Middle East Fertility Society Journal (2011) 16, 77–82

Middle East Fertility Society

Middle East Fertility Society Journal

www.mefsjournal.comwww.sciencedirect.com

ORIGINAL ARTICLE

Comparative study of transvaginal sonography and

hysteroscopy for the detection of pathological endometrial

lesions in women with perimenopausal bleeding

Waleed El-khayat *, Mohamed Ehab Sleet, Enas Yassen Mahdi

Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Egypt

Received 2 July 2010; accepted 27 September 2010Available online 21 January 2011

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KEYWORDS

Transvaginal sonography;

Hysteroscopy;

Endometrial lesions;

Perimenopausal bleeding

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mail address: waleed_elkhya

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Abstract Objective: To estimate the diagnostic accuracy of two dimensional transvaginal ultra-

sound and hysteroscopy compared with histopathology in evaluation of uterine cavity lesions in

perimenopausal women with abnormal uterine bleeding.

Design: Descriptive diagnostic trial.

Setting: Cairo University Hospital.

Materials and methods: A total of 50 patients with perimenopausal bleeding scheduled for 2D TVS,

hysteroscopy and histopathologic examination of tissue specimen.

Results: The commonest bleeding pattern was menorrhagia (40%) followed by menometrorrhagia

in 34%, endometrial hyperplasia was found in about half of these lesions and was associated with

endometrial polyp in half of the multiple lesions, endometrial hyperplasia was the most frequent

finding by TVS (32%) with a mean endometrial thickness of 11.2 ± 2.4 mm followed by endome-

trial polyp (26%) with a mean endometrial thickness of 18.0 ± 5.3 mm. Using hysteroscopy the

commonest lesion diagnosed was endometrial polyp which was found in 28% of cases, while endo-

metrial hyperplasia found only in 20%. 2D ultrasound shows good sensitivity in detection of endo-

metrial polyp, highest specificity and accuracy was for adenomyosis. Hysteroscopy was poorly

sensitive but highly specific for both endometrial hyperplasia and adenomyosis. For endometrial

iro University, 5 Qura Ibn

12211, Egypt. Tel.: +20 202

.com (W. El-khayat).

lity Society. Production and

ved.

dle East Fertility Society.

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78 W. El-khayat et al.

polyp hysteroscopy was highly sensitive, specific and accurate. Ultrasound was more sensitive and

more accurate than hysteroscopy for detection of uterine lesions but hysteroscopy show higher spec-

ificity.

Conclusion: For differentiating normal from abnormal endometrial cavity both 2D TVS and hys-

teroscopy show high accuracy but U/S was more sensitive and a little more accurate than hysteros-

copy while the last was more specific.

� 2011 Middle East Fertility Society. Production and hosting by Elsevier B.V. All rights reserved.

1. Introduction

Abnormal uterine bleeding is a common gynecological presen-tation in out patient clinic, but is often complex and difficult to

diagnose. While most patients have benign diseases, thoroughinvestigation is necessary, particularly in the perimenopausalwoman. Abnormal uterine bleeding (AUB) is the main reason

women are referred to gynecologists and accounts for twothirds of all hysterectomies (1).

AUB is responsible for as many as one-third of all outpa-tient gynecologic visits and this proportion rises to 69% in a

perimenopausal group (2,3).In perimenopausal women, AUB is diagnosed when there is

a substantial change in frequency, duration, or amount of

bleeding during or between periods. In postmenopausal wo-men, any vaginal bleeding 1 year after cessation of menses isconsidered abnormal and requires evaluation (4,5). Fibroids

or polyps are the most common cause of anatomic AUB;Twenty to forty percent of women have fibroids. These womenmight present with abnormal bleeding, anemia, pain, and occa-sionally infertility (4,6). Diagnostic procedures for anatomic

changes and for endometrial carcinoma include ultrasonogra-phy, diagnostic hysteroscopy, sonohysterogram, and dilationand curettage (D&C) (7). Endometrial abnormalities are com-

mon diagnostic challenges facing the radiologist and referringgynecologist. For the evaluation of AUB, TVS plays an impor-tant role as the initial modality (8). A major limitation of TVS

is the higher false-negative rate in diagnosing focal intrauterinepathology. This results in part from the physical inability ofTVS to clearly assess the endometrium when there is concur-

rent uterine pathology such as leiomyomas or polyps. Thesewomen warrant either saline infusion sonography (SIS) or hys-teroscopy for further evaluation regardless of endometrialstripe thickness (9,10). One sixth of endometrial lesions are

missed or are not diagnosed when TVS is used alone in the per-imenopausal patient. Increasingly, hysteroscopy or SIS is rec-ommended to further evaluate the endometrium in

perimenopausal women with abnormal bleeding when theendometrial echo is normal on TVS (9,11).

2. Material and methods

In our study 50 patients were included from those attending

the Obstetrics and Gynecology outpatient clinic at Kasr ElAini hospital, Cairo University during the period from Janu-ary 2009 till June 2009. The patients should have the following

criteria: perimenopausal age group (40–55 years), havingabnormal uterine bleeding, no evident drug intake that canlead to vaginal bleeding, no evident general cause that cancause vaginal bleeding, no vaginal, vulval or cervical causes

of bleeding, preliminary ultrasound to exclude adnexal masses,not using any local or hormonal method of contraception.

All the patients were admitted to Kasr El Aini hospital they

were not divided into groups; all the patients were subjected(detailed clinical history, clinical examination was done includ-ing general, abdominal and Pelvic examination in the form ofbimanual and speculum examination to detect any abnormal

findings and to exclude any local cause of bleeding, laboratoryinvestigations including CBC, coagulation profile, fasting andpostprandial blood sugar, liver and kidney function and preg-

nancy test, conventional 2D-transvaginal ultrasonographyusing general electric (GE) logic 200 ultrasound machine witha transvaginal probe (GE 6.5 MTZ) measuring uterine size and

endometrial thickness, looking for endometrial polypi and anyrelevant adnexal pathology, hysteroscopic examination: undergeneral anesthesia looking for gross endometrial lesions, pol-

yps, and abnormal vascular patterns, fractional curettage toall the patients directed by hysteroscopy. as some have advo-cated hysteroscopy as the primary tool for the diagnosis ofAUB. Although it is highly accurate for identifying endome-

trial cancer, it is less accurate for endometrial hyperplasia.Thus, some recommend EMB or endometrial curettage in con-junction with hysteroscopy (12,13). And in 13 cases hysterec-

tomy were done later. All the specimens were placed informalin 10% and sent for histopathological correlation. Diag-nostic hysteroscopy is carried out to all patients under general

anesthesia by an operator who is blinded to the ultrasoundfindings the hysteroscopy used in this study was Karl Storz(Germany). It is a rigid continuous flow panoramic hysteros-

copy by 25 cm in length, 5 mm diameter of an outer sheathand 30� fibroptic lens. The light source used in this studywas a metal halide automatic light source from Circon AcmiG71A/Germany with a 150 W lamp. A fibroptic cable is con-

nected to the light source and to the hysteroscopy. The tech-nique used to provide constant uterine distention was byattaching plastic bags of saline or glycine solution. Infusion

pressure is elevated by pneumatic cuff under manometric con-trol at a pressure of 100–120 mm Hg.

The first sample was taken from the endocervical canal

before cervical dilatation, then cervical dilatation up to 7–8Hegar. Endometrial polyp removal using ring forceps was car-ried out following hysteroscopic localization of these polyps. Asharp curette was introduced and curettage starting first with

the fundus then posterior wall then anterior wall then rightthen left lateral walls. The sample is placed in formalin 10%until histological staining with haematoxylin and eosin for his-

topathological examinations by the pathologist.

2.1. Statistical methods

Data is statistically represented by the term of range, mean,standard deviation (+SD) and percentages. Accuracy was

represented using the terms of sensitivity, specificity, positivepredictive value, negative predictive value and overall

Table 1 Endometrial thickness as measured by 2D-TVS in relation to histopathology.

Histopathology Total (%) Endometrial thickness Mean ± SD

65 mm 6–9 mm 10–14 mm 15–19 mm P20 mm

Endometrial hyperplasia 12 (24) 5 (25%) 5 (37%) 2 (20%) 11.8 ± 5.2

Endometrial polyp 5 (10) 1 (7%) 1 (33.3%) 3 (30%) 19.9 ± 4.9

Normal 11 (22) 1 (33.3) 7 (35%) 3 (21%) 8.1 ± 2.4

Adenomyosis 5 (10) 2 (67%) 3 (15%) 6 ± 1

Submucosal fibroid 2 (4) 1 (5%) 1 (7%) 9.5 ± 3.5

Endometritis + polyp 1 (2) 1 (33.3%) 15

Atrophic endometrium 1 (2) 1 (5%) 6

Adenomyomatous polyp + hyperplasia 1 (2) 1 (10%) 20

Hyperplasia + endometrial polyp 7 (14) 0 1 (5%) 1 (7%) 1 (33.3%) 4 (40%) 18.7 ± 5.4

Hyperplasia + adenomyosis 5 (10) 2 (10%) 3 (21%) 9.4 ± 2.8

Total 50 (100) 3 (100%) 20 (100%) 14 (100%) 3 (100%) 10 (100%) –

Table 2 TVS and hysteroscopy findings in correlation to histopathology.

Histopathology TVS Hysteroscopy

Endometrial hyperplasia (N= 12) (24%) Hyperplasia (N= 9) (18%) Hyperplasia (N = 8) (16%)

Polyp (N = 2) (4%) Polyp (N= 1) (2%)

Normal (N= 1) (2%) Normal (N= 3) (6%)

Endometrial polyp (N= 5) (10%) Polyp (N = 4) (8%) Polyp (N= 5) (10%)

Hyperplasia (N= 1) (2%)

Hyperplasia + polyp (N= 7) (14%) Hyperplasia (N= 2) polyp (N= 5) Polyp (N= 6) Normal (N= 1)

Adenomyosis (N= 5) (10%) Adenomyosis (N= 3) (6%) Adenomyosis (N = 3) (6%)

Normal (N= 1) (2%) Normal (N= 1) (2%)

Fibroid (N = 1) (2%) Fibroid (N = 1) (2%)

Hyperplasia + adenomyosis (N= 5) (10%) Both (N= 3) (6%) Adenomyosis (N= 1) (2%)

Adenomyosis (N= 1) (2%) Hyperplasia (N = 2) (4%)

Hyperplasia (N= 1) (2%) Normal (N= 2) (4%)

Normal (N= 11) (22%) Normal (N= 8) (16%) Normal (N= 11) (22%)

Hyperplasia (N= 3) (6%)

Submucosal fibroid (N= 2) (4%) Fibroid (N = 2) (4%) Fibroid (N= 2) (4%)

Endometritis + polyp (N= 1) (2%) Polyp (N = 1) (2%) Polyp (N= 1) (2%)

Atrophic endometrium (N= 1) (2%) Normal (N= 1) (2%) Normal (N= 1) (2%)

Adenomyomatous polyp + hyperplasia (N= 1) (2%) Endometrial polyp (N= 1) (2%) Polyp (N= 1) (2%)

Comparative study of transvaginal sonography and hysteroscopy 79

accuracy. All statistical calculations were done using computer

programs Microsoft Excel version 7 (Microsoft Corporation,NY, USA).

To analyze the diagnostic accuracy of hysteroscopy and2D-TVS specifically for intrauterine disorders (X diagnosis),

such as endometrial polyps and hyperplasia 2 X 2 tables wereconstructed (Tables 1 and 2).

3. Results

In our study the 50 perimenopausal women with AUB whowere included had age ranged from 40–55 years (mean of46.8 ± 4.5 years) and their parity ranged from 0–8 (mean3.5 ± 2) the majority of our sample were multiparous 88%,

all the patients complained of AUB (100%). AUB was associ-ated with pain in 38% of the cases and with infertility in 10%of the cases; the commonest bleeding pattern was menorrhagia

(40%) followed by menometrorrhagia in 34%, histopathologyfindings of our patients reveal single lesion in the majority ofthe cases; endometrial hyperplasia was found in about half

of these lesions and was associated with endometrial polyp

in half of the multiple lesions. Endometrial hyperplasia was

the most frequent finding by TVS (32%) with the appearanceof well defined, thick and highly reflective layer occupying thewhole of the endometrial cavity with a mean endometrialthickness of 11.2 ± 2.4 mm followed by endometrial polyp

(26%) with a mean endometrial thickness of 18.0 ± 5.3 mm.The commonest lesion diagnosed by histopathology and 2DTVS is endometrial hyperplasia which was found in 50% of

the examined specimen and 38% of ultrasonic findings. Usinghysteroscopy the commonest lesion diagnosed was endome-trial polyp which was found in 28% of cases while endometrial

hyperplasia found only in 20% with the appearance of thickendometrium with bridging between layers of the endome-trium, increased vascularization, increased bleeding, polypoid

formation, these changes can be focal or global. 2D ultrasoundshow good sensitivity in detection of endometrial polyp, high-est specificity and accuracy was for adenomyosis. Hysteros-copy was poorly sensitive but highly specific for both

endometrial hyperplasia and adenomyosis. For endometrialpolyp hysteroscopy was highly sensitive, specific and accurate.Ultrasound was a little more accurate than hysteroscopy in

Table 5 Accuracy rates of hysteroscopy and 2D-TVS for the

diagnoses of all lesions.

Tool measure Diagnosis

TVS (%) Hysteroscopy

Sensitivity 92.3 78.75

Specificity 72.72 95.83

PPV 92.3 98.43

NPV 72.72 57.5

Accuracy 88 84

Table 3 Accuracy rates of 2D-TVS for diagnosing some

uterine lesions.

Measure Lesion

Endometrial

hyperplasia (%)

Endometrial

polyp (%)

Adenomyosis (%)

Sensitivity 60 76.92 68.18

Specificity 84 91.89 98.78

PPV 78.94 76.92 93.75

NPV 67.74 91.89 92.04

Accuracy 72 88 94

Table 4 Accuracy rates of hysteroscopy for diagnoses of some

uterine lesions.

Measure Lesion

Endometrial

hyperplasia (%)

Endometrial

polyp (%)

Adenomyosis (%)

Sensitivity 40.38 92.3 40.9

Specificity 98.07 94.59 98.78

PPV 95.45 85.71 90

NPV 62.19 97.22 86.17

Accuracy 70 94 88

80 W. El-khayat et al.

diagnosing endometrial hyperplasia. For detection of endome-trial polyp all accuracy measures of hysteroscopy were higherthan those of ultrasound. Ultrasound was more accurate thanhysteroscopy in diagnosing adenomyosis which is diagnosed

by ultrasound based on the following criteria: the anterior orposterior myometrial wall appearing thicker than its counter-part, myometrial heterogeneity, small myometrial hypoechoic

cysts, while adenomyosis is suggested by hysteroscopy withthe presence of irregular endometrium with endometrial de-fects, altered vascularization, cystic hemorrhagic lesions and

bluish discoloration. Ultrasound was more sensitive and moreaccurate than hysteroscopy for detection of uterine lesions buthysteroscopy show higher specificity (Tables 3–5).

4. Discussion

In our study 50 patients complaining of perimenopausal bleed-ing were included, most common presentation was menorrha-gia found in 20 cases (40%) followed by menometrorrhagia 17

cases (34%) and metrorrhagia found in 13 cases (26%). Pyari

et al. studied 70 patients of those 50 having AUB Most com-mon symptoms in patients with AUB were menorrhagia(40%) followed by metrorrhagia (18%), menometrorrhagia(14%), and polymenorrhea (14%) (14). In our study histopa-

thology findings reveal single lesion in 25 cases (50%), two le-sions in 14 cases (28%) and normally functioningendometrium in 11 cases (22%). Endometrial hyperplasia,

which was the commonest finding by histopathology, wasfound in 25 patients (50%) was accompanied by endometrialpolyp in 7 cases (14%) and by adenomyosis in 5 cases

(10%). Endometrial hyperplasia more common than normalendometrium, as anovulatory bleeding occurs more frequentlyat the extremes of reproductive age and in obese women, it is

usually irregular and often heavy. It poses a higher risk ofendometrial hyperplasia (15), accordingly, proliferativechanges or disordered proliferative changes are frequent find-ings on pathologic examination of EMB samples in perimeno-

pausal women (16). In our study, 60% of the patient hadirregular bleeding and 80% had history of irregular bleedingwithin the last 6 months, 77% were obese (BMI > 30 kg/

m2). Histopathology diagnosed endometrial polyp in 13 cases(26%), adenomyosis in 10 cases (20%) and submucosal fibroidwas found in only 2 cases (4%). Endometritis, atrophic endo-

metrium and adenomyomatous polyp each were found in onecase (2%). No endometrial cancer was diagnosed in this cohortof women. Getpook and Wattanakumtornkul studied 111 wo-men with perimenopausal uterine bleeding, 31 (27.9%) had an

abnormal endometrium (hyperplasia 13.5%, polyps 5.4, sub-mucous myomas 5.4%, and adenocarcinoma 3.6%) while 80(72%) had normal endometrium (17). Ozdemir et al. studied

144 women, 113 (78.4%) had normal endometrium and 31(21.6%) had an abnormal endometrium. The abnormal endo-metrium was composed of 11.8% hyperplasia, 4.2% endome-

trial polyp (18). When we compare endometrial thickness byultrasound with histologic diagnoses we found mean ± SDendometrial thickness was 19.9 ± 4.9 in endometrial polyp,

11.8 ± 5.2 in endometrial hyperplasia and 8.1 ± 2.4 in normaluteri. Pyari et al. found mean endometrial thickness of17.1 ± 2.10 mm in endometrial hyperplasia, 10.5 ± 2.89 mmin endometrial polyps, 8.76 ± 1.87 mm in functional endome-

trium (14). In our study the likehood of an endometrial polypwas higher than that of hyperplasia in women with a muchthickened endometrial lining. Thus in those with endometrial

thickness of 20 mm or greater, only 20% had hyperplasiawhereas in 40% the etiology was endometrial polyp theremaining 40% the etiology was both endometrial polyp and

hyperplasia. This is in concurrence with Deckardt et al. whichstudied histological diagnosis and related endometrial thick-ness obtained by endovaginal scanning in a similar study com-

paring TVS, hysteroscopy, and D&C for the diagnoses ofintrauterine pathology in 1286 women complaining of peri-menopausal bleeding (19). In our study 2D TVS was more sen-sitive and a little more accurate than hysteroscopy in the

diagnosis of endometrial hyperplasia while hysteroscopy wasmore specific. Hysteroscopy show highest accuracy for thediagnosis of endometrial polyp and was more sensitive, specific

and accurate than 2D TVS in this diagnosis. 2D TVS was moresensitive and accurate than hysteroscopy in the diagnosis ofadenomyosis but both show same specificity. For differentiat-

ing normal from abnormal endometrial cavity both 2D TVSand hysteroscopy show high accuracy but U/S was more

Comparative study of transvaginal sonography and hysteroscopy 81

sensitive and a little more accurate than hysteroscopy while the

last was more specific. Garuti et al. concluded that the highestaccuracy of hysteroscopy was in diagnosing endometrial pol-yps, whereas the worst results were in estimating hyperplasia(20). Our data are consistent with this report and hysteroscopy

show highest accuracy for the diagnosis of endometrial polyp.Wang and Mechcatie used hysteroscopy to evaluate 56 womenwith menorrhagia found that the sensitivity of using the cra-

tered appearance on hysteroscopy to diagnose adenomyosiswas about 75%, which was described as good and comparableto that of ultrasound, the specificity was 42% (21). In our

study hysteroscopy was poorly sensitive but highly specificand accurate for adenomyosis. To evaluate the accuracy ofTVS in the diagnosis of adenomyosis Bazot et al. studied

TVS findings in 129 women scheduled for hysterectomy andfound that the sensitivity, specificity, positive and negative pre-dictive values of TVS, 100% and 83.3%, and 40% and 82.9%,respectively, and the accuracy of TVS was 91.3% (22). Our

data were consistent with these findings. Using 8 mm endome-trial thickness as a cut-off value, one study of Getpook andWattanakumtornkul and the other study by Ozdemir et al.

investigate cut-off value of the endometrial thickness byTVS, they concluded that endometrial thickness of 8 mm orless is less likely to be associated with pathologies in perimeno-

pausal uterine bleeding (17,18). Ryu et al. studied 105 patientscomplaining of AUB, the patients were initially evaluated onthe same day with both TVS and hysteroscopy, hysteroscopywith biopsy (n= 35), curettage (n= 60) or hysterectomy

(n= 10) was performed, and the results of TVS and hysteros-copy examination were correlated with the pathological find-ings. The sensitivity and specificity were 79.0% and 45.8%

for TVS, and 95.1% and 83.3% for hysteroscopy, respectively.The positive and negative predictive values were 83.0% and39.3% for TVS, and 95.1% and 83.3% for hysteroscopy,

respectively. Eight cases showed a discrepancy between hyster-oscopy and the pathologic diagnosis. Ryu et al. concluded thathysteroscopy can be better used than TVS in evaluating those

patients with AUB (23). In our study, in contrast, we foundthat TVS was a little more accurate than hysteroscopy for dif-ferentiating normal from abnormal endometrial cavity. To re-view the effectiveness of TVS, SIS and diagnostic hysteroscopy

for the investigation of AUB in perimenopausal women. Far-quhar et al. did a meta-analysis of 19 studies involving 2917women concluded that both TVS and hysteroscopy were mod-

erately accurate in detecting intrauterine pathology, but therewas considerable variation between the studies. Hysteroscopyperformed better than TVUS in detecting focal lesions (24).

This is in concurrence with our data, for TVS and hysteros-copy minimal accuracy was 70% and 72%, respectively andhysteroscopy show highest accuracy for the diagnosis of endo-

metrial polyp.

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