Endometrial hysteroscopic and histopathological characteristics in infertile women with polycystic ovary syndrome versus unexplained infertility: a comparative cross-sectional study
DOI:
https://doi.org/10.18203/2320-1770.ijrcog20260186Keywords:
PCOS, Unexplained Infertility, Hysteroscopy, Histopathology, Endometrium, Comparative studyAbstract
Background: Polycystic ovary syndrome (PCOS) affects 5-15% of reproductive-aged women and accounts for nearly 90–95% of anovulatory infertility. Beyond ovulatory dysfunction, PCOS is associated with insulin resistance, obesity, chronic inflammation, and increased metabolic and atherogenic risk. These factors predispose to endometrial dysfunction, hyperplasia, and carcinoma, contributing to implantation failure and miscarriage. Hence, evaluation of endometrial abnormalities in PCOS is essential for comprehensive infertility management. Aim of the study was to compare hysteroscopy and histopathological endometrial findings in infertile women with PCOS and unexplained infertility (UI), and to correlate clinical and hormonal profiles between the groups.
Methods: A cross-sectional analytical study conducted over two years in a tertiary care obstetrics and gynecology center. A total of 165 infertile women were included (85 with PCOS, 80 with UI). After informed consent, detailed clinical evaluation was performed. Hormonal profile and pelvic ultrasound were done on day 2 of menstruation. Diagnostic laparoscopy, hysteroscopy, laparoscopic ovarian cautery (where indicated), and endometrial biopsy were performed. Clinical, hormonal, hysteroscopic, and histopathological findings were compared between both the groups. Statistical analysis was done using statistical package for the social sciences (SPSS) v26; p<0.05 was considered significant.
Results: Women with PCOS were younger and had significantly higher BMI and longer duration of infertility than UI (p<0.05). Day-2 endometrial thickness was significantly higher in PCOS (7.5±1.8 mm versus 5.6±1.7 mm). Hysteroscopy was normal in 82% of PCOS and 70% of UI women. Micropolyps and hyperemic endometrium were more frequent in PCOS, while polyps, adhesions, and uterine anomalies predominated in UI. Histologically, PCOS showed higher rates of proliferative and disordered proliferative endometrium, with endometrial hyperplasia detected in 8.4%, compared to none in UI.
Conclusions: Normal hysteroscopic findings do not reliably indicate a normal endometrial milieu in PCOS. Routine endometrial biopsy alongside hysteroscopy may uncover subclinical pathology and improve infertility management in this population.
Metrics
References
Ajmal N, Khan SZ, Shaikh R. Polycystic ovary syndrome (PCOS) and genetic predisposition: A review article. Eur J Obstet Gynecol Reprod Biol X. 2019;3:100060. DOI: https://doi.org/10.1016/j.eurox.2019.100060
Kayali S, Chitra T, Kamalanathan S, Nandeesha H. Assessment of metabolic syndrome in infertile women with polycystic ovary syndrome in a rural population of South India: A cross-sectional study. Int J Reprod Biomed. 2022;20(3):161-8. DOI: https://doi.org/10.18502/ijrm.v20i3.10707
Chandrasekaran S, Sagili H. Metabolic syndrome in women with polycystic ovary syndrome. Obstet Gynaecol. 2018;20(4):245-52. DOI: https://doi.org/10.1111/tog.12519
Navaratnarajah R, Pillay O, Hardiman P. Polycystic Ovary Syndrome and Endometrial Cancer. Semin Reprod Med. 2008;26(1):62-71. DOI: https://doi.org/10.1055/s-2007-992926
Gadducci A, Gargini A, Palla E, Fanucchi A, Genazzani AR. Polycystic ovary syndrome and gynecological cancers: Is there a link? Gynecol Endocrinol. 2005;20(4):200-8. DOI: https://doi.org/10.1080/09513590400021201
Al-Jefout M, Al-Qtaitat A, Al-Rahal D, Al-Nawaiseh N, Rawashdeh F. Endometrial Thickness as a Predictor of Endometrial Hyperplasia in Infertile Patients with Polycystic Ovary Syndrome. Open J Obstet Gynecol. 2018;08(02):92-104. DOI: https://doi.org/10.4236/ojog.2018.82012
Ramezanali F, Khalili G, Arabipoor A, Bagheri Lankarani N, Moini A. Relationships between Serum Luteinizing Hormone Level, Endometrial Thickness and Body Mass Index in Polycystic Ovary Syndrome Patients with and without Endometrial Hyperplasia. Int J Fertil Steril. 2016;10(1):36-41.
Indhavivadhana S, Rattanachaiyanont M, Wongwananuruk T, Techatraisak K, Rayasawath N, Dangrat C. Endometrial neoplasia in reproductive-aged Thai women with polycystic ovary syndrome. Int J Gynecol Obstet. 2018;142(2):170-5. DOI: https://doi.org/10.1002/ijgo.12522
Amooee S, Akbarzadeh-Jahromi M, Motavas M, Zarei F. Comparing endometrial hysteroscopic and histological findings of infertile women with polycystic ovary syndrome and unexplained infertility: A cross-sectional study. Int J Reprod Biomed IJRM. 2020;33-40. DOI: https://doi.org/10.18502/ijrm.v18i1.6195
Iatrakis G, Zervoudis S, Saviolakis A, Troulos M, Antoniou E, Sarantaki. A Women younger than 50 years with endometrial cancer. Eur J Gynaecol Oncol. 2006;27(4):399-400.
Balaji S, Amadi C, Prasad S, Bala Kasav J, Upadhyay V, Singh AK. Urban rural comparisons of polycystic ovary syndrome burden among adolescent girls in a hospital setting in India. BioMed Res Int. 2015;2015:158951. DOI: https://doi.org/10.1155/2015/158951
Joshi B, Mukherjee S, Patil A, Purandare A, Chauhan S, Vaidya R. A cross- sectional study of polycystic ovarian syndrome among adolescent and young girls in Mumbai, India. Indian J Endocrinol Metab. 2014;18(3):317-24. DOI: https://doi.org/10.4103/2230-8210.131162
Sam S, Scoccia B, Yalamanchi S, Mazzone T. Metabolic dysfunction in obese Hispanic women with polycystic ovary syndrome. Human Reprod. 2015;30:1358-64. DOI: https://doi.org/10.1093/humrep/dev073
Barber TM, Hanson P, Weickert MO, Franks S. Obesity and Polycystic Ovary Syndrome: Implications for Pathogenesis and Novel Management Strategies. Clin Med Insights Reprod Health. 2019;13:1179558119874042. DOI: https://doi.org/10.1177/1179558119874042
Harris HR, Titus LJ, Cramer DW, Terry KL. Long and irregular menstrual cycles, polycystic ovary syndrome, and ovarian cancer risk in a population-based case- control study. Int J Cancer. 2017;140(2):285-91. DOI: https://doi.org/10.1002/ijc.30441
Saxena P, Prakash A, Nigam A, Mishra A. Polycystic ovary syndrome: Is obesity a sine qua non? A clinical, hormonal, and metabolic assessment in relation to body mass index. Indian J Endocrinol Metab. 2012;16(6):996-9. DOI: https://doi.org/10.4103/2230-8210.103011
Ashraf S, Nabi M, Rasool S ul A, Rashid F, Amin S. Hyperandrogenism in polycystic ovarian syndrome and role of CYP gene variants: a review. Egypt J Med Hum Genet. 2019;20(1):25. DOI: https://doi.org/10.1186/s43042-019-0031-4
Shi Y, Cui Y, Sun X, Ma G, Ma Z, Gao Q, et al. Hypertension in women with polycystic ovary syndrome: prevalence and associated cardiovascular risk factors. Eur J Obstet Gynecol Reprod Biol. 2014;173:66-70. DOI: https://doi.org/10.1016/j.ejogrb.2013.11.011
Ben Salem Hachmi L, Ben Salem Hachmi S, Bouzid C, Younsi N, Smida H, Bouguerra R. Hypertension in polycystic ovary syndrome. Arch Mal Coeur Vaiss. 2006;99(7-8):687-90.
Özkan S, Yılmaz ÖÇ, Yavuz B. Increased masked hypertension prevalence in patients with polycystic ovary syndrome (PCOS). Clin Exp Hypertens. 2020;42(8):681- 4. DOI: https://doi.org/10.1080/10641963.2020.1772815
Hepşen S, Karaköse M, Çakal E, Öztekin S, Ünsal İ, Akhanlı P, et al. The assessment of thyroid autoantibody levels in euthyroid patients with polycystic ovary syndrome. J Turk Ger Gynecol Assoc. 2018;19(4):215-9. DOI: https://doi.org/10.4274/jtgga.2018.0001
Kumar AN, Naidu JN, Satyanarayana U, Ramalingam K, Anitha M. Metabolic and Endocrine Characteristics of Indian Women with Polycystic Ovary Syndrome. Int J Fertil Steril. 2016;10(1):22-8.
Hafed NN. Hormones FSH, LH Relationship Polycystic Ovaries Syndrome (PCOS) and Delay Pregnancy in the Woman. Indian J Forensic Med Toxicol. 2019;13(4):1324. DOI: https://doi.org/10.5958/0973-9130.2019.00485.7
Panchal S, Nagori C. Correlation of Ovarian and Stromal Volumes to Fasting and Postprandial Insulin Levels in Polycystic Ovarian Syndrome Patients. Int J Infertil Fetal Med. 2014;5:12-4. DOI: https://doi.org/10.5005/jp-journals-10016-1073
Cheung AP. Ultrasound and menstrual history in predicting endometrial hyperplasia in polycystic ovary syndrome. Obstet Gynecol. 2001;98(2):325-31. DOI: https://doi.org/10.1016/S0029-7844(01)01432-6
McCormick BA, Wilburn RD, Thomas MA, Williams DB, Maxwell R, Aubuchon M. Endometrial thickness predicts endometrial hyperplasia in patients with polycystic ovary syndrome. Fertil Steril. 2011;95(8):2625-7. DOI: https://doi.org/10.1016/j.fertnstert.2011.04.022
Lee TT, Rausch ME. Polycystic Ovarian Syndrome: Role of Imaging in Diagnosis. RadioGraphics. 2012;32(6):1643-57. DOI: https://doi.org/10.1148/rg.326125503
Rani K, Durga Mounika K, Singhal S. Correlation of Hysteroscopy With Histopathological Findings of the Endometrium in Women With Polycystic Ovary Syndrome (PCOS)-Related Infertility. Cureus. 2024;16(4):576-86. DOI: https://doi.org/10.7759/cureus.57666
Garuti G, Sambruni I, Colonnelli M, Luerti M. Accuracy of Hysteroscopy in Predicting Histopathology of Endometrium in 1500 Women. J Minimally Invasive Gynecol. 2001;8(2):207-13. DOI: https://doi.org/10.1016/S1074-3804(05)60579-8
Shokeir TA, Shalan HM, El-Shafei MM. Significance of endometrial polyps detected hysteroscopically in eumenorrheic infertile women. J Obstet Gynaecol Res. 2004;30(2):84-9. DOI: https://doi.org/10.1111/j.1447-0756.2003.00163.x
Kobayashi Y, Tsuji K, Nakamura Kl. Evaluation of safety and diagnostic performance for flexible hysteroscopy in 1591 outpatient cases. Jpn J Clin Oncol. 2020;50(10):1157-61. DOI: https://doi.org/10.1093/jjco/hyaa098
Cenksoy P, Ficicioglu C, Yıldırım G, Yesiladali M. Hysteroscopic findings in women with recurrent IVF failures and the effect of correction of hysteroscopic findings on subsequent pregnancy rates. Arch Gynecol Obstet. 2013;287(2):357-60. DOI: https://doi.org/10.1007/s00404-012-2627-5
Pundir J, Pundir V, Omanwa K, Khalaf Y, El-Toukhy T. Hysteroscopy prior to the first IVF cycle: a systematic review and meta-analysis. Reprod Biomed Online. 2014;28(2):151-61. DOI: https://doi.org/10.1016/j.rbmo.2013.09.025
Koskas M, Mergui JL, Yazbeck C, Uzan S, Nizard J. Office hysteroscopy for infertility: a series of 557 consecutive cases. Obstet Gynecol Int. 2010;2010:168096. DOI: https://doi.org/10.1155/2010/168096
Strowitzki T, Germeyer A, Popovici R, von Wolff M. The human endometrium as a fertility-determining factor. Human Reprod Update. 2006;12(5):617-30. DOI: https://doi.org/10.1093/humupd/dml033
Goldstein, Steven R. The role of transvaginal ultrasound or endometrial biopsy in the evaluation of the menopausal endometrium. Am J Obstet Gynecol. 2009;201:5-11. DOI: https://doi.org/10.1016/j.ajog.2009.02.006
Kamalanathan S, Sahoo JP, Sathyapalan T. Pregnancy in polycystic ovary syndrome. Indian J Endocrinol Metab. 2013;17(1):37-43. DOI: https://doi.org/10.4103/2230-8210.107830
Cicinelli E, Resta L, Nicoletti R, Zappimbulso V, Tartagni M, Saliani N. Endometrial micropolyps at fluid hysteroscopy suggest the existence of chronic endometritis. Human Reprod. 2005;20(5):1386-9. DOI: https://doi.org/10.1093/humrep/deh779
Kitaya K, Tada Y, Taguchi S, Funabiki M, Hayashi T, Nakamura Y. Local mononuclear cell infiltrates in infertile patients with endometrial macropolyps versus micropolyps. Human Reprod. 2012;27(12):3474-80. DOI: https://doi.org/10.1093/humrep/des323
Kitaya K, Matsubayashi H, Yamaguchi K, Nishiyama R, Takaya Y, Ishikawa T et al. Chronic Endometritis: Potential Cause of Infertility and Obstetric and Neonatal Complications. Am J Reprod Immunol. 2016;75(1):13-22. DOI: https://doi.org/10.1111/aji.12438
Lasmar BP, Lasmar RB. Endometrial polyp size and polyp hyperplasia. Int J Gynecol Obstet. 2013;123(3):236-9. DOI: https://doi.org/10.1016/j.ijgo.2013.06.027
Mouhayar Y, Yin O, Mumford SL, Segars JH. Hysteroscopic polypectomy prior to infertility treatment: A cost analysis and systematic review. Eu J Obstet Gynecol Reprod Biol. 2017;213:107-15. DOI: https://doi.org/10.1016/j.ejogrb.2017.04.025
Downloads
Published
How to Cite
Issue
Section
