The female genital tract consists of the uterine corpus and cervix and the uterine corpus consists of endometrium and myometrium [1]. Uterus is a vital reproductive organ and is associated with various benign and malignant pathologies [2]. Surgical removal of uterus is known as hysterectomy and is the most commonly performed major surgery in all gynecological settings. It is the definitive treatment for various benign and malignant conditions of female reproductive tract e.g., fibroid, adenomyosis, dysfunctional uterine bleedings, uterine prolapse, post-partum hemorrhage and malignant lesions of uterus, ovaries and cervix [3]. Charles Clay was the first to perform total hysterectomy in 1929 in England [4]. It is the second most commonly performed surgery after cesarean section in obstetrics and gynecological settings [5]. It can be performed either through abdominal or vaginal route or with the help of minimal invasive surgical procedures like laparoscope. There is diagnostic and therapeutic significance of performing histopathological examinations of hysterectomy specimens or any surgically excised specimens [6]. Hence, this study was conducted to study the clinical and histopathological patterns of changes in the uterus and cervix of the hysterectomy specimens. The aim of the study was to evaluate clinical indications for hysterectomy and the histopathological features of varied lesions of uterus and cervix and their distribution in relation to age at a tertiary care hospital.

Although hysterectomy is ultimate treatment of many pathologies but advancement in imaging technique for diagnosis and advent of novel treatment like endometrial ablation, uterine artery embolization, hysteroscopic myomectomy, MRI focused ultrasound fibroid ablation, radiofrequency ablation and hormonal IUD (mirena), many hysterectomies can be prevented. 

This is a retrospective observational study conducted in Department of Obstetrics & Gynecology, Rama Medical College, Hospital & Research Center from July 2019 to March 2020. A total 250 patients were included in the study with age range from 21-70 years. All the procedures of hysterectomy done for benign indications in the department during this study period were included. Clinical data was collected about age, reproductive status, history, indication for hysterectomy; type of surgical intervention was recorded from patient’s record file. Histopathological examination reports were analyzed and compared with clinical diagnosis. 

The specimens were grossed by the pathologists. All the specimens were fixed in 10% formalin and tissue sections were taken for processing and paraffin block preparation. The paraffin blocks were sectioned and stained by H & E stain. Microscopical examination was performed for histopathological diagnosis.

The study included 250 patients who underwent hysterectomy during the study period.  According to Table 1, the number of patients who underwent hysterectomy was maximum in the age group of 41-50 years (54.4%), followed by 31-40 years (26.8%), 51-60 years (16.4%), >60 years (2%) and the least were <30 years (0.4%).  That is also shown in a pie chart in figure 1.

The most common indication for hysterectomy was fibroid uterus (34.4%), followed by prolapse uterus (23.2%), dysfunctional uterine bleeding (19.6%), adenomyosis (9.6%), endometrial polyp (6.4%), abdominal mass (6.4%) and others (0.4%). The indication for the only hysterectomy done in age group <30 years was obstetric hysterectomy due postpartum hemorrhage with placenta accreta. The most common indications in other age groups were fibroid uterus in 31-40 years (40.29%) and in 41-50 years (37.5%), while prolapse uterus in 51-60 years (56.09%) and in age >60 years (60%).

Figure 1: Age distribution of patients

The most common histopathological finding in the endometrium was proliferative endometrium (40.4%), followed by chronic endometritis (21.2%), endometrial hyperplasia (16%), endometrial polyp (6%), atrophic endometrium (9.2%), secretory endometrium (6.8%) and others (0.4%). The most common histopathological finding in the endometrium of the in-age group <30 years was decidual changes and chorionic villi implanted on the surface of myometrium with no intervening decidua. The most common histopathological finding in the endometrium in other age groups was proliferative endometrium in 31-40 years (47.76%) and in 41-50 years (47.05%) while atrophic endometrium in 51-60 years (39.02%) and in age >60 years (80%). 

The most common histopathological finding in the myometrium was normal myometrium (50.4%), followed by leiomyoma (37.6%) and adenomyosis (12%). The most common histopathological finding in the myometrium was normal myometrium in age groups 41-50 years (47.05%), 51-60 years (73.17%) and in age >60 years (80%) while the most common histopathological finding in the myometrium was leiomyoma in age group of 31-40 years (44.78%).

Table 1: Age distribution of patients.

Table 2: Indications for hysterectomy.

Figure 2: Indications for hysterectomy

Table 3: Histopathological Findings

Figure 3: Histopathological Findings

The most common histopathological finding in the cervix was chronic endocervicitis (72.4%), followed by chronic cervicitis with squamous metaplasia (6%), endocervical polyp (0.4%) and normal cervix (20.8%). The cervix was absent in age group <30 years as it was a supracervical hysterectomy. The most common histopathological finding in the cervix was chronic endocervicitis in age groups 31-40 years (77.6%), 41-50 years (78.6%), 51-60 years (48.78%) and >60(40%).

Hysterectomy is the most commonly performed gynecological procedure worldwide and its number may vary according to region, community and social factors. 

The most common age group undergoing hysterectomy was 41-50 years with the mean age of 44.28 yrs. The results are similar to Siwatch S et al. [7], Zaid et al. [8] and Sreedhar V et al. [9].

In our study, the most common indication for hysterectomy was fibroid uterus, which is similar to the study done by Verma D¹⁰ et al and Jandial R [11] et al. In a study conducted by Siwatch S et al. [7]most common indication for age group<30 years was postpartum hemorrhage, 30-45 years was fibroid, 45-60 years was fibroid and >60 years was prolapsing uterus. All these results are similar to our study. On histopathological examination, most common endometrial finding was proliferative endometrium. This result is similar to study done by Jindal R et al. [11] and Verma D et al. [10]. The most common myometrial finding was leiomyoma. This result was similar to study by Jindal R et al. [11] and Sreedhar V et al. [9]. The most common histopathological finding in cervix was chronic cervicitis, similar findings were observed by Jindal R et al. [11] and Zaid et al. [8].

Hysterectomy is the most commonly performed surgery for gynecological indications. Histopathological examination of all the surgically excised specimens should be done regardless of its benign indication as this helps to correlate with the pre-operative clinical diagnosis and provides the final diagnosis.

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