Does Hysteroscopy Improve the Sensitivity of D&C in Endometrial Hyperplasia or Carcinoma Diagnosis?
ABSTRACT & COMMENTARY
Synopsis: Hysteroscopy does not improve the sensitivity of dilatation and curettage in the diagnosis of endometrial hyperplasia or carcinoma.
Source: Ben-Yehuda OM, et al. Gynecol Oncol 1998; 68:4-7.
Despite a complete lack of prospective, randomized studies suggesting that hysteroscopy is a useful tool in the diagnosis of endometrial hyperplasia or endometrial carcinoma, many clinicians believe that it has been demonstrated to be helpful for these diagnoses. Indeed, in some places, hysteroscopy ± endometrial biopsy has supplanted dilatation and curettage (D&C) as the method of choice of evaluating abnormal uterine bleeding. The purpose of this study was to determine, by retrospective review of charts, whether hysteroscopy improves the sensitivity of D&C.
Three hundred seventy-three combined hysteroscopic and D&C procedures were reviewed. All women had a diagnosis of abnormal uterine bleeding. Twenty percent of the patients had endometrial sampling within the previous year. Ben-Yehuda and associates used the tissue diagnosis from D&C, but, since hysteroscopic biopsies were not obtained (because a D&C was going to be performed), the hysteroscopic "impression" was used. Ben-Yehuda et al used a liberal definition of "hyperplasia" for an impression of hyperplasia by hysteroscopy. That is, a polyp identified by hysteroscopy placed the hysteroscopy in the hyperplasia category.
Overall, hysteroscopy was a poor predictor of the presence of uterine hyperplasia or endometrial cancer. (See Table.) Only two of the 10 cases of endometrial carcinoma were identified by hysteroscopy; only half of the cases of endometrial hyperplasia were identified by hysteroscopy. Hysteroscopy was more accurate in the identification of endometrial polyps, but only half of the cases of polyps identified by D&C were seen on hysteroscopy. Ben-Yehuda et al conclude that hysteroscopy is not a useful adjunct in the diagnosis of endometrial hyperplasia or carcinoma.
Dilatation and Curettage
COMMENT BY KENNETH NOLLER, MD
Hysteroscopy is a useful clinical tool. Nothing else is capable of diagnosing endometrial polyps with great certainty or is as accurate in the diagnosis of submucosal myomas. Hysteroscopy has also been used to diagnose endometrial carcinoma.
However, there is no article in the world literature that supports, in a convincing manner, the use of hysteroscopy as an accurate tool for the diagnosis of endometrial adenocarcinoma or atypical hyperplasia. Despite this lack of supporting data and with the availability of office hysteroscopy, more and more clinicians are using the technique (often without office biopsy) to "rule out" endometrial neoplasia.
How do we clinicians get duped into believing that a technique is useful when there are no data to support it? In the OB/GYN field, there are many examples of such procedures: Electronic fetal heart rate monitoring in low-risk pregnancy, home uterine monitoring, vaginal cytology after hysterectomy for benign disease, and the use of CA125 as a screening tool for ovarian cancer.
While some of these examples might eventually be shown to be clinically efficacious, for the time being, the data to support their use are lacking. The same is true for the use of hysteroscopy to diagnose endometrial hyperplasia and cancer. This article suggests that hysteroscopy is not useful for these diagnoses.
Some day, we will have a prospective trial comparing hysteroscopy to D&C in patients who are undergoing hysterectomy, and we will then know both how accurate D&C is, and whether hysteroscopy is useful for the detection of neoplasia. The study would require large numbers of patients, but the results would be definitive. Until then, we should continue to use tissue diagnosis as the "gold standard" for the diagnosis of uterine neoplasia and reserve the use of hysteroscopy for the identification of polyps, myomas, and intrauterine defects.