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 Table of Contents 
ORIGINAL ARTICLE
Year : 2016  |  Volume : 7  |  Issue : 2  |  Page : 73-77  

Abnormal uterine bleeding in perimenopausal women: Correlation with sonographic findings and histopathological examination of hysterectomy specimens


1 Department of Obstetrics and Gynaecology, Fakhruddin Ali Ahmed Medical College, Barpeta, Assam, India
2 Department of Radiology, Fakhruddin Ali Ahmed Medical College, Barpeta, Assam, India

Date of Web Publication4-Jul-2016

Correspondence Address:
Bharat Talukdar
Department of Obstetrics and Gynaecology, Fakhruddin Ali Ahmed Medical College, Barpeta - 781 301, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0976-7800.185336

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   Abstract 

Background: Abnormal uterine bleeding (AUB) is a frequently encountered gynecologic complaint in perimenopausal woman and also the most common cause of hysterectomy in this age group.
Objective: Evaluation of various clinical presentations of perimenopausal AUB and it is ultrasonographic and histopathological correlation of hysterectomy specimens.
Materials and Methods: This study was carried out in the Department of Obstetrics and Gynaecology among perimenopausal women who underwent hysterectomy for AUB. The clinical presentations, ultrasonographic findings, and histopathological reports of hysterectomy specimen were correlated.
Results: Among 103 number of hysterectomized cases for AUB, most of the patients were between 40 and 45 years of age (67.97%) and menorrhagia was the dominant clinical presentation. The majority (45.63%) of cases were diagnosed as fibroid uterus by ultrasonography with 89.13% sensitivity and 89.47% specificity. Histopathological reports of myometrium showed 44.66% fibromyoma, followed by 34.95% of the normal myometrium. Histopathology of endometrium revealed hyperplasia in the most cases (56.31%) where simple typical type was the predominant.
Conclusion: Uterine fibroid was the leading cause of AUB and radiological, pathological evaluation correlated well to diagnose fibroid.

Keywords: Abnormal uterine bleeding, histopathology, perimenopausal woman, ultrasonography


How to cite this article:
Talukdar B, Mahela S. Abnormal uterine bleeding in perimenopausal women: Correlation with sonographic findings and histopathological examination of hysterectomy specimens. J Mid-life Health 2016;7:73-7

How to cite this URL:
Talukdar B, Mahela S. Abnormal uterine bleeding in perimenopausal women: Correlation with sonographic findings and histopathological examination of hysterectomy specimens. J Mid-life Health [serial online] 2016 [cited 2021 Apr 15];7:73-7. Available from: https://www.jmidlifehealth.org/text.asp?2016/7/2/73/185336


   Introduction Top


Abnormal uterine bleeding (AUB) is a symptom and not a disease. It is one of the most frequently encountered complaints in gynecologic practice. It accounts for more than 70% of all gynecological consultations in the peri- and post-menopausal age group.[1] It occurs in various forms such as menorrhagia, polymenorrhea, polymenorrhagia, metrorrhagia, and menometrorrhagia.[2] The International Federation of Gynaecology and Obstetrics in November 2010, accepted a new classification system for causes of AUB in the reproductive years. The system based on the acronym (polyps, adenomyosis, leiomyoma, malignancy and hyperplasia–coagulopathy, ovulatory disorders, endometrial causes, iatrogenic, not classified) was developed in response to concerns about the design and interpretation of basic science and clinical investigation that relates to the problem of AUB.[3]

AUB may be an expression of hormonal milieu, or it could be the clinical presentation of benign or malignant lesions of female genital tract in perimenopausal woman. However, there are no detectable structural abnormalities in majority of cases, and this is called dysfunctional uterine bleeding (DUB). DUB, fibroid uterus, and adenomyosis are the common hyperoestrogenic conditions where endometrium remains in the proliferative phase and if untreated may lead to endometrial carcinoma. Therefore, clinical examination and investigations are essential to find out the etiological factor in a perimenopausal patient presenting with AUB. Ultrasonography (USG) can be used to exclude organic pathology for AUB. It is well accepted that various disease pathology can be detected accurately by histopathological examination (HPE). The current study was carried out to evaluate various clinical presentations of perimenopausal AUB and to correlate ultrasonographic findings with histopathological examination in those patients undergoing hysterectomy.


   Materials and Methods Top


This study was conducted in a tertiary care hospital in a time span of 1-year from July 1, 2014, to June 30, 2015. The study population consists of perimenopausal women within the age group of 40 years to within 1 year of menopause who underwent hysterectomy for AUB. The proper institutional ethical clearance was taken for the study. After obtaining informed consent from selected patients, the relevant data such as age, parity, menstrual symptoms, and other associated findings in clinical examination were recorded. In all these women, transvaginal ultrasonographic evaluation was done. The clinical presentations and ultrasonographic findings were correlated. Histopathology examination report of hysterectomy specimens such as endometrial, myometrial, and cervical findings was correlated with sonographic reports, and results were analyzed using Graph Pad Software, Inc; Version 3.1.


   Results Top


One hundred and three numbers of patients with AUB who underwent hysterectomy were included in this study. A correlation between age, parity is depicted in [Table 1]. Most of the patients were between 40 and 45 years of age (67.97%). The highest number of AUB in this study was para 4 or more (42.71%) followed by para 3 (26.21%).
Table 1: Distribution of age and parity (n=103)

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The different menstrual pattern of AUB, as well as duration of symptoms, was shown in [Table 2]. The majority of patients gave a history of menstrual problem between 3 and 6 months 56 (54.37%), and menorrhagia was the dominant presentation.
Table 2: Distribution of menstrual complain and duration (n=103)

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Ultrasonographically 47 (45.63%) cases were fibroid uterus, 30 cases (29.12%) were bulky uterus, 11 cases (10.69%) were adenomyosis, and 12 (11.65%) cases were diagnosed as thickened endometrium [Table 3]. Majority of patients diagnosed as fibroid uterus, bulky uterus, adenomyosis, and thickened endometrium by USG had presented with menorrhagia which is shown in [Table 4]. Of the nine postmenopausal bleeding, four patients had findings of endometrial thickening in USG.
Table 3: Ultrasonography findings (n=103)

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Table 4: Patient distribution with respect to bleeding pattern and ultrasonography findings

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Histopathological reports of myometrium were as follows: fibroid 46 (44.66%), adenomyosis 21 (20.39%), and normal myometrium 36 (34.95%) [Table 5]. Of 47 ultrasonographically diagnosed fibroid uterus, 41 were confirmed by histopathologically, and 6 turned out as adenomyosis. Hysterectomy for adenomyosis was done in 11 cases and 10 confirmed by HPE as well. Out of the thirty cases of the bulky uterus in USG, which were clinically diagnosed as DUB, subsequent HPE report revealed normal myometrium in 22 cases, adenomyosis in five, and fibromyoma in three cases. Histopathology of endometrium showed hyperplastic endometrium in 58 cases (56.31%), secretary in 20 cases (19.42%), proliferative in 14 cases (13.59%), inflammatory in two cases, and carcinoma endometrium in two cases. Out of 58 endometrial hyperplasia diagnosed by HPE, USG detected thick endometrium in 12 cases. Among the 12 USG detected thick endometrium, four cases were postmenopausal women (endometrial thickness >5 mm). Simple typical hyperplasia was the dominant HPE finding [Table 6]. Out of the two HPE confirmed carcinoma endometrium cases, USG detected thick endometrium in one case and bulky uterus in the other. USG detected thick endometrium which turned out to carcinoma endometrium in HPE was a postmenopausal woman. There were 59 (57.28%) inflammatory cervix, one carcinoma of cervix and two cases of cervical intraepithelial neoplasia (CIN) in HPE.
Table 5: Histopathological examination findings in relation to ultrasonography diagnosis

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Table 6: Endometrial hyperplasia on histopathological examination (n=58)

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[Table 7] shows the validity of USG in the detection of fibromyoma and adenomyosis in perimenopausal women. The results reveal that the sensitivity is lower in diagnosis of adenomyosis (47.62%).
Table 7: Specificity and sensitivity of ultrasonography diagnosis with histopathological examination diagnosis

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   Discussion Top


AUB is one of the main gynecological reasons of hysterectomy and accounts for two-thirds of all hysterectomies.[4] In this study, 103 numbers of perimenopausal hysterectomized patients were analyzed. Most number of patients (69.67%) were between 40 and 45 years age group. The common menstrual problem was menorrhagia (43.69%). This finding was comparable with the study of Jetley et al.[5] and Shobha,[6] in which clinical presentation as menorrhagia in AUB evaluation revealed 46.4% and 46.6%, respectively. It appeared in this study that the maximum patients attended hospital for treatment after suffering for 3–6 months (54.37%) which was comparable to the study of Kathuria and Bhatnagar (50%).[7]

In this study, ultrasonographic diagnosis of fibromyoma of the uterus was 47 (45.63%). Out of these, 41 were confirmed by histopathologically, and six turned out as adenomyosis. The sensitivity of USG for the diagnosis of leiomyoma was 89.13%, and the specificity was 89.47%, which is similar to the study done by Dueholm et al.[8]

In this study, 21 cases were diagnosed as adenomyosis by histopathologically, ultrasound diagnosed 11 of them. Ultrasound was able to suggest adenomyosis with sensitivity of 47.62%, specificity of 98.78%, positive predictive value of 90.91%, and negative predictive value 80.04% [Table 7]. [Table 8] shows a comparison of sensitivity, specificity, PPV, and NPV of this study with several previous studies that investigated the diagnosis of adenomyosis. The sensitivity in this study is lower as compared to the studies of Siedler et al, Ascher et al, Reinhold et al, Atzori et al and Atri et al but the specificity is the almost similar of those reported.[9],[10],[11],[12],[13] Hence, USG has a limitation in tissue characterization in diagnosis adenomyosis.{Table 7}
Table 8: Sensitivity, specificity, positive, and negative predictive values of transvaginal sonography for the diagnosis of adenomyosis from previous series compared with this series[9],[10],[11],[12],[13]

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Bulky uterus was the sole USG finding in 30 numbers of cases which were clinically diagnosed as DUB. Out of these, histopathologically revealed normal myometrium in 22 cases, adenomyosis in five cases, and fibromyoma in three cases. Histopathologically endometrial hyperplasia was observed in 19 numbers of cases of bulky uterus; two cases revealed CIN I and one case showed carcinoma endometrium.

In this study, USG detected thickened endometrium in 12 cases. Out of these 12 cases, 4 cases clinically presented as postmenopausal bleeding. Among those 4 cases, histopathologically 3 were diagnosed as endometrial hyperplasia and 1 was endometrial carcinoma. Hence, all patients of postmenopausal bleeding with thickened endometrium on USG, HPE revealed abnormal endometrial pathology.

In this study, HPE confirmed endometrial hyperplasia in 58 (56.31%) of cases of which simple typical type was the predominant (46.60%). In the studies done by Khare. found endometrial hyperplasia in 23%, 22.6%, and 36.2%, respectively which were lower than our study.[14],[15],[16]


   Conclusion Top


In our study, uterine fibroid was the leading cause of AUB for which hysterectomy was done. Radiological and pathological evaluation correlated well to diagnose fibroids. USG has good specificity to diagnose adenomyosis, however, because of low sensitivity it is important not to rule out adenomyosis based on USG findings alone. USG alone is not sufficient to diagnose endometrial hyperplasia. However, USG detected thick endometrium in postmenopausal woman is a good indicator of endometrial pathology. Regarding endometrial finding, histopathology revealed hyperplasia in majority of cases of which simple typical type was the predominant.

Financial support and sponsorship

Nil.

Conflflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Mahajan N, Aggarwal M, Bagga A. Health issues of menopausal women in North India. J Midlife Health 2012;3:84-7.  Back to cited text no. 1
    
2.
Kumar P, Malhotra N. Clinical types of abnormal uterine bleeding. In: Kumar P, editor. Jeffcoate's Principle of Gynecology. 7th ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2008. p. 599.  Back to cited text no. 2
    
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;207:259-65.  Back to cited text no. 3
    
4.
Telner DE, Jakubovicz D. Approach to diagnosis and management of abnormal uterine bleeding. Can Fam Physician 2007;53:58-64.  Back to cited text no. 4
    
5.
Jetley S, Rana S, Jairajpuri ZS. Morphological spectrum of endometrial pathology in middle-aged women with atypical uterine bleeding: A study of 219 cases. J Midlife Health 2013;4:216-20.  Back to cited text no. 5
    
6.
Shobha PS. Sonographic and histopathological correlation and evaluation of endometrium in perimenopausal women with abnormal uterine bleeding. Int J Reprod Contracept Obstet Gynaecol 2014;3:113-7.  Back to cited text no. 6
    
7.
Kathuria R, Bhatnagar B. Correlation between D&C, USG and hysteroscopy findings in diagnosing a cause for abnormal uterine bleeding. Indian J Clin Pract 2014;25:466-70.  Back to cited text no. 7
    
8.
Dueholm M, Lundorf E, Hansen ES, Ledertoug S, Olesen F. Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis, mapping, and measurement of uterine myomas. Am J Obstet Gynecol 2002;186:409-15.  Back to cited text no. 8
    
9.
Siedler D, Laing FC, Jeffrey RB Jr., Wing VW. Uterine adenomyosis. A difficult sonographic diagnosis. J Ultrasound Med 1987;6:345-9.  Back to cited text no. 9
    
10.
Ascher SM, Arnold LL, Patt RH, Schruefer JJ, Bagley AS, Semelka RC, et al. Adenomyosis: Prospective comparison of MR imaging and transvaginal sonography. Radiology 1994;190:803-6.  Back to cited text no. 10
    
11.
Reinhold C, Atri M, Mehio A, Zakarian R, Aldis AE, Bret PM. Diffuse uterine adenomyosis: Morphologic criteria and diagnostic accuracy of endovaginal sonography. Radiology 1995;197:609-14.  Back to cited text no. 11
    
12.
Atzori E, Tronci C, Sionis L. Transvaginal ultrasound in the diagnosis of diffuse adenomyosis. Gynecol Obstet Invest 1996;42:39-41.  Back to cited text no. 12
    
13.
Atri M, Reinhold C, Mehio AR, Chapman WB, Bret PM. Adenomyosis: US features with histologic correlation in an in-vitro study. Radiology 2000;215:783-90.  Back to cited text no. 13
    
14.
Dangal G. A study of endometrium of patients with abnormal uterine bleeding at Chitwan valley. Kathmandu Univ Med J (KUMJ) 2003;1:110-2.  Back to cited text no. 14
    
15.
Sloboda L, Molnar E, Popovic Z, Zivkovic S. Analysis of pathohistological results from the uterine mucosa 1965-1998 at the gynecology department in Senta. Med Pregl 1999;52:263-5.  Back to cited text no. 15
    
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Khare A, Bansal R, Sarma S, Elhence P, Makkar N, Tyagi Y. Morphological spectrum of endometrium in patients presenting with dysfunctional uterine bleeding. People J Sci Res 2012;5:13-6.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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