Is outpatient diagnostic hysteroscopy more useful than endometrial biopsy alone for the investigation of abnormal uterine bleeding in unselected premenopausal women? A randomised comparison

Objective To formally evaluate the clinical benefit of additional outpatient hysteroscopy over traditional vaginal examination and endometrial biopsy.
Design A prospective randomised controlled trial.
Setting A large teaching hospital in the northeast of Scotland.
Sample Premenopausal women with abnormal uterine bleeding referred to the general gynaecologic clinic and requiring endometrial biopsy.
Methods Women were randomised to either outpatient hysteroscopy and endometrial biopsy or endometrial biopsy alone.
Main outcome measures Primary outcome: initial surgical intervention rates. Secondary outcomes: procedural success and acceptability, intrauterine pathology identified and changes in management.
Results Three hundred and seventy women were recruited to the study. Initial trends in clinical management were comparable in both groups. No woman was advised to have removal of a localised lesion found at outpatient hysteroscopy and a normal uterine cavity at hysteroscopy did not influence the hysterectomy rate, which was similar in both groups. Outpatient hysteroscopy was found to be as acceptable as an outpatient endometrial biopsy and successfully completed in 85% compared with 91% of women who underwent endometrial biopsy alone. No cases of endometrial malignancy were identified.
Conclusions Outpatient diagnostic hysteroscopy is an acceptable procedure and may give more reassurance. It did not influence clinical management, especially with respect to hysterectomy rate. Outpatient hysteroscopy may be useful in selected cases, but when performed in a non-selective manner, it has little influence on clinical management and increases costs.     

Hysteroscopic findings of endometrial carcinoma. Evaluation of 104 cases

PURPOSE OF INVESTIGATION: Retrospective evaluation of hysteroscopic findings in the accurate diagnosis of endometrial carcinoma. METHODS: A retrospective monocentric study from January 1995 to December 2004. One hundred and four patients with hysteroscopic aspects evocative of endometrial carcinoma confirmed by endometrial biopsy during diagnostic hysteroscopy, by surgical hysteroscopic resection pieces or by hysterectomy specimen were included. RESULTS: Among the 104 patients, diagnostic hysteroscopy pointed out endometrial features suggestive of endometrial carcinoma in 102 cases. In two women diagnostic hysteroscopy failed to diagnose endometrial malignancy which was identified on pieces of polyps by surgical hysteroscopic resection. DISCUSSION: Polypoid proliferations cerebroid in appearance, with ulceration and necrosis, friable and with irregular vessels, represent endometrial findings highly indicative of malignancy. The diagnosis may be missed in cases of focal neoplasias, within endometrial polyps or in conditions of unsatisfactory endouterine visualization.     

Uterine pathologies in patients undergoing tamoxifen therapy for breast cancer: ultrasonographic, hysteroscopic and histological findings

PURPOSE OF INVESTIGATION: To evaluate endometrial abnormalities by ultrasonography, hysteroscopy and biopsy in postmenopausal patients treated with tamoxifen as adjuvant therapy for breast cancer. METHODS: The study was carried out on 113 patients who underwent vaginal ultrasonography, hysteroscopy and endometrial biopsy. RESULTS: There was a significative relation between ultrasonographic and hysteroscopic features (p < 0.001); 58 polyps were diagnosed at hysteroscopy, although 35 were not found at ultrasonography. A significant relation between ultrasonographic and histological findings was also documented (p < 0.005). A significant relation between histological findings and symptomatology was found (p < 0.05), although pathologies were also present in asymptomatic women. CONCLUSIONS: These results show that long-term tamoxifen therapy in breast cancer patients is associated with a higher incidence of uterine pathology. No significant relation has been documented between duration of treatment and grade of endometrial lesion (p > 0.05). Ultrasonography alone is useful in asymptomatic patients because it selects patients with increased endometrial thickness who should undergo hysteroscopy. Hysteroscopy is more accurate in detecting polyps, hyperplastic and neoplastic changes. Asymptomatic tamoxifen treated women should be evaluated as symptomatic patients.     

Role of hysteroscopy and endometrial biopsy in women with unexplained infertility

Objectives

This study was designed to evaluate the role of hysteroscopy and endometrial biopsy in women with unexplained infertility.

Patients and methods

Women with unexplained infertility were included in this prospective study, evaluated with transvaginal sonography and diagnostic hysteroscopy. Diagnostic hysteroscopy was performed between the 7th and 11th day of the cycle. The criteria for hysteroscopic findings were based on the cervical canal, uterine cavity, endometrium, visualization of the ostium tubae and lesions of the utero-tubal junction. After the hysteroscopic examination, endometrial biopsy was performed using a Pipelle^® endometrial suction curette. Patients were classified according to the hysteroscopy results into four groups: patients with no abnormality detected (14), patients with cervical abnormalities (six), patients with endometrial abnormalities (73) and patients with uterine abnormalities (seven).

Results

One hundred women with unexplained infertility were included. All patients underwent diagnostic hysteroscopy, except for seven patients: six patients had stenotic external or internal cervical ostium and one had inadequate visualization as the uterine cavity was filled with blood. Based on hysteroscopic findings, 31 patients were finally diagnosed with endometrial polyps; 14 endometritis; 15 endometrial hyperplasia; six submucous myomas; seven intrauterine synechiae (73 cases = endometrial abnormalities group); seven congenital uterine anomalies (uterine abnormalities group), six cervical stenosis (cervical abnormalities group) and 14 women without any uterine abnormalities (no abnormalities group). Analysis of samples obtained using the Pipelle^® endometrial suction curette was non-diagnostic in 16 cases; the most common endometrial pathological feature detected by this analysis was endometritis (15 %).

Conclusions

Routine hysteroscopy and endometrial biopsy should be used as a basic part of the work-up for women with unexplained infertility.     

Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding: is it always necessary to perform an endometrial biopsy?

OBJECTIVE: This study was undertaken to evaluate whether it was possible to abstain from performing an endometrial biopsy when endometrial thickness according to transvaginal ultrasonography was /=50 years who were referred because of postmenopausal bleeding or irregular bleeding during hormone replacement therapy. If endometrial thickness was /=5 mm underwent either curettage or endometrial biopsy. RESULTS: One hundred sixty-three women had an endometrial thickness /=5 mm. The corresponding figure when atypical hyperplasia and endometrial metastases were included was 20. 2%. CONCLUSION: If the false-negative rate of endometrial biopsy techniques is taken into account, then the combination of transvaginal ultrasonography and cervical cytologic examination is an adequate form of management for women with postmenopausal bleeding or irregular bleeding during hormone replacement therapy as long as endometrial thickness is 相似文献   

Comparison of ultrasonography,hysteroscopy, and biopsy in the diagnosis of endometrial lesions in postmenopausal tamoxifen-treated patients

BACKGROUND: At present, no proven recommendations can be made for the surveillance of tamoxifen-treated women. The aim of the present study was to evaluate ultrasonography and hysteroscopy in this setting. METHODS: Three hundred and ten postmenopausal patients using tamoxifen underwent vaginal ultrasonography, hysteroscopy, and endometrial biopsy; 274 were asymptomatic and 49 had abnormal bleeding. Ultrasonographic endometrial thickness and echotexture were recorded. Hysteroscopic endometrial appearance, presence of focal endometrial lesions and polyps were also recorded. General or selective endometrial biopsy was performed. Ultrasonographic and hysteroscopic follow up was provided. RESULTS: At ultrasonography, mean endometrial thickness was 10.8 mm. At hysteroscopy, cystic atrophy and suspect focal lesions were detected in 49.2% and 5.3% of women, respectively. Polyps were present in 44.8% of women; 38.9% of these polyps were missed at ultrasonography, whereas 11.4% were suspected but were not found at hysteroscopy. At biopsy, non-atypical hyperplasia and atypical changes were found in 4.8% and 1.3% of patients, respectively. Three carcinomas were found, all in asymptomatic women. Logistic regression analysis showed that only suspect focal lesions at hysteroscopy were significantly associated with abnormal histology. With a 6-mm cut-off value for endometrial thickness, negative and positive predictive values for ultrasonography in detecting hyperplastic or neoplastic changes were 96% and 8%, respectively; the corresponding values for hysteroscopy were 96% and 65%. No additional carcinoma was found at follow up. CONCLUSIONS: No single ultrasonographic feature (echotexture and borders) is significantly associated with the detection of endometrial hyperplasia or carcinoma; hysteroscopy, although not predictive unless revealing a focal lesion, is more accurate in detecting polyps and hyperplastic changes.     

Risk of discovering endometrial carcinoma or atypical hyperplasia during hysteroscopic surgery in postmenopausal women.

STUDY OBJECTIVE: To assess the risk of diagnosing endometrial carcinoma or atypical hyperplasia in tissue resected during hysteroscopy performed for intrauterine pathology presumed benign in postmenopausal women. DESIGN: A single-center prospective study (Canadian Task Force classification II-2). SETTING: Department of Gynecology, La Conception Hospital, Marseille, France. PATIENTS: Three hundred twenty-five women with intrauterine pathology, presumed benign, causing postmenopausal bleeding or bleeding related to hormone replacement therapy. INTERVENTION: All women had an endometrial biopsy after diagnostic hysteroscopy to exclude endometrial carcinoma or atypical hyperplasia. Then they underwent hysteroscopic surgical resection (203, 62.5%) or endometrial ablation (122, 37.5%). MEASUREMENTS AND MAIN RESULTS: Two cases each (0.6%) of endometrial carcinoma and endometrial atypical hyperplasia were discovered that were missed by preoperative evaluations. CONCLUSION: Outpatient hysteroscopy and endometrial biopsy do not eliminate the finding of carcinoma or endometrial atypical hyperplasia, as these disorders may be discovered during hysteroscopic surgery.     

A randomized trial of outpatient hysteroscopy with and without intrauterine anesthesia

STUDY OBJECTIVE: To evaluate the amount of pain during office hysteroscopy and endometrial biopsy with and without intrauterine anesthesia. DESIGN: Prospective randomized study (Canadian Task Force classification I). SETTING: Academic teaching center. PATIENTS: A total of 82 women underwent outpatient hysteroscopy for evaluation of their uterine cavity. INTERVENTIONS: Randomization to local cervical or combined cervical and intrauterine anesthesia. MEASUREMENTS AND MAIN RESULTS: Amount of pain experienced during the procedure; 10, 30, and 60 minutes after the procedure; and during endometrial biopsy. We used a visual analog scale ranging from 0 to 10 (0: no pain, 10: excruciating pain). Of 82 patients, 4 patients were excluded, 36 patients underwent hysteroscopy using local cervical anesthesia, and 42 others with combined cervical and intrauterine anesthesia. The mean age of the patients in the local group was 37.4 +/- 0.8 years and in the combined group was 38.3 +/- 0.7 years. In both groups, patients experienced significantly more pain during and 10 minutes after the procedure than 30 and 60 minutes after. No significant differences occurred in the pain scores during the hysteroscopy, and 10, 30, and 60 minutes after between the 2 anesthesia groups. The pain score in the local group during endometrial biopsy was significantly higher than during (p <.05), 10 minutes after (p <.001), 30 minutes after (p <.001), and 60 minutes after (p <.001) the procedure, respectively. In the combined group, compared with the pain score during endometrial biopsy, the scores during the hysteroscopy (p <.05), 10 minutes after (p <.01), 30 minutes after (p <.001), and 60 minutes after (p <.001) the procedure were also less, respectively. CONCLUSION: Intrauterine anesthesia with medicated saline as a distending medium is ineffective. Endometrial biopsy is associated with more pain than hysteroscopy.     

Cervicovaginal psammoma bodies in endosalpingiosis. A case report

BACKGROUND: The presence of psammoma bodies on cervicovaginal smears is a rare finding. These structures have usually been associated with malignant tumors, particularly ovarian carcinoma. However, a review of the literature reveals that up to 50% of these patients will have psammoma bodies in association with benign conditions; thus, this finding does not always correlate with the presence of a malignant tumor. CASE: An asymptomatic, nulliparous woman had psammoma bodies on a cervicovaginal smear. Evaluation, including cervical conization, endometrial sampling, laparoscopy with pelvic washings and ovarian biopsy, revealed cervical intraepithelial neoplasia 1, endosalpingiosis and numerous psammoma bodies in all specimens except from the cervix. Follow-up examinations at three and six months were negative. CONCLUSION: The finding of psammoma bodies in a Pap smear is not always associated with the presence of a pelvic malignancy.     

Vaginoscopic hysteroscopy in management for women with post-menopausal vaginal bleeding

ObjectivesThe feasibility of vaginoscopic hysteroscopy combined with office endometrial biopsy after ultrasonography for management of post-menopausal vaginal bleeding (PMB).Materials and methodsA prospective observational study of with PMB whom attending the Outpatient Clinic of Kang Ning Hospital during a four months period (1st Feb to 31st May 2018) was included. Vaginoscopic hysteroscopy was performed with endometrial biopsy after the initial clinical pelvic examination and transvaginal ultrasound examination.ResultsA total of 45 consecutive women with PMB was included. The hysteroscopy and endometrial biopsy were successful in 44 out of 45 (98%), a complete view in 82%, adequate tissue was in 91%, only one case was failed both procedures due to pain. The correlation between hysteroscopy and endometrial biopsy by was 100%. The mean operation time was 229 ± 68 s. The most common histological findings was atrophic endometrium 18 (42%). Five endometrial polyps and 2 submucosal leiomyomas were found. One rare case of endometrial carcinosarcoma (2%) was detected. Patients reported less pain for hysteroscopy than endometrial biopsy with rated VAS pain score was 3.5 ± 2.2, with 5 more score in 18%, and for endometrial biopsy 4.2 ± 2 and 33% respectively (p < 0.001). Six cases (13%) experienced vasovagal attacks immediately after the procedure. There is no other complication.ConclusionThe Vaginoscopic hysteroscopy combined endometrial biopsy is safe and feasible for assessment of endometrial pathology with postmenopausal bleeding.     

The role of outpatient diagnostic hysteroscopy in identifying anatomic pathology and histopathology in the endometrial cavity

STUDY OBJECTIVE: To evaluate the role of outpatient diagnostic hysteroscopy. DESIGN: Retrospective review (Canadian Task Force classification II-2). SETTING: University teaching hospital-based outpatient clinic. PATIENTS: One thousand six hundred women, 67.3% premenopausal and 32.7% postmenopausal. INTERVENTION: Diagnostic hysteroscopy without premedication or anesthesia; endometrial sampling or hysteroscopy-guided biopsy was performed when appropriate. MEASUREMENTS AND MAIN RESULTS: Outpatient hysteroscopy was successfully performed in 1468 women (91.8%). Eleven women (0. 7%) developed vasovagal response during the procedure, 18 required hospital admission because of pain or hemorrhage, and 2 were suspected of having uterine perforation. All recovered spontaneously without intervention. Intrauterine anatomic pathology was diagnosed in 17.0%; the overall frequency of myomas and endometrial polyps was 12.3% and 7.1%, respectively. The sensitivity and positive predictive value of hysteroscopy without biopsy in diagnosing endometrial carcinoma were only 58.8% and 20.8%, respectively. Of 1112 women with hysteroscopic impression of normal or atrophic endometrium, 10 (0.9%) had endometrial hyperplasia on biopsy. CONCLUSION: Hysteroscopy without biopsy carries low sensitivity and positive predictive value in the diagnosis of endometrial carcinoma and hyperplasia. In our opinion the predictive value of a negative hysteroscopy is inadequate, and endometrial biopsy should be performed during hysteroscopy for accurate diagnosis of endometrial histopathology.     

Usefulness of hysteroscopy in diagnosing sterility]

Sterility is a severe social problem. Using hysteroscopy, which is possible thanks to development of medical technology, seems to be an important improvement in diagnostics and therapy of sterility. The aim of this study is evaluation of the usefulness of hysteroscopy in diagnostics of sterility. There was a group of 106 women with diagnosed primary sterility and 82 women with secondary sterility. Wolf and Storz hysteroscopes were used during examinations, whereas the uterine cavity was dilated by CO2 using Wolf Metrometer 2121. During this examination a normal uterine cavity was found in most cases (32.9%). The next findings were: endometrial polyps (27.6%), intrauterine adhesions (23.4%), sub-serous myomas (14.3%), and congenital uterine abnormalities (1.5%). Comparing outcomes of hysteroscopy in both groups of sterile women, the high rate of intrauterine adhesions in the secondary sterility (43.9%) was detected. Performing hysteroscopy in patients with sterility increases considerably the range of informations about reproductive organs. Also the possibility of eye-controlled biopsy, deliberation of intrauterine adhesions or removing of endometrial polyps during endoscopic procedure increases the value of hysteroscopy.     

How often are endometrial polyps malignant?

OBJECTIVE: Endometrial polyps are a frequent pathology encountered during pelvic sonography and diagnostic hysteroscopies. The true incidence of malignant endometrial polyps is unknown. The estimations range from 0.5 to 4.8%. The objective of this study was to investigate the frequency of malignant endometrial polyps, and to characterize the hysteroscopic image of these polyps. METHODS: The study included 300 consecutive women with endometrial polyps who underwent hysteroscopic polypectomy. Patients' characteristics, operative findings, and pathology reports were analyzed. RESULTS: Four of the 300 endometrial polyps removed by operative hysteroscopy were malignant (1.3%). Patients with malignant polyps were symptomatic peri- or postmenopausal women. All asymptomatic polyps in this series were found to be benign. We could not identify any distinct hysteroscopic feature of malignancy. CONCLUSIONS: Our study shows that about 1.5% of endometrial polyps may be malignant. This finding reinforces the indication for removal of symptomatic endometrial polyps, preferably by a hysteroscopic procedure. The significance of asymptomatic uterine polyps has still to be determined.     

Hysteroscopic evaluation of the endometrium in postmenopausal women taking tamoxifen

STUDY OBJECTIVE: To evaluate hysteroscopic endometrial changes due to tamoxifen therapy in postmenopausal women with breast cancer. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. Patients. Eighty-eight postmenopausal women (or with iatrogenic amenorrhea) receiving tamoxifen 20 mg/day for at least 1 year for breast cancer. INTERVENTION: Record review of patients undergoing transvaginal sonography (TVS) and office hysteroscopy with eye-directed biopsy specimens obtained with a 5-mm, continuous-flow, operative hysteroscope. MEASUREMENTS AND MAIN RESULTS: Patients with thickened endometrium and pathologic findings at hysteroscopy had taken tamoxifen for significantly longer times than those without such findings (p < 0.05). CONCLUSION: Our findings confirm the estrogenic effect of tamoxifen on endometrium. Endometrial evaluation by TVS suggests further diagnostic procedures, but only hysteroscopy allows the surgeon to visualize endometrial lesions and obtain eye-directed biopsy tissue.     

Clinical pathway for the evaluation of postmenopausal bleeding with an emphasis on endometrial cancer detection.

Postmenopausal bleeding (PMB) accounts for about 5% of all office gynaecology visits. The causes of PMB are varied. Many women with endometrial cancer present with this symptom. Although many investigations are described, the most appropriate approach is often unclear. In a patient with no obvious local cause, the emphasis should be on uterine and adnexal evaluation. Based on a literature review, the evidence favours a conservative approach if the endometrial thickness (ET) is < 4mm, unless there are risk factors. All patients with ET 4 mm should have outpatient endometrial sampling. If this is unsuccessful, then outpatient hysteroscopy with directed biopsy or inpatient hysteroscopy is favoured. The role of ancillary investigations are described.     

Pretreatment and prospective assessment of endometrium in menopausal women taking tamoxifen for breast cancer

OBJECTIVES: To estimate the pretreatment incidence of endometrial pathology and to prospectively assess the endometrial morbidity emerging during tamoxifen intake for breast cancer. STUDY DESIGN: One-hundred and forty-six menopausal breast cancer patients, candidate to receive tamoxifen underwent endometrial assessment by Transvaginal Ultrasonography (TU) before the start of therapy. A double-layered endometrial stripe measuring more than 4mm indicated hysteroscopy and endometrial biopsy. Endometrial abnormalities detected before the start of tamoxifen were treated by operative hysteroscopy or by hysterectomy; no therapy and yearly hysteroscopic follow-up was scheduled for patients showing non-atypical hyperplasias. All women were asked to undergo TU on a yearly basis; during the follow-up period, indication for hysteroscopy and endometrial biopsy were the following: (i) an endometrial lining measured above 4mm at the first time, (ii) at least a 50% increase of endometrial thickness since the last finding in patients previously assessed by hysteroscopy, (iii) a recorded vaginal bleeding, and (iv) previous findings of endometrial hyperplasia. Histopathologic result from biopsy or hysterectomy was the reference test to establish the baseline prevalence of endometrial pathology and the emerging prevalences of morbidity after 12, 24, 36, 48 and 60 months of tamoxifen therapy. RESULTS: One-hundred and five patients were followed for 60 months, whereas 113, 126, 137 and 141 patients were evaluated up to 48, 36, 24 and 12 months, respectively. In 44 out of 146 patients, pretreatment TU showed an endometrium thicker than 4mm and in 31 (21.2%) of these patients abnormalities consisting of 16 endometrial polyps, seven polyps harboring simple hyperplasia, four simple hyperplasias, three atypical hyperplasias and one adenocarcinoma were found. During tamoxifen intake benign endometrial abnormalities were detected in 36 out of 114 assessable patients showing normal endometrium before the start of tamoxifen therapy (31.5%) and in seven out of 27 patients with baseline endometrial abnormalities (25.9%). Overall, an endometrial pathology emerged in 30.4% of patients during tamoxifen administration and in no patients we found an atypical lesion. CONCLUSIONS: In menopausal breast cancer patients the incidence of endometrial abnormalities before the start of tamoxifen therapy is high and includes 2.7% of atypical pathology. After the diagnosis and treatment of baseline atypical lesions were accomplished, no atypical endometrial lesion emerged after the start of tamoxifen administration. Based on these findings, we believe that pretreatment assessment of endometrium is recommended in all menopausal women candidate to receive tamoxifen therapy.     

Abnormal uterine bleeding during climacteric. Correlation between transvaginal ultrasonography, hysteroscopy and histology]

BACKGROUND AND AIMS: The authors evaluated the accuracy of ultrasonographic findings compared to hysteroscopic and histological results in the diagnosis of anomalous uterine bleeding in menopause. METHODS: Forty-eight women suffering from the above pathology and attending the Preventive Gynecology outpatient clinic of Department C of the Gynecology and Obstetrics faculty at Turin University during the period between September 1996 and July 1997, underwent first ultasonography using a transvaginal probe and then outpatient hysteroscopy with endometrial biopsy. RESULTS: A total overlap between the ultrasonographic image, hysteroscopic results and histological diagnosis was only obtained in the group of menopausal patients. CONCLUSIONS: In line with the data reported in the literature, the authors imposed a cut-off endometrial thickness of 4 mm above which further diagnostic tests were performed using hysteroscopy with targeted biopsy.     

Detection of benign intracavitary lesions in postmenopausal women with abnormal uterine bleeding: a prospective comparative study on outpatient hysteroscopy and blind biopsy

STUDY OBJECTIVE: To evaluate the specificity of blind biopsy in detecting benign intracavitary lesions as causes of postmenopausal bleeding in comparison with directed biopsy via hysteroscopy. DESIGN: Prospective trial without randomization (Canadian Task Force classification II-1). SETTING: University hospital. PATIENTS: Three hundred nineteen postmenopausal women with abnormal uterine bleeding. INTERVENTIONS: All patients underwent both blind biopsy (Novak's curette) and directed biopsy via hysteroscopy (after at least a week). All patients with benign intracavitary lesions underwent operative hysteroscopy to enable the removal of polyps and intracavitary myomas or endometrial resection if required. All patients with pathologic reports of complex hyperplasia and atypical hyperplasia (20 patients) underwent vaginal hysterectomy with bilateral adnexectomy. All patients with histology reports of endometrial carcinoma (15 patients) underwent abdominal hysterectomy, bilateral adnexectomy, and pelvic lymphadenectomy. Histopathologic findings from endometrial specimens obtained after operative hysteroscopy or uterine specimens obtained after hysterectomy were used as a reference test to establish the prevalence of disease. MEASUREMENTS AND MAIN RESULTS: The sensitivity, specificity, accuracy, and positive and negative predictive values of blind biopsy and hysteroscopy were assessed to distinguish benign intracavitary formations such as polyps, submucous myomas, and endometrial hyperplasia in postmenopausal patients with abnormal uterine bleeding. The level of agreement was evaluated by use of the coefficient of concordance kappa. Blind biopsy showed a sensitivity of 11% and a specificity of 93%, with an accuracy of 59% in detecting endometrial polyps, a sensitivity and specificity of 13% and 100%, respectively, with an accuracy of 98% for submucous myomas, and values of 25%, 92%, and 80%, respectively, in diagnosing hyperplasia. On the other hand, hysteroscopy demonstrated a sensitivity of 100% and a specificity of 97%, with an accuracy of 91% in diagnosing endometrial polyps, a sensitivity and specificity of 100% and 98%, respectively, with an accuracy of 99% for submucous myomas. The coefficient of concordance kappa (95% CI) was 0.12 for blind biopsy and 0.82 for hysteroscopy, corresponding, respectively, to slight concordance and almost perfect agreement with final pathologic diagnosis. CONCLUSIONS: Blind biopsy (Novak's curette) demonstrates very low sensitivity and accuracy in the diagnosis of benign focal intracavitary lesions. Hysteroscopy is confirmed as the gold standard in the assessment of abnormal uterine bleeding in menopause, permitting the elimination of the false-negative results of blind biopsy through direct visualization of the uterine cavity and the performance of targeted biopsy in case of doubt.     

Hysteroscopy and transvaginal ultrasonography in postmenopausal women with uterine bleeding.

OBJECTIVE: To evaluate the accuracy of hysteroscopy and transvaginal ultrasonography (TU), based on a histopathological report from endometrial specimens, in diagnosing endometrial pathology in menopausal women with uterine bleeding. METHODS: Four-hundred and nineteen postmenopausal women with uterine bleeding underwent TU, hysteroscopy and endometrial biopsy. Hysteroscopic and sonographic findings have been evaluated on the basis of the final diagnosis established by histologic examination. Sensitivity, specificity and positive predictive value of TU at an endometrial thickness cut-off point of 4 and 8 mm (double layer technique) and of panoramic hysteroscopy have been detected. RESULTS: Normal and abnormal endometrium was found in 222 and in 197 women, respectively. TU showed sensitivity of 95.1%, specificity of 54.8% and positive predictive value of 63.7% at a cut-off limit of 4 mm. With a cut-off limit of 8 mm the corresponding figures were 83.8%, 81.3% and 79.4%. Hysteroscopy demonstrated a sensitivity of 96.5%, specificity of 93.6% and positive predictive value of 92.6%. The combination of the two diagnostic tools showed a 100% sensitivity, 94.8% specificity and 93.3% positive predictive value. CONCLUSIONS: With cut-off limit of 4 mm, TU can be considered the first choice modality of endometrial investigation in women with postmenopausal uterine bleeding to select patients at risk to carry endometrial pathology. Hysteroscopy is a more accurate technique than TU because of better specificity and must be indicated for all patients showing an endometrial strip more than 4 mm. When an endometrial thickness below 4 mm is detected by ultrasound, hysteroscopy may be indicated on clinical background because of the possibility to miss infrequent (2.5% in our series), but relevant endometrial pathologies. Endometrial sampling should follow hysteroscopic view in all cases showing abnormal or suspicious lesions as well as in all cases with irregularly shaped endometrial lining and/or suboptimal endoscopic vision.