SYSTEMATIC REVIEW OF VARIOUS DIAGNOSTIC TECHNIQUES IN THE ASSESSMENT OF POSTMENOPAUSAL BLEEDING.

Abstract

predictive value in identifying endometrial pathology compared with endometrial sampling.

Sampling of the endometrium must be performed if there is diffuse thickening of the whole endometrium or focal thickening of part of the endometrium measuring 5 mm or more.

Diagnosis was made by uterine dilation and curettage (D&C). Endometrial office sampling was found to be less accurate than D & C in 20% of cases if the lesion was focal and was associated with pain. Thefalse-negative rate for endometrial office sampling was 2% to 6%.

Depending on the availability of each type of procedure, biopsies can be performed using either endoscopic guidance, such as hysteroscopy with direct viewing of the uterine cavity, or various random sample collection methods, such as Pipelle endometrial sampling, Vabra catheter aspiration, Novak curettage or traditional uterine curettage.

Curettage tends to be more highly accurate in diagnosing simple hyperplasia than complex atypical hyperplasia, which is often found by hysterectomy to be associated with endometrial carcinoma . Preoperative endometrial sampling with Pipelle or curettage is sensitive and accurate for the diagnosis of high-grade endometrial tumors, including tumors with non endometrioid histology . Although the statistical analysis predicted accuracy rates of D&C diagnosis that exceeded 90%, the true figures proved to be more limited. D&C is a reliable procedure for establishing the diagnosis of endometrial cancer. However, the procedure significantly underestimates tumor grade. The limitations of D&C are due to the blindness of the sampling procedure .

Preoperative endometrial sampling by Pipelle or curettage is sensitive and accurate for the diagnosis of HG(high grade) endometrial tumors, including nonendometrioid histologic types. However, we found that the Pipelle demonstrated a sensitivity of 99.2% in patients with HG cancer, compared with 93.8% in patients with LG(low grade) cancer. This was comparable to the sensitivity of curettage, which was 100% in patients with HG cancer and 97% in patients with LG cancer. In addition, we observed excellent agreement between the preoperative histology and grade and the final pathology.

A meta-analysis of endometrial sampling methods by pipelle or curretage, finds that the sensitivity for detection of endometrial carcinoma was in the range of 25–100%. The best results are from a single study of pipelle endometrial biopsy in postmenopausal women, with sensitivity of 99.6%. False-negative rates for office-based endometrial biopsy have been reported at more than 15% and D&C has up to an 11% false negative rate for endometrial carcinoma. One study reported that endometrial biopsy had only a 43% sensitivity rate for detecting endometrial carcinoma. False-positive rates for endometrial biopsy are believed to be very low, although no exact figure has been reported.

A systematic review and meta analysis to determine the diagnostic accuracy of outpatient endometrial sampling in detecting endometrial hyperplasia. Postmenopausal women were included in two studies, in which they represented 25% of the (combined) patient sample. In these two articles three different diagnostic devices had been used for endometrial sampling: Accurette®, Pipelle® and Vabra® aspirator. The pre-test probability of 14.3% was increased to a post-test probability for a positive result of 66.7% (95% CI 42.3–83.9%). This review demonstrated that endometrial sampling is moderately accurate in diagnosing (pre)malignant endometrial pathology. A positive test result was more accurate than a negative test result (sensitivity 91.9%, with a specificity of 99.7%).

Diagnostic hysteroscopy plays a major role in assessing bleeding among postmenopausal women due to its high sensitivity and specificity for diagnosing endometrial lesions. This method has increasingly been used as an alternative to uterine curettage with the advantage of enabling directed or guided biopsies of small lesions A review article to determine the accuracy of hysteroscopy in diagnosing endometrial cancer and hyperplasia in women with abnormal uterine bleeding. They received 3486 articles identified through search of the Cochrane Library, MEDLINE and EMBASE (1984-2001). 208 of these articles were deemed to be potentially eligible and were retrieved for detailed data extraction. 65 primary studies were analyzed including 26,346 women. The pretest probability of endometrial cancer was 3.9%. A positive hysteroscopy result increased the probability of cancer to 71.8%, whereas a negative hysteroscopy result reduced the probability of cancer to 0.6%. They concluded that the diagnostic accuracy of hysteroscopy is high for endometrial cancer.

In patients presenting normal hysteroscopy , none of the symptomatic results who subsequently undergo Novak curettage biopsies are diagnosed with carcinomas or hyperplasias. This reinforces the advantage of hysteroscopy in detecting lesions in the endometrial cavity with high sensitivity (94.4%), specificity (97%) and accuracy(96.8%). Blind endometrial sampling is safe in excluding hyperplasias and carcinomas, thus allowing it to be assumed that no cases were actually missed.

In endometrial hyperplasia, hysteroscopy showed an overall sensitivity, specificity, PPV (positive predictive value), and NPV(negative predictive value) of 56.5, 91.6,72.2, and 84.6%, respectively. There are some statistical limitations due to the small number of observations regarding the diagnostic usefulness of hysteroscopy for the patients with postmenopausal bleeding and thickened endometrium.