Imaging Studies Women with abnormal bleeding who have a history consistent with chronic anovulation, who are obese, or who are older than 35 to 40 years of age require further evaluation. A pelvic ultrasonographic examination may be helpful in delineating anatomic abnormalities if the examination results are suboptimal or if an ovarian mass is suspected. A pelvic ultrasonographic examination is the best initial technique for evaluating the uterine contour, endometrial thickness, and ovarian structure (172,173). The use of a vaginal probe transducer allows assessment of endometrial and ovarian disorders, particularly in women who are obese. Because of variation in endometrial thickness with the menstrual cycle, measurements of endometrial stripe thickness are significantly less useful in premenopausal than postmenopausal women (174). Sonohysterography is especially helpful in visualizing intrauterine problems such as polyps or submucous leiomyoma. Although these sonographic techniques are helpful in visualizing intrauterine pathology, histologic evaluation is required to rule out malignancy. Other techniques, such as CT scanning and MRI, are not as helpful in the initial evaluation of causes of abnormal bleeding and should be reserved for specific indications, such as exploring the possibility of other intra-abdominal pathology or adenopathy. MRI can be a secondary step in evaluating location of uterine fibroids with relationship to the endometrial cavity, staging and preoperative evaluation of endometrial cancer, detecting adenomyosis, and delineating adnexal and ovarian pathology (175).
Figure 14.19 Devices used for sampling endometrium. Top: Kevorkian Curette. Bottom: Pipelle.
Endometrial Sampling Endometrial sampling should be performed to evaluate abnormal bleeding in women who are at risk for endometrial pathology, including polyps, hyperplasia, or carcinoma. Such sampling is mandatory in the evaluation of anovulatory bleeding in women older than 35 to 40 years of age, in younger women who are obese, and in those who do not respond to medical therapy or those with a history of prolonged anovulation (143). The technique of D&C, which was used extensively for the evaluation of abnormal bleeding, was largely replaced by endometrial biopsy in the office. The classic study in which a D&C was performed before hysterectomy with the conclusion that less than one-half of the endometrium was sampled in more than one-half of the patients led to questioning the use of D&C for endometrial diagnosis (176,177). Hysteroscopy, either diagnostic or operative, with endometrial sampling, can be performed either in the office or operating room (178).
A number of devices are designed for endometrial sampling, including a commonly used, inexpensive, disposable ﬂexible plastic sheath with an internal plunger that allows tissue aspiration; disposable plastic cannulae of varying diameters that attach to a manually locking syringe that allows the establishment of a vacuum; and cannulae (both rigid metal and plastic) with tissue traps that attach to an electric vacuum pump (Fig. 14.19). Several studies comparing the adequacy of sampling using these devices with D&C showed a comparable ability to detect abnormalities. It should be noted that these devices are designed to obtain a tissue sample rather than a cytologic washing. The diagnostic accuracy of endometrial biopsy for endometrial malignancy and hyperplasia is good, although persistent bleeding should prompt further testing (179,180).