ORIGINAL ARTICLE
ROLE OF HYSTEROSCOPY IN ABNORMAL UTERINE BLEEDING IN
PERIMENOPAUSAL AGE GROUP
Reethu Varadarajan, Sujatha M. Sreekantha
1.
2.
Assistant Professor. Department of Obstetrics & Gynaecology, KIMS.
Professor. Department of Obstetrics & Gynaecology, JSS Medical College,
CORRESPONDING AUTHOR:
Reethu Varadarajan,
No. 55 , 6 th main road, Chamrajpet,
Bangalore- 18,
E-mail: reethu.nandeesh23@gmail.com
Ph: 0091 9886854851.
ABSTRACT: OBJECTIVE: The objectives included evaluation of the role of hysteroscopy in the
diagnosis of abnormal uterine bleeding in women of perimenopausal age group and to correlate
the hysteroscopic findings with that of histopathology. METHODOLOGY: A total of fifty
perimenopausal women were subjected to hysteroscopy followed by endometrial sampling for
histopathological examination. RESULTS: The age of the subjects ranged from 40 years to 53
years, with a mean of 43.64 years. Most of the women were multiparous and presented with
menorrhagia. Hyperplasia was the most common finding observed on hysteroscopy. Polyps,
fibroid and endometrial atrophy were diagnosed with 100% accuracy by hysteroscopy.
Hyperplasia was correctly diagnosed in 94% of the cases. Hysteroscopy showed a high
sensitivity and a good negative predictive value. CONCLUSION: Hysteroscopy increases the
accuracy of clinical diagnosis and may serve as an adjunct in the treatment of patients with
specific intrauterine pathological conditions.
KEY WORDS: Hysteroscopy, Abnormal uterine bleeding, Perimenopause
INTRODUCTION: Abnormal uterine bleeding (AUB) is one of the commonest conditions for
which patients seek advice in the gynecological out-patient department. Many otherwise
healthy women will experience a significant disruption in lifestyle from abnormal uterine
bleeding. The causes and differential diagnosis of abnormal uterine bleeding are heterogeneous
and complex. A systematic evaluation within the framework of a careful history and physical
examination would help in reaching a diagnosis. Hysteroscopy is a surgical procedure in
which a gynecologist uses a small lighted telescopic instrument called a hysteroscope to
diagnose and treat many uterine disorders, including abnormal bleeding. The ability to
observe the entire endometrium provides accuracy and precision in sampling. Hysteroscopy
not only offers a quick, safe and accurate diagnosis, but also curative in cases of fibroid polyps,
intrauterine adhesions, menorrhagia and lost IUCD. (intrauterine contraceptive device).
AIMS & OBJECTIVES: The objectives of the study included
1. To evaluate the role of hysteroscopy in the diagnosis of abnormal uterine bleeding in
women of perimenopausal age group.
2. To correlate the hysteroscopic findings with that of histopathology.
MATERIALS AND METHODS: This prospective study included a total of fifty women of
perimenopausal age group with abnormal uterine bleeding, who were admitted to our hospital.
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All perimenopausal women presenting with abnormal uterine bleeding were included and
women with active or recent pelvic inflammatory disease, patient in menstruation phase ,
suspected cervical malignancy, active uterine bleeding , pregnancy/suspected pregnancy
complications, systemic disorders causing abnormal uterine bleeding were excluded from the
study. A detailed history was taken and a thorough clinical examination was done,
complemented by relevant investigation as required by the study. All the data were duly
recorded in the standard prepared proforma. A valid written consent was taken from all the
cases and subjected to diagnostic hysteroscopy using 4mm rigid Storz Hysteroscope and 5mm
sheath. Normal saline was used as distension media. The procedure was done under short
general anaesthesia. A thorough examination was performed. Endometrial biopsy was taken
from all the cases and tissue specimen sent for histopathological examination. The clinical,
hysteroscopic and histopathological findings were documented and analysed.
RESULTS: Among the 50 cases studied , maximum number of cases (56.0 %) belonged to the
age group 40 – 43 yrs, with a mean age of 43.64 yrs. Forty eight percent of women were
multiparous , thus showing that with increase in parity there is increase in abnormal uterine
bleeding. This observation is significant with a p-value of <0.0001. Fifty two percent had
painless bleeding, and dysmenorrhoea was seen in the remaining cases (48%). Most of the
patients (62%) in the study were anaemic. The commonest type of bleeding was menorrhagia
(68%), followed by polymenorrhagia (22%), metrorrhagia (6%) and metropathia hemorrhagica
(4%). Hyperplasia was the most common finding (50%) followed by a normal hysteroscopic
finding in 30%. In 10% of cases fibroid was seen, polyp in eight percent and atrophic
endometrium in only two percent of cases. Graph 1 shows the hysteroscopic findings. On
histopathological examination of these samples, 48% showed normal endometrium (34%
belonged to proliferative phase and the remaining 14% showed secretory changes). Thirty two
percent of women showed endometrial hyperplasia. Fibroid and endometrial polyp was
observed in 10% and 8% of the cases respectively and only two percent of cases showed
atrophic changes.
On comparing the hysteroscopic findings with that of histopathology, it was observed
that of the twenty five cases labelled as hyperplastic on hysteroscopy, only fifteen cases were
confirmed as hyperplastic on histopathology while remaining 10 cases showed normal findings
on histopathology. Graph2 shows the comparative results of hysteroscopy and the
histopathological features. Fourteen out of 15 cases, which were labelled as normal
endometrium on hysteroscopy showed normal histological features and the other case showed
hyperplastic features on histopathological examination. Endometrial polyps, fibroids and
atrophic changes were defined in similar numbers without any discrepancies on both
hysteroscopy and histopathology. In the present study the sensitivity and specificity of
hysteroscopy was 96.15% and 58.33% respectively. Also the predictive value of a negative test
and the predictive value of a positive test was 93% and 71%, respectively.
DISCUSSION: Abnormal uterine bleeding is one of the commonest conditions for which patients
seek advice in the gynecological out-patient department. Endometrial sampling should be
performed to evaluate abnormal bleeding and diagnostic aids like dilatation and curettage (D &
C), ultrasonogram and hysteroscopy are essential for the evaluation of abnormal uterine
bleeding. However D & C performed before hysterectomy has showed that less than half of the
endometrium was sampled in more than half of the patients has led to questioning of the use of
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ORIGINAL ARTICLE
D & C for endometrial diagnosis [1], and it is realized that routine D & C is ineffective in cases
like focal lesion of endometrium or fibroid polyps [2]. Intrauterine visualisation for the
evaluation of patients with AUB represents the “gold standard” today [3]. Hysteroscopy, either
diagnostic or operative, with endometrial sampling is gaining acceptability over other
diagnostic technique and it can be performed either in the office or operating room. The ability
to observe the entire endometrium provides accuracy and precision in sampling. It not only
offers a quick, safe and accurate diagnosis, but also is curative in cases of fibroid polyps,
intrauterine adhesions, menorrhagia and lost IUCD. Widrich T etal [4] and Haemila FA etal [5]
observed a mean age of 44.8 yrs and 45.7 years respectively which were close to the mean age
of 43.64 years, observed in the present study. Maximum number (48%) of women were
multiparous as observed by Jyotsna and co-workers (54.7%) [6], suggesting that increasing
parity increased the rate of abnormal uterine bleeding. Towbin etal [7] observed menorrhagia
in 61.7% of patients, close to the findings of the present study(68%). Most of the patients were
anaemic which explains the severity and duration of the symptoms. Normal hysteroscopic
findings were observed in 30% of the cases which is similar to the study by Sciarra and Valle [8],
who observed normal hysteroscopic findings in 28.4% of cases. Close to this value, was in the
study by Towbin etal [7] and Jyotsna etal [6] who observed normal hysteroscopic findings in
27% and 34% of cases, respectively. Table 1 shows the comparison of various studies with
regard to the hysteroscopic findings.
In the present study , the most common Hysteroscopic finding observed was
hyperplasia, a similar frequency was observed by Saraiya (13%) [9] . Present study labelled
eight percent of the cases as having endometrial polyp, similar to the observations by Neumann
etal [10] Hunter etal [11] , and Saraiya etal[9]with a value of 6%, 7%, and 9.3% respectively.
Table 1 shows the comparison of the accuracy of hysteroscopy in diagnosing abnormal lesions
in various studies.
Sensitivity of hysteroscopy has been found to be high (96%) in the present study which
is in agreement to the results observed by various authors like Ariel Revel etal [15] who
noticed a sensitivity of 94.2%, Paransis etal ( 92%) [14]. However specificity has been found to
be much lower. Abnormal uterine bleeding which often prevails as an important and common
gynecological ailment in the perimenopausal age group is commonly associated with painless
menorrhagia. Most of the patients may have normal endometrium but however a significant
number have uterine lesions, commonly being hyperplasia. Our study has proved the utility of
hysteroscopy in the diagnosis of various endometrial and intrauterine lesions, with high
sensitivity, predictive value of a negative test and low false negativity. However specificity may
be low and false positive finding may occur, hence biopsy and histological confirmation is
required in all cases. Thus hysteroscopy should be used as a first line diagnostic modality in
patients complaining of abnormal uterine bleeding.
CONCLUSION: The key to the evaluation of abnormal uterine bleeding is a thorough history,
physical and pelvic examinations governed by differential diagnosis of excessive intrauterine
bleeding and selective use of adjunctive diagnostic tests and procedures only when absolutely
necessary. Hysteroscopy may not supplement other diagnostic procedures but compliments
them. Hence can be considered as a safe ambulatory procedure that is appealing to both
patients & gynaecologists in its economy & simplicity, providing alternatives to hysterectomy
in patients who prefer or are best suited by conservative treatment.
REFERENCES:
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1. Grimes D.A. 1982 “Diagnostic dilation and Curettage: a reappraisal”. AM J Obstet
Gynecol, 143: 1-6
2. Patil SK., R.G Daver. 1993 “Hysteroscopy in excessive uterine bleeding”. J Obstet Gynecol
India, 43 : 605-610
3. Donnez J, Nisolle M. Hysteroscopic surgery. Curr Opin Obstet Gynecol 1992; 4: 439-46
4. Widrich T, Bradley LD, Mitchinson AR, Collins RL. Comparison of saline infusion
sonography with office hysteroscopy for the evaluation of the endometrium. Am J Obstet
Gynecol 1996;174:1327–34.
5. Haemila F.A. et al. 2005 “A prospective comparative study of 3-D ultrasonography and
hysteroscopy in detecting uterine lesions in premenopausal bleeding”. MEFSJ, 10: 238 –
43.
6. Jyotsana, Manhas K, Sharma S. Role of Hysteroscopy and Laparoscopy in Evaluation of
Abnormal Uterine Bleeding. JK science 2004;6:23-27
7. Towbin NA, Gviazda IM, March CM. Office hysteroscopy versus transvaginal
ultrasonography in the evaluation of patients with excessive uterine bleeding. Am J Obstet
Gynecol 1996;174:1678-82
8. Sciarra JJ, Valle RF. Hysteroscopy : A clinical experience with 320 patients. AM J Obstet
Gynecol 1977;127: 340-348.
9. Saraiya S., N. Sherian and V.R. Walvekar. 1994 “Hysteroscopy in abnormal uterine
bleeding”. J Obstet Gynaecol Ind, 44: 950-53.
10. Neumann T., J. Astudillo. 1994 “Hysteroscopic study in patients with abnormal uterine
bleeding”. Rev. Chil Obstet Gynecol, 59: 349 – 52
11. Hunter D.C., N. McClure. 2001 “Abnormal Uterine Bleeding : an evaluation endometrial
biopsy, vaginal ultra sound and outpatient hysteroscopy”. Ulster Med J, 70: 25-30
12. Sheth S.S., N.M Nerurkar and P.S. Mangeshikar. 1989 “ Hysteroscopy in Abnormal
Uterine bleeding”. J Obstet Gynecol, 40:451- 54.
13. Bhattacharya B.K. 1992 “Hysteroscopy for gyneclogical diagnosis”. J Obstet Gynecol
India, 42: 373 – 375
14. Parasnis H.B., S.V. Parulekar. 1992 “Significance of negative Hysteroscopic view in
Abnormal Uterine bleeding”. J Postgrad Med, 38:62-4.
15. Revel A., A. Shushan. 2002 “Investigation f the infertile couple: Hysteroscopy with
endometrial biopsy is the gold standard investigation for abnormal uterine
bleeding”.Human Reproduction, 17: 1947 – 49
Table 1:
Authors
Accurate results (in %)
Sheth SS etal (1990) [12]
B.K.Bhattacharya(1992)
[13]
Parasnis etal (1992) [14]
88%
77%
Inaccurate
(%)
12%
23%
93.75%
6.25%
Present study (2008)
78%
22%
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results
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ORIGINAL ARTICLE
Graph 1: Hysteroscopy findings
Percentage of patients
50%
40%
30%
20%
10%
0%
Hyperplasia Normal
Fibroid
Polyp
Atrophy
Hysteroscopic findings
Graph 2: Comparison of hysteroscopic findings with histopathology
15
Hyperplas ia
Normal
F ibroid
P olyp
A trophy
Num ber of patients
12
9
6
3
0
Normal
Hyperplas ia
F ibroid
A trophy
P olyp
Histopa tholog ic a l finding s
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