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Narice BF, Delaney B, Dickson JM. Endometrial sampling in low-risk patients with abnormal uterine bleeding: a systematic review and meta-synthesis. BMC FAMILY PRACTICE 2018; 19:135. [PMID: 30060741 PMCID: PMC6066914 DOI: 10.1186/s12875-018-0817-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 07/10/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND One million women per year seek medical advice for abnormal uterine bleeding (AUB) in the United Kingdom. Many low-risk patients who could be managed exclusively in primary care are referred to hospital based gynaecology services. Performing endometrial sampling (ES) in the community may improve care, reduce the rate of referrals and minimise costs. We aimed to search and synthesise the literature on the effectiveness of ES (Pipelle versus other devices) in managing AUB in low-risk patients. METHODS We undertook an electronic literature search in MEDLINE via OvidSP, Scopus, and Web of Science for relevant English-language articles from 1984 to 2016 using a combination of MeSH and keywords. Two reviewers independently pre-selected 317 articles and agreed on 60 articles reporting data from over 7300 patients. Five themes were identified: sample adequacy, test performance, pain and discomfort, cost-effectiveness, and barriers and complications of office ES. RESULTS Pipelle seems to perform as well as dilation and curettage and, as well or better than other ES devices in terms of sampling adequacy and sensitivity. It also seems to be better regarding pain/discomfort and costs. However, Pipelle can disrupt the sonographic appearance of the endometrium and may be limited by cervical stenosis, pelvic organ prolapse and endometrial atrophy. CONCLUSIONS The current evidence supports the use of Pipelle in the management of low-risk women presenting in the outpatient setting with symptomatic AUB when combined with clinical assessment and ultrasound scanning. However, the implications of its widespread use in primary care are uncertain and more research is required.
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Affiliation(s)
- Brenda F. Narice
- Clinical Research Fellow in Obstetrics & Gynaecology; Academic Unit of Reproductive and Developmental Unit, University of Sheffield, Sheffield, S10 2SF UK
| | - Brigitte Delaney
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, S5 7AU UK
| | - Jon M. Dickson
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, S5 7AU UK
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Du J, Li Y, Lv S, Wang Q, Sun C, Dong X, He M, Ulain Q, Yuan Y, Tuo X, Batchu N, Song Q, Li Q. Endometrial sampling devices for early diagnosis of endometrial lesions. J Cancer Res Clin Oncol 2016; 142:2515-2522. [PMID: 27515060 PMCID: PMC5095161 DOI: 10.1007/s00432-016-2215-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Accepted: 08/03/2016] [Indexed: 11/25/2022]
Abstract
Purpose Endometrial carcinoma is the most common gynecologic malignancy in both developed and some developing countries. Unlike cervical cancer, for which there is routine screening, only patients symptomatic for endometrial carcinoma typically seek medical help for its diagnosis and treatment. Dilatation and curettage (D&C) has been the standard procedure for evaluating suspicious endometrial lesions.
The discomfort and injury caused by the D&C procedure, however, restrict its use as a screening method for early diagnosis of endometrial lesions. High-risk endometrial cancer patients would benefit from an effective and low-cost screening test. In recent years, several endometrial devices have been developed and proposed as screening tools. Methods We have reviewed and evaluated the literature relating to the endometrial sampling devices in clinical use or clinical trials, with the goal of comparing devices and identifying the most appropriate ones for screening for endometrial lesions. Eligible literature was identified from systematic PubMed searches, and the relevant data were extracted. Comments, letters, unpublished data, conference proceedings, and case reports were excluded from our search. Seventy-four articles on endometrial sampling devices were obtained for this review. Results The main screening devices for endometrial carcinoma are aspiration devices (such as the Vabra aspirator), Pipelle, Tao Brush, and SAP-1 device. Among these devices, the Tao Brush is the most promising endometrial sampler for screening for endometrial lesions. However, its sampling insufficiency, cost, and unsuccessful insertion rate (20 % in nulliparous and 8 % in parous women) are problematic. Conclusions A more accurate and low-cost endometrial sampler, with improved specimen sufficiency and higher sensitivity for endometrial lesions, needs tobe developed and clinically verified.
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Affiliation(s)
- Jiang Du
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Yaling Li
- Gongzhuling Health Workers High School, Gongzhuling, 136100, Jilin, China
| | - Shulan Lv
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Qing Wang
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Chao Sun
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Xin Dong
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Ming He
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Qurat Ulain
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Yongxing Yuan
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Xiaoqian Tuo
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Nasra Batchu
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Qing Song
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China.,Cardiovascular Research Institute, Morehouse School of Medicine, Atlanta, GA, 30310, USA.,Center of Big Data and Bioinformatics, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China
| | - Qiling Li
- Department of Obstetrics and Gynecology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China. .,Center of Big Data and Bioinformatics, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710061, Shaanxi, China.
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Dacco' MD, Moustafa M, Papoutsis D, Georgantzis D, Halmos G, Magos A. An audit of using the H Pipelle for endometrial sampling at outpatient hysteroscopy and literature review comparison with the Pipelle de Cornier. Eur J Obstet Gynecol Reprod Biol 2012; 165:299-301. [PMID: 22884589 DOI: 10.1016/j.ejogrb.2012.07.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Revised: 06/29/2012] [Accepted: 07/24/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To analyse the efficiency of the H Pipelle endometrial sampler at "no touch" (vaginoscopic) diagnostic hysteroscopy in terms of biopsy adequacy for histological diagnosis. STUDY DESIGN Retrospective descriptive study of 200 premenopausal women including comparison with previously published data on traditional biopsy instruments. RESULTS Biopsy was adequate in 82% of cases overall, rising to 87% in those without submucous fibroids or polyps. Comparison with published data on other biopsy instruments shows that the H Pipelle is at least as efficient. CONCLUSION The H Pipelle appears to be at least as effective as traditional endometrial samplers even after hysteroscopy but allows hysteroscopy and biopsy to be done using a purely "no touch" (vaginoscopic) technique.
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Affiliation(s)
- Maria Diletta Dacco'
- Minimally Invasive Therapy Unit and Endoscopy Training Centre, University Department of Obstetrics and Gynaecology, The Royal Free Hospital, Pond Street, Hampstead, London NW3 2QG, UK.
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Teale GR, Dunster GD. The Pipelle endometrial suction curette: how useful is it in clinical practice? J OBSTET GYNAECOL 2009; 18:53-5. [PMID: 15512004 DOI: 10.1080/01443619868299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
The Pipelle endometrial sampler is gaining popularity as an alternative to formal dilatation and curettage (D&C). This study demonstrates that the Pipelle reduces the number of D&Cs required to assess the endometrium by 65%. This has significant benefits in terms of patient safety and cost. If an inadequate sample is obtained, which occurs most commonly in the postmenopausal patient, there may be a temptation to ascribe this to the presence of an atrophic endometrium. This study, however, finds a significant chance of an underlying carcinoma in these cases. Thus whereas the Pipelle sampler has clinical usefulness when a sample sufficient for histological analysis is obtained, an equivocal result must lead to further investigation.
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Warwick A, Ferryman S, Musgrove C, Redman C. An evaluation of the Gynocheck for endometrial sampling. J OBSTET GYNAECOL 2009. [DOI: 10.3109/01443619309151829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Bigrigg A, Codling BW, Read MD. Endometrial biopsy with a Z-sampler. A patient-oriented cost effective procedure suitable for general practice and outpatient use. J OBSTET GYNAECOL 2009. [DOI: 10.3109/01443619209013632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Etherington IJ, Harrison KR, Read MD. A Comparison of Outpatient Endometrial Sampling with Hysteroscopy, Curettage and Cystoscopy in the Evaluation of Postmenopausal Bleeding. J OBSTET GYNAECOL 2009. [DOI: 10.3109/01443619509020698] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Shapley M, Redman CWE. Assessment of menstrual blood loss using a pictorial chart and endometrial sampling within the community. J OBSTET GYNAECOL 2009. [DOI: 10.3109/01443619509020674] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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10
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Madari S, Al-Shabibi N, Papalampros P, Papadimitriou A, Magos A. A randomised trial comparing the H Pipelle with the standard Pipelle for endometrial sampling at ‘no-touch’ (vaginoscopic) hysteroscopy. BJOG 2008; 116:32-7. [DOI: 10.1111/j.1471-0528.2008.01992.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Kondo E, Tabata T, Koduka Y, Nishiura K, Tanida K, Okugawa T, Sagawa N. What is the best method of detecting endometrial cancer in outpatients?-endometrial sampling, suction curettage, endometrial cytology. Cytopathology 2007; 19:28-33. [PMID: 17944955 DOI: 10.1111/j.1365-2303.2007.00509.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Office methods of endometrial sampling for outpatients with abnormal uterine bleeding should be minimally invasive. The purpose of this study was to determine the best method for detecting endometrial cancer in an outpatients setting. METHODS In all, 114 symptomatic women who were suspected of having endometrial disease by their local gynaecologist were enrolled in this study. After pelvic examination and transvaginal ultrasonography, endometrial cytology, suction endometrial curettage, and four-site endometrial biopsy were performed, in this order without anaesthesia in each patient. After endometrial sampling, the patient was asked to comment on the intensity of any pain experienced during each procedure. Then the final histological diagnosis made from the surgical materials was compared with the results of the three pre-operative methods. RESULTS Among the 114 consecutive patients, 56 had endometrial carcinoma, three had carcinosarcoma, six had endometrial hyperplasia, and 49 had benign conditions. The sensitivity of detecting malignancy was 88% (52/59) with endometrial cytology, 92% (54/59) with suction curettage, and 88% (52/59) with four-site biopsy. When endometrial cytology was combined with suction curettage, the sensitivity of detecting malignancy was increased from 92% to 98%, whereas the sensitivity was increased from 88% to 97%, when endometrial cytology was added to four-site biopsy. Suction curettage was significantly less painful than four-site biopsy. CONCLUSION Our data indicated that suction curettage plus endometrial cytology was the best combination for pathological examination of outpatients with abnormal uterine bleeding.
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Affiliation(s)
- E Kondo
- Department of Obstetrics and Gynecology, Mie University School of Medicine, Tsu, Mie, Japan.
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Polena V, Mergui JL, Zerat L, Sananes S. The role of Pipelle® Mark II sampling in endometrial disease diagnosis. Eur J Obstet Gynecol Reprod Biol 2007; 134:233-7. [PMID: 17029754 DOI: 10.1016/j.ejogrb.2006.07.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2005] [Revised: 07/11/2006] [Accepted: 07/14/2006] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the feasibility and accuracy of Pipelle Mark II sampling (designed for combined cytology and histology testing) in the diagnosis of endometrial disease. MATERIALS AND METHODS A 97 women with abnormal uterine bleeding or intrauterine lesions on ultrasound examination underwent Pipelle Mark II endometrial sampling, followed by diagnostic hysteroscopy. The adequacy of endometrial samples obtained for cytological and histological analysis was assessed. A correlation was established between endometrial cytology, histology and diagnostic hysteroscopy results. Where discrepancies were found, they were compared with the histological results obtained from operative hysteroscopy. RESULTS The tissue samples obtained for cytological and histological diagnoses were insufficient in 14.4% and 11.3% of patients, respectively. The opposite was found in the group of postmenopausal women (N=52): the tissue samples for cytological and histological diagnoses were insufficient in only 3.8% and 15.4% of cases, respectively. The cytological results corroborated diagnostic hysteroscopy findings and histological results in all cases but 3 (3.6%). Only two cases of endometrial carcinoma were reported in this group of patients, and they were both detected by all three methods. The rate of false positives with endometrial cytological sampling was 3.6%. There were no false negatives. CONCLUSION Pipelle Mark II endometrial sampling is feasible. It provides adequate samples for histological and/or cytological analysis and reliable results. It reduces the rate of false negative results for endometrial cancer. Pipelle Mark II sampling is particularly useful in postmenopausal women and in women with endometrial atrophy. Other larger studies are necessary to evaluate the efficiency of Pipelle Mark II.
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Affiliation(s)
- Viola Polena
- Service de Gynécologie-Obstétrique, Hôpital Tenon, 4 rue de la Chine, 75020 Paris, France
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Naim NM, Mahdy ZA, Ahmad S, Razi ZRM. The Vabra aspirator versus the Pipelle device for outpatient endometrial sampling. Aust N Z J Obstet Gynaecol 2007; 47:132-6. [PMID: 17355303 DOI: 10.1111/j.1479-828x.2007.00699.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To compare the effectiveness of the Vabra aspirator and the Pipelle device as an outpatient endometrial assessment tool. METHOD This was a randomised, prospective trial conducted for a period of one year. RESULTS A total of 147 patients were recruited, of which 71 were in the Vabra group and 76 were in the Pipelle arm. The procedure success rate in the Pipelle group was significantly higher than the Vabra arm (98.7 vs 88.7%, P=0.02). Adequate tissue yield was also significantly more in the Pipelle arm (73.3 vs 52.4%, P=0.02). Cost-benefit analysis revealed a higher average cost per patient in the Vabra group compared to the Pipelle arm. CONCLUSION This study proved that the Vabra aspirator was not as effective as the Pipelle device in obtaining endometrial tissue for histological diagnosis. Despite its higher price per unit, the Pipelle device was a more cost-effective tool for outpatient endometrial assessment.
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Affiliation(s)
- Norzilawati M Naim
- Department of Obstetrics and Gynaecology, Faculty of Medicine, National University of Malaysia, Kuala Lumpur, Malaysia.
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Baxter AJ, Beck B, Phillips K. A randomized prospective trial of rigid and flexible hysteroscopy in an outpatient setting. ACTA ACUST UNITED AC 2003. [DOI: 10.1111/j.1365-2508.2002.00562.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Akande VA, Vyas SK. Questioning the ubiquity of outpatient endometrial sampling in the management of menstrual disorders. BJOG 2003. [DOI: 10.1111/j.1471-0528.2003.02011.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Menzin AW, Gal D, Barakat RR. Should women receiving tamoxifen be screened for endometrial cancer? An argument for screening. Cancer Invest 2001; 18:793-7. [PMID: 11107449 DOI: 10.3109/07357900009012211] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- A W Menzin
- Department of Obstetrics and Gynecology, North Shore University Hospital, North Shore-Long Island Jewish Health System, Manhasset, New York, USA
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Tahir MM, Bigrigg MA, Browning JJ, Brookes ST, Smith PA. A randomised controlled trial comparing transvaginal ultrasound, outpatient hysteroscopy and endometrial biopsy with inpatient hysteroscopy and curettage. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1999; 106:1259-64. [PMID: 10609719 DOI: 10.1111/j.1471-0528.1999.tb08179.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the use of outpatient and inpatient procedures in the investigation of abnormal uterine bleeding. DESIGN A randomised controlled trial. SETTING Two university teaching hospitals. PARTICIPANTS Four hundred women with abnormal uterine bleeding (postmenopausal bleeding, menorrhagia, intermenstrual bleeding, postcoital bleeding, or irregular periods) above the age of 35 years, between June 1993 and January 1995. MAIN OUTCOME MEASURES 1. Incidence of detection of abnormal pathology by vaginal ultrasound, outpatient hysteroscopy and endometrial biopsy compared with inpatient hysteroscopy and curettage; 2. Number of 'lesions' (e.g. fibroids, polyps, endometrial hyperplasia or malignancy) found by hysteroscopy that would have been missed by the combination of endometrial sampling and ultrasound; 3. Comparison of the quality of tissue obtained for histology by outpatient endometrial sampling and inpatient curettage; and 4. An evaluation of patient acceptability of outpatient and inpatient procedures. RESULTS 1. A combination of transvaginal sonography, Pipelle endometrial biopsy and outpatient hysteroscopy has similar efficacy to inpatient hysteroscopy and curettage for the investigation of abnormal uterine bleeding; 2. Hysteroscopy will detect some fibroids and polyps missed by a combination of transvaginal ultrasound and Pipelle endometrial sampling; 3. The quality of histological samples obtained by outpatient Pipelle were comparable to those obtained by formal inpatient curettage; and 4. Outpatient procedures were well tolerated, with good patient acceptability. CONCLUSION Transvaginal sonography and endometrial biopsy can safely be used as the initial investigations in the management of abnormal uterine bleeding. Hysteroscopy can be used as a second line investigation. Outpatient hysteroscopy with local anaesthesia is well tolerated although general anesthesia may occasionally be necessary.
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Affiliation(s)
- M M Tahir
- Department of Women's Health, Southmead Hospital, Bristol
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Melville A, Eastwood A, Kleijnen J, Kitchener H, Martin-Hirsch P, Nelson L. Management of gynaecological cancers. Qual Health Care 1999; 8:270-9. [PMID: 10847890 PMCID: PMC2483671 DOI: 10.1136/qshc.8.4.270] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- A Melville
- NHS Centre for Reviews and Dissemination, University of York, UK
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Munro MG. Abnormal uterine bleeding in the reproductive years. Part I--pathogenesis and clinical investigation. THE JOURNAL OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS 1999; 6:393-416. [PMID: 10548698 DOI: 10.1016/s1074-3804(99)80004-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- M G Munro
- Department of Obstetrics and Gynecology, UCLA School of Medicine, Los Angeles, CA, USA. fax 818 364 3255
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Kremer C, Barik S, Duffy S. Flexible outpatient hysteroscopy without anaesthesia: a safe, successful and well tolerated procedure. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1998; 105:672-6. [PMID: 9647161 DOI: 10.1111/j.1471-0528.1998.tb10185.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The objective of this study was to assess the feasibility and tolerance of diagnostic outpatient flexible hysteroscopy without anaesthesia. Records from 554 consecutive patients were analysed retrospectively. Success rate, reasons for failure, adverse reactions and level of pain were the main outcome measures. Hysteroscopy was successful in 90.5% of patients and well tolerated in 93.3%; 5.4% experienced moderate to severe pain. Inability to negotiate the cervical canal accounted for 47% of failed procedures and poor view for 42%. These results suggest that flexible outpatient hysteroscopy without anaesthesia is a successful and well tolerated procedure.
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Affiliation(s)
- C Kremer
- Department of Obstetrics and Gynaecology, St James's University Hospital, Leeds, UK
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Mårdh PA, Hogg B. Are oral contraceptives masking symptoms of chlamydial cervicitis and pelvic inflammatory disease? EUR J CONTRACEP REPR 1998; 3:41-3. [PMID: 9678072 DOI: 10.3109/13625189809167484] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Tubal factor infertility is often diagnosed without any documented history of pelvic inflammatory disease. Chlamydial infection is one of the most common causes of pelvic inflammatory disease and likely also of infertility and ectopic pregnancy. Oral contraceptives may alter the course of chlamydial infections which may mask the clinical expression of the disease. This paper considers a number of unresolved matters related to oral contraceptive use and its possible influence on the epidemiology and course of chlamydial pelvic inflammatory disease.
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Affiliation(s)
- P A Mårdh
- Uppsala University Center for STD Research, Sweden
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Goldstein SR, Zeltser I, Horan CK, Snyder JR, Schwartz LB. Ultrasonography-based triage for perimenopausal patients with abnormal uterine bleeding. Am J Obstet Gynecol 1997; 177:102-8. [PMID: 9240591 DOI: 10.1016/s0002-9378(97)70446-0] [Citation(s) in RCA: 142] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Abnormal perimenopausal bleeding is common and accounts for much medical and surgical intervention. This study was undertaken to evaluate an ultrasonography-based triage paradigm for perimenopausal patients with abnormal uterine bleeding. STUDY DESIGN Four hundred thirty-three perimenopausal patients with abnormal uterine bleeding (either metrorrhagia, menorrhagia, or both) were evaluated. In lieu of undergoing a sampling procedure they were brought back on days 4 to 6 of the subsequent bleeding cycle, when the endometrium was expected to be its thinnest. If a distinct endometrial echo < or = 5 mm (double layer) was imaged by endovaginal ultrasonography, dysfunctional uterine bleeding was diagnosed. If a thickened endometrial echo > 5 mm or no endometrial echo was reliably visualized, a saline infusion sonohysterography was performed. If saline infusion sonohysterography revealed a symmetric single-layer endometrial thickness < 3 mm, dysfunctional uterine bleeding was diagnosed. If focal lesions were noted (polyps, submucous myomas, focal thickening), the patient was scheduled for curettage with hysteroscopy. If the endometrium was globally thickened, nondirected office biopsy was performed. RESULTS A total of 341 patients (79%) had ultrasonographic evidence of no anatomic abnormality, and dysfunctional uterine bleeding requiring no further studies was diagnosed. Fifty-eight patients (13%) had focal polypold masses, all of which were removed hysteroscopically and confirmed pathologically. Twenty-two patients (5%) had submucous myomas; 10 patients (23%) had globally thickened endometrium on saline infusion sonohysterography, and then nondirected office sampling revealed hyperplasia in 5 and proliferation in 5. Two patients had technically inadequate saline infusion sonohysterography, and thus we proceeded to hysteroscopy with curettage. CONCLUSION Nondirected office biopsy alone without imaging would have potentially missed the diagnosis of focal lesions such as polyps, submucous myomas, and focal hyperplasia in up to 80 patients (18%). Our clinical algorithm for perimenopausal patients with abnormal uterine bleeding used unenhanced endovaginal ultrasonography followed by saline infusion sonohysterography for selected patients. This approach allowed for no endometrial sampling, nondirected sampling, or directed sampling depending on whether the ultrasonography-based triage revealed no anatomic abnormalities, globally thickened endometrial tissue, or focal abnormalities, respectively.
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Affiliation(s)
- S R Goldstein
- Department of Obstetrics and Gynecology, New York University School of Medicine, New York 10016, USA
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Hänggi W, Bersinger N, Altermatt HJ, Birkhäuser MH. Comparison of transvaginal ultrasonography and endometrial biopsy in endometrial surveillance in postmenopausal HRT users. Maturitas 1997; 27:133-43. [PMID: 9255748 DOI: 10.1016/s0378-5122(97)00037-6] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To compare transvaginal ultrasonography with histological findings in endometrial evaluation of postmenopausal women using hormone replacement therapy and to evaluate endometrial safety of three hormone replacement therapy regimens. METHODS In a randomized, comparative study in postmenopausal women, endometrial safety was evaluated using (1) no hormone replacement therapy, (2) oral micronized 17 beta-estradiol/oral sequential dydrogesterone, (3) transdermal 17 beta-estradiol/oral sequential dydrogesterone, or (4) oral tibolone. 85 Non-hysterectomised subjects underwent transvaginal ultrasonography immediately before Pipelle biopsy at baseline and subsequently after 12 and 24 months. Endometrial thickness and uterine dimensions were determined by transvaginal ultrasonography, and endometrial thickness (double-layer) was compared with biopsy results. RESULTS Endometrial evaluation was conveniently performed by transvaginal ultrasonography, and endometrial thickness correlated well with biopsy findings. If endometrial thickness was < 5 mm, the endometrial biopsy sample was either inactive/atrophic or insufficient for histopathological diagnosis. Hyperplastic or malignant changes were not reported. After 24 months, endometrial thickness was increased both in the oral (P < 0.001) and transdermal (P < 0.001) 17 beta-estradiol/dydrogesterone groups, whereas with tibolone the change in endometrial thickness was not different from controls. CONCLUSION transvaginal ultrasonography of the endometrium reliably predicts the histological picture in hormone replacement therapy users. Using 5 mm endometrial thickness as cut-off point, more than 75% of biopsies could be avoided. All three hormone replacement therapies were safe with respect to the endometrium. With sequential 17 beta-estradiol/dydrogesterone the expected progestogen-induced secretory pattern was observed, whereas endometrial histology under tibolone closely mimicked the natural atrophic postmenopausal state.
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Affiliation(s)
- W Hänggi
- Department of Obstetrics and Gynaecology, University Hospital, University of Bern, Switzerland
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Affiliation(s)
- A S Lev-Toaff
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA 19107, USA
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26
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Arthur ID, Khan SM. The application of standard and morphometric dating criteria for luteal phase endometrial specimens collected by outpatient sampling. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1996; 103:473-4. [PMID: 8624324 DOI: 10.1111/j.1471-0528.1996.tb09777.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- I D Arthur
- Department of Obstetrics and Gynaecology, Royal Victoria Infirmary, Newcastle-upon-Tyne, UK
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Van den Bosch T, Vandendael A, Wranz PA, Lombard CJ. Endopap-versus Pipelle-sampling in the diagnosis of postmenopausal endometrial disease. Eur J Obstet Gynecol Reprod Biol 1996; 64:91-4. [PMID: 8801158 DOI: 10.1016/0301-2115(95)02274-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To evaluate the accuracy of Endopap- and Pipelle-sampling in the diagnosis of postmenopausal disease. STUDY DESIGN Observational study in the setting of a University Hospital. One hundred and six consecutive postmenopausal women presenting with uterine bleeding or endometrial cells on cervical cytology underwent an Endopap sampling as well as a Pipelle biopsy. Thereafter, 89 of those women underwent a hysteroscopy and curettage (n = 71) or a hysterectomy (n = 18). The diagnostic accuracy of Pipelle and Endopap was assessed against the final diagnosis. RESULTS Endometrial carcinoma was found in five cases (6%), benign disease in 34 (38%). The sensitivity of Endopap and Pipelle for the detection of endometrial disease was 56 and 51%, respectively, with a specificity of 94 and 100%, respectively. The sensitivity for endometrial carcinoma was 80% for Endopap and 100% for Pipelle. CONCLUSIONS Our data tend to favor Pipelle against Endopap as diagnostic tool in endometrial disease in symptomatic postmenopausal women.
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Affiliation(s)
- T Van den Bosch
- Department of Obstetrics and Gynecology, University of Stellenbosch, Tygerberg Hospital, South Africa
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Coulter A, Long A, Kelland J, O'Meara S, Sculpher M, Song F, Sheldon TA. Managing menorrhagia. Qual Health Care 1995; 4:218-26. [PMID: 10153434 PMCID: PMC1055321 DOI: 10.1136/qshc.4.3.218] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Padwick M. Withdrawal bleeding and endometrial safety. Lancet 1994; 344:1703-4. [PMID: 7996980 DOI: 10.1016/s0140-6736(94)90486-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Batool T, Reginald PW, Hughes JH. Outpatient pipelle endometrial biopsy in the investigation of postmenopausal bleeding. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1994; 101:545-6. [PMID: 8018649 DOI: 10.1111/j.1471-0528.1994.tb13161.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- T Batool
- Department of Obstetrics and Gynaecology, Wexham Park Hospital, Slough, Berkshire, UK
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31
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Abstract
In a pilot study group of 25 women presenting in our clinic after exposure at ovulation to undesired pregnancy, endometrial suction by means of a Pipelle catheter was performed. Sixteen of the 25 women had proven fertility and 9 had never tried to conceive. The women were aged 18 to 38 years. Pathological dating of endometrial sampling verified that the patients were actually post-ovulation in all cases studied. hCG tests were performed 10 to 14 days after endometrial suction and all were negative. We conclude that endometrial suction in the luteal phase is a possible means of postcoital non-hormonal contraception, and we are currently expanding our study.
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Affiliation(s)
- L Harel
- Family Planning Clinic, Kupat Holim, Dan District, Israel
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Coulter A, Klassen A, MacKenzie IZ, McPherson K. Diagnostic dilatation and curettage: is it used appropriately? BMJ (CLINICAL RESEARCH ED.) 1993; 306:236-9. [PMID: 8443521 PMCID: PMC1676730 DOI: 10.1136/bmj.306.6872.236] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To determine patterns of use of dilatation and curettage in Britain as compared with those in the United States; to examine variations in utilisation rates within one regional health authority. DESIGN Analysis of routinely collected hospital inpatient statistics. SETTING Statistics for England, Scotland, and the United States; local statistics for Oxford region. SUBJECTS All inpatient episodes in which dilatation and curettage was performed but excluding those related to pregnancy. RESULTS Dilatation and curettage rates remained stable in Britain between 1977 and 1990, whereas in the United States they declined dramatically. In 1989-90 the rate was 71.1 per 10,000 women in England as compared with only 10.8 per 10,000 in America. In 1989, 6936 women underwent diagnostic dilatation and curettage in the Oxford region, making it the most common elective operation. A total of 2726 (39%) of these women were under 40. There was a more than twofold variation in usage of the procedure among district health authorities within the region and even greater variation in rates in women under 40. The proportion of patients treated as day cases in the district general hospitals ranged from 22% to 82%. CONCLUSIONS Dilatation and curettage may frequently be used inappropriately. The considerable variations in usage of dilatation and curettage internationally and nationally indicate differences in clinical perception of its appropriateness. This makes it suitable for audit. In developing guidelines it will be important to agree on the most appropriate patients and the relative merits of alternative methods of endometrial sampling. Probably this could result in considerable cost savings at no risk and possibly some benefit to patients.
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Affiliation(s)
- A Coulter
- Department of Public Health and Primary Care, University of Oxford, Radcliffe Infirmary
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Marsh MS, Whitehead MI. The practicalities of hormone replacement therapy. BAILLIERE'S CLINICAL ENDOCRINOLOGY AND METABOLISM 1993; 7:183-202. [PMID: 8435052 DOI: 10.1016/s0950-351x(05)80275-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
An appropriate regimen of HRT using oestrogen with or without progestogen can be found for the majority of patients. In many cases this will be the first or second therapy that is chosen and for most women will be one of the combination packs that are commercially available. In a significant number of patients, however, these formulations will either not control symptoms or bleeding or will cause unacceptable progestogenic side-effects. Separate prescribing of oestrogen and progestogen will then be required. We suspect that the reported low compliance of women taking HRT in the general population may be related to the deficiencies of the available combination packs and reluctance of physicians to separately prescribe the oestrogen and progestogen components of HRT. The latter is understandable as the literature contains so few guidelines concerning prescribing. It is hoped that progestogens that have less side-effects than the C-19 steroids (currently universally used in combination packs of HRT) will be incorporated into new formulations. The option of prescribing oestrogens to non-hysterectomized women in the form of continuous combined therapy is not available to many physicians because the necessary endometrial sampling every 12-18 months cannot be arranged; the current outpatient methods of sampling require experience of manipulation of instruments within the uterine cavity that is usually only acquired during gynaecological training. There are still many uncertainties about the appropriate combination of oestrogen and progestogen that should be incorporated into a continuous combined regimen to avoid the troublesome bleeding that occurs in a significant proportion of women when starting this therapy. Many previous studies were seriously flawed and further research, carefully designed and conducted, is urgently needed.
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Fothergill DJ, Brown VA, Hill AS. Histological sampling of the endometrium--a comparison between formal curettage and the Pipelle sampler. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1992; 99:779-80. [PMID: 1308108 DOI: 10.1111/j.1471-0528.1992.tb13887.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Meuwissen JH, van Langen H, Moret E, Navarro-Morquecho I. Monitoring of oestrogen replacement therapy by vaginosonography of the endometrium. Maturitas 1992; 15:33-7. [PMID: 1528130 DOI: 10.1016/0378-5122(92)90059-d] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
To prevent hyperplasia and carcinoma of the endometrium during oestrogen replacement therapy (ORT), the addition of progestogens once a month is considered mandatory. However, there is no sound scientific basis for this assumption. As the addition of progestogens has several disadvantages, it is important to minimize the frequency of progestogen addition. Vaginosonography is a rather new technique which has not yet been used for monitoring ORT. In this study the increase in endometrial thickness, as measured by vaginosonography, was taken as an indicator of stimulation of the endometrium by oestrogens. Oestrogen treatment was started in post-menopausal women with little endometrium (thickness less than 3 mm). As long as there was virtually no increase during oestrogen treatment, no progestogen was added, but where considerable growth occurred (greater than 3 mm) progestogen was administered. By means of vaginosonography the growth of the endometrium can be monitored precisely on an individual basis. It is thus possible to distinguish women with a slow growing endometrium from those with an endometrium that grows fast. In this way it will perhaps become possible to minimize progestogen addition during ERT by tailoring dosage to individual requirements.
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Affiliation(s)
- J H Meuwissen
- Department of Gynaecology, St Joseph Hospital, Veldhoven, Netherlands
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Affiliation(s)
- J Paavonen
- Department of Obstetrics and Gynecology, University Central Hospital, Helsinki, Finland
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Sheehan AL, Read MD, Codling BW. A comparison of two endometrial samplers. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1992; 99:266-7. [PMID: 1606129 DOI: 10.1111/j.1471-0528.1992.tb14514.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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