|Year : 2019 | Volume
| Issue : 1 | Page : 11-15
To correlate histopathological changes and transvaginal sonography findings in the endometrium of patients with abnormal uterine bleeding
Akanksha Wankhade1, Sunita Vagha1, Samarth Shukla1, Arvind Bhake1, Sheronica Laishram1, Deepika Agrawal1, Naincy Rastogi2, Madhuri Wankhade3
1 Department of Pathology, Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
2 Department of Pathology, JNMC, DMIMS, Sawangi (Meghe), Wardha, Maharashtra, India
3 Department of Pathology, District Hospital, Dhamtari, Chhattisgarh, India
|Date of Web Publication||21-May-2019|
Dr. Akanksha Wankhade
Department of Pathology, Jawaharlal Nehru Medical College, Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Menstrual ailments are the common manifestation to call for medical visits among women of heavy menstrual bleeding of procreative age. Abnormal uterine bleeding (AUB) affects up to 30% of females in the society. Aim and Objective: The aim of this study was to establish the role of histopathological diagnosis of uterine lesions in patients of AUB and to correlate the transvaginal sonography (TVS) findings with histopathological examination. Materials and Methods: A observational and analytical study was carried out in 120 patients of AUB. All the patients underwent TVS, followed by a histopathological examination of specimens obtained from either D and C or hysterectomy. Results: Menorrhagia was the most common clinical finding. Mean endometrial thickness measured by TVS was 10.15 ± 3.86. Proliferative endometrium (28.33%) was the most frequent finding in histopathological examination, followed by endometrial hyperplasia comprised of 20.83%. Hyperplasia and carcinoma both had a low sensitivity of 36% and 50%, respectively, on TVS compared with histopathology. Conclusion: According to the histopathological diagnosis based on biopsy or D and C, the treatment plan is formulated and the surgery is planned. Hence, even the prognosis depends upon the histopathological examination, TVS is only the initial screening tool for AUB. We advised the clinicians not to rule out these entities only on the basis of TVS.
Keywords: D and C, hyperplasia, hysterectomy, procreative age, proliferative, transvaginal sonography
|How to cite this article:|
Wankhade A, Vagha S, Shukla S, Bhake A, Laishram S, Agrawal D, Rastogi N, Wankhade M. To correlate histopathological changes and transvaginal sonography findings in the endometrium of patients with abnormal uterine bleeding. J Datta Meghe Inst Med Sci Univ 2019;14:11-5
|How to cite this URL:|
Wankhade A, Vagha S, Shukla S, Bhake A, Laishram S, Agrawal D, Rastogi N, Wankhade M. To correlate histopathological changes and transvaginal sonography findings in the endometrium of patients with abnormal uterine bleeding. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2019 Dec 11];14:11-5. Available from: http://www.journaldmims.com/text.asp?2019/14/1/11/258658
| Introduction|| |
Menstrual ailments are the common manifestation to call for medical visits among women of heavy menstrual bleeding of procreative age. Health-care system is affected due to this malady, which may lead to having an impact on quality of life that landed up in off time from work. The estimated worldwide prevalence of subjective, self-defined abnormal uterine bleeding (AUB) varies greatly, from 4% to 52%. In India, AUB is reported to occur in 9% to 14% of women between menarche and menopause. India has a prevalence of AUB which is 17.9% approximately.
A simple day-care procedure, D and C, is the standard procedure for diagnosis and used for histological evaluation of the endometrium. Earlier, it was recognized as the gold standard procedure for the patients of AUB, but now, it has its own drawback like small lesions which are focal that can be missed with this blind procedure.
Transvaginal ultrasonography (TVUS) is a cheap, noninvasive, and a simple diagnostic modality. The better visualization of the endometrium and entire uterus is possible due to the placement of the ultrasonography (USG) transducer of high frequency nearer to the region of interests.
Histopathologists face a diagnostic challenge in patients of AUB due to numerous endometrial pathologies. Nowadays, USG is preferred over D and C, as being noninvasive. However, at small health centers like primary health care in rural areas where USG is not available, D and C gives same results in such a setting. Hence, the present study is required to correlate these histopathological findings together with TVUS in D and C and/or hysterectomy specimens, in addition, to find out the accuracy of TVUS, which is being used as a screening tool. The implementation of the treatment is achieved by appropriate histopathological diagnosis.
| Materials and Methods|| |
The present study was carried out in the Department of Pathology, JNMC, Wardha. The study was the prospective, observational, and analytical type. Duration of the study was 2 years from August 1, 2016 to August 31, 2018. The total of 120 patients was taken who were inpatients of the department of obstetrics and gynecology. The institutional ethics approval was obtained and consent was obtained from all the patients who complain of AUB. The detailed clinical history was obtained and subsequently, abdominal sonography was performed followed by transvaginal sonography (TVS) using two-dimensional TVS machine using general electric (GE) Logiq C5 ultrasound by transvaginal probe (GE 6.5MHz).
Patients were subsequently undergoing D and C or hysterectomy as indicated by gynecologists. These tissue specimens were then received in the histopathology section of the department of pathology, and then further tissue processing was done followed by routine H and E. In stained slides, the most representative areas were selected and reported by histopathologists. All these cases were further analyzed and correlated with the radiological findings. All the patients with AUB were included in the study irrespective of age and quantified blood loss. Cases of bleeding due to vaginal, cervical, vulval causes; bleeding secondary to contractive or any drug intake and cases of blood dyscrasias were excluded from the study.
All the values of the data were incorporated as a percentage and mean with its standard deviation. Statistical analysis was done using Statistical Package of Social Sciences (version 22.0), North Illinois university, USA. software and P < 0.05 is considered as the significant level of confidence.
| Results|| |
The present study titled “To correlate histopathological changes and transvaginal sonographic findings in the endometrium of patients with AUB” is being conducted in Jawaharlal Nehru Medical College of Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha (Maharashtra). The study was conducted for a duration of 2 years, i.e., from July 2016 to August 2018. The study was the prospective, observational, and analytical type. A total of 120 cases were taken for the study. These patients were having a complaint of AUB. Clinical history was obtained and TVS, as well as abdominal sonography, was carried out. Histopathological findings were duly noted. Comparison of the findings of TVS, abdominal USG, and histopathology was done. All the results of TVS, abdominal USG, and histopathology were recorded and interpreted in tabulated form [Table 1].
|Table 1: Distribution of women in the correlation of histopathology diagnosis with transvaginal sonography|
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The mean age of the study population was found to be 41.7 ± 7.82 years, with maximum population i.e. 45% belonging to the age group of 41-50 years. Menorrhagia (54.17%) was the most frequent clinical complaint in women of perimenopausal as well as in postmenopausal age group. Endometrial thickness noticed in the present study was 8–14 mm which comprised of 67.50%. The mean endometrial thickness was 10.15 ± 3.86 mm. On TVS, a maximum number of cases was 45.83% which had bulky uterus (21.67%). The maximum number of histopathological findings in women who complained of AUB was the proliferative phase which was 28.33%, followed by leiomyoma which was 20%.
The overall sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of TVS with histopathology were 89.47%, 66.67%, 98.08%, and 25%, respectively. Diagnostic accuracy of TVS was 88.33% and P value was 0.003. TVS shows four cases of the fibroid, out of which two cases were fibroid and two cases were turned out to be hyperplasia on histopathology. Two cases were normal uterus on TVS but were turned out to be leiomyoma and simple cystic hyperplasia on histopathology.
In our study, the maximum correlation was found to be present in adenomyosis and polyp (100%) and the least correlation was found to be present in atrophic endometrium (0%) and carcinoma (50%).
In our study, it was observed that the maximum sensitivity of TVS was present in proliferative phase (94.12%) followed by fibroid (70.83%) and the least sensitivity was observed in atrophic endometrium followed by adenomyosis (23.53%) [Graph 1].
| Discussion|| |
AUB is one of the most common clinical ailments encountered in more than 20% of women all across the globe in the gynecology outpatient department. It is a significant debilitating health problem in women of rural areas. Therefore, a proper diagnosis has to be made for adequate treatment and better survival of women of reproductive age. Many of them have normal physiological alterations that are self-limiting, but few experiences impart a prolong debilitating condition which affects the quality of life.
Evaluation of these patients on the basis of clinical history and complaints followed by radiological investigations such as USG and TVS plays a very important role. These investigations are only the screening methods and provide a rough idea about the underlying cause. Further confirmation is provided by the histopathological examination of the tissue sample taken out by dilatation and curettage. However, to be more precise, endometrial biopsy should be performed to include the smallest possible pathological tissue without getting missed. Dilation and curettage are blind procedures, and chances of missing the target tissues are more. Therefore, this study aims at correlating the histopathological changes with TVS findings in patients of AUB. The present study was conducted on 120 patients of AUB. These patients were of different age groups. TVS findings were obtained only in those patients who were included in the study.
It was found that there was concordance with the study carried out by Shah et al., which was 42.6 ± 6.9 years. Gupta et al. conducted a study and 45.74 ± 2.81 years was their mean age in the study. In a study conducted by Desai et al., 45.88 ± 5.88 years was the mean age. However, there was a little difference in the study conducted by Kaur et al., range was 46–65 years with mean 50.80 ± 4.06 years. This was found because of the reason that they had included only patients of postmenopausal bleeding and sample size of 70 which is a small amount as compared to the prevalence of AUB in India. The mean age of the study population was found to be 41.7 ± 7.82 years, with maximum population i.e. 45% belonging to the age group of 41-50 years. The increased incidence of AUB in this age group was maybe because of initiation of menopause due to which the number of ovarian follicles decreases, and there was increased resistance to the stimulation of gonadotropin hormone that resulted in declining the level of estrogen. This event did not help the endometrium to grow further.
A study conducted in another country by Sedeq et al. reported that menorrhagia was the common clinical complaint in their study which constituted about 51%. Studies carried out in India had the same findings in Sajitha et al., in that 47% was the menorrhagia which was the most common complaint. Pillai  had 46.6% of menorrhagia patients; similarly, Talukdar and Mahela  had 43.69% of menorrhagia patients which was the most common complaint in their study and Deshmukh et al. also had 41% of menorrhagia that showed concordance with our study findings. Nair  studied 66 patients in total retrospectively and came up with similar findings such as menorrhagia in 78.8% of cases, followed by polymenorrhea in 10.6% of cases. The present study showed that menorrhagia (54.17%) was the most frequent clinical complaint in women of perimenopausal as well as in postmenopausal age group which was similar to the above studies. On contrary to the above findings, one of the studies conducted in Nepal by Bhatta and Sinha  reported that the most predominant bleeding pattern was metrorrhagia which constituted 38.52%.
Deshmukh et al. reported that the sensitivity, specificity, PPV, and NPV of proliferative phase were 92.64%, 100%, 100%, and 88.09%, respectively, which were similar to our study. Sensitivity, specificity, PPV, and the NPV of secretory phase were 100%, 89.77%, 70%, and 95.60%, respectively, which were similar to our study. Sensitivity, specificity, PPV, and NPV of endometrial hyperplasia were 76% 100%, 100%, and 95.60%, respectively.
A study conducted by Jain and Chakraborty  showed that sensitivity, specificity, PPV, and NPV of adenomyosis were 33.33%, 97.87%, 50%, and 95.83%, respectively. The sensitivity of polyp was 62.5%; specificity was 95.83%; the PPV was 71.42%; and the NPV was 93.02%. Fibroid had sensitivity, specificity, PPV, and NPV of 75%, 97.82%, 75%, and 97.82%, respectively, which was comparable with our study. Endometrial hyperplasia had sensitivity, specificity, PPV, and NPV of 81.81%, 92.3%, 75%, and 94.73%, which were concordant to our study. Choudhary et al. said that the sensitivity, specificity, PPV, and NPV of endometrial hyperplasia with TVS are 81.81%, 92.3%, 75%, and 94.73%, respectively. The present study stated that the endometrial hyperplasia had 36% sensitivity, 98.95% specificity, 90% PPV, and 85.45% NPV. Barman et al., described that the sensitivity, specificity, PPV, and NPV of hyperplasia by TVS were found to be 43.75%, 95.65%, 70%, and 88%, respectively; polyp had 50%, 89.16%, 10%, and 98.67%, respectively; proliferative phase had 62.26%, 78.13%, 82.5%, and 55.56%, respectively, while that of secretory phase had 64.29%, 84.50%, 45%, and 92.30%, respectively.
The findings in our study are in concordance with the study done by Deshmukh et al. and Jain and Chakraborty. The sensitivity of proliferative phase being 94.12%, specificity being 58.14%, PPV being 47.06%, and NPV being 96.15%; sensitivity of secretory phase was 100%, specificity was 66.36%, PPV was 26.53%, and NPV was 100%. Fibroid had a sensitivity of 70.83%, specificity of 95.83%, PPV of 80.95%, and NPV of 92.93%. Polyp had a sensitivity of 33.33%, specificity of 100%, PPV of 100%, and NPV of 98.32%. Endometrial hyperplasia had a sensitivity of 36%, specificity of 98.95%, PPV of 90%, and NPV of 85.45%. Adenomyosis had sensitivity, specificity, PPV, negative values of 23.53%, 100%, 100%, and 88.79%, respectively. This was because the tissue characterization is limited in USG. Adenocarcinoma had a sensitivity of 50%, specificity of 99.15%, PPV of 50%, and NPV of 99.15%.
| Conclusion|| |
On correlating TVS with histopathology in patients of AUB, the study concluded that the histopathological examination is an irreplaceable technique in diagnosing any endometrial or myometrial pathology in perimenopausal or postmenopausal women. TVS is a very cheap and noninvasive tool; nowadays, it is a highly recommended technique to rule out to endometrial lesions in patients of AUB. TVS is used as first initial screening investigating tool for AUB patients, but it is not confirmatory. TVS is preferred over abdominal USG because it gives endometrial thickness more accurately.
The study would recommend stringent histopathological confirmation of endometrial lesions, especially hyperplasia and carcinoma. The estimated risk of endometrial carcinoma to develop is 29% in women with complex atypical hyperplasia and only 2% in women with hyperplasia without atypia. Patients undergoing transvaginal ultrasonography should also undergo endometrial evaluation preferably by biopsy or dilatation and curettage, depending on the availability of technique in their respective areas. In rural areas, D and C should be the choice of evaluation in the patients of AUB. Clinicians can gather an important clue for taking the decision not to rule out these entities only on the basis of TVS.
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Conflicts of interest
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