Dilatation and curettage fails to detect most focal lesions in the uterine cavity in women with postmenopausal bleeding

Atypical Endometrial Hyperplasia and Concurrent Cancer: A Comprehensive Overview on a Challenging Clinical Condition

The present review regarding atypical endometrial hyperplasia (AEH) focused on the main debated factors regarding this challenging clinical condition: (i) predictive variables of occult endometrial cancer (EC); (ii) the rate of EC underestimation according to different endometrial sampling methods; and (iii) the appropriateness of lymph node status assessment. When cancer is detected, approximately 90% of cases include low-risk EC, although intermediate/high-risk cases have been found in 10-13% of women with cancer. Older age, diabetes, high BMI, and increased endometrial thickness are the most recurrent factors in women with EC. However, the predictive power of these independent variables measured on internal validation sets showed disappointing results. Relative to endometrial sampling methods, hysteroscopic endometrial resection (Hys-res) provided the lowest EC underestimation, ranging between 6 and 11%. Further studies, including larger sample sizes of women undergoing Hys-res, are needed to confirm these findings. These data are urgently needed, especially for female candidates for conservative treatment. Finally, the evaluation of lymph node status measured on 660 of over 20,000 women showed a lymph node positivity of 2.3%. Although there has been an increase in the use of this procedure in AEH in recent years, the present data cannot recommend this option in AEH based on a cost/risk/benefit ratio.

Assessment of oncological safety and utility of hysteroscopy in high grade endometrial cancers: Results from an Israel gynecologic oncology group study

OBJECTIVE

To compare survival measures of women with Stage I high-grade endometrial cancer who underwent either hysteroscopy or a non-hysteroscopic procedure as a diagnostic procedure.

STUDY DESIGN

298 patients with stage I high grade endometrial cancer who underwent surgery between 2002 and 2014. Patients were divided into two groups: hysteroscopy and non-hysteroscopy (curettage or office endometrial biopsy). Clinical, pathological, and survival measures were compared between the groups. High grade histology included endometroid grade -3, uterine serous papillary carcinoma, clear cell carcinoma, and carcinosarcoma.

RESULTS

There were 71 patients in the hysteroscopy group and 227 patients in the non-hysteroscopy group. The median follow-up was 52 months (range 12-120 months). There were no differences between the groups in the 5-year recurrence-free survival (73.9 % vs. 79.7 %; p = 0.65), disease-specific survival (79.3 % vs. 83.6 %; p = 0.87), and overall survival (65.7 % vs. 80.3 %; p = 0.35).

CONCLUSION

Hysteroscopic diagnosis in women with early-stage and high-grade endometrial cancer does not adversely affect the survival outcomes.

Comparison of Two-Dimensional Transvaginal Ultrasound, Three-Dimensional Transvaginal Ultrasound and Hysteroscopy to Diagnose in Patients With Abnormal Uterine Bleeding: A Retrospective Observational Study

Objective:

The principal objective was to compare the diagnostic accuracy of two-dimensional transvaginal ultrasonography (2D TVUS), three-dimensional transvaginal ultrasonography (3D TVUS), and hysteroscopy with histopathology in patients with abnormal uterine bleeding.

Materials and Methods:

Fifty patients were included and underwent the three imaging methods. The negative predictive value, positive predictive value, sensitivity, and specificity of the methods were calculated. Determination of endometrial pathology and endometrial polyps by measuring the endometrial thickness, volume, and uterine area was examined.

Results:

The complaint of menorrhagia was reported by 72.0% of participants. Histopathologically, 70.0% of the patients had endometrial polyps and leiomyoma being monitored. An endometrial polyp was detected in 58.0% of the patients by 2D TVUS, 80.0% by 3D TVUS, and 68.0% by hysteroscopy. While 2D TVUS demonstrated 65.71% accuracy in the detection of an endometrial polyp, 3D TVUS had an 80.0% accuracy, and hysteroscopy had a 77.77% accuracy. An endometrial polyp was detected when the uterine area was ≥237 mm2. If the endometrial thickness was over 10.5 mm, it was found to be related to an endometrial polyp. According to the volume measurements by 3D TVUS, the detection of an endometrial polyp was made with 96.4% sensitivity, provided that the pathology volume was ≥0.082 cm3.

Conclusion:

In this cohort of patients, 3D TVUS achieved a high sensitivity to detect abnormalities and could be considered as an initial diagnostic modality, prior to the surgery, and may rival invasive procedures, such as hysteroscopy.

Implementation of Office Hysteroscopy for the Evaluation and Treatment of Intrauterine Pathology

Hysteroscopy provides a minimally invasive strategy to evaluate intrauterine pathology and manage conditions such as abnormal uterine bleeding, infertility, intrauterine adhesions, müllerian anomalies, and intrauterine foreign bodies. Increasing access to hysteroscopy procedures in the office has the potential to improve patient care by minimizing financial and logistical barriers, aiding in streamlined diagnosis and treatment planning, and potentially averting unnecessary operative procedures and anesthesia. Office hysteroscopy refers to procedures performed in outpatient settings where pain management involves no medications, oral nonsedating medications, local anesthetic agents, or oral or inhaled conscious sedation. We present best practices for the implementation of hysteroscopy in an office setting. These include appropriate patient selection, optimal procedural timing, cervical preparation for patients at highest risk of cervical stenosis or pain with dilation, individualized pain-management strategies, use of distension media, and video monitoring to engage patients in the procedure. We describe miniaturized equipment for use in the office setting and "no-touch" vaginoscopic approaches to limit patient discomfort. With appropriate training and experience, office hysteroscopy presents a simple and cost-effective modality for optimizing gynecologic care for our patients.

Ultrasound features of endometrial pathology in women without abnormal uterine bleeding: results from the International Endometrial Tumor Analysis study (IETA3)

OBJECTIVES

The primary aim of this study was to describe the ultrasound features of various endometrial and other intracavitary pathologies in women without abnormal uterine bleeding (AUB) using the International Endometrial Tumor Analysis (IETA) terminology. The secondary aim was to compare our findings with published data on women with AUB.

METHODS

This was a prospective observational study of women presenting at one of seven centers specialized in gynecological ultrasonography, from 2011 until 2018, for indications unrelated to AUB. All patients underwent transvaginal ultrasound using the IETA examination and measurement techniques. Ultrasonography was performed as part of routine gynecological examination or follow-up of non-endometrial pathology, or as part of the work-up before undergoing treatment for infertility, uterine prolapse or ovarian pathology. Ultrasound findings were described using the IETA terminology. Endometrial sampling was performed after the ultrasound scan. The histological endpoints were endometrial atrophy, proliferative or secretory endometrium, endometrial hyperplasia without atypia, endometrial polyp, intracavitary leiomyoma, endometrial intraepithelial neoplasia (EIN), endometrial cancer (EC) and insufficient tissue. The findings in our cohort of women without AUB were compared with those in a published cohort of women with AUB who were examined with transvaginal ultrasound between 2012 and 2015 using the same IETA examination technique and terminology.

RESULTS

In this study (IETA3), we included 1745 women without AUB who underwent a standardized transvaginal ultrasound examination followed by either endometrial sampling with histological diagnosis (n = 1537) or at least 1 year of clinical and ultrasound follow-up (n = 208). Of these, 858 (49.2%) women were premenopausal and 887 (50.8%) were postmenopausal. Histology showed the presence of EC and/or EIN in 29 (1.7%) women, endometrial polyps in 1028 (58.9%), intracavitary myomas in 66 (3.8%), proliferative or secretory changes or hyperplasia without atypia in 144 (8.3%), endometrial atrophy in 265 (15.2%) and insufficient tissue in five (0.3%). Most cases of EC or EIN (25/29 (86.2%)) were diagnosed after menopause. The mean endometrial thickness in women with EC or EIN was 11.2 mm (95% CI, 8.9-13.6 mm), being on average 2.4 mm (95% CI, 0.3-4.6 mm) thicker than their benign counterparts. Women with malignant endometrial pathology manifested more frequently non-uniform echogenicity (22/29 (75.9%)) than did those with benign endometrial pathology (929/1716 (54.1%)) (difference, +21.8% (95% CI, +4.2% to +39.2%)). Moderate to abundant vascularization (color score 3-4) was seen in 31.0% (9/29) of cases with EC or EIN compared with 12.8% (220/1716) of those with a benign outcome (difference, +18.2% (95% CI, -0.5% to +36.9%)). Multiple multifocal vessels were recorded in 24.1% (7/29) women with EC or EIN vs 4.0% (68/1716) of those with a benign outcome (difference, +20.2% (95% CI, +4.6% to +35.7%)). A regular endometrial-myometrial junction was seen less frequently in women with EC or EIN (19/29 (65.5%)) vs those with a benign outcome (1412/1716 (82.3%)) (difference, -16.8% (95% CI, -34.2% to +0.6%)). In women with endometrial polyps without AUB, a single dominant vessel was the most frequent vascular pattern (666/1028 (64.8%)). In women with EC, both in those with and those without AUB, the endometrium usually manifested heterogeneous echogenicity, but the endometrium was on average 8.6 mm (95% CI, 5.2-12.0 mm) thinner and less intensely vascularized (color score 3-4: difference, -26.8% (95% CI, -52.2% to -1.3%)) in women without compared to those with AUB. In both pre- and postmenopausal women, asymptomatic endometrial polyps were associated with a thinner endometrium, and they manifested more frequently a bright edge, a regular endometrial-myometrial junction and a single dominant vessel than did polyps in symptomatic women, and they were less intensely vascularized.

CONCLUSIONS

We describe the typical ultrasound features of EC, polyps and other intracavitary histologies using IETA terminology in women without AUB. Our findings suggest that the presence of asymptomatic polyps or endometrial malignancy may be accompanied by thinner and less intensely vascularized endometria than their symptomatic counterparts. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Outpatient hysteroscopy is effective for uterine cavity evaluation following failed office-based endometrial biopsy

BACKGROUND

Failure to obtain an office-based endometrial biopsy for abnormal uterine bleeding is not uncommon. Although operating room-based procedures are traditionally considered the gold standard assessment tool in these circumstances, outpatient hysteroscopy is a less invasive, more cost-effective, and safer alternative. However, there is no contemporary Canadian literature on the effectiveness of an outpatient approach for this specific population.

OBJECTIVE

We aim to evaluate the effectiveness and outcomes of outpatient hysteroscopy for uterine cavity evaluation for patients who have failed an in-office endometrial biopsy attempt.

METHODS

We conducted a retrospective cohort study of all patients referred to an academic outpatient hysteroscopy unit between January 2015 and January 2018, who underwent an outpatient hysteroscopy following failed endometrial biopsy. Data were collected from electronic medical records.

RESULTS

Of the 407 consecutive patients who underwent an outpatient hysteroscopic procedure, 68 met inclusion criteria. Postmenopausal bleeding was the most common indication for initial biopsy, and most failures were attributed to cervical stenosis. Outpatient hysteroscopies were successfully completed in 96% of cases (n = 65/68). Failure resulted from either anxiety and discomfort (n = 2), or severe intrauterine adhesions (n = 1). Overall, 10% of patients subsequently required an operating room-based hysteroscopy, either to complete a myomectomy or polypectomy, or to allow general anesthesia. Outpatient hysteroscopy identified endometrial hyperplasia and cancer in 4.5% and 3% of patients, respectively.

CONCLUSION

Outpatient hysteroscopy following unsuccessful office endometrial biopsy attempts appears to be a feasible, safe, and cost-effective investigation strategy that may prevent the need for an operating room-based procedure in 90% of cases.

Histopathological pattern of endometrial biopsies in patients with abnormal uterine bleeding in a tertiary referral hospital in Jordan

BACKGROUND

Abnormal uterine bleeding (AUB) is a symptom that deviates from the normal menstrual cycle. AUB is characterized by changes in the frequency, volume, and duration of the menstrual flow. The etiology of AUB, which varies with age, may be attributed to both structural and non-structural causes.

OBJECTIVES

Determine the histopathological pattern of endometrial biopsies in patients with AUB across different age and parity groups who have undergone dilation and curettage (D&C), along with the discrepancy between D&C and histopathological findings after hysterectomy.

DESIGN

Retrospective chart review SETTING: Tertiary referral hospital PATIENTS AND METHODS: We collected data on all patients diagnosed with AUB between January 2015 and December 2020. Histopathological findings of all D&C endometrial biopsy samples were examined after being categorized by age and parity groups. Sensitivity, specificity, positive predictive value, and NPV were calculated to evaluate the diagnostic accuracy of D&C.

MAIN OUTCOME MEASURES

Histopathological pattern of D&C endometrial biopsies by age and parity groups.

SAMPLE SIZE

3233 patients.

RESULTS

Most patients were in the 18-39 year age group, with normal cyclical findings being the most common histopathological finding. Malignant lesions were observed in 42 patients with a majority being older than 50 years. In 13.3% (42/316) of patients, D&C failed to detect intrauterine disorder that was found on hysterectomy. The overall accuracy of D&C in determining the existence of normal versus pathological findings was 75.60%, the sensitivity was 72.90%, the specificity was 77.90%, the positive predictive value was 73.86% and the NPV was 77.05% in our patients.

CONCLUSION

Normal cyclic changes account for the highest proportion of histopathological findings. However, hyperplasia and malignancies are important causes of perimenopausal and postmenopausal bleeding. While the use of D&C as a sampling tool for AUB cases remains questionable, the use of D&C in diagnosing premalignant and malignant cases is highly effective.

LIMITATIONS

Single-center, retrospective design, incomplete medical records, and inter-rater reliability could not be determined.

CONFLICT OF INTEREST

None.

Risk of atypical hyperplasia and endometrial carcinoma after initial diagnosis of non-atypical endometrial hyperplasia: A long-term follow-up study

OBJECTIVES

The strong association between atypical endometrial hyperplasia and endometrial carcinoma is well established, but data on the risk of atypical hyperplasia and carcinoma in Danish women with non-atypical endometrial hyperplasia are almost non-existent. This study aimed to investigate the prevalence of atypical hyperplasia and endometrial carcinoma diagnosed within 3 months of initial diagnosis (defined as concurrent disease) and the risk of atypical hyperplasia and carcinoma more than 3 months after initial diagnosis (classified as progressive disease) in Danish women initially diagnosed with non-atypical endometrial hyperplasia.

DESIGN

This cohort study recruited 102 women diagnosed with non-atypical endometrial hyperplasia at Randers Regional Hospital in Randers, Denmark, between 2000 and 2015.

METHODS

The endometrium was evaluated by transvaginal ultrasound examination and office mini-hysteroscopy with biopsies in all non-hysterectomized women. Data regarding subsequent hysterectomy or endometrial sampling were obtained from medical records and the Danish Pathology Registry (Patobank).

RESULTS

A total of 15 women were diagnosed with atypical hyperplasia or carcinoma during follow-up. Concurrent atypical hyperplasia or carcinoma was seen in 2.9% (3/102), and among women who remained at risk for more than 3 months after initial diagnosis of non-atypical endometrial hyperplasia (n = 94), progression to atypical hyperplasia or carcinoma was seen in 13% (median follow-up 5.2 years, range 3.6 months to 15.1 years). Sixty-six percent of the women with progressive disease were diagnosed with atypical hyperplasia or carcinoma more than 1 year after initial diagnosis, but only two were diagnosed later than 5 years (5.2 and 9 years).

CONCLUSIONS

The risk of being diagnosed with atypical endometrial hyperplasia or endometrial carcinoma more than 5 years after an initial diagnosis of non-atypical endometrial hyperplasia seems to be low in Danish women. Specialized follow-up more than 5 years after diagnosis of non-atypical endometrial hyperplasia may not be warranted.

The significance of "atrophic endometrium" in women with postmenopausal bleeding

We evaluated the interpretation of atrophic endometrium (AE) histology as the most common cause for postmenopausal bleeding (PMB). This theory has been accepted for several generations by gynecologists and gynecologic oncologists and has been published in past and current major gynecology textbooks. In our review of the literature, we did not find sufficient histological or clinical proof for this concept. In our view, AE is not a cause of PMB and we back this up with a review of old and current medical literature. The old studies are based on information which was obtained prior to the existence of transvaginal sonogram, sonohysterogram and hysteroscopy. Focal lesions are notorious for being missed by endometrial sampling and curettage. Recent studies show that focal endometrial lesions are a crucial cause for PMB and some of those lesions can harbor cancer. In our opinion, AE is the most common histology found because it is physiologic and a ubiquitous finding in postmenopausal women, but it is not a cause of PMB. Referring to AE as a cause of PMB may result in misdiagnosis of cancer, management delay and unnecessary intervention. To avoid misdiagnosis of cancer, transvaginal sonogram should be considered in all women with PMB and AE on pathology. If endometrial thickness is found, AE is unlikely to be the cause of the PMB and further workup is warranted to reveal the true etiology for the bleeding.

The Risk of Endometrial Malignancy and Other Endometrial Pathology in Women with Abnormal Uterine Bleeding: An Ultrasound-Based Model Development Study by the IETA Group

OBJECTIVES

The aim of this study was to develop a model that can discriminate between different etiologies of abnormal uterine bleeding.

DESIGN

The International Endometrial Tumor Analysis 1 study is a multicenter observational diagnostic study in 18 bleeding clinics in 9 countries. Consecutive women with abnormal vaginal bleeding presenting for ultrasound examination (n = 2,417) were recruited. The histology was obtained from endometrial sampling, D&C, hysteroscopic resection, hysterectomy, or ultrasound follow-up for >1 year.

METHODS

A model was developed using multinomial regression based on age, body mass index, and ultrasound predictors to distinguish between: (1) endometrial atrophy, (2) endometrial polyp or intracavitary myoma, (3) endometrial malignancy or atypical hyperplasia, (4) proliferative/secretory changes, endometritis, or hyperplasia without atypia and validated using leave-center-out cross-validation and bootstrapping. The main outcomes are the model's ability to discriminate between the four outcomes and the calibration of risk estimates.

RESULTS

The median age in 2,417 women was 50 (interquartile range 43-57). 414 (17%) women had endometrial atrophy; 996 (41%) had a polyp or myoma; 155 (6%) had an endometrial malignancy or atypical hyperplasia; and 852 (35%) had proliferative/secretory changes, endometritis, or hyperplasia without atypia. The model distinguished well between malignant and benign histology (c-statistic 0.88 95% CI: 0.85-0.91) and between all benign histologies. The probabilities for each of the four outcomes were over- or underestimated depending on the centers.

LIMITATIONS

Not all patients had a diagnosis based on histology. The model over- or underestimated the risk for certain outcomes in some centers, indicating local recalibration is advisable.

CONCLUSIONS

The proposed model reliably distinguishes between four histological outcomes. This is the first model to discriminate between several outcomes and is the only model applicable when menopausal status is uncertain. The model could be useful for patient management and counseling, and aid in the interpretation of ultrasound findings. Future research is needed to externally validate and locally recalibrate the model.

Diagnostic Accuracy of Hysteroscopic Scoring System in Predicting Endometrial Malignancy and Atypical Endometrial Hyperplasia

Aims and Objectives:

The aim of this study was to determine the diagnostic accuracy of a hysteroscopic scoring system in predicting endometrial cancer and endometrial hyperplasia with atypia.

Materials and Methods:

This is a prospective study involving 95 peri and postmenopausal women with abnormal uterine bleeding who underwent hysteroscopic-guided endometrial biopsy. After the calculation of hysteroscopic score, biopsy was obtained and sent for histopathological examination. Hysteroscopic diagnosis of carcinoma endometrium was made when the total score was ≥16 and a score ≥7 supported a diagnosis of endometrial hyperplasia with atypia.

Results:

Out of the 95 women, 46 (48.4%) women had postmenopausal bleeding. The mean age of women was 50.4 ± 10.3 years. Eight women were diagnosed to have endometrial cancer and eight had endometrial hyperplasia with atypia on histopathological examination. Using a hysteroscopy score ≥16, the sensitivity and specificity were found to be 62.5% and 90.8%, respectively, for diagnosing endometrial cancer. Hysteroscopy score ≥9 was found to be a better cutoff for diagnosing endometrial cancer using Youden index. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for diagnosing endometrial cancer with score ≥9 was 100%, 67.8%, 22.2%, and 100%, respectively. The sensitivity, specificity, PPV, and NPV for diagnosing endometrial hyperplasia with atypia with score ≥7 was found to be 75%, 58.6%, 14.3%, and 96.2%, respectively.

Conclusion:

The hysteroscopic scoring system has a good diagnostic performance when a cutoff score ≥9 is used in predicting endometrial cancer. However, the scoring system has lower diagnostic accuracy in predicting endometrial hyperplasia with atypia.

Understanding the Endometrium at Menopause: A Hysteroscopist's View

The risk of premalignant and malignant endometrial pathologies increases in the postmenopausal period. Dilatation and curettage fail to diagnose one in ten endometrial pathologies. Hysteroscopy is the gold standard to evaluate the endometrial cavity. Hysteroscopy can identify malignant or benign pathology with approximately 20% false-positive results. Hysteroscopy combined with biopsy increases the accuracy of diagnosis up to 100%. This pictorial review takes you through the hysteroscopic view of normal-looking postmenopausal atrophic uterus, cystic atrophy, benign endometrial pathologies, endometrial hyperplasia, endometrial cancer, tamoxifen-induced endometrial hyperplasia and histiocytic endometritis. The purpose of this pictorial review is to guide the operator in systematic evaluation of the endometrial cavity with special attention to the thickness of the endometrium, vascular architecture, location of the lesion and surface aberrations, which adds value to the diagnosis and management of endometrial pathologies.

Risk of More Advanced Lesions at Hysterectomy after Initial Diagnosis of Non-Atypical Endometrial Hyperplasia in Patients with Postmenopausal Bleeding and Oral Anticoagulant Treatment

Background and Objectives: Endometrial hyperplasia (EH) is a precursor lesion to endometrial cancer (EC), and when cellular atypia is present, in 40% of cases, they are diagnosed with EC on hysterectomy. Usually, EH is clinically manifested by uterine bleeding. In patients with oral anticoagulant therapy (OAT), the uterus is the second most common source of bleeding. The aim of the study was to show that uterine bleeding in postmenopausal patients undergoing OAT may reveal precancerous endometrial lesions with atypia, or neoplastic lesions in patients with an initial diagnosis of endometrial hyperplasia without atypia (non-atypical endometrial hyperplasia, NAEH) on dilation and curettage (D&C). We will be able to estimate the risk of a postmenopausal female patient with uterine bleeding during an OAT to have a precancerous endometrial lesion. Materials and Methods: The subjects of the study were 173 female patients with uterine bleeding, who have had total hysterectomy with bilateral salpingoovarectomy, of whom 99 underwent an OAT. There were 101 female patients initially diagnosed with NAEH, of which 60 did not have anticoagulant treatment (mean age 57.36 ± 6.51) and 41 had anticoagulant treatment (mean age 60.39 ± 7.35) (p = 0.006). From the pathology diagnosis moment, the surgery was performed at 42.09 ± 14.54 days in patients without OAT and after 35.39 ± 11.29 days in those who received such treatment (p = 0.724). Results: Initial diagnosis of NAEH established at D&C was changed at the final diagnosis after hysterectomy in EH with cellular atypia (atypical endometrial hyperplasia AEH) or EC in 18.18% of patients without OAT, and in 40.54% of patients who received this treatment. Conclusions: Based on a logistic regression model, it is estimated that female patients with an initial histopathological diagnosis of NAEH and who underwent OAT have, on average, 4.85 times greater odds (OR = 4.85, 95% CI 1.79–14.06) than the others of being identified postoperatively with more advanced lesions.

[Guidelines for Clinical Practice of the French College of Obstetricians and Gynecologists 2021: Prophylactic procedures associated with gynecologic surgery]

OBJECTIVE

To draw up recommendations on the use of prophylactic gynecologic procedures during surgery for other indications.

DESIGN

A consensus panel of 19 experts was convened. A formal conflict of interest policy was established at the onset of the process and applied throughout. The entire study was performed independently without funding from pharmaceutical companies or medical device manufacturers. The panel applied the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system to evaluate the quality of evidence on which the recommendations were based. The authors were advised against making strong recommendations in the presence of low-quality evidence. Some recommendations were ungraded.

METHODS

The panel studied 22 key questions on seven prophylactic procedures: 1) salpingectomy, 2) fimbriectomy, 3) salpingo-oophorectomy, 4) ablation of peritoneal endometriosis, 5) adhesiolysis, 6) endometrial excision or ablation, and 7) cervical ablation.

RESULTS

The literature search and application of the GRADE system resulted in 34 recommendations. Six were supported by high-quality evidence (GRADE 1+/-) and 28 by low-quality evidence (GRADE 2+/-). Recommendations on two questions were left ungraded due to a lack of evidence in the literature.

CONCLUSIONS

A high level of consensus was achieved among the experts regarding the use of prophylactic gynecologic procedures. The ensuing recommendations should result in improved current practice.

In which cases should endometrial destruction be performed during an operative hysteroscopy? Clinical practice guidelines from the French College of Gynaecologists and Obstetricians (CNGOF)

OBJECTIVE

To provide guidelines from the French College of Obstetricians and Gynaecologists (CNGOF), based on the best evidence available, concerning the impact of endometrial destruction on bleeding and endometrial cancer risk reduction in patients candidates for operative hysteroscopy.

METHODS

Recommendations were made according to AGREE II and the GRADE® (Grading of Recommendations Assessment, Development and Evaluation) systems to determine separately the quality of evidence (QE) and in the level of recommendation.

RESULTS

In a retrospective study comparing the incidence of endometrial cancer in 4776 patients with menorrhagia treated with endometrial destruction vs 229 945 patients with a medical treatment. There was a non-significant reduced risk of developing endometrial cancer (HR, 0.45; 95% CI, 0.15-1.40; p = .17). In premenopausal women, five studies compared the incidence of endometrial cancer in patients treated with endometrial ablation/destruction (EA/D) to the incidence of endometrial cancer in a comparable population of women from national registers, all of which show reduced risk of endometrial cancer after endometrectomy. In case of menopausal metrorrhagia, the prevalence of endometrial cancer is 9%, by analogy with the results found in premenopausal patients, the combination of endometrial ablation during operative hysteroscopy seems justified. In a retrospective cohort of 177 non-menopausal patients treated with myomectomy for metrorrhagia and/or menorrhagia, a significantly better control of bleeding at 12 months was found when myomectomy was combined with endometrectomy using roller-ball (OR: 0.18 [95% Cl 0.05-0.63]; p = 0.003).

CONCLUSION

In premenopausal women with heavy menstrual bleeding, when an operative hysteroscopy is performed, it is recommended to propose an endometrial ablation/destruction in order to prevent the risk of endometrial cancer, (QE3) and to prevent recurrence of bleeding (QE2). In menopausal women, it is probably recommended to also perform an endometrial ablation/destruction in case of operative hysteroscopy in order to prevent the risk of endometrial cancer (QE1).

Endometrial adenocarcinoma initially mistaken as urinary incontinence

OBJECTIVE

The report aims to present a case of endometrial cancer with unusual initial presentation. A literature review is conducted to speculate symptoms presented by endometrial cancer other than vaginal bleeding.

CASE REPORT

A 43-year-old, para 1, lean female suffered from copious watery vaginal discharge that was odorless and colorless for 8 months without any signs of abnormal vaginal bleeding. Preliminary surveys in private clinics with per vaginal examination and Papanicolaou smear were normal. Urinary incontinence was mistakenly impressed. When the patient turned to our center for help as symptoms aggravated, transvaginal sonography revealed hydrometra with papillary endometrium lesions. Hysteroscopy survey with endometrial biopsy revealed endometrial adenocarcinoma.

CONCLUSION

This is a case of endometrial cancer with unusual presentation. Transvaginal sonography and hysteroscopy are easy and sensitive screening tools that should be readily offered to patients with suspicious symptoms.

Non-atypical endometrial hyperplasia: risk factors for occult endometrial atypia and malignancy in patients managed with hysterectomy

Objective

To determine the risk factors for occult endometrial atypia and malignancy in patients diagnosed with non-atypical endometrial hyperplasia (NEH) on endometrial biopsy.

Methods

All new cases of NEH diagnosed between April 2015 and March 2016 at KK Women’s and Children’s Hospital, who underwent hysterectomy as first-line treatment, were included in the study. Patients with a history of endometrial hyperplasia or malignancy were excluded from the study. Patient demographics (e.g., age, parity, body mass index [BMI]), medical history, and clinical presentation were obtained for analysis.

Results

In total, 262 patients were diagnosed with NEH, of which 18.3% (n=48) underwent hysterectomy as first-line management. The average time to surgery was 77.0±35.7 days. All cases were diagnosed by dilation and curettage, and hysteroscopy. The mean age was 51 years, and the mean BMI was 26.9±5.8 kg/m². Histology from the hysterectomy specimen showed 9 (18.8%) patients with atypical hyperplasia and 2 (4.2%) with grade 1, stage 1A endometrioid adenocarcinoma. Patients with higher grade final pathology had significantly lower median parity (1 vs. 2, P=0.039), higher mean BMI (30.1±6.5 vs. 25.9±5.3 kg/m², P=0.033), and BMI ≥30 kg/m² (54.5% vs. 13.5%, P=0.008, odds ratio 7.68), compared to patients whose final histology showed NEH or no residual hyperplasia.

Conclusion

Occult endometrial atypia and malignancy were found in 18.8% and 4.2% of patients with an initial diagnosis of NEH, respectively. High BMI and low parity were identified as significant risk factors for high-grade endometrial lesions in patients with NEH.

Endometrial sampling before or after saline contrast sonohysterography in women with postmenopausal bleeding (ESPRESSO trial): A multicenter randomized controlled trial

INTRODUCTION

The aim of this study is to evaluate the quality of the endometrial sample obtained by office endometrial aspiration when performed before or after saline contrast sonohysterography (SCSH) in women with postmenopausal bleeding and a thickened endometrium. To conduct a complete, minimally invasive and cost-effective diagnostic workup in women with postmenopausal bleeding and a thickened endometrium, ideally both the office endometrial sampling and SCSH are performed. However, it is not known whether both tests affect each other when performed one after another.

MATERIAL AND METHODS

Women with postmenopausal bleeding and an endometrial thickness >4 mm were eligible. Women were randomized into two groups: one group received endometrial aspiration before SCSH, the other group received SCSH before endometrial aspiration. The primary outcome was the proportion of sufficient endometrial samples. Reliability of the SCSH images and pain during procedures were secondary outcomes.

RESULTS

During the inclusion period, 513 eligible women with postmenopausal bleeding visited the participating hospitals, 293 of whom received information about the study. Of these women, 232 (79%) agreed to participate. In the SCSH-aspiration group, 65 women (59%) had a sufficient endometrial sample compared with 70 (67%) in the aspiration-SCSH group (odds ratio 1.46, 95% CI 0.83-2.54, P = .19). The proportion of reliable sonographic images was significantly higher in the SCSH-aspiration group (n = 88, 87%) compared with the aspiration-SCSH group (n = 71, 74%) (OR 2.38, 95% CI 1.38-4.99, P = .02) in the per protocol analysis.

CONCLUSIONS

This study shows that the quality of an endometrial sample in women with postmenopausal bleeding is not affected by SCSH. Both procedures can be performed in one outpatient visit to perform an optimal diagnostic workup.

Typical ultrasound features of various endometrial pathologies described using International Endometrial Tumor Analysis (IETA) terminology in women with abnormal uterine bleeding

OBJECTIVE

To describe the ultrasound features of different endometrial and other intracavitary pathologies inpre- and postmenopausal women presenting with abnormal uterine bleeding, using the International Endometrial Tumor Analysis (IETA) terminology.

METHODS

This was a prospective observational multicenter study of consecutive women presenting with abnormal uterine bleeding. Unenhanced sonography with color Doppler and fluid-instillation sonography were performed. Endometrial sampling was performed according to each center's local protocol. The histological endpoints were cancer, atypical endometrial hyperplasia/endometrioid intraepithelial neoplasia (EIN), endometrial atrophy, proliferative or secretory endometrium, endometrial hyperplasia without atypia, endometrial polyp, intracavitary leiomyoma and other. For fluid-instillation sonography, the histological endpoints were endometrial polyp, intracavitary leiomyoma and cancer. For each histological endpoint, we report typical ultrasound features using the IETA terminology.

RESULTS

The database consisted of 2856 consecutive women presenting with abnormal uterine bleeding. Unenhanced sonography with color Doppler was performed in all cases and fluid-instillation sonography in 1857. In 2216 women, endometrial histology was available, and these comprised the study population. Median age was 49 years (range, 19-92 years), median parity was 2 (range, 0-10) and median body mass index was 24.9 kg/m² (range, 16.0-72.1 kg/m² ). Of the study population, 843 (38.0%) women were postmenopausal. Endometrial polyps were diagnosed in 751 (33.9%) women, intracavitary leiomyomas in 223 (10.1%) and endometrial cancer in 137 (6.2%). None (0% (95% CI, 0.0-5.5%)) of the 66 women with endometrial thickness < 3 mm had endometrial cancer or atypical hyperplasia/EIN. Endometrial cancer or atypical hyperplasia/EIN was found in three of 283 (1.1% (95% CI, 0.4-3.1%)) endometria with a three-layer pattern, in three of 459 (0.7% (95% CI, 0.2-1.9%)) endometria with a linear endometrial midline and in five of 337 (1.5% (95% CI, 0.6-3.4%)) cases with a single vessel without branching on unenhanced ultrasound.

CONCLUSIONS

The typical ultrasound features of endometrial cancer, polyps, hyperplasia and atrophy and intracavitary leiomyomas, are described using the IETA terminology. The detection of some easy-to-assess IETA features (i.e. endometrial thickness < 3 mm, three-layer pattern, linear midline and single vessel without branching) makes endometrial cancer unlikely. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Preoperative assessment of endometrial cancer

Endometrial cancer (EC), the most common among gynaecological malignancies occurs predominantly after the menopause. The diagnosis is most commonly (in about 75-80%) set up at early stage when surgical therapy and if necessary postoperative radiotherapy results in an excellent prognosis, with a 90-95% 5-year overall survival (OS) and a locoregional recurrence rates of 4-8%. Accurate preoperative assessment of the lymph nodes would ideally identify those patients with advanced stage disease, who might benefit from more extensive surgical procedures and adjuvant therapies. magnetic resonance imaging (MRI), hysteroscopic excisional biopsy (HEB) and high resolution 2D or 3D ultrasound performed by expert operator are considered to add valuable information for preoperative staging of EC. The use of biomarkers could be beneficial in decreasing inter-observer variability between the histology of the diagnostic specimen and the final operative sample, as well as to avoid overtreatment in a part of the high-grade tumors with excellent prognosis. The goal of surgical management of EC is to remove the primary tumor and to identify definite prognostic factors to determine whether adjuvant therapy is required. Extended surgery, including para-aortic lymphadenectomy has a significant morbidity, and with the future selection of cases it can be safely avoided, we can decrease complications without compromising oncological safety. In the future, the importance of hysteroscopy guided sampling may increase to gain a representative sample for biomarker detection.

The accuracy of endometrial sampling for the diagnosis of patterns of endometrial pathology in women presenting with abnormal uterine bleeding. More conservative therapeutic approaches

Objectives:

Abnormal uterine bleeding (AUB) is a leading cause of hysterectomies, the cause of which is usually diagnosed with preoperative endometrial sampling. We planned this study to assess the accuracy of diagnosing the histologic patterns of endometrium in the preoperative sample in reference to the final histologic diagnosis in hysterectomy.

Methods:

We retrospectively reviewed medical charts between January 2011 and December 2015 at a tertiary hospital in Saudi Arabia and identified 43 cases of AUB with complete documentation. The histologic diagnoses were classified into normal and benign pathology group (N/B), or carcinoma and hyperplasia category (Ca/H). Measures of validity were used to compare endometrial sampling histological diagnoses to diagnoses following hysterectomy and Cohen’s kappa to assess for agreement between the 2 modalities.

Results:

The median age of all patients was 49 years. Preoperative histologic examination showed 53.8% sensitivity, 90% specificity, 70% positive predictive values and 81.8% negative predictive values, 30.1% false positive rates and 18.2% false negative rates. The agreement between preoperative and postoperative histologic diagnoses was moderate (79.1%, k=0.469).

Conclusion:

The accuracy of preoperative histologic examination was moderate. Our findings recommend cautious clinical decision making and limiting hysterectomy to women who do not respond to other therapeutic measures.

Can we rely on blind endometrial curettage for complete removal of focal intrauterine lesion? A prospective clinical study

OBJECTIVE

To investigate the diagnostic and therapeutic efficiency of dilatation-curettage (D&C) combined with aspiration curettage for endometrial pathology compared to hysteroscopy alone in this study.

MATERIAL AND METHODS

A total of 143 patients who have suspicion of endometrial mass like lesion, increased endometrial thickness (>5-mm at menopause and/or endometrial thickness upper than 5-mm in patients under tamoxifen treatment due to breast cancer during 2-D transvaginal ultrasonography examination) were enrolled. All patients underwent procedures in order of hysteroscopy, D&C plus aspiration and second look hysteroscopy. Data for age, menopausal status, tamoxifen treatment, endometrial histology, hysteroscopy and D&C findings were recorded and statistically analyzed.

RESULTS

Initial hysteroscopy revealed focally growing endometrial lesion in 96 patients. Second look hysteroscopy showed persistent focal lesion in 77 patients (80 %) after D&C plus aspiration. Endometrial blind curettage failed to diagnose 42 % (25/60) of endometrial polyps, none of submucous myomas as well as 27 % (3/11) of premalignant and malignant endometrial lesions. The sensitivity, specificity, overall accuracy, positive predictive value and negative predictive value of hysteroscopy were found as 84.1 %, 83.3 %, 83.9 %, 93.8 %, and 63.8 %, respectively.

CONCLUSIONS

Hysteroscopy showed significant superiority in the diagnosis and definitive treatment of endometrial pathologies specifically in focally growing endometrial lesions compared to D&C plus aspiration.

Diagnostic accuracy of saline contrast sonohysterography in detecting endometrial polyps in women with postmenopausal bleeding: systematic review and meta-analysis

OBJECTIVE

In women with postmenopausal bleeding, endometrial polyps are a frequent finding and the risk of a focal (pre)malignancy in a polyp is up to 6%. Because of this reported risk, the detection of polyps in these women, preferably by a minimally invasive method, is important. The aim of this systematic review was to assess the accuracy of saline contrast sonohysterography (SCSH) for diagnosis of endometrial polyps in women with postmenopausal bleeding.

METHODS

In August 2018, an electronic search was performed of MEDLINE, EMBASE and Web of Science databases to identify all diagnostic studies in which SCSH was used to detect endometrial polyps in postmenopausal women. Studies were included if SCSH was performed to detect endometrial polyps in women with postmenopausal bleeding and if detection of a polyp on hysteroscopy or diagnosis on histopathology was used as a reference standard. Two reviewers assessed methodological quality using the quality assessment of diagnostic accuracy studies (QUADAS-2) tool. Two separate analyses were performed for each reference standard. Pooled sensitivity and specificity were calculated using the hierarchical summary receiver-operating characteristics (HSROC) model and HSROC curves were plotted.

RESULTS

After selection and quality assessment, five studies were included. Using 'polyps diagnosed with histopathology' as the reference standard, the pooled sensitivity of SCSH was 86.5% (95% CI, 63.6-100%) and the pooled specificity was 91.1% (95% CI, 63.2-100%). Using 'polyps seen on hysteroscopy' as the reference standard, the pooled sensitivity of SCSH was 85.1% (95% CI, 66.9-100%) and the pooled specificity was 84.5% (95% CI, 68.1-100%). Excluding the one study that included women in whom the SCSH examination was reported to be suboptimal, the pooled sensitivity increased to 90.7% (95% CI, 72.8-100%) using hysteroscopy as the reference standard. The sensitivity of hysteroscopy to detect polyps, as reported in two studies, was 81-98%.

CONCLUSIONS

Provided that the SCSH examination is of optimal quality, it can be considered as a method to stratify women with postmenopausal bleeding for further diagnostic workup and treatment with hysteroscopy. In women without suspicion of a polypoid lesion on SCSH, and with a benign endometrial sample, expectant management should be considered. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Diagnostic value of histopathological examination results obtained during screening of patients with diagnosed atypical hyperplasia

Vulvovaginal atrophy accompanied by lower urinary tract dysfunction related to low levels of estrogen and androgens is labeled as genitourinary syndrome of menopause (GSM). Although this condition affects most postmenopausal women worldwide, it seems to be underdiagnosed and undertreated. Women should be properly advised to choose an adequate treatment modality to improve their quality of life, sexual relationships and social activity. The aim of this article is to increase knowledge of GSM. The current treatment options, both hormonal and non-hormonal, are reviewed. Topical estrogen therapy still remains the gold standard, but the demand for individually tailored therapy is growing. New treatment modalities are continuously included in clinical practice. They should consider the whole personality of a woman as well as cultural and social factors. Further studies on GSM and on the effectiveness of various treatment options are necessary to achieve this purpose.

Endometrial histopathology results and evaluation of endometrial cancer risk in geriatric women

The incidence of premalignant and malignant endometrial disorders increases during the postmenopausal period. In the literature, endometrial disorders are usually discussed in the context of menopausal status. But there are limited data regarding endometrial disorders in geriatric patients. Early diagnosis of endometrial cancers with aggressive behaviour that increases during the geriatric period may allow simpler treatment options and also decrease the treatment-associated morbidity risk.

Records of geriatric patients who underwent an endometrial histopathological evaluation between 2011 and 2016 were evaluated. Clinical findings, transvaginal ultrasonography findings, endometrial sampling methods, and histopathological results were evaluated.

A total of 188 patients were included in the study (mean age 70.3 ±5.6 years). The most common histopathological results were endometrial polyp, atrophic endometrium, and surface epithelium (26.6%, 22.3%, and 12.8%, respectively). None of the 57 patients without vaginal bleeding had endometrial cancer. In 131 patients with vaginal bleeding, mean endometrial thickness was 9.8 ±8.1 mm (2-49 mm) and the rate of endometrial disorders was 56.5% (74 patients). Endometrial cancer was diagnosed in 19 patients (10.1%), and 36.8% of them had non-endometrioid cancers. The presence of vaginal bleeding was significantly associated with the diagnosis of endometrial cancer and any endometrial disorder (p = 0.001 and p = 0.000, respectively).

The incidence of non-endometrioid endometrial cancers increased in the geriatric period. An endometrial histopathological examination should be considered, especially for patients with a history of vaginal bleeding. Further investigation of the endometrial thickness cut-off levels in the geriatric period will contribute to the literature.

Complex non atypical hyperplasia and the subsequent risk of carcinoma, atypia and hysterectomy during the following 9-14 years

INTRODUCTION

The aim of this study was to evaluate the long-term risk of developing atypical hyperplasia/endometrial cancer or having a hysterectomy after being diagnosed with complex non-atypical hyperplasia (CH).

MATERIAL AND METHOD

A historic cohort study of 114 women diagnosed with CH between January 1st 2000 and December 31st 2005. All patient records and pathologic reports were reviewed with complete follow up on all patients in the national pathologic database until September 1st 2014. Kaplan-Meier analysis was used to determine (1) no hysterectomy and (2) no diagnosis of endometrial cancer or atypia after the CH diagnosis.

RESULTS

15% (n = 17) were diagnosed with endometrial cancer and 7% (n = 8) with atypia, most during the first year (10 cancer, 7 atypia). 9% (8/85) of the remaining women at risk developed cancer or atypia in the follow-up period after one year. By Kaplan-Meier the five-year risk for cancer or atypia was 20% (CI; 14-21). The risk of having undergone hysterectomy within five years was 30% (CI; 22-39).

CONCLUSION

The long-term risk of being diagnosed with atypia or cancer after a CH diagnose is not insignificant, when disregarding patients having undergone hysterectomy. More than half the women with atypia or cancer are diagnosed or operated during the first year. This could indicate the presence of concomitant but unidentified cancer or atypia at the time of initial sampling. This study reinforces the importance of follow up or treatment of women with CH - especially, but not only during the first year.

KEY MESSAGE

The risk of having a hysterectomy or diagnosed with atypical hyperplasia/cancer endometrie is high after a diagnosis of complex hyperplasia without atypia.

Current strategies in the diagnosis of endometrial cancer

PURPOSE

Endometrial cancer is the most common gynecological malignancy in developed countries. There are no uniform recommendations for endometrial cancer screening in the general population. Therefore, it is of paramount importance that the primary physician profoundly understands, and is familiar with the methods for prevention and early detection of endometrial cancer. The aim of this review is to provide the primary physician with a toolbox to reach these goals.

METHODS

We performed a systemic review to summarize the current strategies to diagnose and prevent endometrial cancer. Many published articles from the last years were identified and included.

RESULTS

A systematic review that summarizes the important subjects in the diagnosis and prevention of endometrial cancer.

CONCLUSION

Maintaining a high index of suspicion and obtaining endometrial biopsies from all suspected patients is the key for achieving a timely diagnosis.

Assessment of Endometrial Sampling and Histopathological Results: Analysis of 4,247 Cases

OBJECTIVE

This study aimed to investigate the relationship between indications and histopathological results in patients undergoing endometrial sampling.

MATERIALS AND METHODS

Data of 4,247 patients undergoing endometrial sampling due to non-obstetric gynecological causes between January 2010 and October 2016 were retrospectively evaluated using the archives of the Gynecology and Obstetrics Clinic of Konya Training and Research Hospital.

RESULTS

The mean age of patients was 46.8 ± 8.22 years; the most common indication was menometrorrhagia/menorrhagia (70.66%), and the least common indication was cervical polyp (1.34%). The most common histopathological result was proliferative-secretory endometrium (63.62%); simple hyperplasia with atypia (0.56%) was determined to be the least common result. Endometrial cancer was observed more frequently in the post-menopausal bleeding and increased endometrial thickness group (23.11%). Of patients in whom biopsy was performed, 52.18% had undergone hysterectomy, as a result of which proliferative-secretory endometrium was most commonly (59.52%) and simple hyperplasia with atypia least commonly found as the histopathological diagnosis.

CONCLUSION

Although sampling should be performed following endometrial evaluation in patients with post-menopausal bleeding or increased endometrial thickness, according to the results of our study, routine endometrial biopsy should not be preferred in the other indications.

Endometrial cancer with congenital uterine anomalies: 3 case reports and a literature review

BACKGROUND

Uterine malformation is a rare deformity in woman, and only a few cases concerning endometrial cancer arising in patients with congenital uterine anomalies have been reported. Herein, we present 3 cases of endometrial cancer with different congenital uterine anomalies, and review studies involving congenital uterine anomalies associated with endometrial cancer in the past 25 years, to identify similarities and differences in clinicopathologic characteristics and prognosis between endometrial cancer associated with uterine anomalies, and normal uterus.

CASES

Case 1 was a 75-year-old gravida 1, para 0, woman with carcinosarcoma (mixed well-differentiated endometrial adenocarcinoma and undifferentiated sarcoma) of the right cavity (grade III, and at least stage II ) of a uterus didelphys. The tumor recurred within 7 months after surgery, salvage radiotherapy was unsuccessful; the patient died 8 months after the surgery. Case 2 was a 63-year-old gravida 5, para 3, woman with a bicornuate uterus and uterus papillary serous carcinoma of the right horn (grade III, stage IIIC). She did not respond to the chemotherapy post surgery and died within 4 months. Case 3 was a 60-year-old gravida 0, para 0, woman with a complete septate uterus and an oblique vaginal septum of the upper region of the vagina with endometrioid adenocarchcinoma of the left cavity (grade II, stage IA). No adjuvant therapy was administered and the patient had recovered 2 y after the surgery.

CONCLUSION

Clinicians should be aware of the coexistence of uterine malignancies and uterine anomalies in patients presenting with persistent abnormal uterine bleeding, but with negative endometrial biopsy or failed in the operation of endometrial biopsy. In such cases, magnetic resonance imaging has an important role in the diagnosis of both malformation and malignancy, and an exploratory laparotomy should be performed to avoid delaying the diagnosis and treatment of cancers.

Investigating vaginal bleeding in postmenopausal women found to have an endometrial thickness of equal to or greater than 10 mm on ultrasonography

PURPOSE

This aim of this study is to determine the risk of endometrial cancer in symptomatic postmenopausal women, when endometrial thickness on transvaginal ultrasonography is equal to or greater than 10 mm, and subsequent office-based endometrial sampling histology is negative.

METHODS

This is a prospective cross-sectional study, performed in a gynaecological oncology centre in the United Kingdom between February 2008 and July 2012. All postmenopausal women presenting with vaginal bleeding were investigated using transvaginal ultrasonography. Women with endometrial thickness measurements equal to or greater than 10 mm and negative office-based endometrial biopsy underwent hysteroscopy and endometrial biopsies.

RESULTS

Over a 52-month period, 4148 women were investigated for postmenopausal vaginal bleeding. 588 (14.2%) women were found to have endometrial thickness measurements of equal to or greater than 10 mm on transvaginal ultrasonography. 170 (28.9%) cases of endometrial cancer were diagnosed in this group: 149 (87.6%) of the cancer cases were diagnosed in the outpatient setting with a Pipelle^® endometrial sampler, whilst 21 (12.4%) had a negative Pipelle^® sample and were diagnosed with hysteroscopy. The group diagnosed with hysteroscopy had lower BMI (32.7 kg/m² versus 39.7 kg/m², p < 0.001) whilst the group diagnosed with Pipelle was more likely to have a history of hypertension and diabetes mellitus (p = 0.019 for both). The sensitivity of Pipelle was 87.65%.

CONCLUSION

For women presenting with postmenopausal bleeding and where the endometrial thickness is equal to or greater than 10 mm and Pipelle sampling is negative, hysteroscopic evaluation with directed biopsy is strongly recommended.

Screening and verifying endometrial carcinoma diagnostic biomarkers based on a urine metabolomic profiling study using UPLC-Q-TOF/MS

BACKGROUND

Endometrial carcinoma (EOC) is a gynecological disease with one of the highest worldwide incidences. Due to the lack of typical clinical symptoms and limited sensitive screening methods used to diagnose endometrial carcinoma, the disease is easily neglected before patients are aware of its presence. Therefore, EOC results in serious impacts on women's lives and health. We screened diagnostic biomarkers of EOC with a noninvasive method that compared healthy individuals and endometrial hyperplasia (EOH) patients.

METHODS

The morning urine of 25 healthy individuals, 25 patients with EOC and 10 patients with EOH were analyzed using an ultra-performance liquid chromatography quadrupole time-of-flight mass spectrometry (UPLC-Q-TOF/MS) platform. Metabolomics data were used to screen the different metabolites according to principal component analysis (PCA) and partial least squares discriminant analysis (PLS-DA) analyses. Furthermore, the screened biomarkers of the newly diagnosed EOC and EOH candidates and healthy individuals were verified using the predictive model of the support vector machine (SVM) to obtain EOC diagnostic biomarkers.

RESULTS

An EOC diagnostic biomarker group was found according to the metabolomics method. Five diagnostic biomarkers, including porphobilinogen, acetylcysteine, N-acetylserine, urocanic acid and isobutyrylglycine, were significantly changed in the EOC patients. Among them, porphobilinogen and acetylcysteine were significantly down-regulated, while N-acetylserine, urocanic acid and isobutyrylglycine were significantly up-regulated.

CONCLUSIONS

Disturbances in these biomarkers have negative impacts on the body's metabolic functioning. The EOC diagnostic biomarker group can provide a clinical reference for diagnosing EOC and insight into the diagnosis of other diseases in the clinic.

Structured imaging technique in the gynecologic office for the diagnosis of abnormal uterine bleeding

The aim in the diagnosis of abnormal uterine bleeding (AUB) is to identify the bleeding cause, which can be classified by the PALM-COEIN (Polyp, Adenomyosis, Leiomyoma, Malignancy (and hyperplasia), Coagulopathy, Ovulatory disorders, Endometrial, Iatrogenic and Not otherwise classified) classification system. In a gynecologic setting, the first step is most often to identify structural abnormalities (PALM causes). Common diagnostic options for the identification of the PALM include ultrasonography, endometrial sampling, and hysteroscopy. These options alone or in combination are sufficient for the diagnosis of most women with AUB. Contrast sonography with saline or gel infusion, three-dimensional ultrasonography, and magnetic resonance imaging may be included.

AIM

The aim of this article is to describe how a simple structured transvaginal ultrasound can be performed and implemented in the common gynecologic practice to simplify the diagnosis of AUB and determine when additional invasive investigations are required. Structured transvaginal ultrasound for the identification of the most common endometrial and myometrial abnormalities and the most common ultrasound features are described. Moreover, situations where magnetic resonance imaging may be included are described. This article proposes a diagnostic setup in premenopausal women for the classification of AUB according to the PALM-COEIN system. Moreover, a future diagnostic setup for fast-track identification of endometrial cancer in postmenopausal women based on a structured evaluation of the endometrium is described.

Accuracy of hysteroscopic biopsy, compared to dilation and curettage, as a predictor of final pathology in patients with endometrial cancer

OBJECTIVE

To compare the methods of transcervical resectoscopy versus dilation and curettage (D&C) for endometrial biopsy and to compare these methods for the percentage of histological upgrades at the final posthysterectomy pathology findings in endometrial cancer.

MATERIALS AND METHODS

We retrospectively reviewed 253 cases of uterine cancer diagnosed from May 1995 to January 2014. Included in the study were patients who received transcervical resectoscopy (TCR) or D&C biopsy as the diagnostic method and underwent laparoscopic staging at our institution. The International Federation of Gynecologists and Obstetricians (FIGO) grade in the pathological report of the biopsy and final hysterectomy were recorded. The extrauterine risk was stratified using the initial FIGO grade and depth of myometrium invasion. It was compared to the actual risk using final pathological findings.

RESULTS

We identified 203 cases of endometrial cancer; 18 (8.9%) patients had a higher histological grade at the final hysterectomy. Among the 203 patients, 76 patients underwent TCR biopsy and 127 underwent D&C biopsy. The histological grade was upgraded in two (2.6%) patients in the TCR group. Three (3.9%) patients had positive peritoneal washings. In the D&C group, 16 (12.6%) patients with three (2.4%) positive peritoneal washings were upgraded.

CONCLUSION

Transcervical resectoscopy could provide more precise grading information, compared to D&C (2.6% vs. 12.6%). Doctors could therefore make a more accurate staging plan, based on the preoperative risk evaluation.

Transvaginal ultrasound examination of the endometrium in postmenopausal women without vaginal bleeding

OBJECTIVES

To estimate in gynecologically asymptomatic postmenopausal women with and without hormone replacement therapy (HRT) undergoing transvaginal ultrasound examination the prevalence of: endometrial thickness ≥ 5.0 mm, intrauterine focal lesions if endometrial thickness is ≥ 5.0 mm, and premalignant and malignant endometrial changes if thickness is ≥ 5.0 mm and intrauterine focal lesions are present.

METHODS

Invitation letters were sent to 2951 potentially eligible women recruited from a Swedish population registry; 757 replied, 514 were considered eligible (i.e. were gynecologically asymptomatic postmenopausal women aged 52-62 years with no current or previous gynecological problems) and 510 had complete information and were included. The women were examined using transvaginal ultrasound (5-9-MHz transducer). If endometrial thickness was ≥ 5.0 mm, saline contrast sonohysterography (SCSH) was attempted. The number, size and surface contour of intracavitary focal lesions were recorded. Women with focal lesions were offered hysteroscopic resection of the lesions. Gold standard was histology of the surgical specimen.

RESULTS

The median time in menopause was 5 (range, 1-17) years. There were no substantial differences in ultrasound findings between women with HRT and those without. Sixty-two (12% (95% CI, 9-15%)) women had an endometrial thickness ≥ 5.0 mm. SCSH was attempted in 54 of these women, which was successful in 48 and suboptimal in one. Thirty-three (67%) of the 49 women with successful or suboptimal SCSH and one woman with spontaneous fluid in the uterine cavity had intracavitary focal lesions. Twenty-nine of these women with focal lesions underwent hysteroscopic resection of the lesion(s). Two cases of endometrial complex hyperplasia with atypia but no malignancy were found. Uterine perforation with bowel damage occurred in two women who underwent hysteroscopic surgery.

CONCLUSION

About 10% of gynecologically asymptomatic postmenopausal women have a sonographic endometrial thickness ≥ 5.0 mm. Our results support conservative management of such women. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Diagnostic value of sonography for detecting endometrial pathologies in postmenopausal women with and without bleeding

PURPOSE

To investigate the diagnostic value of endometrial thickness measurement on sonography in predicting endometrial pathologies in postmenopausal women with vaginal bleeding and in those with asymptomatic thickened endometrium.

METHODS

Six hundred two postmenopausal women with vaginal bleeding or asymptomatic thickened endometrium were evaluated in this study. Two hundred seventy-four women with postmenopausal bleeding regardless of endometrial thickness (group 1: symptomatic) and 328 women with an incidental finding of thickened endometrium (≥5 mm) without bleeding (group 2: asymptomatic) underwent endometrial biopsy for histopathologic examination. The receiver operating characteristics curves of endometrial thickness measurement for prediction of endometrial pathologies were analyzed.

RESULTS

Endometrial carcinoma was detected in eight women (2.9%) in group 1 and in three (0.9%) in group 2. The best cutoff point for endometrial thickness in predicting endometrial carcinoma in group 1 was 8.2 mm, which provided 75% sensitivity (95% confidence interval [CI], 40.9-92.9%) and 74% specificity (95% CI, 68-78.5%); area under the receiver operating characteristics curve (AUC), 0.88; 95% CI, 0.76-1.00%; p = 0.0001. In group 2, the AUC was 0.76 (95% CI, 0.46-1.00; p = 0.114); the evidence was inconclusive as to the relationship between endometrial thickness and malignancy. For the prediction of polyps, the AUCs of endometrial thickness were 0.77 for group 1 (95% CI, 0.71-0.83%; p = 0.0001) and 0.61 for group 2 (95% CI, 0.54-0.67%; p = 0.002).

CONCLUSIONS

Sonographically determined endometrial thickness measurement shows high diagnostic performance for detection of endometrial cancer in symptomatic postmenopausal women at the optimal cutoff thickness of approximately 8 mm, although the evidence supporting the use of sonography for predicting malignancy in asymptomatic women is inconclusive. For polyp detection, this technique shows moderate diagnostic ability in symptomatic women, but its predictive value is low in asymptomatic women. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:339-346, 2016.

The yield of endometrial aspiration in women with various risk factors and bleeding abnormalities

Background

Even in the face of a substantial increase in the numbers of endometrial cancer cases and in the numbers of women who have risk factors, there is no clear agreement about the indications for assessing the endometria of women with abnormal bleeding or about the tools to use in that assessment. This study sought to determine in a group of high risk women with abnormal uterine bleeding, the probability that an outpatient endometrial aspiration would identify significant pathology.

Methods

Retrospective cohort study of the histology from endometrial aspirations performed from 2001 to 2008 for abnormal uterine bleeding at Harbor-UCLA Medical Center and its satellite public health clinics. Medical records were reviewed in detail to assess risk factors, descriptions of bleeding abnormalities and histologic results.

Results

The charts of 1601 women who underwent 1636 endometrial biopsies for a wide variety of abnormal uterine bleeding patterns yielded 73 (4.6 %) cases of endometrial carcinoma, 43 cases of atypical endometrial hyperplasia (2.7 %), for an overall yield of significant pathology of 7.2 %. Hyperplasia without atypia was found in another 83 cases (5.2 %). Obesity, diabetes and postmenopausal age are associated with an increased risk of significant pathology. Bleeding patterns were so poorly documented that analysis of yield by this factor should be viewed with caution.

Conclusions

The probability of detecting significant uterine pathology is greatest among obese, diabetic postmenopausal women with diabetes (26.3 %). Conversely, the probability of identifying significant pathology in younger women without risk factors is less than 2 %. For women who perceive their individualized risk estimate to be too small to justify an endometrial biopsy, it may be possible to offer oral higher dose progestin therapy on the condition that persistent abnormal bleeding will require more intensive evaluation. These estimates of absolute risk of being diagnosed with significant pathology on endometrial biopsy may be helpful to patients as they consider giving informed consent for the procedure.

Diagnostic methods for fast-track identification of endometrial cancer in women with postmenopausal bleeding and endometrial thickness greater than 5 mm

OBJECTIVE

This study aims to evaluate the diagnostic efficiency of pattern recognition by transvaginal ultrasonography (TVS) and gel infusion sonography (GIS) for identifying endometrial pathology and to compare this setup with a standard setup of endometrial sampling (ES), hysteroscopy with pattern evaluation (HY(pattern)), or magnetic resonance imaging (MRI).

METHODS

This study used a prospective cohort of 174 women with postmenopausal bleeding and endometrial thickness of 5 mm or greater. Resectoscopic biopsy (hysteroscopy with biopsy) samples or hysterectomy served as reference standard. Malignant and benign endometrial patterns were evaluated with TVS, GIS and HY(pattern) were then added. The efficiency of each diagnostic strategy, including ES and MRI findings (n = 83), was compared and evaluated against the reference standard.

RESULTS

ES, TVS, GIS, and HY(pattern) had high diagnostic efficiency (area under the curve) for malignancy diagnosis (ES, 0.90; TVS, 0.88; GIS, 0.92; HY(pattern), 0.91). When insufficient samples were incorporated, ES was less efficient than the other techniques. ES was not more efficient in the subgroup of women without localized lesions than in the subgroup of women with localized lesions. MRI and HY(pattern) added limited efficiency, whereas hysteroscopy with biopsy was most efficient.

CONCLUSIONS

As a first-line technique, pattern recognition on TVS, GIS, and HY(pattern) correctly identifies 9 of 10 women with malignancy and is superior to pattern recognition on ES when insufficient samples are included. Endometrial pattern evaluated with TVS and GIS is a fast and efficient first-line diagnostic tool that outperforms ES in women with or without localized lesions. Malignant patterns on TVS/GIS should warrant fast-track evaluation, whereas women with benign patterns may be selected for office or operative hysteroscopy. A fast-track diagnostic setup based on pattern recognition is presented.

Hysteroscopic Curettage Using the Lin Snare and Y Adaptor: A Review of 300 Cases

STUDY

To present a de novo technique of endometrial sampling - hysteroscopic curettage.

OBJECTIVE

Aim to describe this new procedure and study its effectiveness and accuracy.

DESIGN

Prospective study (Canadian Task Force Classification II-2).

SETTING

University-affiliated public hospital.

PATIENTS

Two hundred and ninety-three consecutive patients who attended outpatient gynaecological endoscopic centre.

INTERVENTION

A total of 300 hysteroscopic curettage was carried out using flexible hysteroscope and Lin snare system.

MAIN RESULTS

The procedure failure rate is 2.67%. Out of 292 successful hysteroscopic curettages, hysteroscopy alone has a sensitivity of 99% and negative predictive value of 97.7%. The accuracy was further improved to near perfection with curettage histology. The negative predictive value is 99%.

CONCLUSION

Hysteroscopic curettage is easy to perform, highly effective and accurate. It offers an excellent outpatient alternative for patients who require endometrial sampling and/or an evaluation of abnormal uterine bleeding.

The association between endometrial polyps and metabolic syndrome: a case-control study

BACKGROUND

Endometrial polyps are common benign gynaecologic disorders. The etiopathogenesis of this condition remains unclear, however obesity is an important risk factor for the development of endometrial polyps.

AIM

The aim of the study was to evaluate a possible association between endometrial polyps and clinical parameters of metabolic syndrome (MetS).

MATERIALS AND METHODS

Forty-five women with endometrial polyps (study group) and 45 without (control group) were included in this cross-sectional study. The main parameters evaluated between the groups were age, BMI (body mass index), waist circumference (WC), blood pressure, serum lipid profiles, fasting glucose levels and homeostatic model assessment of insulin resistance (HOMA-IR).

RESULTS

There was a significant difference between the groups in terms of BMI, WC, insulin levels and HOMA-IR (P < 0.05). The MetS was present in 32 (71.1%) of women in the study group and in 6 (13.3%) in the control group (P < 0.001). Logistic regression demonstrated that MetS was a significant risk factor for endometrial polyps. ROC curve analysis also showed that MetS was the most significant discriminative risk factor in the study group with an AUC of 0.789 (0.691-0.887; CI 95%).

CONCLUSION

Our study suggests that there may be a relationship between endometrial polyps, MetS and insulin resistance. Further studies are required to explain the role of this relationship in the pathogenesis of the disease.

Reproducibility of Endometrial Pathologic Findings Obtained on Hysteroscopy, Transvaginal Sonography, and Gel Infusion Sonography in Women With Postmenopausal Bleeding

STUDY OBJECTIVE

To evaluate and compare interobserver variation in endometrial pattern recognition with hysteroscopy (HY) and transvaginal sonography (TVS) and gel infusion sonography (GIS) with regard to the diagnosis of endometrial pathology.

DESIGN

Prospective study (Canadian Task Force II-1).

SETTING

University clinic.

PATIENTS

One hundred twenty-two consecutive women with postmenopausal bleeding and an endometrium thickness ≥ 5 mm.

INTERVENTION

Two observers using HY and 2 others using TVS and GIS evaluated the endometrial pattern in recorded video clips. Interobserver agreement regarding findings obtained with TVS, GIS, and HY for a diagnosis of cancer, hyperplasia, polyps, and no endometrial pathology was expressed by κ coefficients and compared.

MEASUREMENT AND MAIN RESULTS

Interobserver agreement (κ) was as follows: identification of normal endometrium: HY (.74), TVS (.68), and GIS (.48); diagnosis of cancer: HY (.56), TVS (.59), and GIS (.34); classification in all categories of endometrial pathology: HY (.70), TVS (.47), and GIS (.41) (p < .05 HY vs GIS). The presence of additional endometrial polyps decreased agreement on HY in patients with hyperplasia or cancer. Observer agreement was poor regarding the diagnosis of hyperplasia by all techniques.

CONCLUSION

Observer agreement regarding both HY and TVS was reliable for the diagnosis of a normal endometrium but poor with HY, TVS, and especially GIS for a diagnosis of cancer. In patients with hyperplasia or cancer, agreement between observers was especially low in the presence of additional polyps when HY was used. These findings call attention to the need for systematic methods to improve reliability in endometrial pattern recognition.