Learning Curve of the Transvaginal Ultrasound Exam for Adenomyosis: A CUSUM Analysis

Objectives Adenomyosis is challenging to diagnose with transvaginal ultrasound (TVUS) and requires operator expertise to recognize its sonographic features; however, little is known about the learning curve for trainees. This study aimed to assess the learning curve of inexperienced residents in diagnosing adenomyosis and identifying its key ultrasound signs using the learning curve–cumulative summation test (LC-CUSUM) method.

This prospective cohort study was conducted in 2 tertiary care centers specializing in endometriosis and adenomyosis. Women aged 18–50 undergoing routine outpatient gynecological visits and ultrasound examinations between April 2023 and February 2024 were included. TVUS exams were initially performed by residents without prior formal training in adenomyosis diagnosis. Each scan was subsequently repeated by an expert sonographer, who provided immediate feedback to the trainee. Concordance between residents and experts was assessed for the presence of adenomyosis, its classification, and specific sonographic features. LC-CUSUM analysis was used to construct learning curves and determine when proficiency was achieved.

A total of 150 patients were evaluated by 3 residents (50 each), with the sample size predetermined based on prior studies. All residents achieved diagnostic proficiency by the end of their training, requiring 16, 17, and 23 scans, respectively. LC-CUSUM analysis indicated that approximately 20 scans are needed to reach proficiency. While most key features were correctly identified, subendometrial lines/buds and diffuse inner myometrial involvement were more difficult to recognize consistently.

Residents without prior experience can achieve proficiency in diagnosing and classifying adenomyosis after approximately 20 TVUS exams, though some features remain more challenging to detect. Data Availability Statement The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Supporting Information | Filename | Description | |---|---| | jum70045-sup-0001-FigureS1.docxWord 2007 document , 210.5 KB | Figure S1. (A) Overall learning curves for the diagnosis of adenomyosis. The x-axis represents the number of examinations performed, while the y-axis represents the CUSUM value. The blue line represents the h limit (1.75), with values above this line indicating acceptable performance. Proficiency was reached after an average of 20 examinations. (B) Overall learning curve for the diagnosis of subendometrial lines and buds: proficiency was reached after an average of 21 examinations. (C) Overall learning curve for the diagnosis of diffuse inner adenomyosis: proficiency was reached after an average of 25 examinations. | | jum70045-sup-0002-FigureS2.docxWord 2007 document , 295.1 KB | Figure S2. Overall learning curves for the diagnosis of adenomyosis classification. The x-axis represents the number of examinations performed, while the y-axis represents the CUSUM value. The blue line represents the h limit (1.75), with values above this line indicating acceptable performance. (A) Focal inner: proficiency was achieved after an average of 15 examinations. (B) Focal outer: proficiency was achieved after an average of 16 examinations. (C) Diffuse outer: proficiency was achieved after an average of 18 examinations. (D) Adenomyoma: proficiency was achieved after an average of 14 examinations. | | jum70045-sup-0003-FigureS3.docxWord 2007 document , 312.9 KB | Figure S3. Overall learning curves for the diagnosis of sonographic signs of adenomyosis. The x-axis represents the number of examinations performed, while the y-axis represents the CUSUM value. The blue line represents the h limit (1.75), with values above this line indicating acceptable performance. (A) Anechoic areas: proficiency was achieved after an average of 17 examinations. (B) Hyperechoic islands: proficiency was achieved after an average of 18 examinations. (C) Asymmetrical myometrial thickening: proficiency was achieved after an average of 19 examinations. (D) Irregularity/interruption of junctional zone: proficiency was achieved after an average of 15 examinations. | | jum70045-sup-0004-FigureS4.docxWord 2007 document , 244.7 KB | Figure S4. Overall learning curves for the diagnosis of sonographic signs of adenomyosis. The x-axis represents the number of examinations performed, while the y-axis represents the CUSUM value. The blue line represents the h limit (1.75), with values above this line indicating acceptable performance. (A) Translesional vascularization: proficiency was achieved after an average of 15 examinations. (B) Rain in the forest: proficiency was achieved after an average of 15 examinations. (C) Globular uterus: proficiency was achieved after an average of 17 examinations. | Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

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