title: Does experience in hysteroscopy improve accuracy and inter-observer agreement in the management of abnormal uterine bleeding?
abstract: Hysteroscopic reliability may be influenced by the experience of the operator and by a lack of morphological diagnostic criteria for endometrial malignant pathologies. The aim of this study was to evaluate the diagnostic accuracy and the inter-observer agreement (IOA) in the management of abnormal uterine bleeding (AUB) among different experienced gynecologists.
  
  
  
  Each gynecologist, without any other clinical information, was asked to evaluate the anonymous video recordings of 51 consecutive patients who underwent hysteroscopy and endometrial resection for AUB. Experts (>500 hysteroscopies), seniors (20-499 procedures) and junior (≤19 procedures) gynecologists were asked to judge endometrial macroscopic appearance (benign, suspicious or frankly malignant). They also had to propose the histological diagnosis (atrophic or proliferative endometrium; simple, glandulocystic or atypical endometrial hyperplasia and endometrial carcinoma). Observers were free to indicate whether the quality of recordings were not good enough for adequate assessment. IOA (k coefficient), sensitivity, specificity, predictive value and the likelihood ratio were calculated.
  
  
  
  Five expert, five senior and six junior gynecologists were involved in the study. Considering endometrial cancer and endometrial atypical hyperplasia, sensitivity and specificity were respectively 55.5 % and 84.5 % for juniors, 66.6 % and 81.2 % for seniors and 86.6 % and 87.3 % for experts. Concerning endometrial macroscopic appearance, IOA was poor for juniors (k = 0.10) and fair for seniors and experts (k = 0.23 and 0.22, respectively). IOA was poor for juniors and experts (k = 0.18 and 0.20, respectively) and fair for seniors (k = 0.30) in predicting the histological diagnosis.
  
  
  
  Sensitivity improves with the observer's experience, but inter-observer agreement and reproducibility of hysteroscopy for endometrial malignancies are not satisfying no matter the level of expertise. Therefore, an accurate and complete endometrial sampling is still needed.
authors.affiliation: Department of Gynecologic Surgery, CHU Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand Cedex 1, France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Bourdel
authors.affiliation: Department of Gynecologic Surgery, CHU Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand Cedex 1, France. modaffari.paola@gmail.com.
authors.forename: Paola
authors.initials: P
authors.lastname: Modaffari
authors.affiliation: Department of Gynecologic Surgery, CHU Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand Cedex 1, France.
authors.forename: Enrica
authors.initials: E
authors.lastname: Tognazza
authors.affiliation: Department of Clinical and Evaluative Epidemiology, Centre for Health Services of Trento, Trento, Italy.
authors.forename: Riccardo
authors.initials: R
authors.lastname: Pertile
authors.affiliation: Department of Gynecologic Surgery, CHU Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand Cedex 1, France.
authors.forename: Pauline
authors.initials: P
authors.lastname: Chauvet
authors.affiliation: Department of Gynecologic Surgery, CHU Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand Cedex 1, France.
authors.forename: Revaz
authors.initials: R
authors.lastname: Botchorishivili
authors.affiliation: Department of Gynecologic Surgery, CHU Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand Cedex 1, France.
authors.forename: Dennis
authors.initials: D
authors.lastname: Savary
authors.affiliation: Department of Gynecologic Surgery, CHU Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand Cedex 1, France.
authors.forename: Jean Luc
authors.initials: JL
authors.lastname: Pouly
authors.affiliation: Department of Gynecologic Surgery, CHU Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand Cedex 1, France.
authors.forename: Benoit
authors.initials: B
authors.lastname: Rabischong
authors.affiliation: Department of Gynecologic Surgery, CHU Estaing, 1 Place Lucie et Raymond Aubrac, 63003, Clermont-Ferrand Cedex 1, France.
authors.forename: Michel
authors.initials: M
authors.lastname: Canis
mesh_terms: D001284:Atrophy; D002983:Clinical Competence; D004714:Endometrial Hyperplasia / Q000175:diagnosis; D016889:Endometrial Neoplasms / Q000175:diagnosis; D004717:Endometrium / Q000473:pathology*; D005260:Female; D006801:Humans; D015907:Hysteroscopy; D008875:Middle Aged; D015588:Observer Variation; D012680:Sensitivity and Specificity; D011795:Surveys and Questionnaires; D014592:Uterine Hemorrhage / Q000209:etiology; D014594:Uterine Neoplasms / Q000175:diagnosis; D014741:Video Recording
keywords: Abnormal uterine bleeding; Accuracy; Hysteroscopy; Inter-observer agreement; Reproducibility