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\begin{document}

\title{Endometrial Pathology in abnormal uterine bleeding (AUB) \& role of
different techniques of endometrial sampling in evaluation of AUB : A
cross sectional study}



\author[1]{MAHESH ASALKAR}%
\author[1]{ilaaf rumani}%
\author[1]{Mangal Supe}%
\author[1]{Smita Thakkarwad}%
\author[1]{Sinchana (MBBS) R}%
\affil[1]{Maharashtra University of Health Sciences}%


\vspace{-1em}



  
  \date{March 13, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
\textbf{Objectives:} \textbf{Primary:} 1. To Analyze prevalence of
various endometrial pathologies among patients presenting with abnormal
uterine bleeding. \textbf{Secondary :} 1. To study age wise distribution
of various endometrial pathologies. 2. To study age wise clinical
presentation (symptomatology) in patients with AUB. 3. To assess the
feasibility and compare different techniques of collecting endometrial
sample. \textbf{Design and setting:} A single center prospective cross
sectional study at teaching institute Population/Sample : 150 females
from 18-70 years presenting with abnormal uterine bleeding. Endometrial
sample was obtained either by OPD Pipelle brush or Surgical Dilatation
and Curettage method or hysteroscopy. Outcome measures : Endometrial
sampling methods used, Endometrial Pathology, Age groups wise clinical
and pathological correlation, Feasibility of technique used. Statistical
Analysis was done by using Epi-Info-7 software. \textbf{Results
:}Commonest age group presenting with AUB was 41-50 (40\%) years ,64 \%
were para 3 or more, Proliferative and secretary changes, 53(35.3\%) and
24(16\%) cases while endometrial hyperplasia without atypia 18 (12\%)
cases and with atypia7cases(4.7\% ),endometrial carcinoma 5 cases(3.3\%)
while endometrial polyp was seen in 8 cases(5.3\% ). Heavy menstrual
bleeding with normal duration was commonest presentation in 64\%.
Endometrial sampling technical failure was seen in 2 cases with pipelle
biopsy while in 7 cases inadequate sample was obtained with pipelle and
dilatation and curettage. Uterine perforation was seen in one case which
was managed conservatively. \textbf{Conclusion: T}echnical failure and
inadequate sample needs to be addressed considering background high risk
factors, TVS imaging and repeat sample and use of hysteroscopy may be
offered case to case basis.%
\end{abstract}%



\sloppy


\textbf{Title :Endometrial Pathology in abnormal uterine bleeding (AUB)
\& role of different techniques of endometrial sampling in evaluation of
AUB : A cross sectional study}

\textbf{Running Title: Endometrial Pathology in AUB and endometrial
sampling techniques.}

\textbf{Key Words:} Abnormal uterine bleeding, AUB, Pipelle biopsy,
dilatation and curettage, Hysteroscopy, Endometrial sampling,
endometrial polyp, endometrial hyperplasia, endometrial carcinoma

\textbf{Authors and Co-Authors}

Dr. MR Asalkar (MD,DNB,FCPS,DGO) -- \textbf{1st and corresponding
Author,}

Professor \& Head, Department of Obstetrics and Gynaecology, PGI-YCMH
Pimpri Pune

411018(MS)India

Address for Correspondence: Department of Obstetrics and Gynaecology,

PGI-YCMH Pimpri Pune 411018(MS)India

Mobile Num: 9326972948

Email : mahesh@asalkarclinic.com

Dr Ilaaf Rumani -2\textsuperscript{nd} Author

Senior Resident

Department of Obstetrics and Gynaecology,PGI-YCMH Pimpri Pune

411018(MS)India

Mobile Num: 9821361599

Email : Ilaafrumani94@gmail.com

Dr. Mangal Supe- 3\textsuperscript{rd} Author

Assistant Professor, Department of Obstetrics and Gynaecology,PGI-YCMH
Pimpri Pune 411018(MS)India

Mobile: 9604167167

Email: drmangalbhokte28@gmail.com

Dr. SM Thakkarwad(MS,DGO,FCPS)- 4\textsuperscript{th} Author,

Associate Professor, Department of Obstetrics and Gynaecology,PGI-YCMH
Pimpri Pune

411018(MS)India

Mobile Num: 9492280859

Email : smitathakkarwad81@gmail.com

Dr. Sinchana R (MBBS) -- 5\textsuperscript{th} Author,

Junior Resident, Department of Obstetrics and Gynaecology,PGI-YCMH
Pimpri Pune

411018(MS)India

Mobile Num: 9606200506

Email : Sinchana.ramesh@gmail.com

\textbf{Abstract:}

\textbf{Objectives:}

\textbf{Primary:} 1. To Analyze prevalence of various endometrial
pathologies among patients presenting with abnormal uterine bleeding.

\textbf{Secondary :}

\begin{enumerate}
\tightlist
\item
  To study age wise distribution of various endometrial pathologies.
\item
  To study age wise clinical presentation (symptomatology) in patients
  with AUB.
\item
  To assess the feasibility and compare different techniques of
  collecting endometrial sample.
\end{enumerate}

\textbf{Design and setting:} A single center prospective cross sectional
study at teaching institute

Population/Sample : 150 females from 18-70 years presenting with
abnormal uterine bleeding. Endometrial sample was obtained either by OPD
Pipelle brush or Surgical Dilatation and Curettage method or
hysteroscopy.

Outcome measures : Endometrial sampling methods used, Endometrial
Pathology, Age groups wise clinical and pathological correlation,
Feasibility of technique used. Statistical Analysis was done by using
Epi-Info-7 software.

\textbf{Results :} Commonest age group presenting with AUB was 41-50
(40\%) years ,64 \% were para 3 or more, Proliferative and secretary
changes, 53(35.3\%) and 24(16\%) cases while endometrial hyperplasia
without atypia 18 (12\%) cases and with atypia7cases(4.7\% ),endometrial
carcinoma 5 cases(3.3\%) while endometrial polyp was seen in 8
cases(5.3\% ). Heavy menstrual bleeding with normal duration was
commonest presentation in 64\%. Endometrial sampling technical failure
was seen in 2 cases with pipelle biopsy while in 7 cases inadequate
sample was obtained with pipelle and dilatation and curettage. Uterine
perforation was seen in one case which was managed conservatively.

\textbf{Conclusion: T} echnical failure and inadequate sample needs to
be addressed considering background high risk factors, TVS imaging and
repeat sample and use of hysteroscopy may be offered case to case basis.

\textbf{Introduction :}

Abnormal uterine bleeding (AUB), traditionally defined as uterine
bleeding that is abnormal in volume, regularity,and/or timing. Abnormal
Uterine Bleeding (AUB) is the most common complaint for which woman
reports gynaecologist and clinical presentation varies from heavy flow
with normal duration(HMB), heavy flow with prolonged duration,
Intermestrual bleeding(IMB) or post-menopausal bleeding and generally it
correlates with different age group of presentation as well as
underlying endometrial pathology.
TransvaginalUltrasonography(TVS),endometrial sampling by pipelle or
dilatation and curettage, hysteroscopy etc plays an important role in
evaluation and management of AUB.

\textbf{Methodology:}

A single center prospective cross sectional study at PCMC'S PGI and Y C
M Hospital, Pune was carried out from 1\textsuperscript{st} Jan 2020 to
31\textsuperscript{st} May 2021.Total 150 female were enrolled between
age group 18 to 70 who presented with Abnormal Uterine bleeding.
Endometrial biopsy sample was obtained either by OPD Pipelle brush or by
Surgical Dilatation and Curettage method or hysteroscopy along with
endometrial biopsy. Histopathological diagnoses were studied for all
samples. Data was collected in the standard format as mentioned in the
data collection tool. Statistical Analysis was done by using Epi-Info-7
software. Informed consent obtained from all participants.

\textbf{Objectives:}

\textbf{Primary:} 1. To Analyze prevalence of various endometrial
pathologies among patients presenting with abnormal uterine bleeding.

\textbf{Secondary :}

\begin{enumerate}
\tightlist
\item
  To study age wise distribution of various endometrial pathologies.
\item
  To study age wise clinical presentation (symptomatology) in patients
  with AUB.
\item
  To assess the feasibility and compare different techniques of
  collecting endometrial sample.
\end{enumerate}

\textbf{Inclusion Criteria:}

Patients presenting with symptoms of AUB between the age group of 18 and
70 who underwent endometrial biopsy were included in the study.

Unmarried patients where sinister pathology (Non benign) is suspected
are considered for endometrial sampling.

\textbf{Exclusion Criteria:}

Unmarried patients where primary conservative management is done in view
of suspected benign pathology are excluded from the study as no
endometrial sampling is done in spite of symptoms of AUB

Patients refusing to consent for participation in the study.

\textbf{Results :}

Table 1 shows most of our patients are para 3 or more96 cases (64\%)
cases and most patients 82 cases (54.6\%) belong to lower socio economic
class.

Table 1 and Table 2 shows age groupwise spectrum of endometrial
pathologies in patients with AUB. In age group 21-30 years 7cases(4.5\%)
underwent endometrial sampling and histological features in this age
group were mainly benign changes such as proliferative and pill
endometrium 2 cases each, secretary change, chronic endometritis, polyp
one case each. Age group 31-40 years 53 cases (35.3\%) underwent
endometrial sampling and histological changes were mostly benign such as
proliferative(23),secretary(11)pill endometrium(2)endometrial
hyperplasia without atypia (4), with atypia(2) chronic endometritis and
endometrial polyp 3 cases each and inadequate sample in 2 cases. Age
group 41-50 contributed to maximum number 60 cases (40\%) and
endometrial changes were Proliferative(22),secretary(12),endometrial
hyperplasia without atypia (7),with atypia(3),carcinoma endometrium (1)
,other changes were chronic endometritis (6),pill
endometrium(1),Polyp(2).Age group 51-60 contributed 22 cases 14\% of
cases and histopathological changes were noted as
proliferative(6),disordered proliferative(1), Atrophic endometrium
(3)and chronic endometritis 2 cases each, endometrial hyperplasia
without atypia(6) with atypia(2),carcinoma endometrium(1),inadequate
sample(1) other changes were benign. Age group 61-70 total 8 cases
(5.2\%) underwent endometrial sampling and pathological changes were
endometrial carcinoma(3), atrophic endometrium (3) and endometrial polyp
(1),inadequate sample for reporting(1). Repeat endometrial sampling was
done in cases after inadequate sample it is reported as chronic
endometritis in one case and atrophic endometrium in 2 cases in this age
group.

Table 3 shows commonest clinical presentation as heavy menstrual
bleeding HMB with normal duration 96 cases (64\%), followed by heavy and
prolonged bleeding in 23 cases (15.3 \%), Post menopausal bleeding 23
cases (15.3\%), Intermenstrual bleeding(IMB) was presentation in 8 cases
5.4\%.

Table 4 shows out of 150 patients out 71 patients subjected to pipelle
biopsy only 69 cases sample was obtained while 2 cases technical failure
was noted. 34 patients endometrial sample was obtained by traditional
dilatation and curettage technique while 47 cases underwent hysteroscopy
along with endometrial biopsy and additional 3 cases who consented for
repeat sampling by hysteroscopy due to inadequate sample for reporting
also underwent hysteroscopy. Inadequate sample was noted in 4 cases in
pipelle group and in 3 cases in D \& c group . One Uterine perforation
was noted in patients undergoing dilatation and curettage. Pipelle
biopsy was found to be more feasible for outpatient procedure however
dilatation and curettage and hysteroscopy with biopsy were less feasible
in our setting

\textbf{Discussion :}

Menstrual disorders are more common with advancing age. In our study,
below 30 years 7 cases (4.5\%) underwent endometrial sampling. Incidence
of AUB may be more in this age group however most cases being low risk
are managed conservatively and are not subjected to endometrial
sampling. Patients with high risk factors such as obesity or family
history of endometrial cancer or non response to medical management are
generally subjected to endometrial sampling. Most common age group
presenting with AUB in our study was 41-50 60 cases (40\%) years
followed by 53 cases (35.3\%) in 31-40 age group and this 31-50 yr age
group combined contributed to 75.3\% cases . Similar finding have been
reported by Doraiswami s et al (1) A similar incidence was reported by
Yusuf et al (2) and Muzaffar et al (3) in their study. After the age of
50 that is 51-60 year age group and 61-70 year age group had 22
cases(15\% ) and8 cases (5.3\%) respectively and this age group(51-70
years) together constituted 30 cases (20\%) of our patients. However
this age group showed significant changes such as endometrial carcinoma
and precursors for endometrial cancer such as endometrial hyperplasia
without atypia and with atypia as discussed below.

96 cases out of 150 patients with AUB were para 3 or more and
nulliparous were only2.7\% in our study. Nulliparous patients less
commonly presents with AUB as compared to multiparous patients similar
finding is observed in other studies (4,5,6). Patients attending health
facilities in public sector are mainly from lower socio economic class
contributed to 82 cases (54.6\%) in our study.

In our study as per table2\emph{,} functional endometrium with
proliferative and secretary changes were noted in 53 cases (35.4\%) and
24 cases (16\%)respectively while Kafle et al (7) in a study of 166
samples noted proliferative and secretary changes in 42.97\% and 14.46\%
cases. Brahmaiah J et al (8) in study of 210 samples noted
proliferativeand secretary changes in 31.3\% and 11.43\% cases
respectively. Endometrial hyperplasia without atypia was seen in 18
cases(12\%) cases and with atypia was seen in 7 cases (4.66\%) in our
study while Kafle et al (7) noted hyperplasia of endometrium without
atypia in 7.23\% cases and atypical hyperplasia in 3.01\% cases.
Brahmaiah J et al (8) noted endometrial hyperplasia in 20\% cases with
no specification of features such as atypia or without atypia. Various
other authors have noted endometrial hyperplasia 6\% to 26\% of
samples(8). Endometrial hyperplasia with or without hyperplasia should
be given immediate attention and patients should be counselled regarding
the nature of pathology detected and appropriate treatment to be
instituted. Incidence of co-existing endometrial carcinoma ranges
6.4-43\% in women undergoing hysterectomy for atypical
hyperplasia(9)\textbf{.} Natural history of endometrial hyperplasia
without atypia suggest that risk of progression to endometrial is 2\% if
remains untreated and this figure is 23-29\% for atypical
hyperplasia(10).

In our study endometrial carcinoma is noted in 5 cases (3.3\%) while
Kafle N et al (7) has reported 2.4\% incidence of malignancy which were
adenocarcinoma. Brahmaiah J et al (8) reported 0.47\% incidence of
malignancy in endometrial sample while various authors have mentioned
0.48 to 6.4\% incidence of carcinoma endometrium in patients presenting
with AUB(8). Incidence of finding carcinoma in endometrial sample varies
with the population screened. AUB patients attending general gynaecology
outpatient department, all age group patients combined may have lower
incidence of detection of carcinoma while screening of patients with
high risk factors such as obesity, nulliparity, family history or
samples from oncological hospital will report higher detection rate for
malignancy.

Atrophic endometrium is noted in 6cases (4\%) in our study which is
similar to rate 3.35\% reported by Brahmaiah J et al (8) and various
authors reported rate of atrophic endometrium from 2-7.38\% (8)Rupture
of dilated blood capillaries beneath the surface of atrophic endometrium
may be responsible for the bleeding in these patients. Study by
Doraiswami et al (1) documented 2.4\% incidence of atrophic endometrium
while Dwivedi et al (11) has reported 11\% atrophic endometrium which is
higher than our present reported incidence.

Endometrial polyp was reported in 8cases (5.3\%) cases in our study
while Kafle N et al (7) has reported 2.41\% incidence of polyp.
Brahmaiah J. et al (8) has reported 0.95\% incidence of endometrial
polyp in AUB patients. Prevalence of endometrial polyp increase with
age, endometrial polyp in postmenopausal women (11.8\%) and
premenopausal women in (5.8\%) have been reported.(12)Sometimes cervical
polyp may be seen on speculum examination which may be symptomatic or
asymptomatic. Symptomatic cervical polyp may be associated with
endometrial polyps and hyperplasia more commonly in perimenopausal and
post menopausal women. Endometrial abnormalities are noted in upto 55\%
of postmenopausal women with cervical polyp and these women should be
offered endometrial sampling with hysteroscopy in addition to avulsion
of polyp.(13)

Heavy menstrual bleeding with normal duration was commonest presentation
96 cases (64\%) in our study. Vijayraghavan et al (14) has reported
menorrhagia in 71.25\% as the commonest presenting complaint in AUB
patients while Kafle N et al (7) has reported 58.43\% of AUB cases with
menorrhagia as presenting complaint. Postmenopausal bleeding was
presentation in 23 cases (15.3 \%) cases in our study while Kafle N et
al (7) has reported 19.27\% incidence of postmenopausal bleeding and
Vijayraghavan et al (14) has reported 12.5\% incidence of postmenopausal
bleeding in patients with AUB. Postmenopausal bleeding should be
evaluated properly to rule out sinister pathology as 90\% of women with
EC present with PMB, but over 90\% of women with PMB have a benign
benign underlying cause for their symptom(15,16).Heavy and prolonged
bleeding was noted in 23 cases (15.4\%) cases in our study, while inter
menstrual bleeding (IMB) was seen in 8 cases (5.4\%).Kafle N et al (7)
and Vijayrghavan et al (14) have reported 15.1\% and 15\% incidence of
metrorrhagia in AUB patients respectively.

Table 4 \& 2 shows inadequate sample was reported in 7 cases (4.6\%)
with pipelle and dilation and curettage. These patients were offered
endometrial sampling by hysteroscopy for which 3 out of 7 patients
consented and underwent repeat sampling by hysteroscopy. Technical
failure was noted 2 cases (1.3\%) cases where endometrial sampling was
attempted by pipelle. These 2 cases were also underwent repeat sampling
by hysteroscopy. Failed endometrial sampling is usually associated with
pain or cervical stenosis, which is more common in nulliparous
women(17). Pipelle endometrial biopsy is an opd procedure and quick to
perform however failure of the procedure in 11\% cases and inadequate
sample 31\%, pain, bleeding, infection and very rarely perforation have
been reported(18), while failure rate for operative hysteroscopy 3.4 \%
and ambulatory procedure 4.2\% have been reported in the literature(18).
Previously it was thought that women with an inadequate sample can be
reassured safely regarding non sinister pathology however study has
shown 4.5\% of women who were diagnosed with endometrial carcinoma had
initial inadequate sample(19) hence it is not appropriate to reassure
the patient on the ground of inadequacy of the sample however
preoperative high risks factors such as obesity, family history and
supporting investigations such as endometrial thickness on TVS,
irregularity of the endometrium are to be taken into account before
reassuring, As a blind procedure endometrial sampling (pipelle or
dilatation and curettage) has potential to miss small, localised cancers
(20),women with benign or inconclusive histology, but persistent
symptoms or suspicious ultrasound finding should be offered
hysteroscopy.

Out of 71 cases (table 4 ) which were subjected to endometrial sampling
by pipelle among 2 cases there was technical failure in nulliparous and
postmenopausal patients due pinpoint os or stenosed cervix and patients
subsequently subjected to hysteroscopy with biopsy under anaesthetia for
obtaining the sample. Technical failure was not observed with D \& C (34
cases) as well as hysteroscopy procedure (47 cases) for obtaining the
endometrial sample. The efficacy of Dilatation and Curettage as a
sampling tool has been questioned(21). Obtaining scant tissue and not
covering the entire endometrium are the drawbacks of D \& C. Hence
histopathological report needs to be interpreted keeping patients
history in mind to avoid under or overtreatment of patient. Pipelle
biopsy was more feasible to use for outpatient services while Dilatation
and curettage as well as Hysteroscopy with biopsy required of admission
of patient, use of anaesthetia and prolonged stay and hence these
methods were less feasible as compared to pipelle biopsy. Though
outpatient hysteroscopy with biopsy is possible with miniature 2.9mm
scope due non availability of same patients were subjected to procedure
under anaesthetia with 4.9 mm hysteroscope. In our study one case of
uterine perforation while performing dilatation and curettage which was
managed conservatively, however uterine perforation can occur with
during hysteroscopy or pipelle biopsy. Average incidence of uterine
perforation has been reported as 0.002-1.7\% during hysteroscopy(22).
Postmenopausal, pregnancy, peurperieum, Acutely anteverted and
retroverted uterus, or septic conditions are high risk factors for
peforation. Perforations are more likely to happen when junior staff is
performing the procedure. Experienced surgeon performing the procedure
especially in presence of high risk factors will not only reduce the
risk of perforation but can reduce the morbidity by early detection and
prompt management.

\textbf{Main Findings :} AUB is commonly in Age group 41-50 followed by
in the age group of 31-40. Higher parity (para 3 more) with AUB.
Functional endometrium with proliferative (35.4\%) and secretary changes
(16\%) were commonly seen in AUB patients. Endometrial polyp was noted
in 5.3\% cases and precursor lesions for malignancy such as endometrial
hyperplasia without atypia 12\% and with atypia 4.7\% and endometrial
cancer was reported in 3.3\% cases. In 7 (4.3\%) cases endometrial
sample obtained was inadequate for reporting and technical failure was
noted in 2 (0.66\%) cases, uterine perforation was noted in one case.
(0.33\%)

\textbf{Strength and Limitations :} Strength of study include
prospective data collection in systematic manner for enrolled cases
however study was limited to clinical and histopathological diagnoses
while inclusion of treatment and comparison of histopathology after
surgical management with the preoperative findings would have given more
information about sensitivity and specificity about the endometrial
sampling technique.

\textbf{Interpretation:} Study is conducted in tertiary teaching
hospital in gynaecology department and results of study may be
generalised to all age group patients similar population with complaints
suggestive of AUB however incidences of pathology may vary if the age
group of population post menopausal) differs or patients have high risk
factors such as patients attending oncological OPD

\textbf{Conclusion} : Pipelle biopsy is feasible as quick and outpatient
procedure however possibility of technical failure should be born in
mind. Cases of inadequate sample should be analysed carefully with
reference to background history, high risk factors, TVS imaging
(endometrial thickness, irregularity of endometrium) and need for repeat
sample and use of hysteroscopy to be considered case to case basis.This
will help in case management as well as avoid over treatment or under
treatment of underlying pathology.

\textbf{DECLARATIONS}

Funding: No Funding received

Conflict of interest: None to declare

Ethical approval: Yes Letter no. YCMH/PG/ETHICS/11/2019 dated 01/11/2019

\textbf{Acknowledgments}

Our sincere gratitude goes to all supervisors, data collectors, ANMs,
study participants with their family members for their cooperation and
support.

\textbf{Authors Contributions}

MA,IR, MS, ST, SR involved in all processes of this research work.. All
authors read and

approved the final manuscript. Conceived and designed the experiments:
MA, MS.

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  Bakkum-GamezJN,Wentzensen N. Association of endometrial cancer risk
  with postmenopausal bleeding in women: a systematic review and
  meta-analysis. JAMA Intern Med 2018;178:1210--22.
\item
  Clarke MA, Long BJ, Sherman ME, Lemens MA, Podratz KC, Hopkins MR,et
  al. A prospective clinical cohort study of women at increased risk for
  endometrial cancer. GynecolOncol 2020;156:169--77.
\item
  Williams AR, Brechin S, Porter AJ, Warner P, Critchley HO. Factors
  affecting adequacy of Pipelle and Tao Brush endometrial sampling. BJOG
  2008;115:1028--36.
\item
  Jones ER, O'Flynn H, Njoku K, Crosbie EJ. Detecting endometrial
  cancer. The Obstetrician \& Gynaecologist 2021;23:103--12.
  https://doi. org/10.1111/tog.12722
\item
  Van Doorn HC, Opmeer BC, Burger CW, Duk MJ, Kooi GS, Mol BWJ, et al.
  Inadequate office endometrial sample requires further evaluation in
  women with postmenopausal bleeding and abnormal ultrasound results.
  Int J GynaecolObstet 2007;99:100--4.
\item
  Bagaria M, Shields E, Bakkum-Gamez JN. Novel approaches to early
  detection of endometrial cancer. CurrOpinObstetGynecol 2017;29:40--6.
\item
  Bettocchi S, Ceci O, Vicino M, Marello F, Impedovo L, Selvaggi L.
  Diagnostic inadequacy of dilatation and curettage. FertilSteril.
  2001;75(4):803-5.
\item
  Royal College of Obstetrics and Gynaecology. Green-Top Guideline: Best
  Practice in Outpatient Hysteroscopy. London: RCOG; 2011.
\end{enumerate}

DATA COLLECTION TOOL\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Demographic data\strut
\end{minipage} & \begin{minipage}[b]{0.47\columnwidth}\raggedright\strut
Age , parity , socio economic status\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Clinical presentation\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Heavy and prolonged menstrual bleeding, heavy menstrual bleeding and
normal duration, intermenstrual bleeding, post menopausal bleeding, Any
other menstrual abnormality\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Method of endometrial Sampling and any technical difficulty\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Pipelle Biopsy, Dilatation and Curettage, Hysteroscopy along with
endometrial biopsy. Any technical difficulty and feasibility of
procedure noted.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Histopathology report\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
As obtained from pathology dept\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Flow chart

(Figure 1)

Tables:

Table 1 : Sociodemographic parameters of patients with AUB\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\textbf{Age group} & Frequency & Percentage\tabularnewline
\midrule
\endhead
21-30 years & 07 & 04.5\tabularnewline
31-40 years & 53 & 35.3\tabularnewline
41-50 years & 60 & 40.0\tabularnewline
51-60 years & 22 & 15.0\tabularnewline
61-70 years & 08 & 05.2\tabularnewline
\textbf{Parity} & \textbf{Parity} & \textbf{Parity}\tabularnewline
Zero & 4 & 02.7\tabularnewline
1 & 5 & 03.3\tabularnewline
2 & 45 & 30.0\tabularnewline
\textgreater{}3 & 96 & 64.0\tabularnewline
\textbf{Socioeconomic status} & \textbf{Socioeconomic status} &
\textbf{Socioeconomic status}\tabularnewline
Upper & 25 & 16.7\tabularnewline
Middle & 43 & 28.7\tabularnewline
Lower & 82 & 54.6\tabularnewline
\bottomrule
\end{longtable}

Table 2: Histopathological Features and Age group\selectlanguage{english}
\begin{longtable}[]{@{}lllllll@{}}
\toprule
Histological pattern of endometrium & Age (in years) & Age (in years) &
Age (in years) & Age (in years) & Age (in years) & Age (in
years)\tabularnewline
\midrule
\endhead
& 21-30 & 31-40 & 41-50 & 51-60 & 61-70 & Total, n (\%)\tabularnewline
Proliferative endometrium & 2 & 23 & 22 & 6 & 0 &
53(35.4\%)\tabularnewline
Disordered proliferative endometrium & 0 & 3 & 4 & 1 & 0 &
8(5.3\%)\tabularnewline
Secretory endometrium & 1 & 11 & 12 & 0 & 0 & 24(16\%)\tabularnewline
Endometrial hyperplasia without atypia & 0 & 4 & 7 & 6 & 1 &
18(12\%)\tabularnewline
Endometrial hyperplasia with atypia & 0 & 2 & 3 & 2 & 0 &
7(4.7\%)\tabularnewline
Atrophic endometrium & 0 & 0 & 0 & 2 (+1*) & 2 (+1*) & 4
(+2)(4\%)\tabularnewline
Endometrial carcinoma & 0 & 0 & 1 & 1 & 3 & 5(3.3\%)\tabularnewline
Chronic endometritis & 1 & 3 & 5 (+1*) & 2 & 0 & 11
(+1)(8\%)\tabularnewline
Pill endometrium & 2 & 2 & 1 & 0 & 0 & 5(3.3\%)\tabularnewline
Endometrial polyp & 1 & 3 & 2 & 1 & 1 & 8(5.3\%)\tabularnewline
Inadequate sample & 0 & 2 & 3 (-1) & 1(-1) & 1(-1) & 7(-3
)(4.7\%)\tabularnewline
Total & 7 & 53 & 60 & 22 & 8 & 150\tabularnewline
Percentage (\%) & 4.5 & 35.3 & 40.0 & 15 & 5.3 &\tabularnewline
\bottomrule
\end{longtable}

Figures in bracket indicate repeat procedure due to inadequate sample
(Refer to footnote in methodology flow chart)

Table 3: Age group and Clinical Presentation\selectlanguage{english}
\begin{longtable}[]{@{}llllllll@{}}
\toprule
Clinical presentation & Age (in years) & Age (in years) & Age (in years)
& Age (in years) & Age (in years) & Total & Percentage\tabularnewline
\midrule
\endhead
& 21-30 & 31-40 & 41-50 & 51-60 & 61-70 & &\tabularnewline
Heavy and prolonged menstrual bleeding & 0 & 13 & 8 & 2 & 0 & 23 &
15.3\tabularnewline
Heavy menstrual bleeding with normal duration & 6 & 36 & 45 & 9 & 0 & 96
& 64.0\tabularnewline
Intermenstrual bleeding & 1 & 4 & 3 & 0 & 0 & 8 & 05.4\tabularnewline
Postmenopausal bleeding & 0 & 0 & 4 & 11 & 8 & 23 & 15.3\tabularnewline
Total & 7 & 53 & 60 & 22 & 08 & 150 &\tabularnewline
Percentage(\%) & 4.5 & 35.4 & 40 & 14.7 & 5.4 & & 100\tabularnewline
\bottomrule
\end{longtable}

Table 4: Comparison of different methods Used for Endometrial Biopsy\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
Pipelle Biopsy\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
D \& c\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
Hscopy with biopsy\strut
\end{minipage} & \begin{minipage}[b]{0.17\columnwidth}\raggedright\strut
Total\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Total cases\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
69\#\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
34\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
45+2*+3**\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
150 (153**)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Technical failure\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
02\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
---\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
---\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
02 *\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Inadequate sample\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
04\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
03\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
---\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
07\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Repeat Sample By Hysteroscopy\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
01\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
02\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
---\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
03**\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Feasibility of procedure\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
More\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Less\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Less\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
--\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
Rare Complication Perforation\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
0\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
1\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\# out of 71 cases 2 cases of technical failure excluded

* 2cases of technical failure by biopsy underwent hysteroscopy with
biopsy (Ref footnote in flowchart)

** out of 7 inadequate sample 3 patients opted for repeat endometrial
sampling with hysteroscopy hence last column total shows 153 in bracket.
(Ref footnote in flowchart)

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