Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
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Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : November | Volume : 16 | Issue : 11 | Page : QC05 - QC08 Full Version

Association of Bleeding Patterns with Thyroid Dysfunction in Patients with Abnormal Uterine Bleeding: A Prospective Cross-sectional Study


Published: November 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/57929.17070
Ashwini Patil, Shobha Shivanand Shiragur, Vijayalaxmi Gobbur, Subhashchandra Mudanur, Shailaja Bidri, Rajashri Yaliwal, Muttappa Ravasaheb Gudadinni

1. Assistant Professor, Department of Obstetrics and Gynaecology, Al Ameen Medical College, Vijayapura, Karnataka, India. 2. Associate Professor, Department of Obstetrics and Gynaecology, Shri B.M. Patil Medical College, BLDE (Deemed to be University), Vijayapura, Karnataka, India. 3. Professor, Department of Obstetrics and Gynaecology, Shri B.M. Patil Medical College, BLDE (Deemed to be University), Vijayapura, Karnataka, India. 4. Professor, Department of Obstetrics and Gynaecology, Shri B.M. Patil Medical College, BLDE (Deemed to be University), Vijayapura, Karnataka, India. 5. Professor, Department of Obstetrics and Gynaecology, Shri B.M. Patil Medical College, BLDE (Deemed to be University), Vijayapura, Karnataka, India. 6. Professor, Department of Obstetrics and Gynaecology, Shri B.M. Patil Medical College, BLDE (Deemed to be University), Vijayapura, Karnataka, India. 7. Professor, Department of Community Medicine, Shri B.M. Patil Medical College, BLDE (Deemed to be Univers

Correspondence Address :
Dr. Shobha Shivanand Shiragur,
Associate Professor, Department of Obstetrics and Gynaecology, Shri B.M. Patil
Medical College, BLDE (Deemed to be University), Vijayapura, Karnataka, India.
E-mail: shobha.shiragur@bldedu.ac.in

Abstract

Introduction: Excessive menstruation outside the normal parameters is one of the most common manifestations of hypothyroidism affecting the females. Thyroid disorders, such as hypothyroidism and hyperthyroidism are associated with late onset puberty, anovulatory cycles and abnormally high incidence of foetal morbidity and mortality.

Aim: To study the association of bleeding pattern with thyroid dysfunction among patients with Abnormal Uterine Bleeding (AUB).

Materials and Methods: This was a prospective cross-sectional study carried out in the Department of Obstetrics and Gynaecology at Shri B.M. Patil Medical College, Hospital and Research Centre, Vijayapura, Karnataka, India, from October 2012 to June 2014, among 140 females with a provisional diagnosis of abnormal uterine bleeding were subjected to testing for serum Triiodothyronine (T3), Thyroxine (T4), Thyroid Stimulating Hormone (TSH) and Thyroid Peroxidase (TPO) antibodies estimation in their serum. Data was analysed using Chi-square test and the p-value <0.05 was considered significant.

Results: Total of 140 patients, with maximum number of patients in the study belonged to the age group 31-40 years, 57 (40.71%) and 46 (32.8%) patients were para 2. Among different bleeding patterns observed, most common was menorrhagia, 62 (44.28%). The prevalence of subclinical hypothyroidism was 10 (7.14%), there were five hypothyroid cases (3.5%), and two hyperthyroid cases (1.4%) among 140 cases. The total thyroid disorders associated were 17 (12.14%).

Conclusion: In the present study, association of thyroid dysfunction with AUB has been noted. With early diagnosis of thyroid disorders in AUB patients, followed by appropriate treatment, the menstrual irregularities can be resolved and major surgical procedures can be avoided.

Keywords

Foetal morbidity, Hyperthyroidism, Hypothyroidism, Thyroid peroxidase antibodies

Abnormal uterine bleeding is defined as atypical bleeding from the uterus in the absence of any detectable pelvic pathology and in the absence of any demonstrable extragenital cause. The abnormal pathology can account for 10% of all gynaecologically-related complaints (1). Disorders of the thyroid gland also have a large association with menstrual irregularities. These disorders, such as hypothyroidism and hyperthyroidism are associated with late onset puberty, anovulatory cycles and abnormally high incidence of foetal morbidity and mortality (2). Excessive menstruation outside the normal parameters is one of the most common manifestations of hypothyroidism affecting the female reproductive tract. Despite documentation of the occurrence of menstrual disturbances in hypothyroid women, the number of these patients requiring treatment for menorrhagia has not been clearly identified (3). Majority of these subclinical cases of hypothyroidism are often missed. The overall prevalence of these subclinical cases of hypothyroidism are as high as 19.5% in women (4). Hypothyroidism is known to cause menorrhagia in early phases and oligomenorrhoea in later phases and hyperthyroidism to cause oligomenorrhoea and amenorrhoea (5). Most cases of anovulatory bleeding can be treated medically, thus, avoiding surgeries (6). Diagnosing and treating thyroid dysfunction has shown to improve the menstrual abnormalities (7).

New tests including serum Triiodothyronine (T3), serum Thyroid Stimulating Hormone (TSH) and Thyroid Peroxidase (TPO) antibody radioimmunoassay have significantly increased the sensitivity and specificity of thyroid function testing. Serum TSH assay is an important sensitive indicator of the reduced thyroid functional reserve. This is because, TSH levels become elevated prior to the fall of circulating serum thyroxine levels below the normal values (8). In a study, patients with menstrual disorders 44% had thyroid disorders in which subclinical hypothyroidism was prevalent in 20%, overt hypothyroidism in 14%, and overt hyperthyroidism in 8% of the women. Autoimmune thyroid antibodies were present in 30% patients of women with menstrual disorders. On endometrial sampling, hypothyroid patients mainly had proliferative endometrium (42.85%), whereas hyperthyroid had atrophic endometrium (60%) (9).

Hence, the present study was done to evaluate the association of bleeding pattern with thyroid dysfunction among patients with abnormal uterine bleeding. This will assist in the further development of managing AUB and also knowing the latest prevalence of hypothyroidism in patients who are provisionally diagnosed as AUB.

Material and Methods

This was a prospective cross-sectional study conducted in the Department of Obstetrics and Gynaecology at Shri B.M. Patil Medical College, Hospital and Research Centre, Vijayapur, Karnataka, India, from October 2012 to June 2014. The study was started after obtaining Ethical Clearance (IEC/046/12/18-10-12). A total of 140 women with abnormal uterine bleeding were selected for the study.

Sample size calculation: With the incidence rate of Dysfunctional Uterine Bleeding (DUB) 10% (10), at 95% confidence interval and at +5 margin of error, the worked-out sample size was 140, using the sample size formula:

N=Zα2×p×q/d2,

where N=sample,

p=proportion in target population with specific characterstics,
q=1-p,
d=degree of accuracy required (11). Hence, 140 cases were included in the present study.

Inclusion criteria: All cases having abnormal uterine bleeding belonging to the puberty to premenopausal age groups were included in the study.

Exclusion criteria: Patients currently or previously on antithyroid medication or thyroid hormones, Intrauterine Contraceptive Device (IUCD) users and history of bleeding disorders, and patients with organic lesions of genital tract were excluded from the study.

Study Procedure

A thorough history of all patients was taken. This included a detailed account of bleeding history, which included, the pattern of bleeding, onset, duration, quantity of bleeding and other complaints related to thyroid dysfunction. A clinical examination was conducted. Examination of the general physical state of the patient, neck/thyroid gland area, gynaecological examination per speculum and bimanual examination, and systemic examination was done thoroughly. Special attention to thyroid dysfunction was given in cases that had a clinically based provisional diagnosis of AUB. The selected patients were subjected to routine investigations like complete blood count, urinary examination for albumin and sugar, coagulation parameters (bleeding time, clotting time) and ultrasonographic evaluation of abdomen and pelvis. Afterwards, all patients were subjected to evaluation of Triiodothyronine (T3), Thyroxine (T4), Thyroid Stimulating Hormone (TSH) and Thyroid Peroxidase antibodies (TPO-Ab) estimations in their serum. Investigations were estimated by Chemiluminescence Immuno Assay (CLIA) method using reagent Monobind IN C; USA Kit. With the help of a fully automatic Alphalite machine in the biochemical laboratory at Vijayapur. Drop of reagent Monobind Inc. is mixed with collected blood and using a special programming chart and place it in the fully automatic analysing machine Alphalite. Tests were done and results were noted. Patients were then grouped into four categories:

• Euthyroid
• Subclinical hypothyroid
• Hypothyroid
• Hyperthyroid

Any patient found to have thyroid dysfunction was referred to a physician for further management.

Statistical Analysis

Data was collected, presented as Mean±SD and was analysed by Chi-square test.

Results

A total of 140 female patients with maximum number in age group of 31-40 years, 57 cases (40.7%). The age group 21-30 years had minimum number of cases i.e, 16 cases (11.4%) (Table/Fig 1).

Among 140 cases of DUB, 25 (17.8%) patients were unmarried and nulliparous were 17 (12.1%). A total of 19 (13.5%) patients were para 1, 46 (32.8%) patients were para 2, 24 (17.1%) patients were para 3 and 9 (6.4%) patients with 4 or more parity. In the present study, maximum number of patients were of para 2 and minimum number of patients presenting as clinical DUB cases were of para 4 or more (Table/Fig 2).

Most common complaint of the study participants was menorrhagia 62 (44.28%). Among others, 27 (19.28%) of cases presented with polymenorrhagia, 20 (14.28%) with acyclical, 13 (9.28%) each with oligomenorrhoea and polymenorrhoea and 5 (3.57%) metrorrhagia. Maximum patients were seen with complaint of menorrhagia (Table/Fig 3).

The prevalence of subclinical hypothyroidism was 10 (7.1%), hypothyroid cases 5 (3.6%) and 2 (1.4%) hyperthyroid cases among the total study patients. The total thyroid disorders associated accounted for 17 (12.1%). The most common thyroid dysfunction among the study group was subclinical hypothyroidism 10 cases (7.1%) (Table/Fig 4).

Below the age 20 years, 18 cases were euthyroid, two had subclinical hypothyroidism and two had hyperthyroidism. Among the cases belonging to 21-30 years, 13 cases were euthyroid and one had hypothyroidism and two had subclinical hypothyroidism. Among the age group of 31-40 years, 51 patients were euthyroid, two had hypothyroidism and four had subclinical hypothyroidism. Above the age of 40 years, two patients had hypothyroidism, two patients had subclinical hypothyroidism (Table/Fig 5).

Patient who presented with menorrhagia had prevalence of 21% (13/62) of thyroid dysfunction, this appears to be the most common bleeding pattern according to this study to be associated with thyroid disorders. Patient who presented with oligomenorrhoea had 2/13 (15%) prevalence of thyroid disorder (Table/Fig 6). Out of 17 patients with thyroid disorders, eight of them had significantly raised anti-TPO antibody levels suggestive of associated autoimmune disease. And most of them showed menorrhagia as common bleeding pattern. T3 levels of four patients out of 17 patients with thyroid disorders were abnormal, two patients had low T3 value and two patients had higher than normal range T4 levels were found to be low in two cases and three cases showed elevated T4 levels.

Discussion

Abnormal uterine bleeding is one of the most common conditions among females of reproductive age. The causes of AUB vary according to age from blood dyscrasias among adolescents, to endometrial hyperplasia in perimenopausal group and others like polyps, leiomyoma in reproductive age group. Thyroid dysfunction also accounts for AUB; many times may be missed out, thyroid dysfunction, are common endocrinological disorders in women (12). They are known to affect all age groups right from menarche to menopause, and cannot be overlooked while treating any forms of menstrual disturbances (13),(14).

It is more commonly encountered in the 4th to 5th decades of life. In the present study, most of the AUB patients were in the age group 31-40 years, which accounted for 41% of cases, which is slightly higher as compared to study done by Verma SK et al., which was 37% (4). Most common menstrual pattern seen in patients with AUB in the present study was menorrhagia seen in 44% of cases which is comparable to previous study (12). In the present study, 87.9% of patients were euthyroid, 12% of patients were associated with thyroid disorders. The prevalence of subclinical hypothyroidism was 7% which was the most common thyroid dysfunction, 4% of the patients were hypothyroid and only 1% of the patients were hyperthyroid. Joshi BR et al., reported 84.21% of patients as euthyroid and 15.79% patients with various thyroid dysfunctions, which is comparable to the present study (13). In the study done by Wilansky DL and Greisman B, hypothyroid was seen in 22% of cases when compared to hypothyroid, incidence is higher (8). Verma SK et al., observed 79.55% of patients as euthyroid, 19.5% of patients as hypothyroid and 1% of patients hyperthyroid (4). So compared to these studies, hypothyroidism was noted in lesser percentage of patients with AUB in present study (3.57%). Few previous studies also mentioned the significance of thyroid immunoassays in AUB, similarly as were done in the present study (14). The menstrual abnormalities observed in patients with thyroid abnormalities were menorrhagia, polymenorrhoea and oligomenorrhoea and hypomenorrhea (15). Menorrhagia was seen in 62 (44.28%) of cases whereas study done by Pahwa S and Mangat S menorrhagia was seen in 50% cases which was comparable (16), and study by Verma SK et al., menorrhagia was seen, in 64.3% of cases. In the present study, T3 levels of four patients out of 17 patients with thyroid disorders were abnormal, two patients had low T3 value and two patients had higher than normal range T4 levels were found to be low in two cases and three cases showed elevated T4 levels (4). A total of 8 patients (47%) out of 17 thyroid dysfunction presented as raised anti-TPO antibodies, most of them presenting as menorrhagia as presenting symptom. Authors of few previous studies observed thyroid autoimmunity in the form of thyroid anti-TPO antibody, significantly more prevalent in the study group (30%) compared to control group (8%) (9),(17). The present study also like previous studies depicted that, early diagnosis of thyroid disorders help in appropriate treatment of patients.

Limitation(s)

Small sample size was a limitation of the present study. Comparative analysis of relevant tests could have been included for better results.

Conclusion

In the present study, association of thyroid dysfunction with in patients presenting with AUB has been noted. With early diagnosis of thyroid disorders in AUB patients followed by appropriate treatment, the menstrual irregularities can be resolved. The various treatment options such as using high dose hormones and surgical procedures such as ablations and hysterectomies can be avoided. So, thyroid function tests should form a part of investigations done for AUB. Even earlier diagnosis and treatment of subclinical hypothyroidism can be initiated to avoid women going for further complications.

References

1.
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DOI and Others

DOI: 10.7860/JCDR/2022/57929.17070

Date of Submission: May 21, 2022
Date of Peer Review: Jul 09, 2022
Date of Acceptance: Oct 20, 2022
Date of Publishing: Nov 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: May 19, 2022
• Manual Googling: Jul 07, 2022
• iThenticate Software: Oct 19, 2022 (12%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
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