Diagnostic Accuracy of Office Hysteroscopy and Three-Dimensional Transvaginal Ultrasonography in Women with Abnormal Uterine Bleeding

& Objective: Abnormal Uterine Bleeding (AUB) is a common gynecological complaint with multiple underlying causes, including structural uterine abnormalities. Accurate, minimally invasive diagnostic tools are essential for identifying intrauterine lesions and guiding appropriate management. The present study was conducted with aim to evaluate the diagnostic agreement between office hysteroscopy and three -dimensional transvaginal ultrasonography (3D TVS) in detecting intrauterine pathology among women presenting with AUB.

& Methods: This cross -sectional analytic study was conducted at the Department of Obstetrics and Gynecology, Kasr Al -Ainy Medical Hospital, Cairo University, from June 2021 to April 2023. Eighty women with AUB were evaluated using 3D TVS followed by office hysteroscopy. Findings from both modalities were recorded and compared for diagnostic correlation. Statistical analysis was performed using IBM SPSS (version 22.0). P<0.05 was considered statistically significant.

The mean age of participants was 28.6±8.8 years and mean BMI was 29.9±6.3 kg/m². Menorrhagia was the most common bleeding pattern (52.3%). Office hysteroscopy detected endometrial polyps in 38.3%, thickened endometrium in 14.1%, and fibroids in 12.8%, while 3D TVS identified polyps in 23.0%, fibroids in 14.1%, and adenomyosis in 11.5%. Diagnostic concordance between the two methods was highest for fibroids (71.4%) and niches (100%), while adenomyosis was detected only by 3D TVS.

Both office hysteroscopy and 3D TVS are effective for evaluating intrauterine pathology in AUB. Hysteroscopy remains the gold standard for focal lesions, whereas 3D TVS offers a reliable, noninvasive alternative with added value in detecting myometrial abnormalities.

Abnormal uterine bleeding , Office hysteroscopy, Three -dimensional transvaginal ultrasonography endometrial polyp , Fibroid, Adenomyosis, Diagnostic accuracy Received: 2025/10/28 Accepted: 2025/12/16 Published Online: 07 Apr. 2026 Corresponding Information: Sherif Hamada, Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt Email: [email protected] Copyright © 2025, This is an original open -access article distributed under the terms of the Creative Commons Attribution-noncommercial 4.0 International License which permits copy and redistribution of the material just in noncommercial usages with proper citation . 1. Introduction Abnormal Uterine Bleeding (AUB) represents one of the most common reasons for gynecological consultations among peri - and postmenopausal women, accounting for approximately 15% of all gynecologic visits (1). AUB is defined as uterine bleeding with abnormal duration, frequency, or volume adversely affecting a woman’s Quality of Life (QoL) and psychological well-being (2). The subjective perception of bleeding severity by women plays a crucial role in assessing the impact of AUB on QoL. However, self -reported bleeding often differs from objectively measured blood loss (3). Munro et al. , Reported that menstrual bleeding exceeding 80 mL, as well as any intermenstrual or postcoital bleeding, should be considered abnormal (4). However, 14% of women with mild to moderate bleeding perceive it as heavy, while 40% of those with objectively excessive bleeding regard it as normal. Pictorial Blood Assessment Charts can provide a semiquantitative evaluation of bleeding severity (2). Given that AUB may indicate underlying endometrial pathology including polyps, submucous myomas, endometrial hyperplasia, or carcinoma appropriate diagnostic evaluation is essential, even when systemic, iatrogenic, or hormonal causes are suspected (1). Transvaginal Ultrasonography (TVS) serves as a rapid, non -invasive, and cost -effective diagnostic method to evaluate uterine structure, detect fibroids, adenomyosis, and assess endometrial 395 Diagnostic Accuracy of Hysteroscopy vs 3D TVS in AUB Volume 11, May 2026 Journal of Obstetrics, Gynecology and Cancer Research thickness and morphology, including endo-myometrial interface (5). Office Hysteroscopy (OH) with high diagnostic accuracy for various intrauterine abnormalities allows direct visualization of uterine cavity and enables targeted sampling of suspected lesions (6). Technological advancements have established OH as a minimally invasive outpatient procedure, replacing blind intrauterine interventions under general anesthesia. This approach reduces complications, facilitates faster recovery, and minimizes healthcare costs by avoiding more invasive hospital -based procedures (7). Moreover, integration of diagnostic and operative hysteroscopy into a single “see -and-treat” session allows simultaneous evaluation and management without cervical dilation or anesthesia (6). The present study was conducted with aims to assess the diagnostic agreement between office hysteroscopy and Three-Dimensional (3D) transvaginal ultrasonography in women with AUB. 2. Materials and Methods This cross-sectional analytic study was conducted on 80 women presenting with AUB at the Department of Obstetrics and Gynecology, Kasr Al -Ainy Medical Hospital, Cairo University, between June 2021 and April 2023. Participants were selected from those attending the outpatient gynecology clinic during the study period. Women of reproductive or perimenopausal age presenting with AUB were eligible for inclusion. Exclusion criteria included hemodynamic instability, severe chronic anemia due to prolonged bleeding , known coagulation or bleeding disorders, cervical lesions or cervical malignancy, and pregnancy. Virgins were also excluded to avoid invasive procedures incompatible with their clinical condition. All participants underwent a standardized evaluation including comprehensive history taking, detailed clinical examination, and routine laboratory investigations. History taking encompassed demographic data, menstrual history, medical and surgical history, and relevant family history. Clinical examination involved a general assessment of the patient’s condition, measurement of height and weight for Body Mass Index (BMI) calculation, and evaluation of pulse rate and blood pressure. Abdominal examination included inspection for scars or distention and palpation to detect organomegaly or masses. Pelvic examination was performed in the lithotomy position using a Cusco s peculum to inspect the cervix and vaginal walls, followed by bimanual palpation to assess uterine size, shape, and mobility, as well as adnexal tenderness or masses. Routine laboratory investigations included a Complete Blood Count (CBC) and coagulation pr ofile to exclude systemic causes of bleeding. Transvaginal ultrasonography was performed for all subjects. Two -Dimensional (2D) Transvaginal Ultrasonography (TVS) was first performed using a General Electric (GE) Logic 200 ultrasound machine equipped with a 6.5 MHz transvaginal probe. The examination was performed in a low lithotomy position, and the uterus and adnexa were evaluated for structural abnormaliti es. Endometrial morphology, thickness, and contour were documented, with endometrial thickness greater than 14 mm considered abnormal. Any focal i ntrauterine lesions, such as endometrial polyps, submucous fibroids, or adenomyosis, were recorded. Subsequently, Three- Dimensional (3D) transvaginal ultrasonography was performed using the same ultrasound system equipped with a 3D transvaginal probe. The 3D examination aimed to confirm the findings observed in 2D TVS or to identify additional abnormalities not detected previously. T he final diagnosis was based on the comprehensive 3D ultrasonographic findings (9-12). Office Hysteroscopy (OH) was also performed for all participants during the early proliferative phase of the menstrual cycle (days 6 -10). The procedure was conducted in the outpatient hysteroscopy unit using a Karl Storz (Germany) rigid continuous -flow panoramic hysteroscope, 25 cm in length, with a 5 mm outer sheath and a 30° fiberoptic lens. Illumination was provided by a Circon Acmi G71A/Germany 150W metal halide light source. Uterine distension was achieved using saline or glycine solution under manometric control, maintaining an intrauterine pressure of 100 -120 mmHg. All patients received an intramuscular injection of nonsteroidal anti - inflammatory drugs (Voltarin 75 mg) 30 -60 minutes prior to the procedure for pain control. The vaginoscopic approach was employed without the use of a speculum or tenaculum. The hysteroscope was gently advanced under direct vision through the cervical canal into the uterine cavity. A panoramic inspection of the uterine cavity was performed, followed by detailed visualizati on of both tubal ostia and systematic assessment of the anterior, posterior, and lateral uterine walls. Any detected lesions, including endometrial polyps, submucous fibroids, or diffuse or focal endometrial thickening, were recorded. The primary outcome was the detection of uterine lesions using 3D transvaginal ultrasonography and office hysteroscopy. Agreement between both diagnostic modalities was analyzed to evaluate the accuracy of 3D TVS in identifying intrauterine pathology and i ts potential to reduce the need for further operative interventions, particularly among high-risk surgical patients. All data were coded, tabulated, and analyzed using IBM SPSS Statistics software (version 22.0) (IBM Corp., Chicago, USA, 2013) and Microsoft Excel 2007. Descriptive statistics were applied for quantitative variables as mean± Standard Deviation (SD) and range, and for qualitative variables as Mohamed El Mahy, et al. 396 Volume 11, May 2026 Journal of Obstetrics, Gynecology and Cancer Research frequencies and percentages. The Shapiro -Wilk test was applied to assess normality of distribution. Independent sample t -tests were used to compare quantitative variables with normal distribution between the groups. The Chi -square test or Fisher’s exact test was used for categorical variables, as appropriate. P<0.05 was considered statistically significant. 3. Results The mean age was 28.6±8.8 years (range: 20 -60), mean BMI was 29.9±6.3 kg/m² (range: 20 -43), and mean parity was 2.1±2.0 (range: 0 -6). Menorrhagia was the most frequent presentation (52.3%), followed by metrorrhagia (21.7%), menometrorrhagia (21.7%), and postmenopausal bleeding (6.4%), indicating that heavy cyclic bleeding was the predominant AUB type (Table 1). Hysteroscopy detected pathology in 77.0% of cases. The most frequent lesion was endometrial polyp (38.3%), followed by thickened endometrium (14.1%), fibroid (12.8%), niche (8.9%), and polyp with thickened endometrium (5.1%). No pathology was identified in 23.0% of patients. Three -dimensional TVS detected lesions in 80.8% of patients, identifying polyps in 23.0%, thickened endometrium in 14.1%, fibroids in 14.1%, adenomyosis in 11.5%, and niches in 8.9%. Combined lesions were observed in 7.7%, while 19.2% s howed normal findings. Hysteroscopy yielded higher detection of focal endometrial lesions, whereas 3D TVS better visualized myometrial pathology (Table 2). Among women with menorrhagia, hysteroscopy detected polyps in 54.7% and 3D TVS in 34.8%. In metrorrhagia, fibroids were the most frequent finding by hysteroscopy (60.0%) and 3D TVS (42.0%). In menometrorrhagia, thickened endometrium was most common by hysteroscopy (48.0%), while both fibroids and thickened endometrium were equally detected by 3D TVS (24.0%). In postmenopausal bleeding, hysteroscopy identified combined polyp with thickened endometrium in 81.6%, whereas 3D TVS demonstrated thickened endometri um in 100%. Hysteroscopy demonstrated greater sensitivity for focal lesions, whereas 3D TVS better detected diffuse myometrial involvement (Table 3). The overall diagnostic agreement between hysteroscopy and 3D TVS was high. Polyps showed 51.0% agreement between both modalities; fibroids demonstrated 71.4% concordance; niches were identical in all cases (100%). Thickened endometrium showed 37.0% agreeme nt, while adenomyosis was identified exclusively by 3D TVS in over half of cases initially labeled as normal on hysteroscopy. Among patients with no hysteroscopic pathology, 3D TVS detected additional abnormalities in 66.0%, primarily adenomyosis (Table 4). Table 1. Demographic and Clinical Characteristics of the Study Population (n=80) Variable Value Age (years) 28.6±8.8 (20-60) BMI (kg/m²) 29.9±6.3 (20-43) Parity 2.1±2.0 (0-6) Menorrhagia 42(52.3%) Metrorrhagia 17(21.7%) Menometrorrhagia 17(21.7%) Postmenopausal bleeding 5(6.4%) Values are presented as mean ±standard deviation (range) or number (percentage). BMI=Body Mass Index. Percentages are calculated based on the total study population (n=80). 397 Diagnostic Accuracy of Hysteroscopy vs 3D TVS in AUB Volume 11, May 2026 Journal of Obstetrics, Gynecology and Cancer Research Table 2. Diagnostic Findings by Office Hysteroscopy and 3D Transvaginal Ultrasonography (n=80) Finding Office Hysteroscopy n (%) 3D TVS n (%) Polyp 30.6(38.3) 18.4(23.0) Niche 7.1(8.9) 7.1(8.9) Fibroid 10.2(12.8) 11.2(14.1) Thickened endometrium 11.2(14.1) 11.2(14.1) Adenomyosis – 9.2(11.5) Combined lesions 4.1(5.1) 6.1(7.7) No identifiable pathology 18.4(23.0) 15.3(19.2) Values represent the number of cases and corresponding percentages based on total n=80. Combined lesions refer to the coexistence of two or more intrauterine abnormalities (e.g., polyp + fibroid ± adenomyosis). 3D TVS=Three-dimensional transvaginal ultrasonography. Table 3. Comparison of Office Hysteroscopy and 3D TVS Findings According to Bleeding Pattern Bleeding Type Hysteroscopy n (%) 3D TVS n (%) Menorrhagia (n=42) Polyp 23 (54.7), Niche 4 (9.9), Thick endometrium 3 (7.4), None 12 (29.8) Polyp 15 (34.8), Adenomyosis 3 (7.4), Combined 6 (14.8), None 12 (29.8) Metrorrhagia (n=17) Fibroid 10 (60.0), Polyp 4 (24.0), None 3 (18.0) Fibroid 7 (42.0), Adenomyosis 3 (18.0), Combined 3 (18.0), None 3 (18.0) Menometrorrhagia (n=17) Thick endometrium 8 (48.0), Polyp 3 (18.0), Niche 3 (18.0), None 3 (18.0) Fibroid 4 (24.0), Thick endometrium 4 (24.0), Polyp 3 (18.0), Niche 3 (18.0), Adenomyosis 3 (18.0) Postmenopausal (n=5) Polyp 1 (20.4), Polyp + Thick endometrium 4 (81.6) Thick endometrium 5 (100) Percentages are calculated within each bleeding type group. Combined findings indicate coexistence of multiple intrauterine abnormalities (e.g., polyp + fibroid or adenomyosis). None = No abnormality detected on either diagnostic modality. Table 4. Concordance Between Office Hysteroscopy and 3D TVS Findings (n=80) Hysteroscopic Diagnosis Corresponding 3D TVS Finding(s) Concordance (%) Polyp (n=31) Polyp 16 (51.0), Thick endometrium 3 (10.2), Fibroid/Adenomyosis 3 (10.2), None 9 (30.6) 51 Niche (n=7) Niche 7 (100) 100 Fibroid (n=10) Polyp + Fibroid 3 (31.0), Fibroid 7 (71.4) 71 Thick endometrium (n=11) Polyp 3 (28.0), Fibroid 4 (37.0), Thick endometrium 4 (37.0) 37 Combined lesions (n=4) Thick endometrium 4 (100) 100 No pathology (n=18) Combined 3 (17.0), Adenomyosis 9 (51.0), None 6 (34.0) 34 Concordance (%) indicates the proportion of identical findings between 3D TVS and hysteroscopy within each diagnostic category. Combined findings refer to overlap of structural lesions identified by both methods. “None” indicates cases where both diagnostic methods failed to identify intrauterine pathology. Percentages are rounded to one decimal point for clarity 4. Discussion Accurate evaluation of the uterine cavity is fundamental in identifying correctable causes of AUB. Structural intrauterine lesions such as endometrial polyps, submucous fibroids, and endometrial thickening significantly contribute to AUB and are often amenable to minimally invasive treatment once identified (9). The selection of precise, reproducible, and accessible diagnostic modalities is crucial for appropriate management. The purpose of the present study was to compare the diagnostic performance of office hysteroscopy and Mohamed El Mahy, et al. 398 Volume 11, May 2026 Journal of Obstetrics, Gynecology and Cancer Research Three-Dimensional Transvaginal Ultrasonography (3D TVS). Both methods were evaluated for their ability to detect intrauterine lesions and thereby minimize unnecessary surgical intervention, particularly among surgically high -risk patients. The mean age of participants in this study was 28.6±8.8 years, the mean BMI was 29.9±6.3 kg/m², and the mean parity was 2.1±2.0. These findings are consistent with similar studies in which participants presented with AUB during the reproductive or perimenopausal period. Nafad et al. , (2022) (1) reported a mean age of 49.4±1.22 years and parity of 3.12±1.6, while Ahmed et al., (2022) (13) and De Franciscis et al., (2019) (14) reported mean ages of 43.5±6.12 and 49.6±4.2 years, respectively. Similarly, Mohammad et al. , (2018) found a mean age of 36.5±9.57 years, BMI of 29.47±4.24 kg/m², and parity of 1.68±2.11, aligning with the present data (15). In the present study, menorrhagia was the predominant bleeding pattern, occurring in 52.3% of women, followed by metrorrhagia (21.7%), menometrorrhagia (21.7%), and postmenopausal bleeding (6.4%). Nafad et al. , (2022) (1) also reported menorrhagia as the most frequent presentation (31%), consistent with findings of other studies which noted comparable distributions of bleeding types among women with AUB (16,17). In the present study, hysteroscopy identified endometrial polyps as the most common finding (37.5%), followed by thickened endometrium (13.8%), fibroids (12.5%), and niches (8.8%). Combined lesions were noted in 5%, and no abnormalities were observed in 22.5%. These results are concordant with reports that establish hysteroscopy as the most sensitive tool for endometrial evaluation (15,16). As the results of the present study showed, Three - dimensional TVS also revealed endometrial polyps as the predominant lesion (22.5%), followed by thickened endometrium (13.8%), fibroids (13.8%), adenomyosis (11.3%), and niches (8.8%). Combined lesions, including polyp with fibroid or adenomyosis, were identified in 7.6%, and 18.8% had normal findings. The detection of adenomyosis by 3D TVS, which was not observed in hysteroscopy, underscores its advantage in assessing myometrial pathology. When comparing both modalities, 3D TVS missed 12 cases of endometrial polyps that were visualized by hysteroscopy, suggesting that while 3D TVS offers noninvasive structural evaluation, hysteroscopy remains the reference method for direct visualization of intrauterine path ology. This observation aligns with Aggarwal and Mishra (2022), who reported that hysteroscopy identified 65 cases (32.5%) with abnormalities compared to 40 (20%) by 3D TVS, with 13 missed cases of polyps (16). Similarly, Mohammad et al., (2018) found that 3D TVS detected abnormalities in 82% compared to 92% with hysteroscopy, reinforcing hysteroscopy’s higher diagnostic accuracy for endometrial lesions (15). Several studies have compared the diagnostic accuracy of 3D TVS with hysteroscopy. Van den Bosch (2010) reported 93% diagnostic accuracy for 3D TVS, with 96% sensitivity and 91% specificity in detecting uterine cavity lesions among women with AUB (18). Balen et al., (2010) confirmed that both 3D TVS and hysteroscopy accurately identified polypoid intrauterine structures, with near-perfect sensitivity and specificity (19). Conversely, Loverro et al. , (2001) reported 84.5% sensitivity and 98.7% specificity fo r sonography compared to hysteroscopy, with a positive predictive value of 98.0% (20). Collectively, these findings confirm the diagnostic utility of 3D TVS while emphasizing that hysteroscopy remains the gold standard for confirming intrauterine lesions. This study’s strengths include its cross -sectional analytic design, use of two validated diagnostic methods, and the absence of attrition during follow-up. All 3D TVS examinations were performed by a single sonographer independent of the hysteroscopy operator, who was blinded to imaging findings, thereby minimizing interobserver and intraobserver bias. This methodological rigor ensured consistency and reliability of the diagnostic comparisons. However, some limitations should be acknowledged. The relatively small, single -center sample size limits the generalizability of the results. The absence of histopathological confirmation as a diagnostic gold standard restricted the ability to fully validate imaging accuracy. Additionally, vascular and hemodynamic characteristics of endometrial lesions were not assessed with Doppler studies, which could have enhanced diagnostic precision. Future multicentric studies with larger cohorts and histopathological correlation are recommended to substantiate these findings. 5. Conclusion Both office hysteroscopy and 3D TVS are valuable diagnostic tools for evaluating intrauterine lesions in women with AUB. Hysteroscopy demonstrated superior detection of focal endometrial abnormalities, particularly polyps, while 3D TVS was advantageous for identifying adenomyosis and combined uterine pathologies. Given its noninvasiveness and diagnostic accuracy, 3D TVS serves as a reliable preliminary assessment, whereas hysteroscopy remains the definitive diagnostic modality. 6. Declarations Acknowledgments The authors gratefully acknowledge the invaluable academic support provided by Mahmoud M. Ali, ITMO University, Saint Petersburg, Russia, and ANCOVA for Clinical Research Solutions, Mansoura City, El Dakahilia Governorate, Egypt and the new branch in Saudi Arbia (https://ancova-research.com/). Their assistance encompassed comprehensive 399 Diagnostic Accuracy of Hysteroscopy vs 3D TVS in AUB Volume 11, May 2026 Journal of Obstetrics, Gynecology and Cancer Research literature retrieval, methodological and statistical guidance, data management, and critical input during manuscript preparation and revision. Ethical Considerations This study was conducted and reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for cross-sectional studies to ensure methodological rigor, transparency, and reproducibility (8). This study was reviewed and approved by the Research Ethics Committee (REC), Faculty of Medicine, Cairo University (Ethical Code: MD -237-2021). Written informed consent was obtained from all participants prior to inclusion in the study. Authors' Contributions All authors contributed substantially to the conception and design of the study, data acquisition, analysis, and interpretation. All authors participated in drafting, revising, and approving the final version of the manuscript and agree to be accountable f or all aspects of the work. Conflict of Interest The authors declare that there are no conflicts of interest related to this study. Fund or Financial Support This research received no specific grant from any funding agency in the public, commercial, or not -for- profit sectors. 1. Nafad M, Zakaria AEM, Abdel Fattah A A. The diagnostic function of office hysteroscopy and three-dimensional (3D) endometrial volume measurement in the evaluation of women with perimenopausal bleeding. Al -Azhar Int Med J. 2022;3:154–9. [doi:10.21608/aimj.2023.144105.1986] 2. Vitale SG, Watrowski R, Barra F, D’Alterio MN, Carugno J, Sathyapalan T, et al. Abnormal uterine bleeding in perimenopausal women: the role of hysteroscopy and its impact on quality of life and sexuality. Diagnostics (Basel). 2022;12(5):1176. 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