Endometrial pathology in the postmenopausal woman - an evidence based approach to management

The Role of Ultrasound in Diagnosing Endometrial Pathologies: Adherence to IETA Group Consensus and Preoperative Assessment of Myometrial Invasion in Endometrial Cancer

Background: Ultrasonography is essential for diagnosing endometrial pathologies, such as hyperplasia, polyps, and endometrial cancer. The International Endometrial Tumor Analysis (IETA) group provides guidelines for using ultrasound to assess endometrial thickness, texture, and irregularities, aiding in the diagnosis of these conditions. The aim of this study was to evaluate the utility of various endometrial morphological features, as assessed by gray-scale ultrasound, and endometrial vascular features, as assessed by power Doppler ultrasound, in differentiating benign and malignant endometrial pathologies. A secondary objective was to compare the effectiveness of these ultrasound techniques in assessing myometrial invasion. Methods: A total of 162 women, both pre- and postmenopausal, with or without abnormal vaginal bleeding were enrolled in a prospective study. All participants underwent transvaginal gray-scale and color Doppler ultrasound examinations, conducted by examiners with over 15 years of experience in gynecological ultrasonography. Endometrial morphology and vascularity characteristics were evaluated based on the IETA group criteria, which include parameters such as endometrial uniformity, echogenicity, the three-layer pattern, regularity of the endometrial-myometrial border, Doppler color score, and vascular pattern (single dominant vessel with or without branching, multiple vessels with focal or multifocal origin, scattered vessels, color splashes, and circular flow). Sonographic findings were compared with histopathological results for comprehensive assessment. Results: The mean age of the study population was 56.46 ± 10.84 years, with a range from 36 to 88 years. Approximately 53.08% of the subjects were postmenopausal. The mean endometrial thickness, as measured by transvaginal ultrasonography, was 18.02 ± 10.94 mm with a range of 5 to 64 mm (p = 0.028), and it was found to be a significant predictor of endometrial malignancy. The AUC for the ROC analysis was 0.682 (95% CI: 0.452-0.912), with a cut-off threshold of 26 mm, yielding a sensitivity of 62.5% and a specificity of 89%. Vascularization was absent in 68.4% of patients with polyps. Among the cases with submucosal myomas, 80% exhibited a circular flow pattern. Malignant lesions were identified in 22.84% of the cases. Subjective ultrasound assessment of myometrial invasion, categorized as <50% or ≥50%, corresponded in all cases with the histopathological evaluation, demonstrating the effectiveness of ultrasound in evaluating myometrial invasion in endometrial cancer. Conclusions: In this study, cystic atrophic endometrium was identified as the most prevalent cause of postmenopausal bleeding. The most significant ultrasound parameters for predicting malignancy included heterogeneous endometrial echogenicity, increased endometrial thickness, and the presence of multiple vessels with multifocal origins or scattered vascular patterns. Additionally, color Doppler blood flow mapping was demonstrated to be an effective diagnostic tool for the differential diagnosis of benign intrauterine focal lesions.

Post-Menopausal Bleeding: Role of Imaging

Post-menopausal bleeding (PMB) accounts for 5% of gynecologic office visits and is the presenting symptom in 90% of women with endometrial cancer, which requires prompt evaluation. The most common etiology of PMB is vaginal or endometrial atrophy and endometrial polyps, while endometrial hyperplasia and carcinoma account for less than 10% of PMB. Transvaginal ultrasonography measurement of an endometrial thickness (EMT) less than or equal to 4 mm has a 99% negative predictive value for endometrial carcinoma. Endometrial sampling is required if EMT >4 mm or persistent bleeding occurs. Further evaluation can be accomplished with saline infusion sonography, magnetic resonance imaging, and hysteroscopy.

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

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

In Vitro Effects of Mitochondria-Targeted Antioxidants in a Small-Cell Carcinoma of the Ovary of Hypercalcemic Type and in Type 1 and Type 2 Endometrial Cancer

Small-cell carcinoma of the ovary of hypercalcemic type (SCCOHT) and endometrial cancer from type 1 and type 2 are gynecological tumors that affect women worldwide. The treatment encompasses the use of cytotoxic drugs that are nonspecific and inefficient. “Mitocans”, a family of drugs that specifically target tumor cells’ mitochondria, might be a solution, as they conjugate compounds, such as antioxidants, with carriers, such as lipophilic cations, that direct them to the mitochondria. In this study, caffeic acid was conjugated with triphenylphosphonium (TPP), 4-picolinium, or isoquinolinium, forming 3 new compounds (Mito6_TPP, Mito6_picol., and Mito6_isoq.) that were tested on ovarian (COV434) and endometrial (Hec50co and Ishikawa) cancer cells. The results of MTT and neutral red assays suggested a time- and concentration-dependent decrease in cell viability in all tumor cell lines. The presence of apoptosis was indicated by the Giemsa and Höechst staining and by the decrease in mitochondrial membrane potential. The measurement of intracellular reactive oxygen species demonstrated the antioxidant properties of these compounds, which might be related to cell death. Generally, Mito6_TPP was more active at lower concentrations than Mito6_picol. or Mito6_isoq., but was accompanied by more cytotoxic effects, as shown by the lactate dehydrogenase release. Non-tumorous cells (HFF-1) showed no changes after treatment. This study assessed the potential of these compounds as anticancer agents, although further investigation is needed.

Pathological pattern of endometrial abnormalities in postmenopausal women with bleeding or thickened endometrium

BACKGROUND

Postmenopausal bleeding and an endometrial thickness ≥ 5 mm on sonograms of menopausal women can indicate the presence of endometrial lesions. Diagnostic hysteroscopy is a powerful method for endometrial diseases.

AIM

To investigate the pathological pattern of endometrial abnormalities in postmenopausal women with bleeding or asymptomatic thickened endometrium diagnosed by hysteroscopy.

METHODS

A total of 187 postmenopausal women with bleeding or asymptomatic thickened endometrium underwent diagnostic hysteroscopy. The women were subsequently divided into three groups: Postmenopausal bleeding (PMB) group (n = 84), asymptomatic group (n = 94), and additional group (n = 9). Women in the additional group manifested abdominal pain and leukorrhagia.

RESULTS

Among the 187 patients examined, 84 (44.9%) were diagnosed with PMB and 94 (50.3%) with asymptomatic thickened endometrium. Endometrial polyp was the most common endometrial abnormality, which was detected in 51.2%, 76.6% and 77.8% of the PMB, asymptomatic, and additional groups, respectively. In the PMB group, 7 (8.3%) women had hyperplasia with atypia and 14 (16.7%) had endometrial adenocarcinoma. Fewer malignant lesions were detected in the asymptomatic group. Endometrial hyperplasia without atypia was found in 8.3% of the PMB group and 7.4% of the asymptomatic group.

CONCLUSION

Endometrial polyp was the most common pathology in the PMB group. Diagnostic hysteroscopy is recommended for women with PMB and asymptomatic thickened endometrium.

Malakoplakia of Endometrium with Osseous Metaplasia on Evaluation of Postmenopausal Leukorrhea: A Rare Case Report

Malakoplakia is a chronic xanthogranulomatous condition that affects the genitourinary tract reported earlier as urinary granulomas and pelvic masses. We report a different clinical manifestation of malakoplakia presenting as postmenopausal pyometra. A 64-year-old postmenopausal female presented with foul-smelling vaginal discharge with a past history of induced abortion, followed by dilatation and evacuation. On examination, abdomen was soft, vaginal examination revealed pus discharge, parous size uterus with free fornices, and pap smear ruled out malignancy. Ultrasonography revealed linear, echogenic structures in the endometrial cavity suspicious of bony spicules with fluid around. Hysteroscopy revealed congested endometrium with multiple pieces of shredded bone-like structures that were removed followed by curettage. Histopathological examination was suggestive of malakoplakia with osseous metaplasia. Retained bony spicules can cause chronic granulomatous inflammation that may become symptomatic postmenopause due to absent cyclical shedding. This is the first reported case of malakoplakia of uterus following retained bony spicules.

Cystic endometrium on ultrasound scan: Sonographic-hysteroscopic-pathologic correlation

OBJECTIVE

To assess the correlation between ultrasound findings of cystic endometrium and hysteroscopic and histopathologic findings.

METHODS

A retrospective study was performed across two London hospital sites between January and December 2020.

RESULTS

The percentage chance of having either endometrial hyperplasia or cancer was lower in our cohort of women with postmenopausal bleeding and ultrasound findings of cystic endometrium, compared with population estimates for women with postmenopausal bleeding alone (4.1% vs 10%-15% for endometrial cancer and 1.4% vs 5%-10% for endometrial hyperplasia). Conversely, a higher proportion of women in our cohort were diagnosed with endometrial polyps compared with population estimates for postmenopausal bleeding (68% vs 2%-12%). The rate of endometrial hyperplasia was significantly higher in our cohort of premenopausal women with abnormal uterine bleeding and cystic endometrium compared with population estimates for premenopausal patients with abnormal uterine bleeding (15.4% vs 1.4%).

CONCLUSION

Cystic endometrium appears to be a powerful predictor of endometrial pathology. The high rate of endometrial hyperplasia in premenopausal women with cystic endometrium would advocate the need to obtain histologic diagnoses. Further studies are required to confirm whether cystic endometrium in women with postmenopausal bleeding confers a lower risk of endometrial hyperplasia and cancer.

Quality of life and sexuality of postmenopausal women with intrauterine pathologies: a recommended three-step multidisciplinary approach focusing on the role of hysteroscopy

Intrauterine pathologies are common in postmenopausal women and clinicians must identify signs and symptoms accurately to provide the adequate diagnosis and treatment. The quality of life (QoL) and sexuality of women are important outcomes to be considered to provide adequate clinical management of the postmenopausal patient with gynecologic pathologies. The aim of this paper is to propose a simple and replicable three-step multidisciplinary approach to evaluate the psychological outcomes of postmenopausal women with intrauterine pathologies, focusing on the role of hysteroscopy. In particular, the article describes three evaluation steps of those psychological outcomes corresponding to three fundamental moments of the patient's diagnostic and therapeutic path: the initial symptoms, diagnosis, and treatment. In our viewpoint, the standard use of such a protocol might considerably improve the QoL of postmenopausal patients undergoing hysteroscopic procedures due to intrauterine pathologies.

Peculiarities of intrauterine pathological processes in women of the postmenopauseal period

Aim of the research is studying the pecularities of the endometrium pathological processes in postmenopausal women on the basis of the hysteroscopy data evaluation, as well as conduction of histopathological and immunochemical studies. Materials and methods. To study the pecularities of intrauterine pathological processes, 100 postmenopausal women were selected and studied. All women underwent hysteroscopy with separate diagnostic scraping of the uterine cavity. Also, 10 samples of glandular-fibrous endometrial polyps (GFEP) in women of reproductive age and 9 samples of such pathology in the postmenopausal period were studied by immunohistochemical method, using 6 primary specific monoclonal antibodies. Results. The results showed that in 64 (64 %) postmenopausal women pathological changes of the endometrium were presented with GFEP, and in 2 patients (2 %) endometrial adenocarcinoma was found. It was also determined that the nuclei of epithelial and stromal cells of GFEP in postmenopausal women are characterized by lower expression of estrogen and progesterone receptors, compared with women with such formations in the reproductive age. In addition, it was found that in postmenopausal women the expression of the apoptosis inhibitor bcl-2 and aromatase P450 in the epithelial and stromal cells of GFEP was more expressed, and the expression of the Bах antigen, on the contrary, was significantly lower than in women of reproductive age. Conclusions. Fundamental molecular-biological differences of GFEP in postmenopausal women compared with women of reproductive age were revealed. It was found that in postmenopausal women there is a significantly lower dependence of such polyps on the effects of estrogen and progesterone. In addition, the data indicate an increased risk of neoplastic transformation in such women.

Clinical and Sonographic Evaluation of Postmenopausal Bleeding (PMB) Followed by Diagnostic and/or Therapeutic Hysteroscopy and Guided Biopsy in Jordanian Hospitals

Background and Objectives: The goal of this study was to evaluate the clinical sonographic evaluation of postmenopausal bleeding (PMB) followed by diagnostic and/or therapeutic hysteroscopy and guided biopsy in Jordanian hospitals. Materials and Methods: A retrospective multi-centric study was performed in hospitals in Al-Karak and Amman from 2014-2016. The study recruited 189 cases to evaluate the aetiology of postmenopausal bleeding. Atrophic endometrium was observed as a major cause of postmenopausal bleeding according to histopathology. The cases were also distributed according to parity in which nulliparous patients were observed. Results: Hysteroscopy was observed to be effective for the diagnosis of postmenopausal bleeding. Conclusion: There is a need to assess more approaches for the diagnosis of postmenopausal bleeding among women.

Outcomes of endometrial assessment in women with unscheduled bleeding on hormone replacement therapy

Objective

This study correlates the transvaginal ultrasound findings with histopathology results in women who present with unscheduled bleeding on hormone replacement therapy.

Study design

Retrospective analysis of 469 consecutive cases with unscheduled bleeding on hormone replacement therapy (203 patients on sequential hormone replacement therapy (seq-HRT) and 266 patients on continuous combined hormone replacement therapy (con-HRT)).

Main outcome measures

Outcomes of endometrial assessment in women with unscheduled bleeding on hormone replacement therapy.

Results

Normal appearance of the endometrium on pelvic ultrasound was seen in 62% patients on seq-HRT and 43% of women on con-HRT. These women required no further assessment and were discharged. Histological assessment showed normal endometrial tissue in 22% of women on seq-HRT and 22% of con-HRT group. Benign endometrial polyps were noted in 8% of women on seq-HRT versus 18% of women on con-HRT. Hyperplasia without atypia was noted in 0.5% of woman on seq-HRT versus 0.4% of women on con-HRT while atypical hyperplasia/endometrial cancer was noted in 2% of women on seq-HRT versus 1% of women on con-HRT.

Conclusion

Women who present with unscheduled bleeding on hormone replacement therapy both on sequential and continuous combined regimens can be reassured that the risk of pathology is low.

Post-menopausal bleeding - Is transvaginal ultrasound a useful first-line investigation in tamoxifen users?

Objective To evaluate the role of transvaginal ultrasound triage in women with a history of tamoxifen treatment who present with post-menopausal bleeding. Study design A retrospective review was undertaken of patients who presented with symptoms of post-menopausal bleeding and underwent ultrasound triage. Endometrial thickness and ultrasonographic features were then correlated with hysteroscopic and histopathological outcome data. The findings and outcomes for women with a history of tamoxifen use (tamoxifen group) were compared to those who had not taken tamoxifen (non-tamoxifen group). Results A total of 614 women with post-menopausal bleeding underwent transvaginal ultrasound triage, of whom 53 had a history of current or previous tamoxifen treatment. An endometrial thickness of ≥5 mm or the presence of other abnormal features was used to triage women to further investigation by hysteroscopy and biopsy. Endometrial thickness was significantly greater in the tamoxifen group (11 mm vs. 6 mm). Nearly all of the tamoxifen group were triaged to further investigation (98.1%), compared with significantly fewer in the non-tamoxifen group (68.3%) Overall, the incidence of endometrial pathology was also significantly higher in tamoxifen patients (43.4% vs. 31.7%). Conclusion For women presenting with post-menopausal bleeding, the use of transvaginal ultrasound as a triage tool is rarely helpful in evaluating women who have a history as tamoxifen use, as most will require further investigation with hysteroscopy and biopsy. A post-menopausal bleeding protocol that omits transvaginal ultrasound for women with a history of tamoxifen use may be an appropriate and effective pathway for managing these patients.