what evidence? Médecine la reproduction 2016; 18: 166–75. Figure 3. Pregnancy and live birth rates (%) after ART treatment in women with adenomyosis. Mod. from [16]. PR = pregnancy rate, LBR = live birth/ongoing pregnancy rate, all = overall, long = GnRH agonist regimen, short = short GnRH agonist or GnRH antagonist regimen *significant difference Figure 2. Pregnancy and live birth rates (%) after surgical treatment of adenomyosis. Mod. from [16]. PR = pregnancy rate, LBR = live birth rate, GnRHa = Gonadotropin Releasing Hormone agonist J Reproduktionsmed Endokrinol_Online 2018; 15 (5–6) Extended Abstracts 258 18. Youm HS, Choi YS, Han HD. In vitro fertilization and embryo transfer outcomes in relation to myometrial thick- ness. J Assist Reprod Genet 2011; 28: 1135–40. 19. Niu Z, Chen Q, Sun Y, Feng Y. Long-term pituitary down regulation before frozen embryo transfer could im- prove pregnancy outcomes in women with adenomyosis. 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Correspondence to: Dr. Klaus Bühler Centre of Excellence for Endometriosis of the University Hospitals of Saarland – Frauenärzte am Staden, Saarbrücken Bismarckstraße 39–41, 66121 Saarbrücken Germany e-mail: [email protected] Pathogenesis of Adenomyosis uteri (AM) – New Concepts S. Mechsner Endometriosis Centre Charité, Department of Gynecology, Charité Medical University Berlin, Germany „ Abstract Adenomyosis (AM) means the occur - rence of endometrial cells within the myometrium. It could be present as a diffuse superficial form or with deeper infiltration. There are also focal forms, which are able to affect the adjacent or - gans such as the bladder or rectum. Over the years the real prevalence of AM uteri has been underestimated. However, the ongoing better quality of ultrasounds and the possibility of MRIs have demonstrat- ed a high prevalence of AM in patients with endometriosis (EM) especially in patients with infertility and ranked the prevalence between 80–91 % of all en- dometriosis patients. This high prevalence may indicate the possible involvement of AM on the pathogenesis of AM and EM-associated infertility. Furthermore, some new data suggest that AM might also have an im- pact on miscarriages. Patients suffer from severe dysmenorrhea, heavy menstrual bleeding, pelvic pain and dyspareunia. The pathogenesis of AM still remains unclear. There is the idea of a peristaltic- dependent induction of microscopic tis- sue injury at the endometrial junctional zone (EMJZ), which in turn leads to the translocation of the basal endometrium into the myometrium with the consecu- tive development of adenomyotic le- sions. This tissue injury might stimu- late a process of tissue repair in which estrogen is locally produced, which in turn stimulates angiogenesis, prolifera- tion and a local OT synthesis. The local OT activated oxytocin receptors on the myometrial smooth muscle cells cause more hyperperistalsis. Subsequently, the tissue injury increases and a vicious circle is established. Microscopic find- ings underlay this theory. Furthermore, ultrastructural analysis of the junctional zone identifies stem cell like cells, which might be involved in the pathogenesis of this disease. The adenomyotic-associated myome- trial cells show an over expression of the oxytocin receptor as well as changes in their architecture. Both might lead to dysperistalsis of the myometrial cells and the reduced uterine blood flow, which causes ischemic pain. The myometrial innervation seems to be disturbed and the deletion of sympathetic nerve fibers might be a further factor in the functional changes of the myometrium. „ Background Adenomyosis (AM) seems to be a fix linked objective to endometriosis. How- ever, over the years the real prevalence of adenomyosis uteri has been underes- timated. The ongoing better quality of ultrasounds and the possibility of MRIs have demonstrated a high prevalence of adenomyosis in patients with endome- triosis, especially in those with infertility [1]. This prevalence is currently ranked between 80–91% of all endometriosis patients. The high prevalence may indicate the possible involvement of AM on a range of endometriosis related symptoms like dysmenorrhoea and heavy menstrual bleeding, pelvic pain and dyspareunia [2]. But furthermore, there seems to be a direct link to the pathogenesis of AM and EM-associated infertility and some new data suggests that AM could be an impact on miscarriages. AM is of great underestimated clinical importance. AM means the occurrence of endometrial cells within the myometrium. It could be present as a diffuse superficial form char- acterised by a thicker junctional zone or with deeper infiltration. In these cases, the complete myometrial wall would be thicker and both uterine walls are more asymmetric to each other. If the infiltra- tion affects both sides, there will be an overall enlargement of the uterus. There are also focal forms, which are able to affect the adjacent organs such the blad- der or lead to retrocervical endometriosis with bowel affection [3] (Fig. 1). It is very important development for cli- nicians to focus on AM, especially when descriptions on the ultrasonographic features of uterine changes are becoming more and more popular [4]. However, all these visible changes have already shown a disturbed uterus. It is a shame that we have no possibility to recognize uterine changes before irreversible damage has occurred. AM is a hard topic and the brilliant review of Yen [5] was summa- rised at the end: “The mechanisms and pathogenesis of AM and its clinical im- pacts are still far from being understood. Consequently, it is difficult to diagnose AM at an early stage.“ This is what we have to focus on to ana- lyse in the near future. All these features need time for development and the be- ginning of these changes has not yet been defined. Maybe it is linked to the pri- mary dysmenorrhoea, which over 90% J Reproduktionsmed Endokrinol_Online 2018; 15 (5–6) Extended Abstracts 259 of endometriosis patients have reported (Leyen decker). There are also hints of presence of adenomyosis in adolescents with severe dysmenorrhoea [6–9]. We know that dysmenorrhoea is associated with a disturbed pattern of contractili- ty and this might be the beginning of the tissue injury and ongoing changes. Maybe AM is more undetectable in its early stages, but already present. In or - der to investigate this in more detail, we examined 38 adolescent patients with severe dysmenorrhoea for the early signs of adenomyosis such as the halo phe- nomenon, inhomogenous myometrium and asymmetry of the uterine walls and found changes in 91% of the cases [un- published data, Abesadze et al., in prep]. „ Pathogenesis – Changes of the Junctional Zone (JZ) However, so far, we have no idea of the pathogenesis of adenomyosis and as long as this remains to be unclear the innova- tive therapeutic approaches to fight this disease are missing. The current leading idea of the pathogenesis of AM in uteri of reproductive aged women is the tis- sue injury and repair concept postulated by Leyendecker. What does this mean.: The uteri of patients with adenomyosis exhibit hyperperistalsis [10]. This is linked with a peristaltic-dependent in- duction of microscopic tissue injury at the endometrial junctional zone (EMJZ), which in turn leads to the translocation of the basal endometrium into the myo- metrium with consecutive development of adenomyotic lesions. This tissue in- jury might stimulate a process of tissue repair mechanisms in which oestrogen is locally produced, this in turn stimulates angiogenesis, proliferation and a local oxytocin (OT) synthesis. The local OT activated oxytocin receptors on the myo- metrial smooth muscle cells cause more hyperperistalsis. Subsequently, more tis- sue injury occurs and a vicious circle is established [11]. In agreement with this, further ongoing studies have analysed the border between the endometrium and myometrium in patients with and without AM and confirmed the concept of dis- rupture of the JZ. The endo-myometrial border in patients with fibroids is very smooth, whereas the endo-myometrial border in patients with AM is disruptured [12, 13]. Interestingly, other than these morphological changes, there is also an upregulation of smooth muscle actin pre- sent in the basal endometrial layer of pa- tients with AM. This is a strong hint for a fibroblast to myofibroblast transition in the JZ [14]. Myofibroblasts are known to secrete Collagen 1, an important factor for fibrosis, which is also upregulated in the adenomyotic uteri [14–16]. So, fibro- blast to myofibroblast transdifferentia- tion (FMT) seems to be an important part of the process, which might be activated by tissue injury. Ongoing platelet aggre- gation seems to induce EMT and FMT in a adenomyosis mice model [15]. The junctional zone was also analysed by ultrastructural investigations and showed a range of changes which are also in line with mechanical alternations. For exam- ple, normally the nucleus of non-adeno- myosis patients is very smooth, whereas the nucleus of patients with adenomyo- sis is irregular with invaginations. This could be a result of mechanical altera- tion due to the strong contractions in this area [13]. Transelectric microscopy gives a deep insight into the composition of the epithelial and stromal cells of the junctional zone. In uteri of adenomyosis patients the arrangement of these cells is interrupted by the myometrial cells. Furthermore, in non-adenomyotic uteri the orientation of the myometrial smooth muscle cells of the inner myometrium is parallel to each other, but in adenomyotic uteri the myometrial cells have no clear orientation as they are directed in diverse alignments. Interestingly, there was a so far undescribed cell population present in patients with and without AM. These cells are electro-lucent and mitochon- dria – and ribosome rich because these are characteristics from stem cell-like cells, which are called pale cells. These cells are mostly localised on the basal of the glands and are sometimes also concentric to the lumen of the gland. Pale cells have no desmosomes and are partially detached from the surrounding cells. A total detachment of these cells was only observable in patients with adenomyosis and interestingly the cell bodies of the neighbouring cells seem to drift apart from each other, with the finding of a thin basal cellular inter- digitations. In a rare number of patients, a micro-perforation of the basement membrane was found with the building of pseudo-pods and even a cytoplasmic migration. The migration of these cells was only seen in AM specimens. So pale cells might also be involved in pathogen- esis of AM (Fig. 2). There seems to be some so far unknown factors (perhaps the severe peristaltic) which lead in turn to an activation of these cells with the in- duction of migration. Translocated pale cells might be able to develop into AM or endometriosis [13]. „ Changes of the Adenomyotic Lesions The adenomyotic lesions also show a range of morphological changes: In AM lesions there are not only isolated isles of endometrial and stromal cells, but also smooth muscle like cells present. These cells are located within the stromal cells, but are also surrounded by the lesions. Figure 1. Adenomyosis uteri. Mod. from [3]. A: Diffuse forms of adenomyosis uteri: a) superficial and b) deep; B: focal forms with bladder or bowel affection; C: clinical presentation of deep infiltration diffuse adenomyosis; D: clinical presentation of focal retrocervical adenomyosis with bowel infiltration J Reproduktionsmed Endokrinol_Online 2018; 15 (5–6) Extended Abstracts 260 The adjacent myometrium seems to be very compact with a changed architec- tural arrangement of the myometrium in comparison to the unaffected myo- metrium. Similar to the junctional zone smooth muscle metaplasia seems to be present in this area, resulting in a com- pact packed myometrium around the lesions. These myometrial cells show a moderate to strong oxytocin and vaso- pressin receptor (OTR/VPR) expres- sion. The adenomyotic stromal cells are mostly OTR negative with the exception of some single cells, which fuse with the surrounding smooth muscle cells of the myometrium. Using the antibody against sm-Actin, this spindle like cell popula- tion has been characterized as smooth muscle cells, which are in direct contact with the adenomyotic stroma cells. OTR and VPR are known as being very im- portant uterotonic peptides and may play a crucial role in the dispersalist of AM. In comparison to the unaffected myome- trium there seems to be an overexpres- sion of the OTR in myometrial cells surrounding the adenomyotic stroma and epithelium, however it might be possible that the OTR-overexpression is due to the compact morphology of the myome- trial cells. OTR expression is present in the normal endometrium of patients with and with- out AM with cyclical changes especially in the functional layer. In AM lesions there is only a weak expression of OTR in epithelial cells present, interestingly the cells do not show a cyclic variation. OTR-expression in the AM lesion is similar to the expression described for the basal layer of the endometrium [12]. VPR is also expressed in all layers of the myometrium of the non-pregnant uterus. Interestingly, an immunoreactive staining in the smooth muscle cells of the blood vessels is also present. In contrast to the OTR expression there is no VPR expres- sion in endometrial epithelial cells. In adenomyotic epithelial and stromal cells there are no VPR expression detectable. In contrast, the smooth muscle cells of the myometrium and blood vessels do show a moderate to strong VPR expres- sion. So both receptor systems might be involved in hyperperistalsis. „ Pathogenesis of Hyper­ peristalsis and Dysmenor­ rhoea Myometrial hyperactivity and reduced uterine blood flow causes ischemic pain. This is a well-established phenomenon in women with primary dysmenorrhoea, meaning women have a painful menstrua- tion starting with their first period [17]. Oxytocin, Vasopressin as well as prosta- glandin (PG) F2a are involved in causing myometrial contractility. Peptides like Vasopressin, Endothelin, noradrenaline and endoperoxides might contribute to the vasoconstriction. However, the rela- tionship between adenomyosis and dys- menorrhoea needs to be clarified. There is still little knowledge about the patho- physiology of adenomyosis-associated dysmenorrhoea. Recently it has been demonstrated that the uteri from patients with adenomyosis and endometriosis show hyper- and dysperistalsis [18–20]. The physiological role of OT and VP in non-pregnant uteri has not been fully understood. There is a body of evidence, that these peptides play an essential role in uterine contractility and dysmenor - rhoea. The changed architectural myo- metrial composition might be the cause of the ongoing hyper- and dysperistalisis, sometimes also with insufficient contrac- tion resulting in high menstrual bleeding. „ Changes in the Uterine Innervation of AM One of the main topic of the last few years was the question: Are there chang- es in the uterine innervation of patients with AM and does this have an impact on the pathogenesis? A systematic inves- tigation regarding the innervation of uteri with AM was performed: full thickness specimens after a hysterectomy were selected and the innervation in all layers were investigated separately. Four differ- ent kinds of pan marker for myelinated and unmyelinated nerve fibers (NF) were used. No significant difference was found between patients with and without AM. There were nearly no nerve fibers in the functional layer, only single ones. More NF were detected in the basal and junctional layer and nearly 4 NF per mm² in the myometrium. The adenomyotic le- sions were also rarely innervated [21]. In order to understand the pathophysiol- ogy and the pain mechanisms in more detail the adenomyosis associated nerve fibers had to be characterised. In general, we were interested in the correlation of sympathetic and sensory nerve fibers, be- cause these two nerve fiber systems seem to have a crucial role in chronic inflam- matory diseases. For this, different nerve fiber markers were used to distinguish between sensory and sympathetic nerve fibers. Interestingly in adenomyotic myo metria there were a reduced num- ber of sympathetic nerve fibers observed [21]. Changes in the sympathetic uter - ine innervation are a known phenom- enon physiologically during cycle and pregnancy. There seems to be hormone dependent changes present in the myo- metrium of rodents. In the estrogen rich phase, the sympathetic nerve fibers de- crease, and remodel in the estrogen-poor phases [22, 23]. This is also observed in Figure 2. Concept of adenomyosis and endometriosis pathogenesis. Reprint from [13] with permission from Elsevier. J Reproduktionsmed Endokrinol_Online 2018; 15 (5–6) Extended Abstracts 261 humans with ongoing pregnancy, with the lowest level at term. Maybe this has an influence on the contractility and make the uterus calm with ongoing pregnancy. But so far there is no data available about the biological reason for this. But the question is what happens in ad- enomyosis, what is the reason for the reduced number of sympathetic nerve fibers in AM? If the higher estrogen expression is involved in this process, then maybe the aromatase overexpres- sion with local estrogen synthesis is the trigger for the disturbed remodelling of sympathetic nerve fibers in adenomyotic uteri. Perhaps this also has a functional effect on adenomyosis associated dys- menorrhea and infertility with disorder in the contraction pattern with dysperi- stalsis. „ Conclusion There seems to be evidence for a micro- trauma associated pathway involved in the pathogenesis of AM like fibroblast to myofibroblast transdifferentiation, especially in the area of the JZ. Activa- tion of pale cells might be involved in the pathogenesis of EM/AM. The translocat- ed pale cells could have the potential to develop into fully differentiated lesions including stromal, epithelial as well as smooth muscle cells. Changes of the architectural morphol- ogy of the myometrium might be a reason for the dys-and hyperperistalsis. The Oxytocin as well as the Vasopressin receptor system might be involved here as well. OTR is expressed in epithelial and smooth muscle cells in adenomyosis uteri. Oxytocin mediates the induction of PGF2α synthesis in epithelial cells, which mediates pain and oxytocin in- duces smooth muscle contraction. The change in the myometrial architecture amplifies the dys- and hyperperistalsis of the myometrial cells. The selective inhi- bition of this receptors system might be a promising new treatment option for en- dometriosis-associated dysmenorrhoea and cyclic pelvic pain, especially for women who want to become pregnant. The disturbed remodeling of sympathetic NF might be another functional problem in the coordination of the myometrial acitivity. Altogether adenomyosis seems to be a disorder which causes defects in the coordination of uterine contractions.

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Sylvia Mechsner Endometriosis Centre Charité, Depart- ment of Gynecology Charité Medical University Berlin Hindenburgdamm 30, 12203 Berlin Germany e-mail: [email protected] J Reproduktionsmed Endokrinol_Online 2018; 15 (5–6) Haftungsausschluss Die in unseren Webseiten publizierten Informationen richten sich ausschließlich an geprüfte und autorisierte medizinische Berufsgruppen und entbinden nicht von der ärztlichen Sorg- faltspflicht sowie von einer ausführlichen Patientenaufklärung über therapeutische Optionen und deren Wirkungen bzw. Nebenwirkungen. Die entsprechenden Angaben werden von den Autoren mit der größten Sorgfalt recherchiert und zusammengestellt. Die angegebenen Do- sierungen sind im Einzelfall anhand der Fachinformationen zu überprüfen. Weder die Autoren, noch die tragenden Gesellschaften noch der Verlag übernehmen irgendwelche Haftungsan- sprüche. 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