Abnormal bleeding is one of the most common gynecologic disorders that prompt a patient to consult a physician. This should not be a surprise, since most intrauterine abnormalities sooner or later generate this alarming symptom. The emergence of new indications and the resulting diversification in the use of hysteroscopy have tended to reduce the indications related to metrorrhagia in young women. In postmenopausal women in whom disease related to reproduction is minimal, abnormal bleeding constitutes the major indication for intervention. Of course, the number of hysteroscopies performed for abnormal bleeding will vary, depending on each physician’s particular orientation in the field of gynecology.

Metrorrhagia was the primary indication for hysteroscopy in 48% of the 500 cases published by Porto in 1974. It accounted for 49.6% of 320 patients reported by Sciarra and Valle in 1977. This symptom was the indication for hysteroscopy in 37.5% of 680 examinations performed by Hamou et al. In a series of 810 contact hysteroscopies we performed in patients with problems not related to pregnancy, abnormal bleeding was the main complaint in 64.8% of the cases. In a recent series of 1,500 hysteroscopies, it accounted for 52.1% of the patients. Essentially one hysteroscopy out of two is performed because of abnormal bleeding.

Bain et al. (2002) randomized women to either outpatient hysteroscopy and endometrial biopsy or endometrial biopsy alone. The addition of hysteroscopy in this series did not increase the accuracy of the biopsy although zero endometrial cancers were diagnosed in the 370 women participating in the study. Gebauer et al (2001) studied whether hysteroscopy improved the detection and extraction of
endometrial polyps in women with postmenopausal bleeding. The authors concluded that curettage was not sufficient for either detection or extraction of polyps. Hysteroscopy picked up 51 polyps among 83 women with postmenopausal bleeding or ultrasonographically thickened endometrium whereas curettage diagnosed 22.

Is the technique of hysteroscopy different when the investigation is performed because of abnormal bleeding? When the endoscopic examination is performed in the absence of blood, the technique is, of course, very straightforward and quite routine. To perform the examination during an episode of bleeding—either because of an emergency or because medical treatment cannot stop the bleeding—requires greater skill. The difficulties will be variable, depending on (a) the magnitude of the bleeding, (b) the available instrumentation, (c) the technique used, and (d) the experience of the hysteroscopist.

The case for emergency hysteroscopy is controversial. In the face of heavy uterine bleeding, the ability to see the entire cavity and to see accurately is questionable. The only medium that does not mix with blood and that permits a reasonably accurate hysteroscopic examination is Hyskon (dextran 32). Hysteroscopy does not in itself provide treatment for menorrhagia but may provide the vehicle through which treatment may be performed, e.g., endometrial ablation. Shalev et al. (2004) reported 41 cases in which emergency hysteroscopy was performed. In 40 cases, a benign, organic lesion was identified, and 1 case of endometrial cancer was diagnosed in the resection material. Quan et al. in China reported transcervical resection via hysteroscopy of placenta increta. This procedure is clearly dangerous and is not a recommended therapy for placenta accreta.

With CO₂ as the distending medium, the presence of blood can cause the formation of gas bubbles, which make vision hazy or may even obtund the whole field of view. Some artifices are useful to know to cope with this particular situation. It is advisable to use a hysteroscope sheath provided with a gas channel opening at the tip of the telescope. The gas flow will clear the optic surface, blowing away bubbles and blood. This device was described by Semm as having a windshield wiper effect (Fig. 22.1A). When this action is incapable of providing clear viewing, one should touch the end of the telescope to the mucosa of the uterine fundus. This simple maneuver often restores satisfactory vision (Fig. 22.1B). In cases of failure, it will be necessary to remove the instrument and clean the tip of the telescope with gauze soaked in sterile saline or water.
Another problem associated with profuse bleeding that causes poor vision is obstruction of the gas channel by blood clots. This causes the uterine cavity to collapse, and a red curtain appears to cover the front of the telescope. The obstruction may be confirmed by removing the endoscope and submerging it in liquid: No bubbles are produced. The gas channel is unclogged by connecting a syringe to the inflow stopcock and injecting liquid under pressure through it. In other circumstances, the field will remain clear but the gas pressure will force a pool of blood to spread out over the posterior wall of the uterine cavity and submerge the cornua. Abnormalities located in those areas will remain undetected until the blood is removed. The easiest remedy is to introduce a catheter connected to a syringe through the operating channel and aspirate the blood under visual control. In case of bubble formation, the hysteroscopist must remain patient. Sometimes, after a short wait, the field will suddenly clear up and the bubbles will disappear. This event can be hastened by varying the gas pressure (either increasing or decreasing it). Since the clear view of the uterine cavity may last only a short time, the endoscopist must be ready to make a rapid diagnosis. When vision is severely restricted to the point of precluding a complete and reliable investigation, another distention technique should be used.

The use of dextran as the distending medium is not common in Europe. Hyskon is worth trying in cases of severe bleeding either as the first technique or following the failure of CO₂. Hyskon flow is used first to clear the uterine cavity of blood; then, vision is maintained because of lack of miscibility of this solution with blood.

Another alternative is to use a contact hysteroscope. When the instrument maintains mucosal contact, bleeding is no longer a problem regardless of the quantity of blood within the uterine cavity. The only limitation to this instrument is the proficiency of the operator to interpret contact vision correctly. However, the increasing tendency when facing profuse uterine bleeding is to turn immediately to a technique of hysteroscopy using a low-viscosity liquid for continuous flushing of the uterus. This has been made possible by the development of multichannel sheaths with separate inflow and outflow channels that allow the liquid medium to cleanse blood and debris from the uterine cavity and, at the same time, to distend the uterus to obtain clear panoramic vision. These sheaths have been designed for operative hysteroscopy but can also be useful for diagnostic hysteroscopy. The only drawback is the large caliber of the sheath, which makes cervical dilatation necessary. A small-caliber dual-channel sheath designed only for diagnosis would be helpful in such cases. The type of low-viscosity liquid that is used for this procedure is not important, and many solutions are safe, among which saline, sorbitol, mannitol, glycine, and lactated Ringer solution are easily available. The short duration of a diagnostic examination rules out any risk of fluid overload.

The findings in a series of 768 hysteroscopies performed for abnormal bleeding appear in Table 22.1. During the women’s reproductive years, submucous myomas, endometrial hyperplasia, and endometrial polyps were the most common lesions detected (Figs. 22.2, 22.3, 22.4, 22.5). These accounted for more than half of all the findings (54% in this series). Pregnancy-related bleeding was the next most common diagnosis. In postmenopausal women, hyperplasia, polyps, and myomas were frequently found, as were endometrial atrophy and carcinoma (Figs. 22.6 and 22.7). Abnormalities that produce uterine bleeding are numerous and provide a microcosm of the whole catalog of intrauterine disease conditions. All cases of abnormal bleeding should be evaluated for pharmacologic and hemostatic factor deficiencies regardless of other suspected diagnostic possibilities.

Philipp et al. evaluated 115 women with an objective diagnosis of menorrhagia. Sixty-five women were between the ages of 20 and 44 years, 25 were adolescent, and 25 perimenopausal. Forty-seven of 115 women were anemic at the time of testing. Fifty-four of 115 women (47%) were found to have one or more hemostatic abnormalities, which included platelet aggregation, von Willebrand factor, and single-factor deficiencies.

Serebruany et al. (2005) analyzed the risk of bleeding complications after different doses of aspirin in 192,036
patients enrolled in 31 randomized, controlled trials. Low daily doses of aspirin (<100 mg) were associated with the lowest risk. Doses of aspirin of 325 mg or more per day were associated with significantly higher risks of major bleeding events.

Endometrial polyps, submucous myomas, and endometrial hyperplasia account for most benign intrauterine disease conditions. They have several features in common. The primary presenting symptom is usually abnormal bleeding. The
gynecologic examination, including speculum examination and bimanual palpation of the uterus, does not usually lead to their diagnosis. It is now well documented that the standard diagnostic procedures designed to detect and differentiate these lesions are unreliable. The interpretation of abnormal shadows appearing on the hysterogram is uncertain or wrong in 30% to 50% of cases. Dilatation and curettage cannot remove the fibroids and often misses the polyps. An accurate diagnosis is absolutely necessary to direct the correct treatment, which is in fact different for the three lesions.

Endometrial hyperplasia requires curettage followed by hormonal therapy to prevent recurrence. A more recent management of this disorder is to substitute the resectoscope for the curette and use the electrical loop to resect the extra mucosa. A polyp requires precise division of its
pedicle at the base either with endoscopic scissors, an electric loop, or a laser fiber (Fig. 22.8). However, when the size of the polyp is important, its resection in fragments is advisable to facilitate its extraction through the cervix. A pedunculated myoma can be managed as a polyp, but the sessile variety requires either hysteroscopic resection when the submucous component is present or laparoscopic or conventional surgical removal when it is entirely intramural. In the absence of accurate diagnosis, frustration is the rule and the patient history is characterized by recurrent bleeding, abnormal filling defects persisting on the hysterogram, and repetitive curetting, culminating in an unnecessary hysterectomy.