Introduction
Abnormal uterine bleeding(AUB) is one of the most common gynaecological problems. It accounts for about 33% of out patient referrals.
Acute AUB is “an episode of bleeding in a woman of reproductive age, who is not pregnant, that is of sufficient quantity to require immediate intervention to prevent further blood loss.”
Chronic AUB is ‘‘ bleeding from the uterine corpus that is abnormal in duration, volume, and/or frequency and has been present for the majority of the last 6 months.”1
It is a debilitating condition with high direct and indirect costs. AUB is considered as a cause of significant health care burden for women, their families and society as a whole.
The causes of Abnormal uterine bleeding may be physiological, pathological or pharmacological.2 It is associated with any type of endometrium ranging from normal endometrium to hyperplasia, irregular ripening, chronic menstrual irregular shedding and atrophy.3 It may be due to fibromyoma, adenomyosis, endometrial polyp, ovarian tumor, pelvic inflammatory disease (PID), endometrial hyperplasia, endometrial carcinoma, hormonal imbalance (like hypothyroidism), or hypothalamic‑pituitary diseases.
It is important to understand the clinical questions, systematic and practical approach to evaluate the endometrial biopsies. Abnormal uterine bleeding is associated with endometrial carcinoma in approximately 10% of cases. Endometrial hyperplasia with atypia is found to be a precursor of endometrial carcinoma and may progress to endometrial carcinoma in 5-25% of patients. Endometrial hyperplasia with atypia is associated with a coexisting endom etrial carinoma in approximately 20% of patients.4 The sensitivity of endometrial biopsy for detection of endometrial abnormalities has been reported to be as high as 96%.5 Even though, endometrial biopsy has high sensitivity for endometrial carcinoma, its sensitivity for detecting endometrial hyperplasia with atypia is found to be low as 81%.7, 6
The aim of this study is to study the various histopathological patterns in the endometrial biopsy of patients presenting with abnormal uterine bleeding.
Materials and Methods
This was a retrospective study conducted in Department of Pathology, JJM medical college fr om January 2016 to December 2017. A total of 212 endometrial biopsies were reviewed in AUB. The slides were obtained from departmental archives and clinical data from the histopathological forms. The data was entered and interpreted in Microsoft Excel. The analysis was done in percentages and proportions and was represented in tables, graphs and pie charts wherever necessary.
Results
A total of 212 endometrial biopsy or curettage samples of women with abnormal uterine bleeding were studied. Age range d from 20 years to 62 years. Out of the 212 patients with abnormal uterine bleeding, maximum was in the age group 36-40 years- 51 patients followed by 50 patients in the age group 41-50 years. 44 patients were in the age group 46-50 years and 30 patients were in the age group 31-35 years. There were 3 patients in the age group 56-60 years and 1 patient above 60 years.
The most frequent histomorphological pattern was Endometrial Hyperplasia without atypia found in 91 patients (43.0%) followed by secretory endometrium in 33 patients (15.6%). Disordered proliferation was found in 31 patients (14.6%), prolife rative endometrium found in 30 patients (14.2%), irregular shedding seen in 8 patients(3.8%) and menstrual endometrium seen in 5 patients (2.4%). Functional endometrial polyp seen in 3 patients (1.4%). Atypical endometrial hyperplasia, arrested secretion, products of conception, hormonal therapy, chronic non-specific endometritis seen in 2 patients each (0.9%) and acute endometritis seen in 1 patient (0.5%).
Table 2
| Age groups (in years) | Number of cases | Percentage (%) |
| ≤20 | 01 | 0.5 |
| 21-25 | 09 | 4.2 |
| 26-30 | 20 | 9.4 |
| 31-35 | 30 | 14.1 |
| 36-40 | 51 | 24.1 |
| 41-45 | 50 | 23.6 |
| 46-50 | 44 | 20.8 |
| 51-55 | 3 | 1.4 |
| 56-60 | 3 | 1.4 |
| >60 | 1 | 0.5 |
| Total | 212 | 100 |
Age distribution of cases
Table 3
Distribution of Endometrial patterns
Discussion
Endometrial hyperplasia without atypia
In our study this phase was the most common endometrial pattern seen in 91 cases (43.0 %). Our study was in coordination with that of Talukdar et al8 (41.66%), Sanjitha et al9 (25.0%) and was second most common in the study by Sudhamani et al10 (20.74%). In contrast, the studies done by Gopalan et al11 (5.4%) and Badary et al12 (3.6%) found this to be in slight predominance.
Secretory phase
It’s divided into early, mid and latte secretory phases.13 In our study this phase was the second common endometrial pattern seen in 33 cases (15.6%). Our study was in coordination with that of Talukdar et al8 (16.11%), Sanjitha et al9 (16.7%), Mahapatra et al14 (30.0%) and in contrast with Badary et al12 (2.4%). It was most common pattern in study done by Jetley et al15 (32.4%)
Disordered proliferation
It is considered as transitional form to simple (glandular cystic) hyperplasia and was the third common endometrial pattern seen in 31 cases (14.6%). Our study was in coordination with that of Sanjitha et al9 (12.2%). It contrast, it was slightly seen in study done by Jetley et al15 (6.8%) and Badary et al12 (6.8%).
Proliferative phase
Proliferative phase suggests an anovulatory phase of the endometrial cycle. In our study this phase was the next common endometrial pattern seen in 30 cases (14.2%). Our study was in coordination with t hat of Talukdar et al8 (20.56%), Sanjitha et al9 (12.2%) and Badary et al12 (4.7%). It contrast, it was most common pattern seen in study done by Gopalan et al,11 Sudhamani et al10 and Jetley et al15 (30.6%).
Endometrial polyps
It was seen in 3 cases (1.4 %) of endometrial biopsies in our study. Our study was in coordination with that of Gopalan et al11 (1.1%), Talukdar et al8 (2.22), and Jetley et al15 (2.7%). There was slight predominance seen in Sanjitha et al9 (5.12%), Sudhamani et al10 (3.65%), Mahapatra et al14 and was in contrast with Badary et al12 (37.9%)
Chronic non-specific endometritis
There were 2(0.9%) cases of Chronic non-specific endometritis. Tuberculosis is one of the major cause of granulomatous endometritis, especially in developing countries like India. Once the endometrium is affected, it suggests a more widespread disease affecting the genital tract; especially the fallopian tubes. Our study correlated with that of Sanjitha et al9 (0.64 %), Gopalan et al11 (0.7%) and Talukdar et al8 (2.22%). Sudhamani et al10 observed 2.43 % cases, Jetley et al15 observed 9.1% cases and Badary et al12 in 4. 1% cases.
Atypical Endometrial hyperplasia
In our study there were 2 cases (0.9%) of atypical endometrial hyperplasia. Our study correlated with that of Gopalan et al11 (0.8%) and in Talukdar et al8 (4.44%), and in Badary et al12 was seen in 6.2% cases.
Table 4
Comparison of endometrial patterns among various studies
Conclusion
In our study, the endometrial hyperplasia without atypia was the most common histomorphological pattern seen in females with abnormal uterine bleeding followed by secretory phase endometrium, disordered proliferation and proliferative phase endometrium. The cause of AUB can be identified by the histopathological study of endometrial curettages and biopsies. Endometrial curettages and biopsy are important diagnostic procedures for assessing all cases of abnormal uterine bleeding to detect endometrial carcinoma and endometrial hyperplasia which has very good prognosis if detected and treated early. Thus, helps to plan for successful management of the females presenting with AUB.
