الفهرس 
Review of LiteratureOnly 14 pages are availabe for public view
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Abstract
Postmenopausal bleeding requires careful evaluation to detect the cause of bleeding and to exclude the possibility of malignancy among the postmenopausal women. Uterine causes of postmenopausal bleeding include atrophic endometrium, proliferative endometrium, hyperplastic
endometrium, endometrial polyps, submucous leiomyomas and endometrial carcinoma. Although fractional curettage is the gold standard
for diagnosis of such conditions, yet the procedure has certain limitations, being an invasive procedure, requires hospitalization and general anaesthesia, together with the possibility of missing intrauterine
pathological lesions.
Diagnostic pelvic ultrasound is a good method for evaluation of endometrial thickness and morphology in menstruating women as well as in postmenopausal women. Initially transabdominal ultrasound was used for detection of these changes but with the introduction of high frequency transvaginal sonography, the endometrium can be clearly visualized as it produces a clear uterine image because of the proximity of the vaginal probe to the uterus. Also pelvic ultrasound can detect other uterine or adnexal abnormalities. In the menopause, the endometrium becomes atrophic and appears with transvaginal sonography as thin, hypoechoic, regular layer. Proliferative endometrium appears as a thick, isoechoic layer and a multilayered appearance may be detected. Endometrial hyperplasia
appears as well defined, thick, highly reflective layer occupying the whole
uterine cavity. The presence of enlarged uterine cavity, irregular
intrauterine echoes, high intensity echoes, in addition to thickened
endometrium are suspicious to the presence of endometrial carcinoma.
Endometrial polyps appear as local thickening of the endometritun
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surrounded by a symmetrical low amplitude echo. Submucous leiomyomas have a variety of appearances from hypoechoic to hyperechoic with a
calcified border.
Hysteroscopic inspection of the uterine cavity offers another simple
outpatient method to investigate uterine, endometrial or endocervical pathology. Although tissue biopsy allows histological confirmation of the
diagnosis in patients with abnormal bleeding, random sampling of the
endometrium had the possibility of error if the lesion is small or inaccessible.
Senile endometrial atrophy, appears hysteroscopically as thin, pale, yellow in colour and the underlying blood vessels could be visualized. Proliferative endometrium appears smooth, white to yellow in colour and the pores of the glands are visible and regularly situated. Hyperplastic endometrium appears as heaped up endometrium all over the cavity or scattered irregularly. The colour varies as does the thickness. The vascularity is increased and bleeding occurs easily if the operator is rough. Endometrial polyps could be directly, visualized by the hysteroscope and their size, shape and number could be accurately identified. Submucous leiomyomas differ from polyps by being more firmer, fixed and do not move in response to pressure of the distending medium. Endometrial
carcinoma appears hysteroscopically as a lesion that shows a frank dimply
appearance with irregular polypoid growing edges. The lesion can be
friable, partially necrotic or haemorrhagic.
The aim of the present study was to assess the value of both transvaginal sonography and hysteroscopy in the detection of endometrial
abnormalities in postmenopausal women.
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The study had been conducted on 80 postmenopausal women and
the cases were grouped in two groups :
-Group A : included 50 patients with postmenopausal bleeding.
-Group B : included 30 cases of postmenopausal women with any complaint other than bleeding.
All cases were one year or more after the last menstrual period and
all of them were subjected to full history taking, clinical examination,
transvagirial sonography, hysteroscopy and lastly dilatation and curettage.
In both groups collectively (80 cases), the following histopathological findings were detected : Atrophic endometrium in 44 cases (55%), proliferative endometrium in 4 cases (5%), endometrial hyperplasia in 29 cases (36.2 %), endometrial polyps in 9 cases (11.3%), submucous leiomyomas in 4 cases (5%) and endometrial carcinoma in 3 cases (3.8%). However, atrophic endometrium was found in 20 cases (40%) of group A and 24 cases (80%) of group B. Endometrial hyperplasia was found in 23 cases (46%) of group A and 6 cases (20%) of group B. Proliferative endometrium, endometrial polyps, submucous leiomyomas and endometrial carcinoma were found only in group A.
The use of 5 mm cut-off value for endometrial thickness measured by transvaginal sonography showed that 23 out of 24 cases of endometrial atrophy in group B were positively diagnosed with one false negative case giving this technique a sensitivity of 95.8% and specificity of 100%. Also in group B, there were 6 cases of endometrial hyperplasia (20 % of cases) and all of them were correctly identified by transvaginal ultrasonograPhy with a sensitivity of 100% and specificity of 95.8%. This proves the value
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of transvaginal sonography as a screening, non invasive method in postmenopausal women.
The diagnosis of endometrial hyperplasia by transvaginal sonography in group A matched with histopathology in all cases with 3 false positive cases, giving the transvaginal sonography a sensitivity of 100%, specificity of 88,9% and accuracy of 94%.
The diagnosis of proliferative endometrium by transvaginal sonography was matched with histopathology in 3 out of 4 cases, giving this technique a sensitivity of 75%, specificity of 100% and accuracy of
98%.
In the present study 3 cases of endometrial carcinoma were diagnosed by histopathology. In all of them, transvaginal sonography showed endometrial abnormalities which were highly suggestive of endometrial carcinoma. This gives the vaginal ultrasonography a sensitivity and specificity of 100% in diagnosis of endometrial carcinoma.
In this study, hysteroscopic diagnosis of endometrial atrophy in group B matched with the histopathology in 21 out of 24 cases, giving this technique a sensitivity of 87.5% and specificity of 100%. On the other hand, the sensitivity of hysteroscopy in the diagnosis of endometrial hyperplasia in group B was 100% and the specificity was 87.5% and this shows the value of hysteroscopy as a screening method in this group of
women.
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In group A, the sensitivity of hysteroscopy in the diagnosis of endometrial atrophy was 90%, specificity was 100% and the accuracy was
96%.
Ilysteroscopic findings in the 23 cases of endometrial hyperplasia in
group A matched with histopathology in all of the cases with a sensitivity
of 100%, specificity of 88.9% and accuracy of 94%. In all 3 cases of
endometrial carcinoma encountered in this study, the sensitivity and
specificity ’of hysteroscopy were 100%.
As regard submucous leiomyomas encountered in group A, both transvaginal sonography and hysteroscopy had a sensitivity and specificity
of 100%.
It had been shown in this study that hysteroscopy had a superiority over transvaginal ultrasound in the diagnosis of endometrial polyps, as hysteroscopy had a sensitivity of 100% and specificity of 97.6% while transvaginal ultrasound had a sensitivity of 55.6% and specificity of
97.6%.
The validity of transvaginal ultrasound in diagnosis of various endometrial patterns and lesions in all cases (80) : In cases of atrophic endometrium, it had a sensitivity of 90.9%, specificity of 97.2% and accuracy of 93.8%. In cases of proliferative endometrium it had a sensitivity of 75%, specificity of 100% and accuracy of 98.8%. In cases of endometrial hyperplasia, the sensitivity was 100%, specificity was 92.2% and accuracy was 95%. By transvaginal ultrasonograPhy we could not differentiate between different types of endometrial hyperplasia. In cases of endometrial carcinoma, the sensitivity and specificity were 100%. As
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regard endometrial polyps, it had a sensitivity of 55.6%, specificity Of 98.6% and accuracy of 93.8%. In cases of submucous leiomyomas,
vaginal ultrasound had a sensitivity and specificity of 100%.
The validity of hysteroscopy in the diagnosis of various endometrial
patterns and lesions in all cases (80) : In cases of atrophic endometrium, it had a sensitivity of 88.6%, specificity of 100% and accuracy of 93.8%. In
cases of proliferative endometrium, it had a sensitivity of 75%, specificity
of 100% ’ and accuracy of 98.8%. In cases of endometrial hyperplasia, the sensitivity was 100% and specificity was 88.2%. As regard endometrial carcinoma and submucous leiomyomas, both sensitivity and specificity were 100%. In cases of endometrial polyps, hysteroscopy had a sensitivity of 100%, specificity of 98.6% and accuracy of 98.8%.
As the 3 cases of endometrial carcinoma (group A) had endometrial thickness greater than 10 mm and the false positive case of endometrial atrophy with endometrial thickness less than 5 mm proved by histopathology to be proliferative endometrium. Thus vaginal ultrasonography can be used as a simple, non invasive method to exclude endometrial carcinoma in patients with postmenopausal bleeding when
endometrial thickness is 5 mm or less.
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CONCLUSION
Based on the previous studies and the results of this study, it can be
concluded that :
- Transvaginal sonography is a fairly simple, non invasive technique
that can be used in the diagnosis of endometrial abnormalities in
postmenopausal women. With high frequency transvaginal sonography, the
endometrium can be easily visualized and its thickness could be measured.
- In postmenopausal women with bleeding having endometrial thickness of 5 mm or less, transvaginal sonography could Le a mita e method to detect endometrial atrophy and to exclude endometrial carcinoma. When endometrial thickness is more than 5 mm, endometrial abnormalities are to be expected with a recommendation of the use of another diagnostic complementary method as hysteroscopy and
histopathology to establish the diagnosis.
- In postmenopausal women without bleeding, transvaginal
sonography is an excellent screening non invasive method with high sensitivity and specificity values using 5 mm endometrial thickness cut-off
value.
- The use of both transvaginal sonography and hysteroscopy in
postmenopausal women with bleeding is not a substitute for fractional curettage in cases with endometrial thickness more than 5 mm or whenever they give a picture suggestive of endometrial hyperplasia or
carcinoma.
- Panoramic hysteroscopy inspection of uterine cavity offers an
accurate method to investigate endometrial pathology with high sensitivity and specificity values. Moreover, it could be an excellent guide for the.