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Grand Rounds

Perform Hysteroscopy or Endometrial Biopsy First for Uterine Bleeding?

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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

METHODS:

  • Prospective single-blind randomized trial
  • Primary outcome
    • 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

RESULTS:

  • 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)

CONCLUSION:

  • 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

Learn More – Primary Sources:

Optimal Order of Successive Office Hysteroscopy and Endometrial Biopsy for the Evaluation of Abnormal Uterine Bleeding: A Randomized Controlled Trial.

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Related ObG Topics:

Reducing Hysteroscopy Pain with Transcutaneous Nerve Stimulation  
How Well Does Sonohysterography Match Up Against the Gold Standard of Hysteroscopy?
Managing Abnormal Uterine Bleeding with Ovulatory Dysfunction
Endometrial Polyps – Do They Always Need To Be Removed?

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