Correlation of Transvaginal USG and Endometrial aspiration findings with various menstruation patterns and histopathological examination of Uterus

Background: Abnormal uterine bleeding (AUB) may be acute or chronic and is defined as bleeding from the uterine corpus that is abnormal in regularity, volume, frequency or duration and occurs in absence of pregnancy and it is a common manifestation of both benign & malignant diseases of the uterus. Material & Methods: This was a prospective study carried out in the department of Obstetrics & Gynecology, Rama Medical College, Mandhana Kanpur during the three-year period from July 2014 July 2017. A total of 106 patients who were willing to participate in the study and had given consent for endometrial aspiration followed by hysterectomy were enrolled for the study. Data were recorded with respect to sociodemographic characteristics, clinical ultrasound and histopathological findings of the study population. Result: Majority of cases of AUB were diagnosed with adenomyosis followed by fibroid. Though ultrasound diagnosis of adenomyosis and fibroid were missed in some cases but the endometrial aspiration correlated well with the histopathological findings on hysterectomized specimen. Conclusion: Every woman presenting with AUB more than 40 Years must undergo endometrial aspiration assessment prior to hysterectomy to rule out any underlying malignancy and every hysterectomy specimen should be sent for final histopathological diagnosis as it is necessary for confirmation of the diagnosis as well as proper management and counseling of the patients.


Introduction
Abnormal uterine bleeding (AUB) may be acute or chronic and is defined as bleeding from the uterine corpus that is abnormal in regularity, volume, frequency or duration and occurs in absence of pregnancy [1,2]. It is a clinical presentation of benign or malignant lesions of female genital tract and not a disease and accounts for more than 70% of all gynecological consultations in the peri and post-menopausal age group [3]. The terminologies like menorrhagia, polymenorrhea, polymenorrhagia, metrorrhagia and menometrorrhagia should be abandoned because of their controversial, confusion and poorly defined usage according to extensive international discussions and have been replaced by new definitions [4][5][6].
AUB can be due to innumerable causes in this perimenopausal age group and therefore the etiology have been grouped under the acronym PALM COIN as described by FIGO.
The present study was carried out with the aim a. To evaluate the various types of clinical presentations of AUB in peri and post menopausal age group.

Shortened menstrual bleeding:
menstrual bleeding of no longer than 2 days in duration which is usually light in volume and is uncommonly associatedwith serious pathology (such asintrauterine adhesions and endometrial tuberculosis).

Light menstrual bleeding:
Rarely related to pathology and is cultural complaint in communities where a heavy, ''red'' bleed is valued as a perceived sign of health.

Materials & Methods
This was a prospective observational study carried out in the department of Obstetrics & Gynecology, Rama Medical College, Mandhana Kanpur over a time period of 3 years duration from July 2014 to July 2017.
All the cases that presented with abnormal uterine bleeding & had given consent for endometrial aspiration followed by hysterectomy above the age of 40 years were reviewed for the important details pertaining to the study.
Data were recorded with respect to their age, parity, clinical presentation with USG findings. All these females underwent endometrial aspiration &followed by which these patients underwent hysterectomy by abdominal or vaginal route tissue and the tissue was sent to the pathology department for examination.
Histopathological reports of the hysterectomy specimens were co-related with USG & EA findings.

Inclusion criteria
 Patients>40 years with AUB.  Patients willing to undergo endometrial aspiration followed by hysterectomy if indicated.  Patients willing to participate in the study Exclusion criteria of patients willing to participate in the study- Patients with medical disorders  Patient <40 years  Patients with coagulopathy  Patients who did not give consent for the study

Results
Majority of the patients who presented with AUB were in the age group of 40-50 yrs with parity of ≥3 (Table1). Majority of the patients had HMB/HMPB accounting for 68.80%.92.45% of patients presented with heavy menstrual bleeding with duration of 3-6 months reflecting that AUB is a major concern to them as it hinders with their day to day activities and make them prone to anemia and its ill effects (Table 2).

Original Research Article
Obsgyne Review: Journal of Obstetrics and Gynecology Available online at: www.medresearch.in 73 |P a g e Majority of the patients who presented with HMB & HPMB had adenomyosis and fibroid respectively while out of 11 patients who had post menopausal bleeding, only 2 patients had endometrial cancer as the primary diagnosis (Table 3 &  Table 4) On transabdominal USG, 35 (33.0%) cases were diagnosed as adenomyosis, 28 (26.49%) cases had bulky uterus followed by 25 cases of fibroid uterus (Table 3). In the remaining 18 cases, the basic pathology was related to the endometrial lining of uterus i.e. 13 cases had thickened endometrium, 3 hadendometrial polyp and 2 cases were diagnosed as carcinoma endometrium.

Original Research Article
Obsgyne Review: Journal of Obstetrics and Gynecology Available online at: www.medresearch.in 74 |P a g e  Table 5 shows the comparison of EA with the final histopathological diagnosis of endometrial disease and was found to be accurate in 100 cases (94.33%) in our study. Majority of the patients who presented with HMB & HPMB had proliferative endometrium followed by simple hyperplasia. Only 2 were the cases of endometrial carcinoma out of 11 patients with PMB.

Discussion
AUB is the term used to describe deviation from a normal menstrual cycle and exhibit considerable variability manifesting with a wide range of bleeding patterns (HMB, HPMB, IMB) and is one of the main gynecological reasons of OPD visits and accounting for 2/3 rd of all hysterectomies [8]. Majority of the patients in our study belonged to 40-50 years group with parity of ≥3 and similar findings were observed by various studies [9,10].
The incidence of AUB in this age group is due to increase number of anovulatory cycles signaling the climacteric phase of the menopausal period. The most common presenting symptom was HMB with the average duration ranging from 3-6 months in our study and was in concordance with the studies conducted by Jetley et al and Shobha et al [11,12].
Only 7.54% of patients presented after 6 months of suffering from AUB & majority seek medical advice within 6 months which was comparable to the study conducted by Talukdar et al and Kathuria et al [10,13]. This finding reflects the concern of this grave symptom in peri and post-menopausal age group along with the significant morbidity for which the patients seek early medical advice.  [18,19,20].
TVS measurement of endometrial thickness showed better discrimination between normal and pathological (hyperplasia/ malignancy) endometrium than any Doppler variable [21]. Anjali et al, in her study concluded that TVS could detect endometrial changes and can be well correlated with histopathology in 92% cases [22].
In the present study the most common finding on endometrial aspiration was normal cyclical pattern (49.06%) out of which 31.13% showing proliferative endometrium and the rest 19.81% showing secretory endometrium. Endometrial aspiration was accurate in 94.33% of cases when compared to final histopathological examination.
The next predominant pattern was simple hyperplasia (31.13%) which was more commonly found in perimenopausal age group. Atrophic and carcinoma endometrium remained confined to postmenopausal age group and similar histological patterns of the endometrium were reported by Shukla et al [9].

Conclusion
Our study was done with the intention to find out the most common cause of AUB in perimenopausal age group at our centre which caters to a large rural and urban areas of Kanpur was fibroid and adenomyosis.
Since the endometrial aspiration correlates well with the histopathological report of the hysterectomy specimens, every woman presenting with AUB >40 Years must undergo EA assessment prior to hysterectomy to rule out any underlying malignancy as it is a very cost effective procedure providing high diagnostic yield.
Also, every hysterectomy specimen should be sent for final histopathological diagnosis regardless of the endometrial sampling as it is of prime importance for confirmation of the diagnosis and for the optimal management and counseling of the patients.
Funding: Nil, Conflict of interest: Nil Permission from IRB: Yes