According to World Health Organization, perimenopause is defined as the period immediately prior to menopause and the first year after menopause. Its the period when different changes including the endocrinological, biological and clinical features of menopause begin.1 Perimenopausal abnormal uterine bleeding is defined as abnormal menstrual bleeding during in perimenousal period.2 Among the gynecological consultations, abnormal uterine bleeding is the leading cause, especially in perimenopausal years. By FIGO (International Federation of Gynecology and Obstetrics) classification in 2018, the causes of abnormal uterine bleeding other than gestation have been classified into nine categories as PALM-COEIN. i.e., structural causes PALM includes polyp, adenomyosis, leiomyoma, malignancy/hyperplasia, and COEIN includes non-structural causes like coagulopathy, ovulatory dysfunction, endometrial, iatrogenic and not otherwise classified. 3 The frequency of abnormal uterine bleeding causes changes with age. In perimenopause age group endometrial hyperplasia, endometrial polyps & fibroids are among the most common structural causes. 4 Along with age, the frequency of uterine malignancies along with structural pathologies like fibroids, polyps, adenomyosis increases.5 Other medical disorders, bleeding disorder and anti-coagulant therapy can lead to abnormal uterine bleeding. In few cases pregnancy related causes may lead to abnormal uterine bleeding as in age above than forty years. Although personal perception of abnormal uterine bleeding is not always accurate but intermenstrual spotting / bleeding and post coital bleeding is considered as abnormal. 6 Regarding personal perception, 40% of female with excessive menstrual bleeding consider it as normal while about 14% of female with mild to moderate menstrual bleeding consider periods as heavy .7 Postmenopausal women presenting with the abnormal uterine bleeding have high incidence of endometrial cancer. Regarding the evaluation of abnormal uterine bleeding, detailed history including gynecological & medical history and specially personal & family history of disposition for genital tract malignancies, colorectal cancers and breast cancer is important .General physical examination specially for anemia and bruises, BMI calculation, abdominal examination for abnormal mass is important. Vaginal speculum examination and bimanual pelvic examination is mandatory. Pelvic ultrasound as basic tool for pelvic evaluation and transvaginal ultrasound (TVS) in certain cases helps in establishing the diagnosis in patients with abnormal uterine bleeding. 8 The gold standard technique for the diagnosis of endometrial cavity is hysteroscopy. At the same time diagnosis of pathology as well as treatment can be done by hysteroscopy. 9 Hysteroscopy is still not in common practice among most of the gynecological setups. This study will be an addition to define the role and importance of hysteroscopy in the management of perimenopausal bleeding.

The prospective study was conducted at Services Hospital, Lahore after the ethical approval. The study was conducted for one year from February 1st, 2024 to January 31st 2025. During this period total 250 patients according to criteria were included in the study. Patients age ranged from 45 years to 53 years. Exclusion criteria was , the patients of perimenopause age with active pelvic infections, medical disorders leading to abnormal bleeding , bleeding tendency, patients taking hormonal treatment / hormonal contraceptives and pregnancy . Speculum examination was done in all the patients. Patients were evaluated by history, examination and relevant investigations Pelvic ultrasound / transvaginal ultrasound was done to know the probable cause of abnormal uterine bleeding. Patients with the diagnosis of fibroid other the polypoidal fibroid in endometrial cavity, were excluded from study. Preoperative evaluation was done. All patients were counselled for the procedure, complications, hospital stay, follow up and prognosis. Informed consent was taken from all patients. All procedures were done in operation theatre under general anesthesia as day care procedures. During the procedure after fulfilling the prerequisites, bimanual examination under anesthesia was done. Vaginal speculum examination was done. Hysteroscopy was performed. Cervical canal and uterine cavity was explored. Any mass in cervical canal and uterine cavity was identified, endometrial lining was noted. Endometrial biopsy was taken in all cases. In case of cervical polyp or endometrial polyp, polypectomy was performed. Tissue removed were inspected and sent for histopathology. Post-operative care was provided .Documentation was done for data collection. Data was analyzed and the results were compiled.

Results of the study were compiled in refence to age group, parity, presenting complaints, hysteroscopic findings and histopathological reports. Out of 250 patients most common age group who presented with abnormal uterine bleeding was among 48-51 years of age i.e. 145 patients (58%) while 75 (30%) patients presented among age group of 45-48 years and 30 (12 %) patients presented between 51-53 years of age (Table1) .Table 2 shows the relationship of parity with abnormal uterine bleeding among perimenopausal women. Regarding the parity of the patients, it was higher in P2 i.e., 98 patients (39.2%) while 61 patients (24.4%) were P 4 or above, 54 (21.6%) patients were P3, 23 (9.2%) patients were P1 and 14 (5.6%) patients were nullipara. Regarding the presenting complaint (Table 3) polymenorrhagia was found in 98 patients (39.2 ) , menorrhagia in 75 patients (30%), polymenorrhagia in 54 (21.6%) patients and post-menopausal bleeding in 23 (9.2 %) patients .Table 4 shows the hysteroscopic findings among the 250 patients undergoing the hysteroscopy . Out of 250 patients, normal looking endometrial cavity was found in 32 (12.8%) cases, endometrial hyperplasia in 145 (58 %), patients , endometrial polyp in 64 (25.6 %) cases while 9 patients (3.6%) had submucosal fibroid .Table 5 shows the histopathological report of the cases as endometrial hyperplasia in 117 (46.8%) cases. Among the endometrial hyperplasia 58 (23.2 %) cases were with simple hyperplasia , 45 cases (18%) were with complex hyperplasia and 14 (5.6 %) cases were with hyperplasia with atypia. Among 250 cases endometrial polyp was found in 64 (25.6) cases, secretary endometrium / hormonal imbalance in 45 (18 %) cases , chronic endometritis 18 (17.2%) cases and endometrial carcinoma in 6 (2.4 %) cases.

Table 1: Age of Patients

Table 2: Parity of Patients

Table 3: Presentation

Table 4 : Hysteroscopic Findings

Table 5: Histopathologic report

Menstrual dysfunction is one of the commonest reasons for gynecological consultations and more common at the perimenopausal years. This abnormal uterine bleeding may be abnormal in regularity, amount or duration. The causes of abnormal uterine bleeding are different at different stages of life. FIGO classification for the causes of abnormal uterine bleeding is a step forward for the better management plans for the clinicians and patients.¹⁰  Due to certain hormonal changes at menopause women may have effects that may significantly effect quality of life ¹¹. Due to heavy menstrual bleeding hemoglobin may decrease leading to anemia, fatigue and affect the physical and quality of life negatively.¹²

To make the diagnosis, evaluation by the history, examination and relevant investigations are important. For uterine evaluation transvaginal sonography, dilation and curettage (D&C), hysteroscopy, hysteroscopic directed biopsy can be performed. Among these, transvaginal sonography can be taken as the base line for the uterine assessment but transvaginal sonography is not accurate in diagnosing benign uterine conditions .^13,14 Although TVS has the advantage of holistic assessment of uterus and adnexa. In postmenopausal women TVS is useful for exclusion of endometrial cancer if the endometrial echo is less than or equal to 4 mm, giving a negative predictive value of >99% .¹⁵ Hysteroscopy is the gold standard for uterine cavity assessment. Hysteroscopy assisted with endometrial biopsy is a safe and reliable diagnostic tool for evaluating patients of abnormal uterine bleeding and accurately detecting conditions such as endometrial

polyps, fibroids & endometrial hyperplasia .¹⁶ Through hysteroscopy, uterine cavity can be explored and if pathology identified, procedure like endometrial biopsy, polypectomy can be done in same sitting. In certain cases, like submucosal fibroids, myomectomy can be done in same procedure ^17-20. In the study out of 250 patients 32 (12.8%) cases had normal looking endometrial cavity, 145 (58 %), patients had endometrial hyperplasia on hysteroscopy and 64 (25.6 %) cases had endometrial polyp while 9 patients (3.6%) had submucosal fibroid. Similarly high diagnostic accuracy of hysteroscopy with regard to endometrial carcinoma was mentioned in a systematic review but only moderate for other types of endometrial disease. ²¹ Regarding the diagnostic accuracy of hysteroscopy, it is useful to compare the reports having only hysteroscopy or results from reports having hysteroscopic endometrial biopsy.²²

Histopathological exanimation of endometrium is important to exclude the complex hyperplasia, hyperplasia with atypia or endometrial carcinoma. In the study 45 patients (18 %) has complex hyperplasia, 14 (5.6%) patients had hyperplasia with atypia and 6 (2.4 %) patients had endometrial carcinoma. Another study shows the correlation between the hysteroscopic impression and histopathological report was 86% for normal endometrium and benign endometrial pathology, but for endometrial hyperplasia it was 58%. In addition, the lowest agreement (52%) was noted for postmenopausal endometrial hyperplasia. In post-menopausal women with abnormal uterine bleeding t, the prevalence of endometrial cancer is 21% .²³

Trans cervical polypectomy thorough hysteroscope is ideal method for polypectomy without damaging endometrium .Recurrence of polyp can be minimized by progesterone therapy.²⁴ So for uterine cavity and endometrial evaluation in perimenopausal women, hysteroscopic evaluation proceeded to endometrial biopsy should be preferred. In certain cases, operative procedures like polypectomy can be performed during the same procedure. Its important to timely diagnose the cases with abnormal uterine bleeding as in most of the cases women report late and remain silent resulting in delayed diagnosis and leading to further complications like anemia, physical & mental stress. ²⁵

Limitation of study: Patients who were not diagnosed by the pelvic / transvaginal ultrasound for the intrauterine pathology and few patients were not willing for admission were not included in the study.

In perimenopausal age group of women, abnormal uterine bleeding is among the commonest cause for the consultations. For effective management, accurate diagnosis and exclusion of premalignant & malignant condition is important. Hysteroscopy is very effective tool for the diagnose of endometrial pathology and for the treatment of intrauterine pathologies. It is a day care procedure with short hospital stay, less pain and early back to work. Best treatment option should be individualized from patient to patient keeping the short term and long term goals in mind.

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