Intra-cavitary uterine pathology in women with abnormal uterine bleeding: a prospective study of 1220 women

Abstract

Objectives: Our primary aim was to assess how patients' characteristics, bleeding pattern, sonographic endometrial thickness (ET) and additional features at unenhanced ultrasound examination (UTVS) and at fluid instillation sonography (FIS) contribute to the diagnosis of intracavitary uterine pathology in women presenting with abnormal uterine bleeding (AUB). We further aimed to report the prevalence of pathology in women presenting with AUB.

Methods: 1220 consecutive women presenting with AUB underwent UTVS, colour Doppler imaging (CDI) and FIS. Most women (n = 1042) had histological diagnosis.

Results: Mean age was 50 years and 37% were postmenopausal. Of 1220 women 54% were normal, polyps were diagnosed in 26%, intracavitary fibroids in 11%, hyperplasia without atypia in 4% and cancer in 3%. All cancers were diagnosed in postmenopausal (7%) or perimenopausal (1%) women. ET had a low predictive value in premenopausal women (LR+ and LR- of 1.34 and 0.74, respectively), while FIS had a LR+ and LR- of 6.20 and 0.24, respectively. After menopause, ET outperformed all patient characteristics for the prediction of endometrial pathology (LR+ and LR- of 3.13 and 0.24). The corresponding LR+ and LR- were 10.85 and 0.71 for CDI and 8.23 and 0.26 for FIS.

Conclusion: About half of the women presenting to a bleeding clinic will have pathology. In premenopausal women, benign lesions are often the cause of AUB. For the prediction of intracavitary pathology ET is of little value in premenopausal women. CDI and FIS substantially improve the diagnostic accuracy.

Keywords: Ultrasonography; endometrial cancer; leiomyoma; metrorrhagia; polyps.

Fig. 1. Images at unenhanced ultrasound (UTVS) and at fluid instillation sonography (FIS) (for case 1 and 2) of endometrial cancer with an endometrial thickness < 5 mm: FIS demonstrates an irregular lesion in case 1 and 2 (in case 1 it is associated with visible vascularity within the irregularity).

Fig. 2. Incidence of intracavitary pathology in patients with uterine fibroids recorded at UTVS: (a) premenopausal group; (b) postmenopausal group.

Fig. 3. Endometrial polyp (gel instillation sonography at grey scale and power Doppler imaging): note the pedicle artery.

Fig. 4. Intracavitary fibroid with circumferential vascularization (gel instillation sonography at grey scale and power Doppler imaging).