A Randomised Controlled Trial Comparing Transvaginal Ultrasound, Outpatient Hysteroscopy and Endometrial Biopsy With Inpatient Hysteroscopy and Curettage

Abstract

Most women with abnormal uterine bleeding are admitted to day surgery for hysteroscopy and curettage. This study was undertaken to compare this practice with one in which patients with abnormal uterine bleeding are evaluated entirely with outpatient procedures. Four hundred women with abnormal uterine bleeding were recruited from the gynecologic clinic to participate in the trial. They were randomly assigned to one of two groups. Group 1 was the inpatient group, and patients underwent examination, followed by hysteroscopy and curettage, in day surgery under light anesthesia. Group 2 patients were treated as outpatients and underwent vaginal ultrasound, followed by outpatient hysteroscopy and Pipelle endometrial biopsy. The outpatients did not have any preoperative systemic analgesia but were given a paracervical block or intracervical injections of 5 to 10 ml of 1 percent lignocaine for the procedure. The women were an average of 43 years of age. Indications for treatment were similar in both groups. Forty-one percent had menorrhagia, 31 percent had postmenopausal bleeding, 17 percent had irregular periods, and 12 percent had intermenstrual or postcoital bleeding. Hysteroscopy could not be performed in seven women in the outpatient group because the hysteroscope could not be inserted. Pipelle biopsy could be performed in five of these seven women, and all 200 underwent transvaginal sonography. The two women in whom no biopsy was performed underwent normal sonography. In each group, normal endometrium was diagnosed in one-half of patients, and fibroid tumors were found in one-fourth. Thirty-one inpatients and 26 outpatients were diagnosed with polyps, and 17 inpatients and 15 outpatients had atrophic lesions. Hyperplasia of the endometrium was found in one inpatient and two outpatients. Carcinoma was diagnosed in six inpatients and five outpatients. On hysteroscopy, four cancerous lesions were found in each group. Two carcinomas and one hyperplasia were not identified during inpatient hysteroscopy under anesthesia; in the outpatient group, one carcinoma and two hyperplasias were missed by hysteroscopy. In the outpatient group, transvaginal sonography and Pipelle sampling failed to diagnose 14 benign lesions that were seen at hysteroscopy. However, one carcinoma and two hyperplasias missed by hysteroscopy were detected with the combination of sonography and Pipelle sampling. Because of the large number of benign lesions that were identified only by hysteroscopy, the total number of pathologic abnormalities detected by hysteroscopy was significantly greater than the number diagnosed by a combination of sonography and biopsy (P = .0076). The quality of the biopsy specimens was similar in both groups. Patient satisfaction, as measured by a postprocedure questionnaire, showed that both procedures were well tolerated and accepted. Br J Obstet Gynaecol 1999;106:1259–1264