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- DOI 10.18231/j.ijogr.2020.085
-
CrossMark
- Citation
Abnormal uterine bleeding in perimenopausal women: Clinical histopathological and sonography correlation
- Author Details:
-
Shahana Ishaq Chandniwala *
-
Mahima Jain
Introduction
Abnormality in frequency, regularity, duration or volume of bleeding in women of reproductive age is called Abnormal Uterine Bleeding (AUB). Quality of life is affected as it is associated with pain and discomfort. AUB leads to loss of productivity[1] and may result in surgical intervention including hysterectomy.[2] AUB affects 9 to 14% women between menarche and menopause.[3] In India, the reported prevalence is around 17.9%.[4] AUB patterns include menorrhagia, metrorrhagia, polymenorrhea, dysfunctional uterine bleeding and heavy menstrual bleeding.
To standardize nomenclature of AUB a system known by acronym PALM-COEIN was introduced in 2011 by FIGO.[5]
| Structural causes (PALM) | Nonstructural causes (COEIN) |
| Polyps | Coagulopathy |
| Adenomyosis | Ovulatory dysfunction |
| Leiomyomas | Endometrial |
| Submucosa | (Primary disorder of mechanisms regulating endometrial hemostasis) |
| Others | |
| Malignancy and hyperplasia | Iatrogenic |
| Not yet specified |
Normal and abnormal parameters of menstruation parameters are characterized under FIGO nomenclature.
| Clinical dimension of menstrual cycle and menses | Term | Normal limits (5th -95th percentiles) |
| Frequency | Frequent | <24 days |
| Normal | 24-38 days | |
| Infrequent | >38 days | |
| Regularity: cycle to cycle variation over 1 year(days) | Absent | No bleeding |
| Regular | Variation(+/- 2-20) | |
| Irregular | Variation >20 days | |
| Prolonged | ||
| Duration of flow | Prolonged | >8.0 days |
| Normal | 4.5-8.0days | |
| Shortened | <4.5 days | |
| Volume of monthly blood loss | Heavy | >80ml |
| Normal | 20-80ml | |
| Light | <20ml |
Materials and Methods
Retrospective observational study was conducted in B.J. Medical college, Ahmedabad, Gujarat from august 2019 to January 2020 (6 months). Total 153 cases were analyzed. History and clinical findings were. ultrasonographic evaluation was done in all patients. The clinical fiindings ultrasonographic findings were correlated. Histopathology examination reports were correlated with sonographic reports.
Inclusion criteria
Women in perimenopausal age group with complaint of AUB were included.
Women who underwent surgical intervention i e hysterectomy were included.
Exclusion criteria
Patient wanted medical management were excluded
Patient who under went hysterectomy for reason other than AUB were excluded (eg: endometriosis, mental retardation).
Results
153 women who underwent hysterectomy in them relation between Age and Parity was compared. Maximum patients are in between 40 and 45 years of age group (67.9%). It also depicts that chances of AUB increases with Parity.
| Parity | Years | Total | ||
| 40-45 | 45-50 | >50 | ||
| 0 | 3 | 1 | 0 | 4 |
| 1 | 12 | 2 | 0 | 14 |
| 2 | 24 | 2 | 0 | 29 |
| 3 | 28 | 9 | 5 | 42 |
| >=4 | 37 | 21 | 6 | 64 |
| Total | 104 | 36 | 13 | 153 |
| Complaint | Duration(month) | Total | |||
| <3 | 3 to 6 | 6- to 12 | >12 | ||
| Menorrhagia | 13 | 38 | 9 | 8 | 68 |
| Polymenorrhoea | 10 | 11 | 4 | 3 | 28 |
| Metrorrhagia | 5 | 16 | 6 | 3 | 30 |
| Menometrorragia | 4 | 9 | 2 | 2 | 17 |
| Post-menopausal | 4 | 4 | 2 | 0 | 10 |
| Total | 36 | 78 | 23 | 16 | 153 |
Majority of patients decides to undergo surgical intervention after 3-6 months of menstrual problem and menorrhagia is dominant symptom. In Indian population they either prefer medical management or donot take any treatment at all.
| Diagnosis | Percentage(%) |
| Fibroid | 76 (49.67) |
| Bulky uterus | 31 (20.26) |
| Adenomyosis | 28 (18.30) |
| Thickened endometrium | 12 (7.84) |
| Endometrial Polyp | 4 (2.61) |
| Malignancy | 2 (1.30) |
| USG finding | Menorrhagia | Polymenorrhia | Metrorrhagia | Menometrorrhagia | Postmenopausal |
| Fibroid | 32 | 16 | 13 | 13 | 2 |
| Bulky Uterus | 14 | 6 | 9 | 2 | 0 |
| Adenomyosis | 19 | 3 | 4 | 2 | 0 |
| Thickened endometrium | 3 | 3 | 2 | 2 | 4 |
| Polyp | - | - | 2 | - | 2 |
| Malignancy | - | - | - | - | 2 |
Histopathology reports of myometrium were suggestive fibroid 74 (48.36%), adenomyosis 42 (27.45%), and normal myometrium 35 (22.87%). Ultrasonographically 76 fibroid uterus were diagnosed, out of which 69 were confirmed by histopathology, and 7 were adenomyosis. USG diagnosed 28 cases with adenomyosis out of which 26 were confirmed by HPE. USG diagnosed 31 cases as having bulky uterus, which were clinically diagnosed as AUB, in which histopathology report were suggestive of normal myometrium in 18 cases, adenomyosis in 7, and leiomyoma in 3 cases. 72 cases had hyperplastic endometrium in histopathology report, only 11 were detected in ultrasonography.
Discussion
Abnormal uterine bleeding is leading cause of hysterectomy in Perimenopausal women. In this study 153 perimenopausal women who underwent hysterectomy were evaluated. Majority of the women were between 40 to 45 years of age with higher parity and most common symptom was Menorrhagia (44.44%). The study of Jetley et al.[6] and Shobha,[7] in which clinical presentation as menorrhagia in AUB evaluation revealed 46.4% and 46.6%, respectively is comparable to this study.
| USG Findings | HPE findings | ||||||
| Myometrium | Endometrium | ||||||
| Nor mal | Leomyomatous changes | Adenomyomatous changes | Proliferative | Secretory | Hyperplastic | Endometrial polyp | |
| Fibroid uterus (n=76) | - | 69 | 7 | 13 | 16 | 32 | - |
| Bulky uterus (n=31) | 18 | 3 | 7 | 3 | 7 | 18 | - |
| Adenomyosis (n=28) | - | 2 | 26 | 7 | 3 | 10 | - |
| Thickened endometrium (n=12) | 12 | - | 2 | - | - | 11 | - |
| Endometrial polyp (n=4) | 4 | - | - | - | - | - | 4 |
| Malignancy (n=2) | 1 | - | - | - | - | 1 | - |
| Total | 35 | 74 | 42 | 23 | 26 | 72 | 4 |
| USG Findings | HPE findings | |||||
| Endometrium | Cervix | |||||
| Atrophic | Inflammatory | Carcinomatous | Normal | Inflammatory | CIN | |
| Fibroid uterus (n=76) | 4 | - | - | 34 | 42 | - |
| Bulky uterus (n=31) | - | 2 | 1 | 13 | 18 | - |
| Adenomyosis (n=28) | - | - | - | 9 | 19 | - |
| Thickened endometrium (n=12) | - | - | 1 | 5 | 9 | - |
| Endometrial polyp (n=4) | - | - | - | 3 | 1 | - |
| Malignancy (n=2) | - | - | - | 1 | - | 1 |
| Total | 4 | 2 | 2 | 65 | 89 | 1 |
Ultrasonography is more sensitive for detection of uterine fibroid and less sensitive for Adenomyosis. Whereas, specicificity to diagnose Adenomyosis is comparatively better.
| USG findings | HPE report | ||||||
| Present | Absent | Total | Sensitivity (%) | Specificity (%) | PPV (%) | NPV (%) | |
| Fibroid Present | 69 | 7 | 76 | 93.24 | 91.13 | 90.78 | 93.50 |
| Absent | 5 | 72 | 77 | ||||
| Adenomyosis Present | 26 | 2 | 28 | 61.9 | 98.19 | 92.85 | 87.2 |
| Absent | 16 | 109 | 125 |
Maximum patient had undergone surgical treatment after suffering for 3 to 6 month (54.98%) which is similar to the study of Kathuria and Bhatnagar (50%).[8]
Out of 76 ultrasonographic diagnosed uterine fibroid was 76 (49.67%) 69 were confirmed on histopathology report, and remaining 7 were adenomyosis. The sensitivity of USG for the diagnosis of uterine fibroid is 93.24%, and the specificity is 91.13%, which is comparable to Dueholm et al.[9]
Among 42 cases of Adenomyosis which were diagnosed in histopathology report, only 26 were detected by ulrasonography. Sensitivity of ultrasound for diagnosis of Adenomyosis is low (61.9%), but specificity is same as compared to the studies of Siedler et al, Ascher et al, and Atri et al.[10], [11], [12] Hence, tissue characterization can be cosidedered as limitation of USG in diagnosis of adenomyosis.
Conclusion
Leiomyoma is major cause of abnormal uterine bleeding for which hysterectomy is done. Clinical, sonography and histopathological findings correlated well for diagnosis of fibroids. As sensitivity of USG to diagnose Adenomyosis is low therefore, USG alone cannot rule out the diagnosis other modalities should be considered if clinical findings were consistent with Adenomyosis.
Source of Funding
None.
Conflict of Interest
None.
References
- I Cote, P Jacob, D Cumming. Work loss associated increased menstrual loss in United States. Obstet Gynecol 2002. [Google Scholar]
- W J Millar. Hysterectomy, 1981/82 to 1996/97. Health Rep 2001. [Google Scholar]
- I S Fraser, S Langham, K Uhl-Hochgraeber. Health-related quality of life and economic burden of abnormal uterine bleeding. Expert Rev Obstet Gynecol 2009. [Google Scholar]
- A Sharma, Y Dogra. Trends of AUB in tertiary centre of Shimla hills. J Midlife Health 2013. [Google Scholar]
- M G Munro, H O Critchley, M S Broader, I S Fraser. FIGO Working Group on Mensrual Disorder.FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011. [Google Scholar]
- Z S Jairajpuri, S Jetley, S Rana. Morphological spectrum of endometrial pathology in middle-aged women with atypical uterine bleeding: A study of 219 cases. J Mid-life Health 2013. [Google Scholar]
- P S Shobha. Sonographic and histopathological correlation and evaluation of endometrium in perimenopausal women with abnormal uterine bleeding. Int J Reprod Contracept Obstet Gynaecol 2014. [Google Scholar]
- R Kathuria, B Bhatnagar. Correlation between D&C, USG and hysteroscopy findings in diagnosing a cause for abnormal uterine bleeding. Indian J Clin Pract 2014. [Google Scholar]
- M Dueholm, E Lundorf, E S Hansen, S Ledertoug, F Olesen. Accuracy of magnetic resonance imaging and transvaginal ultrasonography in the diagnosis, mapping, and measurement of uterine myomas. Am J Obstet Gynecol 2002. [Google Scholar]
- D Siedler, F C Laing, R B Jeffrey, V W Wing. Uterine adenomyosis. A difficult sonographic diagnosis.. J Ultrasound Med 1987. [Google Scholar]
- S M Ascher, L L Arnold, R H Patt, J J Schruefer, A S Bagley, R C Semelka. Adenomyosis: prospective comparison of MR imaging and transvaginal sonography.. Radiol 1994. [Google Scholar]
- M Atri, C Reinhold, A R Mehio, W B Chapman, P M Bret. Adenomyosis: US Features with Histologic Correlation in an in Vitro Study. Radiol 2000. [Google Scholar]