{"paper_id":"4a7bf6b7-fa99-47ab-96dd-2a89af36f5f8","body_text":"DOI: https://doi.org/10.53350/pjmhs211571729 \nORIGINAL ARTICLE \n \nP J M H S  Vol. 15, NO. 7, JUL  2021   1729 \nHistopathological span of diseases in patients going  through \nhysterectomies: an audit of 190 consecutive hysterectomy \nspecimens in Multan \n \nZERTAJ KASHIF1, SONIA ZAFAR WARRIACH2, SEHAR SHAMSHAD ALI3, MUHAMMAD BILAL PASHA4, KANWAR SAJID \nALI5, AYESHA KASHIF6, AAMIR ALI KHAN7 \n1Associate Professor Pathology, Bakhtawar Amin Medical & Dental College, Multan \n2FCPS Obstetrics and Gynaecology, DHQ Jhang \n3Senior Demonstrator, Bakhtawar Amin Medical & Dental College, Multan \n4Assistant Professor Pathology, Bakhtawar Amin Medical & Dental College, Multan \n5Associate Professor, Bakhtawar Amin Medical & Dental College, Multan \n64th Year Trainee FCPS (II), Community Medicine, Nishter Medical University Multan \n7Professor of Pathology, Bakhtawar Amin Medical & Dental College, Multan \nCorrespondence to: Dr. Zertaj Kashif, Email: zkashif786@icloud.com, Cell: 03146121201 \n \nABSTRACT \nIntroduction: Gynecological diseases affect women’s lives in numerous manners. They are frequent in all \ncommunities but the types of disorders and their presentations differ substantially in various regions and races.  \nHowever, the studies and researches specifying these disorders in particular regions and communities are very \nlow in number.  \nHysterectomy is one of the most frequently opted  operations worldwide particularly in developing countries and \nhardly any studies are done about its epidemiology and prevalence in Multan region of Pakistan. \nObjective: The objective of this study is to assess the variety of histopathological diseases in patients undergoing \nhysterectomies in Multan region \nDesign: Retrospective study including 190 hysterectomy specimens. \nPlace and duration:  Department of Histopathology Bakhtawar Amin Medical & Dental Coll ege, Multan from \nJanuary 2019 to December 2020. \nMethodology: Histopathology reports of all hysterectomy specimens removed due to gynecological disorders \nwere included. All the relevant data  like age, parity, clinical manifestations, indication and type of hysterectomy \nwere recorded along with histopathological microscopic diagnosis of cervix, endometrium, myometrium, fallopian \ntubes and ovaries. The data was collected from medical track record, histopathological request form and \nhistopathology report files.  \nResults: A total of 190 hysterectomies were received in histopathology department . The mean age was 47.8 \nyears (ranging from 25 -75 years). Majority of the ladies were between age groups 41 -50 years. The major \npresenting complaint was menstrual irregularity followed by abdominal pain. Out of 190 specimen, 170 (89.5%) of \nhysterectomies were done because of non neoplastic/ benign conditions. Chronic cervicitis, adenomyosis and \nleiomyomata were the most commonly noticed incidental findings. \nConclusion: Hysterectomy is an extensivel y used therapeutic modality, largely for benign non neoplastic \ndisorders to relieve the clinical symptoms and to enhance the living conditions. Presence of incidental diseases in \nmajority of hysterectomy specimens indicates that for conclusive opinion, histopathological examination is must. \nKey words: Histopathology, hysterectomy, benign gynecological disorders, leiomyoma, adenomyosis \n \nINTRODUCTION \nGynecological disorders are one of the common problems \nencountered in clinical practice where large number of \nwomen visit clinical practitioners to seek help; and a major \nbulk of these disorders are benign in nature.1,26 \n These disorders are largely ignored in many low \nresources settings all over the world especially in Pakistan. \nInsufficient knowl edge and understanding of the health \nissues and lack of medical services often lead to late \ndiagnosis, resulting in greater morbidity, more chances of \nuterine removal and increase in mortality as well.3 \n Hysterectomy is an operation to remove the uterus. \nAll around the world this surgery is performed in large \nnumbers.4 \n \n-------------------------------------------------------------------------- \nReceived on 05-01-2021 \nAccepted on 02-06-2021 \n Abdominal hysterectomy is the routinely opted \nsurgical technique for benign disorders in Pakistan.5 \n The chance of hysterectomy in the course of women’s \nlife ranges from 30 -40% as it is the ultimate solution for \nnumerous benign and malignant gynecological disorders.6 \n The gynecological proble ms are universal in \noccurrence but there is hardly any absolute data and \nstatistics available regarding prevalence  and occurrence of \nvarious gynecological diseases in Pakistan except few \nstudies conducted in certain large cities. According to a \nstudy condu cted in Karachi, out of 100, 41 women faced \ngynecological problems.7 \n The most common gynecological disorders \nencountered in women of Pakistan are however, ovarian \ncysts, irregular periods, fibroid uterus, polycystic ovarian \ndisease, infections and cervical cancer.8 \n The objective of this study was to ascertain the \nspectrum of histopathological diagnoses encountered in \nwomen undergoing hysterectomy procedures. \n\nHistopathological span of diseases in patients going through hysterectomies: an audit of 190 consecutive hysterectomy \n \n1730   P J M H S  Vol. 15, NO. 7, JUL  2021 \nMATERIAL AND METHODS \nThis descriptive study was conducted at Bakhtawar  Amin \nHospital, Multan over a per iod of 3 years from January \n2018 to December 2020.Histopathology reports of all \nhysterectomy specimen were included. Obstetrical \nhysterectomies were excluded in this study. Data like age, \nparity, presenting complaints and i ndication for \nhysterectomy and type of hysterectomy  were recorded.  \nPercentage and proportions were calculated for all the \nvariables. Relevant tables and charts were computed. \n \nRESULTS \nDuring th e last two years, a total of 190  hysterectomies \nwere received in the histopathology laboratory. The mean \nage was 47.8 years (ranging from 25-75 years). Majority of \nthe patients were between age group 41-50 years.  \n The major presenting complaint was menstrual \nirregularity followed by pain abdomen. \n \nTable 1: Types of Hysterectomies \nType of Hysterectomy Number of cases \n(n=190) \nPercentage \n(%) \nVaginal Hysterectomies 12 6.3 \nTAH without fallopian tubes & \novaries \n104 54.7 \nTAH with bilateral salpingo-\noophorectomy (BSO) \n52 27.4 \nTAH with unilateral salpingo-\noophorectomy (USO) \n14 7.4 \nSubtotal (only uterus) 8 4.2 \nTotal 190 100 \n \nTable 2: Main Presenting Complaint \nMajor mode of presentation Frequency \n(n=254)  \nPercentage \n(%) \nAbdominopelvic pain 62 24.4 \nBleeding per \nvaginum/menstrual \ndisturbances \n159 62.6 \nCervical discharge 21 8.3 \nUterovaginal prolapse 12 4.7 \n \nTable 3: Distribution of cases according to Age \nAge Group (Years) Number of cases Percentage (%) \n20-30 12 6.3 \n31-40 48 25.3 \n41-50 78 41.1 \n51-60 40 21.1 \n61-70 6 3.1 \n>70 6 3.1 \n \nTable 4: Distribution of cases according to Parity \nParity Number of cases Percentage (%) \nNulliparous 02 1.1 \n1 06 3.1 \n2 14 7.4 \n3 67 35.3 \n4 and more 101 53.1 \n \n Out of 190 hysterectomy specimen, 170 (89.5 %) \nwere non neoplastic (benign), and 20 (10.5 %) were \nmalignant. Among 170 benign lesions, the commonest \nhistopathological finding encountered was chronic cervicitis \n(176 cases). It was an incidental finding in n early all cases. \nOther less common benign lesions were leiomyomata and \nadenomyosis.  \n Out of 190 hysterectomies, 20 (10.5 %) patients had \ngynecological malignancies and squamous cell carcinoma \nof the cervix appeared to be the most frequently detected \nmalignancy noticed in (8/20) 40 % of all malignant lesions. \n \nTable 5: Histopathological diagnosis of Cervical Lesions \nHistopathological diagnosis Number of \ncases \n(n=259) \nPercentage \n(%) \nAcute Cervicitis 02 0.8 \nChronic Cervicitis 159 61.4 \nPapillary Cervicitis 42 16.2 \nSquamous metaplasia 34 13.1 \nMicroglandular hyperplasia 02 0.8 \nCervical Polyp 01 0.4 \nCevical Leiomyoma 03 1.1 \nCervical squamous cell carcinoma 08 3.1 \nCervical adenocarcinoma 04 1.5 \nAdenocarcinoma in situ 01 0.4 \nCervical intraepithelial neoplasia \n(CIN I) \n01 0.4 \nCervical intraepithelial neoplasia \n(CIN III) \n02 0.8 \n \nTable 6: Histopathological diagnosis of Endometrial Lesions \nHistopathological Diagnosis Number of \ncases \n(n=205) \nPercentage \nPHASE OF ENDOMETRIUM   \nProliferative endometrium 95 46.3 \nSecretory endometrium 06 2.9 \nAtrophic endometrium 12 5.9 \nDisordered endometrium 39 19.0 \nENDOMETRIAL HYPERPLASIA   \nSimple hyperplasia without atypia 24 11.7 \nComplex hyperplasia 02 1.0 \nPseudodecidual reaction in the \nstroma \n10 4.9 \nEndometritis 05 2.4 \nBenign endometrial polyp 07 3.4 \nEndometrial Carcinoma 02 1.0 \nMalignant mixed mullerian tumor 03 1.5 \n \nTable 7: Histopathological diagnosis of Myometrial Lesions \nHistopathological Diagnosis Number of cases \n(n=212) \nPercentage \n(%) \nLeiomyoma 71 33.5 \nAdenomyosis 82 38.7 \nNormal Histology 59 27.8 \n \nTable 8: Histopathological diagnosis of Fallopian tube Lesions \nHistopathological Diagnosis Number of cases \n(n=118) \nPercentage \n(%) \nNormal 109 92.4 \nEndometriosis 06 5.1 \nParatubal cysts 03 2.5 \n \nTable 8: Histopathological diagnosis of Ovarian Lesions \nHistopathological Diagnosis Number of \ncases \n(n=119) \nPercentage \n(%) \nNo significant pathology 103 86.6 \nFollicular cyst 05 4.2 \nCorpus luteal cyst 02 1.7 \nEndometriosis 06 5.0 \nBenign Mucinous cystadenoma 01 0.8 \nBenign serous cystadenoma 02 1.7 \n\nZ. Kashif, S. Z. Warriach, S. S. Ali et al \n \nP J M H S  Vol. 15, NO. 7, JUL  2021   1731 \nTable 9: Distribution of all the malignant lesions \nMalignant lesion Number of \ncases \n(n=20) \nPercentage \n(%) \nCERVIX   \nCervical squamous cell \ncarcinoma \n08 40 \nCervical adenocarcinoma 04 20 \nAdenocarcinoma in situ 01 05 \nCervical intraepithelial \nneoplasia (CIN III) \n02 10 \nENDOMETRIUM   \nEndometrial adenocarcinoma 02 10 \nMalignant mixed mullerian \ntumor \n03 15 \n \nDISCUSSION \nHysterectomy is the most commonly executed significant \ngynecological operation all over the world. It helps in \nproviding immediate absolute relief in many benign and \nmalignant conditions of uterus, cervix and adnexae. (9) \n Today hys terectomy is a routine procedure opted \nglobally, offering the chances of cure to many patients; \nhowever the figures of this surgical operation have been \ndeclined remarkably in developed countries due to switch \ntowards conservative approaches. Still the numbers are \nhigher than the developing countries. (10) \n The mean age of women  who underwent \nhysterectomy due to gynecological disorders in our study \nwas 47.8 years in accordance with several studies \nconducted in Pakistan and abroad where the mean ages \nfound were 48.8 years 46.86 years, 45.76years, 45 years, \n43 years and 40.37years respectively.  (2, 11, 12, 13, 14, \n15) \n Most (78/190) 41.1% of these  women were between \nages 41 to 50 years, comparable to the st udies conducted \nby Shahid R, Egbe TO and Imam ZS. (15, 13, 16) \n Irregular excessive bleeding and pain were the most \nfrequent presenting complaints in our study . Similar mode \nof presentations was seen in several other studies. (15, 17) \n Most women presented with single manifestation; \nhowever many others complaint of overlapping symptoms.  \n The overall occurrence of non neoplastic benign \nlesions in this study was 170/190 (89.5%) as compared to \n20/190 (10.5%) malignant neoplastic lesions. These \nfindings are supported by several local studies (5, 14, and \n15) as well as studies from India , China and Michigan. (2, \n12, 18) \n The commonest non neoplastic benign lesion in this \nstudy was chronic cervicitis which is an incidental finding in \nnearly all cases. This is consistent with several studies in \nwhich chronic cervicitis appeared  to be the commonest  \nincidental finding in cervix. (9, 16, 19) \n However, l eiomyomas and adenomyosis were the \nmost frequent  myometrial histopathological lesions and \nindication for hysterectomy in our study, in keeping with \nseveral other studies. (11, 20, 21) \n The most common type of hysterectomy was TAH \nwithout tubes and ovaries in our study. This is in \naccordance with several other studies where number of \ntotal abdominal hysterectomy was much more than vaginal \nhysterectomies. (5, 22, 23) \n Endometriosis was another incidental finding \nobserved in 6% of cases in both fallopian tubes and \novaries; this incidence is quite close to several other \nstudies. (15, 24, 25) \n \nCONCLUSION \nHysterectomy is an extensively used therapeutic modality . \nThe conclusive opinion is eventually made o n \nhistopathological examination. Non neoplastic benign \npathologies are much more frequent reasons for \nhysterectomy than the malignant lesions and majority of \nthese lesions especially chronic cervicitis, adenomyosis \nand even few leiomyomas are encountered as incidental \nfindings along with endometriosis and few ovarian cysts. \nLimitations: In this region of the world most ladies don’t \nconsult doctors especially for gynecological issues until and \nunless there is marked health related disturbanc e; \nespecially single unmarried and young ladies with low \nparity as it is considered a social taboo;  due to such delay \neven mild non neoplastic benign conditions get worse and \nhysterectomy remains the last option.  \n Secondly most people here lack health positive \nattitudes and don’t go for expensive thorough investigations \nthat lead  to missed preoperative diagnosis and increased \nnumber of incidental findings on histopathology.  \n \nREFERENCES \n1. Black KI, Fraser IS. 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