{"paper_id":"137af628-5332-48c3-b221-19181bffd5e8","body_text":"196\nAssociation of the presence of adenomyosis and clinical \ncharacteristics in post-hysterectomy patients\nChristian M. Rivas-Arredondo, Adiel Ortega-Ayala, Rogelio de J. Orozco-Castellanos, \nPamela I. Aguilar-Delgado, Linda C. Quiroz-Gonzalez, and Luis A. Pantoja-Quezada*\nDepartment of Gynecology and Obstetrics, Hospital de la Mujer Juárez, Secretaría de Salud, Ciudad Juarez, Chihuahua, Mexico\nORIGINAL ARTICLE\nAbstract\nIntroduction: It has been estimated that the prevalence of adenomyosis is 5-70% in Mexico. For the correct study of ade -\nnomyosis, the histopathological study of the hysterectomy specimen remains the only confirmatory diagnosis. For this reason, \nthere are not many current studies that tell us the prevalence of this pathology, which is why it is important to carry out \nintentional searches. Objective: T o estimate the prevalence of adenomyosis in patients undergoing total and subtotal hyster\n-\nectomy, abdominal, laparoscopic, and vaginal hysterectomy in the period from 2019 to 2021 in Ciudad Juárez and to determine \nwhether there are clinical factors associated with the presence of adenomyosis. Material and methods: Cross-sectional, \nretrospective, descriptive study. This study was conducted in patients who underwent total and subtotal abdominal, laparo\n-\nscopic, and vaginal hysterectomy, whose histopathological reports were collected from January 2019 to December 2021 . \nPatients with a subtotal hysterectomy were excluded. Results: A  total of 332 patients were studied, in which a prevalence \nof 29.5% was observed, like that established in the general biblio graphy. Conclusions: Adenomyosis is the second gyneco\n-\nlogical pathology in order of frequency, only below leiomyomatosis, by histopathological diagnosis. According to the study, \nthe clinical profile of patients to be ruled out for adenomyosis would be a history of previous uterine surgery, multiparity, in \nthe fifth decade of life (specifically between 40 and 50 years of age), overweight, or obese.\nKeywords: Adenomyosis. Hysterectomy. Uterine hemorrhage. Uterine diseases. Mexico. \n*Correspondence: \nLuis A. Pantoja-Quezada \nE-mail: betopantoja94@icloud.com\nAvailable online: 01-10-2025  \nRev Med Hosp Gen Mex. 2025;88(4):196-201  \nwww.hospitalgeneral.mx\nDate of reception: 14-12-2024\nDate of acceptance: 03-04-2025\nDOI: 10.24875/HGMX.24000096\n0185-1063/© 2025 Sociedad Médica del Hospital General de Mexico. Published by Permanyer. This is an open access article under the  \nCC BY -NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).\nIntroduction\nDysfunctional uterine bleeding is the main cause of \nbleeding in adult women; its diagnosis is the exclusion \nof anatomical alterations, so the clinician must initially \nrule out any organic or endocrinological pathology. It is \nestimated that around 10 million women in Mexico suffer \nfrom uterine bleeding, and annually, only 6 million of \nthem seek medical attention\n1.\nThe exact pathogenesis of adenomyosis has not \nbeen established, but some theories have been widely \naccepted and adopted by physicians\n2. The most com -\nmon theory suggests that adenomatosis results from \nthe invagination of endometrial glands and stroma in \nthe thickness of the myometrium, together with hyper -\nplasia and hypertrophy of smooth muscle fibers of the \nlatter3. Another possible theory is that the adenomyotic \nlesions are due to the metaplasia of displaced Müllerian \nremains or to the differentiation of adult stem cells 4.\nThe prevalence of adenomyosis as an anatomo -\npathological finding is highly variable, ranging from 5% \nto 70%, depending on the depth limit considered in the \nmicroscopic finding of foci in myometrial thickness1. Arel-\nlano Pichardo et al. in a study carried out in the Mexican \npopulation, they showed that the prevalence of \nRevista Médica del  \nHospital General de México\n\nC.M. Rivas-Arredondo et al.  Adenomyosis in hysterectomized women\n197\nadenomyosis in hysterectomy specimens was 33.33% \n(86 out of 258 patients) 3, as well as a study carried out \nin the United States in which a total of 135,162 women \nbetween 16 and 60 years of age were analyzed in 2015, \nin which 1,068 women had a previous diagnosis of \nadenomyosis. Thus, the prevalence of adenomyosis in \n2015 was observed to be 0.8-1.5%; being higher among \nwomen aged 41-45 years\n5.\nThe confirmatory diagnosis requires hysterectomy, in \norder to study the entire piece. The minimum distance \nrequired to make the diagnosis has remained under \ndebate, but ranges from half to two low-power fields \nfrom the endomyometrial junction or a minimum depth \nof invasion ranging from 1 to 4 mm. The involvement \nof at least 25% to one-third of myometrial thickness is \nanother diagnostic criterion that has been used in mag -\nnetic resonance imaging (MRI)\n6,7.\nHysterectomy is the only definitive treatment for ade -\nnomyosis, which allows us to perform the histopatho -\nlogical study of the specimen and thus obtain the \nmicroscopic result and obtain the definitive diagnosis\n8.\nThe objective of this study is to determine if there is \nan association between clinical variables and the pres -\nence of adenomyosis in patients undergoing total \nabdominal and subtotal hysterectomy at the Ciudad \nJuárez Women’s Hospital, with the following specific \nobjectives: (1) to know the age groups with the highest \nfrequency of adenomyosis at the Ciudad Juárez Wom -\nen’s Hospital, (2) to identify the comorbidities present \nin patients diagnosed with adenomyosis at the Wom -\nen’s Hospital of Ciudad Juárez, (3) to perform inference \nbetween patients with adenomyosis and without ade -\nnomyosis, and (4) to perform a multivariate model to \nidentify variables associated with the presence of \nadenomyosis.\nMaterial and methods\nAn observational, retrospective, cross-sectional, \ndescriptive, and analytical study was conducted in 332 \nwomen after total and subtotal non-obstetric hysterec -\ntomy at the Hospital de la Mujer of Ciudad Juarez, from \nJanuary 01, 2019, to December 31, 2021. Clinical \nrecords were reviewed, and a database was built in \nMicrosoft Excel 2019. As selection criteria, patients \nundergoing hysterectomy, both of obstetric and gyne -\ncological origin, with total or subtotal technique, from \nJanuary 01, 2019 to December 31, 2021, had a histo -\npathological report, as well as patients who had in their \nclinical history the variables studied (age, multigesta -\ntion, and body mass index [BMI], history of previous \ngynecology and obstetrics, adenomyosis, diabetes mel -\nlitus, and systemic arterial hypertension), as non-inclu -\nsion criteria we take patients who are not in the virtual \nor physical clinical record, patients whose clinical his -\ntory lacks the previously mentioned variables and \nfinally because they do not have a pathology report.\nStatistical analysis\nTo perform the analysis and graph s of this work, the \nstatistical program IBM Statistical Packages for the \nSocial Sciences V.23 for Windows 10 was used. Kolm -\nogorov-Smirnov normality tests were applied to assess \nthe distribution of variables. The inference analysis for \nthe quantitative variables was performed using Stu -\ndent’s t-test or Mann-Whitney’s U-test, as appropriate, \nwhile Pearson’s Chi-square test was used for the qual -\nitative variables. Logistic regression was performed \nconsidering statistically significant variables as inde -\npendent variables for adenomyosis status. The best \nmodel was constructed using the backward step tech -\nnique considering Wald’s statistic. A value of p < 0.05 \nwas considered to be statistically significant for all sta -\ntistical tests used.\nResults\nIn a sample of 332 women post-operated obstetric \nhysterectomy at the Hospital de la Mujer of Ciudad \nJuarez, from January 01, 2019 to December 31, 2021 . \nA  total of 98  (29.5%) patients with histopathological \ndiagnosis of adenomyosis were detected; in this way, it \nwas determined that the prevalence of adenomyosis in \nthe studied population was 29.5% (98 of 332 patients). \nThe sample found a median age of 45  years with an \ninterquartile range of 39-50 years. In our sample, a total \nof 234 women (70.4%) had a BMI > 25 kg/m\n2. A total \nof 212 women (63.9%) had a history of cesarean sec-\ntion, and 242 (72.9%) were categorized as multigesta-\ntion. 19% (63) of the women in this study had a diagnosis \nof diabetes and 28.6% (95) had hypertension. Among \nthe causes of hysterectomy, it was found that 63.6% \n(211) were due to uterine myomatosis, 11 .7% (39) were \ndue to pelvic organ prolapse, 9.9% (33) due to obstetric \nhemorrhage, and 6.6% (22) due to placental alteration, \nthe rest of the causes are described in table 1 . \nA total of 98 women (29.5%) had a diagnosis of ade-\nnomyosis according to the pathological study (Table 1 ). \nPatients were grouped according to the histopathologi -\ncal diagnosis of adenomyosis, finding that the median \nage in women without adenomyosis was 44  (36-49) \n\nRevista Médica del Hospital General de México. 2025;88(4)\n198\nwhile in women with adenomyosis it was 47  (42-50), \np = 0.010 (Fig . 1 ). In the group of women without ade -\nnomyosis, 68.8% had a BMI > 25  kg/m 2 and in the \ngroup of women with adenomyosis, 75.5% had a BMI \n> 25 kg/m\n2 (p = 0.220). Regarding the history of previ -\nous obstetric surgeries, the history was present in \n57 .1% of the women in the group with a diagnosis of \nadenomyosis, whereas the history was present in 66.7% \nof the women without adenomyosis (p = 0.099) (Table 1). \nRegarding the categorization of multigest, 73.9% and \n70.4% of the group without adenomyosis and with a \ndiagnosis of adenomyosis were found to be multigest, \nrespectively (p = 0.510). 18.4% of women without ade -\nnomyosis had diabetes, and the same diagnosis \noccurred in 20.4% of women with adenomyosis (p = \n0.667). 28.6% of women with and without adenomyosis \nhad hypertension (p = 0.991). 2 logistic models were \nperformed, in the first (Table 2), all binary variables were \nentered, taking the presence of adenomyosis as a \ndependent variable, finding statistical significance with \nage (B = 0.026 [odds ratio (OR) = 1 .026 95% confidence \ninterval (CI) = 1 .002-1 .051], p = 0.035). Due to the result \nobtained, the elimination of covariates was carried out \nusing Wald’s statistical criterion (Table 3), finding statis-\ntical significance for age (B = 0.026 [OR = 1 .026 95% \nCI = 1 .003-1 .049], p = 0.026].\nDiscussion\nTotal hysterectomy is the most common gynecolog -\nical surgery in the world. In our study, hysterectomies \nperformed in 1 year (n = 332) were considered, using \nlaparotomy, laparoscopy, and vaginality. The type of \nsurgery to be performed is decided according to the \ncharacteristics of the uterus and the concomitant \npathologies\n3,9.\nTable 1. General characteristics of the population\nVariable Total (%) Adenomyosis (%) p\nNo (234) Yes (98)\nAge (years) 45 (39‑50) 44 (36‑49) 47 (42‑50) 0.010*u\nBMI > 25 kg/m 2\nYes\nNo\n235 (70.8)\n97 (29.2)\n161 (68.8)\n73 (31.2)\n74 (75.5)\n24 (24.5)\n0.220\nXi\nPrevious gynecological and obstetrical surgeries\nYes\nNo\n212 (63.9)\n120 (36.1)\n156 (66.7)\n78 (33.3)\n56 (57.1)\n42 (42.9)\n0.099\nXi\nMultigesta\nYes\nNo\n242 (72.9)\n90 (27.1)\n173 (73.9)\n61 (26.1)\n69 (70.4)\n29 (29.6)\n0.510\nXi\nCauses of hysterectomy\nPlacental alteration\nObstetric bleeding\nMyomatosis\nNIC 1\nNIC 2\nNIC 3\nOncologic process\nPelvic organ prolapse\nOthers\n22 (6.6)\n33 (9.9)\n211 (63.6)\n3 (0.9)\n4 (1.2)\n5 (1.5)\n8 (2.4)\n39 (11.7)\n7 (2.1)\n19 (8.1)\n27 (11.5)\n145 (62)\n2 (0.9)\n4 (1.7)\n5 (2.1)\n5 (2.1)\n22 (9.4)\n3 (3.1)\n6 (6.1)\n66 (67.3)\n1 (1)\n0 (0)\n0 (0)\n3 (3.1)\n17 (17.3)\n0.035*\nXi \nDiabetes\nYes\nNo\n63 (19)\n269 (81)\n43 (18.4)\n191 (81.6)\n20 (20.4)\n78 (79.6)\n0.781\nXi\nHypertension\nYes\nNo\n95 (28.6)\n268 (81)\n67 (28.6)\n167 (71.4)\n28 (28.6)\n70 (71.4)\n> 0.999\npXi\nThis table shows median and IQR 25‑75% and frequency in number and percentage\n*: statistical significance (p < 0.05).\nu: Mann Whitney´s U test.\nXi: Pearson´s Chi squared.\nBMI: body mass index; NIC: neoplasia intraepitelial cervical. \n\nC.M. Rivas-Arredondo et al.  Adenomyosis in hysterectomized women\n199\nIn the literature, abnormal uterine bleeding with or \nwithout leiomyomatosis is reported as the main cause \nof hysterectomy. Leiomyomatosis is the cause of up to \n55%10. In our study, uterine leiomyomatosis was the \nmost frequent definitive diagnosis, with 211 cases, rep -\nresenting 63.5% of the sample, a percentage higher \nthan what was reported worldwide. Either alone or in \ncombination with other conditions, was the second \nmost frequent diagnosis, with a prevalence of 29.5%. \nThis finding is consistent with global reports, where \nprevalence ranges from 2.6% to 70% in pathology \nspecimens. However, in none of the procedures was \nadenomyosis the primary indication for hysterectomy, \nas it was diagnosed histopathologically and justified by \nother clinical causes\n11,12.\nEndovaginal ultrasound is the most important imag -\ning technique in gynecological patients. The radiologist \nrequires experience to identify adenomyosis. This is \nexplained by the great difficulty in making the prior \ndiagnosis. There are studies that mention that ultra -\nsound and MRI can establish the diagnosis with a \nsensitivity of 89%\n13-15. However, to suspect adenomyo -\nsis, a detailed description of the myometrium described \nin the morphological uterus sono graphic assessment \ncriteria is required, which is not done routinely and only \nhas the experience of some physicians assigned to \ngynecology; for this reason, it is emphasized that each \nof these criteria is made known to all personnel and \nthus be able to carry out an adequate approach to this \npathology16.\nAdenomyosis is a condition with variable frequency \ndepending on the population studied. It is most com -\nmonly diagnosed between 40 and 50 years of age, \naccounting for up to 80% of cases. For the purposes \nof this study, and to better localize the pathology, \npatients were grouped by decades. The highest fre -\nquency of diagnosis was found in the 40-50-year age \ngroup, with a rate of 63.2%, which is consistent with \nfindings reported in the global literature\n9. Regarding \nobstetric history, 70.4% of patients with adenomyosis \nwere multigested. Patients with 2 or fewer gestates \naccounted for 29.6% of reported cases of adenomyo -\nsis. According to several authors, most cases of ade -\nnomyosis occur in multigestation patients (90%), \nconsolidating itself as one of the main risk \nfactors\n4,7,17.\nRegarding the history of previous uterine surgery and \nthe presence of adenomyosis, it occurred in 57.1% of \nthe patients, specifically the history of cesarean section \nand instrumented uterine curettage. Uterine trauma \nduring a cesarean section, curettage, or myomectomy \nare the classic risk factors\n17. BMI also plays an import -\nant role18. Overweight patients or with some degree of \nobesity make up 70.7% of the total number of patients \nTable 2. Multiple logistic regression for the presence of \nadenomyosis in women after hysterectomy obstetric\nVariable B Wald p OR (95% CI)\nBMI >  \n25 kg/m2\n0.307 1.189 0.275 1.359 (0.783‑2.359)\nPrevious \ngyneco‑ \nobstetrical \nsurgeries\n0.306 1.436 0.231 1.358 (0.823‑2.240)\nMultigesta −0.259 0.871 0.521 0.772 (0.448‑1.329)\nDiabetes 0.111 0.124 0.725 1.117 (0.603‑2.068)\nHypertension −0.188 0.430 0.512 0.829 (0.473‑1.452)\nAge 0.026 4.442 0.035* 1.026 (1.002‑1.051)\nB: logistic regression coefficient; Wald: Wald statistic; p: value of p;  \nOR: odds ratio; 95% CI: Confidence interval at 95%. ; BMI: body mass index.\n*: statistical significance (p < 0.05).\nTable 3. Multiple logistic regression for the presence of \nadenomyosis in women after obstetric hysterectomy\nVariable B Wald p OR (95% CI)\nAge 0.026 4.935 0.026* 1.026 (1.003‑1.049)\nB: logistic regression coefficient; Wald: Wald statistic; p: value of p; OR: odds ratio; \n95% CI: confidence interval at 95%.\n*: statistical significance (p < 0.05).\nFigure 1. Age of the patients included in the study \naccording to diagnosis of adenomyosis. The p value \ncorresponds to the Mann’s U‑test.\n\n\nRevista Médica del Hospital General de México. 2025;88(4)\n200\nstudied in our sample, of which 75.5% were diagnosed \nwith adenomyosis. In adenomyosis, the role of hyper -\nestrogenism plays an important role, as it is a risk factor \nand is frequently found in overweight or obese women\n11.\nThe presence of diabetes mellitus or systemic arterial \nhypertension are variables that in our study, we did not \nfind with statistical significance, a total of 63  patients \npresented a diagnosis of diabetes mellitus (18.9%), of \nwhich twenty presented a diagnosis of adenomyosis \n(20.4%), similar figures with systemic arterial hyperten -\nsion, in which we have 95 reported cases (28.6%) of \nwhich 28 patients presented a diagnosis of adenomy -\nosis (28.6%). However, we found that age is associated \nwith the presence of adenomyosis (OR = 1.026, [95% \nCI = 1.003-1.049], p = 0.026).\nClinical diagnosis is difficult, due to nonspecific signs \nand symptoms, which often coexist with other pelvic \ndiseases\n1. In the present study, most of the patients \nhad abnormal uterine bleeding as their main anteced -\nent; in 73.4% of them, so in all patients with a study \nprotocol for abnormal uterine bleeding, adenomyosis \nshould be considered as a diagnostic probability, and \nthe appropriate protocol for its diagnosis should be \nperformed.\nCurrently, there is a limited series of studies, but \nimportant to perform for presurgical diagnosis, which \nare, in addition to clinical suspicion, ultrasound and, in \nsome cases, MRI, this in an attempt by gynecologists \nto define the various characteristics resulted in the \ncriteria for morphological sonograph ic evaluation of \nthe uterus 19. In these cases, adenomyosis is consid -\nered when the uterus has a globular con figuration and \nmultiple areas of shadow, sometimes described as \nfan-shaped, are visible, with difficulty in differentiating \nthe myometrium from the junction zone and cystic \nchanges in the junction zone and myometrium 20. Addi-\ntional features that can be observed include an irreg -\nular or interrupted area of conjunction with islands 18,20. \nUnfortunately, there are no classic findings on physical \nexamination or laboratory studies that identify it as a \nprobable diagnosis\n20.\nFuture applications of artificial intelligence (AI) in \nmedicine, specifically related to our topic of adenomy -\nosis classification 16,18, and need to be discussed. Sys -\ntems based on conjunction zone anomalies have shown \npromising results in terms of observer agreement and \ncorrelation with clinical symptoms. Recently, there has \nbeen growing interest in the potential of AI to improve \nthe accuracy and consistency of the diagnosis and \nclassification of adenomyosis. It has been suggested \nthat AI-based ultrasound or MRI image analysis could \naccurately identify and classify different types of ade -\nnomyosis based on the abnormalities of the conjunc -\ntion zone16. This approach has the potential to improve \nthe standardization and reproducibility of presurgical \ndiagnosis of adenomyosis, as AI algorithms can ana -\nlyze large datasets and identify patterns that may not \nbe immediately apparent to human physicians 15,16,21. \nHowever, as in many areas of medicine, more research \nis needed to evaluate these approaches and explore \nwhether they provide answers to clinically relevant \nquestions.\nConclusions\nThe prevalence of adenomyosis at the Ciudad Juárez \nWomen’s Hospital is 29.4%. Adenomyosis is the second \ngynecological pathology in order of frequency, only \nbelow leiomyomatosis, by histopathological diagnosis. \nAccording to the study, the clinical profile of patients to \nbe ruled out for adenomyosis would be a history of pre -\nvious uterine surgery, multiparity, in the fifth decade of \nlife (specifically between 40 and 50 years of age), over -\nweight, or obese. Previous uterine surgery is an import -\nant factor, found in 57.2% of patients. The most common \nsurgery is cesarean section. It is essential to include in \nthe study protocol of patients with suspected adenomy -\nosis, an ultrasound that includes a complete description \nof the myometrium, subendometrial space, and endome-\ntrium. The outpatient service does not have sonography \nequipment, so the diagnosis of adenomyosis is impos -\nsible. In none of the patients who underwent hysterec -\ntomy was the presence of adenomyosis diagnosed \nbefore the surgical event. Training is required for the \nresident and affiliated physicians of our institute due to \nthe evident lack of knowledge and expertise for the pre -\noperative diagnosis of adenomyosis. None of the patients \nwas the suspicion of adenomyosis contemplated in the \nclinical file. Age may be a factor associated with the \npresence of adenomyosis; however, more observational \nstudies are required to corroborate these findings.\nFunding\nThe authors declare that they have not received \nfunding.\nConflicts of interest\nThe authors declare no conflicts of interest.\n\nC.M. Rivas-Arredondo et al.  Adenomyosis in hysterectomized women\n201\nEthical considerations\nProtection of humans and animals. The authors \ndeclare that no experiments involving humans or ani -\nmals were conducted for this research.\nConfidentiality, informed consent, and ethical \napproval. The authors have obtained approval from the \nEthics Committee for the analysis of routinely obtained \nand anonymized clinical data, so informed consent was \nnot necessary. Relevant guidelines were followed.\nDeclaration on the use of artificial intelligence.  \nThe authors declare that no generative artificial intelli -\ngence was used in the writing of this manuscript.\nReferences\n 1. 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Consensus on revised definitions of morphological \nuterus sonographic assessment (MUSA) features of adenomyosis: results \nof modified Delphi procedure. Ultrasound Obstet Gynecol. 2022;60:118-31.","source_license":"CC0","license_restricted":false}