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CLINICO-PATHOLOGICAL EVALUATION OF PATIENTS WITH ABNORMAL UTERINE BLEEDING.

Byline: Rabiah Anwar, Nighat Jamal and Sobia Anwar

Keywords: Endometrium, Histopathology, Menstrual disturbances.

INTRODUCTION

One of the most common gynecological complaints presented to gynecologist in outdoor patient department is abnormal uterine bleeding (AUB) 1. Women of reproductive age normally have menstrual flow every 24-38 days. It occurs at regular interval with variation of 7-9 days across cycles. Normal duration of menstrual bleed is 4.5-8 days and about 5-80cc of blood loss occur during one menstrual flow 2. Abnormal uterine bleeding can be frequent (38 days), prologed (>8 days), irregular (shortest to longest cycle variation: [greater than or equal to] 8-10 days) 2,3. Clinically, excessive blood loss is defined as a volume that interferes with the women's physical, emotional, social, and/or material quality of life 4. Bleeding between 2 menstrual cycles is called inter-menstrual bleeding 5.

AUB can be due to sructural/organic or non stuctural pathologies. "Structural" lesions can be imaged by ultrasonography and/or defined histopathologically (polyp, adenomyosis, leiomyomas and malignancy or atypical endometrial hyperlasia; PALM). Whereas non structural" cannot be imaged. With detailed history, proper physical examination and sometimes supported by laboratory investigations, we can find the nonstructural cause of abnormal uterine bleeding (coagulopathies, ovulatory disorders, primary endometrial disorders, iatrogenic and not otherwise classified; COEIN) 6. AUB in absence of organic lesion of genital tract can occur at any time during life span of a woman from menarche and occasionally even after the menopause in ovulatory and anovulatory cycles 7. Its management is not complete without tissue diagnosis especially in peri and post-menopause 8.

It has been observed that about one third of gynecological consultations are due to AUB symptoms. However, only half of affected women seek consultation. Out of which only fifty percent are satisfied after their hospital visit 9. Evidence also shows that chronic AUB is associated with 30% reduction in work productivity 10. This is an important factor of absence from work for working women. It equally affects the home environment for house wives as well. Local data in this regard is scarce as this problem has not been addressed well. Our study will help in better understanding of AUB, its ways of presentation and its histopathological finding. So we can handle this problem with more robust approach and patients can get satisfactory treatment. Furthermore, this will aid to research in our country.

METHODOLOGY

This analytic study was conducted in department of Gynae/Obstetics, Pakistan Naval Ship (PNS) Shifa Karachi, from February 2018 to January 2019. The study was approved by the ethics committee of the hospital (ERC/2020/Gynae/12). Informed consent was obtained from all the participants and confidentiality was maintained.

Complete history was taken from patients presented with abnormal uterine bleeding. History included age, parity, socioeconomic status, age of menarche, pattern of menstrual irregularity (type, amount and duration of blood loss), associated pain, bleeding from any other site, history of hormonal treatment and any medical issue. Abdominal and pelvic examination was done to rule out clinical pathology. Cervical smear was taken. Pelvic scan from our radiology department was done to rule out organic pathology. Our setup provides free treatment and investigations for the entitled patients. Women with organic lesions such as tumor, fibroid, polyp, adenomyosis, medical problems such as cirrhosis and thyroid disorders were excluded. Adolescent/teen age group and unmarried ladies were also excluded as endometrial sample could not be taken from them. Only women having menstrual irregularities without organic lesions and with no co morbid (such as thyroid disorders and cirrhosis) were included.

We studied 184 cases of abnormal uterine bleeding. Sample size was calculated using WHO sample size calculator. Assuming 12% frequency of abnormal uterine bleeding among women 11, minimum sample size of 161 was calculated to provide study 80% power in assessing clinical and pathological aspects among women of different age groups presenting with menstrual irregularities without any organic pelvic pathology. Endometrial sample of patients was taken by Pipelle, preserved in 10% formaline and sent for histopathological evaluation to pathology department of PNS Shifa Karachi. Patients who were bleeding were prescribed non hormonal treatment till the procedure. Evaluation of spectrum of clinical presentation and endometrial histopathological findings was done among women of different age groups.

Data was analyzed using SPSS version 19. Mean +- SD were calculated for quantitative variables. Frequency and percentage were calculated for qualitative variables.

Table-I: Clinical presentations of menstrual irregularities in different age groups.

Menstrual Pattern###21-30 years###31-40 years###41-50 years###51-60 years###61-70 years

###n(%)###n(%)###n(%)###n(%)###n(%)

Heavy Menstrual Bleeding###23(12.5%)###34(18.47%)###33(17.93%)###3(1.63%)###-

Irregular Menstrual Bleeding###-###7(3.80%)###15(8.28)###9(4.89%)###2(1.08%)

prolonged Menstrual Bleeding###4(2.17%)###-###11(5.97%)###-###-

Frequent Menstrual Bleeding###-###3(1.63%)###7(3.80%)###6(3.26%)###-

Heavy and Prolonged Menstrual Bleeding###2(1.08%)###5(2.71%)###3(1.63%)###-###-

Infrequent Menstrual Bleeding###-###3(1.63%)###8(4.34%)###1(0.54%)###-

Shortened Menstrual Bleeding###3(1.63%)###2(1.08%)###-###-###-

Total###32(17.39%)###54(29.34%)###77(41.84%)###19(10.32%)###2(1.08%)

Table-II: Histopathological findings of endometrial sample.

Endometrial Status###Cases, n(%)

Proliferative###76(41.30%)

Secretory###39(21.19%)

Atrophic###6(3.26%)

Hyperplastic###51(27.71%)

Simple Hyperplasia###28(15.21%)

Complex###14(7.60%)

Without Atypia###6(3.26%)

With Atypia###3(1.63%)

Irregular Shedding###6(3.26%)

Product of Conception###1(0.54%)

Arias stella Reaction###1(0.54%)

Endometrial Polyp###1(0.54%)

Endometrial Carcinoma###3(1.63%)

Total###184(100%)

Table-III: Histological findings in different age groups.

Endometrial Histology###21-30 year###31-40 year###41-50 year###51-60 year###61-70 year

Proliferative###20(10.8%)###22(11.95%)###34(18.47%)###-###-

Secretory###11(5.97%)###28(15.21%)###-###-

Atrophic###-###-###-###4(2.16%)###2(1.08%)

Hyperplastic Type###-###-###39(21.19%)###12(6.52%)###-

Irregular Shedding###-###3(1.63%)###3(1.63%)###-###-

Arias stella Reaction###-###1(0.543%)###-###-###-

Endometrial Polyp###-###-###1(0.543%)###-###-

Product of Conception###1(0.543%)###-###-###-###-

Endometrial Carcinoma###-###-###-###3(1.63%)###-

Total###32(17.39%)###54(29.34%)###77(41.84%)###19(10.32%)###2(1.08%)

Table-IV: Histopathological findings in relation to clinical presentation.

Histology of###Heavy###Irregular###Prolonged###Frequent###Heavy and###Infrequent###Shortened

Endometrium###Menstrual###Menstrual###Menstrual###Menstrual###Prolonged###Menstrual###Menstrual

###Bleeding###Bleeding###Bleeding###Bleeding###Menstrual###Bleeding###Bleeding

###Bleeding

Proliferative###33(17.93%)###19(10.32%)###4(2.17%)###5(2.71%)###3(1.63%)###10(5.4%)###2(1.08%)

Secretory###18(9.78%)###8(4.34%)###4(2.17%)###3(1.63%)###3(1.63%)###-###3(1.63%)

Atrophic###-###-###-###6(3.26%)###-###-###-

Hyperplastic###36(19.56%)###4(2.71%)###6(3.26%)###-###3(1.63%)###2(1.08%)###-

Irregular shedding###3(1.63%)###-###-###2(1.08%)###1(0.54%)###-###-

Arias stella###1(0.54%)###-###-###-###-###-###-

reaction

Endometrial polyp###-###1(0.54%)###-###-###-###-###-

Product of###-###1(0.54%)###-###-###-###-###-

conception

Endometrial###2(1.08%)###-###1(0.54%)###-###-###-###-

carcinoma

Total###93(50.54%)###33(17.93%)###15(8.15%)###16(8.69%)###10(5.43%)###12(6.52%)###5(2.71%)

RESULTS

The patients presenting with menstrual irregularities had age ranging from 21-70 years with mean age 38.49 +- 9.158. We obtained highest number of cases i.e. 77 out of 184 (41.84%) in 41-50 years of age, 54 (29.34%) in 31-40 years of age, 32 (17.39%) in 21-30 years age, 19 (10.32%) between 51-60 years while lowest being 2 (1.086%) between 61-70 years.

We observed that as compared to nulliparous women, AUB was common in parous women. Out of 184 cases, 146 (79.34%) were multipara, 31 (16.84%) were primipara and 7 (3.86%) were nullipara. Our analysis revealed that 95 (51.63%) cases of AUB were of middle socioeconomic group, 67 (36.41%) of low and 22 (11.95%) of higher socioeconomic status.

Heavy menstrual bleeding (HMB) (excessive menstrual blood loss that interferes with the women's physical, emotional, social and material quality of life and can occur alone or in combinations with other symptoms) was the most common menstrual disorder in women presenting with AUB. Ninety three cases (50.54%) were of HMB, followed by 33 (17.93%) cases of irregular menstrual bleeding (variation of >20 days in individual cycle lengths over a period of one year). Frequent menstrual bleeding (more than four menstrual episodes in a 90 day period) was observed in 16 patients (8.69%). Prolonged menstrual bleeding (periods exceeding 8 days in duration on a regular basis) was seen in 15 women (8.15%). Infrequent menstrual bleeding (one or two menstrual episodes in a 90-day period) in 12 cases (6.52%), heavy and prolonged menstrual bleeding in 10 cases (5.43%) and shortened menstrual bleeding (bleeding of no longer than 2 days) was observed in 5 cases (2.71%).

In all age groups, HMB was prevailing. In 41-50 years of age group, heavy, prolonged, frequent and irregular menstrual bleeding pattern was observed as shown in table-I.

As far as histopathological finding of endometrium is concerned, the most common type of endometrium observed was proliferative (41.30%) followed by Hyperplastic (27.71%) and secretory (21.19%). Malignancy was found in 3 (1.63%) cases as shown in table-II.

We observed that in all age group proliferative endometrium was common (41.30%) whereas hyperplasic type of endometrium was mostly seen in 41-60 years of age groups. Endometrial carcinoma was detected in 51-60 years of age group as shown in table-III.

This study showed that proliferative endometrium was mostly seen in patient of heavy menstrual bleeding (17.93%) and irregular menstrual bleeding (10.32%). Hyperplasia (20.1%) was observed in cases of HMB, whereas 3 cases diagnosed as having endometrial malignancy were of HMB and prolonged menstrual bleed as depicted by table-IV.

DISCUSSION

Abnormal uterine bleeding is one of the significant gynecological problem forcing patients to seek advice from doctor. In our study, we did endometrial sampling by Pipelle. Pipelle is an outdoor patient procedure and is very effective tool of endometrial sampling in low risk patient with abnormal uterine bleeding 12. Endometrial sampling can be done by Pipelle, Vebra and conventional dilatation and currettage. Now a days hysteroscopically directed biopsy is being preferred. In our study, hysteroscopically directed biopsy was not done due to non-availability of this facility in our setup.

In our study, we observed that maximum no. of cases of AUB i.e. 77 cases (41.84%) were between 41-50 years. Nayak et al 7, had similar findings. Whereas Doraiswami et al, reported maximum cases (33.5%) in the 5 th decade of life 13. In our study, the higher frequency of AUB was observed in perimenopausal age group. It may be due to overlook of their symptoms during their reproductive life but increase in severity of symptoms and increasing disability with increasing age may have forced them to seek consultation in hospital.

The commonest presenting complaint in our study was heavy menstrual bleed (50.54%). HMB was observed in 51.87% cases by Nayak et al 7, in 64% cases by Nair et al 14, in 38.67% cases by Palwade 15, and in 40% cases by Verma 16. But Jeffcoate found only in 10% of cases 17.

We observed that 6.52% of cases had infrequent menstrual bleeding pattern. This is comparable to observation by Sharada 18 (8%) and AK et al 7 (6.25%).

In our study, we found 41.30% cases of proliferative pattern of endometrium. Nayak et al, has similar findings 7 (41.88%). Whereas, Gazozai et al 19 (31%) and Muzaffar et al 20 (25.8%) found lower incidence of proliferative pattern of endometrium. Bindroo et al, also observed higher number of cases of proliferative endometrium (37.2%) suggesting that anovulation may be reason of AUB 21.

In our study, out of 32 cases belonging to 21-30 years of age group, 20 (10.8%) had proliferative pattern of endometrium. Similar findings were observed by Nayak et al 7. HMB was the most common bleeding pattern in this type of endometrium.

We observed 21.19% of cases of secretory endometrium and most of them were of 31-40 years of age. Our incidence nearly correlates with finding of Nayak et al 7 (21.88%). Whereas, Bolde et al 22, reported low incidence of 5.97%.

We noticed endometrial hyperplasia in 27.7% cases whereas Khan et al, observed in 20.5% cases 23 and Nayak et al, in 27.5% cases 7. In patients with endometrial hyperplasia, we found 54.90% cases with simple hyperplasia whereas Nayak et al 7, found 65.9% of cases with simple hyperplasia without atypia. Majority of them were between 41-50 years of age.

We found atrophic endometrium in 3.26% of cases whereas Nayak et al, in 2.5% of cases 7, Katuwal et al, in 68% of cases 24. Atrophic endometrium was observed in cases of more than 50 years of age.

Due to persistent corpus luteum, irregular shedding of endometrium was observed in 3.26% cases whereas Nayak et al 7, found in 3.13% and Nagarjuna et al in 6% cases 25.

We found endometrial carcinoma in 1.63% cases whereas Nayak et al, observed 1.25% cases of endometrial carcinoma 7. All of them were >50 years of age.

Our study was conducted in tertiary care hospital which is not representative of the country. PNS Shifa is a teaching hospital and caters for large number of Armed Forces and civilian personnel. Therefore, it gives insight of picture of women with abnormal uterine bleeding, their bleeding pattern and endometrium histopathology.

CONCLUSION

In conclusion, 41-50 years old ladies were mostly affected by AUB. The most common bleeding pattern in all age groups was heavy menstrual bleeding. Proliferative endometrium was the predominant histopathological type obsereved in our set up. Histopathological evaluation of endometrium seems quite helpful in excluding local causes and making diagnosis of AUB. This eventually is useful in determining the mode of management for patient.

CONFLICT OF INTEREST

This study has no conflict of interest to be declared by any author.

REFERENCES

1. Benetti-Pinto CL, Rosa-e-Silva AC, Yela DA, SoaresJunior JM. Abnormal uterine bleeding. Revista Brasileira de Ginecologia e Obstetricia 2017; 39(7): 358-68.

2. Fraser IS, Critchley HO, Munro MG, Broder M. A process designed to lead to international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding. Fertility and Sterility 2007; 87(3): 466-76.

3. Fraser IS, Critchley HO, Munro MG, Broder M. Can we achieve international agreement on terminologies and definitions used to describe abnormalities of menstrual bleeding?. Human Reproduct 2007; 22(3): 635-43.

4. Lumsden MA. Women's Health: Adopt an evidence-based approach to menorrhagia. Practitioner 2007: 1(1); 26-31.

5. Munro MG, Critchley HO, Fraser IS. Research and clinical management for women with abnormal uterine bleeding in the reproductive years: More than Palm Coein. Bjog An Inter J Obstetr Gynaecol 2017; 124(2): 185-89.

6. Munro MG, Critchley HO, Fraser IS, FIGO menstrual disorders committee, Haththotuwa R, Kriplani A, Bahamondes L, Fuchtner C, Tonye R, Archer D, Abbott J. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Inter J Gynecol Obstet 2018; 143(3): 393-408.

7. Nayak AK, Hazra K, Manju KJ. Clinico-pathological evaluation of dysfunctional uterine bleeding. Int J Contemp Med Res 2017; 4(4): 920-24.

8. Kazemijaliseh H, Tehrani FR, Behboudi-Gandevani S, Khalili D, Hosseinpanah F, Azizi F. A population-based study of the prevalence of abnormal uterine bleeding and its related factors among iranian reproductive-age women: an updated data. Archives Iran Med 2017; 20(9): 8-13.

9. Frick KD, Clark MA, Steinwachs DM, Langenberg P, Stovall D, Munro MG, et al. STOP-DUB research group. Financial and quality-of-life burden of dysfunctional uterine bleeding among women agreeing to obtain surgical treatment. Women's Health Issues 2009; 19(1): 70-78.

10. Fraser IS, Mansour D, Breymann C, Hoffman C, Mezzacasa A, Petraglia F. Prevalence of heavy menstrual bleeding and experiences of affected women in a European patient survey. Inter J Gynecol Obstetr 2015; 128(3): 196-200.

11. Abid M, Hashmi AA, Malik B, Haroon S, Faridi N, Edhi MM, et al. Clinical pattern and spectrum of endometrial pathologies in patients with abnormal uterine bleeding in Pakistan: need to adopt a more conservative approach to treatment. BMC Women's Health 2014; 14(1): 1-7.

12. Narice BF, Delaney B. Endometrial sampling in low-risk patients with abnormal uterine bleeding: a systematic review and metasynthesis. BMC Family Practice 2018; 19(1): 135-38.

13. Doraiswami S, Johnson T, Rao S, Rajkumar A, Vijayaraghavan J, Panicker VK. Study of endometrial pathology in abnormal uterine bleeding. J Obstet Gynecol Ind 2011; 61(4): 426-30.

14. Nair R, Mallikarjuna M. Clinical profile of patients with abnormal uterine bleeding at a tertiary care hospital. Int J Reprod Contracept Obstet Gynecol 2015; 4(1): 1753-57.

15. Palwade JM, Borole CS. A study of causes of abnormal uterine bleeding with re classification in the patients at perimenopausal age. Med Pulse Inter Med J 2016; 3(11): 987-91.

16. Verma R. A study on abnormal uterine bleeding in perimenopausal age in rural Bihar. J Med Sci Res 2016; 4(1): 9262-74.

17. Jeffcoate N, Tindall TR. Jeffcoate"s principles of gynaecology, 5 th ed. London Butterworths 1987: 1(1); 513-31.

18. Sharada MS, Ebinesh A. Clinico-pathological study of endometrium in dysfunctional uterine bleeding: An experience with D and C specimens. Sch J App Med 2016; 4(6D): 2144-52.

19. Gazozai S, Bugti QA, Siddiqa A. Excessive uterine haemorrhage-a histopathological study. Gomal J Med Sci 2004; 2(1): 13-15.

20. Muzaffar M, Akhtar KA, Yasmin S, Rehman M, Iqbal W, Khan MA. Menstrual irregularities with excessive blood loss: a clinicopathological correlation. J Pak Med Assoc 2005; 55(11): 486-89.

21. Bindroo S, Garg M and Kaur T. Histopathological spectrum of endometrium in abnormal uterine bleeding. Int J Reprod Coctracept Obstet Gynecol 2018; 7(9): 3633-7.

22. Bolde SA, Pudale SS, Pandit GA, Matkari PP. Histopathological study of endometrium in cases of abnormal uterine bleeding. Int J Res Med Sci 2014; 2(4): 1378-81.

23. Khan R, Sherwani RK, Rana S, Hakim S, Jairajpuri ZS. Clincopathological patterns in women with dysfunctional uterine bleeding. Iran J Pathol 2016;11(1):20-6.

24. Katuwal N, Gurung G, Rana A. A clinicopathological study of dysfunctional uterine bleeding. J Pathol Nepal 2014; 4(8): 635-8.

25. Nagarjuna Chary R, Fatima A, Joya Rani D. Endometrial histopathological changes associated with dysfunctional uterine bleeding, Assian Pac. J Health Sci 2016; 3(2): 106-9.
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Author:Rabiah Anwar, Nighat Jamal and Sobia Anwar
Publication:Pakistan Armed Forces Medical Journal
Date:Jun 30, 2021
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