A review of 2581 out‐patient diagnostic hysteroscopies in the management of abnormal uterine bleeding

Abstract

Objective To evaluate the clinical efficacy, reliability and acceptability of out‐patient diagnostic hysteroscopy at a large teaching hospital. Setting The Women's Endoscopy Unit at Nottingham City Hospital, Nottingham, UK. Subjects Between 1994 and 1997, 2581 women were referred for menstrual problems and abnormal uterine bleeding. The endocervical canal and endometrial cavity were assessed using either a 4‐mm rigid or a 3.5‐mm flexible hysteroscope, according to the preference of the operator. All hysteroscopies were performed by consultants or experienced registrars. Endometrial biopsy was taken when indicated. Results The main indications for referral for diagnostic hysteroscopy included menorrhagia (37.5%), postmenopausal bleeding (33.4%), intermenstrual bleeding (26.7%) and metrorrhagia (8.8%). Less common indications included treatment with tamoxifen, review of previous endometrial pathology or abnormal glandular cells on cervical cytology, and investigation for infertility. The mean age of patients referred was 49.3 years. Hysteroscopy was completed successfully in 96.8% of all patients, with pain being the main reason for failure to complete the procedure. Local anaesthesia with paracervical infiltration was used in 34% of all patients. Submucous fibroids were the commonest cause of intrauterine pathology (11.4%) with the highest incidence found in women referred for menometrorrhagia (17.2%). Endometrial polyps were detected in 10.6% of all the patients. The endometrium was characterized by the hysteroscopist as atrophic, thickened, polypoid, haemorrhagic or malignant. Endometrial Pipelle biopsies were taken in 48.6% of all cases. Abnormal histological findings were reported in 61 cases including 11 instances of endometrial adenocarcinoma. The concordance rate between hysteroscopic and histological findings for all abnormalities was 63.9%. Further medical treatment was offered to 406 patients (16.3%), while 185 patients (17.3%) needed additional surgery as in‐patients. Conclusion Out‐patient hysteroscopy is a safe, acceptable and well‐tolerated procedure that provides useful information about the uterine cavity. Endometrial biopsy improves the diagnostic accuracy of hysteroscopy in detecting endometrial pathology.

The value of outpatient hysteroscopy in the management of postmenopausal bleeding: a review of 862 cases

“…To assess the clinical efficacy, acceptability and reliability of outpatient hysteroscopy in the management of postmenopausal bleeding in a large gynaecological unit, we audited our activities in a purpose‐built outpatient unit. In this study, we extend our results and analysis of 862 postmenopausal women who underwent outpatient hysteroscopies, the preliminary data of which have been presented elsewhere 5 …”

“…There are data which suggest that hysteroscopy may miss up to 3% of cases with intrauterine pathology 20 and that early (stage 1) endometrial cancers are occasionally overlooked 21 . Inadequacy of samples for histological assessment obtained by endometrial Pipelle biopsy is more common in the postmenopausal population, specifically in those cases where the endometrium was characterized as atrophic at hysteroscopy 5 . The cost implications of insufficient sampling of apparently atrophic endometrium must also be considered.…”

“…All hysteroscopies were carried out by experienced operators and the procedure has been described previously 5 . The endometrium was characterized according to the individual clinician's subjective assessment.…”

“…In this study, we extend our results and analysis of 862 postmenopausal women who underwent outpatient hysteroscopies, the preliminary data of which have been presented elsewhere. 5…”

Correspondence

“…Two recent papers address the issue of outpatient hysteroscopy 1,2 . Alexopoulos et al 1 review a large series for a variety of indications while Uhiara et al 2 review its place in a one‐stop menstrual disorder service. Whilst Alexopoulos and colleagues demonstrate how it is possible to perform large numbers of outpatient hysteroscopies, they do not address whether the procedure is necessary in the first place.…”