Comparison of transvaginal sonography, saline infusion sonography and hysteroscopy in the evaluation of uterine cavity pathologies

Predicting nutrition and environmental factors associated with female reproductive disorders using a knowledge graph and random forests

OBJECTIVE

Female reproductive disorders (FRDs) are common health conditions that may present with significant symptoms. Diet and environment are potential areas for FRD interventions. We utilized a knowledge graph (KG) method to predict factors associated with common FRDs (for example, endometriosis, ovarian cyst, and uterine fibroids).

MATERIALS AND METHODS

We harmonized survey data from the Personalized Environment and Genes Study (PEGS) on internal and external environmental exposures and health conditions with biomedical ontology content. We merged the harmonized data and ontologies with supplemental nutrient and agricultural chemical data to create a KG. We analyzed the KG by embedding edges and applying a random forest for edge prediction to identify variables potentially associated with FRDs. We also conducted logistic regression analysis for comparison.

RESULTS

Across 9765 PEGS respondents, the KG analysis resulted in 8535 significant or suggestive predicted links between FRDs and chemicals, phenotypes, and diseases. Amongst these links, 32 were exact matches when compared with the logistic regression results, including comorbidities, medications, foods, and occupational exposures.

DISCUSSION

Mechanistic underpinnings of predicted links documented in the literature may support some of our findings. Our KG methods are useful for predicting possible associations in large, survey-based datasets with added information on directionality and magnitude of effect from logistic regression. These results should not be construed as causal but can support hypothesis generation.

CONCLUSION

This investigation enabled the generation of hypotheses on a variety of potential links between FRDs and exposures. Future investigations should prospectively evaluate the variables hypothesized to impact FRDs.

Predicting nutrition and environmental factors associated with female reproductive disorders using a knowledge graph and random forests

Objective

Female reproductive disorders (FRDs) are common health conditions that may present with significant symptoms. Diet and environment are potential areas for FRD interventions. We utilized a knowledge graph (KG) method to predict factors associated with common FRDs (e.g., endometriosis, ovarian cyst, and uterine fibroids).

Materials and Methods

We harmonized survey data from the Personalized Environment and Genes Study on internal and external environmental exposures and health conditions with biomedical ontology content. We merged the harmonized data and ontologies with supplemental nutrient and agricultural chemical data to create a KG. We analyzed the KG by embedding edges and applying a random forest for edge prediction to identify variables potentially associated with FRDs. We also conducted logistic regression analysis for comparison.

Results

Across 9765 PEGS respondents, the KG analysis resulted in 8535 significant predicted links between FRDs and chemicals, phenotypes, and diseases. Amongst these links, 32 were exact matches when compared with the logistic regression results, including comorbidities, medications, foods, and occupational exposures.

Discussion

Mechanistic underpinnings of predicted links documented in the literature may support some of our findings. Our KG methods are useful for predicting possible associations in large, survey-based datasets with added information on directionality and magnitude of effect from logistic regression. These results should not be construed as causal, but can support hypothesis generation.

Conclusion

This investigation enabled the generation of hypotheses on a variety of potential links between FRDs and exposures. Future investigations should prospectively evaluate the variables hypothesized to impact FRDs.

Office Operative Hysteroscopy for the Management of Retained Products of Conception

The aim of this study was to compare office to conventional operative hysteroscopy for the treatment of retained products of conception (RPOC). This retrospective cohort study included all women who underwent hysteroscopy due to RPOC between January 2018 and December 2019, in a single tertiary medical care center. Exclusion criteria for hysteroscopy included the following: (1) proximity to delivery (up to 3 weeks); (2) hemodynamic instability; (3) active massive bleeding; and (4) genital tract infection. See-and-treat hysteroscopy (study group) outcomes were compared to operative hysteroscopy (controls). Data were collected from women's medical records. Primary outcome was defined as successful removal of all suspected RPOC with no need for additional intervention. Data are presented as median and interquartile range. During the study period, 222 women underwent hysteroscopy due to RPOC. Of them, 138 (62%) and 84 (38%) underwent see-and-treat and operative hysteroscopy, respectively. Symptomatic women were more commonly referred to operative hysteroscopy (60 (71%) vs. 54 (39%); p = 0.001). Maximal diameter of the suspected finding was smaller both by ultrasound examination (13 (10-18) vs. 18 (13-32) mm; p = 0.001) and by surgeon estimation during diagnostic hysteroscopy (12 (8-20) vs. 20 (14-30) mm; p = 0.001), in the see-and-treat compared to the operative hysteroscopy group, respectively. While comparing success rate between groups, no difference was observed. Sub-analysis by the maximal diameter of RPOC findings revealed that see-and-treat success rate is reduced as the RPOC is larger. Success rate was high and comparable to operative hysteroscopy for findings ≤ 2 cm (102/117 (87%) vs. 49/54 (91%); p = 0.79). Nevertheless, for RPOC > 2 cm, success was significantly more frequent in the operative hysteroscopy group (28/30 (93%) vs. 9/16 (57%); p = 0.002). This finding was supported by logistic regression analysis that found maximal diameter of RPOC as the only parameter associated with success rate (B = 0.96; p = 0.03). Office operative hysteroscopy is a feasible treatment option for the removal of RPOC when maximal diameter is taken under consideration due to its association to success rate.Clinical trial registration: The study protocol was approved by the "Sheba Medical Center" Review Board (ID 5200-18 SMC) on June 24, 2018.

Patient and provider satisfaction with saline ultrasound versus office hysteroscopy for uterine cavity evaluation prior to in vitro fertilization: a randomized controlled trial

PURPOSE

To compare patient and provider satisfaction with saline ultrasound (SIS) versus office hysteroscopy for cavity evaluation prior to in vitro fertilization (IVF) and to assess the capability of hysteroscopy to manage pathology at time of diagnosis to reduce delays and supernumerary procedures.

METHODS

This was a randomized, controlled trial in a university fertility clinic. One hundred enrolled subjects undergoing routine uterine cavity evaluation prior to planned embryo transfer were randomized to SIS or office hysteroscopy without anesthesia. Subjects and providers completed surveys about their experience. Subjects with findings on SIS had a hysteroscopy performed or scheduled for further evaluation. Those with hysteroscopy findings had management attempted within the same procedure.

RESULTS

Overall patient satisfaction was high and did not differ between groups, while providers indicated that hysteroscopy provided a better cavity evaluation. There was no difference in time to complete procedures between groups. Pain score on a ten-scale was slightly higher in the hysteroscopy group compared to the SIS group (3.38 ± 1.85 vs. 2.44 ± 1.64, p < 0.01), but this did not impact satisfaction scores. Although pathology was found in a similar rate (22% vs. 36% for SIS and HSC groups, respectively), those in the SIS group all required secondary procedures, while only 1/17 did in the HSC group (p < 0.01).

CONCLUSION

Although the hysteroscopy group exhibited slightly higher pain scores, overall patient and provider satisfaction was high and similar between groups. There were significantly fewer secondary procedures and delays in the hysteroscopy group. Hysteroscopy is a reasonable first line screening tool for patients requiring cavity evaluation.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT04415489.

Comparative retrospective study on transvaginal sonography versus office hysteroscopy in the diagnosis of endometrial pathology among different subgroups

BACKGROUND

Transvaginal sonography (TVS) and office hysteroscopy are considered essential diagnostic tool for the gynecologic everyday practice. Through the years equipment developments in both techniques along with cumulative experience gained by the gynecologists result in a disunity among clinicians in choosing optimal diagnostic approach with regards to endometrial pathology.

AIM

To evaluate the diagnostic accuracy of TVS versus office hysteroscopy (OHSC) in detecting endometrial pathology. Results were compared to available scientific evidence available among similar published studies.

METHODS

Comparative Retrospective study performed at the Endoscopic Unit, Department of Gynecology, University Hospital of Ioannina, Greece. A total of 2675 cases were collected for this study from January 1997 until August 2019. All cases recruited underwent a TVS followed by office hysteroscopy (OHSC) for various indications according to the local protocol. Endometrial samples from all cases were obtained and histology confirmed the diagnosis. Sonographic and hysteroscopic results were correlated with histologic reports to assess the diagnostic accuracy of both techniques.

RESULTS

In a total of 2675 cases recruited for this study, 23.2% were postmenopausal while the majority (76.7%) was of reproductive age. The commonest indication for hysteroscopy was abnormal uterine bleeding (AUB) accounting for 29.7% of the cases. Overall, TVS demonstrated diagnostic accuracy of 84.7%% in detecting endometrial pathology, compared to 97.3% of OHSC. Sensitivity, specificity, positive prognostic value (PPV) and negative prognostic value (NPV) of TVS detecting endometrial pathology were 84.0, 86.8, 95.3 and 63.0%, respectively. The corresponding values for hysteroscopy were 98.9, 95.1, 98.4 and 93.9%, respectively. Diagnostic value of both techniques was estimated in 6 (six) additional subgroups: total sample with AUB, women of reproductive age, women of reproductive age with AUB, women of reproductive age with infertility issues, postmenopausal women and postmenopausal women suffering from postmenopausal bleeding (PMB). All values were calculated with regards to histologic findings as gold standard technique. All results were correlated with scientific evidence collected from the international literature.

CONCLUSION

Office hysteroscopy is a more reliable tool in detecting endometrial pathologies compared to TVS regardless of reproductive status or clinical presentation. TVS is likely to orientate and guide specialists on what to expect prior to an hysteroscopic intervention.

Comparison of diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography, and hysteroscopy in evaluating the endometrial polyps in women with abnormal uterine bleeding: a systematic review and meta-analysis

Introduction

In women with abnormal uterine bleeding (AUB), 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 is important.

Aim

To evaluate and compare the diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography, and hysteroscopy in detecting endometrial polyps in women with AUB.

Material and methods

The searches were conducted by two independent researchers to find the relevant studies published from 1/1/2009 until the end of 30/06/2019. We searched for published literature in English language in MEDLINE, EMBASETM, The Cochrane Library, and Trip database. For literature published in other languages, we searched national databases (Magiran and SID), KoreaMed, and LILACS. The risk of bias of every article was evaluated by using QUADAS-2.

Results

After selection and quality assessment, 11 studies were included. Based on the random effect model the total prevalence of endometrial polyps in women with abnormal uterine bleeding was 38%. The sensitivity and specificity of saline infusion sonohysterography in diagnosis of endometrial polyps were 0.87 and 0.86, respectively. The sensitivity and specificity of transvaginal ultrasonography were 0.62 and 0.73 and the sensitivity and specificity of hysteroscopy were 0.92 and 0.85, respectively.

Conclusions

Although that sonohysterography is a safe and relatively cheap method, which allows ruling out or confirming endometrial polyps, it cannot be replaced with hysteroscopy due to the fact that hysteroscopy combined with biopsy is the gold standard for ruling out malignancies in an endometrial polyp.

Diagnostic Accuracy of Transvaginal Sonography in the Detection of Endometrial Polyps

Background:

Transvaginal sonography (TVS) is considered a simple and generally accepted method for detecting uterine anomalies. With TVS, the uterus can be clearly visualized, but so far, the diagnostic accuracy of TVS varies across different studies. This retrospective study was devised to evaluate the accuracy of a sonographic diagnosis of endometrial polyps in a Ukrainian hospital.

Methods:

This was a single-center retrospective study of woman who underwent TVS and had hysteroscopy or dilation and curettage for endometrial pathology. A cohort of 156 women were included in this yearlong study. A comparative analysis was based on the preoperative diagnosis, according to TVS, compared with the postoperative histopathology results.

Results:

The overall sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of TVS in diagnosing endometrial polyps were 69%, 51%, 73%, 46%, and 63%, respectively.

Conclusion:

This retrospective study provided data on the lack of accuracy for a sonographic diagnosis of endometrial polyps. This was based on 26% of women whose diagnosis was not confirmed by histology. A false-negative result occurred for 54% of women who had polyps that were not detected at the preoperative stage. These data raise the question of the feasibility of further invasive procedures based on a single TVS study.

Comparison of endometrial assessment by transvaginal ultrasonography and hysteroscopy

OBJECTIVE

To compare transvaginal ultrasonography and hysteroscopy for the diagnosis of endometrial pathologies.

METHODS

In the present retrospective cohort study, data were reviewed from women with ultrasonography findings suggestive of endometrial lesions and/or abnormal uterine bleeding who underwent hysteroscopy at a single center in Campinas, Brazil, between January 2011 and December 2013; data were stratified based on reproductive-aged and postmenopausal groups. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ultrasonography and hysteroscopy for the diagnosis of endometrial lesions were determined. Histopathology was used as the gold standard.

RESULTS

There were 754 patients included (256 reproductive age, 498 postmenopausal). In the reproductive-age group, ultrasonography had a sensitivity of 96.0%, specificity of 58.0%, PPV of 94.4%, NPV of 66.6%, and accuracy of 91.5%, whereas hysteroscopy had a sensitivity of 91.8%, specificity of 76.6%, PPV of 96.0%, NPV of 60.5%, and accuracy of 89.7% for the diagnosis of endometrial disease. In the postmenopausal group, ultrasonography had a sensitivity of 99.0%, specificity of 19.0%, PPV of 96.1%, NPV of 50.0%, and accuracy of 95.3%, whereas hysteroscopy had a sensitivity of 96.7%, specificity of 86.9%, PPV of 99.2%, NPV of 58.8%, and accuracy of 96.2%.

CONCLUSION

Ultrasonography was found to be an effective method for the diagnosis of endometrial disease, especially among postmenopausal women.

Accuracy of Two-Dimensional Transvaginal Sonography and Office Hysteroscopy for Detection of Uterine Abnormalities in Patients with Repeated Implantation Failures or Recurrent Pregnancy Loss

Background

We sought to compare diagnostic values of two-dimensional transvaginal sonography (2D TVS) and office hysteroscopy (OH) for evaluation of endometrial pathologies in cases with repeated implantation failure (RIF) or recurrent pregnancy loss (RPL).

MATERIALS AND METHODS

This prospective study was performed at Royan Institute from December 2013 to January 2015. TVS was performed before hysteroscopy as part of the routine diagnostic work-up in 789 patients with RIF or RPL. Uterine biopsy was performed in cases with abnormal diagnosis in TVS and/or hysteroscopy. We compared the diagnostic accuracy values of TVS in detection of uterine abnormalities with OH by receiver operating characteristic (ROC) curve analysis.

RESULTS

TVS examination detected 545 (69%) normal cases and 244 (31%) pathologic cases, which included 84 (10.6%) endometrial polyps, 15 (1.6%) uterine fibroids, 10 (1.3%) Asherman's syndrome, 9 (1.1%) endometrial hypertrophy, and 126 (15.9%) septate and arcuate uterus. TVS and OH concurred in 163 pathologic cases, although TVS did not detect some pathology cases (n=120). OH had 94% sensitivity, 95% specificity, 62% positive predictive value (PPV), and 99% negative predictive value (NPV) for detection of endometrial polyps. In the diagnosis of myoma, sensitivity, specificity, PPV, and NPV were 100%. TVS had a sensitivity of 50% and specificity of 98% for the diagnosis of myoma. For polyps, TVS had a sensitivity of 54% and specificity of 80%. Area under the ROC curve (AUROC) was 70.69% for the accuracy of TVS compared to OH.

CONCLUSION

TVS had high specificity and low sensitivity for detection of uterine pathologies in patients with RIF or RPL compared with OH. OH should be considered as a workup method prior to treatment in patients with normal TVS findings.

Accuracy of saline contrast sonohysterography in detection of endometrial polyps and submucosal leiomyomas in women of reproductive age with abnormal uterine bleeding: systematic review and meta-analysis

OBJECTIVE

To analyze the diagnostic accuracy of two- (2D) and three- (3D) dimensional saline contrast sonohysterography (SCSH) in the detection of endometrial polyps and submucosal uterine leiomyomas in women of reproductive age with abnormal uterine bleeding compared with gold standard hysteroscopy.

METHODS

A systematic review of diagnostic studies that compared 2D- and/or 3D-SCSH with hysteroscopy and anatomopathology was conducted according to PRISMA and SEDATE recommendations. The databases MEDLINE, EMBASE and The Cochrane Library were searched electronically using specific terms with no restriction on language or publication year. Quality assessment of included studies was performed using the QUADAS-2 tool. Meta-analysis was performed with the Meta-DiSk program and data presented as forest plots and summary receiver-operating characteristics (SROC) curves. Pooled sensitivity, specificity and positive (LR+) and negative (LR-) likelihood ratios of SCSH in the detection of uterine cavity abnormalities were calculated.

RESULTS

A total of 1398 citations were identified and five studies were included in the systematic review and meta-analysis. Pooled sensitivity and specificity of 2D-SCSH in detecting endometrial polyps were 93% (95% CI, 89-96%) and 81% (95% CI, 76-86%), respectively, with pooled LR+ of 5.41 (95% CI, 2.60-11.28) and LR- of 0.10 (95% CI, 0.06-0.17). In the detection of submucosal uterine leiomyomas, pooled sensitivity and specificity were 94% (95% CI, 89-97%) and 81% (95% CI, 76-86%), respectively, with pooled LR+ of 4.25 (95% CI, 2.20-8.21) and LR- of 0.11 (95% CI, 0.05-0.22). 2D-SCSH had good accuracy in detecting endometrial polyps and submucosal uterine leiomyomas, with areas under the SROC curves of 0.97 ± 0.02 and 0.97 ± 0.03, respectively. Studies that analyzed the diagnostic accuracy of 3D-SCSH could not be compared due to high heterogeneity related to menopausal status, type of technique used and primary outcome being investigation of infertility.

CONCLUSIONS

2D-SCSH proved to be a highly sensitive method for detection of endometrial polyps and submucosal uterine leiomyomas, making it a potential first-line diagnostic method in the work-up for women with abnormal uterine bleeding. More studies are needed on 3D-SCSH in women of reproductive age. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Assessment of the uterus with three-dimensional ultrasound in women undergoing ART

BACKGROUND

A detailed assessment of the uterus forms a pivotal part of the ART treatment process. The emergence of three-dimensional ultrasound (3D US) has provided clinicians with a highly powerful tool in this respect. Assessments with 3D US range from the reconstruction of anatomical planes elusive to conventional US, to the objective measurement of anatomical volumes and vascularization parameters. However, despite the ever increasing number of publications emerging in the literature, the question of which aspects of 3D US are of most clinical value remains a topic of debate.

OBJECTIVE AND RATIONALE

The objective of this review is to dissect which aspects of the 3D US assessment of the uterus are supported by a strong level of evidence to date, and should therefore be incorporated into current routine clinical practice.

SEARCH METHODS

We conducted a systematic search of the PubMed database up to May 2016, using a combination of text words and Medical Subject Headings (MeSH) pertaining to the 3D US assessment of the uterus. All articles published in the English language were screened to ascertain relevance to women of reproductive age; further citations were retrieved through manual reference list searching.

OUTCOMES

A multitude of predominantly observational studies were identified, which concerned a vast variety of 3D US uterine assessments. All articles unequivocally praised the non-invasive, cost-effective, highly acceptable and objective nature of 3D US. Studies regarding the value of assessing the endometrial volume and vascularization prior to embryo transfer appeared conflicting and inconsistent. Studies regarding the imaging of uterine pathology and identification of intratubal and intrauterine devices consistently reported high rates of diagnostic accuracy. A recent RCT did not show an improvement in clinical outcomes when comparing 3D versus 2D US during embryo transfer. However, preliminary studies suggested that 3D US is superior in determining the site of implantation, particularly in ambiguous cases such as interstitial and angular pregnancies. Finally, pilot studies have suggested that the further integration of 3D and possibly 4D US with surgical interventions of the uterus may be a promising prospect.

WIDER IMPLICATIONS

3D US may prove to be an invaluable tool in the assessment of the uterus within the context of ART. Currently, the aim should be to highlight the aspects of 3D US that are most evidence-based and valuable for patients, and to incorporate these into routine clinical practice.

Impact of Simple Ovarian Cysts on the Interpretation of Endometrial Thickness in Women with Postmenopausal Bleeding

BACKGROUND

There is evidence that premenopausal hormones may persist for variable time after menopause. Histological specimens from postmenopausal women support the presence of follicular growth at that age. Residual ovarian function may explain postmenopausal bleeding (PMB), which is not associated with endometrial pathology. Our objective was to evaluate the effect of sonographic diagnosis of simple ovarian cysts on the association between thickened endometrium and endometrial pathology in women with PMB.

MATERIALS AND METHODS

Data were retrospectively collected from medical records of women who underwent office hysteroscopy for PMB between January 2007 and October 2011. Women with sonographic reports within 3 months of presentation were included. Endometrial thickness and the presence of a simple ovarian cyst (≤5 cm) were documented by reviewing sonographic reports. Diagnosis of endometrial pathology was abstracted according to pathology reports or hysteroscopic impression. Endometria with hyperplasia, cancer, or polyps were considered pathological.

RESULTS

Of 836 women with PMB, 356 had recent transvaginal sonography and were included in the analysis. Pathological endometrium was documented in 129 (36.2%) women, including 29 (8.2%) with endometrial cancer. In women with PMB and no evidence of a simple ovarian cyst, endometrial thickness was an independent predictor of endometrial pathology and endometrial cancer with adjusted OR = 1.13 (95% CI = 1.07-1.19) and 1.16 (95% CI = 1.07-1.25), respectively. In the presence of simple ovarian cysts, the adjusted ORs for endometrial thickness as a predictor of endometrial pathology were 1.06 (95% CI = 0.90-1.25) and 0.84 (95% CI = 0.62-1.14), respectively.

CONCLUSION

The presence of simple ovarian cysts (≤5 cm) tempers the value of endometrial thickness in predicting endometrial pathology in women with PMB.

The role of transvaginal power Doppler ultrasound in the differential diagnosis of benign intrauterine focal lesions

PURPOSE

The purpose of this prospective study was to assess the role of power Doppler imaging in the differential diagnosis of benign intrauterine focal lesions such as endometrial polyps and submucous myomas using the characteristics of power Doppler flow mapping.

METHODS

A total of 480 premenopausal patients with abnormal uterine bleeding were evaluated by transvaginal ultrasonography (TVS) searching for intrauterine pathology. Sixty-four patients with a suspicious focal endometrial lesion received saline infusion sonography (SIS) after TVS. Fifty-eight patients with focal endometrial lesions underwent power Doppler ultrasound (PDUS). Three different vascular flow patterns were defined: Single vessel pattern, multiple vessel pattern, and circular flow pattern. Finally, hysteroscopic resection was performed in all cases, and Doppler flow characteristics were then compared with the final histopathological findings.

RESULTS

Histopathological results were as follows: endometrial polyp: 40 (69 %), submucous myoma: 18 (31 %). Of the cases with endometrial polyps, 80 % demonstrated a single vessel pattern, 7.5 % a multiple vessel pattern, and 0 % a circular pattern. Vascularization was not observed in 12.5 % of patients with polyps. Of the cases with submucousal myomas, 72.2 % demonstrated a circular flow pattern, 27.8 % a multiple vessel pattern, and none of them showed a single vessel pattern. The sensitivity, specificity, and positive and negative predictive values of the single vessel pattern in diagnosing endometrial polyps were 80, 100, 100, and 69.2 %, respectively; and for the circular pattern in diagnosing submucous myoma, these were 72.2, 100, 100, and 88.9 %, respectively.

CONCLUSION

Power Doppler blood flow mapping is a useful, practical, and noninvasive diagnostic method for the differential diagnosis of benign intrauterine focal lesions. Especially in cases of recurrent abnormal uterine bleeding, recurrent abortion, and infertility, PDUS can be preferred as a first-line diagnostic method.

Uterus banding with the Osada method effectively reduces intraoperative blood loss during myomectomy

INTRODUCTION

The surgery of fibroid removal and reconstruction of the uterus is associated with increased blood loss. That is a significant limitation of surgical myomectomy. There are many methods to decrease blood loss during myomectomy. However, in women planning to conceive their reversibility is important. The procedure of uterus banding with the Osada method meets this condition. The objective of this study was a comparison of intraoperative blood loss during the myomectomy with banding according to the Osada technique with blood loss during a classic myomectomy with the Martin method.

MATERIAL AND METHODS

The study group consisted of 140 women with myomatous uterus. In 70 patients myomectomy was performed with the Osada uterus banding method, for the remaining 70 patients the Martin method was applied.

RESULTS

Myomectomy with banding according to the Osada method versus myomectomy with the Martin method: intraoperative blood loss (ml): 56 ± 23 vs 378 ± 186, p < 0.05; a drop in hematocrit levels over 24 hours postoperatively (%): 0.32 ± 0.12 vs 3.42 ± 2.54, p < 0.05; a drop in hemoglobin concentration over 24 hours postoperatively (g/dl): 0.13 ± 0.04 vs 0.79 ± 0.38, p < 0.05. the need for blood transfusion (% of women): 0 vs 4.28, p < 0.05.

CONCLUSION

Myomectomy performed according to the Osada method of uterus banding is associated with less intraoperative blood loss.

Hysteroscopic assessment of postmenopausal endometrial thickening

Introduction

Endometrial thickness is measured by transvaginal sonography and thickening indicates an increased risk of malignancy or other pathology (hyperplasia or polyp) in the postmenopausal period. The main screening methods for the uterine cavity are dilatation and curettage, and hysteroscopy. We sought to correlate hysteroscopic and pathological findings in asymptomatic postmenopausal women with sonographically thickened endometrium (> 5 mm) in this study.

Material and methods

This retrospective cross-sectional study involved case records of 197 women who have thickened (> 5 mm) endometrium in the postmenopausal period. All these women underwent hysteroscopy with diagnostic dilatation and curettage between January 2012 and January 2013 at the Bursa Zübeyde Hanım Maternity Hospital. Sensitivity, specificity, positive, negative predictive values and p value of hysteroscopy were calculated. Dilatation and curettage was set as the gold standard.

Results

For the evaluation of postmenopausal thickened endometrium, hysteroscopy revealed sensitivity, specificity, positive predictive value and negative predictive value as 76.4%, 76.9%, 73.1%, 79.8%, respectively.

Conclusions

Hysteroscopy is a fast and accurate technique in evaluation of the intrauterine space occupying lesions (polyp, fibroid) but only moderate for endometrial hyperplasia. Hysteroscopic view combined with direct biopsy could be a gold standard for endometrial assessment.

Vascular changes responsible for the reduced effectiveness of obliteration of uterine arteries in women with advanced cervical cancer

Introduction

Haemorrhages from the genital tract remain a major threat to the life of patients with advanced cervical cancer. It is possible to achieve haemostasis by both surgical techniques and the procedure of endovascular uterine artery embolization. However, in some women with loco-regionally advanced cervical cancer the obliteration of the uterine arteries is not effective.

Aim

Evaluation of morphological changes in uterine arteries in patients with advanced cervical cancer and comparison of their changes with the achieved haemostatic effect of obliteration.

Material and methods

The prospective study included a group of 8 women with cervical cancer at a clinical stage of IIB to IIIC according to the FIGO classification. 3D quantitative coronary angiography (QCA) was performed before uterine embolization. The haemostatic effect of uterine artery embolization was compared with observed vascular changes.

Results

Mean uterine artery length in patients who achieved complete hemostasis: 39.5 mm – right uterine artery; 38.7 mm – left uterine artery. Mean uterine artery length in patients who achieved partial satisfactory haemostasis: 32 mm – right uterine artery; 30.5 mm – left uterine artery. Mean uterine artery length in patients who achieved unsatisfactory haemostasis: 10.5 mm – right uterine artery; 19 mm – left uterine artery.

Conclusions

Shortening of uterine arteries worsens prognosis of the haemostatic effect of their obliteration in patients with advanced cervical cancer.

Evaluation of sonohysterography in detecting endometrial polyps - 241 cases followed with office hysteroscopies combined with histopathological examination

Introduction

Hysteroscopy is considered the ‘gold standard’ procedure in assessing uterine pathology however it is more expensive and invasive method than ultrasonography. An alternative to the diagnostic hysteroscopy is sonohysterography.

Aim

To evaluate the usefulness of sonohysterography in detecting endometrial polyps in female patients diagnosed with infertility.

Material and methods

We compared the results of sonohysterographic examinations with hysteroscopy combined with histopathological findings.

Results

All the 241 sonohysterography examinations were performed successfully. No complications were observed. Forty-three hysteroscopies (17.8%) and six sonohysterography examinations (2.5%) were performed in short total intravenous anesthesia because of a low pain threshold of the patients. After hysteroscopic resection polyps were diagnosed in 74 (30.7%) patients. In 72 cases both saline infusion sonography (sonohysterography, SIS) examination and hysteroscopy confirmed the occurrence of an endometrial polyp. In 7 examinations (4.2%) the diagnosed polyp was not confirmed in sonohysterography (false-positive results). Two SIS procedures (2.7%) did not confirm the occurrence of the polyp (false-negative results). Sensitivity, specificity accuracy and error of sonohysterography in detecting endometrial polyps were 97.3%, 95.8% 96.2% and 3.7%, respectively. Positive and negative predictive values were 91.1% (PPV) and 98.7% (NPV). The agreement between SIS and hysteroscopy combined with histopathological examination was very high (K = 0.91).

Conclusions

Sonohysterography is a safe and highly sensitive and specific method used in diagnostics of endometrial polyps. Its results closely correspond to those obtained in a hysteroscopic examination and histopathological analysis.

Diagnostic accuracy of transvaginal sonography in the detection of uterine abnormalities in infertile women

BACKGROUND

Accurate diagnosis of uterine abnormalities has become a core part of the fertility work-up. A variety of modalities can be used for the diagnosis of uterine abnormalities.

OBJECTIVES

This study was designed to assess the diagnostic accuracy of transvaginal ultrasonography (TVS) in uterine pathologies of infertile patients using hysteroscopy as the gold standard.

PATIENTS AND METHODS

This was a cross-sectional study carried out in the Department of Reproductive Imaging at Royan Institute from October 2007 to October 2008. In this study, the medical documents of 719 infertile women who were investigated with transvaginal ultrasound (TVS) and then hysteroscopy were reviewed. All women underwent hysteroscopy in the same cycle time after TVS. Seventy-six out of 719 patients were excluded from the study and 643 patients were studied. TVS was performed in the follicular phase after cessation of bleeding. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for TVS. Hysteroscopy served as the gold standard.

RESULTS

The overall sensitivity, specificity, positive and negative predictive values for TVS in the diagnosis of uterine abnormality was 79%, 82%, 84% and 71%, respectively. The sensitivity and PPV of TVS in detection of polyp were 88.3% and 81.6%, respectively. These indices were 89.2% and 92.5%, respectively for fibroma, 67% and 98.3%, respectively for subseptated uterus and 90.9% and 100%, respectively for septated uterus. Adhesion and unicornuated uterus have the lowest sensitivity with a sensitivity of 35% and PPV of 57.1%.

CONCLUSION

TVS is a cost-effective and non-invasive method for diagnosis of intrauterine lesions such as polyps, submucosal fibroids and septum. It is a valuable adjunctive to hysteroscopy with high accuracy for identification and characterization of intrauterine abnormalities. This may lead to a more precise surgery plan and performance.

Clinical approach for the classification of congenital uterine malformations

A more objective, accurate and non-invasive estimation of uterine morphology is nowadays feasible based on the use of modern imaging techniques. The validity of the current classification systems in effective categorization of the female genital malformations has been already challenged. A new clinical approach for the classification of uterine anomalies is proposed. Deviation from normal uterine anatomy is the basic characteristic used in analogy to the American Fertility Society classification. The embryological origin of the anomalies is used as a secondary parameter. Uterine anomalies are classified into the following classes: 0, normal uterus; I, dysmorphic uterus; II, septate uterus (absorption defect); III, dysfused uterus (fusion defect); IV, unilateral formed uterus (formation defect); V, aplastic or dysplastic uterus (formation defect); VI, for still unclassified cases. A subdivision of these main classes to further anatomical varieties with clinical significance is also presented. The new proposal has been designed taking into account the experience gained from the use of the currently available classification systems and intending to be as simple as possible, clear enough and accurate as well as open for further development. This proposal could be used as a starting point for a working group of experts in the field.

Value of 3-dimensional sonohysterography for detection of intrauterine lesions in women with abnormal uterine bleeding

STUDY OBJECTIVE

To compare 2-dimensional (2D) sonohysterography (SHG) and 3D-SHG with saline solution infusion vs diagnostic hysteroscopy for investigation of intrauterine lesions in perimenopausal and postmenopausal women with abnormal uterine bleeding.

DESIGN

Comparative observational cross-sectional study (Canadian Task Force classification II-1).

SETTING

University hospital.

PATIENTS

Fifty perimenopausal and 20 postmenopausal women with abnormal intrauterine bleeding with clinically or ultrasonically suspected intrauterine lesions.

INTERVENTIONS

Conventional 2D- and 3D ultrasonography and 2D- and 3D-SHG with saline solution infusion followed by diagnostic hysteroscopy, and endometrial curettage or subsequent operative treatment (e.g., hysterectomy, myomectomy, or polypectomy). Ultrasonographic and hysteroscopic findings were compared with histopathologic findings.

MEASUREMENTS AND MAIN RESULTS

For 2D-SHG, sensitivity, specificity, positive predictive value, negative predictive value, overall accuracy, likelihood ratio for a positive result, and likelihood ratio for a negative result were 79%, 72%, 89%, 54%, 76%, 2.82, and 0.29, respectively, and for 3D-SHG, were 92%, 89%, 96%, 80%, 91%, 8.36, and 0.09, respectively; and for diagnostic hysteroscopy, were 94%, 89%, 96%, 84%, 93%, 8.55, and 0.07, respectively. Thus, 3D-SHG was superior to 2D SHG (p = .02) and comparable to diagnostic hysteroscopy (p = .75) for diagnosis of intrauterine lesions.

CONCLUSION

3D-SHG can be used in the initial investigation of intrauterine lesions in perimenopausal and postmenopausal women with abnormal uterine bleeding before resorting to invasive procedures such as diagnostic hysteroscopy. Further studies of computer-reconstructed 3D-SHG virtual hysteroscopy are recommended.

Congenital malformations of the female genital tract: the need for a new classification system

Current proposals for classifying female genital anomalies seem to be associated with limitations in effective categorization, creating the need for a new classification system that is as simple as possible, clear and accurate in its definitions, comprehensive, and correlated with patients' clinical presentation, prognosis, and treatment on an evidence-based foundation. Although creating a new classification system is not an easy task, it is feasible when taking into account the experience gained from applying the existing classification systems, mainly that of the American Fertility Society.

Prospective Study of Saline Infusion Sonography and Office Hysteroscopy

BACKGROUND

To evaluate the diagnostic potential of saline infusion sonography to pick up uterine cavity lesions and compare it with the gold standard office hysteroscopy.

METHODS

Study population consisted of women scheduled for office hysteroscopy for various indications. Uterine cavity of 208 women of the study group were evaluated first by saline infusion sonography and then by office hysteroscopy by two separate examiners. Findings were recorded separately for both procedures and compared. Pain rating was also noted after each procedure.

RESULT

In eight patients either or both the procedures could not be performed for various reasons, hence were excluded from the analysis. With saline infusion sonography, pathological findings were identified in 93 (46.5%) patients and hysteroscopy detected lesions in 88 (44%) patients. For all findings combined sensitivity of saline infusion sonography was 90.9%, specificity 88.3%, positive predictive value 86.0% and negative predictive value 92.5% as compared to hysteroscopy. Former was less painful and easier to perform than the latter.

CONCLUSION

The findings of saline infusion sonography and office hysteroscopy did not differ significantly. Thus saline infusion sonography is an excellent option for uterine cavity evaluation.

Management of uterine fibroids in the patient pursuing assisted reproductive technologies

Uterine leiomyomas are present in 30-70% of women of reproductive age. In addition to causing menstrual disorders and pain, uterine fibroids negatively affect fertility and pregnancy outcome for patients pursuing assisted reproduction. The two questions that have to be addressed are: which fibroids should be treated and how should they be treated? Submucosal fibroids are associated with a 70% reduction in delivery rate. Intramural fibroids had a lesser effect and reduced the delivery rate by approximately 30%. By contrast, studies have demonstrated that subserosal fibroids did not negatively impact fertility. Furthermore, both submucosal and intramural fibroids were associated with an increased risk of spontaneous miscarriage. Myomectomy is considered the treatment of choice to alleviate these detrimental effects. Further research is needed before alternative treatments can be recommended.

Transvaginal Ultrasonography and Saline Infusion Sonohysterography for the Detection of Intra-Uterine Lesions in Pre- and Post-Menopausal Women with Abnormal Uterine Bleeding

This prospective study investigated 79 pre- and 25 post-menopausal women with abnormal uterine bleeding who underwent conventional transvaginal ultrasonography (TVS) and saline infusion sonohysterography (SIS) and compared the results with histopathological findings obtained by dilatation and curettage, hysteroscopy or hysterectomy. Histological examination revealed normal endometrial histology in 28 patients, intracavitary polyps in 46 patients, submucosal fibroids in 18 patients, intramural fibroids in six patients and endometrial hyperplasia in six patients. The sensitivity and specificity of TVS in detecting endometrial polyps were 65.2% and 87.9%, respectively, compared with 91.3% and 93.1% for SIS. The sensitivity and specificity of TVS in detecting uterine fibroids were 95.8% and 95.0%, respectively, versus 91.6% and 98.7% for SIS. These results show that SIS is a satisfactory method of identifying lesions and that it is easy and cost-effective, and improves on the diagnostic utility of TVS. SIS is also a less invasive alternative to hysteroscopy, so should result in less morbidity in the evaluation of abnormal uterine bleeding in women.

Progesterone receptor modulators and the endometrium: changes and consequences

Progesterone receptor modulators (PRMs) have been used for contraceptive research, as well as for treatment of fibroids, endometriosis and heavy or irregular menstrual bleeding. Long-term treatment with these compounds results in changes to the endometrium resulting in potential confusion in trying to characterize endometrial biopsies. A meeting was held to discuss the properties of PRMs, the effects of perturbed hormonal control of the endometrium and the need for further understanding of the biology of progesterone receptor action to facilitate the development of new PRMs. A panel of pathologists was convened to evaluate endometrial changes associated with a minimum of three months of chronic treatment with PRMs. Four different agents were used in the treatment regimens but the pathologists were blinded to treatment regimen or agent. The panel agreed that the endometrial biopsies did not fit into a classification of either proliferative or secretory endometrium but exhibited an unusual architecture that could be characterized as glandular dilatation. There was little evidence of mitosis, consistent with a proposed anti-proliferative effect of PRMs. The panel concluded that the biopsies did not reveal evidence of safety concern and that pathologists and investigators familiar with endometrial effects of chronic PRM exposure should consider working with pharmaceutical companies and regulatory agencies to develop standard descriptions of PRM-associated endometrial changes as well as the types of histologic changes that would signal a need for intervention.

Diagnostic hysteroscopy in abnormal uterine bleeding: a systematic review and meta-analysis

BACKGROUND

This study was conducted to assess the accuracy and feasibility of diagnostic hysteroscopy in the evaluation of intrauterine abnormalities in women with abnormal uterine bleeding.

SEARCH STRATEGY

Electronic databases were searched from 1 January 1965 to 1 January 2006 without language selection. The medical subject heading (MeSH) and textwords for the following terms were used: hysteroscopy, diagnosis, histology, histopathology, hysterectomy, biopsy, sensitivity and specificity.

SETTING

University Hospital.

SELECTION CRITERIA

The inclusion criteria were report on accuracy of diagnostic hysteroscopy in women with abnormal uterine bleeding compared to histology collected with guided biopsy during hysteroscopy, operative hysteroscopy or hysterectomy.

DATA COLLECTION AND ANALYSIS

Electronic databases were searched for relevant studies and references were cross-checked. Validity was assessed and data were extracted independently by two authors. Heterogeneity was calculated and data were pooled. Subgroup analysis was performed according to validity criteria, study quality, menopausal state, time, setting and performance of the procedure. The pooled sensitivity, specificity, likelihood ratios, post-test probabilities and feasibility of diagnostic hysteroscopy on the prediction of uterine cavity abnormalities. Post-test probabilities were derived from the likelihood ratios and prevalence of intrauterine abnormalities among included studies. Feasibility included technical success rate and complication rate.

MAIN RESULTS

One population of homogeneous data could be identified, consisting of patients with postmenopausal bleeding. In this subgroup the positive and negative likelihood ratios were 7.9 (95% CI 4.79-13.10) and 0.04 (95% CI 0.02-0.09), raising the pre-test probability from 0.61 to a post-test probability of 0.93 (95% CI 0.88-0.95) for positive results and reducing it to 0.06 (95% CI 0.03-0.13) for negative results. The pooled likelihood ratios of all studies included, calculated with the random effects model, were 6.5 (95% CI 4.1-10.4) and 0.08 (95% CI 0.07-0.10), changing the pre-test probability of 0.46 to post-test probabilities of 0.85 (95% CI 0.78-0.90) and 0.07 (0.06-0.08) for positive and negative results respectively. Subgroup analyses gave similar results. The overall success rate of diagnostic hysteroscopy was estimated at 96.9% (SD 5.2%, range 83-100%).

CONCLUSIONS

This systematic review and meta-analysis shows that diagnostic hysteroscopy is both accurate and feasible in the diagnosis of intrauterine abnormalities.

Treatment of uterine fibroids for abnormal uterine bleeding: myomectomy and uterine artery embolization

Uterine myoma is a common benign tumour in women and most cases do not require treatment. Excessive uterine bleeding is usually due to a submucous myoma or an intramural myoma that is encroaching into the uterine cavity. After eliminating endometrial malignancy, perimenopausal women could be managed expectantly or with gonadotrophin-releasing hormone agonist until menopause. Hysteroscopic myomectomy is highly effective in controlling menorrhagia that is related to submucous myoma. Concomitant endometrial ablation improves menorrhagia; however, the subsequent hysterectomy rate remains the same. For those with an intramural myoma, abdominal myomectomy results in good bleeding control. It could also be done by laparoscopic approach; however, the surgeon should have expertise in laparoscopic suturing and the uterine incision should be properly sutured. In women who have completed their family, hysterectomy remains the most effective treatment for excessive uterine bleeding. Compared with uterine artery embolization (UAE), it is associated with better improvement in pelvic pain. Nevertheless, UAE is a good alternative to hysterectomy.

The role and applications of ultrasound in ambulatory gynaecology

Ultrasound has changed gynaecological practice and continues to do so. One of the earliest applications of abdominal scanning in gynaecology was for monitoring follicular development during fertility treatment with clomiphene citrate or gonadotrophins in the 1960s and 1970s. Subsequently, it was natural that with the introduction of in vitro fertilization, abdominal and transvaginal ultrasound played a key role in the development of oocyte retrieval techniques. These were truly the first interventional ultrasound-guided ambulatory procedures in gynaecology. In this chapter, the reader will be introduced to the roles that the various ultrasound modalities play in our current daily practice, and how they have changed the management of numerous gynaecological conditions in both diagnostic and therapeutic contexts. We will also outline the recent developments and the 'hot' research topics in this field.