RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA
PROFORMA FOR REGISTRATION OF SUBJECTS FOR
DISSERTATION
1

Name of the candidate and

address (in block letters)

Dr. SUCHITHRA.R

Name of the Institution

Vydehi Institute of Medical

Sciences & Research Centre.

Course of the study and

subject

M.S. OBSTETRICS AND

GYNAECOLOGY
(3 YEARS DURATION)

Date of admission to course

05/06/2013

Title of the topic

VYDHEHI INSTITUTE OF
MEDICAL SCIENCES &
RESEARCH CENTRE
#82 EPIP AREA,
NALLURAHALLI,
WHITEFIELD, BANGALORE, 560066

Comparative study of the

diagnostic accuracy of
transvaginal sonography versus
hysteroscopy in abnormal uterine
bleeding

Brief resume of the intended work

6.1

Need for the study

Abnormal uterine bleeding (AUB) is a common gynecologic complaint in
women attending outpatient department. The causes may vary from simple
dysfunctional uterine bleeding without any organic cause to the endometrial
cancer. The cases of AUB usually need thorough investigation to rule out
organic causes especially at perimenopausal and postmenopausal age when
the risk of endometrial carcinoma is 10% to 15%.

6.2

Hysteroscopy :
Hysteroscopy permits direct visualisation of the cervical
canal and uterine cavity, enabling observation of intrauterine
abnormalities through a rigid, flexible or contact hysteroscope .

Transvaginal ultra sonography: ultrasound imaging of female

pelvis using an endoscopic probe placed in the vagina.
Transvaginal sonography (TVS) plays an important role as the
initial modality for evaluation of AUB.

To compare the diagnostic efficacy of transvaginal

ultrasonography with hysteroscopy in abnormal uterine bleeding.

Role of TVS / hysteroscopy in management protocol of abnormal

uterine bleeding.

Review of literature:
A comparision between ultrasonography
hysteroscopy in diagnosis of uterine pathology
1)

OBJECTIVE:

To evaluate
sonograohy (tvs)compared to
abnormalities. In addition, to
diagnostic hysteroscopies can
examinations.

and

the diagnostic accuracy of transvaginal

hysteroscopy in diagnosing uterine
determine whether the number of
be reduced and replaced by tvs

Study design: retrospective study, data from 128 patients were

summarized who underwent tvs examination and hysteroscopy during
last two years. Specimens were obtained and sent for histopathological
examination. Sensitivity , specificity, positive and negative predictive
values for diagnosing uterine pathology were calculated for each method.

BY: Dana vitner,shlcmofilmer,Israel Goldstein,nizar khatib,zeev weiner

IN 2013.

RESULTS:
Hysteroscopy had a significantly higher sensitivity in diagnosing intrauterine fibroids while tvs had a significantly higher sensitivity in
diagnosing retained products of conception. Although hysteroscopy had
better predictive values for diagnosing uterine polyps the difference was
not statistically significant.
CONCLUSION:
TVS is an excellent tool in evaluating retained products of conception in
other cases of uterine pathology,diagnosis with hysteroscopy is needed to
improve diagnostic accuracy

2) Comparative study of transvaginal sonography and

hysteroscopy for the detection of pathological endometrial

lesions in women with perimenopausal bleeding

Objective
To estimate the diagnostic accuracy of two dimensional transvaginal
ultrasound and hysteroscopy compared with histopathology in evaluation
of uterine cavity lesions in perimenopausal women with abnormal
uterine bleeding.

Design
Descriptive diagnostic trial.

Setting
Cairo University Hospital. BY Waleed El-khayat, Mohamed Ehab Sleet,
Enas Yassen Mahdi in 2011

Materials and methods

A total of 50 patients with perimenopausal bleeding scheduled for 2D
TVS, hysteroscopy and histopathologic examination of tissue specimen.

Results:
The commonest bleeding pattern was menorrhagia (40%) followed by
menometrorrhagia in 34%, endometrial hyperplasia was found in about
half of these lesions and was associated with endometrial polyp in half of
the multiple lesions, endometrial hyperplasia was the most frequent
finding by TVS (32%) with a mean endometrial thickness of 11.2 2.4
mm followed by endometrial polyp (26%) with a mean endometrial
thickness of 18.0 5.3 mm. Using hysteroscopy the commonest lesion
diagnosed was endometrial polyp which was found in 28% of cases,
while endometrial hyperplasia found only in 20%. 2D ultrasound shows
good sensitivity in detection of endometrial polyp, highest specificity
and accuracy was for adenomyosis. Hysteroscopy was poorly sensitive
but highly specific for both endometrial hyperplasia and adenomyosis.
For endometrial polyp hysteroscopy was highly sensitive, specific and
accurate. Ultrasound was more sensitive and more accurate than
hysteroscopy for detection of uterine lesions but hysteroscopy show
higher specificity.

Conclusion:
For differentiating normal from abnormal endometrial cavity both 2D
TVS and hysteroscopy show high accuracy but U/S was more sensitive
and a little more accurate than hysteroscopy while the hysteroscopy was
more specific.
3) Comparison of transvaginal sonography, saline infusion

sonography, and office hysteroscopy in reproductiveaged women with or without abnormal uterine
bleeding
SefaKelekci, M.D.ErdalKaya, M.D., Murat Alan, M.D., Yasemin
Alan, M.D., Umit Bilge, M.D.,Leyla Mollamahmutoglu, M.D. in 2006

Objective:
To compare the diagnostic accuracy and acceptability of transvaginal
sonography (TVS), saline infusion sonography (SIS), and office
hysteroscopy (OHS) for detecting intracavitary abnormalities in women
with or without abnormal uterine bleeding (AUB).

Design
Prospective double-blind study.

Setting
Zekai Tahir Burak Womens Health Education and Research Hospital,
Gynecology Clinic (Ankara, Turkey).

Patient(s):
A total of 26 women with AUB and 24 women without AUB were
enrolled in this study.

Intervention(s):
Transvaginal sonography, SIS, and OHS were performed on women
scheduled for hysterectomy.

Main Outcome Measure(s):

Sensitivity, specificity, and positive and negative predictive values of
TVS, SIS, and OHS to detect intracavitary abnormalities (with
histopathologic findings used as the gold standard), duration of
procedure, and pain scores.

Result(s):
The sensitivity and specificity of TVS, SIS, and OHS in detecting
intracavitary abnormalities were 56.3% and 72%, 81.3% and 100%, and
87.5% and 100%, respectively. The prevalence of endometrial polyps
was not different in women with and without AUB. Saline infusion
sonography was less painful than OHS (pain scores of 4.3 and 7.2,
respectively).

Conclusion(s):
The diagnostic accuracy of SIS was equal to that of OHS in diagnosing
intracavitary abnormalities. Moreover, SIS was less painful than OHS for
patients.
4) Comparison of Office Hysteroscopy, Transvaginal

Ultrasonography and Endometrial Biopsy

Evaluation of Abnormal Uterine Bleeding

in

Lubna Pal, MD, L. Lapensee, MD, T.L. Toth MD, and K.B. Isaacson MD
(1997)

Objective:
A comparison between office hysteroscopy, transvaginal ultrasonography
and endometrial biopsy was performed, in terms of detection of
intrauterine lesions. A secondary objective was assessment of evaluatory
approach in the management of abnormal uterine bleeding in an
outpatient setting.

Design:
Prospective observational study.

Material and Methods:

A total of 54 women were evaluated for abnormal uterine bleeding.
Assessment included performance of an endometrial biopsy, a
transvaginal ultra-sound scan followed by office hysteroscopy. Results of
hysteroscopy were taken as the gold standard. Sensitivity and specificity
of the investigations were assessed. The bleeding pattern was classified
as heavy regular, irregular, postmenopausal and heavy or unscheduled
bleeding on hormone replacement therapy.

Results:
The incidence of focal intrauterine lesions in patients presenting with
abnormal bleeding was 52% for all ages and 31% for the
postmenopausal group. Seventy-five percent of the patients with Hb < 11
gm% and 67% with an enlarged uterus harbored a focal pathology. The
incidence of lesions in patients with heavy regular bleeding was 74%.
The sensitivity and specificity of transvaginal ultrasound when compared
with results of hysteroscopy was 0.60 and 0.88 respectively. A normal
endometrial biopsy had a negative predictive value of 51%. The
sensitivity and specificity of endometrial biopsy were 0.04 and 0.83,
respectively.

Conclusion:
Both transvaginal ultrasound and endometrial biopsy exhibited poor
sensitivity for detection of focal intrauterine lesions. Considering the
significantly high incidence of intrauterine lesions in patients presenting
with abnormal bleeding, the most cost-effective approach appears to be
proceeding with hysteroscopy early in assessment.

6.3

Objectives of the study

1) To evaluate the diagnostic accuracy of transvaginal sonography
(TVS) compared to hysteroscopy in diagnosing abnormal uterine
bleeding
2) To determine whether the number of diagnostic hysteroscopies
(invasive) can be reduced by TVS (non invasive) examinations

7
7.1

Materials and Methods

Source of data
The study will be conducted on 100 women fitting into the inclusion
criteria in the Department of Obstetrics and Gynaecology at Vydehi
Institute of Medical Sciences & Research Centre, Bangalore.

7.2

Method of collection of data (including sampling

procedure if any)
This Is a comparative observational study.
After obtaining written informed consent the following will be collected
on a detailed pre structured proforma.
1. Detailed history.
2. Clinical examination.
3. Transvaginal sonography
4. Hysteroscopy
5.Preoperative investigations

Sample Size: 100 women fitting into the inclusion criteria

will be selected.

INCLUSION CRITERIA:

1) Abnormal uterine bleeding

EXCLUSION CRITERIA:
1) Pregnancy
2) Virgin women
3) Pelvic inflammatory disease
4)Morbid medical illness

Methodology:
Basic steps of examination in patients include:
1. Written informed consent and counselling
2. Detailed history
3. Physical examination4.Transvaginal sonography will be done and findings will be recorded
5. Hysteroscopy will be done and findings will be recorded and biopsy
will be taken.
6. All the specimens collected will be sent for histopathological
examination
7.Preoperative investigations-CBC,Blood grouping,Thyroid function
test,renal function test ,ECG,X-RAY of chest,urine routine and
microscopy,bleeding time ,clotting time, HIV,HbsAg,VDRL
8.Statistical analysis is done for above.

Statistical analysis:
Sensitivity, specificity, and positive and negative predictive values of
transvaginal ultrasonography and hysteroscopy in detecting abnormal
uterine bleeding

7.3

Does the study require any investigations or interventions

to be conducted on patients or other humans or animal? If
so, please describe briefly.
YES

The investigations done in the cases selected for the study are :

Transvaginal ultrasonography

Hysteroscopy

Preoperative investigations: CBC,Blood grouping, Thyroid

function test,renal function test ,ECG, X-RAY of chest,urine
routine and microscopy,bleeding time ,clotting time,
HIV,HbsAg,VDRL

7.4

Has ethical clearance been obtained from your institution

in case of 7.3
YES

References
1)
Bingol B,
Gunenc MZ,
Gedikbasi A,
Guner H,
Tasdemir S,Tiras B. Comparison of diagnostic accuracy of saline
infusion
sonohysterography, transvaginal sonography and
hysteroscopy
in
postmenopausal
bleeding. Arch
Gynecol
Obstet.2011;284:111 117
2)

Sheetal G Patil, SB Bhute, SA Inamdar, Neelam S Acharya, Deepti

Role of diagnostic hysteroscopy in abnormal uterine bleeding and its

Histologic correlation. Journal of gynecological endoscopy and
Surgery. 2009; 1:98-104.

3)

Makris N, Skartados N, Kalmantis K, Mantzaris G, Papadimitriou

A, Antsaklis A .Evaluation of abnormal uterine bleeding by

transvaginal
3-D
hysterosonography and
diagnostic
hysteroscopy.Eur J Gynaecol Oncol. 2007;28(1):39-42.
4)
Erdem M, Bilgin U, Bozkurt N, Erdem A. Comparison of
transvaginal ultrasonography and saline infusion sonohysterography
in evaluating the endometrial cavity in pre- and postmenopausal
women with abnormal uterine bleeding. Menopause.2007;14:846852
.5)
GAO Wan-li,FENG Li-min,WANG Wei-juan,LIU Xiao-chun,LI
Jing-hua,WANG
Jun-mei.Comparison
between
transvaginal
ultrasonographic and hysteroscopic endometrial findings in
postmenopausal breast cancer tamoxifen-treated patients[J].China
Journal of Endoscopy,2006,12(10):1032-1034,1037.
6)
Pyari JS, Rekha S, Srivastava PK, Goel M, Pandey M. A
comparative diagnostic evaluation of hysteroscopy, transvaginal
ultrasonography and histopathological examination in cases of
abnormal uterine bleeding. J Obstet Gynaecol India.2006;56:240243
7)
Cepni I, Ocal P, Erkan S, et al. Comparison of transvaginal
sonography, saline infusion sonography and hysteroscopy in the
evaluation of uterine cavity pathologies. Aust N Z J Obstet
Gynaecol. 2005;45:3035
8).
Kelekci S,
Kaya E,
Alan M,
Alan Y,
Bilge U,
Mollamahmutoglu L. Comparison of transvaginal sonography, saline
infusion sonography, and office hysteroscopy in reproductive-aged
women with or without abnormal uterine bleeding. Fertil
Steril. 2005;(84):682686

Signature o f the candidate

10

Remarks of the guide:

FEASABLE AND RECOMMENDED

11.1

Name and designation of Dr. SHREEDHAR VENKATESH

PROFESSOR & HOD
the guide (in block
DEPARTMENT OF
letters) Guide

OBSTETRICSAND GYNAECOLOGY
VYDEHI INSTITUTE OF MEDICAL
SCIENCES AND RESEARCH
CENTRE, BANGALORE.

11.2

Signature

11.3

Head of the Department

11.4

Signature

12.1

Remarks of the
Principal

12.2

Signature

Dr. SHREEDHAR VENKATESH

PROFESSOR & HOD
DEPARTMENT OF
OBSTETRICSAND GYNAECOLOGY
VYDEHI INSTITUTE OF MEDICAL
SCIENCES AND RESEARCH
CENTRE, BANGALORE.