|Year : 2020 | Volume
| Issue : 2 | Page : 109-113
Significance of endometrial thickness on transvaginal ultrasonography in abnormal uterine bleeding
Ankur Nama, Swati Kochar, Arun Kumar, Neha Suthar, Laxmi Poonia
Department of Obstetrics and Gynaecology, S. P. Medical College and Associated Group of Hospitals, Bikaner, Rajasthan, India
|Date of Submission||18-Mar-2020|
|Date of Decision||16-Apr-2020|
|Date of Acceptance||01-Jun-2020|
|Date of Web Publication||21-Dec-2020|
1 B 2 Pawan Puri, Bikaner, Rajasthan
Source of Support: None, Conflict of Interest: None
Background: Abnormal uterine bleeding (AUB) is characterized by excessive flow at the time of an expected menses or by bleeding at abnormal or unexpected times.
Aims: The study aimed to evaluate the endometrial thickness (ET) on ultrasound and histopathological examination and their correlation in patients with AUB.
Materials and Methods: The present prospective study was conducted on 100 female patients of all age groups attending the Department of Obstetrics and Gynaecology at S. P. Medical College and A. G. H. Bikaner, Rajasthan, India, from June 2018 to May 2019, with a clinical diagnosis of AUB. These women underwent clinical examination, investigations, and ultrasound examination, followed by endometrial biopsy.
Results: The mean age of the patients was 43.14 ± 10.44 years. Menometrorrhagia (28%) was the chief complaint. The mean ET in the premenopausal group (7.568 ± 2.774 mm) was more than the postmenopausal group (7.388 ± 4.138 mm) (P = 0.795). Proliferative endometrium (66%) was the most common endometrial pattern, followed by secretory endometrium (16%), endometrial hyperplasia (7%), adenocarcinoma (3%), atrophic endometrium (2%), and pseudodecidual reaction (1%). Out of the total cases, in 5 (5%) cases, no histopathological pattern was observed because of inadequate sample. After applying analysis of variance, the association between histopathological findings and mean ET was found to be statistically significant (P = 0.00). When ET was >12 mm, endometrial hyperplasia and adenocarcinoma were observed in six and one cases, respectively.
Conclusion: ET can be used as a marker of endometrial hyperplasia and malignancy; however, it cannot replace comprehensive tissue diagnosis.
Keywords: Abnormal uterine bleeding, adenocarcinoma, endometrial hyperplasia, endometrial thickness, histopathological examination
|How to cite this article:|
Nama A, Kochar S, Kumar A, Suthar N, Poonia L. Significance of endometrial thickness on transvaginal ultrasonography in abnormal uterine bleeding. J Curr Res Sci Med 2020;6:109-13
|How to cite this URL:|
Nama A, Kochar S, Kumar A, Suthar N, Poonia L. Significance of endometrial thickness on transvaginal ultrasonography in abnormal uterine bleeding. J Curr Res Sci Med [serial online] 2020 [cited 2021 Jun 19];6:109-13. Available from: https://www.jcrsmed.org/text.asp?2020/6/2/109/304197
| Introduction|| |
Approximately one-third of all gynecological consultations are related to abnormal vaginal bleeding, and this proportion rises to 70% in the peri- and postmenopausal years. Abnormal uterine bleeding (AUB) incorporates a vast range of presentations which include heavy cyclical bleeding, frequent menstrual cycles, frequent and heavy cyclical bleeding, irregular bleeding, and postcoital bleeding., It is a mysterious problem both for the gynecologists and patients frequently requiring many diagnostic modalities which include ultrasonography (USG) and endometrial tissue biopsy for further evaluation.,
The basic PALM-COEIN classification system, approved by the International Federation of Gynecology and Obstetrics, uses the term “abnormal uterine bleeding” paired with terms that describe associated bleeding patterns (“heavy menstrual bleeding” or “intermenstrual bleeding”), a qualifying letter (or letters) to indicate its etiology (or etiologies), or both. It includes polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified.
There are different modalities to diagnose the cause of AUB, which is an important step for deciding the management of the patient. Their investigations include USG with endometrial thickness (ET), blood investigations, and endometrial biopsy. Among them, endometrial biopsy is considered gold standard; however, endometrial biopsy is associated with morbidity in terms of pain and risks of anesthesia, so ET is emerging as an important modality in patients with AUB for diagnosis.
In a meta-analysis, it was revealed that 96% of women with endometrial cancer and 92% of those with other endometrial diseases had ET of >5 mm, whether they used hormone replacement therapy or not.
Our study was carried out to evaluate the correlation between ET and histopathological findings in women with AUB.
| Materials and Methods|| |
After receiving approval from the institutional ethical committee, the present prospective study was carried out in the Department of Obstetrics and Gynaecology at S. P. Medical College and Associated Group of Hospitals, Bikaner, Rajasthan, India, over a period of 1 year from June 2018 to May 2019. A total of 100 women of all age groups with a clinical diagnosis of AUB were included in the study. Patients having acute inflammatory disorders of the genital tract, a viable pregnancy, and cervical carcinoma were excluded from the study. After obtaining a detailed clinical history, the patients went through a physical examination and transvaginal USG for ET, and all relevant investigations were carried out. The procedure was well explained to the patients, and their consent was obtained. Under all aseptic conditions, endometrial aspiration was carried out in the operation theater. Endometrial aspiration was performed by a plastic disposable Karman's cannula measuring 4 mm by the gynecologist in the operation theater and without administering anesthesia. The cannula was inserted into the endometrial cavity and connected to 20 cc disposable syringe. Negative pressure was then created by withdrawing the piston and maintained, while the mucosa was uniformly aspirated. The suction was released after aspiration, and the cannula was withdrawn. After removal of the cannula, the surface was wiped to avoid contamination by cervical and vaginal cells. Material obtained was saved in a container. The samples were fixed in 10% formalin. The samples were sent to the Department of Pathology for histopathological examination (HPE) of the endometrium.
Epi info statistical software (Epi info., USA) by Centre for Disease Control and prevention, USA was used for data analysis. The association of the mean ET with HPE findings was calculated by one-way analysis of variance (ANOVA) test. The rest of all data were presented in frequencies and percentages. P < 0.05 was considered statistically significant.
| Results|| |
In our study, 100 women of all age groups with a clinical diagnosis of AUB were evaluated. A maximum number of patients (55%) belonged to the age group of 36–45 years, followed by 26% in the age group of >45 years, 15% in the age group of 26–35 years, and 4% in the age group of <26 years. The age of the youngest patient was 21 years. Six percent of the patients were nulliparous, 3% were para-1, 19% were para-2, 31% were para-3, and 41% were para-4, and above [Table 1].
Chief complaints of our patients are shown in [Table 2].
In our study, fibroid (43%) was the most common finding on USG. Seven percent of the patients had adenomyosis, 3% had thickened endometrium, and 1% had endometrial polyp in their USG. In our study, 79 (79%) women had ET between 4.1 and 8 mm, 10 (10%) women had ET between 8.1 and 12 mm, 5 (5%) women had ET between 12.1 and 16 mm, and 3 (3%) women had ET of 4 mm and <16 mm [Table 3].
|Table 3: Distribution of patients according to ultrasound findings and endometrial thickness|
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Proliferative endometrium (66%) was the most common endometrial pattern, followed by secretory endometrium (16%), endometrial hyperplasia (7%), adenocarcinoma (3%), atrophic endometrium (2%), and pseudodecidual reaction (1%). Out of the total patients, in 5 (5%) patients, no histopathological pattern was observed because of inadequate sample [Table 4]. All five patients had ET between 4.1 and 8 mm.
In our study, endometrial hyperplasia was noted in 5 (5%) women when ET was between 12.1 and 16 mm, in 1 (1%) woman when ET was between 8.1 and 12 mm, and in 1 (1%) woman when ET was >16 mm. Endometrial adenocarcinoma was observed in 2 (2%) women when ET was between 4.1 and 8 mm and in 1 (1%) woman when ET was >16 mm. When ET was <4.1 mm, no endometrial abnormality was detected [Table 5].
|Table 5: Histopathological examination findings according to endometrial thickness (mm)|
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After applying ANOVA, the association between histopathological findings and mean ET was found to be statistically highly significant (P = 0.00) [Table 6].
|Table 6: Association between histopathological examination findings and endometrial thickness (mm)|
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| Discussion|| |
AUB is defined as in the absence of pregnancy, bleeding from the uterine corpus that is abnormal in regularity, volume, frequency, or duration., Anovulatory bleeding is a range of abnormal menstrual bleeding that occurs in women without medical disease or pelvic disorder. AUB is associated with significant modification in the lifestyle, which includes weakness, anxiety, depression, sexual function, social awkwardness, and diminished work capacity.
In the present study, a maximum number of patients were observed in the age group of 36–45 years (55%), followed by the age group of >45 years (26%). In the study by Saikia and Sharma, they reported that most cases of AUB were in the age group of 36–45 years (41.7%), followed by 46–55 years (40.3%), <35 years (17.4%), and >55 years (7%).
In our study, menometrorrhagia was the most common presenting complaint (28%). In the study by Tansathit et al., they reported that metrorrhagia (45.1%) was the most common presenting complaint. Singh reported menorrhagia (40%) as the most common presentation of AUB.
In the present study, proliferative endometrium (66%) was the most common endometrial pattern observed. Singh also observed proliferative endometrium (23.5%) as the most common endometrial pattern. Proliferative phase (34.5%) was the most common histopathological pattern observed in the study by Rezk et al. In our study, secretory endometrium was present in 16% of the patients. Singh reported secretory endometrium in 18.2% of cases, whereas Abdelazim et al. observed secretory endometrium in 23.57% of cases.
In our study, endometrial hyperplasia was noted in 7% of the patients. It was comparable to the study by Singh et al., in which endometrial hyperplasia was found in 7.5% of cases. Singh reported 6.08% of cases of endometrial hyperplasia. In our study, adenocarcinoma was reported in 3% of the patients. Singh noted 2.6% of cases of adenocarcinoma, whereas Saikia and Sharma reported 3.5% of cases of adenocarcinoma.
In our study, six out of seven cases of endometrial hyperplasia were noted when ET was >12 mm, and the rest one case had ET between 8.1 and 12 mm. One out of three cases of adenocarcinoma had ET >16 mm. The rest two cases of adenocarcinoma had ET between 4.1 and 8 mm because these patients had bleeding at the time of presentation. No endometrial abnormality was detected when ET was <4.1 mm. In the study by Singh et al., they reported that there was no hyperplasia below 11 mm and no endometrial abnormality when ET was <5 mm. In the study by Getpook and Wattanakumtornkul, they reported that in women with AUB, malignancy is less likely associated, if ET was <8 mm.
From our study, it was concluded that in patients whose ET >12 mm, it is advisable to go for HPE to rule out endometrial hyperplasia and adenocarcinoma. However, if ET is <12 mm, patients can be managed conservatively.
Till present date, there are no other better alternatives and consensus for any other terminology. AUB is the most commonly used terminology till now. There is no clear consensus regarding the cutoff values of ET, so this study will add to the knowledge of the previous studies.
| Conclusion|| |
In our study, six out of seven cases of endometrial hyperplasia were noted when ET was >12 mm. No endometrial abnormality was detected when ET was <4.1 mm. Comprehensive tissue diagnosis remains the gold standard as there are no sonographic characteristics that correspond perfectly with histopathology. ET can be used as a marker of endometrial hyperplasia and malignancy; however, it cannot replace comprehensive tissue diagnosis.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Mahajan N, Aggarwal M, Bagga A. Health issue of menopausal women in North India. J Midlife Health 2012;3:84-7.
American College of Obstetricians and Gynecologists. ACOG practice bulletin No. 149: Endometrial cancer. Obstet Gynecol 2015;125:1006-26.
American College of Obstetricians and Gynecologists. ACOG committee opinion no. 557: Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Obstet Gynecol 2013;121:891-6.
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.
Bindman RS, Kerlikowske K, Feldstein A. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. J Am Med Assoc 1998;280:1510-7.
Committee on Practice Bulletins – Gynecology. Practice bulletin No. 128: Diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol 2012;120:197-206.
Sweet MG, Schmidt-Dalton TA, Weiss PM, Madsen KP. Evaluation and management of abnormal uterine bleeding in premenopausal women. Am Fam Physician 2012;85:35-43.
Saikia JB, Sharma A. Endometrial aspiration cytology by Karman's cannula with histopathological correlation. Int J Sci Res 2017;6:1679-83.
Tansathit T, Chichareon S, Tocharoenvanich S, Dechsukhum C. Diagnostic evaluation of Karman endometrial aspiration in patients with abnormal uterine bleeding. J Obstet Gynaecol Res 2005;31:480-5.
Singh P. Abnormal uterine bleeding- evaluation by endometrial aspiration. J Midlife Health 2018;9:32-5.
Rezk M, Sayyed T, Dawood R. The effectiveness and acceptability of pipelle endometrial sampling versus classical dilatation and curettage: A three-year observational study. Gynecol Obstet Invest 2016;81:537-42.
Abdelazim IA, Aboelezz A, Abdulkareem AF. Pipelle endometrial sampling versus conventional dilatation & curettage in patients with abnormal uterine bleeding. J Turk Ger Gynecol Assoc 2013;14:1-5.
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. [Full text]
Getpook C, Wattanakumtornkul S. Endometrial thickness screening in premenopausal women with abnormal uterine bleeding. J Obstet Gynaecol Res 2006;32:588-92.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]