Accuracy of hysteroscopy made by young residents in detecting endometrial pathologies in postmenopausal women

Purpose of investigation: The aim of the study was to analyze the diagnostic value of hysteroscopy made by young residents in evaluating uterine cavity compared to experienced hysteroscopists with histological diagnosis as reference in postmenopausal women, with particular attention to endometrial hyperplasia and cancer. Materials and Methods: A total of 600 postmenopausal women that under-went diagnostic hysteroscopy (DH) between January 2011 and December 2013 were evaluated. The authors compared the first 200 hysteroscopic findings of each young resident with those of seniors that supervised all the procedures, regarding the same patients. Subsequent histological evaluation was obtained by operative hysteroscopy or endometrial biopsy. Residents’ and seniors’ data were compared with the final histological diagnosis established by anatomopathologist. Results: No adverse effects such as vasovagal reactions or uterine perforations in DH neither in operative hysteroscopic procedures were reported. Hysteroscopy made by residents had 60%, 9.09%, and 70.4% sensitivity (SE) and 97.1%, 98.8%, and 99.1% specificity (SP) in detecting hyperplasia without atypia, hyperplasia with atypia, and endometrial cancer, respectively. On the other hand, DH made by seniors resulted in 85%, 72.7%, and 96.3% SE and 99.8%, 99.8%, and 100% SP, in detecting the same three histological findings. Conclusion: Outpatient hysteroscopy made by residents at their endoscopic experience beginning has good accuracy in detecting clear endometrial malignant lesions, unlike in detecting premalignant lesion as hyperplasia with atypia. This could signify that more than 200 hysteroscopies are necessary for a resident to well recognize premalignant and malignant lesions.

Diagnostic hysteroscopy; Postmenopausal women; Endometrial cancer; Endometrial hyperplasia; Residents.

[1] Ferlay J., Shin H.R., Bray F., Forman D., Mathers C., Parkin D.M.: “GLOBOCAN 2008 v2.0, Cancer incidence and mortality worldwide: IARC CancerBase No. 10”. Lyon, France: International Agency for Research on Cancer, 2010. Available at: http://globocan.iarc.fr

[2] AIRT Working Group: “I Tumori in Italia, Rapporto 2009. I trend dei tumori negli anni duemila (1998-2005)”. Epidemiologia & Prevenzione, 2009, 33. Available at: http://www.registri-tumori.it.

[3] Astrup K., Olivarius Nde F.: “Frequency of spontaneously occurring postmenopausal bleeding in the general population”. Acta Obstet. Gynecol. Scand., 2004, 83, 203.

[4] Cepni I., Ocal P., Erkan S., Saricali F.S., Akbas H., Demirkiran F., et al.: “Comparison of transvaginal sonography, saline infusion sonography and hysteroscopy in the evaluation of uterine cavity pathologies”. Aust. N. Z. J. Obstet. Gynaecol., 2005, 45, 30.

[5] Bingol B., Gunenc M.Z., Gedikbasi A., Guner H., Tasdemir S., Tiras B.: “Comparison of diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography and hysteroscopy in postmenopausal bleeding”. Arch. Gynecol. Obstet., 2011, 284, 111.

[6] de Vries L.D., Dijkhuizen F.P., Mol B.W., Brölmann H.A., Moret E., Heintz A.P.: “Comparison of transvaginal sonography, saline infusion sonography, and hysteroscopy in premenopausal women with abnormal uterine bleeding”. J. Clin. Ultrasound, 2000, 28, 217.

[7] Lo K.W., Yuen P.M.: “The role of outpatient diagnostic hysteroscopy in identifying anatomic pathology and histopathology in the endometrial cavity”. J. Am. Assoc. Gynecol. Laparosc., 2000, 7, 381.

[8] Garuti G., Sambruni I., Colonnelli M., Luerti M.: “Accuracy of hysteroscopy in predicting histopathology of endometrium in 1500 women”. J. Am. Assoc. Gynecol. Laparosc., 2001, 8, 207.

[9] Lasmar R.B., Barrozo P.R., de Oliveira M.A., Coutinho E.S., Dias R.: “Validation of hysteroscopic view in cases of endometrial hyperplasia and cancer in patients with abnormal uterine bleeding”. J. Minim. Invasive Gynecol., 2006, 13, 409.

[10] Smith-Bindman R., Kerlikowske K., Feldstein V.A., Subak L., Scheidler J., Segal M., et al.: “Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities”. JAMA, 1998, 280, 1510.

[11] Tabor A., Watt H.C., Wald N.J.: “Endometrial thickness as a test for endometrial cancer in women with postmenopausal vaginal bleeding”. Obstet. Gynecol., 2002, 99, 663.

[12] Chandavarkar U., Kuperman J.M., Muderspach L.I., Opper N., Felix J. C., Roman L.: “Endometrial echo complex thickness in postmenopausal endometrial cancer”. Gynecol. Oncol., 2013, 131, 109.

[13] Wang J., Wieslander C., Hansen G., Cass I., Vasilev S., Holschneider C. H.: “Thin endometrial echo complex on ultrasound does not reliably exclude type 2 endometrial cancers”. Gynecol. Oncol., 2006, 101, 120.

[14] Litta P., Merlin F., Saccardi C., Pozzan C., Sacco G., Fracas M., et al.: “Role of hysteroscopy with endometrial biopsy to rule out endometrial cancer in postmenopausal women with abnormal uterine bleeding”. Maturitas, 2005, 50, 117.

[15] Breijer M.C., Peeters J.A., Opmeer B.C., Clark T.J., Verheijen R.H., Mol B.W., Timmermans A.: “Capacity of endometrial thickness measurement to diagnose endometrial carcinoma in asymptomatic postmenopausal women: a systematic review and meta-analysis”. Ultrasound Obstet. Gynecol., 2012, 40, 621.

[16] Elfayomy A.K., Habib F.A., Alkabalawy M.A.: “Role of hysteroscopy in the detection of endometrial pathologies in women presenting with postmenopausal bleeding and thickened endometrium”. Arch. Gynecol. Obstet., 2012, 285, 839.

[17] Litta P., Bartolucci C., Saccardi C., Codroma A., Fabris A., Borgato S., Conte L.: “Atypical endometrial lesions: hysteroscopic resection as an alternative to hysterectomy”. Eur. J. Gynaecol. Oncol., 2013, 34, 51.

[18] Royal College of Obstetricians and Gynaecologists: “Best practice in outpatient hysteroscopy. Greentop Guideline No. 59, March 2011”. Available at: http://www.bsge.org.uk/userfiles/file/ Best%20Prac-tice%20in%20Outpatient%20Hysteroscopy%20GTG%20no%2059.pdf

[19] Litta P., Cosmi E., Saccardi C., Esposito C., Rui R., Ambrosini G.: “Outpatient operative polypectomy using a 5 mm-hysteroscope without anaesthesia and/or analgesia: advantages and limits”. Eur. J. Obstet. Gynecol. Reprod. Biol., 2008, 139, 210.

[20] Florio P., Puzzutiello R., Filippeschi M., D’Onofrio P., Mereu L., Morelli R., et al.: “Low-dose spinal anesthesia with hyperbaric bupivacaine with intrathecal fentanyl for operative hysteroscopy: a case series study”. J. Minim. Invasive Gynecol., 2012, 19, 107.

[21] Angioni S., Loddo A., Milano F., Piras B., Minerba L., Melis G.B.: “Detection of benign intracavitary lesions in postmenopausal women with abnormal uterine bleeding: a prospective comparative study on outpatient hysteroscopy and blind biopsy”. J. Minim. Invasive Gynecol., 2008, 15, 87.

[22] Garuti G., Cellani F., Garzia D., Colonnelli M., Luerti M.: “Accuracy of hysteroscopic diagnosis of endometrial hyperplasia: a retrospec-tive study of 323 patients”. J. Minim. Invasive Gynecol., 2005, 12, 247.

[23] Rokita W., Stanislawska M., Nowak-Markwitz E., Kedzia W., Spaczynski M., Karowicz-Bilinska A., Bednarek W.: “Diagnostic hysteroscopy in women with endometrial hyperplasia and endometrial cancer–9 years of experience analysis of 142 cases”. Int. J. Gynecol. Obstet., 2009, 107, S324.

[24] de Wit A.C., Vleugels M.P., de Kruif J.H.: “Diagnostic hysteroscopy: a valuable diagnostic tool in the diagnosis of structural intracavital pathology and endometrial hyperplasia or carcinoma?. Six years of experience with nonclinical diagnostic hysteroscopy”. Eur. J. Obstet. Gynecol. Reprod. Biol., 2003, 110, 79.

[25] Clark T.J., Voit D., Gupta J.K., Hyde C., Song F., Khan K.S.: “Accuracy of hysteroscopy in the diagnosis of endometrial cancer and hyperplasia: a systematic quantitative review”. JAMA, 2002, 288, 1610.