Diagnosing and treating adenomyosis

Adenomyosis is a benign condition of the uterus characterized by the presence of endometrial glands and stroma within the myometrium. It is a chronic disease for which no preventive or curative uterine-preserving therapies currently exist. It typically presents with abnormal uterine bleeding, dysmenorrhea, chronic pelvic pain, and dyspareunia, and has been associated with subfertility and recurrent miscarriages. In this thesis, we aimed to improve the diagnosis of adenomyosis with ultrasound (part 1) and to investigate whether uterine artery embolization (UAE) is a good uterine-preserving alternative to hysterectomy (part 2). In chapter 2 (part 1), we conducted a multidisciplinary review of the junctional zone in healthy uteri and adenomyosis, relating imaging findings to histology. We found that histologically the junctional zone consists of gradual cellular and vascular changes toward the outer myometrium, whereas imaging suggests a distinct anatomical layer. In addition, junctional zone thickness differs between MRI and ultrasound and may vary with menstrual cycle phase and uterine peristalsis. We therefore concluded that clinicians and researchers should not rely on junctional zone thickness alone, but should focus primarily on direct signs of ectopic endometrium within the myometrium. In chapter 3, we reviewed the tissue characteristics of adenomyosis visible on ultrasound in relation to its underlying pathogenesis. We hypothesized that different sonographic features correspond to four histological counterparts: glandular, microcystic, vascular, and fibrotic tissue. Viewing adenomyosis as a spectrum of these tissue types, rather than as a binary entity, may explain differences in symptom severity and response to medical or minimally invasive treatment. In chapters 4 and 5, we developed and evaluated objective methods to assess the sonographic severity of adenomyosis and correlated these with symptom severity. Of six offline methods using uterine volumes, the XI VOCAL counting method proved feasible and showed good interobserver reliability. Sonographic severity correlated with menstrual blood loss, but not with dysmenorrhea, chronic pelvic pain, or dyspareunia. In part 2, we investigated UAE as an alternative to hysterectomy in patients with symptomatic adenomyosis after failure of conservative treatment. This work was part of the multicenter QUality of life after Embolization versus hySTerectomy for symptomatic Adenomyosis (QUESTA) study, a two-year prospective cohort study in 12 Dutch centers that was initially designed as a randomized controlled trial. In chapter 6, we reported the primary outcome after one year: non-inferiority of UAE compared with hysterectomy regarding health-related quality of life (HRQOL). Neither non-inferiority nor inferiority of UAE could be demonstrated within the predefined margins. Both treatments significantly improved HRQOL, sexual activity, and pain. However, hysterectomy resulted in greater improvements in SF-12 scores and pain reduction, whereas UAE was associated with better urinary symptoms. Patients were generally more satisfied after hysterectomy. In chapter 7, we described peri-procedural and short-term recovery outcomes. Both treatments had comparable, mainly minor complication rates. Hospital stay was shorter after hysterectomy, whereas return to work was faster after UAE. Finally, in chapter 8, we evaluated myometrial changes on MRI six months after UAE and explored baseline imaging characteristics as potential predictors of treatment response that may support patient counseling. | Original language | English | |---|---| | Qualification | PhD | | Awarding Institution | - Vrije Universiteit Amsterdam | | Supervisors/Advisors | - Huirne, Judith Anna Francisca, Supervisor, - - Hehenkamp, W.J.K., Supervisor, - - Lohle, P.N.M., Co-supervisor, - - de Leeuw, Robert Adrianus, Co-supervisor, - | | Award date | 1 Sept 2026 | | Print ISBNs | 9789465345673 | | DOIs | | | Publication status | Published - 1 Sept 2026 |

- adenomyosis - gynecology - transvaginal ultrasound - three-dimensional ultrasound - uterine artery embolization - quality of life - adenomyosis severity - adenomyosis spectrum Fingerprint Dive into the research topics of 'Diagnosing and treating adenomyosis: Insights in ultrasound and embolization of adenomyosis'. Together they form a unique fingerprint.Cite this - APA - Author - BIBTEX - Harvard - Standard - RIS - Vancouver