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Original Article

Transvaginal sonography versus hysteroscopy in evaluation of

abnormal uterine bleeding
a,* b c
Col B.K. Goyal, VSM , Capt Indu Gaur , Gp Capt Sunil Sharma , Maj
d e
Arunabha Saha , Col N.K. Das
a Senior Adviser (Obst-Gynae & Gynae Onco), Command Hospital (West Command), Chandimandir, India
b Medical Officer (Obst-Gynae), Base Hospital, Delhi Cantt 10, India
c Classified Specialist (Obst-Gynae), Naval Hospital, Powai, Mumbai, India
d Graded Specialist (Obst-Gynae), 159 Gen Hospital, C/O 56 APO, India
e Classified Specialist (Obst-Gynae), Command Hospital (Eastern Command), Kolkata 700027, India

article info abstract

Article history: Received 25 Background: Abnormal uterine bleeding (AUB) accounts for 33% of female patients referred to
July 2014 Accepted 1 December gynaecologists. Common causes of AUB include endometrial polyps, endometrial hy-perplasia, submucous
2014 Available online xxx fibroids and anovulation. Accurate diagnosis of the cause of AUB can reduce the frequency of hysterectomy.
This study was aimed at assessing the usefulness of TVS in comparison with hysteroscopy in AUB evaluation.
Methods: 100 female patients with AUB were enrolled in the study. Each patient was sub-jected to TVS where
Keywords: uterine cavity was studied in detail and hysteroscopy under anaes-thesia using saline as distension medium.
Abnormal uterine bleeding Sensitivity, specificity and predictive value of TVS as compared to hysteroscopy were calculated. Subgroup
Transvaginal sonography analysis within each group was also performed.
Hysteroscopy
Endometrial polyp Results: Menorrhagia was the commonest presenting symptom in the study population (n ¼ 58) followed by
Submucous fibroid metrorrhagia, menometrorrhagia and continuous bleeding >21 days. 74 female patients had normal size
uterus. In 57 patients, the uterine cavity was normal on TVS. Thickened endometrium, endometrial polyp and
submucous fibroids were seen in 19, 16 and 6 patients respectively. Hysteroscopy showed normal cavity in 59
female patients and polypoidal endometrium, polyps or submucous fibroids in 41. TVS was found to have
high sensitivity and specificity (95.23 and 94.82 respectively) and high positive and negative predictive value.
Strength of agreement between TVS and hysteroscopy was high (kappa value 0.898).

Conclusion: TVS is recommended as first line investigation in AUB. If TVS shows normal cavity, further
evaluation can be omitted and patient started directly on medical treatment for her symptoms.

© 2014, Armed Forces Medical Services (AFMS). All rights reserved.

* Corresponding author. Tel.: þ91 9831423985.

E-mail address: [email protected] (B.K. Goyal).
http://dx.doi.org/10.1016/j.mjafi.2014.12.001
0377-1237/© 2014, Armed Forces Medical Services (AFMS). All rights reserved.

Please cite this article in press as: Goyal BK, et al., Transvaginal sonography versus hysteroscopy in evaluation of abnormal uterine bleeding, Medical
Journal Armed Forces India (2014), http://dx.doi.org/10.1016/j.mjafi.2014.12.001
2 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a x x x ( 2 0 1 4 ) 1 e6

going pregnancy. Patients with AUB who were hemodynami-cally

Introduction unstable, unmarried young female patients where TVS is not desirable,
uterine size larger than 12 weeks gestation, pa-tients with known
Abnormal uterine bleeding (AUB) describes all abnormal pat-terns of coagulation disorders and those with a cervical lesion or cancer were not
menstrual bleeding that may result from a wide va-riety of causes included in this study.
1
including anovulation, pregnancy, uterine pathology and coagulopathies. Each patient meeting the selection criteria underwent a preliminary
The term AUB usually in-dicates one of the following clinical assessment by history and clinical examination. The bleeding pattern was
presentations e menor-rhagia (abnormally long or heavy menses lasting categorized as either menorrhagia, metrorrhagia, menometrorrhagia or
>7 days or involving blood loss >80 mL), metrorrhagia (menses occurring continuous bleeding for more than 21 days. The uterine size was assessed
at irregular intervals) or menometrorrhagia (a combination of the two). It
clinically and determined as normal or enlarged (in weeks of pregnancy
is the single most common complaint that repro-ductive age females bring
size). TVS examination was performed at the first visit in the office
to their clinicians and it accounts for 33% of female patients referred to
2
setting itself. The uterine anatomy and the adnexae were visualized using
gynaecologists. Differ-ential diagnosis of AUB includes problems a 7.5 MHz vaginal probe transducer (General Electric, Milwaukee, C3
relating to preg-nancy, infection, vaginal and cervical abnormalities, real time sector scanner). Appearance of the endometrial stripe was
benign and malignant uterine neoplasia, coagulopathies, endocrine
recorded as either normal or abnormal; a specific note was made of any
disorders, trauma, foreign bodies, systemic disease and bleeding related to
1
focal lesion seen in terms of an endometrial polyp, submucous fibroid,
medications. In order to arrive at the cause of AUB, the clinician should intramural fibroid, or thickened endometrium (>12 mm). The contour of
evaluate the patient with judicious use of investigative tools available to the endometrial stripe was assessed in the midline sagittal plane and the
him.
point of maximum thickness of the stripe (ET) was measured.

A careful history and physical examination are the most useful tools
for starting the evaluation of AUB. Infrequent, irregular, unpredictable
Hysteroscopy under anaesthesia was then scheduled at a subsequent
menstrual bleeding that varies in amount, duration and character and is
visit. Hysteroscopy was scheduled in the early proliferative phase of the
not preceded by any recognizable or consistent pattern of premenstrual
menstrual cycle in patients com-plaining of regular AUB. Hysteroscopy
molimina and unaccompanied by any visible or palpable genital tract
was performed using a 30 hysteroscope and diagnostic sheath of 5 mm
abnormality, can be diagnosed as anovulatory bleeding. Conversely,
diameter (Karl-Storz Endoscopy) with a fiberoptic cold light source;
regular monthly periods that are heavy or pro-longed are more likely
normal saline was used as the distending medium and the procedure was
related to an anatomical lesion or a bleeding disorder than to anovulation.
performed under direct video monitoring.

A total of 100 patients completed the study and underwent both TVS
Anything that can significantly improve the accuracy of diagnosing and hysteroscopy. The results of hysteroscopy were taken as the “gold
the cause of bleeding, can reduce the frequency of hysterectomy as a cure.
standard” for the diagnosis of intracavitary pathology. Sensitivity,
Dilatation and curettage (D & C) used to be the mainstay of investigation
specificity and predictive value of the TVS in detecting the intracavitary
for abnormal uterine bleeding but it is not accurate for diagnosing focal
intrauterine lesions such as endometrial polyps or submucous fibroids lesions were calculated with hysteroscopy taken as the gold standard.
3e6 Subgroup analysis of various TVS findings was also undertaken and
which may be small or located in areas difficult to curette. Currently,
accuracy of TVS in assigning the cause was determined for each pattern.
the main diagnostic methods which are being used in the evaluation of
7 Statistical analysis was performed online using the facility provided on
AUB are transvaginal ultrasonography and diagnostic hysteroscopy.
the website www.medcalc.org and www.graphpad.com.
According to some authors, diagnostic hysteroscopy represents an
8
indispensable pre-surgical investigation, although the value of
transvaginal ultrasonography compared with hysteroscopy is yet not fully
defined.
Results
In evaluation of AUB, what should be the ideal work-up plan? We
100 consecutive patients presenting with menstrual com-plaints who met
undertook the present study to compare the accu-racy of TVS as
the selection criteria were studied by TVS and hysteroscopy for this study
compared with hysteroscopy in cases of abnormal uterine bleeding and to
and evaluated. The data was ar-ranged in Microsoft Excel sheet and was
formulate the ideal inves-tigation protocol in these female patients with
analysed statistically.
AUB.
The age of our patients ranged from 19 to 55 years but maximum
number of patients who developed menstrual ab-normalities belonged to
41e50 year age group (n ¼ 51). 10 pa-tients were above 51 years of age
Materials and methods and 10 patients below 30 years.

This prospective observational study was conducted at the Department of Parity distribution of the subjects ranged between 0 and 5. Fifty-one
Obstetrics and Gynaecology of a tertiary care teaching hospital of the patients in our study were para-2, which is in keeping with the modern
Armed Forces from January 2012 to June 2014. The study population trends of family size. There were two nulliparas and six with parity four or
included female patients attending the OPD for abnormal uterine bleeding above.
and the sample size consisted of 100 patients not known to have an on- Table 1 depicts the distribution of various menstrual ab-normalities
seen in our study group. Menorrhagia was the

Please cite this article in press as: Goyal BK, et al., Transvaginal sonography versus hysteroscopy in evaluation of
abnormal uterine bleeding, Medical Journal Armed Forces India (2014), http://dx.doi.org/10.1016/j.mjafi.2014.12.001
 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a x x x ( 2 0 1 4 ) 1 e6 3

Table 1 e Distribution of bleeding pattern. Table 3 e TVS findings.

Bleeding pattern Numbers (n ¼ 100) TVS finding Numbers (n ¼ 100)
Menorrhagia 58 Normal endometrium with a trilaminar 57
Metrorrhagia 32 or secretory type ET <12 mm
Menometrorrhagia 7 Thickened ET (>12 mm) 19
Continuous bleeding >21 days 3 Endometrial Polyp 16
Submucous fibroid 6
Irregular shadow? Products of conception 2

most common complaint amongst our patients (n ¼ 58) fol-lowed by

metrorrhagia (n ¼ 32). Menomentrorrhagia and continuous bleeding for
>21 days were less common symp-toms seen in 7 and 3 women also revealed some abnormality in 40 cases. However, in four of these
respectively. cases there was disparity between TVS diagnosis and hysteroscopic
We had clinically assessed the size of the uterus in weeks of gestation diagnosis. On two occasions a thickened endometrium on TVS actually
and found that 74% of our patients with abnormal menstrual pattern had was proven on hysteroscopy to be a polyp and just the reverse on another
normal size uterus. 15 patients had 6-weeks size uterus whereas 8- and 10- two occasions.
weeks size uterus was seen in 9 and 2 patients respectively. We had Sub-group analysis of the various TVS findings is given in Table 6.
excluded uteri larger than 12 weeks from our study because fibroids are When we look at the subset of patients found to have normal endometrial
the most likely cause of such enlargements where the presence of fibroids cavity on TVS, we find that 55 out of 57 patients were actually found to
as the cause of menstrual symptoms may confound the results of have normal uterine cavity on hysteroscopy giving a high accuracy of
evaluation of the cavity. The uterine sizes in our subjects are shown in 96.55% to TVS. In the thickened endometrium TVS subgroup, of the 19
Table 2. patients, 16 were actually seen to have polypoidal endometrium on hys-
teroscopy (accuracy 84.21%) but on 2 occasions, it was in fact an
TVS findings of our patients are summarized in Table 3. On TVS, we endometrial polyp and once it turned out to be a normal uterine cavity. In
found that uterine cavity was normal in 57 of our patients presenting with the endometrial polyp subset of patients on TVS, 13 out of 16 patients
various menstrual abnormalities. The endometrial pattern was either were found to have polyps, two were found to have just polypoidal
trilaminar or secretory but the ET was less than 12 mm. In 19 patients, the endometrium and one had normal uterine cavity. The submucous fibroids
ET was thickened and more than 12 mm. Endometrial polyp was were confirmed on hysteroscopy in five of the six cases whereas the
diagnosed in 16 patients and a submucous fibroid in six (Fig. 1). Two retained products of conception cases have already been mentioned above.
patients with persistent irregular bleeding in the reproductive age group
seemed to have retained products of conception on TVS assessment.

The results of our study were analysed statistically. It was found that
Hysteroscopic findings seen in our patients have been tabulated in TVS finding of a normal endometrium had an ac-curacy of 96.49%. When
Table 4. In 59 cases, hysteroscopy did not reveal any endometrial TVS diagnosis was thickened endo-metrium, hysteroscopy confirmed it to
abnormality in the uterine cavity. Polypoidal endometrium was seen in 17 be polypoidal endometrium in 84.21% cases whereas if TVS diagnosis
cases and a discrete endometrial polyp was identified in 16 cases. was endometrial polyp, the diagnosis was confirmed by hysteros-copy in
Submucous fibroid was identified in five of six cases where a submucous 81.255% cases. Accuracy of TVS in the diagnosis of submucous fibroids
fibroid was suspected on TVS (Fig. 2). The patient where retained was found to 83.33% in our study.
products of conception were suspected on TVS was found to have
retained products in one case and polypoidal endometrium in the other. Sensitivity, specificity, disease prevalence, positive pre-dictive value
and negative predictive value were calculated online by using the facility
available at website www.medcalc. org. TVS was found to have a very
Table 5 brings out the correlation between TVS and hys-teroscopic high sensitivity of 95.23% (CI 84.16e99.30%), specificity of 94.82% (CI
findings. Of the 100 cases evaluated in this study, hysteroscopic findings 85.57e98.71%), disease prevalence rate of 42.0% (CI 32.14e52.29%),
matched the TVS findings 91 times and were at variance with the TVS positive predictive value of 93.01% (CI 82.39e97.6%) and negative
findings in only 9 cases. In 57 cases, when the TVS findings suggested a predictive value of 96.49% (CI 88.07e99.48%).
normal uterine cavity, a normal cavity was confirmed at hysteroscopy in
55 cases whereas in two patients, hysteroscopy revealed abnor-malities in Strength of agreement between TVS and hysteroscopy was determined
the uterine cavity. On the other hand, of the 43 cases where TVS showed by calculating the kappa value online on www. graphpad.com. The kappa
some abnormality, hysteroscopy value for our data was found to be 0.898 (SE 0.045, CI 0.810e0.985),
indicating very good strength of agreement between TVS and
hysteroscopy for assessment of the uterine cavity in patients with AUB.

Table 2 e Uterine size.

Uterine size Numbers (n ¼ 100) Discussion
Normal size 74
6 weeks size 15
Premenopausal female patients with abnormal uterine bleeding constitute
8 weeks size 9
a large proportion of gynaecologic
10 weeks or more 2

Please cite this article in press as: Goyal BK, et al., Transvaginal sonography versus hysteroscopy in evaluation of abnormal uterine bleeding, Medical
Journal Armed Forces India (2014), http://dx.doi.org/10.1016/j.mjafi.2014.12.001
4 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a x x x ( 2 0 1 4 ) 1 e6

Fig. 1 e TVS images. 1. Normal uterine cavity with triple layer endometrium, 2. Thickened endometrium, 3. Endometrial polyp, 4. Submucous fibroid.

9 13
consultations often resulting in a variety of tests being or-dered. Most in this study, 57 had normal endometrial findings on TVS. Wood et al, in
common pathologies causing AUB in premeno-pausal patients are their study of menorrhagia, had found that 33 of 97 patients had normal
submucous fibroids, adenomyosis, endometrial polyps and endometrial uterine cavity.
hyperplasia. Accurate diagnosis of the etiologic cause may result in In our study we found that TVS has a very high predictive value, both
treatment directed at the specific pathology and may avoid major surgery. negative as well as positive. Its high negative predictive value (96.49% in
our study) lends credence to the notion that hysteroscopic investigation
The most common diagnostic tests for evaluation of AUB are may be omitted in patients where TVS suggests a normal uterine cavity.
hysteroscopy, sonohysterography and transvaginal ultra-sonography The physician may directly institute treatment for the patient based on the
(TVS), either alone or in combination. It has been documented that the TVS findings and patient's symptomatology and consider hysteroscopy
performance of the various diagnostic tests available is often poorly only if the problem does not respond to the medical treatment. Vercellini
15
understood by those who order and who administer the diagnostic et al who found negative predictive value of TVS of the order of 94% in
10 their study of menorrhagic patient also support the above contention. Ind-
procedure. Therefore it is essential for the clinician to understand the
14
appropriate place of various diagnostic tools in the evaluation of AUB. man et al studied 238 patients with AUB and found the negative
During the last two decades, TVS has been proposed as an alternative or a 16
predictive value of TVS to be 89%. Barati et al, however, found that
11e13
complement to hysteroscopy in the work-up of patients with AUB. only 21.8% patients with AUB with normal TVS findings were found to
Reliability of TVS in excluding the presence of intracavitary disorders in have some abnormality on hysteroscopy and recommended that even after
pre- and postmenopausal females has been demonstrated repeatedly and a normal TVS, a second-step office hysteroscopy should be considered.
some authors have even questioned the appropriateness of hysteroscopy
14,15
after a negative TVS.

In our study, we found the positive predictive value of TVS to be as

We had undertaken the present study to evaluate the ef-ficacy of TVS high as 93.01% which compares well with the findings of Vercellini et al
in patients with AUB as compared to hysteros-copy (gold standard). (89%) and Indman et al (87%). Abnormal TVS could comprise of
Among 100 patients with AUB included endometrial polyp, submucous fibroid or thickened endometrium. We
used 12 mm thickness of endo-metrium as the upper limit of normal in
premenopausal pa-tients, beyond which it was called thickened
endometrium. Thickened endometrium on TVS is expected to correlate
with endometrial hyperplasia on histopathology or polypoidal
Table 4 e Hysteroscopy findings.
15
Hysteroscopic finding Numbers (n ¼ 100) endometrium on hysteroscopy. Vercellini et al used 14 mm as the cut-off
Normal cavity 59 17
for normal whereas Emmanuel et al used 12 mm as the cut-off. Just as
Polypoidal endometrium 17 TVS can differentiate between endometrial polyp and endometrial
Endometrial polyp 16 hyperplasia with fair ac-curacy, its ability to detect submucous fibroids is
Submucous fibroid 6 also as high
Products of conception 2

Please cite this article in press as: Goyal BK, et al., Transvaginal sonography versus hysteroscopy in evaluation of
abnormal uterine bleeding, Medical Journal Armed Forces India (2014), http://dx.doi.org/10.1016/j.mjafi.2014.12.001
 m e d i c a l j o u r n a l a r m e d f o r c e s i n d i a x x x ( 2 0 1 4 ) 1 e6 5

Fig. 2 e Hysteroscopic images. 1. Normal uterine cavity, 2. Polypoidal thickened endometrium, 3. Endometrial polyp, 4. Submucous fibroid.

12
as 83.33%. Fedele et al also studied efficacy of TVS and hysteroscopy To conclude, our study adds to the body of evidence available in
in detecting submucous myomas in 71 patients scheduled to undergo literature regarding the usefulness of TVS in evaluation of the uterine
hysterectomy for symptomatic fibroids. They found TVS to be 100% cavity for AUB. It is recommended that TVS be used as the first-step
sensitive and 94% specific in diagnosing submucous myomas with a investigation for cases of AUB in the reproductive age group. In case the
negative predictive value of 100% and positive predictive value of 81%. TVS shows normal uterine cavity, further evaluation can be omitted and
Hysteros-copy, on the other hand, had sensitivity of 100%, specificity patient can be started on medical treatment for her symp-toms. If the
96%, negative predictive value 100% and positive predictive value 87%. patient fails to respond to medical treatment, only then should further
14
Indman et al also found that TVS was 99% suc-cessful in detecting evaluation with hysteroscopy or sono-hysterography should be
7 considered. In case the initial TVS shows some abnormality, it can help in
submucous myomas. Results of the meta-analysis of Farquhar et al to
determine the accuracy of TVS, saline hysterography and hysteroscopy directing the appro-priate next intervention. For example, if TVS suggests
showed that TVS is less accurate than saline hysterography and an endometrial polyp, then one could directly plan operative hysteroscopy
hysteroscopy in diagnosing submucous fibroids, which is contrary to our whereas a thickened endometrium could be taken up for office
findings. endometrial sampling.

11
Towbin et al in their study of efficacy of TVS versus hysteroscopy in
evaluation of uterine cavity in patients with excessive uterine bleeding
found hysteroscopy to be signifi-cantly more sensitive as compared to
TVS. They studied 149 cases of menorrhagia, metrorrhagia and
Table 6 e TVS-hysteroscopy correlation: Sub-group analysis.
postmenopausal bleeding and found sensitivity of 54% with TVS and 79%
TVS finding Number Hysteroscopy finding Number
with hysteroscopy. Specificity of the two investigative modalities,
Normal 57 Normal cavity 55
however, was comparable in their study.
endometrium Polypoidal endometrium 1
Endometrial polyp 1
Thickened 19 Polypoidal endometrium 16
endometrium Endometrial polyp 2
Normal cavity 1
Table 5 e TVS-hysteroscopy correlation. Endometrial 16 Endometrial polyp 13
Correlation Numbers (n ¼ 100) polyp Polypoidal endometrium 2
Normal TVS & normal hysteroscopy 55 Normal cavity 1
Normal TVS & abnormal hysteroscopy 2 Submucous 6 Submucous fibroid 5
Abnormal TVS & normal hysteroscopy 3 fibroid Normal cavity 1
Abnormal TVS & abnormal hysteroscopy a Retained 2 Polypoidal endometrium 1
40
products of Retained products 1
a
On four occasions abnormal TVS findings were not correspond- ing with the conception of conception
hysteroscopic abnormality.

Please cite this article in press as: Goyal BK, et al., Transvaginal sonography versus hysteroscopy in evaluation of abnormal uterine bleeding, Medical
Journal Armed Forces India (2014), http://dx.doi.org/10.1016/j.mjafi.2014.12.001
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Please cite this article in press as: Goyal BK, et al., Transvaginal sonography versus hysteroscopy in evaluation of abnormal uterine bleeding, Medical
Journal Armed Forces India (2014), http://dx.doi.org/10.1016/j.mjafi.2014.12.001