What is the role of hysteroscopy in the management of abnormal uterine bleeding?

Abstract

Many otherwise healthy women will experience a significant disruption in lifestyle from abnormal uterine bleeding. Most of those seeking medical attention will not be at risk for developing anemia. In each case, a thorough search for underlying systemic, hormonal, and organic causes should be instituted. The use of blind endometrial sampling to evaluate the uterine cavity, by itself, is an inaccurate technique for diagnosing pathologic conditions commonly associated with menorrhagia, such as endometrial polyps, submucous myomata, and focal endometrial abnormalities including adenocarcinoma and its precursors. The supplementary application of diagnostic hysteroscopy with directed biopsy will ensure the recognition of these intracavitary lesions. The majority of women found to have endometrial polyps and submucous myomata can gain a successful reduction in their menstrual flow without hysterectomy by undergoing hysteroscopic removal of these lesions. Those without other uterine or pelvic pathology and who are closer to perimenopause are more likely to sustain long-lasting relief from these procedures. Medical therapy should be the first line of treatment for premenopausal women who are found to have no obvious cause for their abnormal uterine bleeding. Many of those who do not respond to, are unable to tolerate, or are unwilling to attempt this approach will undergo hysterectomy as the final answer. The absence of uterine pathology in most of these cases places an absolute demand on our specialty to innovate, and, whenever suited, to use more conservative surgical solutions. Our efforts to alter this behavior will undoubtedly be closely monitored by agents of managed care aiming to reward measures that reduce cost and improve the quality of care. The use of hysteroscopic ablation and resection to treat women suffering from intractable menorrhagia can safely and effectively reduce menstrual blood flow and should significantly curtail the performance of unnecessary hysterectomy. The comparative benefits and long-term advantages of these techniques beyond hysterectomy await the results of further studies. Furthermore, the risks of these hysteroscopic procedures to produce iatrogenic adenomyosis or to conceal or delay the usual signs of adenocarcinoma have yet to be ascertained. Vigilance for endometrial disease must not dwindle in the face of amenorrhea, as evidenced by a recent case report describing the development of endometrial carcinoma after 5 years of amenorrhea following endometrial electrocoagulation. Future methods of endometrial destruction for the control of abnormal uterine bleeding may include the nonhysteroscopic use of radio frequency, thermal transfer, hyperthermia, and photodynamic therapy.(ABSTRACT TRUNCATED AT 400 WORDS)