{"paper_id":"235e3dcd-5dd2-4e79-8044-53450d6ec868","body_text":"~ 125 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2020; 4(3): 125-129 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2020; 4(3): 125-129 \nReceived: 01-03-2020 \nAccepted: 03-04-2020 \n \nDr. Sendhil Coumary A \nMahatma Gandhi Medical College \nand RI Pilliyarkuppam, \nPondicherry, India \n \nDr. Ishwarya LD \nMahatma Gandhi Medical College \nand RI, Pilliyarkuppam, \nPondicherry, India \n \nDr. Bhavani \nMahatma Gandhi Medical College \nand RI, Pilliyarkuppam, \nPondicherry, India \n \nDr. Sunil Samal \nAsso Prof-Pathology, \nPilliyarkuppam, Pondicherry, \nIndia \n \nDr. Reddi Rani \nProfessor-OBGYN, \nPilliyarkuppam, Pondicherry, \nIndia \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nSendhil Coumary A \nMahatma Gandhi Medical College \nand RI Pilliyarkuppam, \nPondicherry, India \n \nA clinical study on abnormal uterine bleeding in \npremenopausal women \n \nDr. Sendhil Coumary A, Dr. Ishwarya LD, Dr. Bhavani, Dr. Sunil Samal \nand Dr. Reddi Rani \n \nDOI: https://doi.org/10.33545/gynae.2020.v4.i3c.585 \n \nAbstract \nBackground: Abnormal uterine bleeding is defined as any bleeding outside of normal menstrual cycle \nwith excessive duration, frequency and amount of loss. AUB accounts about 70% in perimenopausal \nwomen in gynaecology OPD. Abnormal uterine bleeding is not a disease, it is a symptom.  The aim of the \nstudy was to evaluate abnormal uterine bleeding in perimenopausal women and to study the various \nmenstrual abnormalities and causes of AUB in perimenopausal women.  \nStudy design:  This study was a h ospital based cross sectional study which included 95 women in \nperimenopausal age group (40 -51 years) with abnormal uterine bleeding. The history, clinical examination, \nUSG and histopathological findings was collected. Clinical findings were classified by PALM-COEIN \nclassification. All women underwent endometrial sampling to rule out endometrial pathology.  \nResults: The mean age of the patients was 44.89(±2.93) years. Parity of more than 2 (46.3%) was most \ncommon. Menorrhagia  (58.9%) was the most common blee ding pattern followed menometrorrhagia  \n(23.2%). Leiomyomo 37 (38.9%) was the most common clinical finding followed by adenomyosis 29 \n(30.5%). Ultrasonographically fibroid uterus (37.8%) was the most common USG findings followed by \nAdenomyosis (30.5%). The most common endometrial thickness was 9 -12mm (43.1%). Histopathological \nexamination revealed secretory phase endometrium (35.8%) was the most common finding followed by \nproliferative endometrium (20%).  \nConclusion: Uterine fibroid was the leading cause of A UB. Clinical examination and ultrasound findings \ncorrelated well in the diagnosis of fibroids. Evaluation of the endometrium in perimenopausal women \npresenting with AUB is essential to rule out  endometrial pathology . \n \nKeywords: Clinical, abnormal uterine b leeding, premenopausal women  \n \nIntroduction  \nMenstruation is a cyclic bleeding from the uterine endometrium in response to ovarian hormones \nwhich is under the control of hypothalomo -pituitary-ovarianaxis. Menstrual disorders are a \ncommon indication for medical visits among women of the reproductive age  [1]. \nAbnormal uterine bleeding (AUB) is defined as any bleeding outside of normal menstrual \npattern with excessive duration, frequency and amount of loss. Abnormal uterine bleeding is not \na disease, it is a sy mptom. AUB accounts for 70% of the complaints among  premenopausal \nwomen in gynaecology OPD. 2 AUB is a general term and can have variable bleeding patterns \nsuch as  menorrhagia, menometrorrhagia, oligomenorrhea, metrorrhagia, polymenorrhea, mid \ncycle spotting [3]. \nAn international expert consensus from the FIGO menstrual disorders working group has \nproposed a standardized classification system for AUB. This classification allows the \ncharacterization of more than one etiology in the same patient. There are 9 m ain categories \nwithin the classification system named for the acronym PALM -COEIN. The PALM side of the \nclassification refers to structural causes that could be evaluated and diagnosed on imaging and or \nbiopsy. The COEIN side allows consideration of underly ing medical disturbances that could \nresult in AUB [4]. \nAll premenopausal women with AUB will need thorough evaluation to rule out malignant \ncauses of AUB. Literature, suggests using the age 45 years as a cut -off for sampling \nthe endometrium in all women wi th AUB. However, irregular menstrual bleeding justifies \ninvestigating women regardless of their age  [5]. Evaluation involves clinical examination,  \ntransvaginal sonography and an endometrial sampling.  TVS is a non invasive and simple  \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 126 ~ \ndiagnostic procedure in st udying the patterns of the \nendometrium by excluding the organic  pathology in AUB cases. \nIt is also used for visualizing the uterine structures.  Endometrial \nsampling is thought to be a safe and effective method for \nhistological assessment of the endometri um. It is used as an \nalternative to the more invasive method of D&C.  Endometrial \nsampling is a valuable tool in the assessment of patients with \nAUB and that Pipelle is the best outpatient device available  [6]. \nDilatation and curettage (D&C) is a simple but  invasive \nprocedure for histopathological evaluation of the endometrium \nand the assessment of AUB. Early detection of precancerous \nlesion like endometrial hyperplasia with atypia can also be ruled \nout. Histopathological examination of endometrial samples \nremain still the gold standard procedure in detection of \nendometrial pathology [7]. \nTVS and D&C together remain as a practical, cost effective and \ndependable investigation for AUB.  \nThe present study aims to evaluate the  various menstrual \nabnormalities and causes of AUB in premenopausal women and \nto correlate clinical evaluation with ultrasonographic and \nhistopathological examination. \n \nMethodology \nThis hospital based cross sectional study was conducted in \nMahatma Gandhi Medical College and Hospital between \nJanuary 2017 and March 2019. All premenopausal women with \nabnormal uterine bleeding attending the OPD formed the study \npopulation. Sample size was calculated based on the National \nfamily health survey 3 in Pondicherry, which showed prevalence \nof premenopaus al women of Pondicherry as 13.6%.  The \nrequired sample size calculated was 95. After obtaining approval \nfrom the Institute Ethics committee, all premenopausal women \n(40-51 years) with abnormal uterine bleeding attending the OPD \nfor the first time were enrolled in the study consecutively. \nWritten and informed consent was obtained from all patients \nbefore enrolling in the study. Participants were clinically \nevaluated by detailed history, clinical examination and a \nprovisional diagnosis was made. They were all subjected to \nultrasound examination (Transabdominal / Transvaginal). The \npresence of any lesions in the uterus, their morphological \nfeatures and endometrial thickness was noted. Adnexal \npathology were looked for and documented. They were all \nsubjected to e ndometrial sampling. Clinical diagnosis was \ncorrelated with USG and HPE findings. They were managed \nconservatively, medically or surgically depending upon the \ncause. Data was collected in a Proforma sheet and analysed.  \n \nResults \nThe mean age of women with a bnormal uterine bleeding in the \npresent study was 44.89 ±2.93years. Among these women a \nparity of more than 2 was most commonly noted. Fifty women \n(52.6%) had a parity of more than 2.  \nThe bleeding patterns of the patients were analysed. Of the 95 \nwomen, 5 6(58.9%) had menorrhagia, 22(23.2%) had \nmenometrorrhagia, 8(8.4%) had polymenorrhea, 5 (5.3%) had \noligomenorrhea and  4 (4.2%)  had metrorrhagia. The pattern of \nmenstrual disorders is shown in table 1. \n \nTable 1: Patterns of Menstrual Disorders  \n \nMenstrual disorders No. of patients Percentage \nMenometrorrhagia 22 23.2% \nMenorrhagia 56 58.9% \nPolymenorrhea 8 8.4% \nOligomenorrhea 5 5.3% \nMetrorrhagia 4 4.2% \nTotal 95 100% \n \nThe history and clinical examination of the patients was used to \nclassify them into the PA LM-COEIN classification. Of all 95 \nwomen with AUB the most common clinical finding was AUB - \nL (Leiomyoma) in 37 (38.9%), followed by 29 (30.5%) with \nAUB - A (Adenomyosis), 12 (12.6%) women with AUB - P \n(Polyp), 12(12.6%) had AUB - E (Endometrial), 4(4.2%) h ad \nAUB- O (Ovulatory) and only 1(1.1%) had AUB -M \n(Malignancy). PALM and COEIN groups accounted for 83.2% \nand 16.8% respectively. The clinical classification of the \npatients is shown in the table 2.  \n \nTable 2: Clinical findings \n \nClinical findings Number of patients Percentage \nAUB(P) 12 12.6% \nAUB(A) 29 30.5% \nAUB(L) 37 38.9% \nAUB(M) 1 1.1% \nAUB(O) 4 4.2% \nAUB(E) 12 12.6% \n \nOf all 95 women the most common abnormality detected on \nUSG was fibroid uterus 36(37.8%), followed by adenomyosis \nwith 29 (30.5%) patien ts. Twenty four (25.2%) women had no \nuterine abnormalities, 5(5.3%) had fibroid polyp and only \n1(1.1%) had uterine collection.  \nIn the present study, 41 women had an endometrial thickness of \n9-12mm (43.1%), 23 women had 13 -16mm (24.2%) thickness \nand 15 had less than 8mm (15.8%) thickness, 7 women had very \nthick endometrium of 21 -24 mm (7.3%) and 9 had 17 -20mm \n(9.4%). The endometrial thicknesses are as shown in table 3.  \n \nTable 3: Endometrial thickness  \n \nEndometrial Thickness  No. Of Patients Percentage \n≤8mm 15 15.8 \n9-12mm 41 43.1 \n13-16mm 23 24.2 \n17-20mm 9 9.4 \n21-24mm 7 7.3 \n \nAll 95 underwent endometrial sampling by way of fractional \ncurettage. Of the 95 premenopausal women, the \nhistopathological study showed secretory phase endometrium in \n34(35.8%) cases, proliferative phase endometrium in 19(20%) \nand disordered proliferative phase endometrium in 16(16.8%). \nEndometrial hyperplasia without atypia was seen in 10(10.5%), \n5(5.3%) had inadequate tissue for sampling. Benign endometrial \nadenomatous polyp wa s the histopathological report in all 7 \ncases of cervical polyp (7.4%),  2(2.1%) had benign \nleiomyomatous polyp, 1(1.1%) had complex hyperplasia with \natypia and 1 (1.1%) had complex hyperplasia without atypia. \nThe histopathological study reports are shown in table 4.  \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 127 ~ \n \n \nTable 4: Histopathological examination (HPE)  \n \nImpression of Histopathological examination  No. of patients Percentage \nSecretory phase 34 35.8 \nProliferative phase 19 20.0 \nDisordered Proliferative phase  16 16.8 \nEndometrial hyperplasia witho ut atypia 10 10.5 \nInadequate tissue for sampling  5 5.3 \nBenign Endometrial adenomatous polyp  7 7.4 \nBenign leiomyomatous polyp  2 2.1 \nComplex hyperplasia with atypia  1 1.1 \nComplex hyperplasia without atypia  1 1.1 \nTotal 95 100.0 \n \nIn the present study 37 women were clinically diagnosed to have \nfibroids and 29 women were diagnosed to have adenomyosis. 7 \nwomen had cervical polyps and 5 had fibroid polyps. The rest of \nthe women had no significant clinical findings and were \nclassified in to the COEIN part of  the classification. The study \ntried to correlate clinical and USG findings. \nUltrasonographically 36 women had fibroid and 29 had \nAdenomyosis. 25 women did not show any abnormality on \nultrasound. The clinical and USG findings correlated well for \nthe women with fibroids and adenomyosis. The USG findings of \nthose women who were classified into the COEIN group did not \ncorrelate therefore the overall correlation between clinical and \nultrasonographic findings was not statistically significant. The \nfindings are shown in table 5. \n \nTable 5: Association between clinical finding and USG finding  \n \nAbnormalities Clinical findings In USG \nFibroid 37 36 \nCervical & Fibroid polyp  12 5 \nAdenomyosis 29 29 \nOthers 17 25 \nTotal 95 95 \nX2 =0.54, p=0.91 \n \nThe present study atte mpted to correlate endometrial thickness \nto the histopathological findings. It showed that secretory phase \nendometrium was the commonest finding in all thicknesses. In \nthe present study proliferative endometrium was the next \ncommonest histopathology despit e varying thickness of \nendometrium. Thicker endometrium did not always show \nhyperplasia and thinner endometrium did not show atrophy. \nStatistically HPE did not correlate with endometrial thickness. \nThe findings are as shown in table 6. \n \nTable 6: Correlation of HPE with Endometrial Thickness  \n \nHistopathological Examination  Endometrial Thickness  \n≤8mm 9-12mm 13-16mm 17-20mm 21-24mm \nSecretory Phase Endometrium  5(33.3%) 13(31.7%) 10(43.4%) 2(22.2%) 4(57.1%) \nProliferative Phase Endometrium  4(26.6%) 6(14.6%) 5(21.7%) 2(22.2%) 2(28.5%) \nDisordered Proliferative Phase Endometrium  3(20%) 8(19.5%) 3(13%) 2(22.2%) 0(0.0%) \nEndometrial Hyperplasia Without Atypia  1(6.6%) 4(9.7%) 3(13%) 1(11.1%) 1(14.2%) \nInadequate Tissue For Sampling  0(0.0%) 4(9.7%) 1(4.3%) 0(0.0%) 0(0.0%) \nbenign endometrial adenomatous polyp  2(13.3%) 2(4.8%) 1(4.3%) 2(22.2%) 0(0.0%) \nBenign leiomyomatous polyp  0(0.0%) 2(4.8%) 0(0.0%) 0(0.0%) 0(0.0%) \nComplex hyperplasia with atypia  0(0.0%) 1(2.4%) 0(0.0%) 0(0.0%) 0(0.0%) \nComplex hyperplasia without  atypia 0(0.0%) 1(2.4%) 0(0.0%) 0(0.0%) 0(0.0%) \nTotal 15(15.8%) 41(43.1%) 23(24.2%) 9(9.4%) 7(7.4%) \nX2=30.05, p=0.874 \n \nDiscussion \nIn the present study the mean age of women with abnormal \nuterine bleeding was 44.89 ±2.93years. Among these women a \nparity of more than 2 was most commonly noted. Fifty women \n(52.6%) had a parity of more than 2, followed by a parity of  1-2 \nin 44 (46.3%) women  and only 1(1.1%) nulliparous woman. \nMany of the analysed literature showed similar age group and \nparity. Nullipara were few in most studies [2, 3, 6]. \nIn the present study menorrhagia was the most common clinical \npresentation seen in 58.9% of cases followed by \nmenometrorrhagia at 23.2%. Most of the analysed literature on \npremenopausal bleeding suggest that menorrhagia is the most \ncommon symptom followed by menometrorrhagia  [2, 3]. \nPALM COEIN classification was used for provisionally \nclassifying patients who presented with abnormal uterine \nbleeding. In the present study 38.9% had AUB (L). Also, 30.5% \nof the women had AUB (A ) and 12.6% had AUB(P). 4.2% were \ndiagnosed to have AUB(O), 12.6% had AUB (E) and 1.1% had \nAUB(M). PALM and COEIN groups accounted for 83.2% and \n16.8% respectively. Leiomyoma was the major components in \nthe structural group and endometrial causes contribut ed \nmaximum in the functional group. \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 128 ~ \nIn the study by Mishra et al the PALM and COEIN components \naccounted for 50.23% and 49.57% respectively. AUB (L) was \nthe major etiological factor in the structural group and ovulatory \ndisorder was the major component in the functional group. 7 In \nthe study by Archana Singh et al  PALM and COEIN groups \naccounted for 60% and 39.9% respectively. Leiomyoma was the \ncommonest cause of AUB 36.75% followed by Ovulatory \ndisorder in 26%. In both the above mentioned studies \nsubsequent histopathological examination accounted for \napproximately 70% of the cases to have PALM component as \nthe cause of AUB.  The clinical findings of the present study are \nsimilar to the studies done by Mishra et al and Archana Singh et \nal. [8, 9] Most women wi th AUB will have a spectrum of hyper \nestrogenic features (eg): fibroids and adenomyosis will co -exist \nwith anovulatory endometrial changes in women with AUB.  \nAll women who presented with AUB underwent a pelvic \nultrasound. Of all 95 women the most common ab normality \ndetected was fibroid uterus 36(37.8%), followed by \nadenomyosis with 29 (30.5%) patients. Twenty four (25.2%) \nwomen had no uterine abnormalities, 5(5.3%) had fibroid polyp, \nand only 1(1.1%) had uterine collection. In the present study, \nclinical di agnosis of Leiomyoma and adenomyosis correlated \nwell with the USG findings. However, there were a large \npercentage of women who had normal clinical findings but \nabnormal endometrial thickness. They were considered as \nnormal uterus as there was no uterine o r adnexal gross \npathology. The study attempted to co -relate clinical findings \nwith that of ultrasonography and found that it was not \nstatistically significant (p=0.91).  \nIn the study by Alakananda et al, clinical and ultrasonographic \nfindings correlated we ll with the diagnosis of benign pathology  \n[10] They showed a 96% correlation between clinical and USG \ndiagnosis of Leiomyoma and 61.5% correlation between clinical \nand ultrasonographic diagnosis of Adenomyosis.  Their findings \nwere similar to our study. The  gold standard to make the final \ndiagnosis of adenomyosis has always been histological \nexamination of hysterectomy specimens.  The advent of new \nimaging techniques such as TVUS and MRI have allowed the \nclinician to make non invasive diagnosis of adenomyosis . \nCurrently TVUS is the first line imaging technique available to \ndiagnose adenomyosis. \n Fibroid polyps that occupy and distort the uterine cavity may \ncause symptoms such as abnormal uterine bleeding, subfertility \nand recurrent pregnancy loss. The best ima ging technique for \nfibroid polyp is usually TVUS and saline infusion \nsonohysterography enhances the ability to detect intrauterine \npathology compared to conventional TVUS alone.  \nAll 95 premenopausal women who presented with abnormal \nuterine bleeding underw ent ultrasonography and their \nendometrial thickness was measured transvaginally. The mean \nendometrial thickness was 12.9mm. The present study attempted \nto correlate endometrial thickness to the histopathological \nfindings. It showed that secretory phase end ometrium was the \ncommonest finding in all thicknesses and proliferative \nendometrium was the next commonest histopathology despite \nvarying thickness of endometrium. Thicker endometrium did not \nalways show hyperplasia and thinner endometrium did not show \natrophy. Statistically HPE did not correlate with transvaginally \nmeasured endometrial thickness. The study by Shobitha et al to \ncorrelated transvaginal sonography of the endometrium to \nhistopathology suggested that a measured thickness of 8mm and \nabove was an indication for diagnostic curettage. The sensitivity \nof detecting endometrial hyperplasia with TVS alone is poor. \nThey did not suggest any cut off value below which no \npathology was found [11]. \nAll 95 women in the premenopausal age group who presented \nwith abnormal uterine bleeding underwent a fractional curettage. \nThirty four women (35.8%) had secretory phase endometrium \nand 19 women (20%) had proliferative phase endometrium. The \nfindings of the present study correlated well with the study of \nJetley et al . In the study by Jetley et al  32.4% of women had \nsecretory phase endometrium, 30.5% had proliferative phase \nendometrium and 6.8% had disordered proliferative phase \nendometrium [12, 13]. In the present study sixteen women (16.8%) \nhad disordered proliferati ve phase endometrium. Endometrial \nhyperplasia was seen in 24(10.9%) cases, among that simple \nhyperplasia without atypia was seen in 19(8.6%), complex \nhyperplasia without atypia was seen in 4(1.8%) and complex \nhyperplasia with atypia was seen in 1(0.4%).  \nIn the present study 5(5.3%) cases were reported as inadequate \ntissue sampling, 7(7.4%) had benign endometrial adenomatous \npolyp and 2(2.1%) turned out to be benign leiomyomatous \npolyp. After the histopathological examination 55.8% of the \nwomen were diagnos ed to have AUB(E). By the clinical \nclassification of PALM -COEIN only 12.6% had AUB(E). The \nincrease in the number of women showing AUB (E) after \nhistopathological examination (55.8%) is because of the \ncombined presence of all hyper estrogenic conditions in  the \nsame women. Also it goes to prove that endometrial sampling \nand HPE are important investigations in premenopausal women \npresenting with AUB.  \n \nSummary and Conclusion \nThe present study was conducted on 95 premenopausal women \nwith AUB, with the objectiv e of studying various menstrual \npatterns and correlation of clinical findings with ultrasound \nfindings and histopathology examination. The data  collected and \nanalysed showed that the most common age group was 45 years \n+ 2.93 and the more common parity was two and above. The \ncommonest menstrual pattern seen was menorrhagia  and fibroid \nuterus was the most common uterine pathology. Also doing an \nendometrial sampling for premenopausal AUB adds more \nmeaning to the management. This study would have been \nvalidated better if it was done on a larger population. Also future \nstudies should include Pipelle sampling as that is an \ninexpensive, non-invasive method of endometrial sampling.  \n \nReferences \n1. 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Int J Reprod Contracept Obstet  \nGynecol. 2015; 4:109-112.","source_license":"CC0","license_restricted":false}