Objective To evaluate the clinical efficacy, reliability and acceptability of out‐patient diagnostic hysteroscopy at a large teaching hospital. Setting The Women's Endoscopy Unit at Nottingham City Hospital, Nottingham, UK. Subjects Between 1994 and 1997, 2581 women were referred for menstrual problems and abnormal uterine bleeding. The endocervical canal and endometrial cavity were assessed using either a 4‐mm rigid or a 3.5‐mm flexible hysteroscope, according to the preference of the operator. All hysteroscopies were performed by consultants or experienced registrars. Endometrial biopsy was taken when indicated. Results The main indications for referral for diagnostic hysteroscopy included menorrhagia (37.5%), postmenopausal bleeding (33.4%), intermenstrual bleeding (26.7%) and metrorrhagia (8.8%). Less common indications included treatment with tamoxifen, review of previous endometrial pathology or abnormal glandular cells on cervical cytology, and investigation for infertility. The mean age of patients referred was 49.3 years. Hysteroscopy was completed successfully in 96.8% of all patients, with pain being the main reason for failure to complete the procedure. Local anaesthesia with paracervical infiltration was used in 34% of all patients. Submucous fibroids were the commonest cause of intrauterine pathology (11.4%) with the highest incidence found in women referred for menometrorrhagia (17.2%). Endometrial polyps were detected in 10.6% of all the patients. The endometrium was characterized by the hysteroscopist as atrophic, thickened, polypoid, haemorrhagic or malignant. Endometrial Pipelle biopsies were taken in 48.6% of all cases. Abnormal histological findings were reported in 61 cases including 11 instances of endometrial adenocarcinoma. The concordance rate between hysteroscopic and histological findings for all abnormalities was 63.9%. Further medical treatment was offered to 406 patients (16.3%), while 185 patients (17.3%) needed additional surgery as in‐patients. Conclusion Out‐patient hysteroscopy is a safe, acceptable and well‐tolerated procedure that provides useful information about the uterine cavity. Endometrial biopsy improves the diagnostic accuracy of hysteroscopy in detecting endometrial pathology.

Objective To evaluate the efficacy, reliability and acceptability of outpatient hysteroscopy in the investigation of postmenopausal bleeding in a major teaching hospital. Design A retrospective descriptive study of 862 women referred with postmenopausal bleeding for outpatient hysteroscopy. Methods Between 1994 and 1997, 862 women were referred to the Women's Endoscopy Unit at Nottingham City Hospital for postmenopausal bleeding. Of these women, 171 were receiving hormone replacement treatment. The endocervical canal and the endometrial cavity were assessed using either a 4‐mm rigid or a 3.5‐mm flexible hysteroscope according to the preference of the operator. All hysteroscopies were performed by consultants or experienced registrars. Pipelle endometrial biopsy was taken when indicated. Results The mean age of patients referred with postmenopausal bleeding was 58 years. Hysteroscopy was completed successfully in 97.2% of all patients. Cervical stenosis and pain were the main reasons for failure to complete the procedure. Local anaesthesia with paracervical infiltration was used in one‐third of all patients undergoing hysteroscopy. Intrauterine polyps were the commonest finding (13.9%) while submucous fibroids were detected in 10.7%. Endometrial biopsies were taken in 34.7%. Abnormal histological findings were reported in 28 cases, including eight instances of endometrial adenocarcinoma. After hysteroscopic assessment, 81% of patients were discharged while further surgical treatment was warranted in 14.6%. Conclusion Outpatient hysteroscopy is a reliable, safe and well‐tolerated diagnostic procedure for investigating endometrial and endocervical pathology in patients with postmenopausal bleeding. Whenever hysteroscopic findings appear suspicious an endometrial biopsy should be taken to exclude endometrial pathology.

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A 30-year-old nulliparous asymptomatic woman presented to a colposcopy clinic with severe dyskaryosis based on a cervical smear test report. The colposcopic impression was high-grade cervical lesion. A large loop excision of the transformation zone was performed. Histologic examination revealed an invasive well-differentiated papillary adenocarcinoma of the endocervix measuring 12 mm across and infiltrated to a depth of 3.5 mm (Stage IB1). The excision was incomplete at the endocervical margin of the lesion. There was no apparent lymph-vascular involvement. Magnetic resonance imaging revealed a small area of high signal in the cervix compatible with a small residual tumor confined to the cervix. The patient was advised to have a radical hysterectomy with pelvic lymph node dissection. However, the patient was anxious to maintain her fertility at all costs and to explore any other options. Subsequently she was referred to a regional gynecologic oncology unit (St Bartholomew's Hospital, London, UK) and was counseled about the possibility of fertility-preserving radical surgery. A radical trachelectomy with a retroperitoneal lymph node dissection was discussed and the patient underwent the procedure without complication. A no. 1 prolene suture was inserted into the lower segment of the uterus to provide sufficient mechanical support in the event of a pregnancy. Histologic analysis revealed no evidence of residual tumor or lymph node metastases, but there was an area of high-grade glandular cervical intraepithelial neoplasia which had been completely excised.The postoperative recovery was uncomplicated. The patient presented amenorrhea and the pregnancy test was positive. A retrospective estimation of the ultrasound dating scan suggested that she must have conceived during the month of the operation. There was no bacterial growth from vaginal swabs. A detailed scan at 19 weeks showed a fetus without anatomic anomalies. Colposcopy at 21 weeks did not show tumor recurrence or herniation of the amniotic membranes.At 23 weeks' gestation the patient presented with clear fluid C Acta Obstet Gynecol Scand 81 (2002) loss per vaginam. A sterile speculum examination revealed intact membranes visible through a gap of the lower uterine segment. High water rupture of membranes was diagnosed. Chlamydial antigens tests and vaginal cultures were negative. Antibiotics and steroids were administered. The patient remained on bed-rest with compression stockings, and close observations were made to detect any sign of ascending uterine infection. An ultrasound scan at 25 weeks confirmed satisfactory growth with oligohydramnios. A few days later the patient had a small antepartum hemorrhage and painful uterine contractions. A classic cesarean section was performed under general anesthesia and a live female baby weighing 650 g was delivered in good condition. The delivery was effected through the anterior placenta that had clear signs of chorioamnionitis. This was confirmed on subsequent histologic examination. Funisitis was also identified....

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