TITLE:
Comparison of Transvaginal Ultrasound, Saline Infusion Sonohysterography versus Diagnostic Hysteroscopy in Evaluation of Endometrial Cavity Pathology amongst Women with Abnormal Uterine Bleeding in Low Resource Setting
AUTHORS:
Jayni Dedhia, Gichuhi J. Wanyoike, Ojwang B. Shadrack, Madadi M. Obimbo, Rafique B. Parkar, Elijah Kwasa
KEYWORDS:
Abnormal Uterine Bleeding, Transvaginal Sonography, Saline Infusion Sonohysterography, Hysteroscopy
JOURNAL NAME:
Open Journal of Obstetrics and Gynecology,
Vol.10 No.5,
May
8,
2020
ABSTRACT: Introduction: Hysteroscopy is currently the gold-standard protocol for evaluating
patients with abnormal uterine bleeding (AUB). Unfortunately, though accurate,
its adoption in low-resource countries such as in Africa is limited due to lack
of equipment and qualified personnel. As such, there is a need for an alternative
diagnostic procedure that is as accurate as hysteroscopy, but also affordable,
easy to administer, and acceptable by women with endometrial pathologies. Transvaginal
Sonography (TVS) and Saline Infusion Sonohysterography (SIS) are proposed.
However, their diagnostic accuracy versus hysteroscopy has not been determined
in low resource setting. Objective: To compare the diagnostic efficacy of TVS and SIS versus diagnostic
hysteroscopy in evaluation of endometrial pathology among pre-menopausal and post-menopausal
women and to determine the etiology of AUB amongst these women. Methodology: A prospective cohort study was done at a hospital in Nairobi, Kenya
between May and September 2019. Forty patients with AUB were recruited using
consecutive sampling, and women who consented were recruited. The etiology of
AUB was recorded. All participants underwent TVS, SIS and Diagnostic
Hysteroscopy (DH) evaluation in the first half of the menstrual cycle and the
findings recorded on a patient’s information sheet. The sociodemographic and
bleeding characteristics of patients and the outcomes of TVS, SIS, and DH
evaluations were also recorded and the data was analysed using version 5 of the
Software for Statistics and Data Science (STATA). Summary statistics on the etiology
of AUB were presented and the sensitivity of TVS and SIS versus DH as the
gold-standard evaluated using two by two tables and the ROC curve. Results: The mean age of participants was 38.1 ± 8.8
years, range of 25 - 71 years. Heavy Menstrual Bleeding (HMB) was reported in
70.0% of participants, while about 12.0%, 7.5%, and 7.5% had post-menopausal
bleeding, amenorrhea, and hypomenorrhea. The incidence of submucosal fibroids
and endometrial polyps was 17.5% and 15.0% via TVS, 47.5% and 20.0% via SIS and 52.5% and 20% via
DH respectively. The overall sensitivity, specificity, Positive Predictive
Value (PPV), Positive Predictive Value
(NPV), and diagnostic accuracy of SIS were 92.1%, 83.3%, 96.9%, 62.5%, and 90.0% while TVS was 38.2%, 100%, 100%, 22.2%, and 47.5%. The
sensitivity, specificity, PPV, and NPV of TVS in diagnosis of endometrial polyp were 75.0%, 100%, 100%, and 94.0%. SIS did better with a sensitivity,
specificity, PPV, and NPV of 100%, 100%, 100%, and 100%. Conclusion: Our data suggests SIS had a higher diagnostic accuracy than TVS
and showcased a comparable diagnostic accuracy to hysteroscopy. SIS is more
suitable safe alternative technique for investigating AUB in
pre/post-menopausal women in low resource setting where hysteroscopy is
unavailable or unaffordable.