Transvaginal sonography and saline infusion sonohysterography in the evaluation of abnormal uterine bleeding

OBJECTIVE: To evaluate the accuracy of transvaginal sonography (TVS) and saline infusion sonohysterography (SIS) in diagnosing submucous fibroids and endometrial polyps in the patients of abnormal uterine bleeding (AUB). DESIGN: Prospective, comparative study. SETTING: Postgraduate Institute of Medical Sciences, Rohtak. POPULATION: Fifty patients with AUB underwent TVS and SIS prior to hysterectomy. MAIN OUTCOME MEASURES: Comparison of diagnosis of submucous fibroids and endometrial polyps at TVS and SIS with the final diagnosis at hysterectomy ie 'gold standard'. RESULTS: Both procedures were helpful in detecting submucous fibroids and endometrial polyps. However, SIS was found to be more useful (sensitivity 89.5%, specificity 100%, likelihood ratios of the presence and absence of submucous fibroids of infinity and 0.1 respectively) than TVS (sensitivity 70% and specificity 96.6% and likelihood ratios of 21.2 and 0.3 respectively) for submucous polyps. Saline infusion sonohysterography was also more accurate for endometrial polyps (sensitivity 100%, specificity 97.8%) than TVS (sensitivity 66.6%, specificity 100%). With SIS and TVS, the post-test probability with negative test was 0% and 4%, respectively, thus suggesting that no endometrial polyp would be missed on SIS. CONCLUSION: Saline infusion sonohysterography is more accurate in diagnosing submucous fibroids and endometrial polyps in the patients of abnormal uterine bleeding than is TVS. TVS should be included in the standard protocol for the management of AUB. Saline infusion sonohysterography should be reserved for those patients who have centrally located fibroids as they may be submucous.     

Long-term results of hysteroscopic myomectomy in 235 patients

OBJECTIVE: To assess the efficacy of transcervical resection of submucous fibroids according to type and size. MATERIALS AND METHODS: Retrospective follow-up of 235 women with submucous fibroids at outpatient hysteroscopy who underwent a hysteroscopic transcervical resection. The main indications were the abnormal uterine bleeding and fertility problems. Thirty-seven percent of patients had an associated endometrial ablation and 32% had a polyp resection. Fifty-one percent of women were menopausal. In cases of incomplete resection a repeat procedure was offered. RESULTS: Intra-operative complications were rare (2.6%) and there was no major complication. Eighty-four percent of cases were followed-up. The median follow-up was 40 months (range 18-66 months). The procedure was classed as a success in 94.4% of patients. Among the cases that were classed as a failure, four patients had a repeated hysteroscopic procedure, three patients had a subsequent hysterectomy and four patients presented with abnormal uterine bleeding at follow-up. CONCLUSION: The hysteroscopic transcervical resection of submucous fibroids is a safe and highly effective long-term therapy for carefully selected women presenting with abnormal uterine bleeding and fertility problems. It produces satisfactory long-term results with few complications.     

Treatment of benign uterine hemorrhage and simple endometrial hyperplasia by endometrial ablation

BACKGROUND AND AIMS: The technique of endometrial resection by resectoscope represents a valid alternative to hysterectomy in patients with a high operating risk suffering from benign uterine bleeding and simple endometrial hyperplasia refractory to medical treatment or uterine curettage. The aim of this study was to demonstrate the validity of the resectoscopic technique of endometrial ablation. METHODS: The authors performed endometrial ablation using a loop and roller resectoscope in a group of 24 women with refractory menorrhagia which failed to respond to other techniques of first choice. RESULTS AND CONCLUSIONS: The results obtained show the good tolerability of resectoscopic surgery by the patients who, for medical reasons, represented a high operating risk if subject to laparohysterectomy.     

Long-term outcome of hysteroscopic endometrial ablation without endometrial preparation

OBJECTIVE: To describe the three-step hysteroscopic endometrial ablation (EA) technique without endometrial preparation, and its long-term outcomes. STUDY DESIGN: Four hundred and thirty-eight premenopausal women with menorrhagia or menometrorrhagia underwent three-step hysteroscopic EA, which consists of rollerball ablation of the fundus and cornual regions, a cutting loop endomyometrial resection of the rest of the cavity, and rollerball redessication of the whole pre-ablated uterine cavity. The main outcome measures were menstrual status, level of satisfaction with the procedure, and the need for repeat ablation or hysterectomy. Questionnaires were completed for 385 women (87.9%) with a mean follow-up of 48.2 months. RESULTS: One hundred and eighty-four responders (47.8%) reported amenorrhea; 177 (46%) had light to normal flow. One patient (0.3%) underwent repeat ablation and 20 (5.2%) underwent hysterectomy: 15 (3.9%) because of endometrial ablation failure and 5 (1.3%) because of indications unrelated to the ablation (three cases of atypical endometrial hyperplasia and two cases of fibroids). Two hundred and ninety-two patients (75.8%) were very satisfied, and 78 (20.3%) satisfied with the results. No major complications occurred and three women (0.8%) became pregnant during the follow-up period. CONCLUSIONS: EA is safe and effective means of treating of menorrhagia and menometrorrhagia in premenopausal women, and helps avoid hysterectomy in 95% of patients suffering from heavy bleeding, with or without uterine fibroids. Women should be informed that the procedure is not contraceptive and that pregnancy is possible after treatment.     

Outcomes after rollerball endometrial ablation for menorrhagia.

OBJECTIVE: To evaluate the outcomes of women undergoing rollerball endometrial ablation for menorrhagia and to identify factors associated with those outcomes. METHODS: Data on the clinical history, operative technique, and follow-up status as of August 1998 were obtained by retrospective medical record review for 240 women undergoing rollerball endometrial ablation with or without resection of polyps or myomas from January 1991 through December 1996. The incidence of subsequent hysterectomy was calculated by survival analysis, and Cox proportional hazard models were used to identify the predictors of success or failure of the procedure. RESULTS: The mean follow-up time was 31.2 months. Twenty-nine women (31% of the available subjects) who had not undergone hysterectomy were still being monitored 5 years after the rollerball endometrial ablation. Overall, the probability of no hysterectomy in the first 5 years was 71%. Ablation was repeated in 10 patients, six of whom eventually underwent hysterectomy. Multivariate analysis identified previous tubal ligation as a statistically significant positive predictor of the risk of hysterectomy (hazard ratio 2.20, 95% confidence interval [CI] 1.18, 4.09). Women at least 45 years old had a lower risk of subsequent hysterectomy than those younger than 35 years of age (hazard ratio 0.28, 95% CI = 0.10, 0.75). CONCLUSION: The results of this study confirm the effectiveness of rollerball endometrial ablation for the treatment of menorrhagia for a longer duration of follow-up than in most previous reports. Repeated ablation and a younger age at the time of ablation increase the risk of requiring a subsequent hysterectomy.     

Submucous Fibroids: Clinical Profile and Hysteroscopic Management

EDITORIAL COMMENTS: This paper was accepted for publication because it reports a further use of the hysteroscope other than endometrial ablation. Some of the cases clearly involved more than pedunculated polyps lying free in the uterine cavity; the technique included removal of intramural fibromyomas. It is too soon to judge the impact this new technology will have on avoidance of hysterectomy in women with menorrhagia and/or pain. The hysteroscopist reviewer made the comment that, in his view, laparoscopy should be performed by a second operator when intramural fibromyomas are resected during hysteroscopy, to avoid perforation of the uterus and thermal damage to pelvic structures. The laparoscopist at these procedures sometimes sees the uterine wall become inverted as the subjacent fibromyoma is resected, a fact that should be drawn to the attention of the hysteroscopist! The author's response to this editorial comment is the paragraph of the discussion section of this paper printed in italics.
Summary: Fifty submucous fibroids were removed by hysteroscopic resection from 37 patients with abnormal uterine bleeding. Thirty-seven fibroids were completely resected and 13 incompletely resected. Nine patients also had rollerball endometrial ablations. The average follow-up period was 14 months (4 to 51 months) in 33 patients available for follow-up. All of these patients had cure of their symptoms, 3 after repeat operations. The 1 immediate complication was a postoperative infection. A normal uterine cavity was found in 13 of 14 patients examined by office hysteroscopy at follow-up.     

Hysteroscopic resection of endometrial polyps: a study of 195 cases

OBJECTIVE: To ascertain the therapeutic efficiency of hysteroscopic resection for the treatment of endometrial polyps in women with abnormal uterine bleeding and postmenopausal metrorrhagia. SETTING: University hospital. DESIGN: Retrospective consecutive patient follow-up. MATERIAL AND METHODS: From 1987 to 1997, 195 patients with haemorrhagic endometrial polyps were treated with hysteroscopic resection in our department. RESULTS: Five complications occurred, but no major complications were noted. A total of 89.2% of the patients remained in contact after hospitalization. After long term follow-up (5.2 years), successful results were obtained in 80% of the patients with polyp resection without associated endometrial ablation. Further surgery (hysterectomy) was required in only five women. CONCLUSION: Transcervical resection is the gold standard for treatment of endometrial polyps.     

Long-term impact and risk factors for hysterectomy after hysteroscopic surgery for menorrhagia

The objective of this study was to assess the long-term impact of management and establish the incidence of hysterectomy, and to identify factors predictive of failure of the procedure among women who had undergone hysteroscopic endometrial resection with or without myomectomy for menorrhagia. Clinical history and data on additional treatment and follow-up status were obtained by medical record review and postal questionnaire for 279 women who had undergone hysteroscopic surgery. Follow-up data were available for 259 (93%) cases, and the mean follow-up was 6.0 years. Subsequent hysterectomy was the primary endpoint, and its incidence was calculated by survival analysis. Univariant analysis and Cox regression model were used to identify predictors of failure. Myomas, polyps, adenomyosis, or endometrial hyperplasia were found in 40.9% of hysteroscopic procedures. Perioperative complications occurred in 5.7% and late complications in 7.7%. During the follow-up period, 97 (37.5%) of 259 women underwent at least one gynecological procedure. The incidence of hysterectomy was 23.6% (95% confidence interval: 18.8–29.1%). Positive predictive factors for hysterectomy were long uterine cavity (≥9 cm) and tubal ligation. Most (82.8%) of the 198 women who did not undergo hysterectomy had postoperative oligo- or amenorrhea. Hormone replacement therapy was common (67%) among postmenopausal women after endometrial resection. Hysteroscopic resection of the endometrium and concomitant hysteroscopic resection of fibroids for the treatment of menorrhagia is a suitable alternative to hysterectomy and offers lasting results. A large uterine cavity indicating possible uterine pathology and tubal ligation associated with hematometra increase the risk of hysterectomy.     

Endometrial ablation with the neodymium:Yag laser

The current study was designed to evaluate Nd:Yag laser endometrial ablation as an alternative to hysterectomy in women with uncontrolled benign uterine bleeding. The subjects were candidates for hysterectomy, had benign endometrial histology, had failed hormonal therapy and/or D&C, and did not desire future childbearing. Medication was given to render the endometrium atrophic, and treatment was carried out using a "touch" technique. Forty-two treated patients have been followed 3-36 months, with a success rate of 81%. Fourteen (33%) are amenorrheic and 13 (31%) estimate that they have less than 25% of their pretreatment flow. Those with uterine size over 10 cm or large submucous fibroids were usually excluded because of technical difficulty in performing the procedure. Treatment outcome was not related to patient weight, uterine size, or small intrauterine abnormalities. Twelve patients had medical conditions that were relative contraindications for hysterectomy, and 11 were treated successfully. Endometrial ablation with the Nd:Yag laser is an effective alternative to hysterectomy in patients with uncontrolled benign uterine bleeding.     

Long-term outcome of hysteroscopic endometrial resection with or without myomectomy in patients with menorrhagia

Objectives  To evaluate the long-term outcomes and hysterectomy rates after hysteroscopic endometrial resection with or without myomectomy for menorrhagia. Study design  Fifty-three women who had submucous myomas with intramural extension of less than 50% and smaller than 5 cm in diameter underwent endometrial resection and concomitant hysteroscopic myomectomy. Each of them was matched with a patient who had no submucous myomas and who had been treated by endometrial resection only. These two groups were compared for operative outcomes, additional procedures, outcome of menstrual bleeding and for subsequent hysterectomy, which was the endpoint of this study. Results  During the mean follow-up period of 6.5 years, 18 (34.6%) women with endometrial resection and myomectomy and 21 (39.6%) without myomectomy underwent at least one gynecological procedure. Hysterectomy was performed in 26.9% [95% confidence interval (CI) 16.8–40.3] of the patients with myomectomy and in 17.0% (95% CI 9.2–29.2) of the patients without myomectomy (P = 0.22). The main indications for hysterectomy were pain and spotting bleeding in seven out of 14 cases with myomectomy and in four out of nine with endometrial resection only. Leiomyomas were found in 12 out of the 14 women who had hysterectomy after hysteroscopic myomectomy and in four out of nine with hysterectomy after endometrial resection only (P = 0.06). Most (75.6%) of the 82 women who had not required hysterectomy had reached menopause. All the patients without hysterectomy in both groups reported amenorrhea or slight bleeding, and this response maintained for years after the treatment. Conclusion  Endometrial resection may be combined with hysteroscopic myomectomy without a significant increase or decrease in hysterectomy rates during a long-term follow-up.     

Outcomes of endometrial-polyp treatment with hysteroscopy in operating room

To assess the results of using a resectoscope in the hysteroscopic resection of endometrial polyps that were previously diagnosed by office hysteroscopy and to demonstrate the necessity of extraction for histological study. A prospective long-term follow-up study (level of evidence II-2). University Hospital. 303 women presenting a hysteroscopic image of an endometrial polyp. Interventions: Office hysteroscopy, hysteroscopic resection of polyps by means of a resectoscope and an anatomopathological study of the polyps. Statistical analysis was performed. 303 diagnosed endometrial polyp formations were resected by means of hysteroscopy during surgery. In all cases, biopsies of the uterine cavity or of the polyp were negative. Resection of the polyps with hysteroscopy in the operating room using a resectoscope proved to be a safe technique. The anatomopathological study of the polyps showed hyperplasia with atypias in 10 cases (3.3%) and endometrial cancer in 9 women (3.0%). Our study data suggest that endometrial polyps should be resected because they may harbor malignant or premalignant lesions. Hysteroscopic surgery is recommended for its simplicity and scant complications.     

Treatment of abnormal uterine bleeding with the gynecologic resectoscope.

The gynecologic resectoscope, recently approved by the Food and Drug Administration for the treatment of abnormal uterine bleeding, was evaluated for its success in the treatment of women with this complaint. Through June 1990, 216 patients were treated with this modality. Ninety were treated with transcervical myomectomy alone since they still desired fertility preservation or wished to avoid hysterectomy. Of the patients treated, 189 (87.5%) had follow-up evaluation for at least three months and some as long as three years. Of the ninety patients treated with resection of a submucous myoma, greater than 90% had a marked improvement in their symptoms, with decreased menstrual bleeding. Of the 96 patients treated with endometrial ablation, 50% were amenorrheic, 26% had hypomenorrhea, 17% had eumenorrhea, and 7% were unimproved. There was only one case of fluid overload, and no patients required a blood transfusion. Complications included two cases of endometritis and one perforation at the time of retrieval of myoma fragments. Four patients required placement of a 30-mL Foley catheter for control of postoperative bleeding. Gynecologic resectoscopy is a safe and effective alternative to major surgery in the management of abnormal uterine bleeding for which conservative measures have not been effective.     

Office Endometrial Ablation with Local Anesthesia Using the HydroThermAblator System: Comparison of Outcomes in Patients with Submucous Myomas with Those with Normal Cavities in 246 Cases Performed Over 5½ Years

Study ObjectiveTo estimate the safety and efficacy of the HydroThermAblator (HTA) system for performance of endometrial ablation in the medical office setting using local anesthesia and minimal oral sedation and to compare results obtained in patients with submucous myomas with those in patients with normal endometrial cavities.DesignRetrospective cohort analysis of 246 HTA procedures (Canadian Task Force classification II-2).SettingMedical offices of a suburban community medical center that is part of a large health maintenance organization.PatientsTwo hundred forty-six women aged 28 to 63 years (mean [SD], 45.1 [6.0] years) with abnormal uterine bleeding unresponsive to conservative management, including 104 patients (42.3%) with submucous myomas. Type 0 or type I myomas were present in at least 86 patients with submucous myomas (82.7%) and ranged from 1 to 4 cm in greatest diameter. In the other 18 patients, submucous myomas were not classified by type. Patients were evaluated at 2 to 70 months after the procedure (median follow-up, 31.0 months). Three patients were lost to follow-up, and 12 patients underwent hysterectomy for indications other than abnormal bleeding and were excluded from the analysis. Thus, 231 patients were included in the analysis.InterventionsEndometrial ablation was performed using the HTA system with paracervical or intracervical block after oral premedication with ibuprophen, diazepam, and acetominophen or hydrocodone and intramuscular ketorolac. No intravenous or intramuscular narcotics were used. The anesthesia regimen was the same in patients with submucous myomas as in those with normal cavities, and the procedure was performed in exactly the same manner. All procedures were performed in the medical office procedure room by 7 board-certified gynecologists; most procedures were performed by the authors.Measurements and Main ResultsOf the 231 patients included in the analysis, 121 (53.4%) reported postablation amenorrhea, 62 (26.8%) reported light menses or spotting, 21 (9.1%) reported normal menses, 15 (6.5%) reported menorrhagia, and 12 (5.2%) underwent hysterectomy because of bleeding. In the 136 patients with normal cavities, amenorrhea was achieved in 84 patients (61.8%), oligomenorrhea in 35 (25.7%), and eumenorrhea in 12 (8.8%). Four patients (2.9%) continued to have menorrhagia requiring medical treatment. In the 95 patients with submucous myomas, amenorrhea was reported by 37 patients (38.9%), oligomenorrhea by 27 (28.4%), eumenorrhea by 9 (9.5%), and menorrhagia by 11 (11.6%). In 11 patients (11.6%), hysterectomy was performed because of menorrhagia. All patients who underwent hysterectomy had multiple myomas, and 9 (81.8%) also had adenomyosis. The failure rate, defined as patients with menorrhagia or undergoing hysterectomy because of bleeding, was 11.7% overall. The failure rate in patients with submucous myomas and normal cavities was 23.2% and 3.7%, respectively (relative risk, 6.3; 95% confidence interval, 2.5–16.0). While the failure rate in the group with myomas was statistically significantly higher than in the group without myomas, the failure rate in the myoma group was still comparable to that achieved using electrosurgical resection and ablation of similar types of myomas as reported in the literature. The amenorrhea rate achieved in the myoma group (38.9%) was also comparable to that achieved in US Food and Drug Administration pivotal trials in patients with normal cavities treated using all of the nonhysteroscopic global ablation devices as well those treated using rollerball endometrial ablation. The rate of hysterectomy because of bleeding was 5.2% overall. The hysterectomy rate in patients with submucous myomas and normal cavities was 11.6% and 0.7%, respectively. Only 1 procedure was discontinued (at 8 minutes) because of pain. Four patients had postoperative endometritis, with 2 requiring hospitalization for intravenous antibiotic therapy. Two false passages were created while dilating the cervix, with subsequent inability to perform the procedure.ConclusionsHydrothermablation performed in the medical office using local anesthesia seems to be a safe, effective, and cost-saving procedure for treatment of abnormal uterine bleeding in women with both normal and myomatous uteri. Although the success rate in patients with normal cavities was higher than that achieved in patients with submucous myomas, hysterectomy because of abnormal bleeding related to myomas was avoided in 88.4% of the group with myomas.     

Transcervical resection of submucous myoma

Thirteen women with chief complaints of menorrhagia and metrorrhagia underwent transcervical resection (TCR) of pedunculated submucous myoma using either an operating hysteroscope or urologic resectoscope. Eight women received TCR with a urologic resectoscope without further operation. Subsequent vaginal hysterectomy was performed on one woman after TCR of a large prolapsed submucous fibroid with a urologic resectoscope because of adenomyosis. Three women underwent TCR of the same type of large prolapsed submucous myoma with an operating hysteroscope. Later, due to other pathologic lesions of the uterus, subsequent vaginal hysterectomies were done on two women and a subsequent abdominal hysterectomy on another woman. Without TCR of these large prolapsed submucous myoma, subsequent vaginal hysterectomies were not possible. Only one woman underwent TCR of submucous myoma with an operating hysteroscope without further operation. All patients showed improvement in such clinical symptoms as menorrhagia, metrorrhagia, and anemia. Before TCR, we make it a rule to use a new diagnostic hysteroscope (4mm external sheath) to reevaluate the position and size of the fibroid. The fluid media used were 10% dextrose for diagnostic hysteroscopy, 5% dextrose for therapeutic hysteroscopy and 10% urigal for urologic resectoscopy. Three months after the operation, second look hysteroscopy is arranged. All patients except one have been followed up at our outpatient department.     

Role of a bipolar resectoscope in subfertile women with submucous myomas and menstrual disorders

AIM: To evaluate the role of the Gynecare (Ethicon, Somerville, NJ, USA) bipolar resectoscope in resecting fibroids, and the effect of hysteroscopic myomectomy on infertility and pregnancy outcomes. METHODS: From January 2000 to December 2005, we studied 59 women of reproductive age with menorrhagia, submucous myomas and one or more infertility factors. All women who participated had been subfertile for over 2 years. Fifteen of the 59 women displayed submucous myoma type O (intracavitary), 34 displayed submucous myoma type I (less than 50% within the myometrium) and the remaining 10 women displayed myoma type II (over 50% being within the myometrium).The mean age and standard deviation of these patients was 34.6 +/- 4.4 years and the average size of myomas was 15 +/- 10 mm. Treatment of these myomas was by hysteroscopic resection using a bipolar resectoscope. RESULTS: Menorrhagic incidents improved in 20 of 32 women (62.5%). Twenty-five women (42.4%) succeeded in becoming pregnant. The pregnancy rate was notably higher when the sole reason of subfertility was the presence of myoma (54.16%), and when the size of the myoma was equal to 2.5 cm (75%) or more. CONCLUSION: The use of the bipolar resectoscope in hysteroscopic removal of small submucous myomas is shown to be both feasible and effective in controlling menorrhagia and increasing the pregnancy rate in subfertile women, when submucous myomas are the only reason of infertility.     

Endometrial cancer following endometrial resection

Endometrial ablation has emerged as a viable alternative to hysterectomy in the treatment of medically intractable dysfunctional uterine bleeding. However, this procedure cannot guarantee complete removal of the entire endometrium. Cases of endometrial cancer after endometrial ablation have been reported in the literature. We reviewed the cases of patients who underwent hysteroscopic endometrial ablation by endometrial resection for abnormal uterine bleeding from 1994 to 2005 at the Department of Obstetrics and Gynecology, Polyclinique, Clermont-Ferrand University. Of the 3769 patients having had hysteroresections, four developed endometrial cancer after complete endometrial ablation (1.06 out of 1000). All four of these patients showed histological evidence of endometrial polyps at endometrial resection, and all of them presented risk factors for endometrial carcinoma, such as obesity and/or arterial hypertension. Endometrial cancer after hysteroscopic endometrial ablation is a rare but possible occurrence, even a long time after the operation. Close monitoring of patients who have undergone endometrial ablation for endometrial polyps and who present risk factors, such as obesity or hypertension, even after apparent total ablation of the endometrium is strongly recommended, independently of the presence of abnormal bleeding that can represent a late symptom of advanced endometrial cancer.     

Endometrial ablation repeat procedures. Case studies.

Of 143 women who underwent endometrial ablation from May 1986 through August 1991, 16 requested repeat endometrial ablation and 7 underwent hysterectomy. Only two of the hysterectomies were performed for bleeding, and no hysterectomy was needed for any woman who had a repeat endometrial ablation. For patients undergoing one ablation, the results were amenorrhea in 55 women (38%), staining in 32 (22%), light flow in 33 (23%), 7 hysterectomies (5%) and 16 patients requesting repeat endometrial ablation (11%). Repeat endometrial ablation resulted in amenorrhea in 10 women (63%), staining in 3 (19%) and light flow in 3 (19%). Repeat endometrial ablation can eliminate the need for hysterectomy in women who continue to have bleeding problems after one endometrial ablation. Gynecologists should not hesitate to offer repeat ablation since the results will usually be excellent.     

Diagnosis and treatment of menorrhagia

One-third of all women experience heavy menstrual bleeding at some point in their life. In western countries, about 5% of women of reproductive age will seek help for menorrhagia annually. Half of all women who consult for hypermenorrhea have some uterine abnormality, most often fibroids (among patients under 40 years of age) and endometrial polyps (above 40 years of age). Appropriate treatment considerably improves the quality of life of these patients, and it is important to make a rigorous assessment of the patient to provide the best treatment options. This guideline provides instructions on how to examine and treat women of fertile age who have menorrhagia. The subject's own assessment of the amount of menstrual blood loss does not generally reflect the true amount. All patients should undergo a pelvic examination and, if the menstrual pattern has changed substantially or if anaemia is present, a vaginal sonography should be carried out as the most important supplemental examination. Vaginal sonography combined with an endometrial biopsy is a reliable method for diagnosing endometrial hyperplasia or carcinoma, but it is insufficient for diagnosing endometrial polyps and fibroids; these can be diagnosed more reliably by sonohysterography or hysteroscopy. Non-steroidal anti-inflammatory drugs and tranexamic acid reduce menstrual blood loss by 20-60%, and the effectiveness of a hormonal intrauterine system (IUS) is comparable with that of endometrial ablation or hysterectomy. Cyclic progestogens do not significantly reduce menstrual bleeding of women who ovulate. Treatment should be started with one of the drug therapies, i.e. the IUS, tranexamic acid, anti-inflammatory drugs, or oral contraceptive. Drug treatment should be used and evaluated before surgical interventions are considered. With an effective training and feedback system, it is possible to organise the diagnostics, medical treatment and follow-up of heavy menstrual bleeding in the primary health care setting or in outpatient clinics, which reduces the burden on specialist health care.     

Hysteroscopic surgery

Hysteroscopy and visually directed endometrial sampling have replaced blind curettage for the diagnosis of endometrial disease. Hysteroscopy can be used to detect endometrial cancer and various premalignant lesions, as well as to diagnose intrauterine polyps and submucous fibroids. It can also be used to locate lost intrauterine devices, assess the shape and size of the endometrial cavity during an infertility work-up and to visualise intrauterine septae and adhesions. If the hysteroscopist possesses special skills and training, it can be used to perform intrauterine sterilisation by occluding the tubal ostia. The ability to perform endometrial ablation as an alternative to hysterectomy in patients with menorrhagia has led to reduction in the number of hysterectomies performed. Long-term follow-up has confirmed the success of this procedure, but it is not without complications. The inherent dangers and complications of endometrial ablation and the considerable skill and training it requires has led to the development of numerous second-generation devices, which can involve balloons that are heated with circulating fluid, impedance-controlled endometrial ablation or surface electrodes, heated fluid running through the hysteroscope under direct vision or the use of microwaves or cryotherapy. This chapter reviews the techniques, potential complications and evidence for the effectiveness of the common diagnostic and therapeutic hysteroscopic procedures.     

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.