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Table of Content - Volume 9 Issue 2 - February 2019

Assessment of postmenopausal bleeding cases with hysteroscopy

 

Ishrath fatima1, Roohi Mushtaque Shaikh2*

 

1Assistant professor, 2Associate professor, Department of Obstetrics and Gynecology, JIIUS Indian Institute of Medical Science and Research Warudi, Tq Badnapur Dist. Jalna, Maharashtra, INDIA

Email: dr.roohi.shaikh@gmail.com

 

Abstract               Background: Early evaluation of PMB cases is very essential as an endometrial carcinoma when fortunately detected at an early stage can be cured with less morbidity and mortality. Aim: To assess the postmenopausal bleeding cases with hysteroscopy. Material and Methods: Diagnostic hysteroscopy was done in 50 cases of postmenopausal bleeding women in whom ET ≥4mm on transvaginal sonography. Sensitivity and specificity of hysteroscopy were calculated. Endometrial biopsy was considered as the gold standard. Results: The sensitivity and specificity of hysteroscopy for the cases of endometrial hyperplasia, endometrial polyp and submucous fibroid were 100% except in case of atrophic endometrium which was slightly less. Conclusion: Hysteroscopy is a gold standard especially in high risk patients and represents an easy, safe and effective means to investigate postmenopausal women with a thickened endometrium found on TVS.

Key Word: Postmenopausal bleeding, hysteroscopy, Endometrial biopsy, sensitivity, specificity

 

 

 

INTRODUCTION

Postmenopausal bleeding (PMB) is a common clinical problem in both general practice and hospital settings. Due to increase in life expectancy, about one third of life span of a woman will be spent during this period. It is very essential to manage postmenopausal period carefully. Any amount of PMB should not be underestimated, as there is a high incidence of endometrial malignancy during this period.1 Hysteroscopy is an endoscopic technique allowing visualization of then dometrial cavity. Recent advances in instrumentation have allowed hysteroscopy to be performed in an outpatient setting, further increasing its use in gynecological practice. Hysteroscopy is likely to become the new gold standard in the future because of its ability to visualize directly the endometrium and perform directed biopsies as indicated.2Early evaluation of PMB cases is very essential as an endometrial carcinoma when fortunately detected at an early stage can be cured with less morbidity and mortality. It has much higher cure rate if diagnosed early. The present study was conducted to assess the postmenopausal bleeding cases with hysteroscopy.

 

MATERIAL AND METHODS

The study included 73 postmenopausal women with bleeding per vaginum attending Gynaecology OPD in the Department of Obstetrics and Gynaecology of Guwahati Medical College and Hospital, Guwahati over a period of two years. Approval from Institutional Ethical Committee was obtained before commencement of the study. Informed written consent was obtained from each patient.

Inclusion criteria

  • Women presented with postmenopausal bleeding per vaginum after the age of 40 years (period of at least 12 months of amenorrhoea).
  • The amenorrhoea was not explained by medication or disease with the complaint of bleeding per vagina.

Exclusion criteria

  • Women with bleeding diathesis and cardiac diseases, grossly abnormal cervix.
  • Women with diagnosed genital tract malignancy.
  • Women with endometrial thickness of <4mm (for hysteroscopy and DandC)

A detailed history with systemic and local examination done. Transvaginal sonography followed by hysteroscopy and DandC done in cases where endometrial thickness ≥4mm.

Hysteroscopy: Diagnostic hysteroscopy was done in 50 cases of postmenopausal bleeding women in whom ET ≥4mm.Diagnostic hysteroscope used was manufactured by Wolf Richard Company with halogen light source(150-250watts).

Procedure: After positioning the patient in dorsal lithotomy position, sedation given with 1ccfortwinand 1cc phenargen. Rigid hysteroscope was inserted into the sheath and the lock ring closed. The distention system was connected to the inflow stopcock and the sheath flushed through to demonstrate easy passage of the medium. Normal saline was used as a distension media. Once the scope was inserted through the external os, it was advanced and with drawns lightly to allow direct visualization of the internal os which appeared as a dark circle. The area that represented the internal os was at 12 o’clock position at the edge of the field of vision when the scope was upright and at 6 o’clock position when the scope was inverted. All surfaces of endometrium anterior, posterior, lateral wall including fundus and tubal ostia visualized. Careful techniques lessen disturbance of the endocervical canal and endometrium and allowed better and more precise visualization.

Statistical Analysis: The data collected in the study, analyzed statistically using descriptive statistics, Chi-square test, percentage, mean and standard deviation.

 

RESULTS

In our study, majority of the cases 16 (32%) were in the age group of 50-55 years followed by 15 (30%) cases were below 50 years of age. Eight (16%) cases were between 56-60 yeas age group while 6 (12%) were between 61-65 years age group. Only 5 (10%) cases were in the age group of 66-70yrs. Mean age of the patient in our study was 54.3 yrs. It was observed that as the age increases, the number of patient decreases. Most of the patients presented with PMB within 10 year of menopause 38 (76%). Nine (18%) cases presented within 11-15 years whereas only 3 (6%) of the cases had menopause more than 16-20yrs.30 (60%) patients came to the hospital with one episode whereas 15 (30%) attended with two episodes of postmenopausal bleeding. 5 (10%) patients presented with three episodes of postmenopausal bleeding, however, more than three episodes were not observed in any patient. It was seen that 49 (98%) of the women were multiparous and only one (2%) woman was nulliparous. Majority of the patients (52%) had associated medical problems like diabetes mellitus 7 (14%), hypertension 10 (20%), obesity 3 (6%), diabetes and hypertension 3 (6%) and hypothyroidism 3 (6%).


 

Table 1: Hysteroscopic finding in PMB cases

Hysteroscopic finding

No. of cases

Normal endometrium

13(26%)

Atrophic endometrium

20(40%)

Thickened endometrium

11(22%)

polyp

2(4%)

Irregular endometrium

2(4%)

Myoma

2(4%)

On hysteroscopic examination, normal endometrium was seen in 26% of cases and atrophic endometrium was seen in 40% cases.Polyp was seen 4% cases whereas myoma was seen in 4%cases.Hyperplasia of the endometrium was seen in 22% of the cases whereas irregular growth was seen in 4% of the cases.

 

Table 2: Sensitivity and specificity of endometrial biopsy and hysteroscopy

Diagnosis

Endometrial biopsy

Hysteroscopy

Sensitivity (%)

Specificity (%)

Sensitivity (%)

Specificity (%)

 

Atrophic endometrium

100

100

97.5

95.23

 

Endometrial hyperplasia

100

100

100

100

 

Endometrial polyp

50

98.4

100

100

 

Submucous fibroid

0.00

0.00

100

100

 

Carcinoma of endometrium

100

100

100

100

 

The sensitivity and specificity of endometrial biopsy was 100% in cases of atrophic endometrium, endometrial hyperplasia and endometrial carcinoma, whereas, in cases of endometrial polyp, submucous fibroid sensitivity and specificity were less. On the other hand, sensitivity and specificity of hysteroscopy for the cases of endometrial hyperplasia, endometrial polyp and submucous fibroid were 100% except in case of atrophic endometrium which was slightly less.So, cases of polyp and submucous fibroid were better seen by hysteroscopy.

Table 3: Comparative hysteroscopic findings

Hysteroscopic

finding

EkinM

et al8

N=70

Marathaoan

et al9

N=329

Tandulwalkar et al4

N=50

Present study

N=50

Normal endometrium

--

26(7.9%)

--

13(26%)

Atrophic endometrium

23(32.4)

55(16.72%)

34(68%)

20(40%)

Endometrial Hyperplasia

17(24.3%)

11(3.34%)

4(8%)

11(22%)

Polyp

3(4.3%)

183(55.62%)

7(14%)

2(4%)

Irregular endometrium

--

13(3.9)

4(8%)

2(4%)

Myoma

10(14.3%)

12(3.65%)

1(2%)

2(4%)

 


DISCUSSION

The postmenopausal bleeding is associated with different types of endometrial pathology. Each postmenopausal bleeding case requires to be investigated. Although the incidence of carcinoma among these women is high but other benign causes such as normal proliferative, endometrial hyperplasia or atrophic endometrium are also common. In our study we have found majority of cases are <55 yrs (62%). Similarly, Das et al also observed majority of the patients in the age group of <55yrs (85%)3 and Tandulwalkar et al study had majority of the patients in the age group of <55yrs.4In present study we had 10% of the patient of >65 years, however Das et al and Tandulwalkar et al did not have any patient of > 65years.Gredmark et al reported that the occurrence of PMB decreased with increasing age but the probability of cancer as the underlying cause increased with age.5 In our study mean age was 54±8.1years. The mean age of Sausa et al study was 62± 8.9 years6 and Doorn HC et al study was 61±9.8 years.7 In the study by Ekin et al atrophic endometrium was seen in 32% cases, endometrial hyperplasia seen in 24% cases, polyp was seen in 4.3% case whereas myoma was seen in 14% cases.8Marathaoan et al had studied 329 patients in which maximum cases were of polyp 183(55.62%),55(16.72%) cases of atrophic endometrium,11(3.34%) cases of endometrial hyperplasia, irregular endometrium 13(3.9%)andmyoma12(3.65%).9 In our study, we had 13(26%) cases of normal endometrium,20(40%) cases of atrophic endometrium, endometrial hyperplasia 11(22%),polyp 2(4%) and2(4%) cases of myoma which was comparable to study by Ekin et al8andTandulwalkar et al.4 The sensitivity of hysteroscopy according to Tandulwalkat et al was 97% which is comparable to our study of sensitivity 97.5%.4Specificity of hysteroscopy by Giusa-Cheifriet al was 96% which is comparable to our study 95.2%.10Sensitivity of endometrial biopsy in Tandulwalkarstudy was 92% whereas in Giusa-Cheifriet al only 84% but in present study it was 98.3%.Similarly, specificity of endometrial biopsy in Tandulwalkaret al and Giusa-Cheifriet al was 88% and 89% respectively but in our study specificity was much higher.

 

CONCLUSION

Hysteroscopy is a gold standard especially in high risk patients and represents an easy, safe and effective means to investigate postmenopausal women with a thickened endometrium found on TVS. Hysteroscopy can differentiate focal lesion such as polyp and myomas better than endometrial biopsy.

 

 

REFERENCES

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  2. Goncharenko VM, Beniuk VA, Kalenska OV, Demchenko OM, Spivak MY, Bubnov RV. Predictive diagnosis of endometrial hyperplasia and personalized therapeutic strategy in women of fertile age. EPMA J. 2013;4(1):24.
  3. Das PS. A Clinicopatholigical study of the endometrium in case of postmenopausal bleeding per vaginum. Submitted to Rajiv Gandhi University of Health Sciences, 2003.
  4. Tandulwadkar S, Deshmukh P, Lodha P, Agarwal B. Hysteroscopy in postmenopausal bleeding. J GynecolEndosc Surg. 2009;1(2):89-93.
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  6. Sousa R, Silvestre M, Almeida e Sousa L, Falcão F, Dias I, Silva T, De Oliveira C, Oliveira HM. Transvaginal ultrasonography and hysteroscopy in postmenopausal bleeding: a prospective study. Acta Obstet GynecolSc and 2001; 80: 856-62.
  7. van Doorn HC, Opmeer BC, Burger CW, Duk MJ, Kooi GS, Mol BW. Inadequate office endometrial sample requires further evaluation in women with postmenopausal bleeding and abnormal ultrasound results. Int J GynecolObstet2007; 99: 100–4.
  8. Ekin M,Karayalçin R, Özcan S,Özcan U. Transvaginal Ultrasonography and Office Hysteroscopic Findings and Their Hystopathologic Correlation in Asymptomatic and Symptomatic Postmenopausal Women. Medical Journal of Bakirköy 2007; 3(2):68-72.
  9. Karinne de Marathaoan, Souza Martins, Castello Branco, HosanaandDepes, Daniella and Farah Baracat, Fausto andGazi Lippi, Umberto andHirome Takahashi, WinnyandGuedes Coelho Lopes, Reginaldo. (2008). Hysteroscopic findings in postmenopausal patients with ultrasonographic diagnosis of endometrial thickening. Einstein 2008;6(3):287-292.
  10. Giusa-Chiferi MG, Gonçalves WJ, Baracat EC, de Albuquerque Neto LC, Bortoletto CC, de Lima GR. Transvaginal ultrasound, uterine biopsy and hysteroscopy for postmenopausal bleeding.Int J Gynaecol Obstet. 1996 Oct;55(1):39-44.