Skip to main content Accessibility help
  • Print publication year: 2014
  • Online publication date: June 2014

3 - Investigation


The purpose of uterine cavity evaluation is to make an accurate diagnosis of the cause of abnormal uterine bleeding, in order that therapy can be appropriately tailored to the woman. This chapter reviews the accuracy and efficacy of currently available tests used to evaluate the uterine cavity. Uterine size can be assessed on bimanual examination; if the uterus is greater in size than 12 weeks of gestation, it may be palpable abdominally. Women with amenorrhoea (no menstrual bleeding for 6 months) should have a full history and examination. Dilatation and curettage (D&C) used to be the method of choice for assessing the uterine cavity. Other methods for assessing the uterine cavity include hysteroscopy, ultrasound, Doppler ultrasound, and outpatient endometrial biopsy. Women presenting with postmenopausal bleeding require urgent referral for pelvic ultrasound and further testing, with endometrial biopsy and/or hysteroscopy undertaken depending on the initial ultrasound result.


1. Hospital Episode Statistics [].
2. MonaghanJM (editor). Rob & Smith’s Operative Surgery: Gynaecology and Obstetrics (4th ed.). London: Butterworths; 1983.
3. StovallTG, SolomonSK, LingFW. Endometrial sampling prior to hysterectomy. Obstet Gynecol 1989;73:405–8.
4. GimplesonRJ, RappoldHO. A comparative study between panoramic hysteroscopy with directed biopsies and dilatation and curettage. A review of 276 cases. Am J Obstet Gynecol 1988;158:489–92.
5. LofferFD. Hysteroscopy with selective endometrial sampling compared with D&C for abnormal uterine bleeding: the value of a negative hysteroscopic view. Obstet Gynecol 1989;73:16–20.
6. GrimesDA. Diagnostic dilatation and curettage: a reappraisal. Am J Obstet Gynecol 1982;142:1–6.
7. CooperNA, SmithP, KhanKS, ClarkTJ. Vaginoscopic approach to outpatient hysteroscopy: a systematic review of the effect on pain. BJOG 2010;117:532–9. Erratum in: BJOG 2010;117:1440.
8. Royal College of Obstetricians and Gynaecologists, British Society for Gynaecological Endoscopy. Best Practice in Outpatient Hysteroscopy. Green-top Guideline no. 59. London: RCOG; 2011 [].
9. van DongenH, de KroonCD, JacobiCE, TrimbosJB, JansenFW. Diagnostic hysteroscopy in abnormal uterine bleeding: a systematic review and meta-analysis. BJOG 2007;114:664–75.
10. ClarkTJ, GuptaJK. Handbook of Outpatient Hysteroscopy: A Complete Guide to Diagnosis and Therapy. London: Hodder Arnold; 2005.
11. ClarkTJ, VoitD, GuptaJK, HydeC, SongF, KhanKS. Accuracy of hysteroscopy in the diagnosis of endometrial cancer and disease: a systematic quantitative review. JAMA 2002;288:1610–21.
12. Smith-BindmanR, KerlikowskeK, FeldsteinVA, et al. Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities. JAMA 1998;280:1510–7.
13. Scottish Intercollegiate Guidelines Network. Investigation of Post-menopausal Bleeding. A national clinical guideline. Edinburgh: SIGN; 2002 [].
14. FarquharC, EkeromaA, FurnessS, ArrollB. A systematic review of transvaginal ultrasonography, sonohysterography and hysteroscopy for the investigation of abnormal uterine bleeding in premenopausal women. Acta Obstet Gynecol Scand 2003;82:493–504.
15. de KroonCD, de BockGH, DiebenSW, JansenFW. Saline contrast hysterosonography in abnormal uterine bleeding: a systematic review and meta-analysis. BJOG 2003;110:938–47.
16. ClarkTJ, BartonPM, CoomarasamyA, GuptaJK, KhanKS. Investigating postmenopausal bleeding for endometrial cancer: cost-effectiveness of initial diagnostic strategies. BJOG 2006;113:502–10.
17. BourneTH, CampbellS, WhiteheadMI, RoystonP, SteerCV, CollinsWP. Detection of endometrial cancer in postmenopausal women by transvaginal ultrasonography and colour flow imaging. BMJ 1990;301:369.
18. KurjakA, ShalanH, SosicA, et al. Endometrial carcinoma in post menopausal women: evaluation by transvaginal color Doppler ultrasonography. Am J Obstet Gynecol 1993;169:1597–603.
19. RodriguezGC, YaqubN, KingME. A comparison of the Pipelle device and the Vabra aspirator as measured by endometrial denudation in hysterectomy specimens: the Pipelle device samples significantly less of the endometrial surface than the Vabra aspirator. Am J Obstet Gynecol 1993;168:55–9.
20. ClarkTJ, MannCH, ShahN, KhanKS, SongF, GuptaJK. Accuracy of outpatient endometrial biopsy in the diagnosis of endometrial cancer: A systematic quantitative review. BJOG 2002;109:313–21.
21. ClarkTJ, MannCH, ShahN, KhanKS, SongF, GuptaJK. Accuracy of outpatient endometrial biopsy in the diagnosis of endometrial hyperplasia. Acta Obstet Gynecol Scand 2001;80:784–93.
22. National Institute for Health and Clinical Excellence. Heavy Menstrual Bleeding. NICE Clinical Guideline 44. London: NICE; 2007 [].
23. LewisBV. Diagnostic dilatation and curettage in young women. BMJ 1993;306:225–6.
24. MacKenzieIZ, BibbyJG. Critical assessment of dilatation and curettage in 1029 women. Lancet 1978;2:566–8.
25. FraserIS. Hysteroscopy and laparoscopy in women with menorrhagia. Am J Obstet Gynecol 1992;162:1264–9.
26. NathaniF, ClarkTJ. Uterine polypectomy in the management of abnormal uterine bleeding: A systematic review. J Minim Invasive Gynecol 2006;13:260–8.
27. CritchleyHO, WarnerP, LeeAJ, BrechinS, GuiseJ, GrahamB. Evaluation of abnormal uterine bleeding: comparison of three outpatient procedures within cohorts defined by age and menopausal status. Health Technol Assess 2004;8:1–139.