STUDY OF IN POSTMENOPAUSAL AGE

by s. C. SAXENA,* M.S. s. AGARWAL** and S. A.fiARWAL,*** M.B.B.S., M.Sc. (Path.)

Although knowledge of the cyclic mor­ and the traditional concept regarding this phologic changes seen in the endometrium needs to be reconsidered. It is with this during the reproductive period have been view that the present study is under­ on record for over 7'0 years, a pro­ taken. per description of the postmenopausal en­ dometrium is found only in recent litera­ Material and Mehods ture. This apparant lack of interest in the The present series consists of a study postmenopausal picture of endometrium of endometrium from 61 hysterectomised was probably based on the assumption specimen from postmenopausal women that it participates in the obvious gene­ who were admitted to Medical College ral involutionary changes in the genitalia. Hospital and Lady Elgin Hospital, Jabal­ The traditional concept of postmenopausal pur, from 1.1.'68 to 30.6.'70. Patients over endometrium is of mucosa which has be­ the age of 40 years and with a history come thin and atrophic with a few small of amenorrhoea for one year or more inactive glands set in a sparse fibrous were selected. Cases who had received stroma. Recent studies on postmenopausal hormone therapy or had uterine bleeding bleeding have further awakened interest were excluded. Hysterectomy was per­ in the study of endometrium and the find­ formed for indications other than men­ ing of CiySti~ glandular hyperpl)asia ~at strual irregularity. The and this age makes one think in terms of rela­ adnexa were also examined histological­ tion between the v.arious types of post­ ly and the histologic appearances of endo­ 1 menopausal endometrial patterns and metrium were correlated with the clinical malignancy of body . data in each case. The criteria of classi­ It is increasingly being realised that fication of endometrium were modified variations in the endometrial pattern in from McBride (1954) and the endome­ normal postmenopauasl women do occur trium was classified into following groups: atrophic, inactive cystic gland pattern, (From the Deptt. of Obst. & proliferative and hyperplastic. & Pathology, Medical College, Jabalpur, M.P.). *Reader in Obst. & Gynaecology. **R .M .O . in Obst. & Gynaecology . Results ***Prof. of Pathology, Medical College, Age: Maximum number of cases were J.abalpur, M.P. in age group of 46-50 yrs, (23 cases, t Paper presented at XVI Obst. & Gynaecolo­ gical Congress, New Delhi, March 1972. 37.7% ). The youngest patient was aged Receiv ed for publication on 4-4-74. 41 yrs., and the oldest was 80 iYTS. old. 808 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA

Duration of Menopause: Table 1 shows Type of Operation Performed: The the duration of menopause in these cases. type of operation perform~d in these patients is shown in Table III. TABLE 1 Duration of Menopause TABLE III I Duration of menopause (in years) No. of cases Type of Operation t 1-5 years 2,4 &--10 years 14 Type of operation No. of cases 11-15 years 11 Vaginal total hysterectomy 41 1&--20 years 8 Vaginal hysterectomy & More than 2·0 years 4 .Salpingoophorectomy 1 Abdominal pan-hysterectomy 16 Age at the Onset of Menopause: Age Abdominal total hysterectomy 1 at onset of menopause varied from 4;0 to Abdominal total hyst'erectomy 52 years. Maximum cases had their with unilateral salpingectomy 1 Abdominal total hysterectomy menopause at the age of 4S yrs. with ovariotomy 1 T'ype of onset of menopause: In 50 cases the menopause was abrupt, in 10 it was preceded by hypomenorrhoea, and in Type of Endometrium.: In 4 patients 1 by oligomenorrhoea. endometrial biopsy preceded hysterecto­ Previous menstrual history: Menstrual my and in 1 dilatation and curettage pre- cycles were regular i:Q 5·5 cases. 3 patients . ceded hysterectomy. Type of endo­ had oligomenorrhoea, 2 had previous his­ metrium obtained in these cases was tory of menorrhagia, and 1 had hypo­ classified according to modified McBride's menorrhoea. criteria, and is shown in Table IX. We had Parity: Three !Jatients were nullipar­ no case of hyperplastic and secretery ous, 35, had between 1 to 5 children, and endometrium. 23 had more than 5 children. Complaints.: The commonest symptom TABLE IV was something coming out per vagina, Type of Endometrium the next common was white discharge per Type of endometrium No. of cases vagina. Clinical Diagnosis: 44 patients had Atrophic 17 (27.9%) genital prolapse. Table II shows the Inactive cystic glandular patt'Endometrial polyp 5 (8.2%) TABLE II Adenocarcinoma of body uterus 2 (3.3%) Clinical Diagnosis .

Clinical diagnosis No. of cases Associated lesions: The associated lesions found in these cases are shown in · Prolapse uterus 44 Ovarian tumour 6 Table V. The type of ovarian tumours Chronic 4 found in these cases were simple serous Carcinoma of body uterus 3 cyst-3' (2 unilateral and 1 bilateral), Fibromyoma uterus 2 dermoid cyst-2 (1 unilateral and 1 bila­ Prolapse uterus with 1 teral) and bilateral solid adenocarci­ 1 noma-!. STUDY OF ENDOMETRIUM IN POSTMENOPAUSAL AGE 809

TABLE V atrophic endometrium had previous nor­ Associated Lesions mal menstrual history and all except one had children. 90. 3% of pa,tients with Associated lesions No. of cases inactive oystic glandular pattern had nor­ 10 mal menstrual history and all but one Ovarian tumour 6 had children. Leiomyoma uterus 5 Follicular cyst of 3 There were six cases with proliferative Medial calcification of blood endometrium in our series. They were vessels 25 bdow 55 years of age. This type of endo­ metrium was found within first 5 years CUnico-pathological Correlation (Table of menopause. This is due to the oestro­ VI) genic effect on the endometrium during The endometrial pattern was studied earlier years of menopause, the source of in the light of .age of patients, duration of oestrogen being either from cortical menopause, age at menopause, type of stromal hyperplasia of ovary (Smith, onset of menopause, previous menstrual 1941), adrenal (Smith and Emerson, history and parity of patient. With the 1954), or anterior pituitary (Novak, exception of duration of menopause, no 1956). Novak suggested that pituitary significant correlation was noticed bet­ may assume oestrogenic functions after ween the endometrial patterns and any menopause. of the above factors. There were five cases of endometrial It was observed that the incidence of pol.yps, all being fow.1d in patients aged atrophic endometrium increased upto 10 51 to 60 years. The incidence was parallel years postmenopausal and thereafter to the duration of menopause. They were showed a remarkable progressive fall, found with equal frequency in multipa­ while the inactive oystic gland pattern rous and nulliparous women. The men­ showed a parallel increase as the duration strual history and type of onset of meno­ of menopause increased. pause had no bearing on their occurrence. The progressive increase in the inci­ In all 5 cases the uninvolved endometrium dence of the cystic pattern with advanc­ was examined and showed cystic gland­ ing years after menopause and a corre­ ular pattern similar to· polyp, thus sup­ sponding decrease in the incidence of porting Speert's view (1949) regarding atrophic endometrium suggested that their pathogenesis. Novak ·and Richard­ more and more simple atrophic endo­ son (1941) thought that they represented metria became cystic as the number of previous hyperplasia at the time of meno­ years postmenopausal increased. This-ex· pause in which retrogression had occur­ plains the pathogenesis of cystic gland ed. But the menstrual history of these pattern due to obstruction of the ducts cases does not support this view. of glands, with slow progressive disten­ Endometrial carcinoma w:as found in sion of glands (Speert, 1949; Parke, et al., two patients aged 50 and 54 years, the 1956). Our findings do not support the duration of menopause being 3 and 5 work of Novak and Richardson (1941) .years, respectively. One was a nullipara that the cystic glandular pattern is initiat­ and the other had only one child. Their ed by anovulatory climacteric menstrual previous menstrual history was noma] cycles. In this study all patients with and the onset of menopause was sudden. 810 JOURNAL OF OBSTETRICS AND GYNAECOLOGY OF INDIA

The late menopause hypertension and dia­ 101re not involved, typical examples are betes were not present in any of them. found in uteri and ovari~s in old persons. The uninvolved endometrium was exam­ Conclus,ion ined in these cases and showed inactive cystic and proliferative pattern, respec­ During e,arly menopause proliferative tively, thus supporting the view of Mc­ endometria become atrophic and later Bride (1955) and Butler, et al., (1963) more and more atrophic endometria be­ that the u;ninvolved endometrium may come cystic as number of years postme­ show any of the pattern found in the nopausal increase. normal postmenopausal ..women and there Spontaneous is is no significantly high incidence of endo­ ~n abnormal finding in postmenopausal metrial hyperplasia associated with endo­ women. metrial carcinoma. In normal' postmenopausal women there ~s no appreciable amount of oestrogen, Associated lesions ~I though they may produce small amount~ Adenomyosis was found in 10 out of 61 for several years ,after cessation of men­ cases, thus giving an incidence of 16.4% . struation, but the quantity is far below It did not show ailiY constant relation the levels associated with proliferation of with the .age of patient or duration of genital tissues. menopause. In 6 of the 10 cases the pat­ tern of ectopic foci of endometrium cor­ Acknowledgeme~t responded with the surface endometrium. We are thankful to Dr. (miss) K. Gupta, The onset of menopause was sudden in Prof. of Obst. & Gynaecology, and Dr. M. all cases and all were parous with nor­ P. Misra, Dean, Medical College Jabal­ mal menstrual history. The lesion was pur, for their kind permission to publish symptomless. this serie~. The incidence of leiomyoma was 8.2% References pnd it did not show ,any correlation with 1. Butler, H . K., Doclerty, M. B. and Randall, duration of menopause or !eindometr'ial L. M.: Am. J. Obst. & Gynec., 86: 433, pattern. Four of these patients were 1963. parous. 2 . McBride, J. M.: J. Obst. & Gynec. Brit. There were 6 cases of ovarian tumours, Emp., 61: 691, 1954. giving an incidence of 9.83%. Age of the 3. McBride, J. M. : In Modern trends in Obstetrics and Gynae!i!ology, ed. Kenneth patients varied from 50 to 65 years and Bowes 2nd. ed., 1955, p. 335-45, Butter­ they were 3 to 16 years postmenopausal. worth & Co. London. The type of tumours were, cystadenoma-1, 4. Novak, E. and Richardson, E . H.: Am. J . pseudonucinous cystadenoma-1, der­ Obst. & Gynec., 42: 564, 1941 . moid-3, and adenocarcinoma ovary-1. 5. Novak, E .: Am. J. Obst. & Gynec., 71: 1312', 1956 . Medial calcification of vessels or 6. Parks, R. D., Scheerer, P. P . and Greene, Monckeberg's sclerosis was found in 25 R . R.: Surg. Gynec. & Obst., 106: 413, oases ( 40.9% ). The frequenoy increased 1958 . with age of the patients and duration of 7. Smith, G. V.: New. Eng. J. Med., 225: menopause. This is a type of arterioscle­ 608, 1941. 8. Smith, G. V. and Emerson, K . Jr. : Proc. rosis which is considered a senile dege­ Soc. Exper. Biol. Med., 85: 264, 1954. nerative change with no correlation to 9. Speert, H.: Surg. Gynec. & Obst ., 89: hypertension. Although visceral arteries 551, 1949.