Diagnostic fibrohysteroscopic evaluation of perimenopausal and postmenopausal uterine bleeding: a comparative study...

The most appropriate hysteroscope is the smallest that allows one to perform a biopsy. We use a 3.5- or 4.9-mm Olympus flexible hysteroscope with a failure rate below 3% for office or hospital ambulatory procedures without anesthesia or cervical dilatation. In postmenopausal women (with no hormone treatment) with uterine bleeding, we do not perform hysteroscopy if vaginal sonography detects endometrial thickness less than 4 mm. At this cut-off limit the calculated risk for not detecting an endometrial abnormality is 5.5%. In all other patients we prefer fibrohysteroscopy because its diagnostic accuracy is higher than that of vaginal ultrasound, vaginal ultrasound can easily miss a focal lesion of hyperplasia or adenocarcinoma incipiens, and abnormal endometrial findings detected by vaginal ultrasound or sonohysterography require directed biopsy during hysteroscopy. A comparative study evaluated the experience in our two series (286 patients), a Belgian report (251), and a Japanese report (444). Apart from myoma, 50% of findings were atrophic normal endometrium, and concordance was good for detecting adenocarcinoma (+/-3%). The results suggest using the fibrohysteroscope rather than the rigid scope because of its excellent accuracy.