Title:

Out-patient hysteroscopy : Are we over-scoping premenopausal women?

 

Authors:

Shen Chuen Khaw, Uloma Okwuosa

 

Affiliations:

Department of Gynaecology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 9DU, United Kingdom.

 

Objectives:

To establish outcomes and evaluate the need for hysteroscopies in premenopausal women with abnormal uterine bleeding.

 

Design:

Retrospective clinical audit of premenopausal women attending outpatient hysteroscopy.

 

Methods:

Data collected from Electronic patient records.

Inclusion criteria: Premenopausal patients with abnormal uterine bleeding attending outpatient hysteroscopy at our tertiary centre fron 01 June – 31 August 2022 ( 3 months)

Age, BMI, referral indication, ultrasound findings , endometrial thickness, hysteroscopic findings, histopathology results, and management analysed.

 

Results:

Majority aged 40 - 50 years

38% had a BMI > 30 kg/m2.

Main referral indication was heavy menstrual bleeding (48%) followed by intermenstrual bleeding (30%). 10% were follow-up cases from endometrial hyperplasia or incidental findings.

Ultrasound results showed fibroids in 30% , endometrial polyps in 17% and thickened endometrium in 15% of women referred. Endometrial thickness ranged between 4mm to 27mm with a median of 11mm.

Hysteroscopy showed normal endometrium in 61% of women, and polyps were seen in 27% of referrals. 47% of polyps were accurately predicted on ultrasound scan.

Of all polyps and fibroids confirmed at hysteroscopy 68% were treated by morcellation at the same appointment, and the remaining were given follow-up appointments for procedure under General Anaesthesia or further imaging.

All histopathology results were benign leading to conservative management in the majority. 10 women (1 fibroid, 3 polyps, 6 normal hysteroscopy) required medical hormonal management for their symptoms.

 

Conclusions:

Guidelines on hysteroscopic evaluation of premenopausal women with abnormal uterine bleeding are often unclear or misinterpreted. Our audit demonstrates that for the vast majority of cases, aetiology is benign and therefore hysteroscopic biopsy may not be necessary.

Quality of life should be prioritised. Many low-risk women could be commenced on pharmacological treatment without the need to endure the anxiety, discomfort and potential complications from carrying out a hysteroscopy.

Hysteroscopies would be better justified for patients with endometrial polyps or fibroids that can be removed at the same appointment

 

Recommendations:

Focused ultrasound training to improve diagnosis of polyps and fibroids – this would improve triage for pre-menopausal women with abnormal bleeding who need treatment at hysteroscopy.

Consider Pipelle biopsy if high index of suspicion for malignancy and ultrasound of high quality rules out removable lesion.