RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE,
KARNATAKA
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. / Name of Candidateand address (in block letters) / Dr. SHERMIN M ALI,
D/O DR. M. ALI
MOTHER HOSPITAL
POST PULLAZHI
OLARI
THRISSUR- 680012,
KERALA.
2. / Name of the Institution / J.J.M. MEDICAL COLLEGE
DAVANGERE-577004,
KARNATAKA.
3. / Course of Study & Subject / POST – GRADUATION
M.D. IN PATHOLOGY
4. / Date of Admission to Course / 22nd MAY 2008
5. / Title of topic / “ENDOMETRIAL HISTOPATHOLOGY IN WOMEN WITH POSTMENOPAUSAL BLEEDING”.
6. / BRIEF RESUME OF THE INTENDED WORK:
6.1 Need for the study :
Bleeding from the genital tract occurring after the menopause is much more sinister than pre-menopausal bleeding. In the absence of hormone therapy; any bleeding after menopause, should prompt evaluation with endometrial sampling1, 2.
As per one study on postmenopausal bleeding, the endometrium contributed to 50% of the causes; in which the findings were atrophied endometrium (16.3%), endometrial hyperplasia (13.4%), proliferative endometrium (8.6%), endometrial polyp (2.8%) and endometrial carcinoma (9.6%)3.The most commonly recovered endometrial biopsy sample from women with postmenopausal bleeding was atrophic endometrium.4
According to a study conducted in Davangere on postmenopausal bleeding, the following endomerial patterns were highlighted; cystoglandular hyperplasia (39.39%), menstrual (15.15%), proliferative (15%), secretory (6%), atrophy (6%), endometritis (6%) and endometrial stromal sarcoma (3%)5.
Atleast ¼th of postmenopausal women with bleeding have a neoplastic lesion; approximately 15% having endometrial carcinoma2. The dictum is “Postmenopausal bleeding indicates malignancy until proved otherwise”3.
The present study is undertaken to study the histomorphological features of endometrium in women presenting with postmenopausal bleeding and to correlate it with clinical diagnosis.
6.2 Review of literature:
Anovulatory bleeding; excluding hormonal medication; represent the most common source of non-cyclic uterine bleeding in the postmenopausal age group6. Endometrial atrophy accounts for upto 82% of postmenopausal vaginal spotting or bleeding. Biopsy of atrophic endometrium typically consists of scant mucus with rare fragments and strips of cuboidal or columnar cells and absence of intact glands7.
Gredmark et al studied 457 postmenopausal women and revealed that the incidence of postmenopausal bleeding decreased with increasing age while the probability of cancer as the cause increased. Endometrial histopathology showed atrophy (50%), profileration (4%), secretion (1%), polyps (9%), hyperplasia (10%), adenocarcinoma (8%) and other disorders (3%)8.
Nofech Mozes et al analysed 827 cases of endometrial carcinoma which revealed that the majority of the cases were type I endometroid carcinoma; the median age of diagnosis being 62 yrs and the commonest complaint was vaginal bleeding9.
Savelli L et al studied the histopathology of 358 endometrial polyps in women with postmenopausal bleeding showing that 70% were benign, 25% were hyperplastic and 4 were cancerous10. Endometrial intraepithelial carcinoma may be identified as malignant surface change in atrophic polyps removed from elderly women7.
About 5% of women with postmenopausal bleeding have endometrial hyperplasia characterized by a proliferating endometrium either simple, complex or atypical featuring glandular architectural abnormalities2,4. Postmenopausal hyperplasia carries a stronger threat of cancer than does premenopausal hyperplasia1.
Among the remaining causes of postmenopausal bleeding 10% were due to cancer of cervix, uterine sarcoma, urethral caruncle, polyp or carcinoma2. In the aforementioned study; 15% of cases were due to non endometrial causes like ovarian carcinoma, fallopian tube caricinoma, hypernephroma with vaginal vault metastasis and endometritis8.
Endometrial biopsy as compared to dilatation and curettage is more reliable to investigate postmenopausal bleeding. For the diagnosis of polyps, endometrial carcinoma and hyperplasia, the accuracy of biopsies are better in menopausal women6.
Notelovitz M cautioned that persistent unexplained postmenopausal bleeding warranted repeat investigations as there may be a small focus of adenocarcinoma11.
6.3 Objectives of the study:
1. To establish the various endometrial causes of postmenopausal bleeding through histopathological evaluation.
2. To correlate the clinical and histopathological findings.
7. / MATERIALS AND METHODS:
7.1 Source of data:
The source of data are patients admitted or managed in gynecology wards of Bapuji Hospital, Chigateri General Hospital, Women and Child Hospital attached to JJM Medical college. Hysterectomy specimens and endometrial biopsies received from other hospitals in and around Davangere will also be studied.
7.2 Method of collection of data (including sampling procedure, if any):
Hysterectomy specimens, endometrial biopsies and curettage samples from women with postmenopausal bleeding which are sent for histopathological examination to the department of pathology, JJM Medical college over a period of 2 years from July 2008 to June 2010 constitute the material for the present study.
This specimens are received in 10% formalin; after adequate fixation, the specimens are subjected to thorough gross examination and appropriate sections will be taken. After tissue processing, 5-7 microns thick sections will be stained with hematoxylin and eosin and special stains wherever necessary will be used.
Sample size : 100 cases
Inclusion criteria:
· Specimens from patients with postmenopausal bleeding who had hysterectomy, endometrial biopsy or dilatation and curettage done.
Exclusion criteria:
· Cases with non endometrial causes of postmenopausal bleeding.
· Hysterectomy specimens and endometrial biopsies from patient without complaints of postmenopausal bleeding.
7.3 Does the study requires any investigations or interventions to be conducted on patients or other humans or animals? If so, please describe briefly?
No
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes
8. / LIST OF REFERENCES:
1) Abnormal and excessive uterine bleeding. In : Bhatla N,editor.Jeffcoate’s principles of gynecology.5th ed.London:Arnold;2001.p. 578-79.
2) Adams Hillard PJ. Benign diseases of the female reproductive tract. In : Berek JS, Rinehart RD, editors. Berek and Novak’s gynecology.14th ed. Lippincott Williams and Wilkins. New Delhi: Wolters Kluwer Health India.pvt.ltd. 2007.p. 490-91.
3) Naik VS, Rege JD, Jashnani KD. Pathology of genital tract in postmenopausal bleeding. Bombay Hospital Journal. Available at URL:http://www.bhj.org/journal/2005_4703_july/html.
4) Hendrickson MR, Longacre TA, Kempson RL. The Uterine Corpus. In : Mills SE, Carter D, Greenson JK, Oberman HA, Reuter VE, Stoler MH, editors. Sternberg’s diagnostic surgical pathology. 4thed. Philadelphia: Lippincott Williams and Wilkins; 2004,vol 3;p. 2454.
5) Das PS. A clinico-pathological study of endometrium in case of postmenopausal bleeding. Unpublished doctoral dissertation, Rajiv Ghandhi University of Health Sciences. Karnataka.2003 sept; 94.
6) Hatasaka H. Evaluation of abnormal uterine bleeding. Clin Obstet Gynecol. 2005;48(2): 259,265.
7) Sherman ME, Mazur MT, Kurman RJ. Benign Diseases of the Endometrium. In : Kurman RJ,editor. Blaustein’s pathology of female genital tract. 5th ed. New York: Springer-Verlag; 2002.p. 437,451.
8) Gredmark T, Kvint S, Havel G, Mattsson L. Histopathological findings in women with postmenopausal bleeding. BJOG. 1995; 102: 133-36.
9) Nofech S, Ghorab Z, Ismiil N, Ackerman I, Thomas G, Barbera L et al. Endometrial Endometroid Adenocarcinoma, A pathologic analysis of 827 consecutive cases. Am J Clin Pathol. 2008; 129: 110-14.
10) Savelli L, De Iaco P, Santini D, Rosati F, Ghi T, Pignotti E et al. Histopathologic features and risk factors for benignity, hyperplasia and cancer in endometrial polyps. Am J Obstet Gynecol 2003; 188: 927-30.
11) Choo YC, Mak KC, Hsu C, Wong TS, Ma HK. Postmenopausal uterine bleeding of nonorganic cause. Obstet Gynecol. 1985; 66(2): 225-27.
9. / Signature of Candidate
10. / Remarks of Guide / Histopathology plays a crucial role in the diagnosis of postmenopausal bleeding in women and can help the clinician in the appropriate management, hence this prospective study confined to the endometrial causes of postmenopausal bleeding is undertaken.
11. / Name and Designation of
(In Block Letters)
11.1 Guide
11.2 Signature
11.3 Co-Guide (If any)
11.4 Signature
11.5 Head of Department
11.6 Signature / Dr. ARUNA S BYATHNAL,MD
ASSOCIATE PROFESSOR,
DEPARTMENT OF PATHOLOGY,
J.J.M MEDICAL COLLEGE,
DAVANGERE – 577004.
Dr. PRAKASH KUMAR,M.D
PROFESSOR AND H.O.D.
DEPARTMENT OF PATHOLOGY,
J.J.M. MEDICAL COLLEGE,
DAVANGERE – 577004.
12. / 12.1 Remarks of the Chairman and
Principal
12.2 Signature.