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Print version ISSN 1667-8682On-line version ISSN 1667-8990

Salud(i)ciencia vol.23 no.2 Ciudad autonoma de Buenos Aires Aug. 2018


Authors' chronicles

Endometrium in middle-aged women with atypical uterine bleeding

El endometrio en mujeres de mediana edad con sangrado uterino atípico


Zeeba Shamin 1

1 Hamdard Institute Of Medical Sciences And Research (HIMSR), Jamia Hamdard, India

Zeeba Shamin describes for SIIC his article published in Journal of Mid-Life Health 4(4):216-220, October 2013



Jamia Handard, India (special for SIIC)
Perimenopause is the period when a woman’s body makes a natural shift from regular cycles of ovulation and menstruation toward permanent infertility, or menopause, and generally occurs at 40-50 years of age. Abnormal uterine bleeding (bleeding pattern differing in frequency, duration, and amount from a pattern observed during a normal menstrual cycle; AUB) is a commonly encountered gynecological problem in this age group. It includes both dysfunctional uterine bleeding (DUB) and bleeding from structural causes like fibroids, polyps, endometrial carcinoma, and pregnancy complications. Endometrial curettage plays an important role in excluding organic uterine disorders.

We undertook a study to determine the types and frequencies of endometrial pathologies in perimenopausal women presenting with abnormal uterine bleeding. All the patients in this study were in the 40-50 age group. Data on the age and presenting clinical features was also retrieved and recorded wherever available.

Endometrial tissue collected by sampling procedures such as dilatation and curettage (D & C), endometrial biopsy and fractional curettage was evaluated.

A total of 219 perimenopausal women underwent endometrial sampling at the Hakeem Abdul Hameed Centenary Hospital, New Delhi over a 4-year period. Details of patterns of bleeding were available in only 155 of the total 219 cases, the most common clinical presentation being menorrhagia.

The PALM-COEIN (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic and not yet classified) classification system for AUB has been recently approved as a FIGO classification system. This classification system was developed to be used by clinicians, investigators, and even patients to facilitate communication, clinical care, and research. Functional causes accounted for majority of the diagnoses. Secretory endometrium seen in 71 cases was the most common diagnosis followed by proliferative endometrium, the second most common diagnosis seen in 67 patients. Other functional causes of atypical uterine bleeding were disordered proliferative endometrium in 15 cases, luteal phase defects in 3 cases. Endometrial hyperplasia was seen in 24 patients who presented with atypical uterine bleeding. On categorizing the types of endometrial hyperplasia, simple hyperplasia without atypia was seen in 19 cases, complex hyperplasia without atypia in 4 cases, and complex hyperplasia with atypia in 1 case. Endometritis was diagnosed in 20 patients in this study, of which tubercular etiology was demonstrated in 2 cases. Endometrial polyps were seen in 6 cases. Polyps were identified as polypoidal fragments with epithelium on three sides, fibrous stroma and thick-walled blood vessels. Irregularly shaped, crowded hyperplastic glands were seen in 4 of the cases while 2 cases showed glands with normal cycling endometrium. Spontaneous pregnancy loss was the cause of bleeding in 3 cases. Evidence of exogenous hormone therapy, which is a common line of medical management in patients of atypical uterine bleeding, and often prescribed empirically, was seen in 6 cases. Finally, in 4 cases, the endometrial curettings were scanty and inadequate for any diagnostic opinion.

Abnormal uterine bleeding that is both excessive and irregular accounts for more than 70% of all gynecological consultations in the peri- and postmenopausal years. Conventional D & C is commonly used in developing countries with limited resources as a standard and an important method of assessing abnormal uterine bleeding. We analyzed atypical uterine bleeding among women in the 40-50 age group. Atypical uterine bleeding without structural pathology is seen in women across all age groups but is more common in adolescent and perimenopausal women.

Hypothalamic-pituitary-ovarian axis derangements may result in changes in the hormonal milieu, leading to abnormal uterine bleeding. We found that the most common histopathological finding was secretory endometrium in 71 cases. Other studies in women with atypical uterine bleeding have shown similar findings. Proliferative endometrium was seen in 67 patients, disordered proliferative endometrium was present in 15 cases and endometrial hyperplasia in 24 cases. Hence 106 of the 219 perimenopausal women studied were exposed to unopposed estrogen. In the absence of ovulation and the production of progesterone, the endometrium responds to estrogen stimulation by proliferation. Painless, irregular bleeding which is characteristic in this clinical setting was seen in all these cases. In perimenopausal years, anovulatory cycles are most frequent and chronic anovulation is associated with an irregular and unpredictable pattern of bleeding. Several studies from the subcontinent have shown similar findings.

This study also detected endometrial polyps in six cases, out of which four were hyperplastic polyps characterized by simple hyperplasia without atypia, and two cases were functional polyps with a normal endometrium. Again the common implicating factor here is increased estrogen secretion, which leads to hyperplasia of the basal endometrial layer.

Endometritis was seen in 20 cases in this study. Nonspecific chronic endometritis as an etiology of atypical uterine bleeding in perimenopausal women has been reported by other workers also.

Out of 20 endometritis cases, tubercular etiology was established in 2 cases. A large Indian study of 500 biopsy proven cases of tuberculosis of the endometrium reported that while sterility was the most common presentation, atypical uterine bleeding was also seen in 22.2% cases.

Scanty endometrium, inadequate for opinion, was seen in 4 cases in this study. A study, which evaluated the negative predictive value of endometrial samples reported as inadequate in diagnosing endometrial hyperplasia and malignancy, was carried out in 2004 at the School of Medicine, Philadelphia. They concluded that an inadequate endometrial sample may be sufficient to rule out endometrial neoplasia because of its high negative predictive value.

Atypical uterine bleeding in perimenopausal women is commonly dysfunctional in origin. A significant number also show underlying organic pathological lesions thus highlighting the importance of histopathological examination of the endometrium. Accurate analysis of endometrial samplings is therefore, critical to effective therapy and optimal outcome.

Other articles published by the author:

Jetley S, Rana S, Khan RN, Jairajpuri ZS. Xanthogranulomatous cholecystitis, a diagnostic challenge: An experience of 13 cases and a review of literature. J Indian Med Assoc 110(11):833-837, 2012.

Jetley S, Rana S, Khan S, Hasan MJ, Jairajpuri ZS. Incidental gall bladder carcinoma in laproscopic cholecystectomy: Report of 6 cases and a review of literature. J Clin Diag Res 7(1):85-88, 2013.

Jetley S, Rana S, Jairajpuri ZS. Low grade endometrial stromal sarcoma in a premenopausal woman: Report of a rare case. J Nat Sc Biol Med 5:214-217, 2014.

Jairajpuri ZS, Rana S, Hassan MH, Nabi F, Jetley S. An analysis of hematological parameters as indicators of Malaria in patients with acute febrile illness: An Institutional experience. Oman Med J 29(1):12-17, 2014.



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