Hysteroscopy or Curettage?

Abstract

Endometrial curettage has long been used to obtain tissue for histological examination in women after the menopause in order to make a diagnosis and exclude pre-malignant and malignant disease. In recent times, office-based, miniature endometrial biopsy devices have largely replaced formal curettage because they are more convenient and are considered to have comparable levels of accuracy. In contrast to blind endometrial sampling, hysteroscopy allows visualisation within the uterine cavity and can facilitate the taking of directed biopsies. Technological advances in endoscopic equipment have shifted hysteroscopy from an inpatient endeavour in anaesthetised women to a convenient, safe and highly feasible office setting. Thus, the threshold for undertaking hysteroscopy has been reduced such that hysteroscopy could potentially replace the need for blind endometrial sampling. Although hysteroscopy is more successful than blind endometrial biopsy, its accuracy, especially in diagnosing endometrial hyperplasia and cancer, has conventionally been considered to be equivalent. Recent data however, challenge this prevailing view. Focal pathologies such as polyps, myomas and endometrial hyperplasia/cancer can be missed without direct visualisation provided by hysteroscopy. Thus, the ability of blind sampling to exclude serious endometrial disease appears to be much lower than previously appreciated. Thus, further testing utilising hysteroscopy for focal intra-cavity pathology in women with a failed, insufficient or benign result of endometrial sampling seems warranted. The role of office hysteroscopy in the diagnostic workup of women presenting with postmenopausal bleeding needs to be re-evaluated. Effectiveness and cost-effectiveness studies should take account of these new data, and practice guidelines should be updated accordingly.