{"paper_id":"aa11993b-59b1-4204-990f-d3643a7379ae","body_text":"~ 329 ~ \nInternational Journal of Clinical Obstetrics and Gynaecology 2020; 4(1): 329-332 \nISSN (P): 2522-6614 \nISSN (E): 2522-6622 \n© Gynaecology Journal \nwww.gynaecologyjournal.com \n2020; 4(1): 329-332 \nReceived: 02-10-2019 \nAccepted: 23-10-2019 \nSmita Sharma \nAssociate Professor, Department of \nObstetrics & Gynecology, NCR \nInstitute of Medical Sciences, \nMeerut, Uttar Pradesh, India \nRitu Kumar \nMS (Obstetrics and & Gynecology), \nConsultant Obstetrics and & \nGynecology, CHC Muradnagar, \nGhaziabad, Uttar Pradesh, India \nVaibhav Tiwary \nProfessor, Department of \nAnesthesiology, LLRM Medical \nCollege, Meerut, Uttar Pradesh, \nIndia \nCorresponding Author: \nSmita Sharma \nAssociate Professor, Department of \nObstetrics & Gynecology, NCR \nInstitute of Medical Sciences, \nMeerut, Uttar Pradesh, India \nCorrelation of abnormal uterine bleeding with \nsonographic findings and histopathological examination \nof hysterectomy specimens \nSmita Sharma, Ritu Kumar, Vaibhav Tiwary   \nDOI: https://doi.org/10.33545/gynae.2020.v4.i1e.807 \nAbstract\nIntroduction: Abnormal uterine bleeding (AUB) at menopausal transition is alarming and needs thorough \nevaluation, as it could be the only clinical manifestation of cancer. The aim of the study was to c orrelate \nabnormal uterine bleeding with sonographic fin dings and histopathological examination of hysterectomy \nspecimens \nMethodology: This prospective study was do ne to evaluate the gynaecological causes of AUB in \nmenopausal transition in OBG Department, LLRM Medical College, Meerut. These women were \nevaluated; clinical, ultrasound 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 for 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 role of health care professionals t o encourage teaching and \nimplementation of alternative procedures to ensure that women receive the maximum benefits with least \nmorbidity. \nKeywords: AUB (Abnormal uterine bleeding), histopathology, hysterectomy, menopausal transition, \nultrasonography \nIntroduction  \nMenopause is t he 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 y ear of amenorrhea. It enco mpasses the \nchange from normal ovulatory cycles to cessation of menses, marked by irregularity of \nmenstrual cycles  [2]. Perimenopause is the period 2 -8 years preceding menopause and 1 year \nafter the final menses (WHO) [3]. However a better practical definition is the phase preceding the \nonset of menopause, generally occurring around 40 -50 years of age (beginning at age 47.5, \nlasting for 4 years) during which the regular cycle of a woman transitions to a pattern of \nirregular cycles. The Perimenopausal Transition: Age of onset for 95% of women is 39-51 years. \nAverage age of onset is 46 years. Duration for 95% of women is 2 -8years. Average duration is 5 \nyears [1]. While significant awareness has been raised about menopause, less attent ion has been \nfocused on th e perimenopausal or \"menopausal transition\" period. Many women and their \nphysicians remain unaware of the impact of this transitional phase into menopause [1]. \nSpecifically, heavy and unpredictable perimenopausal bleeding is extremely common [4]. \nThe purpo se 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 f or effective medical and s urgical \ntreatments. Advances in the understanding of the normal physiology of perimenopause 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 [4]. \nAbnormal uterine bleeding (AUB) refers to a symptom of excessive, prolonged, 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 [5].\n\n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 330 ~ \nThe diagnostic goal with perimenopausal bleeding is to exclude \ncarcinoma and to identify the underlying pathology  to allow \noptimal treatment [6]. Ultrasonography may reve al an obvious \ncavitary lesion or an abnormally thin or thick endometrium. In \nperimenopausal and postmenopausal women with abnormal \nbleeding, endometrial biopsy is generally considered \nunnecessary when the endometrial thickness is less than 4 or 5 \nmm becaus e the risk of endometrial  hyperplasia or cancer is \nremote. Biopsy is indicated when clinical history suggests long \nterm unopposed estrogen exposure. An endometrial stripe of 5 \nmm thickness has been shown to be associated with an \nextremely low risk of endom etrial hyperplasia or car cinoma [2]. \nWomen with endometrial thickness >5 mm warrant additional \nevaluation with saline infusion sonography or endometrial \nbiopsy [4]. \nAn accurate method of determining whether AUB is functional \nor structural, one needs a mini mally invasive accurate m ethod. \nD&C under general anaesthesia was once considered a gold \nstandard investigation in the evaluation of AUB. It can however \nmiss 2-6% of cases of cancer or hyperplasia  [6]. Uterine cancer, \nthe most serious cause of uterine bleed ing is diagnosed in fewe r \nthan 10% of endometrial biopsies in women presenting with \nAUB, indicating that more than 90% of endometrial biopsies \nrevealed benign findings  [7]. The older terms perimenopause or \nclimacteric generally refer to the time period in the late \nreproductive ye ars usually late 40s to early 50s. The more \ncorrect terminology for this term is menopausal transition [8]. \nThe present study is designed to evaluate the causes of abnormal \nuterine bleeding in Menopausal Transition & to correlate t he \nclinical evaluation wi th ultrasonographic  & histopathological \nexamination. \n \nMaterials and Methods \nThe present study was conducted in the Department of \nObstetrics and Gynaecology, LLRM Medical College, Meerut \namong the women who presented with abnormal uter ine \nbleeding in menopausal transition age over a period of two years \nfrom November 2016 to October 2018.  \n \nInclusion criteria  \nA. Patients complaining of abnormal uterine bleeding b. Age 39-\n51 years  \n \nExclusion criteria \nA. Post menopausal women \nEthical commi ttee approval was take n for the study. Before \nrecruiting the patient 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. Detailed cl inical history including \nonset and duration of bleeding, drug history, past obstetric \nmedical and surgical history was taken. Thorough clinical \nexamination which included general physical examination, per \nabdomen, per speculum and per vaginal examination was done. \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, irrespective of the endometrial thick nes. 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 t he endometrium were mea sured, 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 th e 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 sectio ns 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 with appropriate \nStatistical analysis was done.  \n \nResults \nThe study was conducted in the department of obstetrics and \nGynaecology, LLRM Medical College, Meerut. Total number of \n132 cases were studied, age ranging from 39 -51 years (Mean \nage=45years). \nIn the present study of 13 2 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. \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). \nOut of 88 patients with Heavy Menstrual Bleeding (HMB), 55 \npatients had normal menstrual phase of endometrium, 8 patients \nhad diso rdered proliferative endometrium, 15 p atients had \natrophic endometrium, 2 patients had endometrial polyp, 6 \npatients had simple hyperplasia without atypia and 2 patients \nhad chronic endometritis. Out of 22 patients with Heavy with \nIntermenstrual Bleeding ( HIMB), 17 patients had normal \nmenstrual phase of endometrium, 1 patient had disordered \nproliferative endometrium, 1 patient had endometrial polyp, 2 \npatients had simple hyperplasia without atypia and 1 patient had \ncomplex hyperplasia without atypia . Out o f 13 patients with \nIntermenstrual Bleeding (IMB), 9 patients had normal menstrual \nphase, 1 patient had disordered proliferative phase, 2 patients \nhad endometrial polyp,1 patient had simple hyperplasia without \natypia. Out of 9 patients with Frequent Menstru al Bleeding \n(FMB), 7 patients had norma l menstrual phase endometrium, 1 \npatient had atrophic endometrium and 1 patient had simple \nhyperplasia without atypia (Table 1). \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 aty pia in 0.8% \nof patients. \nOut of 132 pati ents, on clinical examination, 100 patients were \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 ad enomyosis, 4% \nfound to be having normal morphology 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 \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 331 ~ \nfound to be having leiomyoma (Table 2). Out of the 28 cases \ndiagnosed to be having DUB, on clinical examination, 6 were \ndiagnosed as leiomyoma, 4 wer e found to be having \nadenomyosis, One was diagnosed to be having adenomyosis and \nleiomyoma. 17 cases were correlated with clinical diagnosis \nsince no gross pathology found in the uterus (Table 2). \nOut of 132 cases, on Ultrasonography 96 patients were \ndiagnosed as leiomyomas. After histopathological examination, \nout of 96 patients, 74 were diagnosed as leiomyomas, 3 were \ndiagnosed as adenomyosis, 16 were diagnosed as leiomyomas  \nwith adenomyosis and 3 patients were diagnosed as \nDysfunctional Uterine Bleeding. Out of the 4 patients diagnosed \nto be having adenomyosis, histopathological examination \ndiagnosed adenomyosis in one case, leiomyoma in one case and \ndual pathology of leiomy oma and adenomyosis in 2 cases. Out \nof 4 patients diagnosed as Adenomyosis + Leio myoma, \nconfirmed by histopathological examination. Out of 28 patients \nwho were labelled as Dysfunctional Uterine Bleeding by \nUltrasonography, 1 patient was diagnosed to be hav ing \nleiomyoma, 8 patients were diagnosed to be having \nadenomyosis, one patient wa s 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). \n \nTable 1: Histopathology findings of endometrium in relation to symptoms \n \nFinal \npathology/ \nSymptoms \nN (%) \nNormal \nmenstrual \nphase N (%) \nDisordered \nproliferative \nphase \nN (%) \nAtrophic \nendometrium N \n(%) \nChronic \nendometritis \nN (%) \nSimple \nhyperplasia \nwithout atypia \nN (%) \nComplex \nhyperplasia \nwithout atypia \nN (%) \nEndometrial \npolyp \nN (%) \nTotal \nN (%) \nHMB 55(62.5) 8(80) 15(93.8) 2(100) 6(60) 0 2(40) 88(66.7) \nHIMB 17(19.3) 1(10) 0 0 2(20) 1(100) 1(20) 22(16.7) \nIMB 9(10.2) 1(10) 0 0 1(10) 0 2(40) 13(9.8) \nFMB 7(8) 0 1(6.2) 0 1(10) 0 0 9(6.8) \nTotal 88(100) 10(100) 16(100) 2(100) 10(100) 1(100) 5(100) 132(100) \n \nTable 2: Clinical diagnosis and HPE report correlation \n \nClinical Leiomyoma N (%) Adenomyosisn (%) Leiomyoma+ Adenomyosisn (%) DUB N (%) Total N (%) \nLeiomyoma 72(72) 6(6) 18(18) 4(4) 100(100) \nAdenomyosis 2(50) 2(50) 0 0 4(100) \nDUB 6(21.4) 4(14.3) 1(3.6) 17(60.7) 28(100) \nTotal 80(60.6) 12(9.1) 19(14.4) 21(15.9) 132(100) \n \nTable 3: USG diagnosis and HPE report correlation \n \nClinical Leiomyoma N (%) Adenomyosisn (%) Leiomyoma+ Adenomyosisn (%) DUB N (%) Total N (%) \nLeiomyoma 74(77.1) 3(3.1) 16(16.7) 3(3.1) 96(100) \nAdenomyosis 1(25) 1(25) 2(50) 0 4(100) \nLeiomyoma+ adenomyosis 4(100) 0 0 0 4(100) \nDUB 1(3.57) 8(28.5) 1(3.57) 18(64.2) 28(100) \nTotal 80(60.6) 12(9.1) 19(14.4) 21(15.9) 132(100) \n \nDiscussion \nAbnormal uterine bleeding is the main reason, women 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: his tory, 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 a woman's risk \nfactors for endometrial hyperplasia o r carcinoma is \nrecommended. Though endometrial sampling can be done by \nendometrial biopsy, endometrial aspiration and hysteroscopy, \nhysteroscopic guided biopsy is considered gold standard. The \nresults from the study were analyzed and compared with results \nof 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 betwee n \n39-51 years, which is comparable with the st udy by Archana B \net al., at LTMMC hospital, Mumbai [10], 76.1% were in the age \ngroup of 40-45 years. \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, i s in concordance with the study done by \nGupta et al. [11]. \nIn the present study, endometrial thickness was as sessed 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 t he study done by Asma Fared et al . [12], \nrecommended a ET of >6mm single layer endometrium as cut \noff point f or the further evaluation of AUB in menopausal \ntransition. \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 \n7.6%, atrophic endometrium in 16%, chronic endometritis in \n1.5%, simple hyperplasia without atypia in 7.6%, endometrial \npolyp in 3.8% of patients. \nNo case of malignancy was found in the present study as  \ncompared to 3% of cases in Gupta et al.  [11] study. Atrophic \nendometrium was found in 12.1% of cases compared to Gupta et \nal. [11]. The study by A rchana et al . [10] found proliferative \nendometrium 66.1% of cases, secretory endometrium in 16.1% \nof cases, which is also comparable to present study.  \nFinally the clinical, radiological and histopathological findings \nof hysterectomy specimens were correlat ed. In 75.76% of \npatients a diagnosis of leiomyoma was made. In 21.2% of \npatients a diagnosis of DUB and in only 3.03% of patients, \nprovisional diagnosis of adenomyosis was done on clinical \n\nInternational Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com \n~ 332 ~ \nexamination. The clinical examination findings were confirmed \nby u ltrasound which detected leiomyoma in 100% of patients \nwho were suspected to have leiomyoma on clinical exam ination. \nOut of 4 patients, who were clinically suspected to have \nadenomyosis, all the 4 were confirmed by USG. The patients \nwho didn’t have any sig nificant finding on clinical examination \nwere labelled as DUB. \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 study \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 concordance w ith 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 reproductive a ged women and upto \n50% of women in menopausal transition. It is a challenging \ngynaecological problem ca used by various structural \nabnormalities of the uterus and endometrial pathologies. \nEndometrium is the mirror image of hormonal status in women \nof diffe rent age groups. It is important in detecting the cause, \nclinching the diagnosis and managing the patien ts 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. \n \nReferences  \n1. Fritz MA, Speroff L. Menopause and the Perimenopausal \nTransition. Clinical Gynecologic Endocrinol ogy and \nInfertility. 8th ed. Lippincott Williams and Wilkins  2011, \n681-84.  \n2. Kumar P, Malhotra N. Abnorm al and Excessive Uterine \nBleeding. Jeffcoate's Principles of Gynaecology. 7th ed. \nArnold 2008, 613-16.  \n3. Bhosle A, Fonseca M. Evaluation and histopathol ogical \ncorrelation of abnormal uterine bleeding in perimenopausal \nwomen. Bombay Hospital Journal 2010;52(1):69-72. \n4. Choudhary S, Berkley C, Warren M. Perimenopausal \nvaginal bleeding: Diagnostic evaluation and therapeutic \noptions. Journal of women's health 2011;21(3):30210.  \n5. McCluggage WG. My approach to the interpretation of \nendometrial biopsies and curettings , J Clin  Pathol \n2006;59:801-12.  \n6. Conoscenti G, Meir YJ, Fischer -Tamaro L, Maieron A, \nNatale R, D'Ottavio 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.  \n7. Bakour S, Khan S, Gupta JK. The risk of premalignant and \nmalignant pathology in endometrial polyps. Aca  Obstet \nGynecol Scand 2000;79:317-20.  \n8. Hoffman, Schorge, Schaffer,  Halvorson, Bradshaw, \nCunningham, Williams Gynecology, Second Edition, \nChapter 21, Menopausal Transition, 555-579.  \n9. Deanna E Telner, Difat  Jakubovicz. Approach to diagnosis \nand managaement of AUB. Can Family P hysician \n2007;53:58-64.  \n10. Archana B, Michelle F. Evaluation and histopathological \ncorrelation of abnormal uter ine bleeding in Perimenopausal \nwomen. Bombay Hospital Journal 2010.  \n11. Avantika Gupta, Asmita  Muthal Rathore, Usha  Manaktala \nand Poonam Rudingwa, Evaluation and Histopathological \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 endometrium in women with peri menopausal \nbleeding. Med J Cairo Univ 1994;62(1)53-58.","source_license":"CC0","license_restricted":false}