Discussion :
Menstrual disorders are more common with advancing age. In our study,
below 30 years 7 cases (4.5%) underwent endometrial sampling. Incidence
of AUB may be more in this age group however most cases being low risk
are managed conservatively and are not subjected to endometrial
sampling. Patients with high risk factors such as obesity or family
history of endometrial cancer or non response to medical management are
generally subjected to endometrial sampling. Most common age group
presenting with AUB in our study was 41-50 60 cases (40%) years
followed by 53 cases (35.3%) in 31-40 age group and this 31-50 yr age
group combined contributed to 75.3% cases . Similar finding have been
reported by Doraiswami s et al (1) A similar incidence was reported by
Yusuf et al (2) and Muzaffar et al (3) in their study. After the age of
50 that is 51-60 year age group and 61-70 year age group had 22
cases(15% ) and8 cases (5.3%) respectively and this age group(51-70
years) together constituted 30 cases (20%) of our patients. However
this age group showed significant changes such as endometrial carcinoma
and precursors for endometrial cancer such as endometrial hyperplasia
without atypia and with atypia as discussed below.
96 cases out of 150 patients with AUB were para 3 or more and
nulliparous were only2.7% in our study. Nulliparous patients less
commonly presents with AUB as compared to multiparous patients similar
finding is observed in other studies (4,5,6). Patients attending health
facilities in public sector are mainly from lower socio economic class
contributed to 82 cases (54.6%) in our study.
In our study as per table2, functional endometrium with
proliferative and secretary changes were noted in 53 cases (35.4%) and
24 cases (16%)respectively while Kafle et al (7) in a study of 166
samples noted proliferative and secretary changes in 42.97% and 14.46%
cases. Brahmaiah J et al (8) in study of 210 samples noted
proliferativeand secretary changes in 31.3% and 11.43% cases
respectively. Endometrial hyperplasia without atypia was seen in 18
cases(12%) cases and with atypia was seen in 7 cases (4.66%) in our
study while Kafle et al (7) noted hyperplasia of endometrium without
atypia in 7.23% cases and atypical hyperplasia in 3.01% cases.
Brahmaiah J et al (8) noted endometrial hyperplasia in 20% cases with
no specification of features such as atypia or without atypia. Various
other authors have noted endometrial hyperplasia 6% to 26% of
samples(8). Endometrial hyperplasia with or without hyperplasia should
be given immediate attention and patients should be counselled regarding
the nature of pathology detected and appropriate treatment to be
instituted. Incidence of co-existing endometrial carcinoma ranges
6.4-43% in women undergoing hysterectomy for atypical
hyperplasia(9). Natural history of endometrial hyperplasia
without atypia suggest that risk of progression to endometrial is 2% if
remains untreated and this figure is 23-29% for atypical
hyperplasia(10).
In our study endometrial carcinoma is noted in 5 cases (3.3%) while
Kafle N et al (7) has reported 2.4% incidence of malignancy which were
adenocarcinoma. Brahmaiah J et al (8) reported 0.47% incidence of
malignancy in endometrial sample while various authors have mentioned
0.48 to 6.4% incidence of carcinoma endometrium in patients presenting
with AUB(8). Incidence of finding carcinoma in endometrial sample varies
with the population screened. AUB patients attending general gynaecology
outpatient department, all age group patients combined may have lower
incidence of detection of carcinoma while screening of patients with
high risk factors such as obesity, nulliparity, family history or
samples from oncological hospital will report higher detection rate for
malignancy.
Atrophic endometrium is noted in 6cases (4%) in our study which is
similar to rate 3.35% reported by Brahmaiah J et al (8) and various
authors reported rate of atrophic endometrium from 2-7.38% (8)Rupture
of dilated blood capillaries beneath the surface of atrophic endometrium
may be responsible for the bleeding in these patients. Study by
Doraiswami et al (1) documented 2.4% incidence of atrophic endometrium
while Dwivedi et al (11) has reported 11% atrophic endometrium which is
higher than our present reported incidence.
Endometrial polyp was reported in 8cases (5.3%) cases in our study
while Kafle N et al (7) has reported 2.41% incidence of polyp.
Brahmaiah J. et al (8) has reported 0.95% incidence of endometrial
polyp in AUB patients. Prevalence of endometrial polyp increase with
age, endometrial polyp in postmenopausal women (11.8%) and
premenopausal women in (5.8%) have been reported.(12)Sometimes cervical
polyp may be seen on speculum examination which may be symptomatic or
asymptomatic. Symptomatic cervical polyp may be associated with
endometrial polyps and hyperplasia more commonly in perimenopausal and
post menopausal women. Endometrial abnormalities are noted in upto 55%
of postmenopausal women with cervical polyp and these women should be
offered endometrial sampling with hysteroscopy in addition to avulsion
of polyp.(13)
Heavy menstrual bleeding with normal duration was commonest presentation
96 cases (64%) in our study. Vijayraghavan et al (14) has reported
menorrhagia in 71.25% as the commonest presenting complaint in AUB
patients while Kafle N et al (7) has reported 58.43% of AUB cases with
menorrhagia as presenting complaint. Postmenopausal bleeding was
presentation in 23 cases (15.3 %) cases in our study while Kafle N et
al (7) has reported 19.27% incidence of postmenopausal bleeding and
Vijayraghavan et al (14) has reported 12.5% incidence of postmenopausal
bleeding in patients with AUB. Postmenopausal bleeding should be
evaluated properly to rule out sinister pathology as 90% of women with
EC present with PMB, but over 90% of women with PMB have a benign
benign underlying cause for their symptom(15,16).Heavy and prolonged
bleeding was noted in 23 cases (15.4%) cases in our study, while inter
menstrual bleeding (IMB) was seen in 8 cases (5.4%).Kafle N et al (7)
and Vijayrghavan et al (14) have reported 15.1% and 15% incidence of
metrorrhagia in AUB patients respectively.
Table 4 & 2 shows inadequate sample was reported in 7 cases (4.6%)
with pipelle and dilation and curettage. These patients were offered
endometrial sampling by hysteroscopy for which 3 out of 7 patients
consented and underwent repeat sampling by hysteroscopy. Technical
failure was noted 2 cases (1.3%) cases where endometrial sampling was
attempted by pipelle. These 2 cases were also underwent repeat sampling
by hysteroscopy. Failed endometrial sampling is usually associated with
pain or cervical stenosis, which is more common in nulliparous
women(17). Pipelle endometrial biopsy is an opd procedure and quick to
perform however failure of the procedure in 11% cases and inadequate
sample 31%, pain, bleeding, infection and very rarely perforation have
been reported(18), while failure rate for operative hysteroscopy 3.4 %
and ambulatory procedure 4.2% have been reported in the literature(18).
Previously it was thought that women with an inadequate sample can be
reassured safely regarding non sinister pathology however study has
shown 4.5% of women who were diagnosed with endometrial carcinoma had
initial inadequate sample(19) hence it is not appropriate to reassure
the patient on the ground of inadequacy of the sample however
preoperative high risks factors such as obesity, family history and
supporting investigations such as endometrial thickness on TVS,
irregularity of the endometrium are to be taken into account before
reassuring, As a blind procedure endometrial sampling (pipelle or
dilatation and curettage) has potential to miss small, localised cancers
(20),women with benign or inconclusive histology, but persistent
symptoms or suspicious ultrasound finding should be offered
hysteroscopy.
Out of 71 cases (table 4 ) which were subjected to endometrial sampling
by pipelle among 2 cases there was technical failure in nulliparous and
postmenopausal patients due pinpoint os or stenosed cervix and patients
subsequently subjected to hysteroscopy with biopsy under anaesthetia for
obtaining the sample. Technical failure was not observed with D & C (34
cases) as well as hysteroscopy procedure (47 cases) for obtaining the
endometrial sample. The efficacy of Dilatation and Curettage as a
sampling tool has been questioned(21). Obtaining scant tissue and not
covering the entire endometrium are the drawbacks of D & C. Hence
histopathological report needs to be interpreted keeping patients
history in mind to avoid under or overtreatment of patient. Pipelle
biopsy was more feasible to use for outpatient services while Dilatation
and curettage as well as Hysteroscopy with biopsy required of admission
of patient, use of anaesthetia and prolonged stay and hence these
methods were less feasible as compared to pipelle biopsy. Though
outpatient hysteroscopy with biopsy is possible with miniature 2.9mm
scope due non availability of same patients were subjected to procedure
under anaesthetia with 4.9 mm hysteroscope. In our study one case of
uterine perforation while performing dilatation and curettage which was
managed conservatively, however uterine perforation can occur with
during hysteroscopy or pipelle biopsy. Average incidence of uterine
perforation has been reported as 0.002-1.7% during hysteroscopy(22).
Postmenopausal, pregnancy, peurperieum, Acutely anteverted and
retroverted uterus, or septic conditions are high risk factors for
peforation. Perforations are more likely to happen when junior staff is
performing the procedure. Experienced surgeon performing the procedure
especially in presence of high risk factors will not only reduce the
risk of perforation but can reduce the morbidity by early detection and
prompt management.
Main Findings : AUB is commonly in Age group 41-50 followed by
in the age group of 31-40. Higher parity (para 3 more) with AUB.
Functional endometrium with proliferative (35.4%) and secretary changes
(16%) were commonly seen in AUB patients. Endometrial polyp was noted
in 5.3% cases and precursor lesions for malignancy such as endometrial
hyperplasia without atypia 12% and with atypia 4.7% and endometrial
cancer was reported in 3.3% cases. In 7 (4.3%) cases endometrial
sample obtained was inadequate for reporting and technical failure was
noted in 2 (0.66%) cases, uterine perforation was noted in one case.
(0.33%)
Strength and Limitations : Strength of study include
prospective data collection in systematic manner for enrolled cases
however study was limited to clinical and histopathological diagnoses
while inclusion of treatment and comparison of histopathology after
surgical management with the preoperative findings would have given more
information about sensitivity and specificity about the endometrial
sampling technique.
Interpretation: Study is conducted in tertiary teaching
hospital in gynaecology department and results of study may be
generalised to all age group patients similar population with complaints
suggestive of AUB however incidences of pathology may vary if the age
group of population post menopausal) differs or patients have high risk
factors such as patients attending oncological OPD
Conclusion : Pipelle biopsy is feasible as quick and outpatient
procedure however possibility of technical failure should be born in
mind. Cases of inadequate sample should be analysed carefully with
reference to background history, high risk factors, TVS imaging
(endometrial thickness, irregularity of endometrium) and need for repeat
sample and use of hysteroscopy to be considered case to case basis.This
will help in case management as well as avoid over treatment or under
treatment of underlying pathology.