The diagnostic function of office hysteroscopy and three-dimensional (3D) endometrial volume measurement in the evaluation of women with perimenopausal bleeding

INTRODUCTION

Abnormal uterine bleeding (AUB) is the most prevalent reason for gynecological appointments in women in their peri- and postmenopausal years, accounting for roughly 15% of all visits. An endometrial pathology (polyps, submucous myomas, endometrial hyperplasia, and endometrial carcinoma) should always be suspected, and evaluation appears to be required, aside from systemic, iatrogenic, or hormonal age-related reasons.¹ Endometrial pathology can now be diagnosed and treated using well-established procedures such as clinical examination, transvaginal ultrasound (TVS), 3D ultrasonography, and hysteroscopy.²

Endometrium which is the inner mucous uterine layer is soft, spongy, and composed of tissue resembling embryonic connective tissue. The endometrial epithelium is columnar and gland forming (tubular glands that open into the cavity of the uterus‎) with a specialized spindle shape stromal cells (Progenitors of decidual cells). ³

The secretory and ciliated cells make up the endometrial epithelium, and they are easily distinguished using scanning electron microscopy (SEM). During the cycle, the shape of ciliated cells does not change substantially. Secretory cells, on the other hand, have microvilli (MV) and undergo hormone-dependent changes.⁴

During the secretory phase, the concentration of these ciliated cells at gland openings, as well as the ciliary beat pattern, influence the mobilization and dispersion of endometrial secretions. Cell surface MV are cytoplasmic extensions that serve to expand the active surface of cells and are also a response to estradiol.⁵

3D ultrasonic tomography combines the benefits of ultrasound, such as safety, ease of use, and low cost (in comparison to MRI and CT), with the benefit of the third dimension. Traditionally, the investigator's brain is responsible for generating a 3D image from 2D parts.⁶

The storage of high-quality two-dimensional images on a computer with a powerful software package for this purpose is required for the generation of three-dimensional ultrasound images. With each rotation of the transducer, up to 240 pictures, spaced 1mm apart, can be stored. The computer will include a volume in the shape of a truncated cone, saved on a hard disc after the storage is complete. ⁷

The main benefit of hysteroscopy is that it can detect intracavitary abnormalities like leiomyomas and polyps that transvaginal sonography or endometrial samples could miss. 8 In fact, several experts recommend hysteroscopy as the primary diagnostic method for irregular uterine bleeding. It is very accurate in detecting endometrial cancer, although it is less accurate in detecting endometrial hyperplasia. As a result, some doctors advise combining hysteroscopy with endometrial biopsy or curettage. 9

Endometrial volume measurement is more accurate than endometrial thickness measurement in diagnosing endometrial disease in women with postmenopausal hemorrhage. 10 Furthermore, 3D US enhanced ultrasound diagnostic accuracy in determining myometrial and cervical invasion in endometrial cancer.. ¹¹

The goal of the study was to see how office hysteroscopy and three-dimensional (3D) ultrasonographic measurements of endometrial volume affected endometrial volume and if those methods could predict malignant conditions and hyperplasia of the endometrium and if they could exclude serious intrauterine pathology in perimenopausal women with irregular uterine bleeding to minimize further operative interventions, especially for surgically high-risk patients or not?

PATIENTS AND METHODS

This research was conducted at Al Azhar University in Al Hussein university hospital from March 2017 to October 2019 Obstetrics and Gynecology department. The research includes a hundred cases complaining of perimenopausal bleeding at the outpatient clinic.

Inclusion criteria: Perimenopausal bleeding, Age 40- 50 years, having any type of bleeding for more than 3 months, such as menorrhagia or metrorrhagia, not known to have general causes of bleeding, no Organic Uterine or ovarian lesions, and Bleeding is not caused by a complication of contraception.

Exclusion criteria: General causes of bleeding, irregular use of hormones, using any type of I.U.D, known to have a contraindication for office hysteroscopy e.g. cervical stenosis, Any abnormal lesion that alters the endometrium during pregnancy.

After selection of all cases, They are subjected to a thorough history taking and general examination, as well as a local pelvic examination, office hysteroscopy, transvaginal 2D pelvic ultrasound, 3D endometrial volume measurement, and then dilatation and curettage (D&C) or hysteroscopic guided biopsy for focal endometrial lesions under general anesthesia after a written consent obtained and pathological examination of the specimens obtained.

Patients were classified into 2 groups according to the results of pathological examination of the specimens obtained by D&C. roup 1 patient with hyperplasia and malignant conditions. Group 2 patients with normal endometrium or other causes of  abnormal uterine bleeding.

Preoperative evaluation of both groups involved the following:

History: A systematic history of age, parity, menstrual and obstetric history, hormone treatment, hypertension, diabetes, and current anticoagulant usage acquired utilizing a validated study technique.

Examination: General including blood pressure and pulse and temperature - Pelvic and bimanual examination.

Examining ultrasound images and videotapes, as well as analyzing ultrasound images and videotapes: Toshiba Femi O 5 (Toshiba Medical Solutions Inc., Ultrasound Division, Japan) equipped with a 6.5 MHz transvaginal transducer was used for transvaginal 2D sonography. Endometrial volume acquisition in 3D was performed utilizing a GE Voluson 730 Expert ultrasound system (GE Healthcare, Zipf, Austria) with a transvaginal 5- to 9-MHz volume transducer up to 2 days before curettage. The examinations were saved digitally on an internal disc drive for use in the virtual organ computer-aided analysis (VOCAL) program for further measures. The polygonal area's 2D outlines in each plane can be defined either automatically or manually. There are three different planes in which measurements can be taken (A, B, and C). A plane, the longitudinal view, was used in this study.

Hysteroscopy: All patients have a diagnostic hysteroscopy in the outpatient clinic using the hagioscopic approach hysteroscopy was used in this study is Karl Storz (Germany). The light source used in this study was a Circon Acmi G71A/Germany metal halide automated light source with a 150 Watt lamp.

Attaching plastic bags of saline or glycine solution to the uterus provides continual uterine distention.

Under manometric control, the infusion pressure was raised to 100-120 mm HG using a pneumatic cuff. A single-chip video was used to monitor the procedure, and the image was shown on a monitor that was viewable to the operator. With a focal length ranging from f 70 to f 140, the camera is either a Karl Storz Germany or a Wisap Autocontrol Germany.

Hysteroscopic picture which appears on the monitor is transmitted through the optic from the camera which is fitted on the eyepiece where the panoramic diagnostic hysteroscopy could be performed with better visualization and accuracy.

Analytical statistics: When statistically suitable, data were presented in terms of range, mean standard deviation (SD), frequencies (number of cases), and relative frequencies (percentages). The Student t-test for independent samples when data are normally distributed and the Mann Whitney U test for independent samples when data are not normally distributed are used to compare quantitative variables between study groups. The Chi square (X2) test was used to compare categorical data. When the anticipated frequency is less than 5, an exact test is employed instead. Statistical significance is defined as a probability value (p value) less than 0.05. Microsoft Excel version 7 (Microsoft Corporation, NY, USA) and SPSS (Statistical Package for the Social Science; SPSS Inc., Chicago, IL, USA) version 13 for Microsoft Windows were used to do all statistical computations.

RESULTS

This research was conducted at Al Azhar University, Al Hussein hospital Obstetrics and Gynecology unit from March 2017 to October 2019.The study included 100 patients complaining of perimenopausal bleeding at the outpatient clinic. Patients were selected according to the criteria mentioned before and they were divided into 2 groups:  Group 1: cases with hyperplasia and malignant conditions. Group 2: patients with normal endometrium or other causes of abnormal uterine bleeding

Table 1: Age and Parity in the two groups

There were no statistically significant differences between the two groups as regard age and parity. Table (1)

Table 2: Bleeding pattern in both groups.

Menorrhagia was the most common bleeding pattern, followed by menometrorrhagia, metrorrhagia, and polymenorrhoea. Table (2)

Table 3 : Number of different endometrial histopathology In both groups

In group 1 Simple endometrial hyperplasia was the most frequent endometrial histopathology, followed by complicated endometrial hyperplasia and only 1 case of endometrial carcinoma was discovered. In group 2 most common endometrial histopathology was discovered proliferative endometrium then secretory endometrium and 6 cases of an atrophic endometrium. Table (3)

S=significant

Table 4: Endometrial thickness in both groups

There was a high statistical significance as regards endometrial thickness in comparison to both groups. Table (4)

Fig. 1 : Endometrial thickness in Group1

Fig. 2: Endometrial thickness in Group two

Table (5): Endometrial volume in both groups

There was a high statistical significance as regard endometrial volume in comparison of both groups. Table (5)

Table 6: Office hysteroscopy results in both groups