{"paper_id":"3e2b9d8a-c048-499f-bc5d-521fd553c4cd","body_text":"~ 80 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2023; 7(6): 80-88 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2023; 7(6): 80-88 \nReceived: 03-08-2023 \nAccepted: 11-09-2023 \n \nDr. Kumkum Avasthi \nProfessor and Head, Department \nof Obstetrics and Gynaecology, \nSatguru Partap Singh Hospital, \nLudhiana, Punjab, India \n \nDr. Boreddi Himaja Bhavani \nDNB Resident, Department of \nObstetrics and Gynaecology, \nSatguru Partap Singh Hospital, \nLudhiana, Punjab, India \n \nDr. Sonam Gilhotra \nDNB Resident, Department of \nObstetrics and Gynaecology, \nSatguru Partap Singh Hospital, \nLudhiana, Punjab, India \n \nDr. Aman Goyal \nMBBS Intern, Department of \nObstetrics and Gynaecology, Adesh \nInstitute of Medical Sciences and \nResearch, Bathinda, Punjab, India \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: \nDr. Kumkum Avasthi \nProfessor and Head, Department \nof Obstetrics and Gynaecology, \nSatguru Partap Singh Hospital, \nLudhiana, Punjab, India \n \nA study to correlate clinical with pathological findings in \nabnormal uterine bleeding (AUB) \n \nDr. Kumkum Avasthi, Dr. Boreddi Himaja Bhavani, Dr. Sonam Gilhotra \nand Dr. Aman Goyal \n \nDOI: https://doi.org/10.33545/gynae.2023.v7.i6b.1400  \n \nAbstract \nIntroduction: Abnormal uterine bleeding (AUB) poses a significant health and financial burden, especially \nin perimenopausa l women. Despite the PALM -COEIN classification, gaps persist in correlating clinical \nand histopathological aspects. Our study, utilizing diagnostic modalities like Ultrasonography, \nHysteroscopy, and Endometrial sampling, seeks to enhance diagnostic precisi on in AUB, contributing to \nimproved management strategies and patient outcomes. \nMaterials and Methods:  This descriptive study investigated Abnormal Uterine Bleeding (AUB) in 126 \nwomen aged 35 and above at our hospital from September 2019 to February 2021. The study utilized the \nPALM-COEIN classification system for categorizing AUB causes. Inclusion criteria covered various AUB \npresentations, while exclusion criteria excluded specific conditions. Data collection involved a structured \nproforma, and diagnostic  interventions encompassed Ultrasonography, Hysteroscopy, and Endometrial \nsampling. Statistical analysis employed various measures, including the concordance index and Chi -square \ntest, utilizing SPSS 21. \nResults: This hospital-based study enrolled 126 women presenting with abnormal uterine bleeding (AUB), \noffering comprehensive insights into their demographic, clinical, and histopathological profiles. The mean \nage of the cohort was 45.96 years, with a notable concentration in the 40 -44.99 age group. The maj ority \nresided in urban areas (96.83%) and belonged to the upper middle class (65.87%), with housewives \nconstituting 97.62%. AUB patterns, including irregular bleeding (56.35%) and postmenopausal bleeding \n(15.87%), were meticulously examined. Comorbidities,  predominantly hypertension (31 patients) and \nhypothyroidism (22 patients), were identified in 60 patients. Ultrasonography revealed Leiomyoma in \n54.76% and Adenomyosis in 24.6%. Clinical diagnoses, utilizing the PALM -COEIN classification, \nhighlighted AUB -L as the primary cause (54.76%). Diagnostic modalities such as Hysteroscopy, \nHysterectomy, and concordance analyses contributed to enhanced diagnostic precision, emphasizing the \nmultidimensional approach imperative for effective AUB management in clinical practice. \nConclusion: Our study underscores the efficacy of the PALM -COEIN classification in correlating clinical \nand histopathological findings for Abnormal Uterine Bleeding (AUB). Leiomyoma emerged as the primary \netiology, showcasing the classification's  utility in identifying dual pathologies. Histopathological \nexamination significantly complemented clinical diagnoses, emphasizing the system's value in optimizing \npatient care. \n \nKeywords: Abnormal Uterine Bleeding (AUB), PALM-COEIN classification, Diagnostic modalities, \nPerimenopausal women \n \nIntroduction  \nAbnormal uterine bleeding (AUB) is characterized by irregular, voluminous, frequent, or \nprolonged bleeding from the uterine corpus, excluding pregnancy [1]. This condition, prevalent \namong perimenopausal women, not only leads to physical and mental distress but also places a \nsubstantial financial burden on affected individuals [2]. Constituting more than 70% of \ngynecological consultations during the perimenopausal and postmenopausal years, AUB \naccounts for  35% of Gynecology OPD visits and 25% of gynecological surgeries [3]. Its \nprominence during the 2-8 years preceding menopause underscores the need for comprehensive \nunderstanding and effective management [4]. \nWhile the International Federation of Gynecolog y and Obstetrics (FIGO) has introduced the \nPALM-COEIN classification to categorize AUB causes, incorporating structural (PALM) and \nfunctional (COEIN) elements, there remains a gap in correlating clinical presentations with \nhistopathological findings [4]. Acute AUB, necessitating immediate intervention, and chronic  \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 81 ~ \nAUB, persisting for the majority of the last 6 months, further \ncomplicate the diagnostic landscape [5]. The potential severity of \nunderlying causes, ranging from physiological processes to \npossible malignancies, underscores the importance of accurate \nidentification through minimally invasive means. \nDiagnostic modalities, such as Ultrasonography, Hysteroscopy, \nand Endometrial sampling, play pivotal roles in discerning \nstructural and functional ca uses of AUB. Ultrasonography, as a \nprimary diagnostic tool, aids in detecting uterine abnormalities, \nwhile Hysteroscopy allows direct visualization and treatment in \na single session. Endometrial sampling, a simple OPD \nprocedure, effectively rules out malig nancy. The historical \nreliance on Dilatation and Curettage (D and C) for endometrial \nsampling has diminished due to associated risks, expenses, and \nthe availability of less invasive alternatives [6]. Despite \nadvancements, diagnosing AUB remains challenging, prompting \nthe need for a comprehensive study to bridge the clinical -\nhistopathological gap. \nThis study seeks to address the existing knowledge gaps by \ncorrelating clinical findings with histopathological insights in \nAUB, employing the PALM -COEIN classific ation. The \noverarching aim is to enhance diagnostic precision, particularly \nin cases where conventional methods may fall short. By \nelucidating these connections, we aspire to contribute to the \nrefinement of AUB management strategies, ultimately \nimproving patient outcomes. \n \nMaterials and Methods \nStudy Design  \nThis descriptive study was done which investigated Abnormal \nUterine Bleeding (AUB) in women aged 35 and above who \npresented to our hospital, from September 2019 to February \n2021. \n \nInclusion criteria \n1. Women of age 35 years and above. \n2. Patients having heavy menstrual bleeding. \n3. Frequent cycles. \n4. Frequent and heavy menstrual bleeding. \n5. Intermenstrual bleeding. \n6. Post-menopausal bleeding. \n \nExclusion criteria \n1. Vaginal bleeding related to pregnancy. \n2. Pelvic inflammatory disease. \n3. Genital prolapse.  \n4. Hormone therapy. \n5. IUCD insertion. \n \nSample size \nThe sample size was calculated using the formula n=z²α x P x \n(Q)/d². In this study, Pearson coefficient, commonly used for \ncorrelation studies, was deemed inapplicable due to the \ncategorical nature of variables. Utilizing assumptions with a \nlikelihood value (P) of 0.09, margin of error (d) of 0.05, and a \nstandard normal variate (z) of 1.96, the sample size was \ndetermined to be 126. \n \nSample technique \nThe sampling technique used was non -probabilistic sampling \nmethod of purposive sampling where all the patients attending to \nthe Department of Obstetrics and Gynecology (OPD and IPD), \nof our hospital from 1 st September 2019 to 28th February 2021 \n(18 months), with complaints of AUB, were screened as per \ninclusion and exclusion criteria and subsequently included or \nexcluded from the study.  \n \nData Collection \nData collection for this study was conducted by the observer, \nusing a designated study proforma. Prior to participation, \neligible women were briefed about the study in their local \nvernacular language, and informed  consent was obtained \nthrough a pre -approved proforma sanctioned by our ethical \ncommittee. Participants were explicitly granted the freedom to \nwithdraw from the study at any stage. \n \nMethods \nThis descriptive study was executed within the Obstetrics and \nGynecology department at our hospital, involving 126 patients \ndiagnosed with Abnormal Uterine Bleeding (AUB) who met the \npredetermined inclusion criteria. Prior to the commencement of \nthe study, informed written consent was meticulously obtained \nfrom all parti cipants, and ethical approval from the institutional \nreview committee was secured. \nA comprehensive medical history, encompassing chief \ncomplaints, history of present illness, demographic details, \ndetailed menstrual history, obstetric history, past medical and \nsurgical history, and personal history, was systematically \ndocumented. Subsequent to this, a thorough general physical \nexamination, with a specific focus on identifying features of \nanemia, was conducted. \nVital signs, including pulse, blood pressure, re spiratory rate, and \ntemperature, were recorded, and a systemic examination \ncovering cardiovascular, respiratory, and per abdomen aspects \nwas undertaken. Pelvic examinations, incorporating local \nexamination, per speculum, and bimanual pelvic examination, \nwere meticulously performed. \nThe investigative phase comprised a set of routine examinations, \nincluding Complete Blood Count (CBC), Urine \nRoutine/Microscopy, ABORh, Random Blood Sugar (RBS), \nThyroid Stimulating Hormone (TSH), Coagulation profile \n(aPTT, PTINR), viral markers, PAP smear, and Ultrasonography \n(TAS - 3-5 MHZ, TVS - 5-7.5 MHZ). Ultrasonography was \nconducted using the E soate Ultrasound Machine. Additional \ninvestigations, such as X-ray and ECG, were implemented when \ndeemed necessary. \nUpon establishi ng a provisional diagnosis, patients underwent \neither Dilatation and Curettage / Endometrial sampling or \nHysteroscopic evaluation. Tissue obtained was systematically \nsubjected to histopathological examination. For patients \nundergoing Hysterectomy (open/lap aroscopic), specimens \ncomprising the uterus, cervix, and ovaries were sent for \nmacroscopic and histopathological examination. \nAll findings were meticulously correlated with the PALM -\nCOEIN classification system, encompassing categories such as \nAUB-P, AUB -A, AUB-L, AUB -M, AUB -C, AUB -O, AUB -E, \nAUB-I, and AUB -N. Subsequently, statistical analyses were \nperformed to discern patterns and associations within these \nclassifications, thereby contributing to a comprehensive \nunderstanding of Abnormal Uterine Bleeding in this cohort. \n \nStatistical Analysis \nThe statistical analysis encompassed a comprehensive \nexamination of the data, employing various measures to \nelucidate the characteristics of the study cohort. Descriptive \nstatistics, including range, mean ± standard devi ation (± SD), \nfrequencies (number of cases), and relative frequencies \n(percentages) were meticulously calculated as deemed \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 82 ~ \nappropriate for each variable. To compare categorical data, the \nanalysis incorporated concordance measures, including the \nconcordance index and Chi -square (χ²) test when applicable. \nConcordance, indicative of the agreement rate between two \nvariables, was assessed through the concordance index, a metric \nevaluating the predictions made by the algorithm. The \nConcordance Index values were c ategorized based on their \nstrength of correlation (>0.20: Poor, 0.21 –0.40: Fair, 0.41–0.60: \nModerate, 0.61–0.80: Good, 0.81 –1.0: Very good). In instances \nwhere expected frequencies were less than 5, the Fisher exact \ntest was employed. A probability value ( p-value) less than 0.05 \nwas deemed statistically significant. All statistical computations \nwere meticulously conducted using the Statistical Package for \nthe Social Science (SPSS) 21 version, a widely recognized \nstatistical program for Microsoft Windows dev eloped by SPSS \nInc. in Chicago, IL, USA. \n \nResults \nThe present study, conducted at our hospital, focused on 126 \nwomen presenting with abnormal uterine bleeding, yielding \nvaluable insights into various aspects of their demographic, \nclinical, and histopathological profiles. \nThe mean age of the study population was 45.96 years, with a \nnotable concentration in the age group of 40 -44.99 years. \nRegarding parity, the majority of subjects were Para 2, \nconstituting 63.49%. Urban residency was predominant, with \n96.83% of subjects residing in urban areas. In terms of \nsocioeconomic status, the study found that 65.87% belonged to \nthe upper middle class. Additionally, an overwhelming majority \nof the participants, 97.62%, were housewives. Obesity and \noverweight were observe d in 14.28% and 26.98% of subjects, \nrespectively. (Table 1) \nPredominantly, irregular menstrual bleeding was identified as \nthe primary concern, with a noteworthy emphasis on Heavy \nMenstrual Bleeding (HMB), observed in 56.35% of subjects. \nPostmenopausal bleeding, accounting for 15.87% of cases, was \nalso a significant aspect of the AUB spectrum. A nuanced \nanalysis revealed that 49.3% of participants experiencing HMB \nendured it for 6 -12 months. For those with postmenopausal \nbleeding, 40% reported a duration of 10-30 days, while another \n40% encountered bleeding for 30.1-6 months. This study further \nelucidated additional AUB patterns, including Heavy and \nProlonged Menstrual Bleeding (9.52%), Prolonged Menstrual \nBleeding and Frequent Cycles (6.35% each), and the le ss \ncommon pattern of Frequent and Heavy Menstrual Bleeding \n(5.56% of subjects). The detailed exploration of these AUB \npatterns contributes valuable insights to the existing body of \nmedical knowledge, providing a comprehensive understanding \nof the diverse presentations of abnormal uterine bleeding. (Table \n2) \nThe investigation involved 60 patients, among whom \nhypertension (31 patients) and hypothyroidism (22 patients) \nwere the predominant comorbidities. A subset of patients (7 \ncases) had undergone previous gy necological surgeries, with \ntubectomy being the most common procedure (5 patients). The \nstudy provides a thorough examination of comorbidity \nprevalence, highlighting hypertension as the most prevalent \nmedical disorder, followed by hypothyroidism and diabet es \nmellitus. A substantial proportion (52.38%) of patients exhibited \nno comorbidities, while 35.71% had a single comorbidity, and \n11.9% presented with multiple comorbidities. Among the \nparticipants, 26 had a history of surgical procedures, with 7 \nundergoing gynecological surgeries, primarily tubectomy. \nGeneral surgical interventions included cholecystectomy (11 \npatients), appendicectomy (3 patients), and various others such \nas hemorrhoidectomy, hernia operation, breast lump excision, \ncraniotomy, and VP shun t, each observed in 1 patient. This in -\ndepth analysis sheds light on the spectrum of comorbidities and \nsurgical histories within the patient population under study. \n(Table 3) \nIn the present study, abdominal examination revealed that \n78.57% of subjects had a non -palpable uterus, with 10.3%, \n4.76%, 3.96%, and 2.38% exhibiting palpable uteri of 12 -14 \nweeks, 14.1 -16 weeks, 16.1 -18 weeks, and >18 weeks sizes, \nrespectively. Pelvic examination, including per speculum \nexamination, identified various cervical condit ions, such as a \nhealthy cervix in 65.08% of subjects, along with hypertrophy, \nchronic cervicitis, erosion, polyps, atrophy, and growth in \nsmaller percentages. Bimanual pelvic examination indicated \ndiverse uterine sizes, ranging from normal to atrophic, wit h \nspecific percentages corresponding to each size category. (Table \n4) \nOn ultrasound (USG), 54.76% of subjects exhibited Leiomyoma, \nand 24.6% showed Adenomyosis. Additionally, Endometrial \nHyperplasia was detected in 17.46% of cases, Endometrial Polyp \nin 16. 66%, Endocervical Polyp in 6.35%, Endometrial \nCarcinoma in 1.59%, and Cervical Carcinoma in 0.79%. \nClinically, Leiomyoma was identified as the predominant cause \nof Abnormal Uterine Bleeding, primarily diagnosed through \nultrasonography. (Table 5) \nClinical p rovisional diagnoses were established through the \ncorrelation of clinical history, examinations, and ultrasound \n(USG) findings, with PALM -COEIN classification guiding the \ncategorization. AUB -L emerged as the predominant clinical \ndiagnosis, affecting 54.76%  of subjects, followed by AUB -A \n(24.6%), AUB-P (23.01%), and AUB -M (19.84%). Notably, no \nsubjects exhibited components of COEIN as the cause of AUB \nin our study. Endometrial pathology was determined through \nendometrial curettings, collected via Hysteroscop y, Pipelle's \nbiopsy, or Dilatation and Curettage (D&C). Among the 39 \nsubjects who underwent hysteroscopy, two necessitated \nsubsequent hysterectomy due to confirmed endometrial \ncarcinoma, while the remaining 37 subjects recovered through \nhysteroscopic interventions. Proliferative pattern emerged as the \nprevailing endometrial pattern in our study, evident in 64.11% of \nsubjects on Hysteroscopic curettings and 67.74% on Pipelle's \nbiopsy. The study underscores the diagnostic significance of \nhistopathological eva luations in refining clinical diagnoses and \noptimizing treatment decisions. (Table 6, 7) \nIn the study, Hysteroscopy was performed in 30.95% of \nsubjects, Hysterectomy in 66.66%, Myomectomy in 3.17%, and \nCervical biopsy in 0.79% of subjects. Among the total 126 \nsubjects, 29.3% underwent Hysteroscopy only, 1.58% had both \nHysteroscopy and Hysterectomy, 24.6% underwent Pipelle‟s \nbiopsy and Hysterectomy, 0.79% underwent D&C and \nHysterectomy, 39.68% directly underwent Hysterectomy, and \n3.17% had Laparoscopic myome ctomy. One subject was \ndiagnosed with cervical carcinoma on cervical biopsy and was \nadvised Radiotherapy and Chemotherapy.  \nRegarding Hysteroscopy, out of 39 subjects, 2 underwent \nhysterectomy due to proven endometrial carcinoma in \nhysteroscopic curettings , while the remaining 37 subjects \nrecovered after Hysteroscopic polypectomy (30), myomectomy \n(2), or curettage (5). USG diagnosed polyps in 29 subjects, and \nHysteroscopy confirmed polyps in 25 subjects. In one case, USG \nmisdiagnosed endometrial hyperplasia  as a polyp, and in three \ncases (2 with polyp and leiomyoma, 1 with polyp and \nadenomyosis), subjects directly underwent Hysterectomy due to \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 83 ~ \nmultiple causes. Hysteroscopy detected polyps in 30 subjects, \nconsistent with USG findings in 25 subjects, while in the \nremaining 5 cases, USG misdiagnosed polyps as endometrial \nhyperplasia, later confirmed as polyps on Hysteroscopy. (Table \n8) \nIn the context of Hysterectomy, out of 84 subjects, 34 had prior \nendometrial sampling, and the remaining 50 underwent direct \nHysterectomy as they did not provide consent for endometrial \nsampling. (Table 8) \nIn the operative findings, Leiomyoma was the predominant \npathology observed in 67 subjects, followed by Adenomyosis in \n41 subjects, Endometrial Polyp in 24 subjects, Endocervical  \nPolyp in 8 subjects, Endometrial Hyperplasia in 10 subjects, and \nBulky uterus in 5 subjects where no other structural \nabnormalities were detected grossly. On histopathology, \nLeiomyoma remained the most prevalent pathology in 67 \nsubjects, followed by Adeno myosis in 46 subjects, Endometrial \nPolyp in 30 subjects, and Endocervical polyp in 8 subjects. \nAdditionally, Endometrial Hyperplasia was identified in 15 \nsubjects, endometrial carcinoma in 4 subjects, CIN in 3 subjects, \nand cervical cancer in 1 subject. The proliferative phase emerged \nas the most common endometrial pattern in 83 subjects, \nfollowed by the secretory phase in 15 subjects, and atrophic \nendometrium in 4 subjects. In 121 subjects, the proliferative \npattern prevailed as the most common endometrial  pattern in \n68.6%, while the secretory and endometrial hyperplasia patterns \nwere observed in 12.4% each, and atrophic and endometrial \ncarcinoma in 3.3% each. (Table 9) \nIn our study, the final diagnosis, based on histopathology reports \nand following the PAL M-COEIN classification, revealed that \nAUB-L was the predominant cause of abnormal uterine bleeding \n(AUB), accounting for 53.17% of subjects, followed by AUB -A \nin 36.5%, AUB -P in 30.15%, and AUB -M in 15.87% of \nsubjects. Among AUB -M cases, Simple Hyperplasia  without \natypia was the most frequent finding (50%), followed by \nMalignancy (25%), with four cases of endometrial carcinoma \nand one case of cervical cancer. \nIn terms of clinical diagnosis, 78.57% had a single identified \ncause of AUB, with AUB -L being the m ost common (38.09%), \nfollowed by AUB -P (17.46%), AUB -A (10.31%), and AUB -M \n(12.70%). Multiple causes were observed in 21.43% of cases, \nwith AUB -A, L being the most common (10.31%). Regarding \nhistopathological analysis, 69.04% of subjects exhibited a single  \nPALM component, with Leiomyoma being the most common \n(25.4%), followed by Polyp (21.43%), Hyperplasia/Malignancy \n(11.9%), and Adenomyosis (10.31%). Multifactorial cases \nincluded Adenomyosis and Leiomyoma (20.63%), Leiomyoma \nand Polyp (1.59%), Polyp and Hyperplasia/Malignancy (2.38%), \nLeiomyoma and Hyperplasia/Malignancy, Polyp and \nAdenomyosis (0.79% each), Adenomyosis, Leiomyoma, and \nMalignancy/Hyperplasia (0.79%), and Polyp, Adenomyosis, and \nLeiomyoma together (3.97%). (Table 10) \n \nDiscussion \nAbnormal uterine bleeding is defined as any bleeding from the \ngenital tract, which is a deviation from the normal in volume, \nduration, regularity or frequency. In present study, 126 women \nwith AUB were examined in Obstetrics and Gynecology \ndepartment. A detailed histor y, clinical examination and routine \ninvestigations were done. USG was offered as initial non -\ninvasive investigation. Further evaluation was done by \nendometrial curettage, either by Dilatation and Curettage, \nPipelle’s biopsy or Hysteroscopy. In subjects who  did not give \nconsent for endometrial curettage, they were subjected directly \nto major surgery (Myomectomy / Hysterectomy). And for \nremaining subjects, further intervention was done as per the \nendometrial histopathology. Various parameters of our study \nwere compared with studies of different authors. \nIn our study, the mean age of participants was 45.96 years, \naligning with the findings of Suseela T L et al . [7]. Regarding \nparity distribution, 80% of women in our study were \nmultiparous, a result consistent with studies by Mohammed N et \nal. [8], Lotha L et al. [3], and Snehkiran et al. [9]. Body Mass Index \n(BMI) was assessed in our study and compared with the research \nof Sajitha et al. [10] (2014) and Mishra D et al. [4] (2017). Mishra \nD et al. [4] reported obesity in 9.3% of women, while Sajitha et \nal. [10] found 3.8% to be obese. In our cohort of 126 women,  \n14.28% were classified as obese, demonstrating similarity to the \nfindings of Mishra D et al. [4]. This correspondence underscores \nthe consistency of BMI r esults between our study and Mishra D \net al. [4]. \nIt was found that, Heavy Menstrual Bleeding (HMB) was \nprevalent in 56.35% of subjects, aligning with findings in studies \nby Bashir H et al . [11] and Khan R et al . [12]. Regarding PAP \nsmear results, our stud y demonstrated normal findings in \n85.71% of cases, comparable to the 96% normalcy reported in \nthe study by Mahapatra M et al. [13]. \nIn our study, the provisional diagnosis was established by \nintegrating clinical history, examination, and ultrasound (USG) \nfindings. Sudhamani S et al . [14] reported AUB -L in 28% of \nsubjects, AUB -M in 18%, AUB -A in 5%, and AUB -P in 3%. \nSimilarly, Mishra D et al. [4] found AUB-L in 41.1% of subjects, \nfollowed by AUB -A, AUB -P, and AUB -M. Misra B et al . [15] \nreported AUB-L in 48.25%, AUB-A in 25.75%, and AUB-P and \nAUB-M in 4.25% each. In our study, AUB -L was the most \nprevalent, observed in 54.76% of 126 subjects, followed by \nAUB-A in 24.6%, AUB -P in 23.01%, and AUB -M in 19.84%. \nOur clinical diagnosis aligns with Sudhamani S et al. [14], Mishra \nD et al. [4], and Misra B et al. [15], emphasizing AUB -L as the \nmost common diagnosis. \nRegarding endometrial patterns, our study obtained curettings \nfrom 121 subjects via Pipelle's biopsy, D&C, Hysteroscopy, and \nHysterectomy. Proliferative pat terns were prevalent in 67.74% \nof subjects in our study, akin to findings in studies by Banale M \net al. [16], Suneet K et al. [17], and Maurya MK et al. [18], where \nproliferative patterns accounted for 32.63%, 36%, and 30.6% of \nsubjects, respectively. Thus, the proliferative pattern observed in \nour study is consistent with previous literature [16-18]. \nIn Hysteroscopic curettage, the proliferative endometrial pattern \nwas identified as the most common pattern in studies by Afghan \nS et al . [19] (34.6%) and Mah apatra M et al . [13] (45.7%). Our \n2021 study found a maximum proliferative pattern in 64.11% of \nsubjects, aligning with Afghan S et al. [19] and Mahapatra M et \nal. [13]. \nRegarding Hysterectomy specimens, Khushnood M et al . [20] \nreported proliferative patterns as the most prevalent, constituting \n53%. In our 2021 study, a maximum proliferative pattern was \nobserved in 74% of subjects, consistent with Khushnood M et al. \n[20]. \nOf the 126 subjects, AUB -L was identified as the most common \nhistopathological diagnosis in 53.17% of subjects, followed by \nAUB-A (36.5%), AUB-P (30.15%), and AUB-M (15.87%). This \nHPE diagnosis aligns with Neena Y et al. [21], Mohammed N et \nal. [8], Mandal SK et al. [22], Mishra D et al. [4], and Misra B et al. \n[15] studies, where AUB -L con sistently emerged as the \npredominant HPE diagnosis. \nFor the AUB -M component, our study revealed a prevalence of \n15.87%, a finding comparable to the study conducted by Misra \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 84 ~ \nB et al. [15]. The distribution of AUB -M, our study reported that \nSimple hyperplasi a without atypia was the most common \nsubtype, observed in 50% of subjects. This prevalence \ncorresponds with the findings of Misra B et al. [15], where Simple \nhyperplasia without atypia accounted for 44.11%. \nthe clinicopathological correlation was highest i n subjects with \nAUB-L, followed by AUB -M, then AUB -P, with the least \ncorrelation observed in subjects with AUB -A. This pattern \naligns with findings from Mishra D et al. [4] and Misra B et al. \n[15] studies, where AUB -L exhibited the highest \nclinicopathological correlation, consistent with our present \nstudy. Similar to Misra B et al. [15] and Mishra D et al. [4] studies, \nAUB-A demonstrated the least clinicopathological correlation in \nour investigation. \nWe observed a statistically significant difference (p< 0.05) in the \nclinical and histopathological diagnosis of AUB -A in our study, \nboth when counted alone and in combination with other PALM \ncomponent pathologies, a result comparable to Mishra D et al. \n[4]. Furthermore, the significant p -value in the clinical an d \nhistopathological diagnosis of the combination of AUB -A, L \nmirrors findings in the Mishra D et al. [4] study. \nOur study highlighted that perimenopausal women, presenting \nwith heavy menstrual bleeding, were predominantly affected. \nThe primary etiology of AUB was clinically and \nhistopathologically identified as Leiomyoma. Adenomyosis was \nbetter diagnosed on histopathological examination, underscoring \nthe significance of HPE in its detection. We observed good \nclinicopathological correlation for AUB -P, AUB -L, and AUB -\nM, while histopathological examination revealed cases of AUB -\nA that were missed clinically. This underscores the gold \nstandard status of HPE in AUB diagnosis. \n \nTable 1: Age distribution, demographic profile, and BMI distribution \n \nAge (Yrs) No. of Subjects Percentage \n35-39.99 18 14.29% \n40-44.99 40 31.75% \n45-49.99 36 28.57% \n50-54.99 18 14.29% \n55-59.99 9 7.14% \n> 60 5 3.97% \nTotal Age Distribution 126 100% \nDemographic Parameters No. of Subjects Percentage \nRural/Urban   Rural 4 3.17% \nUrban 122 96.83% \nReligion \nHindu 58 46.03% \nSikh 67 53.17% \nMuslim 1 0.79% \nOccupation \nHousewife 123 97.62% \nEmployed 3 2.38% \nSocioeconomic Status \nUMC (Upper Middle Class) 83 65.87% \nMC (Middle Class) 43 34.13% \nTotal Demographic Profile 126 100% \nBMI No. of Subjects Percentage \nNormal 74 58.73% \nOverweight 34 26.98% \nObese 18 14.28% \nTotal BMI Distribution 126 100% \nParity No. of Subjects Percentage \n0 1 0.79% \n1 15 11.90% \n2 80 63.49% \n3 22 17.46% \n>3 8 6.35% \nTotal 126 100% \n \nTable 2: Abnormal uterine bleeding and parity \n \nAbnormal Uterine Bleeding No. of Subjects Percentage \nHeavy Menstrual Bleeding 71 56.35% \nProlonged Menstrual Bleeding 8 6.35% \nHeavy and Prolonged Menstrual Bleeding 12 9.52% \nFrequent Cycles 8 6.35% \nFrequent and Heavy Menstrual Bleeding 7 5.56% \nPostmenopausal Bleeding 20 15.87% \nTotal 126 100% \n \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 85 ~ \nTable 3: Comorbidities and Previous Gynecological Surgery \n \nComorbidities No. of subjects Percentage (%) \nNo comorbidity 66 52.38% \nSingle 45 35.71% \nMultiple 15 11.90% \nTotal 126 100% \nGynecological Surgery No. of subjects Percentage \nTubectomy 5 71.42% \nSalpingectomy 1 14.28% \nHysteroscopic Polypectomy 1 14.28% \nTotal 7 100% \n \nTable 4: Abdominal and pelvic examination findings \n \nAbdominal and Pelvic Examination No. of Subjects Percentage (%) \nUterus palpable in weeks \nNot palpable 99 78.57% \n12-14 weeks 13 10.31% \n14.1-16 weeks 6 4.76% \n16.1-18 weeks 5 3.96% \n>18 weeks 3 2.38% \nTotal 126 100% \nPer speculum findings No. of Subjects Percentage (%) \nHealthy cervix 82 65.08% \nCx Hypertrophied 12 9.52% \nCervical erosion 8 6.35% \nCervical polyp 6 4.76% \nChronic cervicitis 12 9.52% \nCx atrophic 5 3.97% \nCx growth 1 0.79% \nTotal 126 100% \nSize of uterus No. of Subjects Percentage (%) \nNormal 24 19.05% \n<8 weeks 16 12.69% \n8-10 weeks 51 40.47% \n10.1-12 weeks 11 8.73% \n12.1-14 weeks 7 5.56% \n14.1-16 weeks 6 4.76% \n16.1-18 weeks 5 3.97% \n>18 weeks 3 2.38% \nAtrophic 3 2.38% \nTotal 126 100% \n \nTable 5: USG findings \n \nUSG findings No. of subjects Percentage (%) \nLeiomyoma 69 54.76% \nAdenomyosis 31 24.60% \nEndometrial Hyperplasia 22 17.46% \nEndometrial polyp 21 16.66% \nEndocervical polyp 8 6.35% \nEndometrial carcinoma 2 1.59% \nCervical carcinoma 1 0.79% \n \nTable 6: Provisional diagnosis and endometrial curettings \n \nProvisional Diagnosis No. of subjects Percentage (%) \nAUB-P 29 23.01 \nAUB-A 31 24.6 \nAUB-L 69 54.76 \nAUB-M 25 19.84 \nCOEIN 0 0 \nEndometrial Curettings \nProcedure (No. of subjects) Hysterectomy done Hysterectomy not done \nHysteroscopy (39) 2 37 \nPipelle's Biopsy (31) 31 0 \nDilatation and Curettage (1) 1 0 \n \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 86 ~ \nTable 7: Pattern of endometrium \n \nEndometrial Pattern \nEndometrial curettings \nHysteroscopy (n = 39) Pipelle’s Biopsy (n = 31) D&C (n = 1) \nNo. % No. % No. % \nProliferative 25 64.11% 21 67.74% 0 0% \nSecretory 3 7.69% 4 12.90% 0 0% \nSimple hyperplasia without atypia 6 15.38% 3 9.68% 0 0% \nSimple hyperplasia with atypia 0 0% 1 3.23% 1 100% \nComplex hyperplasia without atypia 1 2.56% 0 0% 0 0% \nComplex hyperplasia with atypia 0 0% 0 0% 0 0% \nAtrophic 2 5.13% 0 0% 0 0% \nEndometrial ca 2 5.13% 2 6.45% 0 0% \n \nTable 8: Hysteroscopy and Hysterectomy \n \nHysteroscopy No. of subjects \nHysteroscopic Polypectomy 30 \nHysteroscopic Myomectomy 2 \nHysteroscopic Curettings 5 \nHysteroscopy and Hysterectomy 2 \nTotal 39 \nHysterectomy No. of subjects \nHysteroscopy and Hysterectomy 2 \nD&C and Hysterectomy 1 \nPipelle's Biopsy and Hysterectomy 31 \nDirect Hysterectomy 50 \nTotal 84 \n \nTable 9: Showing operative findings, HPE and Endometrial Pattern \n \nOperative Findings No. of Subjects \nLeiomyoma 67 \nAdenomyosis 41 \nBulky Uterus 5 \nEndometrial Polyp 24 \nEndocervical Polyp 8 \nEndometrial Hyperplasia 10 \nHPE (Histopathology) No. of Subjects \nLeiomyoma 67 \nAdenomyosis 46 \nEndometrial Polyp 30 \nEndocervical Polyp 8 \nEndometrial Hyperplasia 15 \nEndometrial Carcinoma 4 \nAtrophic 4 \nCIN 3 \nCervical Cancer 1 \nEndometrial Pattern No. of Subjects \nProliferative 83 \nSecretory 15 \nEndometrial Hyperplasia 15 \nAtrophic 4 \nEndometrial Carcinoma 4 \nTotal 121 \n \nTable 10: Distribution of cases as per clinical diagnosis and histopathology \n \nClinical Diagnosis No. of Subjects Percentage \n AUB-P 22 17.46% \n AUB-A 13 10.31% \n AUB-L 48 38.09% \nSingle factor AUB-M 16 12.70% \n AUB-P, A 3 2.38% \n AUB-P, L 2 1.59% \n AUB-P, M 2 1.59% \n AUB-A, L 13 10.31% \nMultiple factors AUB-A, M 1 0.79% \n AUB-L, M 5 3.97% \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 87 ~ \n AUB-A, L, M 1 0.79% \n AUB-P, A, L 0 0% \nTotal 126 100% \nHistopathological Diagnosis No. of Subjects Percentage \n AUB-P 27 21.43% \n AUB-A 13 10.31% \nSingle factor AUB-L 32 25.40% \n AUB-M 15 11.90% \n AUB-P, A 1 0.79% \n AUB-P, L 2 1.59% \n AUB-P, M 3 2.38% \n AUB-A, L 26 20.63% \n AUB-A, M 0 0% \nMulti factorial AUB-L, M 1 0.79% \n AUB-A, L, M 1 0.79% \n AUB-P, A, L 5 3.97% \nTotal 126 100% \n \nConclusion \nIn conclusion, our study demonstrated a robust \nclinicopathological correlation when employing the PALM -\nCOEIN classification system. Notably, Leiomyoma emerged as \nthe predominant etiology contributing to Abnormal Uterine \nBleeding (AUB) in the perimenopausal age group. The inclusion \nof multiple etiologies in this classification facilitated the \nidentification of dual pathologies, such as AUB-A, L, and AUB-\nA, P in our investigation. Histopathological examination proved \nindispensable in accurately diagnosing cases overlooked \nclinically. Therefore, we assert that the PALM -COEIN \nclassification system is a valuable tool, serving both cl inical and \nhistopathological aspects, with mutual complementarity. Proper \ncategorization within this system aids in optimizing patient \ntreatment. \nIn the con text of AUB -A, a significant ( p< 0.05) disparity \nbetween clinical and histopathological diagnoses wa s noted. \nThis discrepancy is attributed to the similarity in symptoms and \nsigns between adenomyosis and leiomyoma, making clinical \ndifferentiation challenging. Our study further emphasized the \nsignificance of histological examination as a complementary \ndiagnostic tool, particularly evide nt in the highly significant ( p< \n0.03) clinical and histopathological diagnosis of the AUB -A, L \ncombination within the PALM component of AUB. \n \nAcknowledgments \nI extend sincere gratitude to Dr. Kumkum Avasthi for her \nmeticulous guidance and to Dr. Zeenie Sarda Girn for invaluable \nsupport in Obstetrics and Gynaecology. Thanks to Dr. Venus \nBansal, Dr. Muskaan Chhabra, and Dr. Aikaj Jindal for their \ncontributions. I acknowledge Dr. Sonam Gilhotra and colleagues \nfor their unwaveri ng support. Thanks to Miss Sakshi, Mrs. \nJaswinder, and Mrs. Namita Bansal for their assistance. I \nappreciate Mrs. Namita Bansal's statistical analysis and Mr. \nGurdeep Singh (ALPS) for manuscript attention. Profound \nthanks to the Department of Obstetrics an d Gynaecology staff. \nLastly, heartfelt appreciation to the patients for their invaluable \ncooperation in the clinical study. \n \nConflict of Interest \nNot available  \n \nFinancial Support  \nNot available \n \nReferences \n1. Munro MG, Critchley HO, Broder MS, Fraser IS; FIG O \nWorking Group on Menstrual Disorders. FIGO \nclassification system (PALM -COEIN) for causes of \nabnormal uterine bleeding in non -gravid women of \nreproductive age. Int J Gynaecol Obstet. 2011 Apr;113(1):3-\n13. \n2. Mencaglia L, Perino A, Hamou J. Hysteroscopy in \nperimenopausal and postmenopausal women with abnormal \nuterine bleeding. J Reprod Med. 1987 Aug;32(8):577-82. \n3. Lotha L, Borah A. Clinicopathological evaluation of \nabnormal uterine bleeding in perimenopausal women. \nInternational Journal of Reproduction, Contrac eption, \nObstetrics and Gynecology. 2016 Sep 1:5(9):3072-5. \n4. Mishra D, Sultan S. FIGO’S PALM –COEIN Classification \nof abnormal uterine bleeding: A Clinico -Histopathological \ncorrelation in Indian setting. The Journal of Obstetrics and \nGynecology of India. 2017 Apr 1;67(2):119-25. \n5. Singh K, Agarwal C, Pujani M, Raychaudhuri S, Sharma N, \nChauhan V, Chawla R, Ahuja R, Singh M. A \nclinicopathological correlation of international federation of \ngynecology and obstetrics's PALM–COEIN classification of \nabnormal uterine bleeding: Indian scenario. Journal of mid -\nlife health. 2019 Jul;10(3):147-52. \n6. Hoffman BL, Schorge JO, Schaffer JI, Halvorson LM, \nBradshaw KD, Cunningham FG. Williams Gynecology. 2 nd \ned. New York: Mc Graw Hill; c2012. p. 226-423. \n7. Suseela TL, Parveen S, Archan a D, Prasanna KS, Harini N, \nPravallika V. A Study on Incidence, Clinical Profile and \nPrescribing Pattern in Abnormal Uterine Bleeding in a \nTertiary Care Teaching Hospital. International Journal of \nResearch and Review [Internet]. 2019;6(11):548-60. \n8. Mohammed N, Prejisha B. A Study of Correlation of \nEtiological and Histopathological Findings in Females \nUndergoing Hysterectomy for Abnormal Uterine Bleeding – \nin accordance with PALM -COEIN Classification. Indian \nJournal of Research. 2014 Nov;3(11):76-77. \n9. Snehkiran AK, Tiwary B, Sinha A, Parwina P. \nClinicopathological observation of Abnormal uterine \nbleeding in peri -memopausal age female. International \nJournal of Clinical Obstetrics and Gynaecology. 2019;3(1): \n136-138. \n10. Sajitha K, Padma SK, Shetty KJ, KishanPrasad H L, Permi \nHS, Hegde P. Study of histopathological patterns of \nendometrium in abnormal uterine bleeding. CHRISMED \njournal of health and Research. 2014 Apr 1;1(2):76. \n11. Bashir H, Bhat N, Khuroo MS, Reshi R, Nazeir MJ, Qureshi \nMZ. Clinicopathological study of en dometrium in patients \nwith abnormal uterine bleeding. Int J Cur Res Rev| Vol. \n\nInternational Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com \n~ 88 ~ \n2015 Nov 21;7(22):67. \n12. Khan R, Sherwani RK, Rana S, Hakim S, Jairajpuri ZS. \nClinco- pathological patterns in women with dysfunctional \nuterine bleeding. Iranian journal of patholog y. \n2016;11(1):20. \n13. Mahapatra M, Mishra P. Clinico -Pathological evaluation of \nabnormal uterine bleeding. Journal of Health Research and \nReviews. 2015; 2:45-49. \n14. Sudhamani S, Sirmukaddam S, Agrawal D. \nClinicopathological study of abnormal uterine bleeding in \nperimenopausal women. Journal of the Scientific Society. \n2015 Jan 1;42(1):3. \n15. Misra B, Bhol SK. Study of clinical and pathological \ncorrelation of AUB patients undergoing hysterectomy. Int J \nGynaecol. 2017;3:13-8. \n16. Banale M. Clinicopathological spectrum of end ometrial \nchanges in AUB. Sch J App. Med.Sci. 2015; 3(9A): 3168 -\n3172. \n17. Suneet K. Clinicopathological Study of Abnormal Uterine \nBleeding in North Indian Patients. Asian Journal of \nBiomedical and Pharmaceutical Sciences. 2016;6(53):50-1. \n18. Malti Kumari M. Clinic opathological evaluation of \nabnormal uterine bleeding (AUB) and its correlation with \nbiochemical hormone profile in perimenopausal women. J \nClin Exp Pathol. 2018;23:08:31. \n19. Afghan S, Yasmeen A. Abnormal Uterine Bleeding (AUB) \nA Clinicopathological Study of 150 Cases. Ann Pak Inst \nMed Sci. 2013;9(4):201-4. \n20. Khushnood M, Niyaz FF. Study on Hysteroscopic \nevaluation of patients with abnormal Uterine Bleeding \n(AUB) & their Clinical, Sonographic and Histologic \ncorrelation. International J. of Healthcare and Biomedi cal \nResearch. 2019 Jan;7(02):12-9. \n21. Neena Y, Honey B. Clinico -pathological correlation of \nhysterectomy specimens for abnormal uterine bleeding in \nrural area. Journal of Evolution of Medical and Dental \nSciences. 2013 Sep 30;2(39):7506-12. \n22. Mandal SK. Clinico -Pathological Correlation of \nHysterectomy Specimens for Abnormal Uterine Bleeding in \nPeri Menopausal Women. J Med Sci Clinic Res. , 2017, \n5(1).  \n \nHow to Cite This Article \nAvasthi K, Bhavani BH, Gilhotra S , Goyal A. A study to correlate cl inical \nwith pathological findings in abnormal uterine bleeding (AUB) . \nInternational Journal of Clinical Obstetrics and Gynaecology 2023; 7(6): \n80-88. \n \n \nCreative Commons (CC) License \nThis is an open access journal, and articles are distributed under the ter ms \nof the Creative Commons Attribution -NonCommercial-ShareAlike 4.0 \nInternational (CC BY -NC-SA 4.0) License, which allows others to remix, \ntweak, and build upon the work non -commercially, as long as appropriate \ncredit is given and the new creations are licensed under the identical terms.","source_license":"CC0","license_restricted":false}