The Diagnostic Value Of Transvaginal Sonography And Hysteroscopy To The Etiological Factors Of Abnormal Uterine Bleeding In Perimenopausal Period

Perimenopausal period is a necessary phase that women must go throughfrom child-bearing period to senectitude. It includes the time from approachingmenopause, appearing some endocrine, biological and clinical feature to oneyear after the last menstruation. The period usually begins when women areabout forty years old, and the time is possibly long or short. About seventypercents of the reasons that women in perimenopausal period visit thedepartment of gynecology and obstetrics, relate to abnormal uterine bleeding.Because of the deterioration of ovaries, progestogen begins to taper and estrogenbegins to wave when women enter perimenopausal period. This phenomenoninduces some innocent or malignant lesions, which cause abnormal uterinebleeding of perimenopausal period. The intrauterine pathological changes ofabnormal uterine bleeding include endometrial hyperplasia, endometrial polyps,submucous myoma of uterus, endometrial cancer and so on. Because orthodoxdiagnostic curettage usually leads to omit 10%-35% of intrauterine pathologicalchanges, and pathological examination has crucial effect to the qualitation andthe choice of curative modality of diseases, the usual methods to diagnose theetiological factors of abnormal uterine bleeding are transvaginal sonographyand/or hysteroscopy connecting with pathological examination. Transvaginalsonography is the most usual examination method. Its manipulation is simpleand convenient, and it can carry out the initial screening to the etiological factorof abnormal uterine bleeding from imageological point of view. Transvaginalsonography can clear display the type of resonance, the line of uterine cavity, theblood flow, the segregate condition with muscular layer and so on. But itsaccuracy is slightly low to some affection, and it occurs missed-diagnosis andmisdiagnosis easily. From recent years, great changes have taken place in thetechnique of hysteroscopy. Under the aiming and guardianship of thetransabdominal B-ultrasound, hysteroscopy can observe and describe thelocation, quality, quantity, appearance, colour, texture and the relation tomuscular layer in full. It can diagnose the intrauterine pathological changes frommorphological point of view. Many domestic and overseas studies indicate thatthe sensitivity and accuracy are high when the intrauterine pathological changesare diagnosed by hysteroscopy. Although the forte of hysteroscopy is much, itbelongs to the traumatic examination by itself, and it is keeping dispute whetherhysteroscopy can cause dissemination and growth of cancer cell and the effect tothe prognostic condition when it is used to diagnose endometrial cancer.Because both of the examination have each forte and demerit, it has been a focalpoint at present that how to choose the reasonable and precise methods todiagnose the etiological factors of abnormal uterine bleeding.In this research, we choose two hundred and twenty-three patients ofabnormal uterine bleeding in perimenopausal period who have acceptedoperations in the department of gynecology and obstetrics of the second hospitalof Jilin university from June in 2001 to June in 2005. The age of these patientswas from 40 to 56, the average was 48.5±3.7. None of patients had accepted anyformal HRT before they were examined and treated. All patients undertooktransvaginal sonography, hysteroscopy and pathological examination afteroperation, and all results were preserved in the case files. We will carry outretrospective study through these results to analyze the diagnostic value oftransvaginal sonography and hysteroscopy to the etiological factors of abnormaluterine bleeding in perimenopausal period.To be confirmed by pathological examination after operation, there are 4normal endometria, 87 endometrial hyperplasia, 57 endometrial polyps, 52submucous myoma of uterus and 23 endometrial cancer. The final diagnosticcode is the pathological result, both transvaginal sonography and hysteroscopyhave the very high diagnostic value to the etiological factor of abnormal uterinebleeding in perimenopausal period. When we use transvaginal sonography, thehighest sensitivity is 92.93% to diagnose submucous myoma of uterus, thelowest sensitivity is 66.67% to diagnose endometrial polyps, the highestspecificity is 98.50% to diagnose endometrial cancer and the lowest specificityis 86.76% to diagnose endometrial hyperplasia. When we use hysteroscopy, thehighest sensitivity is 94.74% to diagnose endometrial polyps and the highestspecificity is 99.50% to diagnose endometrial cancer. To diagnose endometrialhyperplasia and endometrial polyps, the difference of the coincidence oftransvaginal sonography comparing with pathological examination and thecoincidence of hysteroscopy comparing with pathological examination isdistinguished (p <0.05), and hysteroscopy is better than transvaginal sonographyobviously. To diagnose submucous myoma of uterus and endometrial cancer, thedifference of two coincidence isn't distinguished (p >0.05). Through theinspection of Kappa, we find that the results of transvaginal sonography andpathological examination to diagnose endometrial hyperplasia and endometrialpolyps only have midrange concordance, and the reproducibility is the better.The results of transvaginal sonography and pathological examination todiagnose submucous myoma of uterus and endometrial cancer have highconcordance, and the reproducibility is the best. At the same time, the results ofhysteroscopy and pathological examination to diagnose all above-mentionedintrauterine pathological changes have high concordance, and the reproducibilityis the best. In addition, the concordance and the reproducibility of hysteroscopycomparing with pathological examination are better than those of transvaginalsonography comparing with pathological examination.From this research, the main etiological factors of abnormal uterinebleeding are benign lesions of uterus, endometrial hyperplasia is the mostcommon lesion, but the attack rate of endometrial cancer is also high and it hasclosed to the level of post-menopause. To diagnose the etiological factors ofabnormal uterine bleeding in perimenopausal period, both transvaginalsonography and hysteroscopy have the very high diagnostic value. Although, theconcordance and the reproducibility of hysteroscopy are better than those oftransvaginal sonography, each of two methods has its own superiority.Hysteroscopy can't take the place of transvaginal sonography, thecomplementary relation exist between them. Transvaginal sonography can bethe first step of examinations to evaluate the etiological factors of abnormaluterine bleeding in perimenopausal period. But when the ultrasonogram isabnormal or acataleptic, we must use hysteroscopy and carry out site-specificbiopsy in essential time. To analyse the results of this research, we think thattransvaginal sonography can be used to initially diagnose the etiological factorsof abnormal uterine bleeding in perimenopausal period. To suspect endometrialhyperplasia and endometrial polyps, hysteroscopy should be the next routineexamination, and site-specific biopsy or diagnostic curettage under the hint ofhysteroscopy should be used. To suspect submucous myoma of uterus,hysteroscopy still must be used when we obtain definite diagnosis hardly, whenwe need exclude other intrauterine pathological changes or when we needdetermine whether patients can be treated by hysteroscopic electrotomy. Tosuspect endometrial cancer, although many scholars consider that hysteroscopycan cause dissemination and growth of cancer cell, but it seems that theprognostic condition can't be affected. For security, we may still use diagnosticcurettage after transvaginal sonography at present. If the result of diagnosticcurettage is positive, we can diagnose endometrial cancer definitely. But if theresult of diagnostic curettage is negative because early carcinoma may exist orthe cancer focus is tiny, especially when clinical symptoms are persistent, wemust use hysteroscopy next and carry out site-specific biopsy in essential time toobtain exact pathological results to confirm or remove the diagnosis ofendometrial cancer.This research hints us that if transvaginal sonography, hysteroscopy andpathological examination can be connected together rationally to evaluateintrauterine pathological changes totally and validly from the views ofimageology, morphology and histology, we will be able to diagnose theetiological factors of abnormal uterine bleeding in perimenopausal periodexactly, provide the sufficient evidence for patients to progress the nexttreatment, and strive the curative time.