Do we really need to hysteroscope all the women who have irregular bleeding on hormone replacement therapy?

Abstract

Objective: To find out the importance of hysteroscopy in patients with irregular bleeding on HRT. Methods: Retrospective case note analysis of women attending outpatient hysteroscopy clinic between 1 August 2000 and 31 July 2001. Results: A total of 352 patients were referred to hysteroscopy clinic at Castle Hill Hospital, UK. The mean age of the patients was 57 years (range 48-69 years). The mean duration of HRT usage was 3.5 years (range 2-10 years). Seventy-seven (22%) patients had irregular bleeding on HRT, where hysteroscopy showed normal endometrial appearance. All these patients underwent an endometrial biopsy. Eleven (14%) of the patients had an intrauterine polyp and a polypectomy was performed in each case. The histology results of the endometrial biopsy/polyp were as follows: 42 had atrophic or inactive endometrium; 11 had benign endometrial polyp; 10 had insufficient sample all in women with hysteroscopically normal endometrial cavities; 8 had HRT effect; and 6 had progestogenic effect. There were no cases of malignancy. Conclusion: The incidence of significant pathology in patients with irregular bleeding on HRT is very low; however, benign polyps are common. It is better to adopt "see and treat" policy, where facilities are available. If facilities are not available, consider ultrasound scan or saline infusion sonohysteroscopy and target appropriately.

Postmenopausal Bleeding in Women Utilizing Hormone Replacement Therapy: Not all the patients need to be referred or investigated

“…The mean age from our study was 56 years, slightly higher than the 54 years reported by Hickey et al [10]; however, it was less than 57 years of presentation reported by Lalchandani et al [9] which is likely because the average age of menopause in the United Kingdom is 51 years. However, it ranges from 45 to 55 years [11].…”

“…The One-stop PMB clinic (also called rapid access clinic) was designed to bridge the delays associated with the outpatient assessment of women with PMB and subsequent inpatient endometrial assessment with Hysteroscopy, and populating the clinic with inappropriate referrals defeats the essential purpose of the clinic [8]. The mean duration of HRT use among the study population was 16 months, almost half the mean reported by Hickey et al [10] and significantly less than the 39 months reported in the series by Lanchadnia et al [9].…”

“…The main reason for investigating PMB is to exclude a sinister endometrial pathology [6]. Abnormal vaginal bleeding is the most frequent presenting symptom in women with endometrial cancer, but most of the aetiological causes of PMB are benign in 90-95% of cases [7][8][9][10]. While there are several risk factors for endometrial cancer, HRT, especially unopposed estrogen therapy in un-hysterectomies women, is a significant risk factor that should warrant an assessment regardless of the HRT regimen.…”

A Comparative Observational Study of the Use of Saline Uterine Hydrosonography for the Diagnosis and Assessment of Uterine Cavity Lesions in Women

“…However, despite these developments, it is still not possible to visualize some problems with confidence, such as intrauterine adhesions [ 5 ]. Differentiating submucous fibroids from endometrial polyps can be difficult sometimes [ 6 , 7 ]. Another example is distinguishing submucous fibroids which distort the cavity from those not distorting the cavity [ 8 ].…”