Hysteroscopic Pattern Characterization in Adenomyosis Diagnosed by MUSA 2022 Criteria: A Prospective Observational Study

OBJECTIVE: Despite growing recognition of adenomyosis as a significant gynecological condition, standardized hysteroscopic diagnostic criteria remain lacking. This study aimed to systematically characterize endometrial hysteroscopic findings in ultrasonographically confirmed adenomyosis using a clinically relevant classification framework and determine their frequency and morphological patterns in symptomatic women. STUDY DESIGN: Prospective study of 40 women (18-55 years) with MUSA-confirmed adenomyosis who underwent standardized office hysteroscopy at a tertiary center (August 2022-May 2023). All procedures were video-recorded using high-definition equipment for systematic postprocedural analysis. Endometrial findings were systematically categorized into four clinically relevant domains: structural changes, vascular abnormalities, hemorrhagic manifestations, and endometriotic-like features. RESULTS: Hemorrhagic manifestations were present in all 40 patients in our cohort, with hemorrhagic spots identified in 97.5% of cases. Vascular abnormalities occurred in 97.5% of patients: hypervascularization (35.0%), marked hypervascularization (37.5%), focal hyperemia (65.0%), and diffuse hyperemia (25.0%). Structural abnormalities were identified in 92.5% of cases: irregular endometrium (37.5%), trabeculations with small surface openings (25.0%), and enlarged tubal orifices (30.0%). Endometriotic-like features were present in 67.5% of patients: strawberry pattern appearance (25.0%) and white spot lesions (42.5%). Chocolate-brown hemorrhagic lesions occurred in 17.5% of cases. Multiple morphological categories were present concurrently in 87.5% of patients. CONCLUSION: Patients with ultrasonographically confirmed adenomyosis demonstrate characteristic hysteroscopic patterns with predominantly multiple concurrent morphological abnormalities. This systematic characterization provides a standardized framework for hysteroscopic assessment and establishes the foundation for potential integration with existing imaging-based diagnostic approaches.