Hysteroscopy versus transvaginal ultrasonography: finding the better modality for evaluation of postmenopausal bleeding


  • Mishika Bhoj Department of Obstetrics and Gynecology, Bombay Port Trust Hospital, Mumbai, Maharashtra, India
  • Shakti Kumar Yadav Department of Pathology, North Delhi Municipal Corporation Medical College and Hindu Rao Hospital, New Delhi, India




Endometrial carcinoma, Hysteroscopy, Postmenopausal bleeding, Transvaginal ultrasonography


Background: The most common cause of postmenopausal bleeding is benign pathology, but likelihood of malignancy must be promptly excluded. As excision of localized lesion has higher disease-free survival rate and lower morbidity as opposed to treatment for regional-stage disease. Commonly employed blind dilatation and curettage followed by histopathology is the current standard. A screening method with high sensitivity and specificity can help to prevent the invasive procedure and can also improve the accuracy of the biopsy. The objective of the present study was to study and compare the diagnostic accuracy of hysteroscopy and transvaginal ultrasonography in diagnosis of postmenopausal bleeding.

Methods: 80 female patients with complaints of postmenopausal bleeding were enrolled and followed up for a period of 10 months. Each patient underwent transvaginal ultrasonography and hysteroscopy followed by endometrial biopsy. Result were analyzed to find sensitivity, specificity, accuracy, PPV and NPV taking histopathological diagnosis as gold standard.

Results: Authors found that in 40 patients (50%), the cause of post-menopausal bleeding was caused atrophic endometrium followed by endometrial hyperplasia seen in 14 patients (17.5%). Hysteroscopy had higher overall sensitivity, specificity, NPV and accuracy as compared to transvaginal ultrasonography. Hysteroscopy was found to be highly accurate in diagnosing endometrial carcinoma (100%) and endometrial polyps (100%). However, both methods showed similar accuracy (97.5%) in diagnosis of proliferative endometrium and hyperplasia.

Conclusions: Hysteroscopy is comparable to histopathology and superior to transvaginal sonography in the diagnosis of intrauterine causes for postmenopausal bleeding, it also offers the possibility of visualizing macroscopic or focal intra-uterine abnormalities.


World Health Organization. Research on the menopause in the 1990s: report of a WHO scientific group.

Moodley M, Roberts C. Clinical pathway for the evaluation of postmenopausal bleeding with an emphasis on endometrial cancer detection. J Obstet Gynaecol. 2004;24(7):736-41.

Hacker NF, Moore JG. Essentials of obstetrics and gynaecology, 3rd ed. Philadelphia: WB saunders, 1998:635.

Pacheco JC, Kempers RD. Etiology of postmenopausal bleeding. Obstet Gynecol.1968;32(1):40-6.

Osmers RG, Kuhn W. Endometrial cancer screening. Current Op Obstet Gynecol. 1994;6(1):75-9.

Dutch Society of Obstetrics and Gynecology (NVOG). Diagnostics in abnormal vaginal blood loss in the postmenopausal period; 2003.

Landis SH, Murray T, Bolden S, Wingo PA. Cancer statistics, 1999. CA: A Cancer J Clinic. 1999;49(1):8-31.

American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 426: The role of transvaginal ultrasonography in the evaluation of postmenopausal bleeding. Obstet Gynecol. 2009;113(2 Pt 1):462.

Grimes DA. Diagnostic dilatation and curettage: a reappraisal. Am J Obstet Gynecol. 1982;142:1-6.

Büyük E, Durmuşoĝlu F, Erenus M, Karakoç B. Endometrial disease diagnosed by transvaginal ultrasound and dilatation and curettage. Acta Obstetricia et Gynecologica Scandinavica. 1999;78(5):419-22.

Karlsson B, Granberg S, Hellberg P, Wikland M. Comparative study of transvaginal sonography and hysteroscopy for the detection of pathologic endometrial lesions in women with postmenopausal bleeding. J Ultrasound Med. 1994;13(10):757-62.

O'connell LP, Fries MH, Zeringue E, Brehm W. Triage of abnormal postmenopausal bleeding: a comparison of endometrial biopsy and transvaginal sonohysterography versus fractional curettage with hysteroscopy. Am J Obstet Gynecol. 1998;178(5):956-61.

Mendelson EB, Bohm-Velez M, Joseph N, Neiman H. Endometrial abnormalities: evaluation with transvaginal sonography. Am J Roentgenol. 1988;150(1):139-42.

Osmers R, Volksen M, Schauer A. Vaginosonography for early detection of endometrial carcinoma? Lancet 1990 335/8705 (1569–1571). Maturitas. 1991;13(1):86.

Fleischer AC, Kalemeris GC, Machin JE, Entman SS, James Jr AE. Sonographic depiction of normal and abnormal endometrium with histopathologic correlation. J Ultrasound Med. 1986;5(8):445-52.

Nasri M, Coast G. Correlation of ultrasound findings and endometrial histopathology in postmenopausal women. BJOG: An International J Obstet Gynaecol. 1989;96(11):1333-8.

Karlsson B, Granberg S, Wikland M, Ylostalo P, Torvid K, Marsal K, et al. Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding: a Nordic multicenter study. Am J Obstet Gynecol. 1995;172(5):1488-94.

Smith-Bindman R, Kerlikowske K, Feldstein VA, Subak L, Scheidler J, Segal M et al. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. Jama. 1998;280(17):1510-7.

Weber G, Mere E, Bahlmanw E, Riisch B. Evaluation of different transvaginal sonographic diagnostic parameters in women with postmenopausal bleeding. Ultrasound Obstet Gynecol. 1998;12(4):265-70.

Gimpelson RJ, Rappold HO. A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage: a review of 276 cases. Am J of Obstet Gynecol. 1988;158(3):489-92.

Widrich T, Bradley LD, Mitchinson AR, Collins RL. Comparison of saline infusion sonography with office hysteroscopy for the evaluation of the endometrium. Am J of Obstet Gynecol. 1996;174(4):1327-34.

Osmers R, Puchta J, Suren A. Pathological findings of the postmenopausal endometrium. Ultrasound Uterus. 1995:31-44.

Parsons AK, Lense JJ. Sonohysterography for endometrial abnormalities: preliminary results. J Clinic Ultrasound. 1993;21(2):87-95.

Hsu C-Y, Chen C-P, Wang K-L. Assessment of postmenopausal bleeding. Int J Gerontol. 2008;2:55-9.

Tandulwadkar S, Deshmukh P, Lodha P, Agarwal B. Hysteroscopy in postmenopausal bleeding. Journal Gynecol Endoscopy and Surg. 2009;1(2):89.

Vitner D, Filmer S, Goldstein I, Khatib N, Weiner Z. A comparison between ultrasonography and hysteroscopy in the diagnosis of uterine pathology. European J Obstet Gynecol Reproduct Biol. 2013;171(1):143-5.

Babacan A, Gun I, Kizilaslan C, Ozden O, Muhcu M, Mungen E, Atay V. Comparison of transvaginal ultrasonography and hysteroscopy in the diagnosis of uterine pathologies. Int J Clinical Experiment Med. 2014;7(3):764.

Van Dongen H, De Kroon CD, Jacobi CE, Trimbos JB, Jansen FW. Diagnostic hysteroscopy in abnormal uterine bleeding: a systematic review and meta‐analysis. BJOG: Int J Obstet Gynaecol. 2007;114(6):664-75.

Nikolaou D, Salman G, Richardson R. Operative hysteroscopy in the outpatient setting: its role within a gynaecology service. Gynecol Surg. 2009;6(1):21-4.

Dinić T, Pop S, Kopitović V, Antić V, Stamenović S, Mitić D, et al. Role of Hysteroscopy in Evaluation of Patients with Abnormal Uterine Bleeding. Acta Facultatis Medicae Naissensis. 2011;28(3).

Alfhaily F, Ewies AA. The first-line investigation of postmenopausal bleeding: transvaginal ultrasound scanning and endometrial biopsy may be enough. Int J Gynecol Cancer. 2009;19(5):892-5.

Guida M, Bramante S, Acunzo G, Lavitola G, Sparice S, Cerrota G, Nappi C. Evaluation of endometrial carcinoma using hysteroscopy and transvaginal echography. Tumori. 2003;89(4):253-4.

Sousa R, Silvestre M, Sousa LA, Falcão F, Dias I, Silva T, Oliveira CD, Oliveira HM. Transvaginal ultrasonography and hysteroscopy in postmenopausal bleeding: a prospective study. Acta Obstet et Gynecol Scandinavica. 2001;80(9):856-62.

Angioni S, Loddo A, Milano F, Piras B, Minerba L, Melis GB. Detection of benign intracavitary lesions in postmenopausal women with abnormal uterine bleeding: a prospective comparative study on outpatient hysteroscopy and blind biopsy. J Minimally Invasive Gynecol. 2008 ;15(1):87-91.

Clark TJ, Voit D, Gupta JK, Hyde C, Song F, Khan KS. Accuracy of hysteroscopy in the diagnosis of endometrial cancer and hyperplasia: a systematic quantitative review. Jama. 2002;288(13):1610-21.






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