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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 216-221

Spectrum of endometrial pathology in patients with abnormal uterine bleeding: a rural population experience


1 Department of Pathology & Lab Medicine, All India Institute of Medical Sciences (AIIMS) Bhopal, AIIMS Campus, Bhopal, Madhya Pradesh, India
2 Department of Radio-Diagnosis, City Maternity Charitable Hospital, Bhiwandi, Thane (District), Maharashtra, India
3 Department of Pediatrics, City Maternity Charitable Hospital, Bhiwandi, Thane (District), Maharashtra, India
4 Department of Obstetrics and Gynecology, City Maternity Charitable Hospital, Bhiwandi, Thane (District), Maharashtra, India

Date of Submission06-Jun-2021
Date of Acceptance18-Jun-2021
Date of Web Publication03-Sep-2021

Correspondence Address:
Dr. Abeer M Ilyas
Department of Pathology & Lab Medicine, All India Institute of Medical Sciences (AIIMS) Bhopal, AIIMS Campus, Saket Nagar, Bagh Swaniya, Bhopal 462020, Madhya Pradesh.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mgmj.mgmj_33_21

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  Abstract 

Introduction: Abnormal uterine bleeding (AUB) is one of the most common problems among women of all age groups. Endometrial sampling is a frequently performed procedure by the gynecologist that offers an opportunity to diagnose pathological conditions in the endometrium to accurately evaluate and diagnose the etiology. A study of the endometrium will establish the underlying cause and thereafter help the gynecologist to plan for the management. Aims: To study the histopathological pattern and spectrum of lesions in a patient with AUB. To analyze various pathological conditions and to highlight the importance of endometrial histology. Materials and Methods: This is a retrospective study that evaluated 83 patients with AUB by dilatation and curettage and/or endometrial biopsy of the rural population. Results: The most common endometrial pattern found to be hyperplasia without atypia (19/83) 22.9% followed by disordered proliferative (17/83) 19.27% and later by endometrial polyp (8/83) 9.63%, atypical hyperplasia/endometrioid intraepithelial neoplasia (1/83) 1.2% and lastly one case each of chronic non-specific endometritis, tuberculous endometritis, and histiocytic endometritis. There were 2/83 that is 2.4% case of endometrial adenocarcinoma with age range falling between above 50 years. Conclusion: Endometrial biopsy or curettage could be a safe and effective diagnostic step in the evaluation of AUB after ruling out medical causes with a detailed workup of the patient. This could help the clinician to design therapy for successful management.

Keywords: Abnormal uterine bleeding, endometrial pattern, endometrial polyp, endometrium, inadequate proliferative phase, tuberculousendometritis


How to cite this article:
Ilyas AM, Ilyas MA, Ilyas AM, Pasha SK, Kumar A. Spectrum of endometrial pathology in patients with abnormal uterine bleeding: a rural population experience. MGM J Med Sci 2021;8:216-21

How to cite this URL:
Ilyas AM, Ilyas MA, Ilyas AM, Pasha SK, Kumar A. Spectrum of endometrial pathology in patients with abnormal uterine bleeding: a rural population experience. MGM J Med Sci [serial online] 2021 [cited 2021 Sep 21];8:216-21. Available from: http://www.mgmjms.com/text.asp?2021/8/3/216/325541




  Introduction Top


Abnormal uterine bleeding (AUB) is one of the most common problems among women of all age groups. It is defined as bleeding that differs in the amount or timing from a woman’s usual menstrual flow.[1] Virtually, every woman will at some point in her lifetime experience episodes of bleeding that are perceived as abnormal. Menstrual abnormalities are the cause of the discomfort, inconvenience, and disruption of healthy social and physical lifestyles among millions of women worldwide.[2]

Endometrial curettage and biopsy sample are among the most frequent tissue specimens encountered in the daily clinical practice of most pathologists. Major indications for endometrial biopsy/curettage include AUB, retained products of conception, and monitoring patients undergoing exogenous hormonal therapy. AUB is diagnosed after the exclusion of pregnancy or pregnancy-related disorders, medications, iatrogenic causes, obvious genital tract pathology, and systemic conditions.[3]

Endometrial sampling is a frequently performed procedure by the gynecologist that offers an opportunity to diagnose pathological conditions in the endometrium, but a relevant clinical history is also mandatory for a pathologist to accurately evaluate and diagnose the etiology of AUB. Papanicolaou smear is recognized as the most effective tool that the gynecologist has for screening cervical disease. However, cytologic methods are not as reliable in detecting disorders of the endometrium.

In low-resource countries, endometrial sampling is performed less frequently and the procedure is usually performed without hysteroscopy guidance. The tendency to discard curettage samples—especially those obtained after spontaneous abortion—is high because many patients are unable to afford the extra cost of histopathological analysis. An endometrial biopsy may be recommended for women with abnormal menstrual bleeding, bleeding after menopause, or absence of uterine bleeding. Biopsy results may indicate cell changes related to hormone levels, or the presence of abnormal tissues, such as fibroids or polyps, which can lead to abnormal bleeding. An endometrial biopsy may also be used to check for uterine infections, such as endometritis.[4] A study of the endometrium will help establish the underlying cause and thereafter help the gynecologist to plan for management.

In our study, we tried to analyze the spectrum of endometrial patterns and to find out the explicit pathology in different age groups at a low-resource hospital.

Aims and objectives

  • To study the spectrum of lesions of the endometrium in various age groups.


  • To analyze various pathological diseases.


  • To highlight the importance of endometrial histology.



  •   Materials and methods Top


    This is a retrospective study. It includes two years from January 2017 till December 2018 at a low-resource charitable women and children hospital. It comprises mainly the rural population who were referred from district-run primary health centers. The histopathology slides were retrieved from the archives of the histopathology section at the hospital, and the slides were reviewed. It comprises 83 patients who presented with AUB and underwent the procedure of dilatation and curettage. The study includes all female patients, that is, the reproductive, premenopausal, and postmenopausal group with symptoms of AUB.

    Limited clinical data of the study subjects were received along with samples of the endometrial tissue obtained by dilatation and curettage. Preparation of tissue samples for microscopic examination by a series of processes, namely fixation, dehydration, clearing, embedding, cutting, and staining of the tissue sections with hematoxylin and eosin stain, was done. The histopathological criteria for diagnosis were selected from a textbook titled Gynecologic Pathology, 2nd edition,[5] and New Classification System of Endometrial Hyperplasia[6] [Table 1].
    Table 1: Histopathology criteria for sample selection

    Click here to view


    Inclusion criteria

    All patients in the reproductive, perimenopausal, and postmenopausal groups presenting with AUB.

    Exclusion criteria

    Patients presenting with AUB due to non-endometrial causes, such as lesions of the myometrium and adnexa.[2]


      Results Top


    A total number of 83 cases were enrolled in the study. These were women with secluded endometrial pathology that acted as a cause of AUB. The age of the patients ranged from 21 to 65 years, with the mean age being 43 years. The predominant pattern of endometrial histology noted was normal cyclic, which was closely followed by a disordered pattern.

    [Table 2] illustrates the distribution of percentage and the total number of cases according to histopathology diagnosis and the distribution of cases according to pathology, respectively. The normal cyclic endometrial pattern observed was inadequate proliferative endometrium (17/83, 20.48%), followed by an equal number of late secretory phase and secretory phase (2/83, 2.4%). Overall, 10/83 (12.04%) cases showed decidualization of the endometrium, which is evidence of exogenous hormone therapy.
    Table 2: Distribution of cases of AUB according to pathology

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    The most common “abnormal endometrial pattern” found to be disordered proliferative [Figure 1] (17/83) 19.27% and hyperplasia without atypia [Figure 2] (19/83) 22.9% followed by endometrial polyp (8/83) 9.63%, atypical hyperplasia/endometrioid intraepithelial neoplasia [Figure 3] (1/83) 1.2%. Finally, one case each of chronic non-specific endometritis, tuberculous endometritis, and histiocytic endometritis. It was observed that 2 out of 83 cases (2.4%) of endometrial adenocarcinoma (FIGO Grade I) fell within the age range above 50 years. On three cases of diseased individuals [Table 3], no conclusive opinion could be framed.
    Figure 1: Disordered proliferative: broken glands, areas of hemorrhage, and thin-walled thrombosed vessels, H&E 100×

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    Figure 2: Hyperplasia without atypia: increased gland-to-stroma ratio, closely compacted glands, minimal intervening stroma, H&E 100×

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    Figure 3: Atypical hyperplasia/endometrioid intraepithelial neoplasia: increased gland-to-stroma ratio, closely compacted glands, minimal intervening stroma. Epithelial cells show loss of polarity, enlarged, rounded with coarse chromatin, H&E 100×

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    Table 3: Distribution of AUB according to different age groups

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      Discussion Top


    The term “AUB” implies any bleeding that falls outside the definition of normal physiological menstrual bleeding. It can occur due to structural causes inside the uterine cavity or functional causes due to hormonal imbalance.[1] Initially, routine noninvasive investigations are observed, such as complete blood count, prothrombin time (PT), activated partial thromboplastin time (APTT), and liver function test, to rule out any bleeding or coagulation disorder. Although AUB does not cause medical emergencies, the prevalence of primary coagulation disorder in adolescents requiring hospitalization ranges from 3% to 20%, hence it is mandatory to rule out coagulopathy in all adolescents with menorrhagia.[7]

    Some additional investigations are performed for women of the reproductive age group, such as urine human chorionic gonadotropin (HCG) levels, to rule out pregnancy. Thyroid function tests, follicle-stimulating hormone, luteinizing hormone, prolactin, and androgen levels are assessed to rule out any endocrine disorder. Lastly, imaging studies are performed along with transvaginal tissue sampling or dilation and curettage.

    The youngest patient in our study was a 21-year-old female, and the oldest was a 65-year-old lady. The prevalence increase in AUB increases with age and peaks during the perimenopausal phase. In our study, the most number of patients belong to the perimenopausal age group (54%) than the reproductive age group (46%). A similar result was reported by Doraiswami, et al.[8] and Vaidya, et al.[9] in their study of endometrium pathology. In our study, cases with disordered proliferation more commonly acquired the age group between 35 and 50 years, which is comparable to a study by Muzaffar, et al.[10] This possible reason may be as this age group belong to their climacteric period.

    The incidence of AUB in women older than 50 years was lower compared with other age groups. This may be the verity that endometrial stimulus declines with declining hormonal levels. There were two cases (2.4%) of endometrial carcinoma in this age group; these results are in close concordance with the study by Singh and RamanaBai[11] and Ghani, et al.,[12] in which their results were 1% and 2%, respectively. Hence, caution should be applied while dealing with bleeding in this age group.

    The most common histological pattern encountered in our study was the inadequate proliferative endometrium (20.48%). Our findings were in concordance with a similar result by Singh and RamanaBai.[11] Usually, the endometrium shows proliferative features during the first half of a normal cycle. When these features are seen in the second half of the cycle, it indicates an ovulation.[1] This also shows that there is a climbing frequency of infertility due to the anovulatory cycle, one of the signs of polycystic ovarian disease.[13]

    In addition, our study detected 8/83 (9.63%) endometrial polyp [Figure 4] cases; all were hyperplastic polyps. Histomorphological features indicated the benign proliferation of the glandular component with thick-walled blood vessels without atypia. This reflects the increased estrogen secretions that result in hyperplasia of the basal endometrial layer. A total of three cases of endometritis were detected: One case showed caseating granuloma with epithelioid cells, was diagnosed as “tuberculous endometritis,” and was confirmed by Ziehl-Neelsen stain. In their study, Kumar and Sharma[14] reported that besides infertility menstrual symptoms such as puberty menorrhagia, heavy menstrual bleeding (in early stage), postmenopausal bleeding, oligomenorrhea, dysmenorrhea, and amenorrhea should also be considered as presenting symptoms in cases of female genital tuberculosis.
    Figure 4: Endometrial polyp: highly thick vessels and relatively fewer glands, H&E 40×

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    We had a report (12.04%) of 10 cases younger than the age of 50 years with clinical notes on their requisition, stating that they were on exogenous hormone administration, for treatment of AUB; this was evident on the slide showing histological features of decidualization. A similar study by Jetley, et al.[15] highlights a similar pattern.

    In three cases, the endometrial sample was scanty; therefore, a diagnostic opinion was not possible. A study was carried out by Harmanli, et al.[16] that evaluated the negative predictive value of endometrial samples that were regarded as inadequate for diagnosing endometrial hyperplasia or malignancy. The study suggests that an inadequate sample may be sufficient to rule out endometrial hyperplasia and malignancy because of its high negative predictive value.


      Conclusion Top


    AUB is a common reason for women of all ages to consult their gynecologists. It includes both organic and nonorganic causes of uterine bleeding. Endometrial biopsy or curettage could be a safe and effective diagnostic step in the evaluation of AUB after ruling out medical causes with a detailed workup of the patient. This could help the clinician to design therapy for the successful management.

    This study was done to evaluate the endometrial causes of AUB and to determine the specific pathology in different age groups of the rural population at a low-resource charitable hospital. We concluded that most cases with AUB belong to the reproductive and perimenopausal age group. The premenopausal and postmenopausal age group was more prone to atypical hyperplasia and carcinoma, hence highlighting the importance of endometrial biopsy/curettage for the early detection of such premalignant lesions.

    The limitations of this study are its retrospective design and small sample size, which may affect the significance of this study.

    Ethical consideration

    The ethical approval has been granted by the City Maternity Charitable Hospital and Research Ethics Committee vide their letter dated October 6, 2016.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

    1.
    Ayers DMM, Lappin JES, Liptok LM. Abnormal vs. dysfunctional uterine bleeding: What’s the difference? Nursing 2004;34:11-4.  Back to cited text no. 1
        
    2.
    Mulay PS, Rama S, Deshpande SA. Histopathological spectrum of endometrium in perimenopausal and postmenopausal women in a tertiary care center. J Med Sci Clin Res 2019;07:116-23.  Back to cited text no. 2
        
    3.
    Albers JR, Hull SK, Wesley RM. Abnormal uterine bleeding. Am Fam Physician 2004;69:1915-26.  Back to cited text no. 3
        
    4.
    Medical Health and Research Trust. Endometrial biopsy. Available from: http://drroyarozatimhrt.com/endometrial-biopsy/. [Last accessed on May 25, 2021].  Back to cited text no. 4
        
    5.
    Nucci M. Gynecologic Pathology. 2nd ed. Parra-Herran C, editor. A Volume in Foundations in Diagnostic Pathology Series. Edinburgh, London: Elsevier; 2019. p. 1040.  Back to cited text no. 5
        
    6.
    Emons G, Beckmann MW, Schmidt D, Mallmann P; Uterus Commission of the Gynecological Oncology Working Group (AGO). New WHO classification of endometrial hyperplasias. Geburtshilfe Frauenheilkd 2015;75:135-6.  Back to cited text no. 6
        
    7.
    Shankar M, Lee CA, Sabin CA, Economides DL, Kadir RA. von Willebrand disease in women with menorrhagia: A systematic review. BJOG 2004;111:734-40.  Back to cited text no. 7
        
    8.
    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.  Back to cited text no. 8
        
    9.
    Vaidya S, Lakhey M, Vaidya S, Sharma PK, Hirachand S, Lama S, et al. Histopathological pattern of abnormal uterine bleeding in endometrial biopsies. Nepal Med Coll J 2013;15:74-7.  Back to cited text no. 9
        
    10.
    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.  Back to cited text no. 10
        
    11.
    Singh A, RamanaBai PV. Study of histopathological pattern of endometrium in abnormal uterine bleeding and its management. Int J Reprod Contracept Obstet Gynecol 2016;5:432-6.  Back to cited text no. 11
        
    12.
    Ghani NA, Abdulrazak AA, Abdulla EM. Abnormal uterine bleeding—A histopathological study. J Pathol Res 2014;3:68-70.  Back to cited text no. 12
        
    13.
    Burgers JA, Fong SL, Louwers YV, Valkenburg O, de Jong FH, Fauser BC, et al. Oligoovulatory and anovulatory cycles in women with polycystic ovary syndrome (PCOS): What’s the difference? J Clin Endocrinol Metab 2010;95:E485-9.  Back to cited text no. 13
        
    14.
    Kumar S, Sharma JB. Female genital tuberculosis. In: Sharma SK, Mohan A, editors. Tuberculosis. 3rd ed. Delhi: Jaypee; 2015. p. 362-71.  Back to cited text no. 14
        
    15.
    Jetley S, Rana S, Jairajpuri ZS. Morphological spectrum of endometrial pathology in middle-aged women with atypical uterine bleeding: A study of 219 cases. J Midlife Health 2013;4: 216-20.  Back to cited text no. 15
        
    16.
    Harmanli OH, Shunmugham S, Shen T, Houck KL, Chatwani AJ. The negative predictive value of inadequate endometrial biopsy in diagnosing endometrial neoplasia. J Gynecol Surg 2004;20:13-6.  Back to cited text no. 16
        


        Figures

      [Figure 1], [Figure 2], [Figure 3], [Figure 4]
     
     
        Tables

      [Table 1], [Table 2], [Table 3]



     

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