Diagnostic Evaluation of Postmenopausal Bleeding by Fibrohysteroscopy.

The most appropriate fibrohysteroscope is the smallest with which one can perform a biopsy. We use a 3.5- or 4.9-mm flexible hysteroscope during office or hospital ambulatory procedures without anesthesia or cervical dilatation. Our failure rate is below 3%. In a postmenopausal patient with uterine bleeding we do not perform hysteroscopy if the vaginal sonography (VS) detects an endometrial thickness less than 4 mm. At this cut-off limit the calculated risk for not detecting endometrial abnormality is 5.5%. In any other cases we prefer fibrohysteroscopy because its diagnostic accuracy is higher than that of VS, VS can miss focal lesion of hyperplasia or adenocarcinoma incipiens, and abnormal endometrial findings detected by VS and sonohysterography require a directed biopsy during hysteroscopy. A study compared the experience in France with 286 women, in Belgium with 25 women, and in Japan with 44 women. Apart from myoma, the most frequent findings were atrophic normal endometrium (49%), polyps (26.15%), hyperplasia (4.65%), and adenocarcinoma (1.7%). For the follow-up of these patients a decision tree is suggested with the use of VS or fibrohysteroscopy.