Outpatient hysteroscopy and ultrasonography in the management of endometrial disease

Purpose of review This review is to inform the ongoing debate about the choice between ultrasound and hysteroscopy in the management of endometrial disease presenting with abnormal uterine bleeding using information provided from recently published literature. Recent findings Transvaginal ultrasound measurement of endometrial thickness, using 4 or 5 mm cut-offs to define abnormality, is a good test for excluding endometrial cancer in women with postmenopausal bleeding. In contrast, hysteroscopy is a good test for detecting endometrial cancer, but less effective at excluding serious disease. The accuracy of transvaginal ultrasound in diagnosing intracavity pathology such as submucous fibroids and polyps is improved with saline instillation to levels of accuracy comparable to that of outpatient hysteroscopy. Miniaturization of hysteroscopes and ancillary instrumentation (e.g. development of bipolar intrauterine systems) has facilitated 'see and treat' outpatient hysteroscopy, so that it should no longer be considered simply an outpatient diagnostic modality. Preliminary cost-effectiveness studies have supported the use of ultrasound in the diagnosis of endometrial disease, but further, more comprehensive studies are required comparing ultrasound and outpatient hysteroscopy. Summary Recently published research has provided the clinician with high-quality data regarding the accuracy, of ultrasound and hysteroscopy in the diagnosis of endometrial disease. Despite this, controversy remains regarding the relative roles of these uterine imaging modalities. Future research needs to be directed towards providing effectiveness and cost-effectiveness data in order to resolve the ongoing debate and guide best clinical practice.