Perform Hysteroscopy or Endometrial Biopsy First for Uterine Bleeding?
BACKGROUND AND PURPOSE:
Hysteroscopy is considered the ‘gold standard’ when ruling out intrauterine pathology in the context of abnormal uterine bleeding (AUB), especially when supplemented with endometrial biopsy, especially for
Women ≥ 45 years of age
Younger women with a history of unopposed estrogen or failed medical management
Both procedures can be associated with pain and/or discomfort
Sarkar et al. (Obstet Gynecol., 2017) estimated the optimal order of office hysteroscopy and endometrial biopsy when working up AUB
Prospective single-blind randomized trial
Effect of order of procedures on patients’ pain score
Prespecified secondary outcomes
Procedure duration, hysteroscopic visualization of the uterine cavity, endometrial sample adequacy, and number of attempts at biopsy
A visual analog scale from 0 to 10 assessed pain scores and histopathology report was used to determine endometrial sample adequacy
Hysteroscopy images were recorded
Sample size of 34 per group (n=68) needed to detect a difference of 20% in visual analog scale score between hysteroscopy first vs biopsy first for alpha of 0.05 and 80% power
78 women were randomized to hysteroscopy (n=40) and biopsy first (n=38)
All patients were premenopausal
When comparing hysteroscopy first to endometrial biopsy first there was no difference in the following
Global pain perception [7 (0-10) vs 7 (0-10); P=.57, 95% CI 5.8-7.1]
Procedure duration (min) [3 (1-9) vs 3 (2-10), P=.32, 95% CI 3.3-4.1]
Endometrial sample adequacy (78.9% vs 75.7%, P=.74)
Hysterectomy patients had better endometrial visualization (P<.001) than biopsy-first based on the hysteroscopic images: excellent (50% vs 7.9%), good (20% vs 34.2%), and fair (22.5% vs 44.7%)
Biopsy-first participants required fewer endometrial biopsy attempts at obtaining adequate tissue sample (2 vs 1; P<.001, 1.6-1.9)
Overall, no difference in pain, duration
Performing hysteroscopy first ensures better image, whereas biopsy first yields adequate tissue sample with fewer attempts, although adequacy of samples were comparable regardless of number of attempts
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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