{"paper_id":"800d36ae-59d3-481c-8d22-5e7c832a53e6","body_text":"~ 9 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2019; 3(6): 09-14 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2019; 3(6): 09-14 \nReceived: 06-09-2019 \nAccepted: 10-10-2019 \n \nLohith HM  \nSenior Specialist, District Hospital, \nChikkamagaluru, Karnataka, India \n \nAnjali R \nObstetrician and Gynecologist, \nBengaluru, Karnataka, 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 \n \n \n \n \n \n \n \n \n \n \n \n \n \n \n \nCorresponding Author: \nAnjali R \nObstetrician and Gynecologist, \nBengaluru, Karnataka, India \n \nEvaluation and histopathological correlation of \nabnormal uterine bleeding in menopausal transition in a \ntertiary care centre at Cheluvamba hospital, Mysore \n \nLohith HM and Anjali R \n \nDOI: https://doi.org/10.33545/gynae.2019.v3.i6a.384  \n \nAbstract \nIntroduction: AUB at menopausal transition is alarming and needs thorough evaluation, as it could be the \nonly clinical manifestation of cancer.  \nMethodology: This prostective study was done to evaluate the gynaecological causes of AUB in \nmenopausal transition in OBG Department, MMC&RI, Mysore. These women were evaluated; clinical, \nultrasound and histopathological findings were correlated.  \nResults: In the present study, heavy menstrual bleeding (66.7%) was the commonest type of bleeding \npattern. Leiomyoma, DUB and Adenomyosis were the principle causes of AUB. Leiomyoma accounts for \nthe 60.6% of cases, DUB accounts fo r 15.9%, Adenomyosis accounts for 9.09% and Leiomyoma with \nAdenomyosis accounts for the 14.39% of cases.  \nConclusion: Endometrial biopsy and its interpretation play a pivotal role in the management of AUB cases \nin menopausal transition. It emphasizes the r ole of health care professionals to encourage teaching and \nimplementation of alternative procedures to ensure that women receive the maximum benefits with least \nmorbidity. \n \nKeywords: AUB (Abnormal uterine bleeding), menopausal transition, histopathology \n \nIntroduction  \nMenopause is the permanent cessation of menstruation which occurs following loss of ovarian \nactivity. It is derived from Greek word 'mens' - month, 'pausis'- cessation [1]. Perimenopause is a \nperiod 3-4 years before menopause and followed by 1 year of amenorrhea. It encompasses the \nchange from normal ovulatory cycles to cessation of menses, marked by irregularity of \nmenstrual cycles [2]. \nThe Perimenopausal Transition: Age of onset for 95% of women is 39 -51 years. Average age of \nonset is 46 years. Duration for 95% of women is 2-8years. Average duration is 5 years [1]. \nWhile significant awareness has been raised about menopause, less attention has been focused \non the perimenopausal or \"menopausal transition\" period. Many women and their physicians \nremain unaware of the impact of this transitional phase into menopause  [1]. Specifically, heavy \nand unpredictable perimenopausal bleeding is extremely common [3]. \nThe purpose of this review is to focus on the hormonal and physiologic changes that are \nassociated with perimenopausal heavy vaginal bleeding, to present the essential evaluation of \ncauses for this heavy flow, and to outline the evidence for effective medical and surgical \ntreatments. Advances in the understanding of the normal physiology of perime nopause have led \nto medical therapies that may lead to fewer surgical procedures and hysterectomies and should \nbe of interest to health care practitioners focusing on women's health [3].  \nAbnormal uterine bleeding (AUB) refers to a symptom of excessive, pr olonged, unexpected or \nacyclic bleeding regardless of diagnosis or cause. AUB not only affects quality of life such as \nintimate relationships, day to day living but can have serious adverse consequences as anaemia \nor malignancy [4].  \nThe diagnostic goal wi th perimenopausal bleeding is to exclude carcinoma and to identify the \nunderlying pathology to allow optimal treatment [5].  \nUltrasonography may reveal an obvious cavitary lesion or an abnormally thin or thick \nendometrium. In perimenopausal and postmenopau sal women with abnormal bleeding, \nendometrial biopsy is generally considered unnecessary when the endometrial thickness is less  \n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 10 ~ \nthan 4 or 5 mm because the risk of endometrial hyperplasia or \ncancer is remote. Biopsy is indicated when clinical history \nsuggests long term unopposed estrogen exposure.  An \nendometrial stripe of  5 mm thickness has been shown to be \nassociated with an extremely low risk of endometrial \nhyperplasia or carcinoma [2]. Women with endometrial thickness \n>5 mm warrant additional evaluatio n with saline infusion \nsonography or endometrial biopsy [3].   \nAn accurate method of determining whether AUB is functional \nor structural, one needs a minimally invasive accurate method. \nD&C under general anaesthesia was once considered as gold \nstandard investigation in the evaluation of AUB. It can however \nmiss 2-6% of cases of cancer or hyperplasia.5 Uterine cancer, the \nmost serious cause of uterine bleeding is diagnosed in fewer \nthan 10% of endometrial biopsies in women presenting with \nAUB, indicating tha t more than 90% of endometrial biopsies \nrevealed benign findings [6]. \nThe older terms perimenopause or climacteric generally refer to \nthe time period in the late reproductive years usually late 40s to \nearly 50s. The more correct terminology for this term i s \nmenopausal transition [7]. \nThe present study is designed to evaluate the causes of abnormal \nuterine bleeding in Menopausal Transition & to correlate the \nclinical evaluation with ultrasonographic & histopathological \nexamination. \n \nAims and objectives \n1. To ev aluate clinically the gynaecological causes of \nabnormal uterine bleeding in Menopausal Transition. \n2. To correlate the clinical evaluation with ultrasonographic \nand histopathological examination. \n \nMaterials and Methods \nSource of data : The present study was co nducted in the \nDepartment of Obstetrics and Gynaecology, Cheluvamba \nHospital, attached to Mysore Medical College and Research \nInstitute women who presented with abnormal uterine bleeding \nin menopausal transition age over a period of one year from \nNovember 2013 to October 2014. \n \nInclusion criteria \na. Patients complaining of abnormal uterine bleeding \nb. Age 39-51 years \n \nExclusion criteria \na. Post menopausal women \n \nMethods of collection of data \nEthical committee approval was taken for the study. Before \nrecruiting the p atient into the study, an informed consent was \ntaken. Identification of the patient in relation to name, age, \naddress, religion, socio -economic status, marital status, parity \nand literacy status was done. \nDetailed clinical history including onset and durat ion of \nbleeding, drug history, past obstetric medical and surgical \nhistory was taken. Thorough clinical examination which \nincluded general physical examination, per abdomen, per \nspeculum and per vaginal examination was done. \nThe terms used to categorise th e bleeding patterns are as \nfollows: \nAcceptable Abbreviations Describing Menstrual Symptoms \nEstablished by Popular Usage [8] \n \nAUB: Abnormal uterine bleeding (the overarching symptom) \nHMB: Heavy menstrual bleeding \nHIMB: Heavy with intermenstrual bleeding \nIMB: Inter menstrual bleeding \nPMB: Postmenopausal bleeding \n \nInvestigations like complete heamogram, ABO Rh, RBS, \nThyroid profile, Urine routine, Renal function test, Liver \nfunction test, TVS or TAS and endometrial biopsy was done in \nall patients, irrespe ctive of the endometrial thicknes. The \nendometrium was imaged in the longitudinal and cross -sectional \nplane through the body and the fundus of the uterus. The \nthickest point of the endometrium was measured from the \nanterior to posterior myometrial -endometrial junction. Both \nlayers of the endometrium were measured, that is the anterior \nand posterior layers. Morphological changes like appearance of \nendometrial strip (homogenous/heterogenous), endometrial \nthickness (diffuse/focal), margins (regular/irregular) are also \nnoted. \nEndometrial biopsies were done and the endometrial samples \n(endometrial curettage / hysterectomy specimens) sent to \npathology laboratory, were analysed. These specimens are fixed \nin 10%formalin and gross morphology were recorded. \nHistopathological examination of the endometrial pattern as well \nas that of hysterectomy specimens were done. These bits were \nplaced in cassettes and kept in fixative and processed in the \nautomatic tissue processor. Paraffin tissue blocks were prepared \nand 3 -4micrometer thick sections were cut and stained with \nroutine Haematoxylin and Eosin. A detailed  histological study \nwas carried out and the findings were noted.  \nEvaluation of ultrasound and histopathological findings of \nclinically diagnosed AUB cases was done wit h appropriate \nStatistical analysis was done. \n \nResults \nThe study was conducted in the department of obstetrics and \nGynaecology, Cheluvamba Hospital, MMC and RI Mysore.  \nTotal number of 132 cases were studied, age ranging from 39-51 \nyears (Mean age=45years). \n \n \n \nFig 1: Age distribution pattern \n \nIn the present study of 132 women in menopausal transition \n58.3% belonged to age between 39 -42 years, 23.5% belonged to \nage between 43-46 years, and rest 18.2% belonged to 47-51 year \nage group (Figure 1). \n \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 11 ~ \n \n \nFig 2: Distribution of bleeding patterns \n \nIn the present study 66.7% had Heavy Menstrual Bleeding  \n(HMB), 16.7% had Heavy Bleeding with Intermenstrual \nBleeding (HPIB), 9.8% had Intermenstrual Bleeding  (IMB), and \n6.8% had Frequent Menstrual Bleeding (FMB) (Figure 2).  \n \nTable 1: Histopathology findings of endometrium in relation to symptoms \n \nFinal \npathology/ \nSymptoms \nNormal \nmenstrual \nphase \nDisordered \nproliferative \nphase \nAtrophic \nendometrium \nChronic \nendometritis \nSimple \nhyperplasia \nwithout atypia \nComplex \nhyperplasia \nwithout atypia \nEndometrial \npolyp Total \nHMB 55 8 15 2 6 0 2 88 \n62.5% 80.0% 93.8% 100.0% 60.0% 0.0% 40.0% 66.7% \nHIMB 17 1 0 0 2 1 1 22 \n19.3% 10.0% 0.0% 0.0% 20.0% 100.0% 20.0% 16.7% \nIMB 9 1 0 0 1 0 2 13 \n10.2% 10.0% 0.0% 0.0% 10.0% 0.0% 40.0% 9.8% \nFMB 7 0 1 0 1 0 0 9 \n8.0% 0.0% 6.2% 0.0% 10.0% 0.0% 0.0% 6.8% \nTotal 88 10 16 2 10 1 5 132 \n100.0% 100.0% 100.0% 100% 100.0% 100.0% 100.0% 100% \n \nOut of 88 patients with Heavy Menstrual Bleeding (HMB), 55 \npatients had normal menstrual phase of endometrium,  8 patients \nhad disordered proliferative endometrium, 15 patients had \natrophic endometrium, 2 patients had endometrial polyp, 6 \npatients had simple hyperplasia without atypia and 2 patients \nhad chronic endometritis (Table 1). \nOut of 22 patients with Heavy with Intermenstrual Bleeding \n(HIMB), 17 patients had normal menstrual phase of \nendometrium, 1 patient had disordered proliferative \nendometrium, 1 patient had endometrial polyp, 2 patients had \nsimple hyperplasia without atypia and 1 patient had complex \nhyperplasia without atypia (Table 1). \nOut of 13 patients with Intermenstrual Bleeding (IMB), 9 \npatients had normal menstrual phase, 1 patient had disordered \nproliferative phase, 2 patients had endometrial polyp, 1 patient \nhad simple hyperplasia without atypia (Table 1).  \nOut of 9 patients with Frequent Menstrual Bleeding  (FMB), 7 \npatients had normal menstrual phase endometrium, 1 patient had \natrophic endometrium and 1 patient had simple hyperplasia \nwithout atypia (Table 1). \n \n \nFig 3: Endometrial biopsy reports \n \nIn the present study, of endometrial biopsy, proliferative \nendometrium was found in 43.9% of patients, secretory \nendometrium in 27.3%, disordered proliferative endometrium in \n7.6%, atrophic endometrium in 7.6%, simple hyperplasia \nwithout atypia in 7.6%, chronic endometritis in 3%, endometrial \npolyp in 2.3% and complex hyperplasia without atypia in 0.8% \nof patients (Fig 3). \n \nTable 2: Clinical diagnosis and HPE report correlation \n \nClinical HPE Total Leiomyoma Adenomyosis Leiomyoma+ adenomyosis DUB \nLeiomyoma 72 6 18 4 100 \n72.0% 6.0% 18% 4% 100% \nAdenomyosis 2 2 0 0 4 \n50.0% 50.% 0% 0% 100% \nDUB 6 4 1 17 28 \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 12 ~ \n21.4% 14.3% 3.6% 60.7% 100% \nTotal 80 12 19 21 132 \n60.6% 9.1% 14.4% 15.9% 100% \n \nOut of 132 patients, on clinical examination, 100 patients w ere \ndiagnosed to be having leiomyomas, finally confirmed by \nHistopathological examination. 72 cases were to be having \nleiomyoma, 18 were found to be having leiomyoma and \nadenomyosis, 6 were found to be having adenomyosis, 4% \nfound to be having normal morph ology of uterus. Out of the 4 \npatients found to be having adenomyosis, on clinical \nexamination 2 were found to be having adenomyosis and 2 were \nfound to be having leiomyoma (Table 2). \nOut of the 28 cases diagnosed to be having DUB, on clinical \nexamination, 6 were diagnosed as leiomyoma, 4 were found to \nbe having adenomyosis, One was diagnosed to be having \nadenomyosis and leiomyoma. 17 cases were correlated with \nclinical diagnosis since no gross pathology found in the uterus \n(Table 2). \n \nTable 3: USG diagnosis and HPE report correlation \n \nUSG HPE Total Leiomyoma Adenomyosis Leiomyoma+ adenomyosis DUB \nLeiomyoma 74 3 16 3 96 \n77.1% 3.1% 16.7% 3.1% 100.0% \nAdenomyosis 1 1 2 0 4 \n25% 25% 50% 0% 100.0% \nLeiomyoma + Adenomyosis 4 0 0 0 4 \n100% 0.0% 0.0% 0.0% 100.0% \nDUB 1 8 1 18 28 \n3.57% 28.5% 3.57% 64.2% 100.0% \nTotal 80 12 19 21 132 \n60.6% 9.1% 14.4% 15.9% 100.0% \n \nOut of 132 cases, on Ultrasonography 96 patients were \ndiagnosed as leiomyomas. After histopathological examination, \nout of 96 patients, 74 we re diagnosed as leiomyomas, 3 were \ndiagnosed as adenomyosis, 16 were diagnosed as leiomyomas \nwith adenomyosis and 3 patients were diagnosed as \nDysfunctional Uterine Bleeding (Table 3). \nOut of the 4 patients diagnosed to be having adenomyosis, \nhistopathological examination diagnosed adenomyosis in one \ncase, leiomyoma in one case and dual pathology of leiomyoma \nand adenomyosis in 2 cases. Out of 4 patients diagnosed as \nAdenomyosis + Leiomyoma, confirmed by histopathological \nexamination (Table 3). \nOut of 28 pa tients who were labelled as Dysfunctional Uterine \nBleeding by Ultrasonography, 1 patient was diagnosed to be \nhaving leiomyoma, 8 patients were diagnosed to be having \nadenomyosis, one patient was diagnosed to be having \nadenomyosis with leiomyoma and in the rest of 18 patients no \ngross pathology was detected on histopathological examination \n(Table 3). \nDiscussion \nAbnormal uterine bleeding is the main reason, woman are \nreferred to gynecologists and accounts for two -thirds of all \nhysterectomies [9]. Evaluation of patients with abnormal uterine \nbleeding and identifying those with AUB is achieved with \ncombination of the following: history, physical examination, \nultrasound and histopathological evaluation. AUB in women of \nmenopausal transition age group is associated with endometrial \ncarcinoma in 10% of patients  [9], so evaluation of woman’s risk \nfactors for endometrial hyperplasia or carcinoma is recommended. \nThough endometrial sampling can be done by endometrial \nbiopsy, endometrial aspiration and hysteroscopy, hyster oscopic \nguided biopsy is considered gold standard.  \nThe results from the study were analyzed and compared with \nresults of other published studies. \nIn the present study, most of the women with AUB belonged to \n39-42years age group (58.3%), followed by 23.5% in the age \ngroup of 42 -46 years, in the range of age distribution between \n39-51 years, which is comparable with the study by Archana B \net al., at LTMMC hospital, Mumbai  [10], 76.1% were in the age \ngroup of 40-45 years. \n \nTable 4: Distribution of bleeding pattern \n \nMenstrual complaints Gupta et al [11]  Present study  \n Number Percentage Number Percentage \nHMB 72 72 88 66.7 \nHPMB 13 13 22 16.7 \nIMB 08 08 13 9.8 \nFMB 07 07 09 6.8 \nTotal 100 100 132 100 \n \nIn the present study, heavy menstrual bleeding was the \ncommonest type of bleeding pattern (66.7%) followed by heavy \nand prolonged menstrual bleeding (16.7%), intermenstrual \nbleeding in 9.8% of patients and frequent menstrual bleeding in \n6.8% of patients, is in concordance with the study done by \nGupta et al [11]. \nIn the  present study, endometrial thickness was assessed using \nultrasound, 7.6% had thickness of less than 5mm, 56.8% had ET \nof 5-8mm, 26.5% of women had ET of 9 -12mm and 9.1% had \nET of >12mm. In the study done by Asma Fared et al . [12], \nrecommended a ET of >6mm si ngle layer endometrium as cut \noff point for the further evaluation of AUB in menopausal \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 13 ~ \ntransition. \n \nTable 5: comparative study of HPE report of endometrium \n \nFinal Pathology Gupta et al11 Present study \nNumber % Number % \nNormal menstrual phase 61 61 88 66.7 \nDisordered proliferative phase 7 7 10 7.6 \nAtrophic endometrium 0 0 16 12.1 \nChronic endometritis 9 9 2 1.5 \nSimple hyperplasia without atypia 19 19 10 7.6 \nComplex hyperplasia without atypia 1 1 1 0.8 \nEndometrial polyp 0 0 5 3.8 \nMalignancy 3 3 0 0 \n \nIn the present study, final histopathological examination of \nendometrium shows normal menstrual phase that is, proliferative \nand secretory phase (66.7%), which is in concordance with study \nby Gupta et al. [11] (61%), disordered proliferative phase in 7.6%, \natrophic endometrium in 16%, chronic endometritis in 1.5%, \nsimple hyperplasia without atypia in 7.6%, endometrial polyp in \n3.8% of patients. \nNo case of malignancy was found in the present study as \ncompared to 3% of cases in Gupta et al  [11] study. Atro phic \nendometrium was found in 12.1% of cases compared to Gupta et \nal [11]. The study by Archana et al  [10] found proliferative \nendometrium 66.1% of cases,  secretory endometrium in 16.1% \nof cases, which is also comparable to present study.     \n \nTable 6: Clinical, radiological and HPE correlation \n \nPathology Gupta et al Present study \nClinical Ultrasound HPR Clinical Ultrasound HPR \nLeiomyoma 54 63 53 100 (75.76%) 96 (72.73%) 80 (60.60%) \nAdenomyosis 4 2 6 4 (3.03%) 4 (3.03%) 12 (9.09%) \nLeiomyoma+ adenomyosis 0 1 10 0 (0.00%) 4 (3.03%) 19 (14.39%) \nDUB 39 31 28 28 (21.2%) 28 (21.2%) `21 (15.90%) \nMalignancy 3 3 3 0 0 0 \nTotal 100 100 100 132 132 132 \n \nFinally the clinical, radiological and histopathological findings \nof hysterectomy specimens were correlated.  \nIn 75.76% of patients a diagnosis of leiomyoma was made. In \n21.2% of patients a diagnosis of DUB and in only 3.03% of \npatients, provisional diagnosis of adenomyosis was done on \nclinical examination.  \nThe clinical examination findings were confirmed by u ltrasound \nwhich detected leiomyoma in 100% of patients who were \nsuspected to have leiomyoma on clinical examination. Out of 4 \npatients, who were clinically suspected to have adenomyosis, all \nthe 4 were confirmed by USG. The patients who didn’t have any \nsignificant finding on clinical examination were labelled as \nDUB. \nUltimate diagnosis was made on the basis of final histology of \nthe hysterectomy specimen. Out of 96 patients who were \ndiagnosed to have fibroids on USG, 80 patients were confirmed \nto have leiom yoma and 19 patients had leiomyoma with \nadenomyosis indicating the hyper estrogenic state. \nOut of 28 patients who were labelled as DUB after ultrasound, 8 \npatients were diagnosed to have adenomyosis, 1 patient is found \nto be having adenomyosis  + leiomyoma and 1 more patient \nfound to be having leiomyoma.  \nMajority of women with uterine Leiomyoma associated with \nmennorhagia are treated by hysterectomy. In our study \nLeiomyoma uterus was responsible for AUB in 60.6% of \npatients comparable with the study of LTMMC hospital Mumbai \n[10] 54%, DHQ Hospital, Multan  [13] 54.8% and Gupta et al  [11] \n52% Fl Cornitescu et al  [1] 49.6%, where evaluation of AUB \nrevealed Leiomyoma. \nHeavy menstrual bleeding in fibroids is due to increased size of \nthe uterine cavity thereby incr easing the surface area of \nendometrium, hyperestrogenism causing endometrial \nhyperplasia, vascular alteration of the endometrium and \nobstructive effect of fibroid on uterine vasculature leading to \nendometrial venule ectasia which causes proximal congestion  in \nthe myometrium and endometrium.  \nDiagnosis of adenomyosis on clinical examination is usually \ndifferent [15]. TAS doesn’t allow reliable diagnosis of \nadenomyosis or consistent differentiation from Leiomyoma, \neven TVS has limitation in tissue characterizati on. MRI is more \nhelpful to diagnose Adenomyosis but expensive. In our study \nclinically, only 4 (3.03%) cases were diagnosed as \nAdenomyosis, Ultrasound diagnosed 4 (3.03%) cases and \nhistopathological examination diagnosed 12 (9.09%) cases. The \nreported prevelance of Adenomyosis in hysterectomy specimens \nvaries from 5 to 70 percent.  \nIn the present study DUB was the second most common cause of \nAUB, accounting for the 21% of cases, which is in concordance \nwith the study by Gupta et al  [11] (28%). In the present s tudy \nAdenomyosis with Leimyoma is the third common cause of \nAUB, accounts for the 19% of cases, which is in concordance \nwith the study by Gupta et al  (10%). In the present study \nAdenomyosis is the least common cause of AUB, in 9,09% of \ncases, which is in c oncordance with the study by Gupta et al  \n(6%). The study by Archana et al  [10] found Adenomyosis was \nthe second most common cause of AUB in 29.4% of cases. \n  \nConclusion \nAUB is one of the most common problems in women of all age \ngroups affecting 10 -30% of r eproductive aged women and upto \n50% of women in menopausal transition. It is a challenging \ngynaecological problem caused by various structural \nabnormalities of the uterus and endometrial pathologies.  \nEndometrium is the mirror image of hormonal status in w omen \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 14 ~ \nof different age groups. It is important in detecting the cause, \nclinching the diagnosis and managing the patients with AUB.  \nEndometrium can be easily procured in AUB cases by \nendometrial biopsy which is a simple cost effective and \nappropriate method  that provides accurate diagnostic yield. \nEndometrial biopsy and its interpretation play a pivotal role in \nthe management of AUB cases in menopausal transition. \nIn the present study, Leiomyoma uterus was the most common \ncause of AUB, second common cause was DUB. Histopathology \nrevealed majority of endometrium in normal menstrual phase. \nClinical, radiological and pathological evaluation correlated very \nwell to diagnose Leiomyomas. However clinical examination as \nwell as ultrasonography proved to be of little  help to diagnose \nAdenomyosis. \nMaximum hysterectomies were done for Leiomyoma uterus, \nthus hysterectomy remained the commonest method of \nintervention. However, it is the responsibility of the health care \nprofessionals to encourage teaching and implementati on of \nalternative procedures to ensure that women receive the \nmaximum benefits with least morbidity. \n \nReferences \n1. Fritz MA , Speroff L.  Menopause and the Perimenopausal \nTransition. Clinical Gynecologic  Endocrinology and \nInfertility. 8 th ed. Lippincott Willi ams and Wilkins . 2011, \n681-84. \n2. Kumar P, Malhotra N. Abnormal and Excessive Uterine \nBleeding. Jeffcoate's Principles of Gynaecology. 7 th ed. \nArnold. 2008, 613-16. \n3. Choudhary S, Berkley C, Warren M. Perimenopausal \nvaginal bleeding: Diagnostic  evaluation and t herapeutic \noptions. Journal of women's health 2011; 21(3):30210. \n4. McCluggage WG. My approach to the interpretation of \nendometrial biopsies and  curettings, J Clin Pathol . 2006; \n59:801-12. \n5. Conoscenti G, Meir YJ, Fischer -Tamaro L, Maieron A, \nNatale R, D'Ottavi o G, et al . Endometrial assessment by \ntransvaginal sonography and histological findings after \nD&C in women with postmenopausal bleeding. Ultrasound \nObstet Gynecol. 1995; 61:8-115. \n6. Bakour S, Khan S, Gupta JK. The risk of premalignant and \nmalignant pathology  in endometrial polyps. Aca  Obstet \nGynecol Scand. 2000; 79:317-20. \n7. Hoffman, Schorge, Schaffer, Halvorson, Bradshaw, \nCunningham, Williams Gynecology, Second Edition, \nChapter 21, Menopausal Transition, 555-579. \n8. Fraser IS, Critchley HOD, Broder M, Munro MG. T he \nFIGO recommendations on terminologies and definitions \nfor normal and abnormal uterine bleeding. Semin Reprod \nMed. 2011; 29(5):383-390. \n9. Deanna E Telner, Difat Jakubovicz. Approach to diagnosis \nand managaement of AUB. Can Fam ily Physician 2007; \n53:58-64. \n10. Archana B, Michelle F. Evaluation and histopathological \ncorrelation of abnormal uterine bleeding in Perimenopausal \nwomen. Bombay Hospital Journal, 2010. \n11. Avantika Gupta, Asmita Muthal Rathore, Usha Manaktala \nand Poonam Rudingwa, Evaluation and Histopatholog ical \ncorrelation of abnormal uterine bleeding in perimenopausal \nwomen, Intenational Journal of Biomedical and Advance \nResearch, 2013. \n12. Asmaa Fared, Abdalla Khalil, Sheriff T. E L Ghoneimy & \nOmar Farag Ultrasonographic and histopathological study \nof the endo metrium in women with peri menopaus al \nbleeding. Med J Cairo Univ. 1994; 62(1)53-58. \n13. Rashida Hafiz , Muhammed Ali , Mansoor Ahmed. Fibroid \nas a causative factor in menorrhagia and its management. \nPakistan J Med Res. 2003; 42:3. \n14. Fl. Cornitescu, Florentina Taim ase, Cristiana Simionescu, \nD. Iliescu, Clinical, histopathological and therapeutic \nconsiderations in non -neoplastic abnormal uterine bleeding \nin menopause transition, Rom  J Morphol Embryol. 2011; \n52(3):759-765. \n15. Ken Tamai, Kaori Tagoshi. Department of Radio logy. \nNational hospital organisation Kyoto Medical Centre, \nKyoto Japan.","source_license":"CC0","license_restricted":false}