214 Discussion: This multi-centre prospective study investigated the difference in uterine contractile features between women with adenomyotic versus normal uteri. Generally, adenomyosis patients had a lower CF and velocity, increased amplitude, and reduced contraction coordination compared to controls in most phases of the menstrual cycle, most significantly in the late follicular and late luteal phases. Our findings confirm the hypotheses proffered in previous literature, that uterine (contractile) function is dysfunctional in women with adenomyosis. Several theories have been postulated in the literature to explain the dysfunction. An overexpression of oxytocin receptors in the myometrium of adenomyosis patients which can lead to hyperperistalsis and dysperistalsis has for instance been reported (259,268–270), reflecting increased contractile amplitude and more severe dysmenorrhea in adenomyosis patients. Studies have also reported that uterine oestrogen levels are raised in adenomyosis compared to healthy women (271,272). Oestrogen is known to stimulate uterine peristalsis and proliferation of the endometrium, and it is hence hypothesized that the hyper-estrogenic state may lead to (chronic) hyper-and dys-peristalsis (8). Dysperistalsis is associated with damage to the JZ, which is visible on TVUS and MRI imaging in adenomyosis. Our study supports these findings as amplitude was found to be increased in adenomyosis patients compared to healthy women throughout the menstrual cycle, potentially due to fibrotic changes in the JZ in adenomyosis. Furthermore, our results similarly suggest that more severe dysmenorrhea is associated with more aberrant UC. However, the uterine hyperperistalsis that is described in adenomyosis patients in previous literature (76,77) was not reflected in our results, that is, if hyperperistalsis is to be interpreted as increased contraction frequency. Our findings instead show trends towards decreased CF in adenomyosis patients compared to healthy women, but with higher amplitude. We therefore cannot totally confirm the presence of hyperperistalsis in adenomyosis patients but do confirm fewer organized contractions (or less coordination of contractions) of higher amplitude, better encompassed by the word dysperistalsis. This finding is reflected in our results by way of universally decreased contraction coordination in adenomyosis patients compared to controls throughout the menstrual cycle.
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