study of abnornal uterine bleeding.pdf

3Journal of the Scientific Society, Vol 42 / Issue 1 / January-April 2015

Clinicopathological study of abnormal uterine bleeding in perimenopausal women

INTRODUCTION

Perimenopause refers to the period surrounding the last menstrual event.

In the 21st century, women are living major years of their lifetime in perimenopause state, constituting a large segment of the population. Abnormal uterine bleeding is the most common complaint encountered in these years causing significant physical and mental morbidity and financial burden on these patients.[1]

Although malignancy is not the most common etiology for perimenopausal bleeding, it is the most important. This study was done asses the clinicopathological factors causing perimenopausal uterine bleeding and to study the occurrence of endometrial hyperplasia and carcinoma.

DISCUSSION

Till the end of 19th century, the cause of abnormal uterine bleeding was thought to be chronic inflammation. Now, it has been clear that abnormal uterine bleeding, which is common in perimenopausal women are due to the varied causes ranging from functional to malignancy.

Perimenopause refers to the period surrounding the last menstrual event. In this duration, there exists a situation where the normal diminution in reproductive capacity with its resulting disruption of the normal menstrual pattern coincides with a real risk of pelvic pathology.

S. Sudhamani, Sunila1, Swapnil Sirmukaddam, Durgaprasad AgrawalDepartment of Pathology, Pad Dr. D. Y. Patil Medical College, Nerul, Navi Mumbai, Maharashtra, 1Department of Pathology, Jagadguru Sri Shivarathreeshwara Medical College, Mysore, Karnataka, India

Address for correspondence: Dr. S. Sudhamani, Department of Pathology, Pd. Dr. D. Y. Patil Medical College, Nerul, Mumbai - 400 706, Maharashtra, India. E-mail: [email protected]

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DOI:

10.4103/0974-5009.149457

Abstract

Background: Until recently, perimenopause has been little understood and ignored especially in developing the country like India. It is a distinct entity from menopause and in terms of symptomatology, it may be even more important than postmenopause. Aims and Objectives: (1) To ascertain the cause of abnormal uterine bleeding in perimenopausal women (40-55 years). (2) To study the spectrum of morphological changes in perimenopausal bleeding with high-risk factors predisposing to endometrial hyperplasia and malignancy. Materials and Methods: The study was undertaken in a large tertiary care teaching hospital over a period of 3 years. All the outdoor and indoor patients presenting with abnormal uterine bleeding with or without other clinical features in the perimenopausal age group (40-55 years) were included in the study. Women with menstrual cycles of 21-35 days with a duration of flow of 2-6 days were considered normal and were excluded from the study. Specimen considered for histopathological study included endometrial biopsy, dilation and curettage, fractional curettage, cervical biopsy, and or hysterectomy with or without salpingo-oophrectomy done for diagnostic or therapeutic purposes. Statistics Used: Totally, 100 cases were selected on the basis of simple random sampling and analyzed. Results: Most of the patients were in the age group of 40-45 (45%) with menorrhagia as the chief complaint. The bulk of the specimens were of total hysterectomy with bilateral salpingo-oophrectomy (43%). Functional endometrial changes were the most common cause in 40-50 years age group but endometrial carcinoma was the main cause of bleeding in the 51-55 years group indicating heightened occurrence of malignancy with increasing age.

Key words: Abnormal bleeding, perimenopause, uterine bleeding

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Sudhamani, et al.: Clinicopathological study of abnormal uterine bleeding

4 Journal of the Scientific Society, Vol 42 / Issue 1 / January-April 2015

MATERIALS AND METHODS

The study was undertaken in a large tertiary care teaching hospital on patients presenting with abnormal uterine bleeding in the perimenopausal age group (40-55 years). Women with menstrual cycles of 21-35 days with a duration of flow of 2-6 days were considered normal and were excluded from the study. Specimen considered for histopathological study included endometrial biopsy, dilation and curettage, fractional curettage, cervical biopsy, and or hysterectomy with or without salpingo-oophrectomy done for diagnostic or therapeutic purposes.

In the present study, functional endometrial disorders (23%) was the most common cause for abnormal uterine bleeding followed in the decreasing order by leiomyoma (19%), endometrial hyperplasia (17%), adenomyosis and endometriosis (14%), carcinoma cervix (9%), and malignant tumors of endometrium (6%).

Infections (2%), complications of pregnancy (1%), functional ovarian tumors (2%), and others (4%) formed the rest of the cases.

Functional endometrial disorder, commonly referred to us dysfunctional uterine bleeding formed the largest category, variously reported as normal endometrium,

functional endometrium or physiological changes. It was the cause of abnormal uterine bleeding in all age groups, the percentage ranging from 54% (64), 55.2% (71), 46% (86), and 62% (8), respectively, in various studies. In our study, it was 23% less compared to other studies probably due to the strict age criteria but still forming the largest group as the cause for abnormal uterine bleeding [Table 1].

The highest number of cases of functional disorders were seen in the age group of 40-45 years in our study (69.56%), followed by 46-50 years age group (30.43%) [Table 2]. This correlates well with a study where the mean age at diagnosis was found to be 44 years.[2] None of the patients were above the age of 50 years, indicating increasing number of organic causes and the decrease in functional disorders as the age advances. The most common presenting complaint in our study was menorrhagia (38%) even though polymenorrhea[3] was found to be the main complaint in other studies.

In the present study, out of the 23 cases of functional endometrial changes, 47.82% (11) showed proliferative changes, 17.39% (4) were of irregular proliferation, and 13.04% (3) showed secretory phase indicating an ovulatory cycles as the main cause of abnormal uterine bleeding [Table 3]. This is corroborated in other studies as well.[3-5]

In the present study, uterine leiomyomas formed 19% of cases, next only to functional disorders. The size varied from 1 to 8 cm in the largest dimension.

Leiomyomas were found commonly in the age group of 40-45 years, the frequency decreasing with age. The most common symptom was menorrhagia and the majority was of intramural type (92%) in our study correlating with other studies.[6-8]

In the present study, most of the cases of carcinoma cervix were seen in the age group of 40-45 years with the main complaint as continuous bleeding (66.66%) and after menopause as postmenopausal bleeding (33.33%). This is in accordance with other studies, which showed the average age for the development of in situ carcinoma as 38 years and invasive cancer as 48 years.[8]

Table 1: Clinicopathological correlation (total 100 cases)

Diagnosis Clinical diagnosisPathological

diagnosisDUB 39 23Fibroid 28 19Ca. Cx 10 9Ca. Endometrium 5 6End polyps 3 3Adenomyosis 5 14Ovarian tumors 2 2Infections 2 2End Hyp 3 17Products of conception - 1Others 3 4DUB = Dysfunctional uterine bleeding, Ca Cx = Carcinoma cervix, End polyps = Endometrial polyps, End Hyp = Endometrial hyperplasias

Table 2: Distribution of lesions according to age (100 cases)Age group DUB Fibroid And end End hyp End polyps Ca Cx MT of end Inf Prg Func Ov T Others Percentage40-45 16 12 10 11 2 6 1 2 1 4 6546-50 7 7 3 3 1 2 1 2451-55 1 3 1 4 2 11Total 23 19 14 17 3 9 6 2 1 2 4 100DUB = Dysfunctional uterine bleeding, Adn End = Adenomyosis and endometriosis, End Hyp = Endometrial hyperplasias, End polyps = Endometrial polyps, Ca Cx = Carcinoma cervix, MT of End = Malignant tumors of endometrium, Inf = Infections, Prg = Pregnancy, Funct Ov T = Functional ovarian tumors



5Journal of the Scientific Society, Vol 42 / Issue 1 / January-April 2015

The most common microscopic type of invasive cancer in this study was that of squamous cell carcinoma, keratinizing type.

In our study, cervical dysplasias and infiltration of cervix by ovarian cancer were infrequent causes for abnormal uterine bleeding.

Adenomyosis and endometriosis constituted 14% of cases, majority seen in the age group of 40-45 years (71.43%),

the frequency steadily decreasing with increasing age, probably representing the onset of menopause. Of the 14 cases, 5 cases of adenomyosis were associated with bilateral ovarian endometriosis [Figure 1].

In the present study, endometrial hyperplasia were mainly seen in the age group of 40-45 years (11%) and the maximum number of cases showed features of simple hyperplasia without atypia (47%) and none showed in situ or borderline malignancy [Figure 2]. These findings are in accordance with other studies.[1,9-12]

In this study, the maximum number of cases of endometrial carcinoma, which constituted 6% of total cases were in the age group of 51-55 years and 83.33% of them being of endometrioid type [Figure 3], the others being endometrial stromal sarcoma. Of the endometrial adenocarcinomas, the various histopathological types seen were papillary [Figure 4], clear cell, well-differentiated endometrioid type and

Figure 4: Gross picture of uterus displaying papillary endometrial carcinoma

Figure 1: Gross photograph of uterus showing thickened endometrium (hyperplasia) with trabeculated appearance of myometrium (adenomyosis)

Figure 2: H and E, 10 showing papillary endometrial adenocarcinoma

Figure 3: H and E, 40 showing endometrioid adenocarcinoma of uterus

Table 3: Endometrial changesEndometrial change Number of cases PercentageProliferative phase 40 48.78Secretory phase 14 17.08Hyperplasia 17 20.74Malignant tumors 6 7.32Infections 2 2.43Polyps 3 3.65Total 82 100



6 Journal of the Scientific Society, Vol 42 / Issue 1 / January-April 2015

adenoacanthoma. There was an equal distribution of cases in pre- and post-menopausal groups, correlating with other studies.[13-16]

CONCLUSION

Benign lesions of endometrium and myometrium are the most common causes for abnormal uterine bleeding in perimenopausal women, but the possibility of endometrial hyperplasia and particularly the cancers of uterus must be considered particularly with the advancing age.

A comprehensive clinicopathological study will usually help in arriving at the correct diagnosis. However, in view of the wide array of causes, abnormal uterine bleeding continues to be a diagnostic challenge, especially during perimenopause.

REFERENCES

1. Mencaglia L, Perino A, Hamou J. Hysteroscopy in perimenopausal and postmenopausal women with abnormal uterine bleeding. J Reprod Med 1987;32:577-82.

2. Liza Sister, Rameshkumar K, Lillian Sister. Value of endometrial aspiration cytology in assessing endometrial status in symptomatic peri and postmenopausal women. Indian J Cancer 1999;36:57-61.

3. Singh A, Singh S, Mathur V, Singh K. Transvaginal sonography in dysfunctional uterine bleeding and its correlation with histopathology. J Obstet Gynecol India 2001;51:116-9.

4. Benson RC, Miller JN. Surgical curettage; its value in abnormal uterine bleeding. Obstet Gynecol 1956;8:523-30.

5. Nedoss BR. Dysfunctional uterine bleeding: Relation of endometrial histology to outcome. Am J Obstet and Gynecol 1970;107:852-55

6. GarciaCR.Managementof thesymptomaticfibroidinwomenolderthan40years of age. Hysterectomy or myomectomy?. Obstet Gynecol Clin North Am 1993;20:337-48.

7. OConnor DM, Norris HJ. Mitotically active leiomyomas of the uterus. Hum Pathol 1990;21:223-7.

8. Jutras ML, Cowan BD. Abnormal bleeding in the climacteric. Obstet Gynecol Clin North Am 1990;17:409-25.

9. FerenczyA,GelfandM.The biologic significance of cytologic atypiain progestogen-treated endometrial hyperplasia. Am J Obstet Gynecol 1989;160:126-31.

10. Ng AB, Reagan JW, Cechner RL. The precursors of endometrial cancer: A study of their cellular manifestations. Acta Cytol 1973;17:439-48.

11. Dunn TS, Stamm CA, Delorit M, Goldberg G. Clinical pathway for evaluating women with abnormal uterine bleeding. J Reprod Med 2001;46:831-4.

12. Winkler B, Alvarez S, Richart RM, Crum CP. Pitfalls in the diagnosis of endometrial neoplasia. Obstet Gynecol 1984;64:185-94.

13. Burke TW, Tortolero-Luna G, Malpica A, Baker VV, Whittaker L, Johnson E, et al. Endometrial hyperplasia and endometrial cancer. Obstet Gynecol Clin North Am 1996;23:411-56.

14. Zaino RJ, Kurman R, Herbold D, Gliedman J, Bundy BN, Voet R, et al. The significanceof squamousdifferentiationinendometrialcarcinoma.Datafrom a Gynecologic Oncology Group study. Cancer 1991;68:2293-302.

15. AmbrosRA,BalloukF,MalfetanoJH,RossJS.Significanceof papillary(villoglandular) differentiation in endometrioid carcinoma of the uterus. Am J Surg Pathol 1994;18:569-75.

16. Shwayder JM. Pathophysiology of abnormal uterine bleeding. Obstet Gynecol Clin North Am 2000;27:219-34.

How to cite this article: Sudhamani S, Sunila, Sirmukaddam S, Agrawal D. Clinicopathological study of abnormal uterine bleeding in perimenopausal women. J Sci Soc 2015;42:3-6.

Source of Support: Nil. Conflict of Interest: None declared.


study of abnornal uterine bleeding.pdf

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