Comparative Study between the Diagnostic accuracy of 3D Ultrasound and Hysteroscopy in patients with premenopausal uterine bleeding

INTRODUCTION

One of the most prevalent present complaints in premenopausal women is abnormal uterine haemorrhage. It's a complicated clinical issue with a variety of reasons. Physicians with a strong understanding of menstrual physiology and a thorough strategy for differential diagnosis, on the other hand, may confidently assess and treat the issue.¹

The cervical canal and uterine cavity can be viewed directly with hysteroscopy. Diagnostic hysteroscopy can diagnose intrauterine anomalies and is both precise and practical. Because diagnostic hysteroscopy is typically performed in an outpatient clinic, a precise diagnosis is critical in directing therapy to the specific pathology and avoiding unnecessary surgery.²

The addition of three-dimensional (3D) ultrasound to pelvic sonography has increased its value. It has enabled the presentation of coronal images not previously feasible with 2D ultrasound, improving ultrasound's precision in the detection of uterine abnormalities by allowing it to outline both the exterior uterine contour and abnormalities of the endometrium. 3D ultrasound is superior to 2D ultrasound in defining endometrial pathology and

complements saline infusion sonohysterography (SIS). Volumetric data improves work flow effectiveness and enables data analysis off-line. The storing of data sets which could be manipulated without the requirement for repeat studies allows for consultation with referring physicians as well as other specialists.³

The ability to obtain a coronal (frontal) view of the uterus is one of the most significant benefits of 3D ultrasound. This allows the organ to be visualised lying flat, as it is frequently depicted in medical drawings. The study of the uterus's frontal plane increases visualisation of potential interactions among structures like uterine fibroids and the endometrium. 3D U/S is also necessary to reconstruct the surface views of organs or interfaces. This is particularly useful when evaluating the surface of the endometrium. ⁴

Modern hysteroscopes are cystoscopes that have been modified to allow light to be introduced by fiberoptics. To distend the uterine cavity, which is required for inspection, several infusion media are employed. For diagnostic biopsies and pathology elimination, as well as curative procedures, a variety of surgical equipment and devices are available. Hysteroscopy in the clinic and operating room necessitates a thorough understanding of instruments, techniques, contraindications, indications, and complication treatment.⁵

The use of office hysteroscopy necessitates the implementation of appropriate office safety protocols. Unfortunately, many physicians do not have the equipment and staffing available to perform hysteroscopy in the office. It is a low-risk technique to insert a hysteroscope solely for diagnostic purposes. The key is determining what diagnostic procedures would be difficult due to severe cervical stenosis as well as which complex surgical hysteroscopic procedures will be safer in the operating room. ⁵

Hysteroscopy, both diagnostic and surgical, has become a gynaecological practise standard due to its safety and effectiveness.⁶ Surface rendering mode enables investigation of the lesion's exterior and interior contours, whereas "niche aspect" allows for detection and analysis of specific uterine lesion sections. 3D ultrasound allows for better imaging of lesions, more precise volume estimation, retrospective evaluation of stored data, tumour invasion evaluation, and could pinpoint abnormalities that require operative intervention more precisely by employing rendered images.⁷

The present research is aimed at comparing the diagnostic accuracy of 3D U/S and hysteroscopy in detecting leions of the uterine in cases of perimenopausal bleeding.

PATIENTS AND METHODS

The research involved 100 cases from the outpatient Gynecological Clinic, Al Hussein, Al Sayed Galal Hospitals, Al-Azhar University during the period starting from October 2019 till May 2021. All of the women were between the ages of 41 and 50 and had premenopausal bleeding.

Inclusion criteria: Age between and 50 years, any pattern of abnormal haemorrhage such as menorrhagia or metrorrhagia for more than 3 months, and no ovarian lesions or local causes of bleeding, such as vaginal or cervical ulcer.

Exclusion criteria: Postmenopausal patients, systemic causes of perimenopausal bleeding, patients with Chronic liver diseases, diabetic patients, hypertensive patients, patients on hormonal therapy, using any contraception e.g., IUD, known to have contra indication for hystroscopy e.g. cervical stenosis, pregnancy, not known to have general causes of bleeding, and bleeding is not caused by a complication of contraception

All patients were subjected to the following:

Detailed History: Current haemorrhage history, recent hormonal contraception history, specific drug intake, haemorrhage tendency history, or general cause of haemorrhage history, previous operations or blood transfusion history, family history of comparable conditions, and history of previous fractional curettage or hormonal treatment.

General examination: Weight, height, overall appearance, vital indications (blood pressure and pulse), anaemia manifestations and pallor, and cardiac investigation for the presence of murmurs, chest examination, and abdominal investigation.

Local examination: External genitalia examination, bimanual investigation for uterine size, mobility, tenderness, and adnexal masses, and speculum examination for cervical masses, hypertrophy, erosions, ulcers or vaginal lesions.

Laboratory Investigations: Full blood count, bleeding and clotting times, coagulation profile, fasting and postprandial blood sugar levels, kidney and liver functions, and follicular stimulating hormone FSH

2D-Ultrasound: For all cases, it was done in an outpatient clinic by the same sonographer to detect any focal uterine lesions or adnexal masses. It is performed with Hitachi EUB450 (country of origin Japan) ultrasound machine with transvaginal probe. (5‐7.5 MHz) and 3.5 MHz for the transabdominal probe.

3D Ultrasound: To obtain the coronal plane and the relationship of any focal lesion, such as myomas or polyps, in three planes of endometrium, and to store the data. All of the patients underwent three-dimensional vaginal ultrasounds performed with a Voluson E6 3D system (USA) and an S-VDW 5-8 probe that has a frequency of 5‐8 MHz and is an electronic sector transducer.

Hysteroscopic Evaluation: All cases have been subjected to diagnostic hysteroscopy under general anaesthesia by a single experienced operator who was blind to the ultrasound results. We utilized a 25 cm long rigid continuous flow panoramic hysteroscopy (ENDOMED SYSTEMS) with an outer sheath of 6 mm. By attaching plastic bags of normal saline solution to infusion tubing, the technique provided constant uterine distention. The cavity was explored looking for polyps, masses, myomas or polyploidy endometruim.

Fractional Curettage: Before cervical dilatation, a specimen is taken from the endocervical canal, followed by cervical dilation up to 7‐8 Hegar. Curettage was performed with a sharp curette, beginning with the fundus, afterward the posterior wall, after that the anterior wall, and finally the right and left lateral walls. The specimen is fixed in 10% formalin and sent for histopathological identification of the nature of the endometrium or of the pathological lesion.

Statistical analysis:

When applicable, data has been statistically defined in aspects of range, mean, standard±deviation (±SD), median, frequency (number of instances), and percentages. Agreement between US, hysteroscopy diagnosis and endometrial sampling diagnosis was done using kappa statistic. The Chi square (χ2) test has been used to compare categorical data. When the expected frequency is < 5, the exact test could be used instead, and p values < 0.05 have been regarded as statistically significant. SPSS (Statistical Package for the Social Science; SPSS Inc., Chicago, IL, USA) version 15 for Microsoft Windows has been used for all statistical calculations. ANOVA (analysis of variance): It has been used to test the difference in mean values of some variables among numerous groups by evaluating the equality of many group means. A receiver operating characteristic (ROC) curve: It is a graphical plot of sensitivity vs. 1-specificity that's been used to demonstrate a test's diagnostic properties on a numeral scale.

RESULTS

In our present study, 100 patients were included, complaining of abnormal uterine haemorrhage and were between the ages of 41 and 50, with a mean age of 43.5 years with no subgroup division (Table 1).

Table 1: Age and parity presentation among the study group

In cases of adenomyosis: 3D U/S has a sensitivity, specificity, and accuracy higher than hysteroscopy (Table 2).

Table 2: Comparison between 3D-US and Hysteroscopy in diagnosis of adenomyosis.

In cases of fibroids: 3D U/S has sensitivity similar to hystroscpoy but specificity is higher for hysteroscopy (Table 3).

Table 3: Comparison between 3D-US and Hysteroscopy in diagnosis of fibroids.

In cases of thick endometrium: 3D U/S has sensitivity specificity and accuracy less than for hysteroscopy (Table  4).

Table 4: Comparison between 3D-US and Hysteroscopy in diagnosis of thick endometrium>12mm.

In cases of endometrial polyps: 3D U/S has sensitivity specificity and accuracy less than for hysteroscopy (Table 5).

Table 5: Comparison between 3D-US and hysteroscopy in the prognosis of polyps.

In cases of all lesions: 3D U/S has sensitivity specificity and accuracy less than for hysteroscopy (Table 6).

Table 6: Comparison between 3D-US and Hysteroscopy in diagnosis of all lesions.