Adenomyosis and Polycystic Ovary Syndrome in Adolescents and Young Women: More Common Together or Not?

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Mustafa Kaplanoglu, Dilek Kaplanoglu, Mehmet Ali Sungur This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7282360/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 16 You are reading this latest preprint version Abstract Objectives: This study evaluated the relationship between adenomyosis and polycystic ovary syndrome (PCOS) in adolescents and young adults and compared their clinical and ultrasonographic features when they were present alone or concurrently to support a more comprehensive diagnostic approach. Methods: We retrospectively reviewed the medical records of 319 individuals aged 10–25 years with symptoms suggestive of adenomyosis or PCOS. The participants were grouped as adenomyosis only (n = 29), PCOS only (n = 277), or combined (n = 13). Diagnoses were made via ultrasonography according to international guidelines. The data were analysed via IBM SPSS Statistics v.22. Normality was assessed by the Kolmogorov‒Smirnov test. Independent samples t tests were used for continuous variables; chi-square tests or Fisher’s exact tests were used for categorical variables. P < 0.05 was considered statistically significant. Results: Chronological and gynecologic age did not differ among the groups; however, body mass index was significantly greater in the PCOS group (p < 0.001). Heavy menstrual bleeding (HMB) (34.5% and 61.5%), pelvic pain (24.1% and 38.5%), and dysmenorrhea (89.7% and 69.2%) were significantly more common in the adenomyosis and combined groups than in the PCOS group (all p < 0.001). Uterine wall asymmetry, irregular or interrupted junctional zones (JZs), and echogenic subendometrial lines and buds were also more prevalent in these groups (all p < 0.001). Hyperechoic myometrial islands were the least common ultrasonographic finding (27.6%). Ferriman–Gallwey (FG) scores and free androgen index values were significantly greater in the PCOS group (p < 0.001 and p = 0.029). Conclusions: Adenomyosis and PCOS exhibit distinct clinical and ultrasonographic profiles even in adolescence. Careful ultrasonographic evaluation in PCOS may increase diagnostic accuracy by detecting coexisting adenomyosis, emphasizing the need for early differential diagnosis to guide individualized treatment strategies. Adolescent Young Adult Adenomyosis Polycystic Ovary Syndrome Ultrasonography Figures Figure 1 Introduction Adenomyosis was first described in 1860 by the Austrian pathologist Karl von Rokitansky and is defined by the ectopic presence of endometrial glands and stroma within the uterine myometrium. Although benign, it is now recognized as a clinically significant gynecological disorder [ 1 ]. This early definition established the histopathological basis of the disease and provided a conceptual framework for subsequent clinical evaluation. Contemporary epidemiological data reveal substantial variability in the reported frequency of adenomyosis. An Italian population-based study reported an incidence of 0.02–0.03% and a prevalence of 0.17% among women of reproductive age. In contrast, a 10-year prospective cohort study of 330,000 women in the United States reported an incidence of 1%, with the highest rates observed among black women, the lowest among Asian women, and white women occupying an intermediate position within this spectrum [ 2 ]. Adenomyosis is clinically most commonly associated with dysmenorrhea, heavy menstrual bleeding (HMB), and infertility; however, approximately 30% of cases remain asymptomatic [ 3 ]. The advent and widespread adoption of advanced imaging modalities—such as transvaginal ultrasonography (Tvusg), transrectal ultrasonography (Trusg) and magnetic resonance imaging (MRI)—have enabled the detection of adenomyosis in multiparous women and often through histopathological examination following hysterectomy in younger, infertile, and even asymptomatic women [ 4 ]. This evolution challenges the notion that adenomyosis is exclusive to advanced age and may present with diverse phenotypes in adolescent and young adult women. A meta-analysis evaluating the efficacy of imaging techniques in adenomyosis diagnosis demonstrated that both MRI and Tvusg possess high sensitivity and specificity (MRI: 78% and 88%, respectively; Tvusg 74% and 84%, respectively) [ 5 ]. These findings are consistent with numerous studies reported in the literature [ 6 ]. Nevertheless, the lack of fully standardized diagnostic criteria continues to introduce substantial variability and uncertainty in clinical practice. In response, the Morphological Uterus Sonographic Assessment (MUSA) group has developed revised set of sonographic criteria, representing a significant advancement in the diagnostic process. However, prospective data validating the clinical utility of these criteria remain limited [ 7 ]. Polycystic ovary syndrome (PCOS) is a complex endocrine disorder commonly observed among women of reproductive age and is characterized by heterogeneous clinical and biochemical features. Its prevalence varies according to the diagnostic criteria used, ranging from 8–13% in reproductive-aged women and 3–11% in adolescents [ 8 ]. According to the Rotterdam criteria, a diagnosis of PCOS requires the presence of at least two of the following: hyperandrogenism, oligo/anovulation, and polycystic ovarian morphology. However, physiological variations specific to adolescence—such as multifollicular ovarian morphology and transient menstrual irregularities—limit the validity of these criteria in this age group [ 8 ]. In this context, the 2023 International Evidence-Based Guideline for PCOS stipulate that, in adolescents, a diagnosis requires the presence of clinical or biochemical hyperandrogenism in addition to persistent menstrual irregularity lasting at least two years [ 8 ]. The guidelines further emphasize that ultrasonographic ovarian morphology alone is insufficient for diagnosis, particularly when the gynecological age is < 8 years. Adenomyosis and PCOS are two distinct yet potentially pathophysiologically linked disorders frequently encountered in women of reproductive age [ 9 ]. Both conditions share overlapping clinical manifestations, including abnormal uterine bleeding, infertility, and pregnancy complications. The hyperandrogenism and chronic anovulation characteristics of PCOS disrupt the estrogen–progesterone balance, potentially enhancing inflammatory responses within the endometrium. Similarly, adenomyosis fosters an estrogen-dominant local hormonal microenvironment through increased local estrogen production, progesterone resistance, and myometrial inflammation. Notably, PCOS animal models have demonstrated that activation of the RhoA/ROCK signalling pathways leads to increased uterine contractility, which may compromise the integrity of the endometrial–myometrial interface and create a predisposition for adenomyosis development. The shared clinical features of dysmenorrhea, irregular uterine contractions, and chronic inflammation observed in both disorders further support possible mechanistic crosstalk at the mechanical and immunologic levels [ 10 ]. However, epidemiologic data regarding the co-occurrence and causal relationships between these entities remain exceedingly limited, particularly in the adolescent population. The aim of this study was to further delineate the potential overlap and distinctions between adenomyosis and PCOS in adolescents, characterize the clinical and ultrasonographic features of these two conditions when they are observed together or independently, and provide a more integrated understanding of their diagnosis and management. In this context, we sought to offer new perspectives to facilitate the early diagnosis and differentiation of these conditions in the adolescent population. Materials and methods Study Design and Participants This retrospective, cross-sectional study was conducted between January 2024 and June 2025 at a tertiary referral center. We systematically reviewed the electronic medical records and imaging data of adolescent and young adult patients aged 10–25 years who presented with (i) symptoms suggestive of adenomyosis—chronic pelvic pain, dysmenorrhea, dyspareunia, or HMB—or (ii) clinical features consistent with PCOS, including menstrual irregularities and hirsutism. Patients referred from external centers with these complaints were also included. Eligible participants had a minimum gynecological age of ≥ 2 years and had not received hormonal therapy (e.g., combined oral contraceptives, progestins, gonadotropin-releasing hormone analogues, or anti-androgens) within the preceding three months. The exclusion criteria were as follows: (1) age outside the defined range; (2) previous uterine or ovarian surgery; (3) congenital urogenital anomalies; (4) prior or active malignancy; (5) confirmed or suspected endometriosis; (6) body mass index (BMI) ≥ 35 kg/m²; (7) prior pregnancy; (8) significant psychiatric comorbidities; or (9) incomplete clinical data precluding diagnostic confirmation. Clinical assessment Pain-related symptoms were evaluated via the visual analogue scale (VAS), and a score of ≥ 6 was considered indicative of clinically significant pain. In cases where VAS assessment was not feasible or not documented in medical records, the presence of pain severe enough to cause school or work absenteeism (as documented by prior medical leave or absence records) was taken into account. HMB was defined as the presence of one or more of the following: menstrual bleeding lasting > 7 days, passage of clots, or the need to change sanitary products ≥ 7 times per day (i.e., requiring replacement every 1–2 hours). Ultrasonography Method All ultrasonographic evaluations were performed by a single expert physician (MK) specialized in adolescent gynecology and reproductive health. Assessments were conducted using a Mindray Consona N8 ultrasound system (Shenzhen, China) with a 5–7.5 MHz vaginal transducer, employing two-dimensional (2D) grayscale and power Doppler modes. A Tvusg was preferred by sexually active participants, whereas a Trusg was used by others. Patients who underwent only pelvic ultrasonography were not included in the study. Examinations were performed systematically with the bladder and rectum emptied. The uterus, endometrium, myometrium, and adnexal structures were evaluated in detail, along with their relationships with adjacent structures, including the use of the sliding sign and evaluation for deep infiltrating endometriosis (DIE) when indicated. Any remarkable lesions were digitally archived in the ultrasound system memory during the examination. Diagnostic criteria Adenomyosis was diagnosed according to the MUSA criteria revised by Harmsen et al. in 2022 [ 7 ]. For diagnosis, the presence of at least one direct feature—such as myometrial cysts, hyperechoic myometrial islands, echogenic subendometrial lines and buds—in combination with at least one indirect feature—including a globular uterus, uterine wall asymmetry, fan-shaped shadowing, translesional vascularity, or an irregular and interrupted junctional zone (JZ)—was needed. Patients with endometrioma, fibroids, or other uterine pathologies were excluded from the study. PCOS was diagnosed according to the 2023 International Evidence-Based Guideline, considering adolescent physiology into consideration [ 8 ]. The diagnostic criteria included persistent menstrual irregularity beyond the first two years post-menarche in conjunction with clinical and/or biochemical hyperandrogenism. Ovarian morphology was not used as a diagnostic criterion in individuals with a gynecologic age 6. Biochemical hyperandrogenism was evaluated via the Free Androgen Index (FAI = [total testosterone/SHBG] × 100), and an FAI value > 6 was considered diagnostic. Statistics Statistical analyses were performed via IBM SPSS v.22 software (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). The normality assumption for continuous variables was assessed via the Kolmogorov‒Smirnov test, and the skewness and kurtosis values were also evaluated. Continuous variables were analysed with an independent samples t test. Pearson's chi-square test or Fisher’s exact test was used to compare categorical variables in accordance with the expected count in each cell. Continuous variables are expressed as means ± standard deviations, and categorical variables are expressed as numbers and percentages. A p value of < 0.05 was considered statistically significant. Results In the present study, the demographic characteristics, clinical symptoms, and ultrasonographic findings of adolescents diagnosed with adenomyosis, those with PCOS, and those in the combined group were compared. (Tables 1 and 2 ) No statistically significant differences were observed between the groups concerning chronological age or gynecologic age (p = 0.507 and p = 0.632, respectively). In contrast, BMI was significantly elevated in the PCOS group (p < 0.001), which is consistent with the well-documented metabolic profile associated with PCOS. Compared with the PCOS group, both the adenomyosis group and the combined group presented significantly greater percentages of HMB (34.5% and 61.5% vs. 6.5%), pelvic pain (24.1% and 38.5% vs. 5.4%), and dysmenorrhea (89.7% and 69.2% vs. 6.1%) (all p < 0.001). These findings indicate that the clinical phenotype of adenomyosis differs markedly from that of classical PCOS even in adolescence. Notably, dyspareunia was reported in 38.5% of the combined group but not reported in the PCOS group (p < 0.001). This significant disparity suggests that dyspareunia may represent a potentially discriminative symptom useful in differential diagnosis. Table 1 Clinical and ultrasonographic features of the groups Adenomyosis (n = 29) Anedomyosis + PCOS (n = 13) PCOS (n = 277) p Age (years) 18,62 ± 3,98 20,00 ± 3,32 18,77 ± 3,84 0,507 Gynecologic age (years) 7,17 ± 3,95 8,31 ± 3,43 7,75 ± 3,84 0,632 BMI (kg/m 2 ) 26,26 ± 2,54 25,25 ± 3,29 28,01 ± 3,26 < 0,001 Smoking n (%) 5 (17,2) a 3 (23,1) a 15 (5,4) b 0,013 HMB , n (%) 10 (34,5) a 8 (61,5) a 18 (6,5) b < 0,001 Pelvic pain , n(%) 7 (24,1) a 5 (38,5) a 15 (5,4) b < 0,001 Dysmmenorrhoea , n (%) 26 (89,7) a 9 (69,2) a 17 (6,1) b < 0,001 Dysparonia , n (%) 3 (10,3) a 5 (38,5) b 0 (0,0) c < 0,001 Dysuria , n (%) 0 (0,0) 1 (7,7) 4 (1,4) 0,248 Dyschezia , n (%) 1 (3,4) 1 (7,7) 5 (1,8) 0,355 Myometrial Cycts , n (%) 10 (34,5) a 6 (46,2) a 0 (0,0) b < 0,001 Echogenic subendometrial lines and buds n (%) 11 (37,9) a 7 (53,8) a 0 (0,0) b < 0,001 Hyperecoic myometrial islands , n (%) 8 (27,6) a 3 (23,1) a 0 (0,0) b < 0,001 Globuler Uterus , n (%) 1 (3,4) a 3 (23,1) a 0 (0,0) b < 0,001 Uterine wall asymmetry , n (%) 6 (20,7) a 8 (61,5) b 2 (0,7) c < 0,001 Fan Shaped Shadowing , n (%) 5 (17,2) a 5 (38,5) a 0 (0,0) b < 0,001 Translesional Vascularity , n (%) 14 (48,3) a 6 (46,2) a 0 (0,0) b < 0,001 Irregular and Interrupted JZ n (%) 12 (41,4) a 8 (61,5) a 2 (0,7) b < 0,001 BMI: Body Mass Index; hmb: Heavy Menstral Bleeding; JZ: Junctional Zone Table 2 Androgenic profile of the groups Adenomyosis (n = 7) Adenomyosis + PCOS (n = 13) PCOS (n = 277) p FG 3,71 ± 1,25 a 6,46 ± 2,14 b 7,45 ± 2,06 b < 0,001 FAI 5,07 ± 0,74 a 6,33 ± 2,09 ab 6,88 ± 1,77 b 0,029 FG, Ferriman Gallwey Scores; FAI: Free Androgen Index When all ultrasonographic findings were considered, their prevalence was significantly greater in the adenomyosis and combined groups than in the PCOS group (p < 0.001 for each parameter). These findings suggest that ultrasonography may be used with high sensitivity for the diagnosis of adenomyosis in adolescents. Notably, features such as uterine wall asymmetry, an irregular and interrupted JZ, and echogenic subendometrial lines and buds appear to be particularly prevalent in this age group. Among the direct ultrasonographic markers of adenomyosis, hyperechoic myometrial islands are the least frequently observed finding (%27,6). (Fig. 1 ) In the endocrine evaluation, the FG score was significantly lower in the adenomyosis group (3.71 ± 1.25) than in the PCOS group (7.45 ± 2.06) (p < 0.001). A similar trend was observed for the free androgen index (FAI), which was significantly elevated in the PCOS group (p = 0.029). These findings are consistent with the hyperandrogenic endocrine profile characteristic of PCOS, whereas adenomyosis appears to progress independently of these hormonal parameters. Importantly, FG score and FAI assessments are not routinely performed in patients with adenomyosis. In this study, patients who underwent these evaluations but did not meet the diagnostic criteria for PCOS on the basis of the results were excluded from the combined pathology group. DISCUSSION Adenomyosis in adolescent and young adult women has increasingly gained clinical recognition in recent years, driven by heightened awareness and advances in ultrasonographic diagnostic criteria [ 1 , 11 ]. In contrast, although PCOS has well-established diagnostic criteria, there remains a pressing and previously underappreciated need to reevaluate and refine the diagnostic framework specifically for the adolescent population. This highlights that both pathologies have undergone significant diagnostic evolution, especially within the adolescent age group. Adolescent adenomyosis, particularly its true incidence within this age group, remains poorly defined. The current literature reports a wide range in prevalence among adolescents and young adults presenting with HMB and dysmenorrhea, varying from 5.6–46%, largely depending on the characteristics of the studied populations. For example, Martire et al. assessed 270 adolescents referred for various indications and identified adenomyosis in approximately 5.2% of cases, with the prevalence increasing to 44% among those with concomitant endometriosis. However, because this study was conducted on a selected, clinically referred population, its findings may not fully reflect the general adolescent population. In this context, our study does not aim to establish the true incidence of adolescent adenomyosis; nevertheless, our data show that adenomyosis was detected in 4.48% of patients diagnosed with PCOS. Conversely, 30.95% of patients with adenomyosis also had a concurrent diagnosis of PCOS. These findings reveal a notable overlap between these two gynecologic conditions, particularly during the early reproductive years, underscoring the importance of reciprocal screening during clinical evaluation. In adolescents presenting with dysmenorrhea and HMB, clinical suspicion for adenomyosis should prompt ultrasonographic evaluation—Tvusg or Trusg—as the primary diagnostic modality [ 12 ]. However, in individuals diagnosed with PCOS who lack clinical suspicion for adenomyosis, routine ultrasonographic evaluations rarely include systematic screening for this condition. The findings of our study call this approach into question and underscore the need for its reappraisal. In patients with coexisting PCOS and adenomyosis, ultrasonographic markers such as uterine wall asymmetry and an irregular and interrupted JZ appearance were observed more frequently and with greater prominence than in women diagnosed with adenomyosis alone. These sonographic features align with previously proposed structural criteria for adenomyosis diagnosis [ 12 , 15 ]. Our data suggest that in PCOS patients with concomitant adenomyosis, structural ultrasonographic markers of the disease may present more distinctly, suggesting that PCOS may influence the severity of adenomyosis. In the study by Exacoustos et al., endometriosis lesions were detected concurrently in 44% of adolescents diagnosed with adenomyosis, suggesting that these two pathologies may develop on a shared pathophysiological basis within certain patient subgroups [ 15 ]. Similarly, in our current study, typical adenomyosis sonographic findings—such as uterine wall asymmetry and an irregular, interrupted JZ—were observed in 61.5% of individuals with coexisting PCOS and adenomyosis. These results indicate that these two conditions can cooccur and potentially interact in some patients. These findings support the hypothesis that PCOS may predispose certain individuals to adenomyosis development and emphasize the diagnostic importance of targeted ultrasonographic evaluation in this patient group. Indeed, multiple studies have demonstrated that ultrasound markers specific to adenomyosis can be identified with high diagnostic accuracy in the adolescent population [ 15 ]. In this context, Tvusg, as well as Trusg—particularly in nonsexually active individuals—have been shown to contribute diagnostically [ 16 ]. Notably, nearly all ultrasonographic markers characteristic of adenomyosis were detected at higher rates in individuals with coexisting PCOS and adenomyosis than in those diagnosed with adenomyosis alone. This observation suggests that targeted, short-term screening for adenomyosis in patients with PCOS may improve diagnostic accuracy and facilitate more individualized clinical management strategies. Furthermore, these results underscore the need to reconsider PCOS not only as a disorder of ovarian function but also as a systemic gynecological endocrinopathy that affects uterine micromorphology. Such a broader conceptual framework may enhance the understanding of the pathophysiology and guide more comprehensive care for affected patients. Adenomyosis is a complex gynecological disorder characterized by the infiltration of endometrial basal layer cells into the myometrium [ 17 ]. Recent molecular studies have demonstrated that mutations frequently detected in KRAS and PIK3CA in adenomyosis originate primarily in the eutopic endometrium and subsequently invade the myometrium [ 18 ]. These mutations not only increase the invasive potential and survival of affected cells but also contribute to progesterone resistance, thereby diminishing therapeutic responsiveness. In addition, epigenetic modifications in stromal cells increase aromatase activity, leading to elevated local estrogen production and upregulation of estrogen receptor-β (ERβ) expression, whereas progesterone receptor levels are concurrently downregulated. This hormonal imbalance promotes chronic inflammation and cellular proliferation within adenomyotic lesions, thereby perpetuating disease progression [ 19 ]. Functionally, increased uterine peristalsis plays a central role in the pathogenesis of adenomyosis [ 20 , 21 ]. This heightened contractile activity throughout the menstrual cycle leads to microscopic tissue disruption, particularly at anatomically susceptible sites such as the fundo-cornual ridge, thereby triggering the 'tissue injury and repair' (TIAR) mechanism [ 17 , 20 ]. Damage to the JZ, a critical transitional area within this process, further amplifies local estrogen production, exacerbating uterine motor activity and establishing a self-perpetuating cycle that sustains the disease [ 22 ]. Oestrogen dominance inadequately opposed by progesterone further perpetuates this pathogenic cascade Recent studies using PCOS rat models have shown that irregular uterine contractions are more pronounced in subjects with PCOS [ 23 , 24 ]. Theoretically, this dysregulated uterine peristalsis may contribute to disruption of the JZ, facilitating the migration of basal endometrial cells into the deeper myometrium. This proposed mechanism could predispose patients with PCOS to developing adenomyosis and may partially explain the frequent co-occurrence of these two pathologies in certain individuals. In our study, symptoms such as HMB, dysmenorrhea, and pelvic pain were more frequently observed in both patients with isolated adenomyosis and those with coexisting PCOS. However, these differences did not reach statistical significance, likely due to the limited sample size. The notably high prevalence of HMB in the combined group may be related to delayed endometrial shedding caused by anovulatory cycles, resulting in endometrial thickening and structural irregularities. This finding underscores the clinical importance of conducting advanced evaluations with Tvusg in PCOS patients presenting with heavy bleeding or pelvic pain to assess the potential coexistence of adenomyosis. Hirsutism is a characteristic clinical feature of PCOS and is observed less frequently in patients with adenomyosis. Similarly, FAI values were markedly greater in the PCOS group. In our study, individuals diagnosed with PCOS who presented symptoms suggestive of adenomyosis presented more pronounced ultrasonographic features than did those with classical adenomyosis. Interestingly, several adenomyosis-related sonographic markers have also been detected in asymptomatic PCOS patients. Several factors may explain these observations. First, symptoms of adenomyosis might precede sonographically detectable structural changes, indicating that such patients may represent an early or subclinical stage of the disease. Second, these findings may reflect an adenomyosis-like uterine phenotype within the structurally heterogeneous spectrum of PCOS. Third, shared hormonal imbalances—such as hyperestrogenism or progesterone resistance—may contribute to similar uterine alterations in both conditions. Given these possibilities, careful ultrasonographic monitoring of PCOS patients presenting with adenomyosis-like symptoms is essential for improving diagnostic precision and facilitating early identification of coexisting pathologies. These findings raise important questions regarding the clinical implications of PCOS and adenomyosis co-occurrence and its impact on management strategies. While anovulation in PCOS has long been recognized as a major contributor to infertility, the reproductive consequences of adenomyosis have received increasing attention in recent years. Early diagnosis of adenomyosis plays a pivotal role not only in alleviating symptoms but also in preserving fertility and tailoring individualized treatment approaches—an increasingly emphasized goal in gynecologic care. Therefore, a comprehensive diagnostic approach that considers the possible coexistence of adenomyosis alongside PCOS rather than focusing solely on PCOS-directed interventions is warranted. This integrated perspective is critical for preventing long-term reproductive complications and optimizing clinical outcomes. Rasing clinical awareness may also promote earlier recognition of isolated adenomyosis cases, enabling timely fertility-preserving interventions and improved symptom control. Conclusion This study highlights the potential coexistence of PCOS and adenomyosis in adolescents and young adults, drawing attention to their clinical implications. The detection of adenomyosis-like ultrasonographic features not only in symptomatic but also in asymptomatic PCOS patients suggests a possible structural and hormonal overlap between these two conditions. Early identification of this coexistence is crucial for both symptom management and fertility preservation. Increasing clinical awareness and incorporating routine imaging for adenomyosis in patients diagnosed with PCOS may improve diagnostic accuracy and facilitate individualized treatment strategies. These findings provide a pioneering perspective on an underrecognized relationship in the literature and warrant further validation through studies with larger sample sizes. Strengths and limitations of the study This study provides a novel framework for exploring the underrecognized overlap between PCOS and adenomyosis in adolescents and young adults. A key strength lies in the systematic ultrasonographic assessment of both symptomatic and asymptomatic individuals, allowing for the detection of subtle or early-stage uterine abnormalities. The investigation also addresses a critical gap in the literature by drawing attention to shared clinical and sonographic features. However, several limitations must be acknowledged. The pronounced imbalance in group sizes (29 vs. 13 vs. 277) significantly limited the statistical power and precluded reliable multivariable regression modelling. Additionally, the absence of certain variables in the PCOS group led to zero-cell occurrences and computational errors, whereas multicollinearity among independent predictors further hindered coefficient estimation. Despite these constraints, ongoing data collection aims to expand the sample size and support more robust analyses in future studies, ultimately contributing to more generalizable clinical insights. Future Directions and Recommendations Given the significant overlap between PCOS and adenomyosis observed in this study, future research should prioritize prospective, longitudinal studies with larger and more balanced sample sizes to validate these findings and further clarify the causal or bidirectional relationship between these two disorders. In particular, studies employing standardized ultrasonographic protocols and incorporating molecular or histopathological correlates will help elucidate the underlying pathophysiological mechanisms. There is also a need to establish specific diagnostic and management algorithms tailored for adolescents and young adults, especially in light of the unique hormonal and structural characteristics of this age group. Routine ultrasonographic screening for adenomyosis in adolescents diagnosed with PCOS who present with HMB, dysmenorrhea, or pelvic pain should be evaluated through well-designed clinical trials to assess cost-effectiveness and clinical utility. Furthermore, interdisciplinary collaboration between pediatric/adolescent gynecology, endocrinology, and radiology should be encouraged to develop integrated care models. The incorporation of educational strategies that raise awareness among clinicians about the early manifestations and atypical presentations of adenomyosis may promote timely diagnosis and fertility-preserving interventions. Finally, investigating how coexisting PCOS and adenomyosis affect long-term reproductive and metabolic outcomes is essential to inform personalized therapeutic approaches. Abbreviations PCOS : Polycystic Ovary Syndrome HMB : Heavy Menstrual Bleeding Tvusg : Transvaginal Ultrasonography Trusg : Transrectal Ultrasonography MRI : Magnetic Resonance Imaging MUSA : Morphological Uterus Sonographic Assessment DIE : Deep Infiltrating Endometriosis TIAR: Tissue Injury and Repair JZ : Junctional Zone (the transitional area between endometrium and myometrium) FG : Ferriman–Gallwey Score (used to assess hirsutism) FAI : Free Androgen Index BMI : Body Mass Index VAS : Visual Analog Scale Declarations Contributions MK is the first author, responsible for the study design, data analysis, interpretation of findings, coding, report writing, final evaluation of patients, and preparing the manuscript. DK coordinated the transfer of cases from external centers, organized the data, and provided crucial guidance and constructive feedback to improve the quality of the research. MAS participated in the statistical interpretation of the data. MK, DK, and MAS jointly reviewed, edited, and approved the final version of the manuscript. Ethics Declarations Ethics Approval and Consent to Participate The study protocol was reviewed and approved by the Clinical Research Ethics Committee of Çukurova University Faculty of Medicine (Approval No: 156/55). Written informed consent was obtained from all participants prior to their inclusion in the study. For participants under the age of 18, consent was also obtained from their parents or legal guardians. All data were analyzed anonymously and handled confidentially in accordance with the principles outlined in the Declaration of Helsinki. Consent for Publication Written informed consent for publication of anonymized data was obtained from all participants and/or their legal guardians. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Competing Interests The authors declare that they have no competing interests. Data availability statement The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Vannuccini S, Petraglia F. Recent advances in understanding and managing adenomyosis. F1000Research . 2019;8:283. doi:10.12688/f1000research.17242.1. Fan Z. The incidence and clinical impact of adenomyosis. In: Xue M, Leng J, Wong F, editors. Adenomyosis . Singapore: Springer; 2021. p. 1. doi:10.1007/978-981-33-4095-4_1. Upson K, Missmer SA. Epidemiology of adenomyosis. Semin Reprod Med . 2020;38:89–107. doi:10.1055/s-0040-1718920. Isaacson K, Loring M. Symptoms of adenomyosis and overlapping diseases. Semin Reprod Med . 2020;38:144–150. doi:10.1055/s-0040-1721795. Tellum T, Nygaard S, Lieng M. Noninvasive diagnosis of adenomyosis: a structured review and meta-analysis of diagnostic accuracy in imaging. J Minim Invasive Gynecol . 2020;27:408–418.e3. doi:10.1016/j.jmig.2019.11.001. Chapron C, Tosti C, Marcellin L, et al. Relationship between the magnetic resonance imaging appearance of adenomyosis and endometriosis phenotypes. Hum Reprod . 2017;32:1393–1401. doi:10.1093/humrep/dex088. Harmsen MJ, Van den Bosch T, de Leeuw RA, et al. Consensus on revised definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis: results of modified Delphi procedure. Ultrasound Obstet Gynecol . 2022;60:118–131. doi:10.1002/uog.24786. Teede HJ, Tay CT, Laven J et al. Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. Hum Reprod . 2023;38(9):1655–1679. doi:10.1093/humrep/dead156. Mousa M, Al-Jefout M, Alsafar H, et al. Prevalence of common gynecological conditions in the Middle East: systematic review and meta-analysis. Front Reprod Health . 2021;3:661360. doi:10.3389/frph.2021.661360. Aktas S, Un I, Omer Barlas I, Ozturk AB et al. Evaluation of the Rho A/Rho-kinase pathway in the uterus of the rat model of polycystic ovary syndrome. Reprod Biol . 2019;19(1):45–54. doi:10.1016/j.repbio.2019.01.005. Martire FG, d'Abate C, Schettini G, et al. Adenomyosis and adolescence: a challenging diagnosis and complex management. Diagnostics (Basel) . 2024;14(21):2344. doi:10.3390/diagnostics14212344. Vannuccini S, Meleca C, Toscano F, et al. Adenomyosis diagnosis among adolescents and young women with dysmenorrhoea and heavy menstrual bleeding. Reprod Biomed Online . 2024;48(5):103768. doi:10.1016/j.rbmo.2023.103768. Vercellini P, Buffo C, Bandini V, et al. Prevalence of adenomyosis in symptomatic adolescents and young women: a systematic review and meta-analysis. F&S Rev . 2025;6(1):100083. doi:10.1016/j.xfnr.2024.100083. Martire FG, Lazzeri L, Conway F, et al. Adolescence and endometriosis: symptoms, ultrasound signs and early diagnosis. Fertil Steril . 2020;114(5):1049–1057. doi:10.1016/j.fertnstert.2020.06.012. Exacoustos C, Lazzeri L, Martire FG, et al. Ultrasound findings of adenomyosis in adolescents: type and grade of the disease. J Minim Invasive Gynecol . 2022;29(2):291–299.e1. doi:10.1016/j.jmig.2021.08.023. Güdücü N, Sidar G, İşçi H et al. The utility of transrectal ultrasound in adolescents when transabdominal or transvaginal ultrasound is not feasible. J Pediatr Adolesc Gynecol . 2013;26(5):265–268. doi:10.1016/j.jpag.2013.04.004. García-Solares J, Donnez J, Donnez O et al. Pathogenesis of uterine adenomyosis: invagination or metaplasia? Fertil Steril . 2018;109:371–379. doi:10.1016/j.fertnstert.2017.12.030. Bulun SE, Yildiz S, Adli M, et al. Endometriosis and adenomyosis: shared pathophysiology. Fertil Steril . 2023;119(5):746–750. doi:10.1016/j.fertnstert.2023.03.006. Bulun SE, Yildiz S, Adli M et al. Adenomyosis pathogenesis: insights from next-generation sequencing. Hum Reprod Update . 2021;27(6):1086–1097. doi:10.1093/humupd/dmab017. Leyendecker G, Wildt L, Mall G. The pathophysiology of endometriosis and adenomyosis: tissue injury and repair. Arch Gynecol Obstet . 2009;280(4):529–538. doi:10.1007/s00404-009-1191-0. Leyendecker G, Wildt L. A new concept of endometriosis and adenomyosis: tissue injury and repair (TIAR). Horm Mol Biol Clin Investig . 2011;5:125–142. doi:10.1515/HMBCI.2011.002. Brosens JJ, de Souza NM, Barker FG. Uterine junctional zone: function and disease. Lancet . 1995;346:558–560. doi:10.1016/S0140-6736(95)91387-4. Sajadi M, Noroozzadeh M, Bagheripour F et al. Contractions in the isolated uterus of a rat model of polycystic ovary syndrome compared to controls in adulthood. Int J Endocrinol Metab . 2018;16(2):e63135. doi:10.5812/ijem.63135. Aktas S, Un I, Omer Barlas I et al. Evaluation of the Rho A/Rho-kinase pathway in the uterus of the rat model of polycystic ovary syndrome. Reprod Biol . 2019;19(1):45–54. doi:10.1016/j.repbio.2019.01.005. Vercellini P, Consonni D, Dridi D et al. Uterine adenomyosis and in vitro fertilization outcome: a systematic review and meta-analysis. Hum Reprod . 2014;29:964–977. doi:10.1093/humrep/deu041. Tomassetti C, Meuleman C, Timmerman D et al. Adenomyosis and subfertility: evidence of association and causation. Semin Reprod Med . 2013;31:101–108. doi:10.1055/s-0032-1333475. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7282360","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":509555842,"identity":"e82ce2c8-225b-4366-a513-6dad49292dc2","order_by":0,"name":"Mustafa Kaplanoglu","email":"data:image/png;base64,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","orcid":"","institution":"MedicalPark Hospital","correspondingAuthor":true,"prefix":"","firstName":"Mustafa","middleName":"","lastName":"Kaplanoglu","suffix":""},{"id":509555844,"identity":"06df8405-12d2-492b-8909-d16e7c31c4c9","order_by":1,"name":"Dilek Kaplanoglu","email":"","orcid":"","institution":"Yuregir Goverment Hospital","correspondingAuthor":false,"prefix":"","firstName":"Dilek","middleName":"","lastName":"Kaplanoglu","suffix":""},{"id":509555845,"identity":"270d89dd-ed6e-4ff7-9504-4181fc59de11","order_by":2,"name":"Mehmet Ali Sungur","email":"","orcid":"","institution":"Duzce University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"Ali","lastName":"Sungur","suffix":""}],"badges":[],"createdAt":"2025-08-03 09:08:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7282360/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7282360/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90803774,"identity":"67fade55-6fa6-48a7-8ecf-d828fcfbfa21","added_by":"auto","created_at":"2025-09-08 10:37:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":393844,"visible":true,"origin":"","legend":"\u003cp\u003eThe ultrasonographic features in patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(A)\u003c/strong\u003e Hyperechoic myometrial islands (arrow) (Direct feature).\u003cbr\u003e\n \u003cstrong\u003e(B)\u003c/strong\u003e Myometrial cyst. In other sections, smaller surrounding myometrial cysts were also identified. Although not a mandatory finding, in some cases a hyperechoic rim was observed at the cyst boundary (Direct feature).\u003cbr\u003e\n \u003cstrong\u003e(C)\u003c/strong\u003e Asymmetrical myometrial thickening; the anterior and posterior myometrial wall thicknesses are indicated by white dotted lines. Hyperechoic islands are visible within the thickened myometrial wall. Irregularity and disruption of the junctional zone (JZ) can also be observed in the measured area (Indirect feature).\u003cbr\u003e\n \u003cstrong\u003e(D)\u003c/strong\u003e Translesional myometrial vascularization (arrow) demonstrated on color Doppler imaging (indirect feature); additionally, a globular enlargement of the uterus is observed.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7282360/v1/9f0d96f15c4a8a56a5504bb1.png"},{"id":90806121,"identity":"a4ae8179-7c08-48f2-bae4-ff8c4c2169b5","added_by":"auto","created_at":"2025-09-08 11:01:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1252767,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7282360/v1/0e3dce2f-0140-4509-bad9-78bd56e63d41.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Adenomyosis and Polycystic Ovary Syndrome in Adolescents and Young Women: More Common Together or Not?","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAdenomyosis was first described in 1860 by the Austrian pathologist Karl von Rokitansky and is defined by the ectopic presence of endometrial glands and stroma within the uterine myometrium. Although benign, it is now recognized as a clinically significant gynecological disorder [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. This early definition established the histopathological basis of the disease and provided a conceptual framework for subsequent clinical evaluation. Contemporary epidemiological data reveal substantial variability in the reported frequency of adenomyosis. An Italian population-based study reported an incidence of 0.02\u0026ndash;0.03% and a prevalence of 0.17% among women of reproductive age. In contrast, a 10-year prospective cohort study of 330,000 women in the United States reported an incidence of 1%, with the highest rates observed among black women, the lowest among Asian women, and white women occupying an intermediate position within this spectrum [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAdenomyosis is clinically most commonly associated with dysmenorrhea, heavy menstrual bleeding (HMB), and infertility; however, approximately 30% of cases remain asymptomatic [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The advent and widespread adoption of advanced imaging modalities\u0026mdash;such as transvaginal ultrasonography (Tvusg), transrectal ultrasonography (Trusg) and magnetic resonance imaging (MRI)\u0026mdash;have enabled the detection of adenomyosis in multiparous women and often through histopathological examination following hysterectomy in younger, infertile, and even asymptomatic women [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This evolution challenges the notion that adenomyosis is exclusive to advanced age and may present with diverse phenotypes in adolescent and young adult women.\u003c/p\u003e\u003cp\u003eA meta-analysis evaluating the efficacy of imaging techniques in adenomyosis diagnosis demonstrated that both MRI and Tvusg possess high sensitivity and specificity (MRI: 78% and 88%, respectively; Tvusg 74% and 84%, respectively) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These findings are consistent with numerous studies reported in the literature [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Nevertheless, the lack of fully standardized diagnostic criteria continues to introduce substantial variability and uncertainty in clinical practice. In response, the Morphological Uterus Sonographic Assessment (MUSA) group has developed revised set of sonographic criteria, representing a significant advancement in the diagnostic process. However, prospective data validating the clinical utility of these criteria remain limited [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003ePolycystic ovary syndrome (PCOS) is a complex endocrine disorder commonly observed among women of reproductive age and is characterized by heterogeneous clinical and biochemical features. Its prevalence varies according to the diagnostic criteria used, ranging from 8\u0026ndash;13% in reproductive-aged women and 3\u0026ndash;11% in adolescents [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. According to the Rotterdam criteria, a diagnosis of PCOS requires the presence of at least two of the following: hyperandrogenism, oligo/anovulation, and polycystic ovarian morphology. However, physiological variations specific to adolescence\u0026mdash;such as multifollicular ovarian morphology and transient menstrual irregularities\u0026mdash;limit the validity of these criteria in this age group [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In this context, the 2023 International Evidence-Based Guideline for PCOS stipulate that, in adolescents, a diagnosis requires the presence of clinical or biochemical hyperandrogenism in addition to persistent menstrual irregularity lasting at least two years [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The guidelines further emphasize that ultrasonographic ovarian morphology alone is insufficient for diagnosis, particularly when the gynecological age is \u0026lt;\u0026thinsp;8 years.\u003c/p\u003e\u003cp\u003eAdenomyosis and PCOS are two distinct yet potentially pathophysiologically linked disorders frequently encountered in women of reproductive age [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Both conditions share overlapping clinical manifestations, including abnormal uterine bleeding, infertility, and pregnancy complications. The hyperandrogenism and chronic anovulation characteristics of PCOS disrupt the estrogen\u0026ndash;progesterone balance, potentially enhancing inflammatory responses within the endometrium. Similarly, adenomyosis fosters an estrogen-dominant local hormonal microenvironment through increased local estrogen production, progesterone resistance, and myometrial inflammation.\u003c/p\u003e\u003cp\u003eNotably, PCOS animal models have demonstrated that activation of the RhoA/ROCK signalling pathways leads to increased uterine contractility, which may compromise the integrity of the endometrial\u0026ndash;myometrial interface and create a predisposition for adenomyosis development. The shared clinical features of dysmenorrhea, irregular uterine contractions, and chronic inflammation observed in both disorders further support possible mechanistic crosstalk at the mechanical and immunologic levels [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, epidemiologic data regarding the co-occurrence and causal relationships between these entities remain exceedingly limited, particularly in the adolescent population.\u003c/p\u003e\u003cp\u003eThe aim of this study was to further delineate the potential overlap and distinctions between adenomyosis and PCOS in adolescents, characterize the clinical and ultrasonographic features of these two conditions when they are observed together or independently, and provide a more integrated understanding of their diagnosis and management. In this context, we sought to offer new perspectives to facilitate the early diagnosis and differentiation of these conditions in the adolescent population.\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design and Participants\u003c/h2\u003e\u003cp\u003eThis retrospective, cross-sectional study was conducted between January 2024 and June 2025 at a tertiary referral center. We systematically reviewed the electronic medical records and imaging data of adolescent and young adult patients aged 10\u0026ndash;25 years who presented with (i) symptoms suggestive of adenomyosis\u0026mdash;chronic pelvic pain, dysmenorrhea, dyspareunia, or HMB\u0026mdash;or (ii) clinical features consistent with PCOS, including menstrual irregularities and hirsutism. Patients referred from external centers with these complaints were also included.\u003c/p\u003e\u003cp\u003eEligible participants had a minimum gynecological age of \u0026ge;\u0026thinsp;2 years and had not received hormonal therapy (e.g., combined oral contraceptives, progestins, gonadotropin-releasing hormone analogues, or anti-androgens) within the preceding three months.\u003c/p\u003e\u003cp\u003eThe exclusion criteria were as follows: (1) age outside the defined range; (2) previous uterine or ovarian surgery; (3) congenital urogenital anomalies; (4) prior or active malignancy; (5) confirmed or suspected endometriosis; (6) body mass index (BMI)\u0026thinsp;\u0026ge;\u0026thinsp;35 kg/m\u0026sup2;; (7) prior pregnancy; (8) significant psychiatric comorbidities; or (9) incomplete clinical data precluding diagnostic confirmation.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eClinical assessment\u003c/h3\u003e\n\u003cp\u003ePain-related symptoms were evaluated via the visual analogue scale (VAS), and a score of \u0026ge;\u0026thinsp;6 was considered indicative of clinically significant pain. In cases where VAS assessment was not feasible or not documented in medical records, the presence of pain severe enough to cause school or work absenteeism (as documented by prior medical leave or absence records) was taken into account.\u003c/p\u003e\u003cp\u003eHMB was defined as the presence of one or more of the following: menstrual bleeding lasting\u0026thinsp;\u0026gt;\u0026thinsp;7 days, passage of clots, or the need to change sanitary products\u0026thinsp;\u0026ge;\u0026thinsp;7 times per day (i.e., requiring replacement every 1\u0026ndash;2 hours).\u003c/p\u003e\n\u003ch3\u003eUltrasonography Method\u003c/h3\u003e\n\u003cp\u003eAll ultrasonographic evaluations were performed by a single expert physician (MK) specialized in adolescent gynecology and reproductive health. Assessments were conducted using a Mindray Consona N8 ultrasound system (Shenzhen, China) with a 5\u0026ndash;7.5 MHz vaginal transducer, employing two-dimensional (2D) grayscale and power Doppler modes.\u003c/p\u003e\u003cp\u003e A Tvusg was preferred by sexually active participants, whereas a Trusg was used by others. Patients who underwent only pelvic ultrasonography were not included in the study.\u003c/p\u003e\u003cp\u003eExaminations were performed systematically with the bladder and rectum emptied. The uterus, endometrium, myometrium, and adnexal structures were evaluated in detail, along with their relationships with adjacent structures, including the use of the sliding sign and evaluation for deep infiltrating endometriosis (DIE) when indicated. Any remarkable lesions were digitally archived in the ultrasound system memory during the examination.\u003c/p\u003e\n\u003ch3\u003eDiagnostic criteria\u003c/h3\u003e\n\u003cp\u003eAdenomyosis was diagnosed according to the MUSA criteria revised by Harmsen et al. in 2022 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. For diagnosis, the presence of at least one direct feature\u0026mdash;such as myometrial cysts, hyperechoic myometrial islands, echogenic subendometrial lines and buds\u0026mdash;in combination with at least one indirect feature\u0026mdash;including a globular uterus, uterine wall asymmetry, fan-shaped shadowing, translesional vascularity, or an irregular and interrupted junctional zone (JZ)\u0026mdash;was needed. Patients with endometrioma, fibroids, or other uterine pathologies were excluded from the study.\u003c/p\u003e\u003cp\u003ePCOS was diagnosed according to the 2023 International Evidence-Based Guideline, considering adolescent physiology into consideration [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The diagnostic criteria included persistent menstrual irregularity beyond the first two years post-menarche in conjunction with clinical and/or biochemical hyperandrogenism. Ovarian morphology was not used as a diagnostic criterion in individuals with a gynecologic age\u0026thinsp;\u0026lt;\u0026thinsp;8 years.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eClinical hyperandrogenism was defined as the presence of hirsutism, which was assessed via a Ferriman\u0026ndash;Gallwey (FG) score\u0026thinsp;\u0026gt;\u0026thinsp;6.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBiochemical hyperandrogenism was evaluated via the Free Androgen Index (FAI = [total testosterone/SHBG] \u0026times; 100), and an FAI value\u0026thinsp;\u0026gt;\u0026thinsp;6 was considered diagnostic.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eStatistics\u003c/p\u003e\u003cp\u003eStatistical analyses were performed via IBM SPSS v.22 software (IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.). The normality assumption for continuous variables was assessed via the Kolmogorov‒Smirnov test, and the skewness and kurtosis values were also evaluated. Continuous variables were analysed with an independent samples t test. Pearson's chi-square test or Fisher\u0026rsquo;s exact test was used to compare categorical variables in accordance with the expected count in each cell. Continuous variables are expressed as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviations, and categorical variables are expressed as numbers and percentages. A p value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn the present study, the demographic characteristics, clinical symptoms, and ultrasonographic findings of adolescents diagnosed with adenomyosis, those with PCOS, and those in the combined group were compared. (Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) No statistically significant differences were observed between the groups concerning chronological age or gynecologic age (p\u0026thinsp;=\u0026thinsp;0.507 and p\u0026thinsp;=\u0026thinsp;0.632, respectively). In contrast, BMI was significantly elevated in the PCOS group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), which is consistent with the well-documented metabolic profile associated with PCOS. Compared with the PCOS group, both the adenomyosis group and the combined group presented significantly greater percentages of HMB (34.5% and 61.5% vs. 6.5%), pelvic pain (24.1% and 38.5% vs. 5.4%), and dysmenorrhea (89.7% and 69.2% vs. 6.1%) (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). These findings indicate that the clinical phenotype of adenomyosis differs markedly from that of classical PCOS even in adolescence. Notably, dyspareunia was reported in 38.5% of the combined group but not reported in the PCOS group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This significant disparity suggests that dyspareunia may represent a potentially discriminative symptom useful in differential diagnosis.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eClinical and ultrasonographic features of the groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdenomyosis (n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAnedomyosis\u0026thinsp;+\u0026thinsp;PCOS (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePCOS (n\u0026thinsp;=\u0026thinsp;277)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18,62\u0026thinsp;\u0026plusmn;\u0026thinsp;3,98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20,00\u0026thinsp;\u0026plusmn;\u0026thinsp;3,32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18,77\u0026thinsp;\u0026plusmn;\u0026thinsp;3,84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0,507\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGynecologic age (years)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7,17\u0026thinsp;\u0026plusmn;\u0026thinsp;3,95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8,31\u0026thinsp;\u0026plusmn;\u0026thinsp;3,43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7,75\u0026thinsp;\u0026plusmn;\u0026thinsp;3,84\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0,632\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26,26\u0026thinsp;\u0026plusmn;\u0026thinsp;2,54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25,25\u0026thinsp;\u0026plusmn;\u0026thinsp;3,29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28,01\u0026thinsp;\u0026plusmn;\u0026thinsp;3,26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSmoking\u003c/b\u003e n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (17,2)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (23,1)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15 (5,4)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0,013\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHMB\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (34,5)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (61,5)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18 (6,5)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePelvic pain\u003c/b\u003e, n(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (24,1)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (38,5)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15 (5,4)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDysmmenorrhoea\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26 (89,7)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (69,2)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e17 (6,1)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDysparonia\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (10,3)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (38,5)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0,0)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDysuria\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0,0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (7,7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (1,4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0,248\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDyschezia\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (3,4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (7,7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (1,8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0,355\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMyometrial Cycts\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (34,5)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (46,2)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0,0)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEchogenic subendometrial lines and buds n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (37,9)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (53,8)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0,0)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHyperecoic myometrial islands\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (27,6)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (23,1)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0,0)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGlobuler Uterus\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1 (3,4)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (23,1)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0,0)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUterine wall asymmetry\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (20,7)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (61,5)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (0,7)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFan Shaped Shadowing\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (17,2)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (38,5)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0,0)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTranslesional Vascularity\u003c/b\u003e, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (48,3)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (46,2)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0 (0,0)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIrregular and Interrupted JZ\u003c/b\u003e n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (41,4)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (61,5)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (0,7)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eBMI: Body Mass Index; hmb: Heavy Menstral Bleeding; JZ: Junctional Zone\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAndrogenic profile of the groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAdenomyosis (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAdenomyosis\u0026thinsp;+\u0026thinsp;PCOS (n\u0026thinsp;=\u0026thinsp;13)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePCOS (n\u0026thinsp;=\u0026thinsp;277)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFG\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3,71\u0026thinsp;\u0026plusmn;\u0026thinsp;1,25\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6,46\u0026thinsp;\u0026plusmn;\u0026thinsp;2,14\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7,45\u0026thinsp;\u0026plusmn;\u0026thinsp;2,06\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0,001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFAI\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5,07\u0026thinsp;\u0026plusmn;\u0026thinsp;0,74\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6,33\u0026thinsp;\u0026plusmn;\u0026thinsp;2,09\u003csup\u003eab\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6,88\u0026thinsp;\u0026plusmn;\u0026thinsp;1,77\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0,029\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eFG, Ferriman Gallwey Scores; FAI: Free Androgen Index\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhen all ultrasonographic findings were considered, their prevalence was significantly greater in the adenomyosis and combined groups than in the PCOS group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for each parameter). These findings suggest that ultrasonography may be used with high sensitivity for the diagnosis of adenomyosis in adolescents. Notably, features such as uterine wall asymmetry, an irregular and interrupted JZ, and echogenic subendometrial lines and buds appear to be particularly prevalent in this age group. Among the direct ultrasonographic markers of adenomyosis, hyperechoic myometrial islands are the least frequently observed finding (%27,6). (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn the endocrine evaluation, the FG score was significantly lower in the adenomyosis group (3.71\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25) than in the PCOS group (7.45\u0026thinsp;\u0026plusmn;\u0026thinsp;2.06) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A similar trend was observed for the free androgen index (FAI), which was significantly elevated in the PCOS group (p\u0026thinsp;=\u0026thinsp;0.029). These findings are consistent with the hyperandrogenic endocrine profile characteristic of PCOS, whereas adenomyosis appears to progress independently of these hormonal parameters. Importantly, FG score and FAI assessments are not routinely performed in patients with adenomyosis. In this study, patients who underwent these evaluations but did not meet the diagnostic criteria for PCOS on the basis of the results were excluded from the combined pathology group.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eAdenomyosis in adolescent and young adult women has increasingly gained clinical recognition in recent years, driven by heightened awareness and advances in ultrasonographic diagnostic criteria [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In contrast, although PCOS has well-established diagnostic criteria, there remains a pressing and previously underappreciated need to reevaluate and refine the diagnostic framework specifically for the adolescent population. This highlights that both pathologies have undergone significant diagnostic evolution, especially within the adolescent age group.\u003c/p\u003e\u003cp\u003eAdolescent adenomyosis, particularly its true incidence within this age group, remains poorly defined. The current literature reports a wide range in prevalence among adolescents and young adults presenting with HMB and dysmenorrhea, varying from 5.6\u0026ndash;46%, largely depending on the characteristics of the studied populations. For example, Martire et al. assessed 270 adolescents referred for various indications and identified adenomyosis in approximately 5.2% of cases, with the prevalence increasing to 44% among those with concomitant endometriosis. However, because this study was conducted on a selected, clinically referred population, its findings may not fully reflect the general adolescent population.\u003c/p\u003e\u003cp\u003eIn this context, our study does not aim to establish the true incidence of adolescent adenomyosis; nevertheless, our data show that adenomyosis was detected in 4.48% of patients diagnosed with PCOS. Conversely, 30.95% of patients with adenomyosis also had a concurrent diagnosis of PCOS. These findings reveal a notable overlap between these two gynecologic conditions, particularly during the early reproductive years, underscoring the importance of reciprocal screening during clinical evaluation.\u003c/p\u003e\u003cp\u003eIn adolescents presenting with dysmenorrhea and HMB, clinical suspicion for adenomyosis should prompt ultrasonographic evaluation\u0026mdash;Tvusg or Trusg\u0026mdash;as the primary diagnostic modality [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, in individuals diagnosed with PCOS who lack clinical suspicion for adenomyosis, routine ultrasonographic evaluations rarely include systematic screening for this condition. The findings of our study call this approach into question and underscore the need for its reappraisal. In patients with coexisting PCOS and adenomyosis, ultrasonographic markers such as uterine wall asymmetry and an irregular and interrupted JZ appearance were observed more frequently and with greater prominence than in women diagnosed with adenomyosis alone. These sonographic features align with previously proposed structural criteria for adenomyosis diagnosis [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Our data suggest that in PCOS patients with concomitant adenomyosis, structural ultrasonographic markers of the disease may present more distinctly, suggesting that PCOS may influence the severity of adenomyosis.\u003c/p\u003e\u003cp\u003eIn the study by Exacoustos et al., endometriosis lesions were detected concurrently in 44% of adolescents diagnosed with adenomyosis, suggesting that these two pathologies may develop on a shared pathophysiological basis within certain patient subgroups [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Similarly, in our current study, typical adenomyosis sonographic findings\u0026mdash;such as uterine wall asymmetry and an irregular, interrupted JZ\u0026mdash;were observed in 61.5% of individuals with coexisting PCOS and adenomyosis. These results indicate that these two conditions can cooccur and potentially interact in some patients. These findings support the hypothesis that PCOS may predispose certain individuals to adenomyosis development and emphasize the diagnostic importance of targeted ultrasonographic evaluation in this patient group. Indeed, multiple studies have demonstrated that ultrasound markers specific to adenomyosis can be identified with high diagnostic accuracy in the adolescent population [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In this context, Tvusg, as well as Trusg\u0026mdash;particularly in nonsexually active individuals\u0026mdash;have been shown to contribute diagnostically [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNotably, nearly all ultrasonographic markers characteristic of adenomyosis were detected at higher rates in individuals with coexisting PCOS and adenomyosis than in those diagnosed with adenomyosis alone. This observation suggests that targeted, short-term screening for adenomyosis in patients with PCOS may improve diagnostic accuracy and facilitate more individualized clinical management strategies. Furthermore, these results underscore the need to reconsider PCOS not only as a disorder of ovarian function but also as a systemic gynecological endocrinopathy that affects uterine micromorphology. Such a broader conceptual framework may enhance the understanding of the pathophysiology and guide more comprehensive care for affected patients.\u003c/p\u003e\u003cp\u003eAdenomyosis is a complex gynecological disorder characterized by the infiltration of endometrial basal layer cells into the myometrium [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Recent molecular studies have demonstrated that mutations frequently detected in KRAS and PIK3CA in adenomyosis originate primarily in the eutopic endometrium and subsequently invade the myometrium [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. These mutations not only increase the invasive potential and survival of affected cells but also contribute to progesterone resistance, thereby diminishing therapeutic responsiveness. In addition, epigenetic modifications in stromal cells increase aromatase activity, leading to elevated local estrogen production and upregulation of estrogen receptor-β (ERβ) expression, whereas progesterone receptor levels are concurrently downregulated. This hormonal imbalance promotes chronic inflammation and cellular proliferation within adenomyotic lesions, thereby perpetuating disease progression [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFunctionally, increased uterine peristalsis plays a central role in the pathogenesis of adenomyosis [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. This heightened contractile activity throughout the menstrual cycle leads to microscopic tissue disruption, particularly at anatomically susceptible sites such as the fundo-cornual ridge, thereby triggering the 'tissue injury and repair' (TIAR) mechanism [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Damage to the JZ, a critical transitional area within this process, further amplifies local estrogen production, exacerbating uterine motor activity and establishing a self-perpetuating cycle that sustains the disease [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Oestrogen dominance inadequately opposed by progesterone further perpetuates this pathogenic cascade\u003c/p\u003e\u003cp\u003eRecent studies using PCOS rat models have shown that irregular uterine contractions are more pronounced in subjects with PCOS [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Theoretically, this dysregulated uterine peristalsis may contribute to disruption of the JZ, facilitating the migration of basal endometrial cells into the deeper myometrium. This proposed mechanism could predispose patients with PCOS to developing adenomyosis and may partially explain the frequent co-occurrence of these two pathologies in certain individuals.\u003c/p\u003e\u003cp\u003eIn our study, symptoms such as HMB, dysmenorrhea, and pelvic pain were more frequently observed in both patients with isolated adenomyosis and those with coexisting PCOS. However, these differences did not reach statistical significance, likely due to the limited sample size. The notably high prevalence of HMB in the combined group may be related to delayed endometrial shedding caused by anovulatory cycles, resulting in endometrial thickening and structural irregularities. This finding underscores the clinical importance of conducting advanced evaluations with Tvusg in PCOS patients presenting with heavy bleeding or pelvic pain to assess the potential coexistence of adenomyosis.\u003c/p\u003e\u003cp\u003eHirsutism is a characteristic clinical feature of PCOS and is observed less frequently in patients with adenomyosis. Similarly, FAI values were markedly greater in the PCOS group.\u003c/p\u003e\u003cp\u003eIn our study, individuals diagnosed with PCOS who presented symptoms suggestive of adenomyosis presented more pronounced ultrasonographic features than did those with classical adenomyosis. Interestingly, several adenomyosis-related sonographic markers have also been detected in asymptomatic PCOS patients. Several factors may explain these observations. First, symptoms of adenomyosis might precede sonographically detectable structural changes, indicating that such patients may represent an early or subclinical stage of the disease. Second, these findings may reflect an adenomyosis-like uterine phenotype within the structurally heterogeneous spectrum of PCOS. Third, shared hormonal imbalances\u0026mdash;such as hyperestrogenism or progesterone resistance\u0026mdash;may contribute to similar uterine alterations in both conditions. Given these possibilities, careful ultrasonographic monitoring of PCOS patients presenting with adenomyosis-like symptoms is essential for improving diagnostic precision and facilitating early identification of coexisting pathologies.\u003c/p\u003e\u003cp\u003eThese findings raise important questions regarding the clinical implications of PCOS and adenomyosis co-occurrence and its impact on management strategies. While anovulation in PCOS has long been recognized as a major contributor to infertility, the reproductive consequences of adenomyosis have received increasing attention in recent years. Early diagnosis of adenomyosis plays a pivotal role not only in alleviating symptoms but also in preserving fertility and tailoring individualized treatment approaches\u0026mdash;an increasingly emphasized goal in gynecologic care. Therefore, a comprehensive diagnostic approach that considers the possible coexistence of adenomyosis alongside PCOS rather than focusing solely on PCOS-directed interventions is warranted. This integrated perspective is critical for preventing long-term reproductive complications and optimizing clinical outcomes. Rasing clinical awareness may also promote earlier recognition of isolated adenomyosis cases, enabling timely fertility-preserving interventions and improved symptom control.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights the potential coexistence of PCOS and adenomyosis in adolescents and young adults, drawing attention to their clinical implications. The detection of adenomyosis-like ultrasonographic features not only in symptomatic but also in asymptomatic PCOS patients suggests a possible structural and hormonal overlap between these two conditions. Early identification of this coexistence is crucial for both symptom management and fertility preservation. Increasing clinical awareness and incorporating routine imaging for adenomyosis in patients diagnosed with PCOS may improve diagnostic accuracy and facilitate individualized treatment strategies. These findings provide a pioneering perspective on an underrecognized relationship in the literature and warrant further validation through studies with larger sample sizes.\u003c/p\u003e"},{"header":"Strengths and limitations of the study","content":"\u003cp\u003eThis study provides a novel framework for exploring the underrecognized overlap between PCOS and adenomyosis in adolescents and young adults. A key strength lies in the systematic ultrasonographic assessment of both symptomatic and asymptomatic individuals, allowing for the detection of subtle or early-stage uterine abnormalities. The investigation also addresses a critical gap in the literature by drawing attention to shared clinical and sonographic features. However, several limitations must be acknowledged. The pronounced imbalance in group sizes (29 vs. 13 vs. 277) significantly limited the statistical power and precluded reliable multivariable regression modelling. Additionally, the absence of certain variables in the PCOS group led to zero-cell occurrences and computational errors, whereas multicollinearity among independent predictors further hindered coefficient estimation. Despite these constraints, ongoing data collection aims to expand the sample size and support more robust analyses in future studies, ultimately contributing to more generalizable clinical insights.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eFuture Directions and Recommendations\u003c/h2\u003e\u003cp\u003eGiven the significant overlap between PCOS and adenomyosis observed in this study, future research should prioritize prospective, longitudinal studies with larger and more balanced sample sizes to validate these findings and further clarify the causal or bidirectional relationship between these two disorders. In particular, studies employing standardized ultrasonographic protocols and incorporating molecular or histopathological correlates will help elucidate the underlying pathophysiological mechanisms.\u003c/p\u003e\u003cp\u003eThere is also a need to establish specific diagnostic and management algorithms tailored for adolescents and young adults, especially in light of the unique hormonal and structural characteristics of this age group. Routine ultrasonographic screening for adenomyosis in adolescents diagnosed with PCOS who present with HMB, dysmenorrhea, or pelvic pain should be evaluated through well-designed clinical trials to assess cost-effectiveness and clinical utility.\u003c/p\u003e\u003cp\u003eFurthermore, interdisciplinary collaboration between pediatric/adolescent gynecology, endocrinology, and radiology should be encouraged to develop integrated care models. The incorporation of educational strategies that raise awareness among clinicians about the early manifestations and atypical presentations of adenomyosis may promote timely diagnosis and fertility-preserving interventions. Finally, investigating how coexisting PCOS and adenomyosis affect long-term reproductive and metabolic outcomes is essential to inform personalized therapeutic approaches.\u003c/p\u003e\u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003ePCOS\u003c/strong\u003e: Polycystic Ovary Syndrome\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHMB\u003c/strong\u003e: Heavy Menstrual Bleeding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTvusg\u003c/strong\u003e: Transvaginal Ultrasonography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrusg\u003c/strong\u003e: Transrectal Ultrasonography\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMRI\u003c/strong\u003e: Magnetic Resonance Imaging\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMUSA\u003c/strong\u003e: Morphological Uterus Sonographic Assessment\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDIE\u003c/strong\u003e: Deep Infiltrating Endometriosis\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTIAR:\u0026nbsp;\u003c/strong\u003eTissue Injury and Repair\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJZ\u003c/strong\u003e: Junctional Zone (the transitional area between endometrium and myometrium)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFG\u003c/strong\u003e: Ferriman\u0026ndash;Gallwey Score (used to assess hirsutism)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFAI\u003c/strong\u003e: Free Androgen Index\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e: Body Mass Index\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVAS\u003c/strong\u003e: Visual Analog Scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eContributions\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;MK is the first author, responsible for the study design, data analysis, interpretation of findings, coding, report writing, final evaluation of patients, and preparing the manuscript. DK coordinated the transfer of cases from external centers, organized the data, and provided crucial guidance and constructive feedback to improve the quality of the research. MAS participated in the statistical interpretation of the data. MK, DK, and MAS jointly reviewed, edited, and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eEthics Declarations\u003c/strong\u003e\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThe study protocol was reviewed and approved by the Clinical Research Ethics Committee of \u0026Ccedil;ukurova University Faculty of Medicine (Approval No: 156/55). Written informed consent was obtained from all participants prior to their inclusion in the study. For participants under the age of 18, consent was also obtained from their parents or legal guardians. All data were analyzed anonymously and handled confidentially in accordance with the principles outlined in the Declaration of Helsinki.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eWritten informed consent for publication of anonymized data was obtained from all participants and/or their legal guardians.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003ch4\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/h4\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVannuccini S, Petraglia F. Recent advances in understanding and managing adenomyosis. \u003cem\u003eF1000Research\u003c/em\u003e. 2019;8:283. doi:10.12688/f1000research.17242.1.\u003c/li\u003e\n\u003cli\u003eFan Z. The incidence and clinical impact of adenomyosis. In: Xue M, Leng J, Wong F, editors. \u003cem\u003eAdenomyosis\u003c/em\u003e. Singapore: Springer; 2021. p. 1. doi:10.1007/978-981-33-4095-4_1.\u003c/li\u003e\n\u003cli\u003eUpson K, Missmer SA. Epidemiology of adenomyosis. \u003cem\u003eSemin Reprod Med\u003c/em\u003e. 2020;38:89\u0026ndash;107. doi:10.1055/s-0040-1718920.\u003c/li\u003e\n\u003cli\u003eIsaacson K, Loring M. Symptoms of adenomyosis and overlapping diseases. \u003cem\u003eSemin Reprod Med\u003c/em\u003e. 2020;38:144\u0026ndash;150. doi:10.1055/s-0040-1721795.\u003c/li\u003e\n\u003cli\u003eTellum T, Nygaard S, Lieng M. Noninvasive diagnosis of adenomyosis: a structured review and meta-analysis of diagnostic accuracy in imaging. \u003cem\u003eJ Minim Invasive Gynecol\u003c/em\u003e. 2020;27:408\u0026ndash;418.e3. doi:10.1016/j.jmig.2019.11.001.\u003c/li\u003e\n\u003cli\u003eChapron C, Tosti C, Marcellin L, et al. Relationship between the magnetic resonance imaging appearance of adenomyosis and endometriosis phenotypes. \u003cem\u003eHum Reprod\u003c/em\u003e. 2017;32:1393\u0026ndash;1401. doi:10.1093/humrep/dex088.\u003c/li\u003e\n\u003cli\u003eHarmsen MJ, Van den Bosch T, de Leeuw RA, et al. Consensus on revised definitions of Morphological Uterus Sonographic Assessment (MUSA) features of adenomyosis: results of modified Delphi procedure. \u003cem\u003eUltrasound Obstet Gynecol\u003c/em\u003e. 2022;60:118\u0026ndash;131. doi:10.1002/uog.24786.\u003c/li\u003e\n\u003cli\u003eTeede HJ, Tay CT, Laven J et al. Recommendations from the 2023 International Evidence-based Guideline for the Assessment and Management of Polycystic Ovary Syndrome. \u003cem\u003eHum Reprod\u003c/em\u003e. 2023;38(9):1655\u0026ndash;1679. doi:10.1093/humrep/dead156.\u003c/li\u003e\n\u003cli\u003eMousa M, Al-Jefout M, Alsafar H, et al. Prevalence of common gynecological conditions in the Middle East: systematic review and meta-analysis. \u003cem\u003eFront Reprod Health\u003c/em\u003e. 2021;3:661360. doi:10.3389/frph.2021.661360.\u003c/li\u003e\n\u003cli\u003eAktas S, Un I, Omer Barlas I, Ozturk AB et al. Evaluation of the Rho A/Rho-kinase pathway in the uterus of the rat model of polycystic ovary syndrome. \u003cem\u003eReprod Biol\u003c/em\u003e. 2019;19(1):45\u0026ndash;54. doi:10.1016/j.repbio.2019.01.005.\u003c/li\u003e\n\u003cli\u003eMartire FG, d\u0026apos;Abate C, Schettini G, et al. Adenomyosis and adolescence: a challenging diagnosis and complex management. \u003cem\u003eDiagnostics (Basel)\u003c/em\u003e. 2024;14(21):2344. doi:10.3390/diagnostics14212344.\u003c/li\u003e\n\u003cli\u003eVannuccini S, Meleca C, Toscano F, et al. Adenomyosis diagnosis among adolescents and young women with dysmenorrhoea and heavy menstrual bleeding. \u003cem\u003eReprod Biomed Online\u003c/em\u003e. 2024;48(5):103768. doi:10.1016/j.rbmo.2023.103768.\u003c/li\u003e\n\u003cli\u003eVercellini P, Buffo C, Bandini V, et al. Prevalence of adenomyosis in symptomatic adolescents and young women: a systematic review and meta-analysis. \u003cem\u003eF\u0026amp;S Rev\u003c/em\u003e. 2025;6(1):100083. doi:10.1016/j.xfnr.2024.100083.\u003c/li\u003e\n\u003cli\u003eMartire FG, Lazzeri L, Conway F, et al. Adolescence and endometriosis: symptoms, ultrasound signs and early diagnosis. \u003cem\u003eFertil Steril\u003c/em\u003e. 2020;114(5):1049\u0026ndash;1057. doi:10.1016/j.fertnstert.2020.06.012.\u003c/li\u003e\n\u003cli\u003eExacoustos C, Lazzeri L, Martire FG, et al. Ultrasound findings of adenomyosis in adolescents: type and grade of the disease. \u003cem\u003eJ Minim Invasive Gynecol\u003c/em\u003e. 2022;29(2):291\u0026ndash;299.e1. doi:10.1016/j.jmig.2021.08.023.\u003c/li\u003e\n\u003cli\u003eG\u0026uuml;d\u0026uuml;c\u0026uuml; N, Sidar G, İş\u0026ccedil;i H et al. The utility of transrectal ultrasound in adolescents when transabdominal or transvaginal ultrasound is not feasible. \u003cem\u003eJ Pediatr Adolesc Gynecol\u003c/em\u003e. 2013;26(5):265\u0026ndash;268. doi:10.1016/j.jpag.2013.04.004.\u003c/li\u003e\n\u003cli\u003eGarc\u0026iacute;a-Solares J, Donnez J, Donnez O et al. Pathogenesis of uterine adenomyosis: invagination or metaplasia? \u003cem\u003eFertil Steril\u003c/em\u003e. 2018;109:371\u0026ndash;379. doi:10.1016/j.fertnstert.2017.12.030.\u003c/li\u003e\n\u003cli\u003eBulun SE, Yildiz S, Adli M, et al. Endometriosis and adenomyosis: shared pathophysiology. \u003cem\u003eFertil Steril\u003c/em\u003e. 2023;119(5):746\u0026ndash;750. doi:10.1016/j.fertnstert.2023.03.006.\u003c/li\u003e\n\u003cli\u003eBulun SE, Yildiz S, Adli M et al. Adenomyosis pathogenesis: insights from next-generation sequencing. \u003cem\u003eHum Reprod Update\u003c/em\u003e. 2021;27(6):1086\u0026ndash;1097. doi:10.1093/humupd/dmab017.\u003c/li\u003e\n\u003cli\u003eLeyendecker G, Wildt L, Mall G. The pathophysiology of endometriosis and adenomyosis: tissue injury and repair. \u003cem\u003eArch Gynecol Obstet\u003c/em\u003e. 2009;280(4):529\u0026ndash;538. doi:10.1007/s00404-009-1191-0.\u003c/li\u003e\n\u003cli\u003eLeyendecker G, Wildt L. A new concept of endometriosis and adenomyosis: tissue injury and repair (TIAR). \u003cem\u003eHorm Mol Biol Clin Investig\u003c/em\u003e. 2011;5:125\u0026ndash;142. doi:10.1515/HMBCI.2011.002.\u003c/li\u003e\n\u003cli\u003eBrosens JJ, de Souza NM, Barker FG. Uterine junctional zone: function and disease. \u003cem\u003eLancet\u003c/em\u003e. 1995;346:558\u0026ndash;560. doi:10.1016/S0140-6736(95)91387-4.\u003c/li\u003e\n\u003cli\u003eSajadi M, Noroozzadeh M, Bagheripour F et al. Contractions in the isolated uterus of a rat model of polycystic ovary syndrome compared to controls in adulthood. \u003cem\u003eInt J Endocrinol Metab\u003c/em\u003e. 2018;16(2):e63135. doi:10.5812/ijem.63135.\u003c/li\u003e\n\u003cli\u003eAktas S, Un I, Omer Barlas I et al. Evaluation of the Rho A/Rho-kinase pathway in the uterus of the rat model of polycystic ovary syndrome. \u003cem\u003eReprod Biol\u003c/em\u003e. 2019;19(1):45\u0026ndash;54. doi:10.1016/j.repbio.2019.01.005.\u003c/li\u003e\n\u003cli\u003eVercellini P, Consonni D, Dridi D et al. Uterine adenomyosis and in vitro fertilization outcome: a systematic review and meta-analysis. \u003cem\u003eHum Reprod\u003c/em\u003e. 2014;29:964\u0026ndash;977. doi:10.1093/humrep/deu041.\u003c/li\u003e\n\u003cli\u003eTomassetti C, Meuleman C, Timmerman D et al. Adenomyosis and subfertility: evidence of association and causation. \u003cem\u003eSemin Reprod Med\u003c/em\u003e. 2013;31:101\u0026ndash;108. doi:10.1055/s-0032-1333475.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescent, Young Adult, Adenomyosis, Polycystic Ovary Syndrome, Ultrasonography","lastPublishedDoi":"10.21203/rs.3.rs-7282360/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7282360/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives:\u003c/h2\u003e\u003cp\u003eThis study evaluated the relationship between adenomyosis and polycystic ovary syndrome (PCOS) in adolescents and young adults and compared their clinical and ultrasonographic features when they were present alone or concurrently to support a more comprehensive diagnostic approach.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eWe retrospectively reviewed the medical records of 319 individuals aged 10\u0026ndash;25 years with symptoms suggestive of adenomyosis or PCOS. The participants were grouped as adenomyosis only (n\u0026thinsp;=\u0026thinsp;29), PCOS only (n\u0026thinsp;=\u0026thinsp;277), or combined (n\u0026thinsp;=\u0026thinsp;13). Diagnoses were made via ultrasonography according to international guidelines. The data were analysed via IBM SPSS Statistics v.22. Normality was assessed by the Kolmogorov‒Smirnov test. Independent samples t tests were used for continuous variables; chi-square tests or Fisher\u0026rsquo;s exact tests were used for categorical variables. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eChronological and gynecologic age did not differ among the groups; however, body mass index was significantly greater in the PCOS group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Heavy menstrual bleeding (HMB) (34.5% and 61.5%), pelvic pain (24.1% and 38.5%), and dysmenorrhea (89.7% and 69.2%) were significantly more common in the adenomyosis and combined groups than in the PCOS group (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Uterine wall asymmetry, irregular or interrupted junctional zones (JZs), and echogenic subendometrial lines and buds were also more prevalent in these groups (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Hyperechoic myometrial islands were the least common ultrasonographic finding (27.6%). Ferriman\u0026ndash;Gallwey (FG) scores and free androgen index values were significantly greater in the PCOS group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and p\u0026thinsp;=\u0026thinsp;0.029).\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eAdenomyosis and PCOS exhibit distinct clinical and ultrasonographic profiles even in adolescence. Careful ultrasonographic evaluation in PCOS may increase diagnostic accuracy by detecting coexisting adenomyosis, emphasizing the need for early differential diagnosis to guide individualized treatment strategies.\u003c/p\u003e","manuscriptTitle":"Adenomyosis and Polycystic Ovary Syndrome in Adolescents and Young Women: More Common Together or Not?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-08 10:37:15","doi":"10.21203/rs.3.rs-7282360/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-11T11:11:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-25T09:23:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-09T16:40:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-09T16:38:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"248712457361508175109799741184894497486","date":"2025-09-08T05:00:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332450524837264935943050404486551727931","date":"2025-09-06T15:49:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"203630708956685109486878100563894035817","date":"2025-09-04T14:11:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-04T11:57:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"143645482584665383566102954292303253608","date":"2025-09-04T11:46:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146423649421475291358597431798125137356","date":"2025-08-29T06:38:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"32149160471514326225504470387365864121","date":"2025-08-29T06:25:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-28T15:51:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-28T07:27:39+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-07T09:30:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-06T13:01:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Women's Health","date":"2025-08-06T12:58:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-womens-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmwh","sideBox":"Learn more about [BMC Women's Health](http://bmcwomenshealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bmwh/default.aspx","title":"BMC Women's Health","twitterHandle":"","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ee96f40f-cf70-4522-acff-4225898b4673","owner":[],"postedDate":"September 8th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-08T10:37:15+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-08 10:37:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7282360","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7282360","identity":"rs-7282360","version":["v1"]},"buildId":"0U-iFTyB6qxOgVj8rjrZV","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}