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197]

ORI INAL ARTICLE

Study of histopathological patterns of

endometrium in abnormal uterine bleeding
Sajitha K, She y K Padma, Jayaprakash She y K, Kishan Prasad HL, Harish S Permi, Panna Hegde
Department of Pathology, KS Hegde Medical Academy of Nitte University, Mangalore, Karnataka, India

A B S T R A C T
Background: Abnormal uterine bleeding (AUB) is a common gynecological complaint associated with considerable morbidity
and significantly affects the patient’s family, personal and social life. The aim of the study was to analyze the histomorphological
patterns of endometrium in patients presenting with AUB and also to determine the incidence of AUB in various age groups.
Materials and Methods: This is a prospective study, conducted in the Department of Pathology, in a tertiary care teaching hospital,
Mangalore from October 2011 till date. All cases of AUB with a probable endometrial cause were included in the study. Data was entered
in Microsoft Excel and managed in Statistical Package for the Social Sciences (SPSS) version 16. Analysis was done in the form of
percentages and proportions and represented as tables where necessary. Results: A total of 156 cases were analyzed. Patients’ age
ranged from 23-78 years. AUB was most prevalent in the perimenopausal age group. The most common presenting complaint was
menorrhagia (47%). Endometrial hyperplasia was the most common histopathological finding and was seen in 25% patients, followed
by secretory endometrium in 16.7% patients, and proliferative phase pattern and disordered proliferative endometrium were seen in
12.2% patients each. Malignancy was detected in 6.4% of cases and endometrial carcinoma was the most common lesion (4.5%).
Conclusions: Histopathological evaluation of endometrial samples is especially indicated in women over the age of 35 years to rule
out malignancy and preneoplasia. Among the patients with no organic pathology, normal physiological patterns with proliferative,
secretory, and menstrual changes were observed. The most common endometrial pathology in this series was endometrial hyperplasia.

Keywords: Abnormal uterine bleeding, dilatation and curettage, dysfunctional uterine bleeding, endometrium

INTRODUCTION and the area in question can be curetted. Transvaginal/

transabdominal ultrasonography is another useful
Abnormal Uterine Bleeding (AUB)-a term used to adjunctive technique for examining the endometrium
describe any type of bleeding that does not fall within in the evaluation of AUB.[1-3]
the normal ranges for amount, frequency, duration,
or cyclicity.[1] The most common presentations are The underlying disease can be detected by histological
menorrhagia, polymenorrhoea, metrorrhagia, and variations of endometrium taking into account the age
intermenstrual bleeding. Dilatation and Curettage of the woman, the phase of her menstrual cycle, and
(D and C) is the mainstay of endometrial sampling since use of any exogenous hormones. Pregnancy-related
a long time. D and C also allows for a fractional curettage and dysfunctional uterine bleeding are more common
with separate sampling of both the endometrial and in younger patients, whereas atrophy and organic
endocervical tissue. Hysteroscopy has almost replaced lesions become more frequent in older individuals.
blind curettage as the uterine cavity can be observed Hyperplasia is found in up to 16% and endometrial
carcinoma in fewer than 10% of postmenopausal
Access this article online
patients undergoing biopsy.[2] Patients with a history
Quick Response Code: of anovulation, obesity, hypertension, diabetes, and
Website:
www.cjhr.org exogenous estrogen use are at an increased risk for
hyperplasia and adenocarcinoma.[2] Early evaluation
DOI: in the perimenopausal and postmenopausal women is
10.4103/2348-3334.134265 essential to confirm the exact nature of the lesion and
to rule out malignancy.

Corresponding Author: Dr. Sajitha K, Assistant Professor, Department of Pathology, KS Hegde Medical Academy of Nitte
University, Deralakatte, Mangalore - 575 018, Karnataka, India. E-mail: [email protected]

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Sajitha, et al.: Endometrial pathology in AUB

MATERIALS AND METHODS Endometrial hyperplasia and polyps the most common
patterns seen in the age group ≤35 years. Between
All patients who presented in this hospital with a 36-45 years, secretory pattern was the most common
history of AUB between October 2011 till date and who followed by proliferative change. In the 46-55 age group,
underwent D&C or hysterectomy were included in the endometrial hyperplasia was the most common pattern
study. Patients with a gestational cause, hemostatic followed by disordered proliferative pattern. Most of
disorders, isolated cervical or vaginal pathology, and the endometrial and other carcinomas were presented
leiomyoma excluded. Relevant clinical data regarding after age 55 years [Table 4].
age, pattern and duration of abnormal bleeding,
menstrual history, obstetric history, use of exogenous DISCUSSION
hormones, physical and gynecological examination
findings, lab investigation results, and sonological AUB accounts for almost 25% of gynecological
and hysteroscopic findings were obtained from case operations and 20% of outpatient visits.[3] In this study,
records from Medical Records Department. All data we have studied the histopathology of endometrium to
were recorded in a carefully structured proforma. identify the endometrial causes and also observe the
incidence of various pathologies in different age groups
All the specimens were fixed in 10% formalin, processed and their relation to parity.
and embedded in paraffin, and 3-4 μ thick sections were
made. Sections were stained with hematoxylin and eosin Table 1: Distribution of patients with abnormal uterine
stain. A total of 156 cases were analyzed and histological bleeding in different age groups: (n=156)
diagnosis was made. Data were entered in Microsoft Age (in years) No. of patients Percentage
Excel and managed in SPSS version 16. Analysis was ≤35 13 8.33
done in the form of percentages and proportions and 36-45 62 39.75
46-55 67 42.95
represented as tables and figures where necessary. >55 14 8.97
Total 156 100
RESULTS
Table 2: Distribution of patients according to their body
A total of 156 endometrial specimens submitted with
mass index
a clinical diagnosis of AUB were studied.
BMI No. of patients Percentage
19-24.9 kg/m2 (normal weight) 118 75.6
Patients’ age ranged from 23-78 years and most of them 25-29.9kg/m2 (overweight) 29 18.6
were seen in the age group of 46-55 years, followed by ≥30 kg/m2 (obese) 6 3.8
36-45 years [Table 1]. No data 3 2
Total 156 100
BMI: Body mass index
The commonest complaint was menorrhagia in
73 patients (47%).
Table 3: Distribution of endometrial patterns in abnormal
uterine bleeding patients
Parity in the present study ranged from para 1 to para 8.
Endometrial pattern No. of Percentage
Seventy five (48.4%) of them were in the low parity patients
group (para 1-2) followed by para 3-4 (32.4%). Proliferative phase endometrium 19 12.2
Secretory phase endometrium 26 16.7
In our study, 75.6% of the patients were of normal Mixed patterns (proliferative and secretory) 6 3.84
Pill endometrium 12 7.7
weight, 18.6% patients were overweight, and 3.8% were Disordered proliferative endometrium 19 12.2
obese [Table 2]. Luteal phase defect 4 2.6
Menstrual endometrium 2 1.28
The commonest pathology observed in the study was Atrophic endometrium 8 5.12
Endometritis 1 0.64
endometrial hyperplasia in 39 (25%) patients. Secretory Endometrial polyps 8 5.12
endometrium was the next commonly observed pattern Endometrial hyperplasia 39 25
seen in 26 (16.7%) patients, followed by proliferative Endometrial carcinoma 7 4.5
Endometrial Stromal Sarcoma 1 0.64
and disordered proliferative endometrium in 19 (12.2%) Other carcinomas 2 1.28
patients each. Endometrial carcinoma was seen in Inadequate 2 1.28
7 (4.5%) cases [Table 3]. Total 156 100

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Sajitha, et al.: Endometrial pathology in AUB

In the present study, the maximum incidence of AUB Table 4: Comparison of histological patterns in different
was in the 46-55 years age range (67 patients), followed age groups
by 36-45 years age group (62 patients). Our study and Endometrial pattern Age ( in years)
other studies have found a maximum incidence of AUB ≤35 36-45 46-55 >55 Total
in the perimenopausal age group.[4-10] Perimenopause Proliferative phase - 10 8 1 19
is defined by the World Health Organization as the Secretory phase 1 22 3 - 26
Mixed pattern - 4 2 - 6
2-8 years preceding menopause and the 1 year after the Pill endometrium 1 7 4 - 12
final menses.[3] As women approach menopause, cycles Disordered proliferative 2 5 11 1 19
shorten and often become intermittently anovulatory endometrium
Luteal phase defect 1 2 1 - 4
due to a decline in the number of ovarian follicles and Atrophic endometrium - 2 5 1 8
fluctuations in the estradiol level leading to various Menstrual pattern 1 1 - - 2
patterns of abnormal bleeding.[2] Endometritis - 1 - - 1
Endometrial polyps 3 1 3 1 8
Endometrial hyperplasias 3 10 22 4 39
Our study and other studies found menorrhagia as the Endometrial carcinomas 1 - 2 4 7
most common complaint.[4,5,7,8] Most of our patients Other carcinomas - - - 2 2
ESS - - 1 - 1
were in the low parity category. Other studies reported Inadequate - 2 - - 2
a higher incidence of AUB with increase in parity.[8,11,12] Total 13 67 62 14 156
However, this pattern was not noted in our study and ESS: Endometrial stromal sarcomas
majority of our patients were para 1-2.
Table 5: Correlation of ultrasonography, hysteroscopy and
Endometrial hyperplasia was the most common hypersensitivity pneumonitis in diagnosis of endometrial
histological pattern observed in our study and was hyperplasia
seen in 39 cases (25%). A few studies have reported a Hysteroscopy Hyperplasia ET in mm
similar incidence with 24.7% and 26%, respectively.[5,13] hyperplasia
However, most other studies have observed a lower Hysteroscopy 1.000 Poor correlation Fair correlation
hyperplasia (0.025) (0.350)
incidence with 12.6%, 15%, and 4.33%.[8,14,15] Hyperplasia 0.025 1.000 Fair correlation
(0.205)
In the present study, the maximum incidence of ET in mm 0.350 0.205 1.000
ET: Endometrial thickness, HP: Hyperplasia
hyperplasia was noted in the 46-55-year age group
and was seen in 22 of 39 patients (56.4%). This was
In the present study, body mass index (BMI) was found
consistent with the findings in other studies.[5,13,14,16,17]
to be significantly higher in women with endometrial
In our study, there was a fair correlation between hyperplasia. Of the 39 patients with hyperplasia, 10.2%
a finding of increased endometrial thickness (ET) were found to be obese and 30.76% were overweight. In
by ultrasonography (USG) and histopathological obese women, there is an increased risk of endometrial
diagnosis of endometrial hyperplasia, but there hyperplasia (EH) and endometrial carcinoma which can
was a poor correlation between hysteroscopic be explained by the increased availability of peripheral
and histopathological diagnosis of endometrial estrogens as a result of aromatization of androgens to
hyperplasia [Table 5] as calculated by Spearman estrogens in adipose tissue and lower concentrations of
Correlation Test. sex hormone-binding globulins.[19] Also the occurrence
of other concurrent risk factors like diabetes mellitus
Identification of endometrial hyperplasia is and increased dietary fat intake probably contribute to
important because they are thought to be precursors the pathology in this group.
of endometrial carcinoma. [6] The overall risk of
progression of hyperplasia to cancer is 5-10%. [18] In our study, predominant number of patients in the age
Simple (SH) [Figure 1a], complex (CH) [Figure 1b], group 36-45 years showed normal physiological changes
simple atypical (SAH), and complex atypical like proliferative and secretory phase patterns. Secretory
hyperplasia (CAH) have different progression risks of endometrium was the second most common pattern
1%, 3%, 8%, and 29%, respectively, to carcinoma.[18] The observed in this study and was seen in 26 (16.7%)
different types of hyperplasias observed in this study patients. A similar incidence of secretory pattern (16.6%)
were SH-20 (12.8%), SAH-6 (3.85%), CH-2 (1.28%), and was noted in another study.[7] The bleeding in secretory
CAH-11 (7.05%). phase is due to ovulatory dysfunctional uterine bleeding

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Sajitha, et al.: Endometrial pathology in AUB

and is characterized by regular episodes of heavy Atrophic endometrium is the most common cause
menstrual blood loss. The main defect is in the control of bleeding in postmenopausal stage.[12] Thin walled
of processes regulating the volume of blood lost during veins, superficial to the expanding cystic glands, make
the menstrual breakdown of endometrium.[20] the vessels vulnerable to injury and lead to excessive
uterine bleeding.[16] Atrophic endometrium was seen in
In the present study, a proliferative pattern of 5.13% of the patients in this study and they presented
endometrium [Figure 1c] was observed in 12.2% patients. as postmenopausal bleed. A similar incidence was
Other studies reported incidences of 17.8%, 33%, reported in other studies with incidences of 4.34% and
32.6%, and 32%.[13,17,21,22] This pattern was commonly 7%, respectively.[12,25]
observed in the late reproductive and perimenopausal
women in our study and other studies and may be due In our study, pill endometrium was seen in 12 (7.69%)
to the hormonal imbalance in this group leading to cases. Other studies reported a lower incidence.[5,13,24] In
intermittent anovulatory cycles. this pattern, the endometrium shows a combination of
inactive glands, abortive secretions, decidual reaction,
Disordered proliferative endometrium [Figure 1d] is an and thin blood vessels.[26] This pattern was predominantly
exaggeration of the normal proliferative phase without seen in the perimenopausal age group. This was probably
significant increase in the overall ratio of glands to stroma due to increased number of patients in this age resorting
and is due to persistent oestrogen stimulation.[2,23] This to early medical management for bleeding.
pattern is particularly seen in perimenopausal women.
The disordered proliferative endometrium resembles The other benign patterns included endometrial
normal proliferative tissue in consisting of glands lined polyps (5.12%), irregular shedding (3.84%), luteal phase
by cytologically bland, pseudostratified, proliferative, defect (2.56%), endometritis (0.64%), and menstrual
mitotically active epithelium and in having a normal pattern (1.28%).
ratio of glands to stroma. It differs from the normal
proliferative endometrium in the absence of uniform The malignant conditions observed in this study
glandular development. Disordered proliferative pattern included seven cases of endometrial carcinoma,
lies at one end of the spectrum of proliferative lesions of two cases of squamous cell carcinoma of the cervix
the endometrium that includes carcinoma at the other infiltrating into endometrium, and one case of low-grade
end with intervening stages of hyperplasias.[6] This endometrial stromal sarcoma [Figure 2a and b].
pattern was seen in 19 (12.2%) of our cases. Another
study reported a similar incidence of 10%.[24]

a b

a c

c d
Figure 2: (a) Endometrial stromal sarcoma, gross: Tumour presenting as a
fleshy mass in the parametrium (b) Endometrial stromal sarcoma, composed of
b d cells with uniform round to oval nuclei, finely granular chromatin, small nucleoli,
Figure 1: (a) Simple hyperplasia without atypia, showing mildly irregular, variably and scanty cytoplasmwith ill-defined cell borders. H and E ×100 (c) Endometrial
sized glands in abundant stroma with squamousmetaplasia. H and E ×400 carcinoma, gross: Hysterectomy specimen, showing exophytic irregular growth
(b) Complex hyperplasia without atypia, highly irregular glands with scant involving the endometrial cavity and extending up to the lower uterine segment
stroma and inset showing regular, uniform nuclei. H and E ×400 (c) Proliferative (d) Endometrioid adenocarcinoma, International Federation of Gynecology and
endometrium, glands are tubular and regularly spaced in abundant stroma. Obstetrics (FIGO) grade 2, showing well-defined glands with confluent pattern,
H and E ×100 (d) Disordered proliferative endometrium, showing disorganized nuclei are enlarged, irregular to rounded, vesicular with prominent nucleoli.
proliferative phase glands with focal glandular dilatation. H and E ×100 H and E ×400

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Source of Support: Nil. Conflict of Interest: No.
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