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.     

A comparison of outpatient hysteroscopy with saline infusion hysterosonography

Objectives To establish the accuracy of saline infusion hysterosonography in diagnosing uterine pathology when compared with outpatient hysteroscopy.
Design Prospective, parallel, blinded comparative study.
Setting Outpatient hysteroscopy clinic in a large university teaching hospital.
Population All women referred for outpatient hysteroscopy in a 15-month period.
Interventions Women underwent saline infusion hysterosonography followed by flexible hysteroscopy. The ultrasonographer was blinded to the hysteroscopy result and the gynaecologist was blinded to the saline infusion hysterosonography result.
Main outcome measures The relative success rates and pain scores for each procedure. The validity of saline infusion hysterosonography as a diagnostic test.
Results One hundred and seventeen women entered the study; 70 women were premenopausal and 47 postmenopausal. In 27 women, one or both procedures could not be performed. Saline infusion hysterosonography failed in 20 women, on one occasion hysteroscopy failed and both investigations failed in six women. Ninety cases remained for direct comparison, with 78 cases of agreement on the uterine findings in both investigations. Twelve cases disagreed; in one case, an adhesion was seen, two cases with polyps and five with fibroids seen on ultrasound but not seen on hysteroscopy. There were four cases where polyps were identified on hysteroscopy but not on saline infusion hysterosonography. The median pain scores were 1.6 for saline infusion hysterosonography and 3.2 for hysteroscopy.
Conclusions Both saline infusion hysterosonography and hysteroscopy are well tolerated by women. Saline infusion hysterosonography has a high failure rate but has a lower pain score than hysteroscopy.     

The value of outpatient hysteroscopy in diagnosing endometrial pathology in postmenopausal women with and without hormone replacement therapy

BACKGROUND: This study examined the endometrial pathology in postmenopausal women who had experienced abnormal uterine bleeding, both with and without hormone replacement therapy (HRT), and who subsequently underwent outpatient hysteroscopy. METHODS: This is a retrospective observational and comparative study. Patient data in the period from 1998 to 2001 inclusive were examined. The influence of various factors on the incidence of pathology was determined, for example HRT use, the type of HRT, age, etc. In addition, the reliability of hysteroscopy in identifying pathology was calculated. RESULTS: A total of 503 patients presented with postmenopausal bleeding, 299 postmenopausal women and 204 women on HRT. The incidence of endometrial carcinoma was significantly higher in the postmenopausal women not on HRT (RR > 10), and occurred in women who were significantly older (p = 0.003). Other forms of pathology, such as complex hyperplasia, benign endometrial polyps and fibroids, did not significantly differ between the groups. Outpatient hysteroscopy correctly identified endometrial carcinoma in 98.2% of cases; however, it was less reliable in diagnosing other forms of pathology. CONCLUSIONS: The relative risk of a postmenopausal woman presenting to a hysteroscopy clinic with abnormal bleeding caused by endometrial cancer is more than 10 times the risk of an HRT counterpart. Furthermore, both hysteroscopy and pipelle sampling are required to accurately identify all cases of endometrial carcinoma.     

Effect of Menopausal Status on the Diagnosis of Endometrial Polyp

ObjectiveThis study sought to compare the value of transvaginal ultrasonography (TVUS) and hysteroscopy in premenopausal and postmenopausal women in the diagnosis of endometrial polyp.MethodsThe records of 694 women with an ultrasonographic diagnosis of suspected endometrial polyp who underwent hysteroscopy were studied. Patients were divided into two groups according to menopausal status, and a comparison was made between two groups.ResultsThere were 299 postmenopausal and 395 premenopausal women in the study. Hysteroscopy confirmed the ultrasonographic diagnosis of endometrial polyp in 212 (71%) and 212 (53%) patients in the postmenopausal and premenopausal groups, respectively (P = 0.001). In postmenopausal patients, 94% of the polyps observed by hysteroscopy were confirmed by histology, whereas in premenopausal patients, the percentage was 85% (P = 0.004).ConclusionIn premenopausal patients, the diagnostic value of TVUS and hysteroscopy is lower than in postmenopausal patients. The appropriate time for TVUS and hysteroscopy should be scheduled in premenopausal women, especially in women with abnormal uterine bleeding.     

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.     

Risk of vasovagal syndrome during outpatient hysteroscopy

STUDY OBJECTIVE: To evaluate influence of hysteroscope type and media used during outpatient hysteroscopy on vasovagal syndrome risk. Study Design: Prospective observational study (Canadian Task Force classification II-1). SETTING: University hospital. PATIENTS: Two thousand seventy-nine women undergoing outpatient hysteroscopy without analgesia. INTERVENTION: Office hysteroscopy with a flexible or rigid hysteroscope and normal saline or CO(2). MEASUREMENTS AND MAIN RESULTS: Fifteen cases of vasovagal syndrome were reported. The rate of vasovagal syndrome was higher with use of a rigid hysteroscope (12/647 [1.85%]) vs. a flexible hysteroscope (3/1432 [0.21%]), p =.00013; p =.009 after adjustment for medium used; and with the use of CO2 (10/426 [2.34%]) vs. saline solution (5/1653 [0.30%]), p <.0001; p =.014 after adjustment for hysteroscope type. CONCLUSION: Risk of vasovagal syndrome is higher with the use of a rigid hysteroscope and CO2, regardless of the indication for hysteroscopy or the parity and menopausal status of the patient.     

Factors affecting adequacy of Pipelle and Tao Brush endometrial sampling

Objective  To compare factors influencing adequacy of endometrial samples obtained using two outpatient sampling devices – Pipelle and Tao Brush.
Design  Pragmatic unblinded trial with investigation schedule randomised separately within two groups according to endometrial cancer risk.
Setting  Gynaecology outpatient clinic of a large city hospital in Edinburgh, Scotland.
Population  All women referred to a gynaecology outpatient clinic during a 28-month period complaining of abnormal vaginal bleeding.
Methods  Women were assigned to two 'risk groups' for endometrial cancer ('high risk' for postmenopausal women and 'moderate risk' for premenopausal women aged over 40 years or with other risk factors). Women in each risk group had both types of biopsy and were randomised to two outpatient visualisations: hysteroscopy and/or transvaginal ultrasound scan.
Main outcome measures  Completion of the investigation, adequacy of sample and acceptability of investigation to women.
Results  In 200 high-risk women, adequate samples were significantly more likely to be obtained by Tao Brush than Pipelle ( P < 0.001). Nulliparity was strongly associated with failed insertion for both devices ( P < 0.001). Inadequate samples were strongly associated with postmenopausal status only for Pipelle ( P < 0.001), and among premenopausal women, for both samplers, with nulliparity ( P < 0.001). A significantly greater proportion of women preferred the Tao Brush to the Pipelle endometrial sampler ( P < 0.001).
Conclusions  In postmenopausal women, Tao Brush sampling offers advantages over use of Pipelle, and the former should be considered as an alternative or additional sampling device in this group of women.     

Improved patient compliance using pediatric cystoscope during office hysteroscopy

STUDY OBJECTIVE: To evaluate the use of a pediatric cystoscope in office diagnostic hysteroscopy. DESIGN: Retrospective review (Canadian Task Force classification II-2). SETTING: Maccabi Outpatient Women's Health Center. PATIENTS: One thousand three hundred and thirty-five women; 959 (71.8%) premenopausal and 376 (28.2%) menopausal. INTERVENTION: Office diagnostic hysteroscopy using 2.3-mm diameter pediatric cystoscope, without premedication or anesthesia. MEASUREMENTS AND MAIN RESULTS: Hysteroscopy was successfully completed in 1298 patients (97.3%). The main reason for failure was cervical stenosis. Menopausal status was the only statistically significant factor correlating with increased failure rate. The analysis demonstrates that for every year of age, the OR for success decreases by 0.965, and success rises by 1.29 for every delivery the woman had. In menopausal women, the OR for success decreases by 0.45. Dilatation of the cervix was required in six women (0.46%), and local anesthesia was needed in only two women. One uterine perforation was recorded, and eight women (0.006%) developed vasovagal reflex or severe abdominal cramps. Post procedural oral analgesia was needed in 108 (8%) of the women. CONCLUSION: The combination of a very small diameter continuous flow pediatric cystoscope, together with its ability to deliver high-quality images of the uterine cavity, make this instrument an excellent option for office diagnostic hysteroscopy.     

Comparison of transvaginal sonography, saline infusion sonography and hysteroscopy in the evaluation of uterine cavity pathologies

AIMS: To determine whether performing transvaginal sonography (TVS) and saline infusion sonography (SIS) before hysteroscopy could reduce the number of diagnostic hysteroscopies performed for the evaluation of uterine cavity abnormalities. METHODS: Two hundred and twenty three women with suspected uterine cavity abnormalities were prospectively evaluated by TVS, SIS and hysteroscopy, and had histological evaluation of the endometrium with hysteroscopic biopsy or dilatation and curettage (D&C). One hundred and sixty five patients (74%) were premenopausal and 58 patients (26%) were postmenopausal. RESULTS: The positive predictive value (PPV) for endometrial polyps was 69% for TVS, 78% for SIS and 81% for hysteroscopy in premenopausal patients. In the postmenopausal group, TVS and SIS could detect only 24% of endometrial polyps, whereas 70% were diagnosed by hysteroscopy. The PPV for submucous fibroids was 47% for TVS, 81% for SIS and 77% for hysteroscopy in the premenopausal group. CONCLUSIONS: In premenopausal patients, SIS and hysteroscopy are equally accurate in the diagnosis of endometrial polyps and submucous fibroids. Hysteroscopy is the most accurate test for polypoid lesions in the postmenopausal group. Performing TVS, SIS and D&C could reduce the number of diagnostic hysteroscopies performed for the evaluation of uterine cavity abnormalities by 71.5% in premenopausal patients. However, this rate decreases to 40% in the postmenopausal group.     

Audit of endometrial biopsy at outpatient hysteroscopy

BACKGROUND AND AIM: Outpatient hysteroscopy (OPH) and endometrial biopsy (EMB) are less invasive alternatives to inpatient hysteroscopy and dilatation and curettage for assessment of the endometrium. Using local anaesthetic, the procedure is readily tolerated and can be completed in an ambulatory setting. This study aims to audit OPH and EMB conducted over three consecutive years with regard to the ability to complete the procedure and subsequent pathology. METHODS: Data were retrospectively collected from the medical records of patients who underwent OPH during the study period. Data collected included demography, medical history, procedure details and outcome. An indicative assessment of the resource requirements for provision of these services in an outpatient versus inpatient setting was also conducted based on published cost information. RESULTS: Between June 2003 to June 2006, 435 OPH were performed and 427 of these were available for audit. Four hundred and five (94.8%) of the procedures were successful. Sixty-five (18.8%) EMBs were reported to be insufficient, of which 41 (63%) were in postmenopausal women (P < 0.001). Women who presented with postmenopausal bleeding were significantly more likely to have an insufficient sample (P < 0.001). The Australian Refined Diagnosis Related Groups cost for inpatient hysteroscopy is $A1,786, including $A711 in theatre costs and $A258 in ward costs. These costs are not incurred with OPH. CONCLUSION: This study indicates that hysteroscopy and EMB can be easily and successfully performed as an outpatient procedure in Australia. Pathology can be readily identified and management planned. Moreover, an opportunity exists for a reduction in resource use by utilising this procedure instead of inpatient hysteroscopy where possible.     

Accuracy of hysteroscopic diagnosis of endometrial hyperplasia: a retrospective study of 323 patients

STUDY OBJECTIVE: To evaluate the diagnostic accuracy of hysteroscopic view in endometrial hyperplasia. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: Public hospital in northern Italy. PATIENTS: Three hundred twenty-three patients suffering from endometrial hyperplasia out of 2251 women (1119 premenopausal and 1132 postmenopausal) who underwent office-based hysteroscopy from January 1996 through May 2004. INTERVENTION: Review of 2251 outpatient hysteroscopies carried out with 5- to 6-mm sheathed hysteroscopes and accomplished with blind or hysteroscopically targeted endometrial biopsies. MEASUREMENTS AND MAIN RESULTS: The pathologic report was considered the reference test. Hysteroscopic detection of focal or extensive endometrial thickening, irregular vascular network, architectural distortion and crowding of gland openings, and gland cyst formation were considered endoscopic features consistent with hyperplasia. Overall sensitivity, specificity, negative predictive values (NPV), and positive predictive values (PPV) of hysteroscopy in order to foresee a diagnosis of hyperplasia were calculated. These figures were calculated both in premenopausal and postmenopausal patients. Histopathology yielded a diagnosis of simple, complex, and atypical hyperplasia in 247, 51, and 25 patients, respectively. Hysteroscopy foresaw hyperplasia in 38.4% of patients with simple hyperplasia and in 58.9% of patients with complex or atypical hyperplasia. Normal hysteroscopic findings underestimated simple hyperplasia in 34 patients (13.7%) and complex or atypical hyperplasias in 1 patient (1.3%) (p <.01). To predict the diagnosis of hyperplasia, hysteroscopy showed an overall sensitivity, specificity, NPV, and PPV of 63.7%, 91.7%, 91.3%, and 64.7%, respectively. Among premenopausal patients, hyperplasia was diagnosed in 134 women (11.9%); in this group, hysteroscopy showed sensitivity, specificity, NPV, and PPV of 65.6%, 88.5%%, 93.5%, and 50.5%, respectively. In postmenopausal patients, we found endometrial hyperplasia in 189 women (16.6%); sensitivity, specificity, NPV, and PPV of hysteroscopic view to anticipate hyperplasia were 61.6%, 95.2%, 89.3%, and 79.4%, respectively. A significantly better PPV to foresee hyperplasia was found in postmenopausal women compared with premenopausal patients (p <.01). CONCLUSIONS: Current hysteroscopic criteria suggesting endometrial hyperplasia are inaccurate; in order to exclude hyperplasia, a pathologic assessment is warranted in all hysteroscopies showing an irregularly lined or thick endometrium.     

Influence of obesity and menopausal status on serum leptin, cholecystokinin, galanin and neuropeptide Y levels.

Obesity occurs in 60% of women after menopause and is characterized by an excess of adipose tissue that depends on several orexigenic (neuropeptide Y (NPY) stimulates carbohydrate ingestion, galanin stimulates fat intake) and anorectic (leptin, cholecystokinin (CCK)) factors. Both leptin and insulin can reduce hypothalamic NPY production and secretion. Behavior related to the consumption of food is probably attributed to the NPY-galanin signalling route. We investigated basal levels of serum leptin, CCK, galanin and NPY in 16 non-obese premenopausal women, in 15 obese premenopausal women (body mass index (BMI) 34.6 +/- 1.3 SD) and in ten obese postmenopausal women (BMI 34.7 +/- 1.5 SD) to determine the relationship between obesity, menopause and these neuropeptides. Obese premenopausal women had three-fold elevations of serum leptin (32.1 +/- 3.2 ng/ml) in comparison to non-obese premenopausal women (10.3 +/- 1.5 ng/ml), but similar levels to those in obese postmenopausal women (35.3 +/- 4.1 ng/ml). In all 44 patients and in both sub-groups of premenopausal and postmenopausal women, serum leptin exhibited a strong positive correlation with BMI (r = 0.8692, p < 0.0001; r = 0.8803, p = 0.0001; r = 0.8184, p = 0.0001, respectively). Serum galanin values showed a statistically significant increment in the obese postmenopausal group (51.1 +/- 8.1 pg/ml) compared to both premenopausal groups: the non-obese (34.9 +/- 5.8 pg/ml) and the obese (36.0 +/- 5.5 pg/ml). Non-obese menstruating women demonstrated NPY levels (175.0 +/- 12.8 pg/ml) significantly higher than those of obese premenopausal women (126.0 +/- 12.1 pg/ml) and obese postmenopausal women (138.1 +/- 15.4 pg/ml). CCK values showed no differences between non-obese and obese pre- and postmenopausal groups. Basal insulin values were elevated in both obese groups compared to non-obese premenopausal women. Significantly increased leptin and galanin levels in postmenopausal obese women coupled with decreased NPY levels revealed some changes in the neuropeptides regulating eating behavior, which may be the reason for the onset of postmenopausal obesity.     

Vaginal misoprostol for cervical priming before hysteroscopy in perimenopausal and postmenopausal women.

OBJECTIVE: To evaluate the effectiveness and possible adverse effects of vaginal misoprostol for cervical priming before hysteroscopy in perimenopausal and postmenopausal women. METHODS: A total of 105 women scheduled for hysteroscopy were randomly assigned to 2 groups. The study group (n=51) received 400 microg of vaginal misoprostol at least 12 h before the procedure and the control group (n=54) received no cervical priming agent. The primary outcome measure was the number of women who required cervical dilation. Secondary outcomes were cervical width (the largest size of Hegar dilator inserted without resistance) as well as complications and adverse effects. RESULTS: In the misoprostol group 27 women (52.9%) required cervical dilation vs. 53 (98.1%) in the control group (P<0.0001). The largest size of Hegar dilator inserted without resistance was 7.6+/-1.4 mm in the misoprostol group vs. 5.0+/-1.1 mm in the control group (P<0.0001). A similar effect of misoprostol on cervical dilation was also found in the subgroup of treated postmenopausal women. Only 2 women (3.9%) experienced mild lower abdominal pain after misoprostol application. CONCLUSION: Vaginal misoprostol applied before hysteroscopy reduced cervical resistance and the need for cervical dilation in perimenopausal and postmenopausal women, with only mild adverse effects.     

Accuracy of preoperative diagnostic tools and outcome of hysteroscopic management of menstrual dysfunction

STUDY OBJECTIVES: To review diagnoses, complications, and surgical findings in women treated for abnormal uterine bleeding by operative hysteroscopy, and to assess the accuracy of preoperative transvaginal ultrasound (TVS), saline-infusion sonography (SIS), diagnostic hysteroscopy, and endometrial biopsy. DESIGN: Retrospective study (Canadian task force classification II-2). SETTING: Tertiary care academic medical center. PATIENTS: Three hundred seventy-five women. Intervention. Operative hysteroscopy for abnormal uterine bleeding. MEASUREMENTS AND MAIN RESULTS: Main indications for hysteroscopy were postmenopausal bleeding (164 patients, 43.7%) and abnormal premenopausal uterine bleeding (211, 56.3%). Main pathology findings were endometrial polyps (172, 45.9%) and submucous myomas (105, 28%). Polyps had histologic abnormalities in 18 patients. Sensitivity of preoperative diagnostic tools for all intrauterine abnormalities and specifically for myomas and polyps was TVS 74% and 39%, SIS 96% and 96%, hysteroscopy 100% and 99%, and Pipelle biopsy 24% and 10%. The complication rate was 1.3%. Postmenopausal women felt significantly more improvement in symptoms (p = 0.02), and were more satisfied (p 相似文献   

A randomised controlled trial comparing outpatient versus daycase endometrial polypectomy

OBJECTIVE: To evaluate outpatient versus daycase endometrial polypectomy by comparing success rate, complications, patient tolerance, pain score, analgesia requirement and recovery. DESIGN: A randomised controlled trial. SETTING: A large UK Teaching hospital. POPULATION: Forty consecutive women diagnosed with an endometrial polyp at outpatient hysteroscopy were randomly assigned in equal proportions to outpatient or daycase polyp removal. METHODS: The outpatient cohort underwent endometrial polypectomy either using grasping forceps or a bipolar electrode (Versapoint; Gynecare Inc., Menlo Park, CA, USA) introduced down the operating channel of a rigid hysteroscope (Versascope; Gynecare Inc.). The daycase cohort underwent traditional endometrial polyp resection using a hysteroscopic, monopolar, electrosurgical resecting loop, performed under general anaesthetic. MAIN OUTCOME MEASURES: The main outcome measures were as follows: success rates and intra or postoperative complications, time away from home, analgesia requirements, pain scores on the day of and one day after endometrial polypectomy, return to work and preoperative fitness and preference for the location of a future endometrial polypectomy. RESULTS: The majority of women from both cohorts were premenopausal (62.5%), parous (85%) and in paid employment (62.5%). One woman allocated to outpatient polypectomy had cervical stenosis and dilatation was unsuccessful in the outpatient setting. There were no other intra or postoperative complications in either arm of the study. The mean intraoperative visual analogue style (0-100 mm) pain score during outpatient polypectomy was 23.7 mm (1-62). A proportion of women (20%) described no intraoperative discomfort; however, the majority (75%) described mild or moderate intraoperative discomfort. More women in the outpatient cohort (58%) described themselves as pain free for the remainder of the day than in the daycase cohort (28%) (P= 0.09). The day after the procedure, all women from the outpatient group described slight or no discomfort compared with only 41% of women from the daycase group (P= 0.02). All women undergoing outpatient polypectomy had a significantly shorter mean time away from home (3.24 [1.5-5] hours) than women undergoing daycase polypectomy (7.42 [6-10.5] hours), P < 0.0005. Similarly, women from the outpatient cohort had a significantly faster mean return to preoperative fitness (1 [0-4] day versus 3.2 [1-13] days; P= 0.001) and required less postoperative analgesia than the daycase cohort. Ninety-five percent of women from the outpatient cohort and 82% of women from the daycase cohort stated they would prefer to undergo an endometrial polypectomy in the outpatient setting should they require a further polyp removal. CONCLUSION: Endometrial polypectomy can be successfully performed in the outpatient setting with minimal intraoperative discomfort, a significantly shorter time away from home and faster recovery and is preferred by women when compared with daycase polypectomy. Resources need to be made rapidly available to undertake larger scale research and develop this service across the UK.     

A randomised controlled trial comparing transvaginal ultrasound, outpatient hysteroscopy and endometrial biopsy with inpatient hysteroscopy and curettage

OBJECTIVE: To compare the use of outpatient and inpatient procedures in the investigation of abnormal uterine bleeding. DESIGN: A randomised controlled trial. SETTING: Two university teaching hospitals. PARTICIPANTS: Four hundred women with abnormal uterine bleeding (postmenopausal bleeding, menorrhagia, intermenstrual bleeding, postcoital bleeding, or irregular periods) above the age of 35 years, between June 1993 and January 1995. MAIN OUTCOME MEASURES: 1. Incidence of detection of abnormal pathology by vaginal ultrasound, outpatient hysteroscopy and endometrial biopsy compared with inpatient hysteroscopy and curettage; 2. Number of 'lesions' (e.g. fibroids, polyps, endometrial hyperplasia or malignancy) found by hysteroscopy that would have been missed by the combination of endometrial sampling and ultrasound; 3. Comparison of the quality of tissue obtained for histology by outpatient endometrial sampling and inpatient curettage; and 4. An evaluation of patient acceptability of outpatient and inpatient procedures. RESULTS: 1. A combination of transvaginal sonography, Pipelle endometrial biopsy and outpatient hysteroscopy has similar efficacy to inpatient hysteroscopy and curettage for the investigation of abnormal uterine bleeding; 2. Hysteroscopy will detect some fibroids and polyps missed by a combination of transvaginal ultrasound and Pipelle endometrial sampling; 3. The quality of histological samples obtained by outpatient Pipelle were comparable to those obtained by formal inpatient curettage; and 4. Outpatient procedures were well tolerated, with good patient acceptability. CONCLUSION: Transvaginal sonography and endometrial biopsy can safely be used as the initial investigations in the management of abnormal uterine bleeding. Hysteroscopy can be used as a second line investigation. Outpatient hysteroscopy with local anaesthesia is well tolerated although general anesthesia may occasionally be necessary.     

Hysteroscopic evaluation of menopausal patients with sonographically atrophic endometrium

STUDY OBJECTIVE: To assess the diagnostic and operative potential of hysteroscopy in postmenopausal patients selected by ultrasound criteria. DESIGN: Prospective evaluation (Canadian Task Force classification II-2). SETTING: Outpatient ultrasound and hysteroscopy department of a university-affiliated hospital. PATIENTS: Two hundred twelve women with an endometrial thickness less than 4 mm on ultrasound and in menopause for at least 1 year. INTERVENTIONS: Transvaginal ultrasound and office hysteroscopy, with eye-directed biopsy specimens obtained with a 5-mm, continuous-flow operative hysteroscope, and performed without anesthesia. MEASUREMENTS AND MAIN RESULTS: Only 13 (6%) patients were symptomatic (irregular bleeding). Hysteroscopic diagnosis of endometrial polyps in three women (23%) was confirmed by histology. In the remaining 199 (94%) asymptomatic patients with atrophic endometrium on ultrasound, hysteroscopy showed an endometrial pathology in 10% (16 polyps, 4 submucous myomas); in one patient histologic evaluation disclosed focal adenocarcinoma in an endometrial polyp. CONCLUSION: Hysteroscopy allows a proper histologic diagnosis, even in asymptomatic postmenopausal women with atrophic endometrium on ultrasound.     

Pain relief in outpatient hysteroscopy: a survey of current UK clinical practice

Background

Outpatient hysteroscopy is increasingly being used as a cost-effective alternative to in-patient hysteroscopy under general anaesthesia. Like other outpatient gynaecological procedures, however, it has the potential to cause pain severe enough for the procedure to be abandoned. There are no national guidelines on pain relief for outpatient hysteroscopy.

Methods

A postal survey of UK gynaecologists was carried out to evaluate current clinical practice regarding methods of pain relief used during office hysteroscopy. A total of 250 questionnaires were sent out and 115 responses received.

Results

Outpatient hysteroscopy was offered by 76.5% of respondents. Respondents reported a wide variation in the use of routine and rescue analgesia, and also in the nature of the analgesia used. One-quarter of those offering outpatient hysteroscopy used no form of analgesia.

Conclusion

The results showed that whilst there is no consensus on the type of analgesia provided, rescue analgesia is commonly being used, particularly in the form of intracervical blocks.     

Small low-density lipoprotein particles in women with natural or surgically induced menopause

OBJECTIVE: To investigate the mechanism of the decrease in the size of low-density lipoprotein (LDL) particles in women with natural menopause and women with surgically induced menopause. METHODS: We measured plasma levels of total cholesterol; triglycerides; high-density lipoprotein (HDL) cholesterol; apolipoproteins A-I, A-II, and B; and sex hormones in 45 women; 15 women were premenopausal, 15 were naturally postmenopausal, and 15 were surgically menopausal. Lipoprotein lipase and hepatic triglyceride lipase activities were measured in postheparin plasma. Concentrations of total cholesterol and of apolipoprotein B in LDL also were measured. Low-density lipoprotein particle diameter was determined by gradient gel electrophoresis. RESULTS: Plasma levels of total cholesterol, triglycerides, apolipoprotein B, LDL-total cholesterol, LDL-apolipoprotein B, and the activity of postheparin plasma lipoprotein lipase were significantly higher and concentrations of estrone and estradiol were significantly lower in the naturally postmenopausal and surgically menopausal women than in the premenopausal women. Plasma levels of HDL cholesterol and apolipoproteins A-I and A-II and postheparin plasma hepatic triglyceride activity did not differ significantly between groups. The diameter of LDL particles was significantly reduced in the naturally (25.29 +/- 0.19 nm) and surgically (25.29 +/- 0.22 nm) menopausal women compared with the premenopausal women (25.88 +/- 0.22 nm). Plasma triglyceride levels were negatively correlated with LDL particle diameter in all three groups (premenopausal group: r = -0.64, P < .01; naturally postmenopausal group: r = -0.62, P < .01; and surgically menopausal group: r = -0.76, P < .001). The prevalence of LDL subclass pattern B was significantly increased in the naturally (67%, P < .05) and surgically (60%, P < .05) menopausal women. CONCLUSION: The plasma concentration of LDL particles was increased after menopause, whether natural or surgically induced. An increase in plasma triglyceride levels in women with low levels of endogenous estrogen appeared to cause the size of LDL particles to be reduced.