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125]

Original Article

Clinicopathological study of abnormal

uterine bleeding in perimenopausal women
S. Sudhamani, Sunila1,
Swapnil Sirmukaddam,
DurgaprasadAgrawal

Abstract

Department of Pathology, Pad Dr.

D.Y. Patil Medical College, Nerul, Navi
Mumbai, Maharashtra, 1Department
of Pathology, Jagadguru Sri
Shivarathreeshwara Medical College,
Mysore, Karnataka, India

Address for correspondence:

Dr. S. Sudhamani,
Department of Pathology,
Pd. Dr. D. Y. Patil Medical College, Nerul,
Mumbai-400 706, Maharashtra, India.
E-mail: dr.sudhamani@gmail.com

Background: Until recently, perimenopause has been little understood and ignored
especially in developing the country like India. It is a distinct entity from menopause
and in terms of symptomatology, it may be even more important than postmenopause.
Aims and Objectives: (1) To ascertain the cause of abnormal uterine bleeding in
perimenopausal women (40-55 years). (2) To study the spectrum of morphological
changes in perimenopausal bleeding with high-risk factors predisposing to endometrial
hyperplasia and malignancy. Materials and Methods: The study was undertaken in a
large tertiary care teaching hospital over a period of 3 years. All the outdoor and indoor
patients presenting with abnormal uterine bleeding with or without other clinical features
in the perimenopausal age group (40-55 years) were included in the study. Women
with menstrual cycles of 21-35 days with a duration of flow of 2-6 days were considered
normal and were excluded from the study. Specimen considered for histopathological
study included endometrial biopsy, dilation and curettage, fractional curettage, cervical
biopsy, and or hysterectomy with or without salpingo-oophrectomy done for diagnostic
or therapeutic purposes. Statistics Used: Totally, 100 cases were selected on the basis of
simple random sampling and analyzed. Results: Most of the patients were in the age group
of 40-45 (45%) with menorrhagia as the chief complaint. The bulk of the specimens were
of total hysterectomy with bilateral salpingo-oophrectomy (43%). Functional endometrial
changes were the most common cause in 40-50 years age group but endometrial carcinoma
was the main cause of bleeding in the 51-55 years group indicating heightened occurrence
of malignancy with increasing age.
Key words: Abnormal bleeding, perimenopause, uterine bleeding

INTRODUCTION
Perimenopause refers to the period surrounding the last
menstrual event.
In the 21st century, women are living major years of
their lifetime in perimenopause state, constituting
a large segment of the population. Abnormal
uterinebleeding is the most common complaint
encountered in these years causing significant
physical and mental morbidity and financial burden
on these patients.[1]
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Although malignancy is not the most common etiology

for perimenopausal bleeding, it is the most important.
This study was done asses the clinicopathological
factors causing perimenopausal uterine bleeding and
to study the occurrence of endometrial hyperplasia and
carcinoma.

DISCUSSION
Till the end of 19th century, the cause of abnormal uterine
bleeding was thought to be chronic inflammation. Now,
it has been clear that abnormal uterine bleeding, which
is common in perimenopausal women are due to the
varied causes ranging from functional to malignancy.

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DOI:
10.4103/0974-5009.149457

Perimenopause refers to the period surrounding the last

menstrual event. In this duration, there exists a situation
where the normal diminution in reproductive capacity
with its resulting disruption of the normal menstrual
pattern coincides with a real risk of pelvic pathology.
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Sudhamani, et al.: Clinicopathological study of abnormal uterine bleeding

MATERIALS AND METHODS

The study was undertaken in a large tertiary care teaching
hospital on patients presenting with abnormal uterine
bleeding in the perimenopausal age group (40-55 years).
Women with menstrual cycles of 21-35 days with a
duration of flow of 2-6 days were considered normal and
were excluded from the study. Specimen considered for
histopathological study included endometrial biopsy,
dilation and curettage, fractional curettage, cervical
biopsy, and or hysterectomy with or without salpingooophrectomy done for diagnostic or therapeutic purposes.
In the present study, functional endometrial disorders
(23%) was the most common cause for abnormal uterine
bleeding followed in the decreasing order by leiomyoma
(19%), endometrial hyperplasia (17%), adenomyosis
and endometriosis (14%), carcinoma cervix (9%), and
malignant tumors of endometrium (6%).
Infections (2%), complications of pregnancy (1%),
functional ovarian tumors (2%), and others (4%) formed
the rest of the cases.
Functional endometrial disorder, commonly referred to
us dysfunctional uterine bleeding formed the largest
category, variously reported as normal endometrium,
Table 1: Clinicopathological correlation (total 100 cases)
Clinical
Pathological
diagnosis
diagnosis
DUB
39
23
Fibroid
28
19
Ca. Cx
10
9
Ca. Endometrium
5
6
End polyps
3
3
Adenomyosis
5
14
Ovarian tumors
2
2
Infections
2
2
End Hyp
3
17
Products of conception
1
Others
3
4
DUB = Dysfunctional uterine bleeding, Ca Cx = Carcinoma
cervix, End polyps = Endometrial polyps, End Hyp = Endometrial
hyperplasias
Diagnosis

functional endometrium or physiological changes. It was

the cause of abnormal uterine bleeding in all age groups,
the percentage ranging from 54% (64), 55.2% (71), 46%
(86), and 62% (8), respectively, in various studies. In our
study, it was 23% less compared to other studies probably
due to the strict age criteria but still forming the largest
group as the cause for abnormal uterine bleeding [Table 1].
The highest number of cases of functional disorders
were seen in the age group of 40-45 years in our study
(69.56%), followed by 46-50 years age group (30.43%)
[Table 2]. This correlates well with a study where the
mean age at diagnosis was found to be 44 years.[2]
None of the patients were above the age of 50 years,
indicating increasing number of organic causes and the
decrease in functional disorders as the age advances. The
most common presenting complaint in our study was
menorrhagia (38%) even though polymenorrhea[3] was
found to be the main complaint in other studies.
In the present study, out of the 23 cases of functional
endometrial changes, 47.82% (11) showed proliferative
changes, 17.39% (4) were of irregular proliferation, and
13.04% (3) showed secretory phase indicating an ovulatory
cycles as the main cause of abnormal uterine bleeding
[Table 3]. This is corroborated in other studies as well.[3-5]
In the present study, uterine leiomyomas formed 19% of
cases, next only to functional disorders. The size varied
from 1 to 8 cm in the largest dimension.
Leiomyomas were found commonly in the age group of
40-45 years, the frequency decreasing with age. The most
common symptom was menorrhagia and the majority
was of intramural type (92%) in our study correlating
with other studies.[6-8]
In the present study, most of the cases of carcinoma
cervix were seen in the age group of 40-45 years with
the main complaint as continuous bleeding (66.66%) and
after menopause as postmenopausal bleeding (33.33%).
This is in accordance with other studies, which showed
the average age for the development of in situ carcinoma
as 38 years and invasive cancer as 48 years.[8]

Table 2: Distribution of lesions according to age (100 cases)

Age group DUB Fibroid And end End hyp End polyps Ca Cx MT of end Inf Prg Func Ov T Others Percentage
40-45
16
12
10
11
2
6
1
2
1

4
65
46-50
7
7
3
3
1
2
1

24
51-55

1
3

1
4

11
Total
23
19
14
17
3
9
6
2
1
2
4
100
DUB = Dysfunctional uterine bleeding, Adn End = Adenomyosis and endometriosis, End Hyp = Endometrial hyperplasias, End
polyps = Endometrial polyps, Ca Cx = Carcinoma cervix, MT of End = Malignant tumors of endometrium, Inf = Infections, Prg =
Pregnancy, Funct Ov T = Functional ovarian tumors
4

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Sudhamani, et al.: Clinicopathological study of abnormal uterine bleeding

The most common microscopic type of invasive cancer

in this study was that of squamous cell carcinoma,
keratinizing type.
In our study, cervical dysplasias and infiltration of cervix
by ovarian cancer were infrequent causes for abnormal
uterine bleeding.
Adenomyosis and endometriosis constituted 14% of cases,
majority seen in the age group of 40-45 years (71.43%),
Table 3: Endometrial changes
Endometrial change
Proliferative phase
Secretory phase
Hyperplasia
Malignant tumors
Infections
Polyps
Total

Number of cases
40
14
17
6
2
3
82

Percentage
48.78
17.08
20.74
7.32
2.43
3.65
100

the frequency steadily decreasing with increasing age,

probably representing the onset of menopause. Of the
14 cases, 5 cases of adenomyosis were associated with
bilateral ovarian endometriosis [Figure 1].
In the present study, endometrial hyperplasia were
mainly seen in the age group of 40-45 years (11%)
and the maximum number of cases showed features
of simple hyperplasia without atypia (47%) and none
showed insitu or borderline malignancy [Figure 2].
These findings are in accordance with other studies.[1,9-12]
In this study, the maximum number of cases of
endometrial carcinoma, which constituted 6% of
total cases were in the age group of 51-55 years
and 83.33% of them being of endometrioid type
[Figure3], the others being endometrial stromal sarcoma.
Of the endometrial adenocarcinomas, the various
histopathological types seen were papillary [Figure 4],
clear cell, well-differentiated endometrioid type and

Figure 1: Gross photograph of uterus showing thickened

endometrium (hyperplasia) with trabeculated appearance of
myometrium (adenomyosis)

Figure 2: H and E, 10 showing papillary endometrial

adenocarcinoma

Figure 3: H and E, 40 showing endometrioid adenocarcinoma

of uterus

Figure 4: Gross picture of uterus displaying papillary endometrial

carcinoma

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Sudhamani, et al.: Clinicopathological study of abnormal uterine bleeding

adenoacanthoma. There was an equal distribution of

cases in pre- and post-menopausal groups, correlating
with other studies.[13-16]

CONCLUSION

5. Nedoss BR. Dysfunctional uterine bleeding: Relation of endometrial

histology to outcome. Am J Obstet and Gynecol 1970;107:852-55
6. Garcia CR. Management of the symptomatic fibroid in women older than 40
years of age. Hysterectomy or myomectomy?. Obstet Gynecol Clin North
Am 1993;20:337-48.
7. OConnor DM, Norris HJ. Mitotically active leiomyomas of the uterus.
Hum Pathol 1990;21:223-7.

Benign lesions of endometrium and myometrium are the

most common causes for abnormal uterine bleeding in
perimenopausal women, but the possibility of endometrial
hyperplasia and particularly the cancers of uterus must be
considered particularly with the advancing age.

8. Jutras ML, Cowan BD. Abnormal bleeding in the climacteric. Obstet Gynecol
Clin North Am 1990;17:409-25.

A comprehensive clinicopathological study will usually

help in arriving at the correct diagnosis. However, in view
of the wide array of causes, abnormal uterine bleeding
continues to be a diagnostic challenge, especially during
perimenopause.

11. Dunn TS, Stamm CA, Delorit M, Goldberg G. Clinical pathway for evaluating
women with abnormal uterine bleeding. J Reprod Med 2001;46:831-4.

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How to cite this article: Sudhamani S, Sunila, Sirmukaddam S,
Agrawal D. Clinicopathological study of abnormal uterine bleeding
in perimenopausal women. J Sci Soc 2015;42:3-6.
Source of Support: Nil. Conflict of Interest: None declared.

Journal of the Scientific Society, Vol 42 / Issue 1 / January-April 2015