Structured Hysteroscopic Evaluation of Endometrium in Women With Postmenopausal Bleeding

Metastases and Recurrence Risk Factors in Endometrial Cancer-The Role of Selected Molecular Changes, Hormonal Factors, Diagnostic Methods and Surgery Procedures

The presence of metastatic endometrial cancer (EC) is a key problem in treatment failure associated with reduced overall survival rates. The most common metastatic location is the pelvic lymph nodes, and the least common is the brain. The presence of metastasis depends on many factors, including the molecular profile of cancer (according to the TCGA-Genome Atlas), the activity of certain hormones (estrogen, prolactin), and pro-inflammatory adipocytokines. Additionally, an altered expression of microRNAs affecting the regulation of numerous genes is also related to the spread of cancer. This paper also discusses the value of imaging methods in detecting metastases; the primary role is attributed to the standard transvaginal USG with the tumor-free distance (uTFD) option. The influence of diagnostic and therapeutic methods on EC spread is also described. Hysteroscopy, according to the analysis discussed above, may increase the risk of metastases through a fluid medium, mainly performed in advanced stages of EC. According to another analysis, laparoscopic hysterectomy performed with particular attention to avoiding risky procedures (trocar flushing, tissue traumatization, preserving a margin of normal tissue) was not found to increase the risk of EC dissemination.

A Predictive Model for Endometrial Carcinoma Based on Hysteroscopic Data

Objective

The purpose is to establish a model to predict endometrial carcinoma and assess its value in the preliminary diagnosis of endometrial carcinoma.

Methods

The data of 381 patients undergoing hysteroscopy were incorporated into the model, including 282 cases in the training cohort and 99 cases in the validation cohort. Significant morphological indexes were selected using the chi-square test and subjected to the binary logistic regression analysis. Besides, the scoring interval was set, and the nomogram of the prediction model was established. Model calibration curves were drawn using the data from the validation cohort. The study was approved by the Ethics Committee of the Affiliated Sir Run Run Hospital of Nanjing Medical University, and written informed consent was obtained from the patients.

Results

The sensitivity, specificity, positive predictive value, and negative predictive value of the model were 96.7%, 92.3%, 77.3%, and 99.0%, respectively. Analysis of the receiver operating characteristic curve in the training cohort showed an area under the curve of 0.984 (95% CI: 0.974-0.995). The receiver operating characteristic curve in the validation cohort revealed an area under the curve of 0.976 (95% CI: 0.950-1.000). The calibration curve indicated that the probability in the actual setting was consistent with that predicted by the nomogram in the training cohort.

Conclusion

Our model has high sensitivity and specificity in predicting endometrial carcinoma, and helps clinicians to make accurate diagnosis.

Hysteroscopic biopsy compared with endometrial curettage to assess the preoperative rate of atypical hyperplasia underestimating endometrial carcinoma

PURPOSE

To evaluate the rate of atypical hyperplasia (AH) underestimating endometrial cancer (EC) comparing endometrial biopsy (EB) accomplished by hysteroscopic biopsy with dilatation and curettage (D&C). Second, to compare the two techniques to foresee EC grading.

METHODS

This trial was based on the findings of two Gynecological Departments within the same Public Utility, sharing pathological service and database but routinely performing EB under hysteroscopic visualization (group A) or hysteroscopy followed by D&C (group B). We retrieved the clinical data of patients showing EC on hysterectomy throughout a 10-year period. The accuracy of hysteroscopic-view diagnosis and EB pathology were compared, having the pathologic findings of hysterectomy as reference.

RESULTS

A total of 161 patients met the inclusion criteria. Among these, 109 and 52 were included in groups A and B, respectively. In group A, 32.1% of patients underwent EB in an out-patient setting. To foresee EC, hysteroscopic view showed a sensitivity of 82.5% and 70.2% in groups A and B, respectively (P = 0.019). An underestimation of EC diagnosed as AH on EB was found in 20 patients (12.4%). Among these, 18 (16.5%) and 2 (3.8%) were included in groups A and B, respectively (P = 0.022). In group A, a fault diagnosis of AH resulted higher when EB was performed as out-patient setting (P = 0.006). EB allowed the grading of EC in 73.3% and 90.3% of patients in groups A and B, respectively. The agreement was 73.7% and 85.1%, leading to moderate (κ = 0.56) and good (κ = 0.77) "κ" coefficient of concordance for groups A and B, respectively.

CONCLUSIONS

EB performed by D&C lowers the rate of AH underestimating concurrent EC and improves the grading agreement when compared with hysteroscopic sampling.

Estro-progestin and progestogen intake: What’s the impact on hysteroscopic imaging?

Background: In current literature there is no report aimed to evaluate the effects of exogenous steroids on hysteroscopic imaging. Objectives: To evaluate the hysteroscopic features of endometrium in women undergoing female hormones administration. Material and Methods: We reviewed video-records of hysteroscopies carried-out in women taking estro-progestins (EP), progestogen (P) and Hormonal Replacement Therapy (HRT). All women underwent biopsies resulting in atrophic, functional, or dysfunctional pathological reports. Main Outcome Measures: Description of hysteroscopic pictures related to each schedule of therapy. Results: The study included 117 women. We evaluated 82, 24 and 11 women treated by EP, P and HRT, respectively. In EP users, imaging indistinguishable from physiological pictures was found when high oestrogen dosage and low-potency progestogen as 17-OH progesterone derivatives were administered. By enhancing progestogen potency with 19-norprogesterone and 19-nortestosterone derivatives we observed a promotion of progestogen differentiation such as polypoid-papillary pseudo-decidualisation, spiral artery differentiation, inhibition of gland-proliferation and endometrial atrophy. In P users we distinguished two patterns, depending on continuous or sequential schedules. Continuous therapy resulted in atrophic or proliferative-secretory features whereas sequential ones led to endometrial overgrowth reflecting stromal pseudo-decidualisation. Women undergoing HRT showed atrophic features in combined continuous and polypoid overgrowth in sequential schedules. In women taking Tibolone we found pictures ranging from atrophic to hyperplastic appearances. Conclusions: Exogenous steroids lead to significant endometrial moulding. Depending on schedule, hysteroscopic-view appears predictable and often showing overgrowths mimicking proliferative pathologies. In this case biopsy is recommended but in common practice physicians should gain awareness with hysteroscopic pictures induced from hormone administration. What is new? Systematic assessment of hysteroscopic pictures during estro-progestins intake.

Clinical, Sonographic, and Hysteroscopic Features of Endometrial Carcinoma Diagnosed after Hysterectomy in Patients with a Preoperative Diagnosis of Atypical Hyperplasia: A Single-Center Retrospective Study

BACKGROUND

atypical endometrial hyperplasia (AEH) is a precancerous condition implying a high risk of concurrent endometrial cancer (EC), which might be occult and only diagnosed at postoperative histopathological examination after hysterectomy. Our study aimed to investigate potential differences in preoperative clinical, sonographic, and hysteroscopic characteristics in patients with AEH and postoperative diagnosis of EC.

METHODS

a retrospective single-center study was carried out on a case series of 80 women with AEH undergoing diagnostic workup, including ultrasonography and hysteroscopy, with subsequent hysterectomy. Women with AEH confirmed at the histopathological examination were compared with patients with a postoperative diagnosis of EC.

RESULTS

in our population, EC was diagnosed in 53 women, whereas the preoperative diagnosis of AEH was confirmed in 27 cases. At ultrasonography, women with occult EC showed greater endometrial thickness (20.3 mm vs. 10.3 mm, p 0.001) and size of the endocavitary lesion (maximum diameter 25.2 mm vs. 10.6 mm, p 0.001), and a higher prevalence of irregular endometrial-myometrial junction (40.5% vs. 6.7%, p 0.022) and endouterine vascularization at color Doppler (64.2% vs. 34.6%, p 0.017). At hysteroscopy, patients with occult EC showed a higher prevalence of necrosis (44.2% vs. 4.2%, p 0.001) and atypical vessels (70.6% vs. 33.3%, p 0.003), whereas true AEH mainly presented as a protruding intracavitary lesion (77.8% vs. 50.9%, p 0.029). In EC, subjective assessment by the operator was more frequently indicative of cancer (80.0% vs. 12.5%). No difference was found for clinical variables.

CONCLUSIONS

occult EC in AEH may exhibit some differences in ultrasonographic and hysteroscopic patterns of presentation compared with real AEH, which could prompt a more significant suspect for the possible presence of concurrent EC at preoperative diagnostic workup.

Diagnostic Accuracy of Hysteroscopic Scoring System in Predicting Endometrial Malignancy and Atypical Endometrial Hyperplasia

Aims and Objectives:

The aim of this study was to determine the diagnostic accuracy of a hysteroscopic scoring system in predicting endometrial cancer and endometrial hyperplasia with atypia.

Materials and Methods:

This is a prospective study involving 95 peri and postmenopausal women with abnormal uterine bleeding who underwent hysteroscopic-guided endometrial biopsy. After the calculation of hysteroscopic score, biopsy was obtained and sent for histopathological examination. Hysteroscopic diagnosis of carcinoma endometrium was made when the total score was ≥16 and a score ≥7 supported a diagnosis of endometrial hyperplasia with atypia.

Results:

Out of the 95 women, 46 (48.4%) women had postmenopausal bleeding. The mean age of women was 50.4 ± 10.3 years. Eight women were diagnosed to have endometrial cancer and eight had endometrial hyperplasia with atypia on histopathological examination. Using a hysteroscopy score ≥16, the sensitivity and specificity were found to be 62.5% and 90.8%, respectively, for diagnosing endometrial cancer. Hysteroscopy score ≥9 was found to be a better cutoff for diagnosing endometrial cancer using Youden index. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for diagnosing endometrial cancer with score ≥9 was 100%, 67.8%, 22.2%, and 100%, respectively. The sensitivity, specificity, PPV, and NPV for diagnosing endometrial hyperplasia with atypia with score ≥7 was found to be 75%, 58.6%, 14.3%, and 96.2%, respectively.

Conclusion:

The hysteroscopic scoring system has a good diagnostic performance when a cutoff score ≥9 is used in predicting endometrial cancer. However, the scoring system has lower diagnostic accuracy in predicting endometrial hyperplasia with atypia.

Removal of uterine polyps: clinical management and surgical approach

Endometrial polyps have a reported prevalence from 7.8% up to 30% and are one of the most cost-consuming gynecological conditions for our specialty. There are strong practitioner beliefs that surgical removal of endometrial polyps is highly beneficial, particularly for those with abnormal uterine bleeding and infertility. Additionally, polypectomy is indicated to reduce the risk of malignancy. Transvaginal ultrasound is the first-line diagnostic option for detection of endometrial polyps, while sonohysterography has similar accuracy as hysteroscopy in the diagnostic confirmation. Blind dilatation and curettage is not recommended for polyp removal; rather, hysteroscopy in the operating room and office setting using small-diameter hysteroscopic equipment is the standard approach. This can be performed without anesthesia in most women. While hysteroscopy is an effective method for polypectomy with a low complication rate, it is unknown whether this is truly beneficial for reproductive-age women with infertility and prior assisted reproduction therapy. The risk of malignancy in women with postmenopausal bleeding justifies the necessity of polypectomy with histologic tissue examination. In asymptomatic women, the risk of malignancy is low, and there are no known benefits of polyp removal in the prevention of malignant transformation. Cost-effective studies remain to be done to provide us with the optimal approach to endometrial polyps including the management of asymptomatic and/or infertile women, ideal location including office-based or the operating room setting, complication prevention including intrauterine adhesions, and recurrence issues.

Preoperative assessment of endometrial cancer

Endometrial cancer (EC), the most common among gynaecological malignancies occurs predominantly after the menopause. The diagnosis is most commonly (in about 75-80%) set up at early stage when surgical therapy and if necessary postoperative radiotherapy results in an excellent prognosis, with a 90-95% 5-year overall survival (OS) and a locoregional recurrence rates of 4-8%. Accurate preoperative assessment of the lymph nodes would ideally identify those patients with advanced stage disease, who might benefit from more extensive surgical procedures and adjuvant therapies. magnetic resonance imaging (MRI), hysteroscopic excisional biopsy (HEB) and high resolution 2D or 3D ultrasound performed by expert operator are considered to add valuable information for preoperative staging of EC. The use of biomarkers could be beneficial in decreasing inter-observer variability between the histology of the diagnostic specimen and the final operative sample, as well as to avoid overtreatment in a part of the high-grade tumors with excellent prognosis. The goal of surgical management of EC is to remove the primary tumor and to identify definite prognostic factors to determine whether adjuvant therapy is required. Extended surgery, including para-aortic lymphadenectomy has a significant morbidity, and with the future selection of cases it can be safely avoided, we can decrease complications without compromising oncological safety. In the future, the importance of hysteroscopy guided sampling may increase to gain a representative sample for biomarker detection.

[Diagnostic accuracy of a hysteroscopic score for the detection of endometrial cancer in patients with postmenopausal bleeding and endometrial thickening]

OBJECTIVE

To assess the diagnostic accuracy of hysteroscopic scores in endometrial cancer.

METHODS

Diagnostic accuracy study assembled within a cross-sectional study that included patients with postmenopausal bleeding and endometrial thickening greater than 5 mm in whom hysteroscopy was performed and then compared with endometrial biopsy as the diagnostic gold standard, in two high complexity hospitals. Clinical, sociodemographic variables, as well as hysteroscopic scores and the results of endometrial tissue histopathology were measured. Sensitivity and specificity, likelihood ratios and area under the curve with their respective confidence intervals were estimated in the analysis.

RESULTS

With a 9 % prevalence of endometrial cancer, the hysteroscopic assessment system was shown to have 75 % sensitivity (95 % CI; 30.1- 95.43), 95,1 % specificity (95 % CI; 83.9-98.7), a positive likelihood ratio of 15.38 (95 %; CI 3.55- 66.56), a negative likelihood ratio of 0.26 and area under the curve of 85 %.

CONCLUSIONS

The standardized hysteroscopic assessment system was found to have an acceptable sensitivity for screening in patients with postmenopausal bleeding and endometrial thickening (≥ 5 mm). Further studies with larger sample sizes are required in order to arrive at a more precise estimation of the operational characteristics of the hysteroscopic assessment system for the detection of endometrial cancer.

Hysteroscopic resectoscope-directed biopsies and outpatient endometrial sampling for assessment of tumor histology in women with endometrial cancer or atypical hyperplasia

OBJECTIVE

To evaluate and compare the diagnostic efficiency of outpatient endometrial sampling (OES) and hysteroscopic resectoscope-directed biopsies (HY_biopsy) to distinguish between endometrial cancer (EC) and atypical hyperplasia (AH) and to assess tumor type and grade (histotype) in women with EC.

DESIGN

Patients with AH or EC (n = 266) among 1013 patients consecutively referred because of postmenopausal bleeding were included. Identification of EC versus AH, and unfavorable tumor types (endometrioid grade 3 or non-endometrioid tumors) using OES and HY_biopsy was compared to final histopathology at hysterectomy. AH or EC were identified by OES in 184 patients and by HY_biopsy in212.

RESULTS

OES had only sufficient tissue samples in 72.7% of intended samples. Even when OES did provide sufficient material, addition of HY_biopsy was a better technique than OES alone to distinguish between EC and AH, with an AUC of 95.9% and 79.8%; sensitivity of 97.4% and 64.6% and a specificity of 94.4% and 95.0%, respectively (p = 0.008). AH was falsely diagnosed with OES in 58 (35.4%) of 164 women with a final diagnose of EC. A final diagnosis of stage 1b or more was seen in 22 of these 58 women, while 5 of 194 patients with EC all stage 1a grade 1 had AH by HY_biopsy. HY_biopsy had higher correlation in assessment of tumor type and grade than OES, but OES and HY_biopsy had comparable AUC of 90.3% and 92.4% for identification of unfavorable tumors when tumor histotype was successfully identified. Regarding identification of unfavorable tumors (n = 57), a successfully assessment of histotype by OES combined with HY_biopsy in women without successfully diagnosed histotype by OES alone had AUC of 91.3%.

CONCLUSION

Addition of HY_biopsy may improve diagnosis when preoperative OES identifies AH or is insufficient for explicit diagnosis of tumor type and grade. However, there is limited benefit of the addition of HY_biopsy in the presence of definite diagnosis of grade 1-2 endometrioid tumors by OES.

Office hysteroscopy in the management of women with postmenopausal bleeding

Postmenopausal bleeding (PMB) is a relevant aspect for health-care providers in clinical practice: the first objective is to rule out potential gynecological cancer. The purpose of this narrative review is to evaluate the role of office hysteroscopy in the management of PMB. Office hysteroscopy is a minimally invasive procedure allowing direct visualization of uterine pathology without the need for general anesthesia and the use of an operating room, generating cost savings and greater compliance among patients. Here, we focus on major intrauterine diseases (polyps, submucosal myomas, endometrial hyperplasia, and cancer) as causes of PMB. Office hysteroscopy appears to be safe and feasible, and could allow accurate diagnosis of intrauterine pathologies, especially that with a focal growth pattern, otherwise misdiagnosed with blinded procedures. However, studies focusing exclusively on postmenopausal women are still few, so further research, especially randomized controlled trials, is needed.

Endometrial Cancer Risk Prediction According to Indication of Diagnostic Hysteroscopy in Post-Menopausal Women

We conducted a prospective observational study investigating the clinical relevance of endometrial thickness (ET) and abnormal uterine bleeding (AUB) on endometrial cancer (EC) risk in a cohort of postmenopausal patients undergoing diagnostic hysteroscopy and endometrial biopsy. Patients were divided into two groups according to the indication of diagnostic hysteroscopy: ET_Group (asymptomatic patients with endometrial thickness ≥ 4 mm) and AUB_Group (patients with a history of abnormal uterine bleeding). We further divided the AUB_Group into two subgroups based on endometrial thickness (AUB_Subgroup1: ET < 4 mm; AUB_Subgroup2: ET ≥ 4 mm). The primary outcome was the risk of endometrial cancer and atypical hyperplasia according to the indications of diagnostic hysteroscopy (AUB, ET ≥ 4 mm or both). The secondary outcome was to determine the best cut-off value of endometrial thickness to predict endometrial cancer in asymptomatic postmenopausal women. The prevalence of endometrial cancer and atypical hyperplasia in AUB_Group and ET_Group was 21% and 6.7% respectively. As well as for EC alone, higher prevalence of both conditions was observed in AUB_Subgroup2 (29.3%) in comparison to AUB_Subgroup1 (10.6%; p < 0.001). In asymptomatic patients the cut-off of endometrial thickness that showed the best sensitivity and specificity to diagnose endometrial cancer (100% and 80% respectively) was 11 mm (AUC of 91.4%; Expβ: 1067; CI 95%). In conclusion, considering the high risk of neoplasia, diagnostic hysteroscopy with endometrial biopsy should be mandatory in cases of abnormal uterine bleeding in postmenopausal patients. Moreover, we want to emphasize the need for further evidence stating the clinical relevance of endometrial thickness value in asymptomatic patients and the impact of individual risk factors on endometrial cancer development.

Effect of clinical information and previous exam execution on observer agreement and reliability in the analysis of hysteroscopic video-recordings

INTRODUCTION

Inter-observer agreement and reliability in hysteroscopic image assessment remain uncertain and the type of factors that may influence it has only been studied in relation to the experience of hysteroscopists. We aim to assess the effect of clinical information and previous exam execution on observer agreement and reliability in the analysis of hysteroscopic video-recordings.

MATERIALS AND METHODS

Ninety hysteroscopies were video-recorded and randomized into a group without (Group 1) and with clinical information (Group 2). The videos were independently analyzed by three hysteroscopists, regarding lesion location, dimension, and type, as well as decision to perform a biopsy. One of the hysteroscopists had executed all the exams before. Proportions of agreement (PA) and kappa statistics (κ) with 95% confidence intervals (95% CI) were used.

RESULTS

In Group 2, there was a higher proportion of a normal diagnosis (p < 0.001) and a lower proportion of biopsies recommended (p = 0.027). Observer agreement and reliability were better in Group 2, with the PA and κ ranging, respectively, from 0.73 (95% CI 0.62, 0.83) and 0.44 (95% CI 0.26, 0.63), for image quality, to 0.94 (95% CI 0.88, 0.99) and 0.85 (95% CI 0.65, 0.95), for the decision to perform a biopsy. Execution of the exams before the analysis of the video-recordings did not significantly affect the results.

CONCLUSION

With clinical information, agreement and reliability in the overall analysis of hysteroscopic video-recordings may reach almost perfect results and this was not significantly affected by the execution of the exams before the analysis. However, there is still uncertainty in the analysis of specific endometrial cavity abnormalities.

Common Causes of Postmenopausal Bleeding in Korean Women: 10-Year Outcomes from a Single Medical Center

The common causes of postmenopausal bleeding (PMB), according to the data from the western world, are atrophy, hormone replacement therapy (HRT), endometrial cancer, etc. We conducted a retrospective study to assess whether the causes of PMB in Korean postmenopausal women are similar to those already known. This retrospective study used 10-year medical records (March 2005 to December 2014) of 792 PMB women in the Yonsei University Health System. The data were divided into 2 categories by 5-year intervals to compare the differences between the 2 periods. The most common cause of PMB in Korean women was atrophy (51.1%). Polyps and HRT were the second, followed by anticoagulant medications, cervical cancer, and endometrial cancer. The proportion of patients with cervical cancer significantly decreased during the second half of the decade (8.7% vs. 5.2%; P = 0.048). Although no significant change was noted for HRT, its rank was higher during the latter 5-year period. Only the most common cause of PMB was the same as the conventional data. Interestingly, the proportion of patients with cervical cancer decreased during the latter half of the decade, reflecting the changes in the nation's cancer prevalence rate, while the use of HRT increased.

Structured imaging technique in the gynecologic office for the diagnosis of abnormal uterine bleeding

The aim in the diagnosis of abnormal uterine bleeding (AUB) is to identify the bleeding cause, which can be classified by the PALM-COEIN (Polyp, Adenomyosis, Leiomyoma, Malignancy (and hyperplasia), Coagulopathy, Ovulatory disorders, Endometrial, Iatrogenic and Not otherwise classified) classification system. In a gynecologic setting, the first step is most often to identify structural abnormalities (PALM causes). Common diagnostic options for the identification of the PALM include ultrasonography, endometrial sampling, and hysteroscopy. These options alone or in combination are sufficient for the diagnosis of most women with AUB. Contrast sonography with saline or gel infusion, three-dimensional ultrasonography, and magnetic resonance imaging may be included.

AIM

The aim of this article is to describe how a simple structured transvaginal ultrasound can be performed and implemented in the common gynecologic practice to simplify the diagnosis of AUB and determine when additional invasive investigations are required. Structured transvaginal ultrasound for the identification of the most common endometrial and myometrial abnormalities and the most common ultrasound features are described. Moreover, situations where magnetic resonance imaging may be included are described. This article proposes a diagnostic setup in premenopausal women for the classification of AUB according to the PALM-COEIN system. Moreover, a future diagnostic setup for fast-track identification of endometrial cancer in postmenopausal women based on a structured evaluation of the endometrium is described.

Endometrial adenomyoma polyp caused postmenopausal bleeding mimicking uterine malignancy

This case report presents a 66-year-oId postmenopausal woman with a case of endometrial adenomyomatous polyp (EAP) that presented as postmenopausal vaginal bleeding and mimicked endometrial cancer. The ultrasonography revealed a mildly enlarged uterus approximately 7.1 cm × 3.7 cm in size. The endometrium was 1.9 cm in diameter. The findings of magnetic resonance image (MRI) comprised abnormal intrauterine lesions with multiloculated cystic components. Endometrial biopsy by Pipelle was performed, and revealed hematoma. The hysteroscopy was then arranged, and two polypoid tumors were found. Tumor resection was performed, and the histology of the tumor was adenomyoma. EAP is a rare benign tumor of the uterus that is not easy to differentiate from endometrial cancer by ultrasound or MRI. Hysteroscopy is recommended when the results of tissue sampling by Pipelle differ from the image findings.

Is Hysteroscopy Better than Ultrasonography for Uterine Cavity Evaluation? An Evidence-Based and Patient-Oriented Approach

Evaluation of the uterine cavity is an important part of the gynecological check, especially in symptomatic women and, over the last few decades, a number of technical and technological advancements has allowed a superb investigation of this organ. Traditionally, transvaginal ultrasound (TVUS) has been the first-line diagnostic tool for evaluating uterine diseases, also considering that gynecologists are familiar with the technique since it is included in the basic training in obstetrics and gynecology. Nevertheless, to date “office hysteroscopy” received growing attention since the development of smaller-diameter hysteroscopes which has made it possible to easily perform the hysteroscopy in ambulatory settings, obviating the need for anesthesia and dilatation of the cervical canal.

According to our overview, none of the available methods for endometrial evaluation are ideal and each one has pros and cons. TVUS allows assessment of both the myometrium and the endometrium and typically offers greater patient comfort, but it has a higher false-negative rate in diagnosing focal intrauterine pathology. On the other hand, office hysteroscopy has the advantage of providing (most of the time) a real-time diagnosis avoiding anxiety, inconvenience and costs associated with follow-up appointments. The main advantage of the office hysteroscopy on the TVUS is the possibility to perform an operative phase if necessary during the examination itself. In fact, the modern smaller-diameter hysteroscopes have a working channel through which operative miniaturized instruments (mechanical instruments or bipolar electrodes) can be introduced, allowing the performance of target-eye biopsies and the “instant” treatment of most of uterine diseases in outpatient settings.

Reproducibility of Endometrial Pathologic Findings Obtained on Hysteroscopy, Transvaginal Sonography, and Gel Infusion Sonography in Women With Postmenopausal Bleeding

STUDY OBJECTIVE

To evaluate and compare interobserver variation in endometrial pattern recognition with hysteroscopy (HY) and transvaginal sonography (TVS) and gel infusion sonography (GIS) with regard to the diagnosis of endometrial pathology.

DESIGN

Prospective study (Canadian Task Force II-1).

SETTING

University clinic.

PATIENTS

One hundred twenty-two consecutive women with postmenopausal bleeding and an endometrium thickness ≥ 5 mm.

INTERVENTION

Two observers using HY and 2 others using TVS and GIS evaluated the endometrial pattern in recorded video clips. Interobserver agreement regarding findings obtained with TVS, GIS, and HY for a diagnosis of cancer, hyperplasia, polyps, and no endometrial pathology was expressed by κ coefficients and compared.

MEASUREMENT AND MAIN RESULTS

Interobserver agreement (κ) was as follows: identification of normal endometrium: HY (.74), TVS (.68), and GIS (.48); diagnosis of cancer: HY (.56), TVS (.59), and GIS (.34); classification in all categories of endometrial pathology: HY (.70), TVS (.47), and GIS (.41) (p < .05 HY vs GIS). The presence of additional endometrial polyps decreased agreement on HY in patients with hyperplasia or cancer. Observer agreement was poor regarding the diagnosis of hyperplasia by all techniques.

CONCLUSION

Observer agreement regarding both HY and TVS was reliable for the diagnosis of a normal endometrium but poor with HY, TVS, and especially GIS for a diagnosis of cancer. In patients with hyperplasia or cancer, agreement between observers was especially low in the presence of additional polyps when HY was used. These findings call attention to the need for systematic methods to improve reliability in endometrial pattern recognition.