29 Embolisation and radiofrequency ablation In recent years, more focus is also being laid on minimally invasive treatments such as uterine artery embolisation (UAE) or high-frequency ultrasound (HiFU) ablation strategies (59,60). Both of these methods, though not available to, or suitable for, all adenomyosis patients, also show promise with regards to symptom and lesion reduction whilst being uterus-sparing (61). Surgical treatment If the patient wishes to avoid hormonal therapies, or there are relevant contraindications, surgical therapy by way of local excision of adenomyotic lesions, or a hysterectomy can be indicated. With the ongoing development of a wide array of medicinal therapies, hysterectomy is becoming seen as a lastresort option in women without an active child-wish. Surgical excision of smaller localised lesions can also be an option in women wishing to retain reproductive function (62), but is only feasible in certain cases, and is generally only done in centres with the relevant expertise. Without total hysterectomy, and especially without concomitant hormonal therapy, it is likely, however, that the disease will return over time (63). Effect of adenomyosis on uterine (contractile function) Embryologically, the uterine myometrium is made up two types of tissue: the neometrium and the archimetrium. The neometrium makes up the outer two layers of the myometrium, and is generally thought to be the driving force behind strong uterine contractions, as associated with contractions during labour and pregnancy. The archimetrium, the innermost layer of myometrium bordering on the endometrium (which includes the JZ), is linked to uterine peristaltic contractions outside of pregnancy (64). In the 1990’s and early 2000’s, it was established that normal uterine contractile function follows a distinct pattern throughout the menstrual cycle (65–69). At the start of the cycle, during menstruation, uterine contractions travel mostly from the fundus-to-cervix direction with a relatively low frequency. Subsequently, in the follicular phase, uterine peristalsis travels from the cervix-to-fundus direction, with increasing contraction frequency until the periovulatory (late follicular) phase. After ovulation, during the luteal phase, the uterus enters a relatively quiescent state with the lowest frequency of uterine contractions. The characteristics of these contractions proved of
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