Bombay Hospital Journal, Vol. 52, No. 1, 2010 6 9

Evaluation and Histopathological Correlation ofAbnormal Uterine Bleeding in Perimenopausal Women

Archana Bhosle*, Michelle Fonseca**

AbstractOjectives : 1) To evaluate clinically the gynaecological causes of abnormal uterine bleeding inperimenopausal women. 2) To correlate clinical evaluation with ultrasonographic and histo-pathological examination.Study Method : Retrospective study of 112 perimenopausal women with abnormal uterine bleed-ing for a period of 6 months.These women were evaluated and clinical, ultrasonographic and histopathological findingswere correlated.Results : The major symptom with which the women presented was menorrhagia in 53.3%. Allthese women underwent D and C followed by medical management or hysterectomy depend-ing upon the diagnosis. The HPE of endometrium was analysed. The HPE of uterus confirmedfibroid uterus and DUB correlated well with ultrasonographic and histopathological examina-tion. Clinical as well as USG proved less useful for diagnosing adenomyosis.

Introduction

Perimenopause is the period 2-8 yearspreceding menopause and 1 year after thefinal menses (WHO).However a betterpractical definition is the phase preceding theonset of menopause, generally occurringaround 40-50 years of age (beginning at age47.5, lasting for 4 years) during which theregular cycle of a woman transitions to apattern of irregular cycles. Menorrhagia iscyclical bleeding at regular interval which isexcessive in amount (> 80 ml)3 or duration.Menorrhagia is thought to be associated withuterine fibroid, DUB, adenomyosis, pelvicinfections, endometrial polyp, clotting defects.Polymenorrhagia, intermenstrual bleedingand metrorrhagia are other common disordersat perimenopause. DUB, fibroid uterus and

*Lecturer; **Asso.Prof. and Head of Unit, Dept ofObstetrics and Gynaecology, LTMMC and LTMGH,Sion Hospital, Mumbai.

adenomyosis are the commonhyperoestrogenic conditions whereendometrium is in the proliferative phase andif untreated may lead to endometrialcarcinoma.

Study MethodThis is a retrospective study of 112

perimenopausal women with abnormaluterine bleeding in the age group of 40-52years for a period of 6 months. We analyzedthese women by recording age, parity,menstrual symptoms and associatedsymptoms for clinical evaluation. Women withassociated medical disorders were notincluded in this study. Ultrasonographicevaluation of all the women was done.Clinical impression and USG reports werecorrelated. These women underwent D andC for endometrial sampling and specimensent for histopathological exam (HPE). TheHPE reports were analyzed. These womenwere further managed either conservatively

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or surgically depending upon the response.Histopathological reports of endometrialpattern as well as that of the hysterectomyspecimens were correlated with clinicaldiagnosis and ultrasonographic findings.

ResultsA correlation between age, parity and

incidence of abnormal uterine bleeding isdepicted in Table 1. Out of 112 women 85(76.1%) women were in the age group of 40-45 years. Whereas the incidence was high inparity 3 (28%) and grandmultipara (32%).Thisshows incidence of abnormal uterine bleedingincreases as the parity increases .The differentsymptoms with which they presented. Themajority of the women 53.3% presented withmenorrhagia, 28.2% with polymenorrhagia,12.2% had intermenstrual bleeding and 6.5%had metrorrhagia. The most commonassociated symptom was dysmenorrhoeafound in 70% of women in 40 - 45 yrs of ageand 25% in 46 - 50 yrs of age. Clinically 55(49.1%) were fibroid uterus, 49 women(43.85%) were diagnosd as DUB and 8 (7.14%)were adenomyosis. USG diagnosed 53 (47.3%)fibroid uterus, 40 (35.7%) women had ET > 8mm strong suspicious of DUB and 19 (16.9%)were adenomyosis (Table 2). These womenwere managed by surgical approaches D andC alone or D and C followed by hysterectomy.Histopathological report revealed thatendometrium was proliferative in 74 cases(66.1%), simple hyperplasia 20 (17.8%) and

seretory endometrium in 18 cases (16.1%).Women who underwent hysterectomy were85 (75.8%) and 27 (24.2%) women weremanaged conservatively, 45 (52.9%) womenunderwent hysterectomy for fibroid uterus(8 women with small fibroids received medicalmanagement and were asymptomatic at theend of 3 months). 21 (24.7%) womenunderwent hysterectomy for DUB and 19women treated by medical or hormonaltherapy.19 (22.3%) hysterectomies were donefor adenomyosis. Histopathological reports ofhysterectomy specimen were as follows.Fibroids uterus 46 (54%), Adenomyosis25(29.4%) and DUB 14 (16.4%). Thus out of45 suspected fibroid uterus all wereconfirmed by HPE. There were 26 fundalfibroids, 6 ant. wall, 5 post.wall, 6 submucousfibroid and 2 cervical fibroids.

Out of 21 suspected DUB, 14 were DUBand 6 turned out adenomyosis by HPE.Hysterectomies done for adenomyosis were19 and confirmed by HPE as well. The clinical,USG and histopathological correlation isdepicted in Table 2.

Table 1 : Distribution of age and parity

Parity 40-45 yrs 45-50yrs >50 yrs Total

0 3 (2.6%) 1 (0.9%) 0 4 (3.5%)I 5 (4.4%) 0 0 5 (4.4%)I I 30 (26.78%) 6 (5.4%) 0 36 (32.18%)I I I 21(18.8%) 10 (9%) 0 31 (27.8%)Grand Multipara 26 (23.21%) 7 (6.2%) 3 (2.6%) 36 (32.18%)

Total 85 (76%) 3 (2.6%) 3 (2.6%) 112

Table 2

Disease Clinical USG HPE

Fibroid 55 (49.1%) 53 (47.3%) 46 (55%)D U B 49 (43.8%) 40 (35.7%) 14 (16.47%)Adenomyosis 8 (7.6%) 19 (16.8%) 25 (29.4%)

Total 112 112 85

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DiscussionEvaluation of patients with abnormal

uterine bleeding and identifying those withdysfunctional uterine bleeding is achievedwith a combination of the following: history;physical examination; laboratory evaluation;USG and endometrial sampling. Abnormalperimenopausal bleeding is associated withendometrial carcinoma in approximately 10%of cases,8 so evaluation of womens risk factorsfor endometrial hyperplasia or carcinoma isrecommended. Though endometrial samplingcan be done by D and C, endometrialaspiration and hysteroscopy, hysteroscopydirected histry is considered Gold standard.Though hystero-scopes are not available. Dand C is also an effective way to control uterinebleeding in absence of uterine pathology andsystemic cause. We compared our study ofendometrial patterns with Jordon universitystudy and G.Michail et al study7 (Table 3). Inthese studies no of cases studied were 116and 84 respectively, where proliferativeendometrium was found in 53% and 20.7%and 15% atypia. In our study we had 66.1%proliferative endometrium and 17.8% simplehyperplasia with no atypia. Fibroids arecommon finding in women with menorrhagia.Furthermore, the incidence of fibroids hasbeen shown to be greater in black women.Menorrhagia in fibroids is due to increasedsize of the uterine cavity thereby increasingthe surface area of the endometrium,hyperoestrogenaemia causing endometrialhyperplasia, vascular alteration of the

endometrium and obstructive effect of fibroidon uterine vasculature leading to endometrialvenule ectasia which causes proximalcongestion in the myometrium and theendometrium.

Majority of women with uterine fibroidassociated with menorrhagia are treated byhysterectomy.2.5 In our study, fibroid uteruswas responsible for abnormal uterine bleeding(AUB) in 54% of women comparable with astudy of DHQ hospital and Nishtar hospitalMultan 2 in which AUB evaluation revealed54.8% fibroid uterus.

Diagnosis of adenomyosis on clinicalfindings is usually different.4 Transabdominalsonography (TAS) doesnt allow reliablediagnosis of adenomyosis or consistentdifferentiation from leiomyomas, eventransvaginal sonography (TVS) has limitationin tissue characterization. MRI is morehelpful to diagnose adenomyosis butexpensive. In our study clinically only 7.6%were diagnosed as adenomyosis,USGdiagnosed 16% and HPE diagnosed 29.4%. Thereported prevalence of adenomyosis inhysterectomy specimens varies from 5% to70%. Menorrhagia associated with ovulatorycycles can be treated with or withouthormones. The anti-inflammatory medicationmefenamic acid can reduce bleeding by 225to 46%. We used it for menorrhagiaassociated with small fibroids as well in somecases of DUB in this study successfully. TheLNG-IUS is a relatively new treatment thatremains effective for 5 years. It has been

Table 3 : Comparative study of HPE of endometrium

Place Period No Proliferative Simple Atypia Inflammation EndometrialEndometrium Hyperplasia and others atrophy

Jordan university Oct-98-2000 116 53 % 8.7 % 15 % 14 %LTMMC and 1/5/2007- 112 66.1 % 17.8 % - -Sion hospital 30/10/2007G.Michail et.al Aug-2007 84 9.79 % 8.53 % - 20.7% 21.9 %

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found to reduce menstrual blood loss by 74%-97%. A number of minimally invasive surgicaloptions for hysterectomy now exist and arepromising like endometrial ablation, thermalballoon therapy and uterine arteryembolization but restricted availability andcost factor limit their use.

ConclusionIn our study fibroids of uterus were the

most common cause of abnormal uterinebleeding. Second common cause was DUB.Histopathology revealed majority ofendometrium in proliferative phase. Clinical,radiological and pathological evaluationcorrelated very well to diagnose fibroids.However clinically as well USG proved oflittle help to diagnose adenomyosis. Maximumhysterectomies were done for fibroid uterus.Thus hysterectomy remained the commonestmethod of intervention. However it is theresponsibility of healthcare professionals toencourage teaching and implementation ofalternative procedures to ensure that womenreceive the maximum benefits with leastmorbidity.

SummaryAbnormal uterine bleeding occurring as

heavy cyclical or acyclical flow atperimenopausal age is alarming and needsthorough evaluation, as it could be the onlyclinical manifestation of endometrial cancer.The present study was done to evaluate thegynaecological causes of abnormal uterinebleeding in perimenopausal women. It is aretrospective study of 112 perimenopausalwomen with abnormal uterine bleeding for aperiod of 6 months.These women wereevaluated and clinical ultrasonographic and

histopathological findings were correlated.Fibroid uterus, DUB, and adenomyosis werethe principal causes of abnormal uterinebleeding in this study.All these womenunderwent D and C followed by medicalmanagement or hysterectomy dependingupon the diagnosis. The HPE of endometrialand hysterectomy specimens were analyzedand correlated with clinical andultrasonographic diagnosis.

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