Study of clinical and pathological correlation of AUB patients undergoing hysterectomy

Background: Abnormal uterine bleeding (AUB) is most common in the perimenopausal and postmenopausal age groups. FIGO's acronym (PALM -COEIN) describes the causes of AUB . Polyps, adenomyosis, leiomyoma, mal ignancy, hyperplasia, coagulopathy, Ovulatory dysfunction, endometrial, iatrogenic, and not yet classified are among them. Aim: To determine the preval ence and distribution of various uterine pathologies in hysterectomy specimens as a function of age, parity, and clinical characteristics.

500 women with AUB who are having a hysterectomy between December 2017 and November 2019 will be chosen for the study. All AUB patients undergoing hysterectomy were included in the study.

In the pre sent study, majority of patients were in the age group range of 41 -50 years (37%) followed by 30% in the age group range of 31 -40 years. Majority of patien ts were in the 2 nd parity which constituted 58% and minimum number of cases (2%) in unmarried cases. HMB was seen (47.6%) followed by dysmenorrhoea (14%) and irregular bleeding (13.4%) cases. The most common diagnoses were fibroid uterus in 40% of cases, A denomyosis in 17% of cases, both fibroid and Adenomyosis in 8.2% of cases, polyp in 5% of cases , normal uterus in 14.6 percent of cases, endometrial hyperplasia in 1.6 percent of cases, endometrial carcinoma in 1.2 percent of cases. The most common surgica l approach is abdominal (66.2%), followed by vaginal (18.6%), and laparoscopically (15.2 perce nt). In 102 cases, complications were discovered (19.25 percent). Pyrexia in 28 instances (5.6%), abdominal distension in 17 cases (3.4%), wou nd dehiscence in 15 cases (3%), RTI in 11 cases (2.6%), and UTI in 13 cases are the most common complications (2.6 percent ). Malaria, thrombophlebitis, urinary retention, and subsequent haemorrhage have all been reported in a small number of patients.

The majority of the patients were in the perimenopausal age bracket and were multiparous. HMB was a common AUB symptom. Leiomyoma was a common diagnosis. USG and histology confirmed the diagnosis. Proliferative endometrial patterns were common. Si mple endometrial hyp erplasia in perimenopausal women and complicated hyperplasia in postmenopausal women were the most common findings. In AUB patients, hysterectomy is still the only option.

abnormal uterine bleeding, dysmenorrhea, heavy menstrual bleeding, hysterectomy

The essence of womanhood, the uterus, is controlled by cyclical hormonal changes caused by alterations in the hypothalamus -pituitary-ovary axis [1]. All women of reproductive age have menstruation, which is cyclic uterine bleeding. Normal menstruation is defined as bleeding from the secretory endometrium that occurs during an ovulatory cycle that lasts no longer than seven days. Abnormal uterine bleeding is defined as any bleeding that does not meet these criteria [2, 3]. Bleeding is considered abnormal when the pattern i s irregular or the length exceeds seven days. Abnormal uterine bleeding refers to any bleeding that does not meet these criteria. When the pattern of bleeding is irregular or the duration exceeds se ven days, it is cons idered abnormal. Polyp, adenomyosis, l eiomyoma, malignancy and hyperplasia, coagulopathy, Ovulatory dysfunction, endometrial, iatrogenic, and not yet classified are the causes of AUB, according to FIGO (2011)'s acronym (PALM -COEIN) [4, 5]. Menorrhagia, men orrhagia, dysmenorrhea, polymenorrhoea, intermenstrual bleeding, irregular bleeding, and postmenstrual bleeding are the most prevalent symptoms. Heavy Menstrual Bleeding takes the role of menorrhagia (HMB). Clinically, inquiry, and ultr asonography are used to treat AUB , although there may be a difference between clinical and sonological and histopathological diagnosis. The histology research and the final diagnosis were always in sync. International Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com ~ 100 ~ Medical management, minor surgeries such as D an d C, ablative treatments, and finally hysterectomy are all option s. Hysterectomy can be performed vaginally, abdominally, or laparoscopically, depending on the patient's condition, the size of the uterus, including mobility, the institution's resources, an d the surgeon's experience.

500 women with AUB who are having a hysterectomy between December 2017 and November 2019 will be chosen for the study. All AUB patients undergoing hysterectomy were included in the study. All AUB patients not undergoing hysterectomy and all the hysterectomy causes other than AUB were excluded from the study. Heavy menstrual bleeding, dysmenorrhea, metrorrhagia, irregular bleeding, postmenopausal bleeding, and other symptoms were investigated in all AUB patients. Instances involving pregnancy were omitted from the s tudy, and the remaining cases were investigated further. A complete medical history was collected, including the patient's age, parity, education, socioeconomic level, clinical symptoms, duration o f symptoms, and blood loss. Information was also gathered on any gynaecological complaints, medical conditions, and previous hormonal or surgical treatment. A full history was taken, followed by a thorough physical examination that included a thorough gene ral and systemic exa mination, and a tentative diagnosis was made. After that, all blood tests such as a complete blood count, renal function test, thyroid function test, bleeding time, and clotting time are performed. A Pap smear was also performed. A pelv ic ultrasonographic examination was performed. Endometrial biopsies were kept in 10% formalin saline and forwarded for histological analysis and reporting. The cases where a hysterectomy was performed were saved and sent for histological evaluation. The re ports were gathered, and a definitive diagnosis was arrived upon. Clinical and ultrasound diagnoses were compared to the final diagnosis. The study's data was examined with the help of proper statistical tools and techniques. To explore the pattern of dist ribution, explorator y data analysis using graphs and pie charts was performed.

Table 1: Distribution based on age. Age (Years) No. of cases Percentage Less than 30 20 4% 31-40 150 30% 41-50 185 37% 51-60 95 19% 61-70 30 6% Greater than 70 20 4% Table 1 shows that the majority of patients were in the age group range of 41-50 years (37%). Table 2: Distribution based on parity. Parity No. of cases Percentage Unmarried 10 2% Nulliparous 26 5.2% 1 34 6.8% 2 290 58% 3 85 17% 4 35 7% 5 20 4% Table 2 sh ows that majority of patients were in the 2 nd parity which constituted 58%. Table 3: Distribution based on symptoms. Clinical Symptoms No. of cases Percentage HMB 238 47.6% Dysmenorrhea 70 14% HMB & Dysmenorrhea 31 6.2% HMB & Irregular bleeding 33 6.6% Irregular bleeding 67 13.4% Metrorrhagia 37 7.4% Postmenopausal bleeding 24 4.8% Table 3 shows that heavy menstrual bleeding was the most common symptom for hysterectomy which constituted 47.6%. Table 4: Clinical Diagnosis. Diagnosis No. of cases Percentage Fibroid 205 41% Adenomyosis 127 25.4% Both 34 6.8% Dysfunctional uterine bleeding 66 13.2% Polyp 32 6.4% Endo CA 24 4.8% Cervical CA 12 2.4% Table 4 shows that fibroid was the highest clinical diagnosis which constituted 41%. Table 5: USG Diagnosis. USG Diagnosis No. of cases Percentage Fibroid 200 40% Adenomyosis 85 17% Both 41 8.2% Polyp 25 5% Normal 73 14.6% Endo hyperplasia 8 1.6% Cervical CA 6 1.2% Ovarian Cyst 15 3% Bulky uterus 17 3.4% Atrophic organs 6 1.2% Myohyperplasia 4 0.8% Endo and Myohyperplasia 12 2.4% Endometriosis 2 0.4% Endo CA 6 1.2% Table 5 shows that fibroid was the highest USG diagnosis which constituted 40%. Table 6: Routes of operative procedures Route No. of cases Percentage Abdominal 331 66.2% Vaginal 93 18.6% Laparoscopy 76 15.2% Table 6 shows that abdominal was the most common route of operating which constituted 66.2%. International Journal of Clinical Obstetrics and Gynaecology http://www.gynaecologyjournal.com ~ 101 ~ Table 7: Complications of hysterectomy Complications No. of cases Percentage Wound Sepsis 15 3% Abdominal Distension 17 3.4% Pyrexia 28 5.6% Respiratory infection 11 2.2% UTI 13 2.6% Urinary retention 6 1.2% Malaria 7 1.4% Thrombophlebitis 3 0.6% Haemorrhage 2 0.4% Table 7 shows that pyrexia was the most common complication (5.6%), followed by abdominal d istention (3.4%), wound sepsis (3%), UTI (2.6%), respiratory infection (2.2%), malaria, urinary retention, thrombophlebitis & haemorrhage.

In the present study, majority of patients were in the age group range of 41 -50 years (37%) followed by 3 0% in the age group range of 31 -40 years. Similar results were observed in Rizvi et al. [6], 44.5 percent of cases are in the fifth decade (41 -50 years). In Bharati Misra et al. [7] study; 41.25 percent of the cases are between the ages of 41 and 50, while 30 percent are between the ages of 31 and 40. In Karmakar et al . [8]. study, 87.2% cases were in the age group of 41 -60 years group and rest were above 60. 35.9% of AUB cases were observed in 41 -50 years in Jairajpur et al. [9]. study. 48.1% of AUB cases were observed in 41-50 years in Muzaffer et al . [10] study. 32.1% and 33.5% of AUB cases were observed in 41 -50 years in Abdullah et al. [11] and Saraswati et al . [12]. studies respectively. In the present study, majority of patients we re in the 2 nd parity which constituted 58% and minimum number of cases (2%) in unmarried cases. In Bharati Misra et al. [7]. study second para accounted for 62.5 percent of the instances, with the unmarried cases accounting for the smallest number of cases . 1.75 percentage. In the Mohammad et al. [13]. study, it was discovered (65.9%) cases with a parity of 2, which is similar to the current study. Lee NC et al. [14] discovered a mean parity of 3 in their research, which revealed almost identical results. I n present study, HMB was seen (47.6%) followed by dysmenorrhoea (14%) and irregular bleeding (13.4%) cases. In Bharati Misra et al. [7]. study, similar results were observed as HMB was seen (51.5%) followed by dysmenorrhoea (15%) and irregular bleeding (13.75%) cases. In comparison to our study, Rizvi et al. [6] discovered that 43.7 percent of subjects presented with HMB and irregular bleeding. HMB was discovered in 49.1% of patients by Nayar et al. [15]. study. In Tyagi et al . [16], 41.3 percent of cases w ere having HMB, in 5 .75 percent of patients, metrorrhagia is discovered. In 6% of cases, postmenopausal haemorrhage occurs. In present study, fibroid uterus was found in 41% cases followed by adenomyosis in 25.4% cases and both fibroid uterus and adenomyos is was found in 6.8 % cases. In Bharati Misra et al. study, Fibroid uterus found in 48.25 % cases followed by adenomyosis in 25.75% cases and both adenomyosis and fibroid uterus found in 6.25 % cases. In Rizvi et al. 6 study, it was found fibroi d uterine in 41 .46% of cases, adenomyosis in 46.36 percent of cases, and both fibroid uterus and adenomyosis in 19. percent of cases. In 54.1 percent of patients, fibroid uterus was detected clinically, polyps were discovered in 4.25 percent of cases, according to Begum et al.17 study. According to Doraswami et al. [18], polyps were accounted for 11.2 percent of cases. Polyps were identified in 12 percent and 13 percent of cases, respectively, according to Mirza et al. [19] and Cornitescu et al. [20]. In Jairajpuri et al.9 study, incidence was 1.7%, in Purendare et al . [21] it was found that polyp was observed in 4.8% cases, In Saraswati et al . [12]. study, endometrial carcinoma were found in 2.75 % cases, 4.4% were found for endometrial carcinoma and lower values were documented in Jairajpuri et al. 9 study with 0.5% and Mohammed et al . [13]. Study 0.72 % of endometrial carcinoma was noted . Purendare et al. [21] found that 0.9% were having endometrial carcinoma. Ovulatory dysfunction were found to be present in 11% cases as c ompared to 22.5 % cases found by Mohammed et al. [13]. In this study, the most common diagnoses were fibroid uterus in 40% of cases, Adenomyosis in 17% of cases, both fibroid and Adenomyosis in 8.2% of cases, polyp in 5% of cases, normal uterus in 14.6 perc ent of cases, endometrial hyperplasia in 1.6 percent of cases, endometrial carcinoma in 1.2 percent of cases, 3.25 percent of cases ovarian cyst. In present study, the most common surgical approach is abdominal (66.2%), followed by vaginal (18.6%), and laparoscopically (15.2 percent) The most common surgical approach is abdominal (76.75%), followed by vaginal (15%), and laparoscopically (8 percent) in Bharati Misra et al. [7] study. In Mac Kanzie et al. [22] study, it was observed that abdominal

was preferred in 79 % cases and vaginal route in 17 % cases. In present study, in 102 cases, complications were discovered (19.25 percent ). Pyrexia in 28 instances (5.6%), abdominal distension in 17 cases (3.4%), wound dehiscence in 15 cases (3%), RTI in 11 c ases (2.6%), and UTI i n 13 cases are the most common complications (2.6 percent ). Malaria, thrombophlebitis, urinary retention, and subsequent haemorrhage have all been reported in a small number of patients.

FIGO developed the PALM – COEIN class ification for AUB. This study concluded that the majority of the patients were between the ages of 41 and 50 and were multiparous. HMB was the most common AUB symptom, followed by dysmenorrhoea. Leiomyoma was the most common clinical diagnosis, followed by adenomyosis. Ovulat ory dysfunction was a common non - structural cause of AUB. USG and histopathological procedures were used to confirm the diagnosis. Proliferative endometrial patterns were common. Simple endometrial hyperp lasia was the most common observ ation in perimenopau sal age groups, followed by complex hyperplasia in postmenopausal age groups. Despite the availability of medicinal treatments and conservative operations, hysterectomy is still the most common and effect ive treatment option for AUB patients.

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