ROLE OF HYSTEROSCOPY IN PATIENTS WITH ABNORMAL UTERINE BLEEDING AND ITS HISTOPATHOLOGICAL CO-RELATION

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ROLE OF HYSTEROSCOPY IN PATIENTS WITH ABNORMAL UTERINE BLEEDING AND ITS HISTOPATHOLOGICAL CO-RELATION

V. Pooja, B. G. Lepakshi, Geetha Bhaktha and S. Prashanth *

Department of Obstetrics & Gynaecology, Shimoga Institute of Medical Sciences, Shimoga, Karnataka, India.

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ABSTRACT: Introduction: Abnormal uterine bleeding (AUB) is a common gynecological concern that presents significant diagnostic challenges, particularly because it encompasses a wide range of possible underlying causes, from benign conditions like polyps and fibroids to more serious pathologies such as endometrial cancer. This study aimed to assess the diagnostic accuracy of hysteroscopy in AUB and its concordance with histopathological findings. Materials and Methods: Fifty consecutive women, aged 30-70 years, with AUB were prospectively enrolled. Each underwent hysteroscopy followed by dilatation and curettage (D&C). Clinical data, hysteroscopic findings, and histopathological analysis of endometrial samples were systematically recorded and analyzed. Results: The average age of participants was 43.8 years, with endometrial polyps being the most common abnormality detected on hysteroscopy, accounting for 30% of cases. Hysteroscopy demonstrated 100% sensitivity and 92% specificity. Histopathology, however, missed 10% of polyps and 4% of hyperplasia cases. Mild anemia was present in 66% of patients, indicating potential blood loss due to AUB. Conclusion: Hysteroscopy showed a high diagnostic yield for structural causes of AUB, particularly in detecting endometrial polyps. Its integration into the diagnostic algorithm for AUB enhances diagnostic accuracy and can guide appropriate management decisions. Given its high sensitivity, hysteroscopy is a valuable tool for the evaluation and treatment planning of women with AUB, potentially reducing diagnostic delays and improving clinical outcomes.

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Keywords: Abnormal uterine bleeding, hysteroscopy, Histopathological correlation, Diagnostic accuracy, gynecology

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INTRODUCTION: Abnormal uterine bleeding (AUB) means any deviation from the normal menstrual cycle in respect of regularity, frequency, volume, duration or amount of bleeding during or in between periods ^1-3.

The term heavy menstrual bleeding is used if the bleeding is >80ml or if the duration of bleeding >7 days, frequent cycles if the duration of the cycle is <24 days, infrequent cycles if duration of the cycle is >38 days, scanty menses if bleeding <5ml.

More than one-third of gynecologic consultations and nearly two-thirds of hysterectomies are performed for the complaint of menstrual dysfunction. The proportion of women seeking gynecological consultation for AUB rises to more than 2/3rd when peri & postmenopausal age group is considered ⁴. Goals of clinical management are primarily dependent on attaining a correct etiological diagnosis. The patient history and physical and pelvic examinations attempt to determine the site of the bleeding and its source. Information gathered from this will suggest what direction the investigation would take. Traditionally, dilatation and curettage and ultrasonography were the most common investigations employed in the evaluation of the causes of AUB ⁵ But this detects the cause in less than 50% of the cases ⁶.

Dilatation and curettage is a blind procedure, mainly diagnostic, useful in AUB to study the hormonal pattern causing abnormal bleeding. The endometrial sample collected is sent to the pathologist to study the histological pattern ^7-10. Hysteroscopy is the inspection of the uterine cavity by endoscopy. It allows the diagnosis of intrauterine pathologies such as endometrial hyperplasia and early diagnosis of endometrial carcinoma and uterine polyps. It also serves as a method for surgical intervention (operative hysteroscopy) for various gynecological conditions such as submucous myoma, intrauterine adhesions, septa, and corneal and interstitial tubal obstruction.

Traditionally D and C used to be mainstay of investigation for AUB but it is not accurate for diagnosing focal intrauterine lesion or located in areas difficult to curette so anything which improve the accuracy of diagnosing the cause of bleeding can reduce the frequency of hysterectomy as a cure. Dilatation and curettage i.e. the blind surgery method is now replaced by ‘see and treat’ strategy ^11-13. Now hysteroscopy act as a surgeon’s eye within the uterine cavity. If the correct etiology is not found, the diagnosis is difficult and hence the management of the condition. This study was taken up to analyze the role of hysteroscopy in evaluating abnormal uterine bleeding and contribution of the procedure for clinical diagnosis and treatment. It also aims to correlate histopathological results with hysteroscopy findings.

MATERIALS AND METHODS:

Study Design and Setting: This prospective study titled "Diagnostic role of hysteroscopy in abnormal uterine bleeding and its histopathological correlation" was conducted within the Department of Obstetrics and Gynecology at our institution. The study aimed to evaluate the diagnostic efficacy of hysteroscopy in patients presenting with abnormal uterine bleeding (AUB).

Patient Selection and Criteria: Fifty consecutive cases of AUB were included in the study.

Inclusion Criteria:

1. Patients with age between 30 and 70years with AUB.
2. Both parous and nulliparous women.

Exclusion Criteria:

1. Patients who required immediate intensive care.
2. Patients with profuse bleeding.
3. Cases with large or multiple fibroids.
4. Infection in the uterine tract.
5. Cases of cervical carcinoma.

Hysteroscopic Procedure: Hysteroscopy was performed systematically post-menstrually in most cases, with exceptions made for patients with irregular menstrual cycles or continuous vaginal bleeding. The procedure was conducted in an operation theatre under intravenous anesthesia, utilizing a 4 mm hysteroscope with a 30° oblique lens (Kalelkar, India) and normal saline as the distending medium. Comprehensive evaluations of the cervical canal, internal os, and uterine cavity were meticulously documented.

Histopathological Evaluation: Following hysteroscopy, dilatation and curettage were performed to obtain tissue samples, which were then preserved in formalin and subjected to histopathological examination. The correlation between hysteroscopic findings and histopathological results was analyzed to assess diagnostic accuracy and inform subsequent patient management decisions.

This structured approach ensured systematic data collection and rigorous analysis, facilitating a comprehensive evaluation of the diagnostic utility of hysteroscopy in cases of AUB.

Statistical Analysis: The statistical analysis in the study included descriptive statistics to summarize continuous variables like age and endometrial thickness, and categorical data such as anemia severity and types of endometrial abnormalities.  A comprehensive sensitivity and specificity analysis was meticulously conducted to rigorously evaluate the diagnostic performance of hysteroscopy. This analysis was crucial in determining the accuracy with which hysteroscopy could identify actual cases of endometrial conditions among the participants. The sensitivity measure reflected the test’s ability to correctly identify patients with the condition, while specificity assessed its ability to correctly exclude those without the condition. These metrics are vital for understanding the diagnostic value of hysteroscopy and ensuring reliable clinical assessments.

RESULTS: Out of fifty women, most of the them 23 (46%) belonged to 41- 50 years’ age group, followed by 19 (38%), 5 (10%) and 3(6%) of women belonging to 31- 40 years, 61-70 years and 51-60 years’ age groups respectively. Mean age of presentation was 43.8 years Table 1.

Anemia categorized by measured hemoglobin (Hb) level at the time of hospital attendance of the women in our study. Depending on the reports, anemia was categorized into mild, moderate and severe according to WHO classification of anemia in nonpregnant women. It was seen that majority of women 33(66%) had mild anemia and 9(18%) had moderate anemia, 4 (8%) had severe anemia and 4 (8%) women were free from anemia Table 2.

In our study the endometrial thickness on TVS was predominantly between 5-10mm of 36/50 (72 %) women. Only 5/50 (10%) had endometrial thickness (ET) < 5mm and 9/50 (18%) had ET> 10mm Table 3. The most common presenting menstrual complaint being heavy menstrual bleeding in 60% cases, frequent cycles in 20% cases, post menopausal bleeding in 10% cases and irregular cycles 10% of cases. In this study, abnormal findings on hysteroscopy were found in 27 patients (54%), while in the remaining 23 patients (46%), no abnormality was detected (negative hystroscopic view). The most common abnormal finding was endometrial polyp (15 cases, 30%), followed by endometrial hyperplasia seen in (4 cases, 8%), polypoidal endometrium seen in (3 cases, 6%), sub mucous fibroid seen in (4 cases, 8%) and endometrial carcinoma seen in (1 case, 2%) Table 4. Out of 31 normal cases (60%) reported, 8 case had abnormal finding. The diagnosis of 5 cases of endometrial polyp, 2 cases of endometrial hyperplasia was missed by histopathology.

TABLE 1: AGE DISTRIBUTION OF PARTICIPANTS

Age group	Number	Percentage
31-40yrs	19	38%
41-50yrs	23	46%
51-60yrs	3	6%
61-70 yrs	5	10%

TABLE 2: PREVALENCE OF ANEMIA SEVERITY

	Number	Percentage
Mild anemia	33	66%
Moderate anemia	9	18%
Severe anemia	4	8%
Normal	4	8%

TABLE 3: DISTRIBUTION OF ENDOMETRIAL THICKNESS

Endometrial thickenss	Number	Percentage
<5mm	5	10%
5-10mm	36	72%
>10mm	9	18%

TABLE 4: TYPES OF ENDOMETRIAL ABNORMALITIES

Abnormality	Number	Percentage
Endometrial polyp	15	30%
Endometrial hyperplasia	4	8%
Polypoidal endometrium	3	6%
Fibroid	4	8%
Endometrial carcionma	1	2%

DISCUSSION: Abnormal uterine bleeding is a very common complaint in reproductive, peri-menopausal and post- menopausal age group and forms major bulk of gynecological consultations, management of which depends on diagnostic accuracy. History, clinical examination, ultra-sonography and hysteroscopy are part of the diagnostic evaluation.

The age group in this study was between 30-70 years and the maximum age incidence of AUB was between 40-50 years. Gianninoto et al. found AUB to be common between 30-45 years while Allameh et al between 40-50 years ¹⁴. Panda et al.¹⁵ series had 60% cases of menorrhagia, followed by polymenorrhagia and metrorrhagia.

In our study the most common presenting menstraul complaint being heavy menstrual bleeding in 60% cases, frequent cycles in 20% cases, post menopausal bleeding in 10% cases and irregular cycles 10% of cases. In this study, abnormal findings on hysteroscopy were found in 27 patients (54%), while in the remaining 23 patients (46%), no abnormality was detected (negative hystroscopic view).

The most common abnormal finding was endometrial polyp (15 cases, 30%), followed by endometrial hyperplasia seen in (4 cases, 8%), polypoidal endometrium seen in (3 cases, 6%), sub mucous fibroid seen in (4 cases, 8%) and endometrial carcinoma seen in (1 case, 2%). Wamsteker et al ¹⁶ found endometrial polyp in 19%, endometrial hyperplasia in 12.2%, and submucous myoma in 7.8%.

Study reported by Kumari A et al ¹² shows 53.33% women had mild anaemia (10-10.9 gm %). In their study, moderate (7-9.9 gm %) and severe (<7 gm %) anaemia was found in 16.11% and 6.66% women respectively. On hysteroscopy endometrial polyps appeared as soft, pedunculated or sessile with smooth surface. 15 cases of endometrial polyps were diagnosed by hysteroscopy of which 12 were confirmed by histopathology. In this case the sensitivity was 100% and specificity was 92%. We noted that the diagnostic accuracy in this case was 94% while it was 100% in the study by Panda A et al ¹⁷, a bit lower i.e. 88.6% was noted by Valle RF et al ¹⁸.

A round white coloured bulge with smooth surface as seen on hysteroscopy was diagnosed as submucous myoma. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy in diagnosing submucosal myoma was 100%, 95%, 50%,100% and 96% respectively.

CONCLUSION: Hysteroscopy is an important diagnostic tool in the evaluation of abnormal uterine bleeding and provides valuable insights into planning the management options.

ACKNOWLEDGEMENT: Authors acknowledge the Department of Gynecology and Obstetrics and Administrators of Shimoga Institute of Medical Sciences, Shivamoga. For their support in conducting this study.

Funding: Nil.

Ethical Approval: The study was approved by the Institutional Ethics Committee, Shimoga Institute of Medical Science, Shivamogga, Ref. No.: SIMS/IEC/836/2022-23

CONFLICT OF INTEREST: None declared

REFERENCES:

1. Lasmar RB, Dias R, Barrozo PRM, Oliveira MAP, Coutinho EDSF and Rosa DBD: Prevalence of hysteroscopic findings and histologic diagnoses in patients with abnormal uterine bleeding. Fertil Steril 2008; 89(6): 1803-5.
2. Mishra S and Panda B: Efficacy of ultrasonography and hysteroscopy and their correlation with endometrial histopathology in a case of abnormal uterine bleeding in late reproductive age. AIMDR 2018; 4(5): 10-4.
3. El-Gamal HH, Abd-El-Salam MM, Ghanem RM and Al- Ani S: Role of diagnostic hysteroscopy and histopathology in evaluation of abnormal uterine bleeding. Egypt J Hosp Med 2018; 72(7): 4765-71.
4. Guin G, Sandhu SK, Lele A & Khare S: Hysteroscopy in evaluation of abnormal uterine bleeding. The Journal of Obstetrics and Gynecology of India 2011: 61(5): 546-549.
5. Jones HW and Rock JA: Operative hysteroscopy. In: TeLinde’s Operative Gynecology. 11th ed. Ch. 18. Philadelphia, PA: Wolters Kluwer 2015; 307-36.
6. Patil SG, Bhute SB, Inamdar SA, Acharya NS & Shrivastava DS: Role of diagnostic hysteroscopy in abnormal uterine bleeding and its histopathologic correlation. Journal of Gynecological Endoscopyand Surgery 2009; 1(2): 98.
7. Panda A, Parulekar SV and Gupta A: Diagnostic hysteroscopy in abnormal uterine bleeding and its histopathological correlation. J Obst Gyn India 1999; 175: 74-6.
8. Gianninoto A, Morana C and Campione C: Diagnostic hysteroscopy in abnormal uterine bleeding. Five-years’ experience. Minerva Ginecol 2003; 55: 57-61.
9. van Trotsenburg M, Wieser F and Nagele F: Diagnostic hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal patients. Contrib Gynecol Obstet 2000; 20: 21-6.
10. Wamsteker K: Hysteroscopy in the management of abnormal uterine bleeding in 199 patients. In: Siegler AM, Lindemann HJ, editors. Hysteroscopy: Principles and Practice. Philadelphia, PA: JB Lippincott 1984; 128-131.
11. Sinha P, Yadav N and Gupta U: Use of hysteroscopy in abnormal uterine bleeding: an edge over histopathological examination. J Obstet Gynaecol India 2018; 68(1): 45–50.
12. Kumari A and Kumar R: Abnormal uterine bleeding in perimenopausal age: an observational study. Indian J Obstet Gynecol Res 2018; 5(4): 539-43.
13. Patil SG, Bhute SB, Inamdar SA, Acharya NS and Shrivastava DS: Role of diagnostic hysteroscopy in abnormal uterine bleeding and its histopathologic correlation. J Gynecol Endosc Surg 2009; 1(2): 98–104.
14. Allameh T & Mohammadizadeh F: Diagnostic value of hysteroscopy in abnormal uterine bleeding compared to pathology reports. International Journal of Reproductive BioMedicin 2007; 5(2): 61-64.
15. Panda A, Parulekar SV and Gupta A: Diagnostic hysteroscopy in abnormal uterine bleeding and its histopathological correlation. J Obst Gyn India 1999; 175: 74-6.
16. Wamsteker K: Hysteroscopy in the management of abnormal uterine bleeding in 199 patients. In: Siegler AM, Lindemann HJ, editors. Hysteroscopy: Principles and Practice. Philadelphia, PA: JB Lippincott 1984; 128-131.
17. Panda A, Parulekar SV and Gupta A: diagnostic hysteroscopy in abnormal uterine bleeding and its histopathological correlation. J Obst Gynecol India 1999; 175: 74-76
18. Valle RF: Hysteroscopic evaluation of patients with Abnormal Uterine Bleeding. Surg Gynecol Obstet 1981; 153(4): 521-6.
    

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    How to cite this article:

    Pooja V, Lepakshi BG, Bhaktha G and Prashanth S: Role of hysteroscopy in patients with abnormal uterine bleeding and its histopathological co-relation. Int J Pharm Sci & Res 2025; 16(2): 560-64. doi: 10.13040/IJPSR.0975-8232.16(2).560-64.

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