Laboratory Studies

Preoperative laboratory studies include the following:

Complete blood cell (CBC) count: As in most surgical procedures, the CBC count provides the surgeon with information regarding the patient's baseline status and, if blood loss is encountered, with an idea of how much blood loss is acceptable. A blood count in the reference range also ensures adequate oxygenation to all vital and healing tissues and an adequate immune response.
Blood typing and screening: With the risk of hemorrhage approaching 7-8% in some surgical hysteroscopic procedures, a sample in the blood bank increases the efficiency of access to replacement blood products if needed.
Electrolyte determinations: In patients with medical disorders that predispose them to metabolic abnormalities (eg, diuretic use), electrolytes should be tested preoperatively. Some surgeons routinely obtain baseline levels in case a significant deficit of distention medium occurs (especially with a hyposmolar solution), whereas most obtain electrolyte levels intraoperatively or postoperatively only if a clinically significant fluid deficit occurs. The ultimate decision should be based on the type of case, the surgeon's skill, the suspected fluid absorption, and the ability to accurately ascertain fluid deficits in the operating room.
Determination of human chorionic gonadotropin (hCG) levels: Determination of pregnancy status is mandatory in any woman of reproductive age.
Cervical cultures: Depending on the prevalence of chlamydia and gonorrhea in the population, this may be a worthwhile preoperative test. Also, if the patient is reporting a vaginal discharge, cultures and a wet smear for bacterial vaginosis and trichomoniasis are recommended.
Papanicolaou test (Pap smear): A normal finding on Pap smear, or at least an abnormal finding on Pap smear that has been appropriately evaluated, is required because trauma to the cervix may alter the appearance of any abnormalities.

Hysterosalpingogram or sonohysterogram

For evaluating the uterine cavity and patency of fallopian tubes, hysterosalpingography is the superior study. However, to selectively look at the uterine cavity, sonohysterography or saline-infused sonography are superior. They have better negative and positive predictive values than those of hysterosalpingogram in determining the location and size of fibroids and endometrial polyps and for ascertaining the presence of most uterine anomalies, including septa, bicornuate uteri, didelphic uteri, and even dense adhesions.

Computed tomography (CT) or magnetic resonance imaging (MRI)

These imaging studies are not usually needed unless the findings on sonohysterography or hysterosalpingography are inconclusive. MRI is a useful modality for examining the uterine fundus when distinguishing between a septate and bicornuate uterus.

Diagnostic Procedures

Endometrial biopsy is indicated in perimenopausal/menopausal women and in women older than 35 years with irregular bleeding (eg, heavy menses, irregular spotting, prolonged menses) and in women with absent menses with at least 6 months of unopposed estrogen. It should be considered for women younger than 35 years who are suspected to have anovulatory bleeding, do not respond to medical therapy, or have prolonged unopposed estrogen exposure and for adolescent women with >2 year history of anovulatory bleeding, especially with risk factors (ie, obesity). In these women, the risk for endometrial hyperplasia or cancer is increased.

In any woman undergoing endometrial ablation, benign endometrial tissue should be pathologically confirmed.

Treatment & Management

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Author

John C Petrozza, MD Instructor, Department of Obstetrics and Gynecology, Harvard Medical School; Consulting Staff and Chief, Division of Reproductive Medicine and IVF, Vincent Memorial Obstetrics and Gynecology, Director, MGH Fertility Center, Massachusetts General Hospital

John C Petrozza, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, American Society for Reproductive Medicine, Massachusetts Medical Society

Disclosure: Received stock options from Interlace Medical, Inc. for board membership.

Coauthor(s)

Jill A Attaman, MD Instructor in Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School; Fellow, Reproductive Endocrinology and Infertility, Vincent Obstetrics and Gynecology Services, Massachusetts General Hospital

Jill A Attaman, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, American Society for Reproductive Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Michel E Rivlin, MD Former Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Chief Editor

Additional Contributors

Thomas Michael Price, MD Associate Professor, Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Director of Reproductive Endocrinology and Infertility Fellowship Program, Duke University Medical Center

Thomas Michael Price, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, Phi Beta Kappa, Society for Reproductive Investigation, Society for Reproductive Endocrinology and Infertility, American Society for Reproductive Medicine

Disclosure: Received research grant from: Insigtec Inc<br/>Received consulting fee from Clinical Advisors Group for consulting; Received consulting fee from MEDA Corp Consulting for consulting; Received consulting fee from Gerson Lehrman Group Advisor for consulting; Received honoraria from ABOG for board membership.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Gretchen E H Makai, MD and Emily Sikking, MD to the development and writing of this article.