Dysmenorrhea and uterine innervation in adenomyosis and endometriosis: the role of the sacrouterine ligament: reply.

We thank Quinn et al for sharing their findings with us, as it is an interesting theory concerning how uterine innervation and adenomyosis (symptoms) may be connected. It remains a clinical challenge to separate the effects of endometriosis and adenomyosis from each other, especially concerning which of the 2 conditions plays the primary role in dysmenorrhea. In our study, we were unable to differentiate the groups based on purely uterine characteristics because of the limitation of our anonymized datasets, and thus, we cannot provide a clear answer to your question. Furthermore, we do not have data regarding the state of the sacrouterine ligaments in these patients as these are not looked at in all cases. However, we believe that the presence of adenomyosis itself will still primarily affect uterine innervation and contractility because of the disruption of myometrial tissue and thereby gap junctions and interstitial Cajal-like cells, leading to symptoms. This theory regarding the effect of adenomyosis on uterine peristalsis has been described in detail in the literature in past years.1Leyendecker G. Kunz G. Wildt L. Beil D. Deininger H. Uterine hyperperistalsis and dysperistalsis as dysfunctions of the mechanism of rapid sperm transport in patients with endometriosis and infertility.Hum Reprod. 1996; 11: 1542-1551Crossref PubMed Scopus (251) Google Scholar,2Shaked S. Jaffa A.J. Grisaru D. Elad D. Uterine peristalsis-induced stresses within the uterine wall may sprout adenomyosis.Biomech Model Mechanobiol. 2015; 14: 437-444Crossref PubMed Scopus (27) Google Scholar If the sacrouterine ligaments are additionally affected, this may potentially result in further disruption of uterine innervation, and we know that sacrouterine ligament involvement is associated with more severe dysmenorrhea in endometriosis.3Gruber T.M. Mechsner S. Pathogenesis of endometriosis: the origin of pain and subfertility.Cells. 2021; 10: 1381Crossref PubMed Scopus (50) Google Scholar This would be an interesting area to investigate in prospective studies in the future. However, the question remains whether added pathology comes from the invasion of the sacrouterine ligament or whether the concomitant endometriosis is the added severe disease. Our group is currently in the process of conducting a subanalysis using our existing dataset investigating pregnancy outcomes in women with adenomyosis and concomitant endometriosis vs adenomyosis alone. Potentially, we will be able to answer this query in more detail. Adverse reproductive outcomes in different patterns of adenomyosisAmerican Journal of Obstetrics & GynecologyVol. 229Issue 1PreviewIn their large, retrospective, ADenomyosis and its Effect on Neonatal and Obstetric Outcomes study, Dr Rees and colleagues recorded significant adverse reproductive outcomes in women with histologically proven adenomyosis.1 In Shanghai, we studied 2 patterns of adenomyosis: (1) large (250–1250 g), painless, symmetrical uteri that do not seem to sustain pregnancy (Figures, A–C) and (2) small (80–250 g), painful, asymmetrical, uteri (Figure, D–F). In the former group (n=31), both uterosacral ligaments had been completely avulsed (Figure, B), and there was complete denervation of both the uterus and fallopian tubes (Figure, C). Full-Text PDF