Diagnosis of uterine bleeding

Abnormal uterine bleeding is a gynecological problem frequently seen in wom en from adolescence to the postmenopausal period. Nearly 70% of patients' v isits to the gynecologist in the peri- and postmenopausal period are due to abnormal uterine bleeding. Diagnostic procedures in the gynecologist's office differ greatly and depen d on the reproductive age of the individual patient. It is very important t o have precisely specified the type of bleeding disorder and in premenopaus al patients to differentiate between ovulatory and anovulatory cycles after excluding pregnancy. Taking a family history may provide information about familial coagulation disorders. Laboratory studies should include a pregna ncy test and possibly a diagnosis of any hormonal disorders. For decades the standard diagnostic procedure to distinguish between normal and pathological endometrium was dilatation and curretage. Various studies , however, have cast doubt on the reliability of this method since curettag e only reached less than half of the uterine cavity in 60% of cases and aft er hysterectomy endometrial carcinoma had not been diagnosed in 15% of case s by dilatation and curretage. The preferred diagnostic method in abnormal uterine bleeding is 5-mm hyster oscopy. With this method the whole uterine cavity can be visualized. In com bination with a targeted biopsy, almost 100% rates of sensitivity and speci ficity can be achieved. In particular, intrauterine polyps and submucosal m yomas,which are often missed with dilatation and curretage, can be diagnose d with certainty by hysteroscopy. Diagnostic hysteroscopy involves virtuall y no complications and can be performed on an outpatient basis in 94% of ca ses. Thanks to further improvements in the optics and reductions in the shaft di ameter, the "mini-hysteroscope," a flexible 2.4-mm optic, was developed, ma king dilatation of the cervical canal and any form of anesthetic unnecessar y in 98% of cases. Transvaginal sonography has proven to be a good means of screening to distinguish between normal and pathological endometrium. For such indications, it shows a 96% sensitivity and 86% specificity in premeno pausal patients with respect to hysteroscopic findings. Intrauterine change s cannot be differentiated with certainty on sonography and so any if there are any unusual finding, hysteroscopy should always be performed. Although some authors are in favor of sonohysterography, it has not yet gai ned clinical acceptance everywhere in Germany. By instilling saline solutio n in the uterine cavity a similarly high sensitivity in differentiating bet ween myomas and polyps can be reached as with hysteroscopy; however, specif icity is lower.