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Significance of negative hysteroscopic view in abnormal uterine bleeding. HB Parasnis, SV ParulekarDept of Obstetrics and Gynecology, Seth G S Medical College and KEM Hospital, Parel, Bombay.
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 0001432829
Ninety six cases of abnormal uterine bleeding were evaluated by both panoramic hysteroscopy and dilatation and curettage. The indications for hysteroscopy included postmenopausal bleeding, infertility with abnormal bleeding, abnormal bleeding and suspected leiomyoma with bleeding. Twenty three patients had abnormal hysteroscopy findings. Hysteroscopy diagnosed endometrial polyp and submucus leiomyoma with 100% accuracy. In 17 cases, the results of hysteroscopy and curettage were in agreement and hysteroscopy revealed more information than curettage in 6 cases. Among the remaining 73 cases with 'negative' hysteroscopic view, an abnormality was detected by tissue sampling in only 2 patients. The specificity and positive predictive value of hysteroscopy is 100%. The sensitivity of hysteroscopy was greater (92%) than that of curettage (76%) and the negative predictive value of hysteroscopy was 2.8%. Thus, panoramic hysteroscopy may prove to be superior to curettage in making an accurate diagnosis of intrauterine pathology. Keywords: Adult, Dilatation and Curettage, standards,Female, Hospitals, University, Human, Hysteroscopes, Hysteroscopy, methods,standards,India, epidemiology,Middle Age, Prospective Studies, Sensitivity and Specificity, Uterine Hemorrhage, diagnosis,epidemiology,etiology,
Hysteroscopic examination provides an access to evaluate the intrauterine milieu and is considered today as an essential part of the workup of abnormal uterine bleeding. A number of reports have advocated panoramic hysteroscopy in conjunction with dilatation and curettage for evaluating abnormal uterine bleeding[1],[2] though a few reports show that dilatation and curettage may miss a lesion 10-35% of the time[2],[3]. The purpose of this study was twofold. It assessed the value of a hysteroscopic view in determining whether endometrial sampling should be done in spite of a negative hysteroscopic view. It also attempted to confirm the usefulness of hysteroscopy as a diagnostic procedure in evaluating abnormal uterine bleeding in comparison to dilatation and curettage.
This prospective study involved 96 patients of abnormal uterine bleeding who underwent a diagnostic hysteroscopy and dilatation and curettage during a two-year period (1990-91) [Table - 1] shows the age distribution of the patients with abnormal uterine bleeding and the type of bleeding being evaluated. The majority of the patients were in the older age group (>30 yrs). Diagnostic hysteroscopy was performed using a 4mm 30? foreoblique panoramic hysteroscope (Storz) with a 5mm sheath, under intravenous sedation and local anaesthesia. The distending media used were crystalloids (Ringer lactate, 5% dextrose)[4]-[5]. The operative time was 7 to 10 minutes and there were no complications. Curettage was done by sharp curette and for both endometrial and enclocervical tissue obtained, histopathological examination was carried out to correlate and confirm the hysteroscopic findings. Patients with normal uterine cavities without any questionable area were labelled as "negative hysteroscopic view" when all of the following three criteria were met :(i) good visualisation of the entire uterine cavity (ii) no structural abnormalities in the cavity and (iii) a uniformly thin, homogenous appearing endometrium without variations in thickness[6].
As shown in [Table - 2], abnormal findings were found in 25 of the 96 cases giving an incidence of 26.05% while in the remaining 71 cases (73.95%) no abnormality was detected. In the premenopausal women, the most common abnormality found was endometrial polyp followed by submucous leiomyoma, while in the postmenopausal women, the most common abnormality detected was endometrial hyperplasia. In 17 cases, the hysteroscopic and histological findings were in agreement, while in 6 cases, hysteroscopy yielded more information than curettage, detecting polyps in 2 cases and submucous leiomyoma in 4 cases [Table: 3]. In the 73 cases of negative hysteroscopic view, 2 abnormal findings were detected on histopathology, one case each of endometritis and endometrial hyperplasia. [Table - 4] shows that specificity and the positive predictive value of hysteroscopy was 100%. The sensitivity of hysteroscopy and curettage was 92% and 76% respectively. The negative predictive value of hysteroscopy was 2.8%.
The recent technologic improvements in instrumentation and the development of safe media for uterine distention have increased the applicability, simplicity, safety and effectiveness of hysteroscopy for visual exploration of the uterine cavity-hence the importance of hysteroscopy in evaluating cases of abnormal uterine bleeding[5],[6],[7],[8].[9]. In our study, 71 patients (73.95%) had normal findings. Similar studies by Gimpelson and Rappoid 7 had 60% patients with no abnormality. Intrauterine pathology like endometrial polyp and submucous leiomyoma are diagnosed with 100% accuracy. Both hysteroscopy and curettage were accurate when an abnormality was diagnosed, giving a specificity and positive predictive value of 100%. But the ability to diagnose a lesion (sensitivity) was more with hysteroscopy in comparison to curettage (92 v/s 76%) while a negative diagnosis was less wrongly made with hysteroscopy (2.8 v/s 8%). This diagnostic ability, which is frequently missed on dilatation and curettage, is not worthy especially as these conditions are responsible for many a case of abnormal uterine bleeding. This study confirms the conclusion of others that hysteroscopy is superior to curettage in evaluating patients with abnormal uterine bleeding[3],[6],[7]. The negative predictive value of a hysteroscopic view from this study is 2.8%. Hence, if criteria for negative hysteroscopic view are followed, a follow up curettage (tissue samplin W would not add much to the diagnosis of the case[6]. The concern of today's gynecologist while evaluating abnormal uterine bleeding is not to miss a significant cancerous lesion. The chances that such a lesion would be missed are rare, if we stick to the criteria for negative hysteroscopic view, and usually no further investigation may be necessary. But, in view of the current medicolegal climate, it would be prudent to obtain endometrial tissue for histopathological examination, especially in peri or postmenopausal patients in spite of a negative hysteroscopic view.
We are grateful to the Dean, Seth GS Medical College and King Edward Memorial Hospital for allowing us to publish hospital data.
[Table - 1], [Table - 2], [Table - 3], [Table - 4]
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