28 there is a direct relationship. This is a promising and clinically relevant query that needs further exploration as it would then become possible to predict (risk of) certain outcomes on the basis of non-invasive imaging. There are thus a wide range of parameters on MRI that can be used to characterise and visualise adenomyosis, such as junctional zone thickness, myometrial signal intensity and uterine size (33). However, many of them have not been specifically investigated for diagnostic accuracy versus histopathology, and little is likewise known about how they may correlate to clinical outcomes (32). Despite attempts to create (imaging-based) classification systems for adenomyosis (16,17), there currently exists no widely used tool for prediction of adenomyosis diagnosis. Adenomyosis treatment Once accurately diagnosed, adenomyosis can be (symptomatically) treated fairly effectively using a variety of strategies. . The choice of strategy is the result of type of complaints and clinical issues (e.g. pain, dysmenorrhea, abnormal bleeding, dyspareunia, fertility, age, uterine preservation wishes). All treatment options have a reported positive effect on quality of life, uterine and lesion size, symptoms (e.g. dysmenorrhoea) and fertility to differing extents (7,55). Medical treatment In clinical practice, initial treatment options for adenomyosis often involve symptomatic (pain or bleeding) relief (NSAID’s or tranexaminic acid) and/or hormonal therapy (56,57). Hormonal therapies range from systemic combined oral contraceptive pills (COCs) and progesterone-only pills (POPs) to more localised levonorgestrel intra-uterine devices (Lng-IUDs). All of these hormonal options have the goal of relative suppression of endometrium buildup and stimulation of endometrial atrophy, with subsequent reduction of adenomyosis-related symptoms. As with associated endometriosis, GnRH agonists or antagonists, selective oestrogen and/or progesterone modulators (SERMs and SPRMs) can also be employed in cases resistant to other forms of hormonal therapy (56,58).
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