Accuracy of hysteroscopy in predicting histopathology of endometrium in 1500 women.

STUDY OBJECTIVE: To estimate the accuracy of hysteroscopy in predicting endometrial histopathology. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: Public hospital. PATIENTS: One thousand five hundred women undergoing diagnostic hysteroscopy for suspected endometrial pathology, mostly because of abnormal uterine bleeding. INTERVENTIONS: Hysteroscopy and endometrial biopsy. MEASUREMENTS AND MAIN RESULTS: Hysteroscopy imaging was matched with histology. Functional, dysfunctional, and atrophic endometrium were considered normal findings; endometritis, endometrial polyps, hyperplasia, and carcinomas were considered abnormal. Sensitivity, specificity, and negative (NPV) and positive (PPV) predictive values of hysteroscopy in detecting normal or abnormal endometrium were calculated. These figures were defined to assess hysteroscopic accuracy in estimating pathologic conditions. Histology showed normal endometrium in 927 patients. Endometritis, polyps, hyperplasia, and malignancies were found in 21, 265, 185, and 102 patients, respectively. Hysteroscopy showed sensitivity, specificity, NPV, and PPV of 94.2%, 88.8%, 96.3%, and 83.1%, respectively, in predicting normal or abnormal histopathology of endometrium. Highest accuracy was in diagnosing endometrial polyps, with sensitivity, specificity, NPV, and PPV of 95.3%, 95.4%, 98.9%, and 81.7%, respectively; the worst result was in estimating hyperplasia, with respective figures of 70%, 91.6%, 94.3%, and 60.6%. All failures of hysteroscopic assessment resulted from poor visualization of the uterine cavity or from underestimation or overestimation of irregularly shaped endometrium. CONCLUSION: Hysteroscopy was accurate in distinguishing between normal and abnormal endometrium. Nevertheless, better knowledge of relationship between hysteroscopic imaging and pathophysiologic states of endometrium is necessary to improve its accuracy. Endometrial sampling is recommended in all hysteroscopies showing unevenly shaped and thick endometrial mucosa or an anatomically distorted uterine cavity, and when endouterine visualization is less than optimal.

Prognostic significance of hysteroscopic imaging in endometrioid endometrial adenocarcinoma.

OBJECTIVE: The aim of this study was to relate hysteroscopic features of endometrioid endometrial adenocarcinoma to stage, grade and overall survival. METHODS: Sixty women with endometrioid adenocarcinoma underwent laparotomy and staging according to current FIGO classification. Before surgery hysteroscopy was performed in all patients to establish the morphology of neoplasia, the extent of endometrial lining involvement, and endocervical spreading. These hysteroscopic parameters were related to overall survival, surgical stage, and grade of disease. RESULTS: First-stage carcinomas were found in 50 patients, second-stage in 4, third-stage in 3, and fourth-stage in 3 patients. Well-differentiated tumors were detected in 32, moderately differentiated in 21, and poorly differentiated in 7 patients. The cumulative 48-month probability of survival was 86.6%. The morphology of adenocarcinomas was unrelated to both their stage and their grade; no relationship to survival was found. The extent of carcinomatous spread within the endometrial cavity was significantly related to stage, grade, and survival. Endometrial lining involvement of less than 50% was associated with 100% survival, 97.1% of first-stage diseases, and 96.6% of low-grade carcinomas. These percentages dropped to 73.1, 65.3 (Fisher's exact test, P = 0.001), and 76.9% (Fisher's exact test, P = 0.035), respectively, when tumoral growth involved more than half of the endometrium. Hysteroscopy detected all carcinomas metastasizing to the cervix; in 8 patients we overdiagnosed endocervical spreading, although histology was negative. From these figures, hysteroscopy showed a sensitivity and specificity in predicting cervical spread of 100 and 87.3%, respectively. CONCLUSIONS: The extent of endometrial lining involvement in patients with endometrioid carcinoma provides preoperative information on the risk of extrauterine spread. We confirm the high accuracy of hysteroscopy in excluding cervical spread.

Hysteroscopy and transvaginal ultrasonography in postmenopausal women with uterine bleeding.

OBJECTIVE: To evaluate the accuracy of hysteroscopy and transvaginal ultrasonography (TU), based on a histopathological report from endometrial specimens, in diagnosing endometrial pathology in menopausal women with uterine bleeding. METHODS: Four-hundred and nineteen postmenopausal women with uterine bleeding underwent TU, hysteroscopy and endometrial biopsy. Hysteroscopic and sonographic findings have been evaluated on the basis of the final diagnosis established by histologic examination. Sensitivity, specificity and positive predictive value of TU at an endometrial thickness cut-off point of 4 and 8 mm (double layer technique) and of panoramic hysteroscopy have been detected. RESULTS: Normal and abnormal endometrium was found in 222 and in 197 women, respectively. TU showed sensitivity of 95.1%, specificity of 54.8% and positive predictive value of 63.7% at a cut-off limit of 4 mm. With a cut-off limit of 8 mm the corresponding figures were 83.8%, 81.3% and 79.4%. Hysteroscopy demonstrated a sensitivity of 96.5%, specificity of 93.6% and positive predictive value of 92.6%. The combination of the two diagnostic tools showed a 100% sensitivity, 94.8% specificity and 93.3% positive predictive value. CONCLUSIONS: With cut-off limit of 4 mm, TU can be considered the first choice modality of endometrial investigation in women with postmenopausal uterine bleeding to select patients at risk to carry endometrial pathology. Hysteroscopy is a more accurate technique than TU because of better specificity and must be indicated for all patients showing an endometrial strip more than 4 mm. When an endometrial thickness below 4 mm is detected by ultrasound, hysteroscopy may be indicated on clinical background because of the possibility to miss infrequent (2.5% in our series), but relevant endometrial pathologies. Endometrial sampling should follow hysteroscopic view in all cases showing abnormal or suspicious lesions as well as in all cases with irregularly shaped endometrial lining and/or suboptimal endoscopic vision.

Bicervical uterus and septate vagina: report of a previously undescribed Müllerian anomaly.

A case of non-septate uterus with double cervix and complete longitudinally septate vagina is described. This previously undescribed Müllerian anomaly has been detected by complete clinical and instrumental investigations (transvaginal ultrasonography, urography, hysterosalpingography, hysteroscopy and laparoscopy). Aetiological hypotheses are discussed and we suggest adding the uterovaginal malformation described in this report to the embryological classification recently proposed by Acien et al. (1991, 1992) which postulates isolated Müllerian anomalies as a consequence of a minor mesonephric defect.

Neurophysiological evaluation in detrusor instability.

Different and complex neuronal systems are involved in the control of continence. Detrusor overactivity has been divided by the International Continence Society into two functional subgroups: a) detrusor instability and b) detrusor hypereflexia. Only in the latter group has neurological damage been shown, but pathophysiological mechanisms are still unknown. In order to complete a full investigation of sensory and motor pathways 12 female patients affected by idiopathic detrusor instability (mean age 60.2 years; range 49-73) and 13 age-matched healthy women were studied. All patients were submitted to a subtracted cistometrogram (CMG), anal sphincter electromyography (EMG) with a bipolar coaxial needle, sacral reflex analysis after stimulation of the dorsal nerve of the clitoris, tibial and pudendal somatosensory evoked potentials, motor evoked potentials after magnetic cortical coil stimulation, and recording from anal sphincter and abductor brevis hallucis muscles. All patients had normal neurophysiological tests, and no significant differences between patients and controls could be seen. Our data confirms the absence of both clinical and subclinical damage of central sensory or motor pathways in detrusor instability; an alteration of suprasegmental mechanisms cannot be excluded.