Background

Hysteroscopy is the cornerstone of modern-day outpatient endoscopic treatments in gynaecology. The first successful diagnostic and operative hysteroscopy was performed by DC Pantaleoni of Ireland, in 1869 . He used a modified cystoscope, and he reflected candlelight to examine and treat a polyp in a patient with post-menopausal bleeding (PMB). This paved the way forward for urologists and gynaecologists to develop and achieve advancements in endoscopic procedures. Charles David in 1907 was the first to describe a lens system that would allow uterine cavity visualization . Nevertheless, it was not until 1943 when the combination of a cold light source developed by Forestiere and a rod lens system developed by Professor Hopkins revolutionized uterine cavity assessment and formed the basis of modern-day outpatient and inpatient gynaecologic endoscopy.

Initially, hysteroscopy was developed as an inpatient procedure, which was done under general anaesthesia. Advances in technology and in particular miniaturization of optics have increasingly allowed both diagnostic and minor hysteroscopic surgical procedures to be performed in the outpatient setting . Outpatient hysteroscopy has been shown to be safe and acceptable to women. Research has shown that the outpatient approach is more cost-effective, and patients value the convenience of an immediate diagnosis . This allows women to be counselled about their treatment options, thus avoiding lengthy follow-up appointments. Moreover, in some cases, treatment can be started immediately in what is known as a ‘one-stop’ service. Hence, office hysteroscopy is a well-accepted, convenient, cost-effective and rapid access ‘see-and-treat’ solution for several menstrual disorders .

Menstrual disorders

Menstrual disorders are problems that affect the normal menstrual cycle, and they commonly present as abnormal uterine bleeding (AUB) ( Fig. 1 ). These are fairly common amongst women of childbearing age with a reported incidence of about 9–14%, and these can have a major impact on the quality of life, of women of all ages .

Menstrual disorders affecting women.

Although these irregularities can present as disorders of menstrual flow, timing and duration, there are several organic and non-organic causes for this disruption. The National Institute for Health and Care Excellence (NICE) describes the term as dysfunctional uterine bleeding (DUB) as AUB in the absence of organic disease .

In 2011, the International Federation of Gynecology and Obstetrics (FIGO) approved the polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified (PALM-COEIN) classification as a FIGO classification system for the purpose of standardizing nomenclature for the causes of AUB ( Fig. 2 ) . This new classification was introduced to facilitate clinicians, researchers and patients in their interaction, communication and reporting to provide clinically effective care.

FIGO classification of abnormal uterine bleeding.

It is known that AUB can affect the quality of life of the individual concerned, and it can also represent an early warning sign of uterine malignancy, especially if occurring once menopause ensues. In these cases, careful clinical evaluation and assessment for treatment is merited. Hysteroscopy allows the rapid assessment and treatment of conditions that cause AUB.

This chapter provides an overview of existing evidence and good practice in relation to the role of hysteroscopy in the diagnosis of menstrual disorders presenting as AUB in non-pregnant women.

Menstrual disorders

Menstrual disorders are problems that affect the normal menstrual cycle, and they commonly present as abnormal uterine bleeding (AUB) ( Fig. 1 ). These are fairly common amongst women of childbearing age with a reported incidence of about 9–14%, and these can have a major impact on the quality of life, of women of all ages .

Menstrual disorders affecting women.

Although these irregularities can present as disorders of menstrual flow, timing and duration, there are several organic and non-organic causes for this disruption. The National Institute for Health and Care Excellence (NICE) describes the term as dysfunctional uterine bleeding (DUB) as AUB in the absence of organic disease .

In 2011, the International Federation of Gynecology and Obstetrics (FIGO) approved the polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified (PALM-COEIN) classification as a FIGO classification system for the purpose of standardizing nomenclature for the causes of AUB ( Fig. 2 ) . This new classification was introduced to facilitate clinicians, researchers and patients in their interaction, communication and reporting to provide clinically effective care.

FIGO classification of abnormal uterine bleeding.

It is known that AUB can affect the quality of life of the individual concerned, and it can also represent an early warning sign of uterine malignancy, especially if occurring once menopause ensues. In these cases, careful clinical evaluation and assessment for treatment is merited. Hysteroscopy allows the rapid assessment and treatment of conditions that cause AUB.

This chapter provides an overview of existing evidence and good practice in relation to the role of hysteroscopy in the diagnosis of menstrual disorders presenting as AUB in non-pregnant women.

Approach to clinical evaluation in menstrual disorders

Women with menstrual disorders may present with a wide range of variable symptoms with different aetiologies. It is estimated that a quarter of women are referred to gynaecology clinics with AUB . In women below the age of 40 years, endometrial cancer is rare; however, its incidence rises steeply beyond ages 45 and 50+ years. Up to 10% of women with PMB will have endometrial cancer . Therefore, it is pertinent to adopt a structured approach to clinical evaluation before recommending diagnostic imaging or treatment options. A suggested approach is summarized in Table 1 .

A thorough history and examination provides insight into the possible causes of AUB. From this point on, it is necessary to ascertain whether the suspected cause warrants immediate evaluation, that is, within 2 weeks or a more routine approach with evaluation at 6 weeks or more. In cases where a high risk of malignancy is possible (polycystic ovarian syndrome (PCOS), diabetes, tamoxifen, unopposed oestrogen therapy, palpable abdominal mass, cervical or vulvo-vaginal mass on examination or PMB, non-cyclical bleeding in women on hormone replacement therapy (HRT)), immediate referral to a specialist clinic for further evaluation is warranted. Whereas cases where the bleeding may be secondary to more benign causes, local routine referral pathways should be followed.

Approach to diagnostics in menstrual disorders

Historically, various diagnostic approaches have been suggested for the preliminary investigation of menstrual disorders. Basic blood testing such as a complete blood count allows the evaluation of the degree of anaemia. Other tests such as coagulation screening, renal function tests, prolactin, androgen levels and thyroid function tests are undertaken based on history-defined suspicion of disease.

The most commonly used investigation method in gynaecological imaging is the pelvic transvaginal ultrasound (TVUS); this combined with endometrial biopsy and/or office hysteroscopy provides an invaluable diagnostic combination for the assessment of AUB. Other imaging methods that have been suggested are saline infusion sonography (SIS) and special modalities such as computerized tomography (CT) and magnetic resonance imaging (MRI) (used when malignancy is suspected). These methods are complementary assessment tools. It is also important to note that dilatation and curettage (D&C) is now only used in exceptional circumstances, as it requires general anaesthesia, and it has been largely replaced by outpatient endometrial biopsy.

Pelvic TVUS

With the use of TVUS, it is possible to visualize and assess the uterine cavity and the adjacent adnexa, when planning for further treatment options. This provides valuable information such as endometrial thickness (ET) and the presence or absence of structural abnormalities such as polyps or fibroids. TVUS is also minimally invasive and widely acceptable to women, and it helps triage women requiring further treatment. The sensitivity and specificity of TVUS for the detection of fibroids and polyps alongside ET are 80% and 69%, respectively . Therefore, to prevent endometrial lesions from being missed, it is increasingly being suggested that hysteroscopy or SIS is recommended to further evaluate the endometrium . In premenopausal women, ET is best assessed on days 4–6 of the menstrual cycle as this is the time when the endometrium should be at its thinnest. If uterine cavity pathology is suspected, then further investigation is merited. Furthermore, in cases where medical treatment has been unsuccessful in premenopausal women, hysteroscopy should be performed as there maybe underlying pathology, which may not be visible on TVUS.

In post-menopausal women with PMB, endometrial cancer is a major concern. Measuring ET on TVUS is valuable in triaging women who are at a greater risk of endometrial cancer. A suggested threshold of ≤4 mm for ET with a regular endometrial lining and no fluid within the cavity reduces the possibility of malignancy to <1% in post-menopausal women . An ET measuring >4 mm warrants endometrial sampling as the risk of malignancy is higher . TVUS thus allows adequate sensitivity for this threshold with a false-negative rate of 0.25–0.50% and without excessive false-positive rates . If clinical suspicion of malignancy persists, especially in symptomatic or high-risk cases, then it is advisable to perform hysteroscopic evaluation as some endometrial pathology may be missed. The risk factors for endometrial cancer are obesity, diabetes, nulliparity, history of PCOS and family history of hereditary non-polyposis colorectal cancer.