Risk Factors for Typical Endometrial Polypoid Adenomyoma

Risk Factors for Typical Endometrial Polypoid Adenomyoma | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Risk Factors for Typical Endometrial Polypoid Adenomyoma Xinmei Wang, Hongyuan Zhang, Juan Xu, Pengpeng Qu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-532255/v2 This work is licensed under a CC BY 4.0 License Status: Posted Version 2 posted You are reading this latest preprint version Show more versions Abstract Objective: Typical endometrial polypoid adenomyoma (TPA) is a rare type of lesion in the uterine cavity or cervical canal. Although the clinical and pathologic features of TPA have been described extensively, reports on its pathogenesis and treatment remain inconclusive. This study was conducted to investigate the risk factors for endometrial TPA and recurrence and to further define the pathogenesis and treatment. Study design: This was a retrospective analysis of 488 cases of TPA and 500 cases of normal endometrium. Age, menopausal status, body mass index (BMI), reproductive history, and method of surgery were retrospectively analyzed. Among TPA cases, 360 were treated by conservative surgery. Risk factors for TPA and recurrence were assessed. Results: There was a significant difference in age, menopausal status, BMI, gravidity, and parity between the two groups (P50 years, menopause, obesity, gravidity >3, and parity >2 were risk factors for TPA (P<0.05). The incidence rate of endometriosis and adenomyosis in the TPA group was significantly higher than that in the normal endometrium group (P3, menopause, curettage, and polyp clamp as independent risk factors for the recurrence of TPA (P<0.05). Conclusions: In addition to high estrogen levels, endometrial injury was the main contributor to TPA pathogenesis. Hysteroscopic electrotomy was the preferential treatment for TPA to avoid recurrence, especially for women with risk factors. Increasing the depth of ablation may prevent the recurrence of TPA more efficiently. Health Economics & Outcomes Research Health Policy Women's studies Typical polypoid adenomyoma Atypical polypoid adenomyoma Endometrial injury Estrogen Hysteroscopic electrotomy Figures Figure 1 1. Introduction Typical endometrial polypoid adenomyoma (TPA), also known as adenomyomatous polyp, is rarely detected. It is a benign neoplasm consisting of fibroid stroma and glands whose histological origin is unclear [ 1 ]. TPA accounts for 1.3% of endometrial polyps [ 2 ]. Histologically, endometrial polypoid adenomyomas can be divided into typical and atypical polypoid adenomyomas [ 3 , 4 ]. The former is mainly composed of normal endometrial glands, with interwoven smooth muscle stroma [ 5 , 6 ], whereas the latter is a lesion with unspecified malignant potential due to crowded, irregular, and complex glandular epithelium along with abundant, chaotic, and loose smooth muscle stroma, which can resemble atypical endometrial hyperplasia [ 7 , 8 ]. TPA is easily confused with other uterine lesions, making its clinical diagnosis difficult.. Few reports on TPA diagnosis and treatment, inadequate knowledge of the pathogenesis of TPA, and the lack of a systematic analysis of relevant clinical data justify the need for the present study. This study retrospectively analyzed the clinical data of 488 cases of TPA and 500 cases of normal endometrium. The risk factors for endometrial TPA and recurrence were investigated, and the pathogenesis and treatment were further defined. 2. Material And Methods 2.1. Clinical data This study included 988 women who were admitted for the first time to undergo surgical treatment at Tianjin Central Obstetrics and Gynecology Hospital between January 2011 and December 2017.Data on the patient’s age, body mass index (BMI), reproductive history, and method of surgery were recorded. The height and weight were measured in all patients. BMI was calculated based on the classification criteria recommended by the Asian population experts of the World Health Organization and the Chamber of Commerce (WHO, 2004). According to the pathological examination results, they were divided into two groups: 1) TPA group (n=488; 40–69 [47.26±10.46] years). 2) Normal group (women with a normal endometrium; n=500; 40–68 [47.58±10.45] years). Patients in both groups were divided into two or three levels, depending on age, menopausal status, BMI, gravidity, and parity. In the TPA group, 360 patients underwent conservative surgery, including hysteroscopic electrotomy, curettage, and polyp clamp. These 360 patients were followed up for 22–77 months (Figure 1 ). Patients with a normal endometrium were among inpatients undergoing diagnostic curettage due to other gynecological diseases. The diagnosis criteria of TPA were based on those described by Kenny et al. Polypoid adenomyoma of the uterus is an endometrial polyp in which the stromal component is made up of smooth muscle [ 1 ]. Only those patients with a definite pathological diagnosis of TPA were included; two experienced pathologists in our hospital rereviewed pathological specimens and adjudged the diagnosis. Patients with incomplete information or those lost to follow-up were excluded. 2.2. Statistical methods SPSS21.0 software was used for statistical analysis (SPSS Inc, Chicago, IL, USA). The chi-square test was used for comparison. Multivariate analysis was performed using a logistic regression model. All tests were two-sided, and the level of significance was set at P<0.05. 3. Results 3.1. Risk factors for TPA Among the included 488 TPA patients (40–69 [47.26±10.46] years), 156 patients were premenopausal women and the rest were postmenopausal women. The mean BMI of 156 premenopausal patients was 22.38 ±3.21kg /m 2 , and the mean BMI of 332 postmenopausal patients was 25.31±4.17 kg /m 2 . Three postmenopausal patients had a history of oral tamoxifen before surgery. Among the 488 patients, only 11 had no pregnancy history. Three patients never had sexual life, one patient's husband had infertility, and four patients used contraception methods. The other three patients did not use any contraception and were not pregnant after marriage. The average gravidity was 3.22, and the average parity was 1.74. There were significant differences in age, menopausal status, BMI, gravidity, and parity between the two groups (P50 years, menopause, obesity, gravidity >3, and parity>2 were risk factors for TPA (P<0.05; Table 1 ). Table 1 Univariate and multivariate analyses of the clinical characteristics of TPA Parameter TPA group (n=488) Normal group (n=500) Univariate analysis Multivariate analysis P-value OR (95% CI) P-value Age (years) 0.021 1.41 (1.343-3.224) 0.031 ≤50 189 (38.73) 266 (53.2) >50 299 (61.27) 234 (46.8) Menopause <0.001 0.337 (0.260-0.438) <0.001 No 156 (31.97) 291 (58.2) Yes 332 (68.03) 209 (41.8) BMI 0.011 0.801 (0.370-0.955) 0.032 Normal 146 (29.92) 186 (37.2) Overweight 255 (52.25) 223 (44.6) Obese 87 (17.83) 91 (18.2) Gravidity 3 291 (59.63) 198 (39.6) Parity 0.031 0.759 (0.590-0.976) 0.037 ≤2 201 (41.18) 240 (48) >2 287 (58.81) 60 (52) TPA, typical endometrial polypoid adenomyoma; BMI, body mass index 3.2. Adenomyosis and endometriosis accompanied with TPA The rate of adenomyosis and endometriosis was significantly different (P<0.01) between the two groups (73 vs 12 cases of adenomyosis and 47 vs 43 cases of endometriosis in the TPA and normal groups; Table 2 ). Table 2 Adenomyosis and endometriosis accompanied with TPA Pathology TPA group n (%) Normal group n (%) t-value P-value Endometriosis 47 (9.64) 12 (2.4) 4.987 <0.001 Adenomyosis 73 (14.96) 43 (8.6) 5.630 <0.001 TPA, typical endometrial polypoid adenomyoma 3.3. Risk factors for recurrence of TPA Among 360 TPA patients who underwent conservative surgery, including hysteroscopic electrotomy, curettage, and polyp clamp, there were 32 cases (8.89%) of relapse. Parity, menopausal status, and surgery method were related to TPA recurrence, and gravidity>3, menopause, curettage, and polyp clamp were independent risk factors for the recurrence of TPA (P<0.05; Table 3 ). Table 3 Univariate and multivariate analyses for risk factors of recurrence (n=32) Variable Recurrence rate (%) Univariate analysis Multivariate analysis P-value OR (95% CI) P-value Age (years) 0.021 1.41 (1.343-3.224) 0.031 ≤50 10.10 (20/198) 0.418 Variable removed >50 7.41 (12/162) Menopause <0.001 3.143 (1.986-5.113) 3 12.68 (27/213) Parity 0.517 Variable removed ≤2 7.64 (12/157) >2 9.85 (20/203) Method of surgery 0.026 1.429 (1.056-2.968) 0.037 Hysteroscopic electrotomy 2.41 (8/332) Curettage 80.95 (17/21) Polyp clamp 100 (7/7) BMI, body mass index 4. Discussion TPA is a rare lesion occupying the uterine cavity or the cervical canal consisting of fibroid stroma and glands [ 1 ]. Abnormal bleeding was the most common manifestation of endometrial TPA, followed by menstrual changes; Other manifestations were secondary dysmenorrhea, vaginal discharge. Some patients may even have no symptoms. There was no apparent specificity in endometrial TPA's clinical manifestations, a transvaginal ultrasound, and tumor morphology. It is easily confused with other uterine lesions. Therefore, the pathological examination was the golden standard for a definite diagnosis. The pathogenesis of TPA is still not clear. Some scholars [ 9 , 10 ] believed that adenomyomatous polyps originate from stromal progenitor cells in the endometrium, which can differentiate into smooth muscle and may be the product of long-term estrogen stimulation. Lin et al. reported a case in which a gonadotropin-releasing hormone agonist effectively reduced the size of the lesion, suggesting that the growth is dependent on the estrogen level [ 11 ]. In this study, the average age of onset of the patients was 53.26 years, and the incidence rate was significantly higher in women >50 years old than in women <50 years old, which may be related to the long-term or continuous estrogen stimulation with little or no progesterone antagonism in this age group. Moreover, tamoxifen has been reported to exhibit a weak estrogen-like effect in postmenopausal women that increases the occurrence and recurrence rate of TPA [ 12 , 13 ]. On the contrary, in this study, there was no significant difference in the recurrence rate between the different age groups after conservative surgery of TPA, and age was not a risk factor for the recurrence of TPA. This may be related to the short follow-up duration and the small sample size of the present study. However, our findings revealed that chances of TPA occurrence and relapse were greater in postmenopausal women. The decreased estrogen level in postmenopausal women elevates follicle stimulating hormone level, leading to increased estrogen receptor expression in utero [ 14 ]. Longacre et al. also reported that in addition to the high estrogen level in patients, the abnormal expression of estrogen receptors in the local endometrium is also associated with TPA occurrence [ 15 ]. Postmenopausal women had a significantly higher BMI than premenopausal women in the present study. Overweight and obesity rates were also significantly greater. The BMI of postmenopausal women has been reported to be positively correlated with the estrogen level over an extended period [ 16 ]. Weight gain and obesity result in insulin resistance and hypertension, and insulin resistance is closely linked to abnormally high estrogen levels. Therefore, obese individuals are more likely to develop TPA. In this study, 255 patients (52.25%) were overweight, and 87 patients (17.83%) were obese, supporting the above views on TPA occurrence. Pathologically, TPA resembles adenomyosis, i.e., both conditions are characterized by abundant smooth muscle stroma and endometrial glands. TPA is reported to occur when an adenomyoma breaks into the endometrial cavity, which is why TPA may be considered under the category of uterine adenomyosis [ 17 ]. Although a link between TPA and adenomyosis has been established, there are some differences between the two pathologies. In adenomyosis specimens, the endometrial glands and stroma are divided into islands by the smooth muscle within the myometrium. Moreover, the uterine smooth muscle tissue in adenomyosis is morphologically different from that in TPA. However, polypoid adenomyomas are often accompanied by adenomyosis, and the two pathologies may be similar in histogenesis [ 7 ]. In this study, we found that most patients had a history of pregnancy. Patients with gravidity >3 and parity >2 were more likely to develop TPA, and gravidity >3 and parity >2 were independent risk factors for TPA. Chances of relapse were greater in patients with gravidity >3. Besides, the rate of adenomyosis and endometriosis in the TPA group was higher than that in the normal group. All these results suggest that surgery of the uterine cavity and endometrial injury may be related to the occurrence of TPA [ 5 ]. Among the 360 TPA patients who underwent conservative surgery,hysteroscopic electrotomy, curettage, and polyp clamp, there were 32 cases (8.89%) of relapse. Parity, menopausal status, and surgery method were related to TPA recurrence, and gravidity >3, menopause, curettage, and polyp clamp were independent risk factors for TPA recurrence. This supported the link between elevated levels of estrogen and its receptors and endometrial damage. When planning the surgery, it is important to consider the unique pathogenesis and pathological characteristics of TPA. Because the lesion cannot be directly targeted by curettage and polyp clamp and because the texture of adenomyomatous polyps is arduous and the base is broad, the postoperative residual rate of lesions is high. Hysteroscopy can altogether remove the directly visible lesion, and other suspected endometrial lesions can be biopsied simultaneously, with minimal trauma. In this study, 332 patients who underwent hysteroscopic electrotomy were followed up successfully; only eight patients exhibited recurrence without any malignant change, indicating that hysteroscopic electrotomy is a safe and effective treatment method. Hysteroscopic resection of directly visible lesion tissues could reduce trauma and preserve fertility, yielding a definite curative effect [ 18 ]. Therefore, a four-step hysteroscopic resection of the lesion is preferred: (1) complete resection of the lesion from the root pedicle; (2) removal of 0.2–0.5 cm of the endometrial tissue around the root pedicle; (3) ensuring that the myometrium below the root pedicle is about 0.3 cm deep; (4) multi-point biopsy of the endometrium at other locations of the uterine cavity [ 19 ]. The main strength of this study is that a large number of patients with TPA and normal endometrium were included. Moreover, 360 cases of TPA were followed up for 22–77 months. Besides, patients who underwent conservative surgery were from the same sample group, reducing bias and yielding more accurate results. However, this study also has some unavoidable limitations due to its retrospective design. First, we could not assess all variables potentially associated with the occurrence and recurrence of TPA in this single study. Furthermore, the inclusion of cases involving only one hospital might have reduced the external validity of the results, and further prospective studies with a larger sample size in a broader context are needed. 5. Conclusions In conclusion, endometrial TPA is a particular type of lesion occupying the uterine cavity. The typical pathological manifestations of endometrial TPA were benign endometrial glands proliferate, and the stroma around the glands was characterized by spirally staggered bundles of smooth muscle cells. Abnormal bleeding was the most common manifestation of endometrial TPA.The pathological examination was the golden standard for a definite diagnosis. Although the pathogenesis of the disease is not clear, elevated estrogen levels and its receptors and endometrial damage are risk factors for the occurrence and recurrence of TPA; however, the relationship between these risk factors and the occurrence of the disease still needs further experimental study. Hysteroscopic electrotomy is the preferred treatment for endometrial TPA, especially for women with risk factors. The unique pathogenesis and pathology of TPA suggest that increasing the depth of ablation may prevent the recurrence of TPA. Declarations Ethics approval and consent to participate All methods were performed in accordance with the Declaration of Helsinki and the relevant guidelines and regulations. This study was approved by the ethics committee of Tianjin Central Hospital of Gynecology and Obstetrics. As a retrospective study, informed consent was exempted by the ethics committee of Tianjin Central Hospital of Gynecology and Obstetrics. Consent to publish Not applicable. Availability of data and materials All data generated or analysed during this study are included in this published article Competing interests The authors declare that they have no competing interests. Funding This work was Funded by Scientific and technological personnel training project of Tianjin Health Bureau-no.RC20004 Author contribution Xinmei Wang: Project development, data collection, manuscript writing. Hongyuan Zhang: Data collection and data analysis. Juan Xu: Data collection and data analysis. Pengpeng Qu: Project development. Acknowledgment We thank all participants in the study for their invaluable contribution. References Kenny SL, McCluggage WG (2014) Adenomyomatous polyp of the endometrium with prominent epithelioid smooth muscle differentiation: Report of two cases of a hitherto undescribed lesion. Int J Surg Pathol 22(4):358–363. https://doi.org/10.1177/1066896913499630 . Epub 2013 Aug 7. PMID: 23926192. Gilks CB, Clement PB, Hart WR, Young RH (2000) Uterine adenomyomas excluding atypical polypoid adenomyomas and adenomyomas of endocervical type: a clinicopathologic study of 30 cases of an underemphasized lesion that may cause diagnostic problems with a brief consideration of adenomyomas of other female genital tract sites. Int J Gynecol Pathol 19:195e205. McCluggage WG (2016) A practical approach to the diagnosis of mixed epithelial and mesenchymal tumors of the uterus. Mod Pathol 29(Suppl 1): S78-S91. https://doi.org/10.1038/modpathol.2015.137 . PMID: 26715175. Lu Z, Chen J (2014) [Introduction of WHO classification of tumors of female reproductive organs, fourth edition]. Zhonghua Bing Li Xue Za Zhi 43(10):649–650. Chinese. PMID: 25567588. Raghavendra Babu YP, Karki RK, Menezes RG, Jagadish Rao PP, Shetty BS, Sahu KK (2012) Adenomyomatous polyp of the uterus: Report of an autopsy case and review of the literature. J Forensic Leg Med 19(4):236-238. https://doi.org/10.1016/j.jflm.2012.02.003 . Epub 2012 Mar 6. PMID: 22520379. That A, Nanda A, Mohan H (2006) Uterine adenomyoma: a clinicopathologic review of 26 cases and a review of the literature. Int J Gynecol Pathol 25(4):361-365. https://doi.org/10.1097/01.pgp.0000209570. 08716.b3 . PMID: 16990713. Mazur MT (1981) Atypical polypoid adenomyomas of the endometrium. Am J Surg Pathol 5(5):473-482. https://doi.org/10.1097/00000478-198107000-00006 . PMID: 7282995. Heatley MK (2006) Atypical polypoid adenomyoma: a systematic review of the English literature. Histopathology 48(5):609-610. https://doi.org/10.1111/j.1365-2559.2005.02315.x . PMID: 16623790. Horita A, Kurata A, Komatsu K, Yajima M, Sakamoto A (2010) Coexistent atypical polypoid adenomyoma and complex atypical endometrial hyperplasia in the uterus. Diagn Cytopathol 38(7): 527-532. https://doi.org/10.1002/dc.21263 . PMID: 19950396. 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Jpn J Clin Oncol 27(5):350-352. https://doi.org/10.1093/jjco/27.5.350 . PMID: 9390216. Huang C, Hong MK, Ding DC (2017) Endometrial adenomyoma polyp caused postmenopausal bleeding mimicking uterine malignancy. Gynecol Minim Invasive Ther 6(3): 129–131. https://doi.org/10.1016/j.gmit . 2016.08.006. Epub 2016 Sep 13. PMID: 30254897; PMCID: PMC6135180. Longacre TA, Chung MH, Rouse RV, Hendrickson MR (1996) Atypical polypoid adenomyofibromas (atypical polypoid adenomyomas) of the uterus. A clinicopathologic study of 55 cases. Am J Surg Pathol 20(1): 1-20. https://doi.org/10.1097/00000478-199601000-00001 . PMID: 8540600. Douchi T, Yoshinaga M, Katanozaka M, Mitani M, Nagata Y (1998) Relationship between body mass index and transvaginal ultrasonographic endometrial thickness in postmenopausal women. Acta Obstet Gynecol Scand 77(9):905–908. PMID: 9808378. Kitajima K, Imanaka K, Kuwata Y, Hashimoto K, Sugimura K (2007) Magnetic resonance imaging of typical polypoid adenomyoma of the uterus in 8 patients: correlation with pathological findings. J Comput Assist Tomogr 31(3): 463-438. https://doi.org/10.1097/01.rct. 0000243447.03116.0c . PMID: 17538297. Mazzon I, Corrado G, Masciullo V, Morricone D, Ferrandina G, Scambia G (2010) Conservative surgical management of stage IA endometrial carcinoma for fertility preservation. Fertil Steril 93(4): 1286–1289. https://doi.org/10.1016/j.fertnstert.2008.12.009 . Epub 2009 Aug 22. PMID: 19700153. Di Spiezio Sardo A, Mazzon I, Gargano V, Di Carlo C, Guida M, Mignogna C, Bifulco G, Nappi C (2008) Hysteroscopic treatment of atypical polypoid adenomyoma diagnosed incidentally in a young infertile woman. Fertil Steril 89(2): 456–459. https://doi.org/10.1016/j.fertnstert . 2007. 02.061. Epub 2007 Aug 13. PMID: 17706212. 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-532255","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":59331981,"identity":"a6f28800-0c89-4e8b-aee3-057826c87e50","order_by":0,"name":"Xinmei Wang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCklEQVRIiWNgGAWjYNACAyBmZmx88OGHDUSAhzgtzM2GM3vSJIjUAgbsbdI8bIcJazE4fvbwa56CO9H87IxtkjN4ztfpzkhgfPC2jUHeHJeWM3lpljMMnuXObGZstvhgcVvC7EYCs+HcNgbDnQ3YtZgdyDEz+GBwOHfDYcbGmzN4wFrYpHnbGBIMDuDQcv6NmUECUMv+w4wNQL+cA2lh/41Xy40c4wdgW5gZm4BaDoBtYcanxf7GGzPGGUAtMw4zggI5WXLbmYfNknPOSRhuwKFFsj/H+DPPn8O5/f3HHwKj0o7f7HjywQ9vymzkcdkCBGwSaAKMDUACXRAFMH/AJzsKRsEoGAWjgAEANZhhfPHdGbkAAAAASUVORK5CYII=","orcid":"","institution":"Tianjin Central Hospital of Gynecology and Obstetrics","correspondingAuthor":true,"prefix":"","firstName":"Xinmei","middleName":"","lastName":"Wang","suffix":""},{"id":59331982,"identity":"63f37406-0084-457a-be52-fd0b9f866be3","order_by":1,"name":"Hongyuan Zhang","email":"","orcid":"","institution":"Tianjin Central Hospital of Gynecology and Obstetrics","correspondingAuthor":false,"prefix":"","firstName":"Hongyuan","middleName":"","lastName":"Zhang","suffix":""},{"id":59331983,"identity":"0a69a6a5-f674-4775-82df-1e31fe6a9841","order_by":2,"name":"Juan Xu","email":"","orcid":"","institution":"Tianjin Central Hospital of Gynecology and Obstetrics","correspondingAuthor":false,"prefix":"","firstName":"Juan","middleName":"","lastName":"Xu","suffix":""},{"id":59331984,"identity":"2cc4eb8f-c5be-4714-b332-928aec10a1bd","order_by":3,"name":"Pengpeng Qu","email":"","orcid":"","institution":"Tianjin Central Hospital of Gynecology and Obstetrics","correspondingAuthor":false,"prefix":"","firstName":"Pengpeng","middleName":"","lastName":"Qu","suffix":""}],"badges":[],"createdAt":"2021-05-16 22:38:53","currentVersionCode":2,"declarations":"","doi":"10.21203/rs.3.rs-532255/v2","doiUrl":"https://doi.org/10.21203/rs.3.rs-532255/v2","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":14945220,"identity":"a1ef8400-c2c9-4247-8d02-6ea24b86a815","added_by":"auto","created_at":"2021-10-27 14:14:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":37823,"visible":true,"origin":"","legend":"Study flowchart","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-532255/v2/a01296ab6b53b0b6352ea7e8.png"},{"id":15807494,"identity":"0fb2152f-b580-4fbe-8382-b801c2dd44a6","added_by":"auto","created_at":"2021-11-23 04:44:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":350985,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-532255/v2/1db372e4-b982-4a7b-ab9a-3b0bb21a6afe.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eRisk Factors for Typical Endometrial Polypoid Adenomyoma\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eTypical endometrial polypoid adenomyoma (TPA), also known as adenomyomatous polyp, is rarely detected. It is a benign neoplasm consisting of fibroid stroma and glands whose histological origin is unclear [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. TPA accounts for 1.3% of endometrial polyps [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Histologically, endometrial polypoid adenomyomas can be divided into typical and atypical polypoid adenomyomas [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The former is mainly composed of normal endometrial glands, with interwoven smooth muscle stroma [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], whereas the latter is a lesion with unspecified malignant potential due to crowded, irregular, and complex glandular epithelium along with abundant, chaotic, and loose smooth muscle stroma, which can resemble atypical endometrial hyperplasia [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTPA is easily confused with other uterine lesions, making its clinical diagnosis difficult.. Few reports on TPA diagnosis and treatment, inadequate knowledge of the pathogenesis of TPA, and the lack of a systematic analysis of relevant clinical data justify the need for the present study. This study retrospectively analyzed the clinical data of 488 cases of TPA and 500 cases of normal endometrium. The risk factors for endometrial TPA and recurrence were investigated, and the pathogenesis and treatment were further defined.\u003c/p\u003e"},{"header":"2. Material And Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Clinical data\u003c/h2\u003e \u003cp\u003eThis study included 988 women who were admitted for the first time to undergo surgical treatment at Tianjin Central Obstetrics and Gynecology Hospital between January 2011 and December 2017.Data on the patient\u0026rsquo;s age, body mass index (BMI), reproductive history, and method of surgery were recorded. The height and weight were measured in all patients. BMI was calculated based on the classification criteria recommended by the Asian population experts of the World Health Organization and the Chamber of Commerce (WHO, 2004). According to the pathological examination results, they were divided into two groups: 1) TPA group (n=488; 40\u0026ndash;69 [47.26\u0026plusmn;10.46] years). 2) Normal group (women with a normal endometrium; n=500; 40\u0026ndash;68 [47.58\u0026plusmn;10.45] years). Patients in both groups were divided into two or three levels, depending on age, menopausal status, BMI, gravidity, and parity.\u003c/p\u003e \u003cp\u003eIn the TPA group, 360 patients underwent conservative surgery, including hysteroscopic electrotomy, curettage, and polyp clamp. These 360 patients were followed up for 22\u0026ndash;77 months (Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePatients with a normal endometrium were among inpatients undergoing diagnostic curettage due to other gynecological diseases.\u003c/p\u003e \u003cp\u003eThe diagnosis criteria of TPA were based on those described by Kenny et al. Polypoid adenomyoma of the uterus is an endometrial polyp in which the stromal component is made up of smooth muscle [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Only those patients with a definite pathological diagnosis of TPA were included; two experienced pathologists in our hospital rereviewed pathological specimens and adjudged the diagnosis. Patients with incomplete information or those lost to follow-up were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Statistical methods\u003c/h2\u003e \u003cp\u003eSPSS21.0 software was used for statistical analysis (SPSS Inc, Chicago, IL, USA). The chi-square test was used for comparison. Multivariate analysis was performed using a logistic regression model. All tests were two-sided, and the level of significance was set at P\u0026lt;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Risk factors for TPA\u003c/h2\u003e \u003cp\u003eAmong the included 488 TPA patients (40\u0026ndash;69 [47.26\u0026plusmn;10.46] years), 156 patients were premenopausal women and the rest were postmenopausal women. The mean BMI of 156 premenopausal patients was 22.38 \u0026plusmn;3.21kg /m\u003csup\u003e2\u003c/sup\u003e, and the mean BMI of 332 postmenopausal patients was 25.31\u0026plusmn;4.17 kg /m\u003csup\u003e2\u003c/sup\u003e. Three postmenopausal patients had a history of oral tamoxifen before surgery. Among the 488 patients, only 11 had no pregnancy history. Three patients never had sexual life, one patient's husband had infertility, and four patients used contraception methods. The other three patients did not use any contraception and were not pregnant after marriage. The average gravidity was 3.22, and the average parity was 1.74.\u003c/p\u003e \u003cp\u003eThere were significant differences in age, menopausal status, BMI, gravidity, and parity between the two groups (P\u0026lt;0.05), and age \u0026gt;50 years, menopause, obesity, gravidity \u0026gt;3, and parity\u0026gt;2 were risk factors for TPA (P\u0026lt;0.05; Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\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\u003eUnivariate and multivariate analyses of the clinical characteristics of TPA\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTPA group (n=488)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNormal group (n=500)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUnivariate analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eMultivariate analysis\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.41 (1.343-3.224)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.031\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e189 (38.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e266 (53.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e299 (61.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e234 (46.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenopause\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.337 (0.260-0.438)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e156 (31.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e291 (58.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e332 (68.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e209 (41.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.801 (0.370-0.955)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e146 (29.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e186 (37.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverweight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e255 (52.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e223 (44.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObese\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e87 (17.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGravidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.444 (0.344-0.573)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e197 (40.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e302 (60.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e291 (59.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e198 (39.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.759 (0.590-0.976)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e201 (41.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e240 (48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e287 (58.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eTPA, typical endometrial polypoid adenomyoma; BMI, body mass index\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Adenomyosis and endometriosis accompanied with TPA\u003c/h2\u003e \u003cp\u003eThe rate of adenomyosis and endometriosis was significantly different (P\u0026lt;0.01) between the two groups (73 vs 12 cases of adenomyosis and 47 vs 43 cases of endometriosis in the TPA and normal groups; Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\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\u003eAdenomyosis and endometriosis accompanied with TPA\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathology\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTPA group\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNormal group\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003et-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndometriosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e47 (9.64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.987\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdenomyosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73 (14.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43 (8.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5.630\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eTPA, typical endometrial polypoid adenomyoma\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.3. Risk factors for recurrence of TPA\u003c/h2\u003e \u003cp\u003eAmong 360 TPA patients who underwent conservative surgery, including hysteroscopic electrotomy, curettage, and polyp clamp, there were 32 cases (8.89%) of relapse. Parity, menopausal status, and surgery method were related to TPA recurrence, and gravidity\u0026gt;3, menopause, curettage, and polyp clamp were independent risk factors for the recurrence of TPA (P\u0026lt;0.05; Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate and multivariate analyses for risk factors of recurrence (n=32)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecurrence rate (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnivariate analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMultivariate analysis\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95% CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.41 (1.343-3.224)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.031\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.10 (20/198)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.418\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eVariable removed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.41 (12/162)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMenopause\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.143 (1.986-5.113)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.83 (3/106)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.41 (29/254)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.886\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eVariable removed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.43 (10/106)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverweight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.78 (18/205)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObese\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.16 (4/49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGravidity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.483 (1.345-3.226)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.40 (5/147)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12.68 (27/213)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.517\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eVariable removed\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.64 (12/157)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.85 (20/203)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMethod of surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.026\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.429 (1.056-2.968)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.037\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHysteroscopic electrotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.41 (8/332)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurettage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.95 (17/21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolyp clamp\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100 (7/7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eBMI, body mass index\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eTPA is a rare lesion occupying the uterine cavity or the cervical canal consisting of fibroid stroma and glands [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Abnormal bleeding was the most common manifestation of endometrial TPA, followed by menstrual changes; Other manifestations were secondary dysmenorrhea, vaginal discharge. Some patients may even have no symptoms. There was no apparent specificity in endometrial TPA's clinical manifestations, a transvaginal ultrasound, and tumor morphology. It is easily confused with other uterine lesions. Therefore, the pathological examination was the golden standard for a definite diagnosis.\u003c/p\u003e \u003cp\u003eThe pathogenesis of TPA is still not clear. Some scholars [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] believed that adenomyomatous polyps originate from stromal progenitor cells in the endometrium, which can differentiate into smooth muscle and may be the product of long-term estrogen stimulation. Lin et al. reported a case in which a gonadotropin-releasing hormone agonist effectively reduced the size of the lesion, suggesting that the growth is dependent on the estrogen level [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In this study, the average age of onset of the patients was 53.26 years, and the incidence rate was significantly higher in women \u0026gt;50 years old than in women \u0026lt;50 years old, which may be related to the long-term or continuous estrogen stimulation with little or no progesterone antagonism in this age group. Moreover, tamoxifen has been reported to exhibit a weak estrogen-like effect in postmenopausal women that increases the occurrence and recurrence rate of TPA [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. On the contrary, in this study, there was no significant difference in the recurrence rate between the different age groups after conservative surgery of TPA, and age was not a risk factor for the recurrence of TPA. This may be related to the short follow-up duration and the small sample size of the present study.\u003c/p\u003e \u003cp\u003eHowever, our findings revealed that chances of TPA occurrence and relapse were greater in postmenopausal women. The decreased estrogen level in postmenopausal women elevates follicle stimulating hormone level, leading to increased estrogen receptor expression in utero [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Longacre et al. also reported that in addition to the high estrogen level in patients, the abnormal expression of estrogen receptors in the local endometrium is also associated with TPA occurrence [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Postmenopausal women had a significantly higher BMI than premenopausal women in the present study. Overweight and obesity rates were also significantly greater. The BMI of postmenopausal women has been reported to be positively correlated with the estrogen level over an extended period [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Weight gain and obesity result in insulin resistance and hypertension, and insulin resistance is closely linked to abnormally high estrogen levels. Therefore, obese individuals are more likely to develop TPA. In this study, 255 patients (52.25%) were overweight, and 87 patients (17.83%) were obese, supporting the above views on TPA occurrence.\u003c/p\u003e \u003cp\u003ePathologically, TPA resembles adenomyosis, i.e., both conditions are characterized by abundant smooth muscle stroma and endometrial glands. TPA is reported to occur when an adenomyoma breaks into the endometrial cavity, which is why TPA may be considered under the category of uterine adenomyosis [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Although a link between TPA and adenomyosis has been established, there are some differences between the two pathologies. In adenomyosis specimens, the endometrial glands and stroma are divided into islands by the smooth muscle within the myometrium. Moreover, the uterine smooth muscle tissue in adenomyosis is morphologically different from that in TPA. However, polypoid adenomyomas are often accompanied by adenomyosis, and the two pathologies may be similar in histogenesis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In this study, we found that most patients had a history of pregnancy. Patients with gravidity \u0026gt;3 and parity \u0026gt;2 were more likely to develop TPA, and gravidity \u0026gt;3 and parity \u0026gt;2 were independent risk factors for TPA. Chances of relapse were greater in patients with gravidity \u0026gt;3. Besides, the rate of adenomyosis and endometriosis in the TPA group was higher than that in the normal group. All these results suggest that surgery of the uterine cavity and endometrial injury may be related to the occurrence of TPA [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong the 360 TPA patients who underwent conservative surgery,hysteroscopic electrotomy, curettage, and polyp clamp, there were 32 cases (8.89%) of relapse. Parity, menopausal status, and surgery method were related to TPA recurrence, and gravidity \u0026gt;3, menopause, curettage, and polyp clamp were independent risk factors for TPA recurrence. This supported the link between elevated levels of estrogen and its receptors and endometrial damage. When planning the surgery, it is important to consider the unique pathogenesis and pathological characteristics of TPA. Because the lesion cannot be directly targeted by curettage and polyp clamp and because the texture of adenomyomatous polyps is arduous and the base is broad, the postoperative residual rate of lesions is high. Hysteroscopy can altogether remove the directly visible lesion, and other suspected endometrial lesions can be biopsied simultaneously, with minimal trauma.\u003c/p\u003e \u003cp\u003eIn this study, 332 patients who underwent hysteroscopic electrotomy were followed up successfully; only eight patients exhibited recurrence without any malignant change, indicating that hysteroscopic electrotomy is a safe and effective treatment method. Hysteroscopic resection of directly visible lesion tissues could reduce trauma and preserve fertility, yielding a definite curative effect [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Therefore, a four-step hysteroscopic resection of the lesion is preferred: (1) complete resection of the lesion from the root pedicle; (2) removal of 0.2\u0026ndash;0.5 cm of the endometrial tissue around the root pedicle; (3) ensuring that the myometrium below the root pedicle is about 0.3 cm deep; (4) multi-point biopsy of the endometrium at other locations of the uterine cavity [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe main strength of this study is that a large number of patients with TPA and normal endometrium were included. Moreover, 360 cases of TPA were followed up for 22\u0026ndash;77 months. Besides, patients who underwent conservative surgery were from the same sample group, reducing bias and yielding more accurate results.\u003c/p\u003e \u003cp\u003eHowever, this study also has some unavoidable limitations due to its retrospective design. First, we could not assess all variables potentially associated with the occurrence and recurrence of TPA in this single study. Furthermore, the inclusion of cases involving only one hospital might have reduced the external validity of the results, and further prospective studies with a larger sample size in a broader context are needed.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eIn conclusion, endometrial TPA is a particular type of lesion occupying the uterine cavity. The typical pathological manifestations of endometrial TPA were benign endometrial glands proliferate, and the stroma around the glands was characterized by spirally staggered bundles of smooth muscle cells. Abnormal bleeding was the most common manifestation of endometrial TPA.The pathological examination was the golden standard for a definite diagnosis.\u003c/p\u003e \u003cp\u003eAlthough the pathogenesis of the disease is not clear, elevated estrogen levels and its receptors and endometrial damage are risk factors for the occurrence and recurrence of TPA; however, the relationship between these risk factors and the occurrence of the disease still needs further experimental study. Hysteroscopic electrotomy is the preferred treatment for endometrial TPA, especially for women with risk factors. The unique pathogenesis and pathology of TPA suggest that increasing the depth of ablation may prevent the recurrence of TPA.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eAll methods were performed in accordance with the Declaration of Helsinki and the relevant guidelines and regulations. This study was approved by the ethics committee of Tianjin Central Hospital of Gynecology and Obstetrics. As a retrospective study, informed consent was exempted by the ethics committee of Tianjin Central Hospital of Gynecology and Obstetrics. \u0026nbsp;\u003c/p\u003e\n\u003ch2 skip=\"true\"\u003eConsent to publish\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003ch2 skip=\"true\"\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article \u0026nbsp;\u003c/p\u003e\n\u003ch2 skip=\"true\"\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThis work was Funded by Scientific and technological personnel training project of Tianjin Health Bureau-no.RC20004\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAuthor contribution\u003c/h2\u003e\n\u003cp\u003eXinmei Wang: Project development, data collection, manuscript writing.\u003c/p\u003e\n\u003cp\u003eHongyuan Zhang: Data collection and data analysis.\u003c/p\u003e\n\u003cp\u003eJuan Xu: Data collection and data analysis.\u003c/p\u003e\n\u003cp\u003ePengpeng Qu: Project development.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eAcknowledgment\u003c/h2\u003e\n\u003cp\u003eWe thank all participants in the study for their invaluable contribution.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eKenny SL, McCluggage WG (2014) Adenomyomatous polyp of the endometrium with prominent epithelioid smooth muscle differentiation: Report of two cases of a hitherto undescribed lesion. Int J Surg Pathol 22(4):358\u0026ndash;363. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1066896913499630\u003c/span\u003e\u003c/span\u003e. Epub 2013 Aug 7. PMID: 23926192.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGilks CB, Clement PB, Hart WR, Young RH (2000) Uterine adenomyomas excluding atypical polypoid adenomyomas and adenomyomas of endocervical type: a clinicopathologic study of 30 cases of an underemphasized lesion that may cause diagnostic problems with a brief consideration of adenomyomas of other female genital tract sites. Int J Gynecol Pathol 19:195e205.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMcCluggage WG (2016) A practical approach to the diagnosis of mixed epithelial and mesenchymal tumors of the uterus. 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J Obstet Gynaecol Res 37(5): 468\u0026ndash;471. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1447-0756.2010.01365.x\u003c/span\u003e\u003c/span\u003e. Epub 2011 Jan 27. PMID: 21272150.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLin YH, Chou YY, Huang LW, Seow KM, Hwang JL (2013) An adenomyomatous polyp presenting as a large hypervascular tumor and its response to a gonadotropin-releasing hormone agonist. Taiwan J Obstet Gynecol 52(1):129-130. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.tjog.2013.01.016\u003c/span\u003e\u003c/span\u003e. PMID: 23548234.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTakeuchi M, Matsuzaki K, Uehara H, Shimazu H, Nishitani H (2005) A case of adenomyomatous polyp of the uterus associated with tamoxifen therapy. Radiat Med 23(6): 432-434. PMID: 16389986.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eNasu K, Arima K, Yoshimatsu J, Miyakawa I (1997) Adenomyomatous polyp of the uterus in a patient receiving tamoxifen. Jpn J Clin Oncol 27(5):350-352. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1093/jjco/27.5.350\u003c/span\u003e\u003c/span\u003e. PMID: 9390216.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHuang C, Hong MK, Ding DC (2017) Endometrial adenomyoma polyp caused postmenopausal bleeding mimicking uterine malignancy. Gynecol Minim Invasive Ther 6(3): 129\u0026ndash;131. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.gmit\u003c/span\u003e\u003c/span\u003e. 2016.08.006. Epub 2016 Sep 13. PMID: 30254897; PMCID: PMC6135180.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLongacre TA, Chung MH, Rouse RV, Hendrickson MR (1996) Atypical polypoid adenomyofibromas (atypical polypoid adenomyomas) of the uterus. A clinicopathologic study of 55 cases. Am J Surg Pathol 20(1): 1-20. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/00000478-199601000-00001\u003c/span\u003e\u003c/span\u003e. PMID: 8540600.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDouchi T, Yoshinaga M, Katanozaka M, Mitani M, Nagata Y (1998) Relationship between body mass index and transvaginal ultrasonographic endometrial thickness in postmenopausal women. Acta Obstet Gynecol Scand 77(9):905\u0026ndash;908. PMID: 9808378.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKitajima K, Imanaka K, Kuwata Y, Hashimoto K, Sugimura K (2007) Magnetic resonance imaging of typical polypoid adenomyoma of the uterus in 8 patients: correlation with pathological findings. J Comput Assist Tomogr 31(3): 463-438. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/01.rct. 0000243447.03116.0c\u003c/span\u003e\u003c/span\u003e. PMID: 17538297.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMazzon I, Corrado G, Masciullo V, Morricone D, Ferrandina G, Scambia G (2010) Conservative surgical management of stage IA endometrial carcinoma for fertility preservation. Fertil Steril 93(4): 1286\u0026ndash;1289. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.fertnstert.2008.12.009\u003c/span\u003e\u003c/span\u003e. Epub 2009 Aug 22. PMID: 19700153.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDi Spiezio Sardo A, Mazzon I, Gargano V, Di Carlo C, Guida M, Mignogna C, Bifulco G, Nappi C (2008) Hysteroscopic treatment of atypical polypoid adenomyoma diagnosed incidentally in a young infertile woman. Fertil Steril 89(2): 456\u0026ndash;459.\u0026nbsp;\u003c/span\u003e\u003cspan\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.fertnstert\u003c/span\u003e\u003c/span\u003e. 2007. 02.061. Epub 2007 Aug 13. PMID: 17706212.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Typical polypoid adenomyoma, Atypical polypoid adenomyoma, Endometrial injury, Estrogen, Hysteroscopic electrotomy","lastPublishedDoi":"10.21203/rs.3.rs-532255/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-532255/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e Typical endometrial polypoid adenomyoma (TPA) is a rare type of lesion in the uterine cavity or cervical canal. Although the clinical and pathologic features of TPA have been described extensively, reports on its pathogenesis and treatment remain inconclusive. \u003c/p\u003e\u003cp\u003eThis study was conducted to investigate the risk factors for endometrial TPA and recurrence and to further define the pathogenesis and treatment.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eStudy design:\u003c/strong\u003e This was a retrospective analysis of 488 cases of TPA and 500 cases of normal endometrium. Age, menopausal status, body mass index (BMI), reproductive history, and method of surgery were retrospectively analyzed. Among TPA cases, 360 were treated by conservative surgery. Risk factors for TPA and recurrence were assessed.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e There was a significant difference in age, menopausal status, BMI, gravidity, and parity between the two groups (P\u0026lt;0.05). Age \u0026gt;50 years, menopause, obesity, gravidity \u0026gt;3, and parity \u0026gt;2 were risk factors for TPA (P\u0026lt;0.05). The incidence rate of endometriosis and adenomyosis in the TPA group was significantly higher than that in the normal endometrium group (P\u0026lt;0.05). Follow-up data (22–77 months) were obtained for 360 patients, revealing gravidity \u0026gt;3, menopause, curettage, and polyp clamp as independent risk factors for the recurrence of TPA (P\u0026lt;0.05). \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e In addition to high estrogen levels, endometrial injury was the main contributor to TPA pathogenesis. Hysteroscopic electrotomy was the preferential treatment for TPA to avoid recurrence, especially for women with risk factors. Increasing the depth of ablation may prevent the recurrence of TPA more efficiently.\u003c/p\u003e","manuscriptTitle":"Risk Factors for Typical Endometrial Polypoid Adenomyoma","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2021-10-27 14:14:55","doi":"10.21203/rs.3.rs-532255/v2","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2021-06-09 14:17:17","doi":"10.21203/rs.3.rs-532255/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"819e3aeb-ce18-4e97-8a73-272145f7911d","owner":[],"postedDate":"October 27th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":8129396,"name":"Health Economics \u0026 Outcomes Research"},{"id":8129397,"name":"Health Policy"},{"id":8129398,"name":"Women's studies"}],"tags":[],"updatedAt":"2021-11-23T04:44:11+00:00","versionOfRecord":[],"versionCreatedAt":"2021-10-27 14:14:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v2","identity":"rs-532255","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-532255","identity":"rs-532255","version":["v2"]},"buildId":"B-jG_2CBjPDmsCi4Wdhf-","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}