A Study of the Role of Hysteroscopy in Abnormal Uterine Bleeding

Abstract

Objectives:

There were two study objectives: (1) to determine the diagnostic accuracy of hysteroscopy in women with abnormal uterine bleeding (AUB) and (2) to correlate hysteroscopic and histopathologic findings in patients who had AUB.

Materials and Methods:

Results:

Among the 60 patients who had AUB, 40 % were between 46–55 years. Menorrhagia was seen in 43% of the cases (n = 26) of patients, followed by polymenorrhagia and postmenopausal bleeding in 23.3% (n = 14) and 13.33% (n = 8) of the cases, respectively. Endometrial polyps were the most common cause of AUB, comprising 26.67% (n = 16) of total cases, followed by submucus myomas attributing to 23.33% (n = 14) of the cases. Functional endometrium with a normal appearance was seen in 18.33% the cases (n = 11), followed by endometrial hyperplasia in 11.66% (n = 7) and retained products of conception in 6.67% (n = 4) of the cases, whereas endometritis and adenomysosis was present in 5% (n = 3) and 3.33% (n = 2) of the cases, respectively. The sensitivity of hysteroscopy was 100% for endometrial polyps, whereas specificity was 95%. Hysteroscopy was 100% sensitive and specific for submucous myomas, endometrial atrophy, endometrial carcinomas, retained products of conception, and intrauterine adhesions; was least sensitive for endometrial hyperplasia (54.55%); and was 97.96% specific for endometrial hyperplasia.

Conclusions:

The diagnostic accuracy of hysteroscopy, compared with histopathology was 100% for most intrauterine pathologies but was only 71% for endometrial hyperplasia, mandating a need to combine endometrial sampling with diagnostic hysteroscopy in cases with high risk of hyperplasia. (J GYNECOL SURG 33:226)

Introduction

Abnormal uterine bleeding (AUB) is one of the most common conditions for which patients seek gynecologic outpatient consultations. Any deviation from the normal pattern of menstrual bleeding is considered to be AUB. It is responsible for more than one-third of gynecologic consultations and nearly two-thirds of hysterectomies.^1,2 It is estimated that a woman has a 1 in 20 lifetime chance of consulting her gynecologist because of heavy menstrual bleeding.³ Until recent times, the usual method of evaluating this symptom was dilatation and curettage. However, this detects the cause in <50% of the cases.⁴ Hysteroscopy, with its diagnostic and therapeutic advantage, has ushered in a new era in management of AUB.

This study was carried out with the following aims and objectives:

(1) To determine the diagnostic accuracy of hysteroscopy in women with AUB.

(2) To correlate hysteroscopic and histopathologic findings in patients with AUB.

Materials and Methods

This prospective longitudinal study was conducted at the Dr. D. Y. Patil Medical College, Hospital & Research Centre, in Pimpri, Pune, India, from April 2015 to November 2016. The study included 60 patients who came to the outpatient department with complaints of AUB. Inclusion criteria were all cases of AUB and exclusion criteria were cases of cervical carcinoma, pregnancy, pelvic inflammatory disease, and other severe medical disorders. All of the patients who were selected were subjected to detailed history taking and a complete physical examination, and routine investigations were performed. Hysteroscopic examination was done in all patients postmenstrually, whenever possible, except in cases whose menstrual cycles were grossly irregular or cases with continuous bleeding per vaginum. The patients did not require anesthesia; a 2.9-mm hysteroscope was used, with normal saline as the distending media. The hysteroscope was introduced by a vaginoscopic method and the entire uterine cavity and endometrium were examined systematically. Results were recorded on a prescribed proforma. The patients then underwent dilatation and curettage and endometrial tissue samples were sent for histopathologic examination. The correlation between findings on hysteroscopy and histopathologic examination was tabulated.

Results

Sixty patients were included in the study. Overall, 55% of the patients with AUB were ages 26–45 (Table 1).

Table 1.

Distribution of Patients According to Age (N = 60)

Age (yrs)	# of cases	%
26–35	14	23.33
36–45	19	31.67
46–55	24	40
>55	3	5
Total	60	100

yrs, years.

Menorrhagia was seen in 43% (n = 26) of the cases, followed by polymenorrhagia and postmenopausal bleeding in 23.3% (n = 14) and 13.33% (n = 8) of the cases, respectively. Of these cases, 57.69% (n = 15) and 71% (n = 10) those with menorrhagia and polymenorrhagia, respectively, were in the reproductive age group of 26–45 (Table 2).

Table 2.

Association Between Age & Pattern of AUB

	Age (yrs)
Symptoms	25–35	36–45	46–55	> 55	Total
Menorrhagia	5	10	11	0	26
Polymenorrhagia	4	6	4	0	14
Postmenopausal bleeding	0	0	5	3	8
Polymenorrhea	2	0	4	0	6
Metrorrhagia	1	2	0	0	3
Hypomenorrhea	2	0	0	0	2
Oligomenorrhea	0	1	0	0	1
Total	14	19	24	3	60

χ² = 40.98; p < 0.0001

AUB, abnormal uterine bleeding; yrs, years.

Endometrial polyps were the most common cause of AUB, comprising 26.67% (n = 16) of total cases, followed by submucus myomas attributed to 23.33% (n = 14) cases. Functional endometrium that appeared normal was seen in 18.33% cases (n = 11), followed by endometrial hyperplasia in 11.66% (n = 7) and retained products of conception in 6.67% (n = 4) of the cases, whereas endometritis and adenomysosis was present in 5% (n = 3) and 3.33% (n = 2) of the cases. There was 1 case each of endometrial atrophy and endometrial carcinoma.

In 14 patients with submucous myomas, menorrhagia was the most common pattern of bleeding, seen in 78.5% (n = 11) of cases, whereas endometrial polyps presented as polymenorrhagia in 50% (n = 8) of the cases. Endometrial hyperplasia was associated with menorrhagia in 57% (n = 4) of the cases. Functional endometrium with a normal appearance was seen in 6 cases of polymenorrhea. Of 4 cases with retained products of conception, 3 (75%) presented as polymenorrhagia and 1 (25%) had metrorrhagia. Therefore, patterns of bleeding correlated well with hysteroscopy findings (Table 3).

Table 3.

Association Between Hysteroscopy Finding & Pattern of AUB

	Symptoms
Hysteroscopy finding	Hypomenorrhoea	Menorrhagia	Metrorrhagia	Oligomenorrhoea	Polymenorrhagia	Polymenorrhoea	Postmenopausal bleeding	Total
Endometrial polyp	0	4	1	0	8	0	3	16
Submucous myoma	0	11	0	0	2	0	1	14
Normal endometrium	0	5	0	0	0	6	0	11
Endometrial hyperplasia	0	4	0	0	1	0	2	7
Retained products of conception	0	0	1	0	3	0	0	4
Endometritis	2	0	1	0	0	0	0	3
Adenomyosis	0	2	0	0	0	0	0	2
Adhesions	0	0	0	1	0	0	0	1
Endometrial carcinoma	0	0	0	0	0	0	1	1
Total	2	26	3	1	14	6	8	60

AUB, abnormal uterine bleeding.

Correlation between hysteroscopy and histopathology for submucous myomas, retained products of conception, endometritis, and intrauterine adhesions was found to be 100%, whereas for endometrial polyps, it was 96%. Diagnostic accuracy of hysteroscopy was 76% for endometrial hyperplasia (Table 4).

Table 4.

Comparison of Hysteroscopy & Histopathology Findings

	Procedure
	Hysteroscopy (N = 60)		Histopathology (N = 60)
Intrauterine pathology	#	%	#	%	Diagnostic accuracy
Endometrial polyp	16	26.67	14	23.33	96.0%
Submucous myoma	14	23.33	14	23.33	100%
Normal endometrium	11	18.33	9	15	90.0%
Endometrial hyperplasia	7	11.67	11	18.33	71%
Retained products of conception	4	6.67	4	6.67	100%
Endometritis	3	5	3	5	100%
Adenomyosis	2	3.33	2	3.33	100%
Intrauterine adhesion	1	1.67	1	1.67	100%
Endometrial carcinoma	1	1.67	1	1.67	100%
Endometrial atrophy	1	1.67	1	1.67	100%

The sensitivity and specificity of hysteroscopy was 100% and 95%, respectively, for endometrial polyps. Hysteroscopy was 100% sensitive and specific for submucous myomas, endometrial atrophy, endometrial carcinoma, retained products of conception, and intrauterine adhesions, whereas hysteroscopy was 54.55% sensitive and 97.96% specific for endometrial hyperplasia (Table 5).

Table 5.

Sensitivity & Specificity of Hysteroscopy in Relation to Histopathology

Histopathology result	Sensitivity	Specificity	Positive predictive value	Negative predictive value
Endometrial polyp	100	95.65	87.5	100
Submucous myoma	100	100	100	100
Normal endometrium	77.78	92.16	63.64	95.92
Endometrial hyperplasia	54.55	97.96	85.71	90.57
Endometrial atrophy	100	100	100	100
Intrauterine adhesion	100	100	100	100
Endometrial carcinoma	100	100	100	100
Retained products of conception	100	100	100	100

Discussion

Regular cyclical menstruation is the result of a choreographed relationship between the endometrium and its regulating factors. Disturbance in either of these factors results in AUB. It includes an array of conditions, such as hormonal dysfunctions, infections, neoplasias, coagulopathies and complications of pregnancy. AUB is a challenging condition for the gynecologist and accounts for >20% of office visits.⁵ The use of hysteroscopy in AUB is replacing use of blind curettage, as the instrument “sees” and “decides” the cause of the AUB. The complications in comparison to dilatation and curettage (D & C) are much lower, as the hysteroscope is inserted under visualization.

The age group in this study was between ages 26 and 80 and the maximum incidence was between ages 26 and 45. In Gianninoto's series,⁶ the age range was 38–80 and the most common incidence was between ages 30 and 45, which was similar to the present study; however, in another study in 2007 by Allameh and Mohammadizadeh, the maximum ages of patients were between ages 40 and 50.⁷

In the present study, menorrhagia was the most common type of AUB in 43% of cases, followed by polymenorrhagia, postmenopausal bleeding, and polymenorrhea in 23.3%, 13.33%, and 10% of cases, respectively. Madan and Al-Jufairi found that the majority of their patients (62%) presented with menorrhagia, while postmenopausal bleeding was present in 14% of the patients in that study, comprising the second most common group.⁵ A study by Refaie et al in the United Kingdom, found that menorrhagia was the most common complaint in patients with AUB (46%), followed by postmenopausal bleeding in 40 patients (35.7%).⁸ These results are also comparable to the present study.

Of the 26 cases of menorrhagia, 57.69% cases were in the reproductive age group of ages 26–45. Polymenorrhagia was observed in 14 cases and 71% of cases presented in the reproductive age group. In a similar study, El-Hemaidi et al. reported a 30% incidence of menorrhagia in a reproductive age group.⁹

In the present study, endometrial polyps was the most common cause of AUB, comprising 26.67% of total cases, which is comparable to other studies with a range of endometrial polyps from 15%⁸ to as high as 38%.⁷ There has been an improvement in the detection rate of endometrial polyps with hysteroscopy over the years as is evident from the above data. This probably is the result of an improvement in technology and advancement in this field.

Submucus myomas were seen in 23.3% of the present study's cases. Jyotsana et al.¹⁰ and Jaiswar et al.¹¹ reported rates of 17 % and 34% in their respective studies. The present study's incidence of endometrial hyperplasia of 11% was comparable to the study done by Jaiswar et al.,¹¹ whereby the incidence of endometrial hyperplasia was 10%. A similar incidence of 15.2% was reported by Allameh and Mohammadizadeh.⁷ Endometrial carcinoma was recognized via hysteroscopic examination in only 1 patient, which was 1.67% comparable to studies done by Madan and Al-Jufairi (0.5%)⁵ and Refaie et al. (1.9 %).⁸ Retained products of conception and endometritis comprised 6.67% and 5% of cases, respectively, which were similar to rates reported by Shazia et al.¹² Functional endometrium with a normal appearance was seen in 18.33% cases in the present study, which was similar to the 18% reported by Jaiswar et al.; that study had 18% of cases with no intrauterine pathology.¹¹ Allameh and Mohammadizadeh reported 31% of patients with normal endometrium in their study.⁷

In the present study, menorrhagia was the most common presentation of submucous myomas; this was seen in 78.5% of cases. Endometrial polyps presented as polymenorrhagia in 50% of cases, whereas endometrial hyperplasia was associated with menorrhagia in 57% cases. Functional endometrium with a normal appearance was associated with polymenorrhea and menorrhagia in 54% and 46% of cases, respectively.

In the present study, the diagnostic accuracy, sensitivity, and specificity of hysteroscopy for endometrial polyps was 96.0%, 100%, and 95%, respectively. Valle¹³ and Sheth et al.¹⁴ found diagnostic accuracy to be 88.6% and 81.8%, respectively. Allameh and Mohammadizadeh compared hysteroscopic findings with pathology reports in women with AUB.⁷ In that study, detection of endometrial polyps with hysteroscopy had a sensitivity of 93%, a specificity of 100%, a positive predictive value (PPV) of 100%, and a negative predictive value (NPV) of 95.4%.⁷ The diagnostic accuracy, sensitivity, specificity of hysteroscopy for endometrial myomas in the present study were each 100%, similar to Panda et al.'s results.¹⁵ Hysteroscopy was 100% sensitive and specific for submucous myomas, endometrial atrophy, endometrial carcinomas, retained products of conception, and intrauterine adhesions. The relatively poor sensitivity of both endometrial biopsy and transvaginal ultrasound for detecting intrauterine focal pathology encourage the current authors to propose that office hysteroscopy be utilized as a first-line investigation in evaluations of patients with AUB.¹⁶

The diagnostic accuracy, sensitivity, and specificity of hysteroscopy for endometrial hyperplasia were 71%, 54.55%, and 97.96%, respectively, which was least among all pathologies. Of 11 cases of endometrial hyperplasia diagnosed by histopathologic examination, only 7 were diagnosed during hysteroscopy and 4 cases of hyperplastic endometrium were misdiagnosed as endometrium with a normal appearance. Valle reported that the diagnostic accuracy of hysteroscopy for endometrial hyperplasia was 68.2%, and Sheth et al. and Panda et al. reported this as 71.4% and 76.4% respectively.^13–15 Madan and Al-Jufairi found 30% sensitivity and 85% specificity of hysteroscopy for diagnosing endometrial hyperplasia with a PPV of 37.5% and an NPV of 82.5%.⁵ This shows that hysteroscopy has intermediate accuracy for detecting premalignant lesions and mandates directed endometrial biopsy for confirmation. Endometrial biopsy, thus, has a definite place in the diagnostic workup of postmenopausal patients as well as premenopausal patients who are at high risk for endometrial hyperplasia.¹⁶

More than 50% of all diagnostic hysteroscopies, however, are still being performed in the operating room. Performing an office hysteroscopy early in the evaluation in appropriately selected patients would render utilization of any further investigation such as endometrial biopsy or transvaginal sonogram unnecessary.¹⁶ Furthermore, it dictates the need for a histologic specimen, if indicated, and allows for a directed biopsy, ensuring provision of a representative specimen of the focal pathology for evaluation. The net result would ensure cost containment by reduction in the number of patient visits for investigational purposes. Moreover, the procedure being performed by the investigating gynecologist precludes the involvement, and hence need for reimbursement of an additional specialist.¹⁶ In the present study, although anesthesia was not required for diagnostic hysteroscopy, the procedure was nonetheless performed in the operating room, as the outpatient department does not have a hysteroscope for office hysteroscopy. More studies are needed for evaluating patients who present with AUB by using office hysteroscopy.

Conclusions

The diagnostic value of hysteroscopy, compared with histopathology, in the present study was 100 % for most intrauterine pathologies, including submucous myomas and endometrial polyps, but was relatively less useful for diagnosing endometrial hyperplasia. Therefore, hysteroscopy should be combined with endometrial sampling to increase its sensitivity for endometrial hyperplasia.

Footnotes

Author Disclosure Statement

No financial conflicts of interest exist.

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