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Thyroid function in abnormal uterine bleeding

Abnormal uterine bleeding includes both structural and non structural causes. Structural causes are polyp, adenomyosis, fibroids, malignancies and hyperplasia and non-structural causes includes coagulopathy, endometrial causes, iatrogenic and non classified causes. 20% women in gynaecology present with abnormal uterine bleeding. Abnormal uterine bleeding is any abnormal uterine bleeding in the absence of any palpable pelvic pathology and demonstrable extra genital causes. It is well recognized that thyroid dysfunction has profound effects on female reproductive system in terms of delayed puberty, AUB, infertility, recurrent pregnancy loss, premature menopause. Thyroid disorders are 10 times more common in females than males. This high prevalence in female is possibly due to autoimmune nature of thyroid disorders. The underlying cause of AUB is uncertain but most common associated basic pathology is ovarian dysfunction and consequent hormonal ABSTRACT


INTRODUCTION
Abnormal uterine bleeding includes both structural and non structural causes. Structural causes are polyp, adenomyosis, fibroids, malignancies and hyperplasia and non-structural causes includes coagulopathy, endometrial causes, iatrogenic and non classified causes. 20% women in gynaecology present with abnormal uterine bleeding. 1 Abnormal uterine bleeding is any abnormal uterine bleeding in the absence of any palpable pelvic pathology and demonstrable extra genital causes. It is well recognized that thyroid dysfunction has profound effects on female reproductive system in terms of delayed puberty, AUB, infertility, recurrent pregnancy loss, premature menopause. Thyroid disorders are 10 times more common in females than males. [2][3][4] This high prevalence in female is possibly due to autoimmune nature of thyroid disorders. The underlying cause of AUB is uncertain but most common associated basic pathology is ovarian dysfunction and consequent hormonal imbalance. Ovarian dysfunction may be primary (pathological lesion of ovary) or secondary to endocrine dysfunction e.g. Hypothalamus, pituitary and thyroid. Various studies have done earlier show that menorrhagia being the chief symptom in hypothyroidism. Majority of cases of subclinical hypothyroidism pass unrecognised because these patients are usually asymptomatic. 5,6 Prevalence of subclinical hypothyroidism is so high that it should be given enough consideration justifying the screening of women with menstrual irregularities even if they don't have any symptom or sign related to thyroid disorder. 7, 8 Menon has demonstrated the treatment of AUB with thyroxine. 9 Doifodi and Fernando have also done research to show that unnecessary hormonal treatment and surgeries can be avoided with correction of thyroid disorders. 10 Serum TSH assay is a sensitive indicator of hypothyroidism because TSH levels elevates before circulating thyroxin level fall below normal range.
Thyroid gland is one of the most vital endocrine organs which plays a major role in growth, development, metabolism and function of every organ in the body. Both Hypo and Hyperthyroidism can result in menstrual irregularities. In women thyroid disorders can cause a broad spectrum of reproductive abnormalities ranging from abnormal sexual development, menstrual irregularities, infertility and premature menopause. Abnormal uterine bleeding is one of the most common, yet complicated clinical presentation. Timely detection of thyroid dysfunction in women presenting with AUB and its proper management can prevent unnecessary surgical interventions and helps to reduce financial burden and improves quality of life. Hence this study is undertaken to evaluate the thyroid dysfunction in women with abnormal uterine bleeding.
The objective of this study was to estimate the prevalence of thyroid dysfunctions in women with AUB from puberty to menopause; and to evaluate thyroid function test in women with AUB; and to assess the menstrual pattern in women with thyroid dysfunction.

METHODS
The present study was conducted in the Department of Obstetrics and Gynecology, 80 women of reproductive age group 15-45 years were selected.

Exclusion criteria
Patients with menstrual disorder having any known organic pathology like uterine fibroid, adenomyosis, tubercular endometriosis, polyp, uterine malignancy, etc. and patients with IUCD in utero were excluded from study.
After taking detailed history regarding age, parity, age of menarche, menstrual disorders and dysmenorrhea, general physical examination along with pelvic examination was carried out in women with menstrual complaints. Routine basic investigation and thyroid profile that includes T3, T4 and TSH was performed in all patients. These tests were done in random blood samples as the variation in TSH secretion due to circadian rhythm is small and does not influence the timing of blood sampling.
Direct quantitative determination of T3, T4, and TSH by CLIA estimated in autoanlyser. In necessary cases special investigations were done as Trans-abdominal scan, endometrial sampling, and hysteroscopy.

Statistical analysis
Statistical analysis is done by SPSS software and Difference with a p value of <0.05 was considered statistically significant.

RESULTS
There were 80 women included in the study. The age groups of all the patients are mentioned in Figure 1.     Patients who were sub-clinically hypothyroid were maximally presenting as polymenorrhoea (50%) and menorrhagia (12.1%) and only 6.27% of patients had oligomenorrhoea. Patients who were profound hypothyroid were predominantly having polymenorrhagia (83.3%) and (62.5%) of patients had oligomenorrhoea.

DISCUSSION
Menorrhagia is a frequent symptom in gynaecological practice resulting in need for repeated curettage and hysterectomy with its relative morbidity and mortality. Menstrual blood loss is considered to be excessive when it is greater than 80ml per cycle.
The aetiology of menorrhagia is much differential diagnosis. It may be due to systemic conditions like hormonal imbalance like hypothyroidism and hyperthyroidism, or lesions of genital tract like endometrial hyperplasia, pelvic inflammatory disease, endometriosis, benign tumours (leiomyoma, polyps) and malignant tumours (endometrial carcinoma). In more than half of the subjects the cause is usually not apparent.
Thyroid dysfunction is one of the common causes of excessive menstrual blood loss and menstrual irregularities ( Table 2). It may also lead to anovulation, infertility and recurrent abortion. The onset of hypothyroidism is so insidious that classic clinical manifestation may take months and years to appear. 8 Furthermore menorrhagia may be the only presenting complain in hypothyroid women. 9 With the advent of modern hormonal assay techniques precise estimation of thyroid hormones in serum is possible in a rapid and reliable manner. Treatment of hypothyroidism is very satisfying as it usually relieves patient of all the symptoms.
Hence, in investigating a patient with menorrhagia and/or menstrual irregularities, evaluation of thyroid functional status forms an essential component. Early detection of hypothyroidism in such subjects saves the patient from recurrent curettage and at times hysterectomy.  16 There were also 12% of women presenting with amenorrhoea in the hypothyroid group, and none among the control subjects. The most common menstrual irregularity in our study was oligomenorrhoea followed by menorrhagia. Women with history of recurrent abortions, postpartum psycosis women with sub clinical hypothyroidism, infertility, associated with menstrual irregularities are all to be screened for thyroid dysfunction. Targeted screening at regular intervals should be recommended. This should also be considered in women who have had gynaecological and/or obstetric complications associated with hypothyroidism and in whom treatment is shown to be beneficial.
So, screening selected subject groups is could be justified, based on the significant risks to offspring, the probable benefit of treatment, and the probable low incidence of adverse outcomes from intervention.

CONCLUSION
As there is high incidence of thyroid diseases in women with abnormal uterine bleeding are to be screened. This would also avoid unnecessary hormonal treatment and surgery in these patients. It concludes that thyroid disorder should be considered as an important aetiological factor for menstrual abnormality.
Thus, biochemical evaluation T3, T4 and TSH estimations should be made mandatory in AUB cases to detect profound and subclinical thyroid dysfunction.