Hysteroscopy in Abnormal Uterine Bleeding vs Ultrasonography and Histopathology Report in Perimenopausal and Postmenopausal Women

Introduction: Abnormal uterine bleeding is one of the most common morbidity landing women to attend medical attention in gynecology outpatient department. This study aims to evaluate the hysteroscopy finding in diagnosis of AUB and its correlation with ultrasonography finding and histopathological reports. Methods: This was a prospective comparative study in which ultrasonography was performed in fifty patients with abnormal uterine bleeding attending OPD then hysteroscopy was performed. After removing hysteroscopy dilation and curettage was done and sample sent for histopathology. At the end reports of hysteroscopy finding were compared with sonograhic and pathological results. results: In the study women aged from 45 to 64years with the symptoms duration of 15 days to 6months. Post menopausal women seek medical attention more early then the menstruating women. Common symptoms are menorrhagia, metrorrhagia and postmenopausal bleeding. Most common abnormality was menorrhagia (32%) followed by post menopausal bleeding 28 %. Ultrasonography showed 46% of abnormal finding in which 17 (47%) menstruating women and 6 (43%) women were postmenopausal women. Among 50 women 17 (34%) had negative finding and 43 (66%) had abnormal finding in which most common finding of hyperplastic endometrium. Hysteroscopy correctly diagnose atrophic endometrium, polyp and endometrial Ca which is also confirmed by histopathology finding. conclusions: Hysteroscopy is reliable method for evaluating cases of AUB and it can be used as first line diagnostic method for benign lesions. Hysteroscopy guided biopsy has most accurate in diagnosing pathology. _______________________________________________________________________________________


INtrODUctION
AUB is commonest gynecological problem seen in OPD comprising 30-70% of women of premenopausal period.Main causes are uterine fibroid, endometrial hyperplasia, carcinoma of endometrial and cervix. 1 AUB accounts for two third of hysterectomies. 2y vaginal bleeding after menopause is considered abnormal and requires evaluation in postmenopausal women. 3,4G is noninvasive method with good accuracy in Traditionally D and C used to be mainstay of investigation for AUB but it is not accurate for diagnosing focal intrauterine lesion or located in areas difficult to curette so anything which improve the accuracy of diagnosing the cause of bleeding can reduce the frequency of hysterectomy as a cure.
This study aimed to assess the feasibility of hysteroscopy for diagnosing AUB in correlation with ultrasonographic and histological findings.

MEtHODs
This is a crosssectional study conducted from 1 st January to 31 st June 2014.All the patient who fit our criteria were included and was conducted in the out-patient department of gynecology at Kathmandu Medical collage teaching hospital, Kathmandu, Nepal.
Detailed clinical history was taken and general, systemic and pelvic examination was done.All patient underwent pelvic ultrasound and hysteroscopy followed by dilation and curettage.
Ultrasound was done and uterine size, contour, intramural, sub mucosal lesion if any seen and endometrial thickness were noted.Endometrial echo complex ≥15 mm in menstruating women and ≥5mm in postmenopausal women were considered abnormal.
After informed consent hysteroscopy was performed in Operation Theater under intravenous anesthesia.
Ringer lactate was used as a distending medium in hysteroscopy.Systemic examination of uterine cavity was performed and internal OS and cervical canal visualized and finding noted.Finally dilatation and curettage was performed and tissue collected in formalin and sent for histopathological examination.
Abnormal Uterine bleeding for the age group 45 years to 64years old was included.The Duration of symptom was 15 days to 6 months were included.Bleeding disorder and patient taking anticoagulant, age group between <45 and age >64, duration of symptoms of <15 days and duration of symptoms >6months were excluded.Date were collected and placed in SPSS then statistical analysis was performed.

rEsULt
Patient in the study aged from 45 to 64years with the symptoms duration of 15 days to 6months.Post menopausal women seek medical attention more early then the menstruating women.Common symptoms are menorrhagia, metrorrhagia and postmenopausal bleeding.Most common abnormality was menorrhagia (32%) followed by post menopausal bleeding 28 %( Table 1).Brooks and Serdin 7 did hysteroscopy on 29 patients of abnormal uterine bleeding having negative curettage results in 20and found that 19 had myoma, five had polyp, and two had endometrial atrophy while true negatives were only three.The submucos myoma may be missed during curettage and abnormal bleeding will persist because the myoma has been eroded by scraping.Hysteroscopy was found to better method for diagnosing polyps as three cases were diagnosed in our study.
simple technique allowing the direct visualization of uterine cavity.So, in patients with abnormal uterine bleeding, hysteroscopy gives the immediate diagnosis and prompt and effective treatment.It helps to find focal source of bleeding and perform a visual directed biopsy of the suspected area.It is more accurate diagnosis then blindly done dilation and curettage for intrauterine pathologies, but still histopathology is the gold standard for malignancies.Bradley H, TimemermansA, Van Doorn H, Mol J. Diagnostic strategies for postmenopausal bleeding.Obstetrics Gynecol Int.2010; 850812:5.6. Emanuel MH, Marion J, Verdel MJ, et al.A prospective comparison by TVS and diagnostic hysteroscopy in evaluation of patients with abnormal uterine bleeding.Am J Obstet Gynecol.1995;172:547-52.7. Brooks PG, Serden SP.Hysteroscopic findings after unsuccessful dilation and curettage for abnormal uterine bleeding.Am J Obstet Gynecol.1998;158:1354-7.