Diagnostic Value of Individual Transvaginal Ultrasound Criteria for Adenomyosis and Leiomyoma

Background: Adenomyosis and leiomyoma are common benign uterine disorders with overlapping clinical and imaging features, making accurate preoperative diagnosis challenging. This study evaluated the diagnostic value of individual transvaginal ultrasonography (TVS) cr iteria for adenomyosis and leiomyoma using histopathology as the reference standard. Methods: This analytical cross-sectional study was conducted among 150 women aged 30 –55 years with TVS- diagnosed adenomyosis, leiomyoma, or both who subsequently underwent hysterectomy, myomectomy, or adenomyomectomy and had histopathological confirmation. Participants were enrolled using purposive sampling. Individual TVS criteria for adenomyosis and leiomyoma were compared with corresponding histopathological findings. Statistical analyses were performed using SPSS version 26.0, with p<0.05 considered statistically significant. Results: Leiomyoma was the most common diagnosis (61.33%), followed by combined adenomyosis and leiomyoma (26.00%) and adenomyosis alone (12.67%). For adenomyosis, no distinction of the endometrial-myometrial junction (78.9%), asymmetry of the anterior and posterior myometrium (83.3%), heterogeneous myometrial echotexture (80.3%) and myometrial cysts with fibrosis (62.5%) showed significant associati ons with histopathology (all p<0.0001). For leiomyoma, clear tumor margin demarcation (96.7%), peripheral vascularity on color Doppler (95.6%), irregular uterine surface (93.5%) and irregular endometrial surface (95.7%) were also significantly associated w ith histopathological confirmation (p≤0.005).

Individual TVS criteria demonstrated significant diagnostic value for adenomyosis and leiomyoma. Recognition of these sonographic features may improve preoperative diagnostic accuracy and support appropriate clinical management.

Adenomyosis; Leiomyoma; Transvaginal ultrasonography; Histopathology; Diagnostic accuracy . Copyright © 2026 The Author(s): This is an open -access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY-NC 4.0) which permits unrestricted use, distribution, and reproduction in any medium for non -commercial use provided the original author and source are credited.

Adenomyosis and leiomyoma are among the most common benign uterine disorders affecting women of reproductive age and are important causes of abnormal uterine bleeding, dysmenorrhea, chronic pelvic pain, infertility and reduced quality of life [1]. These co nditions frequently coexist, making accurate preoperative diagnosis challenging because of overlapping clinical manifestations and imaging findings [2]. Precise differentiation between adenomyosis and leiomyoma is essential for selecting appropriate treatment, planning surgical interventions and counseling patients regarding fertility preservation and long-term management [3]. Histopathological examination remains the gold standard for confirming the diagnosis of adenomyosis and leiomyoma [4]. However, histopathological confirmation is only possible after surgical removal of uterine tissue, limiting its role in preoperative deci sion- making [5]. Therefore, reliable noninvasive imaging techniques are essential for the accurate evaluation of women presenting with suspected uterine pathology [6]. Akter, K. et al; Sch Int J Obstet Gynec, Aug. 2026; 9(8): 176-181 © 2026 | Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 177 Transvaginal ultrasonography (TVS) is widely accepted as the first -line imaging modality for the assessment of uterine abnormalities because it is readily available, cost -effective, noninvasive and capable of providing high-resolution visualization of the uterus and adnexa [7]. Advances in ultrasound technology, including high-frequency transvaginal probes and color Doppler imaging, have improved the detection of characteristic sonographic features associated with adenomyosis and leiomyoma [8]. In clinical practice, TVS plays a pivotal role in distinguishing between these conditions and guiding subsequent management [9]. Several individual sonographic criteria have been described for the diagnosis of adenomyosis, including loss of the endometrial -myometrial junction, asymmetry of the anterior and posterior myometrium, subendometrial myometrial striations, myometrial cysts with fibrosis and heterogeneous myometrial echotexture [10]. Similarly, characteristic ultrasound features of leiomyoma include clear tumor margin demarcation, a whorled appearance of the lesion, peripheral vascularity on color Doppler, irregularities of the uterine surface and distortion of the endometrial surface in submucosal tumors [11]. Although combinations of these features are commonly used to establish a diagnosis, the diagnostic contribution of each individual criterion has not been fully elucidated [12]. The present study was undertaken to evaluate the diagnostic value of individual transvaginal ultrasound criteria for adenomyosis and leiomyoma by comparing each sonographic feature with the corresponding histopathological diagnosis, thereby identifying the ultrasound findings that provide the greatest diagnostic utility in clinical practice. METHODOLOGY & MATERIALS This analytical cross -sectional study was conducted in the Department of Obstetrics and Gynecology, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) General Hospital, Dhaka, from January 2023 to Ju ne 2024. A total of 150 women aged 30–55 years with transvaginal ultrasonography (TVS) - diagnosed adenomyosis, leiomyoma, or both who subsequently underwent hysterectomy, myomectomy, or adenomyomectomy and had available histopathological reports were enroll ed using purposive sampling. Postmenopausal women, patients with a uterus larger than 16 weeks' size, uterine malignancy, endometriosis, or pelvic inflammatory disease were excluded. Data on sociodemographic characteristics, symptoms, menstrual and obstetr ic history, TVS findings and histopathological results were collected using a pretested semi-structured questionnaire. TVS examinations were performed before surgery using a LOGIQ 9 ultrasound system (GE Healthcare, Milwaukee, WI, USA) equipped with a 7–9 MHz endovaginal probe, with color Doppler evaluation. All examinations were interpreted by the same investigator with 5 years of experience in female pelvic sonography to minimize interobserver variation. The assessed sonographic criteria for adenomyosis included no distinction of the endometrial -myometrial junction, asymmetry of the anterior and posterior myometrium, subendometrial myometrial striations, myometrial cysts and fibrosis and heterogeneous myometrial echotexture, while those for leiomyoma included clear tumor margin demarcation, whorly tumor appearance, peripheral vascularity on color Doppler, irregular uterine surface and irregular endometrial surface. Histopathological examination of the surgical specimens served as the reference standard. Sta tistical analysis was performed using SPSS version 26.0. Continuous variables were expressed as mean ± standard deviation and categorical variables as frequency and percentage. Chi -square test, Fisher's exact test and ANOVA were applied as appropriate, wit h a p -value <0.05 considered statistically significant. Ethical approval was obtained from the Institutional Review Board of BIRDEM and written informed consent was obtained from all participants before enrollment.

This analytical cross - sectional study was conducted to diagnose of adenomyosis, leiomyoma, or combined adenomyosis and leiomyoma by the use of transvaginal ultrasonography (TVS) which was compared with histopathological findings. A total of 150 women who underwent hysterectomy or myomectomy or adenomyomectomy due to leiomyoma, adenomyosis or combined in the inpatient department of Obstetrics and Gynecology, BIRDEM General Hospital were enrolled for the study. The results, including tables, are presented within this chapter. Table I: Categorization of the respondents according to sociodemographic characteristic by groups Sociodemographic characteristic Adenomyosis (n=19) Leiomyoma (n=92) Combination of Adenomyosis and Leiomyoma (n=39) P value Age Mean ±SD 42.7 ± 2.3 41.3 ± 3.6 45.2 ± 2.0 0.523c Educational qualification Class I-V 7 (36.8) 42 (45.6) 18 (46.2) 0.177* Class VI-X 5 (26.3) 30 (32.6) 14 (35.9) Class XI-XII 5 (26.3) 16 (17.3) 3 (7.7) Graduate 2 (10.5) 4 (4.3) 2 (10.3) Akter, K. et al; Sch Int J Obstet Gynec, Aug. 2026; 9(8): 176-181 © 2026 | Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 178 Sociodemographic characteristic Adenomyosis (n=19) Leiomyoma (n=92) Combination of Adenomyosis and Leiomyoma (n=39) P value Occupation Housewife 18 (94.7) 76 (42.6) 33 (84.6) 0.042* Working woman 1 (5.3) 15 (16.3) 6 (15.4) Monthly income Mean ±SD 40473.7 ± 5368.3 45695.7 ± 5395.8 38230.7 ± 7001.7 0.074c BMI (Mean ± SD) 23.7 ± 1.3 26.3 ± 1.3 25.8 ± 1.3 0.774c cANOVA test, * Fisher’s Exact test Table I shows that the mean age was similar across groups (adenomyosis: 42.7 ± 2.3 years, leiomyoma: 41.3 ± 3.6 years, combination: 45.2 ± 2.0 years; p = 0.523). In terms of education, most had a Class I-V education (adenomyosis: 36.8%, leiomyoma: 45.6%, combination: 46.2%; p = 0.177). The majority were housewives (adenomyosis: 94.7%, leiomyoma: 42.6%, combination: 84.6%; p = 0.042). The mean monthly income varied slightly (adenomyosis: 40,473.7 ± 5,368.3, leiomyoma: 45,695.7 ± 5,395.8, combination: 38,230.7 ± 7,001.7; p = 0.074). BMI averages are similar across groups, approximately 23.7± 1.3 for Adenomyosis, 26.3± 1.3 for Leiomyoma and 25.8 ± 1.3 for the combination group (p=0.774). Figure 1: TVS findings of uterine pathology Figure 1 illustrates that among the respondents, the majority (61.33%) had leiomyoma, followed by 26.00% with both adenomyosis and leiomyoma and 12.67% had adenomyosis. Table II: Comparison of Various Diagnostic Criteria of Transvaginal Ultrasound (TVS) Findings with Histopathology for Diagnosis of Adenomyosis TVS (Adenomyosis) Histopathology (Adenomyosis) P value Yes No No distinction of the endometrial‑myometrial junction Yes 30 (78.9) 2 (1.7) <0.0001* No 8 (21.0) 110 (98.2) Asymmetry of the anterior and posterior myometrium Yes 50 (83.3) 3 (3.3) <0.0001a No 10 (16.6) 87 (96.6) Myometrial cysts and fibrosis Yes 10 (62.5) 1 (1.0) <0.0001* No 6 (37.5) 133 (99.0) Heterogeneous myometrial echotexture Yes 53 (80.3) 5 (5.9) <0.0001* No 13 (19.6) 79 (94.0) aChi square test, * Fisher’s Exact test Akter, K. et al; Sch Int J Obstet Gynec, Aug. 2026; 9(8): 176-181 © 2026 | Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 179 Table II illustrates significant correlations between various Transvaginal Ultrasound (TVS) findings for adenomyosis and their confirmation by histopathology. TVS identified 78.9% of cases with no distinction of the endometrial -myometrial junction, confirmed by histopathology (p < 0.0001). Regarding asymmetry of the anterior and posterior myometrium, 83.3% identified by TVS were confirmed by histopathology (p < 0.0001). TVS identified myometrial cysts and fibrosis in 62.5% of cases confirmed by histopathology (p < 0.0001). For heterogeneous myometrial echotexture, 80.3% identified by TVS were confirmed by histopathology (p < 0.0001). Table III: Comparison of Various Diagnostic Criteria of Transvaginal Ultrasound (TVS) Findings with Histopathology for Diagnosis of Leiomyoma TVS (Leiomyoma) Histopathology (Leiomyoma) P value Yes No Clear demarcation of the tumor margin Yes 120 (96.7) 11 (42.3) <0.0001* No 4 (3.2) 15 (57.6) The presence of blood vessels (by color Doppler) surrounding the tumor Yes 88 (95.6) 02 (3.4) 0.004a No 4 (4.3) 56 (96.5) Irregularities of the uterine surface (subserous and intramural tumors) Yes 58 (93.5) 8 (9.0) 0.005a No 4 (6.4) 80 (90.9) Irregularities of the endometrial surface (submucous tumors type 1 and 2) Yes 67 (95.7) 2 (2.5) 0.004a No 3 (4.2) 78 (97.5) aChi square test, * Fisher’s Exact test Table III shows the comparison of transvaginal ultrasound (TVS) findings with histopathology for diagnosing leiomyoma showed that clear tumor margin demarcation on TVS was highly correlated (96.7%) with histopathological confirmation (p < 0.0001). TVS identified 95.6% of cases of leiomyoma with presence of surrounding blood vessels on color Doppler, confirmed by histopathology (p = 0.004). The irregularities of the uterine surface and irregularities of the endometrial surface in TVS were significantly assoc iated with histopathological confirmation of leiomyoma (93.5% and 95.7%, p= 0.005 and p = 0.004 respectively).

The present study evaluated the diagnostic value of individual transvaginal ultrasonography (TVS) criteria for adenomyosis and leiomyoma using histopathology as the reference standard. TVS demonstrated significant associations between individual sonographi c features and histopathological diagnosis for both conditions. Among adenomyosis cases, no distinction of the endometrial -myometrial junction (78.9%), asymmetry of the anterior and posterior myometrium (83.3%), myometrial cysts and fibrosis (62.5%) and he terogeneous myometrial echotexture (80.3%) were all significantly associated with histopathological confirmation (all p<0.0001). For leiomyoma, clear tumor margin demarcation (96.7%), peripheral vascularity on color Doppler (95.6%), irregular uterine surfa ce (93.5%) and irregular endometrial surface (95.7%) also demonstrated significant correlations with histopathology. The distribution of uterine pathology in the present study showed that leiomyoma was the most frequent diagnosis (61.33%), followed by the coexistence of adenomyosis and leiomyoma (26.00%), while isolated adenomyosis accounted for 12.67% of cases. Similar observations have been reported by Lonky et al., who demonstrated that adenomyosis frequently coexists with uterine leiomyomas in women undergoing hysterectomy, emphasizing the importance of careful preoperative imaging to identify both pathologies simultaneously [13]. Likewise, Moawad et al., and Moldassarina described the considerable overlap between adenomyosis and leiomyoma and highlighted the need for standardized ultrasound criteria to improve diagnostic precision [14,15]. The present study demonstrated that loss of the endometrial-myometrial junction and asymmetry of the myometrium were among the strongest sonographic indicators of adenomyosis. These findings are consistent with those reported by Farooqui et al., who found that disruption of the junctional zone and asymmetrical myometrial thickening were highly predictive of histopathologically confirmed adenomyosis [16]. Similarly, Sayer Dayer et al., reported that characteristic TVS findings showed a strong association wit h histopathological diagnosis, supporting the value of ultrasound as a reliable preoperative diagnostic tool [17]. Furthermore, Yavuz et al., demonstrated that Morphological Uterus Sonographic Assessment (MUSA) features, particularly junctional zone Akter, K. et al; Sch Int J Obstet Gynec, Aug. 2026; 9(8): 176-181 © 2026 | Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 180 abnormalities and myometrial asymmetry, significantly improved the prediction of adenomyosis [18]. Heterogeneous myometrial echotexture was identified in 80.3% of histopathologically confirmed adenomyosis cases in the current study, while myometrial cysts and fibrosis were observed in 62.5%. Comparable findings have been described by Harmsen et al., who reported good agreement between transvaginal ultrasound, MRI and histopathology for evaluating junctional zone abnormalities and heterogeneous myometrium [19]. Ren et al., also emphasized that heterogeneous myometrial echotexture and myometrial cysts are valuable sonographic markers reflecting disease severity and are useful for monitoring treatment response [20]. For leiomyoma, clear tumor margin demarcation demonstrated the highest correlation with histopathology (96.7%), followed closely by peripheral vascularity on color Doppler (95.6%). These findings are in agreement with Abou Elela et al., who concluded that pelvic ultrasonography effectively identifies uterine myomas through characteristic well-defined margins and vascular patterns [21]. Likewise, Zhang et al., reported that vascular characteristics and lesion morphology are important sonographic features for differentiating leiomyomas from focal adenomyosis [22]. Kaya Narçiçeği et al., further demonstrated that combining conventional ultrasound features with tissue elasticity assessment improves discrimination between adenomyosis and leiomyoma [23]. Recent advances in ultrasound technology have further strengthened the diagnostic capability of TVS. Zanolli et al., reported high diagnostic accuracy of clinically interpreted pelvic ultrasound compared with surgical pathology for adenomyosis [24]. Similarly, Raimondo et al., demonstrated that deep learning models applied to ultrasound images further improve the identification of adenomyosis by recognizing subtle sonographic features [25]. These developments support the growing role of ultrasound as an accurate, accessible and noninvasive diagnostic modality.

of the study This study was conducted at a single tertiary care center using purposive sampling, which may limit the generalizability of the findings. In addition, only women who underwent surgical management with available histopathological reports were included, potentially introducing selection bias. Interobserver variability could not be assessed because all transvaginal ultrasound examinations were interpreted by a single experienced investigator.

Individual transvaginal ultrasound criteria showed significant diagnostic value for identifying adenomyosis and leiomyoma when compared with histopathological findings. Features such as loss of the endometrial-myometrial junction, myometrial asymmetry, heterogeneous myometrial echotexture, clear tumor margin demarcation, peripheral vascularity and surface irregularities were strongly associated with histopathological diagnosis. Careful evaluation of these individual sonographic features can improve preoperative diagnostic accuracy and support appropriate clinical management. Financial Support and Sponsorship: No funding sources. Conflicts of Interest: There are no conflicts of interest.

1. Raimondo D, Lazzeri L, Raffone A, Giorgi M, Orsini B, Verrelli L, Lenzi J, Travaglino A, De Meis L, Mollo A, Zupi E. Sonographic assessment of uterine biometry for the diagnosis of diffuse adenomyosis in a tertiary outpatient clinic. Journal of Personalize d Medicine. 2022 Sep 23;12(10):1572. 2. Krentel H, Keckstein J, Füger T, Hornung D, Theben J, Salehin D, Buchweitz O, Mueller A, Schäfer SD, Sillem M, Schweppe KW. Accuracy of ultrasound signs on two ‑dimensional transvaginal ultrasound in prediction of adenomyosis: prospective multicenter study. Ultrasound in Obstetrics & Gynecology. 2023 Nov;62(5):739-46. 3. Biasioli A, Degano M, Restaino S, Bagolin M, Moro F, Ciccarone F, Testa AC, Greco P, Scambia G, Vizzielli G, Driul L. Innovative Ultrasound Criteria for the diagnosis of adenomyosis and correlation with symptoms: a retrospective re -evaluation. Biomedicines. 2024 Feb 19;12(2):463. 4. Young SW, Ramirez NL, Kho RM. Adenomyosis: Transvaginal Ultrasound and Imaging Innovations for Diagnosis. Current Obstetrics and Gynecology Reports. 2023 Sep;12(3):178-85. 5. Valdés-Bango M, Ros C, Daza M, Rius M, Gracia M, Martínez-Zamora M, De Guirior C, Quintas L, Carmona F. Internal and external adenomyosis phenotypes: ultrasound features and association with clinical outcomes. Human Reproduction. 2024 Jul;39(7):1471-80. 6. ELBoghdady AA, Mohamed MI, Mabrouk AM. Role of Transvaginal Ultrasound & Color Doppler in differentiation between Leiomyoma, Adenomyosis and Correlation with Postoperative Histopathology. Al -Azhar International Medical Journal. 2024;5(9):23. 7. Dason ES, Maxim M, Sanders A, Papillon -Smith J, Ng D, Chan C, Sobel M. Guideline No. 437: diagnosis and management of adenomyosis. Journal of Obstetrics and Gynaecology Canada. 2023 Jun 1;45(6):417-29. 8. Săsăran V, Turdean S, Mărginean C, Gliga M, Ilyes L, Grama O, Pușcașiu L. Transvaginal ultrasound combined with strain -ratio elastography for the Akter, K. et al; Sch Int J Obstet Gynec, Aug. 2026; 9(8): 176-181 © 2026 | Published by Scholars Middle East Publishers, Dubai, United Arab Emirates 181 concomitant diagnosis of uterine fibroids and adenomyosis: a pilot study. Journal of clinical medicine. 2022 Jun 28;11(13):3757. 9. Alcázar JL, Vara J, Usandizaga C, Ajossa S, Pascual MA, Guerriero S. Transvaginal ultrasound versus magnetic resonance imaging for diagnosing adenomyosis: a systematic review and head‑to‑head meta‑analysis. International Journal of Gynecology & Obstetrics. 2023 May;161(2):397-405. 10. Maudot C, Vernet T, Debras E, Fernandez H, Capmas P. Diagnostic accuracy study of sonography in adenomyosis: A study of current practice. Journal of Gynecology Obstetrics and Human Reproduction. 2023 Sep 1;52(7):102604. 11. Maghsoudlou P, Chatroux LR, Ajao MO, King LP, Groszmann YS. Diagnostic Accuracy of Ultrasound for Adenomyosis–A Blinded, Retrospective, Single- Expert Validation Study of the 2022 MUSA Guidelines. Journal of Minimally Invasive Gynecology. 2025 Aug 7. 12. Shaikh A, Masroor I, Masood A, Saeed SA. Diagnostic accuracy of transvaginal ultrasound in adenomyosis taking mri as a gold standard. J Coll Physicians Surg Pak. 2023 Oct 1;33(10):1118-23. 13. Lonky NM, Chiu V, Portugal C, Estrada EL, Chang J, Fischer H, Vora JB, Harrison LI, Peng L, Munro MG. Adenomyosis in women undergoing hysterectomy for abnormal uterine bleeding associated with uterine leiomyomas. PLoS One. 2023 Dec 11;18(12):e0294925. 14. Moawad G, Fruscalzo A, Youssef Y, Kheil M, Tawil T, Nehme J, Pirtea P, Guani B, Afaneh H, Ayoubi JM, Feki A. Adenomyosis: an updated review on diagnosis and classification. Journal of clinical medicine. 2023 Jul 21;12(14):4828. 15. Moldassarina RS. Modern view on the diagnostics and treatment of adenomyosis. Archives of Gynecology and Obstetrics. 2023 Jul;308(1):171 - 81. 16. Farooqui BP, Shabab U, Khan QM, Khan W, Qamar J. Role of transvaginal sonography in diagnosing adenomyosis and its correlation with histopathology. Rehman Journal of Health Sciences. 2025 Jun 30;7(1):18-26. 17. Sayer Dayer MZ, Menshawey SS, El -Damaty WG. The Prognostic Significance of Transvaginal Ultrasound for Adenomyosis: Association with Histopathology. Evidence Based Women's Health Journal. 2024 Nov 1;14(4):455-61. 18. Yavuz O, Akdöner A, Özgozen ME, Ertan B, Kurt S, Ulukuş EC, Güney M. Prediction of adenomyosis according to revised definitions of morphological uterus sonographic assessment features. Frontiers in Medicine. 2024 Aug 8; 11:1387515. 19. Harmsen MJ, Trommelen LM, De Leeuw RA, Tellum T, Juffermans LJ, Griffioen AW, Thomassin‑Naggara I, Van den Bosch T, Huirne JA. Uterine junctional zone and adenomyosis: comparison of MRI, transvaginal ultrasound and histology. Ultrasound in Obstetrics & Gynecology. 2023 Jul;62(1):42-60. 20. Ren Q, Yuan M, Wang G. Role of ultrasonography in the evaluation of disease severity and treatment efficacy in adenomyosis. Archives of Gynecology and Obstetrics. 2024 Feb;309(2):363-71. 21. Abou Elela NK, Suliman MM, Soliman DM, Zaki SA, Ibrahim RA, Mohammed MG. Utilization of pelvic ultrasonography and CA125 level to diagnose uterine myoma and adenomyosis. The Egyptian Journal of Hospital Medicine. 2022 Jul 1;88(1):3206-12. 22. Zhang YQ, Chen JH, Zhu TT, Zhao AX, Zhuang LT, Lu CY, Huang Y. Applying contrast -enhanced ultrasound model to distinguish atypical focal adenomyosis from uterine leiomyomas. Annals of Translational Medicine. 2022 Oct;10(20):1108. 23. Kaya Narçiçeği V, Aslan M, Artaş H, Eryeşil H, Yavuzkir Ş, Yurt N, Özercan İH. Transabdominal 2- dimensional shear-wave elastography for diagnostic differentiation between adenomyosis leiomyoma and normal myometrium. Journal of Gynecologic Surgery. 2023 Aug 1;39(4):177-83. 24. Zanolli NC, Cline BC, Befera NT, Martin JG. Diagnostic accuracy of clinically reported adenomyosis on pelvic ultrasound and MRI compared to surgical pathology. Clinical imaging. 2022 Feb 1; 82:117-20. 25. Raimondo D, Raffone A, Aru AC, Giorgi M, Giaquinto I, Spagnolo E, Travaglino A, Galatolo FA, Cimino MG, Lenzi J, Centini G. Application of deep learning model in the sonographic diagnosis of uterine adenomyosis. International Journal of Environmental Resea rch and Public Health. 2023 Jan 18;20(3):1724.