Recommendations
for müllerian anomalies classification
Si Su1,2, Lan Zhu1*
1 Department of Obstetrics and
Gynecology, Peking Union Medical
College Hospital, Chinese Academy of Medical Science and Peking Union
Medical College, National Clinical Research Center for Obstetric and
Gynecologic Diseases, Beijing, China
2 Department of Pathology, Peking Union Medical College Hospital,
Chinese Academy of Medical Sciences and Peking Union Medical College,
Beijing, China
*Corresponding Author: Lan Zhu, MD, Department of Obstetrics and
Gynecology, Peking Union Medical College Hospital, Chinese Academy of
Medical Science and Peking Union Medical College, National Clinical
Research Center for Obstetric and Gynecologic Diseases,
No. 1 Shuaifuyuan, Dongcheng
District, 100730, Beijing, China (zhu_julie@vip.sina.com)
The word count for the main text: 506.
In 2021, a new müllerian Anomalies
Classification was proposed by American Society for Reproductive
Medicine (ASRM 2021), 1 which was based on the
American Fertility Society (AFS) 1988 2 and combined
the benefits of existing classifications. However, mullerian anomalies
is a group of complex diseases with various manifestations. And no
consensus has been reached about the classification and diagnosis in
clinical practice. The purpose of this study is to test the clinical
application value of this new classification through the analysis of the
cases from Peking Union Medical College Hospital in the past 20 years,
and put forward valuable recommendations.
A retrospective study was conducted using clinical data of hospitalized
patients from January 2003 to December 2022 from
Peking Union Medical College
Hospital. Inclusion criteria included
patients with 46, XX karyotype,
diagnosed of müllerian anomalies, and clearly identified alterations of
the uterus, cervix, and vagina. Clinical data of patients were collected
through the hospital information system, and classification was
performed based on the ASRM 2021. SPSS 25.0 version was used for data
analysis.
2671 patients were included, with an average visiting age of 28.9±10.0
years. The most common is septate uterus with 1144 cases (42.8%),
followed by MRKH syndrome (20.4%),
Herlyn-Werner-Wunderlich syndrome
(HWWS) (10.4%), unicornuate uterus (7.4%), cervical agenesis (6.5%),
uterus didelphys (5.6%), bicornuate uterus (2.9%), longitudinal
vaginal septum (without uterine malformation) (2.0%), transverse
vaginal septum (1.2%), complex anomalies (0.5%) and other anomalies
(0.3%) (Table 1). It should be emphasized that HWWS was taken as an
independent classification for statistical analysis, with reference to
the clinical definition (uterus didelphys, obstructed hemivagina and
ipsilateral renal agenesis).3,4 13 cases of complex
anomalies were identified and 8 cases that could not be classified were
classified as other anomalies (Supplement table 1).
ASRM 2021 was proposed based on the AFS 1988, which is the most widely
used classification in the past 30 years. We found ASRM 2021could
distinguish most clinical patients well, but there are still some
shortcomings. First, the classification of patients with uterine
malformations and longitudinal/transverse/oblique vaginal septum is not
clear. We recommend that patients with longitudinal vaginal septum and
uterine anomalies should be classified into the uterine anomalies
respectively, while others without uterine anomalies should be included
in longitudinal vaginal septum. All transverse vaginal septum should be
included in transverse vaginal septum, because the symptoms of
transverse septum are prominent. A new type of HWWS should be added.
Because the obstructive symptom is prominent. Second, we found several
cases of complex anomalies. For these patients, multidisciplinary and
individualized treatment should be carried out. The anomalies we found
that are not currently classified include T-shaped uterus, congenital
vaginal stenosis, and accessory and
cavitated uterine masses (ACUM). With
the deeper insight into this field, there may be a better way to
classify them. The limitation of this study is that as a single-center
retrospective study, there could be statistical biases.
In conclusion, we put forward following suggestions for ASRM 2021
classification: 1) Minimize overlaps of classification and add a type of
HWWS; 2) Update complex anomalies timely; 3) Add other anomalies
classification.