| BackgroundAbnormal uterine bleeding(AUB) in perimenopausal women refers to abnormal uterine bleeding that occurs due to the gradual decline in the ovarian function during menopausal transition. Abnormal uterine bleeding during menopausal transition is a common clinical symptom. As a normal physiological change, ovarian function in perimenopausal women decline, estrogen levels decrease, leading to change in endocrine balance and appearance of clinical symptoms. Perimenopause generally refers to women from the age of 45 or to period of 12 months after the menopause. Abnormal uterine bleeding is a common clinical symptom, clinically manifesting as decreased amount of menstrual blood loss, menorrhagia, shortened the menstrual cycle, oligomenorrhoea, irregular bleeding and other symptoms. The cause of the menopausal transition bleeding is complex, most of the perimenopausal AUB is due to anovulation, other common causes are: endometrial lesions, such as: endometritis, endometrial polyp, endometrial hyperplasia, endometrial cancer, endometrial atrophy, submucosal uterine myoma.Other causes of AUB include coagulant function abnormality, and other related diseases caused by iatrogenic reasons. Due to the complex etiology, although the diagnosis of the cause of AUB possesses difficulty it is important to find the cause of AUB in order to provide appropriate treatment method.Traditionally diagnostic curettage(diagnostic dilatation and curettage, D&C) was considered "gold standard" for management of AUB. However, D&C usually miss a lot of focal lesions in the uterine cavity. Many studies have shown that the misdiagnosis rate of D&C up to 3/10, but also has a certain percentage of false negative rate. In the popularization and application of ultrasonic diagnostic apparatus, the definition of ultrasound image has been continuously improved, and the application and development of the transvaginal ultrasound(TVS) examination method has also been continuous, and the detection rate of endometrial lesions has been improved greatly. In transvaginal ultrasound examination method, the distance between probe and vaginal fornix is very near and there are less disturbances. Therefore, image is clear. Endometrial lesions can be seen very clearly and there is better determination of the relationship between the uterus and adjacent organs. Vaginal B ultrasound is simple and easy to operate, nontraumatic and can be repeated. Therefore, the transvaginal B ultrasound examination method has gained more popularity in the Department of Gynaecology currently, however, the specificity of the test method is not high.Hysteroscopy technology can directly detect the endometrial lesions, enables to perform endometrial biopsy under direct vision and can clearly reflect the morphology, location, size, blood vessels supply and so on. It helps to prevent blind curettage which can result in adverse consequences such as misdiagnosis leading to increased missed diagnosis which has significant impact on the diagnostic accuracy rate. Based on this, it can be said that the histopathological examination of suspected lesions can be used as the gold standard for diagnosis of AUB. However, hysteroscopy cannot determine the status of myometrium, such as the extent of the invasion of the wall by endometrial cancer. In addition, hysteroscopy is a morphological examination, which cannot be completely replaced by pathological examination. Therefore, in theory, there is a certain rate of missed diagnosis. Comprehensive domestic and foreign literature, hysteroscopy can be a better diagnose intrauterine lesions such as uterine submucosal myoma, endometrial cancer, endometrial polyps, retained product of conception, intrauterine device. The exploration of the nature of the endometrial changes, especially when the lesion is non-space occupying and the position is not significant, such as endometrial hyperplasia diagnosis cannot be made. Only after histopathological examination, can the diagnosis of suspicious lesions taken from the site under the direct vision of hysteroscopy be confirmed. It should be noted that hysteroscopy may cause trauma to patients, and the cost of the examination is relatively low.At present, for the diagnosis of etiology of AUB in the menopausal transition the preferred method should be an ultrasound examination, transvaginal ultrasound can be used for early screening examination, and if necessary proceed to hysteroscopy. At present, the research on clinical significance of the transvaginal ultrasonography and hysteroscopy examination and the application in the perimenopausal AUB diagnosis is relatively small, there is small sample sizes and lack of randomized controlled trials.Objective To explore the clinical value of hysteroscopy combined with transvaginal ultrasound in the diagnosis of perimenopausal abnormal uterine bleeding, to perform retrospective analysis of the clinical characteristics of perimenopausal abnormal uterine bleeding and to provide a scientific basis for early diagnosis and treatment of perimenopausal abnormal uterine bleeding.Methods1 MaterialsThe patients with abnormal uterine bleeding perimenopausal treated in the Second People's Hospital of Henan Province from October 2011 to October 2015 were selected as the research objects. Collected from the medical records, accepted vaginal ultrasound screening out, hysteroscopy examination and postoperative pathological inspectors medical records, in 356 cases. To pathological diagnosis as the gold standard of diagnosis, comparison analysis of transvaginal ultrasonography and hysteroscopy two findings and pathological diagnosis results, using SPSS19.0 statistical software for clinical research data processing and analysis, summarize the hysteroscopy combined transvaginal ultrasound clinical value of the cause of abnormal uterine bleeding perimenopausal.2 MethodsFrom October 2011 to October 2015, the Second People's Hospital of Henan Province, Department of gynaecology and obstetrics of abnormal uterine bleeding perimenopausal in patients with clinical data from collected medical screening underwent ultrasonography and hysteroscopy surgery and pathological examination of medical records were 356 cases,to pathologically diagnosed as broken as a result of the gold standard in the diagnosis, comparison and analysis of transvaginal sonography and hysteroscopy two examination results and the results of pathological diagnosis, processing and analysis results to clinical study data using SPSS 19.0 statistical software, hysteroscopy and transvaginal ultrasound examination of the clinical value of abnormal uterine bleeding due to the summary.ResultsTransvaginal ultrasound in perimenopausal AUB patients showed intrauterine lesions in 252 cases, normal endometrium in 106 cases, histopathologic confirmation was done in 248 patients with intrauterine abnormalities. In 102 cases with TVS diagnosis of intrauterine membrane polyp, 73 cases was confirmed by pathology, coincidence rate was 71.57%. Out of 13 cases with TVS diagnosis of submucosal uterine fibroids, 9 cases had confirmed histopathological diagnosis corresponding to coincidence rate of 69.23%. TVS diagnosis of intrauterine mass lesion in 17 cases, had the histopathologic diagnosis of atypical endometrial hyperplasia / endometrial carcinoma with coincidence rate of 47.06%. TVS diagnosis of endometrial atrophy(19 cases) was confirmed in 16 cases, the coincidence rate being 84.21%. TVS diagnosis of 106 cases of normal endometrium, with histopathologic diagnosis of proliferation/secretory endometrium in 78 cases, coincidence rate was 73.58%.Hysteroscopy examination revealed 89 cases of patients with endometrial polyps, 82 of which had histopathologic confirmation, coincidence rate being 92.13%. Out 19 cases with hysteroscopy diagnosis of endometrial cancer, pathology confirmed 18 cases. Out of 23 cases of patients with hysteroscopy diagnosis of submucosal uterine fibroids, all confirmed by pathology, coincidence rate was 100%. Out of 57 cases with hysteroscopy diagnosis of normal endometrium, all were confirmed by pathology, coincidence rate was 100%. Out of 96 cases with hysteroscopy diagnosis of endometritis, pathology was confirmed in 38 cases,coincidence rate was 39.58%. Out of 49 cases with hysteroscopy diagnosis of endometrial hyperplasia, 38 cases were confirmed by pathology, coincidence rate was 77.55%.Hysteroscopy examination of endometrial polyps(EP) revealed sensitivity of 98.79%, specificity of 97.44%, positive predictive value of 92.13% and negative predictive value of 99.63%. Transvaginal ultrasound diagnosis of intrauterine lesions had the sensitivity of 87.24%, specificity of 89.38%, positive predictive value 71.57% and negative predictive value of 96.06%. In the diagnosis of endometrial polyps the comparison of the sensitivity, specificity, and negative predictive value of hysteroscopy examination and transvaginal ultrasound revealed statistical significance(P < 0.05). Out of in 89 patients with diagnosis of endometrial polyps by hysteroscopy, 82 cases were confirmed by pathology. Out of 87 cases with TVS hysteroscopy and diagnosis of endometrial polyps, 83 cases were confirmed by pathology. The coincidence rate of hysteroscopy diagnosis and pathologic diagnosis of EP was 92.13%(82/89). With hysteroscopy combined ultrasonic diagnosis the coincidence rate for EP was 95.41%(83/87), comparing coincidence rate between the two groups the similarity showed statistical significance(P < 0.05).Hysteroscopy examination of endometrial hyperplasia had coincidence rate of 77.55%, the TVS diagnosis of endometrial hyperplasia had coincidence rate of 38%, the difference between the two groups was statistically significant(P < 0.05). Hysteroscopy diagnosis of submucosal uterine fibroids had coincidence rate of 100%, transvaginal ultrasound diagnosis of submucosal uterine fibroids had coincidence rate of 69.23%, the difference was statistically significant(P < 0.05).Sensitivity of TVS in diagnosis of endometrial polyps, submucous myoma, endometrial hyperplasia and normal endometrium was 87.95%, 37.5%, 71.7% and 37.5% respectively, and that for hysteroscopy was 98.8%,100%, 57.58% and 100% respectively. After comparative analysis, the data in the hysteroscopy and TVS examination the palace cavity lesions, in the comparison of the endometrial polyps and submucous uterine myoma and the sensitivity of the normal endometrium difference has significant difference(P < 0.05).Hysteroscopy diagnosis of EP and pathology results had the coincidence rate of 92.13%, hysteroscopy combined ultrasonic diagnosis of EP and pathology results had the coincidence rate of 95.41%. Of 76 cases with hysteroscopy diagnosis of endometrial hyperplasia, confirmation by pathology was found in 36 cases, coincidence rate was 47.37%. Hysteroscopy combined TVS diagnosis of endometrial hyperplasia and pathology results had the coincidence rate of 58.06%. Of 96 cases with hysteroscopy diagnosis of endometritis, 41 cases were confirmed by pathology, coincidence rate was 74.19%. Hysteroscopy combined TVS diagnosis of endometritis and pathology results had the coincidence rate of 58.06%. Compared the coincidence rates, the difference had statistical significance(P < 0.05).Conclusions1. In the diagnosis of the cause of abnormal uterine bleeding in perimenopausal women, compared with transvaginal ultrasound diagnosis, hysteroscopy demonstrated relatively high sensitivity and specificity.2. Hysteroscopy examination and transvaginal ultrasound each has its advantages, and there is a complementary relationship. Hysteroscopy examination and transvaginal ultrasound combination for abnormal uterine bleeding in perimenopausal has good diagnostic value.. |
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