Menstrual bleeding that is more than the normal ranges of duration, volume and frequency known as abnormal uterine bleeding (AUB).¹ Around 10-25% of women experience AUB during their reproductive life. The reported prevalence of AUB in India is around 17.9%.² Patients with AUB usually present in extremes of reproductive life, just after onset of menarche and during the premenopausal phase. Some women experienced AUB post pregnancy and during lactation. At the time of onset of menarche hypothalamic-pituitary-ovarian axis is little immature that causes anovulatory cycles which result in AUB and in perimenopausal women anovulatory cycles are associated with menorrhagia. But as the age advances, it is important to rule out the presence of endometrial hyperplasia and malignancy.³

The AUB can be caused by both organic and functional causes .⁴ The International Federation of Gynaecology and Obstetrics (FIGO) has developed a system called PALM-COEIN for classifying the etiology of AUB. The acronym PALM-COEIN includes nine categories: Polyp, Adenomyosis, Leiomyoma, Malignancy and Hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic and not yet classified. Hence, PALM represents the structural causes whereas COEIN represents the functional causes of AUB.⁵

Histopathological evaluation of endometrial tissue remains an important step in the diagnosis and further treatment of AUB. ⁶ Endometrial biopsy or curettage is a safe and effective diagnostic modality in evaluation of abnormal uterine bleeding after ruling out medical causes. The underlying disease can be detected by histological patterns of endometrium considering the age, menstrual cycle phase and use of any exogenous hormones. Pregnancy-related and dysfunctional uterine bleeding is more common in younger patients, whereas atrophy and organic lesions become more frequent in older individuals.⁷ This study was done to evaluate the endometrial causes of AUB and to determine the specific pathology in different age groups.

This was cross-sectional study conducted on endometrial tissue samples in Histopathology sections of Pathology department at a tertiary health care center in Jalna, Maharashtra, from January 2022 to June 2024. All patients attending gynecology OPD with clinical diagnosis of AUB and referred for the endometrial sampling were included in the study. Patients with pregnancy related bleeding, bleeding disorders, isolated cervical or vaginal pathologies with bleeding, medical conditions such as thyroid dysfunctions, liver and renal disorders were excluded by history, examination and investigations. The primary objective of the study was to find out the most prevalent histopathological findings of endometrium in patients presented with AUB and secondary objective was to find out the different histopathological conditions associated with AUB.

METHODOLOGY:

After getting approval from the IEC, present study was performed according to protocol, Declaration of Helsinki, ICH, Good Clinical Practice (GCP) guidelines, and the ICMR guidelines for Biomedical Research on Human Subjects. To get the informed consent eligible patients were explained in detail about study procedure in language best understood by them. After taking written informed consent all the endometrial tissue samples (endometrial biopsy, dilatation and curettage and pipelle biopsy samples) were included in the study. All demographic and clinical details including findings on local examination and details of investigations (if available) were recorded in pre designed case record form.

Tissue was processed in automated tissue processor and paraffin blocks were prepared. 4 microns sections were cut and stained using H&E stain. Slides were seen by two pathologists separately to reduce observational bias. Various histopathological patterns of endometrium were classified as the following: proliferative, secretory, atrophic, pill endometrium, disordered proliferative, endometritis, polyp, endometrial hyperplasia and endometrial carcinoma. The data were entered in Microsoft Excel and statistically analyzed. Analysis was done in the form of percentage and represented as tables and figures wherever necessary.

A total of 250 cases of AUB were observed during the present study. Menorrhagia was the most prevalent presenting symptom followed by metrorrhagia. We observed that mean age of the patients were 43.15 ± 11.70 years. Minimum age of patient was 16 years and maximum age was 75 years. In the present study highest numbers of patients were found in the age group of 40-49 years followed by age group of 31-40 years (Table No 1). The most common histopathological finding was proliferative endometrium (27.2%) followed by disordered proliferative endometrium (19.2%). Other common observations were endometrial hyperplasia (17.6%) and secretary endometrium (16.4%) (Table No 2). Majority of the cases of endometrial hyperplasia had simple hyperplasia without atypia. We found 3 cases of well differentiated endometrial carcinoma.

Table No 1: Distribution of patients according to Age

Table No 2: Distribution of patients according to Histopathological findings.

Table No 3: Comparison of observation of present study with other similar studies

In the present study maximum patients were belongs to age group of 41-50 years (35.6%) followed by age group of 31-40 years (24.4%) and it means 60% patients had age between 31-50 years.  18.4% patients had age between 51-60 years and 12% patients had age between 21-30 years. In the study of Brahmaiah J et al 35.71% of cases belonged to the age group 41-50 years.⁸ This finding in our study is in concordance with the studies by Brahmaiah J et al.⁸ Kumari SR et al, ⁹ Bhatta S et al,¹⁰ and Doraiswami S et al.⁶ This may be because the women in this age group are in the perimenopausal phase where anovulatory cycles and AUB are common.

In the present study the most common histopathological finding was proliferative endometrium (27.2%) and along with secretory endometrium it constitutes (43.6%) of the observations. These findings were similar to Brahmaiah J et al. study in which they found that proliferative and secretory endometrium constitute 43.33% of the total histopathological findings.⁸ Similar findings were observed in studies of Kumari SR et al (41.47%) and Bhatta S et al, (42.62%).^{9, 10}

Disordered Proliferative endometrium (19.2%) and Endometrial Hyperplasia (17.6%) were other common histopathological findings. In study of Kumari SR et al DPE was found in 22.12% of cases.⁹ The incidence of disordered proliferation in studies of Doraiswami et al.⁶ (20.53%), Bashir H et al.¹¹ (12.17%) and Vaidya et al. (13.4%) .¹² Disordered proliferative endometrium was commonly seen in perimenopausal age group. It denotes an endometrial appearance that is hyperplastic but without an increase in endometrial volume.

Majority of the cases of endometrial hyperplasia had simple hyperplasia without atypia and only 3 cases had hyperplasia with atypia.  The incidence of endometrial hyperplasia observed in studies of Kumari SR et al.⁹ were (16.59%) and Bhatta S et al.¹⁰ (18.03%). In the study of Brahmaiah J et al they found that Endometrial Hyperplasia was present in 20% cases.⁸ Shilpa et al, reported 24% cases of hyperplasia without atypia and 1.5% cases of hyperplasia with atypia.¹³ Diagnosis of endometrial hyperplasia is crucial as it can leads to endometrial carcinoma. Several studies have found that the risk of progression into carcinoma was more in case of atypical hyperplasia.^14-16

Atrophic endometrium was found in 4.8% cases in present study. In the study of Brahmaiah J et al atrophic endometrium was seen in 3.33% of cases. ⁸ This finding is in concordance with studies by Sharma R et al.¹⁷ and Doraiswami S et al.⁶

Atrophic endometrium contained dilated capillaries which may rupture and result in abnormal bleeding.¹⁸ In present study pill endometrium (4.285%), endometritis (5.714%) and endometrial polyp (3.809%) were other important findings. These observations are similar to findings of studies of Brahmaiah J et al.⁸ Kumari SR et al.⁹ and Bhatta S et al. ¹⁰

In the present study cases of endometrial carcinoma were seen in the 51-70 years age group. Endometrial Carcinoma was diagnosed in 1.2% of cases which is similar to study of Kumari SR et al who found that the endometrial carcinoma was present in 1.84% cases. A Similar incidence was reported by Kumari SR et al.⁹ (1.8%) and Dangal et al.¹⁹

Abnormal uterine bleeding was more common in the perimenopausal age group. Histopathological examination of endometrium showed wide spectrum of lesions from normal endometrium to malignancy and helps us to diagnose the underlying pathology and treating the patients appropriately.

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