|Year : 2015 | Volume
| Issue : 2 | Page : 45-49
Clinicopathological evaluation of abnormal uterine bleeding
Mitali Mahapatra, Pratima Mishra
Department of Obstetrics and Gynaecology, Hi-Tech Medical College and Hospital, Bhubaneshwar, Odisha, India
|Date of Web Publication||16-Jul-2015|
Dr. Mitali Mahapatra
Department of Obstetrics and Gynaecology, 213, B-Block, Rajender Vihar Appartment, Forest Park, Near Bharti Tower, Bhuaneshwar, Odisha
Source of Support: None, Conflict of Interest: None
Introduction: Historically our culture has traditionally viewed even the normal menustral cycle as an aberration, ostracizing the reproductive aged women. Aristotle quoted Hippocrates writings by describing the process of heavy uterine bleeding as "In quantity, bleeding in excessive, saith Hippocrates, when they flow about eighteenth ounces". Aims and Objective: To study the various aetiopathological factors responsible for AUB in women ages 20-55 years, and to correlate the clinical presentation with ultrasonography, hysteroscopy, laparoscopy and histopathological finding. Sample: In this study, 140 cases of 15-55 years of age group were randomly selected after the exclusion criteria who were willing to get admitted as well as prepared for follow-up. Inclusion Criteria: The cases of abnormal uterine bleeding, attending the gynecology OPD with complaints of menorrhagia, metrorrhagia, polymenorrhoea, and polymenorrhagia in the age group 20-55 years, were selected. Exclusion Criteria: Pregnant patients and patients below 20 years and above 55 years are excluded from the study. Conclusion: It is seen that incidence of AUB is more common in 5 th decade of life and in multiparous women. Menorrhagia is the most common bleeding pattern followed by metrorrhagia. Histopathological examination of the endometrium revealed that whatever may be the pathology, proliferative endometrium is the most common pattern.
Keywords: Abnormal uterine bleeding, menorrhagia, menstruation
|How to cite this article:|
Mahapatra M, Mishra P. Clinicopathological evaluation of abnormal uterine bleeding. J Health Res Rev 2015;2:45-9
| Introduction|| |
Abnormal uterine bleeding (AUB) is one of the most common conditions for which women consult their gynecologists. AUB may be defined as any variation from the normal menstrual cycle, including alteration in its regularity, frequency of menses, duration of flow, and amount of blood loss. Under the category of AUB, further definitions may be subdivided based on volume of menstruation, regularity, frequency, duration, chronicity, and timing related to reproductive status.
AUB can occur at any age in various forms and has different modes of presentation. Abnormal uterine bleeding during reproductive age can result from a broad spectrum of conditions ranging from physiological process to malignant lesions involving organic, systemic, and hormonal responses. It may be due to fibromyoma, adenomyosis, endometrial polyp, ovarian tumor, pelvic inflammatory disease (PID), endometrial hyperplasia, endometrial carcinoma, hormonal imbalance (like hypothyroidism), or hypothalamic-pituitary diseases. In a large number of patients, AUB occurs without any systemic causes or any organic lesions of the genital tract and for this, the term dysfunctional uterine bleeding is used.
AUB interferes with a woman's physical, social, emotional quality of life. It has been seen that women with heavy bleeding of unpredictable onset take a step back from participating in routine activities, as they may require continuous access to pads and/or tampons, and they have a fear of social activity or sexual relationships because they perceive that they are on the precipice of a heavy period. In many cases, the symptoms will be relatively minor and related to self-limiting alterations in normal physiology.
The key to successful clinical management is to recognize or identify the causative factors responsible. The first aim of the clinician is to reverse the abnormality and induce or restore the cyclic predictable menses of normal volume and duration. This can be achieved by thorough clinical examination, ultrasonography and histopathological examination. When no systemic and pelvic cause is evident to clinician, histopathological examination remains the only alternative to reach the diagnosis, after ruling out the organic causes. The clinician is left with patients for whom no definite diagnosis is made except that the bleeding is dysfunctional.
| Aims and Objectives|| |
To study the various aetiopathological factors responsible for AUB in women ages 20-55 years, and to correlate the clinical presentation with ultrasonography, hysteroscopy, laparoscopy and histopathological finding.
| Sample and Methods|| |
"Clinicopathological Evaluation of Abnormal Uterine Bleeding" was conducted during the period of September 2012-January 2014 in the department of Obstetrics and Gynecology, Hi-Tech Medical College, Bhubaneshwar.
In this study, 140 cases of 15-55 years of age group were randomly selected after the exclusion criteria who were willing to get admitted as well as prepared for follow-up.
The cases of abnormal uterine bleeding, attending the gynecology OPD with complaints of menorrhagia, metrorrhagia, polymenorrhoea, and polymenorrhagia in the age group 20-55 years, were selected.
Pregnant patients and patients below 20 years and above 55 years are excluded from the study.
| Results|| |
The [Table 1] shows incidence of abnormal uterine bleeding between age group 15-55 years. In our clinical study, AUB was commonly seen among 40-45 years of age group. 10 cases (7.1%) are in age group 20-25 years, 12 (8.6%) cases are in age group 26-30 years, 29 (20.7%) cases are in age group 31-35 years, 35 (25%) cases are in the age group 36-40 years, 52 (37.2%) cases are in the age group 41-45 years, and very few cases are seen in the age group of 46-55 years.
[Table 2] shows the majority of AUB cases belong to low socioeconomic status (67.2%), as compared to cases belonging to high socioeconomic status (32.8%).
|Table 2: Distribution of AUB cases in low socioeconomic status and in high socioeconomic status |
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This table shows the incidence of various types of abnormal uterine bleeding. Menorrhagia and metrorrhagia were found in 68 (48.6%) and 32 (22.9%) cases respectively. Incidence of polymenorrhagia were found in 24 (17.1%) cases, polymenorrhoea in 14 (10.0%) cases and continuous bleeding in 2 (1.4%) cases [Table 3].
|Table 3: Incidence of various modes of presentation of abnormal uterine bleeding |
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The above table shows that among 140 patients, 135 patients had normal Pap smear More Detailss and 5 patients had abnormal pap smears. The 5 patients' subsequent coloposcopy findings were normal.
This table shows different endometrial pattern associated with abnormal uterine bleeding. Out of 140 cases, an endometrial biopsy was done in 136 cases and in 4 cases endometrial biopsy was not done. Proliferative endometrium was found in 64 (45.7%) cases, secretory endometriumin 42 (30%) cases, and hyperplastic endometrium in 17 (12.1%) cases. Atrophic endometrium was found in 7 (5%) cases. Endometrial polyp and endometrial carcinoma were found in 5 (3.6%) cases and 1 (0.7%) cases respectively [Table 4], [Table 5], [Table 6].
[Table 7] shows that cystic hyperplasia was common among the AUB patients i.e., 70. 6% and atypical hyperplasia was seen in only 11.8% cases.
[Table 8] shows the endometrial pattern found in dysfunctional uterine bleeding. Out of 60 cases, dysfunctional uterine bleeding (DUB), endometrial biopsy was done in 59 cases. Out of 59 cases, proliferative endometrium was found in 26 (43.3%) cases, secretory in 14 (23.4%) cases and hyperplastic in 13 (21.7%) cases. 6 (10.0%) cases of DUB were found to have atrophic endometrium.
| Discussion|| |
It is concluded that DUB is the most common cause of AUB, and which is also mostly of anovulatory type. Among the other organic pathological causes, fibromyoma is the commonest cause followed by adenomyosis. The age distribution of AUB in our study revealed that 37.9% of cases belonged to 5 th decade (41-50 years) as mentioned in [Table 1]. Saraswathi et al. in 2011 reported that 33.5% of cases belonged to 41-50 years which was similar to our study. Similarly the study conducted by Abdulla et al., 2011 showed 33.1% cases of AUB in 5 th decade which coincides with the present study. The studies conducted by Jetley et al., 2012 and Zeeba et al., 2013 reported that 35.89% and 35.9%, respectively, of cases belonged to 5 th decade and this is in concordance with our study. The reason for increased incidence of abnormal uterine bleeding in this age group (41-50 years) may be due to the fact that these patients are in their climacteric period. As women approach menopause, cycles shorten, and often become intermittently anovulatory due to a decline in the number of ovarian follicles and their increased resistance to gonadotrophic stimulation causes decline in estradiol level, which cannot keep the normal endometrium growing. In this study, our patients presented with different types of AUB; the commonest presenting feature was menorrhagia (48.6%). Nayak et al., 1996 found menorrhagia in 49.1% of cases similar to our study. Similarly Bagle et al., 2013 reported in their study that 48.8% of cases had menorrhagia. The study conducted by Aseel Ghazi Rifat et al., 2014 reported 47.2% of cases with menorrhagia, which is similar to our study. The second common pattern of bleeding is metrorrhagia, which accounts for 22.9% of cases. Saera Afghan et al., 2013 reported 20.6% of cases of metrorrhagia, which is almost similar to our study. Kalpana R Sulhyan et al., 2014 reported 23% cases of metrorrhagia in concordance with our study. Muzaffar et al., 2005 reported 35.4% of metrorrhagia cases which is high, the reason might be the pregnancy related complications and endometritis due to abortion which are excluded in our study. In our study, polymenorrhagia and polymenorrhoea accounts for 17.1% and 10% of cases respectively, which is similar to the study of Tyagi et al., 1996. The study conducted by K Rajani et al., 2014 reported polymenorrhagia in 13.7% of cases and 8.24% in polymenorrhoea, almost similar to our study. Pap smear was taken in all 140 cases and among them only 3.6% of cases had abnormal smear. Those cases were followed up with a coloposcopy, whose findings appeared normal. Biniwale et al. 2014 observed in their study that 95% of cases had normal papsmear and 3. 96% had abnormal smear which is similar to our present study. Histopathological evaluation revealed proliferative endometrium in 45.7% and secretory in 30% of cases in our study. Zawar et al., 2005 reported 43% cases of proliferative endometrium in their study. Doddamani et al., 2014 observed proliferative endometrium in 44.7% and secretory in 23.5% of cases which is almost similar to our study. The secretory phase is 30% in our study; the higher incidence is attributed to inclusion of hormonal treatment taken for menstrual irregularities. Siegel et al., 2012 reported 30.9% of cases of secretory endometrium in their study which is similar to the present study.
| Conclusion|| |
In this study, an attempt has been made to find out the different aetiological factors of AUB and to correlate the clinical presentation with ultrasonography, hysteroscopy and histopathological examination for each case. It is seen that incidence of AUB is more common in 5 th decade of life and in multiparous women. Menorrhagia is the most common bleeding pattern followed by metrorrhagia. Histopathological examination of the endometrium revealed that whatever may be the pathology, proliferative endometrium is the most common pattern. It is concluded that DUB is the most common cause of AUB and which is also mostly of anovulatory type. Among the other organic pathological causes, fibromyoma is the commonest cause followed by adenomyosis. Transvaginal sonography is a noninvasive method in diagnosis of endometrial abnormalities. Laparoscopy appears to be the gold standard method for detection of endometriosis. Hysteroscopy is also a safe, highly sensitive diagnostic procedure that provides useful information about the uterine cavity and represents an ideal method in detecting intracavitary abnormalities. Accurate diagnosis is crucial for selection of relevant treatment of AUB and the avoidance of unnecessary major surgical procedure.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]