{"paper_id":"8bb7b0a7-e384-475d-b66b-896d0c233556","body_text":"Up to one-third of women will experience abnormal uterine bleeding (AUB)\nin their life, with irregularities most commonly occurring at menarche and\nperimenopause. A normal menstrual cycle has a frequency of 24–38 days, lasts 7–9\ndays, with 5–80 millilitres of blood loss 1 .\nFibroids can either present as an asymptomatic incidental finding on\nimaging, or symptomatically. Common symptoms include abnormal uterine bleeding,\npelvic pain, disruption of surrounding pelvic structures (bowel and bladder), and\nback pain 2 .\nAdenomyosis is a gynecologic condition characterized by ectopic\nendometrial tissue within the uterine myometrium.The definitive treatment for women\nwho no longer desire pregnancy is hysterectomy, while a variety of other medical and\nminimally invasive therapies are available for those who want to preserve fertility\nor want to avoid more extensive surgery 3 .\nHysteroscopy is an essential diagnostic tool, particularly in cases\nwhere transvaginal ultrasound findings are inconclusive or equivocal. This is\nespecially relevant in evaluating suspected FIGO type 0, 1, and 2 submucosal myomas,\nwhere ultrasound may not clearly differentiate fibroids from endometrial polyps or\nother intracavitary lesions.\nHysteroscopy allows for direct visualization of the uterine cavity,\nproviding definitive identification of the number, size, and precise location of\nmyomas relative to the endometrial surface. In cases where ultrasound raises\nsuspicion but does not confirm the diagnosis, hysteroscopy can clarify the pathology\nand guide clinical decision-making, particularly when surgical planning or fertility\npreservation is a concern 4 .\nSimilarly, in patients with suspected subendometrial or internal\nmyometrial adenomyosis and inconclusive imaging, hysteroscopy can offer additional\ndiagnostic insights. While it is not the primary modality for diagnosing\nadenomyosis, it can reveal subtle endometrial surface irregularities, vascular\nanomalies, or cystic changes that may reflect underlying\ndisease 4 .\nThese findings, when correlated with clinical symptoms and imaging, can\nstrengthen diagnostic confidence. Thus, hysteroscopy holds significant diagnostic\nvalue as a second-line investigation when ultrasound does not provide definitive\nanswers, enhancing accuracy and helping tailor individualized management\nstrategies 5 .\nHysteroscopy is widely regarded as the gold standard for diagnosing and\ntreating intrauterine pathology and may be particularly beneficial for women with\ninfertility or recurrent pregnancy loss. While some guidelines and studies support\nits use as a routine screening tool during infertility evaluation, others advise\nlimiting its use to cases with specific clinical\nindications 6 .\nThe effectiveness of diagnostic or operative hysteroscopy in improving\nreproductive outcomes—especially in women with unexplained subfertility or suspected\nuterine cavity abnormalities, and in those undergoing IUI or IVF—remains uncertain,\nhighlighting the need for further high-quality research to clarify its role in\nenhancing fertility outcomes 6 .\nThe role of norethindrone acetate (NA) offers promise as an effective\nand well tolerated drug in the management of symptomatic adenomyosis. NA may be a\nmuch cheaper alternative to other treatment options for adenomyosis, with fewer and\nmilder side effects 7 .\nThe choice between regimens depends on the clinical goal where\ncontinuous use is better for menstrual suppression, while intermittent use is\npreferred for cycle regulation or short-term symptom relief. Continuous use may lead\nto more breakthrough bleeding initially, but better long-term control, whereas\nintermittent use maintains cyclic bleeding {Kaldewey, 2021 #2786}.\nThe current study aimed to evaluate the diagnostic accuracy of\nhysteroscopy in differentiating between uterine adenomyosis and fibroids. Also, to\ncompare between continuous versus intermittent administration of Norethindroneto\ncontrol both uterine adenoxmyosis and leiomymatosis.\n\nThis was a prospective study in the management of uterine leiomyoma and\nadenomyosis. This study has been conducted in the Department of Obstetrics and\nGynecology, Ghamra Military Medical Hospital in Cairo.\nThe duration of the study was from January 2021 to January 2023.\nClinical assessment with complete history taking and systemic examination of 100\npatients of reproductive age group was done and relevant findings were recorded with\ninformed consent.\nIn this study hysteroscopy was done in a minor operation theatre\nunder sedation to evaluate abnormal uterine bleeding and dysmenorrhea in the\nreproductive age group women suspected of fibroid or adenomyosis.\nPatients diagnosed by US who has submucous fibroid and adenomyosis\nwith age between 25 and 45 years old and Regular menstrual cycles before\nadministration of norethindrone.\nPregnancy and or breast-feeding women Patients with ovarian neoplasm, benign ovarian cyst\nincluding endometrioma Pelvic inflammatory disease or other endocrine\ndisease\nPregnancy and or breast-feeding women\nPatients with ovarian neoplasm, benign ovarian cyst\nincluding endometrioma\nPelvic inflammatory disease or other endocrine\ndisease\nAll patients were subjected to full history taking and clinical\nevaluation. Baseline blood tests included complete blood count, blood sugar,\nblood urea, serum creatinine and blood grouping. Abdominal and pelvic ultrasound\nand anesthetic fitness was obtained. Prophylactic antibiotics with third\ngeneration cephalosporins were given in pre operative and post operative\nperiod.\nHysteroscopy was done in the proliferative phase of the menstrual\ncycle. The procedure was done with administration of short intravenous\nanesthesia. It was done based on all standard guidelines The anterior lip of\ncervix comes to view and is holded with the volelsellam. The hysteroscopy is\nchecked before introducing for the eye-piece, objective lens, clarity and then\nintroduced through the vagina, ectocervix and the endocervical canal. Any lesion\nfound was documented.\nIllumination of the scope was provided by a high intensity cold\nlight source via a fibro optic cable and the procedure monitored through the\nvideo monitor. Then the hysteroscope was introduced into the uterine\ncavity.\nThe hysteroscopy was guided through the endocervical canal into the\nuterine cavity under vision, The Ostia of the tubes examined, then the\nendometrial surface was examined. All the surfaces of uterine cavity, that is\nthe anterior wall, posterior wall, and lateral walls were examined. The\nappearance of the endometrium, color, any polyps, fibroid, hyperplasia and\nvascularity noted.\nThe examination was considered complete when all parts were\nvisualized. If any difficulty in visualization due to blood clot was documented\nthen the procedure is considered as incomplete and failed. The hysteroscopic\nfindings was correlated with the histopathology results.\nTwo regimens were used by Norethindrone administration the 1st\nregimen as continuous manner from day 5 to day 21 46 patients (46%). The 2nd\nmanner was the intermittent type from day 16 and for 10 days 54 patients (54%).\nThe choice between regimens depends on the clinical goal where continuous use is\nbetter for menstrual suppression, while intermittent use is preferred for cycle\nregulation or short-term symptom relief.\nThe main study variables were chronic pain, dysmenorrhea or pain\nduring uterine bleeding assessed using the visual analog scale (VAS) at baseline\nand then after three months.\nThe study was conducted according to the principles of the\nDeclaration of Helsinki and was approved by the Hospital’s Ethics Committee\npurpose of the study was explained to all participants, and written informed\nconsent was obtained. The study was approved by Assiut Faculty of Medicine,\nInstitutional Review Board (IRB No. 17200648, 2021). The study was explained to\nall patients and only patients who were signing an informed consent were\nparticipated in study. This study was registered on clinicaltrials.gov with\nidentifier: ( NCT05153928 ).\nData entry, processing and statistical analysis was carried out\nusing MedCalc ver. 20 (MedCalc, Ostend, Belgium). Mean, Standard deviation\n(± SD) and range for parametric numerical data and compared with Student t test,\nwhile Median and Inter-quartile range (IQR) for non-parametric numerical data\nand compared by Mann Whiteny test. Frequency and percentage of non-numerical\ndata.\nStudent’s t test was used to assess the statistical significance of\nthe difference between two study group means. Chi-Square test was used to\nexamine the relationship between two qualitative variables. Logistic regression:\nuseful in the prediction of the presence or absence of an outcome based on a set\nof independent variables.\nThe ROC Curve (receiver operating characteristic) provides a useful\nway to evaluate the Sensitivity and specificity for quantitative Diagnostic\nmeasures that categorize cases into one of two groups. Confidence interval was\nkept at 95% and hence,  P  value was\nsignificance if < 0.05.\n\nCharacteristics of studied patients.\nData expressed as mean (SD), frequency\n(percentage).\nThis was a prospective cohort study conducted on 100 women with\nmean age was 41.3 years. A total of 50 (50%) of patients had dysmenorrhea, with\naverage VAS of (3.2 ± 3), (34%) had dyspareunia, with average VAS of\n(1.4 ± 0.9), (85%) had Menorrhagia, with average VAS of (3.9 ± 1.9), and (18%)\nhad Defecation pain, with average VAS of (0.9 ± 0.01).\nHysteroscopic and histopathological data and drug\nintervention.\nData expressed as mean (SD), frequency\n(percentage).\nRegarding Hysteroscopy data; 15 (15%) and 87 (87%) of patients had\nhysteroscopic appearance suggestive of adenomyosis and fibroid, respectively.\nHistopathology data; 15 (15%) and 85 (85%) of patients had adenomyosis, and\nfibroid, respectively.\nCharacteristics of patients based on\nhistopathology.\nData expressed as mean (SD), frequency (percentage).  P  value was significant\nif < 0.05.\n* p  < 0.05, ** p  < 0.01.\nPatients with adenomyosis had significantly longer duration of\nsymptoms. At baseline and during follow up as regard clinical data there was\nsignificant differences between both groups with exception of menorrhagia at\nbaseline.\nHysteroscopy and intervention based on\nhistopathology.\nData expressed as mean (SD), frequency (percentage).  P  value was significant\nif < 0.05.\n* p  < 0.05, ** p  < 0.01.\nThere was significant difference between both groups as regard\nhysteroscopic findings but both of them were comparable as regard drug\ntherapy.\nLogistic regression model for the Factors affecting\ndifferent clinical data.\nOther factors excluded from the model as ( P  value > 0.1). OR: odds\nratio.\n* p  < 0.05, ** p  < 0.01.\nThe decrease in age; and the increase in Adenomyosis in\nhysteroscopy; had an independent effect on increasing the probability of\ndysmenorrhea occurrence.\nThe decrease in age; and the increase in Gravidity, Duration of\nsymptoms and adenomyosis in hysteroscopy were predictors for dyspareunia\noccurrence.\nThe decrease in duration of symptoms; and the increase in\nadenomyosis in hysteroscopy were predictors of menorrhagia.\nThe increase in endometrial depth and adenomyosis in\nhysteroscopy were predictors for defecation pain.\nRoc-curve of hysteroscopy usage to predict\ndiagnosis.\nROC (Receiver operating characteristic), AUC; Area under\ncurve.\n* p  < 0.05, ** p  < 0.01.\nROC curve of hysteroscopy usage (Adenomyosis).\nROC curve of hysteroscopy usage (Fibroid).\nBy using ROC-curve analysis hysteroscopy usage had 73.33%\nsensitivity for prediction of adenomyosis and fibroid with 95.29% and 97.65%\nspecificity for prediction of adenomyosis and fibroid, respectively.\nRole of Norethindrone in each diagnosis.\n* p  < 0.05, ** p  < 0.01.\nBoth groups showed highly significant decrease in follow up\nmenorrhagia pain, in continuous norethindrone group.\nRoc-curve of Norethindrone administration to predict follow\nup obstetric data\nROC (Receiver operating characteristic), AUC; Area under\ncurve.\n* p  < 0.05, ** p  < 0.01.\nROC curve of Norethindrone administration (Menorrhagia\npain).\nBy using ROC-curve analysis, norethindrone administration showed\nnon-significant predictive values regarding dysmenorrhea, dyspareunia and\ndefecation pain except for menorrhagia pain with AUC was 0.793.\n\nIn the currents study, Roc-curve of hysteroscopy usage to predict\ndiagnosis; adenomyosis sensitivity was 73.33% and specificity 95.29% and fibroid\nsensitivity was 73.33% and specificity was 97.65%. Two regimens were used by\nNorethindrone administration the 1st regimen as continuous manner from day 5 to day\n21 46 patients (46%). The 2nd manner was the intermittent type from day 16 and for\n10 days 54 patients (54%). Both groups revealed; highly significant decrease in\nfollow up menorrhagia in continuous Norethindrone group ( P  < 0.001).\nBy using ROC-curve analysis; Norethindrone administration predicted\ndecreased menorrhagia pain with fair (70%) accuracy; sensitivity 80% and specificity\n81%.\nOutpatient hysteroscopy as a mode of diagnostic modality for abnormal\nuterine bleeding has gained popularity and is extremely encouraging. Its high\ndiagnostic reliability, less pain, minimally invasive, office procedure all these\nmake this diagnostic hysteroscopy an ideal method for diagnosis and also for follow\nup of patients with endometrial hyperplasia 8 .\nThe review of the studies about hysteroscopy in abnormal uterine\nbleeding and its meta-analysis showed that diagnostic hysteroscopy is accurate in\ndiagnosing intrauterine pathologies. It is highly sensitive and is useful\nclinically. Moreover, when compared to other studies 9 – 11 .\nOur review confirms that diagnostic hysteroscopy is safe and no\ncomplication has been in our study. Technical failures and patient discomfort were\nnot reported in any of the patients included in our study. All the patients taken\nfor the study underwent hysteroscopy successfully.\nHysteroscopy, a minimally invasive technique, allows direct observation\nof the endometrial thickness and color, the opening of the bilateral fallopian\ntubes, uterine angles, cavity shape, and cervical canal. Despite its growing\npopularity, hysteroscopy faces limitations in clinical practice, such as cost,\ntechnical complexity, invasiveness, and patient tolerance 12 .\nDing et al. 13  demonstrated that combining transvaginal\nultrasound, enhanced by the K-means clustering color image segmentation algorithm,\nwith hysteroscopy significantly increased diagnostic sensitivity.In diagnosing AUB\ncaused by endometrial polyps, the concordance rates for hysteroscopy and\ntransvaginal ultrasound were 93.3% and 77.3%, respectively, with the difference\nbeing statistically significant indicating hysteroscopy’s superior efficacy in\ndetecting endometrial polyps.\nThe concordance rates for diagnosing AUB caused by normal endometrium,\nuterine leiomyoma, malignant transformation of the endometrium, adenomyosis,\natypical hyperplasia, benign hyperplasia, and other factors did not show a\nstatistically significant difference between the two\nmethods 14 – 16 .\nThis discrepancy from previous findings may be attributable to factors\nsuch as small sample size. In diagnosing peri-menopausal AUB, transvaginal\nultrasound showed a sensitivity of 89.7%, a specificity of 66.7%, and a negative\npredictive value of 46.7%. Hysteroscopy demonstrated higher sensitivity,\nspecificity, and negative predictive value of 94.8%, 76.2%, and 66.7%,\nrespectively 16 .\nThe combined diagnostic approach yielded sensitivity and specificity\nrates of 97.4% and 81.0%, respectively, and a negative predictive value of 81.0%,\nsurpassing the individual use of transvaginal ultrasound and\nhysteroscopy 17 .\nThe consistency between transvaginal ultrasound results and the\npathological diagnosis was moderate (Kappa 0.475), while hysteroscopy showed\nsubstantial consistency (Kappa 0.669). The combined use of transvaginal ultrasound\nand hysteroscopy presented a higher consistency with the pathological diagnosis\n(Kappa 0.784), suggesting that this combined approach offers superior diagnostic\nefficacy in the evaluation of peri-menopausal AUB 18 .\nBettocchi reported his experience with more than 11,000 hysteroscopic\nprocedures performed using the vaginoscopic technique, eliminating the use of a\nspeculum and a tenaculum. He found that as many as 99.1% of the patients reported no\ndiscomfort related to the procedure. The mean pain score was significantly lower in\nthe group without the use of speculum 19 .\nThe current study had some limitations selection bias, being conducted\nin single center and relatively small sample size. These make difficulty in\ngeneralizability of such findings with need for further research.\n\nThe current study stated the important use of hysteroscopy in\nmanagement of abnormal uterine bleeding. Norethindrone looks a good alternative for\nmanagement of AUB cases. Future studies are warranted to assess these findings\nparticularly regarding the long-term effects and patient adherence to Norethindrone\ntreatment regimens.","source_license":"CC-BY-4.0","license_restricted":false}