Clinical Review

Assessment of abnormal uterine bleeding: 3 office-based tools

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

References

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Office hysteroscopy is comfortable and quick and associated with low complication rates. Preprocedural nonsteroidal agents or misoprostol may make the procedure more tolerable.

Disadvantages of office hysteroscopy include the need for expensive office equipment (camera, insufflator, hysteroscope, video equipment, etc.) and a skillful and experienced hysteroscopist, as well as the costliness of the procedure.

Complications. The complication rate is low (less than 1%) when a skilled physician performs the procedure. Complications include uterine perforation, infections, and excessive bleeding; complications related to the distending medium also have been recorded.²³

Indications for use. Entities that can be visualized hysteroscopically include:

endometrial polyps
submucosal and intramural fibroids
synechiae
retained products of conception
foreign bodies
endocervical lesions
endometrial atrophy
endometrial hyperplasia and cancer
arteriovenous malformations
gestational trophoblastic disease
pregnancy (although hysteroscopy should be avoided when a viable intrauterine pregnancy has been documented)

Infrequently, endometrial gland openings associated with adenomyosis also can be seen.

On occasion, it may be difficult to distinguish hysteroscopically between a sessile polyp and submucosal fibroid if the typical characteristics of a polyp or fibroid are not appreciated. Luckily, treatment with operative hysteroscopy is the same for both findings.

Special considerations.

Lesion size. The hysteroscopist must remember that it can be difficult to estimate the size of lesions noted. The reason: The eyepiece is focused at infinity, so objects that are closer appear magnified and objects that are further away appear smaller.²⁴ This can lead to surprises in the operating room, especially when the size of a lesion has been underestimated. In this regard, hysteroscopy is not as accurate as TVUS.
Rigid versus flexible. Some gynecologists may prefer to use a rigid hysteroscope because it permits a greater viewing angle than a flexible hysteroscope. In a rigid instrument, that angle ranges from 0 to 30 degrees. The outer sheaths of most rigid hysteroscopes are 3 mm to 7 mm. Larger-diameter sheaths permit insertion of biopsy instruments and graspers for directed endometrial biopsies.
The trouble with high pressure. Hysteroscopy can produce a falsely negative view when the operator uses CO₂ or high intrauterine pressure, since higher pressures can flatten an endometrial lesion. For this reason, it is wise for the hysteroscopist to get in the habit of slowly deflating the uterine cavity and carefully reinspecting the endometrial surface before concluding the procedure. A note about this maneuver should be included in the procedure report. If this approach is followed consistently, it should increase accuracy, reduce false negatives and medicolegal risk, and lead to better outcomes.
The specificity and PPV of hysteroscopy in cases of abnormal uterine bleeding should theoretically be 100%. In practice, however, the false-negative rate is 2% to 4%—the result of operator error.²⁵

Cost issues. The CPT code for office hysteroscopy is 58555. Regrettably, poor reimbursement has prevented rapid assimilation of this unique tool into office practice. Until insurance companies realize the marked advantages of this quick, safe, and comfortable office-based procedure and reimburse accordingly, women will be unnecessarily subjected to the rigors of surgical clearance and preoperative testing, loss of time from work and family, and the increased anxiety of having this procedure performed in an operating suite.

Comparing modalities

Investigators compared the accuracy of TVUS, transabdominal sonohysterography, and hysteroscopy in detecting submucosal fibroids (and determining their size) and myometrial growth in 52 premenopausal women scheduled for hysterectomy.²⁶ Transabdominal sonohysterography most accurately predicted size and myometrial ingrowth of fibroids. Hysteroscopy was least accurate in detecting the myoma’s size, perhaps because of the optical refractive index with which it is associated. Still, hysteroscopy is more accurate than blind biopsy alone in detecting intracavitary lesions such as polyps and fibroids.²⁷

SIS versus TVUS. SIS provides a more comprehensive view of the pelvic anatomy than TVUS alone, with more concentrated visualization of the endometrium. However, it can pose some technical difficulties. One group of investigators was unable to complete the procedure in patients with a uterus larger than 12 to 14 weeks, submucosal fibroids greater than 4 cm, polyps that filled the endometrial cavity, or large transmural fibroids that precluded distention of the endometrium.²⁸ Other limitations of SIS include the inability to thread the catheter, iatrogenic introduction of air bubbles into the uterus, and the inability to maintain distension in patients with a patulous cervix.

Evaluation of the endometrium is not ‘either-or.’ Sometimes a combination of procedures aids diagnosis of menstrual dysfunction.

Patients with a distended cervix may require an SIS catheter with a balloon that occludes the lower uterine segment. Placement of the intrauterine catheter may be difficult in patients with cervical stenosis, isthmic synechiae, a markedly retroverted uterus, or intrauterine septa. Women with cervical stenosis may benefit from placement of laminaria tents or misoprostol²⁹ (orally 100 μg 8 to 12 hours before the procedure or vaginally 200 μg to 400 μg 2 to 4 hours before the procedure). Uterine sounding may sufficiently disrupt synechiae. Cervical traction with a single-toothed tenaculum can straighten the uterine axis if marked retroversion is present.