{"paper_id":"99a38ed3-5f5e-4b39-8bee-e1c7084a01b4","body_text":"~ 98 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2021; 5(6): 98-100 \n \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2021; 5(6): 98-100 \nReceived: 14-09-2021 \nAccepted: 17-10-2021 \n \nDr. Noor Ayesha Begum \nPost graduate,  \nDepartment of OBG, AIMS,  \nBG Nagar, Mandya, Karnataka, \nIndia \n \nDr. Anil Kumar GV \nAssistant Professor,  \nDepartment of OBG, AIMS,  \nBG Nagar, Mandya, Karnataka, \nIndia \n \nDr. Lokesh Chandra HC \nProfessor and Head,  \nDepartment of OBG, AIMS,  \nBG Nagar, Mandya, Karnataka, \nIndia \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: \nDr. Anil Kumar GV \nAssistant Professor,  \nDepartment of OBG, AIMS, \nBG Nagar, Mandya, Karnataka, \nIndia \n \nPerimenopausal women presenting with abnormal \nuterine bleeding: Endometrial thickness \n \nDr. Noor Ayesha Begum, Dr. Anil Kumar GV and Dr. Lokesh Chandra HC \n \nDOI: https://doi.org/10.33545/gynae.2021.v5.i6b.1063 \n \nAbstract \nRelaxin is released by granulocytes. This causes dissolution of stromal fibres. The stratum functionalis is \nbroken down to be discharged as menstruating endometrium. The stratum basalis is not shed from which \nregeneration begins. The presence of spiral arterioles, are the characteristic features of the endometrium. \nThe key event in the menstruation as postulated by Markee is the intense vasoconstriction of spiral \narterioles about 24 hours prior to menstruation, results  in ischaemic necrosis of the endometrial segment \nsupplied by them. This necrotic endometrium gets separated with accumulation of blood underneath. Thus, \nthe endometrial shedding begins at various places with the blee ding lasting over 2 -7 days period.  Written \ninformed consent taken from all patients enrolled in the study. They were evaluated by history, clinical \nexamination and relevant investigations. Transvaginal ultrasound and endometri al biopsy done for all \nsubjects. The endometrial biopsy specimen report obtained and compared and correlated with endometrial \nthickness by TVS. In perimen opausal women, when endometrial thickness of 14mm on transvaginal \nultrasound was taken as cut off, the modality had sensitivity of 9 7.71% and specificity of 84.21 %.  P value \nwith chi square test was found to be < 0.05. \n \nKeywords: Perimenopausal women, abnormal uterine bleeding, endometrial thickness \n \nIntroduction  \nThere are many theories proposed to explain the menstruation. The initiating event is a fall in the \nestrogen and progesterone levels. Corpus luteum regresses about 4 days prior to menstruation  [1, \n2]. The changes are: \n \n1. Vascular change \nThe presence of spiral arterioles, are the characteristic features of the endometrium. The key \nevent in the menstruation as postulated by Markee (1950) is the intense vasoconstriction of \nspiral arterioles about 24 hours prior to menstruation, results in ischaemic necrosis of the \nendometrial segment supplied by them. This necrotic endometrium get s separated with \naccumulation of blood underneath. Thus, the endometrial shedding begins at various places with \nthe bleeding lasting over 2-7 days period. \n \n2. Prostaglandin \nThe prostaglandins are synthesized in the endometrium and to some extent in myometr ium from \nthe arachidonic acid. The activation of the enzyme phospholipaseA2 is the rate limiting step in \nthe prostaglandin synthesis. Progesterone promotes the formation of lysosomes in the \nendometrium. Progesterone has got stabilizing effect and estrogen has labilizing effect on \nlysosomes. Withdrawal of progesterone preceding the menstruation causes breakdown of \nlysosomes and release of phospholipaseA2, which acts on the phospholipids on the cell walls \nand produce large amount of arachidonic acid resulting  in initiation of prostanoid cascade and \nthe synthesis of various prostaglandins. In the proliferative phase of normal menstruation the \nsynthesis of PGF2α and PGE2 are in 1:1 proportion. However in the secretory phase there is \nincrease in PGF2α secretion a nd PGF2α & PGE2 ratio becomes 2:1 causing vasoconstriction, \nplatelet aggregation and myometrial contraction as predominant actions. Thus, relative \nproportion of different prostaglandins in the endometrium is probably responsible for blood flow \nand dysmenrrhoea [3]. \n \n3. Changes in the ground substance \nAcid mucopolysaccharides (AMP) is the most common ground substance, that is carbohydrate\n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 99 ~ \nwhich exist as easily split complex with protein. It is synthesized  \nin the stromal cells and laid down by the effect of estrogen. \nAMPs are present during the proliferative phase and absent \nduring major portion of secretory phase. This increases vascular \npermeability and allows a free flow of nutrients and metabolites. \nDuring the last week of secretory phase AMPs reaccumulat e \nonly in the compacta and around spiral arterioles. During \nmenstruation hydrolytic enzymes depolymerize AMP and it \nloses gel like consistency and facilitates breakdown of the \nendometrium. \n \n4. Role of Relaxin \nRelaxin is released by granulocytes. This  causes dissolution of \nstromal fibres. The stratum functionalis is  broken down to be \ndischarged as menstruating endometrium. The stratum basalis is \nnot shed from which regeneration begins [4]. \n \nRegeneration \nRegeneration of the endometrium begins within 48 hours a fter \nthe onset of bleeding (Ferenczy 1976). Re -epithelialization \ncommences from the basal layer of endometrium, which is not \nshed and this regeneration will be completed in 3-4 days [5]. \n \nMethodology \nWritten informed consent  taken from all patients enrolle d in the \nstudy. They were evaluated by history, clinical examination and \nrelevant investigations. Transvaginal ultrasound and endometrial \nbiopsy done for all subjects. The endometrial biopsy specimen \nreport obtained and compared and correlated with endomet rial \nthickness by TVS. \n \nStudy instrument:  Transvaginal ultrasonography using \nSIEMENS ACUSON *300 5 – 9 M Hz TVS probe. Ultrasound \nwill be done by the transvaginal route. Ultrasound variables to \nbe studied include endometrial thickness, endometrial \nechogenicity, endometrial -myometrial interface and \nmyometrium.  \n1. Endometrial thickness measured in the sagittal plane of the \nuterus, at the thickest part of the endometrium. The \nthickness includes basal layers of both anterior and posterior \nuterine walls . Echogenic ity of the endometrium noted. \nEndometrial-myometrial interface  noted. Any abnormal \npathology such as polyps, abnormal growth noted. \n2. Uterus completely assessed longitudinally and transversely \nfor myometrial pathology. Myometrium  studied for \nasymmetric myome trial thickness, globular enlargement of \nuterus, myometrial cysts, and linear striations. \n3. Colour Doppler ultrasound will be used where required – to \ndistinguish adenomyosis and leiomyoma, endometrial \nhyperplasia and endometrial polyps. \n \nPatient Preparation \nPatient informed consent taken and  asked to empty her bladder \ncompletely. This contributes greatly to patient comfort and \nacceptance of this technique. The best position is the dorsal \nposition employed for vaginal examination. A transabdominal \nsonogram is done prior to vaginal study to exclude large masses \nand if uterus is more than 10 cms as in such conditions, the \nvaginal study will be suboptimal due to its limited field of view. \n \nTransducer Preparation \nVaginal transducer is between 5 -7.5 MHz in frequenc y and the \nsize of the sector image is usually between 900 and 1150. The \ntransducer should be covered by a condom filled with \napproximately 5ml of ultrasonic gel. Additional gel may be \napplied to the outside of the condom prior to its insertion, but \nthis sh ould be omitted in cases of infertility. Following \ncompletion of examination, the transducer assembly should be \nimmersed in disinfectant for ten minutes. \n \nResults \n \nTable 1: Endometrial Thickness \n \nEndometrial thickness (mm) No. of patients (%) \n5 – 9.9 52 (34.67) \n10 – 14.9 81 (54) \n15 – 19.9 11 (7.33) \n≥ 20 6 (4) \nTotal 150 \n \n \n \nFig 1: Endometrial Thickness \n \nTVS examination revealed 52 out of the 150 patients to have \nendometrial thickness between 5 and 9.9 mm, thus accounting \nfor 34.6% of patients. 54% pati ents had endometrial thickness \nbetween 10 and 14.9 mm. \nIn perimenopausal women, when endometrial  thickness of \n14mm on transvaginal ultrasound  was taken as cut off, the \nmodality had sensitivity of 97.71% and specificity of 84.21 %.  P \nvalue with chi square test was found to be < 0.05 \nTherefore it can be seen that with a endometrial  thickness less \nthan 14mm the histopathology report was normal endometrium \neither s ecretory or non -secretory. An endometrial stripe \nthickness more than 14mm has been found to  be associated with \nhyperplasia, adenomatous carcinoma and polyp. \n \nDiscussion \nSuman Agarwal, Rehana Nazam, Chitra Sandeep Diwan studied \nthe role of transvaginal sonographic assessment of endometrium; \na prospective cohort study in 2014. Results of D and C and TVS \ncompared and contrasted.  Endometrial pathology was found in \n38 patients. Endometrial hyperplasia was diagnosed in 13, \npolyps in 14, endometrial carcinoma in 5 cases. An abnormal \nsonography was found in 41 out of 70 cases. \nThus concluded that TVS is non-invasive, simple, reliable \ntechnique to carry out and detect lesions as a first line of \ndiagnostic modality for the females complaining of uterine \nbleeding in majority of cases [6]. \nAmbreen Qureshi, Farhat Ali, Liaquat Malik, studied the \naccuracy of TVS in det ecting endometrial abnormalities in \nwomen with peri and post-menopausal bleeding in 2015.  \n In this study, with endometrial thickness cut off point of 6 mm \nin perimenopausal women, sensitivity and specificity was 83.3% \nand 78.2% respectively, in post-menopausal women at cut off \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 100 ~ \npoint of 4mm sensitivity and specificity was 87.5% and 77.3%.  \nThis study concluded that abnormal endometrial pathology had a \nmean endometrial thickness that was significantly higher than \npatients with normal endometrium [7]. \nCol (Dr) P K Roy, r Pooja Singh, Dr Vijaykumar Singh studied \nthe endometrial thickness as a test for endometrial cancer in \nwomen with abnormal postmenopausal and perimenopausal \nvaginal bleeding and its histopathological correlation in 2013.  \nOut of 75 cases, endome trial thickness >12mm was seen in \n73.4% of perimenopausal and 25.3% of postmenopausal women. \nIn perimenopausal women with abnormal bleeding, \nhistopathology showed benign hyperplasia in 51%, pro liferative \nendometrium in 26.5% , secretory endometrium in 4.08% , \natropic endometrium in 2.05%, atypical hyperplasia in 10.2% \nand carcinoma in 6.12% . In majority, endometrial thickness by \nTVS may be helpful in planning investigation protocol for \nfurther management [8]. \nSuna Ozdemir, Cetin celik, Kazum Gzginc et al . evaluated the \nendometrial thickness with TVS and histopathology in \npremenopausal women with AUB in 2009. 144 premenopausal \nwomen with AUB were evaluated. \nOut of 144 women, 78.4% had normal endometrium, 21.6% had \nabnormal endometrium and endometrial thickness of >8mm had \na sensitivity of 83.6%, specificity of 56.4% and negative \npredictive value of 95.6% to detect the endometrial pathology. \nEndometrial thickness >8mm more likely than that of 8mm or \nless to be indicated with endometrial biopsy in a premenopausal \nuterine bleeding [9]. \nOddvar Bakos, Gun Heimer studied the relation of TVS with the \nhistopathological findings in pre and perimenopausal women. \nUltrasonographically both normal and pathological endometrial \nchanges could be detected. \n 82.5% of the women had  a endometrium characterised as \nnormal. The endometrial phase determination correlated with the \nhistological findings in approximately 50% of the women. \nEndometrial hyperplasia was found in 12% and endometrial \npolyps in 4%.concluded TVS is as effective as D & C for \ndepicting the endometrium in pre and perimenopausal w omen \nwith irregular bleeding [10]. \nShinde CD, Patil P G, Mane R studied the Endometrial thickness \nas a guideline for the treatment of Dysfunctional uterine \nbleeding in premenopausal women \nAmong 60 cases of abnormal uterine bleeding, 23 were more \nthan 36 years of age. In them bleeding disorders had more \nsevere symptoms. Endometrial thickness was more than 8mm . \nEndometrial thickness among younger age group was less than 8 \nmm. Perimenopausal women had endometrial thickness between \n8- 11 mm in perimenopausal age group women, preferred line of \ntreatment will be either dilatation and curettage or hysterectomy \nwhen endometrial thickness is more than 8mm [11, 12]. \n \nConclusion \n Among normal endometrium sec retory endometrium \naccounts for 45.5% \n Endometrial hyperplasia is noticed in 8% cases and \nendometrial carcinoma 3% \n The sensitivity, specificity for TVS is 97.7%, 84.2%  \nrespectively in detecting  abnormal endometrium with an \nEndometrial thickness cut off of 14mm. \n \nReferences \n1. Loverro G, Bettocchi S, Cormio G . Nicoloardiv, \nTransvaginal sonography and hyste roscopy in post -\nmenopausal uterine bleeding. Marturitas 1999;33(2):139-44. \n2. Tong Song T, Pongnarisom C . Mahanuphap, Use of vaginal \nsonographic measurements of e ndometrial thickness in the \nidentification of abnormal endometrium in Peri menopausal  \nand Post -menopausal bleeding. J Clin Ultrasound \n1994;22(8):479-82. \n3. Dubinsky T, Abu Gazzehy, StroehLein K . Role of TVS and \nendometrial biopsy in the evaluation of dysfunct ional \nuterine bleeding in peri and post -menopausal women. J Clin \nultrasound 1998;26(3):180-1. \n4. Get Pook C, Wattanakumtornkill S . Endometrial thickness \nscreening in premenopausal women with abnormal uterine \nbleeding. J obstet Gynaecol Res 2006;32(6):588-92. \n5. Giusa – Chiferi MG, Gonfolalva WJ, Baract EC. \nTransvaginal ultrasound, uterine biopsy and hysteroscopy \nfor postmenopausal bleeding.  Int. J Gynaecol obstet \n1996;55(1);39-44. \n6. Agarwal S, Nazam R,  Diwan C, Jain S. Transvaginal \nSonographic Assessment of Endomet rium A Prospective \nCohort Study. International jou rnal of scientific study  \n2014;2(7):50-2. \n7. Qureshi A, Ali F, Malik L, Ali A, Mushtaq S. Accuracy of  \nTransvaginal Sonography in Detecting Endometrial \nAbnormalities in Women with Peri and Postmenopausal \nBleeding. International journal of A dvanced Research \n2015;3(9):1084-90. \n8. Col (Dr.) Roy PK, Singh P, Singh VK, Mahadik K, Jain R. \nEndometrial Thickness as a Test for Endometrial Cancer in \nWomen with Abnormal Postmenopausal and \nPerimenopausal Vaginal Bleeding and it s Histopathological \nCorrelation. NJIRM 2013;4(2):144-48. \n9. Ozdemir S, Celik C, Gezginc K, Kiresi D,  Esen H. \nEvaluation of endometrial thickness with transvaginal \nultrasonography and histopathology in premenopausal \nwomen with abnormal vaginal  bleeding. Arch G ynaecol \nObstet 2010;282:395-99. \n10. Bakos O, Heimer G. Transvaginal Ultrasonographic \nevaluation of the Endometrium related to Histopathological \nfindings in Pre and Perimenopausal Women. \nGynaecological and Obstetric Investigation 1998;45:199 -\n204. \n11. Shinde CD,  Patil PG, Mane R. Endometrial thickness by \nUSG as a guideline for the treatment of dysfunctional \nuterine bleeding in Premenopausal Women.  International \nJournal of Medical Research and Review 2015;3(3):263-67. \n12. Davey DA. Dysfunctional uterine bleeding. In Whitfield CR \neditor; Dewhursts Textbook of Obstetrics and Gynaecology \nfor postgraduates. Glasgow, Blackwell Science  1997, 590-\n608.","source_license":"CC0","license_restricted":false}