216 Nevertheless, the study also has a several limitations. The clearest limitation is the relatively small sample size of the study population (although it is generally larger than previous studies into uterine peristalsis (266)). Additionally, within-subject comparison was not possible in our groups as most women did not undergo TVUS in every phase of the menstrual cycle. Likewise, no sub-analysis was done to assess how different subtypes, locations and/or severity of adenomyosis may affect UC, as well as the added presence of endometriosis. These factors may all affect UC, as already shown by the significant differences in UC depending on degree of dysmenorrhea in this study. A barrier to carrying out this sub-analysis is the lack of uniform consensus on adenomyosis subtypes and how to define mild versus severe adenomyosis. Another limitation is that the adenomyosis group was significantly older, had higher BMIs, greater uterus sizes, and higher parity than controls. As we do not yet know how age, uterus size, and BMI affect UC, their possible confounding effect cannot be discarded. It should be noted that adenomyosis itself leads to a higher uterine volume however. In addition, there was a relatively high number of recordings (n=33) that had to be excluded during the quality check. Within the adenomyosis group some recordings were excluded due to the severity of the adenomyosis which affected the imaging quality of the uterus. The ultimately analysed study group therefore consists of a higher number of relatively mild adenomyosis cases. Our results could therefore be an underestimation of the differences in UC between adenomyosis patients and healthy controls. Lastly, the TVUS speckle tracking method is not yet applicable for use in daily practice. Currently, contraction features are extracted through offline data processing, which does not allow them to be viewed in real time. Our findings give new insights into the aetiology and clinical presentation of adenomyosis and may provide us with new diagnostic and therapeutic markers. In clinical practice, UC features can be used to objectively identify the initial extent of adenomyosis severity (and potentially its symptoms) and perhaps help to interpret the effect of treatment over time. Uterine contraction coordination especially provides a new avenue for future research to improve fertility in adenomyosis patients. Lastly, speckle tracking could also be used to identify aberrant UC features in other benign uterine disorders, such as
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