http://orcid.org/0000-0001-6871-6097
The menopause is a critical phase in every woman’s life, marked by permanent amenorrhea, the end of reproductive life and a marked decline in sex hormone production. Due to increased longevity of women worldwide, most will spend 30–40% of their lives in menopauseCitation1. Between 4 and 11% of postmenopausal women will experience postmenopausal bleeding (PMB). As approximately 10% of such presentations are an indicator of endometrial cancer, all must be investigatedCitation2. The majority of these presentations will be for benign conditions including cervical and endometrial polyps, myomas, endometrial hyperplasia trauma, cervical cancer and, most commonly, vaginal atrophy, all of which require careful diagnosis and managementCitation3.
Options for such investigation in the past have included office-based endometrial sampling devices, ‘blind’ dilatation and curettage (D&C), and, of course, ultrasound, which has vastly improved pre-interventional diagnosis. Today, hysteroscopy is considered the gold-standard procedure to evaluate the uterine cavity, especially in women with PMB or abnormal uterine bleeding (AUB)Citation4.
AUB is a frequently encountered complaint in gynecologic clinical practice, accounting for more than 70% of all gynecological consults in the perimenopausal and postmenopausal yearsCitation3. For this reason, it is essential to follow a diagnostic algorithm that starts with a thorough history-taking and physical examination, followed by imaging studies and blood test, and ends, when needed, with the evaluation of the uterine cavity with hysteroscopy. Such an evaluation enables differentiation of possible causes of AUB including structural pathology (polyps, adenomyosis, leiomyomas, malignancy and hyperplasia) and/or functional causes (coagulopathy, ovulatory dysfunction, endometrial abnormalities or iatrogenic reasons), as described in The PALM COEIN Classification, thus allowing the determination of appropriate therapy (which, in some cases, may only be expectant management)Citation4.
Hysteroscopy’s preeminent position amongst methodologies for the evaluation of intrauterine pathology in peri- and postmenopausal patients may be justified on several groundsCitation5. First, it offers direct visualization of the uterine cavity allowing for biopsy of suspected lesions that can often be missed, especially when focal, when performing blind procedures such as D&C. It also gives the opportunity to diagnose and treat frequently encountered conditions like polyps, myomas and synechiae during the same visit using the ‘see and treat’ approachCitation4,Citation5. There is clear evidence that hysteroscopy with directed biopsy is a more sensitive diagnostic approach than D&C for patients presenting with intrauterine pathologic conditionsCitation6–8.
Second, hysteroscopy is quick, painless and less invasive, when compared to D&C, and may frequently be performed safely in an office/outpatient settingCitation9. Advances in technology have led to miniaturization of high-definition hysteroscopes without compromising image quality, thereby making hysteroscopy a simple and well-tolerated office procedure. Indeed, in a recent study, office hysteroscopy was successful without anesthesia in 76.4% of postmenopausal women, allowing a quicker recovery timeCitation10. The technique of hysteroscopy is relatively easy to learn with a fast learning curve that may be further expedited with the use of virtual-reality simulators and training programsCitation5,Citation11. The recent incorporation of new technologies such as hysteroscopic tissue removal systems, mini-resectoscopes, and innovative distension media delivery systems has revolutionized this procedure, allowing outpatient treatment of many women who previously were only treated in the operating room. As noted above, outpatient hysteroscopy causes minimal distress for the patients, avoiding the need for general anesthesia which represents an added risk in older patients with comorbid conditionsCitation10.
In conclusion, the modern development of hysteroscopy has completely transformed the diagnostic approach of uterine intracavitary pathologies, especially during menopause, moving from blind procedures performed under general anesthesia to in-office procedures performed under direct visualization, offering a comprehensive diagnosis and management approach that must be embraced by the gynecologist in clinical practice.
Potential conflict of interest
The author reports no conflict of interest.
Source of funding
Nil.
References
- Minkin MJ. Menopause: Hormones, lifestyle, and optimizing aging. Obstet Gynecol Clin North Am 2019;46:501–14
- Brand AH. The woman with post menopausal bleeding. Aust Fam Physician 2007;36:115–20
- Goldstein SR, Lumsden MA. Abnormal uterine bleeding in perimenopause. Climacteric 2017;20:414–20
- Munro MG. Investigation of women with postmenopausal uterine bleeding: Clinical practice recommendations. Permanente J 2014;18:55–70
- Salazar CA, Isaacson KB. Office operative hysteroscopy: An update. J Minim Invasive Gynecol 2018;25:199–208
- Bedner R, Rzepka-Gorska I. Hysteroscopy with directed biopsy versus dilatation and curettage for the diagnosis of endometrial hyperplasia and cancer in perimenopausal women. Eur J Gynaecol Oncol 2007;28:400–2
- van Hanegem N, Prins MM, Bongers MY, et al. The accuracy of endometrial sampling in women with postmenopausal bleeding: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2016;197:147–55
- Vitale SG. The Biopsy Snake Grasper Sec. VITALE: A new tool for office hysteroscopy. J Minim Invasive Gynecol 2019; December 26. Epub ahead of print
- ACOG Technology Assessment No. 13 Summary: Hysteroscopy. Obstet Gynecol 2018;131:952–3
- Vitale SG, Haimovich S, Riemma G, et al. Innovations in hysteroscopic surgery: Expanding the meaning of ‘in-office’. Minim Invasive Ther Allied Technol 2020; Jan 23. Epub ahead of print
- Vitale SG, Caruso S, Vitagliano A, et al. The value of virtual reality simulators in hysteroscopy and training capacity: A systematic review. Minim Invasive Ther Allied Technol 2019; June 6. Epub ahead of print