Histopathology findings in patients presenting with menorrhagia: A study of 100 hysterectomy specimen

Endometrium is a hormonally sensitive and responsive tissue which constantly undergoes changes in the active reproductive life. The normal menstrual cycle has a mean interval of 28 ± 7 days with a mean duration of 4 ± 3 days and the amount of blood loss average 30 ml/cycle, but may be as high as 80 ml.[ 1 ] Menorrhagia refers to excessive or prolonged menstrual bleeding occurring at regular intervals. It is objectively defined as blood loss >80 ml/or menstrual period lasting longer than 7 days.[ 2 ] The causes of menorrhagia may be local, systemic, and dysfunctional. Population studies have shown that approximately 10% women have menstrual blood loss >80 ml cycle.[ 3 ] The most common cause of menorrhagia in postadolescent women is distortion of endometrial architecture from a submucous leiomyoma, endometrial polyp, or adenomyosis. Systemic disorders such as hypothyroidism, liver disease, cirrhosis, chronic renal disease, chronic endometritis, and usage of intrauterine devices are also associated with menorrhagia.[ 4 ] An endometrial biopsy should be performed on all women over 35 years with menorrhagia to rule out endometrial cancer or premalignant lesion (e.g. atypical hyperplasia).[ 5 ] Thus, menorrhagia is an important healthcare problem. It is only after failed trial of appropriate treatment, especially hormonal that hysterectomies are considered, more so in the age group beyond 35 years.[ 6 7 ] Our study aimed at determining the types and frequencies of endometrial pathologies in patients presenting with abnormal uterine bleeding (AUB) at our hospital.

A total of 100 abdominal hysterectomy cases were included in the study. The age range of patients was from 30 to 50 years. Of which, 65 (65%) patients were of abdominal hysterectomy with bilateral salpingo-oophorectomy specimens and remaining 35 (35%) patients were of only hysterectomy specimens [ Table 1 ]. Type of hysterectomy In our study, it was observed that maximum number of cases were in the age group of 41-50 years ( n = 35) followed by the age group of 31-40 ( n = 30) years. Out of 100 cases, 31% cases ( n = 31) showed adenomyosis followed by leiomyomas 25% ( n = 25), endometrial hyperplasia 23% ( n = 23), and endometrial polyp 4% ( n = 4). 11% cases ( n = 11) showed dual pathology consisting of both adenomyosis with endometrial hyperplasia and 6% cases ( n = 6) showed leiomyoma with adenomyosis [Tables 2 and 3 , Figures 1 and 2 ]. Age wise distribution of patients with menorrhagia Frequency of histological pattern in menorrhagia Age wise distribution of patients with menorrhagia Frequency of histological pattern in menorrhagia

Menorrhagia is primarily a subjective complaint perceived by women as heaviness of their period.[ 8 ] Dysfunctional uterine bleeding (DUB) is one of the most common presentations by patients in gynecology outpatient department, accounts for up to 80% cases of menorrhagia.[ 9 ] Hysterectomy is the most common and successful procedure carried out in terms of symptom relief, patient satisfaction, and definitive cure in many diseases. In our study, most of the patients with menorrhagia were in the age group of 41-51 years which was similar to the study by Mackenzie and study by Shaheen et al ., who reported that most of the patients with menorrhagia were above the age of 40 years.[ 10 11 ] In the present study, we had the maximum number of histopathologic diagnosis of adenomyosis (31%) followed by leiomyoma (25%) and 6% cases of leiomyoma with adenomyosis. In a similar study, Khreisat et al . reported that adenomyosis is a common finding in hysterectomy specimen. They found nearly 37% of all the specimens proved to be adenomyosis whereas the second most common finding was fibroid uterus.[ 12 ] These findings were in accordance with our study. Sajjad et al . in their study observed 39% cases of leiomyomas, followed by adenomyosis in 19% cases. 5% cases showed dual pathology consisting of both leiomyomas and adenomyosis.[ 13 ] Our study showed dual pathology consisting of both adenomyosis with endometrial hyperplasia (11%) and 6% cases of leiomyoma with adenomyosis. Leiomyomas and adenomyosis were found to be the common causes of menorrhagia, in other studies by Sarfraz et al ., Tahira et al ., and Khawja et al .[ 14 15 16 ] Gupta et al . in their study observed that menorrhagia was the most common complaint and fibroid uterus was responsible for AUB in 53% of women.[ 17 ] Sajitha et al . and Patil et al . in their histopathological study of endometrium in AUB and DUB, observed that menorrhagia was the most common bleeding pattern in 47% and 73.16% cases, respectively. Common histopathologic diagnosis of endometrial hyperplasia was seen in most of the cases. However, in these studies, organic lesions involving the genital tract infections, systemic causes, iatrogenic causes, polyps, and hysterectomy specimens were excluded.[ 18 19 ] Most international studies showed leiomyomas as the most common pathological lesion with a variable frequency. Its incidence is 25.8% in Abbah City of Saudi Arabia, 78% in the USA, 48% in Nigeria, and 8% in Sweden.[ 20 21 22 23 ] Geographical and racial influences are thus apparent on the prevalence of uterine leiomyoma. In our study, adenomyosis was found to be the most common pathology being the incidence of 31%. While in most of the national and international studies, it is the next common diagnosis. Its incidence in an Indian study is 26%, in Italy 24.9%, and in West Indies 6%.[ 24 25 26 ] Incidence of adenomyosis rises with rising parity which supports the theory of implantation of the basal endometrium deep in the myometrium.[ 14 ] Unopposed estrogen stimulation may lead to endometrial proliferation and hyperplasia, which may cause menorrhagia.[ 8 ] In our study, other histopathologic findings in menorrhagia cases include cases of endometrial hyperplasia in 23% and endometrial polyp in 4% whereas Sajjad et al . reported endometrial polyps in 10%, 5% cases of endometrial hyperplasia, and 1% case of chronic endometritis in their study.[ 13 ] Leiomyoma and adenomyosis are the leading causes for menorrhagia while hysterectomy is widely used treatment modality for the treatment of menstrual problems.

Uterine adenomyosis and leiomyoma are the most common benign conditions found in hysterectomy specimens with peak incidence at 41-50 years. Histopathology is mandatory for confirming diagnosis and ensuring optimal management. Nil. There are no conflicts of interest.

The present study was conducted in the Department of Pathology of People's College of Medical Sciences and Research centre, Bhopal, India, over a period of 1½ years. A total of 100 hysterectomy specimens with or without salpingo-oophorectomy were subjected to examination. Patients' brief clinical data were retrieved with respect to age, parity, clinical manifestation, sonographic findings, and basis of diagnosis. Inclusion criteria were patients coming to the outpatient department with complaint of menorrhagia for which hysterectomy procedure was performed. An exclusion criterion was hysterectomies done for complaints other than menorrhagia and malignancies. On receipt of surgical specimen, they were fixed in 10% neutral buffered formalin for 24-48 h. A detailed gross examination of uterus, cervix with or without bilateral adnexa was carried out. Sections from representative areas were taken, processed, and paraffin embedded. The blocks were sectioned and stained with hematoxylin and eosin. A detailed microscopic examination of the stained slides was carried out. All findings were cumulatively considered and included for appropriate diagnosis. Subsequently, the histopathological diagnoses were correlated with clinical diagnoses.