|Year : 2019 | Volume
| Issue : 3 | Page : 95-98
Histopathological study of endometrium in abnormal uterine bleeding in perimenopausal and postmenopausal women
Ritika Bhat, S Sudhamani, Prakash Roplekar
Department of Pathology, School of Medicine, D. Y. Patil University, Navi Mumbai, Maharashtra, India
|Date of Web Publication||28-Jan-2020|
Dr. S Sudhamani
Department of Pathology, School of Medicine, D. Y. Patil University, 2nd Floor, Navi Mumbai - 400 706, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Abnormal uterine bleeding (AUB) is defined as any change in the frequency of menstruation, duration of flow, or amount of blood loss. Histopathological study of endometrium gives valuable information to arrive at correct diagnosis. Objective: The study was aimed to detect the frequency of various pathological conditions which can cause AUB in perimenopausal and postmenopausal women and to know the distribution of functional changes as well as malignancy causing AUB. Materials and Methods: This is a retrospective study on 200 patients of perimenopausal and postmenopausal women who presented with AUB from May 2016 to May 2018 (2 years), selected on the basis of simple random sampling. Histopathological study was done on the specimens for diagnostic and therapeutic purposes. Histomorphological details were recorded as per standard pro forma along with clinical and other details and entered on a master chart. A statistical analysis was done to record the frequency of distribution and mean of various parameters. Results: Out of 200 cases, the most common histopathological finding was proliferative phase in 65 cases (42.4%), followed by disordered proliferation in 46 cases (30%). Primary endometrioid adenocarcinoma comprised only 6 cases (3%). Conclusion: The most common endometrial pathology found in our study was functional endometrial changes, and the occurrence of malignancy increased with the increasing age of patients.
Keywords: Abnormal uterine bleeding, disordered proliferation, histopathology, perimenopausal, postmenopausal
|How to cite this article:|
Bhat R, Sudhamani S, Roplekar P. Histopathological study of endometrium in abnormal uterine bleeding in perimenopausal and postmenopausal women. J Sci Soc 2019;46:95-8
|How to cite this URL:|
Bhat R, Sudhamani S, Roplekar P. Histopathological study of endometrium in abnormal uterine bleeding in perimenopausal and postmenopausal women. J Sci Soc [serial online] 2019 [cited 2020 Jun 4];46:95-8. Available from: http://www.jscisociety.com/text.asp?2019/46/3/95/277000
| Introduction|| |
Abnormal uterine bleeding (AUB) is a term used to describe any type of bleeding that does not fall within the normal ranges for amount, frequency, duration, or cyclicity. AUB is regarded as a sign of possible uterine disease, including acute and chronic AUB. It is the most common presenting complaint in all age groups. However, the perimenopausal and postmenopausal age groups comprised the majority of the patients in our gynecology outpatient department.
There are structural or functional etiologies for the AUB.
Patients may present with menorrhagia, polymenorrhea, metrorrhagia, and intermenstrual bleeding.
The underlying disease can be detected by histological variations of endometrium taking into account the age of the woman, the phase of her menstrual cycle, and the use of any exogenous hormones. The perimenopausal and postmenopausal women mainly present with organic or atrophic lesions.
AUB can be caused by functional and structural abnormalities, and thorough evaluation is recommended in women of perimenopausal and postmenopausal age groups. Endometrial sampling could be effectively used as the first diagnostic step in AUB. It is a simple, cost-effective, and appropriate method that provides accurate diagnostic yield.
This study was undertaken for the evaluation of endometrial changes in the perimenopausal and postmenopausal women as it is essential to confirm the exact nature of the lesion and to rule out malignancy.
| Materials and Methods|| |
The present study was conducted retrospectively over a period of 2 years from May 2016 to May 2018 (2 years) at a tertiary care PG teaching hospital. It included 200 cases of clinically diagnosed AUB patients above the age of 40 years.
Patients below the age of 40; patients with complaints of AUB due to known pathological causes such as fibroids, cervical lesions, functional ovarian tumors, and complications of pregnancy as well as inadequate and autolyzed specimens were excluded from the study.
Detailed clinical history that included the age, chief complaints, menstrual history and obstetric history was taken and entered into the study pro forma. The physical examination findings and radiological findings were also recorded.
Specimens considered for this study were endometrial biopsies, fractional curettage materials, and/or hysterectomy done for diagnostic and/or therapeutic purposes.
All specimens were fixed in 10% formalin. After detailed gross examination, paraffin blocks of tissue were made; sections were cut and stained with hematoxylin and eosin. Slides were then studied under light microscopy, and findings were entered into a master chart and correlated with clinical and other relevant information and then statistically analyzed.
| Results|| |
In this study, patients' age ranged from 40 to above 70 years, and most of them were seen in the age group of 40–50 years, followed by 51–60 years.
In the age group of 40–50 years, 65 (42.4%) patients presented with proliferative endometrium, 46 (30.0%) cases were of disordered proliferation, 25 (16.3%) cases were of secretory endometrium, and 3 patients (1.9%) were diagnosed with endometrial polyp. Ten patients (6.5%) were reported with simple hyperplasia without atypia.
Malignant cases were relatively few, 2 cases (1.2%): 1 being adenocarcinoma of endometrioid type carcinoma and other being extension of squamous cell carcinoma of the cervix to the uterus.
Among the patients ranging from 51 to 60 years, 10 cases (24.3%) were of disordered proliferation, followed by 7 cases (17%) of secretory endometrium and 6 cases (14%) of proliferative endometrium.
Endometrial polyp (5 cases, 12.1%) and endometrial hyperplasia with atypia (3 cases, 7.3%) were commonly seen in the age group of 51–60 years [Figure 1].
|Figure 1: Age-wise distribution of patients according to cause of abnormal uterine bleeding|
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Malignancy is most commonly seen in the age group of 61 to above 70 years of age.
Out of total of 200 patients, 71 (35.5%) presented with proliferative endometrium, followed by disordered proliferation comprising 58 (29%) patients [Figure 2]. Patients presenting with secretory phase were 32 (16%).
|Figure 2: (a) H and E, ×100, disordered proliferative endometrium, (b) H and E, ×40, endometrial polyp, (c) H and E, ×400 endometrioid adenocarcinoma, (d) Uterus showing an endometrial polyp (e) Uterus showing an endometrial carcinoma|
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In the organic causes, the most common finding was simple hyperplasia without atypia comprising 15 cases (7.5%), followed by endometrial polyp of 8 patients (4%). Malignancy comprising endometrial adenocarcinoma was seen in 6 cases (3%), and extension of squamous cell carcinoma of the cervix to the uterus was seen in 4 cases (2%) [Figure 2].
The least number of cases were Pill-induced endometrial hyperplasia (2 cases) [Table 1].
| Discussion|| |
The International Federation of Gynecology and Obstetrics developed a classification system (PALM–COEIN) for causes of the AUB in nongravid women. There are nine main categories, which are arranged according to the acronym PALM–COEIN: polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified.
In the present study, we have studied the histopathology of endometrium to identify the endometrial causes and also observe the occurrence of various pathologies in different age groups.
The causes of AUB comprise a wide spectrum of diseases of the reproductive system and nongynecologic causes as well. Organic cause of AUB may be subdivided into reproductive tract disease, iatrogenic causes, and systemic disease.
The routine noninvasive investigations recommended for AUB include complete blood count, platelet count, prothrombin time, activated partial thromboplastin time, and liver function test to rule out any coagulation and bleeding disorders. To rule out an endocrine etiology, thyroid function test, follicle stimulating hormone, luteinizing hormone, and prolactin levels are the investigation indicated. On ruling out these causes, the imaging studies such as pelvic ultrasonography (USG) and transvaginal USG and tissue sampling are recommended. Dilation and curettage can be a diagnostic as well as therapeutic procedure. However, blood investigations were not included as part of pro forma in our study.
The most likely etiology of AUB relates to the patient's age as to whether the patient is premenopausal, perimenopausal, or postmenopausal. Our study considered the perimenopausal and the postmenopausal women.
In the present study, the youngest patient was 40 years old and the oldest was 74 years old. The most common age group presenting with AUB was found to be 40–50 years of age (76.5%).
A similar occurrence was reported by Shukla et al., Bolde et al., Shah et al., Doraiswami et al., and Jairajpuri et al. in their study of endometrium ,,,, [Table 2].
Our study like several others showed that proliferative lesions such as disordered proliferative pattern, hyperplasia, and benign endometrial polyp occur more commonly in the age group 41–50 years. The reason for increased occurrence of AUB in this age group (40–50 years) may be due to the fact that these patients are in their critically transitioning period.
The occurrence of AUB between 51 and 70 years was comparatively lower. The reason for this finding may be due to the fact that the patients were evaluated much earlier and treated appropriately, thereby decreasing the occurrence in a later age group. We had only two patients with AUB in the age group of 71–80 years, and both were reported with organic cause.
A predominant number of cases in this study showed normal physiologic phases such as proliferative and secretory pattern. The bleeding in the proliferative phase may be due to anovulatory cycles and bleeding in the secretory phase is due to ovulatory dysfunctional uterine bleeding. This finding was in concordance with the findings of other studies.
A significant number of cases showed disordered proliferative (29%) pattern in this study. Disordered proliferative pattern lies at one end of the spectrum of proliferative lesions of the endometrium which comprises carcinoma at the other end with interfering stages of hyperplasias. The term “disordered proliferative endometrium” denotes an endometrial appearance that is hyperplastic but without an increase in endometrial volume.
The occurrence of endometrial hyperplasia (9%) in this study was relatively less. This could have been possible as most of the patients in the study belonged to lower socioeconomic status, and the exposure to risk factors such as obesity, diabetes, increased intake of animal fat, and sedentary lifestyle was low. The identification of endometrial hyperplasia is significant because they are thought to be precursors of endometrial carcinoma.
The occurrence of benign endometrial polyps in this study was high in 51–60 years (12.1%), followed by 40–50 years (1.9%) of age group.
In the present study, the occurrence of carcinoma endometrium steeply increased with age and was more common in the age group of 51–60 years. All of them showed an endometrioid type of adenocarcinoma. No other malignant tumor was found in our study.
The result of this study was almost similar to data mentioned by Shukla et al., Bolde et al., Shah et al., and Doraiswami et al. in their study ,,, [Table 2].
A study done by Dangal in Nepal documented a lower occurrence of endometrial cancer possibly due to the practice of early childbearing and multiparty.
Four (8%) patients in this study who presented with AUB had extension of squamous cell carcinoma from the cervix to the endometrium. Carcinoma of the cervix can involve the uterine corpus by direct extension or through the parametrium or by lymphatic invasion to the uterine wall. This pathology was found to be more common in patients above 50 years of age. These cases have to be differentiated from the rare cases of primary squamous cell carcinoma of the uterus secondarily involving the cervix. Immunohistochemistry markers and detailed gross and microscopic examination will help in difficult cases.
| Conclusion|| |
In our study, the most common age group presenting with AUB was 40–50 years who presented with endometrium in proliferative phase.
The functional causes of AUB were more common in the younger patients. Overall, the chances of malignancy increase with advancing age.
The present study highlights the importance of endometrial biopsy and its interpretation which plays a pivotal role in the management of AUB. Hence, the endometrial biopsy in correlation to the clinical history and radiological findings still remains the gold standard for diagnosis of AUB.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Mishra D, Sultan S. FIGO's PALM-COEIN classification of abnormal uterine bleeding: A clinico-histopathological correlation in Indian setting. J Obstet Gynaecol India 2017;67:119-25.
Shukla M, Fonseca MN, Kharat D, Tekale P. A study to correlate histopathological findings in patients with abnormal uterine bleeding. Int J Reprod Contracept Obstet Gynecol 2017;6:654.
Bolde SA, Pudale SS, Pandit GA, Matkari PP. Histopathological study of endometrium in cases of abnormal uterine bleeding. Int J Res Med Sci 2014;2:1378-81.
Shah RJ, Dayal A, Kothari SL, Patel SM, Dalal B. Histopathological interpretation of endometrium in abnormal uterine bleeding. Int J Med Sci Public Health 2014;3:452-6.
Doraiswami S, Johnson T, Rao S, Rajkumar A, Vijayaraghavan J, Panicker VK. Study of endometrial pathology in abnormal uterine bleeding. J Obstet Gynaecol India 2011;61:426-30.
Jairajpuri ZS, Rama S, Jetky S. Atypical uterine bleeding: Histopathological audit of endometrium. A study of 638 cases. Al Ameen J Med Sci 2013;6:21-8.
Dangal G. A study of endometrium of patients with abnormal uterine bleeding at Chitwan Valley. Kathmandu Univ Med J (KUMJ) 2003;1:110-2.
Gulati HK, Anand M, Deshmukh SD. Squamous cell carcinoma of the uterine cervix extending to the corpus in superficial spreading manner and causing hematometra. J Midlife Health 2013;4:63-4.
[Figure 1], [Figure 2]
[Table 1], [Table 2]