PREVALENCE OF SUBCLINICAL HYPOTHYROIDISM IN REPRODUCTIVE AGE GROUP WOMEN WITH ABNORMAL UTERINE BLEEDING

Abnormal uterine bleeding is aberrant menstruation characterised by changes in cycle length or duration of flow or both. AUB accounts for 10% of the gynaecology related complaints. Thyroid dysfunction is marked by large number of menstrual aberrations. Both hypothyroidism as well as hyperthyroidism is associated with a variety of changes in reproductive function including delayed onset of puberty, anovulatory cycles and abnormally high foetal wastage. Clinical experiences show increased menstrual flow to be the most common reproductive system manifestation of hypothyroidism. Although the occurrence of menstrual disturbances in hypothyroid woman has been documented, the number of hypothyroid patients originally requiring treatment for menorrhagia has not been carefully elucidated. Moreover majority of the cases has subclinical hypothyroidism and easily pass unrecognized and is now increasingly recognised as a risk factor for menstrual problems, cardiovascular diseases and abnormal mental development in foetus. Danese MD et al recommend hypothyroidism is frequent enough to warrant consideration in women with menstrual dysfunction 4. Hence this study is to evaluate the thyroid function in patients having abnormal menstrual bleeding in reproductive age groups which will be justifiable and will help in further management of AUB. AIM AND OBJECTIVES: This study aimed at analysing the cross sectional population, 1. To determine the association between menstrual irregularities and hyroid function. 2. To analyse the pattern of menstrual dysfunction among women with thyroid disorder. 3. To estimate the prevalence of subclinical thyroid disease among reproductive age group women with abnormal uterine bleeding. 4. To analyse the possible predictors which in a given patient helps in early testing of thyroid function to diagnose them in the subclinical stage. MATERIALS AND METHODS: Study Design: Analytical study. Study Period: August 2008 to September 2009. Sample Population: The study population consisted of 250 women attending the gynaecology outpatient clinic, Institute of social obstetrics & Govt.kasturba Gandhi hospital, with the following complaints in the age group of 18 to45 years, 1. Oligomenorrhea – where the cycle length lasts longer than 35 days 2. Hypomenorrhea – lesser bleeding which lasts for 2 days or less. 3. Menorrhagia- cyclical bleeding at normal intervals which is excessive in amount (>60 ml/ changes 6 pads per day/associated with clots) 4. Polymenorrhea- cyclical bleeding which is normal in amount, but occurs in intervals of <21 days. 5. Amenorrhea – absence of menstruation. The patients were selected on the basis of Inclusion and Exclusion criteria as follows: Inclusion criteria: • age group 18 to 45 years, • with any of menstrual disturbances described above, • no demonstrable pelvic pathology, • not an IUCD user, • not on thyroxine replacement therapy, • with symptoms of thyroid dysfunction. Symptoms of hyperthyroidism: • Weight loss ( >10 kg in 3 months or subjective weight loss), • Diarrhoea, • Heat intolerance, • Tremors, • Eye changes, • Palpitations. Symptoms of hypothyroidism: • Change of voice, • Weight gain, • Constipation, • Dryness of skin, • Cold intolerance, • Fatigue/lethargy, • Sleep disturbances. Exclusion criteria: • Women not in age group 45. • Presence of palpable pelvic pathology. • With overt hypothyroidism on thyroxine. • known thyroid disorders. • On drugs like aspirin, heparin, antithyroid agents, steroids, amiodarone and lithium. SUMMARY: The study was undertaken in 250 women with abnormal uterine bleeding in reproductive age group presenting to our tertiary referral hospital. It was done to assess the prevalence and the possibility of a correlation between subclinical thyroid disease and AUB. A detailed history elicited as per proforma enclosed and anthropometric measurements were taken and a thorough general and systemic examination done. Thyroid function analysis was done in each of these women and the results interpreted. The mean age of women in the study group was 36 years. There was significant correlation between increasing age and thyroid dysfunction. A significant correlation with reproductive failure and thyroid abnormalities was cited in the study. Nulliparous women presented earlier with infertility as their primary complaint and statistical significance was also detected in women with reproductive dysfunction. Women symptomatic of thyroid abnormalities had more incidence of thyroid dysfunction. The symptoms with which they presented were more predictive of the disease. There was also significance between duration of symptoms and presence of thyroid abnormalities. BMI was significantly abnormal more so in patients with hypothyroidism and menorrhagia. In oligomenorrhic women, thyrotoxicosis was more common with incidence of 94.5% and menorrhagia was observed in 59.2% of hypothyroid women. Women detected to have subclinical hypothyroidism also presented with menorrhagia (70%) and amenorrhea (25%).Frequency of polymenorrhea and Hypomenorrhea in the study group was relatively low due to the increased incidence of pelvic pathology associated with polymenorrhea. Among 4 women in the study group with Hypomenorrhea and with Polymenorrhea, none had thyroid abnormalities. In the study group, the overall prevalence of thyroid abnormalities was 30.8%.Among them 15.6% had hypothyroidism and 7.2% had hyperthyroidism and 8% had subclinical hypothyroidism. Prevalence: Hypothyroidism – 15.6%, Hyperthyroidism –7.2%, Subclinical hypothyroidism –8%. The prevalence of preclinical hypothyroidism was 8%. These women had abnormal bleeding of a lesser duration (4-6months). 13 out of 20 women with subclinical hypothyroidism had symptoms attributable to thyroid dysfunction. Detection of this group of women is considered a major benefit of testing because, supplementation of thyroxine to this group of women will revert back their symptoms and checks progression of their endocrinological disease. All of them had their TSH values between 5 and 8 mIU/L. Women detected to have overt hypo/hyperthyroidism had longer duration of symptoms and they are now actually detected at a farther end in the spectrum of disease after acquiring morbidity in the form of affliction of their quality of life due to the abnormal bleeding and by the onset of anaemia. Hence testing for thyroid function is advocated early in the course of the disease. CONCLUSION: Our study highlights the following, • There is significant association between thyroid disorders and abnormal uterine bleeding. • It brings into focus the increased incidence of hypothyroidism among women with menorrhagia and amenorrhea. And increased incidence of hyperthyroidism in women with oligomenorrhea. • The prevalence of subclinical hypothyroidism in the study group was 8%. • It is suggested that women with early onset menorrhagia and oligomenorrhea with or without symptoms & signs attributable to thyroid dysfunction should be offered thyroid function testing to detect them in the subclinical stage. • Early detection by selective screening and specific pharmacotherapy for subclinical thyroid disease early in the course of the disease will prove to be a superior alternative to surgical treatments like hysterectomy.