Abnormal uterine bleeding: a clinicohistopathological analysis

INTRODUCTION

Abnormal Uterine Bleeding (AUB) is considered as one of the most common and perplexing problem both for the patients and the gynecologists. It has an adverse effect on the quality of life and psychological state of women. It is of special concern in developing country as it adds to the causes of anemia which is already prevailing in women. Management of Abnormal Uterine Bleeding (AUB) is not complete without tissue diagnosis especially in perimenopausal and post-menopausal women. Accurate analysis of endometrial sampling¹ and localization of intrauterine lesions is the goal to effective management and better outcome of problem. Histological characteristics of endometrial biopsy material as assessed by light microscopy remains the diagnostic standard for the diagnosis of endometrial pathology.

METHODS

This was a prospective observational study. A total of 359 women, who are more than 45 years of age with abnormal uterine bleeding, who needed endometrial curettage were included in the study. Written, informed consent was taken from the patients. We recorded the details in the designed proforma which included the information about, patient characteristics, obstetric profile, pattern of bleeding, history of drug intake and medical history. The type of abnormal uterine bleeding and the pattern of blood loss were described according to the FIGO recommendations on terminologies and definitions for normal and abnormal uterine bleeding. Amount of bleeding was assessed using pictorial blood assessment chart. General physical examination and local examination was performed. Patients on admission, were screened for hypertension, diabetes mellitus and hypothyroidism. Endometrial curettage was performed by a gynecologist and specimens were transported in 10% formalin to the pathology laboratory. Microscopic examination was done by pathologists. We recorded the details in the designed proforma that included information about patient characteristics, obstetric profile, pattern of bleeding and co morbidities.

Inclusion criteria: we included women with isolated endometrial causes of abnormal uterine bleeding, more than 45 years of age, undergoing endometrial curettage, in the study.

Exclusion criteria: we excluded women with coagulation disorders (thrombocytopathies, Von Willebrand’s disease, and leukemia) and on medications including antiplatelets and anticoagulants, Findings were tabled.

RESULTS

Total 369 patients were included in the study from the age group of 45 years to 73 years.

There are 188 patients were in the age group of 46 to 50 years (52.4%).

Majority of our patients were multiparous women (192 patients, 53.5%). 135 patients, 37.5% were primiparous; 23 patients, 6.4% were nulliparous; 9 patients, 2.5% were grandmultiparous.

No significant association was found between pattern of histopathology & parity distribution with a P value of 0.67.

Type of AUB

Table 3 shows Type of AUB.

A significant association was found between pattern of histopathology & type of AUB with a P value of <0.01. As seen in the above table 157 (43.6%) patients presented with post-menopausal bleeding, followed by 87 (24.2%) patients with chronic AUB.

*P value <0.01; Chi-square test

Most commonly found histopathology was endometrial hyperplasia (26.7%). The incidence of malignancy has been increasing with the age being 1.6% in 46-50 years to 60% in 70-75 years.

The present study included only perimenopausal and post-menopausal women which lead to a greater number of women with malignancy (6.4%) as compared to other studies which included all the women from menarche to menopause (Table 5). A significant association was found between pattern of histopathology & BMI with a P value of <0.01. Majority of the patients with endometrial hyperplasia and malignancy were obese 37 out 96 and 13 out of 23 respectively. In the group of participants with underweight and normal BMI normal cyclical pattern was most commonly found in 32 out of 50 and 28 out of 95 patients respectively. In pre obese and obese group endometrial hyperplasia was most prevalent in 34 of 97 and 37 of 117 patients respectively (Table 6).

*P value <0.01; Chi-square test

*P value <0.01; Chi-square test

A significant association was found between pattern of histopathology & hypertension with a p value of <0.01. Hypertension was more common in patients with atrophic endometrium, endometrial hyperplasia and endometrial malignancy with 12 out of 20, 68 out of 96 and 14 out of 23 patients respectively. Majority of the patients 68 out of 116 with hypertension had endometrial hyperplasia.

*P value <0.01; Chi-square test

A significant association was found between pattern of histopathology & diabetes with a p value of <0.01. Diabetes was more common in patients with atrophic endometrium, endometrial hyperplasia and endometrial malignancy with 6 out of 20, 16 out of 96 and 6 out of 23 patients respectively. Majority of the patients 16 out of 33 with diabetes had endometrial hyperplasia.

*P value <0.01; Chi-square test

A significant association was found between pattern of histopathology & hypothyroidism with a P value of <0.01. Hypothyroidism was more common in patients with endometrial hyperplasia and endometrial malignancy with 19 out of 96 and 6 out of 23 patients respectively. Majority of the patients 19 out of 40 with hypothyroidism had endometrial hyperplasia.

Pattern of bleeding in perimenopausal women

The most commonly noted pattern of bleeding was irregular cycles in 65% of women.

Increased frequency of cycles was found in majority of patients (44%).

Heavy bleeding (80 ml<) was found in 79% of our participants.

No significant association was found between pattern of histopathology & bleeding pattern with a P value of >0.05. The most commonly noted pattern of bleeding was prolonged bleeding in 73% of the patients.

DISCUSSION

AUB is one of the most frequent complaints from the gynecological patients. Dilatation and curettage is the common procedure done to evaluate AUB.¹

In our study 359 patients were included from 46 to 73 years of age. In our present study the age group which was most susceptible to abnormal uterine bleeding was 46-50 years with 52.4% of patients (Table 1).

Doraiswami et al. noted in 41-50 years age group with 33.5% patients.⁴ The reason for increased incidence of AUB in this age group may be due to the fact that these women are in their climacteric period approaching menopause, when cycles become intermittently anovulatory due to decline in the number of ovarian follicles and estradiol level.

We found a maximum incidence (53.5%) of AUB in multiparous women (Table 2). A similar result was also found by Rajesh Patil et al. with a percentage of 71.58%,² Smitha et al. got 60.95%. Most commonly found histopathology was endometrial hyperplasia (26.7%).³ The incidence of malignancy has been increasing with the age being 1.6% in 46-50 years to 60% in 70-75 years.

Postmenopausal women accounted for 43.6% of our patients (Table 3). A significant association was found between pattern of histopathology & type of AUB with a P value of <0.01. As seen in the table 157 (43.6%) patients presented with post-menopausal bleeding, followed by 87 (24.2%) patients with chronic AUB. Amongst the women in perimenopausal age group the most common type of abnormal uterine bleeding was chronic AUB. The most commonly noted pattern of bleeding was irregular cycles in 65% of women, increased frequency of cycles in 44%, heavy bleeding in 79% and prolonged bleeding in 73%. We found endometrial hyperplasia as the most common pathological lesion (26.7%) on histopathology (Table 4).

Ara and Roohi noted hyperplasia in 27.95% of cases.⁵ Smitha et al. was 41.90%⁶ The incidence of hyperplasia was 6.1% in Doraiswami et al. (Table 5).

A significant association was found between pattern of histopathology & BMI with a P value of <0.01. Majority of the patients with endometrial hyperplasia and malignancy were obese 37 out 96 and 13 out of 23 respectively. In the group of participants with underweight and normal BMI normal cyclical pattern was most commonly found in 32 out of 50 and 28 out of 95 patients respectively. In pre obese and obese group endometrial hyperplasia was most prevalent in 34 of 97 and 37 of 117 patients respectively (Table 6).⁷ Another significant relation was found between pattern of histopathology & hypertension and diabetes⁷ with a P value of <0.01. Hypertension was more common in patients with atrophic endometrium, endometrial hyperplasia and endometrial malignancy with 12 out of 20, 68 out of 96 and 14 out of 23 patients respectively. Majority of the patients 68 out of 116 with hypertension had endometrial hyperplasia (Table 7).

Also there with diabetes mellitus as majority of these patients 16 out of 33 with diabetes had endometrial hyperplasia (Table 8).

We have also observed that in hypothyroidism patients a significant P value of <0.01. With endometrial hyperplasia and endometrial malignancy with 19 out of 96 and 6 out of 23 patients respectively (Table 9).

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the institutional ethics committee

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