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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 28-32

Significance of endometrial thickness on transvaginal sonography in heavy menstrual bleeding


1 Department of Obstetrics and Gynaecology, Government Medical College, Ambedkar Nagar, Lucknow, Uttar Pradesh, India
2 Department of Obstetrics and Gynaecology, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission09-Dec-2018
Date of Acceptance29-Jan-2019
Date of Web Publication19-Jun-2019

Correspondence Address:
Rekha Sachan
Department of Obstetrics and Gynaecology, King George Medical University, C-28, Sec-J Aliganj, Lucknow - 226 024, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrsm.jcrsm_43_18

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  Abstract 


Background: Heavy menstrual bleeding (HMB) is defined as excessive menstrual blood loss which interferes with a woman's physical, social, emotional, and/or material quality of life. This is the most distressing complication in perimenopausal women which affects the quality of life.
Aims: This study aimed to evaluate endometrial thickness (ET) by ultrasound and histopathological examination and their correlation with HMB in perimenopausal women.
Materials and Methods: This retrospective analysis was carried out over 1 year. A total of 120 women of 40–55 years' age group who presented with abnormal bleeding pattern were included in the study. These women underwent clinical examination, investigations and ultrasound examination followed by endometrial biopsy.
Results: Majority of the women (47.5%) had menstrual disturbance in the age group of 40–45 years followed by 45.8% of women in the age group of 46–50 years. Menorrhagia was the most common complaint found in 65 (54.2%) women, 10 (8.3%) women suffered from metrorrhagia, 18 (15%) had polymenorrhea, and 22 (18.3%) women had amenorrhea followed by heavy bleeding. Proliferative endometrium was found in 90 (75%), secretory endometrium in 8 (6.7%) and simple hyperplasia without atypia in 3 (2.5%) of the women in the study population. Simple hyperplasia with atypia was observed in 2 women (1.7%), 3 women (2.5%) had complex hyperplasia without atypia, and 1 woman (0.83%) had complex hyperplasia with atypia. Endometritis was present in 5 (4.2%) cases and atrophic endometrium was found in 3 (2.5%)cases and atrophic endometrium was found in 2.5% (3). No endometrial biopsy specimen was suggestive of endometrial carcinoma. Simple hyperplasia with atypia was detected when ET was 11–15 mm and 16–20 mm. Complex hyperplasia without atypia was detected with ET >16–20 mm and >20 mm. Only one case had complex hyperplasia with atypia where ET was >20 mm. No abnormal endometrial pathology was detected when ET was below 11 mm.
Conclusions: Increased ET on transvaginal ultrasound had association with abnormal endometrial tissue histopathology in women with HMB.

Keywords: Endometrial biopsy, heavy menstrual bleeding, histopathological examination, perimenopausal women


How to cite this article:
Singh M, Sachan R, Yadav A. Significance of endometrial thickness on transvaginal sonography in heavy menstrual bleeding. J Curr Res Sci Med 2019;5:28-32

How to cite this URL:
Singh M, Sachan R, Yadav A. Significance of endometrial thickness on transvaginal sonography in heavy menstrual bleeding. J Curr Res Sci Med [serial online] 2019 [cited 2019 Dec 11];5:28-32. Available from: http://www.jcrsmed.org/text.asp?2019/5/1/28/260639




  Introduction Top


Abnormal uterine bleeding is a commonly encountered problem in perimenopausal and postmenopausal women and contributes to 70% of gynecological outpatient visits in this age group.[1] In perimenopausal age, the menstrual pattern might change due to some hormonal disturbance or pathological conditions. Heavy menstrual bleeding (HMB) is defined as excessive menstrual blood loss which interferes with a woman's physical, social, emotional, and/or material quality of life. It can occur alone or in combination with other symptoms.[2] These women present with different menstrual problems such as menorrhagia, metrorrhagia, polymenorrhea, dysfunctional uterine bleeding, and HMB.[3]

Abnormal uterine bleeding is reported to occur in 9%–14% of women between menarche and menopause. In India, the reported prevalence of abnormal bleeding is around 17.9%.[4] The International Federation of Gynecology and Obstetrics introduced a new classification in 2011 for abnormal bleeding pattern. The system is based on the acronym PALM-COEIN. PALM stands for Polyps, Adenomyosis, Leiomyoma, Malignancy. COEIN stands for Coagulopathy, Ovulatory disorder, Endometrial causes, Iatrogenic, and not classified.[5]

In 10% of premenopausal women with abnormal uterine bleeding, histological finding was suggestive of endometrial hyperplasia and 6% of postmenopausal women with uterine bleeding reported endometrial carcinoma.[6] Thus, thorough clinical examination and investigation is required. Ultrasound is thefirst-line investigation to exclude any structural pathology from nonstructural causes. This is a good initial screening tool and noninvasive method.

The endometrial pattern can be detected accurately by histopathological examination (HPE). An endometrial biopsy is a safe and simple office-based procedure. It is an easily available, very cost-effective method, with minimum complication. It has 91% sensitivity and 98% specificity for detecting cancer. It also has 82.3% sensitivity and 98% specificity for detecting hyperplasia with atypia.[7]

This study was carried out to evaluate endometrial thickness (ET) by ultrasound and HPE of endometrium and its clinical correlation in perimenopausal women with HMB.


  Materials and Methods Top


This retrospective study was carried out in the Department of Obstetrics and Gynaecology of a tertiary care center in Uttar Pradesh, India, over a period of 1 year from July 2017 to July 2018. A total of 120 perimenopausal and postmenopausal women of age group 40–55 years, who visited the outpatient department with complaints of HMB and underwent endometrial biopsy, were analyzed. All data were recorded which included age, parity, onset, duration of complaints, interval and amount of bleeding, obstetrical, medical, and surgical interventions and any previous treatment history. All women were clinically evaluated for general, systemic, and gynecological examination including per-speculum and per-vaginal examination. All patients were subjected to routine investigations and ultrasound to rule out any uterine and adnexal pathology. Women with any history of bleeding disorder, systemic disorder, and previous endometrial biopsy were excluded from the study. Informed consent was obtained from all the patients. After transvaginal sonography, endometrial sampling was taken with Karman cannula of 6 mm size, which was inserted into endometrial cavity. The other end of cannula was attached with a 20cc disposable syringe, and endometrial tissue sample was obtained on the same day in perimenopausal women who presented with HMB. Negative suction was created to collect the endometrial tissue from all the uterine walls. No analgesia or anesthesia was given during the procedure. If less amount of tissue was collected, 5 ml of normal saline was pushed with the help of syringe and after that, negative suction was created to collect the endometrial tissues. These tissues were sent to the Department of Pathology for HPE of endometrium. Informed written consent was obtained from each patient for the procedure.

All data were analyzed by simple proportions and percentage.


  Results Top


In this study, 120 perimenopausal women who had different menstrual complaints were evaluated.

HMB was found mainly in the age group of 40–50 years. 57 women (47.5%) who had menstrual disturbances were found in the age group of 40–45 years followed by 55 women (45.8%) in the age group of 46–50 years [Table 1].
Table 1: Demographic feature of perimenopausal women

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Abnormal bleeding was found in 6 (5%) patients with parity 1, 30 (25%) patients had parity 2, 35 (29.2%) women had parity 3, 37 (30.8%) women had parity 4, and 11 (9.2%) had parity 5 [Table 1].

Perimenopausal women had different menstrual complaints including menorrhagia (HMB) in 65 (54.2%) women, metrorrhagia in 10 (8.3%), polymenorrhea in 18 (15%), amenorrhea in 22 (18.3%) followed by heavy bleeding, and 5 (4.1%) of women had hypomenorrhea [Table 2].
Table 2: Abnormal bleeding pattern in perimenopausal women

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Proliferative endometrium was seen in 90 (75%) cases, secretory endometrium in 8 (6.7%), simple hyperplasia without atypia in 3 (2.5%), simple hyperplasia with atypia in 2 (1.7%), complex hyperplasia without atypia in 3 (2.5%), complex hyperplasia with atypia in 1 (0.83%), endometritis in 5 (4.2%), and atrophic endometrium was found in 3 (2.5%) cases. No endometrial biopsy specimen was suggestive of endometrial carcinoma. Out of the total cases, in 5 (4.2%) cases, no histologic pattern was observed because of inadequate tissue sample, and hence no opinion was obtained [Table 3].
Table 3: Endometrial pattern after histopathological examination

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In the present study, 60 (50%) women with abnormal uterine bleeding had ET 11–15 mm and 44 (36.7%) women had ET between 5 and 10 mm. Twelve (10%) cases had ET >15 mm. On ultrasound examination, 30 cases of fibroid uterus, 44 cases of bulky uterus with pelvic inflammatory disease, and 5 cases of adenomyosis were reported. Twelve cases were diagnosed with a thickened endometrium. No case was detected with endometrial malignancy. In 29 cases, no abnormality was detected on ultrasonography [Table 4].
Table 4: Characteristic features on transvaginal ultrasound

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In the present study, endometrial hyperplasia was detected when ET was at least >11 mm. Simple hyperplasia with atypia was detected when ET was 11–15 mm and 16–20 mm. Complex hyperplasia without atypia was detected with ET was >16–20 mm and >20 mm. Only one case had complex hyperplasia with atypia where ET was >20 mm [Table 5]. No endometrial abnormality was detected with ET < 5 mm.
Table 5: Correlation of endometrial thickness (mm) with histopathological finding

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  Discussion Top


Abnormal bleeding pattern is defined as any deviation from a normal menstrual pattern that differs in regularity, frequency, and duration, and quantity of menstrual flow.[8] Abnormal uterine bleeding causes significant alteration in the lifestyle including decreased work capacity, weakness, anxiety, depression, and social embarrassment, and it also compromises sexual function. Anovulatory bleeding is usually heavy, prolonged, and irregular, which is common in perimenopausal women. It is associated with endometrial hyperplasia and occasionally with endometrial carcinoma.[9] The risk of endometrial hyperplasia may exceed 30% in perimenopausal women with abnormal uterine bleeding.[10]

In the present study, menstrual disorder was observed in 57 (47.5%) cases in the age group of 40–45 years followed by age group of 46-50 years. One author reported menstrual disorders to be common in the age group of 41–50 years.[11] Menorrhagia was the most common symptom present in 54.2% of cases in our study; similarly, another author reported menorrhagia to be the major clinical symptom in perimenopausal women.[12] Babbar et al. also reported the most common presentation during perimenopause to be menorrhagia (62.1%).[13]

In the present study, proliferative endometrium was the most common endometrial finding in perimenopausal women, observed in 75% of the cases. One study reported that 75% of cases had proliferative endometrium.[14] Another study by Acharya et al. reported that proliferative endometrium was the most common finding on HPE.[15] In the present study, secretory endometrium was found in 6.7% of women; in contrast, Jetley et al. reported that secretory endometrium was the most common finding found in 32.4% followed by proliferative endometrium.[16] Another author reported that secretory endometrium was associated with 23% of perimenopausal abnormal uterine bleeding.[17]

In our study, chronic endometritis was found in only 0.7% of patients. Similarly, Gopalan and Khan et al. reported the corresponding rate to be 1.1% and 0.6%, respectively.[18],[19] On the contrary, it was reported to be higher (6.1%) in a study conducted by another author.[20] In our study, endometrial hyperplasia was found in 7.5% of cases, whereas Talat Mirza et al. reported it to be 22% and Babbar et al. reported it to be 19.8%.[13],[21] No hyperplasia was detected when ET was <11 mm; similarly, Gazala and Pillai did not found any major endometrial pathology when ET was <14 mm and 14.9 mm, respectively.[22],[23]

No abnormal endometrial pathology was observed when ET was below 11 mm in our study. Getpook et al. also reported that, if ET was of 8 mm or less, it is less likely to be associated with malignant pathology in perimenopausal women with abnormal uterine bleeding.[24]


  Conclusions Top


In our study, simple hyperplasia with atypia was detected when ET was ≥11–16 mm, complex hyperplasia without atypia was found when ET was ≥16–20 mm. Only one endometrial sample with ET >20 mm reported complex hyperplasia with atypia. No endometrial abnormality was detected with thickness <5 mm. Transvaginal ultrasound and endometrial tissue histopathology are necessary tools for detecting endometrial tissue pathology in women of perimenopausal age suffering with heavy menstrual bleeding.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mahajan N, Aggarwal M, Bagga A. Health issues of menopausal women in North India. J Midlife Health 2012;3:84-7.  Back to cited text no. 1
    
2.
Heavy Menstrual Bleeding: Assessment and Management (NG88). NICE Guideline Published; 14 March, 2018. Available from: http://www.nice.org.uk/guidance/ng88. [Last accessed on 2019 Jan 25].  Back to cited text no. 2
    
3.
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.  Back to cited text no. 3
    
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Sharma A, Dogra Y. Trends of AUB in tertiary centre of Shimla hills. J Midlife Health 2013;4:67-8.  Back to cited text no. 4
    
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Munro MG, Critchley HO, Broder MS, Fraser IS; FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet 2011;113:3-13.  Back to cited text no. 5
    
6.
Armstrong AJ, Hurd WW, Elguero S, Barker NM, Zanotti KM. Diagnosis and management of endometrial hyperplasia. J Minim Invasive Gynecol 2012;19:562-71.  Back to cited text no. 6
    
7.
Dijkhuizen FP, Mol BW, Brölmann HA, Heintz AP. The accuracy of endometrial sampling in the diagnosis of patients with endometrial carcinoma and hyperplasia: A meta-analysis. Cancer 2000;89:1765-72.  Back to cited text no. 7
    
8.
Fraser IS, Critchley HO, Broder M, Munro MG. The FIGO recommendations on terminologies and definitions for normal and abnormal uterine bleeding. Semin Reprod Med 2011;29:383-90.  Back to cited text no. 8
    
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Singh S, Best C, Dunn S, Leyland N, Wolfman WL; Clinical Practice – Gynaecology Committee. Abnormal uterine bleeding in pre-menopausal women. J Obstet Gynaecol Can 2013;35:473-5.  Back to cited text no. 9
    
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Salvi A, Mital P, Hooja N, Batar A, Soni P, Beniwal R. Spectrum of endometrial histopathology in women presenting with abnormal uterine bleeding. Sch J Appl Med Sci 2015;3:1-4.  Back to cited text no. 10
    
11.
Thanyapa W. Histopahological result of fractional curettage in Satuk Hospital. Med J Srisaket Surin Buriram Hosp 2010;25:93-100.  Back to cited text no. 11
    
12.
Bhosle A, Fonseca M. Evaluation and histopathological correlation of abnormal uterine bleeding in perimenopausal women. Bombay Hosp J 2010;52:69-72.  Back to cited text no. 12
    
13.
Babbar K, Jogi S, Arya RC. Clinical pattern and spectrum of endometrial pathologies in perimenopausal and post-menopausal women: Experience in a tertiary care institute. JSAFOMS 2015;3:9-14.  Back to cited text no. 13
    
14.
Somboonporn W, Seejorn K, Paojirasinchai S, Puntase S. Comparison between Karman cannula and uterine curette in uterine curettage. Srinagarind Med J 2000;151:18-22.  Back to cited text no. 14
    
15.
Acharya V, Mehta S, Rander A. Evaluation of dysfunctional uterine bleeding by TVS, hysteroscopy and histopathology. J Obstet Gynecol India 2003;53:170-7.  Back to cited text no. 15
    
16.
Jetley S, Rana S, Jairajpuri ZS. Morphological spectrum of endometrial pathology in middle-aged women with atypical uterine bleeding: A study of 219 cases. J Midlife Health 2013;4:216-20.  Back to cited text no. 16
    
17.
Desai K, Patole KP, Kathaley M. Endometrial evaluation by histopathology in abnormal uterine bleeding in perimenopausal and postmenopausal patient MVP. J Med Sci 2014;1:75-9.  Back to cited text no. 17
    
18.
Gopalan U, Rajendiran S, Karnaboopathy R. Study of endometrial histopathology in women with abnormal uterine bleeding. Int J Reprod Contracept Obstet Gynecol 2017;6:824-8.  Back to cited text no. 18
    
19.
Khan S, Hameed S, Umber A. Histopathological pattern of endometrium on diagnostic D and C in patients with abnormal uterine bleeding. Ann King Edward Med Univ 2011;17:166-70.  Back to cited text no. 19
    
20.
Jain M, Gorania N. Abnormal uterine bleeding: A study of menstrual patterns and histopathological patterns in perimenopausal females. Int J Reprod Contracept Obstet Gynecol 2015;4:109-12.  Back to cited text no. 20
    
21.
Mirza T, Akram S, Mirza A, Aziz S, Mirza T, Mustansar T. Histopathological pattern of abnormal uterine bleeding in endometrial biopsies. J Basic Appl Sci 2012;8:114-7.  Back to cited text no. 21
    
22.
Gazala AA. Role of TVS in cases of abnormal uterine bleeding. Prof Med J 2009;1:127-34.  Back to cited text no. 22
    
23.
Pillai SS. Sonographic and histopathological correlation and evaluation of endometrium in perimenopausal women with abnormal uterine bleeding. Int J Reprod Contracept Obstet Gynecol 2016;24;3:113-7.  Back to cited text no. 23
    
24.
Getpook C, Wattanakumtornkul S. Endometrial thickness screening in premenopausal women with abnormal uterine bleeding. J Obstet Gynaecol Res 2006;32:588-92.  Back to cited text no. 24
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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