The relationship between symptoms of adenomyosis and current ultrasonographic diagnostic criteria

Adenomyosis is a uterine disorder defined by presence of endometrial glands and stroma within the myometrium with surrounding myometrial hyperplasia. Research has shown that ultrasound (US) can play a key role in early adenomyosis diagnosis and treatment. The Morphological Uterus Sonographic Assessment (MUSA) recently published standardized criteria for ultrasonographic diagnosis of adenomyosis, but the relationship between these criteria and clinical symptoms, has yet to be clinically validated.

To assess the prevalence of MUSA ultrasound criteria of adenomyosis and relationship between rates of ultrasound features and clinical symptoms of adenomyosis.

This is an analytical cross-sectional study of patients aged 18-52 receiving a transvaginal ultrasound for any indication at a single outpatient imaging center. Patients were excluded if they had a hysterectomy and/or bilateral oophorectomy, were in menopause, or had active gynecologic malignancy. Patients completed a survey to assess for infertility or fertility-related healthcare use, heavy menstrual bleeding, and pelvic pain. Ultrasound images were assessed by a radiologist using MUSA criteria to evaluate for adenomyosis. Multivariate analyses assessed association between MUSA features and patient-reported symptoms.

Of 271 recruited participants, 11.4% had at least one direct feature of adenomyosis, 57.6% had no direct features but at least one indirect feature, and 31.0% had no features. After controlling for potential confounders in multivariable analysis, patients with direct features resulted in 5.955-point higher heavy bleeding scores compared to those with no features (95% CI 1.970-9.939, p=0.004). When controlling for covariates, the association between indirect features and adenomyosis symptoms were not significant. Subjects with middle myometrium invasion reported increased rates of infertility (p=0.006), whereas subjects with outer myometrial involvement reported significantly higher heavy bleeding (p=0.002).

Per MUSA criteria, 1 in 10 participants displayed ultrasonographic findings strongly suggestive of presence of adenomyosis. Patients with direct features were more likely to experience heavy menstrual bleeding. Layer of uterine involvement were found to have greater association with infertility and pelvic pain than any one MUSA feature.