Abnormal Uterine Bleeding in Perimenopausal Age: Different causes and its relation with histopathology

Introduction: Abnormal uterine bleeding (AUB) is a common gynaecological problem and the principal reason for gynaecological consultation, accounting for up to (20%) of office visits to gynecologists. AUB is defined as any bleeding that does not correspond with the frequency, duration or amount of blood flow of a normal menstrual cycle . It is a symptom and not a disease that occurs in different patterns. The terminology of abnormal uterine bleeding includes the following clinical entities: oligomenorrhoea, polymenorrhoea, menorrhagia, menometrorrahagia, metrorrhagia, midcycle spotting, dysfunctional uterine bleeding, abnormal acute uterine bleeding. Perimenopause is the period 2-8 years preceding menopause and 1 year after the final menses (WHO). Menstrual irregularity occurs in more than one half of all women during the menopausal transition. Menorrhagia is cyclical bleeding at regular interval which is excessive in amount (80 ml) or duration. Menorrhagia is thought to be associated with uterine fibroid, DUB, adenomysis, pelvic infections, endometrial polyp, clotting defects. Polymenorrhagia, intermenstrual bleeding and metrorrhagia are other common disorders at

Perimenopause.There are so many studies on these issues in abroad but few in Bangladesh.To establish evidence based treatment guidelines study on AUB in Bangladeshi perimenopausal women is very important.Moreover endometrial sampling should be considered in all women with abnormal uterine bleeding particularly in those above the age of (40) years and in women who are at increased risk of endometrial cancer 16 .

Patients and Methods:
This study was carried out over a period of 12 months extended from the 1 st January, 2012 till 31 st December, 2012.Two hundred eleven women with different patterns of abnormal uterine bleeding admitted were included in this study.All obstetric causes of AUB (including abortion and pregnancy related causes) were excluded.We analyzed these women by recording age, parity, menstrual symptoms and associated symptoms for clinical evaluation.Transvaginal sonography was performed using vaginal transducer of 6.5 MHZ frequency on Logic Pro 100-GE USA.Endometrial thickness was measured in postmenstrual period ( 7-10 day) at the thickest part of endometrium 1cm from the endometrial myometrial interface at the interface at the fundus in the longitudinal plane as described 17,18 .Clinical impression and TVS reports were correlated.These women underwent D&C for endometrial sampling and specimen sent for histopathological examination (HPE).The HPE reports were analyzed.These women were managed either conservatively depending upon the or surgically response.Histopathological reports of endometrial pattern as well as that of the hysterectomy specimens were correlated with clinical diagnosis and ultrasonographic findings.This study was approved by local ethical Committee.
Women included in the present study were complaining of different patterns of AUB and the majority of them presented clinically with menorrhagia (52%).Similar findings were reported by others.Fibroids are common finding in women with menorrhagia.Menorrhagia in fibroids is due to increased in size of the uterine cavity thereby increasing the surface area of the endometrium, hyperestrogenemia causing endometrial hyperplasia , vascular alteration of the endometrium and obstetric effect of fibroid on uterine vasculature leading to endometrial venule ectasia which causes proximal congestion in the myometrium and the endometrium.Majority of women with uterine fibroid associated with menorrhagia are treated by hysterectomy (58%).In our study , Fibroid uterus was responsible for abnormal uterine bleeding (AUB) in 58% of women and the data concurs with the results from the studies performed in DHQ Hospital and Nishtar Hospital Multan -54.8% and Bombay Hospital -54% 23 .
Adenomyosis is a lesion characterized by the presence within the myometrium of foci consisting of glands and endometrial stroma, located at distance of the junction between the endometrium and the myometrium.it occurs more frequently during perimenopause, being a lesion detected in 20% of surgically treated gynaecological cases.Diagnosis of adenomyosis on clinical findings is usually different 24 .Transabdominal sonography (TAS) does not allow reliable diagnosis of adenomyosis or consistent differentiation from leiomyomas, even transvaginal sonography (TVS) has limitation in tissue characterization.MRI is more helpful to diagnose adenomyosis but expensive.In our study clinically only 6.6% were diagnosed as adenomyosis, USG diagnosed 9% and HPE diagnosed 18%.The reported prevalence of adenomyosis in hysterectomy specimens varies from 5% to70%.Menorrhagia associated with cycles can be treated with or without hormone.The anti-inflammatory medication mefenamic acid can reduce bleeding by 225 to 46%.We used it for menorrhagia associated wih small fibroids as well in some cases of DUB in this study successfully.The LNG -IUS is a relatively new treatment that remains effective for 5 years.It has been found to reduce menstrual blood loss by 74 %--97%.
A number of minimally invasive surgical options for hysterectomy now exist and are promising like endometrial ablation, thermal ballon therapy and uterine artery embolization but restricted availability and cost factor limit their use.
Malignancy found in this study was found in 2 (1.06%) of cases and it is Leiomyosarcoma.The rate of diagnosis of endometrial neoplasia in this study did not reflect the real prevalence of these lesions.

Conclusions:
The diagnosis of perimenopausal bleeding and prognostic evaluation is based on the histopathological examination of the endometrium after biopsy.In our study fibroid uterus was the most common cause of abnormal uterine bleeding.Second common cause was DUB.Histopathology revealed majority of endometrium in proliferative phase.Histopathology also revealed malignancy in two out of two houndred and eleven cases which signifies importance of routine histopathology in such cases.Clinical, radiological and pathological evaluation correlated very well to diagnose fibroids.However clinically as well as USG proved of little help to diagnose adenomyosis.As abnormal uterine bleeding (AUB) in perimenopausal age is a common findings so it needs proper evaluation.Accurate diagnosis for the cause of AUB and appropriate management at early stage can minimize patients sufferings.