Abnormal uterine bleeding AUB is the commonest menstrual problem during perimenopause. The present study was conducted with the aim to study the two components of this system in clinical practice in general and to establish a clinico-pathological correlation of AUB with context of PALM component in particular. After all indicated investigations, endometrial sampling and hysterectomy specimen were assessed by histology. A clinicopathological correlation was analysed statistically.
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Abnormal uterine bleeding AUB is the commonest menstrual problem during perimenopause. The present study was conducted with the aim to study the two components of this system in clinical practice in general and to establish a clinico-pathological correlation of AUB with context of PALM component in particular.
After all indicated investigations, endometrial sampling and hysterectomy specimen were assessed by histology. A clinicopathological correlation was analysed statistically. On the other hand, the histological examination revealed significantly more cases of PALM structural or anatomical component of AUB, i.
AUB-L was the commonest The PALM—COEIN classification system should take into account both the clinical and histopathological diagnoses in women having AUB around perimenopause as the two diagnostic modalities are complementary to each other and clinical impression should be placed into proper perspective of this classification in order to optimise outcome.
Abnormal uterine bleeding AUB is one of the common presenting complaints encountered by a gynaecologist. It is a significant cause of hysterectomy and thus is a major health problem [ 1 ].
AUB is also associated with significant social and physical morbidities in all societies and may be a reflection of serious underlying pathology [ 2 ]. AUB may be acute or chronic and is defined as bleeding from the uterine corpus that is abnormal in regularity, volume, frequency or duration and occurs in the absence of pregnancy [ 3 , 4 ]. Follicular development at this time has been demonstrated to be erratic, with consequent variability in oestrogen levels and an increased percentage of anovulatory cycles making them more likely to experience abnormal uterine bleeding.
In addition to the erratic ovulation, there may be many structural or functional aetiologies for the AUB. There are nine main categories, which are arranged according to the acronym PALM—COEIN: polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified.
Perimenopausal women show a significant number of underlying organic pathology. The onus here in AUB management is to exclude complex endometrial hyperplasia and endometrial cancer. A thorough histopathological work up and clinical correlation is mandatory as there is always a possibility of reallocation of category. Assessing a correlation can ascertain the degree of accuracy of clinical assignment to the category of AUB and may provide an insight as to when one must go for a pathological correlation particularly that of the PALM aspect of PALM—COEIN, whereas for COEIN functional aspect, the same is done using other investigations namely haematological and endocrinological work up.
FIGO recommends endometrial tissue testing as a first-line management in women of perimenopausal age group who have AUB [ 7 , 8 ]. Histology clinches the diagnosis and guides the management plan.
When planning hormone therapy, it is mandatory to rule out a precancerous neoplasia like suspicious hyperplasia or sub-clinical endometrial cancer. A histological assessment therefore remains the cornerstone in the current practice as it puts the clinical diagnosis in the accurate perspective and allows standardization of treatment.
The present study was conducted at the tertiary centre, government medical college of Madhya Pradesh from 1 July to 30 June On gynaecological examination, cervix position of cervix, any erythematous lesion, hypertrophy, mobility, presence of polyp or ectopy , uterus size, position, consistency, and mobility and adnexae any palpable enlarged lump, tenderness and mobility were assessed.
A pelvic ultrasound to assess the uterus uterine size, endometrial thickness, presence of endometrial polyp, adenomyosis or fibroids and ovarian status presence of any cyst, mass and its characteristics was done.
Endometrial biopsy and hysterectomy specimens wherever applicable were obtained and sent for histopathology. As per the histopathological findings, possible underlying causes were categorised. Clinical diagnosis was then correlated with histopathology-based final diagnosis.
Following a thorough history and complete clinical examination, investigations including complete blood count, coagulation profile when applicable for all previously known cases of defects of coagulation from younger age and AUB dating back from menarche , thyroid function test and blood sugar level estimations were done, and the results were correlated with the clinical allocation.
Data were analysed by SPSS version 16, and descriptive statistics were presented as frequencies, percentages and bar charts. Z-test was applied to know the significance of the correlation. Out of gynaecological admissions during the study period, there were perimenopausal women who presented with the complaints of abnormal uterine bleeding and were included in the study. The majority An overwhelming majority The most common presenting symptom in our study was heavy menstrual bleed In total 22 9.
The majority had secretory changes in 98 This was followed by simple adenomatous hyperplasia as the third common finding in 21 8. On the other hand, histopathology could diagnose more cases in comparison with clinical-based diagnosis in the categories of AUB-A 8.
The difference was significant statistically in all three. The only instance where clinical diagnosis was ascribed to significantly more number of cases than those confirmed by histology was in AUB-E The PALM—COEIN classification has an advantage of consideration of the entire range of possible aetiologies but should be followed by further investigation to arrive at a more accurate and consistent diagnosis in perimenopausal group of women so as to rule out organic diseases particularly precancerous lesions and cancers.
The demographic profile and the pattern of menstrual complaints were in accordance with other researchers [ 9 — 13 ]. Chronic anovulation is a predominant phenomenon in perimenopause which is associated with an irregular and unpredictable pattern of bleeding that varies in amount, duration and character. Leiomyomas are known be predominant in the age group presently studied. In addition, 9. Obesity has proved to be a main predisposing factor for AUB [ 16 ].
Although hysteroscopy and directed biopsy is the gold standard in diagnostic work up of AUB, endometrial sampling is still the most common available practice in public hospitals. Histopathological pattern of endometrium in women with AUB is quite variable depending upon age, parity, and ethnicity. Endometrial hyperplasia was present in 8. Leiomyoma as the leading cause of AUB in perimenopause is also noted by various researchers [ 11 , 12 , 17 ].
Higher association of AUB is seen with submucosal type, compared with intramural and subserous type [ 15 ]. In perimenopausal years, ovulatory disorders are common due to derangements in the hypothalamo—pituitary—ovarian axis resulting in derangements of follicular maturation, ovulation or corpus luteum formation, and anovulatory cycles are most frequent, and chronic anovulation is associated with an irregular and unpredictable pattern of bleeding.
This explains why ovulatory disorders were found to be the second most common cause of AUB in this study and most other studies. The unopposed oestrogenic action on the endometrium in the anovular cycles found in perimenopausal women predisposes them to develop hyperplasia and eventually endometrial carcinoma. In the present study, endometrial hyperplasia accounted for 8. Most of the cases were cervical polyps in present study which could be diagnosed clinically by per speculum examination.
This observation differs from others [ 12 ] who found the difference to be highly significant in case of polyps. The variation may be attributed to greater number of endometrial polyps in the later study. In present study too, the histopathology identified higher number of polyps although not to significant proportions. This is due to the fact that symptoms and signs of adenomyosis and leiomyoma can be so similar that it can be impossible to differentiate them clinically [ 15 , 20 ].
Our observation is in accordance with others [ 8 , 12 ]. The explanation may be that most symptomatic fibroids can be easily diagnosed by history and clinical pelvic examination.
This is due to the fact that the clinical picture including menstrual history is not specific and that bimanual examination reveals an ordinary small uterus that shows no obvious departure from the normal senile one in most cases. Similar observation was made by others also [ 21 ]. Although clinically indistinguishable from non-malignant causes, the genital malignancies have a protracted course and grim prognosis.
Early detection and prompt management may lead to a better outcome in all these women. The significant difference in clinical and histopathological diagnosis in cases of genital malignancies and hyperplasia reiterates the complementary role of the two modalities where a case of AUB is provisionally classified to one category, but after histopathology it may be reclassified, and in the process, a correct diagnosis is made so that the woman is benefitted.
As the experience of the clinician improve in context of PALM—COEIN classification system both in clinical and in histopathological diagnoses, there will be improved outcomes in women healthcare system. This is due to the fact that perimenopausal women have more anovulatory cycles. In the majority of women with true anovulatory bleeding, the menstrual history alone can establish the diagnosis with sufficient confidence that treatment can begin without additional lab evaluation or imaging.
In frequent, irregular, unpredictable menstrual bleeding that varies in amount, duration and character and is not preceded by any recognisable or consistent pattern of premenstrual molimina or accompanied by any visible or palpable genital tract abnormality is not difficult to interpret.
Conversely, regular monthly periods that are heavy or prolonged are more likely related to an anatomical cause or a bleeding disorder than to anovulation.
This may be because most women in this category tend to have no definable cause of AUB. AUB-E is presently reserved as a diagnosis of exclusion among other causes of AUB and may represent a primary endometrial disorder.
Most AUB-E cases appear to be due to disturbances of metabolic molecular pathways such as those involving tissue fibrinolytic activity, prostaglandins and other inflammatory or vasoactive mediators.
The specific routine tissue assays which are not available at present may lead to negative histopathology in some cases. If available, these sophisticated tests may have a potential in order to establish a clearer diagnosis in the future. In the present study there were significantly greater number of cases assigned to AUB-E on clinical ground can be justified by this arbitrary approach.
If the histological confirmation is not there, the final classification as per pathological diagnosis may be to any other category it belonged to. Although there was no significant difference in cases of AUB-P, AUB-L and AUB-O, all can cause heavy and irregular menstrual bleed which may be clinically indistinguishable from those caused by premalignant or malignant causes which are more common around the menopause. For management part also clinical impression should be placed into proper perspective of this classification so that accurate diagnosis based on proper work up can help in optimising the treatment protocol.
This dictum may require periodic modification and revision based upon further research. She has five publications to her credit as a co-author.
She is recipient of many certificates of merit during her undergraduate course. Devanshi Mishra, Email: moc. Shabana Sultan, Email: moc. National Center for Biotechnology Information , U.
J Obstet Gynaecol India. Published online Jul Devanshi Mishra and Shabana Sultan. Author information Article notes Copyright and License information Disclaimer. Corresponding author. Received Apr 7; Accepted Jul This article has been cited by other articles in PMC. Abstract Introduction Abnormal uterine bleeding AUB is the commonest menstrual problem during perimenopause.
Conclusion The PALM—COEIN classification system should take into account both the clinical and histopathological diagnoses in women having AUB around perimenopause as the two diagnostic modalities are complementary to each other and clinical impression should be placed into proper perspective of this classification in order to optimise outcome.
Introduction Abnormal uterine bleeding AUB is one of the common presenting complaints encountered by a gynaecologist. Materials and Methods The present study was conducted at the tertiary centre, government medical college of Madhya Pradesh from 1 July to 30 June
FIGO classification of uterine bleeding
The International Federation of Gynecology and Obstetrics FIGO is an international organization that links about international professional societies of Obstetricians and Gynecologists. In FIGO recognized two systems designed to aid research, education, and clinical care of women with abnormal uterine bleeding AUB in the reproductive years. This page is a summary of the systems and their use in contemporary gynecology. Abnormal uterine bleeding AUB in the reproductive years, unrelated to pregnancy, is rarely life-threatening, but is frequently life altering. The symptoms frequently interfere with quality of life and those girls and women afflicted with chronic AUB spend significant amounts of personal resources on menstrual products and medications. Such women are 30 per cent less productive at work, and, consequently, suffer a similar reduction in income. The problem of AUB burdens the economy, employers, as well as women and their families.
FIGO Committee for Menstrual Disorders
Continuing on the theme of updating AUB terminology, an expert committee recommended a classification system to describe the causes of AUB in non-gravid women of reproductive age Munro et al, They believed a comprehensive classification system would facilitate communication between clinicians, investigators and patients, with the potential to improve patient health outcomes. However, it was not always possible to distinguish whether an individual component was causal or associated with HMB. In all cases, the presence or absence of each criterion is noted using 0 if absent, 1 if present, and?