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Evaluation of pre-operative endometrial biopsy accuracy and etiological distribution in abnormal uterine bleeding
Rulin Deniz1, Yakup Baykus1, Alihan Tigli1
1Department of Obstetrics and Gynecology, Faculty of Medicine, Bandirma Onyedi Eylül University, Balikesir, Türkiye.
Insights
Abnormal uterine bleeding (AUB) is often caused by structural issues like leiomyomas, leading to hysterectomy. Pre-operative endometrial biopsy (EB) has low sensitivity for focal lesions, necessitating complementary imaging for accurate diagnosis.
Area of Science:
- Gynecology
- Reproductive Medicine
- Pathology
Background:
- Abnormal uterine bleeding (AUB) is a frequent gynecological complaint and a primary indication for hysterectomy.
- The FIGO PALM-COEIN system categorizes AUB etiologies, aiding in standardized diagnosis and management.
- Accurate pre-operative assessment is crucial for determining the appropriate treatment, including hysterectomy.
Purpose of the Study:
- To determine the etiological distribution of AUB in patients undergoing hysterectomy using the FIGO PALM-COEIN classification.
- To evaluate the diagnostic accuracy and concordance between pre-operative endometrial biopsy (EB) and final hysterectomy pathology.
- To assess the effectiveness of EB in identifying specific causes of AUB, particularly focal lesions and pre-malignant conditions.
Main Methods:
- Retrospective analysis of 296 patients who underwent hysterectomy for AUB.
- Categorization of AUB causes according to the FIGO PALM-COEIN system.
- Statistical analysis of pre-operative EB results versus final histopathological findings, including sensitivity, specificity, predictive values, Kappa coefficient, and ROC analysis.
Main Results:
- Structural causes (PALM) were predominant, with leiomyomas being the most frequent etiology (59.8% including isolated cases).
- Pre-operative endometrial biopsy demonstrated high specificity but limited sensitivity for detecting focal lesions and some pre-malignant conditions (e.g., atypical endometrial hyperplasia).
- Overall agreement (Kappa) between EB and final pathology was low to moderate, indicating limited diagnostic concordance for certain pathologies.
Conclusions:
- Leiomyomas are the primary cause of hysterectomy for AUB, highlighting the significance of structural pathologies.
- Pre-operative endometrial biopsy is valuable for ruling out certain conditions but insufficient for diagnosing focal lesions due to low sensitivity.
- Advanced diagnostic imaging should complement EB results, especially in cases with high clinical suspicion, to improve pre-hysterectomy diagnostic accuracy.
Objective:
Abnormal uterine bleeding (AUB) is one of the leading causes of gynecological consultations and indications for hysterectomy. The aim of this study is to determine the distribution of aetiological causes in patients undergoing hysterectomy due to AUB according to the FIGO PALM-COEIN system and to evaluate the diagnostic concordance between pre-operative endometrial biopsy (EB) results and final hysterectomy pathology.
Methods:
This retrospective, descriptive and analytical study included 296 patients who underwent hysterectomy due to AUB at Bandirma Onyedi Eylül University Hospital between 2020 and 2025. The patients' demographic data, clinical characteristics, and histopathological results were examined from hospital records. The causes of AUB were categorized according to the PALM-COEIN system (Polyps, Adenomyosis, Leiomyoma, Malignancy; Coagulopathy, Ovulatory, Endometrial, Iatrogenic, Unclassifiable). The concordance of pre-operative EB results with final pathology was analyzed using sensitivity, specificity, positive/negative predictive values, the Kappa coefficient, and ROC analysis AUC.
Results:
The mean age of the patients was 48.2 ± 6.9 years. According to the PALM-COEIN classification, structural causes (PALM) were the most common etiology, with leiomyomas (35.5% isolated, 59.8% total) forming the pre-dominant group. The rate of post-menopausal bleeding was determined to be 28.0%. Regarding concordance between pre-operative EB and final pathology, EB demonstrated high specificity but limited sensitivity, particularly for focal lesions. For AEH+ (atypical endometrial hyperplasia and above), sensitivity was 22.2%, specificity was 99.6%, and AUC was 0.609; for endometrial polyps, sensitivity was 30.6%, specificity was 83.0%, and AUC was 0.568. Overall agreement between biopsy and final pathology (Kappa) was low to moderate, and ROC analysis indicated limited discriminatory ability across subgroups.
Conclusion:
Among patients undergoing hysterectomy for AUB, structural pathologies, particularly leiomyomas, constitute the primary reason for hysterectomy. Although pre-operative EB is successful in ruling out pathologies, it may be insufficient in detecting focal lesions and some pre-malignant conditions due to its low sensitivity. Therefore, EB results should be supported by advanced diagnostic imaging methods, especially when clinical suspicion exists during the decision-making process for hysterectomy.
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