The value of hysteroscopy and D&C in the assessment of postmenopausal uterine bleeding.

Uterine bleeding occurring in women of postmenopausal age should be considered as the result of malignancies until proved otherwise. The "gold standard" for the ongoing diagnostic steps of postmenopausal bleedings is still fractional D&C. The diagnostic accuracy of D&C, as well as its indications, however, is being increasingly questioned. Hence, this problem whether the diagnostic accuracy of D&C can be improved by additional hysteroscopy merits further investigation. Material and method: From 1/1990 until 12/1996 1198 postmenopausal patients (pts.) with vaginal bleedings were referred to our clinic for a histological determination of the cause of bleeding. From 1031 pts. with a follow-up after at least 6 months 629 received only D&C, while 402 pts. received a hysteroscopy and D&C. Findings and course of illness of pts. who received additionally hysteroscopy (n = 402) were compared with those of pts. who were treated with D&C alone (n = 629). Results: In 45.4% of all postmenopausal bleedings there was no pathological finding. Endometrial polyps were found in 19.5% of cases, endometrial cancer in 17.6%, cancer of the cervix in 5.4% and hyperplasia in 6.8%. Altogether 96 (9.3%) of the 1031 patients had to be subjected to another operation because of persisting or recurrent bleedings. In the group which received D&C only, the figure was 13.4% (84/629) and in the group with additional hysteroscopy it was 3.0% (12/402). With regard to the detection of all pathological findings sensitivity, specificity, positive and negative predictive values amounted to 87.9%, 84.5%, 85.3% and 87.2%, respectively, for hysteroscopy alone; 83.5%, 100%, 100% and 74.5% for fractional D&C alone and 96.7%, 100%, 100% and 96.4% for both method combined. With regard to the detection of endometrial polyps, endometrial cancer and myomas alone, the sensitivity and negative predictive value amounted to 98.2, respectively 98.5% for hysteroscopy alone. Conclusion: Through the use of hysteroscopy the number of additional operations due to persisting postmenopausal bleeding was significantly reduced. Today the "gold standard" for determining the cause of bleeding in postmenopausal women is the combination of hysteroscopy and fractional D&C.