Aijrfans17 306 by IASIR

American International Journal of Research in Formal, Applied & Natural Sciences

Available online at http://www.iasir.net

ISSN (Print): 2328-3777, ISSN (Online): 2328-3785, ISSN (CD-ROM): 2328-3793 AIJRFANS is a refereed, indexed, peer-reviewed, multidisciplinary and open access journal published by International Association of Scientific Innovation and Research (IASIR), USA (An Association Unifying the Sciences, Engineering, and Applied Research)

Histopathological study of endometrium in abnormal uterine bleeding Dr. Kiran Rawat1, Dr. Narendra Rawat2*, Dr. Navgeet Mathur3, Dr. Medha Mathur 4 Associate professor, Department of Pathology, Dr. S. N. Medical College, Jodhpur, Rajasthan, India. 2* Professor, Department of General Medicine, Dr. S. N. Medical College, Jodhpur, Rajasthan, India. 3 Senior Resident, Department of General Medicine, Dr. S. N. Medical College, Jodhpur, Rajasthan, India. 4 Senior Resident, Department of Community Medicine and Family Medicine, A.I.I.M.S., Jodhpur, Rajasthan, India. 1

Abstract Background: Abnormal uterine bleeding is one of the most common and challenging problems presenting as an enigma to the gynecologist regardless of the age of the women. The main aim was to study the frequency of different histopathological patterns of endometrium in patients with abnormal uterine bleeding. Objective: Histopathological study of endometrium in abnormal uterine bleeding. Material and Method: This study was conducted on 306 patients from January 2016 to 15 May 2016 in the department of pathology. Endometrial samples were examined and different endometrial patterns were noted. Results: Abnormal Uterine Bleeding (AUB) presented mostly in the 41-50 years of age. The commonest histopathological pattern in abnormal uterine bleeding was normal physiological changes of menstrual cycle’s proliferative phase (29.5%). Endometrial hyperplasia was the most common endometrial pathology observed in 6.2% patients. Conclusion: Endometrial evaluation in abnormal uterine bleeding helps in early detection of pre-neoplastic conditions and malignancy to provide early treatment and avoid further complications. Keywords: Abnormal uterine bleeding, Biopsy, Endometrium. I. Introduction Abnormal uterine bleeding (AUB) is defined as a bleeding pattern that differs in frequency, duration and amount from a pattern observed during a normal menstrual cycle [1]. It has a negative impact on women’s health and wellbeing including anaemia, absenteeism and social embarrassment. Abnormal uterine bleeding can be caused by a wide variety of disorders such as pregnancy complications, medications, systemic conditions and genital tract pathology. The International Federation of Gynaecology and Obstetrics in November 2010, accepted a new classification system for causes of abnormal uterine bleeding in the reproductive years. The system, based on the acronym PALM-COEIN (polyps, adenomyosis, leiomyoma, malignancy and hyperplasia–coagulopathy, ovulatory disorders, endometrial causes, iatrogenic, not classified) [2]. This study was done to determine the histopathological pattern of endometrium in women presenting with AUB. II. Material and Methods This study was carried out in the department of pathology from January 2017 to 15 May 2017. The study materials included a total number of 306 cases of endometrial sample (endometrial curettage and biopsy) of clinically diagnosed AUB patients. The specimens were received and processed in automated tissue processor. Clinical informations were obtained from the requisition forms. The sections were stained with Hematoxylin and Eosin stain. Microscopic examination was done by two pathologists, individually to reduce observer bias. III. Results Three hundred six samples of endometrium obtained from patients suffering from AUB were included in the present study. Age of the patients ranged from 16 - 78 years with a mean of 37.5 years. The age wise distribution of the study population showed that highest incidence of AUB (n=110 , 35.9%) was found in 41-50 years of age group. Followed by 93 (30.3%) cases in 21-30 years of age group while least number of patients were seen in the 71-80 years of age group (n=2, 0.65%). (Table -1) AGE GROUP (YEARS) UNDER 20YEARS 21 – 30 31 – 40 41 – 50 51 – 60 61 – 70 71 – 80 TOTAL

NO. OF CASES 15 93 67 110 16 03 02 306

PERCENTAGE (%) 4.9 30.3 21.8 35.9 5.2 0.98 0.65 100

Table –1: Age distribution of patients with abnormal uterine bleeding.

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Endometrium revealed various patterns on histopathology. Histopathological examination showed proliferative endometrium as the predominant finding in 90 (29.4%) cases followed by secretory endometrium in 61 (19.9%) cases. Disordered proliferative pattern and atrophic endometrium were seen in 29 (9.4%) cases and 13 (4.2%) cases respectively. Pregnancy related bleeding was seen in 77cases (15.3%) in the present study, 70 patients of which were of retained products of conceptions and 7 were of hydatidiform mole. Endometrial hyperplasia was seen in 19 (6.2%) cases. Chronic endometritis was present in 5(1.6%) cases and endometrial polyps were the cause of bleeding in 4 (1.3%) cases. Frequency of malignancy was low and was detected in 3 (0.98%) cases. Leutel phase defect and irregular shedding of endometrium were seen in 0.98% and 0.65% cases respectively. (Table 2) PATHOLOGY OF ENDOMETRIUM PROLIFERATIVE DISORDERSD PROLIFERATIVE PHASE SECRETORY ATROPHIC SIMPLE ENDOMETRIAL HYPERPLASIA COMPLEX ENDOMETRIAL HYPERPLASIA RETAINED PRODUCTS OF CONCEPTION VESICULAR MOLE ENDOMETRITIS ENDOMETRIAL POLYP LEUTEAL PHASE DEFECT IRREGULAR MALIGNANCY TOTAL

NO. OF CASES 90 29 61 13 18 01 70 07 05 04 03 02 03 306

PERCENTAGE (%) 29.4 9.4 19.9 4.2 5.8 0.326 22.8 2.28 1.6 1.3 0.98 0.65 0.98 100

Table-2: Results of histopathological examination of endometrium in patients with abnormal uterine bleeding. IV. Discussion Endometrium is a dynamic, hormonally sensitive and responsive tissue, which constantly and rhythmically undergoes changes in the active reproductive life. It is a sensitive bioassay for estrogen and progesterone, whose actions are mediated on specific receptors [3]. Our study significantly revealed that the occurrence of menstrual disorders increases with advancing age. Excessive bleeding was commonly noticed in the 41–50 years age. A similar incidence was reported by Singh A et al [4]. The commonest endometrial pattern in our study was normal physiological phases of endometrium i.e. proliferative endometrium in 29% cases and secretory endometrium in 19.9% cases. Desai k et al [5] observed similar findings accounting for 29% and 20% respectively. The bleeding in the proliferative phase may be due to anovulatory cycles and bleeding in the secretory phase is due to ovulatory dysfunctional uterine bleeding. Endometrial hyperplasia was the most common pathology encountered (both simple and complex) in 19 cases (6.2%). Similar observations (5.79%) found in a study by Jairajpuri et al [6]. Studies done by Dangal G [7], Slobada L [8] and Khare et al [9] found endometrial hyperplasia in 23%, 22.6% and 36.2% cases respectively which were higher than our study. Identification of endometrial hyperplasia is important because they are thought to be precursors of endometrial carcinoma. In the present study 4 (1.3%) cases of endometrial polyps were observed. Jairajpuri ZS [6] et al observed similar findings accounting 1.7% cases. Chronic endometritis in our study was in 5 (1.6% )cases, which was similar to the study done by Singh A et al (1.6%) [4]. Diagnose of chronic endometritis is very important because with appropriate antimicrobial therapy, the symptoms of these patients can improve [10]. In present study mean age for endometrial carcinoma was 63 years shows the incidence of endometrial cancer increases with age. The incidence of endometrial carcinoma in the present study was 0.98%. Bolde SA et al [11] found 1.49% incidence. A significant number of cases showed disordered proliferative pattern in this study. The term “disordered proliferative endometrium” has been used in a number of ways and is somewhat difficult to define. It denotes an endometrial appearance that is hyperplastic but without an increase in endometrial volume [12]. It also refers to a proliferative phase endometrium that does not seem appropriate for any one time in the menstrual cycle, but is not abnormal enough to be considered hyperplastic. Disordered proliferative pattern resembles a simple hyperplasia, but the process is focal rather than diffuse. Disordered proliferative pattern in this study was in 29 cases (9.4%) while in the literature its incidence varies from 5.7% to 20.54% [6,13,14]. Cases diagnosed as complications of pregnancy were common in the age group of 16–35 years. Pregnancy related bleeding was seen in 77 (15.3%) cases, similar findings were reported by Jairajpuri ZS et al [6]. Atrophic endometrium comprised in 13 (4.2%) cases of AUB. Incidence of atrophic endometrium in post menopausal patients varies from 4.34% 36.2% [15,16]. Thin walled veins, superficial to the expanding cystic glands make the vessels vulnerable to injury and lead to excessive uterine bleeding. V. Conclusion Histopathological examination of endometrial biopsy in patients with abnormal uterine bleeding showed a wide spectrum of changes ranging from normal endometrium to malignancy. Endometrial evaluation in abnormal

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uterine bleeding is recommended to rule out pre-neoplastic conditions and malignancy to provide early treatment and avoid further complications. References [1]. [2]. [3]. [4]. [5]. [6]. [7]. [8]. [9]. [10]. [11]. [12]. [13]. [14]. [15]. [16].

Wahada Moohmad Taib Al-Neaimy, Manal Thanoon Ahmed, Safwan I. Al-Jawadi. Histopathological interpretation of Abnormal uterine bleeding after the age of 40 years. Iraqi Postgrad Med J. 2010;9(3):274-82. Munro GM, Critchley ODH, Fraser SI. The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years: who needs them? AJOG. 2012;207(4):259-65. Blaustein A. Pathology of the female genital tract. New York: Springer-Verlag; 1994;2:279-31. Singh A, Bai RPV. Study of histopathological pattern of endometrium in abnormal uterine bleeding and its management. Int J Reprod Contracept Obstet Gynecol. 2016;5:432-6. Kairavi Desai, Kiran P. Patole and Manasi Kathaley. Endometrial Evaluation by Histopathology in Abnormal Uterine Bleeding in Perimenopausal and Postmenopausal Patients. MVP Journal of Medical Sciences. 2014;1(2):75–79. Jairajpuri ZS, Rana S, Jetley S. Atypical uterine bleeding- Histopathological audit of endometrium - A study of 638 cases. Al Ameen J Med Sci. 2013; 6(1): 21-8. Dangal G. A study of endometrium in patients with abnormal uterine bleeding at Chitwan valley. Kathmandu University Medical Journal. 2003;1(2):110-2. Sloboda L, Molnar E, Popovic Z, Zivkovic S. Analysis of pathohistological results from the uterine mucosa 1965-98 at the gynecology department in Senta. Med Pregl. 1999;52(6-8):263-5. Khare A. Morphological spectrum of endometrium in patients presenting with dysfunctional uterine bleeding. Peoples’s Journal of scientific research. 2012;5(2):13-6. Vasudeva K, Thrasher TV, Richart RM. Chronic endometritis: a clinical and electron microscopic study. Am J Obstet Gynaecol. 1972;112(6):749-58. Saroj A. Bolde, Smita S. Pudale*, Gopal A. Pandit, Pushkar P. Matkari. Histopathological study of endometrium in cases of abnormal uterine bleeding. International Journal of Research in Medical Sciences. 2014;2(4):1378-1381. Silverberg SG.. Problems in the differential diagnosis of endometrial hyperplasia and carcinoma. Mod Pathol. 2000;13(3): 309327. Doraiswami S, Johnson T, Rao S et al. Study of Endometrial Pathology in Abnormal Uterine Bleeding. J Obstet Gynecol India. 2011; 61: 426-30. Abdullah LS, Bondagji NS. Histopathological Pattern of Endometrial Sampling Performed for Abnormal Uterine Bleeding. Bahrain Med Bull. 2011; 33: 1-6. Cornitescu FI, Tănase F, Simionescu C, Iliescu D. Clinical, histopathological and therapeutic considerations in non-neoplastic abnormal uterine bleeding in menopause transition. Rom J Morphol Embryol. 2011;52:759-65. Devi J, Aziz N. Study of “histopathological pattern of endometrium in abnormal Uterine bleeding in the age group 40-60 years –a study of 500 cases”. International journal of medical science and clinical inventions. 2014;1(10): 579-585.

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