Journal of Datta Meghe Institute of Medical Sciences University

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 14  |  Issue : 4  |  Page : 303--309

Evaluation of abnormal uterine bleeding patients by conventional dilatation and curettage and hysteroscopically guided dilatation and curettage


Puja Kumari Radhikabai, Kiran Borkar 
 Department of Obstetrics and Gynaecology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India

Correspondence Address:
Dr. Puja Kumari Radhikabai
PG Girls Hostel Room No. S-24, Jawaharlal Nehru Medical College Campus, Sawangi (Meghe), Wardha - 442 001, Maharashtra
India

Abstract

Introduction: Abnormal uterine bleeding (AUB) is a newly coined term for describing the condition, wherein there is any deviation from a normal menstrual pattern. It is the most often encountered gynecological problem. Dysfunctional uterine bleeding and bleeding from structural causes both are included in it. Each year approximately 10% of women aged 30–50 years consult a gynecologist for treatment. This makes it imperative to accurately diagnose and treat the cause. This study aims at judging the place of diagnostic hysteroscopy in obtaining an accurate diagnosis of the etiology of AUB and outlining a mode of treatment. This is done by correlating the findings on hysteroscopy and those found on conventional dilatation and curettage (D and C). Materials and Methods: This prospective study was performed in the Department of Obstetrics and Gynecology, Jawaharlal Nehru Medical College (DMIMS), Wardha, Maharashtra. Eighty cases of AUB were chosen based on inclusion and exclusion criteria. The patients were subjected to routine investigations, ultrasonography. Forty patients underwent conventional D and C and next 40 patients underwent hysteroscopic guided curettage with biopsy. The findings of the two were compared and analyzed. Results: AUB was the most common between 30 and 40 years…. Maximum patients had complaints for 3 months to 1 year. Menorrhagia was the most common presenting complaint. Normal findings were observed in 19 cases with conventional D and C of 40 cases and 3 cases with hysteroscopic-guided biopsy out of 40 cases. Abnormal findings were seen in 2.5% of cases of 40 cases with conventional D and C, 42.5% of cases of 40 cases with hysteroscopic guided biopsy. Conclusion: This study reveals the superior ability of hysteroscopic guided D and C with biopsy in evaluating patients with AUB when compared to conventional D and C. These findings are in agreement with those of many other studies.



How to cite this article:
Radhikabai PK, Borkar K. Evaluation of abnormal uterine bleeding patients by conventional dilatation and curettage and hysteroscopically guided dilatation and curettage.J Datta Meghe Inst Med Sci Univ 2019;14:303-309


How to cite this URL:
Radhikabai PK, Borkar K. Evaluation of abnormal uterine bleeding patients by conventional dilatation and curettage and hysteroscopically guided dilatation and curettage. J Datta Meghe Inst Med Sci Univ [serial online] 2019 [cited 2020 Aug 4 ];14:303-309
Available from: http://www.journaldmims.com/text.asp?2019/14/4/303/289838


Full Text



 Introduction



Abnormal uterine bleeding (AUB) term is newly coined for describing the condition, wherein there is any deviation from a normal menstrual pattern. Dysfunctional uterine bleeding and bleeding from structural causes both are included in it.

Munro MGet al. described AUB as a common debilitating problem among woman in all age groups accounting for 20% of gynecology outpatient department (OPD) visits and may account for 25% of all hysterectomies.[1] Efficiency of the women is affected by AUB as it has negative impact on quality of life.

Despite proper diagnosis, AUB management can be complex. After a detailed evaluation and physical examination, physicians are often unable to identify the cause of excessive bleeding. Dilatation and curettage (D&C) is one of the most common studies used to determine the causes of excessive uterine bleeding. However, it is a blind procedure. It detects the cause in <50% of the cases; in rest, focal lesions were missed. Frequently, bleeding persists after curettage, thus repeat curettage is required or eventually a hysterectomy may be mandatory. In D&C the endometrium has to be sent to the pathologist to study. It also requires skill so as to obtain an adequate sample of the endometrial tissue. Complications such as perforations, cervical tears and injuries, scar tissue formation, and intrauterine adhesions are common. Hysteroscopy on the other hand unlike D&C is not a blind procedure. Hysteroscopic evaluation permits direct visualization and assessment of the endocervical uterine cavities, hence proving a reliable method of diagnosing intrauterine abnormalities. Use of hysteroscopy in AUB is almost replacing curettage as it sees and decides the cause. This is because the uterine cavity can be observed and the area in question can be curetted. It can most accurately detect endometrial polyps, fibroids, hyperplasia, etc., better than conventional D&C, wherein the diagnosis is often missed.[2]

Considering these advantages, the hysteroscopy is a useful tool in the diagnosis of AUB. The present study tries to explore its potential in the evaluation of AUB with conventional D and C as the basis for correlation.

Aims

The aim of the study is to compare diagnostic accuracy of conventional D&C with hysteroscopically guided D&C in patients with AUB.

Objectives

To determine the histopathological features of AUB in conventional D&CTo determine the histopathological features of AUB in hysteroscopically guided D&CTo determine the pattern of hysteroscopic abnormalities in AUBTo correlate histopathological finding in conventional D&C and hysteroscopically guided D&C.

 Materials and Methods



A prospective cross-sectional study was performed in the Department of Obstetrics and Gynecology, Jawaharlal Nehru Medical College, Wardha, Maharashtra.

The materials included all the AUB patients attending the OPD and were admitted for hysteroscopic guided curettage with biopsy and conventional D&C.

80 cases of AUB were taken for the study.

All the patients in the study were subjected through detailed history taking, general physical examination, and specific examination in the form of per speculum and per vaginal examination.

Routine blood and urine investigations, blood sugar, bleeding time, and clotting time were ordered for all the patients.

Ultrasonography (USG) of all the patients was done.

Detailed informed consent of all the patients was obtained before taking up for any procedure.

Conventional D&C was done on 40 patients and for the next 40 patients hysteroscopic guided curettage with biopsy was done.

Both group samples were sent for histopathological analysis.

The procedures were done under total intravenous anesthesia in operation theater.

The findings of conventional D&C and hysteroscopic guided D&C were compared with each other.

Ethical clearance

Ethical clearance was obtained from the Institutional Ethical Committee of JNMC, Sawangi (Meghe), Wardha, on 12th Jan 2019. With ethical clearance no DMIMS(DU)/IEC/2019-20/341.

 Observations and Results



As shown in [Table 1], the age of patients varied from 15 to 65 years. The youngest patient included in this study was 18 years old and oldest was 65 years. The two age groups commonly affected were 36–40 years followed by 31–35 years. After which 46–50 years (15%) age group was most commonly affected. 11 patients were found in 26–30 years age group, while 9 patients were there in 41–45 years age group. 3 patients were in the age of 21–25 years and 51–55 years. One patient each belongs to age group 15–20 years, 56–60 years, and 61–65 years.{Table 1}

[Table 2] shows that the most common presentation was menorrhagia (31.25%) followed by polymenorrhea (20%). Metrorrhagia was found in 18.75% patients, oligomenorrhea in 17.5% patients. Postmenopausal bleeding (12.5%) was the least common presentation.{Table 2}

[Table 3] shows that the woman with abnormal uterine bleeding came most commonly after 3 months to 1 year (70%) period of suffering. This was followed by 16 patients (20%) suffering for>1 year. 8 patients (10%) only suffered for a period of 1–3 months.{Table 3}

45% patients were found to have normal ultrasonographic findings. The most commonly detected pathology was found to be endometrial hyperplasia (25%) followed by fibroid uterus (13.75%) on USG.

Diagnostic hysteroscopy guided curettage with biopsy was carried out in 40 patients. The most common finding on hysteroscopy was endometrial hyperplasia (32.5%). Fibroid was detected in 25% and endometrial polyp was detected in 20% patients, respectively, on hysteroscopy. In 12.5% patients, endometritis was found. Only in 2.5% of cases endometrium was atrophic and only 7.5% of cases were found to be normal on hysteroscopy.

40 patients underwent conventional D&C and endometrial tissue was sent for histopathological diagnosis. The most common finding was secretory endometrium (47.5%) which is considered normal mean no abnormality detected. This was followed by proliferative endometrium which was 20% followed by 15% patients having simple hyperplasia without atypia. Complex hyperplasia without atypia was noted in 2.5% patients, endometrial polyp was noted in 5% patients, atrophic endometrium was noted in 2.5% of patients. In 7.5% patients, endometrium was not obtained.

40 patients underwent diagnostic, hysteroscopic guided curettage with biopsy and tissue was sent for histopathological diagnosis. The most common finding was proliferative endometrium (40%), followed by 20% women having endometrial polyp. Simple hyperplasia without atypia was noted in 15% of patients while 10% patients had complex hyperplasia without atypia and 5% patients had simple hyperplasia with atypia. 2.5% of patients showed endometrial atrophy. Only 7.5% of patients showed secretory endometrium which is considered to be normal.

As shown in [Table 8], the histopathological report of conventional D&C group and hysteroscopic guided D&C with biopsy group has been compared. It was seen that simple hyperplasia with atypia was not seen in any patients of conventional D&C group but was seen in 5% patients of hysteroscopic guided D&C group. Complex hyperplasia without atypia was seen in only 2.5% patients of conventional D&C group but in 10% patients of hysteroscopic guided D&C group. Endometrial polyp was only seen in 5% patients of conventional D&C group but was 20% in hysteroscopic guided D&C group. Atrophic endometrium and simple hyperplasia without atypia was equally seen in both the groups. Endometrium proliferative phase was 20% in conventional D&C group, but it was 40% in hysteroscopic guided D&C group. Secretory phase, i.e., normal endometrium was seen in 47.5%patients of conventional D&C group but only in 7.5% of patients of hysteroscopic guided D&C group.

Inconventional D&C group, endometrium was not obtained in 3 cases, while in hysteroscopic guided D&C group, there was not a single case in which endometrium was not obtained.

Comparing the histopath report of both the groups, overall P value was calculated by Chi-square test and it was found to be significant i.e., P = 0.0009 [Graph 1], [Graph 2], [Graph 3], [Graph 4], [Graph 5], [Graph 6], [Graph 7], [Graph 8].[INLINE:1][INLINE:2][INLINE:3][INLINE:4][INLINE:5][INLINE:6][INLINE:7][INLINE:8]

 Discussion



The present study was conducted in the Department of Obstetrics and Gynecology, Acharya Vinoba Bhave Rural Hospital, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha on 80 patients fulfilling the inclusion criteria. This study attempts to analyze the comparison of conventional D&C and hysteroscopic guided D&C with biopsy as diagnosing modalities of intracavitary lesions causing AUB.

The age group in this study was between 18 and 65 years and maximum incidence was found to be between the ages of 35 and 40 years (27.5%) closely followed by 31–35 years (21.5%), as shown in [Table 1]. Gianninoto performed diagnostic hysteroscopy in 512 woman with complaints of AUB, age ranging from 38 to 80 years and the most common incidence was between 30 and 45 years.[3] In the study by Panda et al., maximum incidence was found between 35 and 45 years, which is in agreement with our study.[4]

The most common presenting complaint in this study as shown in [Table 2] was menorrhagia (31.25%) followed by polymenorrhea (20%) followed by metrorrhagia (18.75%). Panda et al. series had 60% cases of menorrhagia followed by polymenorrhea and metrorrhagia which is similar to our study.[4]

Comparing the duration of complaints, as shown in [Table 3], it appears that maximum patients seek medical opinion after suffering for 3 months to 1 year (70%). About 16% of patients presented after 1 year of AUB, as in our country uterine bleeding is mostly neglected.

Ultrasonographic findings are tabulated in [Table 4]. 45% of patients showed no abnormalities on USG of 80 patients. About 31.25% had endometrial hyperplasia on final diagnosis, whereas on USG only 25% of patients had endometrial hyperplasia.{Table 3}{Table 4}

Out of 20% of cases of fibroid on final diagnosis, only 13.75% cases were found on USG.

Of 10 cases of polyp, only 7 cases were diagnosed on USG.

Diagnostic hysteroscopically guided curettage with biopsy was carried out in 40 patients in operation theatre under total intravenous anesthesia and specimen was sent for histopath diagnosis. In the present study, the distending medium used was normal saline. Different distending media has been used by different authors with the hope of achieving the best results. These media have been divided into three groups: high viscosity media, low viscosity media, and gaseous media.

Brusco et al.[5] compared CO2 and normal saline as distending medium in diagnostic hysteroscopy and found that normal saline is technically equal to CO2 in image quality and ease of use but offered more advantages as it was more acceptable and quicker to perform.

Pellicano et al.[6] found that normal saline when compared with CO2 caused significantly lower incidence of vasovagal reaction. A higher satisfaction rate was observed with normal saline.

Here, in this study as shown in [Table 7] of 40 patients of AUB, only 3 patients were found to have normal endometrium and uterine cavity on hysteroscopy and these findings were confirmed by histopath. These findings were close to final diagnosis of the same 40 patients of AUBas on final diagnosis all 40 patients were having pathology in endometrium and uterine cavity.

In this study, we found 13 endometrial hyperplasia, 10 fibroid, 8 polyps, and 1 endometrial atrophy cases in hysteroscopy as shown in [Table 5]. The study of El-Khayat et al.[7] concerning AUB in the age group of 20–60 years recruited 50 patients, predominance of endometrial hyperplasia with a frequency of 24%, followed by polyps in 10% of cases, myomas in 4% of cases and atrophy in 2% of cases were seen on hysteroscopy. These results correspond to those of our study, with a frequency of endometrial hyperplasia in 32.5%, followed by fibroid in 25% of cases, polyps in 20% of cases and endometrial atrophy in only 2.5% of cases.{Table 5}

Out of 40 cases there were 13 cases of endometrial hyperplasia on hysteroscopy in which the endometrium appeared to be undulating, edematous and thickened. These findings were consistent with histology of hysteroscopically guided curettage in 12 cases. Diagnostic accuracy was found to be 100% considering the final diagnosis of these 13 patients.

Of 40 patients in 8 patients small growth in the uterine cavity were seen on hysteroscopy. These growths appeared as endometrial polyps which were further confirmed by histopath. Considering the final diagnosis diagnostic accuracy was 100%. In 1 patient, the endometrium appeared fragile, thin, and flat. The tubal ostia were very prominent. At some points, petechiae and hemorrhages were seen. The picture was suggestive of atrophic endometrium which was further confirmed by histopath.

Forty patients underwent conventional D&C and endometrial tissue was sent for histopathological diagnosis. Since conventional D&C is a blind procedure its result mainly depends on its histopath report. Histopath report is shown in [Table 6]. It was found that of 40 patients, 19 patients had normal endometrium but on the final diagnosis of these patients only 13 patients had normal endometrium. Hence, this conventional D&C procedure has misdiagnosed 4 cases of AUB. In 3 cases, endometrium was not obtained, but in hysteroscopic guided curettage, there was not a single case, in which endometrium was not obtained.{Table 6}

As shown in [Table 8], the histopath report of conventional D&C group and hysteroscopically guided curettage group were compared. It was seen that simple hyperplasia with atypia was not seen in any patient of conventional D&C group where as seen in two patients of hysteroscopically guided curettage group. Complex hyperplasia without atypia was seen in only 1 patient of conventional D&C group whereas in 4 patients of hysteroscopically guided curettage group. Endometrial polyp was seen in 2 patients inconventional D&C group, while on hysteroscopic guided curettage group 8 patients of endometrial polyp were found, which was confirmed on histopath. Endometrium proliferative phase was seen in 16 patients of hysteroscopic guided curettage group, but only in 8 patients of conventional D&C group. Secretory phase was seen in 19 patients of conventional D&C group, but only in 3 patients of hysteroscopic guided curettage group. All of these findings were significant.{Table 7}{Table 8}

In three cases of conventional D&C group, endometrium was not obtained, so no histopath report came, but in hysteroscopy guided curettage group, endometrium of every patient was obtained and histopath report of every patient came, this shows that in conventional D&C group, there are chances of error leading to improper diagnosis and treatment.

In conventional D&C groups of 40 patients, 47.5% of patients had normal endometrium that is more than half of patients had normal histopath reports while on the final diagnosis of these 40 patients, only 37.5% of patients were considered normal. Hence, this group showed more false-negative cases. However on hysteroscopic-guided curettage group, only three patients, i.e., 7.5% of cases showed normal endometrium on histopath and on the final diagnosis, all 40 cases were found to have varying abnormalities of the endometrium. Hence, the findings of hysteroscopic guided curettage were closer to the final diagnosis in comparison to histopath finding of conventional D&C group.

Comparing the histopath report of these two groups, overall P value was calculated by Chi-square test and it was found to be highly significant, i.e., P = 0.0009.

This shows that there is a significant difference between these two modalities of investigations in diagnosing the cause of AUB.

This significant difference has also been shown in various studies.

Like Loffer[8] evaluated 187 patients with AUB. Both procedures had a specificity of 100%, but the sensitivity of hysteroscopically guided D&C with biopsy was greater (98%) than that of conventional D&C (65%).

A study by Panda et al.[9],[10],[11],[12],[13],[14] evaluated the accuracy of hysteroscopy in evaluation of AUB pattern. The sensitivity of hysteroscopically guided D&C with biopsy was 92.5% and that of blind curettage was 83.3% in evaluating of cases with AUB.

This significant difference as shown by the above studies, and our study helps in concluding that hysteroscopic guided D&C with biopsy is superior to conventional D&C in evaluating the patients of AUB.

 Summary and Conclusions



“When there is a complaint there should be a cause” this famous dictum was given by “SIR IAN DONALD” and it is equally applicable in gynecologyThe whole aim of this study was to find the cause of abnormal bleeding by two modalities of investigations, i.e., hysteroscopic guided D&C and conventional D&C and correlated the findings to know which one is more accurate for the diagnosis of AUB. It was found that conventional D&C revealed normal findings in 47.5% of cases out of 50% of cases. This also included reports of inadequate or incorrect samples, which does not help in reaching an accurate diagnosis. It reveals pathological abnormal reports only in 2.5% of cases of 50% of cases, whereas hysteroscopic guided D&C revealed normal findings only in 7.5% of cases and pathological abnormal reports in 42.5% of cases of 50% of cases. These readings reveal that hysteroscopic guided D&C is a better mode of diagnosing the cause of AUB in most of the cases as compared to conventional D&C; hence, it would help in better diagnosis and treatment of AUBThis is in agreement with other similar studies, which also prove that hysteroscopic guided D&C is better than traditional curettage in the evaluation of AUBHysteroscopy has an indispensable advantage of direct visualization of any uterine cavity abnormality. It compliments other diagnostic procedures rather than substituting them. It is quick, reliable, safe procedure, with great potential in gynecology, well accepted by the patient, with high sensitivity, specificity, and negative predictive valueHence, it can be concluded that hysteroscopically guided D&C with biopsy has the superior ability in evaluating patients with AUB when compared to conventional D&C.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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