I-JbRmlol

GYNECOLOGY
& OBSTETRICS
International Journal of Gynecology& Obstetrics54 (1996)I55- I59

Article
Transvaginal sonography and hysteroscopy in women with
postmenopausal bleeding

H. Haller*a, N. MatejCiC”, B. Rukavinaa, M. KraSeviCb,S. RupCiC”, D. MozetiC”

‘Department of Obstetrics and Gynaecology, Clinical Hospital Centre, University of &j&a, Rijeka, Croatia
bDepartment of Pathology, University of Rijeka. Rijeka, Croatia

Received19December1995;revised12 March 1996;accepted18March 1996

Abstract

Objective: To make a prospective comparison between endometrial thickness determined by transvaginal

sonography (TVS) and hysteroscopic findings in women with postmenopausalbleeding with histologic findings obtain-
ed by dilatation and curettage (D&C). Metho&: Eighty-one patients who had not received hormonal replacementther-
apy were scanned by transvaginal probe, and double-layer endometrial thickness was measured 1 day before
hysteroscopy and D&C. Results: The histologic diagnosis was atrophy in 12 cases,irregular proliferative changes in
21, endometrial polyps in 16, hyperplasia in 16 and endometrial carcinoma in 16. TVS detected 46 of 48 pathologic
conditions, including all casesof endometrial carcinoma if the endometrial thickness (both layers) was L 5 mm (sensi-
tivity 95.8%, specificity 45.5%). Hysteroscopy also detected the endometrial pathology in 46 of 48 casesbut with a
higher specificity (sensitivity 95.3%, specificity 93.9%). Conclusion: TVS and hysteroscopy are complementary diagnos-
tic methods and could be accurately used to discriminate between normal and pathologic conditions in patients with
postmenopausal bleeding.

Keywordr: Transvaginal sonography; Hysteroscopy; Postmenopausalbleeding; Endometrial carcinoma; Endometrium;

Endometrial pathology

1. Introduction (D&C) to exclude endometrial malignancy. How-

Postmenopausal uterine bleeding is the most
common presenting clinical symptom of endo-
metrial carcinoma. Most women with postmeno-
pausal bleeding undergo dilatation and curettage
* Correspondingauthor, Tel./Fax: +38551 338555.
ever, endometrial carcinoma is found in about
10%of thesewomen. An additional 15%will have
other morphological endometrial abnormalities
causing the bleeding [l]. This results in many un-
necessaryD&C procedures.
A certain number of endometrial carcinoma
cases are found at an advanced stage (due to

0020-729296/.S15.00
0 1996International Federationof Gynecologyand Obstetrics
PII: SOO20-7292(96)02677-X
156 H. Hailer et al. /International
neglect or lack of symptoms), which indicates that
there is a definite requirement for early identifica-
tion of the malignant process. This implies the
necessity of developing other non-invasive
methods for the earlier identification of malignant
endometrial changes as well as other pathologic
conditions [2].
In recent years, transvaginal sonography (TVS)
has greatly improved the accuracy of evaluating
endometrial morphology. Studies have shown the
usefulness of measuring endometrial thickness
using TVS in detecting endometrial abnormalities
[3-81. On the other hand hysteroscopy offers a
convenient method of visualizing the uterine cavity
and could be used as an outpatient procedure in
assessingendometrial abnormalities [9- 111.
The purpose of this study was to make a pros-
pective comparison betweenendometrial thickness
determined by TVS and hysteroscopic findings in
women with postmenopausal bleeding with
histologic findings obtained by D&C.
2. Materials and methods
Eighty-one women (mean age 60 f 7.8 years,
range 47-78; time after menopause 9.6 f 7.3
years, range l-28; mean number of deliveries
2.2 f 1.1, range O-5; mean number of pregnan-
cies 3.8 & 2.2, range O-9) with postmenopausal
bleeding admitted for D&C during 1993and 1994
were scanned sonographically the day before the
procedure. None of the women included in this
study had received hormonal replacement therapy.
TVS was performed on an empty bladder using a
transducer with an emission frequency of 5.5 MHz
(Aloka, Tokyo, Japan). Endometrial thickness is
measuredat the widest part of the endometrium in
the longitudinal plane of the uterus as describedby
Osmerset al. [8] and was given as a double layer.
Hysteroscopy was performed under general
anesthesiaimmediately before D&C using a Wolf
endoscope (Knittlingen, Germany) with a 5-mm
diagnostic sheath. The uterine cavity was distend-
ed with CO*, 5% glucose or saline solution
depending on the operator’s preference. After
visualizing the endometrial cavity the operator
noted his hysteroscopic impression of the en-
dometrial finding which was classified using the
Journal of Gynecology & Obstetrics 54 (19%) 155-159
same categories as the histologic finding. All pa-
tients underwent D&C after hysteroscopy.
The histologic diagnosis was used as the gold
standard. A final histologic diagnosis classified
patients as either those with a physiologic or those
with a pathologic condition. Samples of endo-
metrial tissue the glands and stroma of which
clearly exceeded those of normal proliferative-
phaseor occasionally focal abortive secretion as a
result of functional disturbances during post-
menopausewere considered irregular proliferative
changes [ 121.Irregular proliferative changes and
atrophy were considered physiologic or normal,
while well-defined clinical entities such as polyps,
all types of hyperplasia (i.e. simplex and complex
with or without atypia) and endometrial car-
cinoma were classified as abnormal or pathologic
findings.
The mean, standard deviation and percentages
were calculated. Evaluation of predictive power
was based on sensitivity, specificity and positive
and negative predictive values. A standard compu-
ter package (Statistica for Windows) was used to
make the comparisons.
3. Results
An endometrial pathology at D&C was found in
48 (59.3%) of 81 women. Of the remaining 33
(40.7%) women the histologic finding after D&C
was atrophy in 12 (14.8O/)and irregular prolifera-
tive changes in 21 (25.9%). The relationships be-
tween endometrial thickness and histologic finding
are shown in Table 1. None of the endometrial car-
cinoma patients had an endometrial thickness < 5
mm.
The thickness of the endometrium was signifi-
cantly lower (P < 0.001) in atrophy patients, while
the greatest thickness (P < 0.01) was found in
those with endometrial carcinoma. However no
statistical difference was found between women
with endometrial irregular proliferative changes,
hyperplasia or polyps.
The results obtained by hysteroscopy are
presentedin Table 2. The uterine cavity could not
be visualized adequately in five (6.2%) cases.All
failures were due to bleeding from the endometrial
cavity, obscuring the operator’s vision. Pathologic
 H. Hailer et al. /International Journal of Gynecology & Obstetrics 54 (19%) 155-159 151

Table I
TVS measurementof endometrial thickness (double layer) compared with histologic findings obtained by D&C

Endometrial Histologic findings after D&C Total

thickness (mm) (“4
Atrophy Irregular Hyperplasia Polyp Cancer
proliferative
changes
o-4 6 9 2 - - 17 (21.0)
S-8 6 5 2 3 1 17 (21.0)
9-12 - 3 5 5 3 16 (19.8)
13-16 - I 6 2 15 (18.5)
17-20 - 2 - 2 4 (4.9)
>20 - 2 - 2 8 12 (14.8)

Total I2 21 16 16 16 81 (100)

Mean 4 9 11 13 22
SD. 1.8 7.0 3.1 4.2 9.4
Range 2-7 4-25 3-15 7-22 8-40

findings were obtained by D&C in all these cases
(four casesof hyperplasia and one of endometrial
carcinoma).
Hysteroscopic visual impressions showed a high
concordance with the histologic findings in cases
of atrophy and irregular proliferative changes
(sensitivity 100%and 90.5%, specificity 97.1% and
lOO%,respectively). Similar accuracy in detecting
pathologic conditions was encountered for en-
dometrial polyps (specificity lOO%, sensitivity
96.9%), while hyperplasia and endometrial car-
cinoma showed reduced sensitivity (50% for both)
with better specificity (86.2% and lOO%, respec-
tively).
TVS detected46 of 48 pathologic conditions, in-
cluding all casesof endometrial carcinoma when
the cut-off limit was set at ~5 mm, with high sen-
sitivity and low specificity (Table 3). Hysteroscopy
also detected the endometrial pathology in 46 of
the 48 cases, with equally high sensitivity and
specificity (Table 3). Two missed endometrial
pathologies at hysteroscopy were endometrial hy-
perplasia complex without atypia.
4. Discussion
Postmenopausal bleeding has always been an
absolute indication for curettage. Although D&C

Table 2
Hysteroscopic findings in relation to histologic findings obtained by D&C

Histologic findings Hysteroscopic findings

Failure Atrophy proliferative Hyperplasia Polyp Carcinoma
changes
Atrophy (n = 12) - 12 (100%) - - -
Irregular proliferative - - 19 (90%) 2 (9.5%) - -
changes (n = 21)
Hyperplasia (n = 16) 4 (25%) 2 (12.5%) - 8 (50%) 2 (12.5%) -
Polyp (n = 16) - - - 16 (100%) -
Carcinoma (n = 16) 1 (6.3%) - - 7 (43.8%) 8 (50%)
158 H. Haller et al. /International
Table 3
Statistical accuracy of TVS and hysteroscopy compared with
D&C
Hysteroscopy
ziometria*
thickness
25 mm)
Sensitivity 95.8 95.3
Specificity 45.5 93.9
Positive predictive value 71.9 95.3
Negative predictive value 88.2 93.9
is used as the gold standard in diagnosing en-
dometrial carcinoma, some authors have shown
that some cases of hyperplasia and endometrial
carcinoma could be missed using this method
[ 1,131.Another study has demonstrated the inac-
curacy of prehysterectomy curettage, where in 60%
of patients less than half of the uterine cavity was
sampled [14].
The introduction of TVS has enormously im-
proved the quality of examination of the endomet-
rium and uterus [ 151. Some studies have shown
that ‘simple’ endometrial measurement by means
of TVS in women with postmenopausal bleeding
could be accurately used to discriminate between
normal and pathologic conditions [5,6,8].
In the present study using a cut-off limit for
endometrial pathology of 5 mm, the sensitivity was
95.8%, the specificity was 45.5%, the positive pre-
dictive value was 71.9%and the negative predictive
value was 88.2%.Low specificity is due to the high
proportion of irregular proliferative changes - a
benign condition related to postmenopause. The
present results are comparable to those of Cac-
ciatore et al. [4], while Karlsson et al. [7] used 6
mm as cut-off value and obtained equal sensitivity
with higher specificity (81%).
In our study, a malignant condition of the endo-
metrium was encountered when there was an en-
dometrial thickness r5 mm measured by TVS.
Using this cut-off value only two casesof hyper-
plasia were missed (both were endometrial hyper-
plasia complex without atypia). No cancer
measuring less than 8 mm was found (one case of
endometrial carcinoma measured 8 mm).
When a cut-off value of 5 mm was used for
Journal of Gynecology & Obstetrics 54 (19%) 155-159
detecting endometrial carcinoma only, the sensi-
tivity, specificity, positive and negative predictive
values were lOO%,26%, 25% and lOO%,respective-
ly. The low specificity could in part be explained
by the relatively high percentage of thicker endo-
metrium related to non-malignant conditions.
Ultrasound could also be a good diagnostic tool
for measuring depth of infiltration of endometrial
carcinoma [ 16- 181. However it is not always
possible to obtain an appropriate measurementof
endometrial thickness, possibly because the
echogenicity of the endometrium is similar to that
of the myometrium in thesecases(not encountered
in our study). Furthermore problems in measuring
the endometrium may also occur in caseswhere
the endometrial carcinoma infiltrates the serosal
surface 171.
Hysteroscopic inspection of the uterine cavity
offers a simple but effective method of investi-
gating uterine, endometrial or endocervical
pathologies [19]. However, tissue biopsy perform-
ed under direct visualization with a hysteroscope
offers further diagnostic possibilities in detecting
endometrial abnormalities compared with random
sampling of the endometrium where a small lesion
could be missed or is inaccessible [20]. Although
hysteroscopy is a simple procedure, failure can
sometimesoccur. In our five casesfailures were
due to inadequate visualization becauseof uterine
bleeding. Endometrial pathology should be
suspectedin such cases(four hyperplasias and one
endometrial carcinoma were found in our study).
Cervical stenosesrepresent another possible cause
of failure 1211,which could however be resolved by
dilating the cervical OS.
Hysteroscopy performed prior to D&C offers a
visual impression of the endometrial cavity in-
cluding visualization and localization of the
possibly abnormal endometrial area with the sub-
sequentpossibilities of ‘repeated’ or ‘forced’ curet-
tage of the area in the endometrial cavity. Direct
visualization of the endometrial cavity in our sub-
jects was superior in detecting the larger en-
dometrial polyps, while small polyps or polypoid
endometrial folds could be missed [4]. En-
dometrial atrophy as well as endometrial polyps
are all detected by hysteroscopy. These two en-
tities represent unique conditions where a
 H. Hailer et al. /International Journal of Gynecology & Obstetrics 54 (19%) 155-159
hysteroscopic diagnosis can be clearly established.
From our results, other hysteroscopic findings
should be histologically proved because of the
high number of false-positive and false-negative
results.
Diagnostic possibilities in detecting postmeno-
pausal bleeding depend in great part on the techni-
cal equipment and diagnostic procedure as well as
the experience and skill of the operators. This
study shows that TVS and hysteroscopy are com-
plementary diagnostic methods and could be ac-
curately used to discriminate between normal and
pathologic endometrial conditions in patients with
postmenopausal bleeding. However the usefulness
in applying these two techniques among asymp-
tomatic women (especially in those at high risk for
endometrial carcinoma) as a screening program in
postmenopauseas well as in perimenopause is still
unknown. Further studies on larger numbers of
patients are necessaryto prove the usefulnessand
applicability of the proposed procedures. The ad-
dition of another non-invasive diagnostic method,
transvaginal color Doppler, may in future improve
the specificity and sensitivity of a possible screen-
ing method for endometrial carcinoma in
postmenopausal women not taking hormone
replacementtherapy [2], and this is currently being
studied in our institution.
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