{"paper_id":"1415f7e8-ee2f-4724-abc7-53bfef721bfc","body_text":"32\nWOMEN’S HEALTH AND\nMULTIDISCIPLINARY RESEARCH\nCoexistence of Adenomyosis and Its Effect on Survival \nin Patients with Endometrial Cancer\n Ozan Can Polat,1  Ali Ulvi Hakverdi2\n1Department of Gynecology and Obstetrics, Buca Seyfi Demirsoy Training and Research Hospital, İzmir, Türkiye\n2Department of Gynecology and Obstetrics, Tınaztepe Galen University, İzmir, Türkiye\nBackground and Aim: To investigate the impact of coexisting adenomyosis on clinicopathological char-\nacteristics and survival outcomes in patients who underwent surgery for endometrial cancer.\nMethods: This retrospective, single-center cohort study included 124 patients who underwent surgi-\ncal treatment for endometrial cancer between January 2015 and May 2022. Patients were categorized \naccording to the presence or absence of adenomyosis based on the final histopathological examination. \nDemographic characteristics, pathological findings, treatment modalities, recurrence, and survival out-\ncomes were compared between the two groups.\nResults: Among the 124 patients, adenomyosis was identified in 31 (25.0%). Endometrioid carcinoma \nwas the predominant histological subtype (91.3%). The coexistence of adenomyosis was significantly \nassociated with the presence of leiomyoma (p=0.002), whereas no significant association was observed \nwith tumor histology (p=0.766). The overall 3-year survival rate was 88.0%. The 3-year survival rates \nwere 86.4% in patients with adenomyosis and 88.7% in those without adenomyosis, with no statisti-\ncally significant difference between the groups (p=0.427). Similarly, mortality rates did not differ signifi-\ncantly between the groups (22.6% vs. 18.3%, p=0.600).\nConclusion: Coexisting adenomyosis was detected in one-quarter of patients with endometrial cancer. \nAlthough adenomyosis was associated with concomitant leiomyoma, it was not associated with survival \noutcomes in patients with endometrial cancer.\nKeywords: Adenomyosis, endometrial cancer, hysterectomy, prognosis, survival\nINTRODUCTION\nEndometrial cancer is the most common gynecological malignancy in developed countries and the \nsecond most common gynecological cancer in developing countries after cervical cancer. It is the \nfifth most frequently diagnosed cancer among women worldwide and remains an important cause \nof cancer-related morbidity and mortality.[1] The majority of patients present with abnormal uter-\nine bleeding, leading to diagnosis at an early stage and consequently resulting in favorable survival \noutcomes. Endometrioid adenocarcinoma accounts for approximately 75–80% of all endometrial \ncancers, and surgical treatment remains the cornerstone of management.[1–4]\nAdenomyosis is a benign gynecological disorder characterized by the presence of endometrial \nglands and stroma within the myometrium, surrounded by hypertrophic and hyperplastic smooth \nmuscle tissue.[4–8] It most commonly affects women between 40 and 50 years of age and is typical-\nCite this article as: \nPolat OC, Hakverdi AU. \nCoexistence of Adenomyosis \nand Its Effect on Survival in \nPatients with Endometrial Cancer.  \nWomens Health Multidisc Res  \n2026;2(2):32–37.\nAddress for correspondence:\nOzan Can Polat\nDepartment of Gynecology and \nObstetrics, Buca Seyfi Demirsoy \nTraining and Research Hospital, \nİzmir, Türkiye\nE-mail: \nozancanpolat.92@gmail.com\nSubmitted: 17.07.2026\nAccepted: 05.08.2026\nOnline: 24.08.2026\nWomen’s Health and Multidisciplinary \nResearch - Available online at\nwww.whmresearch.com\nCopyright © Author(s)\nThis work is licensed under \na Creative Commons \nAttribution-NonCommercial \n4.0 International License.\nResearch Article\nABSTRACT\nDOI: 10.14744/whmr.2026.05772\n2026;2(2):32–37Womens Health Multidisc Res \n\nPolat and Hakverdi. Coexistence of Adenomyosis and its Effect\n2026;2(2):32–37\n33\nWomens Health Multidisc Res \nly associated with abnormal uterine bleeding, dysmenorrhea, \nand chronic pelvic pain. Histopathological examination remains \nthe gold standard for diagnosis, and adenomyosis is reported \nin approximately 20–30% of hysterectomy specimens.[8,9]\nSeveral studies have demonstrated that adenomyosis fre-\nquently coexists with endometrial cancer, with reported \nprevalence rates ranging from 15% to 70%. [10] However, the \nclinical significance of this coexistence remains controversial. \nWhile some investigators have suggested that adenomyo-\nsis may contribute to myometrial invasion and influence tu-\nmor progression, others have reported that it may exert a \nprotective effect by improving prognosis and survival. [11–14] \nTherefore, the prognostic value of coexisting adenomyosis \nin patients with endometrial cancer has not yet been clearly \nestablished. The present study aimed to evaluate the effect of \ncoexisting adenomyosis on clinicopathological characteristics \nand survival outcomes in patients who underwent surgery for \nendometrial cancer.\nMATERIALS AND METHODS\nThis retrospective, single-center study included patients who \nunderwent surgery for endometrial cancer at the Department \nof Obstetrics and Gynecology between January 1, 2015, and \nMay 31, 2022. The study protocol was approved by Hatay \nMustafa Kemal University Tayfur Ata Sökmen Hospital Non-in-\nterventional Clinical Research Ethics Committee (Approval \nNumber: 11/2022, Date: 16.06.2022). Informed consent was \nobtained from all patients. This study was conducted in accor-\ndance with the principles of the Declaration of Helsinki.\nA total of 124 patients with histopathologically confirmed en-\ndometrial cancer who underwent at least total hysterectomy \nwith bilateral salpingo-oophorectomy were included. Patients \nwith incomplete medical records, those who continued fol-\nlow-up at another institution, patients with metastatic tumors \ninvolving the endometrium, and those without reliable surviv-\nal data were excluded from the study. Medical records were \nreviewed retrospectively using the hospital information sys-\ntem, pathology reports, and the Turkish Ministry of Health \nDeath Notification System.\nPatients were divided into two groups according to the pres-\nence or absence of adenomyosis on final pathological exam-\nination. The following variables were recorded: demographic \ncharacteristics (age, gravida, parity), accompanying systemic \ndiseases, laboratory findings, preoperative imaging findings, \nendometrial biopsy results, histopathological characteristics, \nsurgical procedures, adjuvant treatment, recurrence, mortal-\nity, and survival outcomes. Histopathological evaluation of all \nsurgical specimens was performed by experienced patholo-\ngists at our institution.\nThe primary outcome of the study was to evaluate the effect \nof coexisting adenomyosis on survival in patients with endo-\nmetrial cancer. Secondary outcomes included comparisons \nof clinicopathological characteristics, surgical findings, recur-\nrence, and mortality between patients with and without ade-\nnomyosis. Overall survival was defined as the interval from the \ndate of primary surgery to death from any cause or the last \nconfirmed follow-up. Patients who were alive at the end of \nfollow-up were censored on the date they were last known to \nbe alive. Vital status was determined using institutional medical \nrecords and the Turkish Ministry of Health Death Notification \nSystem. Overall survival was estimated using the Kaplan–Mei-\ner method, and survival curves were compared using the log-\nrank test. Three-year overall survival estimates are reported \nwith 95% confidence intervals. The median follow-up duration \nwas calculated using the reverse Kaplan–Meier method.\nA total of 124 patients with histopathologically confirmed pri-\nmary endometrial cancer were included in the final analysis. \nOf these, 31 had coexisting adenomyosis, whereas 93 had no \nadenomyosis on final histopathological examination. Adeno-\nmyosis was diagnosed histopathologically by the presence of \nectopic endometrial glands and stroma within the myometri-\num, accompanied by surrounding smooth muscle hypertro-\nphy/hyperplasia. Cases in which apparent adenomyosis rep-\nresented only direct tumor extension into the myometrium \nwere not classified as adenomyosis.\nStatistical Analysis\nThe normality of continuous variables was assessed using the \nKolmogorov–Smirnov test, Q–Q plots, and histograms. Contin-\nuous variables were expressed as the mean±standard deviation \n(SD) or median (minimum–maximum), as appropriate. Cate-\ngorical variables were presented as frequencies and percentag-\nes. Comparisons of categorical variables were performed using \nPearson’s chi-square test or Fisher’s exact test. For compari-\nsons of continuous variables between two groups, the inde-\npendent-samples t-test was used for normally distributed data, \nwhereas the Mann–Whitney U test was used for non-normally \ndistributed data. Univariate logistic regression analysis was per-\nformed to identify factors associated with adenomyosis. Agree-\nment between Pipelle biopsy, dilatation and curettage (D&C), \nand the final surgical histopathological diagnosis was evaluated \nusing Cohen’s kappa test. The sensitivity, specificity, positive \npredictive value, negative predictive value, and diagnostic ac -\ncuracy of Pipelle biopsy and D&C for detecting endometrioid \ncarcinoma were calculated. Overall survival according to the \npresence of adenomyosis was analyzed using the Kaplan–Meier \nmethod and compared using the log-rank (Mantel–Cox) test. \nA two-sided p value of <0.05 was considered statistically sig-\nnificant. All statistical analyses were performed using IBM SPSS \nStatistics, version 22.0 (IBM Corp., Armonk, NY, USA).\n\nPolat and Hakverdi. Coexistence of Adenomyosis and its Effect\n2026;2(2):32–37\n34\nWomens Health Multidisc Res \nRESULTS\nA total of 124 patients with histopathologically confirmed \nendometrial cancer were included in the study. Coexisting \nadenomyosis was identified in 31 patients (25.0%), whereas \n93 patients (75.0%) had no evidence of adenomyosis on final \nhistopathological examination. The mean age was comparable \nbetween patients with and without adenomyosis (59.0±10.1 \nvs. 60.3±10.2 years, p=0.545). Likewise, no significant differ-\nences were observed between the two groups with regard to \nbody mass index, gravida, parity, smoking status, diabetes mel-\nlitus, hypertension, or menopausal status (p>0.05) (Table 1).\nEndometrioid carcinoma was the predominant histological \nsubtype in both groups, accounting for 92.9% of patients \nwith adenomyosis and 90.8% of those without adenomyosis. \nNo significant difference was observed in the distribution of \nhistological subtypes between the two groups (p=0.766). \nSimilarly, tumor grade, tumor diameter, lymphovascular \nspace invasion, depth of myometrial invasion, cervical stro-\nmal involvement, and adnexal involvement were compa-\nrable between patients with and without adenomyosis (all \np>0.05). However, leiomyoma was significantly more fre-\nquent in patients with adenomyosis than in those without \nadenomyosis (45.2% vs. 17.2%, p=0.002). Overall, no sig-\nnificant association was found between adenomyosis and \nadverse histopathological prognostic factors in patients with \nendometrial cancer (Table 2).\nNo significant differences were observed between patients \nwith and without adenomyosis regarding the type of surgical \nprocedure performed or the administration of radiotherapy \nor chemotherapy (p>0.05). During follow-up, recurrence \nwas observed in 20 patients (16.1%). Recurrence rates were \ncomparable between patients with and without adenomy -\nosis (19.4% vs. 15.1%, p=0.573). Similarly, no significant \ndifference in overall mortality was observed between the \ntwo groups (22.6% vs. 18.3%, p=0.600). The mean over-\nall survival time was 44.0±26.4 months and did not differ \nsignificantly according to adenomyosis status (50.4±28.1 vs. \n41.9±25.6 months, p=0.130) (Table 3).\nT able 1. Baseline demographic and clinical \ncharacteristics according to adenomyosis status\nVariables Adenomyosis \n(+) (n=31)\nAdenomyosis \n(−) (n=93)\np\nn % n %\nAge (years), mean±SD 59.0±10.1 60.3±10.2 0.545\nBMI (kg/m²), mean±SD 35.6±4.2 33.8±4.6 0.052\nGravida, median (min–max) 5 (0–9) 4 (0–12) 0.405\nParity, median (min–max) 4 (0–8) 4 (0–12) 0.530\nSmoking 0.155\nYes 9 29.0 16  17.2\nNo 22 71.0 77  82.8\nDiabetes mellitus 0.586\nYes 12 38.7 31  33.3\nNo 19 61.3 62  66.7\nHypertension 0.582\nYes 9 29.0 32  34.4\nNo 22 71.0 61  65.6\nCholecystectomy 1 3.2 13  14.0 0.186\nIleus surgery 1 3.2 1  1.1 0.439\nAppendectomy 1 3.2 4  4.3 1.000\nMenopausal status 0.799\nPostmenopausal 24 77.4 74  79.6\nPremenopausal 7 22.6 19  20.4\nBMI: Body mass index, SD: standard deviation.\nT able 2. Histopathological characteristics according to \nadenomyosis status\nVariables Adenomyosis \n (+) (n=31)\nAdenomyosis \n(−) (n=93)\np\nn % n %\nFinal histopathology 0.766\nEndometrioid carcinoma 26 92.9 79  90.8\nSerous carcinoma 2 7.1 4  4.6\nClear cell carcinoma 0 0.0 3  3.4\nMucinous adenocarcinoma 0 0.0 1  1.1\nTumor grade 0.279\nGrade 1 10 32.3 18  19.4\nGrade 2 16 51.6 52  55.9\nGrade 3 5 16.1 23  24.7\nTumor diameter (mm),\nmedian (min–max)\n30.0 \n(2.0–67.5)\n37.5 \n(2.0–180.0) 0.184\nLymphovascular space\ninvasion 0.573\nPresent 4 12.9 16 17.2\nAbsent 27 87.1 77  82.8\nMyometrial invasion, n (%) 1.000\n<50% 21 67.7 63  67.7\n≥50% 10 32.3 30  32.3\nCervical stromal involvement 0.353\nPresent 2 6.5 14  15.1\nAbsent 29 93.5 79  84.9\nLeiomyoma 0.002\nPresent 14 45.2 16  17.2\nAbsent 17 54.8 77  82.8\n\nPolat and Hakverdi. Coexistence of Adenomyosis and its Effect\n2026;2(2):32–37\n35\nWomens Health Multidisc Res \nDISCUSSION\nThe present study investigated the association between coex-\nisting adenomyosis and clinicopathological characteristics, as \nwell as survival outcomes, in patients with endometrial cancer. \nAdenomyosis was identified in 25% of the study population, \na prevalence consistent with previous reports. Although leio-\nmyoma was significantly more frequent in patients with ade-\nnomyosis, no significant associations were observed between \nadenomyosis and histological subtype, tumor grade, tumor di-\nameter, myometrial invasion, lymphovascular space invasion, \ncervical stromal involvement, adnexal involvement, recur-\nrence, or overall survival. Furthermore, 3-year overall survival \nrates were comparable between patients with and without \nadenomyosis. These findings suggest that adenomyosis is not \nassociated with more aggressive clinicopathological features \nor poorer oncological outcomes in endometrial cancer.\nThe reported prevalence of adenomyosis in women with \nendometrial cancer ranges from approximately 15% to 70%.\n[10,11] This variability is likely related to differences in patient \nselection, pathological diagnostic criteria, and the extent of \nhistopathological examination. Adenomyosis is defined by the \npresence of ectopic endometrial glands and stroma within the \nmyometrium, surrounded by hypertrophic smooth muscle tis-\nsue.[8] Because its diagnosis relies on histopathological evalua-\ntion, variations in tissue sampling and pathological assessment \nmay substantially influence the reported prevalence. In our \nstudy, adenomyosis was identified in 25% of hysterectomy \nspecimens, supporting previous observations that adenomyo-\nsis frequently coexists with endometrial carcinoma. However, \ncoexistence alone does not establish a causal relationship be-\ntween these two conditions.\nThe prognostic significance of adenomyosis in endometrial can-\ncer remains controversial. Several studies have suggested that \nadenomyosis is associated with favorable pathological charac-\nteristics, including lower tumor grade, superficial myometrial \ninvasion, earlier FIGO stage, and improved survival.[11–14] Pro-\nposed mechanisms include the hypertrophic myometrium sur-\nrounding adenomyotic foci acting as a mechanical barrier against \ntumor invasion, together with alterations in the local hormonal \nand inflammatory microenvironment. In contrast, other inves-\ntigators have found no association between adenomyosis and \npathological prognostic factors or survival.[11] Our findings are \nconsistent with these latter reports. We observed no significant \ndifferences between patients with and without adenomyosis \nregarding histological subtype, tumor grade, tumor diameter, \nmyometrial invasion, lymphovascular space invasion, cervical \nstromal involvement, or adnexal involvement. The only signifi-\ncant pathological difference was the higher prevalence of leio-\nmyoma in the adenomyosis group, a finding that is biologically \nplausible given the shared hormonal dependence and frequent \ncoexistence of these two benign uterine disorders.\nThe biological relationship between adenomyosis and endo-\nmetrial cancer remains incompletely understood. Experimen-\ntal studies suggest that alterations in inflammatory mediators, \nextracellular matrix remodeling, angiogenesis, and steroid \nhormone signaling within adenomyotic tissue may influence \ntumor behavior.[8,12–14] These mechanisms have led to the hy -\npothesis that adenomyosis may exert a protective effect by \nlimiting local tumor spread or promoting earlier diagnosis \nthrough abnormal uterine bleeding. Nevertheless, the avail-\nable clinical evidence remains inconsistent, and our findings \ndo not support a clinically meaningful protective or adverse \neffect of adenomyosis on tumor progression or prognosis.\nSimilarly, adenomyosis was not associated with recurrence, \nmortality, mean overall survival, or 3-year overall survival in \nour cohort. Differences among published studies may reflect \nvariations in sample size, patient characteristics, pathological \nevaluation, follow-up duration, surgical staging, and adjuvant \ntreatment protocols. Consequently, the current evidence is \nT able 3. Treatment characteristics and oncological \noutcomes according to adenomyosis status\nVariables Adenomyosis \n(+) (n=31)\nAdenomyosis \n(−) (n=93)\np\nn % n %\nSurgical procedure 0.279\nTAH+BSO 2 6.5 10  10.8\nTAH+BSO+PPLND 24 77.4 69  74.2\nTAH+BSO+PPLND+ \nomentectomy 5 16.1 14  15.0\nRadiotherapy 0.157\nReceived 17  54.8 64  68.8\nNot received 14 45.2 29  31.2\nChemotherapy 0.799\nReceived 6  19.4 20  21.5\nNot received 25 80.6 73  78.5\nRecurrence 0.573\nPresent 6 19.4 14  15.1\nAbsent 25  80.6 79  84.9\nMortality 0.600\nAlive 24 77.4 76  81.7\nDead 7 22.6 17  18.3\nOverall survival (months), \nmean±SD 50.4±28.1 41.9±25.6 0.130\n3-year overall survival (%) 86.4 88.7 0.427\nBSO: Bilateral salpingo-oophorectomy, PPLND: Pelvic and para-aortic lymph node dissec-\ntion, SD: Standard deviation, TAH: Total abdominal hysterectomy.\n\nPolat and Hakverdi. Coexistence of Adenomyosis and its Effect\n2026;2(2):32–37\n36\nWomens Health Multidisc Res \ninsufficient to support adenomyosis as an independent prog-\nnostic marker in patients with endometrial cancer.\nThe present study has several strengths. All patients were \nmanaged at a single tertiary referral center using relatively \nstandardized surgical and postoperative treatment proto-\ncols, and all pathological specimens were evaluated within the \nsame pathology department, thereby reducing interobserver \nvariability. In addition, survival data were obtained from insti-\ntutional medical records and the national death notification \nsystem, minimizing incomplete follow-up. However, several \nlimitations should be acknowledged. The retrospective design \nintroduces the possibility of selection bias, the relatively small \nnumber of patients with adenomyosis may have limited sta-\ntistical power, and the single-center design may restrict the \ngeneralizability of our findings.\nOverall, our findings indicate that adenomyosis is a common \nhistopathological finding in patients with endometrial cancer \nbut is not associated with adverse clinicopathological char-\nacteristics or decreased survival. Although adenomyosis has \nbeen proposed as a potential prognostic factor, our results \ndo not support its independent prognostic significance. Larger \nprospective multicenter studies with standardized pathologi-\ncal assessment are needed to further clarify the biological and \nclinical relationship between adenomyosis and endometrial \ncancer. The relatively small overall sample and, particularly, \nthe limited number of patients with adenomyosis and death \nevents reduced the statistical power of the survival analysis. \nThe small number of outcome events precluded a reliable \nmultivariable Cox proportional hazards analysis. Therefore, \npotential confounding by age, tumor stage, grade, histological \nsubtype, treatment, and other prognostic factors could not \nbe adequately controlled, and the absence of a statistically \nsignificant association should not be interpreted as evidence \nof prognostic equivalence.\nCONCLUSION\nAdenomyosis was identified in one-quarter of patients with \nendometrial cancer in the present study. Although leiomyoma \nwas significantly more frequent among patients with adeno-\nmyosis, no significant associations were observed between \nadenomyosis and unfavorable clinicopathological characteris-\ntics, including tumor grade, histological subtype, myometrial \ninvasion, lymphovascular space invasion, cervical stromal in-\nvolvement, recurrence, or survival outcomes. These findings \nsuggest that adenomyosis is not an independent prognostic \nfactor in patients with endometrial cancer. Nevertheless, giv-\nen the conflicting evidence in the current literature, larger pro-\nspective multicenter studies with standardized pathological \nevaluation are warranted to better clarify the biological and \nprognostic significance of adenomyosis in endometrial cancer.\nEthics Committee Approval: The study was approved by the \nHatay Mustafa Kemal University Tayfur Ata Sökmen Hospital Non-in-\nterventional Clinical Research Ethics Committee (Approval Number: \n11/2022, Date:  16.06.2022).\nInformed Consent: Written informed consent was obtained from all \nthe patients.\nConflict of Interest: The authors have no conflicts of interest to de-\nclare.\nFunding: The authors declared that this study received no financial \nsupport.\nUse of AI for Writing Assistance: No use of AI-assisted technolo-\ngies was declared by the authors.\nAuthor Contributions: Concept – A.U.H.; Design – A.U.H; Super-\nvision – A.U.H; Resource – A.U.H; Materials – A.U.H; Data Collection \nand/or Processing – O.C.P .; Analysis and/or Interpretation – O.C.P .; \nLiterature Review – A.U.H.; Writing – A.U.H.; Critical Review – A.U.H.\nPeer-review: Externally peer-reviewed.\nREFERENCES\n1. 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