Causes of abnormal uterine bleeding in women of 20–60 years of age based on polyp, adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not-yet-classified at a tertiary care hospital: A cross-sectional study

Manager Save my selection Original Article Causes of abnormal uterine bleeding in women of 20–60 years of age based on polyp, adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not-yet-classified at a tertiary care hospital: A cross-sectional study Department of Obstetrics and Gynecology, Malla Reddy Institute of Medical Sciences, Suraram, Hyderabad, Telangana, India Address for correspondence: Dr. Swapna Rani Seedipally, Department of Obstetrics and Gynecology, Malla Reddy Institute of Medical Sciences, Suraram, Hyderabad, Telangana, India. E-mail: [email protected] This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License (http://creativecommons.org/licenses/by-nc-sa/4.0/), which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms. Approximately 10%–25% of women are affected with abnormal uterine bleeding (AUB). It is essential to have a thorough understanding and knowledge about the disease, causative factors, pathophysiology, incidence and prevalence of various causative factors, clinical presentations, and diagnostic aids for an early prediction and diagnosis of disease to treat the condition at the earliest possible phase and with minimum morbidity and costs.

The objective of this study was to study the causes of AUB women of 20–60 years of age based on polyp, adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not-yet-classified (PALM COEIN).

It was a hospital-based prospective study among 136 patients with AUB aged 20–60 years. History, general and gynecological examination, and routine gynecological examination were done using speculum examination of the vagina and the cervix and a bimanual examination. Routine investigations and an ultrasonography were done. Some were subjected to PAP smear as a routine procedure.

Women aged 31–50 years and multiparous were most affected with AUB in 84.6% and 88.9% of cases, respectively. According to the International Federation of Gynecology and Obstetrics type classification, the most common type of presentation was heavy menstrual bleeding in 54% of cases. The most common presenting symptom was pain in the abdomen in 4.4%. The most common-related symptom was spasmodic dysmenorrhea in 36%. The most common clinical sign was pallor in 25%. The most common associated comorbidity was anemia in 49%. Leiomyoma was the most common ultrasound diagnosis of underlying pathology in 52.2%. The most common cause of AUB as per PALM COEIN was AUB leiomyoma in 52.2%.

Our study shows that the causation of AUB was multifactorial (though in some cases, solitary lesions were found) involving the entire female reproductive system resulting in a single common presentation as AUB.

Abnormal uterine bleeding (AUB) is a broad term which is defined as any type of bleeding which does not fall under the normal range for amount, frequency, duration, or cyclicity. AUB is considered a major and complex problem and is responsible for approximately 25%–33% of total outpatient gynecological visits. Regular menstruation results from the synchronized relationship between hypothalamus, pituitary, and ovary (also known as the hypothalamo–pituitary–ovarian axis or HPO axis) and their effect on the endometrium. Any disruption in the HPO axis or any pelvic disorder results in AUB.[1] Approximately 10%–25% of women are affected at one time or the other. The prevalence is also more common in the adolescent and perimenopausal age groups. Fifty percentage of the patients do not seek treatment or attend the clinics though the facilities for better management of the condition are present. This explains one of the reasons for variations in the prevalence in various studies related to AUB. The prevalence rises to 35% where there is a coexistence of heavy menstrual bleeding, irregular bleeding, and intermenstrual bleeding.[2] Patients present to the gynecological OPD with various irregularities of menstrual bleeding which, if not promptly detected and diagnosed early, result in excessive morbidity mainly due to excessive blood loss and also the growing disease perse, which results in major work hour loss affecting the productivity and also the quality of life of a woman. Delay in diagnosis and treatment result in increased treatment costs and is a burden to the health-care system.[3] Fibroids are a major cause of hysterectomies.[4] Fibroids are also one of the major causes of AUB. It is essential to have a thorough understanding and knowledge about the disease, the demographic, the causative factors, the pathophysiology, the incidence and prevalence of various causative factors, the clinical presentations, and diagnostic aids for an early prediction and diagnosis of the disease to treat the condition at the earliest possible phase and with minimum morbidity and costs. In 2011, the International Federation of Gynecology and Obstetrics (FIGO) proposed polyp, adenomyosis, leiomyoma, malignancy, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not-yet-classified (PALM COEIN) as the categorization of various causes of AUB falling under 9 heads to maintain the uniformity and simplicity in diagnosis with the goal of making diagnosis and treatment simpler, easier, and better. The present study was carried out to study and categorize the causes of AUB in 20–60 years of age group according to PALM COEIN and to study the structural and functional abnormalities behind PALM COEIN and correlate with the clinical presentations.

It was a hospital-based prospective study conducted over a period of 22 months from 2019 to 2021 including the period of COVID-19 lockdown. Patients were selected with complaints of AUB of age group 20–60 years who attended the outpatient and inpatient of Obstetric Gynecology Department at Malla Reddy Hospital, a tertiary care hospital, on a random basis. Sample size was calculated using OpenEpi software as 136 (OpenEpi: Open Source Epidemiologic Statistics for Public Health, Version. www.OpenEpi.com). Approval for the study is taken from the head of the Department of Obstetric Gynecology, scientific committee, and institutional ethics committee of MRIMS. Women aged 20–60 years age group; patients with AUB attending the OPD, patients at Malla Reddy Hospital, and patients who signed the informed consent to participate in the study were included in the study. Patients with bleeding caused by pregnancy and related factors, with vaginitis and cervical disorders were excluded from the study. After getting approval from the scientific and institutional ethics committee MRIMS, the patient selection was done who were satisfying the inclusion and exclusion criteria. Patients were explained about the study, in which they will be involved and the method of the study and its consequences in their own understandable language, and their written and signed consent was obtained. Regular history was obtained as per the preformed questionnaire. All were subjected to regular general and gynecological examinations. The parameters studied under general examination were built of the patient, anemia, cyanosis, clubbing, jaundice, edema and lymphadenopathy, breasts, thyroid, and spine. This was followed by physical and systemic examination. Later, they were subjected to routine gynecological examination by doing a speculum examination of the vagina and the cervix and a bimanual examination to know the size, version, and mobility of the uterus, any fullness, or tenderness in the vaginal fornices. Routine investigations and an ultrasonography (USG) were done. Abnormal values were noted and further investigated on the respective lines. Some were subjected to PAP smear as a routine procedure. Medical conditions were treated, anemia was corrected, dilatation and curettage procedures were performed as per requirement, and depending on the severity of symptoms and the specimen collected were sent for histopathology. As a part of management after dilatation and curettage, patients were followed up and the hysterectomy procedure was done as per the prescribed protocol and the specimen was subjected to gross appearance, cut section, and histopathological examination, and the results were noted. After the hysterectomy procedure, the patient was followed up periodically for postoperative follow-up. Not all the patients were subjected to all the procedures. Some were OPD cases treated symptomatically on the basis of USG diagnosis. Some were not subjected to routine PAP smear examination though PAP smear was a prescribed screening procedure. Some were not undergone dilation and curettage procedures. Not all were taken for hysterectomy. The data were entered in the Microsoft Excel worksheet and analyzed using proportions.

The most common affected age group with AUB was 31–50 years in 84.6% of the cases. Multipara women were more affected with AUB in 88.9% of the cases [Table 1]. Distribution as per different characteristics of the study subjects According to the FIGO type classification, the most common type of presentation was heavy menstrual bleeding in 54% of the cases, followed by irregular heavy bleeding in 18% of the cases [Table 2]. Abnormal menstrual patterns according to the International Federation of Gynecology and Obstetrics type-1 classification The most common presenting symptom was pain in the abdomen in 4.4% of the cases. The most common-related symptom was spasmodic dysmenorrhea in 36% of the cases. The most common clinical sign found was pallor in 25% of the cases. The most common associated comorbidity was anemia in 49% of the cases [Table 3]. Leiomyoma was the most common ultrasound diagnosis of underlying pathology in 52.2% of the cases, followed by no abnormality in 40.4% of the cases [Table 4]. Most common cause of AUB as per PALM COEIN was AUB-leiomyoma in 52.2% of the cases, followed by AUB-adenomyosis and AUB-endometrial disorders in 19.9% of the cases each [Table 5]. Distribution as per polyps, adenomyosis, leiomyoma, and malignancy or hyperplasia coagulopathies, ovulatory disorders, endometrial disorders, iatrogenic causes, and not otherwise classified representing nonstructural causes

In the present study, the most common affected age group with AUB was 31–50 years in 84.6% of the cases. Multipara women were more affected with AUB in 88.9% of the cases. According to the FIGO type classification, the most common type of presentation was heavy menstrual bleeding in 54% of the cases, followed by irregular heavy bleeding in 18% of the cases. The most common presenting symptom was pain in the abdomen in 4.4% of the cases. The most common-related symptom was spasmodic dysmenorrhea in 36% of the cases. The most common clinical sign found was pallor in 25% of the cases. The most common associated comorbidity was anemia in 49% of the cases. Leiomyoma was the most common ultrasound diagnosis of underlying pathology in 52.2% of the cases, followed by no abnormality in 40.4% of the cases. The most common cause of AUB as per PALM COEIN was AUB-leiomyoma in 52.2% of the cases, followed by AUB-adenomyosis and AUB-endometrial disorders in 19.9% of the cases each. Sarala and Gopalan[5] studied 280 patients with AUB. Most of the patients belonged to the age of 41–50 years which is similar to the present study. AUB was common in multiparous women which is also similar to the present study findings. Menorrhagia was the most common bleeding pattern seen. Vitale etal.[6] stated that AUB is common among perimenopausal females. It affects the quality of life. It has a tremendous impact on psychological well-being. Hysterectomy is useful in most of the cases with structural pathology in the uterus. However, in recent times, there is more emphasis on the conservative approach. However, the risk of AUB can be there in the case of conservative approach. Hence, the treatment should be personalized. Ansari and Urooj[7] enrolled 238 women with AUB to study the causes of AUB. They found that using the PALM-COEIN classification, the incidence of AUB was 11%. Leiomyoma was the most common seen in 53.7% of the cases and we also found that leiomyoma was the most common ultrasound diagnosis of underlying pathology in 52.2% of the cases, followed by no abnormality in 40.4% of the cases. Among nonstructural causes, the author found that the most common was ovulatory in 37.6% of the cases. Kotagasti[8] observed that the incidence of AUB was 18.23% in their settings. Menorrhagia was the most common pattern in 33% of the cases. The authors concluded that menorrhagia was common in the age group of 25–34 years. Mahapatra and Mishra[9] studied 140 cases of AUB in the age group of 15–55 years. The authors commented that AUB was common in the fifth decade and in multiparous women and this finding is similar to the present study finding. Sahu etal.[10] noted that the mean age of patients with AUB was 44 years which is similar to the present study. The thyroid profile was deranged in 48% of the cases. Hypothyroidism was seen in 91.6% of the cases. In 81.3% of the cases, there was a structural cause. Like the present study, they also found that the leiomyoma was the most common cause. Boeckstaens etal.[11] in their systematic review included 41 studies. They observed that the AUB was the most commonly investigated symptom in relation to cancer of the uterus. The authors concluded that there is a lack of knowledge in relation to diagnostic accuracy of signs and symptoms of cancer of the uterus.

of the study Some of the patients were dropped in between the study so only their ultrasonographic reports were taken into consideration while categorizing under the heads of PALM COEIN. The COVID-19 pandemic is a limiting factor acting as a real break when the study was on.

Our study shows that AUB is affecting up to one-third of the cases attending our gynecology OPD. Patients mostly belong to low socioeconomic strata. The most common age group involved 40–45 years (46.3%). Most of the patients of parity 2 (52%) and the age at menarche was 12 years (40%). The most common pattern of menstrual irregularity was heavy menstrual bleeding (menorrhagia) (77%). The most common associated symptom was spasmodic dysmenorrhea. Pallor (25%) was the most common associated sign. The most common associated medical disorder was mild anemia (49%). The most common cause of AUB was found to be AUB-L (52.2%), followed by AUB-M (22.1%), but most of the patients were also having other pathologies of PALM COEIN on investigation. Type 4 AUB-L (22.6%) was the most common among AUM-L types. Our study shows that the causation of AUB was multifactorial having more than a single pathology when studied (though in some cases, the solitary lesions were found) involving the entire female reproductive system resulting in a single common presentation of the AUB. FIGO had taken an extensive undertaking in simplifying the causes under the head of PALM COEIN which makes the diagnosis simpler and easier. The study makes clear the magnitude of the problem which when identified at an early stage can reduce the morbidity of the disease and its consequences, mortality due to cancers in women, and can reduce an economic burden to her family and the health-care system and improve her health-related quality of life index. A woman is the main pillar and support not only to the family but to society as such. A woman taken care of the family is taken care of and in turn the society is taken care of. Author contribution The authors confirm contribution to the paper as follows: study conception and design: Sarojini Arikarevula, Swapna rani seedipally i; data collection: Swapna rani seedipally, Ragoor sujatha; analysis and interpretation of results: Sarojini Arikarevula, Ragoor sujatha; draft manuscript preparation: Sarojini Arikarevula, Swapna rani seedipally. All authors reviewed the results and approved the final version of the manuscript. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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