Do we really need to hysteroscope all the women who have irregular bleeding on hormone replacement therapy?

To find out the importance of hysteroscopy in patients with irregular bleeding on HRT.

Retrospective case note analysis of women attending outpatient hysteroscopy clinic between 1 August 2000 and 31 July 2001.

A total of 352 patients were referred to hysteroscopy clinic at Castle Hill Hospital, UK. The mean age of the patients was 57 years (range 48–69 years). The mean duration of HRT usage was 3.5 years (range 2–10 years). Seventy-seven (22%) patients had irregular bleeding on HRT, where hysteroscopy showed normal endometrial appearance. All these patients underwent an endometrial biopsy. Eleven (14%) of the patients had an intrauterine polyp and a polypectomy was performed in each case. The histology results of the endometrial biopsy/polyp were as follows: 42 had atrophic or inactive endometrium; 11 had benign endometrial polyp; 10 had insufficient sample all in women with hysteroscopically normal endometrial cavities; 8 had HRT effect; and 6 had progestogenic effect. There were no cases of malignancy.

The incidence of significant pathology in patients with irregular bleeding on HRT is very low; however, benign polyps are common. It is better to adopt “see and treat” policy, where facilities are available. If facilities are not available, consider ultrasound scan or saline infusion sonohysteroscopy and target appropriately.