Determining the relationship between hysteroscopy and histopathological examination in abnormal uterine bleeding

Background: Abnormal Uterine Bleeding (AUB) is a common gynecologic condition that significantly affects women’s health, quality of life, and productivity. Accurate identification of the underlying pathology is essential to guide appropriate treatment. Hysteroscopy, as a minimally invasive procedure, allows direct visualization of the uterine cavity and targeted biopsy, while histopathology remains the definitive diagnostic tool. Objective: To assess the correlation between hysteroscopic findings and histopathological examination in women presenting with AUB and to evaluate the diagnostic accuracy of hysteroscopy in identifying intrauterine abnormalities. Methods: A prospective, hospital-based observational study was conducted at the Department of Obstetrics and Gynecology, Tikrit Teaching Hospital, from October 1, 2024, to June 30, 2025. Sixty women aged 21 to 50 years presenting with AUB were included. Detailed demographic data (age, parity, menopausal status) and clinical characteristics (type and pattern of bleeding, duration, and associated symptoms) were recorded. All participants underwent transvaginal ultrasonography, followed by diagnostic hysteroscopy and endometrial sampling. Hysteroscopic findings included normal endometrium, endometrial polyps, fibroids, proliferative or polypoidal endometrium, adenomyosis, adhesions, and endometritis. Histopathological analysis categorized the samples into proliferative, secretory, atrophic endometrium, chronic endometritis, hyperplasia, adenomyosis, leiomyoma, and endometrial polyps. Results: AUB was most prevalent in women aged 41-50 years (58.3%) and in those with 1-2 previous pregnancies (58.3%). Menorrhagia (36.7%) and menometrorrhagia (21.7%) were the most common bleeding patterns. On ultrasonography, 40.0% had normal findings, while 21.7% had a bulky uterus, and 18.3% had fibroids. Hysteroscopy showed a normal endometrium in 38.3% of cases, followed by endometrial polyps (16.7%), polypoidal endometrium (13.3%), and adenomyosis (8.3%). Histopathological evaluation revealed proliferative endometrium in 45.0% of patients, secretory endometrium in 28.3%, and endometrial polyps in 11.7%. There was high concordance between hysteroscopy and histopathology in detecting polyps (Kappa=0.95) and endometritis (Kappa=0.846), but poor agreement for hyperplasia (Kappa=-0.022). Hysteroscopy showed high sensitivity and specificity in detecting endometrial polyps (90.0% and 96.2%, respectively), adenomyosis (80.0% and 98.0%), and fibroids (85.7% and 100.0%). Conclusion: Hysteroscopy is an effective, reliable, and minimally invasive diagnostic procedure for evaluating women with AUB. It offers high diagnostic accuracy for structural intrauterine abnormalities, particularly polyps, fibroids, and adenomyosis. However, histopathological confirmation remains essential, especially in identifying hyperplasia or malignancy. Routine use of hysteroscopy can enhance early diagnosis and improve the clinical management of AUB.