Perimenopausal period is defined by Soules and Parrott [1], as a timeframe starting from menstrual transition up to a year after the last menstruation that can range from four to eight years. Menopausal signs can be observed in this time, such as anomalies in the menstrual cycle brought by shifting levels of estrogen causing irregularities in terms of chronicity and mass. When perimenopausal women usually experience such bleeding anomalies, cases of uterine pathology and affiliated complications, for instance, abnormal uterine bleeding, correspondingly rise in them [2]. 

Contrary to popular belief, abnormal uterine bleeding (AUB) is not a disease, but instead, a symptom. More than 70 percent of all gynecological consultation is about AUB, making it one of the most frequently engaged complaint in the peri- and post-menopausal age cohort [3]. According to Kumar and Malhotra, AUB comes in different forms like menorrhagia, polymenorrhea, polymenorrhagia, metrorrhagia and menometrorrhagia. It is also a sign of contradiction for it may only display as normal bodily functions such as estrogen withdrawal, which can be guaranteed by observation alone. However, it may also be a symptom of severe underlying complications, such as malignancy in female genitals, specifically, in postmenopausal women that requires the srugical removal of the uterus, also known as hysterectomy. The International Federation of Gynaecology and Obstetrics credited a new classification system for various causes of AUB in November 2010 for the upcoming years [4]. The system utilizing the acronym PALM-COEIN (polyps, adenomyosis, leiomyoma, malignancy and hyperplasia–coagulopathy, ovulatory disorders, endometrial causes, iatrogenic, not classified) was developed in response to concerns about the design and interpretation of basic science and clinical investigation that relates to the matter of AUB.

In the midst of the information discussed above, there are other implications which could be correlated to the presence of AUB. One of which is hormone milieu. AUB could also be of concern for perimenopausal women, as its presence could indicate benign of malignant lesions in their genital tract. In most cases however, there are no structural abnormalities detected. This is called dysfunctional uterine bleeding or DUB, which is a common hyperoestrogenic condition where the endometrium remains in the proliferative phase. Other hyperoestrogenic conditions include fibroid uterus and adenomyosis. However, if left untreated, these conditions may lead to endometrial carcinoma. As a result, clinical examination and investigations are vital in looking for the etiological factors concerning perimenopausal patients with AUB. Excluding organic pathology in AUB could be done using ultrasonography (USG). Also, histopathological examination of HPE has been widely accepted to be an effective instrument in accurately detecting various disease pathology. The current study was done in order to assess different clinical diagnosis of AUB and to find the significant relationship between ultrasonographic findings and histopathological examinations on patients undertaking hysterectomy.

Objectives of The Study

Generally, the study aimed to determine the correlation of sonographic and histopathological findings of hysterectomy specimens among perimenopausal women with abnormal uterine bleeding. Specifically, this study aimed to:

• Describe The Profile of the Participants in Terms of:

• Age

• Parity

• Menstrual complaints

• Duration of menstrual complaints

• Diagnose The Patients’ Condition Using the Following Procedures:

• Ultrasonography

• Histopathology

• Determine The Correlation of the Ultrasonography Diagnosis with Histopathological Finding

Significance of the Study

This study highlights the use of existing technology in medicine in diagnosing various health conditions. More importantly, it provides an avenue to appraise the reliability and accuracy of ultrasonography as a diagnostic tool in ruling out gynecologic problems. For medical practitioners, this study could make medical practitioners informed of the extent of reliability of ultrasonography as a tool in diagnosing medical conditions. This may likewise give them idea on the use of other pertinent tests to validate and support ultrasonography findings.

Research Design

This research is a retrospective study using descriptive research design. A retrospective study searches for the relationship between one (usually current) phenomenon or condition and another that occurred on the past. In this study, patients who underwent hysterectomy due to abnormal uterine bleeding in the past two years were included. It tried to correlate the sonographic findings and histopathological examination of the hysterectomy specimens collected from the patients.

Participants and Locale of the Study

Perimenopausal women who underwent hysterectomy due to abnormal uterine bleeding were the participants of the study. The study was conducted in selected hospitals in the province of Cavite from 01 January 2015 to 31 December 2016.

Sampling Design

Purposive sampling was used in the study. It is a non-probability sampling method that is selected based on the desired characteristics of a population and the objective of the study. In this study, women in their perimenopausal period who underwent hysterectomy due to abnormal uterine bleeding were selected as participants of the study.

Data Gathering Procedure

Before the actual conduct of the study, permission from the hospital was sought. As soon as the permission for the conduct of the study was granted, an informed consent was secured from the target participants. Before any participant gave her informed consent, it was ensured that they had clear and explicit information on all the aspects of the study – the procedure to be followed and the reasons, the exact nature of the participants’ role; the risks and benefits involved; psychological stress and embarrassment; and the way in which the data would be handled and reported.

Upon having secured the participants’ informed consent, their medical records were accessed to generate the information needed. The raw data were arranged and then encoded in a prepared database ready for analysis. The analysis and interpretation of data was done through the aid of an appropriate statistical tool. The related literatures collected were also used as bases to describe and validate the participants’ responses in the study.

Data Analysis

Descriptive statistics such as frequency and percentage was used to describe the distribution of the participants. Furthermore, suitable kinds of tables and figures were used to ensure clarity and intelligibility in the presentation of the findings.

The correlation of sonographic and histopathological findings was determined by computing for the specificity, sensitivity and positive and negative predictive values.

Profile of the Participants

The participants’ profile was gathered by reviewing the medical record of the identified participants. As per records, 48 patients qualified as the participants of the study. Table 1 shows the distribution of the participants in terms of age and parity. As shown in the table, majority of the participants are 40-45 years old (54%) who have given birth twice (29%). Interestingly, almost a quarter of the number of the participants have zero parity, which indicates that they have not yet experienced giving birth.

Table 1: Distribution of the Participants in Terms of Age and Parity

In the study of Ananth et al., [5], multiparity has been found to be correlated with the incidence of placenta previa, abruptio placenta but not with other forms of uterine bleeding. In spite of this, they have found out that increasing maternal age can be correlated with the occurrence of abnormal uterine bleeding. Kaunitz [6], cited that abnormal uterine bleeding among perimenopausal women can be attributed to atrophy of the uterine lining, hyperplasia, fibroids and infection.

The menstrual complaints of the participants, as well as its duration, have been summarized in Table 2. Results show that half of the participants are complaining of menorrhagia with 12 of them experiencing it for four to six months already. Menorrhagia refers to menstrual periods with abnormally heavy or prolonged bleeding [7]. The least of the participants (4%) reported experiencing metrorrhagia, uterine bleeding at irregular intervals, particularly between the expected menstrual periods, for at least one to three months.

Table 2: Distribution of The Participants in Terms of Menstrual Complaint and Duration

Diagnostic Findings among the Research Participants

Two diagnostic procedures were used to find out the underlying condition behind the patients’ chief complaints: Ultrasonography and histopathology. According to Ahmed and Diggory [8], the use of ultrasonography has been the accepted gold standard in diagnosing diseases that involve the internal organs of the body. Improvements in the use of this technology have been done and the accuracy of this procedure has been tested in various studies through the use of other tests such as histopathology. Table 3 shows the ultrasonography findings among the participants of the study.

As shown in the foregoing result, ultrasonography findings reveal that almost half of the participants have fibroid uterus while there is only one of them who is found to have endometrial polyp. Moreover, 31 percent of the participants has been ruled out to have adenomyosis, a condition in which the inner lining of the uterus (the endometrium) breaks through the muscle wall of the uterus (the myometrium).

Table 3: Ultrasonography Findings

Finding out the distribution of the participants in terms of bleeding pattern and ultrasonography findings (Table 4) shows that majority of those diagnosed with fibroid uterus, adenomyosis, thickened endometrium and endometrial polyp all experience menorrhagia. The nature of the patients’ condition explains why the patients experience menorrhagia. According to Smith [9], menorrhagia is relative to fibroid uterus and adenomyosis as one of its manifestations. He cited that uterine fibroids commonly cause heavier than normal or prolonged menstrual bleeding while the disease process of adenomyosis is often causing heavy bleeding and painful periods.

Table 4: Distribution of the Participants in Terms of Bleeding Pattern and Ultrasonography Findings

The histological evaluation of surgical biopsies from affected tissues is a standard way of assessing pathological change and determining treatment in many diseases. In this study, histopathology was used to validate the ultrasonography findings. Histopathological reports of myometrium (Table 5) reveals 33 cases of fibroid (M2) and 20 cases of adenomyoma (M3). Of the 27 patients diagnosed with fibroid uterus via ultrasonography, 23 are confirmed histopathologically while the remaining four are found to have adenomyoma. On the other hand, among the 19 patients ultrasographically diagnosed with adenomyosis, 12 are confirmed correctly via histopathology while seven are found to have fibroid uterus.

Table 5: Histopathological Examination Findings in Relation to Ultrasonography Diagnosis

M1: Normal, E1: Proliferative, C1: Normal, M2: Myomatous Changes, E2: Secretory, C2: Inflammatory, M3: Adenomyomatous Changes, E3: Hyperplastic, C3: Carcinoma, E4: Endometrial polyp, C4: CIN, E5: Atrophic, E6: Inflammatory, E7: Carcinoma

Correlation of the Ultrasonography Diagnosis with Histopathological Finding

Findings gathered from ultrasonography and histopathology done among the participants of the study were correlated by computing for the sensitivity, specificity, positive predictive and negative predictive values. In the context of medical tests, sensitivity is the extent to which true positives are not missed/overlooked (so false negatives are few) and specificity is the extent to which positives really represent the condition of interest and not some other condition being mistaken for it (so false positives are few). Thus a highly sensitive test rarely overlooks a positive (for example, showing "nothing bad" despite something bad existing); a highly specific test rarely registers a positive for anything that is not the target of testing (for example, finding one bacterial species when another closely related one is the true target); and a test that is highly sensitive and highly specific does both, so it "rarely overlooks a thing that it is looking for" and it "rarely mistakes anything else for that thing." Because most medical tests do not have sensitivity and specificity values above 99%, "rarely" does not equate to certainty.

Table 6 shows the correlation of the ultrasonography diagnosis with the histopathology findings. Results reveal 70 percent sensitivity, 80 percent specificity, 85 percent positive predictive value and 15 percent negative predictive value for fibroid. On the other hand, for adenomyosis, correlation of the results between the two procedures yields 60 percent sensitivity, 79 percent specificity, 63 percent positive predictive values and 76 percent negative predictive values. The findings imply that using ultrasonography can somehow be reliably used to rule out fibroid and adenomyosis (as shown by the sensitivity values). Nevertheless, the computed specificity values which are apparently higher than the sensitivity values for both fibroid and adenomyosis imply that other procedures and tests have to be validate ultrasonography findings before giving out the final diagnosis. Interestingly, similar findings and recommendation were obtained in the study of Talukdar and Mahela [10], Atzori et al. and Siedler et al. [11].

Table 6: Specificity and Sensitivity of Ultrasonography Diagnosis with Histopathological Examination Diagnosis

Based from the Findings Obtained in The Study, The Following Conclusions Are Formulated

• Majority of the participants whose ages range from 40 to 45 years old have given birth twice and experienced menorrhagia for four to six months

• Fibroid and adenomyosis cause the abnormal uterine bleeding of the participants based on ultrasonography and histopathological findings

• Ultrasonography and histopathological examination moderately correlate in diagnosing fibroid and adenomyoma. Pertinent test and procedures have to be carried out to validate the ultrasonography findings

1. Soules, M.R. et al. "Stages of reproductive aging workshop (STRAW)." Journal of Women’s Health & Gender-Based Medicine, vol. 10, 2001, pp. 843–848.

2. Speroff, L. and M.A. Fritz. Clinical Gynecologic Endocrinology and Infertility. 7th ed., Lippincott Williams & Wilkins, 2005.

3. Mahajan, N. et al. "Health issues of menopausal women in north India." Journal of Mid-Life Health, vol. 3, 2012, pp. 84–87.

4. Munro, M.G. et al. "The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years: Who needs them?" American Journal of Obstetrics and Gynecology, vol. 207, 2012, pp. 259–265.

5. Ananth, C.V. et al. "Effect of maternal age and parity on the risk of uteroplacental bleeding disorders in pregnancy." PubMed, 2006. Accessed November 2027. https://www.ncbi.nlm.nih.gov/pubmed/8841208.

6. Kaunitz, A.M. "Patient education: Abnormal uterine bleeding." UpToDate, 2017. Accessed November 2027. https://www.uptodate.com/contents/abnormal-uterine-bleeding-beyond-the-basics.

7. "Menorrhagia." Mayo Clinic, 2017. Accessed November 2027. https://www.mayoclinic.org/diseases-conditions/menorrhagia/symptoms-causes/syc-20352829.

8. Ahmed, M. and R. Diggory. "The correlation between ultrasonography and histology in the search for gallstones." Annals of The Royal College of Surgeons of England, vol. 93, no. 1, 2011, pp. 81–83. https://doi.org/10.1308/003588411X12851639107070.

9. Smith, L. "Menorrhagia: Causes and treatments." Medical News Today, 2017. Accessed November 2027. https://www.medicalnewstoday.com/articles/295202.php.

10. Talukdar, B. and S. Mahela. "Abnormal uterine bleeding in perimenopausal women: correlation with sonographic findings and histopathological examination of hysterectomy specimens." Journal of Mid-Life Health, 2016. Accessed November 2027. http://www.jmidlifehealth.org.

11. Siedler, D. et al. "Uterine adenomyosis: A difficult sonographic diagnosis." Journal of Ultrasound in Medicine, vol. 6, 2007, pp. 349–355.