РИЗИК ФАКТОРИ ЗА ПАТОЛОШКИ ПРОМЕНИ НА ЕНДОМЕТРИУМОТ И НИВНА АСОЦИЈАЦИЈА СО ЕНДОКРИНИТЕ НАРУШУВАЊА, МЕТАБОЛИЧЕН СИНДРОМ И ОСТЕОПОРОЗА

Abstract

Introduction: The International Federation of Gynecology and Obstetrics (FIGO) has defined a classification system for abnormal uterine bleeding, called PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory disfunction, endometrial dysfunction, iatrogenic causes, unclassified reasons). Dysfunctional uterine bleeding is often during the menopausal transition as a result of hormonal changes during this period. In postmenopause there should be no uterine bleeding, the thickness of the endometrium should be less than 5 mm, and if it is above 5mm, the presence of polyp, hyperplasia or cancer is possible. Postmenopausal bleeding occurs in approximately 90% of patients with endometrial cancer, but only 9% of women with postmenopausal bleeding have endometrial cancer. Endometrial hyperplasia and endometrial polyps are associated with development of endometrial cancer and therefore these changes can be called premalignant. Atypical endometrial hyperplasia is a preneoplastic condition that precedes the most common malignant tumor of the uterus, endometrioid adenocarcinoma. Risk factors such as obesity, chronic anovulation, nulliparousness, late menopause, unopposed estrogen (without progesterone), hypertension and diabetes, all increase the risk of endometrial hyperplasia and endometrial cancer. Objectives: To determine the histopathological changes of the endometrium that occur during the period of perimenopause and postmenopause; to determine their association with the presence of diabetes, hypertension, metabolic syndrome, thyroid disorders, glycosylated hemoglobin levels, Vitamin D levels, and to determine the dynamics of bone markers in the peri and postmenopausal period. Material and methods: The study was a prospective observational cohort, involving a total of 160 respondents. The study group consisted of 120 patients who underwent fractionated explorative curettage due to a medical indication (abnormal bleeding or ultrasound-diagnosed endometrial abnormality). They were divided into two subgroups: perimenopausal and postmenopausal. The control group consisted of 40 healthy women without fractionated explorative curettage. Anamnestic data were taken from all respondents. Blood pressure, body weight, height, waist circumference, anteroposterior diameter of the uterus and endometrial thickness were measured. This laboratory analyses were performed: Glycemia, glycosylated hemoglobin (HbA1c), Hormonal Status - FSH, LH, Estradiol, Serum insulin, Thyroxine (fT4), Parathormon (PTH), lipid status, ionized calcium, serum iron, bone markers (Osteocalcin, β-Cross Laps), vitamin D (25-Hydroxyvitamin D). Results: The most common pathological change of the endometrium was an endometrial polyp, and it was present in 45% of the respondents. Endometrial hyperplasia without atypia was present in 23.3% of perimenopausal and 15% of postmenopausal women. Endometrial adenocarcinoma was present in 3% of perimenopausal and in 5% of postmenopausal women. Patients with endometrial pathology were older than healthy women and had significantly more frequently: greater endometrial thickness, higher blood pressure, body mass index, waist circumference, glycemia, triglycerides, serum insulin and metabolic syndrome. Vitamin D levels were lower in women with explorative curettage than in healthy women, and significantly lower in those with organic changes compared with those with functional pathological changes of the endometrium. Women with organic changes of the endometrium, compared with those with functional changes, had significantly higher: body mass index, waist circumference and endometrial thickness. Perimenopausal women, compared with those in postmenopause, had significantly longer duration and intensity of bleeding, larger anteroposterior diameter of the uterus and thickness of the endometrium. Postmenopausal women had higher body mass index, waist circumference, blood pressure, glucose, HbA1c, serum iron and bone markers (osteocalcin and β Cross Laps), than those in perimenopause. Postmenopausal duration in patients with explorative curettage was significantly positively correlated with serum values of bone markers osteocalcin and β Cross Laps. Conclusions: Fractionated explorative curettage is an effective method for timely and effective diagnosis of pathological changes of the endometrium in women with abnormal uterine bleeding or ultrasound-diagnosed abnormal endometrial findings. In the period of perimenopause and postmenopause, there are changes in the genital organs, but also there are internal disorders (obesity, metabolic syndrome, diabetes, thyroid disorders, cardiovascular disease, osteoporosis), which should be timely prevented, diagnosed and treated. According to our study, some of them are related to the occurrence of changes in the endometrium and the need for fractionated explorative curettage for timely diagnosis, especially of premalignant and malignant changes.