{"paper_id":"66ebcd18-4474-4461-acca-817c9a7fec59","body_text":"Abnormal uterine bleeding (AUB) is a commonly encountered gynecological complaint affecting women across all age groups, particularly\nduring the peri-menopausal period. It refers to bleeding from the uterine corpus that is irregular in volume, duration, or frequency and\nnot associated with regular menstruation [ 1 ]. AUB significantly impacts a woman's physical\nhealth, emotional well-being and overall quality of life, contributing to a substantial number of outpatient visits and hospital\nadmissions in gynecology departments worldwide [ 2 ,  3 ]. The\netiologies of AUB are diverse, ranging from hormonal imbalances to structural abnormalities such as fibroids, polyps, and malignancies.\nTo standardize the diagnosis, the International Federation of Gynecology and Obstetrics (FIGO) introduced the PALM-COEIN classification,\nwhich categorizes the causes into structural (PALM: Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia) and non-structural\n(COEIN: Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, and Not otherwise classified) components [ 4 ].\nHowever, clinical assessment alone often fails to distinguish benign from potentially serious pathologies. Histopathological evaluation\nof endometrial tissue is considered the gold standard for identifying the underlying cause of AUB [ 5 ],\nas it confirms clinical suspicions, informs treatment strategies, and enables early detection of premalignant or malignant changes\n[ 6 ]. Endometrial sampling via dilatation and curettage or pipelle biopsy is particularly\ninformative in women over 40 years or those with risk factors for endometrial carcinoma [ 7 ].\nTherefore, it is of interest to describe the clinico-histopathological correlation in women presenting with abnormal uterine bleeding\nfor improved diagnostic accuracy and management.\n\nThis hospital-based cross-sectional study was conducted in the Department of Obstetrics and Gynaecology, Institute of Medical\nSciences - Banaras Hindu University, Varanasi, Uttar Pradesh, India. Over a period of one year, Ethical clearance was obtained from the\nInstitutional Ethics Committee prior to the commencement of the study. Informed consent was obtained from all participants. A total of\n120 women aged between 25 and 55 years who presented with complaints of abnormal uterine bleeding (AUB) were included. Patients were\nselected using a consecutive sampling technique. Women with pregnancy-related bleeding, known bleeding disorders, or on anticoagulant\ntherapy was excluded from the study. A detailed history was recorded for each participant, including age, menstrual history, parity, and\nassociated symptoms. General physical and gynecological examinations were performed. Routine investigations such as hemoglobin levels,\nthyroid profile, and pelvic ultrasonography were done to rule out other possible causes. All patients underwent endometrial sampling\neither by pipelle biopsy or dilatation and curettage (D & C), depending on the clinical indication. The endometrial specimens were\nfixed in 10% neutral buffered formalin, processed, and embedded in paraffin. Sections of 4-5 µm thickness were stained with\nhematoxylin and eosin (H & E) and examined under a light microscope by an experienced pathologist. The histopathological findings\nwere categorized into normal (proliferative or secretory phase endometrium) and abnormal (hyperplasia, atrophy, polyp, chronic\nendometritis, or malignancy). The clinical diagnosis and histopathological findings were compared and analyzed statistically. Data were\nentered into Microsoft Excel and analyzed using SPSS software version XX. The Chi-square test was used to assess the correlation between\nclinical and histopathological findings. A p-value < 0.05 was considered statistically significant.\n\nA total of 120 women presenting with abnormal uterine bleeding were enrolled in the study. The age distribution showed that the\nmajority of patients (42.5%) were in the age group of 41-50 years, followed by 31-40 years (30.8%) (Table 1 - see PDF). The most common\nclinical pattern of bleeding observed was menorrhagia, seen in 54 patients (45%), followed by metrorrhagia in 30 patients (25%),\nPolymenorrhea in 18 (15%) and postmenopausal bleeding in 18 patients (15%) (Table 2 - see PDF). Histopathological evaluation of\nendometrial samples revealed that proliferative endometrium was the most common pattern, observed in 42 cases (35%), followed by\nsecretory endometrium in 30 (25%), simple hyperplasia without atypia in 18 (15%), and endometrial polyp in 12 (10%). Other findings\nincluded atrophic endometrium in 10 (8.3%), chronic endometritis in 6 (5%), and endometrial carcinoma in 2 cases (1.7%) (Table 3 - see PDF).\nA statistically significant association was found between clinical diagnosis and histopathological findings (p = 0.03), indicating a\ngood correlation between clinical presentation and underlying pathology. The majority of postmenopausal women with bleeding were found\nto have atrophic endometrium or hyperplastic changes (Table 4 - see PDF).\n\nAbnormal uterine bleeding (AUB) remains a frequent gynecological concern, particularly among women in the perimenopausal age group.\nIn the present study, the majority of women presenting with AUB belonged to the age group of 41-50 years, consistent with findings from\nearlier studies [ 1 ,  2 ]. Hormonal fluctuations during this\ntransitional period are often responsible for endometrial instability and irregular shedding. Menorrhagia was identified as the most\nprevalent pattern of bleeding in this study, followed by metrorrhagia and polymenorrhea. These findings are comparable to those reported\nby Mishra  et al.  [ 3 ] and Taludkar  et al.  [ 4 ],\nwho also found menorrhagia to be the leading symptom of AUB. The variations in clinical patterns highlight the importance of individualized\ndiagnostic approaches. Histopathologically, the most common finding was proliferative endometrium (35%), followed by secretory\nendometrium (25%), and simple hyperplasia without atypia (15%). These results align with studies conducted by Jose  et al. \n[ 5 ] and Gothwal  et al.  [ 6 ], who reported\nsimilar distributions. Proliferative endometrium in AUB cases may reflect anovulatory cycles, particularly in perimenopausal women,\nwhere the hormonal imbalance often results in unopposed estrogen stimulation [ 7 ]. Endometrial\nhyperplasia without atypia was observed in 15% of cases, which is significant because, if untreated, it can progress to carcinoma in a\nsubset of patients [ 8 ]. This underscores the necessity of histopathological evaluation even in\nclinically benign cases. Only 1.7% of patients in our study had endometrial carcinoma, comparable to the low prevalence reported in\nother Indian and international studies [ 9 ,  10 ]. Atrophic\nendometrium was found in 8.3% of women, predominantly in those presenting with postmenopausal bleeding. Similar findings have been\ndocumented by Damle  et al.  [ 11 ], emphasizing that atrophy is a common cause of\nbleeding in postmenopausal women and often benign in nature. Chronic endometritis, found in 5% of cases, often presents with nonspecific\nbleeding symptoms and is commonly associated with lower genital tract infections or retained products of conception [ 12 ].\nThe PALM-COEIN classification proposed by FIGO has streamlined the diagnostic process for AUB by segregating structural from non-structural\ncauses [ 13 ]. However, our study reinforces that histopathological analysis remains a cornerstone\nin determining the exact etiology and guiding appropriate therapy. Studies by Martinez  et al.  [ 14 ]\nand Nguyen  et al.  [ 15 ] have also highlighted the role of tissue sampling in\nimproving diagnostic accuracy and ensuring early detection of premalignant lesions. In our study, a statistically significant\ncorrelation (p = 0.03) was observed between clinical patterns and histopathological findings, suggesting that while clinical evaluation\nis useful, it cannot replace histopathological confirmation. This is particularly vital in differentiating benign conditions like polyps\nor hyperplasia from malignancies, which require more aggressive intervention. The PALM-COEIN classification system has become integral\nto the standardized diagnosis and management of abnormal uterine bleeding (AUB), particularly in reproductive and perimenopausal women\n[ 16 ]. Among the various presentations, heavy menstrual bleeding and ovulatory dysfunction are\nmost frequently reported, while leiomyomas and adenomyosis are common structural causes identified through imaging and histopathology\n[ 17 ]. Effective patient care hinges on a strong clinicopathological correlation, emphasizing the\nimportance of endometrial tissue sampling-especially in women over 45-to exclude malignancy and guide individualized treatment\nstrategies. Histopathological evaluation plays a critical role in confirming clinical diagnoses of abnormal uterine bleeding (AUB),\nespecially in reproductive and perimenopausal women [ 18 ]. Studies consistently highlight a strong\nclinico-histopathological correlation in cases of AUB, emphasizing the importance of endometrial sampling in guiding treatment\nstrategies, including decisions regarding hysterectomy [ 19 ]. Across different tertiary care\ncenters in India, proliferative endometrium and endometrial hyperplasia emerge as the most common histopathological patterns associated\nwith AUB, underlining the need for routine histological screening to rule out premalignant or malignant conditions\n[ 20 ].\n\nAbnormal uterine bleeding in perimenopausal women presents with varied clinical patterns and histopathological evaluation remains\nessential for accurate diagnosis. The strong correlation between clinical presentation and endometrial histology highlights the\nimportance of combining both approaches for effective patient management and timely identification of premalignant or malignant\nconditions.","source_license":"CC-BY-4.0","license_restricted":false}