STUDY OBJECTIVE:To compare transvaginal ultrasound, hysteroscopy, and dilation and curettage (D&C) in the evaluation of women with perimenopausal and postmenopausal bleeding.DESIGN:Descriptive study (Canadian Task Force classification II-1).SETTING:Seven outpatient clinics.PATIENTS:One thousand two hundred eighty-six women.INTERVENTION:Transvaginal ultrasound, hysteroscopy, and D&C.MEASUREMENTS AND MAIN RESULTS:Of our patient population, 29 (2.26%) had a histologic diagnosis of endometrial carcinoma; in 2 of them (7.14%) endometrial thickness was 5 mm or less. In 10 women (34.5%), endometrial carcinoma was missed by hysteroscopy (sensitivity 65.52%, specificity 99.92%). Complication rate of D&C was 1.4%.CONCLUSION:In women with perimenopausal and postmenopausal bleeding neither transvaginal ultrasound nor hysteroscopy as a single diagnostic tool is suitable to rule out endometrial cancer.

OBJECTIVE:In order to assess the efficacy and tolerability of leuprorelin acetate depot in pre-operative flattening of the endometrium prior to hysteroscopic endometrial ablation, 94 patients from eight centres were included in the per protocol analysis.MATERIAL AND PATIENTS:The patients included were pre- or peri-menopausal, had completed their family planning and had intractable uterine bleeding. The primary target criterion was the reduction in maximum endometrial thickness after two injections of leuprorelin acetate depot with an interval of four weeks between injections. Surgery took place two weeks after the second injection.RESULTS:Sufficient pre-treatment was achieved in 91.5% of the patients with > 50% decrease and/or a type 1 endometrium according to sonographic and/or endometrial atrophy (Score 11) according to the central histological evaluation. The endometrium was flattened by a mean of 4.0 +/- 4.1 mm. In terms of clinical response, amenorrhoea, hypomenorrhoea or normal menstruation were achieved after endometrial ablation. Hence 91.5% of patients benefited from the overall treatment after six weeks and still 83% after six months. The trial medication was well tolerated overall. The most common side-effect described was hot flushes which could be attributed to the deliberate oestrogen withdrawal.CONCLUSION:In view of the good study results, hormone-suppressive pretreatment of the endometrium can be recommended prior to elective ablation. Surgery should take place during the oestrogen-suppressed phase.

In contrast to other countries, gynaecological ambulatory surgery in Germany today is mainly performed in private free-standing units. They perform approximately 98% of all ambulatory operations. A quality assurance programme in gynaecological ambulatory surgery started in the early 1980s and proved the safety of outpatient surgery in experienced hands. Gynaecological ambulatory surgery proved to be far more cost effective than inpatient operations. Independently specialised free-standing units seem to be able to work economically with a high level of quality. Due to the special legal situation in Germany the increasing number of outpatient operations led to a sharp drop in fees for individual operations. Quality assurance consists of many aspects. Most are well established and accepted. Apparently in ambulatory surgery the structural requirements of the operative unit, the organisation of postoperative care, the risk of thrombosis, the risk of infection and other aspects seem to be different to inpatient surgery. Comparative studies are required to investigate these differences. Only then it may be possible to optimise the integration of ambulatory surgery into the health system.

Internal and external tubal pathology are the decisive factors for evaluating tubal function. Salpingoscopy is the most reliable method to determine the mucosal status as the correlation of external and internal pathology is low. We performed distal salpingoscopies according to the method and classification described by Brosens et al on 253 tubes in 159 women and compared external pathology with intratubal findings. In 126 tubes without external pathology, only 2 cases showed moderate mucosal damage (class III), whereas 124 tubes had an intact mucosa (119 class I) or minor pathology (5 class II). Of 127 tubes with external pathology, the mucosa was determined to be class I in 51 cases, class II in 17, class III in 30, class IV (severe damage) in 22, and class V (severe damage) in 7. The correlation of external and internal damage is low. For example, we found that from 10 thin-walled hydrosalpinges, that was formerly a strong indication for microsurgical intervention, 4 showed severely damaged mucosa and were sent for in vitro fertilization (IVF), 3 showed moderate damage (mucosa class III), and only 3 had minor damage (mucosa class II). For complications, we observed four cases with slight bleeding from the fimbriae, two with slight damage of the mucosa, and one incomplete perforation of the tubal wall. We conclude that salpingoscopy should be performed whenever external pathology is detected in an infertility workup. It leads to better evaluation for either microsurgery or IVF. Microsurgical intervention can be avoided in cases with a poor prognosis. If no external pathology of the tube is detected salpingoscopy is not necessary.