Comparison of Transvaginal Ultrasound, Saline Infusion Sonohysterography Versus Diagnostic Hysteroscopy in Evaluation of Endometrial Cavity Pathology Amongst Women With Abnormaluterine Bleeding in Nairobi.a Prospective Cohort Study

Abstract

Background: Hysteroscopyiscurrently the gold-standardprotocol for evaluating patients with abnormal uterine bleeding (ABU).Unfortunately, though accurate, its adoptionin low-resource countries such as Kenya is limited due to lack of equipment and qualified personnel.As such, there is a need for an alternative diagnostic procedure that is as accurate as hysterectomy, but is also affordable, easy to administer,and acceptable by women with endometrial pathologies. Transvaginal Sonography (TVS) and Saline Infusion Sonohysterography (SIS) are proposed. However, their diagnostic accuracy versus hysterectomy have not been determined in Kenya. Objective: Compare the diagnostic efficacy of TVS and SIS versus diagnostic hysteroscopy in evaluation of endometrial pathology among pre-menopausal and post-menopausal women and to determine the etiology of AUB amongst these women. Methodology: A prospective cohort study was done at the Mediheal Minimal Access Surgery Hospital, Nairobi between May and September 2019.Forty patients referred for diagnostic hysteroscopy due to AUB were recruited using consecutive sampling, hospital files reviewed, and women who met our inclusion criteria consented and recruited until we reached our sample size. All participants underwentTVS, SIS and Diagnostic Hysteroscopy (DH) evaluation in the first half of the menstrual cycle and the findings recorded on a patient’s information sheet. The etiology of AUB was recorded. The sociodemographic and bleeding characteristics of patients and the outcomes of TVS, SIS, and DH evaluations were also recorded and data analysed using version 5 of the Software for Statistics and Data Science (STATA). The descriptive and health characteristics of patients were summarized and visualized in a table. Summary statistics on the etiology of AUB were presented in a table and a bar graph and the sensitivity of TVS and SIS versus DH as the gold-standard evaluated using two by two tables and the ROC curve. Results:The mean age of participants was 38.1±8.8 years, range of 25-71 years. A majority were nulliparous (62.5%), of African descent (75.0%), married (67.5%), and were unemployed (52.5%).Heavy Menstrual Bleeding (HMB)was reported in 70.0% of participants, while about 12.0%, 7.5%, and 7.5% had post-menopausal bleeding, amenorrhea, and hypomenorrhea. The incidence of submucosal fibroids and endometrial polypswere 17.5% and 15.0% via TVS, 47.5% and 20.0% via SIS and 52.5% and 20% via DH respectively. The overall sensitivity, specificity, PPV, NPV, and diagnostic accuracy of SIS was 92.1%, 83.3%, 96.9%, 62.5%, and 90.0% while TVS was 38.2%, 100%, 100%, 22.2%, and 47.5%. The sensitivity, specificity, PPV, andNPV of TVS in diagnosis of endometrial polyp was 75.0%, 100%, 100%, and 94.0%. SIS did better with asensitivity, specificity, PPV, and NPV of 100%, 100%, 100%, and 100%. Conclusion:With hysteroscopy as a reference, the sensitivity, NPV, and accuracy of SIS of 92.1%, 62.5%, and 90.0% was higher than TVS (38.2%, 22.2% and 47.5%). TVS demonstrated a higher specificity (100%) and PPV (100%) than SIS (83.3% and 96.9%) but could not detect synechia and endometrial cysts that were detected via SIS. Overall, SIS had a higher diagnostic accuracy than TVS and showcased a comparable diagnostic accuracy to hysteroscopy. Thus, it makes a suitable alternative technique for investigating AUB in pre/post-menopausal women.