Hysteroscopic criteria for the diagnosis of chronic endometritis: a systematic review and diagnostic test accuracy meta-analysis

Gaetano Riemma, John Preston Parry, Pasquale De Franciscis, José Carugno, Davide Lettieri, Luigi Cobellis, Amerigo Vitagliano, Andrea Etrusco, Li‐Te Lin, Stefano Angioni, Salvatore Giovanni Vitale
In: American Journal of Obstetrics and Gynecology · 2025 · vol. 233(1) , pp. 12–24.e4 · doi:10.1016/j.ajog.2025.03.005 · PMID:40073921 · W4408284060
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This systematic review and meta-analysis evaluated hysteroscopic criteria for diagnosing chronic endometritis, synthesizing findings from diagnostic test accuracy studies to inform clinical practice.

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Abstract

ObjectiveTo assess the diagnostic accuracy of current hysteroscopic criteria compared with histopathological analysis (with or without additional immunohistochemistry) for the detection of chronic endometritis.Data sourcesMEDLINE, Scopus, SciELO, Embase, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, LILACS, conference proceedings, and international controlled trials registries were searched without date limit or language restrictions.Study eligibility criteriaStudies were selected if they were randomized, prospective, or retrospective and estimated the diagnostic accuracy of hysteroscopy for chronic endometritis by comparing hysteroscopic criteria with histopathological (with or without immunohistochemistry) diagnosis. Primary outcomes were the diagnostic odds ratio, area under the summary receiver operating characteristic curve, sensitivity, and specificity. Positive and negative likelihood ratios were secondary outcomes.MethodsDiagnostic accuracy meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Synthesizing Evidence from Diagnostic Accuracy Tests recommendations and Synthesizing Evidence from Diagnostic Accuracy Tests methodological guidelines. Quality assessment was conducted using the Quality Assessment Tool for Diagnostic Accuracy Studies 2. Publication bias was evaluated with Deeks funnel plot asymmetry test.ResultsThirteen studies compared available hysteroscopic criteria (stromal edema, diffuse or focal hyperemia, "strawberry aspect," micropolyposis) with subsequent histopathological analysis of endometrial sampling. After pooling all the studies, the diagnostic odds ratio was 40 (95% confidence interval, 12-133). The evaluated area under summary receiver operating characteristic curve was 0.93 (95% confidence interval, 0.90-0.95), correlating with very high diagnostic accuracy. Sensitivity and specificity were 84% (95% confidence interval, 0.68-0.93) and 89% (95% confidence interval, 0.75-0.95), respectively. In addition, the positive and negative likelihood ratios were 7.4 (95% confidence interval 3.2-17.0) and 0.19 (95% confidence interval, 0.09-0.39), respectively.ConclusionHysteroscopic diagnostic criteria are highly accurate and sensitive for detecting chronic endometritis. Absence of hysteroscopic suspicion might be sufficient to exclude disease. However, in cases in which hysteroscopic diagnostic findings of chronic endometritis are present, performing endometrial biopsy is recommended to confirm the diagnosis due to risk of false positives with hysteroscopy alone.

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