Context Hysteroscopy (direct endoscopic visualization of the endometrial cavity)
is used extensively in the evaluation of common gynecologic problems, such
as menorrhagia and postmenopausal bleeding. However, there is a continuing
debate about the value of this technology in the diagnosis of serious endometrial
Objective To determine the accuracy of hysteroscopy in diagnosing endometrial
cancer and hyperplasia in women with abnormal uterine bleeding.
Data Sources Relevant articles were identified through searches of the Cochrane Library,
MEDLINE, and EMBASE (1984-2001), manual searches of bibliographies of known
primary and review articles, and contact with manufacturers.
Study Selection Studies were selected blindly, independently, and in duplicate if accuracy
of hysteroscopy was estimated in women with abnormal uterine bleeding, using
histopathologic findings as a reference standard. Our search identified 3486
articles; 208 of these were deemed to be potentially eligible and were retrieved
for detailed data extraction. Sixty-five primary studies were analyzed, including
26 346 women.
Data Extraction Data were abstracted on characteristics and quality from each study.
Results for diagnostic accuracy were extracted to form 2 × 2 contingency
tables separately for endometrial cancer and endometrial disease (cancer,
hyperplasia, or both). Pooled likelihood ratios (LRs) were used as summary
Data Synthesis The pretest probability of endometrial cancer was 3.9% (95% confidence
interval [CI], 3.7%-4.2%). A positive hysteroscopy result (pooled LR, 60.9;
95% CI, 51.2-72.5) increased the probability of cancer to 71.8% (95% CI, 67.0%-76.6%),
whereas a negative hysteroscopy result (pooled LR, 0.15; 95% CI, 0.13-0.18)
reduced the probability of cancer to 0.6% (95% CI, 0.5%-0.8%). There was statistical
heterogeneity in pooling of LRs, but an explanation for this could not be
found in spectrum composition and study quality. The overall accuracy for
the diagnosis of endometrial disease was modest compared with that of cancer,
and the results were heterogeneous. The accuracy tended to be higher among
postmenopausal women and in the outpatient setting.
Conclusion The diagnostic accuracy of hysteroscopy is high for endometrial cancer,
but only moderate for endometrial disease (cancer or hyperplasia).