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Abnormal uterine bleeding in perimenopausal women: Correlation with sonographic findings and histopathological examination of hysterectomy specimens

Background: Abnormal uterine bleeding (AUB) is a frequently encountered gynecologic complaint in perimenopausal woman and also the most common cause of hysterectomy in this age group. Objective: Evaluation of various clinical presentations of perimenopausal AUB and it is ultrasonographic and histopathological correlation of hysterectomy specimens. Materials and Methods: This study was carried out in the Department of Obstetrics and Gynaecology among perimenopausal women who underwent hysterectomy for AUB. The clinical presentations, ultrasonographic findings, and histopathological reports of hysterectomy specimen were correlated. Results: Among 103 number of hysterectomized cases for AUB, most of the patients were between 40 and 45 years of age (67.97%) and menorrhagia was the dominant clinical presentation. The majority (45.63%) of cases were diagnosed as fibroid uterus by ultrasonography with 89.13% sensitivity and 89.47% specificity. Histopathological reports of myometrium showed 44.66% fibromyoma, followed by 34.95% of the normal myometrium. Histopathology of endometrium revealed hyperplasia in the most cases (56.31%) where simple typical type was the predominant. Conclusion: Uterine fibroid was the leading cause of AUB and radiological, pathological evaluation correlated well to diagnose fibroid.


INTRODUCTION
Abnormal uterine bleeding (AUB) is a symptom and not a disease. It is one of the most frequently encountered complaints in gynecologic practice. It accounts for more than 70% of all gynecological consultations in the peri-and post-menopausal age group. [1] It occurs in various forms such as menorrhagia, polymenorrhea, polymenorrhagia, metrorrhagia, and menometrorrhagia. [2] The International Federation of Gynaecology and Obstetrics in November 2010, accepted a new classification system for causes of AUB in the reproductive years. The system based on the acronym (polyps, adenomyosis, leiomyoma, malignancy and hyperplasia-coagulopathy, ovulatory disorders, endometrial causes, iatrogenic, not classified) was developed in response to concerns about the design and interpretation of basic science and clinical investigation that relates to the problem of AUB. [3] AUB may be an expression of hormonal milieu, or it could be the clinical presentation of benign or malignant lesions of female genital tract in perimenopausal woman. However, there are no detectable structural abnormalities in majority of cases, and this is called dysfunctional uterine bleeding (DUB). DUB, fibroid uterus, and adenomyosis are the common hyperoestrogenic conditions where endometrium remains in the proliferative phase and if untreated may lead to endometrial carcinoma. Therefore, clinical examination and investigations are essential to find out the etiological factor in a perimenopausal patient presenting with AUB. Ultrasonography (USG) can be used to exclude organic pathology for AUB. It is well accepted that various disease pathology can be detected accurately by histopathological examination (HPE). The current study was carried out to evaluate various clinical presentations of perimenopausal AUB and to correlate ultrasonographic findings with histopathological examination in those patients undergoing hysterectomy.

MATERIALS AND METHODS
This study was conducted in a tertiary care hospital in a time span of 1-year from July 1, 2014, to June 30, 2015. The study population consists of perimenopausal women within the age group of 40 years to within 1 year of menopause who underwent hysterectomy for AUB. The proper institutional ethical clearance was taken for the study. After obtaining informed consent from selected patients, the relevant data such as age, parity, menstrual symptoms, and other associated findings in clinical examination were recorded. In all these women, transvaginal ultrasonographic evaluation was done. The clinical presentations and ultrasonographic findings were correlated. Histopathology examination report of hysterectomy specimens such as endometrial, myometrial, and cervical findings was correlated with sonographic reports, and results were analyzed using Graph Pad Software, Inc; Version 3.1.

RESULTS
One hundred and three numbers of patients with AUB who underwent hysterectomy were included in this study. A correlation between age, parity is depicted in Table 1. Most of the patients were between 40 and 45 years of age (67.97%). The highest number of AUB in this study was para 4 or more (42.71%) followed by para 3 (26.21%).
The different menstrual pattern of AUB, as well as duration of symptoms, was shown in Table 2. The majority of patients gave a history of menstrual problem between 3 and 6 months 56 (54.37%), and menorrhagia was the dominant presentation.
Histopathological reports of myometrium were as follows: fibroid 46 (44.66%), adenomyosis 21 (20.39%), and normal myometrium 36 (34.95%) [ Table 5]. Of 47 ultrasonographically diagnosed fibroid uterus, 41 were    Table 6]. Out of the two HPE confirmed carcinoma endometrium cases, USG detected thick endometrium in one case and bulky uterus in the other. USG detected thick endometrium which turned out to carcinoma endometrium in HPE was a postmenopausal woman. There were 59 (57.28%) inflammatory cervix, one carcinoma of cervix and two cases of cervical intraepithelial neoplasia (CIN) in HPE. Table 7 shows the validity of USG in the detection of fibromyoma and adenomyosis in perimenopausal women. The results reveal that the sensitivity is lower in diagnosis of adenomyosis (47.62%).

DISCUSSION
AUB is one of the main gynecological reasons of hysterectomy and accounts for two-thirds of all hysterectomies. [4] In this study, 103 numbers of perimenopausal hysterectomized patients were analyzed. Most number of patients (69.67%) were between 40 and 45 years age group. The common menstrual problem was menorrhagia (43.69%). This finding was comparable with the study of Jetley et al. [5] and Shobha, [6] in which clinical presentation as menorrhagia in AUB evaluation revealed 46.4% and 46.6%, respectively. It appeared in this study that the maximum patients attended hospital for treatment after suffering for 3-6 months (54.37%) which was comparable to the study of Kathuria and Bhatnagar (50%). [7] In this study, ultrasonographic diagnosis of fibromyoma of the uterus was 47 (45.63%). Out of these, 41 were confirmed by histopathologically, and six turned out as adenomyosis. The sensitivity of USG for the diagnosis of leiomyoma was 89.13%, and the specificity was 89.47%, which is similar to the study done by Dueholm et al. [8] In this study, 21 cases were diagnosed as adenomyosis by histopathologically, ultrasound diagnosed 11 of them. Ultrasound was able to suggest adenomyosis with sensitivity of 47.62%, specificity of 98.78%, positive predictive value of 90.91%, and negative predictive value 80.04% [ Table 7].  [9][10][11][12][13] Hence, USG has a limitation in tissue characterization in diagnosis adenomyosis.
Bulky uterus was the sole USG finding in 30 numbers of cases which were clinically diagnosed as DUB. Out of these, histopathologically revealed normal myometrium in 22 cases, adenomyosis in five cases, and fibromyoma in three cases. Histopathologically endometrial hyperplasia was observed in 19 numbers of cases of bulky uterus; two cases revealed CIN I and one case showed carcinoma endometrium.
In this study, USG detected thickened endometrium in 12 cases. Out of these 12 cases, 4 cases clinically presented as postmenopausal bleeding. Among those 4 cases, histopathologically 3 were diagnosed as endometrial hyperplasia and 1 was endometrial carcinoma. Hence, all patients of postmenopausal bleeding with thickened endometrium on USG, HPE revealed abnormal endometrial pathology.

CONCLUSION
In our study, uterine fibroid was the leading cause of AUB for which hysterectomy was done. Radiological and pathological evaluation correlated well to diagnose fibroids. USG has good specificity to diagnose adenomyosis, however, because of low sensitivity it is important not to rule out adenomyosis based on USG findings alone. USG alone is not sufficient to diagnose endometrial hyperplasia. However, USG detected thick endometrium in postmenopausal woman is a good indicator of endometrial pathology. Regarding endometrial finding, histopathology revealed hyperplasia in majority of cases of which simple typical type was the predominant.