Abnormal uterine bleeding (AUB) is one of the most frequent reasons for gynecological consultations and accounts for a significant proportion of outpatient visits and hospital admissions among women of reproductive and perimenopausal age groups (1,2). It is characterized by any deviation in the normal menstrual cycle in terms of frequency, duration, or volume of blood loss, occurring in the absence or presence of organic pelvic pathology (3). The International Federation of Gynecology and Obstetrics (FIGO) has standardized the classification of AUB under the PALM–COEIN system, dividing causes into structural (polyp, adenomyosis, leiomyoma, malignancy, and hyperplasia) and non-structural (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not otherwise classified) categories (4).

Histopathological examination of the endometrium remains the gold standard for establishing the underlying cause of AUB, especially in cases where medical history and imaging are inconclusive (5,6). The diagnostic yield is particularly valuable in perimenopausal and postmenopausal women, where the prevalence of premalignant and malignant endometrial lesions increases (7). Timely identification of such pathologies is crucial for preventing disease progression and improving prognosis (8).

Several studies have demonstrated a wide variation in histopathological patterns associated with AUB, ranging from normal physiological phases of the endometrium to hyperplasia and carcinoma (9,10). The distribution of these findings often varies with age, parity, and hormonal status (11). In resource-limited settings, histopathology also provides an affordable, definitive diagnostic tool that can be integrated into routine clinical care (12).

The present study was undertaken to evaluate the clinical profile of patients with AUB and correlate it with histopathological findings of the endometrium, thereby aiding in targeted management strategies and early detection of significant pathology.

A total of 120 women aged 18–60 years presenting with abnormal uterine bleeding to the outpatient and inpatient departments were enrolled after obtaining informed written consent.

Inclusion Criteria:

• Women presenting with changes in menstrual cycle frequency, duration, or volume not attributable to pregnancy.
• Patients willing to undergo endometrial sampling for diagnostic purposes.

Exclusion Criteria:

• Pregnant women or those with pregnancy-related bleeding disorders.
• Patients with bleeding due to systemic illnesses such as coagulation disorders, thyroid dysfunction, or liver disease.
• Patients on hormonal therapy within the last three months.

Clinical Evaluation:

Detailed demographic data, menstrual history, obstetric history, and associated symptoms were recorded. General and systemic examinations were carried out, followed by pelvic examination. Relevant baseline investigations such as hemoglobin estimation, coagulation profile, and pelvic ultrasonography were performed in all cases.

Endometrial Sampling:

Endometrial tissue was obtained by dilatation and curettage (D&C) or endometrial biopsy using a Pipelle cannula, depending on the patient’s clinical condition and suitability for the procedure. All samples were fixed in 10% neutral buffered formalin, processed, and embedded in paraffin blocks.

Histopathological Examination:

Sections of 4–5 μm thickness were stained with hematoxylin and eosin (H&E) and examined under light microscopy. Histopathological patterns were categorized into normal physiological phases, hyperplasia (with or without atypia), inflammatory changes, and malignant lesions.

Data Analysis:

All collected data were entered into Microsoft Excel and analyzed using SPSS version 25.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were used for frequency and percentage distribution. The Chi-square test was applied to assess associations between age groups and histopathological findings, with p < 0.05 considered statistically significant.

A total of 120 women with AUB were evaluated. The majority belonged to the 41–50 years age group (46.7%), followed by the 31–40 years group (27.5%). The least affected group was women above 50 years (10.8%). The mean age was 41.3 ± 8.2 years.

Clinical Presentation

The most common presenting symptom was heavy menstrual bleeding (58.3%), followed by intermenstrual bleeding (21.7%) and postmenopausal bleeding (10.0%) (Table 1).

Table 1. Distribution of clinical presentations in women with AUB

Heavy menstrual bleeding was most frequent in the 41–50 years age group, whereas postmenopausal bleeding was observed exclusively in women over 50 years.

Histopathological Findings

Histopathological evaluation revealed proliferative phase endometrium in 38.3% of cases, secretory phase in 26.7%, and simple hyperplasia without atypia in 15.8%. Malignant lesions were seen in 3.3% of patients, all aged above 50 years (Table 2).

Table 2. Histopathological patterns in AUB

Age-Wise Distribution of Endometrial Pathologies

A significant association was observed between age group and histopathological pattern (p = 0.002), with hyperplastic and malignant lesions more common in women above 40 years (Table 3).

Table 3. Age-wise distribution of histopathological findings

Patients in the perimenopausal and postmenopausal groups showed higher rates of endometrial hyperplasia and malignancy compared to younger women.

Abnormal uterine bleeding is a multifactorial clinical problem that affects women of all ages and has a significant impact on quality of life, productivity, and health care utilization (1,2). In our study, the majority of cases were observed in the perimenopausal age group (41–50 years), consistent with earlier reports indicating that hormonal fluctuations during the perimenopausal transition increase the likelihood of endometrial abnormalities (3,4).

Heavy menstrual bleeding was the most common presenting symptom, in line with findings by Bhatta and Sinha (5) and Singh and Dwivedi (6), who reported a similar predominance of this symptom in their series. This pattern may be attributed to anovulatory cycles and unopposed estrogen stimulation during this stage of life (7).

Histopathological examination revealed proliferative and secretory phases as the most common patterns, followed by hyperplasia without atypia. These results are comparable to those documented by Saraswathi et al. (8) and Sarwar and Haque (9). Hyperplastic lesions were more common in women above 40 years, supporting the notion that prolonged estrogen exposure and metabolic risk factors such as obesity increase susceptibility (10).

Endometrial carcinoma accounted for 3.3% of cases, all in women over 50 years. Although this percentage appears small, it underscores the importance of evaluating postmenopausal bleeding with endometrial sampling, as recommended by FIGO guidelines (11). Ely et al. (12) also emphasized that any bleeding in postmenopausal women warrants exclusion of malignancy.

The statistically significant association between age and histopathological diagnosis in our study corroborates previous findings that age is an important predictor of pathological severity (13). In resource-limited settings, histopathology remains a cost-effective diagnostic tool, enabling early detection of premalignant and malignant conditions (14).

Our findings also highlight that non-structural causes (normal cyclical endometrium, endometritis) are not uncommon, especially in younger women. This aligns with the PALM–COEIN classification, which advocates a comprehensive approach considering both structural and functional etiologies (15).

Strengths and Limitations:

The strength of this study lies in its prospective design and inclusion of a wide age range. However, limitations include the single-center setting and lack of long-term follow-up to assess treatment outcomes. Future multi-centric studies with larger sample sizes could provide a more robust epidemiological profile of AUB in different populations.

Histopathological evaluation remains an essential diagnostic tool in abnormal uterine bleeding, particularly in women over 40 years, where the risk of premalignant and malignant lesions is higher. Correlation of clinical findings with histopathology ensures accurate diagnosis, timely intervention, and improved patient outcomes.

1. Fraser IS, Mansour D, Breymann C, Hoffman C, Mezzacasa A, Petraglia F. Prevalence of heavy menstrual bleeding and experiences of affected women in a European patient survey. Int J Gynaecol Obstet. 2015;128(3):196-200.
2. Munro MG, Critchley HO, Broder MS, Fraser IS; FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM–COEIN) for causes of abnormal uterine bleeding. Int J Gynaecol Obstet. 2011;113(1):3-13.
3. Mishra D, Panda S. Histopathological evaluation of endometrium in abnormal uterine bleeding. J Clin Diagn Res. 2016;10(8):EC05-EC08.
4. Farquhar CM, Steiner CA. Hysterectomy rates in the United States 1990–1997. Obstet Gynecol. 2002;99(2):229-34.
5. Bhatta S, Sinha AK. Histopathological study of endometrium in abnormal uterine bleeding. J Pathol Nepal. 2012;2(4):297-300.
6. Singh P, Dwivedi P. Histopathological patterns of endometrium in abnormal uterine bleeding. Int J Reprod Contracept Obstet Gynecol. 2017;6(8):3441-5.
7. Spencer CP, Whitehead MI. Endometrial assessment revisited. Br J Obstet Gynaecol. 1999;106(7):623-32.
8. Saraswathi D, Thanka J, Shalinee R, Aarthi R, Jaya V, Kumar PV. Study of endometrial pathology in abnormal uterine bleeding. J Obstet Gynaecol India. 2011;61(4):426-30.
9. Sarwar A, Haque A. Types and frequencies of pathologies in endometrial curettings of abnormal uterine bleeding. Int J Pathol. 2005;3(2):65-70.
10. Wise MR, Jordan V, Lagas A, Showell M, Wong N, Lensen S, Farquhar C. Obesity and endometrial hyperplasia and cancer in premenopausal women: A systematic review. Am J Obstet Gynecol. 2016;214(6):689.e1-17.
11. American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 734: The role of transvaginal ultrasonography in evaluating the endometrium of women with postmenopausal bleeding. Obstet Gynecol. 2018;131(5):e124-9.
12. Ely JW, Kennedy CM, Clark EC, Bowdler NC. Abnormal uterine bleeding: a management algorithm. J Am Board Fam Med. 2006;19(6):590-602.
13. Salman MC, Bozdag G, Dogan S, Yuce K. Role of clinical and histopathological evaluation in management of abnormal uterine bleeding. Arch Gynecol Obstet. 2013;288(6):1275-9.
14. Dangal G. A study of endometrium in patients with abnormal uterine bleeding at Chitwan Valley. Kathmandu Univ Med J. 2003;1(2):110-2.
15. Critchley HO, Munro MG, Broder M, Fraser IS. A five-year international review process concerning terminologies, definitions, and related issues around abnormal uterine bleeding. Semin Reprod Med. 2011;29(5):436-42.