|Year : 2019 | Volume
| Issue : 4 | Page : 288-292
Sonography evaluation of abnormal uterine bleeding in perimenopausal women with pathological correlation
Sakshi Daga, Suresh Phatak
Department of Radio-Diagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
|Date of Submission||26-Jun-2019|
|Date of Decision||20-Aug-2019|
|Date of Acceptance||28-Sep-2019|
|Date of Web Publication||16-Jul-2020|
Department of Radio-Diagnosis, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha - 442 001, Maharashtra
Source of Support: None, Conflict of Interest: None
Context: Ultrasound plays an important role in the diagnosis of structural or organic causes of abnormal uterine bleeding in perimenopausal females, thereby aiding surgeons and gynecologist to plan an appropriate management plan for patients. Aims: The aim of the present study was to evaluate the sensitivity and specificity of ultrasound in abnormal uterine bleeding in perimenopausal females with pathological correlation. Settings and Design: A prospective study was conducted over a period of 2 years from 2017 to 2019. Materials and Methods: A total of 82 perimenopausal females with complaints of abnormal uterine bleeding were selected for this study. Transabdominal scan and wherever required transvaginal scan were done to assess any organic cause of abnormal bleeding. Later on, findings on ultrasound were correlated on pathological studies. Statistical Analysis Used: Statistical analysis was performed using descriptive and inferential statistics using sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy, descriptive statistics, and Chi-square test. Results: Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of ultrasound in comparison to pathological studies were found to be 86.96%, 84.62%, 96.78%, 55%, and 86.58%, respectively. Conclusions: Ultrasound is a noninvasive and cost-effective modality with no risk of radiation exposure serves as a primary imaging modality in the evaluation of perimenopausal females with menstrual complaints.
Keywords: Bleeding, pathological, perimenopausal, ultrasound
|How to cite this article:|
Daga S, Phatak S. Sonography evaluation of abnormal uterine bleeding in perimenopausal women with pathological correlation. J Datta Meghe Inst Med Sci Univ 2019;14:288-92
|How to cite this URL:|
Daga S, Phatak S. Sonography evaluation of abnormal uterine bleeding in perimenopausal women with pathological correlation. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 Sep 22];14:288-92. Available from: http://www.journaldmims.com/text.asp?2019/14/4/288/289866
| Introduction|| |
Menstrual problems are the frequent cause of medical visit among the perimenopausal age group. Abnormal uterine bleeding refers to any alteration in normal menses, including alteration in its regularity, frequency, extend, and amount of flow. The World Health Organization regards perimenopause as a period 2–8 years prior and 1 year after cessation of menstruation.
The International Federation of Gynecology and Obstetrics propound a new classification system for structural and nonstructural causes of abnormal uterine bleeding based on the PALM-COEIN acronym. It is an abbreviation used for polyps either endometrial or cervical [Figure 1], adenomyosis, leiomyomas, or fibroids [Figure 2], malignancy [Figure 3] and hyperplasia, coagulation defects, ovulatory dysfunction, endometrial disorders, iatrogenic, and not known or not yet classified.
|Figure 1: Grayscale ultrasound image showing large well-defined hypoechoeic lesion in uterus suggestive of uterine fibroid|
Click here to view
|Figure 2: Grayscale ultrasound image shows an enlarged globular uterus with heterogeneity at endometrial–myometrial interface. There is asymmetrical myometrial bulkiness where posterior wall appears thickened than of anterior wall suggestive of adenomyosis|
Click here to view
|Figure 3: Grayscale ultrasound image showing thickening of endometrium suggestive of endometrial hyperplasia|
Click here to view
Ultrasound is a noninvasive and inexpensive modality for assessing organic causes of abnormal uterine bleeding. Its helps in determining the size of lesion, contour or texture, site of origin, and relation to adjacent pelvic structures.
| Materials and Methods|| |
The present study was conducted in Radio Diagnosis Department of Acharya Vinobha Bhave Rural Hospital, Sawangi (Meghe), Wardha for 2 years (2017–2019). This was a prospective type of study where a total of 82 females in a perimenopausal age group of 40–50 years with a history of abnormal uterine bleeding were selected. The exclusion criteria for the study included patients with abnormal uterine bleeding in other age groups, pregnancy and related causes of bleeding Per Vagina (PV), postoperative patients those on chemotherapy or radiotherapy, and the ones not willing to be part of the study.
The ethical committee approved our study protocol. All the patients who were willing to participate gave their informed consent. During ultrasound evaluation, a female attendant always accompanied the patients. Initially, the patient was asked to full bladder. A 3–5 MHz convex probe was used for transabdominal scan (TAS) and wherever required patient was asked to empty bladder to perform transvaginal sonography using 5–11 MHz transvaginal probe. TAS and transvaginal scans were performed using a ultrasonography (USG) machine (Hitachi Arietas S70). Later on, findings of ultrasound study were correlated with pathological findings.
Statistical analysis was performed using descriptive and inferential statistics using sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy, descriptive statistics, and Chi-square test.
Ethical clearance was obtained from the Institutional Ethical Committee of JNMC, Sawangi (Meghe), Wardha, on 18th April 2019. With ethical clearance no DMIMS(DU)/IEC/2019-20/341
| Results|| |
A maximum number of patients were found in the age group of 40–45 years accounting for 53 (64.63%) followed by patients in the age group of 45–50 years with a median age of 44 years [Table 1].
Most of the patients of abnormal uterine bleeding were multiparous, with 76.80% of cases with parity 2 followed by 8.50% cases having parity 1 [Graph 1].
It was observed that heavy menstrual bleeding was the most frequent presenting menstrual complaint in perimenopausal females accounted for 53.7% followed by shortened menstrual bleeding which was 13.4%[Graph 2].
A majority of the organic lesions causing abnormal uterine bleeding were uterine in origin (68.29%). Ultrasound findings were normal in 11 cases (13.41%). The lesions of cervical origin accounted for 18.29% of cases[Graph 3].
A total of 71 organic pathologies were encountered in the present study. The most common uterine pathologies were found to be uterine leiomyoma of fibroid accounting for 28 patients (78.87%) followed by equal number of adenomyosis and endometrial hyperplasia accounting for 11 patients each (15.49%). The most common cervical pathologies were found to be cervical carcinoma constituting 8.46%[Table 2].
A majority of the organic lesions found in the study were benign in nature constituting for 90.14% followed by malignant lesions accounting for 9.86% [Graph 4].
On comparison of ultrasound with pathological studies, the overall sensitivity was found to be 86.96%, specificity was 84.62%, positive predictive value was 96.78%, negative predictive value was 55%, and diagnostic accuracy was 86.58% [Graph 5].
| Discussion|| |
Perimenopause is a period of transformation from women's regular monthly menstrual cycles till the attainment of menopause. Abnormal uterine bleeding poses a major health problem for females. The advent of ultrasound has played a pivotal role in the diagnosis of causes of abnormal bleeding, thereby helping gynecologists and surgeons to plan appropriate treatment and surgical intervention if required.
In our study, the maximum patients belonged to 40–45 years age group comprising 64.63% of total cases. These findings were coherent with the study conducted by Byna et al. in which he found maximum patients in 40–45 years of age group. The results were also comparable with the study carried out by Bhosle and Fonseca and Deshmukh et al. Jain and Chakraborty found predominance of 40–44 years of age group constituting 48% in their study. Similar findings were reported in the study carried out by Baghel et al. who found a predominance of 40–45 years age group.
A majority of the patients who presented with complaints of abnormal uterine bleeding in our study were multiparous, with 76.8% of cases having parity 2 followed by parity 1 (8.5%) and least in patients with parity ≥4 (1.2%). These findings were compared with the study conducted by Byna et al. Similar findings were seen in studies conducted by Pillai which reported predominance of para 2 or less in perimenopausal females with menstrual complaints.
On the contrary to the above findings, one of the studies conducted by Gupta et al. who found majority of patients presenting with abnormal uterine bleeding were para 3 followed by para 2. Talukdar and Mahela reported para 4 predominance in patients of abnormal uterine bleeding followed by para 3. The predominance of parity 2 was found in our study because most of the females undergo family planning operation after 2 years.
Heavy menstrual bleeding or menorrhagia was the predominant menstrual complaint in our study, accounting for 53.7% of cases. Studies carried out by Pillai had 46.6% of patients with complaint of menorrhagia. Similarly, Talukdar and Mahela had 43.69% of menorrhagia patients. Jonathan and Saravanan and Damle et al. also had 43.7% and 48.86% of cases, respectively, presenting with heavy menstrual bleeding (menorrhagia), thereby showing concordance with our study findings.
In the present study, we observed that the majority of lesions were uterine in origin 68.29%, followed by cervical pathologies comprising 18.29% of cases. About 13.41% of perimenopausal females had no organic lesions detected on ultrasound. Pathak et al. in their study found uterus as the most common site of origin for organic lesions.
The present study revealed fibroids as the predominant structural or organic cause of abnormal uterine bleeding, accounting for 39.44% followed by equal number of adenomyosis and endometrial hyperplasia cases (15.49%). Talukdar and Mahela stated the maximum number of cases of uterine fibroids in his study comprising 45.63% of cases. These findings were comparable in studies carried out by Pillai who reported maximum cases of fibroids as a cause of abnormal bleeding in perimenopausal females with an incidence of 55.7%. In a study conducted by Jain and Chakraborty, they found maximum normal cases in her study accounting for 50% followed by endometrial hyperplasia constituting 24%.
The present study stated the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy of ultrasound in comparison to pathological studies was found to be 86.96%, 84.62%, 96.78%, 55%, and 86.58%, respectively. These findings in our study are in concordant with the study conducted by Haq et al. stated that sensitivity of ultrasound was 94.3%, specificity was 80%, positive predictive value was 91.6%, and the negative predictive value was 85.7% with an accuracy of 90%. The results were comparable with the study conducted by Sedaq etal.,,,,, reported sensitivity and specificity of transabdominal ultrasound in comparison to histopathological results as 92.8% and 65%, respectively, and that of transvaginal sonography as 100% and 92.9%, respectively. Jain and Chakraborty concluded in their study that the sensitivity, specificity, positive predictive value, and negative predictive value of ultrasound in compassion to histopathology was 76%, 94%, 76%, and 94%, respectively.
| Conclusion|| |
In rural India where most of the patients cannot afford modalities like computed tomography and magnetic resonance imaging ultrasound serves as cost effective modality that provides immediate diagnosis. This helps gynecologicals and surgeons to plan appropriate management plan for patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Kjerulff KH, Erickson BA, Langenberg PW. Chronic gynecological conditions reported by US women: Findings from the National Health Interview Survey, 1984 to 1992. Am J Public Health 1996;86:195-9.
Kumar P, Malhotra N. Clinical types of abnormal uterine bleeding. In: Kumar P, editor. Jeffcoate's Principle of Gynecology. 7th
ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd; 2008. p. 599.
World Health Organization. Research on the Menopause in the 1990s: Report of a WHO Scientific Group. World Health Organization; 1990
Munro MG, Critchley HO, Fraser IS. The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years: Who needs them? Am J Obstet Gynecol 2012;207:259-65.
Emanuel MH, Verdel MJ, Wamsteker K, Lammes FB. A prospective comparison of transvaginal ultrasonography and diagnostic hysteroscopy in the evaluation of patients with abnormal uterine bleeding: Clinical implications. Am J Obstet Gynecol 1995;172:547-52.
Okaro E, Condous G, Bourne T. The role of transvaginal ultrasound in the management of abnormal uterine bleeding. Gynecol Surg 2004;1:119-26.
Byna P, Siddula S, Kolli S, Shaik MV. Histopathological correlation of abnormal uterine bleeding in perimenopausal women. Int J Reprod Contracep Obstet Gynecol 2015;4:1876.
Bhosle A, Fonseca M. Evaluation and histopathological correlation of abnormal uterine bleeding in perimenopausal women. Bombay Hosp J 2010;52:69-72.
Deshmukh V, Yelikar KA, Davile M. Clinical study of endometrial pattern in dysfunctional uterine bleeding by transvaginal Sonography and it's histopathological correlation. J Evol Med Dent Sci 2013;2:2440-6.
Jain M, Chakraborty S. Evaluation of abnormal uterine bleeding with transvaginal sonography. Int J Reprod Contracept Obstet Gynecol 2017;6:2794-9.
Baghel M, Chandwaskar N, Agrawal S, Sonker S. Assessment of perimenopausal bleeding. Int J Reprod Contracept Obstet Gynecol 2016;5:487-90.
Pillai SS. Sonographic and histopathological correlation and evaluation of endometrium in perimenopausal women with abnormal uterine bleeding. Int J Reprod Contracept Obstet Gynecol 2016;3:113-7.
Gupta A, Rathore AM, Manaktala U, Rudingwa P. Evaluation and histopathological correlation of abnormal uterine bleeding in perimenopausal women. IJBAR 2013;4:509-13.
Talukdar B, Mahela S. Abnormal uterine bleeding in perimenopausal women: Correlation with sonographic findings and histopathological examination of hysterectomy specimens. J Midlife Health 2016;7:73.
Jonathan AA, Saravanan S. A two-year clinicopathological study of non-gravid women with abnormal uterine bleeding in a rural tertiary care centre in Tamilnadu: In concurrence with the Figo recommendations. J Evol Med Dent Sci 2015;4:10990-1001.
Damle RP, Dravid NV, Suryawanshi KH, Gadre AS, Bagale PS, Ahire N. Clinicopathological spectrum of endometrial changes in peri-menopausal and post-menopausal abnormal uterine bleeding: A 2 years study. J Clin Diagn Res 2013;7:2774.
Pathak S, Joshi S, Kendre D, Jaison J, Banwaskar P. Study of organic lesions causing abnormal uterine bleeding (AUB). Indian Journal of Basic and Applied Medical Research; 2015;4:171-8.
Haq K, Chowdhury SF, Mannan M, Ivy R, Tasnim KS. Transvaginal ultrasonography is the diagnostic method for evaluation of abnormal uterine bleeding. J Shaheed Suhrawardy Med Coll 2009;1:11-3.
Alalaf SK, Mohammed SS, Muhammad PR. A prospective comparison of transvaginal transabdominal ultrasound and diagnostic curettage in the evaluation of endometrial pathology in Erbil. Zanco J Med Sci 2016;20:1206-12.
Deshpande SS, Phatak SV. A Rare Case of Bilateral Multiple Ovarian Dermoids with Uterine Fibroid and Ectopic Kidney. J Datta Meghe Inst Med Sci Univ 2019:14:39-41. Available from: https://doi.org/10.4103/jdmimsu.jdmimsu_79_18
. [Last accessed on 2019 Sep 28].
Selvanathan S, Acharya N, Singhal S. Quality of Life after Hysterectomy and Uterus-Sparing Hysteroscopic Management of Abnormal Uterine Bleeding or Heavy Menstrual Bleeding. J Midlife Health 2019;2:63-9. Available from: https://doi.org/10.4103/jmh.JMH_15_19
. [Last accessed on 2019 Sep 28].
Wankhade A, Vagha S, Shukla S, Bhake A, Laishram S, Agrawal D, et al
. 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. Available from: https://doi.org/10.4103/jdmimsu.jdmimsu_70_18
. [Last accessed on 2019 Sep 28].
Gadge A, Acharya N, Shukla S, Phatak S. Comparative Study of Transvaginal Sonography and Hysteroscopy for the Detection of Endometrial Lesions in Women with Abnormal Uterine Bleeding in Perimenopausal Age Group. J SAFOG 2018;10:155-60. Available from: https://doi.org/10.5005/jp-journals-10006-1580
. [Last accessed on 2019 Sep 28].
Phatak S, Shrivastav D, Marfani G, Daga S, Madurwar K, Samad S. “Transvaginal Sonography and Elastography Evaluation of Ectopic Pregnancy.” Journal of Datta Meghe Institute of Medical Sciences University 2019;14:86-9. Available from: https://doi.org/10.4103/jdmimsu.jdmimsu_13_19
. [Last accessed on 2019 Sep 28].
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]