Sonohysterography versus transvaginal sonography for screening of patients with abnormal uterine bleeding.

OBJECTIVES: To compare the accuracy of saline infusion sonohysterography (SIS) with transvaginal sonography (TVS) for the screening of causes of abnormal uterine bleeding (AUB) in out-patients. METHODS: 81 patients with AUB were studied. All cases who were examined with TVS, were further investigated with SIS using saline as contrast medium, finally hysteroscopy was used as the gold standard. RESULTS: TVS had sensitivity of 72%, specificity of 92%, positive predictive value of 94% and negative predictive value of 65%, while SIS had sensitivity of 94.1%, specificity of 95%, positive predictive value of 96% and negative predictive value of 90%. TVS had kappa measure of agreement of 0.60 while 0.86 was reported for SIS. CONCLUSIONS: In this study SIS was more sensitive and specific in diagnosing polyp, myoma and adenomyosis with high positive and negative predictive value. Furthermore, results obtained by SIS demonstrate more agreement with that obtained by hysteroscopy than TVS.     

Challenges in the transvaginal management of abnormal uterine bleeding secondary to cesarean section scar defect

Objective

Research suggests that the resectoscopic management of abnormal uterine bleeding (AUB) following cesarean section (CS) is safe and effective. There is, however, a lack of complementary data from routine clinical practice. We aimed to evaluate the efficacy of resectoscopic remodeling of the CS scar in the management of post CS AUB (pCSAUB).

Study design

The case notes of 57 women with pCSAUB who had undergone a resectoscopic remodeling procedure were reviewed retrospectively. Primary outcome measures were the duration of preoperative and postoperative menstruation, and postoperative menstrual change. Secondary outcome measures were the impact of patient-dependent variables on the success of the resectoscopic remodeling procedure. The CS scar was located using transvaginal ultrasonography and hysteroscopy. The remodeling procedure was performed with a hysteroscopic resectoscope, and commenced with resection of the fibromuscular scar. This started at the roof of the scar pouch and progressed towards the external os. It then continued along a line parallel to the axis of the cervical canal. The exposed dilated blood vessels and endometrial-like tissue in the roof of the remaining pouch were electrocauterized with a roller-ball electrode.

Results

The mean operating time was 30.2 ± 6.6 min. There was a significant difference in the mean duration of preoperative and postoperative menstruation (12.9 ± 2.9 days and 9.4 ± 4.1 days, respectively; p < 0.001). However, only 59.6% of patients (34/57) reported a postoperative improvement in symptoms. A significant postoperative improvement was observed more frequently in patients with anteflexed uteri than in patients with retroflexed uteri, and this difference was significant (90.6% (29/32) and 20.0% (5/25), respectively; p < 0.001). No correlations were found between treatment outcome and age, body weight, parity, number of cesarean deliveries, duration of preoperative menstruation, or operating time.

Conclusions

Resectoscopic uterine remodeling is an appropriate therapy in patients with pCSAUB and an anteflexed uterus.     

Uterine artery blood flow in patients with copper intrauterine device-induced abnormal uterine bleeding

ObjectiveTo test the hypothesis that copper intrauterine device (CIUD) induced abnormal uterine bleeding is secondary to an increase in the uterine artery blood flow and to determine whether transvaginal color Doppler can be used to identify women at risk of developing abnormal uterine bleeding after CIUD insertion.DesignProspective clinical study.SettingUniversity teaching hospital.MethodsNinety three women were examined by transvaginal color Doppler to detect the pulsatility index (PI) and resistance index (RI) in the uterine artery. Women were divided into three groups. Group I; included 32 women using CIUD (TCu-380A) and complaining of menorrhagia or menometrorrhagia, group II; included 30 women using CIUD with normal menstrual flow and group III which was a control group that included 31 women with normal menstrual flow and not using any contraceptive methods.Mean outcome measuresPI and RI of the uterine artery.ResultsPI and RI were significantly lower in women with CIUD-induced abnormal uterine bleeding compared to women using CIUD with normal menstrual flow or women in the control group. The ROC curves for PI and RI revealed that PI?2.07 had sensitivity 84.4% and specificity 83.3% and RI?0.7 had sensitivity 78.1% and specificity 80% in detecting women with CIUD-induced abnormal uterine bleeding.ConclusionThe results of our study confirm the hypothesis that there is an increase in the uterine blood flow (as indicated by decreased PI and RI in uterine artery) in women with CIUD-induced abnormal uterine bleeding.     

The role of transvaginal ultrasound in the management of abnormal uterine bleeding

Abnormal uterine bleeding is a common symptom. Modern management should be based on a one-stop approach to which transvaginal ultrasound is ideally suited as a primary diagnostic tool. In premenopausal women focal pathology, such as fibroids and polyps, as well as extra uterine pathology, can be accurately diagnosed. In postmenopausal women endometrial cancer can be excluded. In the majority of women diagnostic hysteroscopy can thus be avoided, and patients with focal pathology detected with transvaginal ultrasound can be triaged for operative intervention. Outpatient endometrial biopsy should still be used to exclude endometrial pathology. This one-stop ultrasound-based clinical approach provides a rapid, accurate diagnosis, with the minimum of investigations and invasive procedures. In this way multiple outpatient visits and unnecessary inpatient admissions can be avoided.     

宫腔镜检查术在异常子宫出血中的诊断价值

探讨宫腔镜检查术在各种异常子宫出血中的诊断价值。方法应用宫腔镜检查异常子宫出血患者３１４例,术中行定位取材或诊断性刮宫。结果宫腔镜诊断子宫内膜息肉的敏感性为９６．１５％,子宫粘膜下肌瘤为８５．７１％,子宫内膜增殖症为６０．９４％,子中内膜癌６０％,结论宫腔镜检查异常子宫出血,可提高对子宫内膜肉及粘膜子下宫肌瘤的诊断率,尽管对子宫内膜增殖症及宫内膜癌的舔生与单纯诊刮相似,但可观察到更详细的形态学变经     

Office hysteroscopy versus transvaginal ultrasonography in the evaluation of patients with excessive uterine bleeding

OBJECTIVE: Our purpose was to compare office hysteroscopy with transvaginal ultrasonography for diagnosing intrauterine pathologic disorders in patients with excessive uterine bleeding, with specimens obtained from either hysterectomy or operative hysteroscopy used to represent the true diagnosis. STUDY DESIGN: A total of 149 patients underwent office hysteroscopy between July 1993 and December 1994. They were evaluated for complaints of menorrhagia, metrorrhagia, or postmenopausal bleeding. Data encompassing patient age, gravidity, parity, indication, ultrasonographic and hysteroscopic findings, comfort level, time required, and complications were gathered by resident physicians. Most hysteroscopic examinations were preceded by transvaginal ultrasonography. All patients received premedication with 600 mg of ibuprofen and a paracervical block with 1% lidocaine without epinephrine. Sixty-five patients underwent operative hysteroscopy or hysterectomy later. The pathologic diagnoses of these specimens were compared with hysteroscopic and ultrasonographic findings, and the sensitivity and specificity of each test were calculated. RESULTS: Hysteroscopy was 79% sensitive and 93% specific in diagnosing intracavitary pathologic disorders, whereas transvaginal ultrasonography was only 54% sensitive and 90% specific. One hundred forty-one patients were comfortable during the procedure, and inspection of the uterine cavity was considered adequate in 136. The majority of procedures were completed in <10 minutes. Twenty-six patients underwent operative hysteroscopy and another 39 underwent hysterectomy. No patient who underwent operative hysteroscopy has had a recurrence of abnormal bleeding over a 12- to 30-month follow-up. CONCLUSION: Office hysteroscopy is a rapid, safe, well-tolerated, and highly accurate means of diagnosing the cause of excessive uterine bleeding. It permits patient and physician to discuss more treatment options before surgery, including outpatient operative hysteroscopic procedures. This means savings in time and in drug, procedure, professional, and hospital costs. (Am J Obstet Gynecol 1996;174:1678-82.)     

Abnormal uterine bleeding in adolescents: ultrasound evaluation of uterine volume

Objective: To evaluate ultrasonographic measurements of internal genitalia in girls suffering from abnormal uterine bleeding (AUB) and to compare the appearances with those of healthy girls. DESIGN Prospective case – control study.

Methods: One hundred and five not sexually active adolescent girls were enrolled – 67 patients were suffering from AUB and there were 38 healthy peers. The groups did not differ in chronological age, or in postmenarcheal age. All girls underwent assessment of their history, clinical data and transabdominal pelvic ultrasound to evaluate their uterus and ovaries. In order to avoid the impact of endometrium cycle fluctuations, the uterine volume was calculated including and excluding its thickness.

Results: The uterine volume among the girls suffering from AUB was significantly larger than in the control group. The mean uterine volume including endometrium in the study and control groups was 63.2?±?24.8 and 47.8?±?17.5?cm³, respectively (p=.001), and excluding the endometrium was 34.7?±?13.1 and 29.1?±?13.8?cm³ (p=.043). We did not find any significant difference in ovarian volume between the groups.

Conclusions: The girls in the AUB group have significantly larger uterine volume than healthy girls. This finding does not depend on endometrial thickness.     

The clinical relevance of hysteroscopic polypectomy in premenopausal women with abnormal uterine bleeding

This study assessed the efficacy of hysteroscopic polyp removal in the management of abnormal uterine bleeding (AUB) of premenopausal patients. The monthly menstrual blood loss, measured semi-objectively by the pictorial blood loss assessment chart (PBAC) and patients satisfaction were recorded prospectively preoperatively and postoperatively. Twenty-one patients were included. Median monthly PBAC-score before treatment was 288 (range 142–670) and 6 months after polyp removal 155 (range 39–560). It was concluded that hysteroscopic polyp removal in premenopausal women with AUB reduces the monthly blood loss significantly and has a high satisfaction rate on the short term.     

宫腔镜在围绝经期异常子宫出血诊断中的临床价值

目的 探讨围绝经期异常子宫出血患者采用宫腔镜诊断的临床价值。方法 选取100例围绝经期异常子宫出血患者,患者均实施宫腔镜下活检或分段诊刮术,对刮出组织行病理检查。以病理诊断为金标准,分析宫腔镜检查与病理诊断结果诊断符合率,并分析宫腔镜检查对各疾病诊断的敏感性、特异性,评价其诊断效能。结果 宫腔镜检查与病理诊断结果的符合率为92.00%,Kappa值为0.90,一致性较好。对诊断异常子宫出血类疾病的敏感性、特异性均处于较高水平。结论 围绝经期异常子宫出血患者采用宫腔镜检查具有较高的诊断价值,可及时明确病因,为早期诊断与治疗提供可靠依据。     

门诊宫腔镜对10565例异常子宫出血患者PALM-CORIN病因分类的应用

目的:探讨门诊宫腔镜及PALM-CORIN病因分类方法对异常子宫出血(AUB)患者病因、诊断、临床治疗的价值。方法:回顾分析2008年1月1日至2015年12月31日在湖北省妇幼保健院妇科门诊宫腔镜诊治中心因异常子宫出血就诊的10565例患者的临床资料,分析其就诊原因、阴道出血模式及宫腔镜检结果,并重新进行PALMCORIN分类,梳理其诊治流程。结果:10565例AUB患者的就诊原因和阴道出血模式依次为:月经频发、月经过多、月经期延长、不规律月经、月经异常合并不孕、经期间出血、月经过少、月经稀发,分别具有不同的PALM-CORIN病因分类。按PALM-COEIN病因分类系统,10565例AUB患者中,存在结构异常者4318例,占40.9%;存在非结构异常者6247例,占59.1%;非结构异常者的年龄显著高于结构异常者(P0.05)。结构异常的患者中,病因分类排序依次为AUB-P、AUB-L、AUB-A、AUB-M;非结构异常的患者中,病因分类排序依次为AUB-O、AUB-I、AUB-E、AUB-N、AUB-C。结论:门诊宫腔镜和PALM-COEIN病因分类系统在AUB的诊治、分流中扮演着重要角色,有助于急慢性AUB患者的流行病学、病因学和治疗等多方面的研究。     

Comparison of saline infusion sonohysterography and hysteroscopy in diagnosis of premenopausal women with abnormal uterine bleeding

Objective

The aim of this study was to compare the diagnostic effectiveness of transvaginal sonography (TVS), saline infusion sonohysterography (SIS), and diagnostic hysteroscopy (HS), with the pathologic specimen as a gold standard diagnostic method, in detecting endometrial pathology in premenopausal women with abnormal uterine bleeding.

Study design

This prospective cohort study was conducted at Zeynep Kamil Education and Training Hospital, Istanbul, Turkey, and included 89 premenopausal women. All participants were examined first by TVS, further investigated with SIS and HS, and finally dilatation and curettage was performed when needed. The results obtained from these three methods were compared with the pathologic diagnoses. The positive and negative likelihood ratios (LR+ and LR−) of TVS, SIS and HS were calculated by comparison with the final pathological diagnosis. In addition, area under the curve (AUC) values were also calculated.

Results

Polypoid lesion was the most common abnormal pathology. LR+ and LR− of TVS, SIS, and HS were 3.13 and 0.15, 9.83 and 0.07, 13.7 and 0.02 respectively in detection of any abnormal pathology, and the AUCs of TVS, SIS, and HS were 0.804, 0.920, and 0.954 respectively. When the three procedures were compared with each other separately, HS had the best diagnostic accuracy, and the diagnostic accuracy of HS and SIS was superior to TVS (p₁ = 0.000, p₂ = 0.000). For the detection of polypoid lesions, HS was the most accurate diagnostic procedure (AUC = 0.947), followed by SIS (AUC = 0.894) and TVS (AUC = 0.778).

Conclusion

HS provides the most accurate diagnosis and allows treatment in the same session in premenopausal women with abnormal uterine bleeding.     

Abnormal uterine bleeding, a new terminology is needed

The current terminology describing abnormal uterine bleeding (AUB) is not universally agreed upon. A new AUB terminology must be uniform, unambiguous, and symptom focused. A prototype letters and numbers formula covering the entire spectrum of AUB is proposed that may contain sequences such as B1D2F1A2P1 (i.e., moderate-1 bleeding, lasting for 2 days-duration, with frequent monthly-1 presentation, causing significant-anemia and mild-1 pains). Universal acceptance of a similar standard and reproducible terminology will add semiquantitative information, enable accurate reporting, and facilitate clinical research.     

Investigation of abnormal uterine bleeding in perimenopausal women by hysteroscopy and endometrial biopsy

The causes of abnormal uterine bleeding (AUB) during the perimenopausal period in women receiving hormone replacement therapy (HRT) were investigated, along with the causes of postmenopausal bleeding, the efficacy of hysteroscopy in the diagnosis of endometrial pathology was investigated. The patients studied were referred to our academic gynaecological clinic during the period 1999–2003. 145 cases that had undergone hysteroscopy and endometrial biopsy for AUB during the perimenopausal period over the last four years were reviewed retrospectively. The main group (76 patients) presented AUB while they were taking sequential or continuous HRT for menopausal symptoms and to prevent osteoporosis. The control group (69 patients) presented postmenopausal bleeding. There was an increased incidence of endometrial pathology in the group receiving HRT in comparison with the control group (52.6% vs. 40.4%), but this difference was not significant. The main findings were functional endometrium (38.1%) in the group receiving HRT and atrophic endometrium (40.6%) in the control group, respectively. These differences were statistically significant between the two groups. Diagnostic hysteroscopy was performed successfully with no serious complications and was performed without anesthesia in over 30% of the patients in both groups. The incidence rates of the structural endometrial causes of AUB in perimenopausal period are similar in women taking HRT and those presenting postmenopausal bleeding. Hysteroscopy is a safe and efficient method of investigating women with AUB during the perimenopausal period. In addition, the increasing use of outpatient hysteroscopy will simplify assessments of patients presenting with AUB during the perimenopausal period.     

Diagnostic evaluation of Karman endometrial aspiration in patients with abnormal uterine bleeding

AIM: To assess sensitivity and specificity of Karman aspiration in the diagnosis of abnormal endometrium compared with the final diagnosis and evaluate tissue adequacy obtained by Karman aspiration. METHODS: The study group were women who presented with abnormal uterine bleeding to Songklanagarind Hospital between August 2003 and July 2004 and who underwent Karman aspiration prior to conventional curettage. The final diagnosis was defined as the most severe histopathology from either Karman aspiration or conventional curettage. Abnormal endometrium included inflammation, polyp, hyperplasia and malignant changes. RESULTS: Two hundred and twenty-six women were assessed. Endometrial aspiration showed a sensitivity of 89.6% and specificity 100.0% in diagnosis of abnormal endometrium. Abnormal endometrium was detected in 58 women. Of 11 women diagnosed with endometrial cancer, only one case was undetected by Karman aspiration due to a failure to create negative pressure in the uterus. Endometrial aspiration yielded adequate tissue in 86.7%. CONCLUSION: Karman endometrial aspiration is an accurate and easy procedure, and should be considered in the initial evaluation of abnormal uterine bleeding.     

彩色多普勒超声检查子宫动静脉瘘14例临床分析

目的探讨子宫创伤所致子宫动静脉瘘患者彩色多普勒超声血流特征及指导临床治疗的价值。方法采用彩色多普勒超声观察14例既往有流产或剖腹产史子宫异常出血患者的子宫血流情况。结果14例创伤性子宫异常出血患者彩色多普勒频谱超声均观察到子宫肌层丰富血流信号；表现为特征性动静脉瘘区五彩镶嵌血流信号，瘘口处探及高速动脉血流频谱3例，表现为肌层回声不均，肌层湖泊样低速低阻血流频谱11例，其中1例动静脉瘘合并假性动脉瘤保守治疗成功；1例单纯子宫动静脉瘘行球囊压迫止血成功；1例子宫动静脉瘘合并宫腔残留，在子宫动脉栓塞后刮宫治愈；另11例抗炎止血保守治疗。结论子宫动静脉瘘是创伤性子宫异常出血的原因之一，彩色多普勒超声可用于其诊断并指导临床治疗和监测治疗效果。     

Perspectives on “Abnormal uterine bleeding—an international agreement on terminologies and definitions”

Abnormal uterine bleeding (AUB) is a common reason for a woman to present at her gynaecologist. In this issue of Gynecological Surgery, a new terminology for AUB is proposed. The terminology used at present is not accurate for the characterisation of a normal menstruation. The need for a consensus on the nomenclature and the clinical application of the terms describing AUB is urgently needed.