The Effectivenss of Hysteroscopy in Evaluating Asymptomatic Postmenopausal Patients with Thickened Endometrium

Yıl 2020, Cilt: 42 Sayı: 1, 7 - 13, 01.01.2020

Vehbi Yavuz Tokgöz , Tufan Öge

https://doi.org/10.20515/otd.567303

Öz

To assess the
association between the hysteroscopy and histopathological findings in
asymptomatic postmenopausal patients with thickened endometrium. This retrospective study was performed
in asymptomatic postmenopausal patients with endometrial thickness that was
revealed by transvaginal ultrasonography as > 5mm. Office hysteroscopy and
endometrial biopsy were performed to all patients. The outcomes of hysteroscopy
and histopathology were compared and sensitivity, specificity, positive and
negative predictive values of hysteroscopy were determined. One hundred and
sixty-eight patients were evaluated, patients who have not enough data and
histopathological findings were excluded. After exclusion criterias, totally
106 patients were analyzed. Mean age(years), age of menopause(years) and
endometrial thickness(mm) were 55.3±8.5, 47.8±5.4 and 9.5±4.2 respectively. We
assessed the histopathological findings as normal or atrophic, endometrial
polyp, simple endometrial hyperplasia, atypical/complex endometrial
hyperplasia, endometrial carcinoma and insufficient material in 9(8.5%),
61(57.5%), 6(5.7%), 16(15.1%), 5(4.7%), 1(0.9%) and 8(7.5%) patients,
respectively. Hysteroscopic findings were established as normal appearance,
hyperplasia, endometrial polyp, submucous myoma and tumor/carcinoma in 30(28.3%),
16(15.1%), 53(50%), 6(5.7%) and 1(0.9%) patients, respectively.  Hysteroscopy evaluation was compared with the
histopathology which approved as a gold standard procedure to determine the
definitive diagnosis and the analysis was performed for each finding
separately. The hysteroscopy was more sensitive in normal or atrophic
endometrium and endometrial polyps were determined by hysteroscopy with high
sensitivity. The lowest sensitivity was obtained in endometrial hyperplasia. Hysteroscopy
enables effective and accurate diagnosis to evaluate benign and suspected
malign cases in postmenopausal patients with thickened endometrium. The
advantages of hysteroscopy were opportunity for concurrent biopsy and detection
the correct location of the lesions. Hysteroscopy also eliminates the unnecessary
biopsies for atrophic endometrium. The sensitiviy of hysteroscopy increases
especially in intracavitary pathologies such as endometrial polyps. It should
not be forgotten the necessity of curettage in endometrial hyperplasias that
can not be detected clearly with hysteroscopy

Anahtar Kelimeler

hysteroscopy, postmenopause, endometrial thickness

Asemptomatik Postmenopozal Endometrial Kalınlık Artışının Değerlendirilmesinde Histeroskopinin Etkinliği

Öz

Asemptomatik postmenopozal
endometrial kalınlık artışı olan olgularda histeroskopinin etkinliğinin ve
histopatolojik bulgular ile ilişkisinin belirlenmesi. Retrospektif olarak
planlanan çalışmamız, transvajinal ultrasonografide(TVUS) endometrium kalınlığı
>5 mm olan asemptomatik postmenopozal kadınların analizi ile
gerçekleştirilmiştir. TVUS’de endometrium kalınlığı >5 mm olan hastalara
ofis koşullarında histeroskopi ve endometrial biyopsi örneklemesi
uygulanmıştır. Yapılan ofis histeroskopi ve histopatolojik inceleme sonuçları
karşılaştırmalı olarak analiz edilmiş, histeroskopinin predikte edici etkisi
sensitivite, spesifisite, pozitif ve negatif prediktif değerlerine göre
değerlendirilmiştir. Retrospektif analizde 168 hasta değerlendirilmiş, eksik
verileri  olan ve histopatolojik inceleme
sonuçlarına ulaşılamayan 62 hasta çalışma dışı bırakılmıştır. Toplamda 106
hasta çalışma grubu olarak belirlenerek analizler gerçekleştirilmiştir.
Hastaların ortalama yaşları(yıl), menopoz yaşları(yıl) ve endometrium
kalınlıkları(mm) sırasıyla; 55.3±8.5, 47.8±5.4 ve 9.5±4.2 olarak tespit
edilmiştir. Histopatolojik bulguların dağılımına bakıldığında normal veya
atrofik bulgular, endometrial polip, leiomyoma uteri, basit endometrial
hiperplazi, atipili/kompleks endometrial hiperplazi, endometrial karsinom ve
yetersiz materyal oranları sırasıyla 9(%8.5), 61(%57.5), 6(%5.7), 16(%15.1),
5(%4.7), 1(%0.9) ve 8(%7.5) olarak saptanmıştır. Histeroskopi buluguları
değerlendirildiğinde ise normal görünüm, hiperplazik görünüm, endometrial
polip, submuköz myom ve tümör/karsinom görünümü olarak sırasıyla 30(%28.3), 16(%15.1),
53(%50), 6(%5.7) ve 1(%0.9) olguda tespit edilmiştir. Histeroskopi
incelemesinin nihai tanı yöntemi olan histopatolojik sonuçlarını öngörme
durumunu değerlendirmek için yapılan ve her bulgu için ayrı ayrı
gerçekleştirilen analizde histeroskopinin en duyarlı olduğu normal veya atrofi
bulguları olan ve ikinci sırada en duyarlı olduğu ise endometrial polip
saptanan olgular olarak belirlenmiştir. Duyarlılığının en düşük olduğu lezyon
ise endometrial hiperplazi olguları olmuştur. Histeroskopi, postmenopozal
endometrial kalınlık artışı olan hastalarda benign veya şüpheli malign
olguların değerlendirilmesinde doğru tanı olanağı sağlamaktadır. Eş zamanlı
biyopsi olanağı sağlaması lezyonun yerinin net belirlenmesi faydaları arasında
yer almaktadır. Atrofik endometrium gibi olgularda da gereksiz biyopsi durumunu
ortadan kaldırmaktadır. Özellikle polip gibi intrakaviter patolojilerde saptama
oranı belirgin artmaktadır. Endometrial hiperplazi gibi histeroskopi ile
saptanma oranı düşük olgularda küretaj ile örnekleme yapılması gerekliliği de
unutulmamalıdır. 

Anahtar Kelimeler

histeroskopi, postmenopoz, endometrial kalınlık artışı, küretaj

Kaynakça

• Siegel R, Ma J, Zou Z, Jemal A. Cancer statistics, 2014. CA Cancer J Clin. 2014;64(1):9-29.2. Elfayomy AK, Habib FA, Elkablawy MA. Role of hysteroscopy in the detection of endometrial pathologies in women presenting with postmenopausal bleeding and thickened endometrium. Arch Gynecol Obstet. 2012;285(3):839-43.3. Smith-Bindman R, Kerlikowske K, Feldstein VA, Subak L, Scheidler J, Segal M, et al. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA. 1998;280(17):1510-7.4. Smith-Bindman R, Weiss E, Feldstein V. How thick is too thick? When endometrial thickness should prompt biopsy in postmenopausal women without vaginal bleeding. Ultrasound Obstet Gynecol. 2004;24(5):558-65.5. Goldstein SR. Modern evaluation of the endometrium. Obstet Gynecol. 2010;116(1):168-76.6. Schmidt T, Breidenbach M, Nawroth F, Mallmann P, Beyer IM, Fleisch MC, et al. Hysteroscopy for asymptomatic postmenopausal women with sonographically thickened endometrium. Maturitas. 2009;62(2):176-8.7. Bourdel N, Modaffari P, Tognazza E, Pertile R, Chauvet P, Botchorishivili R, et al. Does experience in hysteroscopy improve accuracy and inter-observer agreement in the management of abnormal uterine bleeding? Surg Endosc. 2016;30(12):5558-64.8. Korkmazer E, Solak N, Ustunyurt E. Hysteroscopic assessment of postmenopausal endometrial thickening. Prz Menopauzalny. 2014;13(6):330-3.9. Lasmar RB, Dias R, Barrozo PR, Oliveira MA, Coutinho Eda S, da Rosa DB. Prevalence of hysteroscopic findings and histologic diagnoses in patients with abnormal uterine bleeding. Fertil Steril. 2008;89(6):1803-7.10. Arslan S, Aytan H, Gunyeli I, Koc O, Tuncay G, Tapisiz OL. Office hysteroscopic evaluation of endometrium: can we hit the target? Arch Gynecol Obstet. 2005;271(3):200-2.11. Loiacono RM, Trojano G, Del Gaudio N, Kardhashi A, Deliso MA, Falco G, et al. Hysteroscopy as a valid tool for endometrial pathology in patients with postmenopausal bleeding or asymptomatic patients with a thickened endometrium: hysteroscopic and histological results. Gynecol Obstet Invest. 2015;79(3):210-6.12. Sarvi F, Alleyassin A, Aghahosseini M, Ghasemi M, Gity S. Hysteroscopy: A necessary method for detecting uterine pathologies in post-menopausal women with abnormal uterine bleeding or increased endometrial thickness. Turk J Obstet Gynecol. 2016;13(4):183-8.13. Kurosawa H, Ito K, Nikura H, Takano T, Nagase S, Utsunomiya H, et al. Hysteroscopic inspection and total curettage are insufficient for discriminating endometrial cancer from atypical endometrial hyperplasia. Tohoku J Exp Med. 2012;228(4):365-70.14. Spicer JM, Siebert I, Kruger TF. Postmenopausal bleeding: a diagnostic approach for both private and public sectors. Gynecol Obstet Invest. 2006;61(3):174-8.15. Lee DO, Jung MH, Kim HY. Prospective comparison of biopsy results from curettage and hysteroscopy in postmenopausal uterine bleeding. J Obstet Gynaecol Res. 2011;37(10):1423-6.16. Bettocchi S, Ceci O, Di Venere R, Pansini MV, Pellegrino A, Marello F, et al. Advanced operative office hysteroscopy without anaesthesia: analysis of 501 cases treated with a 5 Fr. bipolar electrode. Hum Reprod. 2002;17(9):2435-8.17. Trojano G, Damiani GR, Casavola VC, Loiacono R, Malvasi A, Pellegrino A, et al. The Role of Hysteroscopy in Evaluating Postmenopausal Asymptomatic Women with Thickened Endometrium. Gynecol Minim Invasive Ther. 2018;7(1):6-9.18. Şendağ F, Akman L, Bilgin O, Öztekin K. POSTMENOPOZAL UTERİN KANAMA VEYA ENDOMETRİAL KALINLAŞMASI OLAN KADINLARDA HİSTEROSKOPİK DEĞERLENDİRME. Ege Journal of Medicine. 2007;4(2):144-7.19. Garuti G, Cellani F, Garzia D, Colonnelli M, Luerti M. Accuracy of hysteroscopic diagnosis of endometrial hyperplasia: a retrospective study of 323 patients. J Minim Invasive Gynecol. 2005;12(3):247-53.20. Daud S, Jalil SS, Griffin M, Ewies AA. Endometrial hyperplasia - the dilemma of management remains: a retrospective observational study of 280 women. Eur J Obstet Gynecol Reprod Biol. 2011;159(1):172-5.