Abnormal uterine bleeding: the importance of uterine cavity visualization

Abstract

Abnormal uterine bleeding is a common gynaecological problem. It is usually due to local pathology such as uterine myoma, endometrial polyp, or to anovulatory bleeding. Occasionally, it is a manifestation of a systemic disease. In this issue of Human Reproduction Update, Livingstone and Fraser discuss the mechanism of abnormal uterine bleeding. They correctly state that there are many causes of abnormal uterine bleeding and that its mechanism is complex. Abbott and Garry discuss the treatment of abnormal uterine bleeding. They imply that the success rate of medical treatment is inferior to that of surgical treatment. One of the accepted surgical treatments is endometrial ablation. If the first generation endometrial ablation is done under hysteroscopic control, some of the second generation techniques including the balloon technique, microwave endometrial ablation and others are performed blindly. These are acceptable techniques, providing a hysteroscopic evaluation of the uterine cavity is incorporated. Anecdotally, myself and others have encountered a suspicious lesion just prior to an endometrial ablation that turned out to be endometrial cancer. This underscores the importance of visualization of the endometrial cavity prior to endometrial ablation. Without hysteroscopy, it is also difficult to ascertain the completeness of the ablation. Hysteroscopy is a powerful and yet simple technique to perform. I recommend hysteroscopy examination before and after non-hysteroscopic endometrial ablation. Missed intact endometrium after ablation can then be removed. This is in disagreement with some that promote ‘office endometrial ablation’ without any visualization of the uterine cavity. Performing the procedure blindly is equivalent to returning to the old era of missing endometrial lesions with blind curettage. Approximately 10‐15% of women require another surgery following endometrial ablation. Women with uterine myoma or adenomyosis tend to be in the ablation-failure group. Here, either uterine artery embolization or hysterectomy can be offered. Because the underlying pathology is above the cervix, a laparoscopic supracervical hysterectomy is a viable option. I hope that the papers contained in this issue will provoke more research on the subject and will assist readers in the management of women with abnormal uterine bleeding.