Two Step Procedure; Radiofrequency Ablation and Second Look Hysteroscopy in a Patient with Diffuse Adenomyosis: An Interesting Case Report and Review of the Literature

Case Report

Austin J Reprod Med Infertil. 2023; 9(1): 1061.

Two Step Procedure; Radiofrequency Ablation and Second Look Hysteroscopy in a Patient with Diffuse Adenomyosis: An Interesting Case Report and Review of the Literature

Kolovos G*; Dedes I; Lanz S; Mueller M

Department of Obstetrics and Gynecology, University of Bern, Bern, Switzerland

*Corresponding author: Kolovos G Department of Obstetrics and Gynecology, University of Bern, Theodor-Kocher-Haus, Friedbühlstrasse 19, 3010 Bern, Switzerland Tel: +41 31 632 10 10 Email: georgios.kolovos@insel.ch

Received: July 11, 2023 Accepted: August 09, 2023 Published: August 16, 2023

Abstract

Background: Radiofrequency Ablation (RFA) is an FDA-approved minimally invasive technique widely used for the treatment of uterine fibroids. Recent studies have explored the potential of RFA for the management of adenomyosis, a benign disorder characterized by the infiltration of endometrial glands and stroma into the myometrium, resulting in dysmenorrhea and abnormal uterine bleeding.

Case Report: In this case report, we present the clinical findings of a patient who experienced persistent hypermenorrhea and dysmenorrhea ten months after undergoing RFA for symptomatic uterine fibroids and diffuse adenomyosis. Magnetic Resonance Imaging (MRI) revealed significant regression of necrotic tissue with associated cystic hemorrhages measuring approximately 4 cm in diameter. During therapeutic hysteroscopy, necrotic adenomyotic tissue was observed protruding from the posterior uterine wall and cautiously resected.

Conclusions: We summarize our experience with this case and provide conclusions based on a comprehensive review of the relevant literature. These findings highlight the challenges and potential considerations in the management of adenomyosis using RFA and emphasize the importance of further research in this area.

Keywords: Case report; Adenomyoma; Radiofrequency ablation; Uterus sparing

Introduction

Adenomyosis, a condition characterized by the invasion of endometrial glands and stroma into the myometrium, was first described by the German pathologist Carl von Rokitansky in 1860. However, it took more than a century to fully understand the origin and nature of this disease. In 1972, Bird provided a comprehensive definition of adenomyosis as a "benign invasion of endometrium into the myometrium, with ectopic non-neoplastic, endometrial glands and stroma surrounded by hypertrophic and hyperplastic myometrium." Initially, adenomyosis was predominantly diagnosed through histopathological examination of hysterectomy specimens in perimenopausal women, primarily presenting with bleeding disorders. The estimated prevalence among hysterectomy patients varies significantly, ranging from 8.8% to 61.5%. This wide range can be attributed to the challenges associated with histopathological diagnosis, as adenomyosis can manifest in different extents. It may appear as a solitary unifocal lesion on a normal-sized uterus or as diffuse, globular enlargement of the uterus, resembling multiple-week-sized masses due to a diffuse infiltration of the uterine wall. Another relatively rare subtype of adenomyosis is the "chimera" between uterine fibroids and adenomyosis, referred to as adenomyoma. Focal disease can easily be missed during histopathological examination if multiple sections of the hysterectomy specimen are not thoroughly examined.

Several theories regarding the pathogenesis of adenomyosis have been suggested, though its pathogenesis is not yet fully understood [1]. The clinical presentation of adenomyosis is highly heterogeneous, often coexisting with other benign gynecological conditions such as endometriosis and uterine fibroids. Onchee et al., in a population-based retrospective study, demonstrated a substantial healthcare burden associated with adenomyosis. Among women included in the study, 82.0% underwent hysterectomies, nearly 70% underwent imaging studies (e.g., MRI) suggestive of adenomyosis, and 37.6% relied on chronic pain medications [2]. Recent meta-analyses conducted by Nirgianakis et al. [3] revealed important implications for reproductive outcomes in women with adenomyosis. It was found that women with adenomyosis exhibit lower clinical pregnancy rates and higher miscarriage rates compared to those without the condition. Additionally, the severity of adenomyosis was found to correlate with reproductive outcomes, further underscoring the importance of disease severity in determining fertility outcomes. Similar trends were observed in Assisted Reproductive Technology (ART) settings, with significantly lower rates of implantation, clinical pregnancy per cycle, clinical pregnancy per embryo transfer, ongoing pregnancy, and live birth among women with adenomyosis compared to those without adenomyosis [4].

Advancements in imaging techniques, specifically transvaginal ultrasound and Magnetic Resonance Imaging (MRI), have significantly improved the ability to diagnose adenomyosis in a non-invasive manner. These imaging modalities have facilitated the establishment of a diagnosis "in vivo," reducing the reliance on histopathological examination alone. Currently, the prevalence of adenomyosis in symptomatic women, as determined by imaging studies, is reported to be around 20% to 30% [5]. These improved imaging techniques have contributed to a shift in the age profile of patients diagnosed with adenomyosis, with a greater number of women of childbearing age being identified with the condition.

Adenomyosis, a prevalent gynecological disorder, necessitates an expanded treatment approach encompassing conservative surgical interventions and medical therapies. Unlike endometriosis, specific medications approved for the treatment of adenomyosis are currently unavailable, and standardized management guidelines remain elusive. However, hormonal treatments have demonstrated efficacy in alleviating adenomyosis-related symptoms. Notably, Dienogest, although effective for managing endometriosis, may not adequately address Abnormal Uterine Bleeding (AUB) associated with adenomyosis. Consequently, there is a pressing need to explore alternative therapeutic strategies that specifically target the unique challenges posed by adenomyosis, particularly in terms of AUB management. Further research is imperative to develop targeted therapies and establish evidence-based guidelines for the optimal management of adenomyosis [6].

Levonogestrel IUDs, which are effective in improving both dysmenorrhea and abnormal uterine bleeding, are limited to small uteri due to a higher expulsion rate reported in larger adenomyotic uteri of up to 150mL [6,7]. Regarding the surgical strategies, the standard of care for the patients with severe symptomatology, impaired quality of life and no desire to have children is hysterectomy [8].

Uterus-sparing surgical approaches, such as metroplasty, are employed in the management of adenomyosis but demand exceptional surgical proficiency and entail heightened perioperative risks and morbidity, including the potential for uterine rupture during pregnancy [9,10]. Alternative methods encompass uterine artery embolization, endometrial ablation (suitable when adenomyosis does not extensively infiltrate the myometrium), High-Intensity Focused Ultrasound (HIFU), and the recently introduced minimally invasive option of Radiofrequency Ablation (RFA). Among these, ultrasound-guided Radiofrequency Ablation (RFA) exhibits promising potential, a treatment which has already been approved from the FDA for the treatment of uterine fibroids. Ning Hai et al. recently reported a significant decrease on VAS Scores of Dysmenorrhea and in the mean volume of focal adenomyosis change at 1, 6 and 12 months after RFA application [11].

Case Presentation

We present a case study of a 40-year-old premenopausal patient who experienced secondary infertility and progressive dysmenorrhea (Visual Analog Scale [VAS] score: 7/10), necessitating the use of analgesics such as NSAIDs and paracetamol. The patient had previously undergone laparoscopic myomectomy in 2013, followed by a vaginal delivery one year later, and subsequently experienced a miscarriage in 2017. Given the secondary infertility, persistent fibroids observed on ultrasound, and diffuse adenomyosis affecting the posterior wall of the uterus, an MRI scan was conducted, confirming the presence of diffuse adenomyosis throughout the fundus (Figure 1) and posterior wall. Additionally, at least six intramural fibroids were identified, with some demonstrating slight progression in size compared to an MRI performed two years earlier, wherein no intracavitary fibroids were detected. A three-month course of Lucrin therapy was prescribed, successfully inducing secondary amenorrhea. Subsequently, the patient was admitted to our clinic for diagnostic hysteroscopy and transcervical sonographically guided radiofrequency ablation using the Sonata system.