|Year : 2016 | Volume
| Issue : 2 | Page : 178-182
Pattern and frequency of endometrial changes and pathologies among pregnant and nonpregnant women presented with abnormal uterine bleeding in rural inhabitants of north India: A retrospective secondary data analysis
Seema Dayal1, Ashish K Maurya2
1 Department of Pathology, Rural Institute of Medical Sciences and Research, Etawah, Uttar Pradesh, India
2 Department of ENT, Peoples College of Medical Sciences and Research Centre, Peoples Medical College, Bhopal, Madhya Pradesh, India
|Date of Web Publication||5-Jul-2016|
Department of Pathology, Rural Institute of Medical Sciences and Research, Saifai, Etawah, Uttar Pradesh
Background: Abnormal uterine bleeding i.e., dysfunctional uterine bleed is one of the most frequent problems that occur in women of all ages. It occurs due to various disorders. Endometrial biopsy remains a preferred sampling procedure for the diagnosis of endometrial pathology. This study was conducted to determine the type, frequency of endometrial pathologies in women presenting with AUB, and their association with different age groups. Materials and Methods: This was retrospective study conducted in Histopathology Section of the Pathology Department of the Rural Institute of Medical Science and Research, Saifai, Etawah. Five hundred and forty seven (547) patients who have undergone endometrial biopsies and who clinically presented with AUB were included in this study. The pattern of endometrial pathologies was diagnosed, classified, and it was compared in terms of age. Result: Out of the 563 patients who have undergone endometrial biopsies and who presented with AUB, 547 were included in study and others were discarded because of scanty tissue. The patients were aged between 15 years and 72 years, and most of the patients were aged between 41 years and 50 years (36.56%). The common clinical presentation was menorrhagia (42.96%). The most common pattern on histopathology was secretory endometrium (28.33%). Pregnancy related pathology was also forming a bulk (17.36%), whereas incidence rate of malignancy was low (1.09%). Conclusion: AUB is the common clinical complaint interfering with the quality of life in healthy women. Endometrial sampling therefore, biopsy or curettage, is an important diagnostic procedure for the evaluation of AUB with special preference above 35 years of age to rule out malignancy.
Keywords: Abnormal uterine bleeding, endometrial biopsy, histopathology
|How to cite this article:|
Dayal S, Maurya AK. Pattern and frequency of endometrial changes and pathologies among pregnant and nonpregnant women presented with abnormal uterine bleeding in rural inhabitants of north India: A retrospective secondary data analysis. Trop J Med Res 2016;19:178-82
|How to cite this URL:|
Dayal S, Maurya AK. Pattern and frequency of endometrial changes and pathologies among pregnant and nonpregnant women presented with abnormal uterine bleeding in rural inhabitants of north India: A retrospective secondary data analysis. Trop J Med Res [serial online] 2016 [cited 2020 Jul 12];19:178-82. Available from: http://www.tjmrjournal.org/text.asp?2016/19/2/178/185459
| Introduction|| |
Abnormal uterine bleeding (AUB) is defined as a bleeding pattern that differs in frequency, duration, and amount from a pattern observed during a normal menstrual cycle or after menopause.  It is one of the commonest complaints leading to endometrial sampling by endometrial biopsy. Examination of endometrial biopsy is a challenge to a gynecologist as well as to pathologist because of the wide range of morphologic patterns resulting from both normal and abnormal changes such as exogenous hormone, infections, and intrauterine tumor.  AUB may be seen with endometrial polyp, atrophy, adenomyosis, leiomyomas, endometritis, intrauterine device, oral contraceptive use, abortion, ectopic pregnancy, hyperplasia, malignant tumors, gestational trophoblastic disease, blood dyscrasias, severe renal or liver diseases, and hyper- and hypothyroidism.  AUB can be a sign of a serious underlying condition necessitating aggressive treatment. Endometrial tissue can be obtained through several techniques such as pipelle and vebra, but biopsy remain the preferred sampling process.  Biopsy is a comparatively economical office procedure.  It is considered as a first-line diagnostic tool because of its diagnostic accuracy, safety, quickness, and convince. The aim of our study is to determine the type, frequency of endometrium pathology in women presenting with AUB and their association with different age groups.
| Materials and Methods|| |
This was a retrospective study (January 2008 to 20 May 2015) conducted in the Histopathology Section of the Rural Institute of Medical Science and Research, Saifai, Etawah (UP). A predesigned pro forma was filled that included all the relevant information regarding age and presenting clinical complaints. All formalin fixed biopsies were thoroughly, grossly, and histopathologically examined. Tissues were processed, sectioned at 4u, and stained with hematoxylin and eosin (H and E) stain. Additional section if required were also taken. Histopathological pattern was diagnosed and categorized. The results of endometrial biopsies were correlated with clinical presentation and age of the patients and were compared.
Statistical analysis was done by percentage.
| Results|| |
A total of 563 patients who underwent endometrial biopsies presenting with AUB and other clinical details were examined in the period of January 2008-20 May 2015. In 547 patients who underwent biopsies, definite diagnosis was made and these patients were included in the study, whereas others were discarded because of inadequate sampling. The most common clinical complaint was menorrhagia (42.96%), followed by metrorrhagia (19.19%), continuous bleeding (16.45%), polymenorrhagia (10.78%), oligomenorrhea (6.94%), and lastly postmenopausal bleeding (3.6%) [Table 1].
|Table 1: Distribution of age and clinical complaints of patients with AUB |
Click here to view
Metrorrhagia was also one of the chief clinical complaints in the 41-50 years age group (39.57%).
The age group of patients presenting with AUB was 15-72 years. The age group was categorized in six groups. The mean age was 43.5 years. The most common age group was 41-50 years (36.56%), followed by 31-40 years (32.35%) and least common was above 60 years (2.01%) [Table 2].
|Table 2: Distribution of age and histopathological diagnosis of endometrial biopsies with AUB |
Click here to view
Histopathological examination of biopsies revealed various patterns. Major bulk of patients (59.59%) revealed no organic pathology that included secretory phase of endometrium was most common (28.33%), proliferative phase (19.74%), disordered proliferation (4.57%), irregular shedding (2.01%), irregular ripening (1.27%), luteal phase defect (2.55%), and lastly an ovulatory (1.09%) [Table 2].
The different endometrial pathologies were hyperplasia (9.14%)most common, endometritis (7.67%), pregnancy associated (17.36%), polyp (2.37%), Atrophy (2.74%), carcinoma (1.09%).
Endometrial pathologies such as hyperplasia (64%), endometritis (42.85%), and polyp (53.84%) were common in the 41-50 years age group, whereas pregnancy associated pathology (49.47%) was common in the 21-30 years age group [Table 2].
| Discussion|| |
AUB is a common gynecological problem accounting for up to 20% of the visit to the gynecologist.  Evaluation of patients with AUB is achieved with the combination of following history, physical examination, laboratory evaluation, ultrasonography (USG), and confirmation by endometrial biopsy. Endometrial biopsy is useful and cost effective processor to diagnose endometrial pathologies, especially in a rural setting where resources are limited. The clinical differential diagnosis is different for various age groups and histopathological examination of the endometrial biopsy help in confirming the diagnosis of the diseases associated with AUB. It is highly significant for the perimenopausal women because of the increase in the rate of incidence of endometrial pathology in these women.
Menorrhagia was a chief clinical complaint (42.96%) in this study. Similar results were observed by Mogal  who reported menorrhagia as the chief complaint accounting for 41%. In this study, menorrhagia was found to be more common among the perimenopausal women [Table 1]. Praveen  also reported the same.
Metrorrhagia was the second most common clinical complaint to menorrhagia that was 19.19%. This finding was concordant with that of Muzzafar,  who evaluated (35.4%) metrorrhagia cases in his study.
Continuous bleeding per vaginum was the next clinical complaint seen with pregnancy associated pathologies in younger patients,  which include miscarriage, ectopic pregnancy, placenta previa, abruption placentae, and trophoblastic diseases. Such patients should be investigated to diagnose pregnancy associated pathologies.
The age of the patients ranged was from 15 to 72 years. Abnormal and excessive endometrial bleeding occurs in reproductive women of all ages but is more common in adolescent and perimenopausal women.  Our result justify the same, maximum patients with AUB was in the 41-50 years age group (35.83%).
Pregnancy associated complications was common in the 21-30 years age group (49.47%). Similar result was seen in study done by Zeeba. 
Histopathologic diagnosis of endometrial biopsies yielded different patterns. These were ranging from physiological to pathological lesions of endometrium presenting with AUB [Table 2]. Secretory phase of endometrium was the commonest histopathological diagnosis aggregating 28.33%, followed by proliferative phase (19.74%). This was in concordance with the study done by Abdullah,  in which secretory phase was the commonest (24.9%) followed by the proliferative phase (21.7%).
Endometrium is capable of marked hyperplasia as a response of prolonged and unopposed estrogen. It is common among the perimenopausal women causing symptoms of irregular or prolonged bleeding due to ovulatory cycles. , The incidence rate of endometrial hyperplasia was 9.14%. This was very low in comparison to the findings of Muzzafar,  and the reason behind this may be less registration of cases. In rural population, majority of the women with AUB go to quacks for medication because most of them have low socioeconomic status and low education status.
Majority of the endometrial hyperplasia patients belonged to the perimenopausal group (64%). The histopathological evaluation of endometrial hyperplasia is important because it is a precursor of endometrial carcinoma that accounts for 3% female cancer death. 
Endometritis was diagnosed in 7.67%. Chronic nonspecific and acute endometritis may result from abortion, pregnancy, and intrauterine contraceptive device (IUCD). Among endometritis, Chronic nonspecific endometritis is common and its incidence was(6.94%) which was in concordance with others authors study (24%).  Tubercular endometritis, a form of chronic endometritis, that is uncommon in the Western countries but not so in the developing countries. Its incidence rate in India is approx. 5%, but in the present study tubercular endometritis accounts for 0.73%.
Pregnancy is the first consideration in women of childbearing age who present with AUB. Pregnancy related AUB was common in the 21-30 years age group. Pregnancy related bleeding was 17.36%. A similar result of 57.6% with AUB as complication of pregnancy has been reported in this age. 
Endometrial polyp is composed of irregular spaced glands in which scattered glands may differ from native endometrium due to their tendency to have reduced hormonal responsiveness. They are usually encountered in routine surgical pathology practice careful examination should be done to diagnose malignancy. In this study, 2.37% of the cases of polyp were observed. Its incidence was lower than that in the study by Mirza. 
Disordered proliferation endometrium is an amplification of the normal proliferation phase without noteworthy increase in the overall gland-to-stroma ratio. It occupies the lower end of spectrum that passes through hyperplasia to endometrial carcinoma.  In the present study, the rate of incidence of disordered proliferation was 4.57%, which was very much lower than the rate of incidence (23%) reported by Mirza. 
Other functional disorders were irregular shedding (2.01%), irregular ripening (1.27%), luteal phase (2.55%), and anovulatory (1.09%). A higher number of cases in the perimenopausal age group was explained by the fact that perimenopausal is the transition from normal ovulation to anovulation, which then eventually leads to permanent loss of ovarian function. 
Atrophic changes in endometrium were seen in 2.74%, which were found in perimenopausal and menopausal women. The exact cause of bleeding in atrophic endometrium is not known but is thought to be due to anatomic vascular variation or defective local hemostatic mechanism. 
Carcinoma was (1.09%) that was common in postmenopausal women (66.66%).
Carcinoma cervix was the most common cause of malignancy followed by carcinoma endometrium. Supportive of this observation is that carcinoma cervix is still the commonest malignancy of female genital tract in a developing country like India.
| Conclusion|| |
AUB is a major health problem that adversely affects the lives of women of all age groups. Pathologies with AUB may vary according to different age groups. Endometrial biopsy is office processor and first-line diagnostic tool used in the diagnosis of AUB pathology. It reveals endometrium patterns in various forms of AUB and help to exclude any organic pathology. It is specially recommended for women above 35 years presenting with AUB, i.e., perimenopausal women, to diagnose preneoplasia and malignancy. Besides aiding in diagnosis, it may help physician to plan therapy for successful management of women presenting with AUB.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ely JW, Kennedy CM, Clark EC, Bowdler NC. Abnormal uterine bleeding: A management algorithm. J Am Board Fam 2006;19:590-602.
Crum CP, Hornstein MD, Nucci MR, Mutter GL. A systemic and practical approach to endometrial biopsies. Adv Anat Pathol 2003;10:301-18.
Sherman ME, Mazur MT, Kurman RJ. Benign disease of the endometrium. In: Kurman RJ, editor. Blaustein's Pathology of the Female Genital Tract. 5 th
ed. New Delhi: Thomson Press; 2004. p. 432.
O'Connell LP, Fries MH, Zeringue E, Brehm W. Triage of abnormal postmenopausal bleeding: A comparison of endometrial biopsy and transvaginal sono hysterography verses fractional curettage with hysteroscopy. Am J Obstet Gynecol 1998;178:956-61.
Saadia A, Mubarik A, Zubair A, Jamal S, Zafar A. Diagnostic accuracy of endometrial curettage in endometrial pathology. J Ayub Med Coll Abbottabad 2011;23:129-31.
Neese RE. Abnormal vaginal bleeding in perimenopausal women. Am Fam Physician 1989;40:185-92.
Moghal N. Diagnostic value of endometrial curettage in abnormal uterine bleeding-a histopathological study. J Pak Med Assoc 1997;47:295-9.
Perveen S. Endometrium histology in abnormal uterine bleeding. MC 2011;17:68-70.
Muzaffar M, Akhtar KA, Yasmin S, Mahmood-Ur-Rehman, Iqbal W, Khan MA. Menstrual irregularities with excessive blood loss: A clinico-pathological correlation. J Pak Med Assoc 2005;55:486-9.
Padubidri VG, Daftary SN. Disorders of menstruation. Howkin's and Bourne Shaw's Textbook of Gynaecology. 12 th
ed. New Delhi, India: Churchill Living Stone; 1990. p. 229-38.
Sharma JB. Dysfuntional uterine bleeding. O and G Today 2000;5:20-5.
Jairajpuri ZS, Rana S, Jetley S. Atypical uterine bleeding-Histopathological audit of endometrium. A study of 638 cases. Al Ameen J Med Sci 2013;6:21-8.
Abdullah LS, Bondagji NS. Histopathological pattern of endometrial sampling performed for abnormal uterine bleeding. Bahrain Med Bull 2011;33:1-6.
Kurman RJ, Kamiriski PF, Norris HJ. The behavior of endometrial hyperplasia. A long-term study of "untreated" hyperplasia in 170 patients. Cancer 1985;56:403-12.
Sarwar A, Haque A. Types and frequencies of pathologies in endometrial currettages of abnormal uterine bleeding. IJP 2005;3:65-70.
Ara S, Roohi M. Abnormal uterine bleeding-Histopathological diagnosis by conventional dialation and curettage. Professional Med J 2011;18:587-91.
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.
[Table 1], [Table 2]