A comprehensive one-stop menstrual problem clinic for the diagnosis and management of abnormal uterine bleeding

Is outpatient diagnostic hysteroscopy more useful than endometrial biopsy alone for the investigation of abnormal uterine bleeding in unselected premenopausal women? A randomised comparison

OBJECTIVE

To formally evaluate the clinical benefit of additional outpatient hysteroscopy over traditional vaginal examination and endometrial biopsy.

DESIGN

A prospective randomised controlled trial.

SETTING

A large teaching hospital in the northeast of Scotland. SAMPLE Premenopausal women with abnormal uterine bleeding referred to the general gynaecologic clinic and requiring endometrial biopsy. METHODS Women were randomised to either outpatient hysteroscopy and endometrial biopsy or endometrial biopsy alone.

MAIN OUTCOME MEASURES

PRIMARY OUTCOME

initial surgical intervention rates.

SECONDARY OUTCOMES

procedural success and acceptability, intrauterine pathology identified and changes in management.

RESULTS

Three hundred and seventy women were recruited to the study. Initial trends in clinical management were comparable in both groups. No woman was advised to have removal of a localised lesion found at outpatient hysteroscopy and a normal uterine cavity at hysteroscopy did not influence the hysterectomy rate, which was similar in both groups. Outpatient hysteroscopy was found to be as acceptable as an outpatient endometrial biopsy and successfully completed in 85% compared with 91% of women who underwent endometrial biopsy alone. No cases of endometrial malignancy were identified.

CONCLUSIONS

Outpatient diagnostic hysteroscopy is an acceptable procedure and may give more reassurance. It did not influence clinical management, especially with respect to hysterectomy rate. Outpatient hysteroscopy may be useful in selected cases, but when performed in a non-selective manner, it has little influence on clinical management and increases costs.

Ultrasound, hysteroscopy and endometrial biopsy in the investigation of endometrial cancer

Over the course of the last two decades hysteroscopy with endometrial biopsy has begun to replace dilation and curettage as the method of choice for the diagnosis of endometrial carcinoma. In the majority of women this can be performed as an outpatient procedure with no loss in diagnostic accuracy. Transvaginal ultrasound measurement of endometrial thickness provides a highly sensitive and less invasive alternative means of assessing the endometrium but has a low positive predictive value for cancer, especially in women taking hormone replacement therapy. The cut-off value used to define normality needs to take into account patient age and ethnic origin. Ultrasound screening may not be suitable for women taking tamoxifen and those with recurrent or late-onset abnormal uterine bleeding.

The feasibility of a 'one stop' ultrasound-based clinic for the diagnosis and management of abnormal uterine bleeding

OBJECTIVES

We have established a 'one stop' clinic for the management of women with abnormal uterine bleeding based on transvaginal sonography and saline contrast sonohysterography. This report reviews our experience with the first 93 patients attending the clinic.

DESIGN AND METHODS

Patients were seen with the intention of performing a transvaginal scan, saline contrast sonohysterography, endometrial biopsy, full blood count and thyroid function tests. The findings were prospectively recorded on a computer database and a management plan formulated.

RESULTS

A transvaginal scan was performed on 89 (95.7%) women, 70 (75.3%) also undergoing saline contrast sonohysterography. An endometrial biopsy was carried out in 67 (72%) women aged 40 years and above, and 79 (84.9%) had blood tests. The median age of patients was 44 (range, 21-78) years. The majority of women presented with menstrual disorders. Uterine pathology was detected on transvaginal scan in 42 (47.2%) cases. Adnexal pathology was detected in 12 (13.5%) of the patients. Endometrial biopsy detected three (4.5%) cases of endometrial atypia, and three (4.5%) cases of adenocarcinoma. A hemoglobin level of < 10 g/dL was detected in 3 (3.4%) patients. A single clinic visit was thought sufficient for 83 (89.2%) women. Medical therapy was started in 47 (50.5%) patients, 15 (16.3%) were brought back for inpatient diagnostic hysteroscopy, and nine (9.7%) were booked for operative endoscopy, while six (6.5%) had conventional surgery; the remainder were reassured.

CONCLUSIONS

This study demonstrates that a 'one stop' management philosophy based on pelvic ultrasound is feasible. Our data suggest that diagnostic hysteroscopy can be decreased using this approach, and challenge the use of hysteroscopy as the first stage test.

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

OBJECTIVE

To compare the use of outpatient and inpatient procedures in the investigation of abnormal uterine bleeding.

DESIGN

A randomised controlled trial.

SETTING

Two university teaching hospitals.

PARTICIPANTS

Four hundred women with abnormal uterine bleeding (postmenopausal bleeding, menorrhagia, intermenstrual bleeding, postcoital bleeding, or irregular periods) above the age of 35 years, between June 1993 and January 1995.

MAIN OUTCOME MEASURES

1. Incidence of detection of abnormal pathology by vaginal ultrasound, outpatient hysteroscopy and endometrial biopsy compared with inpatient hysteroscopy and curettage; 2. Number of 'lesions' (e.g. fibroids, polyps, endometrial hyperplasia or malignancy) found by hysteroscopy that would have been missed by the combination of endometrial sampling and ultrasound; 3. Comparison of the quality of tissue obtained for histology by outpatient endometrial sampling and inpatient curettage; and 4. An evaluation of patient acceptability of outpatient and inpatient procedures.

RESULTS

1. A combination of transvaginal sonography, Pipelle endometrial biopsy and outpatient hysteroscopy has similar efficacy to inpatient hysteroscopy and curettage for the investigation of abnormal uterine bleeding; 2. Hysteroscopy will detect some fibroids and polyps missed by a combination of transvaginal ultrasound and Pipelle endometrial sampling; 3. The quality of histological samples obtained by outpatient Pipelle were comparable to those obtained by formal inpatient curettage; and 4. Outpatient procedures were well tolerated, with good patient acceptability.

CONCLUSION

Transvaginal sonography and endometrial biopsy can safely be used as the initial investigations in the management of abnormal uterine bleeding. Hysteroscopy can be used as a second line investigation. Outpatient hysteroscopy with local anaesthesia is well tolerated although general anesthesia may occasionally be necessary.