The female genital  tract comprises the uterine corpus and cervix, with the corpus further divided into the endometrium and myometrium.^[1] The uterus, a crucial hormone-responsive reproductive organ, is prone to various benign and malignant pathologies.^[2] Under hormonal regulation, the endometrial lining undergoes cyclical shedding. Lesions affecting the uterine corpus and cervix are among the most frequent reasons for gynecological consultation.^[3]

These conditions are predominantly observed in middle-aged and elderly women. Common clinical manifestations include abdominal pain, abnormal uterine bleeding (AUB), postmenopausal bleeding, vaginal discharge, and the presence of a pelvic mass or uterine prolapse. Although conservative medical and hormonal therapies are often employed initially, hysterectomy continues to be a widely adopted definitive treatment in cases where other options prove ineffective.

Hysterectomy involves the surgical removal of the uterus and cervix, sometimes also including unilateral or bilateral related organs like ovaries or fallopian tubes. The first subtotal hysterectomy was performed by Charles Clay in Manchester, England, in 1843, while the first total abdominal hysterectomy was conducted in 1929.^[4].

This procedure can be carried out via abdominal, vaginal, or laparoscopic approaches, with or without salpingo-oophorectomy. Laparoscopic methods are increasingly preferred due to their minimally invasive nature, faster recovery, and better cosmetic outcomes.

Menstrual irregularities and heavy bleeding account for approximately 25%–33% of gynecological outpatient visits. AUB, defined as any abnormal variation in the frequency, regularity, volume, or duration of menstrual bleeding, is a significant health concern.^[5]. It affects 14%–25% of women in the reproductive age group, with prevalence rising to 50% in perimenopausal women.^[6] In India, the reported prevalence of AUB is around 17.9%, often leading to complications such as severe anemia that may necessitate surgical intervention.^[7]

The most frequent indication for hysterectomy is AUB, commonly associated with uterine pathologies such as prolapse, leiomyoma, adenomyosis, and endometriosis.^[8] To classify AUB based on etiology, the PALM–COEIN system  categorizes the causes of AUB:PALM refers to structural causes like Polyp, Adenomyosis, Leiomyoma, Malignancy and Hyperplasia; COEIN refers to non-structural causes  such as Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, and Not yet classified.^[9]

AIMS AND OBJECTIVE

The study aims to evaluate the spectrum of histomorphological lesions observed in hysterectomy specimens. Additionally, the study seeks to correlate these findings with the patient’s age and their respective clinical presentations, enhancing diagnostic accuracy and improve clinicopathological understanding of uterine pathology in a tertiary care setting.

MATERIALS AND METHODS

This one year retrospective observational study was conducted in the Department of Pathology at Rama Medical College Hospital and Research Centre, Hapur, Uttar Pradesh included 155 hysterectomy specimens, obtained for various gynecological indications.

All specimens were received in the histopathology laboratory, properly labeled, and immediately fixed in 10% buffered formalin at a 1:10 specimen-to-fixative volume ratio. After adequate fixation for 8–10 hours, a thorough gross examination of each specimen was performed. Representative tissue sections were taken from the cervix, endometrium, myometrium, ovaries, and fallopian tubes. The tissues underwent processing using standard histological techniques, including embedding and sectioning at 2–5 µm thickness. The resulting sections were stained with hematoxylin and eosin (H&E) and examined microscopically.

Histopathological findings from cervix, endometrium, myometrium, ovaries and fallopian tubes of every hysterectomy specimen were noted and subsequently correlated with the patients clinical presentation and age.

Inclusion Criteria

• All hysterectomy specimen (total and subtotal) regardless of whether they included bilateral or unilateral salpingo-oophorectomy, were included in the study.

Exclusion Criteria

• Specimens from patients with a preoperative confirmed diagnosis of malignancy.
• Endometrial and cervical biopsy samples (i.e.,specimens other than complete hysterectomy specimens)

We analyzed all  155 hysterectomy specimens and  findings were summarized in the  following tables are based on the observations made histopathologically.

The highest incidence was shown in  the  41–50 years age group (70 cases, 45.2%), followed by the 31–40 years group (52 cases, 33.5%) (Figure-1)

                               Figure 1: Age –wise distribution of hysterectomy specimen (N=155)

The most common indication was AUB due to Leiomyoma (71 cases, 45.8%), followed by adenomyosis (35 cases, 22.6%), utero-vaginal prolapse (20 cases, 12.9%) and ovarian cystic lesions/tumor (13 cases, 8.4%) . Other indications included endometrial polyps (9 cases, 5.8%) and endometrial malignancy/hyperplasia accounting for 7 cases (4.5%) (Table 1).

                                       Table.1 Clinical Indication of hysterectomy (N=155)

The most common procedure performed was total abdominal hysterectomy with adnexal  preservation (65 case, 41.9%). This was followed by total abdominal hysterectomy with bilateral salpingo-oophorectomy, ( 50 cases 32.3%) (Figure-2)

                                                       Figure 2: Distribution of Hysterectomy cases

The most prevalent histopathological pattern of the endometrium was the proliferative phase, identified in 60 cases (38.7%), followed by atrophic endometrium in 37 cases (23.9%). Other findings included the secretory phase in 21 cases (13.5%), disordered proliferative endometrium in 19 cases (12.2%), endometrial polyps in 7 cases (4.5%), and pill endometrium in 3 cases (1.9%). Less frequent  findings included hyperplastic changes specifically  simple hyperplasia (0.7%) and complex hyperplasia with atypia (1.3%). Endometrial stromal nodule and Low grade Endometrial stromal sarcoma were each found in one cases. Endometrial adenocarcinoma was identified in two cases (1.3%) (Table 2) (Figures-3,4 &5 )

                              Table-2. Distribution of histopathological findings in  endometrium (N=155)

 Leiomyoma was the most frequent myometrial pathology identified in 69 cases (44.5%).Adenomyosis was observed in 32 cases (20.6%), while 20 cases (12.9%) presented with both leiomyoma and adenomyosis.. The remaining 34 cases (22%) exhibited no significant pathological changes.(Table-3)(Figure-6)

                              Table 3: Distribution of histopathological findings in  myometrium  (N=155)

Site Distribution of Leiomyoma:

The most frequent location was intramural (92 cases,59.4%), followed by subserosal (52 cases, 33.5%) (Table.4)

                                                            Table.4 Site Distribution of Leiomyoma

Pathological changes in  leiomyomas:

120 cases of typical leiomyomas (77.4%), followed by degenerative changes in 31 cases (20%) and four variants of leiomyoma  (2.6%) (Figure-7)

                                         Figure 7:Various pathological changes in leiomyoma

Degenerative changes: were observed in 20% of leiomyomas, with hyalinization being most common (13.6%).

(Figure-8)

Unusual variants: identified included cellular, epithelioid, lipoleiomyoma, and vascular leiomyoma—each comprising 0.65% of cases.(Figure -9)

Age-wise analysis revealed a predominance of leiomyomas and adenomyosis in the 41–50 year age group (55% and 53.9%, respectively). (Table-5)

                                        Table 5:  Age -wise distribution of Leiomyoma & Adenomyosis

Chronic cervicitis constituted the predominant cervical pathology, diagnosed in 79 cases (51%). Other findings included chronic cervicitis with nabothian follicle in 42 cases (27%), and squamous metaplasia in 24 cases (15.5%). Cervical polyps and dysplasia each accounting for (1.3%), four cases of carcinoma (2.6%) were also diagnosed. Rare lesions included cervical leiomyoma (1.3%).(Table-6 (Figures-10&11)

                            Table-6  Distribution of histopathological  findings in  cervix  (N = 155)

Among the 90 cases where ovaries were available for examination, 52 cases (57.8%) showed no pathological changes. Non-neoplastic lesions were identified in 25 cases (27%), predominantly follicular cysts (15.6%) followed by luteal cysts (8.9%). Neoplastic lesions comprised 13 cases included serous cystadenoma (5.6%), mucinous cystadenoma (2.2%), teratoma (2.2%), and malignant tumors such as serous and mucinous cystadenocarcinomas (each 2.2%).(Table-8)

                             Table-7 Distribution of histopathological  findings in  ovary  (N = 90)

Among 90 fallopian tube specimens, the majority (87.7%) exhibited normal histology. Nonneoplastic lesions

included salpingitis (3.3%) and paratubal cysts (7.8%).One case (1.1%) of focal serous tubal intraepithelial lesion (STIL) is also found in present study.It is a rare pathological finding in the fallopian tubes, characterized by epithelial stratification, loss of polarity, mild nuclear atypia, and papillary architecture. (Table-8)

                         Table-8  Distribution of histopathological  findings in fallopian tube (N = 90).

Correlation between preoperative clinical diagnosis and histopathological findings showed high concordance rates: leiomyoma (97.2%), adenomyosis (91.4%), endometrial polyp (77.7%), suspected endometrial malignancy/hyperplasia (71.4%), uterovaginal prolapse (96.2%), and ovarian cystic lesions (100%).(Table-9)

         Table.9: Correlation of pre-operative clinical diagnosis with histopathological diagnosis  ( N=155 cases)

DISCUSSION

Hysterectomy remains a very common global gynecological surgery, offering symptom relief and definitive treatment for a various benign and malignant conditions affecting the uterus and adnexa. Despite advancements in conservative medical and minimally invasive surgical treatments for uterine pathologies, hysterectomy continues to be a preferred intervention for several refractory or severe cases gynecologic conditions. In India the reported incidence of hysterectomy is around 6–8%, with this rate gradually increasing, partly due to its role in preventing uterine malignancies and managing severe premenopausal bleeding and prolapse.^[10,11]

The study aimed to evaluate the histomorphological spectrum of lesions identified in hysterectomy specimens and establish a correlation with clinical indications and  patient age. We  analyzed 155 cases over a one-year duration  at Rama Medical College Hospital and Research Centre, Hapur, Uttar Pradesh.

 Our study revealed that hysterectomies were most prevalent in the 41–50-year age group (45.2%) followed by the 31–40-year group (33.5%). This pattern aligns with previous studies by Ticku et al., Chaware et al., and Sujatha et al., who also reported peak incidences in the same age range .^[12-14].

Abdominal hysterectomy was frequently performed than vaginal hysterectomy, a finding aligning with studies conducted by Ajmera et al. and Gupta et al. ^[15,16]. Uterine leiomyoma (AUB-L) constituted the most common clinical indication in our study, reported in 45.8% of cases, which corroborates with observations by Ajmera et al. and Archana et al. ^[15,17]

Histologically, the most frequently observed endometrial pattern was proliferative endometrium (38.7%), in accordance with study by Ticku et al. (38.4%) and Kaur et al. (31%). ^[12,18]Atrophic endometrium was the second most common pattern (23.8%), similar to results reported by Gangadharan et al. (24.5%).^[19]. Secretory endometrium was noted in 13.5% of cases, in concordance with Kaur et al. (13%).^[18]Chronic endometritis was an incidental finding, found in only 0.7% of cases, aligning with Ticku et al..^[12].

Endometrial adenocarcinoma was detected in 1.3% of cases, predominantly in the 51–60 years age group, which corresponds with the findings of Pervez et al.^[20](1.87%)

One case of each low-grade endometrial stromal nodule and low grade endometrial stromal sarcoma were also diagnosed.

Leiomyoma was the most predominant myometrial lesion, identified in 44.5% of cases, aligning with the studies by Tiwana et al., Maheshwari et al., and Gangadharan et al., who found similar frequencies 43.7%, 42.3%, and 41%, respectively . ^[19,21,22]

Intramural leiomyomas were the predominant subtype (59.4%), corroborates with the studies by Jung et al. (55.7%).^[23] Gowri et al. (48%) and Rosario et al. (52%) ^24].

Degenerative changes were identified in 20% of leiomyomas, with hyalinization (13.6%) being the most common, comparable to the findings of Gowri et al (16.9%).^[24]

 Rare variants of leiomyomas, including cellular, lipoleiomyoma, epithelioid, and vascular types, were found in 2.6% of cases, corresponds with the 4.55% incidence reported by Manjula et al. ^[25].

Leiomyoma and adenomyosis exhibited the highest diagnostic frequency within the 41–50-year age group (55% and 53.9%, respectively), paralleling the observations by Ticku et al.(49.64% and 46.58%).^[12]

Chronic cervicitis was identified as the predominant cervical pathology (51%), consistent with findings by Mallappa et al., who reported an incidence of 55.8%.^[26]

In ovarian lesions, non-neoplastic cysts, particularly follicular cysts (15.6%), were most prevalent, followed by luteal cysts (8.9%) and endometriosis (3.3%). These findings corroborates prior observtion by Nausheen et al., Pandey et al., and Perveen et al.^[27-29]. Among neoplastic lesions, serous cystadenoma was the most frequent benign tumor. Malignant tumors included serous and mucinous cystadenocarcinomas (each 2.2%).

The most frequently encountered benign lesion in the fallopian tubes was chronic salpingitis (3.3%), consistent

with Imam Z.S. et al., who reported 8.6%.^[24]It is currently accepted that serous tubular intraepithelial lesion or

carcinoma (STIL or STIC) is a precursor lesion to ovarian HGSCs. ^[30-32]

In our study majority of the preoperative clinical diagnoses were corresponds with the histopathological reports, with a proportion ranging from 70% to 100%. Jaleel et al. ^[33]. There were a high concordance, especially for leiomyoma (97.2%) and adenomyosis (91.4%), indicating the reliability of clinical evaluation in preoperative diagnosis. However, discrepancies were noted in endometrial hyperplasia/malignancy (71.4%) and endometrial polyps (77.7%). underscoring the importance of histopathological confirmation for accurate diagnosis and management.

CONCLUSION

This study highlights the critical importance of correlating histopathological findings with clinical indications and patient age in hysterectomy cases. While the majority of cases demonstrated strong concordance between preoperative clinical diagnoses and final histopathological outcomes, several instances revealed coexisting or incidental pathologies—including precancerous and occult malignant lesions—that were clinically or radiologically undetected.

Consequently, these Observations emphasize the critical and indispensable role of routine histopathological examination in all hysterectomy specimens, regardless of their gross appearance. Such examination enables accurate diagnosis, informs postoperative management, and ensures that clinically silent but significant pathologies are not overlooked.

Therefore, hysterectomy remains a pivotal therapeutic intervention in gynecological practice. Histopathological evaluation of each specimen should be considered mandatory to achieve optimal patient outcomes, guide treatment decisions, and enhance long-term prognosis.

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