Spectrum of Histopathological Findings in Hysterectomy Specimens for Abnormal Uterine Bleeding: A Clinicopathological Correlation Study at a Tertiary Care Center.

Background: Abnormal uterine bleeding (AUB) is a common gynaecological complaint in reproductive and perimenopausal women, often requiring hysterectomy when refractory to conservative management. Histopathological examination of hysterectomy specimens is essential to confirm diagnoses and detect incidental pathologies.

This study evaluated the spectrum of diseases associated with AUB in hysterectomy specimens and their clinico-pathological correlation.

A cross-sectional study was conducted over 18 months at the Department of Pathology, T.S. Misra Medical College and Hospital, Lucknow. Eighty-seven hysterectomy specimens from women with AUB were included. Clinical details, ultrasonographic findings, and h istopathological features (H&E, special stains, ER/PR immunohistochemistry where indicated) were recorded and analysed.

Heavy menstrual bleeding was the commonest presentation (46.0%), followed by peri - menopausal bleeding (21.8%). Ultrasonography most frequently showed uterine fibroid (34.6%) and thickened endometrium (33.3%). Histopathologically, leiomyoma predominated (37 .9%), followed by endometrial hyperplasia (17.2%), endometrial polyp (12.6%), and adenomyosis (11.5%). Cervical carcinoma (3.4%) and endometrial carcinoma (2.3%) were also identified. Multiple pathologies coexisted in 45.5% of leiomyoma cases. A significan t association existed between clinical presentations and hysterectomy indications (p < 0.001). International Journal for Multidisciplinary Research (IJFMR) E-ISSN: 2582-2160 ● Website: www.ijfmr.com ● Email: [email protected] IJFMR260271746 Volume 8, Issue 2, March-April 2026 2

Leiomyoma was the most frequent histopathological diagnosis in AUB -related hysterectomies, followed by endometrial hyperplasia, with peak incidence in perimenopausal women. Good clinicopathological correlation was observed, particularly for benign lesions. Routine histopathological examination is recommended to identify unsuspected malignancies and coexisting pathologies.

Abnormal uterine bleeding, Hysterectomy, Leiomyoma, Clinico -pathological correlation Histopathology

Abnormal uterine bleeding (AUB) is a common problem affecting the women of reproductive age group and may also have a significant impact on their physical, social and emotional aspects directly affecting their quality of life. According to the International Federation of Gynecology and Obstetrics (FIGO) acute AUB could be classified as “an episode of bleeding in a woman of reproductive age, who is not pregnant that is of sufficient quantity to require immediate intervention to prevent further blood loss.” I n the premenopausal period, it may cause anemia and in the postmenopausal period it may raise the suspicion of malignancy.1 It is estimated that about 10% to 30% of women will be affected by abnormal uterine bleeding during their lifetime.2 The classification system is divided into nine categories that are arranged according to the acronym PALM-COEIN: Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia, Coagulopathy, Ovulatory disorders, Endometrial, Iatrogenic and Not Classified.3 International federation of Gynecology & obstetrics (FIGO) proposed three main causes of classification for uterine disorders: coagulopathy (AUB-C), disorder of ovulation (AUB-O), primary endometrial disorder (AUB-E).4 The histopathological examination of hysterectomy specimens is an essential component of the diagnostic workup, treatment planning and follow-up of patients undergoing this procedure.5 The burden of gynecological disorders in India is high with an estimated 25% of women suffering from menstrual disorders, 20-25% from fibroids and 10% from endometriosis. The prevalence of gynecological cancers is also increasing in India, particularly in urban areas.6 The clinicopathological correlation was found good when the cases were classified under PALM–COEIN classification.

The present study was a cross -sectional study conducted in the Department of Pathology, T.S. Misra Medical College and Hospital, Lucknow, over a period of 18 months. The study population included all female patients presenting with abnormal uterine bleedin g to the Department of Obstetrics and Gynecology of the same institution, who were scheduled to undergo hysterectomy either by the abdominal or vaginal route. Patients with relevant laboratory and radiological investigations and those who provided informed written consent were included in the study. The cases were recruited over a period of one year during the study duration. Complete enumeration of all hysterectomy specimens with AUB complaints within the 18-month period was targeted, with a minimum of 87 cases or all eligible cases, whichever was achieved first. Ultimately, 87 cases were included. Clinical data were collected from patient case sheets, including name, age, presenting signs and symptoms, clinical history, Pap smear results, ultrasonographic findings, and clinical diagnoses. These data were International Journal for Multidisciplinary Research (IJFMR) E-ISSN: 2582-2160 ● Website: www.ijfmr.com ● Email: [email protected] IJFMR260271746 Volume 8, Issue 2, March-April 2026 3 recorded using a standardized proforma and compiled into a Microsoft Excel spreadsheet for analysis. All hysterectomy specimens were processed following standard histopathological protocols. Special stains, such as Periodic Acid-Schiff (PAS), were applied when necessary to aid diagnosis. Immunohistochemical (IHC) assessment was performed for markers including estrogen receptor (ER) and progesterone receptor (PR) in cases with suspected malignancy to confirm diagnoses. IHC runs included negative and positive control slides, as recommended by the manufacturer, and were reviewed by an experienced pathologist. Lesions associated with AUB were classified according to standard criteria, and tumors were categorized as per the World Health Organization (WHO) Classif ication. Histopathological evaluations were conducted on H&E-stained sections and independently reviewed by two pathologists to ensure diagnostic accuracy..

AND OBSERV ATION The study included 87 patients who underwent hysterectomy for abnormal uterine bleeding. Table 1: Distribution of the studied patients based on age group Age group Number of patients (n=87) Percentage 30-40 Year 28 32.2% 41-50 Year 50 57.5% 51-60 Year 7 8.0% >60 Year 2 2.3% MEAN±SD 44.11±5.8 Table 2: Distribution of the studied patients based on clinical diagnosis Clinical Diagnosis Number of patients (n=87) Percentage Abnormal uterine bleeding 19 21.8 Adenomyosis 8 9.2 Endometrial polyp 16 18.4 Cervical polyp 6 6.9 Fibroids 33 37.9 Post menopausal Bleeding 4 4.6 Severe dysmenorrhea with AUB 4 4.6 Ovarian cyst (Benign + Malignant) 3 3.4 Table 3: Distribution of the studied patients based on histopathological findings Histopathological findings Number of patients (n=87) Percentage Leiomyoma 33 37.9 Endometrial Hyperplasia 15 17.2 Endometrial polyp 11 12.6 Adenomyosis 10 11.5 Cervical polyp 5 5.7 CIN/ Dysplasia 5 5.7 International Journal for Multidisciplinary Research (IJFMR) E-ISSN: 2582-2160 ● Website: www.ijfmr.com ● Email: [email protected] IJFMR260271746 Volume 8, Issue 2, March-April 2026 4 Ovarian tumor 3 3.4 Cervical cancer 3 3.4 Endometrial cancer 2 2.3 Table 4: Association of diseases for leiomyoma in the study Leiomyoma findings Number of patients (n=33) Percentage No association 5 15.2% Adenomyosis 4 12.1% Endometrial polyp 4 12.1% Endometrial Hyperplasia 2 6.1% Chronic cervicitis 3 9.1% Multiple pathology 15 45.5% The most common clinical diagnosis(reference table 2) was fibroids, assigned to 33 patients (37.9%), followed by abnormal uterine bleeding in 19 patients (21.8%) and endometrial polyp in 16 patients (18.4%). Adenomyosis was diagnosed in 8 patients (9.2%), cervical polyp in 6 patients (6.9%), and both post-menopausal bleeding and severe dysmenorrhea with AUB in 4 patients each (4.6%). Benign or malignant ovarian cyst was the clinical diagnosis in 3 patients (3.4%). The distribution of the studied patients based on histopathological findings (reference table 3) was analyzed. The most common finding was leiomyoma, observed in 33 patients (37.9%) (reference table 4). This was followed by endometrial hyperplasia (17.2%). Endometrial Hyperplasia showed considerable morphological variation among all 15 patients. There were cases of ovarian tumour encountered in the present study, comprising two cases of benign serous cystadenoma and one case of dermoid cyst. Three cases of cervical squamous cell carcinoma were encountered in the present study. Of these, two cases were of the non-keratinizing type, characterized histologically by malignant squamous cells arranged in sheets and nests with marked nuclear pleomorp hism, hyperchromasia, increased mitotic activity, and absence of keratin pearl formation. One case was of the keratinizing type, which on histopathological examination showed prominent keratin pearl formation, individual cell keratinization, intercellular bridges, and malignant squamous cells exhibiting marked nuclear atypia and frequent mitoses. Two cases of endometrial carcinoma were observed during the present study. One case was of villoglandular carcinoma, which on histopathological examination showed complex villous and papillary glandular architecture lined by stratified malignant endometrial cells exhibiting mild to moderate nuclear atypia and increased mitotic activity. The other case was mucinous endometrial carcinoma, characterized histologically by glands and tumor cells containing abundant intracellular mucin, mucin -secreting columnar cells resembling endocervical epithelium, and varying degrees of nuclear atypia. International Journal for Multidisciplinary Research (IJFMR) E-ISSN: 2582-2160 ● Website: www.ijfmr.com ● Email: [email protected] IJFMR260271746 Volume 8, Issue 2, March-April 2026 5 PHOTO PLATE Plate 1: A large subserosal leiomyoma Plate 2: Endometrial polyp International Journal for Multidisciplinary Research (IJFMR) E-ISSN: 2582-2160 ● Website: www.ijfmr.com ● Email: [email protected] IJFMR260271746 Volume 8, Issue 2, March-April 2026 6 Plate 3: Leiomyoma at 40X (H&E stain) Plate 4: Endometrial hyperplasia without atypia ER 20X strong gland and stroma positivity International Journal for Multidisciplinary Research (IJFMR) E-ISSN: 2582-2160 ● Website: www.ijfmr.com ● Email: [email protected] IJFMR260271746 Volume 8, Issue 2, March-April 2026 7 Plate 5- Cervix Squamous cell carcinoma keratinizing type at 20 X (H&E stain) Plate 6: Endometrial carcinoma (Villoglandular Variant) ER 20X faint

The clinico-pathological correlation of AUB is vital, as clinical presentation alone may not reliably predict the underlying pathology. Histopathological examination not only confirms the diagnosis but also International Journal for Multidisciplinary Research (IJFMR) E-ISSN: 2582-2160 ● Website: www.ijfmr.com ● Email: [email protected] IJFMR260271746 Volume 8, Issue 2, March-April 2026 8 identifies incidental or coexisting lesions that may alter management strategies. Studies across diverse populations have consistently demonstrated that the spectrum of diseases associated with AUB in hysterectomy specimens ranges from benign conditions su ch as leiomyomas, adenomyosis, and endometrial hyperplasia to malignant lesions including endometrial carcinoma. 7,8 A structured approach to establishing the cause using the FIGO - PALMCOEIN classification system facilitates accurate diagnosis and treatme nt options. 9 Hysterectomy, which involves removing the uterus, is the most commonly performed major gynecological surgery worldwide, with its prevalence varying by region. In the present study, the mean age of the studied cases was 44.11±5.8 years, with the majority of the cases in the age range from 41-50 years (57.5%) followed by 30-40 years (32.2%), 51-60 years (8.0%) and more than 60 years (2.3%). Our findings were compa rable to the findings of Sofiatamilarasi C et al 10 who reported that the mean age of the study participants was 45.41 ± 7.24 years. Majority of participants (n=145) were in 41 to 50 years age group, followed by 58 participants in 31 to 40 years age group. 31 participants were from 51 to 60 years of age, 9 participants were from 61 to 70 years of age and 6 participants were from 21 to 30 years of age. In the present study, the predominant clinical presentation was heavy menstrual bleeding, accounting for nearly half of the cases (46%), underscoring its role as the most common indication for hysterectomy in women with abnormal uterine bleeding. Postmenop ausal bleeding was the second most frequent presentation (21.8%), highlighting its clinical importance as a potential marker of underlying pathology requiring definitive evaluation. Abnormal uterine bleeding in general was noted in 13.8% of patients, while intermenstrual bleeding contributed to 8%. Our findings were consistent with the findings of Shah D et al11, who reported that heavy menstrual bleeding was the most common presenting symptom, accounting 86 (29%) out of 300 women followed by Intermenstrual bleeding (25.0%), Frequent menstrual bleeding (21.0%), Postmenopausal bleeding (19.0%) and Heavy prolonged m enstrual bleeding (6.0%). In the Kinake MS et al 12 study, predominant pattern of AUB were reported as menorrhagia in 338 cases (51.13%), followed b y intermenstrual bleeding in 115 cases (17.39%), polymenorrhagia in 79 cases (11.95%), while metrorrhagia was seen in 73 cases (11.04%). Bindu PJ et alError! Bookmark not defined. saw heavy menstrual bleeding in 239 (75%) women, Intermenstrual bleeding was seen in 40 (12%) cases. Postmenopausal bleeding was seen in 31 (10%) women. Nine (3%) women showed breakthrough bleeding. In the present study, the most frequent findings were endometrial pathology (39.1%) and uterine fibroids (34.5%), reflecting their dominant role in the etiological spectrum of AUB. Other notable diagnoses included bulky uterus (13.8%), cysts (12.6%), and adenomyosis (11.5%), all of which are common benign conditions contributing to menstrual disturbances. Less frequent but clinically significant findings were pelvic inflammatory disease (2.3%), cervical cancer (1.1%), and isolated cases of IUCD -related changes (1.1%) and leiomyoma (1.1%). Our findings were in concordance with the findings of Kondareddy R, and Gomathy E14, who reported that 46.67% were diagnosed to have fibroid, 23.3% had Adenomyosis, 12.22% had DUB, 5.56% had polyp, 3.33% had endometrial and 2.22% had cervical carcinoma. Similar study by Bharti M and Bhol SK15 the most common ultrasound diagnosis was leiomyoma/fibroid/AUB- L, followed by adenomyosis/ AUB -A i.e., structural causes were more common than non -structural. In contrast to the study done, according to Anupamasuresh Y et al16 the most common USG diagnosis was non-structural followed by structural causes (AUB-L, AUB-A).

International Journal for Multidisciplinary Research (IJFMR) E-ISSN: 2582-2160 ● Website: www.ijfmr.com ● Email: [email protected] IJFMR260271746 Volume 8, Issue 2, March-April 2026 9 AUB comprises a wide spectrum of symptoms and presentations, taking into consideration various factors. Every case of AUB has its own characteristic findings on USG, endometrial biopsy and histopathology; hence a generalized or a single modality of treatment cannot be applicable for every patient. The clinical findings suggest the different causes of AUB are narrowed by taking proper history, ultrasonography and the confirmed diagnosis is achieved after histopathological examination. In patients with AUB the most common complaint and clinical presentation is HMB. Among them the most common histopathological diagnosis is Leiomyoma. The present study confirms a good correlation between clinical findings and histopathology especially in benign conditions. REFRENCES 1. Singh K, Agarwal C, Pujani M et al. A Clinicopathological Correlation of International Federation of Gynecology and Obstetrics's PALM -COEIN Classification of Abnormal Uterine Bleeding: Indian Scenario. J Midlife Health. 2019;10(3):147-152 2. Banmeru AP, Narayanaswamy M. From symptoms to surgery: clinicopathological correlation in women undergoing hysterectomy for abnormal uterine bleeding. Int J ReprodContracept Obstet Gynecol 2025;14:555-60. 3. Munro MG, Critchley HO, Fraser IS. The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years: who needs them? Am J Obstet Gynecol. 2012; 207: 259-265 4. Khrouf M, Terras K. Diagnosis and Management of Formerly Called "Dysfunctional Uterine Bleeding" According to PALM -COEIN FIGO Classification and the New Guidelines. J Obstet Gynaecol India. 2014;64(6):388-93 5. Gul G, Manzoor R, Lone IR. Abnormal uterine bleeding and hysterectomy: Insights from histopathological analysis of hysterectomy specimens from a tertiary care hospital. Indian J Pathol Oncol 2024;11(3):232-237 6. Maheshwari A, Kumar N, Mahantshetty U. Gynecological cancers: A summary of published Indian data. South Asian J Cancer. 2016;5(3):112–20 7. Shrivastava K, Mishra RT, Tiwari P et al. Histopathological spectrum of uterine lesions in hysterectomy specimens of patients with abnormal uterine bleeding. Int J Clin Trials 2024;11(4):252- 9 8. Dhakar JS, Shrivastava K, Mishra RT et al. Histopathological spectrum of uterine lesions in hysterectomy specimens of patients with abnormal uterine bleeding. Int J Clin Trials. 2024;11(4) 9. Munro M. G., Critchley H. O. D., Border, M. S. Et al. FIGO Working Group on Menstrual Disorders. International Journal of Gynecology and Obstetrics. 2011;113(1):3–13. 10. Sofiatamilarasi C, Umasamundeeswari R, Nithyananthinie V . Analysis of histopathological spectrum of hysterectomy specimens in Dindigul Medical College - a cross -sectional study. Int J Acad Med Pharm 2023;5(6);9-13 11. Shah D, Savsaviya MJ, Patel NP. Histopathological spectrum of endometrium in hysterectomy specimens from cases of abnormal uterine bleeding. International Journal of Clinical and Diagnostic Pathology 2022; 5(1): 11-16 International Journal for Multidisciplinary Research (IJFMR) E-ISSN: 2582-2160 ● Website: www.ijfmr.com ● Email: [email protected] IJFMR260271746 Volume 8, Issue 2, March-April 2026 10 12. Kinake MS, Watane S, Deshpande S. Clinico -Pathological Study of Abnormal Uterine Bleeding -A Two Year Study at Tertiary Care Center. International Journal of Medical Research & Health Sciences, 2021;10(6):1-8 13. Bindu PJ, Madhavi BV , Vasundara G et al. Clinicopathological Correlation of Endometrial Lesions in Abnormal Uterine Bleeding at a Tertiary Care Hospital. International Journal of Current Pharmaceutical Review and Research 2025; 17(3); 657-661 14. Kondareddy R, Gomathy E. Clinico -pathological correlation of AUB patients undergoing hysterectomy in a rural tertiary care centre. Indian Journal of Obstetrics and Gynecology Research 2019;6(4):495–498 15. Bharati M, Bhol SK. Study of clinical and pathological correlation of AUB patients undergoing hysterectomy. Int J Gynaecol. 2017;3:13-8 16. Anupamasuresh Y , Suresh YV , Jain P. Abnormal uterine bleeding: a clinico- histopathological analysis. Int J Reprod Contracept Obstet Gynecol. 2014;3:656- 61