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Association of thyroid dysfunction with abnormal uterine bleeding

Abnormal uterine bleeding is a common complaint for women being referred to the gynaecologist and is associated with an array of symptoms. 20-30% patients present to OPD with this complaint in India. Any disruption in the normal physiology or anatomy of the endometrium results in abnormal uterine bleeding. After November 2010, The International Federation of Gynaecology and Obstetrics formally accepted a new classification system for causes of AUB in reproductive years. The system is based on acronym-PALM-COEIN. PALM (structural causes): Polyp, Adenomyosis, Leiomyoma, Malignancy and hyperplasia, COEIN: (Nonstructural causes) Coagulopathy, Ovulatory disorders, Endometrial causes, Iatrogenic, Not classified.

Women with hypothyroidism usually present with menorrhagia (Goldsmith et al, 1952). Hyperthyroidism, on the other hand, is associated with amenorrhea, oligomenorrhea and the decrease in flow is proportional to the severity of thyrotoxicosis (Benson and Dailey, 1955) Hypothyroidism even in sub clinical form may result in excessive menstrual bleeding and severe blood loss. The exact mechanism of menorrhagia in hypothyroidism is not well understood. TRH causes increase in prolactin which thereby inhibits the LH surge. This leads to anovulatory cycle finally causing breakthrough bleeding associated with menorrhagia. 5 Hypothyroidism alters the peripheral metabolism of oestrogen; thereby decreasing sex hormone binding globulin (SHBG) production. Both the pathways may lead to abnormal feedback at the level of the pituitary gland. Independent of the hormonal mechanisms, hypothyroidism can cause menorrhagia by altered production of coagulation factors (decreased levels of factor 7, 8,9,11) Hyperthyroidism-etiology of menstrual dysfunction is not known, whether it is primary effect of thyroid on ovary or uterus or mediated by pituitary dysfunction. The disturbances are probably a result of the effect of hypersecretion of thyroid hormones on the hypothalamicpituitary axis with changes in gonadotrophin secretion, or on circulating SHBG, the levels of which are increased in thyrotoxicosis.
Thus, thyroid dysfunction is one very important cause of menstrual disturbances experienced by women. Its recognition is valuable as specific and reliable therapy is available.

METHODS
This non-interventional prospective study was done over a period of one and half years in a private medical college in Mangalore. 85 patients were included in the study. Detailed history was obtained with special relevance to age, bleeding pattern, onset, duration and amount of bleeding.

Inclusion criteria
• Patients belonging to any age group (15-50 years) complaining of irregular bleeding P/V (abnormality in frequency, amount or duration) • No detectable disease in the genital tract.

Exclusion criteria
Patients suffering from the following conditions • Endometrial or cervical cancer • Pelvic infections including endometritis • Endometriosis, PCOD • Ovarian cyst, tumour • Patient using intrauterine contraceptive device.
A thorough clinical examination including general physical examination, gynaecological and systemic examination was carried out with special reference to thyroid dysfunction; in cases with a provisional diagnosis of AUB.
Patients were subjected to routine investigations like Hb, BT, CT and platelets (to rule out coagulation defects).All patients were subjected to T3,T4 and TSH estimation in their sera by Electro Chemiluminescence Labelled Antibody Immunoassay by Cobas e 411 machine. Normal serum concentration taken for standard references • T3 -0.85 -2.02 ng/ml • T4 -5.14 -14.1 μg/dl • TSH -0.27 -4.2 μIU/ml Ultrasonography (USG -Abdomen and Pelvis with endometrial thickness) was done to rule out the structural causes associated with menstrual irregularities.

Statistical analysis
Frequency distribution tables were made. Based on thyroid dysfunction, the cases were categorised to 3 groups -hypothyroid, euthyroid and hyperthyroid.

Ethical considerations
The following ethical issues were considered for the study • There was no physical harm for the participants as there was no intervention • Written informed consent was obtained from all the participants.
Ethical clearance approval obtained from the institutions ethical committee.

RESULTS
Abnormal uterine bleeding is one of the most commonly encountered conditions in gynaecological practice.

Various parameters analyzed were
• Age • Parity • Menstrual irregularities • Thyroid status • Association of menstrual irregularities with thyroid dysfunction.
Majority patients belonged to age group between 41-50 years (45.9%) followed by age group of 31-40 years (34.1%). 12 patients belonged to age group 21-30 years. Least common age group was 15-20 years (5.9%).      Similar results were obtained in various other studies also. The most common parity group in our study was found to be P2-P4 with 65.9% of the patients. Second most common group was P1L1 with 14.6% of the patients. The commonest menstrual irregularity in the study was menorrhagia with 47 patients (55.3%). 14 patients (16.5%) came to the OPD with complaints of oligomenorrhea. 7 patients (8.2%) came with complaints of polymenorrhea and 7 (8.2%) with menorrhagia. 10 patients (11.8%) of patients had irregular bleeding pattern.
Nearly similar results were obtained in other studies also-Shapely in his study found 41% patients to have menorrhagia and 36% presented with polymenoorhea. 7   In the present study, 2 (40%) of the hyperthyroid patients had oligomenorrhea, 2 (40%) had menorrhagia and 1 (10%) patient with irregular bleeding pattern. Discussing the treatment modalities, in a study conducted by Rosenfeld, mennorhagia was cured and did not recur in all patients with early hypothyroidism to whom Lthyroxine was given, with decline in TSH levels and rise in T3, T4 levels.

CONCLUSION
Prevalence of hypothyroidism was more common than hyperthyroidism in AUB cases Thyroid dysfunction is associated with menstrual disturbances which can get relieved with normalization of thyroid status, so thyroid assessment should be performed in all patients with menstrual irregularities. The menstrual abnormalities most commonly seen are menorrhagia, oligomenorrhea, polymenorrhoea and in majority of the cases menstrual irregularity precedes the occurrence of other clinical symptoms of thyroid dysfunction. Therefore, we summarize that any type of menstrual disorder should be considered as a possible presenting symptom of thyroid dysfunction and it may even indicate subclinical abnormality. These patients with thyroid abnormalities, if given medical line of management, it is possible to avoid unnecessary hormonal treatment and costly surgical interventions.