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.     

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   

How often are endometrial polyps malignant?

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

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.     

Postmenopausal bleeding: a diagnostic approach for both private and public sectors

OBJECTIVE: To assess the optimal diagnostic approach to women with postmenopausal bleeding by comparing transvaginal ultrasound and endometrial sampling with office hysteroscopy. METHODS: A prospective collective study was performed on 102 consecutive patients with postmenopausal bleeding who were evaluated by ultrasound measurement of the endometrial thickness (EL), endometrial sampling by Accurette and outpatient hysteroscopy and directed biopsy. RESULTS: Accurette was inadequate for histological diagnosis in 65 of 136 samples and many repeat investigations were required. In all 16 cases of endometrial polyps, ultrasound measurement of the EL was > or =4 mm and hysteroscopy confirmed the findings. Accurette detected only 5 polyps. All 7 cases of endometrial hyperplasia were detected using an EL of > or =4 mm and hysteroscopy confirmed the findings. Accurette failed to detect 5 out of 7 cases of endometrial hyperplasia. Five cases of endometrial cancer were diagnosed: all had an EL > or =4 mm but were inadequately sampled for diagnostic purposes in 3 cases. A definitive diagnosis was made on hysteroscopy in 4 cases (1 patient did not have a hysteroscopy). CONCLUSION: Accurette is not a good sampling device for the diagnosis of postmenopausal bleeding. An ultrasound measurement of the EL > or =4 mm in patients with postmenopausal bleeding warrants further investigation. Outpatient office hysteroscopy is an accurate and sensitive modality to employ as a first line investigation for definitive diagnosis.     

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.     

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.     

Découvertes hystéroscopiques chez les femmes de 40 ans et moins avec saignement utérin anormal

Objective: describe hysteroscopic findings among women of 40 years old or less with abnormal uterine bleeding.Methods: this is a retrospective cohort study, using hospital and clinic files for the period of January 1988 to April 1997, where 191 patients 40 years old or younger had a diagnostic hysteroscopy for abnormal uterine bleeding. The rate of successful hysteroscopies, the type of anaesthesia, and hysteroscopic complications were listed. Type and frequency of intrauterine pathology, such as endometrial polyps, submucous myomas, hyperplasia and atrophy, were analyzed. Particular attention was devoted to the incidence of pathology which were not identified by endometrial biopsy (polyps and submucous myomas. Prior treatment before hysteroscopy was also assessed.Results: hysteroscopy was successfully completed in 95.8 percent of cases and the majority of the procedures 67.5% were done under local anaesthesia (paracervical block). No perforation or other major complication has been listed. Intrauterine pathology was diagnosed in 24 percent of patients and, among them, 9.8 percent had an endometrial polyp and 6.6 percent had a submucous myoma. About half of patients 45.9% had no treatment prior to hysteroscopy. Among those with previous treatments, 41 percent failed to respond to oral contraceptive therapy: in those patients, 13.3 percent had an endometrial polyp and 8.0 percent had a submucous myoma.Conclusion: hysteroscopy is a useful diagnostic approach for the investigation of patients 40 years old or less with abnormal uterine bleeding. In 24 percent of these patients, hysteroscopy enables the detection of intrauterine lesions. Most of which could not be detected by endometrial biopsy. According to this retrospective study, it seems preferable to recommend a diagnostic hysteroscopy rather than an endometrial biopsy for the investigation of abnormal uterine bleeding among women 40 years old or younger.     

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

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

Transvaginal ultrasound and diagnostic hysteroscopy as a predictor of endometrial polyps: risk factors for premalignancy and malignancy

The aim of this study is to assess accuracy of transvaginal ultrasound (TVUS) and diagnostic hysteroscopy in diagnosing endometrial polyps and to determine premalignancy and malignancy rates in asymptomatic women. The study was designed to retrospectively analyze 438 women who underwent operative hysteroscopy in a day-care unit when endometrial polyp was suspected after TVUS and diagnostic hysteroscopy. Multivariate logistic regression modeling showed effects of age, previous breast cancer with tamoxifen treatment, and menopause with or without bleeding on pathologic results. The results indicate that positive predictive value of TVUS with diagnostic hysteroscopy was 79.9%. Premalignancy or malignancy occurred in 3.2% and was significantly related to menopause with abnormal bleeding (P < 0.001), which carried a 20-fold higher risk of pathology than any other group. Age was also a risk factor. It was concluded that TVUS with diagnostic hysteroscopy reliably evaluates endometrial polyps. The low incidence of endometrial tumors in asymptomatic (especially premenopausal) women suggests that their operative evaluation may not be cost effective. Larger studies are needed to support this tentative conclusion.     

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.     

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.     

Ambulatory hysteroscopy: evidence-based guide to diagnosis and therapy

Healthcare providers are facing increasing demands for improvement in quality of life for patients. Improvements in service provision for women are being ensured by the introduction of minimally invasive technologies into all spheres of gynaecologic practice. Ambulatory hysteroscopy (direct endoscopic visualization of the endometrial cavity) is an extremely exciting and rapidly advancing field of gynaecologic practice. It advanced dramatically during the 1990s, shifting the focus in healthcare away from inpatient diagnosis and treatment. Hysteroscopy is used extensively in the evaluation of common gynaecological problems that were previously evaluated with blind and inaccurate techniques (e.g. premenopausal menstrual disorders, infertility and postmenopausal bleeding). It allows direct visualization of the uterine cavity and the opportunity for targeted biopsy, safe removal of endometrial polyps, and treatment of submucous fibroids, septa and adhesions. Ambulatory hysteroscopy is safe, with a low incidence of serious complications; it has a small failure rate. There is a general consensus that hysteroscopy is the current gold standard for evaluating intrauterine pathology, including submucous myomas, polyps, hyperplasia and cancer. Hysteroscopy in the ambulatory setting appears to have an accuracy and patient acceptability equivalent to inpatient hysteroscopy under general anaesthetic. The primary goal of this chapter is to provide a high-quality, evidence-based text on ambulatory diagnostic and operative hysteroscopy. The chapter includes in-depth analysis of the indications for outpatient hysteroscopy, its contraindications, the accuracy of diagnostic hysteroscopy, relevant risk management issues and, training and teaching.     

Hysteroscopy in cases of abnormal uterine bleeding and abnormal ultrasonographic findings of uterine cavity-own experience

OBJECTIVES: In the paper authors present indications and results of using diagnostic and operative hysteroscopy in the clinical practise and compare histological result with introductory diagnosis of ultrasonography and hysteroscopy. MATERIALS AND METHODS: In period of 01.06.1998-01.09.2002 148 hysteroscopy were done with in 58 diagnostic and 90 operative histeroscopies. Received material was sent to histological research. RESULTS: non-pathologic change was diagnosed in 37 women, 43 endometrial polyps, 20 submucous myomas, 5 polyps and myomas together. CONCLUSIONS: 1. Most often observed change in intrauterine pathology were endometrial polyps and submucous myomas. 2. In a few cases only hysteroscopy let us discover the reason of pathological bleedings from the uterus. 3. hysteroscopy has become the method necesary in some cases of gynaecological pathology.     

Detection of feeding artery improves the ultrasound diagnosis of endometrial polyps in asymptomatic patients

OBJECTIVE: To investigate whether transvaginal power Doppler imaging of the vascularity improves the ultrasound detection rate of endometrial polyps in symptomatic and asymptomatic patients. STUDY DESIGN: Forty-one patients with endometrial polyps confirmed by operative hysteroscopy and histologic examination. They were all examined with grey-scale and subsequent power Doppler enhanced ultrasound preoperatively according to the same protocol. Double layer endometrium and detailed endometrial morphology were described at grey scale scan. With power Doppler imaging pattern of endometrial vascularity. In the presence of a single feeding artery the ultrasound diagnosis of an endometrial polyp was made. RESULTS: With grey-scale imaging 20 polyps (49%) were recognized, while the subsequent application of power Doppler diagnosed the remaining 21 polyps increasing the overall detection rate to 10% (P < 0.01). The grey-scale detection rate for the polyp was 11/30 (0.37) in the asymptomatic patients and 9/11 (82%) in the symptomatic patients. No difference in endometrial thickness was observed. With power Doppler imaging, the detection rate for the feeding arteries was 97% (29/30) in the asymptomatic polyps and a similar 91% (10/11) in the symptomatic polyps. In the 21 polyps, where imaging of the vascularity was the only diagnostic marker, all but two were asymptomatic. CONCLUSION: Power Doppler enhanced ultrasound detection of the feeding vessels can be a simple, non-invasive and highly effective first line test for the diagnosis of endometrial polyps in asymptomatic patients.     

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

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

Outpatient hysteroscopy and ultrasonography in the management of endometrial disease

PURPOSE OF REVIEW: This review is to inform the ongoing debate about the choice between ultrasound and hysteroscopy in the management of endometrial disease presenting with abnormal uterine bleeding using information provided from recently published literature. RECENT FINDINGS: Transvaginal ultrasound measurement of endometrial thickness, using 4 or 5 mm cut-offs to define abnormality, is a good test for excluding endometrial cancer in women with postmenopausal bleeding. In contrast, hysteroscopy is a good test for detecting endometrial cancer, but less effective at excluding serious disease. The accuracy of transvaginal ultrasound in diagnosing intracavity pathology such as submucous fibroids and polyps is improved with saline instillation to levels of accuracy comparable to that of outpatient hysteroscopy. Miniaturization of hysteroscopes and ancillary instrumentation (e.g. development of bipolar intrauterine systems) has facilitated 'see and treat' outpatient hysteroscopy, so that it should no longer be considered simply an outpatient diagnostic modality. Preliminary cost-effectiveness studies have supported the use of ultrasound in the diagnosis of endometrial disease, but further, more comprehensive studies are required comparing ultrasound and outpatient hysteroscopy. SUMMARY: Recently published research has provided the clinician with high-quality data regarding the accuracy of ultrasound and hysteroscopy in the diagnosis of endometrial disease. Despite this, controversy remains regarding the relative roles of these uterine imaging modalities. Future research needs to be directed towards providing effectiveness and cost-effectiveness data in order to resolve the ongoing debate and guide best clinical practice.     

Significance of abnormal sonographic findings in postmenopausal women with and without bleeding

ObjectiveWe sought to determine the incidence of cancer and to compare pathologic outcomes in bleeding and non-bleeding postmenopausal patients who underwent hysteroscopy.MethodsWe conducted a retrospective chart review of 294 postmenopausal women with abnormal uterine bleeding and 142 postmenopausal women without symptoms who underwent hysteroscopy. An 11 mm cut-off for asymptomatic women was applied to determine whether this endometrial thickness threshold would differentiate women with and without endometrial cancer in the asymptomatic group.ResultsIn symptomatic patients, 14 were found to have endometrial cancer and 10 were found to have endometrial hyperplasia. In the asymptomatic group, two women (1. 4%) were found to have endometrial cancer with average thickness 17 . 5 mm, and one (0 . 71%) was found to have endometrial hyperplasia . Logistic regression models showed the risk of a bleeding patient developing endometrial cancer at an endometrial thickness of 4 mm was the same as the risk in a non-bleeding patient at a thickness of 15 mm.ConclusionAsymptomatic postmenopausal women have a low risk of having significant endometrial pathology . Cancer was approximately four times more prevalent in women with bleeding than in women with no bleeding     

Transvaginal ultrasonography and hysteroscopy in postmenopausal bleeding: a prospective study

OBJECTIVE: To determine the diagnostic value of transvaginal ultrasonography and hysteroscopy in patients with postmenopausal bleeding. MATERIAL AND METHODS: Between January 1, 1998 and June 30, 1999, 88 outpatient women with postmenopausal bleeding were enrolled in a prospective study. They underwent transvaginal ultrasonography and hysteroscopy, and were submitted to directed biopsy during hysteroscopy. Findings were classified as normal endometrium, suggestive of atrophy, focal abnormality (benign or suspicious), and diffuse thickness (benign or suspicious). Data was compared with the final diagnosis, established by histological examination, as atrophy, benign pathology, atypical hyperplasia and endometrial carcinoma. RESULTS: Among 88 women enrolled, 15 were excluded because hysteroscopy was impossible, and four had abandoned the study. The histological findings were scanty material in 12 (17.4%), atrophy in 24 (34.8%), cystic atrophy in one (1.4%), normal endometrium in five (7.2%), tuberculous endometritis in one (1.4%), polyps in 12 (17.4%), leiomyoma in one (1.4%), non-atypical hyperplasia in three (4.3%), atypical hyperplasia in one (1.4%) and endometrial carcinoma in nine cases (13.0%). For the assessment of endometrial carcinoma, ultrasonography revealed sensitivity 77.8%, specificity 93.3%, positive predictive value 63.6%, negative predictive value 96.6%; and hysteroscopy revealed sensitivity of 88.9%, specificity 98.3%, positive predictive value 88.9%, negative predictive value 98.3%. The combined use of both methods revealed sensitivity 100%, specificity 91.7%, positive predictive value 64.3%, negative predictive value 100%. CONCLUSIONS: Both imagiological methods were found to be useful screening tests for endometrial carcinoma. Hysteroscopy was a superior diagnostic procedure.