Regardless of the patient’s age, abnormal uterine bleeding requires an aggressive workup.
SIS versus hysteroscopy. Compared with hysteroscopy, SIS more reliably predicts uterine fibroids’ size and the depth of myometrial involvement (TABLE 2).26 In addition,SIS permits classification of location, size, and degree of intramural extension. This allows the clinician to determine the resectability of the lesion and select the appropriate surgical approach.15
However, a recent comparison of SIS and hysteroscopy in diagnosing uterine pathology in 90 women with abnormal uterine bleeding showed that SIS had a high failure rate (34%) among postmenopausal women, usually because of cervical stenosis.30 In premenopausal women, that rate was lower (10.3%). The failure rate of hysteroscopy, meanwhile, was 10.6% in postmenopausal women and 2.9% in premenopausal women. Another investigation of hysteroscopy noted a failure rate of 8% in postmenopausal women.31
Complementary technologies. Although SIS overcomes many of the limitations of TVUS, in some cases the endometrium simply cannot be visualized or is indistinct, or findings are indeterminate. If the endometrium is not well visualized with SIS, then hysteroscopy plays a definitive role in ascertaining endometrial morphology. In addition to evaluating equivocal or indeterminate SIS findings, hysteroscopy is invaluable when menstrual aberrations persist despite a normal SIS.
Fortunately, evaluation of the endometrium is not an “either-or” proposition. Sometimes a combination of procedures may be important in solving the puzzle of menstrual dysfunction.
- Equivocal TVUS results. If the patient had a TVUS that led to an equivocal interpretation of the endometrium, clinicians should proceed with SIS or office hysteroscopy. If the woman continues to experience abnormal uterine bleeding after a normal SIS, diagnostic hysteroscopy should be performed to rule out occult lesions in the cornu, endocervix, or uterus.
- Pap test. It seems prudent to perform a Papanicolaou test, including an endocervical and endometrial biopsy, in high-risk patients. (This includes patients who are chronically anovulatory, obese, or nulliparous; those who use tamoxifen or unopposed estrogen; and women with untreated endometrial hyperplasia.) Keep in mind, however, that only 50% of women with endometrial cancer actually have risk factors for the disease.32
TABLE 2
Comparison of saline-infusion sonography (SIS) and hysteroscopy
| CHARACTERISTIC | SIS | HYSTEROSCOPY |
|---|---|---|
| Pain | Less | More |
| Adnexal imaging | Possible | Impossible |
| Determination of depth of fibroid penetration | Possible (accurate) | Not possible unless lesion is pedunculated |
| Cost | Less | More |
| Office based | Yes | Yes |
| Large uterine size | Difficult if uterus is >14 weeks’ size | Yes |
| Ability to complete exam | >95% cases | >95% cases |
| Complication rate | <1% | <1% |
Aggressive workup is warranted
Regardless of the patient’s age, abnormal uterine bleeding requires an aggressive workup. If we are diligent and find atrophy, we can reassure and educate the patient about the fragility of the menopausal endometrium. In most women, short-term, low-dose hormone replacement therapy is the right antidote. For the perimenopausal woman, “hormonal problems” can best be verified by a negative workup with hysteroscopy or SIS. Treatment usually consists of a low-dose contraceptive or a levonorgestrel intrauterine device, which is associated with shorter, lighter periods.
Dr. Bradley reports that she serves as a consultant to Olympus and Karl Storz.