Hysteroscopy: Evaluation and treatment of abnormal bleeding

Hysteroscopy:  Evaluation and treatment of abnormal bleeding

Part 1 in our series on Minimally Invasive Solutions

Written by Dr. Teng


Many women at some point in their lives will report abnormal uterine bleeding.  It is the single most common reason for gynecology referrals and accounts for one third of outpatient visits to the gynecologist.  The causes of abnormal uterine bleeding can vary from external stressors to poor nutrition, coagulation disorders, anatomical abnormalities, and hormonal imbalance.  The most common causes in women of reproductive age, aside from pregnancy, include uterine pathology, such as uterine polyps, fibroids, or thickened endometrium.


Initial workup with your gynecologist usually includes a thorough history and physical with blood tests to rule out causes of hormone imbalance.  If you are of reproductive age, a pregnancy test is always performed.  In certain patient populations, workup for coagulation disorders and anemia is warranted.  Having a menstrual calendar to keep track of bleeding episodes is a helpful way to characterize the amount and frequency of bleeding.  Does the bleeding occur in between your periods or is it only heavy with your periods?  Does it occur after intercourse?  How long do the bleeding episodes last?  All of these questions will provide useful information for your doctor to reach a diagnosis.  Imaging studies such as pelvic ultrasound or sonohysterography (infusion of saline into the uterine cavity during an ultrasound) can help to identify a thickened endometrial lining, fibroids, or polyps.  Any woman who has bleeding after having gone through menopause should undergo an endometrial biopsy to rule out cancer.  This biopsy can be done in the office or hospital setting.  Biopsy is also recommended for women who are at risk for endometrial hyperplasia, for example women who are obese, who have a history of tamoxifen use, unopposed estrogen use, or chronic anovulation. 


What if my labs are all normal?


Transvaginal ultrasound can be a useful screening tool to assess the uterine cavity for fibroids or polyps (fleshy growths of endometrial tissue).  It can also measure the thickness of the endometrial lining.  Although it can be helpful, the sensitivity is only 56%, meaning it can miss close to half of the patients that have intracavitary pathology.  Sonohysterography allows us to differentiate a thickened endometrial lining from a fibroid or a polyp, and can give us more information regarding the size and location of the lesion.  If your ultrasound is normal and your doctor has suspicion for a pathological process, he or she may recommend a biopsy or a more invasive procedure.



What are the treatment options?


If the blood tests reveal a hormonal imbalance stemming from the brain or thyroid gland, then the underlying cause must be corrected.  In the absence of organic causes of abnormal bleeding, such as endometrial polyps and fibroids, medical management is usually the initial approach to control disordered or heavy menstrual bleeding.  Effective options include hormonal methods, such as the birth control pill or intrauterine device, as well as nonsteroidal anti-inflammatory drugs. For those patients that fail a trial of medical management, a minimally-invasive procedure would be an appropriate next step.


What is hysteroscopy?


Hysteroscopy is a minimally invasive procedure that allows direct visualization of the uterine cavity, allowing for accurate localization of pathology.  It can be performed in the office or hospital setting with local anesthesia.  A small camera, or hysteroscope, is inserted through the cervix to access the endometrial cavity.  Saline is infused through a small opening in the scope, and the endometrium is carefully evaluated.  Hysteroscopy is an excellent diagnostic technique and also has the advantage of being able to treat the abnormality at the same time, for example, removing a polyp.  Being able to see inside the uterus can allow for more accurate diagnosis and biopsy of lesions that may be missed during a dilation and curettage (D&C) procedure.


For anatomic causes of abnormal uterine bleeding, such as fibroids or polyps, surgery may be indicated.  In 2007 a large meta-analysis showed that 47% of women with abnormal uterine bleeding had an anatomic abnormality.  The systematic review also demonstrated that hysteroscopy is accurate and clinically useful for diagnosis intrauterine abnormalities, and that it is safe with low incidence of serious complications.  If medical management has failed, hysteroscopy is a safe and proven method that gives women the option to avoid a larger surgery. 





El Camino Women’s Medical Group offers the latest Minimally Invasive Solutions for gynecologic problems.   Drs. Amy Teng and Erika Balassiano, both members of AAGL (American Association of Gynecologic Laparoscopy) are highly trained and experienced in the field of Minimally Invasive Gynecologic Surgery.   Dr. Erika Balassiano is also a graduate of the Minimally Invasive Gynecologic Surgery Fellowship at Stanford University, under the supervision of world-renowned Dr. Camran Nezhat.

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