{"paper_id":"2dd8373f-ad28-416a-895d-7fc88c164d59","body_text":"Bagcilar Med Bull \nORIGINAL RESEARCH\nCopyright© 2026 The Author(s). Published by Galenos Publishing House on behalf of Health Sciences University Turkey, \nİstanbul Bagcilar Training and Research Hospital.  This is an open access article under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 (CC BY-NC-ND) International License.\nÖz\nAmaç: Adenomyozis sık görülen benign bir jinekolojik durum \nolmasına rağmen, kesin prevalansı ve ilişkili faktörler hala araştırma \nkonusudur. Bu çalışmanın amacı, kliniğimizde benign nedenlerle \nhisterektomi yapılan hastalarda adenomyozis prevalansını belirlemek \nve bu durumla ilişkili demografik ve klinik özellikleri analiz etmektir.\nYöntem: Bu retrospektif çalışma, Sağlık Bilimleri Üniversitesi, Prof. \nDr. Cemil Taşcıoğlu Şehir Hastanesi’nde gerçekleştirildi. Ocak 2016 \nile Aralık 2020 arasında benign nedenlerle histerektomi yapılan 1734 \nhastanın histopatoloji raporları incelendi. Hastalar, adenomyozis \nvarlığına veya yokluğuna göre iki gruba ayrıldı. Demografik veriler, \nklinik prezentasyonlar, cerrahi endikasyonlar ve eşlik eden patolojiler \ngruplar arasında karşılaştırıldı. İstatistiksel analiz için SPSS 27.0 \nkullanıldı.\nBulgular: Bin yedi yüz otuz dört hastanın 526’sında histopatolojik \nolarak adenomyozis doğrulandı ve prevalans %30,3 olarak bulundu. \nAdenomyozis grubundaki hastaların yaş ortalaması (51,4’e karşı 50,2 \nyıl, p<0,001), gravida (4,49’a karşı 3,67, p<0,001) ve parite (3,21’e karşı \n2,77, p<0,001) anlamlı olarak daha yüksekti. Adenomyozis grubunda \nen sık görülen semptom anormal uterin kanama (%59,2) idi. En sık \neşlik eden patoloji, adenomyozis olgularının %48,9’unda bulunan \nleiomyom idi. Dikkate değer bir şekilde, olguların %22,6’sında \nherhangi bir ek patoloji olmaksızın saf adenomyozis tespit edildi.\nAbstract\nObjective: Adenomyosis is a common benign gynecological \ncondition, yet its exact prevalence and associated factors remain \nsubjects of investigation. This study aimed to determine the \nprevalence of adenomyosis in patients who underwent hysterectomy \nfor benign indications at our clinic and to analyze the demographic \nand clinical characteristics associated with the condition.\nMethod: This retrospective study was conducted at the University of \nHealth Sciences Turkey, Prof. Dr. Cemil Taşcıoğlu City Hospital. The \nhistopathology reports of 1734 patients who underwent hysterectomy \nfor benign reasons between January 2016 and December 2020 \nwere reviewed. Patients were divided into two groups based on the \npresence or absence of adenomyosis. Demographic data, clinical \npresentations, surgical indications, and co-existing pathologies were \ncompared between the groups. Statistical analysis was performed \nusing SPSS 27.0.\nResults: Adenomyosis was histopathologically confirmed in 526 \nof the 1734 patients, yielding a prevalence of 30.3%. Patients in \nthe adenomyosis group had significantly higher mean age (51.4 \nvs. 50.2 years, p<0.001), gravida (4.49 vs. 3.67, p<0.001), and parity \n(3.21 vs. 2.77, p<0.001). The most common presenting symptom \nin the adenomyosis group was abnormal uterine bleeding (59.2%). \nLeiomyoma was the most frequent co-existing pathology, found in \n48.9% of adenomyosis cases. Notably, pure adenomyosis without any \naccompanying pathology was identified in 22.6% of the cases.\nAddress for Correspondence: Aybekcan Batman, MD, University of Health Sciences Turkey, Başakşehir Çam and Sakura City Hospital, \nDepartment of Obstetrics and Gynecology, İstanbul, Turkey\nE-mail: batman.aybek.can@gmail.com ORCID: orcid.org/0000-0001-7651-3409  \nReceived: 27.01.2026 Accepted: 02.05.2026 Epub: 06.05.2026 \nCite this article as: Batman A, Mihmanlı V . The prevalence of adenomyosis in patients who underwent hysterectomy for benign gynecological \ndiseases. Bagcilar Med Bull.  [Epub Ahead of Print]\n1University of Health Sciences Turkey, Başakşehir Çam and Sakura City Hospital, Department of Obstetrics and Gynecology, İstanbul, Turkey\n2University of Health Sciences Turkey, Prof. Dr. Cemil Taşcıoğlu City Hospital, Department of Obstetrics and Gynecology, İstanbul, Turkey\n Aybekcan Batman1,  Veli Mihmanlı2\nBenign Jinekolojik Hastalıklar Nedeniyle Histerektomi Yapılan \nHastalarda Adenomyozis Prevalansı\nThe Prevalence of Adenomyosis in Patients \nWho Underwent Hysterectomy for Benign \nGynecological Diseases\nDO I: 10.4274/BMB.galenos.2026.19484\n\nBatman and Mihmanlı. \nPrevalence of Adenomyosis in Hysterectomy Cases\nBagcilar Medical Bulletin,\nIntroduction\nAdenomyosis is a benign gynecological condition defined \nby the presence of ectopic endometrial glands and stroma \nwithin the myometrium, accompanied by surrounding \nsmooth muscle hypertrophy and hyperplasia (1,2). This \npathological process often results in uterine enlargement \nand may contribute substantially to gynecological \nmorbidity, particularly among women of reproductive and \nperimenopausal age (3,4). Despite increasing recognition, \nadenomyosis continues to pose diagnostic and clinical \nchallenges due to its heterogeneous presentation and \nfrequent coexistence with other uterine disorders (5).\nAlthough the precise pathophysiological mechanisms \nunderlying adenomyosis remain unclear, several \nhypotheses have been proposed. The most widely accepted \ntheory suggests that disruption of the endometrial-\nmyometrial junctional zone facilitates the invagination \nof basal endometrial tissue into the myometrium \n(6,7). Alternative mechanisms include metaplastic \ntransformation of Müllerian remnants and structural or \nfunctional alterations of the uterine junctional zone, often \ndescribed as the “archimetra” (6,8). These mechanisms \nmay act synergistically, contributing to the development \nand progression of adenomyosis in susceptible individuals \n(9).\nGiven that many cases are asymptomatic or present with \nnon-specific symptoms that overlap with other common \nconditions like leiomyomas, the true prevalence of \nadenomyosis is likely underestimated (3). Understanding \nthe frequency of this condition and its associated clinical \nand demographic factors is crucial for accurate diagnosis \nand effective management. This study was therefore \nconducted to determine the prevalence of adenomyosis \nin a large cohort of patients who underwent hysterectomy \nfor benign gynecological indications at a tertiary care \ncenter and to identify the key characteristics of this patient \npopulation.\nMaterials and Methods\nThe study was conducted at the Department of Obstetrics \nand Gynecology, University of Health Sciences Turkey, Prof. \nDr. Cemil Taşcıoğlu Hospital, after receiving approval from \nthe institutional ethics committee (approval no: 282, date: \n06.07.2020). Due to the retrospective nature of the study, the \nrequirement for informed consent was waived by the ethics \ncommittee. The study included all patients who underwent \nhysterectomy for benign gynecological indications between \nJanuary 2016 and December 2020.\nPatient data were retrieved from hospital records and the \nelectronic information system. A total of 1734 patients were \nincluded in the final analysis. Patients with malignancies or \nthose with incomplete data were excluded. The collected \ndata included demographic characteristics (age, gravida, \nparity, number of abortions, and cesarean sections), \nmenopausal status, co-morbidities, previous uterine \nsurgeries, surgical indications, type of hysterectomy \n(total abdominal, vaginal, or total laparoscopic), and \npostoperative complications.\nAll hysterectomy specimens were processed and examined \nin the pathology department of our hospital. The \nhistopathological diagnosis of adenomyosis was based on \nthe established criterion of finding endometrial glands and \nstroma at a depth of at least 2.5 mm from the endometrial-\nmyometrial junction (1,10).\nStatistical Analysis\nFor statistical analysis, patients were divided into two \ngroups: Those with a histopathological diagnosis of \nadenomyosis (adenomyosis group) and those without \n(control group). The statistical analysis was performed \nAbstract Öz\nConclusion: The prevalence of adenomyosis in our study population \nwas significant, confirming its common occurrence in patients \nundergoing hysterectomy for benign causes. Advanced age, high \ngravidity, and parity were identified as significant associated \nfactors. These findings underscore the importance of considering \nadenomyosis in the differential diagnosis of abnormal uterine \nbleeding and other common gynecological complaints.\nKeywords: Adenomyosis, benign gynecological diseases, leiomyoma, \nhysterectomy, prevalence \nSonuç: Çalışma popülasyonumuzda adenomyozis prevalansı \nanlamlı olup, benign nedenlerle histerektomi yapılan hastalarda sık \ngörüldüğünü doğrulamaktadır. İleri yaş, yüksek gravida ve parite \nönemli ilişkili faktörler olarak tanımlanmıştır. Bu bulgular, anormal \nuterin kanama ve diğer yaygın jinekolojik şikayetlerin ayırıcı tanısında \nadenomyozisin dikkate alınmasının önemini vurgulamaktadır.\nAnahtar kelimeler: Adenomyozis, benign jinekolojik hastalıklar, \nhisterektomi, leiomyom, prevalans\n\nBatman and Mihmanlı. \nPrevalence of Adenomyosis in Hysterectomy Cases\nBagcilar Medical Bulletin,\nusing SPSS for Windows, version 27.0 (SPSS Inc., Chicago, \nIL, USA). The distribution of variables was assessed using \nthe Kolmogorov-Smirnov test. Non-normally distributed \ncontinuous variables were compared using the Mann-\nWhitney U test, while categorical variables were analyzed \nusing the chi-square test. A p-value of less than 0.05 was \nconsidered statistically significant.\nResults\nOf the 1734 patients who underwent hysterectomy for \nbenign indications during the study period, adenomyosis \nwas confirmed by histopathological examination in 526 \npatients, resulting in a prevalence of 30.3%. The remaining \n1208 patients formed the control group.\nDemographic and Clinical Characteristics\nThe demographic and clinical characteristics of the \nadenomyosis and control groups are compared in \nTable 1. The mean age of patients in the adenomyosis \ngroup was significantly higher than in the control group \n(51.4±8.4 vs. 50.2±9.5 years, p<0.001). Similarly, patients \nwith adenomyosis had significantly higher mean gravida \n(4.49±2.74 vs. 3.67±2.45, p<0.001), parity (3.21±2.13 vs. \n2.77±1.92, p<0.001), and number of abortions (0.52±0.96 \nvs. 0.35±0.78, p<0.001). There were no statistically \nsignificant differences between the groups regarding the \nhistory of cesarean section, rates of co-morbidities such as \nhypertension and diabetes, or history of previous uterine \nsurgery (p>0.05).\nSurgical Details and Co-existing Pathologies\nThe most common indication for hysterectomy in the \nadenomyosis group was myoma uteri (37.6%), followed \nclosely by abnormal uterine bleeding (36.9%). The \ndistribution of hysterectomy types (abdominal, vaginal, \nlaparoscopic) did not differ significantly between the two \ngroups (p>0.05).\nCo-existing pathologies were common, with only 22.6% \nof patients (n=119) having pure adenomyosis. The most \nfrequently encountered co-existing pathology was \nleiomyoma, present in 48.9% (n=257) of the adenomyosis \ncases. Other associated findings included benign ovarian \ncysts (12.9%), endometrial polyps (9.5%), and endometriosis \n(3.4%), as detailed in Table 2.\nAmong patients with adenomyosis, 86.7% were \nsymptomatic. The most common complaint was abnormal \nuterine bleeding, reported by 59.2% of symptomatic \npatients, followed by pelvic pain (21.1%) and uterine \nprolapse (20.2%).\nDiscussion\nIn this large retrospective cohort of patients who underwent \nhysterectomy for benign gynecological indications, \nTable 1. Comparison of demographic and clinical characteristics\nCharacteristic Adenomyosis (+) (n=526) Adenomyosis (-) (n=1208) p-value\nAge (years, mean ± SD) 51.4±8.4 50.2±9.5 <0.001\nGravida (mean ± SD) 4.49±2.74 3.67±2.45 <0.001\nParity (mean ± SD) 3.21±2.13 2.77±1.92 <0.001\nAbortus (mean ± SD) 0.52±0.96 0.35±0.78 <0.001\nPrevious C-section (%) 82.6 84.5 0.643\nPremenopausal status (%) 39.2 37.2 0.431\nSD: Standard deviation\nTable 2. Co-existing pathologies in patients with adenomyosis (n=526)\nPathology Number of patients (n) Percentage (%)\nLeiomyoma 257 48.9\nBenign ovarian cysts 68 12.9\nEndometrial polyp 50 9.5\nEndometriosis 18 3.4\nSimple hyperplasia 11 2.1\nCervical dysplasia 9 1.7\nAtrophic endometrium 9 1.7\nPure adenomyosis (none) 119 22.6\n\nBatman and Mihmanlı. \nPrevalence of Adenomyosis in Hysterectomy Cases\nBagcilar Medical Bulletin,\nadenomyosis was histopathologically confirmed in 30.3% of \ncases. This prevalence falls within the broad range reported \nin previous studies and reflects the well-documented \nvariability across different populations and diagnostic \napproaches (11-13). Differences in histopathological \ncriteria, the extent of specimen sampling, and patient \ncharacteristics have been proposed as major contributors \nto the wide variation in reported prevalence rates (10,14). \nIn this context, the prevalence observed in our cohort \nprovides a representative estimate for patients treated at a \ntertiary care center.\nA notable finding of this study is the association between \nadenomyosis and increased age, gravidity, and parity . \nThese associations support current concepts regarding \nthe pathogenesis of adenomyosis, particularly theories \nemphasizing mechanical and hormonal factors affecting the \nendometrial-myometrial interface. Repeated pregnancies \nand childbirth are thought to induce microtrauma at the \njunctional zone, thereby facilitating the displacement \nof endometrial tissue into the myometrium (6,14,15). \nIn contrast, a history of prior uterine surgery, including \ncesarean section, was not significantly associated with \nadenomyosis in our cohort. This observation suggests \nthat physiological processes related to pregnancy and \nparturition may play a more prominent role than surgical \ndisruption alone, consistent with findings reported in \nseveral previous studies (14,16).\nThe clinical presentation in our cohort was dominated by \nabnormal uterine bleeding (59.2%) and pelvic pain (21.1%), \nconsistent with the classic symptom profile of adenomyosis \n(3,17). However, these symptoms are non-specific and \nfrequently serve as primary indications for hysterectomy . \nCo-existing pathologies were present in 77.4% of patients, \nwith leiomyomas being the most common (48.9%), which \noften complicates preoperative attribution of symptoms to \nadenomyosis alone (3,4). Nevertheless, the identification \nof pure adenomyosis in 22.6% of cases underscores that \nadenomyosis can be the sole cause of clinically significant \nuterine pathology .\nNon-invasive diagnostic modalities, particularly \ntransvaginal ultrasonography and magnetic resonance \nimaging, have shown increasing accuracy in identifying \nadenomyosis preoperatively (18-20). Additionally, \nadenomyosis has been associated with genitourinary \nsymptoms such as overactive bladder, further broadening \nits clinical spectrum (21). Notably, had a preoperative \ndiagnosis been established, the 22.6% of patients with \npure adenomyosis in our cohort could have potentially \nbeen managed with conservative approaches, such as \nthe levonorgestrel-releasing intrauterine system, which \nhas demonstrated efficacy in alleviating adenomyosis-\nrelated dysmenorrhea and menorrhagia (22,23). This \nfinding highlights the clinical importance of improving \npreoperative diagnostic accuracy, as it may enable a \nsubstantial proportion of patients to avoid hysterectomy .\nStudy Limitations\nThe main limitation of our study is its retrospective design, \nwhich relies on the accuracy and completeness of existing \nmedical records. This design prevents the establishment of \ncausal relationships and may be subject to selection bias, as \nonly patients who underwent hysterectomy were included. \nThe strengths of the study include its large sample size \nand the use of definitive histopathological diagnosis for all \ncases, providing a high degree of diagnostic certainty .\nConclusion\nOur results confirm that adenomyosis is a frequent \nhistopathological finding among patients undergoing \nhysterectomy for benign gynecological indications, with \na prevalence of 30.3%. Advanced age, higher gravidity, \nand increased parity were identified as significant factors \nassociated with the presence of adenomyosis, highlighting \nthe potential contribution of reproductive history to disease \ndevelopment. Given the non-specific nature of its clinical \npresentation and its frequent coexistence with other uterine \npathologies, adenomyosis should be considered even when \nalternative diagnoses appear more prominent.\nFrom a clinical perspective, these findings underscore \nthe importance of maintaining a high index of suspicion \nfor adenomyosis in multiparous women presenting \nwith abnormal uterine bleeding or pelvic pain. Although \nhistopathological examination remains the definitive \ndiagnostic method, further prospective studies are \nwarranted to improve non-invasive diagnostic strategies, \nparticularly through advances in ultrasonography and \nmagnetic resonance imaging, and to better clarify the \nnatural course of the disease.\nEthics\nEthics Committee Approval: The study was conducted at \nthe Department of Obstetrics and Gynecology, University \nof Health Sciences Turkey, Prof. Dr. Cemil Taşcıoğlu \nHospital, after receiving approval from the institutional \nethics committee (approval no: 282, date: 06.07.2020). \n\nBatman and Mihmanlı. \nPrevalence of Adenomyosis in Hysterectomy Cases\nBagcilar Medical Bulletin,\nInformed Consent: Due to the retrospective nature of the \nstudy, the requirement for informed consent was waived by \nthe ethics committee.\nFootnotes\nAuthorship Contributions\nSurgical and Medical Practices: A.B., V .M., Concept: A.B., \nV .M., Design: A.B., V .M., Data Collection or Processing: A.B., \nAnalysis or Interpretation: A.B., V .M., Literature Search: \nA.B., Writing: A.B., V .M.\nConflict of Interest: No conflict of interest was declared by \nthe authors.\nFinancial Disclosure: The authors declared that this study \nreceived no financial support.\nReferences\n1. 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