Akshata A.C and Rani K.M: Cliniopathological profile in women with abnormal uterine bleeding


Introduction

The endometrium is uniquely endowed throughout the female reproductive lifespan with a complex of periodic proliferation, differentiation, breakdown and regeneration.1 Abnormal uterine bleeding (AUB) is a symptom and not a disease and it accounts for more than 70% of all gynecological consultations in the perimenopausal and postmenopausal age group.2 AUB is defined as changes in frequency of menstruation, duration of flow or amount of blood loss.3 It includes both dysfunctional uterine bleeding (DUB) and bleeding from structural causes like fibroids, polyps, endometrial carcinoma, and pregnancy complications.4 It occurs in various forms such as menorrhagia, polymenorrhea, polymenorrhagia, metrorrhagia, and menometrorrhagia.2 Endometrium is a hormonally sensitive, dynamic and responsive tissue which constantly and rhythmically undergoes changes in the active reproductive life.5 Wide range of morphologic patterns resulting from both normal and abnormal changes offer a diagnostic challenge to practicing pathologists. Endometrial samplings by dilatation and curettage, endometrial biopsy, pipelle and hysterectomy specimens are chosen methods to evaluate AUB.

Aims and Objectives

To find out the pathological spectrum of different endometrial lesions in Abnormal uterine bleeding and Correlation of different pathological findings with clinical history and examination.

Materials and Methods

Detailed clinical history and relevant diagnostic findings were collected from patients presenting with abnormal uterine bleeding during a period of two years, from August 2017 to July 2019. All specimens were transported in 10% formalin to the Department of Pathology, VIMS Bellary. The tissue bits were processed and paraffin blocks were prepared. Tissue sections (3-5 µ) were cut and stained with hematoxylin and eosin stain (H&E). A detailed histological study was carried out and the findings were noted and classified.

Results

The study material included a total number of 247 endometrial samples (endometrial curettage and biopsy). Age range in the study group was from 22 years to 70 years, thus including reproductive to postmenopausal age group with more number of cases seen to be clustered in reproductive age group (Table 1). Predominant histopathological pattern noted was proliferative endometrium (Figure 1) seen in 23.1% cases (Table 2).

Out of 247 cases, only 200 cases were included in our table, after excluding non-diagnostic cases. Out of 200 cases, 126 cases were non neoplastic and 74 cases were pre- neoplastic/ neoplastic (Table 3). Under non neoplastic conditions, proliferative phase endometrium (57 cases) was most common finding and simple hyperplasia was documented as most common finding under pre neoplastic conditions (Figure 2).

Hyperplasia was observed in 67 cases (Table 4), simple hyperplasia was most common which includes cystic glandular hyperplasia and of 67 hyperplasia, 20 cases presented with atypia (Figure 3)

Table 1

Distribution of cases in different age categories

Category

No. of cases

Percentage

Reproductive

136

55.1

Perimenopausal

75

30.4

Postmenopausal

36

14.6

Total

247

100

Table 2

Analysis ofhistopathological findings in endometrial biopsy samples

S. No

Histological feature

No. of cases

Percentage

1

Proliferative phase

57

23.1

2

Secretory phase

33

13.4

3

Menstrual phase

9

3.6

4

Endometrial polyp

6

2.4

5

Progesterone exposed endometrium

3

1.2

6

Anovulatory Cycle

6

2.4

7

Irregular shedding

7

2.8

8

Inadequate secretory phase

3

1.2

9

Inadequate proliferative phase

2

0.8

10

Endometritis

4

1.6

11

Atrophic

2

0.8

12

Stromal hyperplasia

1

0.4

13

Cystic glandular hyperplasia

11

4.5

14

Simple hyperplasia

34

13.8

15

Simple hyperplasia with atypia

3

1.2

16

Complex hyperplasia

2

0.8

17

Complex hyperplasia with atypia

17

6.9

18

Products of conception

2

0.8

19

Inadequate

45

18.2

Total

247

100.0

Table 3

Distribution of Pre-neoplastic and Non neoplastic conditions

Non neoplastic conditions

Pre neoplastic conditions

Proliferative phase

57

Simple hyperplasia

34

Secretory phase

33

Simple hyperplasia with atypia

3

Menstrual phase

9

Complex hyperplasia without atypia

2

Progesterone exposed endometrium

3

Complex hyperplasia with atypia

17

Anovulatory

6

Cystic glandular hyperplasia

11

Irregular shedding

7

Stromal hyperplasia

1

Inadequate secretory phase

3

Endometrial polyp

6

Inadequate proliferative phase

2

Endometritis

4

Atrophic

2

Total

126

Total

74

Table 4

Types of Hyperplasia

S. No

Type of Hyperplasia

No. of cases

Percentage (%)

1

Simple hyperplasia

34

50.75

2

Simple hyperplasia with atypia

3

4.48

3

Complex hyperplasia without atypia

2

2.98

4

Complex hyperplasia with atypia

17

25.38

5

Cystic glandular hyperplasia

11

16.41

Total

67

100

Table 5

Comparative study of incidence of endometrial hyperplasia in AUB

Authors

Year

Percentage of cases of hyperplasia in endometrial samples

Mehrotra6

1972

19.4%

Saraswathi Doraiswami 7

2011

6.1%

Bolde SA et al8

2014

19.40%

Gorla P et al9

2016

10.37%

Present study

2019

27.12%

Figure 1
https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/db861748-0d4e-48ef-ab24-a89f1b5e68c1image1.png
Figure 2
https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/db861748-0d4e-48ef-ab24-a89f1b5e68c1image2.png
Figure 3
https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/db861748-0d4e-48ef-ab24-a89f1b5e68c1image3.png

Discussion

Endometrial sampling is an indispensable and an outstanding tool in the assessment of underlying pathology in patients with AUB. The main purpose of endometrial sampling is early detection of endometrial hyperplasia and carcinoma.2

The age distribution of AUB in our study revealed that most of the cases were seen in 31-40 years of age group which is in concordance with study done by Mitali Mahapatra et al 10 and Hetal et al.11 The number of cases of AUB in the age group of >50 years (14.6%) which is almost similar to the data mentioned by Smita S. Pudale et al. 8 ( 14.3%) and Bindroo S et al. 12 (13.2%)

Proliferative phase (23.1%) was most common histopathologic pattern, similar observations were made by Sadia Khan et al 13 (46.6%), Mitali Mahapatra et al 10 (45.70%), Hetal Rajendra Patel et al 11 (47.69%) but with a higher incidence.

Incidence of endometrial polyp was seen in 2.4% of cases in our study which is comparable with that of Shruti Singh et al 14 (4.8%) and Rehana Khan et al 15 (3.33%). Atrophic endometrium in the present study comprised of 0.80% cases of AUB while its incidence was higher in study done by Bhatta S et al 3 (7.38%) and Jairajpuri ZS et al 5 (1.10%).

Endometrial hyperplasia was observed in 27.12% of cases. Present study shows a higher incidence of hyperplasia when compared with the studies (Table 5). 12, 6, 9, 7 In the present study it was noted that hyperplasia without atypia were more common in cases <40 years of age while hyperplasia with atypia were most commonly seen in cases >40 years of age.

Conclusion

Malignancy in particular is common in patients over 40 years of age. Hence the histopathological study of endometrium in abnormal uterine bleeding in women above the age of 40 years plays an important role in diagnosing various histological patterns and aetiopathological factors. A comparative clinicopathological study will help in arriving at the cause and correct diagnosis, proper management of cases.

Source of Funding

No financial support was received for the work within this manuscript.

Conflict of Interest

The authors declare that they have no conflict of interest.

References

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S Khan S Hameed A Umber Histopathological Pattern of Endometrium on Diagnostic D & C in Patients with Abnormal Uterine BleedingAnnls2011172

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