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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/

Abnormal Uterine Bleeding (AUB)-a term used to
describe any type of bleeding that does not fall within
the normal ranges for amount, frequency, duration,
or cyclicity.[1] The most common presentations are
menorrhagia, polymenorrhoea, metrorrhagia, and
intermenstrual bleeding. Dilatation and Curettage
(D and C) is the mainstay of endometrial sampling since
a long time. D and C also allows for a fractional curettage
with separate sampling of both the endometrial and
endocervical tissue. Hysteroscopy has almost replaced
blind curettage as the uterine cavity can be observed
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DOI:
10.4103/2348-3334.134265
transabdominal ultrasonography is another useful
adjunctive technique for examining the endometrium
in the evaluation of AUB.[1-3]
The underlying disease can be detected by histological
variations of endometrium taking into account the age
of the woman, the phase of her menstrual cycle, and
use of any exogenous hormones. Pregnancy-related
and dysfunctional uterine bleeding are more common
in younger patients, whereas atrophy and organic
lesions become more frequent in older individuals.
Hyperplasia is found in up to 16% and endometrial
carcinoma in fewer than 10% of postmenopausal
patients undergoing biopsy.[2] Patients with a history
of anovulation, obesity, hypertension, diabetes, and
exogenous estrogen use are at an increased risk for
hyperplasia and adenocarcinoma.[2] Early evaluation
in the perimenopausal and postmenopausal women is
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: drsk29@hotmail.com

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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
menstrual blood loss. The main defect is in the control
of processes regulating the volume of blood lost during
the menstrual breakdown of endometrium.[20]
In the present study, a proliferative pattern of
endometrium [Figure 1c] was observed in 12.2% patients.
Other studies reported incidences of 17.8%, 33%,
32.6%, and 32%.[13,17,21,22] This pattern was commonly
observed in the late reproductive and perimenopausal
women in our study and other studies and may be due
to the hormonal imbalance in this group leading to
intermittent anovulatory cycles.
Disordered proliferative endometrium [Figure 1d] is an
exaggeration of the normal proliferative phase without
significant increase in the overall ratio of glands to stroma
and is due to persistent oestrogen stimulation.[2,23] This
pattern is particularly seen in perimenopausal women.
The disordered proliferative endometrium resembles
normal proliferative tissue in consisting of glands lined
by cytologically bland, pseudostratified, proliferative,
mitotically active epithelium and in having a normal
ratio of glands to stroma. It differs from the normal
proliferative endometrium in the absence of uniform
glandular development. Disordered proliferative pattern
lies at one end of the spectrum of proliferative lesions of
the endometrium that includes carcinoma at the other
end with intervening stages of hyperplasias.[6] This
pattern was seen in 19 (12.2%) of our cases. Another
study reported a similar incidence of 10%.[24]
a c
b d
Figure 1: (a) Simple hyperplasia without atypia, showing mildly irregular, variably
sized glands in abundant stroma with squamousmetaplasia. H and E ×400
(b) Complex hyperplasia without atypia, highly irregular glands with scant
stroma and inset showing regular, uniform nuclei. H and E ×400 (c) Proliferative
endometrium, glands are tubular and regularly spaced in abundant stroma.
H and E ×100 (d) Disordered proliferative endometrium, showing disorganized
proliferative phase glands with focal glandular dilatation. H and E ×100
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Atrophic endometrium is the most common cause
of bleeding in postmenopausal stage.[12] Thin walled
veins, superficial to the expanding cystic glands, make
the vessels vulnerable to injury and lead to excessive
uterine bleeding.[16] Atrophic endometrium was seen in
5.13% of the patients in this study and they presented
as postmenopausal bleed. A similar incidence was
reported in other studies with incidences of 4.34% and
7%, respectively.[12,25]
In our study, pill endometrium was seen in 12 (7.69%)
cases. Other studies reported a lower incidence.[5,13,24] In
this pattern, the endometrium shows a combination of
inactive glands, abortive secretions, decidual reaction,
and thin blood vessels.[26] This pattern was predominantly
seen in the perimenopausal age group. This was probably
due to increased number of patients in this age resorting
to early medical management for bleeding.
The other benign patterns included endometrial
polyps (5.12%), irregular shedding (3.84%), luteal phase
defect (2.56%), endometritis (0.64%), and menstrual
pattern (1.28%).
The malignant conditions observed in this study
included seven cases of endometrial carcinoma,
two cases of squamous cell carcinoma of the cervix
infiltrating into endometrium, and one case of low-grade
endometrial stromal sarcoma [Figure 2a and b].
a b
c d
Figure 2: (a) Endometrial stromal sarcoma, gross: Tumour presenting as a
fleshy mass in the parametrium (b) Endometrial stromal sarcoma, composed of
cells with uniform round to oval nuclei, finely granular chromatin, small nucleoli,
and scanty cytoplasmwith ill-defined cell borders. H and E ×100 (c) Endometrial
carcinoma, gross: Hysterectomy specimen, showing exophytic irregular growth
involving the endometrial cavity and extending up to the lower uterine segment
(d) Endometrioid adenocarcinoma, International Federation of Gynecology and
Obstetrics (FIGO) grade 2, showing well-defined glands with confluent pattern,
nuclei are enlarged, irregular to rounded, vesicular with prominent nucleoli.
H and E ×400
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Sajitha, et al.: Endometrial pathology in AUB
The predominant type of endometrial carcinoma
was endometrioid type which constituted five cases.
One each of classical endometrioid adenocarcinoma
[Figure 2c and d] and villoglandular variants and
three were endometrioid carcinoma with squamous
differentiation. We had one case each of serous
carcinoma and clear cell carcinoma. The most common
presentation in these patients was postmenopausal
bleeding and incidence of endometrial carcinoma was
21.73% in the postmenopausal group. This was similar
to that reported by Baral R et al. with an incidence
of 21%.[16] Nulliparity, increased BMI, and chronic
anovulation have been implicated as risk factors for
endometrial carcinoma. Out of the total seven cases
of endometrial carcinomas in our study, two (28.6%)
were nulliparous and two (28.6%) were overweight
(BMI 25-30 kg/m2). Similar pattern was reported in
another study with an incidence of 20% in nulliparous
women and 60% in patients with a BMI of >30 kg/m2.[27]
Primary cancer of cervix extending to the endomerium
was observed in two cases (1.28%) and they presented
with postmenopausal bleed. This was consistent with
the findings of Ara S who reported an incidence of
1.24%.[25] The patient with low-grade Endometrial
Stromal Sarcomas (ESS) was 47-years old and presented
with menorrhagia and mass in the pelvis. In a previously
reported study of 14 cases of low grade ESS, the most
common presentation was vaginal bleed (86%), followed
by pelvic mass (7%) and pelvic pain (7%).[28]
CONCLUSION
Endometrial lesions vary according to the patient’s age.
Endometrial sampling by dilatation and curettage is an
effective and reliable diagnostic test. Its interpretation
can be quite challenging and also may show considerable
interobserver variability. Clinical information regarding
age, menstrual history, parity, and imaging studies
are important prerequisites in the interpretation of
endometrial samples. Dilatation and curettage reveals
the endometrial patterns in various forms of AUB
and also helps to exclude the presence of any organic
pathology. Thus, histopathological evaluation of
endometrium is especially indicated in women over
the age of 35 years to rule out preneoplastic lesions
and malignancies.
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Cite this article as: Sajitha K, Padma SK, Shetty KJ, Kishan Prasad HL,
Permi HS, Hegde P. Study of histopathological patterns of endometrium in
abnormal uterine bleeding. CHRISMED J Health Res 2014;1:76-81.
Source of Support: Nil. Conflict of Interest: No.

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