European Journal of Cardiovascular Medicine

Abnormal uterine bleeding (AUB) refers to any bleeding that deviates from the normal parameters of volume, frequency, duration, and cyclicity.  AUB is a prevalent occurrence in the Gynaecology outpatient department (1). Approximately one-third of hysterectomies are performed just for menstrual abnormalities, with thyroid dysfunction being a significant contributor to these disturbances.  Both hyperthyroidism and hypothyroidism can cause menstrual irregularities (2).  Hypothyroidism typically results in menorrhagia, whereas hyperthyroidism leads to oligomenorrhea.  Consequently, recognising the incidence of thyroid diseases in individuals presenting with abnormal uterine bleeding (AUB), the menstrual patterns linked to various thyroid disorders, and their corresponding endometrial histological findings is essential for the effective therapy of AUB.  The thyroid function test (TFT) is a cost-effective and readily accessible examination that can uncover a possibly curable cause of abnormal uterine bleeding (AUB), hence preventing unneeded procedures such as hormone therapy and hysterectomy (3).  An endometrial biopsy is performed when medical therapy is ineffective or when the patient presents with a thicker endometrium and/or possesses risk indicators for endometrial cancer (4).  Multiple techniques exist for endometrial sampling, such as dilatation and curettage (D&C), endometrial biopsy, hysteroscopy-guided endometrial biopsy, and Pipelle aspiration. Pipelle aspiration is regarded as a safe and straightforward alternative to dilation and curettage (D&C), functioning as an outpatient operation with satisfactory diagnostic accuracy (5). The assessment of endometrial biopsies aids in determining the aetiology of abnormal uterine bleeding (AUB) and facilitates suitable treatment, thereby diminishing the necessity for difficulties linked to hysterectomies (6). This study seeks to identify the range of endometrial diseases in patients of various age groups presenting with abnormal uterine bleeding (AUB).

This is a retrospective study. It includes one year from July 2024 to December 2024 at World College of Medical Sciences Research and Hospital, Jhajjar.

Inclusion Criteria: All the endometrial biopsies sent for histopathological evaluation to the Pathology Department with a history of abnormal uterine bleeding were included in the study.

Exclusion Criteria: Biopsies without adequate clinical history were not available were excluded from the study.

The endometrial specimens were preserved in 10% formalin for 12-24 hours, and patient clinical information was acquired from the requisition forms and medical records.  The complete tissue specimen was collected for standard processing.  Sections of 5μm thickness obtained from paraffin blocks were stained with Haematoxylin and Eosin (H&E) and examined using light microscopy.  The patients' ages were classified into reproductive (21-30 years), peri-menopausal (41-50 years), and postmenopausal (>70 years) categories.  The histological findings of abnormal uterine bleeding were classified into functional and organic aetiologies.  This study identified the functional reasons of abnormal uterine bleeding (AUB) as the normal cyclical stages of the endometrium (proliferative and secretory) and several pathological physiological alterations in the endometrium (atrophic endometrium, disordered proliferative endometrium, and pill endometrium).  In this study, the organic intrauterine lesions responsible for abnormal uterine bleeding (AUB) comprise endometrial hyperplasia, both atypical and non-atypical, polyps, and endometrial cancer (7).

This study analysed 110 endometrial biopsy samples from women with abnormal uterine bleeding (AUB).  The 110 cases of AUB were classified into six age categories, with the majority occurring in the 41-50 years group (40 cases, 36.40%), followed by the 51-60 years group (33 cases, 30%) and the 31-40 years group (22 cases, 20%).  Table 1 indicates the highest occurrence within the perimenopausal age demographic.  The predominant bleeding pattern was menorrhagia (31.81%), followed by metrorrhagia (22.7%), polymenorrhea (18.2%), oligomenorrhea (13.7%), post-menopausal haemorrhage (9.09%), and intermenstrual bleeding (4.5%), as illustrated in Table 2 and Figure 1.  The predominant histological finding was disorganised proliferative endometrium, succeeded by proliferative endometrium and secretory phase endometrium. A minor number of cases exhibited atypical hyperplasia and endometrial cancer, as illustrated in Table 3.  Clinico-pathological correlation indicated strong relationships between age group and the kind of endometrial disease, as illustrated in Table 4, with sample images of the histological findings presented in Figure 2.

Figure 1- Bleeding pattern of AUB

Table 1: Age-wise Distribution of Patients with AUB

Table 2: Distribution of AUB Patterns Among Patients

Table 3: Histopathological Patterns in Endometrial Biopsies

Table 4: Histopathological patterns according to age group (n=110)

Figure 2- H&E images of Spectrum of Endometrial changes

a-Secretory endometrium, b- Pill endometrium, c- Atrophic endometrium, d- Disordered proliferative endometrium, e- Polyp, f- Endometrial carcinoma.

AUB is the most common presenting condition among gynaecology outpatients, and endometrial samples from these cases are routinely submitted to histopathology.  The histological evaluation of the endometrium is notably subjective and presents significant challenges for the reporting pathologist, owing to its dynamic cyclical alterations and diverse histomorphological patterns in reaction to hormonal influences.  The pathologist is crucial for the early identification of endometrial precursor lesions and the differentiation of cancer.  Abnormal uterine bleeding denotes excessive and irregular uterine bleeding that fails to meet the requirements for normal monthly bleeding, resulting from reproductive, iatrogenic, and systemic factors.

In our analysis of 110 cases, the highest incidence occurs in the perimenopausal age group of 41-50 years (40 cases, 36.40%), followed by the menopausal age group of 51-60 years (33 instances, 30%).  This aligns with other research by Ishani Gupta et al. (40.4%) and Sharma K et al. (37.26%).  In our study, patients exhibited various forms of abnormal uterine bleeding (AUB), with menorrhagia being the most prevalent pattern found at 36.8%.  The women in this demographic were experiencing climacteric changes.  This period is characterised by a reduction in oestradiol levels and ovarian follicle count, leading to anovulatory cycles (9&10). The present study identified a significant proportion of individuals exhibiting a disordered proliferative pattern, peaking in the 41-50 years age group (20.90%), comparable to the findings of Vaidya S et al. (51.8%) (11).  The histological characteristics of the disorganised proliferative phase exhibit similarities to simple hyperplasia; however, the process is more localised than widespread.  The heightened prevalence of dysfunctional uterine haemorrhage in the 41–50 age group may be attributed to their climacteric phase, marked by diminished ovarian reserve, sporadic anovulatory cycles, and reduced oestrogen levels.

 Proliferative endometrium was the second most prevalent endometrial pattern observed in 18 patients (16.38%), comparable to the findings of Rajesh Patil et al (22.1%) and Bhoomika Dadhania et al (21.33%).  The secretory endometrial pattern was seen in 14 individuals, constituting 12.72% of cases, aligning with the findings of Pilli et al (13%).  Abnormal bleeding during the proliferative phase may come from hormonal imbalances causing anovulatory cycles, whereas abnormal uterine bleeding in the secretory phase can stem from ovulatory dysfunction, such as the absence of an LH surge (12).

Endometrial hyperplasia is characterised by an increased proliferation of the endometrial glands relative to the stroma, leading to an elevated gland-to-stroma ratio.  The recent WHO classification categorises endometrial hyperplasia into non-atypical and atypical forms, highlighting the prognostic significance of this classification, as atypical hyperplasia presents a heightened risk of malignant development.  The diagnosis of endometrial hyperplasia is crucial as it serves as a precursor to endometrial cancer.  Unopposed oestrogen exposure to the endometrium results in endometrial hyperplasia.  Our analysis indicates an observation in 10.90% of cases.  Vaidya et al. and Khan et al. reported rates of 10.9% and 12.6%, respectively, in their studies (11 & 13).

Atrophic endometrium was identified in 8 cases of abnormal uterine bleeding (7.30%), predominantly in the 41-50 and 51-60 age cohorts in our investigation.  This aligns with the findings of More S et al (2%) and Vaidya et al (4.7%).  Post-menopausal bleeding is often linked to an atrophic endometrium.  The precise aetiology of haemorrhage from the atrophic endometrium remains unidentified.  It is hypothesised to result from sclerotic degeneration of the vascular wall or localised aberrant haemostatic processes (11&14).

Prolonged oestrogen stimulation leads to the development of an endometrial polyp.  The incidence of benign endometrial polyps in our study was 9.10% (10), which is comparable to Silander's finding of 6.66% (18).  Azim et al. reported a higher prevalence of polyps with increasing age, specifically 5%, 8%, and 11% in the reproductive, perimenopausal, and postmenopausal age groups, respectively (15&16).  Polyp is the second most common pathology following hormonal imbalance patterns; however, it is not considered a significant risk factor for carcinoma development.  Additionally, endometrial polyp emerged as the predominant pathology among postmenopausal women in our study.

 Endometrial carcinoma may arise from excessive oestrogenic stimulation and can develop in the context of endometrial hyperplasia or de novo.  It predominantly occurs in postmenopausal women and is characterised by bleeding.  Our study identified 5 cases (4.50%) of endometrial carcinoma, all occurring in postmenopausal women.  The incidence aligns with findings from other studies, including More S et al (1.98%), Vaidya S et al (2.5%), and Baral R et al (1.0%).  (14, 11, 17).

AUB significantly affects women's quality of life and leads to anaemia.  Endometrial sampling should be contemplated for individuals in the perimenopausal and postmenopausal age brackets, as well as for those of reproductive age who do not respond to medical intervention. Thus, histological investigation is essential for the early detection of endometrial pathology and facilitates optimal gynaecological therapy.

Abbreviations: AUB – abnormal uterine bleeding, DUB – dysfunctional uterine bleeding

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