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

Users Online : 102576

AbstractMaterial and MethodsResultsDiscussionConclusionReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
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.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
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.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
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.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



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.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
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 : December | Volume : 16 | Issue : 12 | Page : QC09 - QC13 Full Version

Prevalence of Abnormal Uterine Bleeding and its Associated Risk Factors in Women of Perimenopausal Age Group- A Retrospective Study


Published: December 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/59994.17252
Rajani Vaidya, S Vinayachandran, Sumangala Devi, B Prejisha, G Lekshminath, Sily Sreedharan, PK Jahrin

1. Assistant Professor, Department of Obstetrics and Gynaecology, Malabar Medical College, Kozhikode, Kerala, India. 2. Professor, Department of Obstetrics and Gynaecology, Malabar Medical College, Kozhikode, Kerala, India. 3. Professor, Department of Obstetrics and Gynaecology, Malabar Medical College, Kozhikode, Kerala, India. 4. Professor, Department of Obstetrics and Gynaecology, Malabar Medical College, Kozhikode, Kerala, India. 5. Professor, Department of Obstetrics and Gynaecology, Malabar Medical College, Kozhikode, Kerala, India. 6. Professor, Department of Pathology, Malabar Medical College, Kozhikode, Kerala, India. 7. Junior Resident, Department of Obstetrics and Gynaecology, Malabar Medical College, Kozhikode, Kerala, India.

Correspondence Address :
Rajani Vaidya,
No. 302, Om Shakti Nivas, 3rd Floor, Jalaram Industrial Estate, Bangalore-560076, Karnataka, India.
E-mail: dr.rajanivaidya@gmail.com

Abstract

Introduction: Abnormal Uterine Bleeding (AUB) is defined as any deviation from the normal menstrual cycle that is abnormal in regularity, duration, volume and frequency. AUB may be accompanied by pain and discomfort which presents a substantial burden on patient’s health, quality of life, society and healthcare system. There is also an increased incidence of associated co-morbidities like thyroid disease, diabetes and hypertension in AUB cases.

Aim: To estimate the prevalence of AUB according to the PALM-COEIN classification and its associated risk factors in the perimenopausal age group.

Materials and Methods: This retrospective study was conducted in the Gynaecology Department of Malabar Medical College, Kozhikode, Kerela, India. The data was collected from the medical records and computerised system of the hospital for a period of one year from January 2021 to December 2021. A total of 225 patients in the perimenopausal age group (40 years and above) attending Gynaecology Outpatient Department (OPD) and admitted with complaints of AUB was included. Patient’s information such as age, menstrual history, obstetric history, medical and surgical history, laboratory tests, imaging findings, endometrial biopsy results was obtained and analysed. Data was entered in Microsoft excel and analysed by using Statistical Package for the Social Science (SPSS) version 24.0.

Results: The total number of patients attending the Gynaecology OPD during the study period was 11765. The total number of AUB cases during the study period were 2154, so the prevalence for AUB was 18.3%. For the associated risk factors, 255 patients were considered, where maximum number of patients 103 (45.3%) were in the age group of 45-49 years. Structural causes accounts for 175 (77.6%) cases. Hypertension was the most common risk factor associated with AUB 68 (30.2%), followed by diabetes 32 (14.2%) and thyroid disorders 15 (6.6%).

Conclusion: The prevalence of AUB was 18.3% in present study. Abnormal Uterine Bleeding-Ovulatory dysfunction and Abnormal Uterine Bleeding- Endometrial had statistically significant association with thyroid disease.

Keywords

Co-morbidities, Endometrial biopsy, Heavy menstrual bleeding, Thyroid disease

Abnormal Uterine Bleeding (AUB) is a common condition in the perimenopausal age group women (1). AUB leads to loss of productivity and may result in surgical interventions including hysterectomy. More than one third of the patients present with AUB to the OPD (1). The management of such a common ailment in a population with wide healthcare diversity like India, requires uniform clinical practice guidelines. The main goal of AUB management is to identify the patients with potential risk of developing malignancy and to rule out the underlying endometrial hyperplasia with atypia or endometrial cancer by subjecting to histopathological examination (1). The International Federation of Gynaecology and Obstetrics (FIGO) and the American College of Obstetricians and Gynaecologists (ACOG) have recommended that a systematised nomenclature, the PALM-COEIN acronym, [Polyp, Pdenomyosis, Leiomyoma, Malignancy, and Hyperplasia, Coagulopathy, Ovulatory dysfunction, Endometrial, Iatrogenic, and not yet classified] be used to describe abnormal menses and to abandon the terminologies like menorrhagia and menometrorrhagia. (1),(2) A standard menstrual pattern index has been incorporated in the classification based on frequency, duration, regularity, volume and intermenstrual bleeding (2),(3).

The PALM-COEIN classification is aetiopathogenesis based where PALM describes the structural (organic) causes like polyp, adenomyosis, leiomyoma, malignancy and COIEN denoting the non structural (Non organic) causes like coagulopathy, ovulatory dysfunction and other causes of AUB (1),(2) The reported prevalence of AUB in India is about 17.9% (4). Previous studies have shown that prevalence varies between different regions and it ranges between 10-30% (4),(5),(6). AUB and Heavy Menstrual Bleeding (HMB) are not synonymous. HMB is defined as excessive menstrual blood loss which interferes with a woman’s physical, emotional and social quality of life. (1) The diagnosis of AUB depends on comprehensive assessment of the medical history and examination combined with blood tests, imaging modalities and histopathology. Different bleeding patterns also helps in the clinical diagnosis of various causes of AUB. The bleeding patterns, according to the new nomenclature is based on frequency, regularity, duration and volume of blood flow during menses. Based on this, it is categorised into frequent/infrequent cycles, regular/irregular cycles, prolonged/shortened cycles, heavy/light flow (1).

Diabetes and hypertension are known risk factors associated in the people at risk of developing endometrial malignancy and premalignant conditions (1). The management options for women with AUB is either medical or surgical interventions. Medical management is the first line therapeutic option once malignancy has been ruled out. Surgical management includes both minimally invasive and open techniques such as hysterectomy and myomectomy (1). There are only few studies comparing the association of AUB in perimenopausal age group with medical disorders (4),(5),(6). In this study, we have analysed the perimenopausal age group and associated co-morbidities compared to the other studies where reproductive age group population was considered.

Hence, present study was conducted to find the association and prevalence of medical co-morbidities in the people with AUB and to analyse the prevalence of AUB according to the PALM COEIN classification in perimenopausal age group and the risk factors associated with it.

Material and Methods

This retrospective study was conducted in the Department of Obstetrics and Gynaecology (OBG), Malabar Medical College, Kozhikode, Kerala, India. The data of January 2021 to December 2021 was collected retrospectively and data were analysed during March 2022 to July 2022. Ethical Committee clearance was obtained before collecting the data [IEC no-MMCHRC &IEC/2022]. As it is a retrospective observational study, data was collected from the medical records, verbal telephonic consent was taken and confidentiality was maintained.

Inclusion criteria: The patients in the perimenopausal age group (40 years and above) attending OBG, OPD and admitted with complaints of AUB were included.

Exclusion criteria: Patients with pregnancy and pregnancy related conditions, postmenopausal women, vaginal bleeding caused by vaginal and cervical causes were excluded.

Sample size calculation: Sample size was calculated using the formula:

n=Z2 P(100-P)/ d2

Where n=sample size,

Z=standard normal deviate (for 95% confidence interval, the value is taken as 1.96)
P=prevalence or proportion of interest (from previous similar studies)
d=precision (allowable error)
N=(1.96)2*30*70/ (6)2
=224.09

For an estimated prevalence of 30% AUB, with 6% absolute precision, 95% confidence interval, a minimum sample size of 225 was calculated (1),(4).

Study Procedure

Data Collection: The data was collected retrospectively from the medical records and computerised system of the hospital. Patient’s information such as age, parity, menstrual history (Bleeding patterns according to FIGO classification (1), obstetric history, medical [associated co-morbidities] and surgical history, laboratory tests {Complete Blood Count (CBC), Coagulation tests, Thyroid Stimulating Hormone (TSH), Prolactin, Random Blood Sugar (RBS)], imaging findings (transabdominal/transvaginal ultrasound), endometrial biopsy results were obtained. The data was collected through a structured proforma. For prevalence of AUB, total number of AUB cases among the total number of patients attending the Gynaecology OPD was taken.
• As per the PALM-COEIN classification system (2), the potential causes of AUB were established and then categorised accordingly. The diagnosis was done, according to the FIGO classification system by one or more of these assessments like history, physical examination, imaging studies, blood investigations. Histopathological examination by endometrial sampling was employed in the OPD whenever required for diagnosis.

P-Polyps categorised as present or absent based on the history, per speculum examination, ultrasound/histopathological examination.
A-Adenomyosis diagnosis was made based on history, ultrasound features (asymmetrical myometrial appearance and enlarged uterus).
L-Leiomyoma identified by clinical examination and ultrasound.
M-If malignancy or premalignancy was suspected, endometrial biopsy will be obtained.
C-Coagulopathy was identified by medical history and diagnosed by coagulation tests.
O-Ovulatory dysfunction included AUB cases due to anovulation, attributable to endocrinopathies, polycystic ovarian syndrome, hypo/hyperthyroidism, hyperprolactinaemia and weight changes.
E-Endometrial causes include those AUB cases who have predictable and cyclical bleeding typical to ovulatory cycles. The cause may be endometrial in origin. It is a diagnosis of exclusion.
I-Iatrogenic group includes intrauterine contraceptives, gonadal steroids, antibiotics, anticoagulants.
N-Not yet classified, rare pathologies or poorly defined causes which do not fit in the above categories.

Bleeding pattern was defined by following FIGO 2018 criteria (1).

1. Frequency-amenorrhoea for duration of 90 days, cycle length >38 days (infrequent) or <24 days (frequent).
2. Duration-normal duration is ≤8 days; prolonged duration >8 days.
3. Regularity-normal or regular (shortest to longest variation ≤7-9 days); irregular (≥8-10 days).
4. Volume-only patient determined-light, normal and heavy; heavy (HMB)-bleeding volume sufficient to interfere with the woman’s quality of life.
5. Intermenstrual bleeding-bleeding between cyclically regular onset of menses, either random or cyclic.

Statistical Analysis

Data was entered in MS excel and analysed by using SPSS version 24.0. Descriptive statistical measure like percentage and inferential statistical test like Chi-square and Fisher’s exact probability test was applied. Association was interpreted statistically significant at p-value <0.05. Categorical variables were summarised as percentages. The statistical analysis was done on the basis of percentage distribution of the total number of patients. The results are expressed in terms of percentages and proportions.

Results

The total number of patients attending the Gynaecology OPD during the study period was 11765. To know the prevalence, total AUB cases encountered OBG OPD during the study duration was considered. The total number of AUB cases during the study period was 2154. The prevalence of AUB was 18.3% [2154/11765]. Among these AUB cases, the data of 225 patients was collected through random sampling, to study the associated factors.

Structural (polyp+adenomyosis+leiomyoma+malignancy) causes accounts for 175 (77.6%) cases as per the PALM-COEIN classification, leiomyoma (AUB-L) was the most prevalent cause of AUB in the study. Next common cause of abnormal uterine bleeding was adenomyosis (AUB-A) followed by AUB-P (Table/Fig 1).

Maximum number of patients, 102 (45.3%) were in the age group of 45-49 years followed by 90 (40%) patients aged between 40-44 years and 33 (14.6%) aged 50 years and above.

Majority of patients, 88 (39.1%), complained of HMB as chief complaint. The other menstrual irregularities found were prolonged bleeding 52 (23.1%), frequent bleeding 35 (15.5%) and intermenstrual bleeding 24 (10.6%). Around 68 (30.2%) women had associated hypertension with AUB, followed by diabetes and thyroid disorders (Table/Fig 2). Hypertension was the most common risk factor associated with AUB. Hypertension was seen in 23 (26.1%) AUB-L patients, 13 (26.5%) AUB-A cases and 11 (50%) AUB-O cases. Among 88 AUB-L patients, 23 patients had associated hypertension. However, the association between hypertension and none of the types of AUB was statistically significant (Table/Fig 3).

Diabetes mellitus was also seen more commonly in AUB-L, AUB-O, AUB-A. Out of total 88 patients with AUB-L, 8 had diabetes and there was a significant association found between diabetes and AUB-L. However, the association between hypertension and none of the types of AUB other than AUB-L was statistically significant (Table/Fig 4).

Thyroid diseases was seen more commonly in AUB-O, AUB-E. Out of 22 AUB-O cases, 5 (22.7%) patients had associated thyroid disease. Among 20 AUB-E cases, 4 (25%) patients had a history of thyroid disease. AUB-O and AUB-E had statistically significant association with thyroid diseases (Table/Fig 5).

Discussion

Prevalence of AUB among the patients attending Gynaecology OPD during the study period was 18.3%. Kotagasti T in their study, found prevalence of AUB as 18.23% which is similar to present study (6). The prevalence of AUB varies between 9-14% among menarche and menopause women (7). In India, prevalence of AUB is reported to be 17.9% (4). AUB was found to be more common in 45-49 years (45.3%) of age group followed by 40-44 years (40%) of age group. The comparison of findings of present study with contrast studies (8),(9),(10) are shown in (Table/Fig 6).

The incidence of menstrual disorders increases with increase in age (10). In this study, HMB was the most common complaint found in 39.1% women. Similar findings were reported by Nair R and Mallikarjuna M, (8), which found heavy menstrual bleeding in 64% followed by intermenstrual bleeding in 18% of cases. The most common cause of AUB in the present study is leiomyoma with a prevalence of 39.10%, followed by adenomyosis (21.7%) and polyp (13.3%), ovulatory, unlike studies by Gouri SR et al., (11) and Goel P and Rathore SB, (12) where most common was AUB-O but disorders were comparable to Qureshi FU and Yusuf AW, (13) and Ratnani R and Meena NA, (14), where the common cause of AUB was leiomyoma. The comparison of findings of present study with contrast studies [11-14] are shown in (Table/Fig 7).

AUB is one of the common menstrual problems faced by women during their perimenopausal period, which is defined as the period of 2-8 years preceding menopause and one year after the final menses (15). Follicular development during perimenopause is very unpredictable which leads to variable estrogen levels. This results in anovulatory cycles which causes irregular abnormal uterine bleeding. (15)

The prevalence of AUB-L from previous studies varies between 9-30% (16). Prevalence of AUB-L is more with advancing age, 35.1% in 40-49 years age group when compared to young people i.e. (24.3%) in age group of 30-39 years (16). AUB-M accounts for 1.9-5% of AUB cases (16). The prevalence of AUB -M in the present study was 3.5%.

The prevalence of adenomyosis is different among different subset of population. Prevalence of adenomyosis in women undergoing assisted reproductive technology is 20-25% (17), with associated endometriosis in 20-80% (18), and 20.9% in the general population undergoing ultrasound (19). Uterine polyps are hyperplastic overgrowths of endometrial glands with prevalence of 7.8-34.9% (20).

Hypertension is the most common co-morbidity which was associated with AUB in the present study (30.8%), followed by diabetes and thyroid disease. Both hypertension and fibroid are highly prevalent diseases that are associated with significant subsequent morbidity [21,22]. Both these conditions involve alterations of smooth muscle cells; in case of fibroids, there are alterations seen in the myometrium and vascular smooth muscle, whereas in hypertension, only the vascular smooth muscle is altered. Hypertension is a consistently identified risk factor for uterine fibroids (23).

In the study conducted by Subedi S et al., thyroid disorders were seen in 10.6% patients with AUB. Thus, there is an association among causes of AUB and medical disorders (24). The perimenopausal age is also associated with development of medical comorbidities like diabetes, hypertension (25). Significant association was found between thyroid disease and AUB-O and AUB-E which explains the hormonal imbalance and causes of AUB. In the study done by Mitra N et al., hypertension was found in 18% patients, followed by diabetes in 12% patients of AUB, followed by hypothyroidism in 6% patients (26).

Limitation(s)

Because of the limitations in data collection and small sample size, the association between hypertension and diabetes could not be established adequately in the present study. The association of medical co-morbidities with AUB was also limited only to hypertension, diabetes, thyroid disease.

Conclusion

The prevalence of AUB was 18.3% in the study population. AUB-O and AUB-E had statistically significant association with thyroid diseases. Clinicians should emphasise in the assessment and treatment of co-existent risk factors. Structural causes were the most common cause of AUB, among which AUB-L accounted for the majority of cases. A detailed history with special importance on age and type of bleeding pattern with gynaecologic examination helps in reaching a proper diagnosis in the OPD. PALM-COEIN classification helps in reaching the proper diagnosis and to decide the management options for different causes. This study serves as a pilot analysis to assess the association between the different AUB types and chronic medical conditions.

References

1.
Munro MG, Critchley HOD, Fraser IS, FIGO Menstrual Disorders Committee. The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions. Int J Obs Gynecol. 2018;143(3):393-08. [crossref] [PubMed]
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 in nongravid women of reproductive age. Int J Gynecol Obstet. 2011;113(1):03-13. [crossref] [PubMed]
3.
Management of acute abnormal uterine bleeding in nonpregnant reproductive-aged women. Committee Opinion No. 557. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2013;121:891-96. [crossref] [PubMed]
4.
Sharma A, Dogra Y. Trends of AUB in tertiary centre of Shimla hills. J Midlife Health. 2013;4(1):67-68. [crossref] [PubMed]
5.
Kazemijaliseh H, Tehrani FR, Behboudi-Gandevani S, Khalili D, Hosseinpanah F, Azizi F. A population-based study of the prevalence of abnormal uterine bleeding and its related factors among iranian reproductive-age women: An updated data. Arch Iran Med. 2017;20(9):558-63.
6.
Kotagasti T. Prevalence of different menstrual irregularities in women with abnormal uterine bleeding (AUB)-an observational study. Int J Curr Res. 2015;7(10):66-70.
7.
Fraser IS, Langham S, Uhl-Hochgraeber K. Health-related quality of life and economic burden of abnormal uterine bleeding. Expert Rev Obstet Gynecol. 2009;4(2):179-89. [crossref]
8.
Nair R, Mallikarjuna M. Clinical profile of patients with abnormal uterine bleeding at a tertiary care hospital. Int J Reprod Contracept Obstet Gynecol. 2015;4(6):1753-57. [crossref]
9.
Kumari A, Kumar R. Abnormal uterine bleeding in perimenopausal age: An observational study. Indian J Obstet Gynecol Res. 2018;5(4):539-43. [crossref]
10.
Sinha K, Gurung P, Sinha HH, Bhadani PP. Study on abnormal uterine bleeding among adult women in a tertiary care hospital in Bihar, India. Int J Reprod Contracept Obstet Gynecol. 2018;7(8):3136-41. [crossref]
11.
Gouri SR, Lakshmi PV, Rani NG, Kumar NA. Categorization of the causes of abnormal uterine bleeding according to PALM-COEIN classification. Int J Sci Study. 2016;4(2):104-07.
12.
Goel P, Rathore SB. PALM-COEIN FIGO classification for diagnosis of abnormal uterine bleeding: Practical Utility of same at Tertiary Care Centre in North India. Sch J App Med Sci. 2016;4(8A):2771-73.
13.
Qureshi FU, Yusuf AW. Distribution of causes of abnormal uterine bleeding using the new FIGO classification system. JPMA. 2013;63(8):973-75.
14.
Ratnani R, Meena NA. Clinico-pathological analysis of causes of abnormal uterine bleeding according to PALM-COEIN classification: Study based in a rural teaching hospital of Central India. J Med Sci Clin Res. 2017;5(09):28196-00. [crossref]
15.
World Health Organization. Research on menopause in the 1990’s: Report of a WHO Scientific group. Geneva: WHO Technical Report Series number 866; 1996.
16.
Sun Y, Wang Y, Mao L, Wen J, Bai W. Prevalence of abnormal uterine bleeding according to new International federation of gynecology and obstetrics classification in Chinese women of reproductive age: A cross-sectional study. Medicine. 2018;97(31):e11457. [crossref] [PubMed]
17.
Puente JM, Fabris A, Patel J, Patel A, Cerrillo M, Requena A. et al. Adenomyosis in infertile women: Prevalence and the role of 3D ultrasound as a marker of severity of the disease. Reprod Biol Endocrinol. 2016;14(1):60. [crossref] [PubMed]
18.
Di Donato N, Montanari G, Benfenati A, Leonardi D, Bertoldo V, Monti G, et al. Prevalence of adenomyosis in women undergoing surgery for endometriosis. Eur J Obstet Gynecol Reprod Biol. 2014;181:289-93. [crossref] [PubMed]
19.
Eisenberg VH, Arbib N, Schiff E, Goldenberg M, Seidman DS, Soriano D. Sonographic signs of adenomyosis are prevalent in women undergoing surgery for endometriosis and may suggest a higher risk of infertility. Biomed Res Int. 2017;2017:8967803. [crossref] [PubMed]
20.
Lee SC, Kaunitz AM, Sanchez-Ramos L, Rhatigan RM. The oncogenic potential of endometrial polyps: A systematic review and meta-analysis. Obstet Gynecol. 2010;116(5):1197-205. [crossref] [PubMed]
21.
Muntner P, Carey RM, Gidding S, Jones DW, Taler SJ, Wright Jr JT, et al. Potential US population impact of the 2017 ACC/AHA high blood pressure guideline. Circulation. 2018;137(2):109-18. [crossref] [PubMed]
22.
Stewart EA. Clinical practice. Uterine fibroids. N Engl J Med. 2015;372(17):1646-55. [crossref] [PubMed]
23.
Stewart EA, Cookson CL, Gandolfo RA, Schulze-Rath R. Epidemiology of uterine fibroids: A systematic review. BJOG: An International Journal of Obstetrics & Gynecology. 2017;124(10):1501-12. [crossref] [PubMed]
24.
Subedi S, Banerjee B, Manisha C. Thyroid disorders in women with dysfunctional uterine bleeding. Journal of Pathology of Nepal. 2016;6(12):1018-20. [crossref]
25.
Matthews KA, Gibson CJ, El Khoudary SR, Thurston RC. Changes in cardiovascular risk factors by hysterectomy status with and without oophorectomy: Study of women’s health across the nation. J Am Coll Cardiol. 2013;62(3):191-200. [crossref] [PubMed]
26.
Mitra N, Patil P, Sethia A. Etiological factors of abnormal uterine bleeding according to PALMCOEIN classification in perimenopausal women in a tertiary care centre. Int J Reprod Contracept Obstet Gynecol. 2020;9(2):799-04. [crossref]

DOI and Others

DOI: 10.7860/JCDR/2022/59994.17252

Date of Submission: Sep 03, 2022
Date of Peer Review: Sep 21, 2022
Date of Acceptance: Nov 21, 2022
Date of Publishing: Dec 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: Sep 09, 2022
• Manual Googling: Nov 15, 2022
• iThenticate Software: Nov 18, 2022 (19%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com