Magnetic resonance imaging-based Classification criteria combined with Serum CA125 for dysmenorrhea before focused ultrasound ablation surgery in adenomyosis

Magnetic resonance imaging-based Classification criteria combined with Serum CA125 for dysmenorrhea before focused ultrasound ablation surgery in adenomyosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Magnetic resonance imaging-based Classification criteria combined with Serum CA125 for dysmenorrhea before focused ultrasound ablation surgery in adenomyosis Bin Su, Jun-rong Huang, Hang Wang, Hong-ni He, Wen Tang, Ming-tao Yang, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5025850/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Nov, 2025 Read the published version in Scientific Reports → Version 1 posted 11 You are reading this latest preprint version Abstract Objectives To inform dysmenorrhea for exploring the possible pathogenesis of adenomyosis based on MRI classification criteria and serum CA125. Methods Patients before focused ultrasound ablation surgery were categorized into MRI -based severity group (Group A) and MRI -based non-severity group (Group B). Binary logistic regression was employed to identify the factors associating dysmenorrhea and CA125 level in total cohort and subgroups via MRI-based classifications criteria. The receiver-operating characteristic (ROC) curve was applied to assess the utility of CA125 for dysmenorrhea the subgroups. Results Patients in dysmenorrhea subtype exhibited higher CA125 levels compared with those in non-dysmenorrhea subtype in total cohort and Group A(P<0.05). In terms of those with dysmenorrhea, CA125 levels of Group A were shown to be higher when compared with those of Group B(P<0.05). In Group A, multivariate logistic regression showed that age and CA125 were related to dysmenorrhea in adenomyosis(P 44.8 U/ml were more probably to suffer from dysmenorrhea. Furthermore, the multiple regression analysis demonstrated that CA125 level exhibited a positive correlation with the lesion volume and negatively related to age(P44.8 U/ml were prone to suffer from dysmenorrhea secondary to adenomyosis in MRI -based severity group. Besides, age and the lesion volume were associated with CA125 levels. Health sciences/Biomarkers Health sciences/Diseases Health sciences/Medical research CA125 MRI classification adenomyosis dysmenorrhea severity Figures Figure 1 INTRODUCTION Adenomyosis is a commonly seen disorder of the uterus in women of child-bearing age, characterizing by the lesion invasion into uterus, present with dysmenorrhea, menorrhagia and larger uterus, affecting the quality of women 1 , 2 . The etiology and pathogenesis adenomyosis is not well known at present 3 , in which inflammation might be one main factor associated with dysmenorrhea secondary to adenomyosis. Cancer antigen 125 (CA125), a high macromolecule glycoprotein, is increasingly secreting from the embryonic coelomic epithelium to serum by peritoneal irritation or peritoneal stretch in inflammatory microenviroment 4 – 6 . It is mainly used as biomarker for investigating diagnosis and survival of ovarian cancer 7 , 8 . Our previous study has found that CA125 levels were closely correlated to dysmenorrhea in adenomyosis before focused ultrasound ablation surgery (FUAS), and CA125 levels in diffuse subtype was higher in relative to those in focal subtype, informing that CA125 might be one biomarker associated with disease severity for adenomyosis 4 . Magnetic resonance imaging (MRI) is considered as a moderately accurate test to diagnose and predict the disease severity for patients before FUAS 9 – 11 . Recently, researchers have explored the classifications of adenomyosis according to MRI 10 – 14 . Our previous study has found that based on the affected area, pattern, size (volume), localization of adenomyotic lesions, and concomitant pathology, classification criterion 4 (C4) was considered to be the suitable classification criterion for dysmenorrhea secondary to adenomyosis 12 . However, it is unclear which classification criterion is the suitable one for serum CA125 and whether classification criterion combined with CA125 could inform dysmenorrhea in adenomyosis. Thus, we retrospectively explored the data from a cohort of patients before FUAS, aiming to investigate the combined value of classification criterion and serum CA125 for dysmenorrhea, and study the factors influencing dysmenorrhea and the elevated CA125 level for investigating the possible pathogenesis of adenomyosis. MATERIALS AND METHODS Study design and patients This retrospective study involved 502 patients, who were diagnosed as adenomyosis by MRI scan and treated by FUAS for dysmenorrhea or menorrhagia. Patients who had complete demographic and disease characteristics data were extracted from medical records in the Affiliated Nanchong Central Hospital of North Sichuan Medical College from June 2017 to March 2021. The study was conducted in accordance with the Declaration of Helsinki and performed in accordance with relevant guidelines/regulations. Approved by ethics committee of the Affiliated Nanchong Central Hospital of North Sichuan Medical College (permit number 2021/104), the study waived the need of obtaining informed consent due to the retrospective nature. The inclusion criteria for patients were patients with dysmenorrhea or menorrhagia secondary to adenomyosis, diagnosed by MRI before FUAS, received CA125 test and MRI examination before FUAS, and performed by FUAS 4 , 5 . The exclusion criteria for patients were those receiving no pre-FUAS CA125 test or MRI examination, with uterine fibroids or endometriosis or suspected malignant tumor in MRI imaging, which might lead to dysmenorrhea or menorrhagia, with inflammatory disease within a week, as well as a history of medicine for dysmenorrhea within 6 months, influencing the symptoms investigation before FUAS 4 , 5 . Assessments Adenomyosis was diagnosed by imaging physicians based on MRI examination, which was defined as the maximal junctional zone thickness (JZmax) max ≥ 12 mm) 15 , 16 , or the ratio of JZmax to the entire myometrium thickness > 40% 11 , or the difference between the maximal and minimal JZ thickness > 5 mm 15 , 17 . The lesion size of uterine wall was defined as the size of lesion invasive into uterine wall. The uterine volume and the adenomyotic lesion volume were calculated using the following formula: 4/3πABC, where A, B, and C represent the long diameter, wide diameter, and thickness diameter of the lesion, respectively 1 . As patient-reported pain during menstrual cycles, dysmenorrhea secondary to adenomyosis was acquired from medical records, and recorded in the clinical encounter before FUAS and follow-up 1 , 18 . Menorrhagia secondary to adenomyosis was set as the clinically recorded increasing patient-reported menstrual blood volume, and recorded in the clinical encounter before FUAS and follow-up 1 , 19 . Symptom recurrence was set as patient-reported dysmenorrhea and/or menorrhagia 12 months after a period when symptomatic relief lasted for at least 3 months after FUAS1. Serum CA125 test before FUAS CA125 test samples of collecting and measurement followed the standard procedure, which were transported to the laboratory center at room temperature, measured by two-step immunoassay for the quantitative determination with flexible assay protocols within 24 h before FUAS, and assayed in a central laboratory 4 , 5 . MRI-based classifications for adenomyosis Imaging system by a 1.5 T MRI system informed the images information of pelvic-enhanced MRI patients. Based on the professional opinion, adenomyosis was also divided according to ultrasound-based classification system (C1, the morphological features of C1 were also assessable by MRI imaging 11 , 14 ) and the MRI findings (C2-C5 10 , 11−14 ). Based on the five classification criteria, imaging physicians (ZJ, 10 years of experience; JZ, with 10 years of experience) and a gynecologist (YT, with 11 years of experience) were individually invited to reclassify adenomyosis 1 . Different classification standard criteria are listed in Supplementary Table 1. The classification parameters were used if the results were consistent between two readers, the third reader was invited to discuss the final classification parameters in the case of ambiguous or controversial results 1 . Statistical methods Analysis were performed in total cohort and stratified by the lesion size of uterine wall based on MRI: Group A, the lesion size of uterine wall ≥ 2/3, MRI-based severity group; Group B, the lesion size of uterine wall<2/3, MRI-based non-severity group. Continuous variables were summarized by the mean and standard deviation or median (P25, P75). In addition, interquartile range (IQR) and categorical variables were shown to be counts and percentages. This study adopted χ2 test, t test or Mann-Whiney U test for examining the differences of demographic and clinical factors between patients with and without dysmenorrhea in total cohort and subgroups. A logistic regression mode was used to explore the correlation between clinicopathlogical features (age, the lesion volume, the uterine volume, subcutaneous fat thickness, serum CA125) and dysmenorrhea by odds ratios (ORs) with 95% confidence intervals (95% CIs) in total cohort and subgroups. Using a Receiver Operating Characteristic (ROC) curve, the optimal cut-off of CA125 levels for dysmenorrhea before FUAS in adenomyosis were investigated. The logistic regression model was used for establishing the associations between elevated CA125 and dysmenorrhea before FUAS in adenomyosis in total cohort and subtype groups. To investigate the factors (age, the lesion size) influencing CA125 level before FUAS, multivariate logistic regression model was employed. GraphPad Prism 7.0 (Version X; La Jolla, CA, USA) was used for image editing. SPSS 22.0 (IBM, Armonk, NY) was adopted for the statistical analysis, and p < 0.05 was thought to be of significance. The data was reviewed by the Data Survilliance and Monitoring Committee of the State Key Laboratory of Ultrasound in Medicine and Engineering. This committee is consisted of multidisciplinary experts in the clinical research. RESULTS Clinicopathlogical features in the total cohort The baseline characteristics, which included age, body mass index (BMI), serum CA125, uterine position and volumes, lesion position and volumes, distribution of dysmenorrhea and menorrhagia and symptom recurrence were summarized in Table 1 . Table 1 Clinicopathlogical features in total cohort Variable Total cohort Age (years) 43.8 ± 5.2 BMI (kg/m2) 23.6 ± 2.8 Parity 1 (1, 2) Uterus position (n(%)) Anteverted 292 (58.2%) Retroverted 192 (38.2%) Neutral 18 (3.6%) Uterus volume(cm3) 231.3 ± 124.5 Adenomyosis location (n(%)) Anterior 148 (29.5%) Posterior 263 (52.4%) Fundus 38(7.6%) Lateral (left or right) 27(5.4%) Anterior/Posterior/ Fundus/ Lateral 26(4.2%) Lesion volume (cm3) 54.6 ± 56.8 Subcutaneous fat thickness (mm) 19.1 ± 8.2 Distance (mm) 22.0 ± 14.8 Serum CA125 (U/ml) 55.9 (30.0, 106.4) Dysmenorrhea (n(%) Yes 381(75.9%) No 121(24.1%) Menorrhagia (n(%)) Yes 272 (54.2%) No 230 (45.8%) Symptom recurrence (n(%)) Yes 133 (26.5%) No 369 (73.5%) BMI, body mass index; CA125, cancer antigen 125; distance, distance from the posterior surface of the adenomyosis lesion to the sacrum. The magnitude of classifications associated with the CA125 of adenomyosis Table 2 showed χ2 value in C4, considered as the suitable one for CA125, was higher than those in other classification criteria (χ2 = 22.003, P<0.001). In C1, serum CA125 levels in subtype-2 (60.0 U/ml (30.2 U/ml, 124.8U/ml)) were higher than those in subtype-1 (52.2 U/ml (31.1 U/ml, 81.3 U/ml), p = 0.007). In C2, serum CA125 levels in subtype-4 (106 U/ml (47 U/ml, 182.5 U/ml) were higher than those in other subtypes (P = 0.006). In C4, no matter intrinsic or external subtype, serum CA125 of Group A was higher than that of Group B (Z = 22.003, P0.05) . Table 2 The identification of different classifications based on MRI for serum CA125. Variable Subtype-1 Subtype-2 Subtype-3 Subtype-4 Subtype-5 Subtype-6 χ 2 P-value Classification 14 52.2 (31.1, 81.3) 60.0 (30.2, 124.8) 7.380 0.007 Classification 2 10 55 (27.5,98.5) 57(30.3,104.8) 45(24,67.5) 106(47,182.5) 12.395 0.006 Classification 3 11 55 (28.8,108.5) 45(28.0,69.0) 60(33,123) 4.444 0.108 Classification 4 12 20 (12.0,42.0) 33.5(13.7,61.8) 55(30,108) 93(51-) 35(26.3,67.8) 59(34,123) 22.003 <0.001 Classification 5 13 50.5 (27.0,93.5) 72.5(23.3,121.8 58(31,108) 45(29.5,67.5) 94(41.8, 173) 123(51,213.5) 16.265 0.006 * p<0.05 14.Hulka CA, Hall DA, McCarthy K, Simeone J. Sonographic findings in patients with adenomyosis: can sonography assist in predicting extent of disease? AJR American journal of roentgenology 2002;179(2):379 − 83. 10.Kishi Y, Suginami H, Kuramori R, Yabuta M, Suginami R, Taniguchi F. Four subtypes of adenomyosis assessed by magnetic resonance imaging and their specification. American journal of obstetrics and gynecology 2012;207(2):114.e1-7. 11. Bazot M, Daraï E. Role of transvaginal sonography and magnetic resonance imaging in the diagnosis of uterine adenomyosis. Fertility and sterility 2018;109(3):389 − 97. 12. Kobayashi H, Matsubara S. A Classification Proposal for Adenomyosis Based on Magnetic Resonance Imaging. Gynecologic and obstetric investigation 2020;85(2):118 − 26. 13. Gong C, Wang Y, Lv F, Zhang L, Wang Z. Evaluation of high intensity focused ultrasound treatment for different types of adenomyosis based on magnetic resonance imaging classification. International journal of hyperthermia : the official journal of European Society for Hyperthermic Oncology, North American Hyperthermia Group 2022;39(1):530-8. Clinicopathlogical features according to Classification criterion 4 According to the results of priority study, dysmenorrhea and menorrhagia rates were different upon the size of uterine wall based on C4. Patients were included into the lesion size of uterine wall ≥ 2/3 group (Group A, N = 446, 88.8%, and 68% failure with gonadotrophin-releasing hormone agonist (GnRH-a) or levonorgestrel within 2 years) and the lesion size of uterine wall<2/3 group (Group B, N = 56,11.2%, and 35.7% failure with GnRH-a or levonorgestrel within 2 years). The uterine volumes(236.9 ± 125.6 cm3), lesion volumes (56.1 ± 55.7 cm3) and CA125 57.9 U/ml (31.1 U/ml, 111.1 U/ml) in Group A were higher than those in Group B (P<0.001, Table 3 ). Table 3 Patient characteristics in subtype groups. Variable Variable MRI-based severity group (n = 446, 88.8%) MRI-based non-severity group (n = 56, 11.2%) Test value P-value Age (years) 43.9 ± 5.2 42.6 ± 5.6 1.777 0.076 BMI (kg/m2) 23.6 ± 2.8 24.1 ± 2.8 -1.337 0.182 Parity 1 (1, 2) 1 (1, 1) -0.901 0.368 Uterus position 1.115 0.572 Anteverted 263(59.0%) 29 (51.8%) Retroverted 167 (37.4%) 25 (44.6%) Neutral 16 (3.6%) 2 (3.6%) Uterine volume(cm3) 236.9 ± 125.6 185.0 ± 105.0 2.889 0.004 Adenomyosis location 2.117 0.714 Anterior 135 (30.3%) 13(23.2%) Posterior 231 (51.8%) 32(12.2%) Fundus 33 (7.4%) 5 (8.9%) Lateral (left or right) 25(5.6%) 2 (3.6%) Anterior/Posterior/undus/ Lateral 22(4.9%) 4 (7.2%) Adenomyotic lesion 56.1 ± 55.7 32.3 ± 51.6 3.067 0.003 (cm3) Subcutaneous fat 19.2 ± 8.0 20.5 ± 15.3 -0.637 0.527 thickness (mm) Distance (mm) 23.9 ± 14.7 25.1 ± 15.7 -0.504 0.614 Hemoglobin (g/dl) 97.7 ± 19.3 100.2 ± 24.7 -0.397 0.694 CA125 (U/ml) 57.9(31.1, 111.1) 35.1(16.8, 67.0) -3.236 0.001 Dysmenorrhea(n(%)) 2.227 0.136 Yes 343(76.9%) 38(67.9%) No 103 (23.1%) 18(32.1%) Menorrhagia(n(%)) 2.333 0.127 Yes 247(55.4%) 23(44.2%) No 199 (44.6%) 29(55.8%) Symptom recurrence(n(%)) 9.883 0.002 Yes 125 (28.0%) 8 (15.4%) No 321 (72.0%) 66 (84.6%) Group A, the lesion size of uterine wall ≥ 2/3; Group B, the lesion size of uterine wall<2/3; BMI, body mass index; CA125, cancer antigen 125; distance from the posterior surface of the adenomyosis lesion to the sacrum. We further explored the relationship between CA125 and dysmenorrhea in different groups, as shown in Fig. 1 . CA125 levels in patients suffering from dysmenorrhea were higher when compared with those in patients without dysmenorrhea in total cohort(Z=-3.597, P<0.001, Fig. 1 A)and Group A (Z=-3.150, P = 0.002, Fig. 1 B), while no significant difference was found in Group B (Z=-1.350, P = 0.177, Fig. 1 C). In terms of those with dysmenorrhea, CA125 levels of Group A were higher than those in Group B (Z=-2.503, P = 0.012). The factors influencing dysmenorrhea in total cohort and subtypes subgroups In total cohort, univariate logistic regression demonstrated that age (OR = 0.909, 95% CI 0.869 ~ 0.951, P < 0.001), CA125 (OR = 1.004, 95% CI 1.001 ~ 1.017, P = 0.012) and subcutaneous fatthickness (OR = 0.97, 95% CI 0.94–0.99, P = 0.007) were related to dysmenorrhea of patients with adenomyosis. However, there were no associations between BMI, the lesion size of uterine wall(≥2/3 vs.0.05). According to multivariate logistic regression, age (OR = 0.900, 95% CI 0.855 ~ 0.947, P = 0.007), and CA125 (OR = 1.004, 95% CI 1.001 ~ 1.007, P = 0.018) were correlated with dysmenorrhea of patients with adenomyosis, while subcutaneous fatthickness showed no significant association with dysmenorrhea (P = 0.073) (Table 4 ). Table 4 Binary logistic regression analysis of factors impacting dysmenorrhea of adenomyosis in total cohort. Variable Univariate Multivariate OR 95%CI P OR 95%CI P Age (years) 0.909 0.869 ~ 0.951 <0.001 0.900 0.855 ~ 0.947 <0.001 BMI (kg/m2) 0.940 0.873 ~ 1.012 0.098 1.015 0.927 ~ 1.111 0.753 Menorrhagia 1.162 0.774 ~ 1.748 0.468 1.144 0.727 ~ 1.801 0.561 (Yes vs. No) The volume of uterine wall 1.577 0.864 ~ 2.881 0.138 1.299 0.644 ~ 2.622 0.465 (≥ 2/3 vs.<2/3) Serum CA125 (U/ml) 1.004 1.001 ~ 1.017 0.012 1.004 1.001 ~ 1.007 0.018 Subcutaneous fatthickness (mm) 0.967 0.944 ~ 0.991 0.007 0.975 0.948 ~ 1.002 0.073 CA125, cancer antigen 125; BMI, body mass index In severity group (Group A) based on MRI, multivariate logistic regression showed that age (OR = 0.897, 95% CI:0.849 ~ 0.948, P<0.001) and CA125 (OR = 1.004, 95% CI 1.001 ~ 1.008, P = 0.021) were related to dysmenorrhea of patients with adenomyosis, while did not significantly associated with dysmenorrhea in Group B (P = 0.073) (Table 5 ). Table 5 Binary logistic regression analysis of factors for dysmenorrhea of adenomyosis in subgroups. Variable The volume of uterine wall ≥ 2/3(Group A) The volume of uterine wall<2/3(Group B) OR 95%CI P OR 95%CI P Age (years) 0.897 0.849 ~ 0.948 <0.001 0.887 0.763 ~ 1.031 0.119 BMI (kg/m2) 1.019 0.924 ~ 1.124 0.701 0.983 0.750 ~ 1.289 0.903 Menorrhagia 1.272 0.783 ~ 2.066 0.331 0.494 0.123 ~ 1.985 0.320 (Yes vs. No) Serum CA125(U/ml) 1.004 1.001 ~ 1.008 0.021 0.999 0.987 ~ 1.012 0.908 Subcutaneous fatthickness (mm) 0.976 0.943 ~ 1.011 0.173 0.967 0.914 ~ 1.023 0.246 CA125, cancer antigen 125; Group A, the lesion size of uterine wall ≥ 2/3; Group B, the lesion size of uterine wall<2/3; BMI, body mass index. Identification of CA125 for dysmenorrhea in MRI-based severity group ROC curves were employed to assess the magnitude of CA125 for dysmenorrhea in Group A. Sensitivity, specificity, optimal value, area under the curve, 95 CIs and p-value were 59.2%, 59.2%, 44.8, 0.594, 0.547 ~ 0.640, P = 0.002. The factors impacting CA125 level in MRI-based severity group Then, we investigated the factors causing the increased CA125 levels in MRI-based severity group by multivariate logistic regression. Based on the results, the lesion volume positively related to elevated CA125 levels (OR = 1.016, 95%: 1.008–1.025, P < 0.001), while the ages exhibited a negative correlation with elevated CA125 levels (OR = 0.943, 95%༚0.898–0.991, P = 0.021) (Table 6 ). Table 6 Multivariate binary logistic regression analysis of factors for CA125 in MRI-based severity group. Variable B S.E. Wald OR 95%CI P Age (years) -0.058 0.025 5.342 0.943 0.898–0.991 0.021 BMI (kg/m2) -0.037 0.046 0.643 0.964 0.880–1.055 0.423 Menorrhagia -0.137 0.236 0.336 0.872 0.549–1.386 0.562 (Yes vs. No) Uterine volume (cm3) 0.000 0.001 0.058 1.000 0.998–1.003 0.810 Lesion volume (cm3) 0.016 0.004 15.408 1.016 1.008–1.025 <0.001 Subcutaneous fatthickness (mm) 0.007 0.017 0.195 1.007 0.975–1.041 0.659 CA125, cancer antigen 125; BMI, body mass index DISCUSSION Our study showed that C4 based on MRI was the suitable classification criterion for CA125 in patients with adenomyosis before FUAS. For those with dysmenorrhea, CA125 levels in MRI-based severity group were shown to be higher than those of the non-severity group, while they showed no significant difference in those without dysmenorrhea. CA125 level of 44.8 U/ml was found to be the optimal cut-off point of dysmenorrhea in severity group based on MRI. When we extended the study to investigate the factors related to the elevated CA125 in MRI-based severity group, the lesion volume was considered as the positively one, while the ages negatively one. Consist with the results that adenomyosis is actually related to expression of uterine inflammatory mediators and cytokines 3 , 4 , including tumor necrosis factor-α, β (TNF- α, β), interleukin (IL)-1β, IL-18 and CA125, our results again demonstrated that elevated CA125 level was associated with dysmenorrhea secondary to adenomyosis in patients without uterine fibroids and endometriosis 4 . It indicated the higher level of serum CA125, the higher possibilities of dysmenorrhea secondary to adenomyosis 4 . Classification criterion based on MRI also could inform the severity of dysmenorrhea. In the previous study, we found the severity disease was different considered the lesion size of uterine wall. In this study, we found that the C4 was the suitable classification criterion for CA125. Furthermore, we explored the association between CA125 and dysmenorrhea based on C4. While the lesion size of uterine wall ≥ 2/3, CA125 was positively associated with the severity of dysmenorrhea. In the previous study, we confirmed the commonly used diagnosis value, and 35 U/ml was the optimal cut-point for dysmenorrhea 20 . In this study, we further investigated CA125 as 48.4 U/ml was the optimal cut-point for dysmenorrhea in the patients whose lesion size of uterine wall ≥ 2/3. Meanwhile, no matter what is the cut-off point of CA125 for dysmenorrhea, elevated CA125 level was positively associated with the lesion volume, and negatively associated with the age. As the main symptom of adenomyosis, dysmenorrhea is probably the results of inflammation, neurogenesis, angiogenesis, and contractile abnormalities in the endometrial and myometrial components 3 . Dysmenorrhea can be adjusted by abnormal genetic, including CYP1A1 and A2, catechol-O-methyltransferas, Cytochrome P450, lipoxygenase-5 and Cyclooxygenase-2 3, 21, 22 , involving the key processes in adenomyosis development. Dysmenorrhea could be illuminated by myometrial hypercontractility, and indicated by higher expression of oxytocin receptors and increased contractile amplitude of uterine smooth muscle cells (uSMCs) in adenomyotic uteri, resulting in hyperestrogenism, progesterone resistance, and inflammatory microenvironment 3 . Then, inflammatory microenviroment promoted the ectopic endometrium secretion of significantly higher CA125 level compared with the normal endometrium 23 . The high expression of IL-1β, CRH, and UCN observed in adenomyotic lesions may mediate prostaglandins synthesis and stimulate peritoneal irritation and peritoneal stretch, and therefore CA125 reached the blood circulation through changing endothelial permeability 3 , 24 . Furthermore, our study attempted to explore the combined value of MRI and CA125 for dysmenorrhea secondary to adenomyosis. The results showed that when the MRI imaging informing the invasion wall ≥ 2/3, the larger areas of lesion, the higher levels of CA125 in adenomyosis. Meanwhile, CA125 may aggravate inflammation through promoting ectopic endometrium migration and adhesion in the surrounding myometrium in adenomyosis development 6 , which might result in a relatively severity level of the disease. While the MRI imaging informing the invasion lesion of uterus wall, the patients have higher possibilities of dysmenorrhea before FUAS. These findings might offer clues for investigating the pathogenesis of dysmenorrhea based on MRI and CA125. The suitable classification criterion based on MRI for CA125 might be beneficial for exploring the possible mechanisms with disease development. Limitations and Strengths The strength of the current retrospective study was that we informed a suitable classification criterion based on MRI for CA125, further showing that CA125 was associated with dysmenorrhea secondary to adenomyosis upon severity disease based on MRI with a relatively large sample size. This might be of interest to researchers to study pathogenesis of dysmenorrhea based on MRI and CA125. However, this study still had the following limitations. Firstly, patients included in this study were those who received FUAS, which had potential limitation for selection bias and might limit the interpretation of our results to the general patient population. We will include the patients with non FUAS treatment and compare the predictive value of MRI and CA125 for clinic symptom of patients between the FUAS group and non-FUAS group in the future. Secondly, we could not conclude that CA125 was a risk factor of dysmenorrhea in MRI -based severity group in adenomyosis for the retrospective design. However, we demonstrated that CA125 is associated with dysmenorrhea secondary to adenomyosis in MRI -based severity group. Thirdly, although a few patients without complete data were excluded for the retrospective design, the clinicopathologic features of our cohort showed no significant difference from epidemiology of adenomyosis 25 . Finally, CA125 results might be interfered by sample collection and test. We collected and measured CA125 within one day before FUAS, aiming to minimize interference factors for the findings. Meanwhile, we will assess the severity level of dysmenorrhea by Numerical Rating Scale, not just by describing dysmenorrhea as yes or no with design prospective and multicenter studies. Conclusions In summary, this study informed that C4 based on MRI was the suitable one for CA125. Patients with increased CA125>44.8 U/ml were prone to suffer from dysmenorrhea secondary to adenomyosis in MRI-based severity group. Besides, the lesion volume positively related to elevated CA125 levels, while the ages exhibited a negative correlation with elevated CA125 levels. Declarations Statement of Ethics The approval of this study was approved by ethics committee of the Affiliated Nanchong Central Hospital of North Sichuan Medical College (permit number. 2021/104). Due to data anonymization and the retrospective nature of the study, the need for consent was waived. Conflict of Interest Statement The authors have no conflicts of interest to declare. Funding This work was supported by the Ministry of Science and Technology of China (Grant No.2022YFE0133100), foundation of State Key Laboratory of Ultrasound in Medicine and Engineering (Grant No. 2020KFKT003, 2021KFKT022), the Bureau of Science and Technology Nanchong City Program (No. 20SXQT0320, 22SXQT0254, 22SXQT034) and university project of North Sichuan Medical College (NO. CBY23-ZDA12, CBY23-QNA11 and CBY23-QNA19). Author Contributions This study was designed by YT, HQH, BS, QLS and carried out by YT, JL,WH, JRH and MTY, BS, HNH, WT, ZJJ, and LJZ provided data from medical records. All drafted the first manuscript with help from HQH and YT. All authors contributed to and approved the final version of the article for publication. Data availability statement The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. References Tang, Y. et al. Magnetic Resonance Imaging-Based Classification Systems for Informing Better Outcomes of Adenomyosis After Ultrasound-Guided High-Intensity Focused Ultrasound Ablating Surgery. J. Magn. Reson. imaging: JMRI (2023). Sheth, S. S. & Ray, S. S. Severe adenomyosis and CA125. J. Obstet. gynaecology: J. Inst. Obstet. Gynecol. 34 (1), 79–81 (2014). Zhai, J., Vannuccini, S., Petraglia, F. & Giudice, L. C. Adenomyosis: Mechanisms and Pathogenesis. Semin. Reprod. Med. 38 (2–03), 129–143 (2020). Tang, Y. et al. Serum CA125 as a biomarker for dysmenorrhea in adenomyosis. Int. J. Gynaecol. Obstet. (2023). Tang, Y. et al. Preoperative CA125 as a risk factor for symptom recurrence of adenomyosis after ultrasound-guided high-intensity focused ultrasound ablation surgery. Int. J. hyperthermia: official J. Eur. Soc. Hyperthermic Oncol. North. Am. Hyperth. Group. 39 (1), 1164–1169 (2022). Kil, K. et al. Usefulness of CA125 in the differential diagnosis of uterine adenomyosis and myoma. Eur. J. Obstet. Gynecol. Reprod. Biol. 185 , 131–135 (2015). Tang, Y. et al. Combined Preoperative LMR and CA125 for Prognostic Assessment of Ovarian Cancer. J. Cancer . 11 (11), 3165–3171 (2020). Zhang, M., Cheng, S., Jin, Y., Zhao, Y. & Wang, Y. Roles of CA125 in diagnosis, prediction, and oncogenesis of ovarian cancer. Biochim. et Biophys. acta Reviews cancer . 1875 (2), 188503 (2021). Kobayashi, H., Matsubara, S. & Imanaka, S. Relationship between magnetic resonance imaging-based classification of adenomyosis and disease severity. J. Obstet. Gynaecol. Res. 47 (7), 2251–2260 (2021). Kishi, Y. et al. Four subtypes of adenomyosis assessed by magnetic resonance imaging and their specification. Am. J. Obstet. Gynecol. 207 (2), 114e1–114e7 (2012). Bazot, M. & Daraï, E. Role of transvaginal sonography and magnetic resonance imaging in the diagnosis of uterine adenomyosis. Fertil. Steril. 109 (3), 389–397 (2018). Kobayashi, H. & Matsubara, S. A Classification Proposal for Adenomyosis Based on Magnetic Resonance Imaging. Gynecol. Obstet. Invest. 85 (2), 118–126 (2020). Gong, C., Wang, Y., Lv, F., Zhang, L. & Wang, Z. Evaluation of high intensity focused ultrasound treatment for different types of adenomyosis based on magnetic resonance imaging classification. Int. J. hyperthermia: official J. Eur. Soc. Hyperthermic Oncol. North. Am. Hyperth. Group. 39 (1), 530–538 (2022). Hulka, C. A., Hall, D. A., McCarthy, K. & Simeone, J. Sonographic findings in patients with adenomyosis: can sonography assist in predicting extent of disease? AJR Am. J. Roentgenol. 179 (2), 379–383 (2002). Struble, J., Reid, S. & Bedaiwy, M. A. Adenomyosis: A Clinical Review of a Challenging Gynecologic Condition. J. Minim. Invasive. Gynecol. 23 (2), 164–185 (2016). Reinhold, C. et al. Diffuse adenomyosis: comparison of endovaginal US and MR imaging with histopathologic correlation. Radiology . 199 (1), 151–158 (1996). Kishi, Y. et al. Phenotypic characterization of adenomyosis occurring at the inner and outer myometrium. PloS one . 12 (12), e0189522 (2017). Chen, Q. et al. Clinical Manifestations Of Adenomyosis Patients With Or Without Pain Symptoms. J. pain Res. 12 , 3127–3133 (2019). Agostinho, L. et al. MRI for adenomyosis: a pictorial review. Insights Imaging . 8 (6), 549–556 (2017). Tang, Y. et al. Serum CA125 as a biomarker for dysmenorrhea in adenomyosis. Int. J. Gynaecol. Obstet. 163 (1), 131–139 (2023). Jin, Z., Liu, H. & Xu, C. Estrogen degrades Scribble in endometrial epithelial cells through E3 ubiquitin ligase HECW1 in the development of diffuse adenomyosis†. Biol. Reprod. 102 (2), 376–387 (2020). Liang, S. et al. Celecoxib reduces inflammation and angiogenesis in mice with adenomyosis. Am. J. translational Res. 13 (4), 2858–2866 (2021). Kobayashi, H., Ida, W., Terao, T. & Kawashima, Y. Molecular characteristics of the CA 125 antigen produced by human endometrial epithelial cells: comparison between eutopic and heterotopic epithelial cells. Am. J. Obstet. Gynecol. 169 (3), 725–730 (1993). Liu, S. et al. LncRNA H19 Overexpression in Endometriosis and its Utility as a Novel Biomarker for Predicting Recurrence. Reproductive Sci. (Thousand Oaks Calif) . 27 (9), 1687–1697 (2020). Upson, K. & Missmer, S. A. Epidemiology of Adenomyosis. Semin Reprod. Med. 38 (2–03), 89–107 (2020). Additional Declarations No competing interests reported. Supplementary Files Supplementarytable1.pdf Cite Share Download PDF Status: Published Journal Publication published 27 Nov, 2025 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 08 Oct, 2024 Reviews received at journal 03 Oct, 2024 Reviewers agreed at journal 27 Sep, 2024 Reviewers agreed at journal 24 Sep, 2024 Reviews received at journal 18 Sep, 2024 Reviewers agreed at journal 18 Sep, 2024 Reviewers invited by journal 18 Sep, 2024 Editor assigned by journal 17 Sep, 2024 Editor invited by journal 17 Sep, 2024 Submission checks completed at journal 16 Sep, 2024 First submitted to journal 03 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5025850","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":363450198,"identity":"b9a5cc02-b4b2-49f3-a348-19342f88ae7e","order_by":0,"name":"Bin Su","email":"","orcid":"","institution":"The Affiliated Nanchong Central Hospital of North Sichuan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Bin","middleName":"","lastName":"Su","suffix":""},{"id":363450200,"identity":"56b8ce7e-8371-400c-96e8-7903a140488e","order_by":1,"name":"Jun-rong Huang","email":"","orcid":"","institution":"The Affiliated Nanchong Central Hospital of North Sichuan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Jun-rong","middleName":"","lastName":"Huang","suffix":""},{"id":363450204,"identity":"c122612e-0d73-4fd6-ac82-635ec0a9d458","order_by":2,"name":"Hang Wang","email":"","orcid":"","institution":"Si Chuan Mian Yang 404 Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hang","middleName":"","lastName":"Wang","suffix":""},{"id":363450205,"identity":"d5e77960-e5f1-41df-84e8-60f06bdd1de0","order_by":3,"name":"Hong-ni He","email":"","orcid":"","institution":"The Affiliated Nanchong Central Hospital of North Sichuan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Hong-ni","middleName":"","lastName":"He","suffix":""},{"id":363450210,"identity":"fb37ed8e-f296-4bda-8610-399b88d0e1f8","order_by":4,"name":"Wen Tang","email":"","orcid":"","institution":"The Affiliated Nanchong Central Hospital of North Sichuan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Wen","middleName":"","lastName":"Tang","suffix":""},{"id":363450211,"identity":"b5dd1562-74ff-4780-abff-97e89a4390c9","order_by":5,"name":"Ming-tao Yang","email":"","orcid":"","institution":"The Affiliated Nanchong Central Hospital of North Sichuan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Ming-tao","middleName":"","lastName":"Yang","suffix":""},{"id":363450215,"identity":"7f7f450e-9c9a-4d7c-9231-02fb3facf50a","order_by":6,"name":"Zhi-jun Jiang","email":"","orcid":"","institution":"Chongqing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhi-jun","middleName":"","lastName":"Jiang","suffix":""},{"id":363450218,"identity":"fcfb8c1b-7ebc-4b93-a723-574af13ffe55","order_by":7,"name":"Li-juan Zhu","email":"","orcid":"","institution":"The Affiliated Nanchong Central Hospital of North Sichuan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Li-juan","middleName":"","lastName":"Zhu","suffix":""},{"id":363450223,"identity":"24a76812-42db-4b40-a507-b493d5c0d8f2","order_by":8,"name":"Hui-quan Hu","email":"","orcid":"","institution":"The Affiliated Nanchong Central Hospital of North Sichuan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Hui-quan","middleName":"","lastName":"Hu","suffix":""},{"id":363450225,"identity":"89782f12-9591-4201-8e6e-2aba776618cf","order_by":9,"name":"Jun Li","email":"","orcid":"","institution":"The Affiliated Nanchong Central Hospital of North Sichuan Medical College","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Li","suffix":""},{"id":363450226,"identity":"656e9fca-e756-4aae-9464-3f22d4f4df69","order_by":10,"name":"Qiuling Shi","email":"","orcid":"","institution":"Chongqing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Qiuling","middleName":"","lastName":"Shi","suffix":""},{"id":363450227,"identity":"d370cc3c-fd89-4e57-8228-09d3557fd29b","order_by":11,"name":"Ying Tang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIiWNgGAWjYBACfvb+xw8+/LCxs29vIFKLZM8ZNsOZPWnJBjwHiNRicCOHQZqH7TDjBokEYrUcyD1gzMPDzGwu+XjjDYYam2jCDjtwLuHhHAs2PsvZacUWDMfSchsIaeE72GBg8AZoDcPtHDMJxobDhLUwHGYwkOBhAyq+eYZILQLHeAwkedgMGDfc4CFSi2QPWxowkBOSJXuAfkkgxi/88o8PA6Pyvx0/++GNNz7U2BDhFyRgQHTUIGkhVccoGAWjYBSMDAAAUvpBKxGm5aEAAAAASUVORK5CYII=","orcid":"","institution":"The Affiliated Nanchong Central Hospital of North Sichuan Medical College","correspondingAuthor":true,"prefix":"","firstName":"Ying","middleName":"","lastName":"Tang","suffix":""}],"badges":[],"createdAt":"2024-09-03 14:41:53","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5025850/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5025850/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-26412-3","type":"published","date":"2025-11-27T15:57:03+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":68000019,"identity":"4d4ba858-5a46-4cc1-a25d-609284592579","added_by":"auto","created_at":"2024-11-01 07:51:23","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":121215,"visible":true,"origin":"","legend":"\u003cp\u003eCA125 level in dysmenorrhea and non-dysmenorrhea group in different subgroups.\u003c/p\u003e\n\u003cp\u003eCA125 levels in patients with dysmenorrhea were higher than those in patients without dysmenorrhea in cohort（Z=-3.597，P＜0.001, Fig A）and the volume of uterine wall≥2/3 subgroup (Z=-3.150, P=0.002, Fig B), while no significant difference the volume of uterine wall＜2/3 subgroup(Z=-1.350, P=0.177, Fig C). For those with dysmenorrhea, CA125 levels of the volume of uterine wall≥2/3 subgroup were higher than those the volume of uterine wall＜2/3 subgroup (***Z=-2.503, P=0.012).\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5025850/v1/e85df0ce74d0fffa17d39722.png"},{"id":97178621,"identity":"18b1e59f-d9bb-4a0d-a169-ac67a61c1f4c","added_by":"auto","created_at":"2025-12-01 16:11:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1313610,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5025850/v1/2b29b2e6-eeea-4a73-a533-86b43a26760d.pdf"},{"id":68000020,"identity":"5eda4af9-3f71-4280-8610-a74ad101ec9d","added_by":"auto","created_at":"2024-11-01 07:51:23","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":127054,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarytable1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5025850/v1/7e855ef3e1ae71ad578ca034.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Magnetic resonance imaging-based Classification criteria combined with Serum CA125 for dysmenorrhea before focused ultrasound ablation surgery in adenomyosis","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAdenomyosis is a commonly seen disorder of the uterus in women of child-bearing age, characterizing by the lesion invasion into uterus, present with dysmenorrhea, menorrhagia and larger uterus, affecting the quality of women\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. The etiology and pathogenesis adenomyosis is not well known at present\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e, in which inflammation might be one main factor associated with dysmenorrhea secondary to adenomyosis.\u003c/p\u003e \u003cp\u003eCancer antigen 125 (CA125), a high macromolecule glycoprotein, is increasingly secreting from the embryonic coelomic epithelium to serum by peritoneal irritation or peritoneal stretch in inflammatory microenviroment\u003csup\u003e\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. It is mainly used as biomarker for investigating diagnosis and survival of ovarian cancer\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Our previous study has found that CA125 levels were closely correlated to dysmenorrhea in adenomyosis before focused ultrasound ablation surgery (FUAS), and CA125 levels in diffuse subtype was higher in relative to those in focal subtype, informing that CA125 might be one biomarker associated with disease severity for adenomyosis\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMagnetic resonance imaging (MRI) is considered as a moderately accurate test to diagnose and predict the disease severity for patients before FUAS\u003csup\u003e\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Recently, researchers have explored the classifications of adenomyosis according to MRI\u003csup\u003e\u003cspan additionalcitationids=\"CR11 CR12 CR13\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Our previous study has found that based on the affected area, pattern, size (volume), localization of adenomyotic lesions, and concomitant pathology, classification criterion 4 (C4) was considered to be the suitable classification criterion for dysmenorrhea secondary to adenomyosis\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. However, it is unclear which classification criterion is the suitable one for serum CA125 and whether classification criterion combined with CA125 could inform dysmenorrhea in adenomyosis.\u003c/p\u003e \u003cp\u003eThus, we retrospectively explored the data from a cohort of patients before FUAS, aiming to investigate the combined value of classification criterion and serum CA125 for dysmenorrhea, and study the factors influencing dysmenorrhea and the elevated CA125 level for investigating the possible pathogenesis of adenomyosis.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and patients\u003c/h2\u003e \u003cp\u003eThis retrospective study involved 502 patients, who were diagnosed as adenomyosis by MRI scan and treated by FUAS for dysmenorrhea or menorrhagia. Patients who had complete demographic and disease characteristics data were extracted from medical records in the Affiliated Nanchong Central Hospital of North Sichuan Medical College from June 2017 to March 2021. The study was conducted in accordance with the Declaration of Helsinki and performed in accordance with relevant guidelines/regulations. Approved by ethics committee of the Affiliated Nanchong Central Hospital of North Sichuan Medical College (permit number 2021/104), the study waived the need of obtaining informed consent due to the retrospective nature.\u003c/p\u003e \u003cp\u003eThe inclusion criteria for patients were patients with dysmenorrhea or menorrhagia secondary to adenomyosis, diagnosed by MRI before FUAS, received CA125 test and MRI examination before FUAS, and performed by FUAS\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe exclusion criteria for patients were those receiving no pre-FUAS CA125 test or MRI examination, with uterine fibroids or endometriosis or suspected malignant tumor in MRI imaging, which might lead to dysmenorrhea or menorrhagia, with inflammatory disease within a week, as well as a history of medicine for dysmenorrhea within 6 months, influencing the symptoms investigation before FUAS\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eAssessments\u003c/h2\u003e \u003cp\u003eAdenomyosis was diagnosed by imaging physicians based on MRI examination, which was defined as the maximal junctional zone thickness (JZmax) max\u0026thinsp;\u0026ge;\u0026thinsp;12 mm)\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, or the ratio of JZmax to the entire myometrium thickness\u0026thinsp;\u0026gt;\u0026thinsp;40%\u003csup\u003e11\u003c/sup\u003e, or the difference between the maximal and minimal JZ thickness\u0026thinsp;\u0026gt;\u0026thinsp;5 mm \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. The lesion size of uterine wall was defined as the size of lesion invasive into uterine wall. The uterine volume and the adenomyotic lesion volume were calculated using the following formula: 4/3πABC, where A, B, and C represent the long diameter, wide diameter, and thickness diameter of the lesion, respectively\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAs patient-reported pain during menstrual cycles, dysmenorrhea secondary to adenomyosis was acquired from medical records, and recorded in the clinical encounter before FUAS and follow-up\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Menorrhagia secondary to adenomyosis was set as the clinically recorded increasing patient-reported menstrual blood volume, and recorded in the clinical encounter before FUAS and follow-up\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Symptom recurrence was set as patient-reported dysmenorrhea and/or menorrhagia 12 months after a period when symptomatic relief lasted for at least 3 months after FUAS1.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSerum CA125 test before FUAS\u003c/h2\u003e \u003cp\u003eCA125 test samples of collecting and measurement followed the standard procedure, which were transported to the laboratory center at room temperature, measured by two-step immunoassay for the quantitative determination with flexible assay protocols within 24 h before FUAS, and assayed in a central laboratory\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eMRI-based classifications for adenomyosis\u003c/h2\u003e \u003cp\u003eImaging system by a 1.5 T MRI system informed the images information of pelvic-enhanced MRI patients. Based on the professional opinion, adenomyosis was also divided according to ultrasound-based classification system (C1, the morphological features of C1 were also assessable by MRI imaging\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e) and the MRI findings (C2-C5 \u003csup\u003e10\u003c/sup\u003e,\u003csup\u003e11\u0026minus;14\u003c/sup\u003e). Based on the five classification criteria, imaging physicians (ZJ, 10 years of experience; JZ, with 10 years of experience) and a gynecologist (YT, with 11 years of experience) were individually invited to reclassify adenomyosis\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Different classification standard criteria are listed in Supplementary Table\u0026nbsp;1. The classification parameters were used if the results were consistent between two readers, the third reader was invited to discuss the final classification parameters in the case of ambiguous or controversial results\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical methods\u003c/h2\u003e \u003cp\u003eAnalysis were performed in total cohort and stratified by the lesion size of uterine wall based on MRI: Group A, the lesion size of uterine wall\u0026thinsp;\u0026ge;\u0026thinsp;2/3, MRI-based severity group; Group B, the lesion size of uterine wall\u0026lt;2/3, MRI-based non-severity group. Continuous variables were summarized by the mean and standard deviation or median (P25, P75). In addition, interquartile range (IQR) and categorical variables were shown to be counts and percentages. This study adopted χ2 test, t test or Mann-Whiney U test for examining the differences of demographic and clinical factors between patients with and without dysmenorrhea in total cohort and subgroups. A logistic regression mode was used to explore the correlation between clinicopathlogical features (age, the lesion volume, the uterine volume, subcutaneous fat thickness, serum CA125) and dysmenorrhea by odds ratios (ORs) with 95% confidence intervals (95% CIs) in total cohort and subgroups. Using a Receiver Operating Characteristic (ROC) curve, the optimal cut-off of CA125 levels for dysmenorrhea before FUAS in adenomyosis were investigated. The logistic regression model was used for establishing the associations between elevated CA125 and dysmenorrhea before FUAS in adenomyosis in total cohort and subtype groups. To investigate the factors (age, the lesion size) influencing CA125 level before FUAS, multivariate logistic regression model was employed. GraphPad Prism 7.0 (Version X; La Jolla, CA, USA) was used for image editing. SPSS 22.0 (IBM, Armonk, NY) was adopted for the statistical analysis, and p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was thought to be of significance. The data was reviewed by the Data Survilliance and Monitoring Committee of the State Key Laboratory of Ultrasound in Medicine and Engineering. This committee is consisted of multidisciplinary experts in the clinical research.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eClinicopathlogical features in the total cohort\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe baseline characteristics, which included age, body mass index (BMI), serum CA125, uterine position and volumes, lesion position and volumes, distribution of dysmenorrhea and menorrhagia and symptom recurrence were summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinicopathlogical features in total cohort\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal cohort\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1, 2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUterus position (n(%))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnteverted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e292 (58.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetroverted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e192 (38.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUterus volume(cm3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e231.3\u0026thinsp;\u0026plusmn;\u0026thinsp;124.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenomyosis location (n(%))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e148 (29.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e263 (52.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFundus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38(7.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLateral (left or right)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27(5.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior/Posterior/ Fundus/ Lateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26(4.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLesion volume (cm3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.6\u0026thinsp;\u0026plusmn;\u0026thinsp;56.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubcutaneous fat thickness (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistance (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.0\u0026thinsp;\u0026plusmn;\u0026thinsp;14.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum CA125 (U/ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.9 (30.0, 106.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDysmenorrhea (n(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e381(75.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e121(24.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenorrhagia (n(%))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e272 (54.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e230 (45.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptom recurrence (n(%))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e133 (26.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e369 (73.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eBMI, body mass index; CA125, cancer antigen 125; distance, distance from the posterior surface of the adenomyosis lesion to the sacrum.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eThe magnitude of classifications associated with the CA125 of adenomyosis\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e showed χ2 value in C4, considered as the suitable one for CA125, was higher than those in other classification criteria (χ2\u0026thinsp;=\u0026thinsp;22.003, P\u0026lt;0.001). In C1, serum CA125 levels in subtype-2 (60.0 U/ml (30.2 U/ml, 124.8U/ml)) were higher than those in subtype-1 (52.2 U/ml (31.1 U/ml, 81.3 U/ml), p\u0026thinsp;=\u0026thinsp;0.007). In C2, serum CA125 levels in subtype-4 (106 U/ml (47 U/ml, 182.5 U/ml) were higher than those in other subtypes (P\u0026thinsp;=\u0026thinsp;0.006). In C4, no matter intrinsic or external subtype, serum CA125 of Group A was higher than that of Group B (Z\u0026thinsp;=\u0026thinsp;22.003, P\u0026lt;0.001). In C5, serum CA125 in subtype-6 was higher when compared with that in other subtypes (P\u0026thinsp;=\u0026thinsp;0.006). There existed no significant differences for CA125 in C3 (P\u0026gt;0.05) .\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe identification of different classifications based on MRI for serum CA125.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSubtype-1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubtype-2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSubtype-3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSubtype-4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSubtype-5\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSubtype-6\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClassification \u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52.2 (31.1, 81.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e60.0 (30.2, 124.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e7.380\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClassification 2\u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55 (27.5,98.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57(30.3,104.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45(24,67.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e106(47,182.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e12.395\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClassification 3\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55 (28.8,108.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45(28.0,69.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e60(33,123)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e4.444\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.108\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClassification 4\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (12.0,42.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e33.5(13.7,61.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55(30,108)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e93(51-)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35(26.3,67.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e59(34,123)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e22.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClassification 5\u003csup\u003e13\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e50.5 (27.0,93.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72.5(23.3,121.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58(31,108)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e45(29.5,67.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e94(41.8, 173)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e123(51,213.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e16.265\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e* p\u0026lt;0.05\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e14.Hulka CA, Hall DA, McCarthy K, Simeone J. Sonographic findings in patients with adenomyosis: can sonography assist in predicting extent of disease? \u003cem\u003eAJR American journal of roentgenology\u003c/em\u003e 2002;179(2):379\u0026thinsp;\u0026minus;\u0026thinsp;83.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e10.Kishi Y, Suginami H, Kuramori R, Yabuta M, Suginami R, Taniguchi F. Four subtypes of adenomyosis assessed by magnetic resonance imaging and their specification. \u003cem\u003eAmerican journal of obstetrics and gynecology\u003c/em\u003e 2012;207(2):114.e1-7.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e11. Bazot M, Dara\u0026iuml; E. Role of transvaginal sonography and magnetic resonance imaging in the diagnosis of uterine adenomyosis. \u003cem\u003eFertility and sterility\u003c/em\u003e 2018;109(3):389\u0026thinsp;\u0026minus;\u0026thinsp;97.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e12. Kobayashi H, Matsubara S. A Classification Proposal for Adenomyosis Based on Magnetic Resonance Imaging. \u003cem\u003eGynecologic and obstetric investigation\u003c/em\u003e 2020;85(2):118\u0026thinsp;\u0026minus;\u0026thinsp;26.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003e13. Gong C, Wang Y, Lv F, Zhang L, Wang Z. Evaluation of high intensity focused ultrasound treatment for different types of adenomyosis based on magnetic resonance imaging classification. \u003cem\u003eInternational journal of hyperthermia : the official journal of European Society for Hyperthermic Oncology, North American Hyperthermia Group\u003c/em\u003e 2022;39(1):530-8.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eClinicopathlogical features according to Classification criterion 4\u003c/h2\u003e \u003cp\u003eAccording to the results of priority study, dysmenorrhea and menorrhagia rates were different upon the size of uterine wall based on C4. Patients were included into the lesion size of uterine wall\u0026thinsp;\u0026ge;\u0026thinsp;2/3 group (Group A, N\u0026thinsp;=\u0026thinsp;446, 88.8%, and 68% failure with gonadotrophin-releasing hormone agonist (GnRH-a) or levonorgestrel within 2 years) and the lesion size of uterine wall\u0026lt;2/3 group (Group B, N\u0026thinsp;=\u0026thinsp;56,11.2%, and 35.7% failure with GnRH-a or levonorgestrel within 2 years). The uterine volumes(236.9\u0026thinsp;\u0026plusmn;\u0026thinsp;125.6 cm3), lesion volumes (56.1\u0026thinsp;\u0026plusmn;\u0026thinsp;55.7 cm3) and CA125 57.9 U/ml (31.1 U/ml, 111.1 U/ml) in Group A were higher than those in Group B (P\u0026lt;0.001, Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics in subtype groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable Variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMRI-based severity group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;446, 88.8%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMRI-based non-severity group\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;56, 11.2%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTest value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e43.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.777\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.076\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.337\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.182\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1, 2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1, 1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.901\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.368\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUterus position\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.572\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnteverted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e263(59.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (51.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetroverted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e167 (37.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (44.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUterine volume(cm3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e236.9\u0026thinsp;\u0026plusmn;\u0026thinsp;125.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e185.0\u0026thinsp;\u0026plusmn;\u0026thinsp;105.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.889\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenomyosis location\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.117\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.714\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e135 (30.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13(23.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e231 (51.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32(12.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFundus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (8.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLateral (left or right)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25(5.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnterior/Posterior/undus/ Lateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22(4.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (7.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenomyotic lesion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56.1\u0026thinsp;\u0026plusmn;\u0026thinsp;55.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.3\u0026thinsp;\u0026plusmn;\u0026thinsp;51.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(cm3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubcutaneous fat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.5\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.637\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.527\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ethickness (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistance (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.9\u0026thinsp;\u0026plusmn;\u0026thinsp;14.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.1\u0026thinsp;\u0026plusmn;\u0026thinsp;15.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.504\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.614\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemoglobin (g/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97.7\u0026thinsp;\u0026plusmn;\u0026thinsp;19.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e100.2\u0026thinsp;\u0026plusmn;\u0026thinsp;24.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.397\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.694\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCA125 (U/ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.9(31.1, 111.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35.1(16.8, 67.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-3.236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDysmenorrhea(n(%))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.227\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.136\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e343(76.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38(67.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103 (23.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18(32.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenorrhagia(n(%))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.333\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.127\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e247(55.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23(44.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e199 (44.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29(55.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptom recurrence(n(%))\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9.883\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e125 (28.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (15.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e321 (72.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66 (84.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eGroup A, the lesion size of uterine wall\u0026thinsp;\u0026ge;\u0026thinsp;2/3; Group B, the lesion size of uterine wall\u0026lt;2/3; BMI, body mass index; CA125, cancer antigen 125; distance from the posterior surface of the adenomyosis lesion to the sacrum.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWe further explored the relationship between CA125 and dysmenorrhea in different groups, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. CA125 levels in patients suffering from dysmenorrhea were higher when compared with those in patients without dysmenorrhea in total cohort(Z=-3.597, P\u0026lt;0.001, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA)and Group A (Z=-3.150, P\u0026thinsp;=\u0026thinsp;0.002, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB), while no significant difference was found in Group B (Z=-1.350, P\u0026thinsp;=\u0026thinsp;0.177, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). In terms of those with dysmenorrhea, CA125 levels of Group A were higher than those in Group B (Z=-2.503, P\u0026thinsp;=\u0026thinsp;0.012).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eThe factors influencing dysmenorrhea in total cohort and subtypes subgroups\u003c/h2\u003e \u003cp\u003eIn total cohort, univariate logistic regression demonstrated that age (OR\u0026thinsp;=\u0026thinsp;0.909, 95% CI 0.869\u0026thinsp;~\u0026thinsp;0.951, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), CA125 (OR\u0026thinsp;=\u0026thinsp;1.004, 95% CI 1.001\u0026thinsp;~\u0026thinsp;1.017, P\u0026thinsp;=\u0026thinsp;0.012) and subcutaneous fatthickness (OR\u0026thinsp;=\u0026thinsp;0.97, 95% CI 0.94\u0026ndash;0.99, P\u0026thinsp;=\u0026thinsp;0.007) were related to dysmenorrhea of patients with adenomyosis. However, there were no associations between BMI, the lesion size of uterine wall(\u0026ge;2/3 vs.\u0026lt;2/3) and dysmenorrhea (P\u0026gt;0.05). According to multivariate logistic regression, age (OR\u0026thinsp;=\u0026thinsp;0.900, 95% CI 0.855\u0026thinsp;~\u0026thinsp;0.947, P\u0026thinsp;=\u0026thinsp;0.007), and CA125 (OR\u0026thinsp;=\u0026thinsp;1.004, 95% CI 1.001\u0026thinsp;~\u0026thinsp;1.007, P\u0026thinsp;=\u0026thinsp;0.018) were correlated with dysmenorrhea of patients with adenomyosis, while subcutaneous fatthickness showed no significant association with dysmenorrhea (P\u0026thinsp;=\u0026thinsp;0.073) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBinary logistic regression analysis of factors impacting dysmenorrhea of adenomyosis in total cohort.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eUnivariate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eMultivariate\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.909\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.869\u0026thinsp;~\u0026thinsp;0.951\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.855\u0026thinsp;~\u0026thinsp;0.947\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.940\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.873\u0026thinsp;~\u0026thinsp;1.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.927\u0026thinsp;~\u0026thinsp;1.111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.753\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenorrhagia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.162\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.774\u0026thinsp;~\u0026thinsp;1.748\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.468\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.727\u0026thinsp;~\u0026thinsp;1.801\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.561\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Yes vs. No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe volume of uterine wall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.577\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.864\u0026thinsp;~\u0026thinsp;2.881\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.299\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.644\u0026thinsp;~\u0026thinsp;2.622\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.465\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(\u0026ge;\u0026thinsp;2/3 vs.\u0026lt;2/3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum CA125 (U/ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.001\u0026thinsp;~\u0026thinsp;1.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.001\u0026thinsp;~\u0026thinsp;1.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubcutaneous fatthickness (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.967\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.944\u0026thinsp;~\u0026thinsp;0.991\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.975\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.948\u0026thinsp;~\u0026thinsp;1.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eCA125, cancer antigen 125; BMI, body mass index\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn severity group (Group A) based on MRI, multivariate logistic regression showed that age (OR\u0026thinsp;=\u0026thinsp;0.897, 95% CI:0.849\u0026thinsp;~\u0026thinsp;0.948, P\u0026lt;0.001) and CA125 (OR\u0026thinsp;=\u0026thinsp;1.004, 95% CI 1.001\u0026thinsp;~\u0026thinsp;1.008, P\u0026thinsp;=\u0026thinsp;0.021) were related to dysmenorrhea of patients with adenomyosis, while did not significantly associated with dysmenorrhea in Group B (P\u0026thinsp;=\u0026thinsp;0.073) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBinary logistic regression analysis of factors for dysmenorrhea of adenomyosis in subgroups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eThe volume of uterine wall\u0026thinsp;\u0026ge;\u0026thinsp;2/3(Group A)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eThe volume of uterine wall\u0026lt;2/3(Group B)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.897\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.849\u0026thinsp;~\u0026thinsp;0.948\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.887\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.763\u0026thinsp;~\u0026thinsp;1.031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.119\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.924\u0026thinsp;~\u0026thinsp;1.124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.701\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.983\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.750\u0026thinsp;~\u0026thinsp;1.289\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.903\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenorrhagia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.272\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.783\u0026thinsp;~\u0026thinsp;2.066\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.331\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.494\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.123\u0026thinsp;~\u0026thinsp;1.985\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.320\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Yes vs. No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSerum CA125(U/ml)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.001\u0026thinsp;~\u0026thinsp;1.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.999\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.987\u0026thinsp;~\u0026thinsp;1.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.908\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubcutaneous fatthickness (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.976\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.943\u0026thinsp;~\u0026thinsp;1.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.967\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.914\u0026thinsp;~\u0026thinsp;1.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.246\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eCA125, cancer antigen 125; Group A, the lesion size of uterine wall\u0026thinsp;\u0026ge;\u0026thinsp;2/3; Group B, the lesion size of uterine wall\u0026lt;2/3; BMI, body mass index.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eIdentification of CA125 for dysmenorrhea in MRI-based severity group\u003c/h2\u003e \u003cp\u003eROC curves were employed to assess the magnitude of CA125 for dysmenorrhea in Group A. Sensitivity, specificity, optimal value, area under the curve, 95 CIs and p-value were 59.2%, 59.2%, 44.8, 0.594, 0.547\u0026thinsp;~\u0026thinsp;0.640, P\u0026thinsp;=\u0026thinsp;0.002.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eThe factors impacting CA125 level in MRI-based severity group\u003c/h2\u003e \u003cp\u003eThen, we investigated the factors causing the increased CA125 levels in MRI-based severity group by multivariate logistic regression. Based on the results, the lesion volume positively related to elevated CA125 levels (OR\u0026thinsp;=\u0026thinsp;1.016, 95%: 1.008\u0026ndash;1.025, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while the ages exhibited a negative correlation with elevated CA125 levels (OR\u0026thinsp;=\u0026thinsp;0.943, 95%༚0.898\u0026ndash;0.991, P\u0026thinsp;=\u0026thinsp;0.021) (Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate binary logistic regression analysis of factors for CA125 in MRI-based severity group.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eS.E.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWald\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95%CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.342\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.943\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.898\u0026ndash;0.991\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.037\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.643\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.964\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.880\u0026ndash;1.055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.423\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenorrhagia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.137\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.236\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.336\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.872\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.549\u0026ndash;1.386\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.562\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Yes vs. No)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUterine volume (cm3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.998\u0026ndash;1.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.810\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLesion volume (cm3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.408\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.008\u0026ndash;1.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubcutaneous fatthickness (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.975\u0026ndash;1.041\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.659\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eCA125, cancer antigen 125; BMI, body mass index\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eOur study showed that C4 based on MRI was the suitable classification criterion for CA125 in patients with adenomyosis before FUAS. For those with dysmenorrhea, CA125 levels in MRI-based severity group were shown to be higher than those of the non-severity group, while they showed no significant difference in those without dysmenorrhea. CA125 level of 44.8 U/ml was found to be the optimal cut-off point of dysmenorrhea in severity group based on MRI. When we extended the study to investigate the factors related to the elevated CA125 in MRI-based severity group, the lesion volume was considered as the positively one, while the ages negatively one.\u003c/p\u003e \u003cp\u003eConsist with the results that adenomyosis is actually related to expression of uterine inflammatory mediators and cytokines\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e, including tumor necrosis factor-α, β (TNF- α, β), interleukin (IL)-1β, IL-18 and CA125, our results again demonstrated that elevated CA125 level was associated with dysmenorrhea secondary to adenomyosis in patients without uterine fibroids and endometriosis\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. It indicated the higher level of serum CA125, the higher possibilities of dysmenorrhea secondary to adenomyosis\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Classification criterion based on MRI also could inform the severity of dysmenorrhea. In the previous study, we found the severity disease was different considered the lesion size of uterine wall. In this study, we found that the C4 was the suitable classification criterion for CA125. Furthermore, we explored the association between CA125 and dysmenorrhea based on C4. While the lesion size of uterine wall\u0026thinsp;\u0026ge;\u0026thinsp;2/3, CA125 was positively associated with the severity of dysmenorrhea. In the previous study, we confirmed the commonly used diagnosis value, and 35 U/ml was the optimal cut-point for dysmenorrhea\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. In this study, we further investigated CA125 as 48.4 U/ml was the optimal cut-point for dysmenorrhea in the patients whose lesion size of uterine wall\u0026thinsp;\u0026ge;\u0026thinsp;2/3. Meanwhile, no matter what is the cut-off point of CA125 for dysmenorrhea, elevated CA125 level was positively associated with the lesion volume, and negatively associated with the age.\u003c/p\u003e \u003cp\u003eAs the main symptom of adenomyosis, dysmenorrhea is probably the results of inflammation, neurogenesis, angiogenesis, and contractile abnormalities in the endometrial and myometrial components\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Dysmenorrhea can be adjusted by abnormal genetic, including CYP1A1 and A2, catechol-O-methyltransferas, Cytochrome P450, lipoxygenase-5 and Cyclooxygenase-2\u003csup\u003e3, 21, 22\u003c/sup\u003e, involving the key processes in adenomyosis development. Dysmenorrhea could be illuminated by myometrial hypercontractility, and indicated by higher expression of oxytocin receptors and increased contractile amplitude of uterine smooth muscle cells (uSMCs) in adenomyotic uteri, resulting in hyperestrogenism, progesterone resistance, and inflammatory microenvironment\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Then, inflammatory microenviroment promoted the ectopic endometrium secretion of significantly higher CA125 level compared with the normal endometrium\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. The high expression of IL-1β, CRH, and UCN observed in adenomyotic lesions may mediate prostaglandins synthesis and stimulate peritoneal irritation and peritoneal stretch, and therefore CA125 reached the blood circulation through changing endothelial permeability\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Furthermore, our study attempted to explore the combined value of MRI and CA125 for dysmenorrhea secondary to adenomyosis. The results showed that when the MRI imaging informing the invasion wall\u0026thinsp;\u0026ge;\u0026thinsp;2/3, the larger areas of lesion, the higher levels of CA125 in adenomyosis. Meanwhile, CA125 may aggravate inflammation through promoting ectopic endometrium migration and adhesion in the surrounding myometrium in adenomyosis development\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, which might result in a relatively severity level of the disease. While the MRI imaging informing the invasion lesion of uterus wall, the patients have higher possibilities of dysmenorrhea before FUAS. These findings might offer clues for investigating the pathogenesis of dysmenorrhea based on MRI and CA125. The suitable classification criterion based on MRI for CA125 might be beneficial for exploring the possible mechanisms with disease development.\u003c/p\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and Strengths\u003c/h2\u003e \u003cp\u003eThe strength of the current retrospective study was that we informed a suitable classification criterion based on MRI for CA125, further showing that CA125 was associated with dysmenorrhea secondary to adenomyosis upon severity disease based on MRI with a relatively large sample size. This might be of interest to researchers to study pathogenesis of dysmenorrhea based on MRI and CA125. However, this study still had the following limitations. Firstly, patients included in this study were those who received FUAS, which had potential limitation for selection bias and might limit the interpretation of our results to the general patient population. We will include the patients with non FUAS treatment and compare the predictive value of MRI and CA125 for clinic symptom of patients between the FUAS group and non-FUAS group in the future. Secondly, we could not conclude that CA125 was a risk factor of dysmenorrhea in MRI -based severity group in adenomyosis for the retrospective design. However, we demonstrated that CA125 is associated with dysmenorrhea secondary to adenomyosis in MRI -based severity group. Thirdly, although a few patients without complete data were excluded for the retrospective design, the clinicopathologic features of our cohort showed no significant difference from epidemiology of adenomyosis\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. Finally, CA125 results might be interfered by sample collection and test. We collected and measured CA125 within one day before FUAS, aiming to minimize interference factors for the findings. Meanwhile, we will assess the severity level of dysmenorrhea by Numerical Rating Scale, not just by describing dysmenorrhea as yes or no with design prospective and multicenter studies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn summary, this study informed that C4 based on MRI was the suitable one for CA125. Patients with increased CA125\u0026gt;44.8 U/ml were prone to suffer from dysmenorrhea secondary to adenomyosis in MRI-based severity group. Besides, the lesion volume positively related to elevated CA125 levels, while the ages exhibited a negative correlation with elevated CA125 levels.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eStatement of Ethics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe approval of this study was approved by ethics committee of the Affiliated Nanchong Central Hospital of North Sichuan Medical College (permit number. 2021/104). Due to data anonymization and the retrospective nature of the study, the need for consent was waived.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Ministry of Science and Technology of China (Grant No.2022YFE0133100), foundation of State Key Laboratory of Ultrasound in Medicine and Engineering (Grant No. 2020KFKT003,\u0026nbsp;2021KFKT022), the Bureau of Science and Technology Nanchong City Program (No. 20SXQT0320, 22SXQT0254, 22SXQT034) and university project of North Sichuan Medical College (NO.\u0026nbsp;CBY23-ZDA12, CBY23-QNA11 and\u0026nbsp;CBY23-QNA19).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was designed by YT, HQH,\u0026nbsp;BS, QLS and carried out by YT,\u0026nbsp;JL,WH, JRH and MTY, BS,\u0026nbsp;HNH,\u0026nbsp;WT, ZJJ, and LJZ provided data from medical records. All drafted the first manuscript with help from HQH and\u0026nbsp;YT. All authors contributed to and approved the final version of the article for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTang, Y. et al. Magnetic Resonance Imaging-Based Classification Systems for Informing Better Outcomes of Adenomyosis After Ultrasound-Guided High-Intensity Focused Ultrasound Ablating Surgery. \u003cem\u003eJ. Magn. Reson. imaging: JMRI\u003c/em\u003e (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSheth, S. S. \u0026amp; Ray, S. S. Severe adenomyosis and CA125. \u003cem\u003eJ. Obstet. gynaecology: J. Inst. Obstet. Gynecol.\u003c/em\u003e \u003cb\u003e34\u003c/b\u003e (1), 79\u0026ndash;81 (2014).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhai, J., Vannuccini, S., Petraglia, F. \u0026amp; Giudice, L. C. Adenomyosis: Mechanisms and Pathogenesis. \u003cem\u003eSemin. Reprod. Med.\u003c/em\u003e \u003cb\u003e38\u003c/b\u003e (2\u0026ndash;03), 129\u0026ndash;143 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang, Y. et al. Serum CA125 as a biomarker for dysmenorrhea in adenomyosis. \u003cem\u003eInt. J. Gynaecol. Obstet.\u003c/em\u003e (2023).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang, Y. et al. Preoperative CA125 as a risk factor for symptom recurrence of adenomyosis after ultrasound-guided high-intensity focused ultrasound ablation surgery. \u003cem\u003eInt. J. hyperthermia: official J. Eur. Soc. Hyperthermic Oncol. North. Am. Hyperth. Group.\u003c/em\u003e \u003cb\u003e39\u003c/b\u003e (1), 1164\u0026ndash;1169 (2022).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKil, K. et al. Usefulness of CA125 in the differential diagnosis of uterine adenomyosis and myoma. \u003cem\u003eEur. J. Obstet. Gynecol. Reprod. Biol.\u003c/em\u003e \u003cb\u003e185\u003c/b\u003e, 131\u0026ndash;135 (2015).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTang, Y. et al. Combined Preoperative LMR and CA125 for Prognostic Assessment of Ovarian Cancer. \u003cem\u003eJ. Cancer\u003c/em\u003e. \u003cb\u003e11\u003c/b\u003e (11), 3165\u0026ndash;3171 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang, M., Cheng, S., Jin, Y., Zhao, Y. \u0026amp; Wang, Y. Roles of CA125 in diagnosis, prediction, and oncogenesis of ovarian cancer. \u003cem\u003eBiochim. et Biophys. acta Reviews cancer\u003c/em\u003e. \u003cb\u003e1875\u003c/b\u003e (2), 188503 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKobayashi, H., Matsubara, S. \u0026amp; Imanaka, S. Relationship between magnetic resonance imaging-based classification of adenomyosis and disease severity. \u003cem\u003eJ. Obstet. Gynaecol. Res.\u003c/em\u003e \u003cb\u003e47\u003c/b\u003e (7), 2251\u0026ndash;2260 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKishi, Y. et al. Four subtypes of adenomyosis assessed by magnetic resonance imaging and their specification. \u003cem\u003eAm. J. Obstet. Gynecol.\u003c/em\u003e \u003cb\u003e207\u003c/b\u003e (2), 114e1\u0026ndash;114e7 (2012).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBazot, M. \u0026amp; Dara\u0026iuml;, E. 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J. translational Res.\u003c/em\u003e \u003cb\u003e13\u003c/b\u003e (4), 2858\u0026ndash;2866 (2021).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKobayashi, H., Ida, W., Terao, T. \u0026amp; Kawashima, Y. Molecular characteristics of the CA 125 antigen produced by human endometrial epithelial cells: comparison between eutopic and heterotopic epithelial cells. \u003cem\u003eAm. J. Obstet. Gynecol.\u003c/em\u003e \u003cb\u003e169\u003c/b\u003e (3), 725\u0026ndash;730 (1993).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu, S. et al. LncRNA H19 Overexpression in Endometriosis and its Utility as a Novel Biomarker for Predicting Recurrence. \u003cem\u003eReproductive Sci. (Thousand Oaks Calif)\u003c/em\u003e. \u003cb\u003e27\u003c/b\u003e (9), 1687\u0026ndash;1697 (2020).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUpson, K. \u0026amp; Missmer, S. A. Epidemiology of Adenomyosis. \u003cem\u003eSemin Reprod. Med.\u003c/em\u003e \u003cb\u003e38\u003c/b\u003e (2\u0026ndash;03), 89\u0026ndash;107 (2020).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"CA125, MRI, classification, adenomyosis, dysmenorrhea, severity","lastPublishedDoi":"10.21203/rs.3.rs-5025850/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5025850/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo inform dysmenorrhea for exploring the possible pathogenesis of adenomyosis based on MRI classification criteria and serum CA125.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients before focused ultrasound ablation surgery were categorized into MRI -based severity group (Group A) and MRI -based non-severity group (Group B). Binary logistic regression was employed to identify the factors associating dysmenorrhea and CA125 level in total cohort and subgroups via MRI-based classifications criteria. The receiver-operating characteristic (ROC) curve was applied to assess the utility of CA125 for dysmenorrhea the subgroups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients in dysmenorrhea subtype exhibited higher CA125 levels compared with those in non-dysmenorrhea subtype in total cohort and Group A(P\u0026lt;0.05). In terms of those with dysmenorrhea, CA125 levels of Group A were shown to be higher when compared with those of Group B(P\u0026lt;0.05). In Group A, multivariate logistic regression showed that age and CA125 were related to dysmenorrhea in adenomyosis(P\u0026lt;0.05). CA125 level of 44.8 U/ml was demonstrated as the optimal cut-off point for dysmenorrhea by ROC curves in Group A. In relative to patients whose CA125 ≤ 44.8 U/ml, those with CA125 levels \u0026gt; 44.8 U/ml were more probably to suffer from dysmenorrhea. Furthermore, the multiple regression analysis demonstrated that CA125 level exhibited a positive correlation with the lesion volume and negatively related to age(P\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients with CA125\u0026gt;44.8 U/ml were prone to suffer from dysmenorrhea secondary to adenomyosis in MRI -based severity group. Besides, age and the lesion volume were associated with CA125 levels.\u003c/p\u003e","manuscriptTitle":"Magnetic resonance imaging-based Classification criteria combined with Serum CA125 for dysmenorrhea before focused ultrasound ablation surgery in adenomyosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-01 07:51:18","doi":"10.21203/rs.3.rs-5025850/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-08T05:32:30+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-10-03T19:30:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"237473927047849013081507860186820956208","date":"2024-09-27T16:21:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"71061047983151331440379480047930493527","date":"2024-09-24T19:40:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-18T18:09:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"107451301938563535547493936911270615552","date":"2024-09-18T18:03:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-18T07:50:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-17T17:26:46+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-09-17T14:36:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-16T09:56:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-09-03T14:40:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5c88e1bf-7c82-407a-9b69-1d79adcc9dc1","owner":[],"postedDate":"November 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":38661848,"name":"Health sciences/Biomarkers"},{"id":38661849,"name":"Health sciences/Diseases"},{"id":38661850,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2025-12-01T16:05:21+00:00","versionOfRecord":{"articleIdentity":"rs-5025850","link":"https://doi.org/10.1038/s41598-025-26412-3","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-11-27 15:57:03","publishedOnDateReadable":"November 27th, 2025"},"versionCreatedAt":"2024-11-01 07:51:18","video":"","vorDoi":"10.1038/s41598-025-26412-3","vorDoiUrl":"https://doi.org/10.1038/s41598-025-26412-3","workflowStages":[]},"version":"v1","identity":"rs-5025850","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5025850","identity":"rs-5025850","version":["v1"]},"buildId":"WvIrzKhiLBfengagbw6Ux","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}