Transvaginal sonography and hysteroscopy in postmenopausal uterine bleeding

To compare the diagnostic accuracy of transvaginal ultrasound and hysteroscopy in the detection of endometrial pathologies in women with postmenopausal bleeding not using hormonal replacement therapy (HRT).

Between January 1997 and April 1998, 106 postmenopausal women with uterine bleeding not using HRT underwent a diagnostic work-up including pelvic examination, transvaginal ultrasound, hysteroscopy and endometrial biopsy. Sonographic measurement of endometrial thickness and hysteroscopic findings were compared with histological results. The 'classification tree' method was used to identify cut-off values of sonographic endometrial thickness that could be indicative of a class of uterine pathology. Statistical analysis was performed with the McNemar test.

No case of endometrial cancer was found with a cut-off point of 5 mm of endometrial thickness evaluated by ultrasound, whereas all patients with endometrial thickness > or = 15 mm at sonography had an endometrial carcinoma. In the group of patients with endometrial thickness between 6 and 14 mm, we found normal atrophic endometria, benign and malignant pathology. On the other hand, the McNemar test showed a very good correspondence between hysteroscopy and histology (sensitivity 97.5% and specificity 100%), confirming its usefulness in diagnosis of postmenopausal uterine bleeding.

Transvaginal ultrasound has revealed some limitations, mainly in the group of patients with endometrial thickness between 6 and 14 mm. The absence of endometrial malignancy in women with endometrial thickness < or = 5 mm and the high possibility of cancer in those with endometrial thickness > or = 15 mm should be confirmed in larger series. Hysteroscopy proved to be a simple and safe outpatient procedure with a high diagnostic accuracy, and in our opinion it should be considered in all women with postmenopausal uterine bleeding.