191 Discussion In summary, the available literature suggests that uterine abnormalities may indeed influence uterine peristalsis even though measurement methods differed across studies. Findings of included studies report that presence of leiomyomas generally lead to a decreased presence of uterine contractions in various menstrual phases, whereas endometriosis/adenomyosis lead to an increased frequency across menstrual phases. No changes in the presence of uterine contractions were noted in patients with a bicornuate uterus or chronic endometritis. Studies were contradictory on the influence of uterine abnormalities on contraction direction. Only patients with chronic endometritis exhibited clearly altered contraction direction was described. The influence of uterine abnormalities on contraction amplitude has not yet been studied extensively. Endometriosis, however, seems produce an increase in contraction amplitude. Dysperistalsis was noted in patients with leiomyomas, endometriosis, adenomyosis and an asymmetric bicornuate uterus. Another observation in patients with leiomyomas was that the treatment of leiomyomas re-established normal uterine contractions, which could confirm the effect of leiomyomas on uterine peristalsis. Previously published systematic reviews have mainly focused on the influence of uterine contractions on fertility. Kuijsters et al. (2017) briefly described the influence of uterine abnormalities on peristalsis. The results of this systematic review supports their reported influence of uterine abnormalities on uterine contraction features (233). It was postulated that abnormal uterine contractions in patients with uterine abnormalities could be the cause of infertility (233), a hypothesis supported by Hunt et al. (2020). Effects of endometriosis, adenomyosis and leiomyomas on uterine peristalsis were also described by Hunt et al. (2020), with similar conclusions to this review. A clear influence of endometriosis on contraction direction was reported; however, this could not be confirmed in our review (259). Even though more attention is being given to uterine peristalsis recently, few systematic reviews have been conducted on this subject. This review gives a clear summary of the published studies on the influence of uterine abnormalities on uterine peristalsis up to now. To give an overview of all gathered knowledge, it was chosen to include studies regardless of the
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