Clinical, Ultrasound, and Endometrial Histopathological features of Perimenopausal and Postmenopausal women with abnormal uterine bleeding at a tertiary hospital in Western Kenya

Abstract

Background: Abnormal uterine bleeding (AUB) affects 3–30% of perimenopausal women and 5–10% of those who are postmenopausal. While the aetiology of the condition in these women is mostly benign, it could also be a symptom of endometrial hyperplasia (EH) and endometrial cancer (EC). Conditions linked to EH and EC, such as obesity, diabetes, and hypertension, are on the rise in Kenya. Despite studies in various populations reporting differences in endometrial histopathology and the prevalence of EH and EC, data from sub-Saharan Africa remain scarce. Objectives: To describe the clinical, ultrasound, and endometrial histopathological features; determine the prevalence of EH and EC; and identify factors associated with the diagnosis of the two conditions in peri- and postmenopausal women with AUB at the Moi Teaching & Referral Hospital (MTRH), a tertiary hospital in Eldoret, Kenya. Methods: This was a cross-sectional study of women aged ≥40 years with AUB, conducted between June 2019–May 2020 at MTRH. A total of 64 perimenopausal women and 36postmenopausal women were enrolled. Endometrial biopsies were performed using a Pipelle® (Cooper Surgical Inc., Trumbull, Connecticut, USA) endometrial suction curette, followed by histopathological evaluation by two pathologists. Data on sociodemographic, clinical and reproductive characteristics (BMI, chronic illness, bleeding patterns, parity, contraception use), and ultrasound findings (presence of uterine mass, endometrial thickness) were recorded. Associations between these characteristics and the diagnosis of EH/EC were tested using χ² or Fisher’s exact test, and significance was accepted at a p value ≤0.05. Results: Of 64 perimenopausal women, 42 (65.6%) were either overweight or obese, and 11 (17.2%) had at least one chronic illness linked to EC. Of the 36 postmenopausal women, 31 (86.1%) were either overweight or obese, and 20 (55.5%) had at least one chronic illness linked to EC. From the perimenopausal group, 40 (62.5%) had cyclical or benign patterns, 23 (35.9%) had EH with or without atypia, and one (1.6%) had EC. EH without atypia was the most frequently seen individual pattern in this group (32.8%). Among the 36 postmenopausal women, 15 (41.7%) had cyclical or benign patterns, 14 (38.9%) had EH with or without atypia, and seven (19.4%) had EC. EH without atypia was also the most frequently seen individual pattern in this group (25.0%). None of the clinical and reproductive characteristics were significantly associated with the diagnosis of EH/EC. A thickened endometrium on ultrasound was the only feature associated with the diagnosis of EH/EC (p=0.004) on multivariate analysis. Conclusion: The most frequently observed histopathological features in perimenopausal women with AUB and in women with postmenopausal bleeding at MTRH were normal cyclical patterns (secretory or proliferative) in the perimenopausal group, benign pathologies (chronic endometritis in perimenopausal and atrophic endometrium in postmenopausal), and EH without atypia in both groups of women. Only a small proportion of perimenopausal women were diagnosed with EH with atypia (3.1%) and EC (1.5%), the two pathologies of greatest clinical concern. Based on these findings, the authors do not recommend the routine performance of endometrial biopsies for perimenopausal women with AUB unless symptoms persist despite medical therapy and risk factor modification. Conversely, in women with postmenopausal bleeding, the authors strongly recommend histological evaluation of the endometrium, particularly in those with an endometrial thickness >4 mm on ultrasound, given the relatively high prevalence of EH with atypia (13.8%) and EC (19.4%) observed in this study.