A clinicopathological study of dysfunctional uterine bleeding

Correspondence: Dr Neeta Katuwal, MD Department of Obstetrics and Gynaecology Tribhuvan University Teaching Hospital, Kathmandu, Nepal. E mail:neetakums@hotmail.com Background: Dysfunctional uterine bleeding is a form of abnormal uterine bleeding when there is absence of organic disease of the genital tract. The objective of this study was to find out the clinical and pathological aspect of women presenting with dysfunctional uterine bleeding.

polyp etc and the second is the so called dysfunctional uterine bleeding (DUB) when there is absence of organic disease of the genital tract' or, in words of Novak et al. 'abnormal bleeding from the uterus unassociated with tumor, inflammation or pregnancy'. 5,6B can be classified into primary, secondary and iatrogenic groups. 6Primary DUB is due to dysfunction arising in the hypothalamo-pitutary -ovarian axis or dysfunction in the endometrium itself.Secondary DUB is due to endocrinopathies, hematological, vascular disease, liver disorders.Iatrogenic DUB is caused by drugs, exogenous hormone administration, intrauterine contraceptive devices.It is a diagnosis of exclusion; and one should proceed through logical stepwise evaluation to rule out all other causes of abnormal uterine bleeding.
DUB may be associated with almost any type of endometrium, even apparently normal endometrium like proliferative and secretory.7][8] This study aims to find clinical and pathological aspect of women presenting with DUB.

MATERIALS AND METHODS
A descriptive study was conducted over a period of one year from April 14 th 2010 to April 13 th 2011 in the Department of Obstetrics and Gynaecology and Department of Pathology, Tribhuvan University Teaching Hospital Maharajgunj, Kathmandu, Nepal.Patients attending the Gynecological outpatient department with abnormal uterine bleeding were included in the study.Adolescent age was not included in the present study as endometrial sampling is not the primary diagnostic tool for this age group.A complete history, clinical examination, pelvic scan and hormonal status and endometrial biopsy were done to diagnose DUB.
Endometrial biopsy was performed by the researcher using Karman cannula in OPD basis.Time of endometrial biopsy was taken after 15 days from the last menstrual period (preferably Day 21-22) so that hormonal status could be determined in addition to pathology.Women who were bleeding were put on non-hormonal methods of treatment till the procedure was awaited.Endometrial tissue obtained was immediately kept in 10% formalin and sent to Pathology Department, TUTH.In the labratory, paraffin embedded tissue sections were made, stained with Hematoxylin and Eosin and studied under microscope by pathologist.
A total of 145 clinically considered cases of DUB were subjected to endometrial biopsy.Out of these endometrial biopsies revealing organic causes (10 cases) and those samples inadequate for opinion (15 cases) were excluded.Thus total of 120 cases of DUB was included in the analysis.
The data were analysed using Stastical Package for Social Studies (SPSS) version 18.

DISCUSSION
AUB is a common gynecological condition.Evaluation of patient with abnormal uterine bleeding and identifying those with DUB is achieved with the combination of the following: history, physical examination, laboratory evaluation, USG and confirmed by endometrial sampling.
The present study showed DUB, most common in the age group 40-44 years, accounting for 30% followed by 27.5% in 45-49 years age group.Present study findings were comparable to studies done by Muzaffar et al 9 and Thanyapa W10 who reported menstrual disorders to be common in age group 41-50 years.
The present study showed menorrhagia as the most common menstrual disorder in women presenting with DUB accounting for 41.6% of cases followed by menometrorrhagia of 39.2% and metrorrhagia 7% which was less compared to 51.9% of cases of menorrhagia and 35.4% metrorrhagia mentioned by Muzaffar M et al. 9 Also study by Bhosle A et al 11 showed menorrhagia as major clinical symptom in perimenopausal women with abnormal uterine bleeding.There were 9 cases (7.5%) in the present study with postmenopausal DUB which was comparable 9.2% cases in study by Thanyapa W10, 8.6% by Ha BS et al. 12 In a study by Dangal G 13 where peri and postmenopausal women were included, there were higher percentage (53.5%)cases of postmenopausal bleeding.
In the absence of ovulation and the production of progesterone, endometrium responds to excessive or unopposed estrogen stimulation with proliferation and this over time may induce hyperplastic response in the proliferating endometrium. 5,6 n present study most common histology of endometrium in anovulatory DUB was proliferative 48.6 percent.Similar results of proliferative endometrium as the most common pattern was obtained in the study in study by Ha BS et al 12 of 99%, that by Hoon CN et al 14 of 50.85%,Somboonporn W et al. 15 of 75%, Muzaffar M et al. 9 of 27.4% and also by other studies. 10,11,16,17The second common endometrial histology in anoulatory DUB in present study was Disordered proliferative endometrium 33.8 percent.This type of endometrial histology was also seen in the study by Hoon CN et al. 14 of 49%, Vakiani M et al 18 of 41.86% and Baral R, Pudasaini S of 10 percent. 19rophic endometrium as a type of anovulatory pattern In the present study endometrial pathology as hyperplasia was seen only in perimenopausal women not in reproductive or post-menopausal age group which is similar to study by Dangal G. 13 DUB also develops when ovulation occurs but corpus luteum function is insufficient leading to irregular ripening of endometrium (luteal phase defect) or there may be abnormal persistence of corpus luteum leading to irregular shedding. 5,6Secretory bleeding pattern in ovulatoty DUB may be described when there is bleeding present in secretory but non menstrual background Ovulatory DUB was associated with only secretory endometrium and accounted 35.3% of the cases in the present study.However in addition to secretory endometrium in ovulatory DUB, study by Patel BS, Delvadia JL, Desai DA15 showed irregular ripening, Vakiani M et al. 18 showed corpus luteum defect (15.4%), study by Hoon CN et al 14 showed abnormal secretory type (0.3%) and that by Ha BS et al 12 showed irregular shedding (1.2%).

CONCLUSION
The present study showed DUB most common in perimenopausal age group (>40 years).Anovulatory pattern is observed in majority of cases.Histopathological evaluation of endometrium helps exclude the local causes and establishes the diagnosis of DUB, its types, clinical correlation to histopathological findings and finally helps to determine the mode of management.
Katuwal N et al.

Figure 1 .Figure 2 :
Figure 1.Distribution of women by age (in years)

Table 1 : Menstrual disorders in women with DUB
20s seen in 6.8% cases in the present study.Atrophic endometrium was seen mostly in the postmenopausal followed by perimenopausal women and was not seen in reproductive age group.Higher incidence atrophic endometrium of 17% by Ejaz S et al20is due to inclusion of only postmenopausal cases and 34.5% by Dangal G 13 due to inclusion of perimenopausal and postmenopausal DUB excluding reproductive age group.