Endometrial polyps. An evidence-based diagnosis and management guide

Intrauterine adhesion

Intrauterine adhesions (IUA) occurred in the reproductive-age women are a big economic and health problem, resulting in severe impairment of social, psychological and physical function of the female genital organs. IUA-related symptoms or signs are varied greatly from free of symptoms or ambiguous symptoms (an incidental finding during the intervention) to ceased menstruation and loss of fecundability. The underlying pathophysiology is not completely understood, but intrauterine damage with broken basal layers of the endometrium formatting scar tissues or fibrosis in the endometrium with subsequently causing partial or complete occlusion of the uterine cavity may be a well-accepted hypothesis. Previously, infection is the most common cause to develop IUA, but now, intrauterine surgery may be a critical cause contributing to the majority of cases of IUA. In the current review, update information about the etiology, epidemiology, pathophysiology, sequelae and prevention of IUA will be renewed. We emphasize the importance of awareness of IUA, and primary prevention should be considered in the routine clinical practice if intrauterine surgery has been applied, based on uncertainty of ideal treatment for the established IUA and unpredictable outcomes after IUA treatment. So far, evidence supports that hyaluronic acid with/without other strategy is the most valuable and effective method to reduce the formation and re-formation of IUA as well as to achieve the best fertility outcome.

Effectiveness of Manual Hysteroscopic Tissue Removal Device for Intrauterine Polyps in Infertile Women in Both Operating and Office Settings

Background: Mechanical hysteroscopic tissue removal (mHTR) systems are widely used for removing intrauterine pathology. Given the startup and procedural costs for electrically powered mechanical units, disposable manual mHTR systems have been developed. Methods: With little published, we describe its effectiveness for hysteroscopic intrauterine polypectomy. Results: One-hundred fifty-seven infertile women underwent hysteroscopic polypectomy with the manual mHTR device. Complete removal was accomplished in all but three cases, with blood loss being <10 mL and all specimens deemed sufficient for histopathologic diagnosis. Conclusions: These results suggest that the disposable manual mHTR system is effective in removing endometrial polyps. Head-to-head comparisons with other alternative technologies are needed.

Abnormal Uterine Bleeding: A Pictorial Review on Differential Diagnosis and Not-So-Common Cases of Interventional Radiology Management

Abnormal uterine bleeding (AUB) poses a multifaceted challenge in women's health, necessitating an integrated approach that addresses its diverse etiologies and clinical presentations. The International Federation of Gynecology and Obstetrics PALM-COEIN classification system provides a systematic approach to the diagnosis of AUB in non-pregnant women, based on clinical and imaging-based categorization of causes into structural (Polyps, Adenomyosis, Leiomyomas and Malignancy; PALM), and non-structural causes (Coagulopathies, Ovulatory disorders, primary Endometrial disorders, Iatrogenic and Not otherwise classified; COEIN). On the other hand, placental disorders, uterine rupture, ectopic pregnancy and retained products of conceptions are the main causes of uterine bleeding during pregnancy and in the peripartum period. Ultrasound is usually the first-line imaging technique for the differential diagnosis of causes of AUB. Computed Tomography may be useful if ultrasound findings are unclear, especially in emergency settings. Magnetic resonance imaging, when indicated, is an excellent second-line diagnostic tool for a better non-invasive characterization of the underlying cause of AUB. This pictorial review aims to illustrate the main causes of AUB from the point of view of diagnostic imaging and to show not-so-common cases that can be treated by means of interventional radiology.

Guideline No. 447: Diagnosis and Management of Endometrial Polyps

OBJECTIVE

The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the diagnosis and management of endometrial polyps.

TARGET POPULATION

All patients with symptomatic or asymptomatic endometrial polyps.

OPTIONS

Options for management of endometrial polyps include expectant, medical, and surgical management. These will depend on symptoms, risks for malignancy, and patient choice.

OUTCOMES

Outcomes include resolution of symptoms, histopathological diagnosis, and complete removal of the polyp.

BENEFITS, HARMS, AND COSTS

The implementation of this guideline aims to benefit patients with symptomatic or asymptomatic endometrial polyps and provide physicians with an evidence-based approach toward diagnosis and management (including expectant, medical, and surgical management) of polyps.

EVIDENCE

The following search terms were entered into PubMed/Medline and Cochrane: endometrial polyps, polyps, endometrial thickening, abnormal uterine bleeding, postmenopausal bleeding, endometrial hyperplasia, endometrial cancer, hormonal therapy, female infertility. All articles were included in the literature search up to 2021 and the following study types were included: randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations).

INTENDED AUDIENCE

Gynaecologists, family physicians, registered nurses, nurse practitioners, medical students, and residents and fellows.

TWEETABLE ABSTRACT

Uterine polyps are common and can cause abnormal bleeding, infertility, or bleeding after menopause. If patients don't experience symptoms, treatment is often not necessary. Polyps can be treated with medication but often a surgery will be necessary.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Glandular Crowdings in Endometrial Polyps: Clinical Follow-Up and Possible Worrisome Features

INTRODUCTION

Interpretation of changes and premalignant lesions in endometrial polyps can be challenging. We evaluated the clinical course of patients with focal gland crowdings in endometrial polyps via repeat biopsies and searched for possible morphological findings in the initial biopsy that may foresee a premalignant course.

METHODS

Specimens diagnosed as endometrial polyp and focal gland crowding in patients who had a repeat biopsy in a 1-year period were reexamined. Morphological findings in the initial biopsies were recorded. The group whose repeat biopsies were "premalignant or malignant" (Group 1), and the group with "benign" repeat biopsies (Group 2) were compared.

RESULTS

"Endometrial polyp and gland crowdings" was diagnosed in 115 specimens of which 38 patients had repeat biopsies. Among these 8 (21%) were diagnosed as "endometrial intraepithelial neoplasia (EIN)" (Group 1) and 30 (79%) as "benign" (Group 2). Morphological features in the initial biopsies were evaluated; PAX2 loss was 6 of 8 (75%) for Group 1 and 7 of 30 (23%) for Group 2 (P = .020), and altered epithelial cytological features were present in 5 of 8 (62%) versus 4 of 30 (13%) (P = .015), both significantly higher in Group 1. Dark intraluminal secretion, intraluminal histiocytes, intraglandular epithelial proliferation, and mean diameter of crowded gland areas were not statistically different between the 2 groups.

CONCLUSION

"Focal gland crowdings" in endometrial polyps do carry a risk of EIN in subsequent biopsies. We suggest that the loss/decrease of PAX2 and altered epithelial cytological features in these areas in the initial biopsy are indicative of a premalignant course.

Role of Transvaginal Sonography in the Diagnosis of Female Infertility: A Comprehensive Review

Female infertility, a complex and emotionally challenging condition, impacts millions of women worldwide. Timely and accurate diagnosis is crucial for tailoring effective solutions to overcome fertility challenges. Transvaginal sonography, a real-time and non-invasive imaging modality, is pivotal in this diagnostic process. This review focuses on the structural abnormalities of the female reproductive system related to female infertility, particularly highlighting the capabilities of transvaginal sonography in assessing ovulatory disorders, structural anomalies, endometrial conditions, ovarian reserve, and other contributing factors. It is important to note that while transvaginal sonography excels in detecting structural abnormalities, it may not effectively identify lifestyle and hormonal changes. This limitation underscores the necessity for a comprehensive diagnostic approach that includes additional modalities to address the multifaceted nature of female infertility. Despite acknowledging the inherent limitations and operator dependence of transvaginal sonography, we emphasize its significance in guiding clinicians toward well-informed decisions and personalized treatment plans. Looking forward, we anticipate the continual evolution of sonographic technology, offering enhanced diagnostic capabilities. The commitment to improving fertility outcomes for individuals and couples navigating the intricate path toward parenthood remains paramount. In conclusion, a holistic diagnostic approach incorporating various modalities is essential for a thorough understanding and effective management of female infertility.

Endometrial polyps effect on pregnancy outcomes in infertile women with minimal/mild endometriosis: A retrospective study

OBJECTIVE

To assess the pregnancy outcomes and associated influencing factors of pregnancy after hysteroscopy combined with laparoscopy treatment in infertile patients with minimal/mild endometriosis.

DESIGN

A retrospective study.

SETTING

West China Second University Hospital of Sichuan University.

PATIENTS

We enrolled 898 infertile women who had their minimal/mild endometriosis lesions removed by laparoscopy, including 271 patients additionally diagnosed with endometrial polyps who also underwent hysteroscopic polypectomy.

METHODS

Based on the existence of endometrial polyps, patients with minimal/mild endometriosis were enrolled and divided into polyps group and non-polyps group.

MAIN OUTCOME MEASURES

Pregnancy outcomes.

RESULTS

A total of 271 women with minimal/mild endometriosis were included in polyps group while 491 women with minimal/mild endometriosis were included in non-polyps group. The pregnancy rate of polyps group was not statistically significant compared with non-polyp group (60.15% vs. 58.25%). The pregnancy rate was higher among patients with polyps ≥1 cm (76.06%, 54/71) than patients with polyps <1 cm (54.50%, 109/200) or patients without polyps (58.25%, 286/491) (p = 0.006). The pregnancy rate was higher for patients with multiple polyps (67.86%, 95/140) than for patients with single polyp (51.91%, 68/131) or without polyps (p = 0.025).

CONCLUSIONS

Among women with minimal/mild endometriosis, hysteroscopic polypectomy did significantly increase fertility in infertile patients with multiple polyps or size of polyp ≥1 cm compared with those without endometrial polyps, single polyp, and size of polyp <1 cm. The size and number of polyps were independently associated with the reproductive ability of women with minimal/mild endometriosis.

Evaluation of Comt2, Comt3, Cyp1b1, and Esr1 gene polymorphisms as risk factor for endometrial polyp

The aim of this study is to evaluate COMT2, COMT3, CYP1B1, and ESR1 gene polymorphisms and occurrence of endometrial polyps. In addition, we intended to evaluate the clinical and epidemiological features of patients with and without the presence of the disease, characterizing the possible risk factors. A cross-sectional study was performed, with a total of 309 women, including 236 in the group of women with endometrial polyp confirmed by hysteroscopy and anatomical pathological examination and 73 in the group of people with diagnostic hysteroscopy without abnormal findings from the macroscopic point of view. Polymorphisms of four genes were studied: COMT2 (rs4680), COMT3 (rs5031015), CYP1B1 (rs1056836), and ESR1 (rs2234693). Polymorphism genotyping was determined using real-time polymerase chain reaction. Considering the results, no differences were identified between the two groups with respect to age, body mass index, diabetes, dyslipidemia, or smoking. The group of women without endometrial polyps showed higher use of hormone therapy than the other group (16.4 percent versus 3.8 percent, p < .001). The COMT2, COMT3, CYP1B1, and ESR1 genes exhibited no significant difference for the occurrence of endometrial polyp between the two groups. The research concluded that no correlation was identified between the genetic polymorphisms evaluated and the presence of endometrial polyps.

Impact of estrogen and progesterone receptor expression on the incidence of endometrial polyps

Aim: We studied the association of estrogen receptor (ER) and progesterone receptor (PR) with endometrial polyp (EP) formation. Methods: A total of 129 EP patients and an equal number of disease-free women were evaluated for ER and PR expression in endometrial tissues. Correlation with EP incidence was analyzed, as well as diagnostic value via receiver operating characteristic curve. Results: ER expression was higher and PR was lower in patients than in controls (p < 0.01). ER levels positively correlated with EP incidence, and PR negatively (p < 0.01). Receiver operating characteristic curves gave ER an area under the curve of 0.6168 (95% CI: 0.5479-0.6856; p < 0.0001) and PR 0.739 (95% CI: 0.6776-0.8003; p < 0.0001). Conclusion: Imbalance in ER and PR expression associates with EPs formation, offering clinical insights into EP pathology.

Case report: septic shock after endometrial polypectomy with tissue removal system

As an emerging surgical technology, tissue removal systems have been widely used in the treatment of endometrial polyps due to its characteristics of less endometrial damage, shorter learning curve and clearer vision of the operative field. There are few cases in the literature reporting serious complications after endometrial polypectomy using tissue removal systems. As known, septic shock is a rare complication following hysteroscopic polypectomy. Now, we present the case of a 23-year-old woman who developed septic shock after polypectomy with tissue removal system. The patient had a history of recurrent vaginitis for more than half a year. Due to endometrial polyps, she was admitted to our hospital and scheduled to undergo hysteroscopic endometrial polypectomy. Three hours after the endometrial polypectomy using the tissue removal system, the patient had shock symptoms such as increased body temperature, decreased blood pressure and increased heart rate. Then, the patient was successfully treated and discharged after anti-infection and anti-shock treatments. The purpose of this case report is to remind clinicians to consider the possibility of serious infection and comprehensively evaluate the risk of infection before choosing hysteroscopic devices for endometrial polyps, especially for patients who choose the mechanical hysteroscopic tissue removal systems. Furthermore, the mechanical hysteroscopic tissue removal systems should be used with caution in patients with previous recurrent vaginitis.

The role of hysteroscopy in fertility preservation in endometrial cancer and atypical endometrial hyperplasia: a semi-systematic literature review

PURPOSE

Endometrial premalignancies are among the common reasons for outpatient gynecology visits among women in reproductive ages. Due to the continued increase in global obesity incidence among them, endometrial malignancies are expected to become even further prevalent. Hence, fertility-sparing interventions are essential and needed. In this semi-systematic literature review, we aimed to investigate the role of hysteroscopy in fertility preservation in endometrial cancer and atypical endometrial hyperplasia. Our secondary goal is to analyze the pregnancy outcomes following fertility preservation.

METHODS

We conducted a computed search in PubMed. We included original research articles including hysteroscopic interventions in pre-menopausal patients with endometrial malignancies and premalignancies who underwent fertility-preserving treatments. We collected data on medical treatment, response, pregnancy outcomes, and hysteroscopy.

RESULTS

Of the query results (n = 364), our final analysis included 24 studies. Overall, 1186 patients with endometrial premalignancies and endometrial cancer (EC) were included. More than half of the studies were retrospective design. They included almost ten different forms of progestins. Of the reported pregnancies (n = 392), the overall pregnancy rate was 33.1%. The majority of the studies used operative hysteroscopy (87.5%). Only three (12.5%) reported their hysteroscopy technique in detail. Although more than half of the studies did not provide any information on adverse effects due to hysteroscopy, there were no serious adverse effects among the reported ones.

CONCLUSION

Hysteroscopic resection may increase the success rate of fertility-preserving treatment of EC and atypical endometrial hyperplasia. The clinical significance of the theoretical concern of the dissemination of cancer is not known. Standardization of the use of hysteroscopy in fertility-preserving treatment is needed.

Clinical evaluation of a new hand-driven hysteroscopic tissue removal device, Resectr™ 5fr, for the resection of endometrial polyps in an office setting

PURPOSE

A first clinical evaluation of a new hand-driven hysteroscopic tissue removal device, Resectr™ 5fr, for office polypectomy without any anesthesia.

METHODS

Women with at least one small endometrial polyp were eligible. Hysteroscopic polypectomy was performed using the Resectr™ 5fr in an office setting, without any anesthesia.

RESULTS

One hundred and two hysteroscopic polypectomies were included in the analysis. The median installation time was 1.9 min (95% confidence interval (CI) 1.6-2.1). The median time to complete polyp removal was 1.2 min (95% CI 0.8-1.6). The median surgeon's safety, practical, and comfort scores on a 5-point Likert scale were high (5 (5-5), 5 (4-5), and 5 (4-5), respectively). Women's pain score was low (median 1 (0-3)), whereas the satisfaction rate was high (median 5 (5-5)), both on a 5-point Likert scale. There were two conversions (hysteroscopic scissors (n = 1), a new Resectr™ 5fr device (n = 1)). There was one incomplete procedure (tissue hardness).

CONCLUSION

Hysteroscopic removal of small polyps, using the [Formula: see text] 5fr in an office setting is feasible in terms of installation and resection time. Surgeon's practical, comfort, and safety scores are high, whereas women report low pain scores and high satisfaction rates.  TRIAL REGISTRATION: Dutch Clinical Trial Registry (NTR 7119, NL6923): https://www.trialregister.nl/trial/6923 . Date of registration: 27/03/2018.

Analysis of factors related to endometrial cancer in postmenopausal women with endometrial thickening

OBJECTIVE

To investigate the factors related to endometrial cancer (EC) in postmenopausal women with endometrial thickening and the value of endometrial thickness (ET) in predicting EC.

METHODS

A retrospective study of 385 referrals to our department for hysteroscopic diagnostic curettage assessment was carried out. Univariate analysis and multiple logistic regression analysis were used to identify the independent contributors to the development of EC. The ability of ET to predict EC was evaluated by receiver operating characteristic curve analysis.

RESULTS

The follow-up period from the identification of endometrial thickening to pathological confirmation of EC was from 2 weeks to 3 months. In the postmenopausal bleeding (PMB) group, a total of 47 participants' specimens were pathologically malignant. Older age and polypoid mass-like lesions ( P < 0.001) were independent factors associated with EC. The optimal critical value of ET in predicting EC was 9.5 mm, with a sensitivity and specificity of 70.21% and 70.67%, respectively. In the non-PMB group, six participants had evidence of malignant pathology, and only polypoid mass-like lesions were an independent factor associated with EC ( P < 0.001).

CONCLUSIONS

For postmenopausal women with increased ET and PMB, older age, thicker ET, and polypoid mass-like lesions on transvaginal ultrasound were independent associated factors for EC. An ET greater than 9.5 mm is a threshold for predicting EC. For postmenopausal women with increased ET without PMB, the incidence of endometrial malignancy is low. If the woman has polypoid mass-like lesions on transvaginal ultrasound, she should receive further attention.

Contemporary evaluation of women and girls with abnormal uterine bleeding: FIGO Systems 1 and 2

Abnormal uterine bleeding (AUB) is common, often debilitating, and may affect over 50% of reproductive-aged women and girls. Whereas AUB is a collection of symptoms that include intermenstrual bleeding and abnormalities in period duration, cycle length, and regularity, it is heavy menstrual bleeding (HMB) that is most contributory to iron deficiency and related anemia. It is apparent that AUB, in general, and HMB, in particular, remain underrecognized and underreported. FIGO created two systems for assessing and classifying AUB. FIGO System 1 defines the bleeding pattern using four primary descriptors: frequency, duration, regularity, and flow volume. FIGO System 2 provides a structured classification system of possible causes of AUB, using the acronym PALM-COEIN. "PALM" refers to structural causes of AUB (Polyp, Adenomyosis, Leiomyoma, Malignancy), and "COEI" refers to nonstructural causes (Coagulopathy, Ovulatory dysfunction, Endometrial, and Iatrogenic). The "N" is reserved for those entities that are currently not otherwise classified. Using FIGO System 1 as a gateway to FIGO System 2 streamlines the investigation of reproductive-aged women and girls with AUB. Understanding the pathogenesis of the FIGO System 2 "PALM-COEIN" causes helps interpret investigations and the onward management of AUB. Numerous evidence gaps exist concerning AUB; however, if researchers and trialists universally adopt FIGO Systems 1 and 2 for the assessment and diagnosis of AUB, clear translatable research findings can be applied globally.

A novel machine learning model for predicting clinical pregnancy after laparoscopic tubal anastomosis

BACKGROUND

Laparoscopic tubal anastomosis (LTA) is a treatment for women who require reproduction after ligation, and there are no reliable prediction models or clinically useful tools for predicting clinical pregnancy in women who receive this procedure. The prediction model we developed aims to predict the individual probability of clinical pregnancy in women after receiving LTA.

METHODS

Retrospective analysis of clinical data of patients undergoing LAT in the Second Hospital of Lanzhou University from July 2017 to December 2021. Least absolute shrinkage and selection operator (LASSO) regression was used for data dimension reduction and feature selection. We incorporated the patients' basic characteristics, preoperative laboratory tests and laparoscopic tubal anastomosis procedure signature and obtained a nomogram. The model performance was evaluated in terms of its calibration, discrimination, and clinical applicability. The prediction model was further internally validated using 200 bootstrap resamplings.

RESULTS

A total of 95 patients were selected to build the predictive model for clinical pregnancy after LTA. The LASSO method identified age, intrauterine polyps, pelvic adhesion and thyroid stimulating hormone(TSH) as independent predictors of the clinical pregnancy rate. The prediction nomogram included the abovementioned four predictive parameters. The model showed good discrimination with an area under the curve (AUC) value of 0.752. The Hosmer‒Lemeshow test of calibration showed that χ2 was 4.955 and the p value was 0.838, which indicates a satisfactory goodness-of-fit. Decision curve analysis demonstrated that the nomogram was clinically useful. Internal validation shows that the predictive model performs well.

CONCLUSION

This study presents a nomogram incorporating age, intrauterine polyps, pelvic adhesion and TSH based on the LASSO regression model, which can be conveniently used to facilitate the individualized prediction of clinical pregnancy in women after LTA.

Association of endometrial polyps with STC-1 and STC-2 in infertile patients

OBJECTIVE

The present study aimed to evaluate the impact of endometrial polyps (EPs) on the endometrium of patients with unexplained infertility using stanniocalcin-1 and -2 proteins (STC), whose effects on endometrial receptivity have been reported recently.

MATERIALS AND METHODS

A case-control study was performed, consisting of 26 patients who underwent endometrial sampling for diagnosis and/or treatment and diagnosed with EP on biopsy and/or excision material, and 23 patients with normal endometrial findings in the pathology, for a total of 49 patients with unexplained infertility. An immunohistochemistry examination was performed on paraffin-embedded tissue samples from both groups to understand whether there was a relationship between EP and STC. Staining results of the polyp and control groups for STC-1 and STC-2 were compared, and it was investigated whether STCs were predictive for EP.

RESULTS

In the comparison performed between the H-score evaluation results of the control and polyp groups after the immunohistochemical staining method, the staining in the polyp group was significantly higher for both STC-1 (p < 0.001) and STC-2 (p < 0.001). There was more staining with STC-1 than STC-2 in all groups (STC-1: 15.08; STC-2: 8.27; p < 0.05). In the logistic regression analysis established with STC-1, STC-2, and age, the predictive effect of STC-1 for EP was statistically significant (p = 0.040; odds ratio: 1.66; 95% confidence interval: 1.02-2.68). In EP, according to receiver operating characteristic curve analysis, area under the curve was 0.980 (likelihood ratio: 20.35; p < 0.05), and the cut-off value was 18 for STC-1.

CONCLUSION

In infertile patients, since STC-1, which affects endometrial receptivity, is found to be significantly higher in polyps and has a predictive effect on polyps, in patients with unexplained infertility, routine uterine cavity evaluation and routine excision of polypoid lesions detected during this period may have a positive effect on endometrial receptivity.

Polycystic ovary syndrome is associated with a higher risk of premalignant and malignant endometrial polyps in premenopausal women: a retrospective study in a tertiary teaching hospital

Background

Polycystic ovary syndrome (PCOS) is characterized by anovulation, insufficient progesterone, hyperandrogenism, and insulin resistance. These factors can disrupt the endometrium of PCOS patients and can lead to chronic low-grade inflammation in the endometrium, endometrial hyperplasia, or even endometrial cancer.

Objective

The aim of this study was to investigate the prevalence of premalignant and malignant endometrial polyps in premenopausal women and to further explore whether PCOS is associated with premalignant and malignant changes in endometrial polyps.

Methods

This study was conducted by retrieving the medical data of 4236 premenopausal women who underwent hysteroscopic polypectomies between January 2015 and December 2021. Demographic and clinical data regarding age, height, weight, parity, hormone replacement therapy, oral contraceptives, abnormal uterine bleeding, hypertension, diabetes mellitus, PCOS, number of polyps, and size of polyps were collected, and their associations with premalignant and malignant changes in endometrial polyps were analysed.

Result

Among the endometrial polyps removed by hysteroscopic polypectomy in premenopausal women, the prevalence of premalignant and malignant polyps was 2.15%, which comprised hyperplasia with atypia at 1.13% and endometrial carcinoma at 1.02%. PCOS was associated with a higher risk of premalignant and malignant endometrial polyps in premenopausal women after adjustment for potential confounding factors.

Conclusion

PCOS is associated with a higher risk of premalignant and malignant endometrial polyps in premenopausal women. Therefore, it is important to evaluate the endometrium in PCOS patients with ultrasonography or hysteroscopy, and active management involving hysteroscopic polypectomy should be offered to PCOS patients diagnosed with endometrial polyps regardless of symptoms.

An Assessment of MT1A (rs11076161), MT2A (rs28366003) and MT1L (rs10636) Gene Polymorphisms and MT2 Concentration in Women with Endometrial Pathologies

Several studies have indicated a relationship between metallothionein (MT) polymorphisms and the development of different pathologies, including neoplastic diseases. However, no studies thus far have been conducted on the influence of MT polymorphisms and the development of endometrial lesions, including endometrial cancer. This study included 140 patients with normal endometrial tissue, endometrial polyps, uterine myomas and endometrial cancer. The tissue MT2 concentration was determined using the ELISA method. MT1A, MT2A and MT1L polymorphisms were analyzed using TaqMan real-time PCR genotyping assays. We found no statistical difference between the tissue MT2 concentration in patients with EC vs. benign endometrium (p = 0.579). However, tissue MT2 concentration was significantly different between uterine fibromas and normal endometrial tissue samples (p = 0.019). Menopause status did not influence the tissue MT2 concentration (p = 0.282). There were no significant associations between the prevalence of MT1A, MT2A and MT1L polymorphisms and MT2 concentration. The age, menopausal status, and diabetes status of patients were identified as EC risk factors.

Diagnosis and medical management of abnormal premenopausal and postmenopausal bleeding

Abnormal uterine bleeding is a common reason for presentation to health-care providers: it is estimated that one woman in three will present to a care provider with abnormal uterine bleeding (AUB) during the reproductive years, and that at least one woman in 10 will experience postmenopausal bleeding. Although there are some variations in national guidelines for investigation, diagnosis and management of premenopausal AUB, there are far more areas of agreement than disagreement. A comprehensive literature search was undertaken to review national and international guidelines regarding investigation, diagnosis and management of AUB in both premenopausal and postmenopausal women. Areas of controversy are identified, and latest evidence reviewed. Although efforts to reduce hysterectomies for premenopausal AUB through medical management have largely been successful, there are areas where more research is necessary to guide optimal investigation and management. Many countries have well-defined guidelines for investigation and management of premenopausal AUB: there are fewer well-developed guidelines for investigation and management of postmenopausal bleeding. There is a paucity of evidence-based data on management of unscheduled bleeding on menopausal hormone therapy.

The Expanding Role of Sonography in the Clinical Practice of Modern Obstetrics and Gynecology: A Clinical Perspective

A list of gynecologic diagnoses is provided, which shows the use of sonography in significantly assisting the practice of modern clinical gynecology. The clinical value of this technology to assist in formulating diagnoses for the presenting patients is discussed. Sonography has become a necessary tool for today’s practice of gynecology, and women’s health, in general.

Epidemiological analysis of hydrometra and its predictive value in gynecological tumors

Introduction

Hydrometra is a common gynecological disease, especially in postmenopausal women. However, its epidemiology, harmfulness, and value in predicting gynecological tumors have not been clearly elucidated.

Methods

In this study, the prevalence rate of and risk factors for hydrometra were investigated in 3,903 women who underwent screening for gynecological diseases at Zhoupu Hospital in Shanghai from 1 January to 31 December 2021. In addition, pathological distribution of hydrometra and its predictive value in gynecological tumors were studied in another 186 patients in whom hydrometra was diagnosed sonographically at Zhoupu Hospital, from 1 January 2020 to 31 December 2021, and who underwent hysteroscopy and postoperative pathological examination.

Results

The observed prevalence rate of hydrometra was 10.86%, which was higher than the prevalence of other gynecological diseases. Univariate and multivariate analysis indicated that advanced age (OR 1.11) and vaginitis (OR 3.18) were independent risk factors for hydrometra. Among 186 patients with a sonographic diagnosis of uterine fluid, simple hydrometra accounted for 34.41% of cases, inflammation accounted for 16.23%, and hematometra accounted for 2.15%, while gynecological tumors accounted for 5.91%. Moreover, univariate and multivariate analysis indicated that a higher body mass index (>23.92 kg/m²), greater hydrometra volume (i.e., distance between the two layers of endometrium>4.75 mm), and abnormal vaginal bleeding were high-risk predictive factors for gynecological tumors.

Discussion

In conclusion, hydrometra is a common disease, and is a risk factor for endometrial cancer and cervical cancer, especially in patients with higher hydrometra volume, higher BMI, and abnormal vaginal bleeding. It is necessary to pay more attention to hydrometra.

Risk of endometrial cancer in asymptomatic postmenopausal women in relation to ultrasonographic endometrial thickness: systematic review and diagnostic test accuracy meta-analysis

OBJECTIVE

This study aimed to evaluate the risk of endometrial carcinoma and atypical endometrial hyperplasia in asymptomatic postmenopausal women concerning the endometrial thickness measured by stratified threshold categories used for performing subsequent endometrial sampling and histologic evaluation.

DATA SOURCES

MEDLINE, Scopus, ClinicalTrials.gov, SciELO, Embase, the Cochrane Central Register of Controlled Trials, LILACS, conference proceedings, and international controlled trials registries were searched without temporal, geographic, or language restrictions.

STUDY ELIGIBILITY CRITERIA

Studies were selected if they had a crossover design evaluating the risk of atypical endometrial hyperplasia and endometrial carcinoma in postmenopausal asymptomatic women and calculated the diagnostic accuracy of transvaginal ultrasonography thresholds (at least 3.0 mm) confirmed by histopathologic diagnosis.

METHODS

This was a systematic review and diagnostic test accuracy meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses of Diagnostic Test Accuracy and Synthesizing Evidence from Diagnostic Accuracy Tests guidelines. Endometrial thickness thresholds were grouped as follows: from 3.0 to 5.9 mm; between 6.0 and 9.9 mm; between 10.0 and 13.9 mm; and ≥14.0 mm. Quality assessment was performed using the Quality Assessment Tool for Diagnostic Accuracy Studies 2 tool. Publication bias was quantified using the Deek funnel plot test. Coprimary outcomes were the risk of atypical endometrial hyperplasia or endometrial carcinoma according to the endometrial thickness and diagnostic accuracy of each threshold group.

RESULTS

A total of 18 studies provided the data of 10,334 women who were all included in the final analysis. Overall, at an endometrial thickness threshold of at least 3.0 mm, the risk of atypical endometrial hyperplasia or endometrial carcinoma was increased 3-fold relative to women below the cutoff (relative risk, 3.77; 95% confidence interval, 2.26-6.32; I2=74%). Similar degrees of risk were reported for thresholds between 3.0 and 5.9 mm (relative risk, 5.08; 95% confidence interval, 2.26-11.41; I2=0%), 6.0 and 9.9 mm (relative risk, 4.34; 95% confidence interval, 1.68-11.23; I2=0%), 10.0 and 13.9 mm (relative risk, 4.11; 95% confidence interval, 1.55-10.87; I2=86%), and ≥14.0 mm (relative risk, 2.53; 95% confidence interval, 1.04-6.16; I2=78%) with no significant difference among subgroups (P=.885). Regarding diagnostic accuracy, the pooled sensitivity decreased from thresholds below 5.9 mm (relative risk, 0.81; 95% confidence interval, 0.49-0.85) to above 14.0 mm (relative risk, 0.28; 95% confidence interval, 0.18-0.40). Furthermore, the specificity increased from 0.70 (95% confidence interval, 0.61-0.78) for endometrial thickness between 3.0 and 5.9 mm to 0.86 (95% confidence interval, 0.71-0.94) when the endometrial thickness is ≥14.0 mm. For 3.0 to 5.9 mm and 10.0 to 13.9 mm thresholds, the highest diagnostic odds ratios of 10 (95% confidence interval, 3-41) and 11 (95% confidence interval, 2-49), with areas under the curve of 0.81 (95% confidence interval, 0.77-0.84) and 0.82 (95% confidence interval, 0.79-0.86), respectively, were retrieved. The summary point analysis revealed that the 3.0 to 5.9 mm cutoff point was placed higher in the summary receiver operator curve space than the other subgroups, indicating increased endometrial carcinoma or atypical endometrial hyperplasia diagnosis using these cutoffs.

CONCLUSION

Both low and high endometrial thickness thresholds in postmenopausal asymptomatic women seem equally effective in detecting endometrial carcinoma and atypical endometrial hyperplasia. However, although using a 3.0 to 5.9 mm cutoff results in a lower specificity, the offsetting improvement in sensitivity may justify using this cutoff for further endometrial evaluation in patients with suspected endometrial malignancy.

Chronic Endometritis in Infertile Women: Impact of Untreated Disease, Plasma Cell Count and Antibiotic Therapy on IVF Outcome-A Systematic Review and Meta-Analysis

This systematic review and meta-analysis aims to evaluate the impact of chronic endometritis (CE) and its therapy on in vitro fertilization (IVF) outcome. Additionally, we aim to investigate whether various degrees of CE severity may exert a different effect on IVF outcome. Ongoing-pregnancy rate/live-birth-rate (OPR/LBR), clinical-pregnancy rate (CPR), and miscarriage rate (MR) were calculated. A total number of 4145 patients (from ten studies) were included. Women with CE had lower OPR/LBR (OR 1.97, p = 0.02) and CPR (OR 2.28, p = 0.002) compared to those without CE. CE cure increased OPR/LBR (OR 5.33, p < 0.0001) and CPR (OR 3.64, p = 0.0001). IVF outcome was comparable between women with cured CE and those without CE (OPR/LBR, CPR and MR: p = ns). Women with severe CE had lower OPR/LBR (OR 0.43, p = 0.003) and CPR (OR 0.40, p = 0.0007) compared to those mild CE. Mild CE showed no influence on the IVF outcome as compared to women without CE (OPR/LBR, CPR and MR: p = ns). Based on this data analysis, CE significantly reduces OPR/LBR and CPR in women undergoing IVF. Importantly, CE resolution after antibiotic therapy may improves IVF outcome, leading to similar OPR/LBR and CPR as compared to unaffected patients. The negative effects of CE on IVF outcome may be restricted to severe disease, whereas mild CE may have no influence on IVF success.

Multivariate Analysis of Recurrence after Hysteroscopic Diagnosis and Treatment of Endometrial Polyps following IVF-ET Failure

Objective

To explore the risk factors affecting the recurrence of endometrial polyps (EPs) after hysteroscopic diagnosis and treatment of EPs following in vitro fertilization-embryo transfer (IVF-ET) failure by multivariate analysis.

Methods

The clinical data of 369 patients with EPs hysteroscopically treated in our department due to IVF-ET failure from January 2017 to January 2020 were retrospectively analyzed, including the number and size of polyps, postoperative treatment, endometriosis (EM), hydrosalpinx (HSP), and polycystic ovarian syndrome (PCOS), and the effects of these factors on EP recurrence were observed.

Results

Of the patients enrolled, 184 cases (49.9%) were treated by curettage, and 185 cases (50.1%) by electrotomy. A total of 72 cases (19.5%) of postoperative recurrence were determined, including 34 cases (9.2%) without postoperative medication, 31 cases (8.4%) with one month of postoperative Didroxyprogesterone (DG) administration, and 7 cases (1.9%) with three months of postoperative DG administration. Surgical methods, 3 months of postoperative medication, PCOS, and polyp number and size significantly influence the recurrence of EPs, which were all the influencing factors of polyp recurrence. After controlling for other factors, the risk of EP recurrence after electrotomy was found to be lower than that after curettage, with an odds ratio (OR) (95% confidence interval (CI)) of 0.354 (0.163–0.767); the risk of EP recurrence after 3 months of postoperative medication was lower than that without postoperative medication, with an OR (95% CI) of 0.024 (0.005–0.104); the risk of EP recurrence in patients with PCOS was higher than that without PCOS, and the OR (95% CI) was 2.505 (1.113–5.639); patients with multiple polyps (≥2) were at an increased risk of recurrence than those with a single polyp, with an OR (95% CI) of 66.552 (14.711–301.084); patients with polyp diameter ≥ 2 cm had a higher risk of recurrence than those with polyp diameter < 2 cm, and the OR (95% CI) was 1084.76 (148.743–7910.999).

Conclusions

PCOS patients are at an elevated risk of EP recurrence than non-PCOS patients. In patients with multiple polyps, those with a diameter ≥ 2 cm have an increased risk of polyp recurrence compared with those with polyp diameter < 2 cm; electrotomy is associated with a lower recurrence risk of EPs than curettage. The risk of EP recurrence in patients treated with postoperative progesterone for 3 months is lower than that of patients without postoperative medication.

Hysteroscopy Combined with Laser Vaporesection for Endometrial Polyps

OBJECTIVE

To compare the safety and efficiency of hysteroscopic laser vaporesection and hysteroscopic resection in the treatment of endometrial polyps.Methods: The literatures in databases were searched comprehensively, the literatures that met the inclusion criteria were screened out and the data were extracted. The data were combined with Stata12.0 statistical software.

RESULTS

4 literatures were included with a total sample size of 334. Meta-analysis showed that intraoperative blood loss in laser group was less than that in electrosurgical group [-3.043, 95% CI (-4.09, -2.00), P < 0.001]. Length of stay in the laser group was shorter than that in the electrotomy group [-1.013, 95% CI (-1.37, -0.65), P < 0.001]. The recurrence rate [0.275, 95%CI (0.135,0.563), P < 0.001] and complication rate [0.148, 95%CI (0.07,0.32), P < 0.001] in the laser group were lower than those in the electrotomy group. There was no significant difference in operative time between hysteroscopy combined with 2 μm laser and hysteroscopic electrotomy for endometrial polyps [-0.38, 95% CI (-1.34, 0.58), P = 0.441 > 0.05].

CONCLUSION

Hysteroscopic 2 μm laser vaporesection for the treatment of endometrial polyps has better safety and clinical efficacy. Compared with hysteroscopic electroresection, hysteroscopic laser vaporesection in the treatment of endometrial polyps may be safer and more effective. Given the potential limitations, we need larger, well-designed randomized controlled trials to verify our findings.

Endometrial Abnormalities: Correlation Between Different Diagnostic Modalities

OBJECTIVES

We sought to evaluate the diagnostic accuracy of transvaginal ultrasound (TVUS) saline infusion sonohysterogram (SIS), and hysteroscopy for diagnosing endometrial abnormalities and their correlation with histological findings. In addition, we sought to validate the subsistence of a more subtle abnormality called "redundant endometrium" (RE).

METHODS

Retrospective cohort study of patients presenting with infertility and diagnosed with endometrial abnormalities who underwent hysteroscopy and pathology evaluation. Each patient underwent TVUS at the first visit regardless of the cycle phase, followed by SIS during proliferative phase, and then hysteroscopy, which was performed when abnormal SIS findings were diagnosed. Endometrial abnormalities were categorized as polyps (EP), RE, or normal. Frequencies of the abnormalities were recorded for the 3 imaging modalities and their sensitivity, specificity, positive predictive value, and negative predictive value were calculated for each.

RESULTS

A total of 105 TVUS and 73 SIS were performed. Because of the frequent association of EP with RE, when all endometrial pathologies were combined, the three diagnostic modalities showed high sensitivity (TVUS 88.9%, SIS 100%, hysteroscopy 82.9%, respectively), but they also showed low specificity (TVUS 56.7%, SIS 56.1%, hysteroscopy 58.2%, respectively). Pathological evaluation showed isolated RE (26 cases), to harbor polyps (19.2%), disordered endometrium (19.2%), and complex atypical hyperplasia (3.8%).

CONCLUSIONS

The three diagnostic modalities showed high sensitivity in diagnosing endometrial abnormalities. We identified RE as an independent endometrial abnormality. Benign endometrium is the predominant histology in RE, however, a small proportion harbors endometrial hyperplasia. Based on these results, we advocate further evaluation when this condition is diagnosed with TVUS, or SIS.

Modern assessment of the uterine cavity and fallopian tubes in the era of high-efficacy assisted reproductive technology

The high efficacy of modern assisted reproductive technology (ART) and increase in the number of noninfertile patients who are using ART for family building in the United States call into question the relevance of the standard, one-size-fits-all infertility evaluation. Here, we explore whether all patients presenting for ART need uterine cavity and tubal assessment and what tests are most appropriate, efficient, and cost-effective in current times.

Prediction of Factors Associated with Abnormal Uterine Bleeding by Transvaginal Ultrasound Combined with Bleeding Pattern

In order to explore the ability of vaginal ultrasound combined with bleeding pattern to predict factors related to abnormal uterine bleeding (AUB), a total of 205 patients with abnormal uterine bleeding were selected as experimental subjects. According to the corresponding diagnostic criteria, patients were divided into the endometrial polyp group (56 cases), endometrial hyperplasia and canceration group (84 cases), and normal cycle endometrial group (65 cases). The efficiency of the method was determined by comparing the prediction efficiency of the single/joint model. The results showed that there were statistically significant differences in the body mass index, dysmenorrhea, endometrial thickness, diabetes, hypertension, and polycystic ovary syndrome among the three groups, P < 0.05. The sensitivity, specificity, positive predictive value, negative predictive value, and Youden index of endometrial polyp diagnosis were 86.89%, 88.12%, 83.54%, 90.11%, and 0.74, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and JordAn index in diagnosing endometrial hyperplasia and canceration were 96.71%, 98.40%, 96.54%, 98.24%, and 0.96, respectively. In summary, the body mass index, dysmenorrhea, endometrial thickness, diabetes, hypertension, and polycystic ovary syndrome were related factors, and the combination of vaginal ultrasound and bleeding pattern had a stronger predictive power for abnormal uterine bleeding.

Effect of Hysteroscopic Polypectomy Combined with Mirena Placement on Postoperative Adverse Reactions and Recurrence Rate of Endometrial Polyps: Based on a Large-Sample, Single-Center, Retrospective Cohort Study

Objective. To investigate the effect of hysteroscopy surgery combined with Mirena on postoperative adverse reactions and recurrence rate of endometrial polyps (EP). Methods. A total of 312 patients who underwent hysteroscopic polypectomy of EP in our hospital from June 2017 to November 2020 were enrolled retrospectively. Among them, 42 patients did not take any treatment after the operation (control group), 156 patients were treated with levonorgestrel intrauterine birth control system (Mirena group), and 114 patients were treated with oral spironolone ethinylestradiol tablets (oral group). The clinical data of 312 patients were recorded and followed up regularly. All patients were followed up through an outpatient clinic or telephone to 12 months after the operation. The patients’ age, disease course, number of pregnancies, clinical manifestations, endometrial thickness before the operation, duration of operation, amount of bleeding during the operation, and number and size of polyps were analyzed. The recurrence and postoperative side effects of EP in the three groups were followed up within 12 months after the operation. Results. There was no significant difference in endometrial thickness among the three groups before treatment ( $P>0.05$ ). After 3 months, 6 months, and 12 months of treatment, the endometrial thickness of the three groups decreased, while the decrease in the Mirena group and the oral group was better compared to the control ( $P<0.05$ ). The decrease in the Mirena group was better than that in the oral group ( $P<0.05$ ). There was no significant difference in hemoglobin levels among the three groups before treatment ( $P>0.05$ ). After 3, 6, and 12 months of treatment, the hemoglobin levels of the three groups increased to varying degrees, while the levels of the Mirena group and oral group were better compared to the control ( $P<0.05$ ). Three months after the operation, the improvement of clinical symptoms was similar in the three groups, and there was no significant difference among the three groups ( $P>0.05$ ). At 6 and 12 months after the operation, the improvement of clinical symptoms in the oral group and Mirena group was better compared to the control group ( $P<0.05$ ), but there was no significant difference between the oral group and Mirena group ( $P>0.05$ ). After the operation, some patients had complications such as lower abdominal pain, breast distension pain, irregular vaginal bleeding, and abnormal liver function. There was no significant difference in the number of complications among the three groups ( $P>0.05$ ). During the follow-up to 12 months after the operation, the recurrence rate in the oral group and Mirena group was lower compared to the control ( $P<0.05$ ), and the recurrence rate in the Mirena group was lower than that in the oral group ( $P<0.05$ ). Conclusion. Placing Mirena immediately after hysteroscopic polypectomy of EP can reduce the recurrence rate of endometrial polyps, increase the level of hemoglobin, and reduce the thickness of the endometrium, which can be employed and popularized according to the condition of patients in clinical work.

EndMT: New findings on the origin of myofibroblasts in endometrial fibrosis of intrauterine adhesions

BACKGROUND

Intrauterine adhesion (IUA) is one of the leading causes of infertility and the main clinical challenge is the high recurrence rate. The key to solving this dilemma lies in elucidating the mechanisms of endometrial fibrosis. The aim of our team is to study the mechanism underlying intrauterine adhesion fibrosis and the origin of fibroblasts in the repair of endometrial fibrosis.

METHODS

Our experimental study involving an animal model of intrauterine adhesion and detection of fibrosis-related molecules. The levels of molecular factors related to the endothelial-to-mesenchymal transition (EndMT) were examined in a rat model of intrauterine adhesion using immunofluorescence, immunohistochemistry, qPCR and Western blot analyses. Main outcome measures are levels of the endothelial marker CD31 and the mesenchymal markers alpha-smooth muscle actin (α-SMA) and vimentin.

RESULTS

Immunofluorescence co-localization of CD31 and a-SMA showed that 14 days after moulding, double positive cells for CD31 and a-SMA could be clearly observed in the endometrium. Decreased CD31 levels and increased α-SMA and vimentin levels indicate that EndMT is involved in intrauterine adhesion fibrosis.

CONCLUSIONS

Endothelial cells promote the emergence of fibroblasts via the EndMT during the endometrial fibrosis of intrauterine adhesions.

Endometrial polyps are non-neoplastic but harbor epithelial mutations in endometrial cancer drivers at low allelic frequencies

Endometrial polyps (EMPs) are common exophytic masses associated with abnormal uterine bleeding and infertility. Unlike normal endometrium, which is cyclically shed, EMPs persist over ovulatory cycles and after the menopause. Despite their usual classification as benign entities, EMPs are paradoxically associated with endometrial carcinomas of diverse histologic subtypes, which frequently arise within EMPs. The etiology and potential origins of EMPs as clonally-derived neoplasms are uncertain, but previous investigations suggested that EMPs are neoplasms of stromal origin driven by recurring chromosomal rearrangements. To better define benign EMPs at the molecular genetic level, we analyzed individual EMPs from 31 women who underwent hysterectomy for benign indications. The 31 EMPs were subjected to comprehensive genomic profiling by exome sequencing of a large panel of tumor-related genes including oncogenes, tumor suppressors, and chromosomal translocation partners. There were no recurring chromosomal rearrangements, and copy-number analyses did not reveal evidence of significant chromosome-level events. Surprisingly, there was a high incidence of single nucleotide variants corresponding to classic oncogenic drivers (i.e., definitive cancer drivers). The spectrum of known oncogenic driver events matched that of endometrial cancers more closely than any other common cancer. Further analyses including laser-capture microdissection showed that these mutations were present in the epithelial compartment at low allelic frequencies. These results establish a link between EMPs and the acquisition of endometrial cancer driver mutations. Based on these findings, we propose a model where the association between EMPs and endometrial cancer is explained by the age-related accumulation of endometrial cancer drivers in a protected environment that-unlike normal endometrium-is not subject to cyclical shedding.

Novel microarchitecture of human endometrial glands: implications in endometrial regeneration and pathologies

BACKGROUND

Human endometrium remains a poorly understood tissue of the female reproductive tract. The superficial endometrial functionalis, the site of embryo implantation, is repeatedly shed with menstruation, and the stem cell-rich deeper basalis is postulated to be responsible for the regeneration of the functionalis. Two recent manuscripts have demonstrated the 3D architecture of endometrial glands. These manuscripts have challenged and replaced the prevailing concept that these glands end in blind pouches in the basalis layer that contain stem cells in crypts, as in the intestinal mucosa, providing a new paradigm for endometrial glandular anatomy. This necessitates re-evaluation of the available evidence on human endometrial regeneration in both health and disease in the context of this previously unknown endometrial glandular arrangement.

OBJECTIVE AND RATIONALE

The aim of this review is to determine if the recently discovered glandular arrangement provides plausible explanations for previously unanswered questions related to human endometrial biology. Specifically, it will focus on re-appraising the theories related to endometrial regeneration, location of stem/progenitor cells and endometrial pathologies in the context of this recently unravelled endometrial glandular organization.

SEARCH METHODS

An extensive literature search was conducted from inception to April 2021 using multiple databases, including PubMed/Web of Science/EMBASE/Scopus, to select studies using keywords applied to endometrial glandular anatomy and regeneration, and the references included in selected publications were also screened. All relevant publications were included.

OUTCOMES

The human endometrial glands have a unique and complex architecture; branched basalis glands proceed in a horizontal course adjacent to the myometrium, as opposed to the non-branching, vertically coiled functionalis glands, which run parallel to each other as is observed in intestinal crypts. This complex network of mycelium-like, interconnected basalis glands is demonstrated to contain endometrial epithelial stem cells giving rise to single, non-branching functionalis glands. Several previous studies that have tried to confirm the existence of epithelial stem cells have used methodologies that prevent sampling of the stem cell-rich basalis. More recent findings have provided insight into the efficient regeneration of the human endometrium, which is preferentially evolved in humans and menstruating upper-order primates.

WIDER IMPLICATIONS

The unique physiological organization of the human endometrial glandular element, its relevance to stem cell activity and scarless endometrial regeneration will inform reproductive biologists and clinicians to direct their future research to determine disease-specific alterations in glandular anatomy in a variety of endometrial pathological conditions.

Hystero-salpingo scintigraphy for fallopian tubal patency assessment: results from a prospective study

OBJECTIVE

To evaluate the diagnostic accuracy of a bygone method, hystero-salpingo-scintigraphy (HSSG), for tubal patency assessment of infertile women.

MATERIAL AND METHODS

Prospective cohort study involving women in the infertility workup at the University of Debrecen, Hungary. Seventy infertile patients were scheduled to either basic dynamic HSSG, post-purge dynamic HSSG, or post-purge dynamic HSSG followed by SPECT/CT for reducing tracer contamination. The primary endpoint was the evaluation of the diagnostic accuracy of HSSG for the three methods.

RESULTS

During the basic dynamic group, the examination yielded a sensitivity of 87.5%, with a specificity of 71.7%, while positive and negative predictive values were 31.8%, and 97.4% respectively. Using post purge dynamic HSSG, it resulted in a sensitivity of 87.5%, a specificity of 88.7%, a positive predictive value of 53.8%, and a negative predictive value of 97.9%. Adding SPECT/CT to post-purge dynamic HSSG increased diagnostic accuracy with 100% sensitivity and 88.7% specificity, while positive and negative predictive values were 57.1% and 100%, respectively.

CONCLUSION

HSSG is a non-invasive and well-tolerated technique for tubal patency. It could be used initially to predict tubal patency in case of infertility. Its diagnostic accuracy is higher when it is carried out by adding SPECT/CT to the post-purge dynamic method.

Pipelle endometrial sampling success rates in Kazakhstani settings: results from a prospective cohort analysis

The aim of this study was to evaluate the feasibility of Pipelle endometrial sampling and to explore factors influencing Pipelle success rate in the clinical settings of Kazakhstan. This prospective analysis included 87 patients who had undergone Pipelle biopsy due to medical indications for endometrial sampling. We analysed physician and patient-related factors potentially influencing the success rate of this method. Pipelle endometrial biopsy overall success rate was 82.76%. The indications for the procedure and patients' age were key factors influencing Pipelle sampling success (p < .001). The success rate was the highest in the group with abnormal uterine bleeding as a biopsy indication in the reproductive age group (93.19%; p < .001).Pipelle biopsy was found to be an acceptable option for endometrial sampling in our clinical setting; at the same time, physicians should consider the potential influencing factors on its success rate like indications for the procedure, BMI and patients' age as well as their menopausal status. In order to provide precise future directions, there is a need to study a larger number of patients.IMPACT STATEMENTWhat is already known on this subject? Compared to dilation and curettage sampling conducted in the operation room, Pipelle endometrial sampling is relatively inexpensive, associated with less morbidity, safe, accurate, and can be performed in an office setting.What do the results of this study add? This is the first prospective data analysis about Pipelle endometrial sampling in Kazakhstani population.What are the implications of these findings for clinical practice and/or further research? Enabling the timely diagnosis of current endometrial pathology, Pipelle endometrial sampling approach may have an important impact on healthcare safety and efficiency, and improve overall treatment outcomes and the quality of life of Kazakhstani population if used consistently.

Pipelle Endometrial Biopsy for Abnormal Uterine Bleeding in Daily Clinical Practice: Why the Approach to Patients Should Be Personalized?

Background. Abnormal uterine bleeding (AUB) is a common gynecologic condition, and proper management is based on the histological evaluation of an adequate endometrial sample obtained via biopsy. The aims of this study were to evaluate factors influencing the reliability and success rate of Pipelle endometrial sampling for histopathological diagnosis. Methods. One hundred and eighty patients with AUB underwent endometrial sampling using both Pipelle and dilatation and curettage (D&C) procedures at the Clinical Academic Department of Women’s Health, University Medical Center between January 2019 and April 2021. We analyzed the effects of age, menopausal status, ethnicity, body mass index (BMI), provider experience, and procedure indication on the success and reliability of each procedure. Results. Pipelle sampling was successful in 144 (80.56%) women, while D&C was successful in 164 (91.11%) women. Analysis using Fisher’s exact test showed that age, menopausal status, and biopsy indication were factors affecting the success rate of both methods, while ethnicity, BMI, and physician experience had no influence. Overall concordance in the histopathological results between Pipelle and D&C was 91.72%. Conclusion. Pipelle sampling was found to be reliable for the detection of endometrial carcinoma and endometrial hyperplasia, while its reliability was low in cases of endometrial polyps. The endometrial sampling approach should be personalized in daily clinical practice for women with AUB, and Pipelle sampling is not suitable for all patients. If an endometrial polyp is suspected, the physician should consider other diagnostic tools, bearing in mind all of the factors influencing endometrial sampling success and reliability rates.

Predictive factors of spontaneously regressed uterine endometrial polyps during the waiting period before hysteroscopic polypectomy

BACKGROUND

The presence of uterine endometrial polyps is associated with not only abnormal uterine bleeding but also infertility, so the use of hysteroscopic polypectomy has been increasing. This operation is considered to increase cost-effectiveness when performed prior to infertility treatments. However, there are typical problems to consider, including the possibility of spontaneous regression of the polyp and the duration of complete endometrial wound healing after surgery. Meaningless interventions must be avoided, when possible. Therefore, data acquisition and analysis of various findings obtained from surgery have become important for improving treatment procedures and patient selection. To estimate the spontaneous regression rates and contributions of multiple factors to uterine endometrial polyps during the waiting period (approximately 2-3 months) before hysteroscopic polypectomy, we performed a multivariate analysis of data from the records in our hospital.

METHODS

The medical records of 450 cases from September 2014 to April 2021 in our hospital were retrospectively reviewed under the approval of our Institutional Review Board. We included all cases of hysteroscopic polypectomy with postoperative pathological diagnosis. We defined cases as having a "spontaneously regressed polyp" when the target polyp was not detected by postoperative pathological examination. We extracted data on the following ten factors: "Advanced age" (≥ 42 years), "Small polyp" (< 10 mm), "High body mass index" (≥ 25 kg/m2), "Nulliparity," "Single polyp," "Infertility," "Hypermenorrhea," "Abnormal bleeding," "No symptom," and "Hormonal drug use." We also classified cases into five groups according to the size of the polyp (≤ 4.9 mm, 5.0-9.9 mm, 10.0-14.9 mm, 15.0-19.9 mm, and ≥ 20.0 mm) and determined the frequency of spontaneously regressed polyp in each group.

RESULTS

After exclusion of cases with insufficient data or other diseases, such as submucosal leiomyoma, 424 cases were analyzed. Among them, 28 spontaneously regressed polyps were identified, and the highest frequency of spontaneously regressed polyp was detected among the cases with polyps measuring 5.0-9.9 mm (16.4%). On multivariate analysis of the ten factors, "Small polyp" and "Hormonal drug use" were found to significantly impact the frequency of spontaneously regressed polyp.

CONCLUSIONS

On the basis of the factors identified in this analysis, the indications for observation or medical therapy adapted to small polyps might be expanded.