{"paper_id":"6552e88d-9bea-4f35-ba04-e201d2aaf80f","body_text":"~ 111 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2020; 4(1): 111-115 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2020; 4(1): 111-115 \nReceived: 24-11-2019 \nAccepted: 26-12-2019 \n \nDr. Meena Jain \nMS (Obstetrics & Gynaecology), \nMICOG, FIMS, Assistant \nProfessor, Department of \nObstetrics & Gynaecology, Sri \nShankaracharya Medical College, \nBhilai, Durg, Chhattisgarh, India \n \nDr. Shrikrishna Kumar Agrawal  \nMD (Obstetrics & Gynaecology), \nAssistant Professor, Department of \nObstetrics & Gynaecology, Sri \nShankaracharya Medical College, \nBhilai, Durg, Chhattisgarh, India  \n \nDr. Sangeeta Patre \nDGO, DNB, Jawaharlal Nehru \nHospital & Research Centre, \nBhilai, Chhattisgarh, 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 \n \n \n \nCorresponding Author: \nDr. Shrikrishna Kumar Agrawal  \nMD (Obstetrics & Gynaecology), \nAssistant Professor, Department of \nObstetrics & Gynaecology, Sri \nShankaracharya Medical College, \nBhilai, Durg, Chhattisgarh, India \n \nMRI as an imaging tool in abnormal uterine bleeding \namong non gravid women \n \nDr. Meena Jain, Dr. Shrikrishna Kumar Agrawal and Dr. Sangeeta Patre \n \nDOI: https://doi.org/10.33545/gynae.2020.v4.i1b.451  \n \nAbstract \nBackground: The causes of Abnormal Uterine Bleeding and its differential diagnosis are heterogeneous \nand complex. TAS , TVS and histopathological investigations were found to be controversial. MRI is an \nadvanced, noninvasive and can be an accurate diagnostic imaging modality in AUB diagnosis.  \nObjectives: This study was conducted to evaluate the role MRI in abnormal uteri ne bleeding (AUB) \npatients. \nMethods: It was a prospective, analytical study where 101 patients with complaints suggestive of abnormal \nuterine bleeding, with varying the age of 31 -84 years as well as those who underwent surgery were \nevaluated. Proper histor y clinical and systemic examination was done. After which each patient was \nplanned for MRI. On the basis of age, parity, desire to have further pregnancy, medical conditions, MRI \ndiagnosis, treatment strategy was planned. \nResult: The maximum number of pati ents fall in the age group of 31 -50 years with mean age 47.4 years. \nParity 2 was highest followed by nulliparity, 22.77% patients have acute while 77.23% have chronic onset \nmenstrual complaints.  \nMenorrhagia in 68 patients, Heavy Menstrual bleeding (HMB) i n 36 (35.69%) and Heavy and Prolonged \nMenstrual Bleeding (HPMB) in 32 (31.68%), 21(20.79%) patients were found. Most common systemic \ndisease was Hypothyroidism. Myoma was most common followed by Adenomyosis alone and with \ncombination of Adenomyosis and myoma. \nConclusion: When clinical diagnosis is not confirmed and sonography is deceptive inspite of normal \nfindings the patient remains symptomatic, MRI stands to be promising and accurate imaging modality. \n \nKeywords: Abnormal uterine bleeding (AUB), abnormal menstrual bleeding (AMB), adenomyosis, \nmagnetic resonance imaging (MRI) \n \nIntroduction  \nAny uterine bleeding outside the normal volume, duration, regularity or frequency is considered \nabnormal uterine bleeding (AUB). Abnormal menstrual bleeding pattern expr essed by terms like \nmenorrhagia, Metorrhagia, Polymenorrhea and oligomenorrhea. The causes of Abnormal \nUterine Bleeding and its differential diagnosis are heterogeneous and complex. Various causes \nof AUB include pregnancy, miscarriage, ectopic pregnancy, A denomyosis, fibroids, uterine and \n/or cervical infection, polyps, IUCD, OC pills, PCOS, coagulation defects, uterine synechea etc. \nAUB is one of the common presentations of endometrial hyperplasia (precancerous), \nadenocarcinoma, other uterine tumors, cervi cal malignancy, vaginal cancer etc. Thus, \nidentifying the etiology is important [1, 2, 3].  \nAbnormal uterine bleeding can be evaluated by careful history, clinical examination, blood \ninvestigations, hormonal profile, ultrasonography, sonohysterography, hys teroscopy, MRI and \nendometrial sampling to reach a diagnosis.  \nInvestigation and management of abnormal uterine bleeding (AUB) among nongravid women of \nreproductive age has been hampered both by confusing and inconsistently applied nomenclature \nand by the lack of standardized methods for investigation and categorization of t he various \npotential etiologies [4, 5]. \nTherefore in 2011, the FIGO classification system, there are 9 main categories, which are \narranged according to the acronym PALM -COEIN (pronounced  “pahm-koin”): polyp, \nAdenomyosis, leiomyomas, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, \nendometrial, iatrogenic and not yet classified. In general, the components of the PALM group \nare discrete (structural) entities that can be meas ured visually with imaging techniques and/or \nhistopathology, whereas the COEIN group is related to entities that are not defined by imaging \nor histopathology (non-structural) [6]. \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 112 ~ \nTransvaginal ultrasound is an appropriate screening tool and, in \nmost instances, should be performed first or early in the course \nof the investigation. Even in ideal circumstances, TVUS is not \n100% sensitive because polyps and other small lesions may \nelude detection, even i n the context of a normal study [7, 8]. \nHowever, if offi ce hysteroscopy is available, there may be \nadditional value should polyps be identified because they could \nbe removed in the same setting. When vaginal access is difficult, \nas may be the case with adolescents and virginal women, TVUS, \nSIS, and office hyste roscopy may not be feasible. In such cases, \nthere may be a role for MRI [6]. \nEstimates of the prevalence of adenomyosis vary widely, \nranging from 5% to 70% 9— an observation that, at least in part, \nis probably related to inconsistencies in the histopatholog ic \ncriteria for diagnosis. Consequently, and because there exist \nboth sonographic  [10] and magnetic resonance imaging (MRI) -\nbased [11, 12] diagnostic criteria, adenomyosis has been included \nin the classification system. Adenomyosis is a disorder that \nshould have its own sub -classification system [13] and it is clear \nthat there should be an initiative to standardize methods of both \nimaging and histopathological diagnosis. \nThe myometrium should also be evaluated for the presence of \nadenomyosis or to distingui sh between leiomyoma’s and \nadenomyomas [12] If available, MRI may be used to evaluate the \nmyometrium to distinguish between leiomyomas and \nadenomyosis [11] It may also be superior to TVUS, SIS, and \nhysteroscopy for measuring the myometrial extent of sub \nmucosal leiomyoma’s [7].  \nWhen uterine conservation is desired in women with fibroids \nand TVUS or SIS is indeterminate in localizing depth of \nmyometrial involvement of a fibroid, MR imaging should be \nconsidered as a part of the clinical algorithm. The precis ion of \nMR imaging localization of submucosal fibroids can obviate the \nneed for hysterectomy and permit a skilled surgeon to \nhysteroscopically resect the fibroids. If the clinical examination \nis suspicious for adenomyosis and the US is no diagnostic , the \nclinician should consider MR imaging strongly.  \nWhen the results of the imaging study would influence surgical \nroute and planning, MR imaging should be considered in the \npreoperative evaluation [14].  \nAtypical hyperplasia and malignancy are important potenti al \ncauses of, AUB and must be considered in nearly all women of \nreproductive age. The present classification system is not \ndesigned to replace those of WHO and FIGO for categorizing \nendometrial hyperplasia and neoplasia  [15, 16]. Consequently, \nwhen a prema lignant hyperplastic or malignant process is \nidentified during investigation of women of reproductive age \nwith AUB, it would be classified as AUB -M and then sub \nclassified using the appropriate WHO or FIGO system.  \nThe appearances of endometrial cancer, hy perplasia, and benign \npolyps may overlap on magnetic resonance imaging and MRI \nhas role is in the staging of biopsy confirmed endometrial \ncancer. \nMagnetic resonance imaging is more sensitive than transvaginal \nultrasound or computed tomography in the detect ion of deep \nmyometrial invasion and tumor spread beyond the uterus. The \nnatural contrast between the endometrial tumor and surrounding \nmyometrium is poor on transvaginal ultrasound. Consequently, \nmagnetic resonance imaging is more sensitive than ultrasound  \n(84-87% (specificity 91-94%) v 77%) [17, 18, 19]. \nMagnetic resonance imaging (MRI) is an imaging modality that \nhas been developed and used since the mid1970s. MRI has \nseveral advantages over computed tomography (CT) and \nultrasonography. One important feat ure is its noninvasiveness. \nThe imaging components include a large static magnetic field \nand an electromagnetic field produced by radio frequency (RF) \nwaves. Although once termed nuclear magnetic resonance \nimaging, MRI uses no ionizing radiation. A second feature that \nmakes MRI particularly attractive is its capability for \nmultiplanar imaging. Without repositioning the patient, \ntransverse, sagittal, coronal, and non-orthogonal views may be \nobtained in a short time. Such capabilities allow excellent study \nof normal and abnormal anatomy.  \nA third advantage of MRI is its excellent tissue differentiating \ncapabilities, made possible because the biochemical \ncharacteristics of the nuclei within their microscopic \nenvironment alter the information (called signals) re ceived \nduring an MRI acquisition. MRI acquisitions may further alter \nand different contrast. These signals are not influenced by the \namount of bladder filling, the size of a patient, or the amount of \ngas in the surrounding bowel, but these factors have an \nimportant role in the quality of an ultra  sonographic image. With \nMRI, excellent tissue differentiation is possible wit hout the use \nof contrast agents [6]. \nA fourth advantage of MRI is its intrinsic sensitivity to flowing \nblood. As with Doppler ultrasonogr aphy, flow direction and \nspeed may be determined. Both arterial and venous \nabnormalities can be assessed by MRI. Additionally, \nbiochemical states of blood can be characterized by MRI.  \nHowever, it is clear that MRI can serve as an alternative or an \nadjunctive tool in many instances. This study was conducted to \nevaluate the role MRI in AUB patients. \n \nMaterial and Methods \nA prospective, analytical study was conducted at the Department \nof Obstetrics and Gynecology, Sri Shankaracharya Medical \nCollege, Bhilai, C hhattisgarh, from September 2018 - September \n2019. It was a prospective, analytical study where 101 patients \nwith complaints suggestive of abnormal uterine bleeding, after \nthe age range of 30 years and above and those who underwent \nsurgery were evaluated.  \nA total of 101 women with consent and various age group \nhaving complaints suggestive of abnormal uterine bleeding were \nincluded in the study. AUB with adnexal pathology were \nexcluded from the study. \nPatients fulfilling the inclusion criteria were selected through \ndetailed clinical history, examination: general physical, \nsystemic, gynecological (per speculum, per vaginal) and all \ngeneral and specific investigations were carried out. Each patient \nirrespective of the baseline investigations and transabdominal \nsonography findings were directly subjected to the investigation \nMRI pelvis. \nProper history clinical and systemic examination was done. \nAfter which each patient was planned for MRI, following which \ndilatation and curettage was planned. In 20 patients all f indings \nwere normal and hence they were excluded from study and \nproper counseling was done and simultaneously new patients \nwere taken. On the basis of age, parity, desire to have further \npregnancy, medical conditions, MRI, treatment strategy was \nplanned.  \nMRI of 1.5 Tesla with a three plane localizer must be taken in \nthe beginning to localize and plan the sequences, localisers are \nnormally less than 25sec. T1and T2 weighted low resolution \nscans were used for the scans. \nAll subjects were followed up for 4 we eks. 1 st follow up for 1 st \nweek and 2 nd follow up at the end of 4th week for \nhistopathological complications and treatment planning.  \nAfter primary data collection, a master chart was prepared with \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 113 ~ \nthe help of Microsoft excel sheet and data entered into it  was \nanalyzed according to the set objectives. Non -parametric \n(discrete) data was analyzed using chi -square test. Mean \nstandard deviation and percentage was used for analysis of \nparametric (continuous) data. P - Value of < 0.05 was considered \nto be statistically significant. \n \nResults \nThe age group in the present study was between 31 -85 years. \nAmong them 62.38% of cases belonged to the age group of 41 -\n50 years. Maximum cases found were of age group 31 -50 years. \nMinimum age was 31 years.  Maximum age was 84 yea rs. Mean \nage was 47.4 years. Patient having Abnormal uterine bleeding, \nmaximum number were of para 2 that is 49 patients (48.5%) the \nnext were nullipara 26(25.74%). We found 2 unmarried patients \nwith AUB in the perimenopausal group. Lastly there were 4 \ncases (3.96%) of grand multipara. \n \nTable 1: Age and parity wise distribution of patients \n \nVariable Subgroup N % \nAge \n31-40 17 16.83 \n41-50 63 62.38 \n51-60 11 10.89 \n61-70 8 7.92 \n>70 2 1.98 \nParity \nP0 26 25.74 \nP1 11 10.891 \nP-2 49 48.515 \nP-3 11 10.891 \nGrand multipara 4 3.96 \n \nOut of total 101 cases 23 cases (22.78%) presented with Acute \nOnset of Abnormal uterine bleeding i.e within 6 months of onset \nof symptoms whereas (77.23%) that is 78 cases have chronic \nOnset of Abnormal uterine bleeding i.e mor e than 6 months of \nonset of symptoms. When studied Cases of AUB for thyroid \ndisorders the Hypothyroidism was noted in total of 62 patients; \nof which 34(33.67%) have Sub -clinical hypothyroidism and \n28(27.72%) have overt hypothyroidism and 6 have \nhyperthyroidism and 33(32.67%) have euthyroid status. \nMaximum number of patients has menorrhagia as their primary \nComplaints in about 68 patients. Heavy Menstrual bleeding \n(HMB) in 36 (35.69%) and Heavy and Prolonged Menstrual \nBleeding (HPMB) in 32 (31.68%), 21(20.79 %) patients have \nirregular Menstrual bleeding patterns, while 12 (11.88%) \npatients had post-Menopausal bleeding.  \n  \nTable 2: Complains among patients with AUB \n \nClinical condition Subgroups N % \nDuration of complaints Acute AUB(<6months) 23 22.77 \n Chronic AUB(>6months) 78 77.23 \nThyroid disorder Euthyroid 33 32.67 \n Sub-clinical Hypothyroid 34 33.66 \n Hypothyroid 28 27.72 \n Hyperthyroidism 6 5.94 \nBleeding Pattern HMB 36 35.64 \n HPMB 32 31.68 \n IMB 21 20.79 \n PMB 12 11.88 \n \nHeavy menstrual bleeding at the a ge group of 31 -40 years was \nseen in about 9 patients and in age group of 41 -50 years was \nseen in 25 patients while in age group of 51 -60 and 61 -70 years \nonly 1 patient had complaints of heavy menstrual bleeding. \nTable 3: Distribution of menstrual pattern in various age groups \n \nAge group (years) 31-40 41-50 51-60 61-70 >70 Total \nMenstrual pattern       HMB 9 25 1 1 0 36 \nHPMB 7 22 3 0 0 32 \nIMB 1 15 3 2 0 21 \nPMB 0 1 4 5 2 12 \nTotal 17 63 11 8 2 101 \n \nIn 17 cases (5.54%) there was no complaint except menor rhagia. \nIn 62 cases (20.20%), besides menorrhagia there was pain in \nabdomen. In other cases heaviness in lower abdomen was seen \nin about 39 cases (12.39%), 46 (14.98%) have discharge per \nvagina, 35(11.40%) have dyspareunia, 48(15.64) have \nassociated dysmen orrhoea, 31(10.10%) have pressure \nsymptoms, 29(9.45%) have nonspecific symptoms. \n34 (33.66%) cases were having mild anaemia. 21(20.79%) cases \nwere having moderate anaemia 9 cases were having severe \nanaemia and were given blood transfusions. \n \nTable 4: Other associated complaints among AUB \n \nClinical condition Subgroups n % \nOther associated complaints No Complaints 17 5.54 \n Pain in lower Abdomen 62 20.20 \n Heaviness in lower Abdomen 39 12.70 \n Discharge per Vaginum 46 14.98 \n Dyspareunia 35 11.40 \n Dysmenorrhoea 48 15.64 \n Pressure Symptoms 31 10.10 \n Non-Specific Symptoms 29 9.45 \nAnaemia No Anaemia (≥ 11 gm/dL) 37 36.63 \n Mild Anaemia (9.5 - 11 gm/dL) 34 33.66 \n Moderate Anaemia (8 - 9.5 gm/dL) 21 20.79 \n Severe Anaemia (< 8 gm/dL) 9 8.91 \n \nDiscussion \nIn our present study, highest number of cases having abnormal \nuterine bleeding were in the age grou p of 41 -50 years which is \n63 corresponding to 62.38% of cases. 17 patients were of age \ngroup in 31-40 years.11 patients are in age group of 51 -60 years. \n10 patients are in age group more than 60 years. \nIn a study conducted by Ghazala Rizvi et al . (2015) sa me age \ngroup of 40 -50 years were the highest numbers of patients \ncomplaining of abnormal uterine bleeding i.e. 44.56% of the \npatients.20 Similarly, in a study conducted by MS Bhansali et al. \n(2017) Majority of the patients complaining of abnormal uterine \nbleeding were in the age group of 41 -50 years i.e. about 35.92% \nof the total cases [21] \nThus the demographic findings of our study were consistent with \nother studies. There was higher number of patients in the 41 -50 \nage groups than in post-menopausal age gr oup. In our present \nstudy maximum number of patients complaining of Abnormal \nuterine bleeding were of parity – 2 i.e. 48.5% of the total cases \n49 patients followed by parity – 0 in which we had 26 patients \ncorresponding to 25.74%. \nIn a study conducted by N . Bhavani et al . (2015), Abnormal \nuterine bleeding was found to be most commonly associated \nwith parity – 2 about 43 patents i.e. 21.5% followed by parity -3 \ni.e. 20.5% and followed by Nulliparous i.e. 19.5%. 22 Whereas in \nthe study conducted by Meghna Sure sh Bhansali et al . (2017) \n37.32% of the patients were of parity -3 where as 31.69% of the \npatents were Multiparous [21]. \nIn our study Abnormal uterine bleeding was associated in parity \n2 because the number of patients with parity 2 was high. The \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 114 ~ \nparity 2 w as followed by nulliparity in our study which may be \nattributable to the increased age of marriage these days and early \nconsultation for infertility. \nIn our study, out of 101 AUB patients, 23 patients i.e. 22.78% \nhad acute onset of symptoms while the reset  of 78 patients \n77.23% have a chronic onset of symptoms. No study was found \nregarding duration of complains in patients complaining of \nabnormal uterine bleeding. \nBut we compared the duration of complaints in our study, \nbecause the patients with acute onset  of complaints required \nimmediate intervention in form of hormonal therapy and in form \nof emergency polypectomy or hysterectomy.  \nIn our present study, hypothyroidism was found to be maximally \nassociated with Abnormal uterine bleeding i.e. 27.22% and total  \nof 28 patients have overt hypothyroidism while 34 patients have \nsubclinical hypothyr oidism and 6 patients i.e. 5.94 % have \nhyperthyroidism. \nIn a study conducted by N. Bhavani et al . (2015) 76.3% of \nthyroid dysfunction was seen in nonstructural causes of \nAbnormal uterine bleeding and 23.6 % of thyroid dysfunction \nwas seen in structur al causes of AUB and about 1.29 % of \nhyperthyroidism was seen in structural causes of Abnormal \nuterine bleeding [22]. \nIn our present study association of thyroidism was found more \nwhich may be due to the higher incidence of thyroid disorders in \nour areas moreover we compared the structural causes of \nabnormal uterine bleeding and hence the association was found \nmore.  \nMost of the patients of Abnormal uterine bleeding complains of \nmenorrhagia this is as per study conducted of Rehana et al . \n(2016) in which 55.8% of the patients had menorrhagia  [23]. In \nMeghna S Bhansali et al . (2017) study also the most common \npresenting symptom was found to be menorrhagia i n about \n60.56% of the patients [22]. \nIn our present study, the Menorrhagia was again the most \ncommon presenting complaint seen in about 68 patients \ncorresponding to 67.33% followed by irregular Menstrual \nbleeding in 21 patients of 20.79% While 12 patient i.e. 11.8 % \nhave post menopausa l bleeding. Thus the findings of our study \nwere consistent with other studies. \nHeavy menstrual bleeding at the age group of 31 -40 years was \nseen in about 9 patients and in age group of 41 -50 years was \nseen in 25 patients while in age group of 51 -60 and 61 -70 years \nonly 1 patient had complaints of heavy menstrual bleeding. \nSimilarly heavy and prolonged menstrual bleeding was found in \n7 patients at the age group of 31 -40 years, and in age group of \n41-50 years it was found in 22 patients while 3 patients had \nheavy and prolonged menstrual bleeding in age group of 51 -60 \nyears. Intermenstrual bleeding was complained by 15 patients in \nage group of 41 -50 years, while only 1 patient had \nIntermenstrual bleeding in age group of 31 -40 years, 3 patients \nin age group of 51-60 and 2 patients in age group of 61-70 years. \nPost-menopausal bleeding was seen in about 5 patients in the \nage group of 61 -70 years while 2 patients in age group of >70 \nyears has Post-menopausal bleeding 1 patient in age group of \n41-50 years and 4 patie nt in age group of 51 -60 years were \nfound to have post-menopausal bleeding.  \nThus we conclude that menorrhagia is the main complaint \namong reproductive age group and post-menopausal bleeding in \npost-menopausal age group. In our present study the most \nrecurring complaint followed by Menorrhagia is pain in lower \nAbdomen which was repeatedly observed 62 times i.e. in \n20.20% circumstances along with other associated complaints \nwhich is followed by Dysmenorrhoea in 15.64% circumstances. \nDischarge per Vaginum was observed 46 times i.e 14.98%. Only \n5.54% of the panties had no other complaints 9.45% have Non -\nSpecific symptoms. \nSimilarly in the study conducted by Radha Nair et al . (2015), \ntitled “Clinical profile of patients with abnormal uterine \nbleeding” had the mo st common presenting symptom of pain in \nAbdomen 28% followed by dysmenorrhoea 16% and backache \nin 2%  [24]. Thus the findings of our study were consistent with \nother studies. \nIn our study among 101 patients 64 had been diagnosed with \nanaemia in which 9 were  diagnosed as severe anaemia and \nrequired blood transfusion. There was no study for the \nComparision of the data. \n \n \n \nConclusion \nWe can conclude from our discussion that AUB Abnormal \nuterine bleeding was common during the peri -menopausal age \ngroup of 40 -51 years while the causes ranged from medical \ndisorders to simple pathologies like Myoma to malignancy.  \nThough MRI is an costly investigation but for the patients who \ncan afford this investigation, and also when clinical diagnosis is \nnot confirmed or inspite  of normal findings the patient remains \nsymptomatic, the choice as well as indication is to be precisely \nexplained and whenever needed patient must be asked to get \nthrough this imaging modality. MRI also has a major role in \ndiagnosing and staging carcinoma s which also present as major \ncause of abnormal uterine bleeding. \n \nReferences \n1. Alanis Fuentes J, Obregón Zegarra EH . Hysteroscopy \nclinic: diagnostic and therapeutic method in abnormal \nuterine bleeding.  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