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A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage
Hepatitis B and pregnancy outcome
Volume 158 Number 3, Part I
4. 5.
6. 7. 8.
and active immunization for preventing perinatal transmission of hepatitis B virus carrier state. Pediatrics 1982;70:613-9. Centers for Disease Control. Recommendations for protection against viral hepatitis. MMWR l 985;34:313-35. Summers PR, Biswas MK, PastorekJG, Pernoll ML, Smith LG, Bean BE. The pregnant hepatitis B carrier: evidence favoring comprehensive antepartum screening. Obstet Gynecol 1987;69:701-4. Cruz AC, Frentzen BH, Behnke M. Hepatitis B: a case for prenatal screening of all patients. AM J 0BSTET GYNECOL 1987;156:] ]80-3. Ohto H, Lin H-H, Kawana T, Etoh T, Tohyama H. Intrauterine transmission of hepatitis B virus is closely related to placental leakage.] Med Virol 1987;21:1-6. Okada K, Kamiyama I, Inomata M, Imai M, Miya-
kawa Y, Mayumi M. e Antigen and anti-e in the serum of asymptomatic carrier mothers as indicators of positive and negative transmission of hepatitis B to their infants. N Engl J Med I 976;294:746-9. 9. Beasley RP, Trepo C, Stevens CE, Symuness W. The e antigen and vertical transmission of hepatitis B surface antigen. AmJ Epidemiol 1977;105:94-8. JO. Malecki JM, Guarin 0, Hulbert A, Brumback CL. Prevalence of hepatitis B surface antigen among women receiving prenatal care at the Palm Beach County Health Department. AMJ OBSTF.T GYNF.COL 1986;154:625-6. 11. Miller JM, Kissling GE, Korndorffer FA, Brown HL, Gabert HA. A cross-sectional study of in utero growth of the above average sized fetus. AM J 0BSTET GYNF.COL 1986; 155: 1052-5.
A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage A review of 276 cases Richard J. Gimpelson, MD, and Henry 0. Rappold, MD ChesterfieUl, Missouri A total of 276 women underwent both panoramic hysteroscopy and dilatation and curettage. All of these patients underwent directed endometrial biopsies through the hysteroscope. Indications for operation included abnormal bleeding, postmenopausal bleeding, suspected leiomyoma with bleeding, follow-up for adenomatous hyperplasia, intrauterine contraceptive device with bleeding, retained products of conception, infertility with bleeding, abnormal hysterosalpingogram with bleeding, and abnormal endometrial cells on Papanicolaou smear. In 223 cases the results of hysteroscopy and curettage were in agreement. Hysteroscopy revealed more information than curettage in 44 patients, whereas curettage revealed more information than hysteroscopy in only nine patients. When the results of this study are combined with those of previous studies, there is little doubt that panoramic hysteroscopy is superior to curettage in making an accurate diagnosis of pathologic conditions in the uterine cavity. (AM J OBSTET GYNECOL
1988;158:489-92.)
Key words: Panoramic hysteroscopy, dilatation and curettage, endometrial biopsy In an earlier study by Gimpelson' of 66 patients, panoramic hysteroscopy with directed biopsy was compared with dilatation and curettage for the accurate diagnosis of pathologic conditions in the uterine cavity. That study illustrated that panoramic hysteroscopy yielded better results than dilatation and curettage. In this new study an additional 276 patients were evaluated to determine whether the directed endometrial Presented at the Third Wor/,d Congress and Workshop of Hysteroscapy, Miami, Florida, January 15-18, 1987. Received for publication February 20, 1987; revised September JO, 1987; accepted November 6, 1987. Reprint requests: Richard]. Gimpelson, MD, 222 South Woods Mill Road, Suite 400, Chesterfield, MO 63017.
Table I. Indications for hysteroscopy Indication
No. of patienl1
Abnormal bleeding Postmenopausal bleeding Suspected leiomyoma with bleeding Follow-up adenomatous hyperplasia Intrauterine contraceptive device with bleeding Retained products of conception Infertility with bleeding Abnormal hysterosalpingogram with bleeding Abnormal endometrial cells on papanicolaou smear
210 23 12 JI 8
Total
276
6 3 2
489
490 Gimpelson and Rappold
March 1988 Am J Obstet Gynecol
Table II. Patients with hysteroscopic biopsy results more informative than results of curettage No. of patients Hysteroscopy be[ore curettage
Hysteroscopy after curettage
Endometrial polyp Submucous leiomyoma Menstrual phase endometrium* Proliferative phase endometrium* Adenomatous hyperplasia Atypical hyperplasia Dysplastic trophoblastic tissue Papillary adenofibroma Atrophic endometrium Anovulatory endometrium* Mucous metaplasia Squamous metaplasia Metallic foreign body Abnormal secretory pattern
10 12 3 2 I I I I I I I I I
5 I
I
I I I I I I I I I
Total
36
8
44
His tologic results of directed biopsy
Total 15 13 3 2
2
*Insufficient tissue on curettage specimen in all patients.
Table III. Patients with directed biopsy results. less informative than curettage results* Histologic results of curettage
No. of patients
Anovulatory bleeding pattern Atrophic endometriumt Adenomatous hyperplasia Endometrial polyp
4
Total
9
3 I 1
*All patients in this category had hysteroscopy before curettage. tlnsufficient tissue on panoramic hysteroscopy in two cases.
biopsy by panoramic hysteroscopy is consistently better than curettage. Material and methods
This study involved a total of 276 women, 265 of whom underwent panoramic hysteroscopy before dilatation and curettage, and 11 of whom underwent panoramic hysteroscopy after dilatation and curettage. The patients ranged in age from 22 to 71 years, with a mean age of 42. All 276 patients had undergone biopsy of the endometrium or lesions performed through the hysteroscope under direction vision. The preoperative indications for operation included abnormal bleeding, postmenopausal bleeding, suspected Jeiomyoma with bleeding, follow-up of adenomatous hyperplasia, intrauterine contraceptive device with bleeding, retained products of conception, infertility with bleeding, abnormal hysterosalpingogram with bleeding, and abnormal endometrial cells on Papanicolaou smear (see Table 1). Procedures were performed in the office (236 cases) or in the operating room of the hospital (40 cases).
Instruments used were 7 mm operating hysteroscopes (Karl Storz Endoscopy-American, Inc., Culver City, Calif., and Richard Wolf Medical Instrument Corp., Rosemont, Ill.). All biopsies were done with Fr. 7 flexible forceps and/or scissors, except one case in which the Nd: YAG (neodymium: yttriumaluminum-garnet) laser (Cooper LaserSonics Model 8000, Cooper Laboratories Inc., Palo Alto, Calif.) was also used. The distention media used were carbon dioxide, 32% dextran 70 (Hyskon), and normal saline solution. The techniques were those proposed by Lindemann and Mohr, 2 Edstrom and Fernstrom,' and Valle and Sciarra.• General anesthesia was induced in the 40 patients undergoing the procedure in the hospital. The 236 patients who had the surgical procedure performed in the office received a paracervical block with either 1% lidocaine hydrochloride with 1 : 200,000 epinephrine or 0.25% bupivocaine hydrochloride, 5 ml per side with 1 ml in the anterior cervical lip. Most patients in whom paracervical block was done also received either 550 mg of naproxen sodium or 400 mg of ibuprofen. Most also received diazepam and/or meperidine hydrochloride. Curettage was carried out by either sharp curette or suction with both endometrial and endocervical tissue obtained. Before hysteroscopy and curettage, the procedure was explained to the patient with photographs, drawings, videotape, and anatomic models. The possible risks and benefits were explained and informed consent was obtained. Results
Results of this study show in the 276 cases investigated, that 223 cases (81 %) had hysteroscopic biopsy results that agreed with those of curettage, 44 cases (16%) had biopsy results that were more revealing than
Volume 158 Number 3, Part I
Panoramic hysteroscopy versus curettage 491
Table IV. Results of this study and earlier study by Gimpelson' Results
j
Original study*·t
This study*·t
Total*·t
Panoramic hysteroscopy equal to curettage Panoramic hysteroscopy greater than curettage Panoramic hysteroscopy less than curettage
48
223
271
16
44
60
2
9
11
Total
66
276
342
*p < 0.001 (X2 test).
tP < 0.001 (binomial test).
those of curettage, and biopsy alone was less revealing in only nine cases (3%). Of the 265 patients who underwent panoramic hysteroscopy before curettage, 220 patients had the same tissue diagnosis in both the directed biopsy and the curettage. In 36 cases the biopsy procedure yielded more information than the curettage, and in nine cases it yielded less information. Of the 11 patients who underwent dilatation and curettage before panoramic hysteroscopy, three patients had the same diagnosis and more information was obtained from directed biopsy in eight patients. The results of the 44 cases in which directed biopsy gave more information than curettage are shown in Table II. The results of the nine cases in which directed biopsy gave less information than curettage are shown in Table Ill. In the 11 cases in which curettage was performed before panoramic hysteroscopy, the diagnosis was missed in eight of the 11 cases, which confirmed the findings of several articles showing that curettage may miss a lesion 10% to 35% of the time. u- 13 Note in Table II, in the 15 cases of endometrial polyps and in the 13 cases of biopsy-verified leiomyomas, that curettage was of no help in making the diagnosis. Also note that one case of dysplastic trophoblastic tissue, one case of atypical endometrial hyperplasia, and two cases of adenomatous hyperplasia diagnosed by direct hysteroscopic biopsy were missed by curettage alone, whereas only one case of focal adenomatous hyperplasia was missed on hysteroscopic biopsy. Three cases of adenocarcinoma of the endometrium were confirmed on both hysteroscopic biopsy and curettage. Two patients had hysterosalpingograms consistent with a leiomyoma or polyp, with hysteroscopy confirming the polyp in one while hysteroscopy revealed a normal cavity in the other. Thirteen cases of endometrial polyps, 10 cases of uterine synechiae, and seven cases of leiomyomas that were obvious on hysteroscopic visualization were not documented by either directed endometrial biopsy or curettage; thus these cases were considered equal to curettage and were not included in Table II. One patient was unable to tolerate the
discomfort of the dilatation in the office; she was operated on successfully while under general anesthesia in the hospital.
Comment Table IV illustrates the results of this study combined with those of an earlier study by Gimpelson.' In that earlier study 48 (73%) from a total of 66 patients had findings on panoramic hysteroscopy that were in agreement with those of dilatation and curettage, 16 (24%) had findings greater than those of dilatation and curettage, and only two (3%) had findings less than those found at dilatation and curettage. The new study, combined with this earlier one, include a total of 342 cases in which hysteroscopy gave the same information as curettage alone in 271 cases (79%), more information than curettage in 60 cases (18%), and less information in only 11 cases (3%). One patient with a history of daily bleeding for 14 months had undergone three dilatation and curettage procedures (at 13 months, 7 months, and 1 month) before evaluation and all examinations demonstrated no pathologic conditions. During hysteroscopy a single submucous leiomyoma was removed by hysteroscopic resection with Fr. 7 flexible scissors and the Nd: YAG laser. This patient now has normal monthly menstrual periods. One of the most consistent findings in this study has been the detection of endometrial polyps and submucous myomas by hysteroscopy in patients who had undergone multiple curettage procedures with no pathologic conditions demonstrated. One patient had mild to moderate dysplasia on endocervical curettage, so that procedure should still be performed. Sixteen cases of uterine synechiae, 14 ofleiomyomas, and 13 of endometrial polyps were obvious on hysteroscopic visualization but were not detected by either endometrial biopsy or curettage. One point that may be raised is the presumed curative aspect of dilatation and curettage in cases of heavy uterine bleeding. Articles by Haynes et al.,. and Strickler" disagree with this theory. No additional references could be found in the literature to support or
492 Gimpelson and Rappold
dispute the curative aspects of dilatation and curettage. However, the very contents of this article could certainly serve to put this theory into serious doubt. It is felt that this study, as well as the earlier ones by Gimpelson,' Valle, 12 and Mohr," shows convincing evidence that hysteroscopy should become the procedure of choice in evaluating intrauterine pathologic conditions as both the present study and the earlier study have p < 0.00 I (X 2 test) and p < 0.00 I (binomial test). REFERENCES I. Gimpelson R. Panoramic hysteroscopy with directed biopsies vs dilatation and curettage for accurate diagnosis. J Reprod Med 1984;29:8. 2. LindemannJH, Mohr J. C0 2 hysteroscopy: diagnosis and treatment. AM J OBSTET GYNECOL 1976; 124: 129. 3. Edstrom K, Fernstrom I. The diagnostic possibilities of a modified hysteroscopic technique. Acta Obstet Gynecol Scand I 970;49:324. 4. Valle RF, Sciarra JJ. Current status of hysteroscopy in gynecologic practice. Fertil Steril 1970;32:6!9. 5. Speroff L, Glass RH, Kase NG. Clinical gynecologic endocrinology and infertility. 3rd ed. Baltimore: Williams & Wilkins, 1983:225-41.
March 1988 Am J Obstet Gynecol
6. Englund S, Ingelman-Sundberg A, Weston B. Hysteroscopy in diagnosis and treatment of uterine bleeding. Gynaecologia 1957; 143:217. 7. Cribb JJ. Hysteroscopy: an aid in gynecologic diagnosis. Obstet Gynecol 1960;15:593. 8. Norment WB, Sikes H. Fiber-optic hysteroscopy: an improved method for viewing the interior of the uterus. NC Med J 1970;3 l :251. 9. Norment WB. The hysteroscope. AM j 0BSTET GYNECOL 1956;7 l :425. 10. Silander T. Hysteroscopy through a transparent rubber balloon. Surg Gynecol Obstet 1962; 114: 125. 11. Word B, Gravlee LC, Wideman GL. The fallacy of simple uterine curettage. Obstet Gynecol 1958; 12:642. 12. Valle RF. Hysteroscopic evaluation of patients with abnormal uterine bleeding. Surg Gynecol Obstet 1981; 153:521. 13. Mohr JW. Hysteroscopy as a diagnostic tool in postmenopausal bleeding. In: Phillips JM, ed. Endoscopy in gynecology. Downey, California: American Association of Gynecologic Laparoscopists, 1978:347-50. 14. Haynes PJ, Hodgson H, Anderson ABM, et al. Measurement of menstrual blood loss in patients complaining of menorrhagia. Br J Obstet Gynaecol 1977;84:763. 15. Strickler RC. Dysfunctional uterine bleeding, diagnosis and treatment. Postgrad Med I 979;66:235.
Volume 158 Number 3, Part I
4. 5.
6. 7. 8.
and active immunization for preventing perinatal transmission of hepatitis B virus carrier state. Pediatrics 1982;70:613-9. Centers for Disease Control. Recommendations for protection against viral hepatitis. MMWR l 985;34:313-35. Summers PR, Biswas MK, PastorekJG, Pernoll ML, Smith LG, Bean BE. The pregnant hepatitis B carrier: evidence favoring comprehensive antepartum screening. Obstet Gynecol 1987;69:701-4. Cruz AC, Frentzen BH, Behnke M. Hepatitis B: a case for prenatal screening of all patients. AM J 0BSTET GYNECOL 1987;156:] ]80-3. Ohto H, Lin H-H, Kawana T, Etoh T, Tohyama H. Intrauterine transmission of hepatitis B virus is closely related to placental leakage.] Med Virol 1987;21:1-6. Okada K, Kamiyama I, Inomata M, Imai M, Miya-
kawa Y, Mayumi M. e Antigen and anti-e in the serum of asymptomatic carrier mothers as indicators of positive and negative transmission of hepatitis B to their infants. N Engl J Med I 976;294:746-9. 9. Beasley RP, Trepo C, Stevens CE, Symuness W. The e antigen and vertical transmission of hepatitis B surface antigen. AmJ Epidemiol 1977;105:94-8. JO. Malecki JM, Guarin 0, Hulbert A, Brumback CL. Prevalence of hepatitis B surface antigen among women receiving prenatal care at the Palm Beach County Health Department. AMJ OBSTF.T GYNF.COL 1986;154:625-6. 11. Miller JM, Kissling GE, Korndorffer FA, Brown HL, Gabert HA. A cross-sectional study of in utero growth of the above average sized fetus. AM J 0BSTET GYNF.COL 1986; 155: 1052-5.
A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage A review of 276 cases Richard J. Gimpelson, MD, and Henry 0. Rappold, MD ChesterfieUl, Missouri A total of 276 women underwent both panoramic hysteroscopy and dilatation and curettage. All of these patients underwent directed endometrial biopsies through the hysteroscope. Indications for operation included abnormal bleeding, postmenopausal bleeding, suspected leiomyoma with bleeding, follow-up for adenomatous hyperplasia, intrauterine contraceptive device with bleeding, retained products of conception, infertility with bleeding, abnormal hysterosalpingogram with bleeding, and abnormal endometrial cells on Papanicolaou smear. In 223 cases the results of hysteroscopy and curettage were in agreement. Hysteroscopy revealed more information than curettage in 44 patients, whereas curettage revealed more information than hysteroscopy in only nine patients. When the results of this study are combined with those of previous studies, there is little doubt that panoramic hysteroscopy is superior to curettage in making an accurate diagnosis of pathologic conditions in the uterine cavity. (AM J OBSTET GYNECOL
1988;158:489-92.)
Key words: Panoramic hysteroscopy, dilatation and curettage, endometrial biopsy In an earlier study by Gimpelson' of 66 patients, panoramic hysteroscopy with directed biopsy was compared with dilatation and curettage for the accurate diagnosis of pathologic conditions in the uterine cavity. That study illustrated that panoramic hysteroscopy yielded better results than dilatation and curettage. In this new study an additional 276 patients were evaluated to determine whether the directed endometrial Presented at the Third Wor/,d Congress and Workshop of Hysteroscapy, Miami, Florida, January 15-18, 1987. Received for publication February 20, 1987; revised September JO, 1987; accepted November 6, 1987. Reprint requests: Richard]. Gimpelson, MD, 222 South Woods Mill Road, Suite 400, Chesterfield, MO 63017.
Table I. Indications for hysteroscopy Indication
No. of patienl1
Abnormal bleeding Postmenopausal bleeding Suspected leiomyoma with bleeding Follow-up adenomatous hyperplasia Intrauterine contraceptive device with bleeding Retained products of conception Infertility with bleeding Abnormal hysterosalpingogram with bleeding Abnormal endometrial cells on papanicolaou smear
210 23 12 JI 8
Total
276
6 3 2
489
490 Gimpelson and Rappold
March 1988 Am J Obstet Gynecol
Table II. Patients with hysteroscopic biopsy results more informative than results of curettage No. of patients Hysteroscopy be[ore curettage
Hysteroscopy after curettage
Endometrial polyp Submucous leiomyoma Menstrual phase endometrium* Proliferative phase endometrium* Adenomatous hyperplasia Atypical hyperplasia Dysplastic trophoblastic tissue Papillary adenofibroma Atrophic endometrium Anovulatory endometrium* Mucous metaplasia Squamous metaplasia Metallic foreign body Abnormal secretory pattern
10 12 3 2 I I I I I I I I I
5 I
I
I I I I I I I I I
Total
36
8
44
His tologic results of directed biopsy
Total 15 13 3 2
2
*Insufficient tissue on curettage specimen in all patients.
Table III. Patients with directed biopsy results. less informative than curettage results* Histologic results of curettage
No. of patients
Anovulatory bleeding pattern Atrophic endometriumt Adenomatous hyperplasia Endometrial polyp
4
Total
9
3 I 1
*All patients in this category had hysteroscopy before curettage. tlnsufficient tissue on panoramic hysteroscopy in two cases.
biopsy by panoramic hysteroscopy is consistently better than curettage. Material and methods
This study involved a total of 276 women, 265 of whom underwent panoramic hysteroscopy before dilatation and curettage, and 11 of whom underwent panoramic hysteroscopy after dilatation and curettage. The patients ranged in age from 22 to 71 years, with a mean age of 42. All 276 patients had undergone biopsy of the endometrium or lesions performed through the hysteroscope under direction vision. The preoperative indications for operation included abnormal bleeding, postmenopausal bleeding, suspected Jeiomyoma with bleeding, follow-up of adenomatous hyperplasia, intrauterine contraceptive device with bleeding, retained products of conception, infertility with bleeding, abnormal hysterosalpingogram with bleeding, and abnormal endometrial cells on Papanicolaou smear (see Table 1). Procedures were performed in the office (236 cases) or in the operating room of the hospital (40 cases).
Instruments used were 7 mm operating hysteroscopes (Karl Storz Endoscopy-American, Inc., Culver City, Calif., and Richard Wolf Medical Instrument Corp., Rosemont, Ill.). All biopsies were done with Fr. 7 flexible forceps and/or scissors, except one case in which the Nd: YAG (neodymium: yttriumaluminum-garnet) laser (Cooper LaserSonics Model 8000, Cooper Laboratories Inc., Palo Alto, Calif.) was also used. The distention media used were carbon dioxide, 32% dextran 70 (Hyskon), and normal saline solution. The techniques were those proposed by Lindemann and Mohr, 2 Edstrom and Fernstrom,' and Valle and Sciarra.• General anesthesia was induced in the 40 patients undergoing the procedure in the hospital. The 236 patients who had the surgical procedure performed in the office received a paracervical block with either 1% lidocaine hydrochloride with 1 : 200,000 epinephrine or 0.25% bupivocaine hydrochloride, 5 ml per side with 1 ml in the anterior cervical lip. Most patients in whom paracervical block was done also received either 550 mg of naproxen sodium or 400 mg of ibuprofen. Most also received diazepam and/or meperidine hydrochloride. Curettage was carried out by either sharp curette or suction with both endometrial and endocervical tissue obtained. Before hysteroscopy and curettage, the procedure was explained to the patient with photographs, drawings, videotape, and anatomic models. The possible risks and benefits were explained and informed consent was obtained. Results
Results of this study show in the 276 cases investigated, that 223 cases (81 %) had hysteroscopic biopsy results that agreed with those of curettage, 44 cases (16%) had biopsy results that were more revealing than
Volume 158 Number 3, Part I
Panoramic hysteroscopy versus curettage 491
Table IV. Results of this study and earlier study by Gimpelson' Results
j
Original study*·t
This study*·t
Total*·t
Panoramic hysteroscopy equal to curettage Panoramic hysteroscopy greater than curettage Panoramic hysteroscopy less than curettage
48
223
271
16
44
60
2
9
11
Total
66
276
342
*p < 0.001 (X2 test).
tP < 0.001 (binomial test).
those of curettage, and biopsy alone was less revealing in only nine cases (3%). Of the 265 patients who underwent panoramic hysteroscopy before curettage, 220 patients had the same tissue diagnosis in both the directed biopsy and the curettage. In 36 cases the biopsy procedure yielded more information than the curettage, and in nine cases it yielded less information. Of the 11 patients who underwent dilatation and curettage before panoramic hysteroscopy, three patients had the same diagnosis and more information was obtained from directed biopsy in eight patients. The results of the 44 cases in which directed biopsy gave more information than curettage are shown in Table II. The results of the nine cases in which directed biopsy gave less information than curettage are shown in Table Ill. In the 11 cases in which curettage was performed before panoramic hysteroscopy, the diagnosis was missed in eight of the 11 cases, which confirmed the findings of several articles showing that curettage may miss a lesion 10% to 35% of the time. u- 13 Note in Table II, in the 15 cases of endometrial polyps and in the 13 cases of biopsy-verified leiomyomas, that curettage was of no help in making the diagnosis. Also note that one case of dysplastic trophoblastic tissue, one case of atypical endometrial hyperplasia, and two cases of adenomatous hyperplasia diagnosed by direct hysteroscopic biopsy were missed by curettage alone, whereas only one case of focal adenomatous hyperplasia was missed on hysteroscopic biopsy. Three cases of adenocarcinoma of the endometrium were confirmed on both hysteroscopic biopsy and curettage. Two patients had hysterosalpingograms consistent with a leiomyoma or polyp, with hysteroscopy confirming the polyp in one while hysteroscopy revealed a normal cavity in the other. Thirteen cases of endometrial polyps, 10 cases of uterine synechiae, and seven cases of leiomyomas that were obvious on hysteroscopic visualization were not documented by either directed endometrial biopsy or curettage; thus these cases were considered equal to curettage and were not included in Table II. One patient was unable to tolerate the
discomfort of the dilatation in the office; she was operated on successfully while under general anesthesia in the hospital.
Comment Table IV illustrates the results of this study combined with those of an earlier study by Gimpelson.' In that earlier study 48 (73%) from a total of 66 patients had findings on panoramic hysteroscopy that were in agreement with those of dilatation and curettage, 16 (24%) had findings greater than those of dilatation and curettage, and only two (3%) had findings less than those found at dilatation and curettage. The new study, combined with this earlier one, include a total of 342 cases in which hysteroscopy gave the same information as curettage alone in 271 cases (79%), more information than curettage in 60 cases (18%), and less information in only 11 cases (3%). One patient with a history of daily bleeding for 14 months had undergone three dilatation and curettage procedures (at 13 months, 7 months, and 1 month) before evaluation and all examinations demonstrated no pathologic conditions. During hysteroscopy a single submucous leiomyoma was removed by hysteroscopic resection with Fr. 7 flexible scissors and the Nd: YAG laser. This patient now has normal monthly menstrual periods. One of the most consistent findings in this study has been the detection of endometrial polyps and submucous myomas by hysteroscopy in patients who had undergone multiple curettage procedures with no pathologic conditions demonstrated. One patient had mild to moderate dysplasia on endocervical curettage, so that procedure should still be performed. Sixteen cases of uterine synechiae, 14 ofleiomyomas, and 13 of endometrial polyps were obvious on hysteroscopic visualization but were not detected by either endometrial biopsy or curettage. One point that may be raised is the presumed curative aspect of dilatation and curettage in cases of heavy uterine bleeding. Articles by Haynes et al.,. and Strickler" disagree with this theory. No additional references could be found in the literature to support or
492 Gimpelson and Rappold
dispute the curative aspects of dilatation and curettage. However, the very contents of this article could certainly serve to put this theory into serious doubt. It is felt that this study, as well as the earlier ones by Gimpelson,' Valle, 12 and Mohr," shows convincing evidence that hysteroscopy should become the procedure of choice in evaluating intrauterine pathologic conditions as both the present study and the earlier study have p < 0.00 I (X 2 test) and p < 0.00 I (binomial test). REFERENCES I. Gimpelson R. Panoramic hysteroscopy with directed biopsies vs dilatation and curettage for accurate diagnosis. J Reprod Med 1984;29:8. 2. LindemannJH, Mohr J. C0 2 hysteroscopy: diagnosis and treatment. AM J OBSTET GYNECOL 1976; 124: 129. 3. Edstrom K, Fernstrom I. The diagnostic possibilities of a modified hysteroscopic technique. Acta Obstet Gynecol Scand I 970;49:324. 4. Valle RF, Sciarra JJ. Current status of hysteroscopy in gynecologic practice. Fertil Steril 1970;32:6!9. 5. Speroff L, Glass RH, Kase NG. Clinical gynecologic endocrinology and infertility. 3rd ed. Baltimore: Williams & Wilkins, 1983:225-41.
March 1988 Am J Obstet Gynecol
6. Englund S, Ingelman-Sundberg A, Weston B. Hysteroscopy in diagnosis and treatment of uterine bleeding. Gynaecologia 1957; 143:217. 7. Cribb JJ. Hysteroscopy: an aid in gynecologic diagnosis. Obstet Gynecol 1960;15:593. 8. Norment WB, Sikes H. Fiber-optic hysteroscopy: an improved method for viewing the interior of the uterus. NC Med J 1970;3 l :251. 9. Norment WB. The hysteroscope. AM j 0BSTET GYNECOL 1956;7 l :425. 10. Silander T. Hysteroscopy through a transparent rubber balloon. Surg Gynecol Obstet 1962; 114: 125. 11. Word B, Gravlee LC, Wideman GL. The fallacy of simple uterine curettage. Obstet Gynecol 1958; 12:642. 12. Valle RF. Hysteroscopic evaluation of patients with abnormal uterine bleeding. Surg Gynecol Obstet 1981; 153:521. 13. Mohr JW. Hysteroscopy as a diagnostic tool in postmenopausal bleeding. In: Phillips JM, ed. Endoscopy in gynecology. Downey, California: American Association of Gynecologic Laparoscopists, 1978:347-50. 14. Haynes PJ, Hodgson H, Anderson ABM, et al. Measurement of menstrual blood loss in patients complaining of menorrhagia. Br J Obstet Gynaecol 1977;84:763. 15. Strickler RC. Dysfunctional uterine bleeding, diagnosis and treatment. Postgrad Med I 979;66:235.