Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




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On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Lucknow
On Sep 2018




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Calcutta National Medical College & Hospital , Kolkata




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Best regards,
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Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help oneĺs reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journalsľNo manuscriptsľNo authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2010 | Month : April | Volume : 4 | Issue : 2 | Page : 2175 - 2182 Full Version

Endovaginal Sonographic Evaluation of Postmenopausal Uterine Bleeding.


Published: April 1, 2010 | DOI: https://doi.org/10.7860/JCDR/2010/.700
KAUR M *, SINGH R**, SHARMA M***

*(M.D), Asstt. Prof. Radiodiagnosis , ** (M.D), Asstt. Prof, *** (M.D), Asstt. Prof Adesh Institute Of Medical Sciences & Research, Bathinda, (India).

Correspondence Address :
DR. Manjot Kaur,118/1 Gurjaipal Nagar, Jalandhar,(India).144001. Ph: 9779109999, 9815409999.E-mail: drmanjot@hotmail.com

Abstract

Aims and Objectives- To evaluate the role of endovaginal sonography (EVS) in postmenopausal women (PMW) with postmenopausal bleeding (PMB) and to correlate it with the histopathological diagnosis at curettage, so that unnecessary operations in postmenopausal women could be spared where sonography depicts normal findings.
Materials And Methods-The present study was conducted on postmenopausal women (PMW) with postmenopausal bleeding, who were referred to the department of Radio diagnosis by the department of Gynaecology of Adesh Institute Of Medical Sciences and Research, Bathinda. A total of 112 patients were observed from 2006 to 2008. A written informed consent was taken.
EVS was done to measure endometrial thickness in post menopausal women with postmenopausal bleeding (PMB).
Results-The mean endometrial thickness in PMW with PMB was 8.21┬▒6.88mm and in those without PMB was 3.83┬▒2.14mm.
With a cutoff value of 4mm endometrial thickness, EVS showed a sensitivity of 100%, specificity 73.33%, a positive predictive value of 76.47%, a negative predictive value 100% and an accuracy of 85.71%.
Conclusion- EVS is a useful method for screening for endometrial abnormalities and we recommend its use in women with postmenopausal bleeding.
Hence, unnecessary operations in postmenopausal women could be spared where the endometrium is ultrasonographically normal.

Keywords

Endometrial Thickness, Endovaginal Sonography (EVS), Postmenopausal Bleeding (PMB), Postmenopausal Women (PMW), Transvaginal Sonography (TVS).

Introduction
Menopause is the termination of the reproductive phase of life in a woman. Menopause is a greek word and means ‘men’ (month) and pause (cessation) i.e. cessation of menstruation. Vaginal bleeding occurring any time after six months of amenorrhea in a woman of menopausal age should be considered as post menopausal bleeding and should be investigated.

Endovaginal ultrasonography has provided new anatomical and pathophysiological information about the female organs. Because of the close proximity to the organ of interest and the higher insonating frequency, the resolution is dramatically improved (7).

Transvaginal Sonography (TVS) is an efficient and acceptable non-invasive method for the early detection of endometrial pathology in postmenopausal women. The thickened endometrium during menopause is the most significant ultrasonographical criterion implicating its pathology (24).

Approximately 80% of all curettage procedures performed for postmenopausal bleeding result in benign diagnosis, and therefore, if a non-invasive modality such as TVS can be accurately used to determine endometrial thickness and the measurement below which pathology is less likely, sampling must be avoided. TVS is found to perform slightly less accurately than MRI. The role of TVS is well established in the search for endometrial hyperplasia and carcinoma (14). The results of various studies have shown that the TVS measurement of endometrial thickness is currently used as a diagnostic tool in patients with postmenopausal bleeding. The studies consistently show that an ultrasonographically measured endometrial thickness of 4 or 5 mm or less almost completely excludes endometrial carcinoma (2),(5),(6),(8),(16),(18),(22),(25).

The advantage of TVS is that it can be performed with empty bladder and is convenient for the patient and at the same time, it is suitable for getting more correct gynecological diagnosis, especially in fatty women with a thick abdomen. TVS is superior to CT and approaches MRI in its ability to provide information about myometrial, cervical and perhaps, myometrial invasion of endometrial carcinoma. TVS is clinically established as the preferred technique for the evaluation of endometrial disorders, especially abnormal uterine bleeding (23).

Endometrial biopsy has been considered as a standard for the clinical diagnosis of endometrial disease among asymptomatic patients, but it is invasive, may be uncomfortable, and may not be able to be performed in some patients with cervical stenosis. Ultrasound evaluation is less invasive and more comfortable and can be performed in patients with cervical stenosis (13).

Material and Methods

The present study was conducted on postmenopausal women with PMB who were referred to the department of Radio diagnosis by the department of Gynaecology of Adesh Institute of Medical Sciences and Research, Bathinda, from 2006 to 2008.

Menopause was defined as one year of amenorrhea in the age of 40-50 yrs. Patients with PMB, at least 6 months after cessation of menstruation, were considered in the study. No hormonal parameters were used to characterize the women as postmenopausal. PMW on hormone replacement therapy were not included in the study. The patient’s other complaints, clinical examination and relevant investigations were recorded.

The study was approved by the ethical committee of A.I.M.S.R. Bathinda.

A written and informed consent was obtained. The study included 112 postmenopausal women with postmenopausal bleeding.
The patients were subjected to endovaginal sonography for evaluating endometrial thickness. TVS was performed on the Nemio (Toshiba, Tokyo, Japan) machine. The probe was a micro-convex device for conducting TVS. A permanent record was taken on a thermal paper roll on a Sony videographic printer.

Before TVS, the patient was asked to empty the urinary bladder. The examination was performed with the patient in the lithotomy position, with a pillow under the buttocks. The probe was placed inside a condom that contained coupling gel. Additional gel was placed on the covered probe.

The transducer was introduced into the posterior vaginal fornix and the uterus was scanned longitudinally and transversely. The thickness of the endometrium was measured at the thickest part in the longitudinal plane. It was measured from the highly reflective interface of the junction of the endometrium and the myometrium. This measurement represented two layers of the endometrium. In the presence of fluid in the endometrial canal, the two half thickness endometrial measurements were added together.
Correlation between the transvaginal sonographical findings of the endometrium was done with histopathological findings.

Statistics
The mean endometrial thickness and SD for each diagnostic category were calculated. Sensitivity, specificity, positive and negative predictive values and the accuracy of EVS in diagnosing endometrial abnormality at a certain cut off for this endometrial thickness, were calculated.


Observations
The present study included 112 postmenopausal women with PMB.

After taking the detailed history, all patients were subjected to thorough clinical examination. The history, clinical findings and biochemical investigations were recorded. All the patients were subjected to EVS and the findings were recorded and correlated with histopathological findings wherever applicable.

84 patients belonged to rural areas and 28 patients were from urban areas.

96 patients were indoor patients and 16 were outdoor patients.

The mean age of the patients was 57 ┬▒ 6.41 years. The maximum number of patients (80) were between 51-60 years of age.

The mean parity in the patients was 3.03 ┬▒1.59 (range 0-7).
The mean age of menarche in group A was 15.1 ┬▒ 0.86 (range 13-17 years).

A majority of the patients (85%) had regular menstrual cycles in their reproductive period. Only 15% patients had irregular menstrual cycles.

The mean age of menopause was 48.71 ┬▒ 2.37years.

In most of the patients (84) the duration of postmenopausal bleeding was from 6 months to 1 year. The lowest duration of postmenopausal bleeding was 2 months and the highest duration was 3 years.

The mean weight of the postmenopausal women was 62.57 ┬▒ 7.17 kg (range 45-81 Kgs). The maximum number of patients (60) had weight between 56-65 Kgs.

On per vaginum examination, bleeding per vaginum was found in 88 patients at the time of examination.

The maximum number of patients (56) in group A had atrophic uterus on P/V examination. Normal sized uterus was found in 20 patients and multiparous uterus was found in 28 patients.

Enlarged uterus was palpated in 8 patients.

The mean+- SD endometrial thickness in group A was 8.21+-6.88 mm (range 1.8-27.7mm). The maximum number of patients (50%) had endometrial thickness between 1 to 5mm as shown in (Table/Fig 1).



Fractional curettage was done in 57.15% cases and dilatation and curettage was done in 42.85% cases.

EVS and Histopathological Findings
Based on histopathological studies, endometrial atrophy was found in 60 patients, benign endometrial polyps in 12 patients, simple endometrial hyperplasia in 20 patients; endometrial carcinoma is 16 patients and pyometra in 4 patients as shown in (Table/Fig 2).



Additional findings as fibroids uterus (20 patients), nabothian follicles in cervix (20 patients), irregular thickened cervix which proved to be squamous cell carcinoma of cervix invading the myometrium on histopathology (4) and fluid in cul-de-sac (4) were noted.

With a cut off value of 4mm endometrial thickness, EVS showed a sensitivity of 100%, specificity of 73.33%, a positive predictive value of 76.47%, a negative predictive value 100% and an accuracy of 85.71%.

Discussion

EVS is better able to visualize and depict subtle abnormalities within the endometrium and to clearly define the endometrial-myometrial border (17). With high frequency vaginal transducers, the endometrium can easily be studied with regards to changes in the thickness. The thicker the endometrial lining on EVS, the higher the risk of endometrial disease (28).

In the present study, endometrial thickness was measured in postmenopausal women by transvaginal sonography, so that unnecessary interventions in postmenopausal women where the endometrium was ultrasonically normal could be spared. Correlation with endometrial histopathological findings was done.

The present study was conducted on 112 postmenopausal women with postmenopausal bleeding.

The present study showed that the median age for women with benign changes in the endometrium was found to be 56 years and the median age for women with malignant changes in the endometrium was 64 years, which is consistent with other studies (26). It also showed that the median age for women with malignant histological changes was 66 years and that for women with benign histological changes was 55 years.

In the present study, four out of six cases of endometrial carcinoma were nulliparous and the other two were multiparous. The mean parity of malignant cases was 1.6 ┬▒ 0.5 and that of non-malignant cases was 3.2 ┬▒ 1.55. This is similar to the observation made in other studies (3), (23) that nulliparity or low parity is a risk factor which is associated with endometrial cancer. The difference in parity between the women with benign and malignant changes was not significant, as the number of patients with endometrial carcinoma was very less in the present study.

In our study, the mean age of menarche in women with endometrial cancer was 14.8 ┬▒ 0.57 years and in non-malignant cases, it was 15.28 ┬▒0.84 years. The difference was not significant, which is similar to the findings of other studies (21). The mean age of menopause in six women with endometrial cancer was 51 years, which showed that late age of menopause is a risk factor which is associated with endometrial carcinoma (3),(23).
The study of the age of postmenopausal women at the time of study, age of menopause, duration of menopause and parity was not particularly rewarding.

In the present study, 48% postmenopausal women gave preference to EVS, 44% to TAS and 8% gave no such preference. TVS was actually preferred by a majority of patients because a full bladder was not required (27).

In the present study, endometrial thickness was measured from the highly reflective interface of the junction of the endometrium and the myometrium in the sagittal section. This measurement represented two layers of endometrium (12), (26), (28). In the present study, if there was fluid in the endometrial cavity then the two half thickness endometrial measurements were added together (15).

Our study showed that the mean ┬▒ SD endometrial thickness of 112 patients in group A was found to be 8.21 ┬▒ 6.88mm (range 1.8-27.7). 43% cases had endometrial thickness <4mm. This is similar to the findings of other studies (12), (21). The present study had 50% cases with endometrial thickness <5mm, 35.42% cases had endometrial thickness between 5-15mm and14.28% cases had endometrial thickness between 15-30mm (12).

Histopathological study was done after fractional curettage in 64 patients and after dilatation and curettage in 48 cases. Endometrial atrophy was considered as a normal finding.

Endometrial atrophy was found in 53% patients (Table/Fig 3). Out of these patients, 78.5% patients had endometrial thickness ≤ 4mm and 21% had endometrial thickness between 4-5mm. Two cases had endometrial thickness between 4-5mm and showed endometrial hyperplasia in the histopathological studies. Four patients with endometrial thickness between 6-8mm showed an atrophic endometrium at curettage. A possible explanation could be that the women had endometrial polyp which is often difficult to remove by blind curettage (12).


A high proportion of women with atrophic endometrium with atypical uterine bleeding which supports the suggestion that sclerotic vessel changes with consequent venous or arterial ruptures are the commonest causes of atypical postmenopausal bleeding (4).

Endometrial polyps were detected in 10.7% cases. The range of endometrial thickness as measured by EVS was 10.2-14.6mm and the mean was 12.61 ┬▒ 2.26mm. Endometrial polyps were diagnosed ultrasonically in 6 patients by the presence of a well defined local thickening of the endometrium with increased reflectivity, surrounded by a symmetrical area of low amplitude echoes. The cranial part of the uterine axis is thinner than the caudal part (20). All 12 cases of endometrial polyps were confirmed by histopathological examination.

In the present study, 28 patients showed a well defined, thick and highly reflective endometrium surrounded by an asymmetrical poorly reflective zone with a mean endometrial thickness of 11.92 ┬▒ 5.8mm and a range of 5.6-20.1mm. This picture was highly suggestive of endometrial hyperplasia (Table/Fig 4).



Histopathology revealed simple diffuse hyperplasia (cystic glandular hyperplasia) in 16 cases. No case of atypical hyperplasia was present. 8 cases of endometrial thickness between 6-8mm, turned out to be endometrial atrophy on histopathology and 4 cases with endometrial thickness 11.5mm, 12.4mm, 13.1mm and14.9 mm were found to be endometrial adenocarcinoma (Table/Fig 5).Four cases with endometrial thickness between 4-5mm on EVS were found to be endometrial hyperplasia by histopathological studies. The mean endometrial thickness in women with endometrial carcinoma was 19.23 ┬▒ 10.06mm (range 8.1-27.7). In our study, no endometrial carcinoma was found in endometrium ≤ 8mm (9).


In the present study, EVS correctly predicted carcinoma of the endometrium in 12 cases. The lesion appeared as an irregular, thickened, highly reflective area of endometrial lining, with loss of the surrounding symmetrical area of low amplitude echoes (20). Four cases showed uterine cavity distended with thick fluid, and pyometra was suspected. Biopsy showed invasive squamous cell carcinoma of the cervix in these cases and uterine cavity distended with pus.

The overall sensitivity and specificity of EVS to exclude endometrial pathology was found to be 93.3% and 100%, respectively (19).

At a cut off limit of 4mm endometrial thickness (endometrium >4mm indicating pathology), the sensitivity of the present study was 100% and the specificity was 73.3%. The positive predictive value was 76%, the negative predictive value was 100% and the accuracy was 85.71%. At a cut off limit of 5mm endometrial thickness (endometrium >5mm indicating pathology), the sensitivity of the present study was 92.3% and the specificity was 86.6 %. The positive predictive value was 85.71%, the negative predictive value was 92.86 % and the accuracy was 89 %, as shown in (Table/Fig 6).Two cases of endometrial hyperplasia would have been missed if a cutoff of 5mm was used. No case of endometrial carcinoma with a cut off of 5mm endometrial thickness was overlooked (1). No pathology was overlooked when a cutoff limit of 4mm was used. So curettage could be avoided in cases with endometrial thickness ≤ 4mm. The difference between the thickness of the atrophic endometrium as measured by vaginal ultrasonography and the thickness of the endometrium with carcinoma indicate that EVS could be used as a very simple method to exclude endometrial carcinoma as a cause of postmenopausal bleeding.



The cutoff limit of 4mm used in the present study is consistent with the cutoff limit used by other studies (10), (11), (12), (28). This indicated that when 4mm was used as a cutoff limit of the endometrial thickness measured vaginosonographically in a woman with PMB, endometrial abnormality could be excluded with reasonable certainty. EVS was also helpful in obese patients, in patients with a retroverted uterus and it bypassed obstacles such as bone, gas filled bowel and extensive pelvic adhesions.

The limitations encountered with EVS were, the limited maneuverability of the probe and the unorthodox position and angle of the transducer due to which correct orientation was difficult initially.

Conclusion

78% of the patients with endometrial atrophy had an endometrial thickness ≤4mm. No case with endometrial pathology had endometrial thickness ≤4mm.

We concluded that EVS is an excellent first step diagnostic method for excluding endometrial abnormalities in women with PMB. The changes in the thickness and texture of the endometrium as depicted by EVS correlated with subsequent pathological findings.

The accuracy of the present study at a cutoff value of 4mm endometrial thickness was 85.71%. Thus, in women with postmenopausal bleeding and an endometrial thickness ≤ 4mm, it is justified to refrain from curettage. The risk of endometrial pathology increases with an increase in the endometrial thickness, as measured by EVS.

The major limitation of EVS is the relatively small field of view. It is not possible to obtain a panoramic view of the pelvis. Our study showed that EVS is a useful method for screening for endometrial abnormalities and we recommend its use for women with postmenopausal bleeding.

Acknowledgement

The authors declare that there is no financial or other conflict of interest.

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