Caterina Exacoustos

Background: The introduction of the Morphological Uterus Sonographic Assessment (MUSA) 2022 criteria for diagnosing adenomyosis has reduced diagnoses compared with previous criteria. However, the impact of each ultrasonographic sign on diagnosis and symptom management remains unexplored. Methods: We retrospectively re-evaluated data from our 2015 study, which used criteria available before the first MUSA consensus. Nulligravid women aged 18–30 years without endometriosis were included to determine whether MUSA 2022 criteria result in fewer diagnoses than previous criteria. Sonographic images were reviewed and MUSA 2022 criteria applied. The primary outcome was to estimate previous overdiagnosis; the secondary outcome was to identify correlations between ultrasound features and symptoms. Results: Among 156 patients, at least one direct MUSA 2022 sign was present in 36 women; 17 had only indirect signs; and 103 had no ultrasound signs. MUSA 2022 criteria reduced adenomyosis prevalence from 34% to 23.1%. Direct signs were associated with greater dyspareunia (44.4% vs. 11.8%) and higher VAS scores. Hypermenorrhoea was associated with asymmetrical thickness (Odds Ratio 2.84) and a globular uterus (Odds Ratio 4.03). Conclusions: Applying MUSA 2022 criteria reduces adenomyosis diagnoses, suggesting that previous criteria may have overestimated prevalence. Nevertheless, ultrasound remains an adjunct to clinical assessment, and symptoms should guide management when direct signs are absent.

A T‐shaped uterus is a uterine malformation, which can be either congenital or acquired, potentially impairing fertility and increasing the risk of miscarriage. Diagnosis primarily relies on three‐dimensional ultrasound and hysteroscopy. Hysteroscopic metroplasty is the standard surgical intervention aimed at restoring normal uterine anatomy and potentially improving reproductive outcomes. This narrative review, conducted in accordance with SANRA (Scale for the Assessment of Narrative Review Articles) guidelines, is based on a comprehensive database search and critically evaluates observational and interventional studies on the definition, diagnosis, and management of T‐shaped uterus in the context of in vitro fertilization. Recent studies indicate that correction of this anomaly might not only improve spontaneous conception rates but also enhance the outcomes of IVF. However, the precise role of metroplasty in patients undergoing IVF outcomes remains controversial. Some evidence indicates that surgical correction might improve embryo implantation and endometrial perfusion. Despite these promising observations, randomized controlled trials are necessary to define optimal patient selection criteria and to confirm the true benefit of metroplasty in the context of IVF. Future research should also address the potential risks associated with the procedure. A standardized diagnostic and therapeutic approach might contribute to improved reproductive outcomes in affected patients.

Purpose: Review and compare current classifications for diagnosing T-shaped uterus using three-dimensional transvaginal ultrasound (3D-TVS) measurements, identifying measurements that best correlate with the diagnosis. Methods: This retrospective cohort study analyzed diagnostic measurements in patients with T-shaped uterus who underwent 3D-TVS at the University of Rome ‘Tor Vergata’ from 2016 to 2022. Of 7588 patients, four sonographers re-evaluated 3D-TVS images of 72 initially diagnosed cases. Uterine morphology was assessed in the coronal plane by measuring fundal cavity width (R0), corpus-isthmic cavity width (Wi), lateral indentation angle (AI), lateral bulging (LB), T-angle (AT), fundal/isthmic cavity width ratio (R0/Wi), and the length of intracavitary line parallel to interostial line (R10). All cases were confirmed by hysteroscopy, excluding ambiguous findings. Results: Of 72 initially evaluated patients, 50 met the inclusion criteria for final analysis. These patients had consistent 3D-TVS diagnoses from four sonographers and hysteroscopic confirmation from two experts. The combination of three CUME criteria (AT ≤ 40°, AI ≤ 130°, LB ≥ 7 mm) identified only 8% of T-shaped uteri. Notably, 30 patients (60%) had an R10 measurement of ≤ 10 mm. In addition, 31 uteri (62%) met all three criteria: LB ≥ 5 mm, AI ≤ 140°, and R0/Wi ≥ 5. Overall, 48 uteri (96%) satisfied at least two criteria. The study concluded that LB, R10, and R0/Wi are independent predictors of T-shaped uterus. Conclusions: Significant discrepancies exist among current classifications for diagnosing T-shaped uterus. This study identified LB, R10, and R0/Wi as key parameters for accurate diagnosis. These measurements provide a precise and objective approach, aiding in the evaluation of the anomaly's impact on reproductive outcomes and the benefits of hysteroscopic treatment.

Purpose Evaluating menstrual blood loss (MBL) in primary healthcare is challenging. Our study aimed to assess MBL using two methods: self-perception and pictograms (Pictorial Blood Assessment Chart—PBAC and Menstrual Pictogram superabsorbent polymer-c version—MP) in women undergoing transvaginal ultrasound (TVS). Methods We enrolled 221 premenopausal women with spontaneous menstruation, no hormonal therapy, and no ongoing pregnancy. They were divided into four age groups (12–20, 21–30, 31–40, and 41–55 years). Women self-reported normal (NMB) or heavy menstrual bleeding (HMB) and filled out PBAC and MP. A PBAC score ≥ 150 and MP score ≥ 80 ml indicated HMB. TVS was conducted on all patients, recording any pelvic pathologies. We compared self-perception with pictograms across the cohort, age groups, and ultrasound findings. Results Of the cohort, 50.2% reported normal periods and 49.8% heavy periods. No significant differences were found between self-perception and pictograms in identifying NMB and HMB across all groups. However, significant differences were observed between PBAC and MP scores for NMB (56.1% vs 41.2%, p = 0.001) and HMB (43.9% vs 58.8%, p = 0.001), particularly in the 31–40 age group. Significant differences in PBAC and MP scores were noted between age groups 12–20 and 41–55, and 31–40 and 41–55. No significant differences were found between self-perception and pictograms regarding ultrasound findings like adenomyosis, fibroids, endometrial pathology, and uterine congenital malformations. Conclusion Self-perception could be a reliable method for describing MBL across all age groups and ultrasound findings. Given the complexity and potential errors in using pictograms, clinicians should consider relying on self-perception for assessing menstrual cycle quantity.

Background/Objectives: Endometriosis and inflammatory bowel disease (IBD) share some epidemiological, clinical and pathogenetic features. A differential diagnosis between pelvic endometriosis and IBD may be challenging, even for expert clinicians. In the present review, we aimed to summarize the currently available data regarding the relationship between endometriosis and IBD and their possible association. Methods: The PubMed and Scopus database were considered, by searching the following terms: “Crohn’s Disease”, “Ulcerative Colitis”, “Endometriosis”, “Adenomyosis”, and “Inflammatory Bowel Disease”, individually or combined. Full-text papers published in English with no date restriction were considered. Results: Few studies have researched the possible association between endometriosis and IBD. Both conditions are characterized by chronic recurrent symptoms, which may be shared (abdominal pain, fatigue, infertility, menstrual irregularities, diarrhea, constipation). Deep infiltrating endometriosis (DIE) can cause bowel symptoms. In a large Danish study, a 50% increased risk of IBD was observed in women with endometriosis. A missed diagnosis of endometriosis and an increased risk of endometriosis has been reported in IBD. Current evidence does not support an association between endometriosis and IBD characteristics. However, IBD may be associated with DIE, characterized by pelvic symptoms (dyschezia, dyspareunia). Preliminary observations suggest an increased IBD risk in patients with endometriosis treated with hormonal therapy. Conclusions: Current findings suggest that a careful search is needed for concomitant endometriosis in subgroups of patients with IBD showing compatible symptoms and vice versa. A multidisciplinary approach including dedicated gastroenterologists and gynecologists is required for a proper search for IBD and endometriosis in subgroups of patients. This approach may avoid diagnostic delays or overtreatments for these conditions.

Purpose: Evaluating menstrual blood loss (MBL) in primary healthcare is challenging. Our study aimed to assess MBL using two methods: self-perception and pictograms (Pictorial Blood Assessment Chart -PBAC- and Menstrual Pictogram -MP-) in women undergoing transvaginal ultrasound (TVS). Methods: We enrolled 221 premenopausal women with spontaneous menstruation, no hormonal therapy, and no ongoing pregnancy. They were divided into four age groups (12-20, 21-30, 31-40, 41-55 years). Women self-reported normal (NMB) or heavy menstrual bleeding (HMB) and filled out PBAC and MP. A PBAC score ≥150 and MP score ≥80 ml indicated HMB. TVS was conducted on all patients, recording any pelvic pathologies. We compared self-perception with pictograms across the cohort, age groups, and ultrasound findings. Results: Of the cohort, 50.2% reported normal periods and 49.8% heavy periods. No significant differences were found between self-perception and pictograms in identifying NMB and HMB across all groups. However, significant differences were observed between PBAC and MP scores for NMB (56.1% vs 41.2%, p=0.001) and HMB (43.9% vs 58.8%, p=0.001), particularly in the 31-40 age group. Significant differences in PBAC and MP scores were noted between age groups 12-20 and 41-55, and 31-40 and 41-55. No significant differences were found between self-perception and pictograms regarding ultrasound findings like adenomyosis, fibroids, endometrial pathology, and uterine congenital malformations. Conclusion: Self-perception could be a reliable method for describing MBL across all age groups and ultrasound findings. Given the complexity and potential errors in using pictograms, clinicians should consider relying on self-perception for assessing menstrual cycle quantity.

The current knowledge on adenomyosis as a risk factor for RPL is very scant. Overall 120 women were included in this retrospective observational study. They were divided in three groups each of which consisted of 40 subjects: Group 1: women with RPL who were diagnosed to have adenomyosis on transvaginal ultrasound (TVS); Group 2: patients with RPL without ultrasonographic findings of adenomyosis; Group 3: patients with ultrasound diagnosis of adenomyosis without RPL and at least one live birth pregnancy. The copresence of endometriosis was also investigated. Among women with RPL, patients with adenomyosis (Group 1) had higher number of pregnancy losses (p = 0.03) and lower age at first pregnancy loss (p = 0.03) than women without adenomyosis (Group 2). Moreover, they had more frequently primary RPL (p = 0.008). Adenomyosis of the inner myometrium was found more frequently (p = 0.04) in patients of Group 1 than in patients of Group 3 in which adenomyosis was mainly in the outer myometrium (p= 0.02). No differences were found in the severity of adenomyosis between these two groups of women. TVS findings for endometriosis were observed more frequently in women with adenomyosis without RPL (Group 3) than in the other two groups of patients. Adenomyosis can be a factor involved in RPL. Differences in adenomyosis localization are associated with different risks for RPL. Patients with RPL should be investigated for the presence of adenomyosis and also for the type and localization of the disease in the different myometrial layers.

Background and Objectives: The association between endometriosis and breast cancer still remains controversial. The aim of this study was to investigate the different subtypes of breast cancer, immunohistochemical markers, hormone receptors, and ki67 proliferation indexes in patients with and without endometriosis and/or adenomyosis. Materials and Methods: All patients with endometriosis and breast cancer were enrolled. Women with endometriosis and breast cancer (Group BC+EN+) were compared to patients with breast cancer without endometriosis (group BC+EN−) and those with endometriosis without breast cancer (group BC-EN+). General population characteristics and histological and immunohistochemical subtypes of breast cancer were compared between groups. Results: Our study included 41 cases affected by both endometriosis and/or adenomyosis and breast cancer (Group BC+EN+) that were matched (1:2) with 82 patients affected only by breast cancer (group BC+EN−) and 82 patients affected only by endometriosis and/or adenomyosis (group BC-EN+). Group BC+EN+ presented a higher percentage of ER receptor expression (83% vs. 70%, p = 0.02), as well as lower values of Ki 67% (15% vs. 24%, p < 0.0001) and HER2+ (9.8% vs. 28%, p = 0.022). These findings were more evident when comparing patients with premenopausal status, while in postmenopausal patients, this difference was no longer significant. Regarding endometriosis, no statistical differences were observed in type or specific localization of the disease among the groups with and without breast cancer. Conclusions: Patients with endometriosis presented lower aggressive breast cancer rates with higher values of ER% and lower values of Ki 67 and HER2neu+. The type and severity of endometriotic diseases seemed not to influence breast cancer occurrence.

To evaluate the feasibility of hysteroscopy with morcellator without anesthesia and the diagnostic accuracy of 2D, 3D and power Doppler transvaginal sonography (TVS) in patients with abnormal uterine bleeding (AUB). This was a retrospective study including women with AUB. All patients underwent 2D, 3D and power Doppler TVS evaluation of the uterine cavity, and patients with suspicion on ultrasound (US) of endometrial pathology (EP) underwent hysteroscopy with morcellator without anesthesia. The painful symptomatology was assessed during the procedure using a visual analogue scale (VAS). Additionally, histological evaluation was performed. A total of 182 women underwent US imaging, of whom 131 (72%) had hysteroscopy. 130/131 patients completed the hysteroscopic examination with good compliance (VAS <4). One patient (0.8%) was unable to complete the procedure due to nulliparity and cervical stenosis. Of the 130 patients the US diagnosis was confirmed in 120 (92.3%), while in 10 patients (7.7%) the hysteroscopic diagnosis was different from the US diagnosis. Histological examination confirmed benign endometrial polyps in 115/130 patients (88.5%), while premalignant conditions were diagnosed in 3/130 patients (2.3%) and malignant conditions in 2/130 (1.5%). Of the 10 patients with endometrial thickening, two were diagnosed with a malignant condition. This study confirmed the feasibility of managing patients with AUB and suspicion of EP using "see-and-treat" hysteroscopy with morcellator without anesthesia. This procedure has the potential to yield desired outcomes while minimizing pain and discomfort, presenting a feasible outpatient approach for both treating and preventing endometrial carcinoma without requiring anesthesia.

Endometriosis has a prevalence of 10% worldwide in premenopausal women. Probably, endometriosis begins early in the life of young girls, and it is commonly diagnosed later in life. The prevalence of deep infiltrating endometriosis (DIE) in adolescence is currently unknown due to diagnostic limits and underestimation of clinical symptoms. Dysmenorrhea is a common symptom in adolescents affected by DIE, often accompanied by dyspareunia and chronic acyclic pelvic pain. Ultrasonography—either performed transabdominal, transvaginal or transrectal—should be considered the first-line imaging technique despite the potential for missed diagnosis due to early-stage disease. Magnetic resonance imaging should be preferred in the case of virgo patients or when ultrasonographic exam is not accepted. Diagnostic laparoscopy is deemed acceptable in the case of suspected DIE not responding to conventional hormonal therapy. An early medical and/or surgical treatment may reduce disease progression with an immediate improvement in quality of life and fertility, but at the same time, painful symptoms may persist or even recur due to the surgery itself. The aim of this narrative review is to report the prevalence of DIE in adolescents, describe the pathogenetic theories and discuss the management in adolescent women, including the challenging road to diagnosis and the treatment alternatives.