A Prospective study for the correlation of diagnostic accuracy of transvaginal ultrasonogram with sonohysterography and hysteroscopy for the screening of intracavitary pathologies in women with abnormal uterine bleeding

INTRODUCTION: Abnormal uterine bleeding is a common women’s health disorder, affects 20% of reproductive age women. Diagnostic evaluations and treatment modalities for abnormal uterine bleeding are rapidly evolving the diagnostic ones in abnormal uterine bleeding is to exclude endometrial hyperplasia and endometrial carcinoma. Sonohysterography and even diagnostic hysteroscopy with direct visualization cannot reliably diagnose a malignancy without tissue biopsy. Therefore, the gold standard for diagnosis of endometrial hyperplasia or carcinoma is tissue biopsy either blind endometrial biopsy or directed endometrial biopsy done after sonohysteroscopy or diagnostic hysteroscopy. Blind endometrial biopsy with transvaginal ultrasound is the most readily available technique but the increasing availability of sonohysterography allows more specific anatomical endometrium detail and can diagnose endometrial polyps. The echogenicity of the endometrium has certain characteristics during various phases of the menstrual cycle, thus enabling the histology to be evaluated with precision by examining with transvaginal sonogram during the early proliferative phase the endometrial thickness is 2-4mm. Endometrium functionalis is hypoechoic or isoechoic and endometrium basalis echogenic. AIM OF THE STUDY: To evaluate the diagnostic accuracy of transvaginal ultrasonogram with sonohysterography and hysteroscopy for the screening of intracavitary pathologies in women with abnormal uterine bleeding and to correlate the findings with the histopathological specimens of the endometrium obtained by dilation and curettage or hysterectomy. MATERIALS AND METHODS: The study included 200 women who had come to the Institute of Social Obstetrics and Government Kasturba Gandhi hospital with complaints of abnormal uterine bleeding were selected, admitted and subjected for transvaginal ultrasonogram followed by sonohysterography using saline instilled through an endocervically placed catheter in sequence of the same day of admission. 24 hours later diagnostic hysteroscopy was performed under intravenous sedation and endometrial tissue collected for histology by D&C/directed biopsies. This is prospective one year study conducted September 2010 to August 2011 and the study was conducted in our hospital after getting approval from the ethical committee of Madras Medical College. PATIENT SELECTION: Inclusion Criteria: • Only parous women of age 25years to 45 years, • No demonstratable pelvic pathology, • Not on hormonal therapy, • No evidence of haematological disorder/medical illness/surgical complications so as to avoid any anaesthetic or surgical risk during hysteroscopy. Exclusion Criteria: • Nulliparous women, • Age more than 45 years, • Post menopausal bleeding, • Associated adnexal, pelvic pathologies like fibroid uterus, • IUCD in situ, • History of PID, endometriosis, tuberculosis, • Severe anaemia due to AUB requiring immediate ICU care, SUMMARY: This is a prospective study to evaluate the diagnostic accuracy of transvaginal ultrasonogram with sonohysterography and hysteroscopy for the screening of intracavitary pathologies in women with abnormal uterine bleeding and to correlate the findings with the histopathological specimens of the endometrium obtained by dilation and curettage or hysterectomy conducted at ISO-KGH, Chennai. Study period was 1 year September 2010 to August 2011. The study included 200 women who had come to the Institute of Social Obstetrics and Government Kasturba Gandhi hospital with complaints of abnormal uterine bleeding were selected, admitted and subjected for transvaginal ultrasonogram followed by sonohysteroography using saline instilled through an endocervically placed catheter in sequence of the same day of admission. 24 hours later diagnostic hysteroscopy was performed under intravenous sedation and endometrial tissue collected for histology by D&C/directed biopsies .Among the 200 patients in the study group 91 patients underwent hysterectomy (i.e) those patients who had abnormal findings in the above investigations and also for patients with h/o long standing AUB not ready for regular follow up. who wanted hysterectomy. The findings of TVS, SIS and hysteroscopy were correlated with hysterectomy which is considered the gold standard and the diagnostic accuracy of individual tests was evaluated. CONCLUSION: Among the 200 patientswith AUB in our study group, abnormal findings was found in the mean age group of 41 years. • Mean duration of complaint among the patients with abnormal findings was 7 months in our study. • In our study ,TVS detected 92% abnormalities whereas 17% false negative results were found comparing with gold standard hysterectomy. • SIS detected 96% abnormalities and13% false negative which is better than that of the TVS. • Hysteroscopy showed high positive predictive value 98% however the false negativity was 20% in our study. suggesting SIS as a better modality than the other two investigations. • Hysteroscopy had high positive predictive value 98% but sensitivity was low 86% and diagnostic accuracy 90%.. • SIS has highest diagnostic accuracy 92% and negative predictive value 86%.this concludes that there is an improved demonstration of endometrial polyps and submucousmyomas using saline enhanced vaginal sonohysterography