Standardizing the histopathological diagnosis of adenomyosis: an international Delphi consensus

To use the Delphi consensus methodology to establish standardized criteria for the histopathological diagnosis of adenomyosis. Between April and September 2024, a modified three-round Delphi consensus study was conducted. Thirty-one gynaecological pathologists from 18 countries participated in surveys to evaluate and refine a diagnostic framework for adenomyosis in hysterectomy specimens. Key areas achieving the highest level of agreement included: 4-6 blocks for routine histopathological examination of hysterectomy specimens with benign indications; defining adenomyosis as endometrial glands and/or stroma greater than 2 mm into the myometrium or more than one-third of myometrial thickness; that the absolute number of glands or stromal tissue does not contribute to the diagnosis of adenomyosis; a single gland or stromal focus can be diagnostic; and definitions of focal, extensive, superficial and deep adenomyosis. In total, 93% of respondents were in favour of standardizing the diagnosis to reduce inter-pathologist variability. This study proposes the first consensus-based guideline for the histopathological diagnosis of adenomyosis. Supported by the responses of 31 international experts through a modified Delphi method, this framework provides pathologists with clear diagnostic criteria. Further research should correlate these criteria with clinical symptoms and outcomes.