Diagnostic hysteroscopy: a valuable diagnostic tool in the diagnosis of structural intra-cavital pathology and endometrial hyperplasia or carcinoma?

Abstract

Objective: 1045 diagnostic hysteroscopic procedures performed throughout six consecutive years were evaluated, focussing on its value in diagnosing endometrial hyperplasia and carcinoma. Design: Retrospective study performed in the gynaecological endoscopy clinic of a training hospital. Subjects were 1045 pre- and post-menopausal patients. Results: A normal cavity was found in 54.2%. Most common abnormal findings were fibroids (21.0%) and endometrial polyps (14.4%). Hysteroscopically diagnosed hyperplasia of the endometrium was confirmed histologically in only less than half the cases. Endometrial carcinoma was suspected on hysteroscopic view in two cases of a total of seven proven cases. In three cases initially an endometrial polyp and in two cases a fibroid was diagnosed. Once the diagnosis was missed even after biopsy taking. Conclusions: Diagnostic hysteroscopy is a valuable diagnostic tool in diagnosing structural intra-cavital pathology, very suitable for the outpatient clinic. The value in diagnosing hyperplasia or endometrial carcinoma is limited and even after guided biopsy a malignancy cannot be ruled out.

Introduction

Diagnostic hysteroscopy becomes a more and more widely applied procedure in the gynaecologic clinic for evaluation of the uterine cavity in case of abnormal uterine bleeding. Early developments date from the 19th century [1]. Although the basic principle never changed, new developments concerning diagnostic hysteroscopy are still going on in the last 10 years. Initially a clinical procedure under general anaesthesia, the procedure became an outpatiënt procedure with local or none anaesthesia.

In case of post-menopausal bleeding outpatiënt transvaginal ultrasound followed by endometrial sampling (D & C, Pipelle or Vabra curettage) is the generally accepted primary diagnostic procedure. Diagnostic hysteroscopy with biopsy or D & C is often used as a secondary line diagnostic procedure in case ultrasound and endometrial sampling do not provide enough information [2].

Hysteroscopy is more accurate in diagnosing structural pathology as polyps, fibroids and congenital malformations compared to D & C [3], [4], [5], which will only scrap less than 50% of the uterine wall in 60% of the patiënts [6].

Whereas endometrial polyps can reliably be recognised on hysteroscopic view, hyperplasia, with or without complex atypia, or an endometrial carcinoma within a benign looking polyp can easily be overlooked. The hysteroscopic macroscopic diagnosis in case of (pre)-malignant cavital abnormalities must be accurate enough and histological sampling must be reliable, especially in case of endometrial polyps.

In this retrospective study, we analysed 1045 diagnostic hysteroscopic procedures for indications, outcome, failure rate and previously performed outpatient ultrasound throughout 6 years. We focussed on the value of the hysteroscopy in diagnosing hyperplasia and endometrial carcinoma.