Scoping Review of High-Intensity Focused Ultrasound (HIFU) Procedure in Adenomyosis

Adenomyosis is a gynecological disease characterized by ectopic endometrial tissue in the myometrium which often occurs in women of reproductive age, between 30-40 years. The prevalence of adenomyosis currently ranges from 20-35%. The patient’s main clinical symptoms include abnormal uterine bleeding, menstrual pain (dysmenorrhea), and impaired fertility (infertility). The pathological mechanism for the occurrence of adenomyosis is an imbalance of steroid hormones, a local inflammatory process that causes changes in cell proliferation which may lead to neuro angiogenesis in myometrial tissue (1,4). Current therapy for adenomyosis includes oral medications, progesterone, contraceptive pills or anti-inflammatory pills as well as GnRH Agonist injections and adenomyomectomy that can be performed by conducting minimally invasive laparoscopic surgery/laparotomy surgery (5). Surgical removal of the uterus (hysterectomy) is the main option for women who no longer want children, but hysterectomy for adenomyosis that occurs in infertile couples is not a good choice for women who still want children. Although UEA treatment can improve patient symptoms, its effect on ovarian function and pregnancy is still uncertain (4,5). \n \nHigh Intensity Focused Ultrasound (HIFU), an emerging non-invasive surgical technique for the treatment of benign tumors, has been used for adenomyosis since 2008. Under ultrasound or magnetic resonance (MRI) examination, HIFU high intensity ultrasound energy can penetrate the abnormal target tissue and remove the lesion through thermal effects and cavitation and allows the preservation of normal tissue around the lesion. The cavitation process is a condition in which HIFU will create static pressure on the targeted cells so that the liquid in the cells decreases until it is under the pressure of liquid vapor, which results in the formation of bubbles filled with small vapor bubbles in the liquid. The bubble eventually explodes and the liberated gas passes into the surrounding liquid through a mechanism that initially softens and then gets absorbed by healthy body tissue. \n \nIn recent years, HIFU therapy has become a viable surgical alternative for patients who still wish to retain their uterus. However, adenomyosis is a disease that is very sensitive to the estrogen hormone, and HIFU therapy will not change the working of hormones in the body. The risk of recurrence therefore still exists. Gonadotrophin Releasing Hormone Agonist (GnRH-A) is a hormone that is commonly used for the treatment of adenomyosis, it lowers estrogen levels to menopausal levels and increase adenomyotic apoptosis in the myometrium. \nThis chapter provides several systematic reviews and meta-analyses of HIFU combined with GnRH- A in adenomyosis and provides proof-based medical evidence for clinical applications