Visually Directed Hysteroscopic Biopsy in the Evaluation of Abnormal Uterine Bleeding and Postmenopausal Bleeding: A Joint Society Practice Guideline

To provide evidence-based recommendations for the histopathologic evaluation of patients with abnormal uterine bleeding (AUB) and postmenopausal bleeding (PMB).

Individuals presenting with AUB and PMB undergoing histopathologic evaluation for suspected intrauterine pathology, including endometrial polyps, submucosal myomas, endometritis, endometrial hyperplasia, atypical endometrial hyperplasia, endometrial intraepithelial neoplasia, and malignancy.

The AAGL, European Society for Gynaecological Endoscopy, and Global Community on Hysteroscopy convened to develop a joint society guideline that systematically reviewed the available evidence using the PICO (Patient, Intervention, Comparison, Outcome) framework. The intervention of interest was diagnostic hysteroscopy performed in outpatient or inpatient settings, including hysteroscopy alone, hysteroscopy combined with ultrasound, or hysteroscopy with biopsy. These approaches were compared with blind endometrial sampling performed without preceding hysteroscopy. The primary outcome was diagnostic accuracy, measured by sensitivity and specificity, using histopathology from endometrial sampling or hysterectomy specimens as the reference standard. Study quality and risk of bias were assessed using established methodological frameworks.

Meta-analyses results showed that hysteroscopy, with or without concomitant endometrial sampling, provided higher diagnostic accuracy than blind endometrial biopsy for detecting and excluding endometrial cancer, endometrial intraepithelial neoplasia, endometrial hyperplasia with or without cytological atypia, endometrial polyps and submucous myomas. Accuracy estimates were generally higher for detecting than excluding intrauterine pathology. Only 1 study compared hysteroscopy versus blind endometrial biopsy for endometritis, and no comparative data were available for other intrauterine conditions, including uterine niches or retained pregnancy tissue.

The available evidence supports hysteroscopy as a valuable diagnostic modality in the evaluation of AUB and PMB, particularly when imaging or endometrial sampling is inconclusive and when focal intrauterine pathology is suspected. Hysteroscopy demonstrates high diagnostic accuracy for pre-malignant and malignant endometrial disease, endometrial polyps and submucosal fibroids, and moderate accuracy for excluding these uterine pathologies. When endometrial tissue assessment is indicated in patients with AUB or PMB, sampling should be performed in conjunction with hysteroscopic evaluation, with visually directed biopsy favored over blind sampling. Hysteroscopy should therefore be incorporated into diagnostic algorithms for AUB or PMB.