Role of Transvaginal Ultrasonography in the Evaluation of Abnormal Uterine Bleeding

Background: Abnormal uterine bleeding (AUB) is one of the most common gynecological complaints affecting women of reproductive and perimenopausal age. Transvaginal ultrasonography (TVUS) is widely used as the initial imaging modality for identifying the underlying causes of AUB.

To evaluate the role of transvaginal ultrasonography in women presenting with abnormal uterine bleeding and to assess its diagnostic performance in detecting endometrial pathology.

This prospective observational study included 150 women with abnormal uterine bleeding attending a tertiary care hospital. Detailed clinical evaluation and transvaginal ultrasonography were performed in all participants. Ultrasonographic findings , endometrial thickness, and uterine abnormalities were recorded. Hi stopathological examination was used for correlation wherever indicated. Data were analyzed using IBM SPSS Statistics version 25.0 , and a p-value <0.05 was considered statistically significant.

The mean age of participants was 43.9 ± 9.6 years , with the majority (40.0%) belonging to the 41–50 years age group. Heavy menstrual bleeding was the most common presenting complaint (48.0%). Leiomyoma (32.0%) was the most frequent ultrasonographic finding , followed by endometrial hyperplasia (18.7%) and ade nomyosis (13.3%). Women aged 41 –50 years had significantly greater endometrial thickness (p = 0.018). TVUS demonstrated a sensitivity of 91.2%, specificity of 87.5%, positive predictive value of 88.6% , negative predictive value of 90.3% , and an overall dia gnostic accuracy of 89.3% for detecting endometrial pathology.

Transvaginal ultrasonography is an effective and accurate first -line diagnostic tool for evaluating abnormal uterine bleeding. Its high diagnostic accuracy and non -invasive nature m ake it valuable for the early detection of uterine and endometrial abnormalities , thereby guiding appropriate clinical management.

Abnormal uterine bleeding , Transvaginal ultrasonography , Endometrial thickness , Leiomyoma, Endometrial hyperplasia, Diagnostic accuracy

Abnormal uterine bleeding (AUB) is one of the most common gynecological complaints affecting women of reproductive and perimenopausal age and accounts for a substantial proportion of outpatient visits. It is defined as bleeding from the uterine corpus that is abnormal in volume , regularity, frequency, or duration and occurs in the absence of pregnancy. The International Federation of Gynaecology and Obstetrics (FIGO) introduced the PALM -COEIN classification system to stan dardize the etiological diagnosis of AUB into structural and non - structural causes , thereby improving clinical evaluation and management [1, 2]. Transvaginal ultrasonography (TVUS) has emerged as the first -line imaging modality for evaluating women with AU B because it is non -invasive, widely available , cost-effective, and provides excellent visualization of the uterus , endometrium, ovaries, and adnexa. It plays an important role in identifying structural abnormalities such as leiomyomas , endometrial polyps , adenomyosis, endometrial hyperplasia, and endometrial carcinoma while also assessing endometrial thickness and morphology [3, 4]. Several studies have demonstrated that measurement of endometrial thickness by TVUS has high sensitivity for detecting endome trial pathology , particularly in postmenopausal women with bleeding. Its diagnostic accuracy has made TVUS an indispensable initial investigation before proceeding to invasive procedures such as endometrial biopsy or hysteroscopy [5, 6]. In addition to eva luating endometrial pathology , TVUS combined with Doppler imaging improves the characterization of endometrial lesions and contributes to the diagnosis of adenomyosis and other uterine abnormalities, thereby facilitating appropriate International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 878 ~ treatment planning [7, 8]. Considering its widespread use and diagnostic utility, the present study was undertaken to evaluate the role of transvaginal ultrasonography in women presenting with abnormal uterine bleeding attending a tertiary care hospital.

and Methodology Study Design This was a hospital -based prospective observational study conducted to evaluate the role of transvaginal ultrasonography in the assessment of abnormal uterine bleeding. Study Setting The study was carried out in the Department of Obstet rics and Gynaecology, in collaboration with the Department of Radiodiagnosis, at a tertiary care teaching hospital. Study Duration The study was conducted over a period of 18 months after obtaining approval from the Institutional Ethics Committee. Study Population Women presenting with complaints of abnormal uterine bleeding and referred for transvaginal ultrasonography were included in the study. Sample Size A total of 150 women with abnormal uterine bleeding were enrolled consecutively during the study period. Inclusion Criteria  Women aged 18 years and above presenting with abnormal uterine bleeding.  Premenopausal, perimenopausal, and postmenopausal women with uterine bleeding.  Patients willing to provide written informed consent. Exclusion Criteria  Pregnancy or pregnancy-related bleeding.  Known bleeding disorders.  Acute pelvic inflammatory disease.  Patients with cervical malignancy diagnosed on clinical examination.  Women unwilling to participate. Study Procedure After obtaining informed written cons ent, a detailed history regarding age, parity, menstrual history, duration and pattern of bleeding, medical illnesses , and drug history was recorded. General physical and gynecological examinations were performed. All participants underwent transvaginal ul trasonography (TVUS) using a high -frequency (5 –9 MHz) transvaginal probe by an experienced radiologist. The following parameters were evaluated:  Endometrial thickness  Endometrial echogenicity  Uterine size and morphology  Presence of leiomyoma  Endometrial polyp  Adenomyosis  Endometrial hyperplasia  Ovarian pathology  Other pelvic abnormalities Histopathological examination of endometrial tissue , obtained by endometrial biopsy or hysterectomy wherever clinically indicated, was used as the reference standard for correlation. Outcome Measures  Spectrum of abnormalities detected on TVUS.  Measurement of endometrial thickness in women with AUB.  Correlation of TVUS findings with histopathological diagnosis where available.  Diagnostic accuracy of TVUS in identifying ute rine pathology. Statistical Analysis Data were entered into Microsoft Excel and analyzed using IBM SPSS Statistics version 25.0. Continuous variables were expressed as mean ± standard deviation , while categorical variables were presented as frequencies an d percentages. Associations between categorical variables were analyzed using the Chi -square test or Fisher's exact test. The diagnostic performance of TVUS was assessed by calculating sensitivity , specificity, positive predictive value (PPV) , negative predictive value (NPV), and overall diagnostic accuracy. A p -value <0.05 was considered statistically significant.

A total of 150 women presenting with abnormal uterine bleeding (AUB) were included in the study. The mean age of the participants was 4 3.9 ± 9.6 years (range: 22 –68 years). The majority of women belonged to the 41 –50 years age group (40.0%). Heavy menstrual bleeding was the most common presenting complaint. Transvaginal ultrasonography (TVUS) detected structural uterine abnormalities in a majority of patients, with leiomyoma being the most frequent finding. Histopathological correlation, wherever available, demonstrated good diagnostic accuracy of TVUS for endometrial pathology. Table 1: Demographic and clinical characteristics of study participants (n = 150) Variable Number (n) Percentage (%) Age (years) 21–30 18 12.0 31–40 42 28.0 41–50 60 40.0 >50 30 20.0 Parity Nulliparous 24 16.0 Multiparous 126 84.0 Presenting complaint Heavy menstrual bleeding 72 48.0 Intermenstrual bleeding 24 16.0 Irregular menstrual bleeding 30 20.0 Postmenopausal bleeding 24 16.0 Mean age: 43.9 ± 9.6 years Most participants (40.0%) were aged 41 –50 years , and 84.0% were multiparous. Heavy menstrual bleeding was the most common presenting complaint (48.0%), followed by irregular menstrual bleeding (20.0%). International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 879 ~ Table 2: Transvaginal ultrasonography findings among women with abnormal uterine bleeding (n = 150) TVUS Finding Number (n) Percentage (%) Leiomyoma 48 32.0 Endometrial hyperplasia 28 18.7 Adenomyosis 20 13.3 Endometrial polyp 16 10.7 Ovarian cyst 10 6.7 Normal study 22 14.6 Other pelvic pathology 6 4.0 Leiomyoma was the most common abnormality detected on TVUS (32.0%) , followed by endometrial hyperplasia (18.7%) and adenomyosis (13.3% ). Only 14.6% of women had normal ultrasonographic findings. Table 3: Endometrial thickness according to age group (n = 150) Age Group Endometrial thickness 10 mm Total p-value 21–30 years 2 12 4 18 31–40 years 6 26 10 42 41–50 years 8 30 22 60 >50 years 16 10 4 30 Total 32 78 40 150 0.018* *Chi-square test; p 10 mm, whereas women aged >50 years predominantly ha d endometrial thickness <5 mm. The association between age and endometrial thickness was statistically significant (p = 0.018). Table 4: Diagnostic performance of transvaginal ultrasonography for detecting endometrial pathology (Histopathology as reference standard) Parameter Value (%) Sensitivity 91.2 Specificity 87.5 Positive Predictive Value (PPV) 88.6 Negative Predictive Value (NPV) 90.3 Overall Diagnostic Accuracy 89.3 Transvaginal ultrasonography demonstrated high diagnostic performance in de tecting endometrial pathology , with a sensitivity of 91.2% , specificity of 87.5% , and an overall diagnostic accuracy of 89.3%, indicating that TVUS is a reliable first-line imaging modality in the evaluation of abnormal uterine bleeding.

The present prospective observational study evaluated the role of transvaginal ultrasonography (TVUS) in women presenting with abnormal uterine bleeding (AUB). The majority of patients were in the 41–50 years age group, reflecting the increased frequency of AUB during the perimenopausal period due to hormonal fluctuations and structural uterine abnormalities. TVUS successfully identified the underlying pathology in most patients, confirming its value as an effective first -line diagnostic modality. Leiomyoma was t he most common ultrasonographic finding (32.0%), followed by endometrial hyperplasia and adenomyosis. These findings are consistent with those reported by Dreisler et al., who demonstrated that TVUS accurately detects common structural causes of AUB and as sists in selecting patients who require further invasive evaluation [10]. Similarly, Farquhar et al. observed that endometrial hyperplasia is an important cause of abnormal uterine bleeding , particularly among women with increased endometrial thickness and associated risk factors [11]. The present study showed a significant association between increasing age and endometrial thickness, with women aged 41– 50 years exhibiting a higher frequency of endometrial thickening. These findings are in agreement with Wo lfman, who emphasized that measurement of endometrial thickness by TVUS is an important predictor of underlying endometrial pathology and helps determine the need for endometrial sampling [12]. TVUS demonstrated high sensitivity (91.2%) , specificity (87.5%), and overall diagnostic accuracy (89.3%) for detecting endometrial pathology. Similar observations were reported by Bradley and Gueye and Van den Bosch and Van Schoubroeck , who concluded that TVUS provides excellent visualization of the endometrium and m yometrium and significantly improves the diagnostic evaluation of women with AUB [13, 14]. Current NICE guidelines recommend transvaginal ultrasonography as the preferred initial imaging investigation for women with suspected structural causes of AUB becau se of its non-invasive nature, accessibility, and high diagnostic accuracy. Timely diagnosis with TVUS facilitates appropriate management and reduces unnecessary invasive procedures [15].

Transvaginal ultrasonography is a reliable , safe, and co st- effective first -line imaging modality for evaluating abnormal uterine bleeding. It accurately detects structural uterine abnormalities, assesses endometrial thickness , and demonstrates high diagnostic accuracy for identifying endometrial pathology. Early use of TVUS enables appropriate clinical decision - making, guides the need for histopathological evaluation , and contributes to improved patient management. Conflict of Interest Not available Financial Support Not available

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