Introduction

Abnormal Uterine Bleeding (AUB) refers to bleeding that occurs outside of the regular menstrual cycle, and which can involve changes in the usual pattern of bleeding. Changes in the frequency, duration, or amount of bleeding may occur in women, either during their periods or between them. AUB is a frequently occurring issue among women in their reproductive age, and it can have significant social and financial consequences. 1 Menstrual dysfunction is a prevalent problem that can lead to discomfort, inconvenience, and disturbance in the daily lives of countless women globally, irrespective of their location in either developed or developing countries.2 On average, menstrual bleeding lasts for about 4.7 days, with approximately 89.0% of menstrual cycles lasting 7 days or more AUB is a condition that causes significant impairment in women's health, impacting a substantial proportion of women in different stages of their reproductive life with 14-25% of women of reproductive age and up to 50% of women in the perimenopausal phase experience the effects of this condition.3, 4, 5 The prevalence of abnormal uterine bleeding in India is 17.9%.1, 6 AUB affects 9-14% of women between menarche and menopause, Having a profound effect on their standard of living and imposing financial constraints.7 On average, the amount of blood lost per menstrual cycle is 35ml.8 The classification system for AUB is known as FIGO PALM-COEIN. The acronym represents nine major groups used to classify the causes of AUB. These groups are: Polyp, Adenomyosis, Leiomyoma, Malignancy, Coagulopathy, Ovulatory dysfunction, Endometrial causes, Iatrogenic causes, and Not yet specified.9

Sonography, also known as ultrasound imaging, is commonly used as the initial diagnostic tool for assessing AUB because it is non-invasive and provides a relatively quick assessment of the uterus and ovaries. It can detect uterine abnormalities such as fibroids and ovarian cysts, which may be causing the AUB.

However, as you mentioned, sonography may not always provide information about the uterine cavity, where the endometrium (the lining of the uterus) is located. For example, it may not be able to detect polyps or adhesions inside the uterus. In such cases, other diagnostic tests such as hysteroscopy or saline infusion sonography (SIS) may be needed to visualize the uterine cavity.

It's important to note that the diagnostic approach to AUB depends on various factors such as age, medical history, symptoms, and physical examination findings. A healthcare provider may order additional tests based on their clinical judgment and the individual patient's needs.

In earlier times, the method widely employed for obtaining samples of the endometrium was dilation and curettage. However, this method is less sensitive for obtaining a definitive diagnosis, with a diagnostic error rate ranging from 10.0 to 25.0%.10 The medical procedure known as dilatation and curettage (D&C) is typically performed without direct visualization, meaning that the doctor cannot see the inside of the uterus during the procedure, This indicates that in approximately 60.0% of patients, the device is capable of scraping less than 50.0% of the endometrial cavity. Consequently, its diagnostic accuracy in identifying structural pathologies such as polyps, fibroids, intrauterine adhesions, and congenital malformations is lower compared to hysteroscopy. Hysteroscopy provides a direct visualization of the endometrial cavity, which allows for more accurate diagnosis and treatment of these pathologies.11 Hysteroscopy has a very low cancer detection failure rate of 0.9%.12 Polyps and submucous fibroids are often not detected by curettage alone, highlighting the limitations of this method. The assessment of abnormal uterine bleeding is crucial for identifying the underlying cause and determining the appropriate treatment. There are several techniques available for assessing abnormal uterine bleeding.

In the era of modern endoscopic surgery, hysteroscopy-guided endometrial sampling plays a significant role in detecting intrauterine pathology for precise and accurate diagnosis.13 Following visualization, an endometrial biopsy is taken from the exact suspicious site for histopathological diagnosis. As a result, curettage performed after hysteroscopy should now replace conventional dilatation and curettage.14

The aim of this research was to assess the extent of the correlation between hysteroscopic diagnosis and histopathological findings when investigating cases of abnormal uterine bleeding.

Materials and Methods

This analytical observational investigation was conducted in the Department of Obstetrics and Gynaecology at the Integral Institute of Medical Sciences and Research in Lucknow over a period of eighteen months from March 2021 to September 2022.

A comprehensive assessment was conducted by obtaining a detailed medical history and conducting a thorough general and systemic examination. The study population underwent routine investigations, including transvaginal sonography. Following that, hysteroscopy was performed, and endometrial biopsy was taken for histopathology after obtaining informed consent following counseling. The procedure was conducted in an operating room under sedation. The patient was transferred to the procedural area and placed in the dorsal lithotomy position. After performing a bimanual examination, before inserting the tenaculum, either a 10% povidone-iodine solution was used to clean the cervix or the anterior lip of the cervix was grasped with a single-toothed tenaculum.a small quantity of local anesthetic was administered, the uterine sound was introduced and the size and position of the uterus were confirmed. With all aseptic precautions, the vagina was distended and the cervix and the external os were located gently, the cervix was dilated to the diameter of the hysteroscope being used, after which the hysteroscope (4mm Rigid Storz Hysteroscope and 5mm sheath of 30º oblique angle) was carefully inserted and passed through the internal os of the cervix. Hysteroscope was connected to the liquid distention medium for which 0.9% normal saline was used, maintaining the pressure of 70 to 100mmHg, and then it was advanced into uterine cavity. The endocervical canal, uterine fundus, bilateral ostia, and uterine cavity were visualized in a systematic manner. This was followed by endometrial curettage by curette from the suspicious areas if any, present in the uterine cavity, and the sample was sent in 10% neutral buffer formalin to the pathology department for histopathological examination. As per ACOG 2004, Histopathological diagnosis is considered the gold standard for determining the effectiveness of hysteroscopy in diagnosing endometrial pathologies. Patients were observed in the recovery room for two hours and most of the patients were discharged on the same day or the next day. The findings obtained by hysteroscopy were compared and correlated with histopathological findings2 categorical variables were presented as counts and percentages (%), while continuous variables were presented as mean ± standard deviation (SD) or median. Qualitative variables were compared using either the Chi-Square test or Fisher's exact test. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for each method were assessed and determined. To assess statistical significance, a significance level (p-value) of 0.05 or less was utilized. The data were recorded in a Microsoft Excel spreadsheet and analyzed using the Statistical Package for the Social Sciences (SPSS), specifically version 23.0.

Results

Over a span of eighteen months, the study enrolled 63 women who presented with symptoms at the Department of Obstetrics and Gynaecology at the Integral Institute of Medical Sciences and Research in Lucknow.

The study enrolled a total of 63 female patients starting at age 35 years. The age distribution of patients with AUB is presented in the following table. The age distribution of the 63 patients with AUB showed that the majority (52.4%) were aged 40 years or younger, Out of the respondents, 55.6% belonged to the 31-40 years age group, while 38.1% were in the 41-50 years age group. A smaller proportion, 6.3%, fell into the 51-60 years age group, and only 3.2% in the 61-70 years age group. The patients' average age was 42.98±19.09 years, and their ages ranged from 35 to 70 years old.

Of the 63 patients included in the study, 28 (44.4%) had regular menstrual cycles and 35 (55.6%) had irregular menstrual cycles. The frequency of menses was normal in 42 (66.7%) patients, frequent in 8 (12.7%) patients, and infrequent in 13 (20.6%) patients. For patients with complaints of the duration of the flow, there were 41 (65.1%) patients with a normal duration of flow followed by 15 (23.8%) patients with a prolonged duration of flow and 7 (11.1%) patients with duration of flow shortened. Out of the total of 63 patients, 15 (23.8%) patients had normal blood loss, 40 (63.5%) patients had heavy monthly blood loss during menses, and 8 (12.7%) patients had light blood loss.

Discussion

AUB is a frequent complaint among women who visit gynecologists. The condition can manifest in various forms, such as heavy menstrual bleeding, frequent or infrequent cycles, irregular bleeding, and post-coital bleeding. Due to the complex nature of AUB, gynecologists and patients may require several diagnostic methods, including ultrasound, to accurately diagnose and treat the condition."

The use of hysteroscopy provides a valuable addition to the diagnostic tools available to gynecologists. It may enable more effective reproductive illness therapy and increase diagnosis precision. Following hysteroscopy, patient care can be better managed. 7 Due to its ability to "see" and "decide" the reason, hysteroscopy is almost completely substituting blind curettage in the treatment of irregular vaginal haemorrhage. This is possible due to the ability to visualize the uterus canal and curet the troublesome region.

The standard procedure for diagnosing endometrial pathology is histopathological examination of an endometrial biopsy obtained through dilatation and curettage (D&C) is a recommended diagnostic method.8 This approach should be considered for women with menstrual complaints if abnormal uterine bleeding (AUB) does not improve with medical management, particularly those who are over 40 years old or at a higher risk of endometrial cancer.

The current investigation recruited 63 women who were over the age of 35. Among the participants, the majority (52.4%) were in the 35-40 years age group, followed by 24 (38.1%) patients in the 41-50 years age group, 4 (6.3%) patients in the 51-60 years age group, and only 2 (3.2%) patients were in the 61-70 years age group. The participants in the current study had a mean age of 42.98±19.09 years, with an age range of 35-70 years. According to a study by Puhan JN et al15 (2019), abnormal uterine bleeding is most commonly observed in the 35-50 years age group, with 118 out of 200 cases (59.0%) belonging to this group. This suggests that the majority of women with AUB are in the perimenopausal age range. Hormonal imbalance is most frequently observed during the perimenopausal period, which could be a contributing factor to the development of AUB in this age group. In a study by Khushnood M and Niyaz FF16 (2019), the age range of their participants was 20-70 years, with a mean age of 40.33 years.

Out of all the patients, the largest percentage (40%) fell into the 40-50 years age range. The next highest percentages were the 20-30 and 30-40 years age groups at 20% each, followed by the 50-60 years age group at 13.8%. A smaller percentage of patients (10%) were in the 50-60 years age group, while only 3.33% were below 20 years old. Distribution according to AUB pattern in patients. In our study, out of 63 patients, there were 28 (44.4%) patients had regular menses, and 35 (55.6%) patients had irregular menses. The frequency of menses was normal in 42 (66.7%) patients, frequent in 8 (12.7%) patients, and infrequent in 13 (20.6%) patients. For patients with complaints of the duration of the flow, there were 41 (65.1%) patients with a normal duration of flow followed by 15 (23.8%) patients with a prolonged duration of flow and 7 (11.1%) patients with a duration of flow shortened. Out of the total 63 patients, 15 (23.8%) patients had normal blood loss, 40 (63.5%) patients had heavy monthly blood loss during menses, and 8 (12.7%) patients had light blood loss. 61 Similarly in the study done by Khan R et al8 (2016) Upon analysis, the distribution of patients was categorized according to their bleeding pattern.

The prevalent presenting illness was menorrhagia (55.8%).According to a study conducted by Kazemijaliseh and colleagues in 2017, approximately 10.6% (with a 95% confidence interval between 6.3% and 12.5%) of the female participants experienced irregularity disturbances. The same study found that 23.8% (with a 95% confidence interval between 18.4% and 26.1%) of the female participants reported disturbances in frequency, 16.0% (95% CI: 12.7% – 19.2%) of participants reported a disturbance in the heaviness of their menstrual flow, while 11.5% (95% CI: 8% – 15.4%) reported a disturbance in the duration of their flow. Walraven G et al9 (2002) reported that more than 40.0% of women suffered from menstrual disorders. Also, 16.0% complained of irregular cycles, 14.0% with dysmenorrhea, 8.0% spot, and 4.0% of cases heavy or prolonged bleeding. However, the prevalence of menstrual disorders in our study was slightly lower compared to a previous study. In our study, heavy menstrual bleeding (HMB) was the most common disorder reported by 84.0% of women. HMB is a serious problem that can contribute to anemia and could potentially be life-threatening if left untreated. A study by Fraser IS et al. (2015) reported the prevalence of HMB among women aged 18-57 years in five European countries through an internet-based survey. The study found that out of 4506 respondents, 1225 (27.2%) had experienced HMB symptoms within the previous year, which is lower than the prevalence observed in our study. This difference could be attributed to the shorter duration of HMB experienced in the European study. It has been reported by Shapley M et al.4 (2004) that the perimenopausal years are associated with a high incidence rate of resolution of heavy menstrual bleeding.

Hysteroscopy findings In our study, based on hysteroscopy findings, out of 63 patients, 26 patients were reported with normal hysteroscopy findings inclusive of proliferative and secretory endometrium, and the rest of the patients with abnormal hysteroscopy findings, the majority of patients i.e. 17 (26.9%) were diagnosed with endometrial hyperplasia, followed by 13 (20.6%) patients were reported as a polyp in the endometrium 2 (3.2%) patients reported as submucous fibroid and endometritis each, 2 (3.2%) patients reported with atrophic endometrium and 1 (1.6%) patient was reported with adhesions.

Histopathological findings It was observed that out of 63 patients in our study, 30 (47.6%) patients showed normal endometrium (proliferative and secretory phase of the endometrium), there were 14 patients diagnosed with endometrial hyperplasia in which 11 (17.4%) patients showed hyperplasia without atypia, and 3 (4.8%) patients showed hyperplasia with atypia. There were 13 (20.6%) reported polyps, 3 (4.8%) patients had fibroid, and 1 (3.2%) patient had endometritis, atrophic endometrium, and disordered proliferative endometrium.

In a study conducted by Bhatiyani BR et al11 in 2018, the histopathological findings on HPE reports were analyzed for a group of patients. After analyzing the data, it was discovered that the majority of patients, specifically 39, had secretory phase endometrium. This was followed by 16 patients who had proliferative phase endometrium. Additionally, 14 patients exhibited disordered proliferative endometrium, endometrial polyp, and endometrial hyperplasia without atypia. Additionally, endometrial hyperplasia with atypia was reported in 2 patients, while leiomyoma was reported in 1 patient. The study showed that 43.0% of patients had an abnormal histopathology report, while the remaining 57.0% had a normal report.

A study conducted by Kathuria R et al19 in 2014 showed results that are almost identical to ours: 40% of patients exhibited abnormalities, while 60% had normal HPE reports. According to a study by Patil SG et al10 in 2009, proliferative phase endometrium was found to be the most common finding, which contrasts with the results of our study, where secretory endometrium was the most frequently reported histopathology. In the study of Bashir H et al20 (2015) endometrial hyperplasia was found in 18.9% of cases, which was also concordant with observations made by Patil SG et al10 (2009) reported 20.0% of patients had endometrial hyperplasia, but higher than that observed by Doraiswami S et al21 (2011) in 6.11% patients and Abid M et al22 (2014) reported endometrial hyperplasia in 5.0% patients. In 12% of instances, the most prevalent form of hyperplasia was simple hyperplasia without atypia. It was discovered that hyperplasia was the most frequent biological cause of AUB in post-menopausal women as well as in fertile and peri-menopausal women. However, its frequency peaked in the peri-menopausal age group accounting for about 50% of cases. Similar observations were made by Vaidiya S et al23 (2013) and Muzaffar M et al24 (2005). Similar observations were made by Dangal G25 (2003) in 10.7% of patients, and Gredmark T et al26 in 10% of patients. However, its incidence was lower in a study by Jairajpuri ZS et al27 (2013) reported in 5.79% of patients and a higher incidence was seen in studies done by Baral R et al28 (2011) that is in 18.3% of the patients. The most frequently observed type of hyperplasia in the present study was simple hyperplasia without atypia, which is consistent with the findings of Pilli GS et al.29 (2002) and Vakiani M et al.30 Endometrial hyperplasia is a prevalent diagnosis, particularly among women aged 41-50, often presenting symptoms of irregular or prolonged bleeding resulting from anovulatory cycles in most cases.31 The observed variation in the prevalence of endometrial hyperplasia could be attributed to various factors such as differences in socioeconomic status, the presence of risk factors such as obesity, diabetes, sedentary lifestyle, and variations in early diagnosis. It is important to identify endometrial hyperplasia as it is believed to be a precursor to endometrial carcinoma. Furthermore, the prevalence of endometrial hyperplasia peaks among perimenopausal and postmenopausal women.10

Overall comparison of validities of Hysteroscopy and Histopathology On hysteroscopy, the overall sensitivity, specificity, positive predictive value, and negative predictive value were as follows 96.15%, 86.49% 83.33%, and 96.97% respectively. On histopathology, the overall sensitivity, specificity, positive predictive value, and negative predictive value were as follows 80%, 72.73% 92.31%, and 84.21% respectively. The overall diagnostic accuracy of our study came out to be 90.48%. The result of our study indicates 96.15% sensitivity and 86.49% specificity.

The correlation between hysteroscopic findings and histopathological findings was found to be significant, on the Kappa test (Kappa value=0.282) and p-value <0.05).

Figure 1

Endometrial hyperplasia

Figure 2

Hyperplasia without atypia

Figure 3

Hyperplasia with atypia

Figure 4

Polyp

Conclusion

Hysteroscopy can aid in the diagnosis of the underlying cause of AUB, and appropriate management will depend on factors such as the patient's age, fertility goals, and the results of the final histopathology. While hysteroscopy is a useful diagnostic tool, it should not replace tissue diagnosis, which remains the gold standard. Both hysteroscopy and biopsy are necessary for accurate diagnosis of AUB and for developing a proper treatment plan. After careful analysis, it can be concluded that Hysteroscopy offers the advantage of providing direct visualization of any abnormalities present within the uterine cavity. As a result, it proves to be a valuable diagnostic tool for identifying the underlying cause of AUB. However, it should not be considered a substitute for other diagnostic procedures such as tissue biopsy, ultrasound, or blood tests. Rather than being considered as a primary diagnostic tool, hysteroscopy should be perceived as a supplementary method that can furnish supplementary information to facilitate the diagnosis and treatment of AUB.

Source of Funding

None.

Conflict of Interest

The author(s) declare(s) that there is no conflict of interest.