Commentary

AUB, a common women’s health disorder, affects 20% of reproductive aged women. Diagnostic evaluations and treatment modalities for AUB are rapidly evolving.¹ The review by Farquhar et al was reported to be in premenopausal women; however, 3 studies did not report age. Distinguishing between postmenopausal and premenopausal women is important as pathological findings and patient satisfaction with TVUS, SH, and DH vary between these groups.²

This review concluded that SH and DH were better than TVUS for detecting submucous fibroids. This is not surprising because 3 dimensional SH provides better anatomical delineation, and DH affords direct intrauterine visualisation.

Common causes of AUB include submucous fibroids and endometrial polyps. The diagnostic onus in AUB is to exclude endometrial hyperplasia (EH) and endometrial cancer. SH and even DH with direct visualisation cannot reliably diagnose a malignancy without tissue biopsy. Therefore, the gold standard for diagnosis of EH or carcinoma remains tissue biopsy—either blind endometrial biopsy or directed endometrial biopsy done after SH or DH. Blind endometrial biopsy with TVUS is the most readily available technique, but the increasing availability of SH allows more specific anatomical endometrium detail and can diagnose endometrium polyps in postmenopausal women with AUB and normal TVUS results.² After excluding cancer, treatment of common benign lesions is the goal.

Cost effective analyses need to be done comparing these techniques including the more invasive but potentially therapeutic hysteroscopy with resection of polyps and submucosal fibroids. Typically, patients with a normal SH result are reassured and spared an endometrial biopsy, whereas patients with focal lesions can proceed with biopsy and/or therapeutic operative hysteroscopy. Patients who have normal SH results but continue to have AUB should still be considered for DH as it allows more complete visualisation of the cornual areas. Refinements in diagnosing the aetiology of AUB allows for increased options for targeted treatment, thus potentially reducing the number of hysterectomies, particularly in women with anatomically normal uteri.