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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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?