LAUSR

The menopause is a critical phase in every woman’s life, marked by permanent amenorrhea, the end of reproductive life and a marked decline in sex hormone production. Due to increased longevity of women worldwide, most will spend 30–40% of their lives in menopause. Between 4 and 11% of postmenopausal women will experience postmenopausal bleeding (PMB). As approximately 10% of such presentations are an indicator of endometrial cancer, all must be investigated. The majority of these presentations will be for benign conditions including cervical and endometrial polyps, myomas, endometrial hyperplasia trauma, cervical cancer and, most commonly, vaginal atrophy, all of which require careful diagnosis and management. Options for such investigation in the past have included office-based endometrial sampling devices, ‘blind’ dilatation and curettage (D&C), and, of course, ultrasound, which has vastly improved pre-interventional diagnosis. Today, hysteroscopy is considered the gold-standard procedure to evaluate the uterine cavity, especially in women with PMB or abnormal uterine bleeding (AUB). AUB is a frequently encountered complaint in gynecologic clinical practice, accounting for more than 70% of all gynecological consults in the perimenopausal and postmenopausal years. For this reason, it is essential to follow a diagnostic algorithm that starts with a thorough history-taking and physical examination, followed by imaging studies and blood test, and ends, when needed, with the evaluation of the uterine cavity with hysteroscopy. Such an evaluation enables differentiation of possible causes of AUB including structural pathology (polyps, adenomyosis, leiomyomas, malignancy and hyperplasia) and/or functional causes (coagulopathy, ovulatory dysfunction, endometrial abnormalities or iatrogenic reasons), as described in The PALM COEIN Classification, thus allowing the determination of appropriate therapy (which, in some cases, may only be expectant management). Hysteroscopy’s preeminent position amongst methodologies for the evaluation of intrauterine pathology in periand postmenopausal patients may be justified on several grounds. First, it offers direct visualization of the uterine cavity allowing for biopsy of suspected lesions that can often be missed, especially when focal, when performing blind procedures such as D&C. It also gives the opportunity to diagnose and treat frequently encountered conditions like polyps, myomas and synechiae during the same visit using the ‘see and treat’ approach. There is clear evidence that hysteroscopy with directed biopsy is a more sensitive diagnostic approach than D&C for patients presenting with intrauterine pathologic conditions. Second, hysteroscopy is quick, painless and less invasive, when compared to D&C, and may frequently be performed safely in an office/outpatient setting. Advances in technology have led to miniaturization of high-definition hysteroscopes without compromising image quality, thereby making hysteroscopy a simple and well-tolerated office procedure. Indeed, in a recent study, office hysteroscopy was successful without anesthesia in 76.4% of postmenopausal women, allowing a quicker recovery time. The technique of hysteroscopy is relatively easy to learn with a fast learning curve that may be further expedited with the use of virtual-reality simulators and training programs. The recent incorporation of new technologies such as hysteroscopic tissue removal systems, mini-resectoscopes, and innovative distension media delivery systems has revolutionized this procedure, allowing outpatient treatment of many women who previously were only treated in the operating room. As noted above, outpatient hysteroscopy causes minimal distress for the patients, avoiding the need for general anesthesia which represents an added risk in older patients with comorbid conditions. In conclusion, the modern development of hysteroscopy has completely transformed the diagnostic approach of uterine intracavitary pathologies, especially during menopause, moving from blind procedures performed under general anesthesia to in-office procedures performed under direct visualization, offering a comprehensive diagnosis and management approach that must be embraced by the gynecologist in clinical practice.