INTRODUCTION 
In 2001, the Stages-of-Reproductive-Aging-Workshop 
(STRAW) dened 'perimenopause' as the period beginning 
with menopausal transition and ending 12 months after the 

1last menstrual period . This may last for 4-8 years. During this 
period, the endocrinological, biological and clinical features 
of approaching menopause commence. In perimenopause, 
volume and frequency of menses vary due to uctuating 
estrogen levels, which is unpredictable and unique for each 
woman. Abnormal uterine bleeding accounts for more than 
50% of all gynaecologist's consultation in the perimenopausal 
years, which causes nancial and emotional burden on the 
quality of the woman's life.

Prolonged unopposed estrogen stimulation in anovulatory 
cycles causes endometrial hyperplasia, thus increasing the 
risk of endometrial cancers. Therefore, diagnosing the proper 
cause of AUB in perimenopausal women become essential, so 
that proper intervention can be initiated at the earliest 
possible time. The TVS is a simple, non-invasive, easily 
available and cheap diagnostic modality to assess the 
organic cause of AUB. It permits better visualization of uterus, 
endometrium and adnexa. So we planned to assess the 
diagnostic accuracy of TVS in various uterine causes of AUB 
by correlating it with histopathology.

AIMS AND OBJECTIVE:
To evaluate the accuracy of TVS to diagnose organic uterine 
pathology causing abnormal uterine bleeding in 
perimenopausal women with histopathological correlation.

MATERIALS AND METHODS 
This prospective study was done in the Department of 

Radiodiagnosis of Mahatma Gandhi Memorial Medical 
College & M. Y. Hospital, Indore, Madhya Pradesh, India after 
getting approval by Institutional Scientic Review Board. A 
total of 152 perimenopausal patients between 39 to 51 years of 
age, who were referred to our department with clinical 
symptom of bleeding per vagina underwent transvaginal 
ultrasound using Siemens USG machine. Out of 152 patients, 
18 patients were lost during the course of study and in 34 
patients histopathological correlation was not established. 
Therefore, the nal study group comprised of 100 
perimenopausal patients. Women excluded: Age <39 or > 51 
years, menopausal women, Women on hormonal treatment, 
IUCD in situ, endocrine disorders, bleeding disorders, 
cervical or vaginal cause of bleeding, pregnancy, traumatic 
bleeding and unmarried.

RESULTS:
Out of 100 perimenopausal women in our study, the mean age 
of women was 46 years and majority (39%) of them belonged 
to the age group 48-51 years. Majority of the women were 
multiparous (79%). Common clinical presentation of AUB in 
perimenopausal women in our study was menorrhagia (51%) 
followed by menometrorrhagia (19%).

(Table 1)In our study, 35% women had ET>16mm on TVS 
followed by 21% of women having ET between 4-8mm range. 
On histopathological analysis of the endometrial biopsy in 
100 perimenopausal women in our study, the most common 
HPE nding was proliferative endometrium (34%) followed by 
secretory endometrium (17%).

THE ROLE OF TRANSVAGINAL ULTRASOUND IN ABNORMAL UTERINE 
BLEEDING IN PERIMENOPAUSAL WOMEN AND ITS HISTOPATHOLOGICAL 

CORRELATION

Original Research Paper

Dr. (prof.) Alka 
Agrawal

Professor & Hod Department Of Radiodiagnosis, Mgm Medical College & 
M. Y. Hospital

Radiodiagnosis

BACKGROUND: Abnormal uterine bleeding accounts for more than 50% of all gynaecologist's 
consultation in the perimenopausal years. 

AIMS AND OBJECTIVE: To evaluate the accuracy of TVS to diagnose organic uterine pathology causing abnormal uterine 
bleeding in perimenopausal women with histopathological correlation. 
RESULTS: Total 100 perimenopausal women were included, the most common age group was 48-51 years,51% patients 
presented with menorrhagia. 79% patients were multiparous. Uterine broid was the commonest uterine pathology (42%). 35% 
of patients had ET>16mm.On TVS, ET>8mm had signicantly higher chance to be abnormal histopathologically.7% and 
10%patients revealed endometrial malignancy on TVS and HPE respectively. The sensitivity, specicity, PPV, NPV of TVS for 
benign lesions was 99%, 60%, 96% and 86% respectively and sensitivity, specicity, PPV, NPV of TVS for malignant lesion was 
60%, 99%, 86% and 96% respectively. 
CONCLUSION: Perimenopausal women with ET>8 mm on TVS, should undergo histopathological evaluation.

ABSTRACT

KEYWORDS : Aub, Tvs, Et, Perimenopausal.

VOLUME-8, ISSUE-10, OCTOBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra

Dr Aakanksha 
Verma

PG Resident, Radiodiagnosis. Mgmmc, Indore

Dr Jaipal Singh PG Resident, Radiodiagnosis. Mgmmc, Indore

Dr Rajkumar 
Patidar

PG Resident, Radiodiagnosis. Mgmmc, Indore

Dr Gaurav 
Bhandari*

Assistant Professor, Radiodiagnosis, Mgm Medical College, Indore
*Corresponding Author

Table 1: Comparing ET on TVS with endometrial histopathology.

ET (in mm) on TVS No. of cases on TVS Endometrial histopathology

48 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS



On retrospectively comparing ET on TVS with nal HPE of 
endometrium (table 1), in 34(97%) out of 35 patients with 
ET>16mm on TVS, had pathological endometrial 
histopathology. Similarly, in 10(66%) out of 15 patients with ET 
between 12-16mm on TVS and 2(18%) out of 11 patients with 
ET between 8-12 mm on TVS, had pathological endometrial 
histopathology respectively. While, only 3 (14%) out of 21 
patients with ET between 4-8mm on TVS, had pathological 
endometrial histopathology and all the cases with ET<4 mm 
on TVS had normal endometrial histopathology. In our study, 
statistical analysis for relation of ET with probability of 
abnormal endometrial ndings on histopathology revealed 
that ET> 8 mm on TVS had statistically signicant higher 

2chance to be abnormal histopathologically (X -value=43.65, P 
<0.001).

Finally, 156 pelvic lesions were diagnosed in 100 
perimenopausal women on TVS. Out of these 156 pelvic 
lesions, 124 lesions were conrmed by histopathology.7 out of 
these 124, were diagnosed malignant (endometrial 
carcinoma) and rest 117 as benign lesions on TVS (Table 3). 
The most common diagnosed benign lesion on TVS was 
uterine broids (42%) followed by adenomyosis (23%). Other 
benign lesions found were endometrial hyperplasia (15%), 
polyp (15%) and endometritis (8%).

The nal HPE reported 10 cases of endometrial carcinoma 
and rest 114 cases as benign in nature.

Table 3: Distribution of nal TVS diagnosis in 100 
perimenopausal women presenting with abnormal uterine 
bleeding compared with nal HPE.

DISCUSSION:
AUB is the most common gynaecological complaint among 
women in perimenopausal age group. In our study, analysis of 
patients according to bleeding pattern, the most common AUB 
pattern was menorrhagia (51%) which was comparable to the 

2study conducted by Acharya et al , who observed that 50% 
patients with menstrual complaints were of menorrhagia. 
Majority of the women were multiparous (79%) followed by 
primipara (16%). This distribution of parity is similar to the 

3study by Shobhita GL et al in 2015 .

In our study most of the cases (35%) had ET in >16 mm 
followed by 4-8 mm range. All the cases of endometrial 
hyperplasia (10%) and endometrial carcinoma (7%) had ET of 
>16 mm on TVS. These ndings were in accordance with 

4study done by Aliya A. et al  in 2009, in which all the cases of 
endometrial hyperplasia and endometrial carcinoma had ET 

above 15 mm.

In 34 (97%) patients out of 35 patients with ET>16mm on TVS, 
had pathological endometrium on histopathology and 10 
(66%) out of 15 patients with ET between 12-16 mm on TVS, 
had pathological endometrium on histopathology. While 
among 8-12 mm and 4-8 mm ET on TVS, only 18% and 14% of 
cases showed pathological thickening on HPE respectively. 
However, patients with ET<4 mm revealed normal 

5histopathology. A Study by Machado et al in 2005 concluded 
that ET less than 5 mm did not need D&C as none of these 
patients had atypia or malignancy, which was also 
corroborated in the present study.

There is no clear denition of what constitutes an abnormal ET 
in the still menstruating perimenopausal woman. The upper 
limit for normal ET remains controversial, but most studies, 

6 like that of Chatapavit et al have reported transvaginal 
sonographic ET 8 mm as the abnormal cut off value, 
necessitating further investigations. In our study, 49 patients 
had abnormal endometrial on HPE. 46 patients out of 49 
patients, had ET >8mm and only 3 patients had ET < 8 mm. 
Patients with ET > 8 mm on TVS has signicant higher chance 

2of having abnormal endometrium (X -value=43.65, P <0.001).
In our study the most common benign and overall pathology 
diagnosed on TVS was uterine broids found in 43% of the 
cases. Among these 12 women had multiple uterine broids 
and 19 women had other associated pelvic pathologies along 
with uterine broids. The most common type of broid on TVS 
was intramural followed by submucosal. This is in accordance 

2with a study conducted by Archana et al in 2018 which 
revealed broids in 41% of cases.

In our study, TVS diagnosed 7 cases of endometrial 
carcinoma (7%) and 10 cases of endometrial hyperplasia 
(10%). All these cases were having ET>16 mm on TVS and 
were present in late perimenopausal age group. This is in 
accordance with the previous population-based study by 

7Susan DR et al in 2009, which revealed that the incidence of 
endometrial hyperplasia with and without atypia peaks in the 
late perimenopausal   and postmenopausal years. 

Our study on 100 perimenopausal women presenting with 

AUB revealed a total of 153 lesions on TVS examination. Out of 

these, 124 lesions were correlated histopathologically. TVS 

diagnosed 7 lesions as malignant and 117 cases as benign. 

On histopathology 10 cases were identied as malignant and 

114 cases were diagnosed as benign.

(Table 4) Our study revealed that TVS has excellent statistical 

results in detecting and characterizing various pelvic 

pathologies.

Table4: The sensitivity, specicity, PPV and NPV of TVS for 

various pelvic pathologies.

VOLUME-8, ISSUE-10, OCTOBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra

Normal endometrium Abnormal endometrium

proliferative Secretor
y

Endometrial 
hyperplasia

Atrophic 
endometrium

polyp endometritis Endometrial 
carcinomas

<4 18 18 0 0 0 0 0 0

4-8 21 11 7 1 2 0 0 0

8-12 11 5 4 1 1 0 0 0

12-16 15 0 5 4 0 5 1 0

>16 35 0 1 11 0 8 5 10

Total 100 34 17 17 3 13 6 10

TVS DIAGNOSIS/MODAILITY ON TVS ON HPE

Intramural broid 31 30

Submucosal broid 16 16

Subserosal broid 9 9

Adenomyosis 23 26

polyp 15 13

Hyperplasia 15 14

Endometritis 8 6

Endometrial carcinoma 7 10

Total no. of lesion in 100 
perimenopausal

124 124

TVS 
diagnosis

Sensitivity (%) Specicity (%) PPV (%) NPV (%)

Benign 
lesion

99 60 96 86

Malignant 
lesion

60 99 86 96

  X 49GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS



The sensitivity, specicity, PPV and NPV of TVS in our study is 
8in agreement with previous studies of Urvashi et al , Acharya 

2 9et al  and Ritu et al . Therefore, TVS can be practically used as 
initial and one of the best diagnostic modalities to assess the 
pelvic pathologies.

CONCLUSION:
AUB is a common and debilitating condition with high direct 
and indirect costs. The data from our study on statistical 
analysis for relation of ET with probability of abnormal 
endometrial ndings on histopathology revealed that ET> 8 
mm on TVS had statistically signicant higher chance to be 
abnormal. Therefore, ET>8 mm on TVS in perimenopausal 
women, irrespective of phase of menstrual cycle, echogenicity 
of the endometrium, its margin or any added abnormality 
should be subjected to histopathology.

In our study, the diagnostic value of TVS turned out to be 
excellent for almost all uterine pathologies. The sensitivity, 
specicity, PPV, NPV of TVS for benign lesions was 99%, 60%, 
96% and 86% respectively and sensitivity, specicity, PPV, NPV 
of TVS for malignant lesion was 60%, 99%, 86% and 96% 
respectively.

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transvaginal sonography and hysteroscopy in perimenopausal women.” 
(2017).

3. Shobhitha GL et al. Endometrial study by TVS and It’s correlation with 
histopathology in abnormal uterine bleeding. J Dental Med Sci. 
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4. Aliya Aslam, Gazala. Role of TVS in cases of abnormal uterine bleeding. 
Professional Med J. 2009;(16)1:127-34. 

5. Machado LS et al. Correlation of ET, cycle day and histopathology in women 
with abnormal uterine bleeding. Saudi Med J. 2005;26(2):260-3.

6. Getpook C et al. ET screening in premenopausal women with abnormal 
uterine bleeding. Journal of Obstetrics and Gynaecology Research. 
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7. Reed SDet al. Incidence of endometrial hyperplasia. Am J Obstet Gynecol. 
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8. Verma U et al. Diagnostic approach in perimenopausal women with 
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9. Mishra R et al. To compare the result of TVS and SIS with hysteroscopy and 
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VOLUME-8, ISSUE-10, OCTOBER-2019 • PRINT ISSN No. 2277 - 8160 • DOI : 10.36106/gjra

Uterine 
broid

91 91 89 92

Adenomyosis 71 96 86 92

Endometrial 
hyperplasia

76 98 86 94

50 X GJRA - GLOBAL JOURNAL FOR RESEARCH ANALYSIS