A study to correlate clinical with pathological findings in abnormal uterine bleeding (AUB)

Introduction: Abnormal uterine bleeding (AUB) poses a significant health and financial burden, especially in perimenopausa l women. Despite the PALM -COEIN classification, gaps persist in correlating clinical and histopathological aspects. Our study, utilizing diagnostic modalities like Ultrasonography, Hysteroscopy, and Endometrial sampling, seeks to enhance diagnostic precisi on in AUB, contributing to improved management strategies and patient outcomes.

This descriptive study investigated Abnormal Uterine Bleeding (AUB) in 126 women aged 35 and above at our hospital from September 2019 to February 2021. The study utilized the PALM-COEIN classification system for categorizing AUB causes. Inclusion criteria covered various AUB presentations, while exclusion criteria excluded specific conditions. Data collection involved a structured proforma, and diagnostic interventions encompassed Ultrasonography, Hysteroscopy, and Endometrial sampling. Statistical analysis employed various measures, including the concordance index and Chi -square test, utilizing SPSS 21.

This hospital-based study enrolled 126 women presenting with abnormal uterine bleeding (AUB), offering comprehensive insights into their demographic, clinical, and histopathological profiles. The mean age of the cohort was 45.96 years, with a notable concentration in the 40 -44.99 age group. The maj ority resided in urban areas (96.83%) and belonged to the upper middle class (65.87%), with housewives constituting 97.62%. AUB patterns, including irregular bleeding (56.35%) and postmenopausal bleeding (15.87%), were meticulously examined. Comorbidities, predominantly hypertension (31 patients) and hypothyroidism (22 patients), were identified in 60 patients. Ultrasonography revealed Leiomyoma in 54.76% and Adenomyosis in 24.6%. Clinical diagnoses, utilizing the PALM -COEIN classification, highlighted AUB -L as the primary cause (54.76%). Diagnostic modalities such as Hysteroscopy, Hysterectomy, and concordance analyses contributed to enhanced diagnostic precision, emphasizing the multidimensional approach imperative for effective AUB management in clinical practice.

Our study underscores the efficacy of the PALM -COEIN classification in correlating clinical and histopathological findings for Abnormal Uterine Bleeding (AUB). Leiomyoma emerged as the primary etiology, showcasing the classification's utility in identifying dual pathologies. Histopathological examination significantly complemented clinical diagnoses, emphasizing the system's value in optimizing patient care.

Abnormal Uterine Bleeding (AUB), PALM-COEIN classification, Diagnostic modalities, Perimenopausal women

Abnormal uterine bleeding (AUB) is characterized by irregular, voluminous, frequent, or prolonged bleeding from the uterine corpus, excluding pregnancy [1]. This condition, prevalent among perimenopausal women, not only leads to physical and mental distress but also places a substantial financial burden on affected individuals [2]. Constituting more than 70% of gynecological consultations during the perimenopausal and postmenopausal years, AUB accounts for 35% of Gynecology OPD visits and 25% of gynecological surgeries [3]. Its prominence during the 2-8 years preceding menopause underscores the need for comprehensive understanding and effective management [4]. While the International Federation of Gynecolog y and Obstetrics (FIGO) has introduced the PALM-COEIN classification to categorize AUB causes, incorporating structural (PALM) and functional (COEIN) elements, there remains a gap in correlating clinical presentations with histopathological findings [4]. Acute AUB, necessitating immediate intervention, and chronic International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 81 ~ AUB, persisting for the majority of the last 6 months, further complicate the diagnostic landscape [5]. The potential severity of underlying causes, ranging from physiological processes to possible malignancies, underscores the importance of accurate identification through minimally invasive means. Diagnostic modalities, such as Ultrasonography, Hysteroscopy, and Endometrial sampling, play pivotal roles in discerning structural and functional ca uses of AUB. Ultrasonography, as a primary diagnostic tool, aids in detecting uterine abnormalities, while Hysteroscopy allows direct visualization and treatment in a single session. Endometrial sampling, a simple OPD procedure, effectively rules out malig nancy. The historical reliance on Dilatation and Curettage (D and C) for endometrial sampling has diminished due to associated risks, expenses, and the availability of less invasive alternatives [6]. Despite advancements, diagnosing AUB remains challenging, prompting the need for a comprehensive study to bridge the clinical - histopathological gap. This study seeks to address the existing knowledge gaps by correlating clinical findings with histopathological insights in AUB, employing the PALM -COEIN classific ation. The overarching aim is to enhance diagnostic precision, particularly in cases where conventional methods may fall short. By elucidating these connections, we aspire to contribute to the refinement of AUB management strategies, ultimately improving patient outcomes.

Study Design This descriptive study was done which investigated Abnormal Uterine Bleeding (AUB) in women aged 35 and above who presented to our hospital, from September 2019 to February 2021. Inclusion criteria 1. Women of age 35 years and above. 2. Patients having heavy menstrual bleeding. 3. Frequent cycles. 4. Frequent and heavy menstrual bleeding. 5. Intermenstrual bleeding. 6. Post-menopausal bleeding. Exclusion criteria 1. Vaginal bleeding related to pregnancy. 2. Pelvic inflammatory disease. 3. Genital prolapse. 4. Hormone therapy. 5. IUCD insertion. Sample size The sample size was calculated using the formula n=z²α x P x (Q)/d². In this study, Pearson coefficient, commonly used for correlation studies, was deemed inapplicable due to the categorical nature of variables. Utilizing assumptions with a likelihood value (P) of 0.09, margin of error (d) of 0.05, and a standard normal variate (z) of 1.96, the sample size was determined to be 126. Sample technique The sampling technique used was non -probabilistic sampling

of purposive sampling where all the patients attending to the Department of Obstetrics and Gynecology (OPD and IPD), of our hospital from 1 st September 2019 to 28th February 2021 (18 months), with complaints of AUB, were screened as per inclusion and exclusion criteria and subsequently included or excluded from the study. Data Collection Data collection for this study was conducted by the observer, using a designated study proforma. Prior to participation, eligible women were briefed about the study in their local vernacular language, and informed consent was obtained through a pre -approved proforma sanctioned by our ethical committee. Participants were explicitly granted the freedom to withdraw from the study at any stage.

This descriptive study was executed within the Obstetrics and Gynecology department at our hospital, involving 126 patients diagnosed with Abnormal Uterine Bleeding (AUB) who met the predetermined inclusion criteria. Prior to the commencement of the study, informed written consent was meticulously obtained from all parti cipants, and ethical approval from the institutional review committee was secured. A comprehensive medical history, encompassing chief complaints, history of present illness, demographic details, detailed menstrual history, obstetric history, past medical and surgical history, and personal history, was systematically documented. Subsequent to this, a thorough general physical examination, with a specific focus on identifying features of anemia, was conducted. Vital signs, including pulse, blood pressure, re spiratory rate, and temperature, were recorded, and a systemic examination covering cardiovascular, respiratory, and per abdomen aspects was undertaken. Pelvic examinations, incorporating local examination, per speculum, and bimanual pelvic examination, were meticulously performed. The investigative phase comprised a set of routine examinations, including Complete Blood Count (CBC), Urine Routine/Microscopy, ABORh, Random Blood Sugar (RBS), Thyroid Stimulating Hormone (TSH), Coagulation profile (aPTT, PTINR), viral markers, PAP smear, and Ultrasonography (TAS - 3-5 MHZ, TVS - 5-7.5 MHZ). Ultrasonography was conducted using the E soate Ultrasound Machine. Additional investigations, such as X-ray and ECG, were implemented when deemed necessary. Upon establishi ng a provisional diagnosis, patients underwent either Dilatation and Curettage / Endometrial sampling or Hysteroscopic evaluation. Tissue obtained was systematically subjected to histopathological examination. For patients undergoing Hysterectomy (open/lap aroscopic), specimens comprising the uterus, cervix, and ovaries were sent for macroscopic and histopathological examination. All findings were meticulously correlated with the PALM - COEIN classification system, encompassing categories such as AUB-P, AUB -A, AUB-L, AUB -M, AUB -C, AUB -O, AUB -E, AUB-I, and AUB -N. Subsequently, statistical analyses were performed to discern patterns and associations within these classifications, thereby contributing to a comprehensive understanding of Abnormal Uterine Bleeding in this cohort. Statistical Analysis The statistical analysis encompassed a comprehensive examination of the data, employing various measures to elucidate the characteristics of the study cohort. Descriptive statistics, including range, mean ± standard devi ation (± SD), frequencies (number of cases), and relative frequencies (percentages) were meticulously calculated as deemed International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 82 ~ appropriate for each variable. To compare categorical data, the analysis incorporated concordance measures, including the concordance index and Chi -square (χ²) test when applicable. Concordance, indicative of the agreement rate between two variables, was assessed through the concordance index, a metric evaluating the predictions made by the algorithm. The Concordance Index values were c ategorized based on their strength of correlation (>0.20: Poor, 0.21 –0.40: Fair, 0.41–0.60: Moderate, 0.61–0.80: Good, 0.81 –1.0: Very good). In instances where expected frequencies were less than 5, the Fisher exact test was employed. A probability value ( p-value) less than 0.05 was deemed statistically significant. All statistical computations were meticulously conducted using the Statistical Package for the Social Science (SPSS) 21 version, a widely recognized statistical program for Microsoft Windows dev eloped by SPSS Inc. in Chicago, IL, USA.

The present study, conducted at our hospital, focused on 126 women presenting with abnormal uterine bleeding, yielding valuable insights into various aspects of their demographic, clinical, and histopathological profiles. The mean age of the study population was 45.96 years, with a notable concentration in the age group of 40 -44.99 years. Regarding parity, the majority of subjects were Para 2, constituting 63.49%. Urban residency was predominant, with 96.83% of subjects residing in urban areas. In terms of socioeconomic status, the study found that 65.87% belonged to the upper middle class. Additionally, an overwhelming majority of the participants, 97.62%, were housewives. Obesity and overweight were observe d in 14.28% and 26.98% of subjects, respectively. (Table 1) Predominantly, irregular menstrual bleeding was identified as the primary concern, with a noteworthy emphasis on Heavy Menstrual Bleeding (HMB), observed in 56.35% of subjects. Postmenopausal bleeding, accounting for 15.87% of cases, was also a significant aspect of the AUB spectrum. A nuanced analysis revealed that 49.3% of participants experiencing HMB endured it for 6 -12 months. For those with postmenopausal bleeding, 40% reported a duration of 10-30 days, while another 40% encountered bleeding for 30.1-6 months. This study further elucidated additional AUB patterns, including Heavy and Prolonged Menstrual Bleeding (9.52%), Prolonged Menstrual Bleeding and Frequent Cycles (6.35% each), and the le ss common pattern of Frequent and Heavy Menstrual Bleeding (5.56% of subjects). The detailed exploration of these AUB patterns contributes valuable insights to the existing body of medical knowledge, providing a comprehensive understanding of the diverse presentations of abnormal uterine bleeding. (Table 2) The investigation involved 60 patients, among whom hypertension (31 patients) and hypothyroidism (22 patients) were the predominant comorbidities. A subset of patients (7 cases) had undergone previous gy necological surgeries, with tubectomy being the most common procedure (5 patients). The study provides a thorough examination of comorbidity prevalence, highlighting hypertension as the most prevalent medical disorder, followed by hypothyroidism and diabet es mellitus. A substantial proportion (52.38%) of patients exhibited no comorbidities, while 35.71% had a single comorbidity, and 11.9% presented with multiple comorbidities. Among the participants, 26 had a history of surgical procedures, with 7 undergoing gynecological surgeries, primarily tubectomy. General surgical interventions included cholecystectomy (11 patients), appendicectomy (3 patients), and various others such as hemorrhoidectomy, hernia operation, breast lump excision, craniotomy, and VP shun t, each observed in 1 patient. This in - depth analysis sheds light on the spectrum of comorbidities and surgical histories within the patient population under study. (Table 3) In the present study, abdominal examination revealed that 78.57% of subjects had a non -palpable uterus, with 10.3%, 4.76%, 3.96%, and 2.38% exhibiting palpable uteri of 12 -14 weeks, 14.1 -16 weeks, 16.1 -18 weeks, and >18 weeks sizes, respectively. Pelvic examination, including per speculum examination, identified various cervical condit ions, such as a healthy cervix in 65.08% of subjects, along with hypertrophy, chronic cervicitis, erosion, polyps, atrophy, and growth in smaller percentages. Bimanual pelvic examination indicated diverse uterine sizes, ranging from normal to atrophic, wit h specific percentages corresponding to each size category. (Table 4) On ultrasound (USG), 54.76% of subjects exhibited Leiomyoma, and 24.6% showed Adenomyosis. Additionally, Endometrial Hyperplasia was detected in 17.46% of cases, Endometrial Polyp in 16. 66%, Endocervical Polyp in 6.35%, Endometrial Carcinoma in 1.59%, and Cervical Carcinoma in 0.79%. Clinically, Leiomyoma was identified as the predominant cause of Abnormal Uterine Bleeding, primarily diagnosed through ultrasonography. (Table 5) Clinical p rovisional diagnoses were established through the correlation of clinical history, examinations, and ultrasound (USG) findings, with PALM -COEIN classification guiding the categorization. AUB -L emerged as the predominant clinical diagnosis, affecting 54.76% of subjects, followed by AUB -A (24.6%), AUB-P (23.01%), and AUB -M (19.84%). Notably, no subjects exhibited components of COEIN as the cause of AUB in our study. Endometrial pathology was determined through endometrial curettings, collected via Hysteroscop y, Pipelle's biopsy, or Dilatation and Curettage (D&C). Among the 39 subjects who underwent hysteroscopy, two necessitated subsequent hysterectomy due to confirmed endometrial carcinoma, while the remaining 37 subjects recovered through hysteroscopic interventions. Proliferative pattern emerged as the prevailing endometrial pattern in our study, evident in 64.11% of subjects on Hysteroscopic curettings and 67.74% on Pipelle's biopsy. The study underscores the diagnostic significance of histopathological eva luations in refining clinical diagnoses and optimizing treatment decisions. (Table 6, 7) In the study, Hysteroscopy was performed in 30.95% of subjects, Hysterectomy in 66.66%, Myomectomy in 3.17%, and Cervical biopsy in 0.79% of subjects. Among the total 126 subjects, 29.3% underwent Hysteroscopy only, 1.58% had both Hysteroscopy and Hysterectomy, 24.6% underwent Pipelle‟s biopsy and Hysterectomy, 0.79% underwent D&C and Hysterectomy, 39.68% directly underwent Hysterectomy, and 3.17% had Laparoscopic myome ctomy. One subject was diagnosed with cervical carcinoma on cervical biopsy and was advised Radiotherapy and Chemotherapy. Regarding Hysteroscopy, out of 39 subjects, 2 underwent hysterectomy due to proven endometrial carcinoma in hysteroscopic curettings , while the remaining 37 subjects recovered after Hysteroscopic polypectomy (30), myomectomy (2), or curettage (5). USG diagnosed polyps in 29 subjects, and Hysteroscopy confirmed polyps in 25 subjects. In one case, USG misdiagnosed endometrial hyperplasia as a polyp, and in three cases (2 with polyp and leiomyoma, 1 with polyp and adenomyosis), subjects directly underwent Hysterectomy due to International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 83 ~ multiple causes. Hysteroscopy detected polyps in 30 subjects, consistent with USG findings in 25 subjects, while in the remaining 5 cases, USG misdiagnosed polyps as endometrial hyperplasia, later confirmed as polyps on Hysteroscopy. (Table 8) In the context of Hysterectomy, out of 84 subjects, 34 had prior endometrial sampling, and the remaining 50 underwent direct Hysterectomy as they did not provide consent for endometrial sampling. (Table 8) In the operative findings, Leiomyoma was the predominant pathology observed in 67 subjects, followed by Adenomyosis in 41 subjects, Endometrial Polyp in 24 subjects, Endocervical Polyp in 8 subjects, Endometrial Hyperplasia in 10 subjects, and Bulky uterus in 5 subjects where no other structural abnormalities were detected grossly. On histopathology, Leiomyoma remained the most prevalent pathology in 67 subjects, followed by Adeno myosis in 46 subjects, Endometrial Polyp in 30 subjects, and Endocervical polyp in 8 subjects. Additionally, Endometrial Hyperplasia was identified in 15 subjects, endometrial carcinoma in 4 subjects, CIN in 3 subjects, and cervical cancer in 1 subject. The proliferative phase emerged as the most common endometrial pattern in 83 subjects, followed by the secretory phase in 15 subjects, and atrophic endometrium in 4 subjects. In 121 subjects, the proliferative pattern prevailed as the most common endometrial pattern in 68.6%, while the secretory and endometrial hyperplasia patterns were observed in 12.4% each, and atrophic and endometrial carcinoma in 3.3% each. (Table 9) In our study, the final diagnosis, based on histopathology reports and following the PAL M-COEIN classification, revealed that AUB-L was the predominant cause of abnormal uterine bleeding (AUB), accounting for 53.17% of subjects, followed by AUB -A in 36.5%, AUB -P in 30.15%, and AUB -M in 15.87% of subjects. Among AUB -M cases, Simple Hyperplasia without atypia was the most frequent finding (50%), followed by Malignancy (25%), with four cases of endometrial carcinoma and one case of cervical cancer. In terms of clinical diagnosis, 78.57% had a single identified cause of AUB, with AUB -L being the m ost common (38.09%), followed by AUB -P (17.46%), AUB -A (10.31%), and AUB -M (12.70%). Multiple causes were observed in 21.43% of cases, with AUB -A, L being the most common (10.31%). Regarding histopathological analysis, 69.04% of subjects exhibited a single PALM component, with Leiomyoma being the most common (25.4%), followed by Polyp (21.43%), Hyperplasia/Malignancy (11.9%), and Adenomyosis (10.31%). Multifactorial cases included Adenomyosis and Leiomyoma (20.63%), Leiomyoma and Polyp (1.59%), Polyp and Hyperplasia/Malignancy (2.38%), Leiomyoma and Hyperplasia/Malignancy, Polyp and Adenomyosis (0.79% each), Adenomyosis, Leiomyoma, and Malignancy/Hyperplasia (0.79%), and Polyp, Adenomyosis, and Leiomyoma together (3.97%). (Table 10)

Abnormal uterine bleeding is defined as any bleeding from the genital tract, which is a deviation from the normal in volume, duration, regularity or frequency. In present study, 126 women with AUB were examined in Obstetrics and Gynecology department. A detailed histor y, clinical examination and routine investigations were done. USG was offered as initial non - invasive investigation. Further evaluation was done by endometrial curettage, either by Dilatation and Curettage, Pipelle’s biopsy or Hysteroscopy. In subjects who did not give consent for endometrial curettage, they were subjected directly to major surgery (Myomectomy / Hysterectomy). And for remaining subjects, further intervention was done as per the endometrial histopathology. Various parameters of our study were compared with studies of different authors. In our study, the mean age of participants was 45.96 years, aligning with the findings of Suseela T L et al . [7]. Regarding parity distribution, 80% of women in our study were multiparous, a result consistent with studies by Mohammed N et al. [8], Lotha L et al. [3], and Snehkiran et al. [9]. Body Mass Index (BMI) was assessed in our study and compared with the research of Sajitha et al. [10] (2014) and Mishra D et al. [4] (2017). Mishra D et al. [4] reported obesity in 9.3% of women, while Sajitha et al. [10] found 3.8% to be obese. In our cohort of 126 women, 14.28% were classified as obese, demonstrating similarity to the findings of Mishra D et al. [4]. This correspondence underscores the consistency of BMI r esults between our study and Mishra D et al. [4]. It was found that, Heavy Menstrual Bleeding (HMB) was prevalent in 56.35% of subjects, aligning with findings in studies by Bashir H et al . [11] and Khan R et al . [12]. Regarding PAP smear results, our stud y demonstrated normal findings in 85.71% of cases, comparable to the 96% normalcy reported in the study by Mahapatra M et al. [13]. In our study, the provisional diagnosis was established by integrating clinical history, examination, and ultrasound (USG) findings. Sudhamani S et al . [14] reported AUB -L in 28% of subjects, AUB -M in 18%, AUB -A in 5%, and AUB -P in 3%. Similarly, Mishra D et al. [4] found AUB-L in 41.1% of subjects, followed by AUB -A, AUB -P, and AUB -M. Misra B et al . [15] reported AUB-L in 48.25%, AUB-A in 25.75%, and AUB-P and AUB-M in 4.25% each. In our study, AUB -L was the most prevalent, observed in 54.76% of 126 subjects, followed by AUB-A in 24.6%, AUB -P in 23.01%, and AUB -M in 19.84%. Our clinical diagnosis aligns with Sudhamani S et al. [14], Mishra D et al. [4], and Misra B et al. [15], emphasizing AUB -L as the most common diagnosis. Regarding endometrial patterns, our study obtained curettings from 121 subjects via Pipelle's biopsy, D&C, Hysteroscopy, and Hysterectomy. Proliferative pat terns were prevalent in 67.74% of subjects in our study, akin to findings in studies by Banale M et al. [16], Suneet K et al. [17], and Maurya MK et al. [18], where proliferative patterns accounted for 32.63%, 36%, and 30.6% of subjects, respectively. Thus, the proliferative pattern observed in our study is consistent with previous literature [16-18]. In Hysteroscopic curettage, the proliferative endometrial pattern was identified as the most common pattern in studies by Afghan S et al . [19] (34.6%) and Mah apatra M et al . [13] (45.7%). Our 2021 study found a maximum proliferative pattern in 64.11% of subjects, aligning with Afghan S et al. [19] and Mahapatra M et al. [13]. Regarding Hysterectomy specimens, Khushnood M et al . [20] reported proliferative patterns as the most prevalent, constituting 53%. In our 2021 study, a maximum proliferative pattern was observed in 74% of subjects, consistent with Khushnood M et al. [20]. Of the 126 subjects, AUB -L was identified as the most common histopathological diagnosis in 53.17% of subjects, followed by AUB-A (36.5%), AUB-P (30.15%), and AUB-M (15.87%). This HPE diagnosis aligns with Neena Y et al. [21], Mohammed N et al. [8], Mandal SK et al. [22], Mishra D et al. [4], and Misra B et al. [15] studies, where AUB -L con sistently emerged as the predominant HPE diagnosis. For the AUB -M component, our study revealed a prevalence of 15.87%, a finding comparable to the study conducted by Misra International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 84 ~ B et al. [15]. The distribution of AUB -M, our study reported that Simple hyperplasi a without atypia was the most common subtype, observed in 50% of subjects. This prevalence corresponds with the findings of Misra B et al. [15], where Simple hyperplasia without atypia accounted for 44.11%. the clinicopathological correlation was highest i n subjects with AUB-L, followed by AUB -M, then AUB -P, with the least correlation observed in subjects with AUB -A. This pattern aligns with findings from Mishra D et al. [4] and Misra B et al. [15] studies, where AUB -L exhibited the highest clinicopathological correlation, consistent with our present study. Similar to Misra B et al. [15] and Mishra D et al. [4] studies, AUB-A demonstrated the least clinicopathological correlation in our investigation. We observed a statistically significant difference (p< 0.05) in the clinical and histopathological diagnosis of AUB -A in our study, both when counted alone and in combination with other PALM component pathologies, a result comparable to Mishra D et al. [4]. Furthermore, the significant p -value in the clinical an d histopathological diagnosis of the combination of AUB -A, L mirrors findings in the Mishra D et al. [4] study. Our study highlighted that perimenopausal women, presenting with heavy menstrual bleeding, were predominantly affected. The primary etiology of AUB was clinically and histopathologically identified as Leiomyoma. Adenomyosis was better diagnosed on histopathological examination, underscoring the significance of HPE in its detection. We observed good clinicopathological correlation for AUB -P, AUB -L, and AUB - M, while histopathological examination revealed cases of AUB - A that were missed clinically. This underscores the gold standard status of HPE in AUB diagnosis. Table 1: Age distribution, demographic profile, and BMI distribution Age (Yrs) No. of Subjects Percentage 35-39.99 18 14.29% 40-44.99 40 31.75% 45-49.99 36 28.57% 50-54.99 18 14.29% 55-59.99 9 7.14% > 60 5 3.97% Total Age Distribution 126 100% Demographic Parameters No. of Subjects Percentage Rural/Urban Rural 4 3.17% Urban 122 96.83% Religion Hindu 58 46.03% Sikh 67 53.17% Muslim 1 0.79% Occupation Housewife 123 97.62% Employed 3 2.38% Socioeconomic Status UMC (Upper Middle Class) 83 65.87% MC (Middle Class) 43 34.13% Total Demographic Profile 126 100% BMI No. of Subjects Percentage Normal 74 58.73% Overweight 34 26.98% Obese 18 14.28% Total BMI Distribution 126 100% Parity No. of Subjects Percentage 0 1 0.79% 1 15 11.90% 2 80 63.49% 3 22 17.46% >3 8 6.35% Total 126 100% Table 2: Abnormal uterine bleeding and parity Abnormal Uterine Bleeding No. of Subjects Percentage Heavy Menstrual Bleeding 71 56.35% Prolonged Menstrual Bleeding 8 6.35% Heavy and Prolonged Menstrual Bleeding 12 9.52% Frequent Cycles 8 6.35% Frequent and Heavy Menstrual Bleeding 7 5.56% Postmenopausal Bleeding 20 15.87% Total 126 100% International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 85 ~ Table 3: Comorbidities and Previous Gynecological Surgery Comorbidities No. of subjects Percentage (%) No comorbidity 66 52.38% Single 45 35.71% Multiple 15 11.90% Total 126 100% Gynecological Surgery No. of subjects Percentage Tubectomy 5 71.42% Salpingectomy 1 14.28% Hysteroscopic Polypectomy 1 14.28% Total 7 100% Table 4: Abdominal and pelvic examination findings Abdominal and Pelvic Examination No. of Subjects Percentage (%) Uterus palpable in weeks Not palpable 99 78.57% 12-14 weeks 13 10.31% 14.1-16 weeks 6 4.76% 16.1-18 weeks 5 3.96% >18 weeks 3 2.38% Total 126 100% Per speculum findings No. of Subjects Percentage (%) Healthy cervix 82 65.08% Cx Hypertrophied 12 9.52% Cervical erosion 8 6.35% Cervical polyp 6 4.76% Chronic cervicitis 12 9.52% Cx atrophic 5 3.97% Cx growth 1 0.79% Total 126 100% Size of uterus No. of Subjects Percentage (%) Normal 24 19.05% 18 weeks 3 2.38% Atrophic 3 2.38% Total 126 100% Table 5: USG findings USG findings No. of subjects Percentage (%) Leiomyoma 69 54.76% Adenomyosis 31 24.60% Endometrial Hyperplasia 22 17.46% Endometrial polyp 21 16.66% Endocervical polyp 8 6.35% Endometrial carcinoma 2 1.59% Cervical carcinoma 1 0.79% Table 6: Provisional diagnosis and endometrial curettings Provisional Diagnosis No. of subjects Percentage (%) AUB-P 29 23.01 AUB-A 31 24.6 AUB-L 69 54.76 AUB-M 25 19.84 COEIN 0 0 Endometrial Curettings Procedure (No. of subjects) Hysterectomy done Hysterectomy not done Hysteroscopy (39) 2 37 Pipelle's Biopsy (31) 31 0 Dilatation and Curettage (1) 1 0 International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 86 ~ Table 7: Pattern of endometrium Endometrial Pattern Endometrial curettings Hysteroscopy (n = 39) Pipelle’s Biopsy (n = 31) D&C (n = 1) No. % No. % No. % Proliferative 25 64.11% 21 67.74% 0 0% Secretory 3 7.69% 4 12.90% 0 0% Simple hyperplasia without atypia 6 15.38% 3 9.68% 0 0% Simple hyperplasia with atypia 0 0% 1 3.23% 1 100% Complex hyperplasia without atypia 1 2.56% 0 0% 0 0% Complex hyperplasia with atypia 0 0% 0 0% 0 0% Atrophic 2 5.13% 0 0% 0 0% Endometrial ca 2 5.13% 2 6.45% 0 0% Table 8: Hysteroscopy and Hysterectomy Hysteroscopy No. of subjects Hysteroscopic Polypectomy 30 Hysteroscopic Myomectomy 2 Hysteroscopic Curettings 5 Hysteroscopy and Hysterectomy 2 Total 39 Hysterectomy No. of subjects Hysteroscopy and Hysterectomy 2 D&C and Hysterectomy 1 Pipelle's Biopsy and Hysterectomy 31 Direct Hysterectomy 50 Total 84 Table 9: Showing operative findings, HPE and Endometrial Pattern Operative Findings No. of Subjects Leiomyoma 67 Adenomyosis 41 Bulky Uterus 5 Endometrial Polyp 24 Endocervical Polyp 8 Endometrial Hyperplasia 10 HPE (Histopathology) No. of Subjects Leiomyoma 67 Adenomyosis 46 Endometrial Polyp 30 Endocervical Polyp 8 Endometrial Hyperplasia 15 Endometrial Carcinoma 4 Atrophic 4 CIN 3 Cervical Cancer 1 Endometrial Pattern No. of Subjects Proliferative 83 Secretory 15 Endometrial Hyperplasia 15 Atrophic 4 Endometrial Carcinoma 4 Total 121 Table 10: Distribution of cases as per clinical diagnosis and histopathology Clinical Diagnosis No. of Subjects Percentage AUB-P 22 17.46% AUB-A 13 10.31% AUB-L 48 38.09% Single factor AUB-M 16 12.70% AUB-P, A 3 2.38% AUB-P, L 2 1.59% AUB-P, M 2 1.59% AUB-A, L 13 10.31% Multiple factors AUB-A, M 1 0.79% AUB-L, M 5 3.97% International Journal of Clinical Obstetrics and Gynaecology https://www.gynaecologyjournal.com ~ 87 ~ AUB-A, L, M 1 0.79% AUB-P, A, L 0 0% Total 126 100% Histopathological Diagnosis No. of Subjects Percentage AUB-P 27 21.43% AUB-A 13 10.31% Single factor AUB-L 32 25.40% AUB-M 15 11.90% AUB-P, A 1 0.79% AUB-P, L 2 1.59% AUB-P, M 3 2.38% AUB-A, L 26 20.63% AUB-A, M 0 0% Multi factorial AUB-L, M 1 0.79% AUB-A, L, M 1 0.79% AUB-P, A, L 5 3.97% Total 126 100%

In conclusion, our study demonstrated a robust clinicopathological correlation when employing the PALM - COEIN classification system. Notably, Leiomyoma emerged as the predominant etiology contributing to Abnormal Uterine Bleeding (AUB) in the perimenopausal age group. The inclusion of multiple etiologies in this classification facilitated the identification of dual pathologies, such as AUB-A, L, and AUB- A, P in our investigation. Histopathological examination proved indispensable in accurately diagnosing cases overlooked clinically. Therefore, we assert that the PALM -COEIN classification system is a valuable tool, serving both cl inical and histopathological aspects, with mutual complementarity. Proper categorization within this system aids in optimizing patient treatment. In the con text of AUB -A, a significant ( p< 0.05) disparity between clinical and histopathological diagnoses wa s noted. This discrepancy is attributed to the similarity in symptoms and signs between adenomyosis and leiomyoma, making clinical differentiation challenging. Our study further emphasized the significance of histological examination as a complementary diagnostic tool, particularly evide nt in the highly significant ( p< 0.03) clinical and histopathological diagnosis of the AUB -A, L combination within the PALM component of AUB. Acknowledgments I extend sincere gratitude to Dr. Kumkum Avasthi for her meticulous guidance and to Dr. Zeenie Sarda Girn for invaluable support in Obstetrics and Gynaecology. Thanks to Dr. Venus Bansal, Dr. Muskaan Chhabra, and Dr. Aikaj Jindal for their contributions. I acknowledge Dr. Sonam Gilhotra and colleagues for their unwaveri ng support. Thanks to Miss Sakshi, Mrs. Jaswinder, and Mrs. Namita Bansal for their assistance. I appreciate Mrs. Namita Bansal's statistical analysis and Mr. Gurdeep Singh (ALPS) for manuscript attention. Profound thanks to the Department of Obstetrics an d Gynaecology staff. Lastly, heartfelt appreciation to the patients for their invaluable cooperation in the clinical study. Conflict of Interest Not available Financial Support Not available

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