Clinical Review

Assessment of abnormal uterine bleeding: 3 office-based tools

OBG Manag. 2003 May;15(5):51-66

Sophisticated, user-friendly tools now available for office diagnosis of dysfunctional bleeding are underutilized. Here, a thorough assessment of transvaginal ultrasound, saline-infusion sonography, and hysteroscopy.

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References

1. Rogerson L, Duffy S. A national survey of outpatient hysteroscopy. Gynecol Endosc. 2001;10:343-348.

2. Sheikh M, Sawhney S, Khurana A, Al-Yatama M. Alteration of sonographic texture of the endometrium in post-menopausal bleeding. A guide to further management. Acta Obstet Gynecol Scand. 2000;79:1006-1010.

3. Persadie RJ. Ultrasonographic assessment of endometrial thickness: A review. J Obstet Gynaecol Can. 2002;24(2):131-136.

4. Goldstein RB, Bree RL, Benson CB, et al. Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored Consensus Conference statement. J Ultrasound Med. 2001;20:1025-1036.

5. Weigel M, Friese K, Strittmatter HJ, Meichert F. Measuring the thickness—is that all we have to do for sonographic assessment of endometrium in postmenopausal women? Ultrasound Obstet Gynecol. 1995;6:97-102.

6. Schwartz LB, Snyder J, Horan C, Porges RF, Nachitgall LE, Goldstein SR. The use of transvaginal ultrasound and saline infusion sonohysterography for the evaluation of asymptomatic postmenopausal breast cancer patient on tamoxifen. Ultrasound Obstet Gynecol. 1998;11:48-53.

7. Shalev J, Meizner I, Bar-Hava I, Dicker D, Mashiach R, Ben-Rafael Z. Predictive value of transvaginal sonography performed before routine diagnostic hysteroscopy for evaluation of infertility. Fert Steril. 2000;73:412-417.

8. Dueholm M, Lundorf E, Olesen F. Imaging techniques for evaluation of the uterine cavity and endometrium in premenopausal patients before minimally invasive surgery. Obstet Gynecol Surv. 2002;57:389-403.

9. Langer RD, Pierce JJ, O’Hanlan KA, et al. Transvaginal ultrasonography compared with endometrial biopsy for the detection of endometrial disease. N Engl J Med. 1997;337:1792-1798.

10. Gull B, Karlsson B, Milson L, Granberg S. Can ultrasound replace dilation and curettage? A longitudinal evaluation of postmenopausal bleeding and transvaginal sonographic measurement of the endometrium as predictors of endometrial cancer. Am J Obstet Gynecol. 2003;188:401-408.

11. Carlson JA, Arger P, Thompson S, Carlson EJ. Clinical and pathologic correlation of endometrial cavity fluid detected by ultrasound in the postmenopausal patient. Obstet Gynecol. 1991;77:119-123.

12. Weber A, Belinson J, Bradley LD, Piedmonte M. Vaginal ultrasound versus endometrial biopsy in women with postmenopausal bleeding. Am J Obstet Gynecol. 1997;177:924-929.

13. Laifer-Narin S, Ragavendra N, Parmenter EK, Grant EG. False-normal appearance of the endometrium on conventional transvaginal sonography: Comparison with saline hysterosonography. AJR. 2002;178(1):129-133.

14. Widrich T, Bradley L, Mitchinson AR, Collins R. Comparison of saline infusion sonography with office hysteroscopy for the evaluation of the endometrium. Am J Obstet Gynecol. 1996;174:1327-1334.

15. Bradley LD, Falcone T, Magen AB. Radiographic imaging techniques for the diagnosis of abnormal uterine bleeding. Obstet Gynecol Clin North Am. 2000;27:245-276.

16. Mihm LM, Quick VA, Brumfield JA, Connors AF, Jr, Finnerty JJ. The accuracy of endometrial biopsy and saline sonohysterography in the determination of the cause of abnormal uterine bleeding. Am J Obstet Gynecol. 2002;186:858-860.

17. Goldstein SR. Saline infusion sonohysterography. Clin Obstet Gynecol. 1996;39(1):248-258.

18. Dijkhuizen FP, DeVries LD, Mol BW, et al. Comparison of transvaginal ultrasonography and saline infusion sonography for the detection of intracavitary abnormalities in premenopausal women. Ultrasound Obstet Gynecol. 2000;15:372-376.

19. Karlsson B, Granberg S, Wikland M, et al. Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding—a Nordic multicenter study. Am J Obstet Gynecol. 1995;172:1488-1494.

20. Goldstein S. Use of ultrasonohysterography for triage of perimenopausal patients with unexplained uterine bleeding. Obstet Gynecol. 1994;170:565-570.

21. Bradley L, Widrich T. State-of-the-art flexible hysteroscopy for office gynecologic evaluation. J Am Assoc Gynecol Laparosc. 1995;2:263-267.

22. Nagele F, O’Connor H, Davies A, Badawy A, Mohamed H, Magos A. 2,500 outpatient diagnostic hysteroscopies. Obstet Gynecol. 1996;88:87-92.

23. Serden SP. Diagnostic hysteroscopy to evaluate the cause of abnormal uterine bleeding. Obstet Gynecol Clin North Am. 2000;27:277-286.

24. Apgar B, Dewitt D. Diagnostic hysteroscopy. Am Fam Physician. 1992;46(5 suppl):19S-26S.

25. Gimpelson R, Roppold HA. Comparative study between panoramic hysteroscopy with directed biopsies and dilation and curettage. Am J Obstet Gynecol. 1988;158:489-494.

26. Cincinelli E, Romano F, Anastasio P, et al. Transabdominal sonohysterography, transvaginal sonography, and hysteroscopy in the evaluation of submucous myomas. Obstet Gynecol. 1995;85:42-47.

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KEY POINTS

Identification and measurement of the endometrial echo and descriptions of the echogenicity and heterogeneity of the endometrium are key to defining endometrial health.
The introduction of intracervical fluid (saline-infusion sonography) during transvaginal ultrasound is one of the most significant advances in ultrasonography of the past decade.
Hysteroscopic visualization has several advantages: immediate office evaluation, direct visualization of the endometrium and endocervix, and the ability to detect minute focal endometrial pathology and to perform directed endometrial biopsies.
Sometimes a combination of procedures may be the best way to determine the cause of abnormal uterine bleeding.

Because office-based physicians tend to feel comfortable relying upon endometrial biopsy or dilation and curettage (D&C) to evaluate abnormal uterine bleeding, newer tools—transvaginal ultrasound (TVUS), saline-infusion sonography (SIS), and hysteroscopy—see far too little utilization. Although these modalities are remarkably user-friendly when employed correctly, only 28% of gynecologists perform office hysteroscopy, and even fewer use SIS.¹

This article reviews indications for use, sensitivity and specificity, advantages and disadvantages, special considerations including cost issues, and suggestions for incorporating these modalities into gynecologic practice.

For most patients, neither endometrial biopsy nor D&C is particularly helpful in the assessment of abnormal uterine bleeding (see “Limitations of D&C and endometrial biopsy”). Does a negative biopsy signify health? An absence of intracavitary pathology? Or does it mean that we failed to sample the culprit?

Fortunately, abnormal uterine bleeding usually is attributable to endometrial conditions other than cancer, such as atrophy, hyperplasia, polyps, or fibroids. These pathologies may be benign, but they are still a nuisance. When left undetected and untreated, they can cause the patient much worry, along with weeks or months of unnecessary medical therapy and surgical procedures.

Limitations of D&C and endometrial biopsy

Dilation and curettage (D&C) detects benign pathology in about 80% of patients with menstrual dysfunction.¹ It is most likely to detect the problem when pathology affects the endometrium globally.

A recent study reported on 105 postmenopausal women with bleeding and an endometrial echo of more than 5 mm who were evaluated with both hysteroscopy and D&C.² Although 80% of the women had pathology in the uterine cavity, and 98% of the pathologic lesions manifested a focal growth pattern at hysteroscopy after D&C, the whole or parts of the lesion remained in situ in 87% of the women. In addition, D&C failed to detect 58% of polyps, 50% of hyperplasias, 60% of complex atypical hyperplasias, and 11% of endometrial cancers. When disease was global, D&C detected 94% of abnormalities.

Focal disease therefore mandates operative hysteroscopic-directed biopsy and removal of suspicious pathology.

Endometrial biopsy can be performed in the office without anesthesia—a great advantage. The technique is most helpful in “dating” the endometrium and diagnosing endometrial cancer or hyperplasia. Unfortunately, blind endometrial biopsy studies are frequently returned with pathology reports of insufficient tissue, atrophic changes, mucus and debris, scanty tissue, no visible endometrial tissue, endocervical tissue, or proliferative or secretory endometrium.

Further, when a blindly performed biopsy reveals normal histology, it does not necessarily rule out other pathology. In addition, a biopsy via endometrial suction curette frequently misses focal lesions such as endometrial polyps and submucosal fibroids. Global noninvasive surveillance of the endometrium is more effective at detecting such focal lesions.

Investigators who performed endometrial biopsy prior to hysterectomy in patients with known endometrial cancer demonstrated that the sensitivity of diagnosing endometrial cancer with a biopsy via endometrial suction curette increases when the pathology affects more than 50% of the surface area of the endometrial cavity.³ However, biopsy failed to detect cancer in 11 of 65 patients in whom the malignancy affected less than 50% of the endometrium. These 11 false negatives included 5 cases of endometrial polyps, 3 malignancies that affected less than 5% of the endometrium, and 7 cancers that affected less than 25% of the endometrium.

REFERENCES

1. Holst J, Koskela O, von Schoultz B. Endometrial findings following curettage in 2,018 women according to age and indications. Ann Chir Gynaecol. 1983;72:274-277.

2. Epstein E, Ramirez A, Skoog L, Valentin L. Dilation and curettage fails to detect most focal lesions in the uterine cavity in women with postmenopausal bleeding. Acta Obstet Gynecol Scand. 2001;80:1131-1136.

3. Guido RS, Kanbour-Shakir A, Rulin MC, Christopherson WA. Pipelle endometrial sampling: sensitivity in the detection of endometrial cancer. J Reprod Med. 1995;40:553-555.

Transvaginal ultrasound

TVUS is quick, convenient, inexpensive, and comfortable for the patient. It can evaluate the endometrium utilizing gray scale, color or power Doppler, contrast media (SIS), or 3-dimensional ultrasound technology. In addition, TVUS permits visualization of the adnexa and pelvic organs, including the bladder and cul de sac. Among the abnormalities detectable with TVUS are fibroids (including submucosal leiomyomas) and endometrial polyps. Not surprisingly, an experienced operator is crucial for a precise diagnosis.