{"paper_id":"d5e9c829-c87e-48b1-a2b5-24a2c7d8022f","body_text":"4040\nPathology Section\nClinicopathological Correlation of \nNon Oncological Hysterectomies \nat a Tertiary Healthcare Centre\nNational Journal of Laboratory Medicine. 2022 Jul, Vol-11(3): PO40-PO45 \nOriginal Article DOI: 10.7860/NJLM/2022/54846.2643\nINTRODUCTION\nHysterectomy is a commonly performed surgical procedure for \nbenign pathologies like leiomyoma, Abnormal Uterine Bleeding \n(AUB), chronic pelvic pain, adenomyosis, pelvic inflammatory \ndisease (PID), endometriosis despite the availability of several \neffective medical and conservative treatment options. Although the \nincidence of hysterectomy in India is lower than western nations, \nowing to its longterm side effects, it has emerged as an important \nissue in debates on healthcare and medical ethics [1].\nThere is growing evidence to indicate that many health and \npsychosexual complications occur following hysterectomy [2-7]. \nPostmenopausal symptoms start prematurely in atleast 30% of \nwomen within two years post hysterectomy despite preservation of \nadnexa [8]. This implies that uterus should not be considered as just \nan organ for child bearing and its functions have an overall impact \non the quality of a woman’s life. Thus, the decision for hysterectomy \nshould be meticulously planned after thorough discussion and \ncounselling of the patients.\nHistopathology helps to confirm the suspected clinical indication \nfor hysterectomy and allows to verify the appropriateness of the \nsurgical procedure.\nRegular histopathological audit of hysterectomy specimens for \nnon oncological indications gives an overall perspective to the \nclinician regarding the structural pathologies that were histologically \nconfirmed, as well as additional or alternate structural pathologies \nthat were hitherto clinically missed. This improves the knowledge \nand expertise of the healthcare provider, helping them make better \nfuture clinical decisions thus, augmenting the quality of healthcare \nprovided to the patient.\nThe present study was undertaken to correlate clinical and \nhistopathological diagnosis in hysterectomies that were performed \nfor non oncological indications and to assess the agreement \nbetween the two.\nMATERIALS AND METHODS\nThis was a retrospective cross-sectional study carried out over a \nperiod of one year (April 2019 to March 2020) in the Department of \nPathology at a tertiary healthcare centre in Ajmer, Rajasthan, India, \nafter taking Institutional Ethical Committee approval (735/Acad-III/\nMCA/2021;07/04/21). The data analysis was done in the months of \nApril and May 2021.\nInclusion criteria: All the hysterectomies performed for non \noncological indications during the study period were included.\nExclusion criteria: Hysterectomy procedures performed for \noncological causes were excluded.\nStudy Procedure\nNecessary clinical data i.e., age, presenting complaints, clinical \nindications, type of surgery performed were recorded from the \nhistopathology requisition forms. Identity of the patient and the treating \ndoctor were not recorded. The gross pathological information was \nretrospectively collected from the histopathology records as all the \nspecimens received for histopathology were routinely subjected to \ndetailed gross examination, noted for the presence of definite structural \nKALPANA SHARMA\n \nKeywords: Adenomyosis, Benign gynaecologic pathologies,  Histopathological audit, Leiomyoma, Polyps\nABSTRACT\nIntroduction: Hysterectomy is a common surgical procedure \nfor benign gynaecologic pathologies despite the availability \nof conservative treatment options. However, studies indicate \nmany health and psychosexual complications following this \nprocedure. Regular histopathological audit of hysterectomies in \nrelation to the clinical rationale will provide valuable data and \ninsight and thus, lead to improved knowledge and expertise.\nAim: To correlate clinical and histopathological diagnosis in \nhysterectomies for non oncological indications and assess the \nagreement between the two modalities.\nMaterials and Methods:  A retrospective cross-sectional study \nwith comparative clinicopathological analysis which included 702 \nhysterectomies for non oncological indications during a one-year \nperiod (April 2019 to March 2020) was carried out in the Department \nof Pathology at a tertiary healthcare centre in Ajmer, Rajasthan, \nIndia. Cohen-kappa value was determined to measure the degree \nof agreement between clinical and histopathological diagnosis. A \ncomparative clinicopathological analysis was done by segregating \ncases into two categories-those with structural pathologies and \nthe other with non structural/functional pathologies.\nResults: A total of 702 hysterectomy specimens were \nstudied. The clinicopathological concordance for structural \nlesions was better than functional aetiologies (87.52% vs \n57.8%). Leiomyoma was the most frequent clinical and \nhistopathological diagnosis. Histopathology revealed more \nstructural lesions than clinically suspected (81.2% vs 75.36%). \nThe Cohen-kappa value revealed an overall fair agreement \nbetween clinical and histopathological judgement ( κ=0.27). \nClinicopathological-agreement was lower in adenomyosis, \ndual structural pathologies while it was better for polyps, \nleiomyomas, obstetric pathologies and procidentia.\nConclusion: Although, an overall fair degree of agreement \nwas found between clinical and histopathological diagnosis, \nconditions that lack a specific clinical presentation or a \nsensitive diagnostic test like adenomyosis showed poor \nclinicopathological agreement. Histopathology is a vital \ntool to verify the appropriateness of the clinical indication of \nhysterectomies. Frequent clinicopathological correlation helps \nin improving knowledge and expertise of the healthcare provider, \nthus improving future clinical judgements.\n\n\nwww.njlm.net Kalpana Sharma, Clinicopathological Correlation of Non Oncological Hysterectomies\nNational Journal of Laboratory Medicine. 2022 Jul, Vol-11(3): PO40-PO45 4141\nKeywords: Adenomyosis, Benign gynaecologic pathologies,  Histopathological audit, Leiomyoma, Polyps\nabnormalities like leiomyomas, polyps with special attention to \nendometrial thickness and trabeculations in myometrium for endometrial \nhyperplasia and adenomyosis respectively. In the presence of polyps \nand fibroids, their number, location and dimensions were noted. In cases \nwhere adnexa (unilateral/bilateral) were received, ovaries and fallopian \ntube were evaluated separately after taking due measurements. Both \nexternal and cut surfaces were thoroughly examined for any obvious \nstructural pathology, foci of endometriosis, cysts. Fallopian tube lumen \nwas examined for any dilatations and collections. Representative \ntissue samples were taken from cervix (including transformation zone), \nendometrium, myometrium, adnexa (when present) and any other \nexisting structural lesions like polyps, leiomyomas.\nAfter routine tissue processing, 4-5 micron thick Haematoxylin and \nEosin ( H&E) stained sections were subjected to detailed microscopic \nexamination. A review of the histological slides was done for arriving \nat the final histopathological diagnosis.\nA comparative clinicopathological analysis was done by segregating \ncases into two categories-those with structural pathologies and \nthe other with non structural/functional pathologies. The structural \ngroup included cases of AUB-PALM (Abnormal Uterine Bleeding-\nPolyp, Adenomyosis, Leiomyoma, Hyperplasia/Malignancy-as per \nInternational Federation of Gynaecology and Obstetrics classification] \n[9], prolapse, obstetric pathologies, Pelvic Inflammatory Disease \n(PID) and more than one structural abnormality [dual pathology]. \nThe functional/non structural group were the cases where no \ndefinite structural alteration was suspected/seen which included \nAUB-COEIN [Abnormal Uterine Bleeding-Coagulopathy, Ovulatory, \nEndometrial, Iatrogenic, not otherwise specified- as per International \nFederation of Gynaecology and Obstetrics classification] [9].\nIn cases of structural pathologies, it was assessed if histopathology \ncorrelated with the primary clinical diagnosis or it showed some \nadditional pathologies or if it showed an entirely different diagnosis \naltogether. For cases where a functional cause was the indication \n(AUB-COEIN), if the histopathology failed to detect any definite \nstructural pathology it was considered to have justified the primary \nclinical diagnosis.\nSTATISTICAL ANALYSIS\nTo measure the degree of agreement between clinical and \nhistopathological diagnosis with respect to various structural pathologies, \nCohen kappa statistical value ( κ value) was determined. For every \nstructural pathology, the following were noted- namely the number \nof cases in which both the modalities (clinical and histopathological) \nagreed to include; the number of cases in which both modalities agreed \nto exclude and the number of cases in which only one of the modalities \nshowed the particular diagnosis. κ value for all the above parameters \nwas determined. Concordance between clinical and histopathological \nfindings was further statistically analysed with p-value less than 0.05 \nbeing considered statistically significant. The 3.6.1 version of R software \nwas used in calculating the statistical values.\nRESULTS\nDuring the study period of one year, a total of 702 hysterectomies \nwere performed for non oncological indications. The clinical profile \nof the patients showed ages ranging from 19-79 years and for the \npurpose of study were divided into five age group categories with \nthe numbers and type of surgery depicted in detail in [Table/Fig-1]. \nThe various clinical indications for hysterectomy are depicted as a \npie-chart in [Table/Fig-2].\nOf the 702 cases a suspected structural pathology (AUB-PALM/\nprolapse/PID/ obstetric/dual pathology) was the indication in 529 \ncases (75.4%) [Table/Fig-3-5] and a functional aetiology (AUB-\nCOEIN) in 173 cases (24.6%). AUB-L was overall the most common \nclinical indication (37.32%;262/702).\nBased on the histological findings a final reallocation of the cases \nwas done in the same categories as shown in [Table/Fig-6].\n[Table/Fig-2]: Distribution of cases as per primary clinical diagnosis.\n*AUB-P: Abnormal uterine bleeding-polyp; AUB-A: Abnormal uterine bleeding-adenomyosis; \nAUB-L: Abnormal uterine bleeding-leiomyoma; AUB-M: Abnormal uterine bleeding-hyperplasia/\nmalignancy; PID: Pelvic inflammatory disease; AUB-COEIN: Abnormal Uterine Bleeding- Coagul-\nopathy, ovulatory, endometrial, Iatrogenic; Not otherwise specified\n[Table/Fig-3]: Abnormal Uterine Bleeding (AUB)-structural causes PALM Category \n(Haematoxylin and Eosin stain); a) Endometrial Polyp (P) [×100]; b) Adenomyosis (A) \n[×40]; c) Leiomyoma (L) [×100]; d) Endometrial hyperplasia without atypia (M) [×100].\n[Table/Fig-1]: Age-wise distribution of Types of hysterectomies.\n*TAH: Total Abdominable Hysterectomy; TAH USO: Total Abdominable Hysterectomy with \nUnilateral Salpingo-oopherectomy; TAH BSO-Total Abdominable Hysterectomy with Bilateral \nSalpingo-oopherectomy; VH- Vaginal Hysterectomy; TAH with BSO was the most frequent surgi-\ncal procedure between age 31-50 years with Abnormal Uterine Bleeding [AUB] being the most \ncommon presenting complaint; Vaginal hysterectomy for prolapse dominated in patients older \nthan 51 years. TAH was the most common procedure in the age group less than 30 years as \nobstetric causes were the predominant indication\n\nKalpana Sharma, Clinicopathological Correlation of Non Oncological Hysterectomies www.njlm.net\nNational Journal of Laboratory Medicine. 2022 Jul, Vol-11(3): PO40-PO454242\n[Table/Fig-8]: Correlation of clinical and histopathological diagnosis.\n*AUB-P [Abnormal Uterine Bleeding-Polyp]; AUB-A [Abnormal Uterine Bleeding-Adenomyosis]; \nAUB-L [Abnormal Uterine Bleeding-Leiomyoma]; AUB-M [Abnormal Uterine Bleeding-Hyperpla-\nsia/Malignancy]; PID [Pelvic Inflammatory Disease]\n[Table/Fig-4]: a) Cervical epithelial changes induced by uterine prolapse [×100]; \nb) Obstetric causes of hysterectomy- placenta accreta showing chorionic villous \nimplantation directly onto myometrial fibres with no intervening decidua (x100) \n(Haematoxylin and Eosin stain).\n[Table/Fig-5]: Pelvic inflammatory disease (Haematoxylin and Eosin stain); a) \nChronic Endometritis [×100]; b) Chronic Salpingitis [×100].\n[Table/Fig-7]: Co-existent premalignant/dysplastic cervical epithelial lesions (Hae-\nmatoxylin and Eosin stain); a) Koilocytic atypia/Low grade squamous intraepithelial \nlesion (LSIL) [×100]; b) High grade squamous intraepithelial lesion (HSIL) [×100].\n[Table/Fig-6]: Distribution of cases as per final histopathological diagnosis.\n*AUB-P: Abnormal uterine bleeding-polyp; AUB-A: Abnormal uterine bleeding-adenomyosis; \nAUB-L: Abnormal uterine bleeding-leiomyoma; AUB-M: Abnormal uterine bleeding-hyperplasia/\nmalignancy; PID: Pelvic inflammatory disease\nsuspected and in 32 cases no structural pathology was detected \nhistologically. Good clinicopathological correlation was observed \nwith AUB-P (80%), AUB-L (89.69%), prolapse (100%) and obstetric \npathologies (100%). Low concordance between clinical judgement \nand histopathological diagnosis was seen with AUB-A, AUB-M and \nPID (52.94%,16.67%, 27.27% respectively) [Table/Fig-9].\nPrimary clinical diagnosis\nTotal \nno. of \ncases\nNo. of cases\nThat were \nhistologically \nconfirmed\nConcordance \nPercentage \n(%)\n1. Structural Pathology 529 463 87.52\nAUB-\nPALM\nPolyp 10 08 80\nAdenomyosis 17 09 52.94\nLeiomyoma 262 235 89.69\nEndometrial hyperplasia 06 01 16.67\nDual Structural Pathology\n(AUB-PALM /in conjunction with \nprolapse/PID)\n12 12 100\nProlapse 171 171 100\nPelvic inflammatory disease 33 09 27.27\nObstetric Pathology 18 18 100\n2. Functional Pathology\n(AUB-COEIN) 173 100 57.8\nTotal 702 563 80.2\n[Table/Fig-9]: Concordance between primary clinical diagnosis and histopathology.\nHistopathology also showed leiomyoma to be the most common \nstructural pathology (28.63%;201/702) but the overall identification \nof cases with dual structural pathology showed a marked increase \nvis-à-vis clinical suspicion (21.2% vs 1.7%). Premalignant cervical \nlesions, unsuspected clinically were additionally detected in 6/702 \ncases (0.85%) [Table/Fig-7].\nThe results were analysed to see the number of cases in which \nthe primary clinical diagnosis was confirmed on histology and a \nconcordance percentage calculated [Table/Fig-8,9].\nOf the 529 cases clinically suspected of a structural pathology, the \ndiagnosis was histologically confirmed in 463 cases with 87.52% \noverall concordance. Of these in 322 cases the agreement was perfect \nand in 141 additional structural abnormalities apart from primary \nclinical suspicion, were identified on histology. In the remaining 66 \ncases where a particular structural pathology was clinically suspected, \n34 cases showed a different structural pathology than clinically \nOf the 173 cases suspected of a functional aetiology (AUB-\nCOEIN), 100 cases did not reveal any definite structural \npathology on histological examination thus indirectly justifying \nthe primary clinical judgement while 73 cases revealed some \nstructural pathology that was previously missed clinically (57.8% \nconcordance). Of these the most common were AUB-A (28/73) \nAUB-L (20/73), AUB-A, L (8/73).\nA final tabulation and comparison of the cases into different \ncategories as per the two modalities [clinical and histopathological] \nis shown in [Table/Fig-10].\n\nwww.njlm.net Kalpana Sharma, Clinicopathological Correlation of Non Oncological Hysterectomies\nNational Journal of Laboratory Medicine. 2022 Jul, Vol-11(3): PO40-PO45 4343\nCategory\nPrimary clinical \ndiagnosis\n(N=702)\nFinal histopathological \ndiagnosis\n(N=702) p-value\nStructural \npathology 529 (75.36%) 570 (81.2%) 0.0078 (S)\nAUB\nP 10 (1.42%) 13 (1.85%) 0.6741 (NS)\nA 17 (2.42%) 49 (6.98%) <0.0001 (HS)\nL 262(37.32%) 201 (28.63%) 0.001 (S)\nM 06 (0.85%) 02 (0.28%) 0.2875 (NS)\nDual \nstructural \npathologies\n(P, A; A, L; \nP, A, L; P, L; \nL, M)\n10 (1.42%) 80 (11.4%) <0.0001 \n(HS)\nProlapse 171 (24.36%) 115 (16.38%) 0.0002 (S)\nProlapse coexistent \nwith other structural \npathology of PALM \ncategory\n01 (0.14%) 57 (8.12%) <0.0001 \n(HS)\nPelvic inflammatory \ndisease 33 (4.7%) 17 (2.42%) 0.0307 (S)\nPelvic inflammatory \nDisease coexistent \nwith other structural \npathology of PALM \ncategory\n01 (0.14%) 12 (1.7%) 0.0053 (S)\nObstetric pathology 18 (2.56%) 18 (2.56%) 1.0000 (NS)\nPremalignant cervical\nLesions (LSIL/HSIL) 00 (0%) 06 (0.85%) 0.0309 (S)\nFunctional \npathology\n(No definite structural \nabnormality)\n173 (24.64%)  132 (18.8%) 0.0078 (S)\n[Table/Fig-10]: Classification and comparison of cases as per clinical and final \nhistopathological diagnosis.\n*HS: Highly significant; S: Significant; NS: not significant; LSIL: Low grade squamous intraepithe-\nlial lesion; HSIL: High grade squamous intraepithelial lesion\n[Table/Fig-12]: Status and details of adnexae in different age groups.\n*USO: Unilateral salpingo-oopherectomy; BSO: Bilateral salpingo-oopherectomy\nAge group \n(Yrs)\nTotal \nno.\nAdnexa \npre-\nserved\nUSO BSO\nNo. with \npositive\npathological \nfinding\nPercentage \nof positive \npathological \nfinding (%)\n≤30 25 19 05 01 0/6 0\n31-40 229 75 43 111 22/154 14.28\n41-50 296 100 34 162 20/196 10.2\n51-60 96 56 06 34 4/40 10\n>60 56 49 - 07 0/7 0\nTotal 702 299 88 315 46/403 11.41\ndiagnosis of AUB-L, AUB-P . However, with AUB-A and dual pathologies \nthe agreement was ‘none to slight’, since these diagnoses were more \noften than not missed clinically and detected only on histopathology. \nWith AUB-M and PID, it was fair with cases being suspected clinically \nbut not finding an equivalent histopathological correlation and vice-\nversa. The overall agreement between clinical and histopathological \njudgement for structural pathologies was found to be fair (κ=0.27).\n[Table/Fig-12] shows the age-wise distribution of the types of \noophorectomies. Total 88.3% (356/403) of the patients who underwent \nsimultaneous oophorectomy (unilateral/bilateral) were under the age \nof 50 years and a significant proportion of 39.7% (160/403) were \nunder the age of 40 years. However, only 11.41% (46/403) of all \nthe oophorectomies showed some definite structural pathology \n(endometriosis/salpingo-oophoritis/haemato-salpinx/ hydro-salpinx/\nsimple serous cyst/ovarian stromal hyperplasia). Most ovaries were \nunremarkable with others showing functional cysts (cystic follicles, \ncorpus luteal cysts) only.\nDISCUSSION\nThe present study was a clinicopathological correlation in a total \nof 702 hysterectomies performed for non oncological indications \nin a year across various age groups. As expected, and seen \nin various other studies too, majority of the patients were in the \nperimenopausal age group of 41-50 years (42%; 296/702) [10,11]. \nUnderstandably, the most frequent guiding indication varied as per \ndifferent age group with obstetric causes in patients 30 years and \nbelow, AUB between 31-50 years and prolapse in patients older \nthan 51 years.\nThe overall concordance between clinical and histological diagnosis \nwith respect to structural pathologies was found to be good at \n87.52%. As compared to clinical diagnosis, histopathological \nexamination detected structural abnormalities in more cases \n(529 vs 570 out of 702 cases) which was statistically significant \ntoo. Similar studies analysing clinicopathological correlation found \nhistopathology detecting more structural pathologies than clinically \nsuspected [Table/Fig-13] [12,13]. This was majorly due to additional \nhistological detection of adenomyosis, co-existent dual structural \npathologies like missed leiomyomas, polyps and premalignant \ncervical lesions.\nAuthors and studies\nClinical diagnosis of  \nAUB-PALM\nHistopathological\ndiagnosis of AUB-PALM*\nPresent study 75.36% (n=529/702) 81.2% (n=570/702)\nMishra D and Sultan S [12] 50.42% (n=119/236) 63.98% (n=151/236)\nSingh K et al., [13] 91.16% (n=134/147) 95.24% (n=140/147)\n[Table/Fig-13]: Comparative clinicopathological correlation of structural lesions [12,13].\n*Histopathological analysis detected more structural pathologies than clinical suspicion\nCategory of Structural Pathology κ value\nDegree of  \nassociation\nAUB-P 0.51 Moderate\nAUB-A 0.11 None to slight\nAUB-L 0.64 Substantial\nAUB-M 0.24 Fair\nDual pathologies (AUB P, A; A, L; P, A, L; P, \nL; L, M / in conjunction with Prolapse/PID) 0.03 None to slight\nProlapse 1.00 Perfect\nPID 0.25 Fair\nObstetric pathology 1.00 Perfect\nAll structural pathologies 0.27 Fair\n[Table/Fig-11]: Agreement between clinical and histopathological diagnosis in dif-\nferent structural pathologies. *Cohen suggested the Kappa result be interpreted as follows: \nvalues ≤0 as indicating no agreement and 0.01-0.20 as none to slight, 0.21-0.40 as fair, 0.41- \n0.60 as moderate, 0.61–0.80 as substantial, and 0.81-1.00 as almost perfect agreement.\nClinicopathological correlation showed good concordance of \n80% and 89.69% with polyps (AUB-P) and leiomyomas (AUB-L) \nrespectively as these structural lesions are quite easily diagnosed \nwith confidence clinically and radiologically. As shown by κ value too, \nthe clinicopathological agreement in these conditions was moderate \nand substantial respectively. Majority of the polyps that went clinically \nIn comparison to the clinical diagnosis, histopathology revealed \nstructural pathologies in a greater number of cases (570 vs 529 \nout of 702 cases). This was especially due to additional histological \ndetection of adenomyosis (AUB-A), co-existent dual structural \npathologies, premalignant cervical lesions which remained clinically \nelusive. This difference was found to be statistically significant with \np-values less than 0.05 as shown in [Table/Fig-10].\nThe degree of agreement between clinical and histopathological \ndiagnosis with respect to various structural pathologies using Cohen \nkappa statistical value ( κ value) and its interpretation is shown in \n[Table/Fig-11].\nAs can be seen, the agreement was almost perfect in cases of prolapse \nand obstetric pathologies and substantial to moderate with the \n\nKalpana Sharma, Clinicopathological Correlation of Non Oncological Hysterectomies www.njlm.net\nNational Journal of Laboratory Medicine. 2022 Jul, Vol-11(3): PO40-PO454444\nundetected were endometrial polyps as cervical polyps were more \neasily spotted on per speculum examination. Overall histopathology \ndetected more polyps but the difference was not statistically \nsignificant. Our findings were similar to other such studies [12,13].\nMajority (86.6%) of clinically missed leiomyomas which were \ndetected on histopathology were small [around 1 cm in diameter]. \nIn most cases the clinical impression was AUB due to functional \ncauses and PID in others. It’s difficult to ascertain whether these \nsmall lesions were responsible for the clinical symptoms or mere \nincidental findings. However, we do know that fibroids can be \nsymptomatic irrespective of their size and location [14].\nAdenomyosis did not show a comparative clinicopathological \nconcordance (only 52.94%) with none to slight clinicopathological \nagreement [ κ=0.11]. Other researchers too have highlighted \nthe difficulty in the clinical diagnosis of adenomyosis [12,13,15]. \nHistopathology detected significantly more cases of adenomyosis \n(p-value<0.0001). This could be because adenomyosis has vague \npresenting complaints and can often go undetected radiologically \ntoo. Co existent leiomyomas can also make detection of \nadenomyosis difficult by transabdominal sonography which was \nthe usual primary radiological investigation employed [12,16,17]. \nIncreased histological identification of adenomyosis as the sole or \nadditional structural abnormality led to reallocation of diagnosis to \ncategories of AUB-A and dual diagnosis like AUB-P , A; A, L; P , A, \nL respectively.\nHistological detection of co-existent dual structural pathologies was \nsignificantly higher as compared to clinical suspicion (21.2% vs 1.7%) \nwith none to slight clinicopathological agreement ( κ=0.03). 33% of \nprolapsed uterus showed additional structural pathologies of PALM \ncategory. Co-existent structural pathologies like adenomyosis, \nleiomyomas or in some cases both can add to the bulkiness of \nuterus, aggravating pressure on an already weakened pelvic floor \nthus further contributing to procidentia.\nThe AUB-A,L was histologically the most commonly detected dual \npathology followed by AUB-P ,L. Detection of additional unsuspected \nstructural pathologies led to reallocation of the AUB-PALM category \nemphasising the role of histopathology as a complementary \ndiagnostic tool in PALM component of AUB [12,18,19].\nMore cases of AUB due to endometrial hyperplasia (AUB-M) \nwere suspected clinically with no corresponding histopathological \nconfirmation showing a low concordance of 16.67%. Most of these \ncases revealed some other structural pathology belonging to AUB-\nPALM category. Singh K et al found a better clinicopathological \nconcordance [55.6%] in AUB-M [13]. Mishra D and Sultan S found \nmore cases of AUB-M diagnosed histologically than clinically, with \nthe difference being statistically significant [12]. The present study \nhowever, did not reveal any significant increase in histological \ndetection of endometrial hyperplasia. This was probably because \nSingh K et al and Mishra D and Sultan S included cases of \nendometrial malignancies in their study, while the present study \nexcluded all oncological causes of hysterectomies.\nWith PID too, the clinicopathological agreement was only fair ( κ= \n0.25) with clinically suspected cases not finding corresponding \nhistological affirmation and vice-versa. This could be because \nendometrial hyperplasia and PID are associated with non specific \nclinical presentations which can overlap with other causes of AUB \nand there is no single test sensitive or specific enough for definite \nclinical diagnosis.\nHysterectomy performed for AUB due to suspected functional \naetiology (AUB-COEIN) showed a corresponding 57.8% histological \nconcordance. Absence of a definite structural pathology on histology \nwas taken as an agreement to primary clinical diagnosis as AUB-\nCOEIN component does not show any specific histological findings. \nIn the remaining 42% ca ses clinically suspected of a functional \naetiology, structural lesions like adenomyosis, leiomyomas, or both \nwere detected thus reassigning the cause of AUB from suspected \nfunctional cause to structural category.\nConversely, in 32 cases a primary structural pathology was clinically \nassigned but histopathology was unremarkable, thus reallocating \nthe diagnosis from structural to functional aetiology.\nThis reiterates the complementary role of the two modalities with \nhistological assessment helping in putting clinical diagnosis in the \ncorrect perspective and guiding appropriate management plan thus \nultimately benefiting the patient [12].\nClinicopathological findings were perfectly complementary in \nobstetric cases as clinical judgement in these conditions is \nunquestionable.\nA significant 88% of patients undergoing simultaneous adnexa \nremoval [unilateral/bilateral] were younger than 50 years. However, \nonly a nominal 11.41% showed some definite pathology on \nhistological examination. Age of the patient, route of hysterectomy \nand concomitant gynaecologic diagnosis are some of the guiding \nfactors that influence the decision of oophorectomy. Whether \nor not to preserve ovaries at the time of hysterectomy for benign \nconditions is a topic of debate. Preserving ovaries is associated with \nfuture complications of residual ovary syndrome and ovarian cancer \nrisk while removing them especially in premenopausal women may \nset in early menopause and complications of hormone replacement \ntherapy. Therefore, a final decision should be established on an \nindividual basis, taking into consideration age, individual and family \nrisk factors, the patient's preference and ability to ensure long-\nterm compliance to exogenous hormone replacement therapy \n[8,20,21,22].\nLimitation(s)\nThe fact that the diagnosis of the functional causes of abnormal \nuterine bleeding was essentially based on exclusion of a primary \nstructural pathology was the main limitation of the research. A \ndetailed work up of these cases would have greatly enhanced \nthe understanding of the aetiopathogenesis of abnormal uterine \nbleeding.\nCONCLUSION(S)\nThe present study showed a good concordance between primary \nclinical diagnosis and histopathological findings with an overall \nfair degree of agreement between the two. Histopathology is a \nvital tool to verify the appropriateness of the clinical indication of \nsurgical procedures like hysterectomy which has a profound impact \non a woman’s overall well-being. Frequent clinicopathological \ncorrelation studies can help in improving knowledge and expertise \nof the healthcare provider, improving future clinical judgements thus, \nbenefitting patients.\nREFERENCES\n Desai S, Shukla A, Nambiar D, Ved R. Patterns of hysterectomy in India: a national [1]\nand state-level analysis of the Fourth National Family Health Survey (2015-2016). \nBJOG. 2019 Aug;126 Suppl 4(Suppl Suppl 4):72-80. [Doi: 10.1111/1471-\n0528.15858. PMID: 31309706; PMCID: PMC6772015].\n Ding DC, Tsai IJ, Hsu CY, Wang JH, Lin SZ, Sung FC. Risk of hypertension after [2]\nhysterectomy: a population-based study. BJOG. 2018 Dec;125(13):1717-24. \n[doi: 10.1111/1471-0528.15389. Epub 2018 Aug 6. PMID: 29953717].\n Yeh JS, Cheng HM, Hsu PF, Sung SH, Liu WL, Fang HL, et al. 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Ovarian [21]\nconservation at the time of hysterectomy for benign disease. Obstet Gynecol. \n2005 Aug;106(2):219-26. [Doi: 10.1097/01.AOG.0000167394.38215.56. PMID: \n16055568].\n Evans EC, Matteson KA, Orejuela FJ, Alperin M, Balk EM, El-Nashar S, et [22]\nal. Society of Gynecologic Surgeons Systematic Review Group. Salpingo-\noophorectomy at the Time of Benign Hysterectomy: A Systematic Review. Obstet \nGynecol. 2016 Sep;128(3):476-85. [Doi: 10.1097/AOG.0000000000001592. \nPMID: 27500347; PMCID: PMC5100819].\nPARTICULARS OF CONTRIBUTORS:\n1. Associate Professor, Department of Pathology, J.L.N Medical College, Ajmer, Rajasthan, India.\nPLAGIARISM CHECKING METHODS: [Jain H et al.]\n•  Plagiarism X-checker: Jan 24, 2022\n•  Manual Googling: Mar 26, 2022\n•  iThenticate Software: Apr 09, 2022 (6%)\nETYMOLOGY: Author OriginNAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR:\nDr. Kalpana Sharma,\nB 21, Arawali Vihar, Ajmer, Rajasthan, India.\nE-mail: pkss75780507@gmail.com\nDate of Submission: Jan 09, 2022\nDate of Peer Review: Feb 22, 2022\nDate of Acceptance: Mar 28, 2022\nDate of Publishing: Jul 01, 2022\nAUTHOR DECLARATION:\n•  Financial or Other Competing Interests:  None\n•  Was Ethics Committee Approval obtained for this study?   Yes\n•  Was informed consent obtained from the subjects involved in the study?  No\n•  For any images presented appropriate consent has been obtained from the subjects.  No","source_license":"CC0","license_restricted":false}