Diagnostic hysteroscopy in abnormal uterine bleeding: a systematic review and meta-analysis

BACKGROUND

This study was conducted to assess the accuracy and feasibility of diagnostic hysteroscopy in the evaluation of intrauterine abnormalities in women with abnormal uterine bleeding.

SEARCH STRATEGY

Electronic databases were searched from 1 January 1965 to 1 January 2006 without language selection. The medical subject heading (MeSH) and textwords for the following terms were used: hysteroscopy, diagnosis, histology, histopathology, hysterectomy, biopsy, sensitivity and specificity.

SETTING

University Hospital.

SELECTION CRITERIA

The inclusion criteria were report on accuracy of diagnostic hysteroscopy in women with abnormal uterine bleeding compared to histology collected with guided biopsy during hysteroscopy, operative hysteroscopy or hysterectomy.

DATA COLLECTION AND ANALYSIS

Electronic databases were searched for relevant studies and references were cross-checked. Validity was assessed and data were extracted independently by two authors. Heterogeneity was calculated and data were pooled. Subgroup analysis was performed according to validity criteria, study quality, menopausal state, time, setting and performance of the procedure. The pooled sensitivity, specificity, likelihood ratios, post-test probabilities and feasibility of diagnostic hysteroscopy on the prediction of uterine cavity abnormalities. Post-test probabilities were derived from the likelihood ratios and prevalence of intrauterine abnormalities among included studies. Feasibility included technical success rate and complication rate.

MAIN RESULTS

One population of homogeneous data could be identified, consisting of patients with postmenopausal bleeding. In this subgroup the positive and negative likelihood ratios were 7.9 (95% CI 4.79-13.10) and 0.04 (95% CI 0.02-0.09), raising the pre-test probability from 0.61 to a post-test probability of 0.93 (95% CI 0.88-0.95) for positive results and reducing it to 0.06 (95% CI 0.03-0.13) for negative results. The pooled likelihood ratios of all studies included, calculated with the random effects model, were 6.5 (95% CI 4.1-10.4) and 0.08 (95% CI 0.07-0.10), changing the pre-test probability of 0.46 to post-test probabilities of 0.85 (95% CI 0.78-0.90) and 0.07 (0.06-0.08) for positive and negative results respectively. Subgroup analyses gave similar results. The overall success rate of diagnostic hysteroscopy was estimated at 96.9% (SD 5.2%, range 83-100%).

CONCLUSIONS

This systematic review and meta-analysis shows that diagnostic hysteroscopy is both accurate and feasible in the diagnosis of intrauterine abnormalities.

Reproductive outcome following hysteroscopic adhesiolysis in patients with infertility due to Asherman's syndrome

OBJECTIVES

To evaluate the outcome of hysteroscopic adhesiolysis in patients with infertility due to Asherman's syndrome.

MATERIALS AND METHODS

This was a retrospective clinical analysis of 89 patients who underwent hysteroscopic adhesiolysis by monopolar electrode knife. A second-look office hysteroscopy was performed in all cases after 2 months. On second-look hysteroscopy, 12 patients showed reformation of adhesions and needed a repeat procedure.

RESULTS

The mean age of the patient was 28.4 years. In the majority (64%) of patients, the possible cause of Asherman's syndrome was previous curettage on gravid uterus. The overall conception rate was 40.4% after hysteroscopic adhesiolysis. The mean conception time after surgery was 12.8 months. There was no conception in patients who needed repeat adhesiolysis. The conception rate was higher (58%) in mild Asherman's syndrome compared to 30% conception rate in moderate and 33.3% conception rate in severe cases. There was no significant association between conception rate and preoperative menstrual pattern. There was significant higher likelihood of conception rate (44.3%) in those who continued to have improved menstrual pattern compared to only 10% likelihood of conception in those who continued to have amenorrhea after adhesiolysis. The live birth rate was 86.1% and miscarriage rate was 11.1%. Cumulative pregnancy rate showed that 97.2% patients conceived within 24 months. There was increased incidence (43.8%) of cesarean section. Four (12.5%) patients had postpartum hemorrhage for adherent placenta.

CONCLUSION

Hysteroscopic adhesiolysis for Asherman's syndrome is a safe and effective method of choice for restoring menstrual function and fertility.

Detection of chronic endometritis by diagnostic hysteroscopy in asymptomatic infertile patients

Chronic endometritis has been related to infertility and recurrent abortion. It is usually asymptomatic, and the diagnosis is rarely clinically suspected. We performed a prospective study to evaluate both the role of diagnostic hysteroscopy in the detection of chronic endometritis in infertile patients and Chlamydia trachomatis is a potential etiologic factor. Fifty consecutive patients who sought treatment for infertility in a tertiary academic hospital were submitted to diagnostic hysteroscopy and an endometrial biopsy for histopathological study and for diagnosis of C. trachomatis by polymerase chain reaction. The patients' mean age was 33.7 +/- (SD) 5.4 years, and the duration of the couples' infertility ranged from 1 to 18 years. The overall prevalence of chronic endometritis was 12% (6 patients). Among all patients, no cases of chlamydial infection were detected by polymerase chain reaction. In the detection of chronic endometritis, with 95% confidence intervals, the hysteroscopy sensitivity was 16.7% (range 0.9-63,5%), the specificity was 93.2% (range 80.3-98.2%), the positive predictive value was 25% (range 1.3-78.1%), and the negative predictive value was 89.1% (range 65.6-95.9%). These data suggest that hysteroscopy is not useful in the screening for chronic endometritis in asymptomatic infertile women. Further studies are needed to establish the etiology of endometritis in infertile patients.

Success rate and patient satisfaction with the Essure™ sterilisation in an outpatient setting: a prospective study of 857 women

After 857 women with Essure system inserted for tubal obstruction as a method of sterilization in an outpatient setting, insertion is achieved in close to 99% of the women. Physician described the procedure as very difficult in 15% of the cases, mainly due to anatomical tubal anomalis or tubal spasm, and women felt highly satisfied in all cases.

A new curriculum for hysteroscopy training as demonstrated by an objective structured assessment of technical skills (OSATS)

OBJECTIVE

The purpose of this study was to develop an effective curriculum to teach hysteroscopy, as well as to develop an objective assessment instrument (OSATS).

STUDY DESIGN

All 24 residents in our training program attended a 3-hour hysteroscopy curriculum in each of 3 years. Each year after the curriculum, an OSATS was administered consisting of an assembly and operative task. Each task was evaluated with a task-specific checklist and a previously validated global assessment form. Twenty-four residents from an outside institution served as controls. All residents were examined by blinded and unblinded examiners.

RESULTS

The reliability coefficient was .7857 for the checklist and .9763 for the global scale. Interrater reliability for the checklist was .7478 and ranged from .4222 to .9329 for the global instruments. Evaluation of construct validity revealed that the junior residents at both locations did significantly worse on the checklist and global scale than the senior residents for all 3 years of the study (P < .001). Those residents provided the curriculum did significantly better on both the checklist and the global scale than the resident controls with a mean of 45% versus 63% for the checklist and 18.3 versus 24.9 for the global score. (P = .001 checklist, P = .007 global scale).

CONCLUSION

This curriculum is an effective way to impart knowledge and skill in the assembly and use of the operative hysteroscope. The checklist developed for this OSATS has excellent reliability and construct validity.

Hysteroscopy is superior to hysterosalpingography in infertility investigation

BACKGROUND

The development of advanced endoscopic instrumentation in recent years has demonstrated the superiority of direct visual examination over radiographic demonstration of various body cavities. Just as laparoscopy has gradually taken a primary role in the surgical investigation of the ovulatory infertile patient, the role of intrauterine endoscopy in comparison to hysterosalpingography (HSG) needs to be reevaluated.

METHODS

Four hundred and sixty-four infertile women had undergone both hysterosalpingography and a diagnostic hysteroscopy and the findings were analysed.

RESULTS

Compared to hysteroscopy the sensitivity of HSG was 98%, but its specificity only 15%, the positive predictive value 45%, and negative predictive value 95%. On hysteroscopy a normal uterine cavity was found in 53% of the cases with a filling defect and in 56% of those with uterine wall irregularity on HSG.

CONCLUSIONS

Hysteroscopy, a safe and rapid direct visualisation of the uterine cavity, is superior to HSG in the identification of intrauterine pathology. In view of the low positive predictive value and the low specificity of the HSG, we believe it should be replaced by the diagnostic hysteroscopy as a first line infertility investigation.

Tolerability of the mini-pan-endoscopic approach (transvaginal hydrolaparoscopy and minihysteroscopy) versus hysterosalpingography in an outpatient infertility investigation

OBJECTIVE

To compare the acceptance and tolerability of the mini-pan-endoscopic approach (transvaginal hydrolaparoscopy [THL] combined with minihysteroscopy) versus hysterosalpingography (HSG) for evaluating tubal patency and the uterine cavity in an outpatient infertility investigation.

DESIGN

Randomized controlled study.

SETTING

University hospital.

PATIENT(S)

Twenty-three infertile patients without obvious pelvic pathology.

INTERVENTION(S)

Women were randomly divided into two groups. One group underwent minihysteroscopy and THL with tube chromoperturbation as first investigation and HSG within the following 7 days, while in the other group the investigation sequence was inverted. Women reported pain experienced before and at the end of procedures.

MAIN OUTCOME MEASURE(S)

Mean duration of procedures, level of pain experienced, diagnostic agreement about tubal patency and uterine cavity normality.

RESULT(S)

THL and minihysteroscopy took significantly more time but was significantly less painful than HSG. Regarding tubal patency, in 95.5% of cases THL agreed with HSG. In one case, HSG diagnosed a bilateral obstruction of tubes, whereas at THL a bilateral spreading of methylene blue was seen. Agreement on intrauterine pathologies between minihysteroscopy and HSG was poor (43%); the number of intrauterine abnormalities found at hysteroscopy was significantly greater than at HSG.

CONCLUSION(S)

THL in association with minihysteroscopy provided more information and was better tolerated than HSG in an outpatient infertility investigation.

Randomised comparison of distension media for outpatient hysteroscopy

OBJECTIVE

To compare saline with and without added lignocaine and carbon dioxide distension for out patient hysteroscopy with regards to patient discomfort and hysteroscopic view.

DESIGN

Single blind prospective randomised controlled trial.

SETTING

Specialist out patient clinics in a large teaching hospital.

POPULATION

Women undergoing out patient hysteroscopy and endometrial biopsy for abnormal uterine bleeding.

METHOD

Out patient hysteroscopy using carbon dioxide, saline or saline with lignocaine.

MAIN OUTCOME MEASURES

Visual analogue score (VAS) for pain and present pain intensity (PPI) as assessed by patients and the quality of hysteroscopic view as assessed by the operator.

RESULTS

Of the 305 women approached, 300 women were randomised into the study. The mean [SD] VAS for pain in the carbon dioxide group was 2.9 [2.3] and in the saline group was 3.1 [2.6], the difference was not statistically significant (P= 0.49). The mean [SD] VAS for pain in the saline plus lignocaine group was 3.2 [2.4]. This was not significantly different from the saline group (P= 0.72). There was a statistically significant difference between the confidence rating for the hysteroscopic view for the carbon dioxide compared with the saline group; mean [SD] was 8.3 [2.1] and 9.6 [1.1], respectively (P= 0.001).

CONCLUSION

Carbon dioxide and saline as distension media are comparable in terms of overall patient discomfort and satisfaction, but saline provides better views and increases confidence in diagnosis. Adding lignocaine to the saline distension medium does not confer any additional benefit.

A prospective comparative study between hysterosalpingography and hysteroscopy in the detection of intrauterine pathology in patients with infertility

AIM

To investigate the accuracy of hysterosalpingography (HSG) in comparison to hysteroscopy in the detection of intrauterine pathology in patients with infertility, where hysteroscopy is the gold standard.

METHODS

A prospective, comparative study included 336 patients undergoing both HSG and diagnostic hysteroscopy. Main outcome measures were sensitivity, specificity, positive and negative predictive value, and accuracy rate of HSG.

RESULTS

Intrauterine abnormalities were shown on HSG in 286 patients and confirmed in 200 at hysteroscopy. Contrarily intrauterine lesions were detected by hysteroscopy in 4 out of 50 patients in whom HSG were normal. The most common intrauterine finding of 336 patients on hysteroscopy were intrauterine adhesions (IUA) (74), followed by endometrial polyps (56), and submucous myoma, 26 patients. Statistical analysis revealed that HSG in the detection of intrauterine pathology had a sensitivity of 98.0%, specificity of 34.9%, positive predictive value of 69.9%, negative predictive value of 92.0%, and accuracy rate of 73.2% with false-positive and false-negative rates of 30.1% and 8.0%, respectively. The common incorrect diagnoses of HSG were misdiagnosing a condition of cervical stenosis as severe IUA in 24 patients, endometrial polyps as submucous myoma in 22 out of 50 patients, and submucous myoma as endometrial polyps in 12 out of 72 patients.

CONCLUSIONS

Hysterosalpingography is still a useful screening test for the evaluation of the uterine cavity. If a hysterogram demonstrates intrauterine abnormalities, hysteroscopy should be considered to make a definite diagnosis and treatment. Both procedures should be complementary to each other.

Does hysteroscopy improve upon the sensitivity of dilatation and curettage in the diagnosis of endometrial hyperplasia or carcinoma?

OBJECTIVE

The objective of this study was to determine whether hysteroscopy improved upon the diagnostic sensitivity of dilatation and curettage (D+C) in the detection of endometrial hyperplasia and carcinoma.

METHODS

A retrospective chart review was conducted of all patients undergoing hysteroscopy/D+C for abnormal uterine bleeding between 1991 and 1995. Hysteroscopic impressions and D+C diagnoses were compared.

RESULTS

Three hundred seventy-three patients were included in the study. Of the 61 patients with D+C demonstrating hyperplasia, the hysteroscopic impression was hyperplasia in 32 (52%). Of the 10 patients with D+C demonstrating carcinoma, the hysteroscopic impression was hyperplasia in 8 (80%) and carcinoma in 2 (20%). Two additional cases of carcinoma were diagnosed within 6 months of hysteroscopy/D+C, and both had been missed on both hysteroscopy and D+C. Of 204 patients with a normal hysteroscopic impression, 23 (11%) had hyperplasia on D+C.

CONCLUSIONS

Hysteroscopy did not improve upon the sensitivity of D+C in the detection of endometrial hyperplasia or carcinoma.

The value of measuring endometrial thickness and volume on transvaginal ultrasound scan for the diagnosis of incomplete miscarriage

OBJECTIVE

To identify ultrasound measurements that are the best predictors of the presence of retained products of conception (RPOC) within the uterine cavity in women with clinical diagnosis of incomplete miscarriage.

METHODS

This was a prospective observational study, set in a dedicated early pregnancy assessment unit in a London teaching hospital. Endometrial thickness and the volume of suspected retained products of conception were measured by transvaginal ultrasound scan preoperatively. Indications for surgical intervention were heavy vaginal bleeding or continuous bleeding lasting > 7 days. The main outcome measure was histological evidence of chorionic villi in surgical specimens.

RESULTS

Among the patients, 109 (85%) had evidence of chorionic villi on histology, whilst decidua was only found in the remaining 19 (15%). There was no identifiable cut-off for endometrial thickness or volume that could be used to differentiate between retained products of conception and decidua.

CONCLUSION

Measurements of endometrial thickness or volume on ultrasound scan are not good tests for diagnosing an incomplete miscarriage.

Diagnostic accuracy of endometrial thickness for the detection of intra-uterine pathologies and appropriateness of performed hysteroscopies among asymptomatic postmenopausal women

OBJECTIVE

To measure the diagnostic accuracy of endometrial thickness for the detection of intra-uterine pathologies among asymptomatic postmenopausal women, and to test the diagnostic accuracy and appropriateness of performed hysteroscopies.

STUDY DESIGN

Prospective study of 268 asymptomatic postmenopausal women with endometrial thickness ≥4 mm referred to diagnostic hysteroscopy. The diagnostic accuracy of various endometrial thickness cut-off values was tested. Histological and hysteroscopic results were compared to measure the diagnostic accuracy of outpatient hysteroscopies.

RESULTS

No endometrial thickness cut-off values had optimal diagnostic accuracy [positive likelihood ratio (LR+) >10 and negative likelihood ratio (LR-) <0.1]. The best endometrial thickness cut-off value for the detection of all intra-uterine pathologies was ≥8 mm (LR+ 10.05 and LR- 0.22). An endometrial thickness cut-off value ≥10 mm did not miss any cases of endometrial cancer. The success rate of diagnostic hysteroscopy was 89%, but 97% of these revealed a benign intra-uterine pathology. The diagnostic accuracy of hysteroscopy was optimal for all intra-uterine pathologies, except endometrial hyperplasia (LR- 0.52).

CONCLUSION

Using an endometrial thickness cut-off value ≥4 mm, only 3% of performed hysteroscopies were useful for the detection of pre-malignant or malignant lesions. Despite the finding that endometrial thickness did not show optimal diagnostic accuracy, using the best cut-off value (≥8 mm) may be helpful to decrease the number of false-positive results. No cases of endometrial cancer were diagnosed in asymptomatic postmenopausal women with endometrial thickness <10mm.

Investigation of the infertile couple: hysteroscopy with endometrial biopsy is the gold standard investigation for abnormal uterine bleeding

During the last decade hysteroscopy has become the tool of choice for the evaluation of the endometrial cavity, including for assessment of abnormal uterine bleeding (AUB). Many clinicians would consider that, in most patients, the combination of transvaginal sonography and out-patient endometrial biopsy with diagnostic hysteroscopy could replace the need for dilation and curettage. Hysteroscopy was reported to have sensitivity, specificity, negative predictive value and positive predictive value of 94.2, 88.8, 96.3 and 83.1% respectively, in predicting normal or abnormal endometrial histopathology. The highest accuracy of hysteroscopy was in diagnosing endometrial polyps, whereas the worst result was in estimating hyperplasia. Therefore, since the incidence of focal lesions in patients with AUB is high, it seems that the most beneficial approach is to proceed with hysteroscopy complemented by endometrial biopsy early in the assessment of AUB. Nevertheless, the usage of distension media to flush the uterine cavity raises the concern that when the endometrium harbours pathology, there is the potential risk of retrograde dissemination of malignant cells into the peritoneal cavity. The clinical significance of the dissemination of endometrial cells during hysteroscopy is still undetermined.

Preventing intravasation in women undergoing hysteroscopic procedures

Hysteroscopic procedures, which are an alternative to hysterectomy for surgical treatment of menorrhagia and uterine fibroids, place women at risk for intravasation of uterine distention fluid. Intravasation can produce fluid overload, pulmonary edema, congestive heart failure, and electrolyte imbalances. To examine risk factors for and evaluate nursing interventions to decrease the incidence of intravasation, the researchers compared mean arterial pressures (MAPs) and intrauterine pressures (IUPs) in two groups of women undergoing elective outpatient hysteroscopic procedures. The experimental group consisted of 20 women in whom fluid infusion pump pressures were maintained below the women's MAPs. The control group consisted of 20 women whose fluid infusion pump pressures were set at random. Distention fluid deficits and the total infused distention fluid volume differed significantly between the two groups, supporting the study hypothesis that maintaining equilibrium between women's IUPs and MAPs decreases the risk of uterine distention fluid absorption into the vasculature and fluid overload complications. Perioperative nurses need to monitor women's MAPs before and during hysteroscopic procedures and maintain fluid infusion pump pressures at or below women's MAPs to decrease the potential for intravasation.

Diagnostic accuracy of saline contrast sonohysterography in detecting endometrial polyps in women with postmenopausal bleeding: systematic review and meta-analysis

OBJECTIVE

In women with postmenopausal bleeding, endometrial polyps are a frequent finding and the risk of a focal (pre)malignancy in a polyp is up to 6%. Because of this reported risk, the detection of polyps in these women, preferably by a minimally invasive method, is important. The aim of this systematic review was to assess the accuracy of saline contrast sonohysterography (SCSH) for diagnosis of endometrial polyps in women with postmenopausal bleeding.

METHODS

In August 2018, an electronic search was performed of MEDLINE, EMBASE and Web of Science databases to identify all diagnostic studies in which SCSH was used to detect endometrial polyps in postmenopausal women. Studies were included if SCSH was performed to detect endometrial polyps in women with postmenopausal bleeding and if detection of a polyp on hysteroscopy or diagnosis on histopathology was used as a reference standard. Two reviewers assessed methodological quality using the quality assessment of diagnostic accuracy studies (QUADAS-2) tool. Two separate analyses were performed for each reference standard. Pooled sensitivity and specificity were calculated using the hierarchical summary receiver-operating characteristics (HSROC) model and HSROC curves were plotted.

RESULTS

After selection and quality assessment, five studies were included. Using 'polyps diagnosed with histopathology' as the reference standard, the pooled sensitivity of SCSH was 86.5% (95% CI, 63.6-100%) and the pooled specificity was 91.1% (95% CI, 63.2-100%). Using 'polyps seen on hysteroscopy' as the reference standard, the pooled sensitivity of SCSH was 85.1% (95% CI, 66.9-100%) and the pooled specificity was 84.5% (95% CI, 68.1-100%). Excluding the one study that included women in whom the SCSH examination was reported to be suboptimal, the pooled sensitivity increased to 90.7% (95% CI, 72.8-100%) using hysteroscopy as the reference standard. The sensitivity of hysteroscopy to detect polyps, as reported in two studies, was 81-98%.

CONCLUSIONS

Provided that the SCSH examination is of optimal quality, it can be considered as a method to stratify women with postmenopausal bleeding for further diagnostic workup and treatment with hysteroscopy. In women without suspicion of a polypoid lesion on SCSH, and with a benign endometrial sample, expectant management should be considered. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

ACOG technology assessment in obstetrics and gynecology, number 4, August 2005: hysteroscopy

Hysteroscopy is an effective, minimally invasive procedure for the diagnosis and treatment of intrauterine pathology. Selection of a distending medium requires consideration of the advantages, disadvantages, and risks associated with various media as well as their compatibility with electrosurgical or laser energy. Preoperative discussions with patients should address risks and benefits of the procedure, comorbidities, analgesia or anesthesia, and possible preoperative cervical dilation. Pregnancy, genital tract infection, and uterine carcinoma are contraindications to hysteroscopy. Possible complications include hemorrhage, fluid overload, perforation, visceral injury, infection, and embolization.

Hysteroscopy: an evolving case of minimally invasive therapy in gynaecology

Hysteroscopy is an endoscopic technique, allowing inspection of the intrauterine cavity. Diagnostic applications of the technique began to develop in the 1970s. Although it is often claimed that diagnosis under direct visualization is better than standard dilatation and curettage, it has not yet been proved that hysteroscopic diagnosis has better results than curettage. The clinical application of therapeutic hysteroscopy, mainly in the field of the treatment of abnormal uterine bleeding, started in the 1980s. Two thousand patients have been treated with either hysteroscopic myomectomy, endometrial resection, or endometrial laser ablation, according to the literature. No randomized trials have been conducted. The first clinical results of hysteroscopic treatment seem satisfactory, with average success rates of 85%. There is some evidence that the therapy is cost saving, because hysteroscopic procedures only require one or two nights in hospital. The technique is not yet widely diffused, mainly because of technical difficulties and lack of definite evidence on its effectiveness.

Hysteroscopy as a standard procedure for assessing endometrial lesions among postmenopausal women

CONTEXT AND OBJECTIVES

Endometrial cancer is the most prevalent type of malignant neoplasia of the genital tract. The objective of this study was to calculate the sensitivity, specificity, accuracy and positive and negative predictive values for diagnostic hysteroscopy, in comparison with histopathological tests, for all lesions of the endometrial cavity.

DESIGN AND SETTING

Retrospective descriptive study at the public tertiary-level university hospital of Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo.

METHODS

Diagnostic hysteroscopy was indicated in the following instances: endometrial thickness > 4 mm in asymptomatic patients; postmenopausal bleeding; and irregular endometrium or endometrium difficult to assess from ultrasound, with or without vaginal bleeding. Ultrasound evaluations were carried out no more than three months prior to hysteroscopy.

RESULTS

There were 510 patients, with a mean age of 61.1+/-2.0 years and mean time elapsed since the menopause of 12.7+/-2.5 years. Endometrial biopsies were performed on 293 patients (57.5%). Histopathological analysis showed that 18 patients presented endometrial carcinoma or typical or atypical hyperplasia, and none of them presented endometrial thickness of less than 8 mm. No significant differences were found between the median thicknesses of the various benign lesions (p > 0.05). In our data, the sensitivity, specificity, accuracy and positive and negative predictive values for cancer or hyperplasia were 94.4%, 97.0%, 96.8%, 68% and 99.6%, respectively.

CONCLUSIONS

Our results suggest that hysteroscopy is valuable as a diagnostic tool for malignant/hyperplastic and benign lesions, except for submucous myomas, for which the sensitivity was only 52.6%.

Evaluation of outpatient hysteroscopy and ultrasonography in the diagnosis of endometrial disease

OBJECTIVE

To develop a multivariable approach to determine the added value of tests in routine practice where some diagnostic information is already available from clinical history.

METHODS

Multivariable logistic regression models were built in a stepwise fashion, considering the clinical sequence used in the rapid access ambulatory diagnosis clinic (clinical history followed by transvaginal ultrasonography and hysteroscopy). The reference standard for confirmation of diagnosis was endometrial biopsy. The diagnostic accuracy of the models was determined by the area under the receiver operating characteristic curve.

RESULTS

The area under the receiver operating characteristic curve for the model including historical features alone was 0.78. When hysteroscopy and ultrasonography were each added to the model, it increased to 0.81 (P =.008 for improvement) and 0.82 (P =.02 for improvement), respectively.

CONCLUSION

The type of stepwise analysis we have developed is crucial in facilitating meaningful clinical interpretation about the value of diagnostic technology. Our finding that hysteroscopy or ultrasonography marginally but significantly increased the prediction of serious endometrial pathology above that predicted from patient history alone needs validation in an independent data set. The use of this approach is recommended when evaluating strategies for diagnosis.

Diagnostic value of sonohysterography in the evaluation of submucosal fibroids and endometrial polyps

AIMS

To evaluate the diagnostic value of sonohysterography in the evaluation of submucosal fibroids and endometrial polyps.

METHODS

Thirty-two women whose preliminary transvaginal ultrasound suggested endometrial abnormality underwent sonohysterography. The findings were then compared with histopathological results.

RESULTS

The sonohysterographic diagnosis was fibroid in seven patients, endometrial polyp in 23 patients and simple hyperplasia in two patients. Histopathological findings confirmed our diagnosis in all except three patients with endometrial polyps, who had normal secretory endometrium. Sonohysterography was found to have a sensitivity of 100%, a positive predictive value of 90% and diagnostic accuracy of 90.6%.

CONCLUSION

Sonohysterography is a useful, minimally invasive and accurate technique to evaluate the pathologies involving endometrium and uterine cavity.

Hysteroscopic sterilization in the office setting

Hysteroscopic sterilization is growing in popularity. Nearly 500,000 women have been sterilized using this method, and an increasing number of physicians are now performing this procedure in the office setting. The office setting can provide a cost-effective, convenient, and safe environment for hysteroscopic sterilization. Patients may benefit from avoiding hospital preoperative visits, excessive laboratory evaluation, operating room wait times, and expense associated with hospital care. Physicians may improve productivity through remaining in their office or avoiding operating room delays. This article reviews office-hysteroscopic sterilization with the Essure microinsert system.

Concordance between hysteroscopic impression and endometrial histopathological diagnosis

OBJECTIVE

The aim of this study was to evaluate the accuracy of hysteroscopic impression for diagnosing benign and malignant endometrial pathology.

METHOD

This is a retrospective cross-sectional study involving case records of 412 patients who underwent hysteroscopy with diagnostic dilatation and curettage (D&C) at the University of Malaya Medical Centre from January 2009 to August 2011, and cases with records of previous hysteroscopies (2007-2008). Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values, likelihood ratios (LR) and post-test probabilities of hysteroscopy were calculated. D&C was set as the 'gold standard'.

RESULTS

Hysteroscopy and histology results were concordant in 366 (88.8%) subjects. Sensitivity, specificity, PPV and NPV were high exceeding 80%. Moderate sensitivity for endometrial hyperplasia (64.4%, 95% CI=49.8%-76.8%) with moderate PPV for malignancy (62.1%, 95% CI=44.0%-77.3%) due to misdiagnosing hyperplasia as malignant was observed. PPV for leiomyoma was reduced (83.3%, 95% CI=60.8%-94.2%) despite 100% sensitivity, due to D&C false negatives. High positive LR (>10) and low negative LR (<0.2) were observed generally except for endometrial hyperplasia (0.36). Hysteroscopy had moderate positive post-test probability for malignancy (0.62) but effective in ruling out malignancy (negative post-test probability=0.00).

CONCLUSION

Hysteroscopy is accurate for diagnosing focal and malignant endometrial pathology but only moderate for hyperplasia. Endometrial sampling is recommended for all cases especially when suspecting hyperplasia or malignancy.