Clinical evaluation of high-intensity focused ultrasound ablation combined with mifepristone and levonorgestrel-releasing intrauterine system to treat symptomatic adenomyosis

Abstract Objective To evaluate the clinical efficacy of the combination of high-intensity focused ultrasound (HIFU), mifepristone, and levonorgestrel-releasing intrauterine system (LNG-IUS) in adenomyosis treatment. Methods HIFU treatment was performed in 123 patients with symptomatic adenomyosis who had refused treatment with gonadotropin-releasing hormone agonist (GnRH-a) at Anyang Maternal and Child Health Care Hospital. In the control group, 34 patients were treated with HIFU alone, 29 patients with HIFU combined with mifepristone, 10 patients with HIFU combined with LNG-IUS. In the study group, 50 patients were treated with HIFU combined with mifepristone and LNG-IUS. Results Uterine volume, dysmenorrhea pain score, menstruation volume score, and serum CA125 level were significantly lower after treatment with HIFU combined with mifepristone and LNG-IUS than before treatment (p < .05). Moreover, hemoglobin level was significantly higher than that before treatment (p < .05). After 24 months, the efficacy of HIFU combined with mifepristone and LNG-IUS was significantly higher than that of HIFU alone, HIFU combined with mifepristone or HIFU with LNG-IUS (p < .05). Conclusions Combination therapy of HIFU, mifepristone, and LNG-IUS is an effective, safe, and inexpensive treatment for patients with symptomatic adenomyosis. This combination therapy demonstrates superior efficacy to treatment with HIFU alone, HIFU combined with mifepristone, and HIFU combined with LNG-IUS.


Introduction
Adenomyosis is a benign disorder characterized by uterine enlargement, mainly caused by endometrial glands and stroma invading the myometrium.This disorder occurs among people of reproductive age.Approximately 20% of patients are younger than 40 years old, and the remaining 80% are 40-50 years old [1].The main symptoms are progressive dysmenorrhea, hypermenorrhea, and infertility [2].Women with serious adenomyosis experience physical and mental health problems, including sleep and eating disorders and depression [3,4].Currently, hysterectomy is the gold standard radical treatment for adenomyosis and the most effective way to control symptoms and achieve high satisfaction rates.However, hysterectomy is unsuitable for young patients or women who desire fertility.In addition, hysterectomy can result in complications such as wound infections, genitourinary tract injuries, vaginal cuff dehiscence, urinary incontinence, sexual dysfunction, vaginal dryness, hormonal changes, gastrointestinal tract injuries, pelvic organ prolapse, and pelvic organ fistula disease [5].
High-intensity focused ultrasound (HIFU) ablation, a novel, noninvasive therapy for adenomyosis, is often accepted by patients who refuse hysterectomy.Under ultrasound guidance, HIFU utilizes the thermal effects of the ultrasound beam to induce target adenomyotic coagulative necrosis without damaging the normal tissue [6].Previous studies have shown that HIFU is a safe and effective therapy that can improve the clinical outcomes of severe adenomyosis [7].However, other studies have shown that approximately 20% of patients relapse soon after HIFU treatment [8].
Levonorgestrel-releasing intrauterine system (LNG-IUS) can alleviate dysmenorrhea and decrease blood loss.It acts directly on adenomyosis foci by releasing levonorgestrel for five years and downregulating the estrogen receptor, resulting in atrophy and shrinkage of the adenomyotic lesion.This method is suitable for long-term management of symptomatic adenomyosis, as it exhibits a continued decrease in dysmenorrhea and uterine volume.Furthermore, the satisfaction of patients treated with LNG-IUS is greater than 72% [9].However, LNG-IUS is unsuitable for patients with an enlarged uterus, especially for those whose uterine size is > 12 weeks of gestation, due to the increased risk of expulsion and prolapse [10].
Furthermore, adenomyosis is an estrogen-dependent disease.Gonadotropin-releasing hormone agonist (GnRH-a) can significantly reduce uterine volume and ameliorate pelvic pain and bleeding by decreasing the excitability of ovarian function, thereby inhibiting the secretion of estrogen [11].For those with a uterine cavity depth greater than 9 cm, GnRH-a can also be used as adjuvant therapy before LNG-IUS placement.
Some studies have demonstrated that combination treatment of HIFU, GnRH-a, and LNG-IUS enhances the long-term efficiency and decreases the recurrence rate of adenomyosis compared to HIFU treatment alone or HIFU combined with GnRH-a [7,12].However, some patients refuse GnRH-a due to its high cost (more than $200/month [13]), side effects such as premenopausal syndrome, and high relapse rate after drug withdrawal [14].
Mifepristone is a selective progesterone receptor modulator that can relieve dysmenorrhea by inhibiting the migratory capacity of nerve cells in adenomyosis.The cost of this drug is less than $4/month, which is far less than the cost of GnRH-a [13].Thus, mifepristone may be a promising costeffective alternative for treating adenomyosis, especially in patients that refuse GnRH-a or whose uterine cavity depth is greater than 9 cm.Thus, combination therapy of HIFU, mifepristone, and LNG-IUS may be used as a treatment for patients with symptomatic adenomyosis, though this treatment modality has not yet been investigated.Therefore, this study investigated the treatment effect of combining HIFU with mifepristone and LNG-IUS in patients with symptomatic adenomyosis and evaluated the long-term effects of this combination therapy.

Ethics statement
This retrospective study was approved by the ethics committee of Anyang Maternal and Child Health Care Hospital.The approved protocol number was 20200301008.The requirement for informed consent to publish these results was waived since patient confidentiality was maintained.Informed consent to deliver HIFU was obtained from each patient before treatment.

Patients
Between September 2018 and September 2020, 123 patients with symptomatic adenomyosis at the Anyang Maternal and Child Health Care Hospital were enrolled in this study.Specifically, in the control group, 34 patients were treated with HIFU alone, 29 with HIFU combined with mifepristone, and 10 with HIFU combined with LNG-IUS, and in the study group, 50 patients were treated with HIFU combined with mifepristone and LNG-IUS.All patients had a history of childbearing.
The inclusion criteria were as follows: (1) greater than 18 years of age but not menopausal; (2) diagnosis of adenomyosis by magnetic resonance imaging (MRI); (3) presence of severe symptoms such as dysmenorrhea or hypermenorrhea; (4) refusal to undergo hysterectomy or adenomyectomy; (5) presence of uterine lesions thicker than 3 cm; (6) unwillingness to take oral medication for a prolonged period; and (7) unwilling to take GnRH-a due to its high price.The exclusion criteria included: (1) a strong desire to cure adenomyosis; (2) menstruating, breastfeeding, or pregnant; (3) confirmed or suspected gynecological malignancy; (4) damage to liver and kidney function; and (5) severe pelvic adhesions.

Preparation before HIFU therapy
Two-dimensional pelvic color Doppler ultrasound and MRI were performed to establish the location, extent, vascular perfusion, or signal of the lesion.The patients were given a protocol for diet preparation and precautions to take during treatment.In short, patients were asked to consume liquid food and avoid milk and gas-producing food for three days for routine bowel preparation.Cleansing enemas were performed on the morning of HIFU treatment.The patient's abdominal skin was degassed and degreased before treatment.The bladder was perfused with warm saline to establish a safe ultrasonic channel.

HIFU treatment
HIFU ablation was performed using an ultrasound-guided HIFU therapeutic system (JC200; Haifu Medical Technology Co., Ltd., Chongqing, China).The patient was propped on the HIFU treatment bed, and the anterior abdominal wall was in contact with degassed cold water.A degassed water balloon was placed between the abdomen and the transducer to push the bowel away from the ultrasound pathway.Patients were intravenously injected with sedative and analgesic drugs (midazolam and fentanyl) in case of any movement.At the start of treatment, patients were intravenously injected with SonoVue (Bracco Suisse SA, Plan-Les-Ouates, Switzerland) to evaluate the boundary and vascular supply of the lesion.The treatment was guided by real-time ultrasound imaging to protect the normal tissue when ablating the lesion.The sonication power usually ranged from 300 to 400 W, and the sonication point was placed in the center of the lesion.The intensity and range of treatment were regulated according to grayscale changes in the lesion and the patient's tolerance.At the end of treatment, contrastenhanced ultrasonography (CEUS) was performed to assess the ablation volume and non-perfused volume (NPV) ratio of the adenomyotic lesions (Figure 1).The NPV ratio was calculated as follows: NPV ratio (%) ¼ NPV/Target lesion Â 100.

Mifepristone and LNG-IUS insertion
Mifepristone (10 mg, Wuhan Jiulong Pharmaceutical Co. Ltd., Wuhan, China) was administered the day after HIFU treatment for three months for patients treated with HIFU combined with mifepristone or HIFU combined with mifepristone and LNG-IUS.The LNG-IUS (Mirena, Bayer Oy, Turku, Finland) was placed in the uterine cavity the day after HIFU treatment for patients in the HIFU combined with LNG-IUS group.In the patients from the group treated with HIFU combined with mifepristone and LNG-IUS, the LNG-IUS was inserted at the end of the three-month treatment period with mifepristone.

Clinical evaluation indicators
The uterine volume reduction rate was determined before and at 1, 3, 6, 12, and 24 months after HIFU treatment.The visual analogue scale (VAS) score, as well as the CA125 and hemoglobin serum levels were measured before and 3, 6, 12, and 24 months after HIFU treatment.The menstrual volume was assessed before and at 6, 12, and 24 months after HIFU ablation.The uterine volume was calculated according to the two-dimensional color Doppler ultrasound image using the following formula: V ¼ 0.523 Â long diameter (not including the cervical length) Â anteroposterior diameter Â transverse diameter [15].The VAS score represents the degree of dysmenorrhea.The left end of the scale was marked '0 0 , which indicated 'no pain', while the right end of the scale was marked '100', which indicated 'the most severe pain imaginable' [16].The menstrual volume was assessed using the pictorial blood loss assessment chart (PBAC), and the specific assessment methods were described in a previous study [17].

Statistical analysis
Data were analyzed using IBM SPSS Statistics software version 22 and are presented as the mean ± standard deviation (SD).p < .05indicated statistical significance.For intra-group comparisons, continuous variables before and after the combination treatment of HIFU, mifepristone, and LNG-IUS were compared using the paired Wilcoxon signed rank test.For inter-group comparisons, the Kruskal-Wallis test was applied to compare variables among the four treatment groups and for multiple comparisons (pairwise comparison of the four treatment groups).

Baseline characteristics
The baseline characteristics of the patients before HIFU treatment were compared among the different groups.As shown in Table 1, age (p > .05),dysmenorrhea (p > .05),and menstrual volume (p > .05)were not significantly different among the four groups, but the uterine volume (p < .05)was.Therefore, multiple comparisons were performed for uterine volume.As shown in Table 2, the results indicated that uterine volume showed no significant difference in any pairwise comparisons.

Peri-HIFU evaluation
All patients were treated once with HIFU ablation.No significant difference was observed among the four groups in the total energy, average power, treatment time, and NPV ratio (p > .05)(Table 3).

Efficacy of treatment on uterine volume
As shown in Figure 2, in the group treated with HIFU combined with mifepristone and LNG-IUS, the uterine volume was significantly reduced at all times after treatment compared with that before treatment (p < .05).Moreover, the uterine volume at 3 (117.67± 47.18 cm 3 ), 6 (113.42 ± 42.05 cm 3 ), 12 (106.10± 38.10 cm 3 ), and 24 (111.17± 50.72 cm 3 ) months after treatment was significantly reduced compared with that at 1-month after treatment (126.90 ± 46.65 cm 3 ) (p < .05).Moreover, the uterine volume at 12 months after treatment was reduced considerably, even compared with that at 3 and 6 months after treatment (p < .05).However, the uterine volume reduction stopped at 24 months after treatment, and no significant difference was found between 12 and 24 months after treatment.Moreover, two-dimensional color Doppler ultrasound showed that the uterine size was significantly smaller and almost recovered to its normal size 12 months after HIFU treatment (Figure 3).
In the study group, the uterine cavity depth was 10.14 ± 0.86 cm, 9.38 ± 0.85 cm, and 8.61 ± 0.53 cm before and one and three months after HIFU treatment, respectively.

Effect of treatment on dysmenorrhea
The degree of dysmenorrhea was assessed using the VAS score.As shown in Figure 4, the VAS score significantly decreased after treatment of HIFU combined with mifepristone and LNG-IUS (p < .05).The VAS score was lowest (27.74 ± 7.67) at 3 months after HIFU treatment compared with that before treatment and 6, 12, and 24 months after treatment.Then, the VAS score slightly increased and reached 29.86 ± 9.21 6 months after treatment (p < .05).However, no significant differences were found between 6, 12, and 24 months after treatment.
Table 5 shows no significant difference was observed before HIFU treatment among the four groups (p > .05).Additionally, the VAS score decreased at 3, 6, 12, and 24 months after HIFU treatment in all four groups.Furthermore, the VAS score of the HIFU combined with mifepristone and LNG-IUS treatment group decreased from 80.82 ± 12.49 before HIFU to 29.58 ± 9.29 at 24 months after HIFU treatment, which was much lower than that in the other three groups (p < .05).
0.529 Notes: The Kruskal-Wallis test was used to compare variables between two groups.p < .05 was considered statistically significant.Table 3. HIFU treatment parameters.
HIFU alone

Effect of treatment on menstruation volume
As shown in Figure 5, menstruation volume was compared before and after HIFU combined with mifepristone and LNG-IUS treatment.The scores at 6 (37.04 ± 15.13), 12 (35.72 ± 16.50), and 24 months (35.36 ± 14.95) after treatment were significantly lower than that before treatment (208.44 ± 144.53) (p < .05).However, no significant differences were found between 6, 12, and 24 months after treatment.
Table 6 shows no significant differences among the four groups before HIFU treatment.The menstruation volume score in the HIFU combined with mifepristone and LNG-IUS group was significantly lower than that in the other three groups at 6, 12, and 24 months (35.36 ± 14.95) after treatment (p < .05).

Comparison of serum marker levels
As shown in Figure 6, the serum CA125 level was significantly lower at 3 (38.92± 53.81), 6 (32.67 ± 41.37), 12 (28.05± 24.30), and 24 months (29.16 ± 23.82) after treatment than before treatment (78.53 ± 81.45).Additionally, the serum CA125 level was significantly decreased at 6 and 12 months after treatment compared with 3 months after treatment and significantly increased at 24 months after treatment compared with 12 months after treatment.
As shown in Figure 7, the serum hemoglobin level was significantly increased at 3 (107.14± 14.21), 6 (112.92 ± 12.86),    As shown in Tables 7 and 8, no significant difference in serum CA125 or hemoglobin levels was observed among the four groups before HIFU treatment (p > .05).However, the serum CA125 level in the HIFU combined with mifepristone and LNG-IUS group was significantly lower than that in the other three groups at 24 months after HIFU treatment (p < .05).In contrast, the four groups showed no significant difference at 3, 6, and 12 months after HIFU treatment (Table 7).Similarly, Table 8 shows that the serum hemoglobin levels at 3, 6, 12, and 24 months did not differ significantly among the four groups (p > .05).

Complications and adverse effects
No severe complications, such as intestinal injury, uterine bleeding, skin bure, or infection, were reported after HIFU treatment.Minor vaginal bleeding was observed after HIFU treatment, but it resolved within one month.Moreover, 74 (60.1%) patients reported irregular scanty vaginal bloody discharge after the LNG-IUS was inserted, which resolved within six months.Finally, none of the patients had an abnormal liver function.

Discussion
Adenomyosis is a common benign gynecological disease affecting patients' mental and physical health.The development of therapeutic strategies with minimal trauma for symptomatic patients based on their symptoms, age, the requirement for fertility, and the need to preserve their uterus is vital.Current treatments for adenomyosis include curative surgical therapy and conservative medical treatment [18].Some guidelines recommend that adenomyosis treatment aims to relieve the clinical symptoms and preserve fertility as much as possible.Although hysterectomy is the gold-standard therapy resulting in no chance of recurrence, it may lead to complications, such as premature ovarian failure, pelvic organ prolapses, and urinary incontinence [5].Hysterectomy can resolve menorrhagia permanently; however, for premenopausal patients with concomitant endometriosis, pelvic pain may be cyclic and persistent [19].This method is also unsuitable for patients who desire fertility or wish to conserve the uterus.Therefore, conservative medical treatment is necessary for patients that desire fertility.However, neither conservative surgery nor drugs can completely eliminate the lesion; therefore, long-term management is necessary for patients that undergo uterine-sparing treatment.
HIFU is a novel, noninvasive treatment for adenomyosis, which may relieve dysmenorrhea and menorrhagia by inducing inflammatory factors and downregulating the expression of vascular endothelial growth factors in adenomyotic lesions [7].A previous review showed that after HIFU treatment, dysmenorrhea and menorrhagia were significantly ameliorated in 202 patients with adenomyosis [20].However, other studies reported that with the prolongation of follow-up time, the efficacy of HIFU treatment in relieving dysmenorrhea and reducing menstrual volume gradually decreased [7].In another study, approximately 80% of patients were satisfied after HIFU treatment, and 26% experienced recurrence [8].In the 24-month follow-up, the reduction rates in the HIFU group and HIFU combined with the mifepristone group were only 2.12 and 2.42, respectively, which were much lower than those 12 months after HIFU treatment.Additionally, the uterine volume at 24 months after HIFU treatment was similar to that before HIFU treatment, which also implied recurrence.These results were similar to the previous study [7,8].To improve the rate of symptom relief and reduce the recurrence rate, adjuvant therapies after HIFU ablation have been increasingly adopted.According to a previous study, HIFU treatment combined with GnRH-a or LNG-IUS could provide a superior effect to HIFU treatment alone [21].A retrospective study on 1982 patients with adenomyosis treated with HIFU alone, HIFU combined with GnRH-a, HIFU combined with LNG-IUS, and HIFU combined with GnRH-a and LNG-IUS showed that the efficacy of HIFU combined with GnRH-a and LNG-IUS was significantly higher than that of HIFU alone and HIFU combined with GnRH-a (p < .05)[7].However, since GnRH-a treatment is expensive, costing more than 200 US dollars per month, some patients refuse GnRH-a.In contrast, mifepristone treatment costs less than 4 US dollars per month.
Hence, this study investigated the clinical efficacy of the combination of HIFU, mifepristone, and LNG-IUS in adenomyosis treatment.In this study, one month after HIFU treatment, the uterine volume reduction rate in the HIFU combined with the mifepristone group was significantly higher than that in the HIFU alone group (p < .05)(Tables 4 and 9).In addition, in the study group, the uterine cavity depth was less than 9 cm (8.61 ± 0.53 cm) three months after HIFU treatment.Therefore, the LNG-IUS could be placed in the uterus at the end of the three-month treatment period with mifepristone.Hence, mifepristone may effectively reduce the uterine volume after HIFU treatment.Therefore, if the uterine cavity depth is greater than 9 cm, 10 mg of mifepristone per day for three months after HIFU treatment may help reduce the size of the uterus to insert the LNG-IUS.
HIFU combined with mifepristone and LNG-IUS effectively improved clinical symptoms.The VAS score and PBAC are widely used methods to assess dysmenorrhea and menstruation volume, respectively [16,17].A previous study demonstrated that the VAS score of adenomyosis patients after mifepristone treatment was significantly lower than the pretreatment score [13].In this study, the VAS score in the study group was significantly lower than that of other groups at 24 months after HIFU treatment (p < .05).Additionally, the menstruation volume gradually decreased after HIFU treatment (p < .05).Moreover, the PBAC score in the study group was significantly lower than that in the other three groups at 6, 12, and 24 months after HIFU treatment.These results confirm the effectiveness of HIFU combined with mifepristone and LNG-IUS in relieving the symptoms of adenomyosis and demonstrate that this combination was superior to the other three methods.
In addition, the serum levels of CA125 and hemoglobin were used to evaluate clinical efficacy comprehensively.A previous study reported that serum CA125 level decreased significantly while the hemoglobin level increases significantly after treatment with HIFU combined with GnRH-a and LNG-IUS [14].This is in accordance with our findings.In this study, the serum CA125 level was significantly decreased after treatment with HIFU combined with mifepristone and LNG-IUS and was lower than that of the other three groups at 24 months after HIFU treatment (p < .05).Moreover, after HIFU therapy combined with mifepristone and LNG-IUS, the serum level of hemoglobin significantly increased; however, no significant difference was observed among the four groups in the hemoglobin level (p > .05).The anemic patients were treated with different drugs, which may have contributed to the lack of significant differences among the groups.In conclusion, treatment with HIFU combined with mifepristone improved the serum levels of CA125 and hemoglobin.
This study has two limitations.First, the sample size was small, and the follow-up time was short.Second, this was a retrospective, nonrandomized study.These two limitations may have led to biased results.Therefore, a prospective .0000Notes: Mean ± SD; The Kruskal-Wallis test was used to compare variables among the four groups.p < .05 was considered statistically significant.study with many randomized patients and a more extended follow-up period is warranted.Despite these limitations, the current study is the first to demonstrate that HIFU combined with mifepristone and LNG-IUS is a cost-effective and effective treatment for symptomatic adenomyosis.
In summary, the three-step therapeutic method comprising HIFU, mifepristone, and LNG-IUS could significantly reduce the uterine volume, effectively improve symptoms, decrease the serum CA125 level, and increase the hemoglobin level in patients with adenomyosis.This combination therapy may be a promising treatment for adenomyosis, especially for patients whose uterus is too large to receive LNG-IUS directly after HIFU treatment and refuse GnRH-a, which may be an alternative approach.In the future, a study should be conducted to compare treatment with HIFU combined with mifepristone and LNG-IUS with treatment with HIFU combined with GnRH-a and LNG-IUS.

Figure 1 .
Figure 1.Preoperative and postoperative CEUS images.(A) CEUS image of diffused adenomyosis before HIFU treatment.The myometrium of the posterior uterine wall with abundant vascular supply was thicker than the anterior uterine wall.(B) CEUS image with a non-defused area in the lesion, which indicated that more than 85% of the lesion was ablated.

Figure 2 .
Figure 2. The uterine volume before and after treatment.The uterine volume significantly decreased after HIFU treatment combined with mifepristone and LNG-IUS (p < .05)and continued shrinkage until 12 months after treatment.The significant difference between the timepoints is represented by the symbol Ã .

Figure 3 .
Figure 3.The ultrasound scan before and after combination therapy.(A) Ultrasound image of the adenomyotic uterus before HIFU treatment, which indicated the long diameter and anteroposterior diameter of the uterus to be 8.05 mm and 5.99 mm, respectively.(B) Ultrasound image of the patient's uterus 12 months after combination therapy, which indicated the long diameter and anteroposterior diameter of the uterus to be 4.62 mm and 3.98 mm, respectively.The size of the uterus was almost normal.

Table 4 .
Comparison of uterine volume reduction rates (%) after HIFU treatment.Follow-up time HIFU alone

Figure 4 .
Figure 4.The VAS score before and after treatment.The VAS score significantly decreased after HIFU treatment combined with mifepristone and LNG-IUS (p < .05).The significant difference between the timepoints is represented by the symbol Ã .

Table 5 .Figure 5 .
Figure 5.The menstruation volume before and after treatment.The menstrual blood loss significantly decreased after HIFU treatment combined with mifepristone and LNG-IUS (p < .05).The significant difference between the timepoints is represented by the symbol Ã .

Figure 6 .
Figure 6.The serum CA125 level before and after treatment.The serum CA125 level significantly decreased after treatment of HIFU combined mifepristone and LNG-IUS (p < .05).The significant difference between the timepoints is represented by the symbol Ã .

Figure 7 .
Figure 7.The serum hemoglobin level before and after treatment.The serum hemoglobin level significantly increased after treatment of HIFU combined with mifepristone and LNG-IUS (p < .05).The significant difference between the timepoints is represented by the symbol Ã .

Table 1 .
Baseline characteristics of patients with adenomyosis.Mean ± SD; The Kruskal-Wallis test was used to compare variables among the four groups.Statistical significance was set at p < .05.HIFU: high-intensity focused ultrasound; VAS: visual analogue scale.

Table 2 .
Multiple comparisons of uterine volume before HIFU treatment (p value).

:
Mean ± SD; The Kruskal-Wallis test was used to compare variables among the four groups.p < 0.05 was considered statistically significant.NPV, non-perfused volume.

Table 6 .
Comparison of menstruation volume before and after HIFU treatment in the four groups.