A Novel Semi-Quantified Method for Grading Sonographic Severity of Adenomyosis and its Relation With Clinical Symptoms: An Observational Study

Objective: To correlate the sonographic severity of adenomyosis, assessed with real-time ultrasound and a novel semi-quantified method (XI-VOCAL counting and categories) with adenomyosis-associated symptoms. Methods: This observational study was conducted in a tertiary referral outpatient clinic. We consecutively included 115 participants with ≥1 direct ultrasonographic adenomyosis feature; those with dominant myoma, malignancy, pelvic infection, pregnancy, breastfeeding, inadequate imaging, postmenopause, or hormonal medication use were excluded. A routine clinical protocol was followed for anamnestic and ultrasound data. Menstrual bleeding was assessed subjectively (three-point scale) and with a pictorial blood loss analysis chart (PBAC). Dysmenorrhea, dyspareunia, and chronic pelvic pain were evaluated using a numeric rating scale (NRS). A retrospective questionnaire was sent for missing items. Real-time severity was scored by experienced gynecologists. XI-VOCAL-based severity was assessed independently and blinded to clinical data, providing two severity scores: XI-VOCAL counting and XI-VOCAL categories. Correlations with symptoms were analyzed using Jonckheere-Terpstra, linear and logistic regression. Results: The real-time severity (severe vs mild) showed a strong correlation with adjusted PBAC (β 590.01, 95% CI 207.16–972.86, P <.01) and subjective blood loss assessment (OR 5.48, 95% CI 1.14–26.28, P <.05). Additionally, a strong correlation was found between XI-VOCAL counting and XI-VOCAL categories with adjusted PBAC score (XI-VOCAL counting: β 53.15, 95% CI 12.06–94.24, P <.05; XI-VOCAL categories (severe vs mild): β 627.36, 95% CI 165.92–1088.81, P <.05). No correlations were found with adjusted dysmenorrhea, chronic abdominal/pelvic pain, or dyspareunia. Conclusion: Both real-time severity and XI-VOCAL-assessed severity correlate with adjusted PBAC scores and subjective blood assessment. XI-VOCAL appears more standardized, while real-time assessment may be influenced by symptom severity. Larger studies correcting for pain-related confounders are needed.