Correlation of clinical manifestations of adenomyosis with revised Morphological Ultrasonographic Assessment (MUSA) features.

Adenomyosis is defined as a benign uterine pathology in which there is presence of endometrium glands and stroma in the myometrium1. It can either be a focal or a diffuse lesion in inner or outer myometrium. A classical histological definition for adenomyosis is the invasion of the myometrium by endometrial glands and/or stroma, deeper than 2.5 mm from the endometrial –myometrial junction, accompanied by adjacent smooth muscle hyperplasia. It is commonly found among the age group of 35-50 years2.The prevalence of adenomyosis is difficult to estimate due to the existence of asymptomatic variants and varied diagnostic techniques (histological or imaging). The prevalence is estimated to be on the order of 20-30% based on a series of patients treated by hysterectomy, however there is a significant degree of heterogeneity in this estimation, ranging from 5% to 70%­­3.

It[ss1]  is hard to associate one pathognomonic feature to the presence of adenomyosis.

Common symptoms associated with the condition can include pelvic pain (dysmenorrhea, dyspareunia, chronic pelvic pain), abnormal uterine bleeding and reduced reproductive potential. Although about 30% of the patients with adenomyosis are asymptomatic4. Traditionally it was diagnosed mainly on histological specimens obtained after surgical intervention. However, with recent advances in the field of non-invasive diagnostic tools, modalities like Magnetic Resonance Imaging (MRI) and Transvaginal Ultrasonography (TVUS) have made it possible to make diagnosis of adenomyosis, prior to surgical intervention. A consensus on the terminology to use when characterizing ultrasound pictures of adenomyosis was released in 2015 by the worldwide Morphological Uterus Sonographic Assessment (MUSA) group5. A standard categorization and reporting system for adenomyosis’s morphological variants and its ultrasound-based extent was proposed by the MUSA group in 20196. The definitions of MUSA features of adenomyosis were revised in 2022. The distinction between direct and indirect signs and its correlation with symptoms of adenomyosis like pain, bleeding and subfertility can help facilitate recognition and diagnosis of adenomyosis in clinical practice7.

The relation between direct and indirect MUSA characteristics of adenomyosis, as well as the correlation of disease location, extent, and size with clinical symptoms and therapeutic effects needs to be further evaluated using prospective studies.

Lack of prospective studies to link revised MUSA ultra-sonographic features with the clinical symptom forms the lacunae in the existing knowledge. Therefore, we aim to conduct a study to establish the correlation of one or more direct or indirect features of adenomyosis (as per revised MUSA definitions) and clinical outcomes as well as the association between number, size of features and their location (with relation to the junctional zone or layer of involvement) and clinical symptoms.

[ss1]Prevalence, general, infertility