{"paper_id":"aa76e6a2-39bb-4dd4-af32-e8f5bf7bda7d","body_text":"Arch Obstet Gynecol. 2026\nVolume 7, Issue 1\nArchives of Obstetrics and Gynaecology Original Research\n35\nArch Obstet Gynecol. 2026;7(1):35–48.\nEvaluation of Adenomyosis by MUSA Based Transvaginal Ultrasound \nin Women Undergoing Hysterectomy\nMerve Nur Taşpınar1, Çetin Çelik1, Ersin Çintesun1,*\n1Department of Obstetrics and Gynecology, Selçuk University Faculty of Medicine, Konya, Turkey\n*Correspondence should be addressed to Ersin Çintesun, ersincintesun@gmail.com\nReceived date: July 06, 2026, Accepted date: July 14, 2026\nCitation: Taşpınar MN, Çelik C, Çintesun E. Evaluation of Adenomyosis by MUSA Based Transvaginal Ultrasound in Women \nUndergoing Hysterectomy. Arch Obstet Gynecol. 2026;7(1):35–48.\nCopyright: © 2026 Çintesun E, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution \nLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are \ncredited.\nIntroduction\nAdenomyosis is a chronic, estrogen- and progesterone-\ndependent benign uterine condition defined by the ectopic \npresence of endometrial glands and stroma within the \nmyometrium, accompanied by adjacent smooth muscle \nhyperplasia and hypertrophy. It is increasingly recognized as a \nheterogeneous condition with distinct subtype’s inner, outer, \nand diffuse myometrial involvement each potentially differing \nin pathogenesis, clinical presentation, and treatment response \n[1]. The clinical spectrum ranges from incidental asymptomatic \nfindings to severe dysmenorrhea, heavy menstrual bleeding, \nchronic pelvic pain, dyspareunia, and infertility, with significant \nimpairment of health-related quality of life [2].\nAbstract\nIntroduction: Adenomyosis diagnosis has improved substantially with high-resolution transvaginal ultrasound and the standardized \nMorphological Uterus Sonographic Assessment (MUSA) criteria; however, the relative diagnostic contribution of individual sonographic signs \nto histopathological confirmation remains incompletely defined. This study evaluated clinical and ultrasonographic markers associated with \nhistopathologically confirmed adenomyosis.\nMaterials and methods: We conducted a single-center prospective observational study of consecutive women scheduled for hysterectomy \nat a tertiary referral center. Clinical symptoms and a comprehensive set of direct and indirect MUSA criteria were systematically recorded using \na standardized reporting form. Associations with histopathologically confirmed adenomyosis were evaluated by univariate logistic regression; \nOdds Ratios (OR) with 95% Confidence Intervals (CI) and corresponding p-values are reported. A multivariable model was not constructed \nowing to sample size constraints and the exploratory nature of the study.\nResults: Clinically, Heavy Menstrual Bleeding (HMB) demonstrated the strongest association with adenomyosis (OR=4.81, 95% CI: 2.33–9.92; \np<0.001), followed by dyspareunia (OR=1.11, 95% CI: 1.01–1.23; p=0.02). Dysmenorrhea, chronic pelvic pain, dyschezia, and dysuria were \nnot statistically significant predictors in univariate analysis. Ultrasonographically, five MUSA criteria demonstrated statistically significant \nassociations with histopathologically confirmed adenomyosis: subendometrial echogenic lines/buds (OR=8.51, 95% CI: 2.20–32.9; p<0.001), \nmyometrial asymmetry (OR=6.88, 95% CI: 2.22–21.3; p<0.001), myometrial heterogeneity (OR=4.96, 95% CI: 1.28–19.3; p=0.015), myometrial \ncysts (OR=3.30, 95% CI: 1.67–6.56; p<0.001), and junctional zone irregularity (OR=2.57, 95% CI: 1.18–5.40; p=0.047). In contrast, uterine size in \nthe leiomyoma-free subset, myometrial shadowing patterns, lesion vascularization, lesion echogenicity, and lesion definition demonstrated \nno statistically significant associations with adenomyosis. Hyperechoic islands showed a non-significant trend toward association with \nadenomyosis (OR=2.67, 95% CI: 0.94–7.52; p=0.058). Myometrial cysts demonstrated a sensitivity of 67.3% and specificity of 61.6%; \nsubendometrial echogenic lines/buds showed lower sensitivity (17.3%) but higher specificity (97.6%) for histopathologically confirmed \nadenomyosis.\nConclusion: Transvaginal ultrasound incorporating MUSA criteria is clinically useful for preoperative adenomyosis diagnosis, particularly \nthrough markers like subendometrial lines, myometrial asymmetry, heterogeneity, cysts, and junctional zone irregularity.\nKeywords: Adenomyosis, Transvaginal ultrasound, MUSA criteria, Myometrial cysts, Subendometrial echogenic lines, Junctional zone, Heavy \nmenstrual bleeding, Dyspareunia, Hysterectomy\n\nTaşpınar MN, Çelik C, Çintesun E. Evaluation of Adenomyosis by MUSA Based Transvaginal Ultrasound in Women \nUndergoing Hysterectomy. Arch Obstet Gynecol. 2026;7(1):35–48.\nArch Obstet Gynecol. 2026\nVolume 7, Issue 1\n36\nThe true prevalence of adenomyosis remains uncertain. \nHistopathological examination of hysterectomy specimens \nhas reported widely varying rates of 5–70%, with a consensus \nestimate of approximately 20–35% when standardized \ndiagnostic criteria are applied [3]. However, with the advent \nof high-resolution transvaginal ultrasound and improved \nimaging protocols, adenomyosis is increasingly identified \nin younger, nulliparous, and infertile women who would \nnot previously have been captured in hysterectomy-based \nprevalence studies, suggesting that the true population \nprevalence may be substantially higher than historically \nreported [4,5].\nThe pathogenesis of adenomyosis remains incompletely \nunderstood. The most widely accepted hypothesis involves \ninvagination of the endometrial basalis layer into the inner \nmyometrium along the junctional zone, facilitated by tissue \ninjury and repair (TIAR) mechanisms, which are thought to \nbe triggered by uterine peristaltic dysfunction, repeated \nmicrotraumatic insults, and altered immune surveillance \n[1,6]. Alternative pathogenic hypotheses include de novo \ndevelopment from Müllerian remnants, metaplasia of adult \nstem cells, and lymphatic or hematogenous dissemination of \nendometrial cells [6]. Regardless of the initiating mechanism, \nectopic endometrial tissue within the myometrium induces a \nsustained localized inflammatory response, smooth muscle \nhyperplasia and hypertrophy, aberrant angiogenesis, and \nprogesterone resistance — collectively contributing to the \nhallmark clinical manifestations of heavy menstrual bleeding \nand pelvic pain [1]. \nThe Morphological Uterus Sonographic Assessment \n(MUSA) consensus was first published in 2015, establishing \nstandardized terminology and sonographic criteria for \nuterine morphological evaluation [7]. In 2022, a modified \nDelphi procedure led to a substantive revision of MUSA \ndefinitions, refining the classification of direct adenomyosis \nmarkers — including myometrial cysts, hyperechoic \nislands, and subendometrial echogenic lines and buds — \nand indirect markers, comprising myometrial asymmetry, \nmyometrial heterogeneity, junctional zone irregularity, fan-\nshaped shadowing, and translesional vascularization [8]. \nThese updated 2022 MUSA criteria form the methodological \nbackbone of the present study and represent the current \nstandard for sonographic adenomyosis assessment in \nboth clinical practice and research settings. The concurrent \npresence of multiple sonographic markers has been shown \nto improve overall diagnostic accuracy, and MUSA criteria \nadditionally facilitate differentiation between focal and diffuse \nadenomyosis subtypes, thereby informing individualized \nclinical management decisions [7–9].\nAccurate preoperative identification of adenomyosis \nin patients scheduled for hysterectomy is important for  \npatient counseling and for objective assessment of surgical \nindications [10]. Evaluating the concordance between \npreoperative transvaginal ultrasound using MUSA criteria and \npostoperative histopathological diagnosis will help determine \nthe clinical utility of these sonographic criteria.\nWhile magnetic resonance imaging (MRI) is considered the \nreference standard for adenomyosis diagnosis with reported \nsensitivity of 77–78% and specificity of 85–89%, its limited \navailability, higher cost, and patient-related contraindications \nrestrict its routine clinical use. Transvaginal ultrasound, \nparticularly when performed using standardized MUSA \ncriteria by trained operators, achieves comparable diagnostic \nperformance and remains the first-line imaging modality \nrecommended by international guidelines including ESHRE \nand ISUOG [10,11].\nThe primary aim of this study was to evaluate the association \nbetween preoperative transvaginal ultrasound findings \nbased on MUSA criteria and histopathologically confirmed \nadenomyosis in women undergoing hysterectomy at a tertiary \nreferral center. Secondary aims included: (i) assessment of \nthe individual diagnostic value of direct and indirect MUSA \nsonographic markers; (ii) identification of clinical symptoms \nindependently associated with adenomyosis in univariate \nanalysis; (iii) estimation of odds ratios with 95% confidence \nintervals for each clinical and sonographic marker to quantify \nthe magnitude of association with adenomyosis; and (iv) \nevaluation of the additive diagnostic value of a composite \nMUSA score derived from eight binary sonographic criteria.\nMaterials and Methods\nStudy design and ethical approval\nThis prospective observational cohort study was conducted \nat a single tertiary referral center (Department of Obstetrics \nand Gynecology, Selçuk University Faculty of Medicine, Konya, \nTurkey) between December 2024 and January 2026. The \nstudy was designed, conducted, and reported in accordance \nwith the Strengthening the Reporting of Observational \nStudies in Epidemiology (STROBE) guidelines for prospective \nobservational cohort studies. Ethical approval was obtained \nfrom the Selçuk University Faculty of Medicine Clinical Research \nEthics Committee (Registration No: E.892571; Decision No: \n2024/22). The study was conducted in accordance with the \nprinciples of the Declaration of Helsinki (2013 revision) and \napplicable Good Clinical Practice guidelines. Written informed \nconsent was obtained from all participants prior to enrollment. \nA total of 177 women were included in the final analysis. A \npriori power analysis was performed based on an expected \nadenomyosis prevalence of 25–30% in the hysterectomy \npopulation, a minimum detectable odds ratio of 2.5 for key \nsonographic markers, 80% statistical power, and a two-sided  \n\nTaşpınar MN, Çelik C, Çintesun E. Evaluation of Adenomyosis by MUSA Based Transvaginal Ultrasound in Women \nUndergoing Hysterectomy. Arch Obstet Gynecol. 2026;7(1):35–48.\nArch Obstet Gynecol. 2026\nVolume 7, Issue 1\n37\nalpha level of 0.05, indicating a required minimum sample size \nof approximately 150 participants. The final enrolled sample \nof 177 women was therefore considered adequate to meet \nthe primary study objectives. However, given the exploratory \nnature of the study and the absence of multivariable modeling, \nfindings should be interpreted with appropriate caution.\nInclusion and exclusion criteria\nInclusion criteria were (i) Women aged 18–52 years; \n(ii) scheduled for hysterectomy for benign or malignant \ngynecological indications; and (iii) provision of written \ninformed consent prior to enrollment. Exclusion criteria were \n(i) incomplete clinical or ultrasonographic data precluding \nfull MUSA assessment; (ii) prior uterine surgery including \nmyomectomy, endometrial ablation, or cesarean section, \nowing to potential distortion of myometrial architecture \nand junctional zone morphology; (iii) current pregnancy \nor postpartum state within six months of examination; (iv) \ninadequate or insufficient histopathological specimens \nprecluding definitive adenomyosis assessment; (v) use of \nhormonal therapy within three months prior to ultrasound \nexamination, including combined oral contraceptives, \nprogestins, GnRH analogues, or levonorgestrel-releasing \nintrauterine system, due to potential suppression of \nsonographic adenomyosis features; (vi) known or suspected \nuterine or endometrial malignancy at the time of ultrasound \nexamination; and (vii) technically inadequate transvaginal \nultrasound examination due to patient body habitus or probe \nintolerance.\nClinical data collection\nDemographic and clinical data, surgical indications, \nand preoperative endometrial pathology results were \nprospectively recorded on a standardized data collection \nform. Histopathological diagnosis of adenomyosis was based \non internationally accepted standardized criteria: the presence \nof endometrial glands and stroma within the myometrium, \nlocated more than 2.5 mm (one low-power microscopic field) \nbelow the endometrial-myometrial junction, accompanied \nby adjacent smooth muscle hyperplasia and hypertrophy \n[12]. All hysterectomy specimens were evaluated by a single \nexperienced gynecological pathologist who was blinded \nto preoperative ultrasound findings and clinical symptom \ndata. Tissue sections were obtained at standardized intervals \nof 3–5 mm throughout the full thickness of the uterine \nwall to minimize sampling error and ensure adequate \nhistopathological representation [12]. All women were \nsystematically questioned about the presence and severity \nof chronic pelvic pain, abdominal bloating, dysmenorrhea, \ndyspareunia, dysuria, and dyschezia during a structured \npreoperative interview. Symptom severity was quantified \nusing a validated 10-point Visual Analog Scale (VAS), where \n0 indicated complete absence of symptoms and 10 indicated \nthe worst imaginable pain intensity. VAS assessments were \nconducted exclusively by a single trained investigator to \nminimize interobserver variability. Symptoms were recorded \nas present if the VAS score was ≥1. VAS scores were additionally \nanalyzed as continuous variables to preserve full distributional \ninformation. Heavy menstrual bleeding and intermenstrual \nbleeding were assessed as binary variables (present/absent) \nbased on clinical history and FIGO PALM-COEIN criteria, rather \nthan VAS scoring, given their volumetric rather than pain-\nbased nature. All symptom assessments were performed \nindependently of and prior to review of ultrasound findings, \nand the assessing investigator was blinded to the anticipated \nsurgical indication and postoperative histopathological \noutcome. Symptom definitions followed current international \nguidelines: dysmenorrhea, dyspareunia, dyschezia, and \nchronic pelvic pain were defined according to the American \nSociety for Reproductive Medicine (ASRM) and European \nSociety of Human Reproduction and Embryology (ESHRE) \nendometriosis management guidelines [13,14]. Heavy \nmenstrual bleeding (HMB) and intermenstrual bleeding (IB) \nwere defined according to the FIGO PALM–COEIN classification \nsystem for abnormal uterine bleeding [9,15].\n\"Operational definitions applied in this study were as follows\nDysmenorrhea: cyclic pelvic pain occurring during \nmenstruation of sufficient severity to interfere with daily \nactivities, requiring analgesic use or resulting in activity \nlimitation, consistent with ESHRE endometriosis guideline \ndefinitions [12].\nDyspareunia: pelvic or genital pain occurring during or after \nsexual intercourse, assessed as superficial or deep in location, \nconsistent with ASRM and ESHRE definitions [12, 13].\nDyschezia: pain or significant discomfort during defecation, \nparticularly if cyclically exacerbated during the menstrual \nperiod, consistent with ESHRE deep endometriosis symptom \n[12] criteria [12].\nDysuria: pain, burning, or discomfort during urination, \nrecorded irrespective of menstrual cycle phase; urinary tract \ninfection was excluded clinically prior to symptom attribution \n[12].\nHeavy menstrual bleeding (HMB): menstrual blood loss \nexceeding 80 ml per cycle, or clinically significant menstrual \nbleeding that impairs physical, social, emotional, or material \nquality of life, irrespective of measured volume, consistent \nwith FIGO PALM–COEIN criteria [9,14].\nIntermenstrual bleeding (IB): uterine bleeding occurring \noutside the expected menstrual period, including both \nrandom and predictable patterns of non-menstrual bleeding, \nconsistent with FIGO PALM–COEIN criteria [9,14].\n\nTaşpınar MN, Çelik C, Çintesun E. Evaluation of Adenomyosis by MUSA Based Transvaginal Ultrasound in Women \nUndergoing Hysterectomy. Arch Obstet Gynecol. 2026;7(1):35–48.\nArch Obstet Gynecol. 2026\nVolume 7, Issue 1\n38\nChronic pelvic pain (CPP): non-menstrual or non-cyclical \npelvic pain persisting for a minimum of six months, located in \nthe anatomical pelvis, anterior abdominal wall, lower back, or \nbuttocks, of sufficient severity to cause functional disability or \nrequire medical treatment, consistent with ASRM and ESHRE \ndefinitions [12,15].\nAbdominal bloating: self-reported sensation of abdominal \ndistension or fullness, recorded as a binary variable (present/\nabsent) based on patient report during structured interview; \nno validated scoring instrument was applied for this symptom.\nUltrasonographic assessment\nAll transvaginal ultrasound examinations were performed by \ntwo investigators (E.Ç. and M.N.T.), each with a minimum of \nfive years of dedicated experience in gynecological ultrasound \nand formal training in MUSA-based uterine assessment. \nSonographic findings were recorded by consensus following \nsimultaneous dual-operator review of each examination. In \ncases of disagreement between the two primary investigators, \na third senior investigator (Ç.Ç.) with subspecialty \nexpertise in gynecological imaging was consulted for final \nadjudication. Formal interobserver agreement statistics were \nnot calculated, as all examinations were performed and \ninterpreted by consensus rather than independently; this \nrepresents a limitation of the present study.  All transvaginal \nultrasound examinations were performed using a Mindray \nDC-80 ultrasound system (Mindray Medical International, \nShenzhen, China) equipped with a 3–11 MHz transvaginal \ntransducer. Examinations were conducted with the woman \nin the dorsal lithotomy position following complete bladder \nemptying. The uterus was systematically evaluated in both \nsagittal and transverse planes, with additional oblique plane \nimaging performed when required for complete myometrial \nassessment. Uterine length was measured in the sagittal plane \nfrom the uterine fundus to the external cervical os. Anterior \nand posterior myometrial wall thickness was measured from \nthe endometrial-myometrial interface to the serosal surface at \nthe point of maximum thickness in the sagittal plane at the \nuterine midpoint. All color and power Doppler assessments \nwere performed using standardized gain settings, pulse \nrepetition frequency, and wall filter parameters to minimize \noperator-dependent variability, consistent with ISUOG \ntechnical recommendations. Sonographic evaluation followed \nthe 2022 revised MUSA criteria [8] and included systematic \nassessment of the following parameters: \n• Uterine size: For uterine size analysis, women with \nsonographically confirmed leiomyomas were excluded to \nminimize confounding from leiomyoma-related uterine \nenlargement.\n• Myometrial echogenicity: classified as homogeneous \nor heterogeneous based on the overall myometrial \nechotexture pattern, excluding areas occupied by  \ndiscrete lesions.\n• Myometrial asymmetry: defined as an absolute \ndifference of more than 5 mm between the anterior and \nposterior myometrial wall thickness, measured from the \nendometrial-myometrial interface to the serosal surface \nin the sagittal plane at the uterine midpoint, consistent \nwith MUSA 2022 consensus definitions [9]. An anterior-to-\nposterior wall thickness ratio was additionally calculated \nfor descriptive purposes; however, the absolute difference \nthreshold of >5 mm was used as the primary binary \ncriterion for statistical analysis, as ratio-based definitions \nhave demonstrated lower interobserver reproducibility in \npublished MUSA validation studies [8,9,14].\n• For assessment of uterine size, myometrial asymmetry, and \nmyometrial heterogeneity, women with sonographically \nconfirmed leiomyomas were excluded from the analysis, \nas leiomyomas may enlarge the uterus and distort \nmyometrial wall thickness and echogenicity. Accordingly, \nthese parameters were evaluated in a leiomyoma-free \nsubset of the study population (adenomyosis group \nn=24, control group n=41; total n=65).\n• Leiomyomas: the presence, number, FIGO subtype \nclassification, and maximum diameter of leiomyomas \nwere systematically recorded. In analyses of adenomyosis-\nspecific lesion characteristics including lesion \nechogenicity, shadowing pattern, and vascularization \ncases with concurrent leiomyomas were analyzed \nseparately and results interpreted with caution, given \nthe potential for leiomyomas to confound myometrial \nsonographic features.\n• Lesion definition: myometrial lesions were categorized \nas well-defined (typically consistent with leiomyoma, \ncharacterized by a distinct echogenic pseudocapsule and \nsmooth borders) or ill-defined (suggestive of adenomyosis, \ncharacterized by indistinct margins and gradual transition \nto surrounding myometrium), consistent with MUSA \n2022 criteria [8]. For well-defined lesions, FIGO subtype \nlocation, number, and largest diameter were recorded. \nFor ill-defined lesions, distribution pattern (focal or \ndiffuse), estimated depth of myometrial penetration \n(inner, middle, or outer third), and border characteristics \nwere systematically documented.\n• Lesion echogenicity: myometrial lesion echogenicity was \nclassified using the five-tier MUSA grading system as very \nhypoechoic (−−), hypoechoic (−), isoechoic, hyperechoic \n(+), or very hyperechoic (++), with the myometrium serving \nas the reference tissue for echogenicity comparison.\n• Myometrial shadowing: the presence, pattern, and \nintensity of myometrial acoustic shadowing were \nsystematically documented. Shadowing pattern was \n\nTaşpınar MN, Çelik C, Çintesun E. Evaluation of Adenomyosis by MUSA Based Transvaginal Ultrasound in Women \nUndergoing Hysterectomy. Arch Obstet Gynecol. 2026;7(1):35–48.\nArch Obstet Gynecol. 2026\nVolume 7, Issue 1\n39\nclassified as: peripheral (edge shadowing, typically \nassociated with leiomyoma), internal (arising from within \nthe lesion), or fan-shaped (arising from the endometrial-\nmyometrial interface and spreading into the myometrium \nin a fan-like distribution, considered an indirect MUSA \nmarker of adenomyosis). Shadowing intensity was graded \nas mild, moderate, or strong, consistent with MUSA 2022 \ndefinitions [8].\n• Myometrial cysts: the presence, sonographic type, \nnumber, and largest diameter of myometrial cysts were \nsystematically recorded. Cyst echogenicity was classified \naccording to MUSA 2022 criteria as: anechoic, low-level \nechoes, ground-glass appearance, or mixed echogenicity \n[8].The presence of an echogenic rim considered a specific \nsonographic feature of adenomyosis-related hemorrhagic \ncysts was specifically documented. Cyst number was \nrecorded as the primary diagnostic parameter, consistent \nwith MUSA guideline recommendations prioritizing cyst \ncount over maximum dimension as the diagnostically \nrelevant metric.\n• Hyperechoic islands: the presence, number, and \nmaximum diameter of hyperechoic myometrial islands \nwere recorded. Hyperechoic islands were defined as \ndiscrete, well-circumscribed, hyperechoic foci within the \nmyometrium, not associated with acoustic shadowing, \nand distinct from calcifications, consistent with MUSA \n2022 revised definitions [8]. Their presence was recorded \nas a binary variable (present/absent) for primary statistical \nanalysis.\n• Subendometrial echogenic lines and buds: the presence, \nnumber, and uterine wall location (anterior, posterior, or \nboth) of subendometrial echogenic lines and buds were \nsystematically recorded. These features were defined \nas thin, echogenic linear projections or small bud-like \nechogenic foci arising from the endometrial-myometrial \ninterface and extending into the inner myometrium, \nrepresenting sonographic correlates of basalis \nendometrial invagination, consistent with MUSA 2022 \nrevised definitions [8]. Their presence was recorded as a \nbinary variable (present/absent) for primary univariate \nanalysis, with anterior and posterior wall localization \nassessed separately as secondary endpoints.\n• Junctional zone (JZ): the sonographic appearance of the \njunctional zone was systematically assessed and classified \ninto three categories consistent with MUSA 2022 revised \ndefinitions [9]: (i) regular a clearly visible, uniform \nhypoechoic inner myometrial layer with smooth and well-\ndefined borders; (ii) irregular a visible but non-uniform \nhypoechoic inner myometrial layer demonstrating focal \nindentations, interruptions, or asymmetric thickening \nwithout complete loss of continuity; and (iii) interrupted \na junctional zone that is partially or completely disrupted, \nwith loss of the continuous hypoechoic layer and direct \ninterface between endometrium and outer myometrium. \nFor primary statistical analysis, junctional zone status was \ndichotomized as regular versus irregular or interrupted, \nconsistent with MUSA 2022 consensus recommendations \n[9]. Three-dimensional ultrasound was not available in this \nstudy; JZ assessment was therefore performed exclusively \nin two-dimensional sagittal and transverse planes, which \nmay have limited detection sensitivity compared to 3D \ncoronal plane reconstruction as reported in published \ncomparative studies [8].\n• Vascularization: myometrial lesion vascularization was \nassessed using color and power Doppler imaging and \ncategorized according to MUSA 2022 definitions [8] as: \n(i) absent no detectable vascular signal within or around \nthe lesion; (ii) intralesional — vascular signals distributed \nrandomly within the lesion without a specific pattern; (iii) \ntranslesional — vascular signals traversing the lesion in \na linear or branching pattern from periphery to center; \nand (iv) circumferential — vascular signals forming a \nperipheral rim around the lesion. Doppler parameters \nincluding gain, pulse repetition frequency, and wall filter \nsettings were standardized across all examinations to \nminimize operator-dependent variability, consistent with \nISUOG technical recommendations.\nGrouping\nPreoperative symptoms and ultrasound data were recorded \nindependently. Final grouping was based on postoperative \nhistopathology: patients with histopathologically confirmed \nadenomyosis comprised Group 1 (n = 52) and those without \nadenomyosis comprised Group 2 (control, n = 125).\nStatistical analysis\nData are summarized using descriptive statistics. Continuous \nvariables are presented as mean ± Standard Deviation (SD) \nfor normally distributed data, or as median with minimum–\nmaximum range for non-normally distributed data; categorical \nvariables are presented as absolute frequency and percentage \n[n (%)]. Normality of continuous variables was assessed using \nthe Kolmogorov–Smirnov test with Lilliefors correction; \nvariables with a test statistic yielding p<0.05 were treated \nas non-normally distributed. For comparisons between two \nindependent groups, Student's independent samples t-test \nwas used for normally distributed continuous variables \nand the Mann–Whitney U test was used for non-normally \ndistributed continuous variables. Categorical variables were \ncompared between groups using the Pearson chi-square test; \nFisher's exact test was applied where any expected cell count \nwas less than five. A two-sided p-value of less than 0.05 was \nconsidered statistically significant for all analyses. All statistical \nanalyses were performed using IBM SPSS Statistics version \n26.0 (IBM Corp., Armonk, NY, USA).\n\nTaşpınar MN, Çelik C, Çintesun E. Evaluation of Adenomyosis by MUSA Based Transvaginal Ultrasound in Women \nUndergoing Hysterectomy. Arch Obstet Gynecol. 2026;7(1):35–48.\nArch Obstet Gynecol. 2026\nVolume 7, Issue 1\n40\nAssociations between individual clinical and sonographic \nvariables and histopathologically confirmed adenomyosis \nwere evaluated by univariate binary logistic regression \nanalysis, with adenomyosis status (present/absent) as the \nbinary dependent variable. Odds Ratios (ORs) with 95% \nConfidence Intervals (CIs) and corresponding two-sided \np-values are reported for each variable. Continuous variables \nwere entered into logistic regression as continuous predictors; \ncategorical variables were entered as binary or nominal \ndummy-coded predictors as appropriate. Multivariable \nlogistic regression was not performed owing to the exploratory \nnature of the study, the relatively small number of outcome \nevents (n=52 adenomyosis cases), and the associated risk \nof model overfitting with multiple candidate predictors; \nthe rule of thumb of a minimum of ten outcome events per \npredictor variable was used as the guiding criterion. Variables \ndemonstrating p<0.10 in univariate analysis were recorded as \ncandidates for inclusion in future multivariable modeling in \nlarger independent cohorts.\nDiagnostic performance metrics including sensitivity, \nspecificity, positive predictive value (PPV), and Negative \nPredictive Value (NPV) were calculated for each statistically \nsignificant MUSA criterion and for each statistically significant \nclinical symptom variable, using histopathologically \nconfirmed adenomyosis as the reference standard. For binary \nsonographic and clinical variables, a two-by-two contingency \ntable was constructed and diagnostic metrics derived \naccordingly. Exact binomial 95% confidence intervals were \ncalculated for sensitivity and specificity estimates. Receiver \nOperating Characteristic (ROC) curve analysis was performed \nfor the composite MUSA score as a continuous ordinal \nvariable; the Area Under the Curve (AUC) with 95% CI was \nreported as a measure of overall discriminatory performance, \nwhere AUC values of 0.50, 0.60–0.70, 0.70–0.80, 0.80–0.90, and \n>0.90 were interpreted as no discrimination, poor, acceptable, \nexcellent, and outstanding discrimination, respectively. The \noptimal cut-off threshold for the composite MUSA score \nwas determined using the Youden index (J = sensitivity + \nspecificity − 1), which identifies the threshold maximizing the \nsum of sensitivity and specificity. Likelihood ratios — positive \nlikelihood ratio (LR+) and negative likelihood ratio (LR−) were \nadditionally calculated for the composite MUSA score at \nthe optimal cut-off to facilitate clinical interpretation of the \ndiagnostic findings. \"\nTo evaluate the additive diagnostic value of simultaneously \nassessed multiple MUSA sonographic criteria, a composite \nMUSA score was prospectively calculated for each woman \nby summing eight pre-specified binary MUSA variables: (i) \nmyometrial cysts (present=1, absent=0); (ii) subendometrial \nechogenic lines and buds (present=1, absent=0); (iii) \nhyperechoic islands (present=1, absent=0); (iv) myometrial \nasymmetry (present=1, absent=0); (v) myometrial \nheterogeneity (present=1, absent=0); (vi) junctional zone \nstatus (irregular or interrupted=1, regular=0); (vii) fan-shaped \nshadowing (present=1, absent=0); and (viii) translesional \nvascularization (present=1, absent=0); yielding a total \ncomposite MUSA score ranging from 0 to 8. These eight \nvariables were selected a priori based on their representation \nof both direct and indirect MUSA adenomyosis markers as \ndefined in the 2022 revised MUSA consensus [9] and were \nnot selected post-hoc based on univariate analysis results, to \navoid incorporation bias.\nJunctional zone status was dichotomized as regular versus \nirregular or interrupted per MUSA 2022 definitions [9]. The \ncomposite score was compared between groups using the \nMann–Whitney U test and evaluated by ROC analysis; AUC, \noptimal cut-off via Youden index, sensitivity, specificity, PPV, \nand NPV are reported. Women were stratified as low risk \n(0–1), intermediate risk (2–3), or high risk (≥4); adenomyosis \ndistribution across categories was assessed by chi-square test \nfor trend.\nResults\nDemographic characteristics and symptom scores of \npatients with and without adenomyosis are summarized in \nTable 1. Mean age was similar between groups (46.4 ± 4.1 vs \n46.4 ± 3.8 years; p>0.9; OR=0.99, 95% CI: 0.92–1.07). Gravidity \nwas comparable (median 3 [1–6] vs 3 [1–7]; p>0.9; OR=1.21, \n95% CI: 0.96–1.54). Parity did not differ significantly between \ngroups (median 3 [1–5] vs 2 [1–5]; p>0.9; OR=1.01, 95% CI: \n0.76–1.37). Number of living children was also similar (median \n3 [1–5] vs 2 [1–5]; p=0.60; OR=1.07, 95% CI: 0.71–1.60).\nRegarding symptom scores, dysmenorrhea was higher in the \nadenomyosis group but the difference was not statistically \nsignificant (median 4 [0–10] vs 2 [0–10]; p=0.21; OR=1.06, \n95% CI: 0.96–1.16). Dyspareunia showed a significant positive \nassociation with adenomyosis (median 2 [0–10] vs 0 [0–10]; \np = 0.02; OR = 1.11, 95% CI: 1.01–1.23). No difference was \nobserved for dyschezia (median 0 [0–10] vs 0 [0–10]; p=0.88; \nOR=1.02, 95% CI: 0.91–1.16) or dysuria (median 0 [0–7] vs 0 \n[0–10]; p=0.36; OR=0.95, 95% CI: 0.81–1.11).\nHeavy menstrual bleeding was significantly more frequent \nin the adenomyosis group (75.0% vs 38.4%; p<0.001; OR=4.81, \n95% CI: 2.33–9.92), representing the strongest clinical \npredictor of adenomyosis in this cohort. Intermenstrual \nbleeding (IB) did not differ between groups (9.6% vs 13.6%; \np=0.46; OR=0.68, 95% CI: 0.24–1.94). Bloating was more \ncommon in the adenomyosis group but not statistically \nsignificant (63.5% vs 52%; p=0.16; OR=1.60, 95% CI: 0.83–\n3.12). Chronic pelvic pain was observed more frequently in \nthe adenomyosis group (42.3% vs 34.4%) but this difference \nwas not significant (p=0.32; OR=1.39, 95% CI: 0.72–2.71).\n\nTaşpınar MN, Çelik C, Çintesun E. Evaluation of Adenomyosis by MUSA Based Transvaginal Ultrasound in Women \nUndergoing Hysterectomy. Arch Obstet Gynecol. 2026;7(1):35–48.\nArch Obstet Gynecol. 2026\nVolume 7, Issue 1\n41\nHeavy Menstrual Bleeding (HMB) showed the highest \nsensitivity at 75% with a specificity of 61.6%. Intermenstrual \nBleeding (IB) had very low sensitivity (9.6%) but high specificity \n(86.4%). Bloating demonstrated moderate sensitivity (63.5%) \nwith low specificity (48.0%), while Chronic Pelvic Pain (CPP) \nwas associated with lower sensitivity (42.3%) and moderate \nspecificity (65.6%). Overall, HMB emerged as the most sensitive \nclinical symptom, whereas IB provided the greatest specificity \nfor adenomyosis. Cyst size, number of islands, presence of \nechogenic line and myometrial features between patients \nwith and without adenomyosis. In the leiomyoma-free subset, \nmean uterine length was 90.7±9.4 mm in the adenomyosis \ngroup and 87.4±16.9 mm in the control group.\nMyometrial cysts were significantly more frequent in the \nadenomyosis group (67.3%, 35/52) than in the control group \n(38.4%, 48/125) (p < 0.001; OR = 3.30, 95% CI: 1.67–6.56). \nCyst number was higher in the adenomyosis group (median \n3 [1–6] vs 2 [1–7]) and this difference was statistically \nsignificant (p = 0.02; OR = 1.37, 95% CI: 0.98–1.98). Although \nthe median maximum echogenic cyst size was 7 mm (2–15) \nin the adenomyosis group and 8 mm (1.3–49) in the control \ngroup, this difference was not significant (p = 0.12; OR = \n0.90, 95% CI: 0.81–1.00). Hyperechoic islands were observed \nin 15.4% (8/52) of the adenomyosis group and 6.4% (8/125) \nof controls; this difference approached but did not reach \nstatistical significance (p = 0.058; OR = 2.67, 95% CI: 0.94–7.52). \nThe number of islands (median 2 [1–5] vs 1.5 [1–3]) and the \nmaximum island size (median 11 mm in both groups) did not \ndiffer significantly (p = 0.43 and p > 0.9, respectively).\nMyometrial asymmetry was assessable in a subset of \nwomen without concurrent leiomyomas distorting uterine \narchitecture (adenomyosis group n=24, control group n=41). \nIn this leiomyoma-free subset, myometrial asymmetry was \nsignificantly more common in the adenomyosis group (62.5% \nvs 19.5%; p<0.001; OR=6.88, 95% CI: 2.22–21.3). Similarly, \nmyometrial heterogeneity was significantly more frequent in \nthe adenomyosis group within this subset (87.5% vs 58.5%; \np=0.015; OR=4.96, 95% CI: 1.28–19.3). These analyses were \nrestricted to leiomyoma-free cases to avoid confounding of \nindirect myometrial markers by concurrent leiomyoma-related \narchitectural distortion. Subendometrial echogenic lines \nand buds were detected in 17.3% (9/52) of the adenomyosis \ngroup versus 2.4% (3/125) of controls, representing the \nhighest specificity MUSA criterion identified in this study \n(specificity 97.6%, PPV 75.0%). Anterior and posterior \npositive subendometrial findings were more frequent in the \nadenomyosis group (anterior 3.8% vs 0.8%; posterior 13.5% \nvs 1.6%), with posterior localization showing a significant \nassociation (OR = 9.93, 95% CI: 1.98–49.6).\nVariables Adenomyosis (n=52) No adenomyosis (n=125) P value OR (95% CI)\nAge (years) 46.4 (±4.1) 46.4 (±3.8) >0.9 0.99 (0.92–1.07)\nGravidity 3 (1-6) 3 (1-7) >0.9 1.21 (0.96–1.54)\nParity 3 (1–5) 2 (1–5) >0.9 1.01 (0.76–1.37)\nLiving children 3 (1–5) 2 (1–5) 0.60 1.07 (0.71–1.60)\nDysmenorrhea 4 (0–10) 2 (0–10) 0.21 1.06 (0.96–1.16)\nDyspareunia 2 (0–10) 0 (0–10) 0.02 1.11 (1.01–1.23)\nDyschezia 0 (0–10) 0 (0–10) 0.88 1.02 (0.91–1.16)\nDysuria 0 (0–7) 0 (0–10) 0.36 0.95 (0.81–1.11)\nHMB Yes\nNo\n39 (75)\n13 (25)\n48 (38.4)\n77 (61.6)\n<0.001 4.81 (2.33–9.92)\nIB Yes\nNo\n5 (9.6)\n47 (90.4)\n17 (13.6)\n108 (86.4)\n0.46 0.68 (0.24–1.94)\nBloating Yes\nNo\n33 (63.5)\n19 (36.5)\n65 (52)\n60 (48)\n0.16 1.60 (0.83–3.12)\nCPP Yes\nNo\n22 (42.3)\n30 (57.7)\n43 (34.4)\n82 (65.6)\n0.32 1.39 (0.72–2.71)\nHMB: Heavy Menstrual Bleeding; IB: Intermenstrual Bleeding; CPP: Chronic Pelvic Pain; OR: Odds Ratio; 95% CI: 95% Confidence Interval. Data are presented as \nmean ± standard deviation, median (min–max), or n (%) as appropriate. p<0.05 was considered statistically significant.\nTable 1. Demographic characteristics and symptom scores by group.\n\nTaşpınar MN, Çelik C, Çintesun E. Evaluation of Adenomyosis by MUSA Based Transvaginal Ultrasound in Women \nUndergoing Hysterectomy. Arch Obstet Gynecol. 2026;7(1):35–48.\nArch Obstet Gynecol. 2026\nVolume 7, Issue 1\n42\nMyometrial cysts showed a sensitivity of 67.3% and a \nspecificity of 61.6%. Hyperechoic islands had low sensitivity \n(15.4%) but high specificity (93.6%). Myometrial asymmetry \ndemonstrated a sensitivity of 62.5% and a specificity of 80.5%. \nMyometrial heterogeneity was highly sensitive (87.5%) but \nless specific (41.5%). Subendometrial echogenic line and buds \npresented a sensitivity of 17.3% with very high specificity \n(97.6%). Overall, myometrial heterogeneity emerged as the \nmost sensitive finding, while subendometrial echogenic line \nand buds provided the greatest specificity for adenomyosis.\nTable 3 summarizes the comparison of well- defined versus \nill-defined lesions, myometrial lesion echogenicity, junctional \nzone appearance, and vascularization patterns between \npatients with and without adenomyosis. Well- defined lesions \n(typically compatible with leiomyoma/myoma) were observed \nin 57.7% (30/52) of the adenomyosis group and 67.2% (84/125) \nof the control group, with no significant difference (p = 0.22; \nOR = 0.66, 95% CI: 0.34–1.30). Ill- defined lesions were mostly \nabsent (adenomyosis 86.5% vs control 90.4%); there were no \nsignificant differences for focal type (5.8% vs 6.4%; OR = 0.94, \n95% CI: 0.24–3.71) or diffuse type (7.7% vs 3.2%; OR = 2.51, \n95% CI: 0.60–10.5) (p = 0.42).\nMyometrial lesion echogenicity did not differ significantly \nbetween groups for isoechoic (38.5% vs 34.4%), hypoechoic \n(13.5% vs 11.2%; OR = 0.88, 95% CI: 0.41–1.90), hyperechoic \n(9.6% vs 20.8%; OR = 0.95, 95% CI: 0.33–2.80), or very \nhypoechoic lesions (1.9% vs 1.6%; OR = 0.95, 95% CI: 0.08–\n11.1) (p = 0.37). Conversely, very hyperechoic lesions were \nabsent in the adenomyosis group and present in 3.2% (4/125) \nof controls; owing to zero cells in the adenomyosis group, a \nmeaningful odds ratio could not be estimated by standard \nlogistic regression (complete separation); this finding is \nreported descriptively only.\nJunctional zone assessment in the adenomyosis group \nshowed regular 40.4% (21/52), irregular 38.5% (20/52), \nand interrupted 21.2% (11/52). In controls, the distribution \nwas regular 55.2% (69/125), irregular 20.8% (26/125), and \ninterrupted 24.0% (30/125).\nShadowing patterns in the adenomyosis group were \nfan-shaped 28.8% (n = 15), internal 21.2% (n = 11), and \nperipheral 13.3% (n = 7); in the non-adenomyosis group \nthese were 33.6% (n = 42), 25.6% (n = 32), and 11.2% (n = 14), \nrespectively. Among cases without shadowing, adenomyosis \nwas present in 36.5% (n = 19) versus 29.6% (n = 37) in \nthe control group. These differences were not statistically \nsignificant (p = 0.73).\nTable 2. Ultrasonographic data by group: Key measurements (uterine length, cyst and island features).\nVariables Adenomyosis \n(n=52)\nNo adenomyosis \n(n=125)\nP value OR (95% CI)\nUterine length (mm) 90.7 (±9.4) 87.4 (±16.9) 0.59 0.99 (0.99–1.01)\nMyometrial cysts Yes\nNo\nNumber\nMax echogenic cyst size (mm)\n35 (67.3)\n17 (32.7)\n3 (1–6)\n7 (2–15)\n48 (38.4)\n77 (61.6)\n2 (1–7)\n8 (1.3–49)\n<0.001\n0.02\n0.12\n3.30 (1.67–6.56)\n1.37 (0.98–1.98)\n0.90 (0.81–1.00)\nHyperechoic islands Yes\nNo\nNumbers\nMax island size (mm)\n8 (15.4)\n44 (84.6)\n2 (1–5)\n11 (0.7–17)\n8 (6.4)\n117 (93.6)\n1.5 (1–3)\n11 (3.2–20)\n0.058\n0.43\n>0.9\n2.67 (0.94–7.52)\n1.63 (0.57–4.65)\n0.97 (0.81–1.17)\nMyometrial asymmetry Yes\nNo\n15 (62.5)\n9 (37.5)\n8 (19.5)\n33 (80.5)\n<0,001 6.88 (2.22–21.3)\nMyometrial heterogeneity Yes\nNo\n21(87.5)\n3 (12.5)\n24 (58.5)\n17 (41.5)\n0.015 4.96 (1.28–19.3)\nSubendometrial \nechogenic line and buds\nPositive\nNegative\nNumbers\nNegative\nPositive (+/anterıor)\nPositive (+/posterıor)\n9 (17.6)\n122 (97.6)\n3 (1–6)\n43 (82.7)\n2 (3.8)\n7 (13.5)\n3 (2.4)\n43 (82.7)\n2 (1–7)\n122 (97.6)\n1 (0.8)\n2 (1.6)\n<0.001\n0.73\n<0.001\n8.51 (2.20–32.9)\n1.60 (0.24–10.9)\n-\n5.58 (0.50–64.2)\n9.93 (1.98–49.6)\n\nTaşpınar MN, Çelik C, Çintesun E. Evaluation of Adenomyosis by MUSA Based Transvaginal Ultrasound in Women \nUndergoing Hysterectomy. Arch Obstet Gynecol. 2026;7(1):35–48.\nArch Obstet Gynecol. 2026\nVolume 7, Issue 1\n43\nNo significant differences were found in lesion vascularization \nbetween groups. Absence of vascularization was observed in \n38.5% (20/52) of the adenomyosis group and 30.4% (38/125) \nof controls (p = 0.22). Intralesional vascularization was present \nin 23.1% (12/52) of adenomyosis cases and 29.6% (37/125) \nof controls (OR = 0.62, 95% CI: 0.26–1.44). Translesional \nvascularization was observed in 9.6% (5/52) of the adenomyosis \ngroup and 19.2% (24/125) of controls, without statistically \nsignificant difference (OR=0.39, 95% CI: 0.13–1.19; p=0.10). \nCircumferential vascularization was observed in 28.8% (15/52) \nof adenomyosis patients and 20.8% (26/125) of controls (OR = \n1.09, 95% CI: 0.48–2.53).\nTable 4 summarizes the distribution of MUSA scores between \npatients with and without adenomyosis, presenting median \nvalues and risk group classifications along with their statistical \nsignificance. The composite MUSA score was significantly \nhigher in the adenomyosis group than in the control group \n(median 3.0, range 0–5 versus median 2.0, range 0–5; Mann–\nWhitney U test, p=0.003), confirming the additive diagnostic \nvalue of simultaneously assessed multiple MUSA criteria.\nRisk stratification demonstrated a significant difference in \nadenomyosis prevalence across MUSA score categories (chi-\nsquare test for trend, p=0.002): adenomyosis was confirmed \nin 20.0% (7/35) of low-risk women (score 0–1), 24.5% (26/106) \nof intermediate-risk women (score 2–3), and 52.8% (19/36) of \nhigh-risk women (score ≥4), representing a significant stepwise \nincrease in adenomyosis probability with increasing composite \nscore. Conversely, the majority of non-adenomyosis patients \nfell into the intermediate risk category (64.0%), while 50.0% of \nadenomyosis patients were also in this group. The chi-square \ntest confirmed a statistically significant association between \nMUSA risk categories and adenomyosis status (p = 0.002).\nTable 3. Ultrasonographic characteristics of myometrial lesions, junctional zone, shadowing, and vascularization in patients with and without \nadenomyosis.\nVariables Adenomyosis \n(n=52)\nNo adenomyosis \n(n=125)\nP value OR (95% CI)\nMyometrial lesion Well-defined (leiomyoma\nIll-defined lesion\nNegative\nPositive\nNegative\nPositive (focal)\nPositive (diffuse)\n22 (42.3)\n30 (57.70)\n45 (86.5)\n3 (5.8)\n4 (7.7)\n41 (38.8)\n84 (67.20)\n113 (90.4)\n8 (6.4)\n4 (3.2)\n0.22\n0.42\n0.66 (0.34–1.30)\n-\n0.94 (0.24–3.71)\n2.51 (0.60–10.5)\nMyometrial lesion \nechogenicity\nIsoechoic\nHypoechoic\nHyperechoic\nVery hypoechoic\nVery hyperechoic\n20 (38.5)\n7 (13.5)\n5 (9.6)\n1 (1.9)\n0\n43 (34.4)\n14 (11.2)\n26 (20.8)\n2 (1.6)\n4 (3.2)\n0.37 -\n0.88 (0.41–1.9)\n0.95 (0.33–2.8)\n0.95 (0.08–11.1)\nNot estimable\nJunction Zone Regular\nIrregular\nInterrupted\nRegular\nIrregular and Interrupted\n21 (40.4)\n20 (38.5)\n11 (21.2)\n21 (40.4)\n31 (59.6\n69 (55.2)\n26 (20.8)\n30 (24)\n69 (55.2)\n56 (44.8)\n0.047\n0.073\n-\n2.57 (1.18–5.40)\n1.21 (0.52–2.81)\n1.81 (0.94–3.50)\nShadowing No\nFan-shape shadowing \nInternal Shadowing\nEdge Shadowing\n19 (36.5)\n15 (28.8)\n11 (21.2)\n7 (13.5)\n37 (29.6)\n42 (33.6)\n32 (25.6)\n14 (11.2)\n0.73 -\n0.69 (0.31–1.56)\n0.67 (0.29–1.61)\n0.97 (0.34–2.80)\nVascularization of\nMyometrial lesion\nAbsent\nIntralesional\nTranslesional\nCircumferential\n20 (38.5)\n12 (23.1)\n5 (9.6)\n15 (28.8)\n38 (30.4)\n37 (29.6)\n24 (19.2)\n26 (20.8)\n0.22 -\n0.62 (0.26–1.44)\n0.39 (0.13–1.19)\n1.09 (0.48–2.53)\nOR: Odds Ratio; 95% CI: 95% Confidence Interval. Data are presented as mean ± standard deviation, median (min– max), or n (%) as appropriate. p <0.05 was \nconsidered statistically significant.\n\nTaşpınar MN, Çelik C, Çintesun E. Evaluation of Adenomyosis by MUSA Based Transvaginal Ultrasound in Women \nUndergoing Hysterectomy. Arch Obstet Gynecol. 2026;7(1):35–48.\nArch Obstet Gynecol. 2026\nVolume 7, Issue 1\n44\nROC curve analysis of the composite MUSA score \ndemonstrated an AUC of 0.636 (95% CI: 0.543–0.729; \nSE=0.047; p=0.004), indicating poor discriminatory ability per \nthe prespecified AUC classification, though significantly above \nchance level. At the optimal cut-off of 3.5 (corresponding to a \nscore of ≥4) determined by the Youden index, the composite \nscore yielded a sensitivity of 36.5%, specificity of 86.4%, PPV of \n57.6%, and NPV of 75.0%. The high specificity at this threshold \nindicates that a composite MUSA score of ≥4 functions \nprimarily as a rule-in marker for adenomyosis, whereas the low \nsensitivity indicates limited ability to exclude adenomyosis \nwhen the score is below this threshold.\nVariables Adenomyosis (n=52) No adenomyosis (n=125) P value\nMUSA score points 3.0 (0–5) 2.0 (0–5) 0.003\nMUSA Score Low risk \nIntermediate risk \nHigh risk \n7 (13.5%)\n26 (50.0%)\n19 (36.5%)\n28 (22.4%)\n80 (64.0%)\n17 (13.6%)\n0.002\nMUSA = Morphological Uterus Sonographic Assessment, OR = Odds Ratio, CI = Confidence Interval, SD = Standard Deviation, n = number of cases, \np-value = probability value.\nTable 4. Comparison of MUSA score between adenomyosis and non-adenomyosis groups.\nTable 5. ROC curve analysis of the composite MUSA score for detection of histopathologically confirmed adenomyosis.\nTest Variable AUC (95% CI) SE P-value Optimal \nCut-off\nSensitivity (%) Specificity (%) PPV (%) NPV (%) Y ouden \nIndex\nMusa score 0.636 (0.543–0.729) 0.047 0.004 3.5 (≥4) 36.5 86.4 57.6 75.0 0.229\nAUC: Area Under the Curve; CI: Confidence Interval; SE: Standard Error; PPV: Positive Predictive Value; NPV: Negative Predictive Value. The optimal cut-\noff of 3.5 corresponds to a composite MUSA score of ≥4. Sensitivity, specificity, PPV, NPV, and Youden index were calculated using histopathologically \nconfirmed adenomyosis as the reference standard.\nFigure 1. Receiver Operating Characteristic (ROC) curve for the composite MUSA score in the detection of histopathologically confirmed \nadenomyosis. The blue line represents the discriminatory performance of the composite score; the red diagonal reference line represents \nchance-level performance (AUC=0.50). The AUC of 0.636 (95% CI: 0.543–0.729; p=0.004) indicates poor discriminatory ability per the \nprespecified classification, though significantly above chance level. The optimal cut-off of 3.5 (corresponding to a composite MUSA score of \n≥4), determined by the Youden index, yielded a sensitivity of 36.5%, specificity of 86.4%, PPV of 57.6%, and NPV of 75.0%. At this threshold, \na composite score of ≥4 functions as a rule-in marker for adenomyosis (high specificity, SpPin), whereas a score below this threshold does \nnot reliably exclude the diagnosis.\n \n \n\n\nTaşpınar MN, Çelik C, Çintesun E. Evaluation of Adenomyosis by MUSA Based Transvaginal Ultrasound in Women \nUndergoing Hysterectomy. Arch Obstet Gynecol. 2026;7(1):35–48.\nArch Obstet Gynecol. 2026\nVolume 7, Issue 1\n45\nDiscussion\nThe present study evaluated the diagnostic value of \npreoperative TVUS using MUSA criteria in 177 women \nundergoing hysterectomy, with histopathological confirmation \nserving as the reference standard. Adenomyosis was confirmed \nin 52 women (29.4%), consistent with previously reported \nprevalence rates of 20–35% in hysterectomy specimens. The \nkey findings of this study were: (a) heavy menstrual bleeding \nand dyspareunia were the strongest clinical correlates of \nadenomyosis; (b) subendometrial echogenic lines/buds, \nmyometrial asymmetry, heterogeneity, cysts, and junctional \nzone irregularity were the most diagnostically informative \nMUSA criteria; and (c) uterine size in the leiomyoma-free \nsubset, shadowing patterns, vascularization, and lesion \nechogenicity demonstrated no significant associations \nwith adenomyosis [9,14]. These findings broadly support \nthe MUSA consensus recommendation for comprehensive \nmulti-criterion evaluation rather than reliance on any single \nsonographic feature.\nNo significant differences in age, gravidity, parity, or number \nof living children were observed between groups, consistent \nwith contemporary evidence challenging the classical \ncharacterization of adenomyosis as a disease exclusively of \nolder multiparous women. The mean age of approximately \n46 years in both groups reflects the hysterectomy population \nrather than the broader adenomyosis population; advanced \nimaging now enables diagnosis in younger and nulliparous \nwomen who would not historically have been captured in \nhysterectomy-based prevalence studies [7,12,16,17]. These \nfindings support the view that demographic factors alone are \ninsufficient to guide clinical suspicion for adenomyosis and \nthat objective imaging-based assessment is essential across \nall age and parity groups.\nAdenomyosis is most often associated with heavy menstrual \nbleeding, dysmenorrhea, chronic pelvic pain, and infertility \n[6,17]. However, these symptoms are not specific, as similar \ncomplaints occur in leiomyoma, endometriosis, and other \nbenign gynecological conditions. Therefore, diagnosis cannot \nrely solely on clinical findings. Heavy menstrual bleeding \nwas the strongest clinical predictor of adenomyosis in our \ncohort, increasing the likelihood of histopathologically \nconfirmed disease nearly fivefold. This finding is consistent \nwith previous evidence identifying heavy menstrual bleeding \nas a frequent manifestation of adenomyosis and may be \nexplained by impaired uterine contractility and hemostasis, \nlocal inflammation, aberrant angiogenesis, progesterone \nresistance, and increased endometrial surface area secondary \nto myometrial hypertrophy [17,19,20]. Accordingly, \nadenomyosis should be considered in the differential diagnosis \nof women presenting with unexplained or treatment-resistant \nheavy menstrual bleeding.\nDyspareunia was significantly associated with adenomyosis \nin our cohort (p=0.02; OR=1.11), albeit with a modest effect \nsize. This association is likely mediated by posterior myometrial \nwall involvement, which has been demonstrated in up to 60% \nof adenomyosis cases. The proposed mechanisms include \nincreased density of substance P-positive nerve fibers within \nadenomyotic lesions, elevated expression of pro-inflammatory \ncytokines including IL-1β, IL-6, and TNF-α, enhanced local \nprostaglandin E2 synthesis, and sensitization of pelvic \nnociceptors through repeated inflammatory stimulation \n[15,17,18]. Notably, the co-occurrence of deep infiltrating \nendometriosis — which shares overlapping symptom \nprofiles and is present in 35–80% of adenomyosis cases — \nmay have contributed to dyspareunia scores in our cohort, \nas endometriosis was not systematically excluded. Future \nstudies should prospectively stratify dyspareunia analysis \nby endometriosis status to better isolate the adenomyosis-\nspecific contribution. \nContrary to the classical association between adenomyosis \nand dysmenorrhea, our study found no statistically significant \ndifference in dysmenorrhea VAS scores between groups \n(p=0.21; OR=1.06). This finding warrants careful interpretation \nfor several reasons. First, dysmenorrhea is inherently non-\nspecific, occurring in leiomyoma, endometriosis, primary \ndysmenorrhea, and pelvic inflammatory disease all of which \nwere present in our surgical cohort. Second, the use of \nVAS as a continuous measure rather than a binary present/\nabsent variable may have reduced statistical power to detect \ngroup differences. Third, preoperative analgesic or hormonal \nmedication use — which was not systematically recorded \nmay have attenuated reported pain scores in both groups. \nFourth, the relatively advanced mean age of our cohort \n(46.4 years) may reflect a shift toward HMB as the dominant \nsymptom, as dysmenorrhea severity has been reported \nto paradoxically decrease with age in some adenomyosis \nphenotypes. These considerations suggest that the absence \nof a significant dysmenorrhea association in our study reflects \nmethodological factors rather than a true biological absence \nof this symptom [3]. Intermenstrual bleeding and bloating \nalso lacked diagnostic value, being reported as nonspecific \nsupportive findings rather than primary indicators [1,16].\nAmong direct MUSA markers, myometrial cysts were \nsignificantly more frequent in the adenomyosis group (67.3% \nvs 38.4%; OR=3.30; p<0.001). Histopathologically, these cysts \nrepresent dilated ectopic endometrial glandular spaces within \nthe myometrium, often related to cyclic hemorrhage and fluid \naccumulation. Although MUSA 2022 classifies myometrial \ncysts as a direct marker of adenomyosis, the specificity in our \ncohort was lower than that reported in dedicated ultrasound \nstudies, probably reflecting the high prevalence of coexisting \nleiomyomas and other non-adenomyosis-related cystic or \npseudocystic myometrial changes. Importantly, cyst number \n\nTaşpınar MN, Çelik C, Çintesun E. Evaluation of Adenomyosis by MUSA Based Transvaginal Ultrasound in Women \nUndergoing Hysterectomy. Arch Obstet Gynecol. 2026;7(1):35–48.\nArch Obstet Gynecol. 2026\nVolume 7, Issue 1\n46\nrather than maximum cyst size was the diagnostically relevant \nparameter, supporting MUSA recommendations to document \ncyst count during structured reporting. Hyperechoic islands \nshowed a borderline association with adenomyosis (p=0.058; \nOR=2.67), suggesting a potential confirmatory role in larger \ncohorts because of their low sensitivity but relatively high \nspecificity profile [4,17].\nMyometrial asymmetry demonstrated one of the strongest \nassociations with adenomyosis in the leiomyoma-free subset \nof our cohort (OR=6.88, 95% CI: 2.22–21.3; sensitivity 62.5%, \nspecificity 80.5%), consistent with findings of Van den Bosch \net al. and the MUSA 2022 Delphi consensus [7,8]. Since \nleiomyomas can directly distort myometrial wall thickness \nand confound asymmetry assessment, this analysis was \nintentionally restricted to leiomyoma-free cases. The relatively \nmodest sensitivity indicates that absence of asymmetry does \nnot reliably exclude adenomyosis, particularly in early or focal \ndisease.\nMyometrial heterogeneity demonstrated the highest \nsensitivity among all MUSA criteria in the leiomyoma-\nfree subset (87.5%), albeit with limited specificity (41.5%), \nconsistent with its role as a sensitive but non-specific indirect \nadenomyosis marker reflecting disorganized myometrial \narchitecture and fibrotic stromal changes [4]. Given that \nheterogeneity assessment was restricted to leiomyoma-free \ncases in the present study, the observed specificity may be \nhigher than would be expected in an unselected hysterectomy \npopulation where concurrent leiomyomas frequently produce \nheterogeneous myometrial echotexture.\nNo significant differences were observed for well- or ill-defined \nlesions and fibroid presence. The coexistence of leiomyomas \nis frequently reported, with hysterectomy series showing \nrates of 35–60% [3,12]. Fibroids complicate diagnosis due to \nacoustic shadowing and distortion but are not protective or \nrisk-enhancing factors. Similarly, lesion echogenicity patterns \nwere not distinctive, as described in MUSA-based sonographic \nassessment studies [14,16].\nNeither myometrial shadowing patterns nor vascularization \ncharacteristics demonstrated significant associations with \nadenomyosis in our cohort (p=0.73 and p=0.22, respectively). \nThese negative findings are consistent with published meta-\nanalyses reporting high operator dependency and low \ninterobserver reproducibility for both parameters. Fan-shaped \nshadowing, while described in the MUSA consensus as an \nindirect adenomyosis marker, has been shown to have limited \nstandalone diagnostic value when evaluated independently \nof other criteria, with sensitivity estimates of 30–40% and wide \nconfidence intervals across studies. Similarly, Doppler-based \nvascularization assessment is highly technique-dependent; \nstandardized gain settings, pulse repetition frequency, and \nwall filter parameters critically influence vascular signal \ndetection, and the absence of a standardized Doppler \nprotocol in our study may have reduced the reliability of these \nassessments. MUSA consensus recommendations support \ninterpreting Doppler findings as supportive features within \na comprehensive MUSA evaluation rather than as primary \ndiagnostic criteria, a recommendation strongly supported by \nour finding [16].\nSubendometrial echogenic lines and buds demonstrated the \nstrongest sonographic association with adenomyosis in our \ncohort (OR=8.51, 95% CI: 2.20–32.9; p<0.001) and the highest \nspecificity among evaluated MUSA criteria (97.6%). Despite \nlow sensitivity, their presence can therefore be considered \na strong rule-in marker. Posterior wall localization showed a \nparticularly strong association, consistent with the reported \npredilection of adenomyosis for the posterior myometrium. \nHistopathologically, these findings likely represent basalis \nendometrial invaginations into the inner myometrium, \nsupporting the junctional zone invagination hypothesis. Their \nlow sensitivity in this study may partly reflect the exclusive use \nof two-dimensional TVUS, as three-dimensional coronal plane \nreconstruction improves assessment of subendometrial and \njunctional zone abnormalities [8, 9].\nJunctional zone irregularity was significantly associated \nwith adenomyosis in our cohort (OR=2.57, 95% CI: 1.18–5.40; \np=0.047), with a calculated sensitivity of 48.8% and specificity \nof 72.6%. The junctional zone, representing the inner \nmyometrium adjacent to the endometrial basalis, is the primary \nsite of adenomyosis initiation according to the invagination \nhypothesis. Its disruption manifesting sonographically \nas irregularity or interruption of the hypoechoic inner \nmyometrial layer is considered a pathognomonic early marker \nof adenomyosis. The relatively modest sensitivity observed \nin our 2D TVUS study is consistent with published literature \ndemonstrating superior JZ assessment with 3D ultrasound \nand MRI. Harmsen et al. demonstrated that 3D TVUS achieves \nsubstantially higher interobserver agreement for JZ assessment \ncompared to 2D TVUS, and MRI-based JZ thickness exceeding \n12 mm has been established as a validated diagnostic \nthreshold. The use of 2D TVUS in our study may therefore have \nunderestimated the true diagnostic value of JZ assessment; \nfuture studies incorporating 3D TVUS or MRI are needed to \nfully characterize JZ performance in this [19]. \nSeveral limitations should be considered. First, this was a \nsingle-center study, which may limit generalizability. Second, \nformal interobserver agreement could not be calculated \nbecause ultrasound examinations were performed by \nsimultaneous dual-operator consensus review rather than \nindependent assessment; this should be addressed in future \nstudies. Third, although all hysterectomy specimens were \nreviewed by a single blinded gynecological pathologist using \nstandardized diagnostic criteria and 3–5 mm tissue sampling  \nintervals, histopathological diagnosis of adenomyosis may \n\nTaşpınar MN, Çelik C, Çintesun E. Evaluation of Adenomyosis by MUSA Based Transvaginal Ultrasound in Women \nUndergoing Hysterectomy. Arch Obstet Gynecol. 2026;7(1):35–48.\nArch Obstet Gynecol. 2026\nVolume 7, Issue 1\n47\nstill be affected by sampling error because adenomyotic foci \ncan be patchy and heterogeneous. Fourth, the exclusion of \nwomen using hormonal therapy within three months before \nultrasound may reduce, but cannot completely eliminate, the \npotential effect of prior or unreported hormonal exposure \non myometrial echogenicity or junctional zone appearance. \nFifth, the absence of multivariable logistic regression limits \nassessment of independent predictors after adjustment for \nconfounders. Sixth, endometriosis was not systematically \nrecorded, preventing evaluation of its potential confounding \neffect on symptoms and sonographic findings.\nConclusion\nOur findings support the use of structured preoperative \nTVUS assessment in women scheduled for hysterectomy. \nEvaluation should focus on the MUSA criteria most strongly \nassociated with adenomyosis in this cohort: myometrial \ncysts, myometrial asymmetry, myometrial heterogeneity, \nsubendometrial echogenic lines/buds, and junctional zone \nirregularity. Multiple positive criteria may increase diagnostic \nsuspicion and support preoperative counseling, particularly \nin women with heavy menstrual bleeding and dyspareunia. \nMRI may be considered when TVUS findings are equivocal or \ntechnically limited.\nConflict of Interest\nThe authors declare no conflict of interest.\nFunding\nThis research received no specific grant from any funding \nagency in the public, commercial, or not-for-profit sectors.\nAuthor Contributions\nMerve Nur Taşpınar contributed to data collection, ultrasound \nassessment, data organization, and manuscript preparation. \nÇetin Çelik contributed to ultrasound assessment, clinical \nsupervision, interpretation of findings, and critical manuscript \nrevision. Ersin Çintesun contributed to study conception and \ndesign, data collection, ultrasound assessment, supervision, \nand manuscript revision. All authors reviewed and approved \nthe final manuscript.\nAcknowledgements\nNone declared.\nReferences\n1. 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Uterine junctional zone and adenomyosis: \ncomparison of MRI, transvaginal ultrasound and histology. \nUltrasound Obstet Gynecol. 2023 Jul;62(1):42–60.","source_license":"CC0","license_restricted":false}