Diagnostic value of hysteroscopy and hysterosonography in endometrial abnormalities in asymptomatic postmenopausal women

Objective  To estimate the diagnostic value of hysteroscopy and hysterosonography in endometrial pathologies in asymptomatic postmenopausal women. Materials and methods  In this prospective study, 77 asymptomatic postmenopausal women that had a suspicion of endometrial abnormalities based upon transvaginal ultrasonography were studied. The patients underwent transvaginal ultrasonography and hysterosonography. All patients then had office diagnostic hysteroscopy or operative hysteroscopy. The final diagnosis was made by operative hysteroscopy with resection and excision of the lesions or endometrial biopsy with vacuum curettage. Sensitivity, specificity, positive predictive value and negative predictive value of transvaginal ultrasonography, hysterosonography and diagnostic hysteroscopy were calculated. Results  The patients’ age ranged from 45 to 80. The most common frequent abnormalities were endometrial hyperplasia in transvaginal ultrasonography (62.33%), endometrial polyp in sonohisterography (57.14%), and also endometrial polyp in diagnostic hysteroscopy (51.94%). Transvaginal ultrasonography revealed a sensitivity of 59.7% and a specificity of 35.5%. Sonohysterography revealed a sensitivity of 88.8% and a specificity of 84.4%. Diagnostic hysteroscopy revealed a sensitivity of 91% and a specificity of 82%. Conclusion  Hysterosonography showed very good agreement with hysteroscopy for the diagnosis of endometrial abnormalities in asymptomatic postmenopausal women. In asymptomatic postmenopausal women that had a suspicion of endometrial abnormalities based upon transvaginal ultrasonography should undergo both hysterosonography and hysteroscopy.     

The value of sonohysterography in detecting intracavitary benign abnormalities

The aim of this retrospective study was to assess the diagnostic value and the usefulness of sonohysterography in the detection of uterine intracavitary benign abnormalities, compared with other diagnostic methods (transvaginal ultrasonography and diagnostic hysteroscopy). From January 2003 to December 2003, a total of 73 patients (47 premenopausal (middle age 38.9) and 26 postmenopausal women (middle age 60.5)) underwent transvaginal ultrasonography (TVS) and sonohysterography (SHG), consisting of an intrauterine infusion of saline solution during transvaginal ultrasound. The women referred to our Ultrasonography Center because of intermenstrual (38) or postmenopausal bleeding (19), or an abnormal or a poorly defined endometrial interface (16) as seen as baseline ultrasonography. The findings at TVS and SHG were compared with hysteroscopy (HS). In one case, the SHG was technically impossible to perform. In premenopausal group the sensitivity of SHG had been 100% in detecting submucosal fibroids, endometrial polyps and hyperplasia and 75% in detecting normal uterus. The specificity had been always 100%. In postmenopausal group the sensitivity of SHG had been 75% in detecting submucosal fibroids, 93.8% in endometrial polyps and 100% in hyperplasia and normal uterus. The specificity had been 100% in submucosal fibroids and hyperplasia and had been 90.0 and 95.5% in endometrial polyps and normal uterus, respectively. SHG allows to obtain a precise diagnosis of benign uterine pathology and it is more accurate in the diagnosis of intracavitary abnormalities than that obtained by TVS. Preoperative use of SHG may assist in choosing the best surgical treatment for the patient.     

Transvaginal ultrasonography and endometrial cytology as a diagnostic schema for endometrial cancer

OBJECTIVE: To determine whether the combined use of transvaginal ultrasonography and endometrial cytology is an effective diagnostic schema for endometrial cancer and hyperplasia of the uterus. METHODS: Five hundred fifty-two women were enrolled in this study. For all subjects, endometrial thickness was evaluated by transvaginal ultrasonography. Endometrial cytology was carried out according to the following criteria: all women with atypical uterine bleeding, for asymptomatic postmenopausal women with endometrial thickness >or=5 mm, and for asymptomatic premenopausal women with endometrial thickness >or=20 mm. When the cytological findings were abnormal, we performed a hysteroscopy-guided biopsy within 2 weeks. Women who received transvaginal ultrasonography alone, or those who showed negative cytology, underwent repeated gynecological examination and transvaginal ultrasonography 3, 6, and 12 months after the first examination. RESULTS: Endometrial cytology was done on 129 women (23.4% of all subjects), of whom 14 were diagnosed as 'positive' cytology, 20 as 'suspicious positive', and 95 as 'negative'. A total of 34 women with 'positive' or 'suspicious positive' cytological result underwent hysteroscopy-guided endometrial biopsy. The histological diagnosis of the endometrium included 13 endometrial cancers, 9 endometrial hyperplasias (one atypical hyperplasia and 3 hyperplastic polyps), and 10 normal endometria. As a diagnostic schema for endometrial cancer, this combined method resulted in 100% sensitivity, 99.1% specificity, 92.9% positive predictive value, and 100% negative predictive value. For endometrial hyperplasia, the method resulted in 100% sensitivity, 89.6% specificity, 40.0% positive predictive value, and 100% negative predictive value. CONCLUSION: A combination of transvaginal ultrasonography and endometrial cytology may be an effective diagnostic schema for endometrial cancer and hyperplasia.     

Rating of transvaginal sonography in the evaluation of postmenopausal bleeding

OBJECTIVE: The purpose of this study was to evaluate transvaginal ultrasonography (TVS) in differential diagnosis of vaginal bleedings in postmenopausal patients. MATERIAL AND METHODS: Between January 1990 and December 1996, 1198 postmenopausal patients with vaginal bleedings were sent to our clinic for a histological evaluation. Eight hundred and seventy-nine patients (73.4%) were preoperatively scanned by transvaginal probe, and endometrial thickness (< 5, 5-7, 8-10, > 10 mm) was measured. RESULTS: Atrophy was found in 46.3%, endometrial polyps in 19.8%, endometrial cancer in 17.5%, and hyperplasia in 6.7%. An endometrial thickness of lower than 5 mm (p < 0.0001) was shown in TVS patients with atrophy in 71%, with endometrial polyps in 10.9%, with endometrial cancer in 3.9% and hyperplasia in 6.8%. In 55.2% of these eases with endometrial cancer the preoperatively estimated thickness was 10 mm or more. The additionally morphologic examination in cases with an endometrium smaller than 5 mm was false positive in 75% (9/12). Thus an endometrial thickness of > 5 mm had a sensitivity of 92.5%, specificity of 71.0%, positive and negative predictive value of 75.6, respectively 90.9% for the detection of endometrial pathology. CONCLUSIONS: TVS allows the detection of an endometrial pathology in the vast majority of patients with postmenopausal bleedings. In cases with a single postmenopausal bleeding and an endometrium smaller than 5 mm we recommend expectative procedures with repeated ultrasound examination of the endometrium.     

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.     

电视宫腔镜诊治91例绝经后子宫出血的效果分析

目的回顾性分析电视宫腔镜对绝经后子宫出血的诊断和治疗效果.方法对91例绝经后子宫出血患者行宫腔镜检查,其中21例行电切术或病灶摘除术,病变组织送病理.结果绝经后出血的病因依次为粘膜下肌瘤、子宫内膜炎、子宫内膜息肉、子宫内膜单纯增生、萎缩性子宫内膜、子宫内膜癌等,宫腔镜诊断与病理诊断符合率依次为95.2%、100%、88.9%、100%、90%、80%.宫腔镜治疗宫腔良性病变所致子宫出血无一例复发.结论宫腔镜诊断绝经后子宫出血,优于诊断性刮宫;部分患者可同时行病灶摘除或电切术,减少了开腹手术对患者的创伤.     

Diagnostic accuracy of sonohysterography in the evaluation of uterine cavities in tamoxifen administered asymptomatic postmenopausal breast cancer patients with endometrial thickness ≥5 mm

To evaluate diagnostic efficacy of transvaginal saline infusion sonohysterography (TV-SHG) in the evaluation of uterine cavities in tamoxifen (TAM) administered asymptomatic postmenopausal breast cancer patients with increased endometrial thickness, sixty asymptomatic postmenopausal breast cancer women receiving adjuvant TAM treatment for at least 6 months and with endometrial thickness’ ≥5 mm measured in transvaginal ultrasonography (TVS) were enrolled. Each patient underwent TV-SHG, followed by outpatient hysteroscopy (HYS) with endometrial biopsy. TV-SHG application was accepted as unsuccessful in four cases (6.7%). When office HYS combined biopsy was considered as gold standard, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of TV-SHG were estimated as 90%, 100%, 100%, and 95%, respectively. Our findings showed that TV-SHG was a valuable diagnostic tool in the evaluation of uterine cavities of TAM administered asymptomatic postmenopausal patients having an increased endometrial thickness.     

One-stop clinic for postmenopausal bleeding

OBJECTIVE: To evaluate the role of one-stop clinic for early diagnosis and management of women with postmenopausal bleeding by means of transvaginal ultrasonography, outpatient hysteroscopy and endometrial biopsy. STUDY DESIGN: A prospective analysis was performed on 522 women with postmenopausal bleeding who were referred directly to the gynecology outpatient clinic for evaluation of postmenopausal bleeding. Endometrial thickness of 6 mm, as measured by a transvaginal scan, was considered the cutoff limit for further investigation by hysteroscopy and endometrial biopsy. RESULTS: One hundred ninety-one women were using hormone replacement therapy. Thirty-two were taking tamoxifen. Outpatient hysteroscpoy was performed in 157 (71.3%) cases. Thirty-seven (16.8%) cases had general anesthesia for hysteroscopy. Twenty-four (11%) cases had only an endometrial sample obtained. Twenty-one cases of endometrial carcinoma, 20 of endometrial hyperplasia, 4 of cervical carcinoma and 5 of other genital tract malignancies along with several benign pathologies, including submucosal myomas, were detected. Seven (2.3%) cases of endometrial thickness below the cutoff limit had recurrent bleeding due to benign conditions. CONCLUSION: A one-stop clinic is effective for early diagnosis of genital tract malignancy in a majority of patients with postmenopausal bleeding and significantly help in reducing the hospital waiting list.     

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.     

Transvaginal Sonography of the Endometrium in South Indian Postmenopausal Women

EDITORIAL COMMENT: We accepted this paper because it has a simple important message, namely that postmenopausal women with an endometrial thickness ≤4 mm will not have an endometrial cancer; they are likely to have endometrial atrophy. A vaginal ultrasound examination to measure endometrial thickness is a noninvasive investigation. There are about 100 papers on this subject in the world literature at present, and it appears that this investigation will adequately exclude endometrial malignancy in postmenopausal women. This is especially useful in older, unfit or frail women. However, if bleeding is heavy or persists it would still be recommended that hysteroscopy and/or curettage be performed.
Summary: Endometrial carcinoma is not commonly seen in India as in the West. Nevertheless, the diagnosis has to be entertained in women presenting with postmenopausal bleeding. The aim of the study was to compare die transvaginal sonographically-measured endometrial thickness with the histopathological diagnosis in postmenopausal women. Eighty postmenopausal women were studied prospectively. All of them underwent transvaginal sonography followed by eidier an office dilatation and curettage and/or a hysterectomy. Eight women had endometrial carcinoma and their mean endometrial thickness was 12.6±5 mm (mean ± SD). Taking 4 mm endometrial thickness as cut off the sensitivity of transvaginal scan to detect endometrial pathology was 97%, specificity 98%, positive predictive value 97% and negative predictive value 94%. Hence, we conclude that measurement of endometrial thickness by transvaginal scan is a good screening test in postmenopausal women for differentiating endometrial pathology from those who do not have an endometrial lesion.     

Prospective study of saline infusion sonohysterography in evaluation of perimenopausal and postmenopausal women with abnormal uterine bleeding

AIM: To evaluate saline infusion sonohysterography as an investigative modality in abnormal uterine bleeding in perimenopausal and postmenopausal women. METHODS: Fifty-eight patients, 52 perimenopausal and six postmenopausal women, with abnormal uterine bleeding were selected from the department of Obstetrics and Gynecology of Shrimati Sucheta Kriplani Hospital. After complete work-ups, transvaginal examinations were performed followed by sonohysterographies. The sensitivity, specificity, positive predictive values and negative predictive values were calculated for transvaginal sonography (TVS) and saline infusion sonohysterography as compared with findings of hysteroscopy/hysterectomy. RESULTS: Saline infusion sonohysterography was performed in 56 cases. It could not be done in one perimenopausal and one postmenopausal woman. Cavity was normal in 41 perimenopausal and five postmenopausal women. Ten women displayed abnormalities. Two had submucosal fibroids, two had intramural fibroids, one had fibroid polyp, three had endometrial polyps and two patients had endometrial growths. We found that TVS missed three endometrial polyps and one endometrial growth and led to mislabeling two intramural fibroids as submucosal. On comparing the sonohysterographic findings with those of hysteroscopy or hysterectomy, one endometrial polyp and one endocervical polyp was missed on sonohysterography, and one false positive growth was observed on sonohysterography. The sensitivity, specificity, positive predictive value and the negative predictive value of TVS were 84.8%, 79%, 82.4% and 82%, respectively. The sensitivity, specificity, positive predictive value and the negative predictive value of saline infusion sonohysterography were 94.1%, 88.5%, 91.4% and 92%, respectively. CONCLUSION: Saline infusion sonohysterography is a safe, convenient, time conserving, cost effective, easily accessible and acceptable investigative modality. It definitely enhances the diagnostic potential of TVS in assessment of endometrium and intracavitary pathologies.     

Transvaginal ultrasonography and endometrial histology in peri- and postmenopausal women on hormone replacement therapy.

OBJECTIVE: To determine the association between endometrial thickness and endometrial histology in a large sample of women using HRT. DESIGN: Results from three multi-centre studies were combined. PARTICIPANTS: Five hundred and sixty-four climacteric women were treated with either sequential, continuous combined or long-cycle therapy. MAIN OUTCOME MEASURES: The women underwent 717 examinations with both transvaginal ultrasonography and histological examination of the endometrium. Endometrial thickness was measured and associated with the histological findings. RESULTS: Eight cases of endometrial hyperplasia were diagnosed. All the hyperplasias were simple without atypia. Two cases had an endometrial thickness < 4 mm and two a thickness > 8 mm. The > 4 mm threshold for abnormal endometrium had a sensitivity of 75%, a specificity of 47%, a positive predictive value of 2% and a negative predictive value of 99%. CONCLUSION: No association could be found between the endometrial thickness measured by transvaginal ultrasonography and endometrial pathology. In six out of eight women with simple hyperplasia the endometrium measured > 4 mm.     

Transvaginal ultrasonography and endometrial histology in peri- and postmenopausal women on hormone replacement therapy

Objective To determine the association between endometrial thickness and endometrial histology in a large sample of women using HRT.
Design Results from three multi-centre studies were combined.
Participants Five hundred and sixty-four climacteric women were treated with either sequential, continuous combined or long-cycle therapy.
Main outcome measures The women underwent 717 examinations with both transvaginal ultrasonography and histological examination of the endometrium. Endometrial thickness was measured and associated with the histological findings.
Results Eight cases of endometrial hyperplasia were diagnosed. All the hyperplasias were simple without atypia. Two cases had an endometrial thickness < 4 mm and two a thickness > 8 mm. The > 4 mm threshold for abnormal endometrium had a sensitivity of 75%, a specificity of 47%. a positive predictive value of 2% and a negative predictive value of 99%.
Conclusion No association could be found between the endometrial thickness measured by transvaginal ultrasonography and endometrial pathology. In six out of eight women with simple hyperplasia the endometrium measured > 4 mm.     

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.     

Prospective Study to Compare Endometrial Cytology and Transvaginal Ultrasonography for Identification of Endometrial Malignancies

We compared transvaginal ultrasonography (TVS) and endometrial cytology by the Endocyte method for endometrial cancer screening. A total of 600 postmenopausal women who hoped for endometrial cancer screening (mean age, 61.1 ± 8.8 years; range, 44–87 years) underwent TVS, endometrial cytology (Endocyte method), and endometrial histology. The endometrial borders could be visualized by TVS in all women studied. However, cytology could not be performed in 59 women (9.8%) due to cervical stenosis. These 59 women were excluded from further study. Of the 541 remaining women, 38 had pathologic conditions (16 had endometrial cancer and 22 had endometrial hyperplasia). One (6.3%) of the 16 endometrial cancer patients and 10 (45.5%) of the 22 hyperplasia patients were asymptomatic. One hundred thirty-nine (83.7%) of the 166 women with postmenopausal bleeding had no pathological condition. When the cutoff value of endometrial thickness was set at 4 mm for women <5 years since menopause and 3 mm for those ≧5 years since menopause, TVS showed a 97.4% sensitivity, 75.7% specificity, 23.8% positive predictive value, and 99.7% negative predictive value. Thirty-seven of the 38 patients with endometrial disease were detected by TVS. Eight patients with a benign Endocyte examination were found to have endometrial hyperplasia. However, all endometrial cancers were detected by cytological examination. The Endocyte method exhibited 78.9% sensitivity, 95.4% specificity, 56.6% positive predictive value, and an 88.5% negative predictive value. In conclusion, TVS is thought to be useful for identification of patients who required further diagnostic investigation including endometrial histology.     

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.     

An assessment of the value of ultrasonographic screening for endometrial disease in postmenopausal women without symptoms

OBJECTIVE: Our purpose was to evaluate the use of transvaginal ultrasonography for the detection of endometrial disease in a population of postmenopausal women who were without symptoms. STUDY DESIGN: Postmenopausal women were screened for potential inclusion in 2 multicenter, double-blind, placebo-controlled studies of 2 years' duration to evaluate the safety and efficacy of idoxifene in the prevention of osteoporosis. Baseline endometrial evaluation was performed by transvaginal ultrasonography and aspiration biopsy of the endometrium. RESULTS: A total of 1926 women were screened by transvaginal ultrasonography, and 1833 of them had endometrial thickness < or =6 mm. Five cases of endometrial abnormality (adenocarcinoma [n = 1] and atypical hyperplasia [n = 4]) were detected in the 1750 women from this cohort who underwent biopsy. The negative predictive value was >99%. One case of adenocarcinoma was detected in the 42 women who had endometrial thickness >6 mm and underwent biopsy. However, the sampling rate (45%) of women with endometrial thickness >6 mm was too low for confidence in the positive predictive value of 2%. CONCLUSIONS: Despite a high negative predictive value, transvaginal ultrasonography may not be an effective screening procedure for detection of endometrial abnormality in untreated postmenopausal women who are without symptoms.     

Transvaginal ultrasonography versus hysteroscopy in the diagnosis of uterine submucous myomas

Seventy-one women with symptomatic uterine myomas, hospitalized for hysterectomy, underwent preoperative transvaginal ultrasonography and hysteroscopy to compare their reliability in the diagnosis of submucous myomas. After the operation, the surgical specimen was studied carefully and the results were compared with the preoperative diagnostic findings. Transvaginal ultrasonography had a sensitivity of 100% and specificity of 94%; the predictive value of an abnormal ultrasound scan was 81% and that of a normal one was 100%. The sensitivity of hysteroscopy was 100% and the specificity 96%; the predictive value of an abnormal hysteroscopic finding was 87% and that of a normal result was 100%. Mapping of uterine myomas is more precise with transvaginal ultrasonography than with hysteroscopy, but the former method cannot distinguish between a myoma and an endometrial polyp.     

Hysteroscopically targeted biopsies compared with blind samplings in endometrial assessment of menopausal women taking tamoxifen for breast cancer

STUDY OBJECTIVE: To determine the validity of tissue sampling accomplished by hysteroscopically targeted or blind biopsies in the assessment of endometrial morbidity associated with tamoxifen treatment. DESIGN: Retrospective, unrandomized study (Canadian Task Force classification II-2). SETTING: Public hospital. PATIENTS: One hundred seventy-six menopausal women who had an endometrial stripe of more than 4 mm on transvaginal ultrasonography. INTERVENTION: Review of histopathologic reports of patients undergoing hysteroscopy followed by targeted (94 samplings) or blind (82 samplings) endometrial biopsies. MEASUREMENTS AND MAIN RESULTS: Histopathology was considered the reference test to assess endometrial morbidity, and correlates with hysteroscopic findings were made to evaluate the validity of the two sampling procedures. Overall, in 23 women (13.0%) tissue samples were insufficient for pathologic evaluation. Functional or atrophic endometrium and cystic atrophy were found in 51 (28.8%) and 37 patients (21.0%), respectively. Polyps, hyperplasias, and carcinomas were found in 38 (21.5%), 19 (10.7%), and 6 (3.3%), respectively. Blind biopsies failed to detect 5 of 5 polyps and 33 of 37 cystic atrophies, and in 34.1% of cases provided insufficient tissue for diagnosis; however, no hyperplasias or carcinomas were undetected. All specimens collected under vision were pathologically evaluable; 34 of 38 hysteroscopic reports of cystic atrophy were confirmed, and neither endometrial polyps nor hyperplasias and carcinomas were undetected. In distinguishing between normal and abnormal endometrium, hysteroscopy showed sensitivity and negative predictive value of 100% regardless of sampling modality. We found better specificity (80.0% vs 68.9%) and positive predictive value (68.9% vs 43.7%) for hysteroscopic diagnosis when tissue was collected under vision compared with blind sampling. CONCLUSION: In women taking tamoxifen, endometrial evaluation performed by blind sampling is safe in excluding hyperplasias or carcinomas. For complete understanding of tamoxifen-associated morbidity, hysteroscopy with sampling under vision has better diagnostic compliance.