Measurement of endometrial thickness at US in multicenter drug trials: value of central quality assurance reading

An endometrium of type C along with an endometrial thickness of < 8 mm are risk factors for ectopic pregnancy after stimulated cycles with fresh embryo transfer

BACKGROUND

The study investigated whether specific ultrasonographically observed endometrial features (including endometrium type and thickness) were linked to ectopic pregnancy after stimulated cycles with fresh embryo transfer.

METHOD

Of 6246 pregnancy cycles after fresh embryo transfer, 6076 resulted in intrauterine pregnancy and 170 in ectopic pregnancy. The primary outcome of the study was ectopic pregnancy, with the main variables being endometrium type and endometrial thickness. Univariate and subsequent multiple-stepwise logistic regression analyses were used to identify the risk factors of ectopic pregnancy.

RESULTS

1. Compared with patients with an endometrial thickness ≥ 8 mm, the adjusted odds ratio for those with an endometrial thickness < 8 mm was 3.368 (P < 0.001). The adjusted odds ratio for women with a type-C endometrium was 1.897 (P = 0.019) compared with non-type C. 2. A larger dose of gonadotropin used during controlled ovarian hyperstimulation was a protective factor against ectopic pregnancy (P = 0.008). 3. The GnRH antagonist protocol (P = 0.007) was a risk factor for ectopic pregnancy, compared with the use of GnRH agonists.

CONCLUSION

(1) An endometrial thickness < 8 mm coupled with a type C endometrium significantly increased the risk of ectopic pregnancy after fresh embryo transfer. (2) A thin endometrial thickness and a type C endometrium could be further related to an abnormal endometrial receptivity/peristaltic wave. (3) Patients at a high risk of ectopic pregnancy should therefore be given special attention, with early diagnosis during the peri-transplantation period may assist in the prevention of ectopic pregnancy.

An Endometrial Thickness < 8 mm Was Associated With a Significantly Increased Risk of EP After Freeze-Thaw Transfer: An Analysis of 5,960 Pregnancy Cycles

INTRODUCTION

Endometrium characteristics that are most likely to induce ectopic pregnancy were investigated on the basis of the data of 5,960 pregnant freeze-thaw cycles.

METHODS

A total of 5,960 pregnancy cycles after freeze-thaw embryos transfer were included, with the number of intrauterine and ectopic pregnancies being 5,777 and 183, respectively. Ectopic pregnancy was the primary outcome. Endometrial thickness was the main measured variable. The risk factors of ectopic pregnancy were eventually determined based on univariate analysis and subsequent multiple-stepwise logistic regression analysis.

RESULTS

1. After adjusting for confounders, endometrial thickness could independently predict ectopic pregnancy. The adjusted odd ratios for women with endometrial thickness in the ranges of < 8 mm, 8-9.9 mm, and 10-11.9 mm were 3.270 [95% confidence interval (CI), 1.113-9.605, P = 0.031], 2.758 (95% CI, 0.987-7.707, P = 0.053), and 1.456 (95% CI, 0.502-4.225, P = 0.489), respectively, when compared with those having an endometrial thickness of 12-13.9 mm. 2. Endometrial type and preparation protocol were however not identified as risk factors for ectopic pregnancy.

DISCUSSION

1. After freeze-thaw embryo transfer, risks of ectopic pregnancy were significantly higher when the endometrial thickness was < 8 mm. 2. A thin endometrial thickness could be linked with abnormal endometrial peristaltic waves or abnormal endometrial receptivity. 3. Adequate attention should therefore be paid to patients with a thin endometrial thickness to prevent EP or to achieve early diagnosis during the peri-transplantation period.

Asymptomatic postmenopausal women: what are the risk factors for endometrial malignancies? A multicentric retrospective study

OBJECTIVE

To evaluate the prevalence and risk factors for endometrial malignancies in asymptomatic postmenopausal women.

METHODS

Multicentric retrospective analytical study in two Brazilian Reference Centers. All women without postmenopausal bleeding who were submitted to hysteroscopy with biopsy were included (1665). Excluded women without anatomopathological results (625) and whose medical records were incomplete (37). The variables analyzed were age; parity; body mass index; duration of menopausal status; systemic arterial hypertension; diabetes mellitus; use of hormone replacement therapy; use of tamoxifen; duration of use of tamoxifen; endometrial thickness and biopsy results.

RESULTS

The frequency of endometrial malignancies in asymptomatic postmenopausal women was 2.39%. Endometrial thickness ≥8 mm increased the chance of endometrial malignancies, even more, with an endometrial thickness ≥12.55 mm the chance of endometrial malignancies increased by 4.68 times (p < .001 and 95% CI: 1.99-11.03).

CONCLUSION

The prevalence of endometrial malignancies was low and the only risk factor for endometrial malignancies in asymptomatic postmenopausal women was endometrial thickness.

Unravelling the endometrium: a pictorial review of saline infusion sonohysterography in the evaluation of abnormal uterine bleeding

This article describes the diagnosis of causes of abnormal uterine bleeding with experience of the biggest medical institute in Kashmir, India. We work in a low resource setting where unavailabity of hysteroscopy made us acknowledge the accuracy and efficacy of saline infusion sonohysterography in diagnosis of patients with AUB thus helping guide their management.

Evaluation of sonographic endometrial patterns and endometrial thickness as predictors of ectopic pregnancy

OBJECTIVE

To evaluate whether endometrial patterns and thickness could be used for the prediction of ectopic pregnancy (EP).

METHODS

A prospective study was conducted in a center in India between October 2007 and December 2008. It included 100 women with an early pregnancy confirmed by urine pregnancy testing but for whom an intrauterine gestational sac was not visualized on transvaginal ultrasonography (TVS). The women were divided into an EP group and an intrauterine pregnancy (IUP) group depending on the final diagnosis. The endometrial pattern and endometrial thickness were determined by TVS. Sensitivity and receiver operating characteristic curve analyses were performed to determine the predictive value.

RESULTS

A heterogenous hyperechoic or trilaminar endometrial pattern was noted in 53 (77%) of 69 women in the EP group and 12 (39%) of 31 in the IUP group, and a homogenous hyperechoic pattern in 3 (4%) women in the EP group and 13 (42%) in the IUP group. An endometrial thickness of less than 9.8 mm was predictive of EP (P<0.001), and an endometrial pattern other than homogenous hyperechoic had a sensitivity and a negative predictive value of 81.3% for the diagnosis of EP.

CONCLUSION

Evaluation of endometrial thickness and pattern by TVS helps to identify women with a pregnancy of unknown location for close supervision.

Sonographic Evaluation for Endometrial Polyps: The Interrupted Mucosa Sign

OBJECTIVES

To evaluate the interrupted mucosa sign for identification of endometrial polyps, using pathologic confirmation as the reference standard, compared to other accepted sonographic findings.

METHODS

We reviewed 195 patients referred for pelvic sonographic evaluations for suspected endometrial polyps in this retrospective Institutional Review Board-approved study. Of these, 82 had tissue sampling of the endometrium and constituted the final study group. Patient data, including age, menopausal status, last menstrual period, and final pathologic diagnosis, were recorded. Sonograms were reviewed by 2 blinded board-certified radiologists for endometrial features, including thickness, echogenicity, vascularity, presence of a mass, and the interrupted mucosa sign. Descriptive statistics and multivariate logistic regression analysis were performed.

RESULTS

The mean age of the patients was 44.99 (SD, 9.88) years, 79.1% of whom were premenopausal. Pathologic diagnosis confirmed polyps in 58 (70.73%). A single feeding vessel was visualized in 36 patients with polyps (62.07%), whereas the interrupted mucosa sign was visualized in 34 (58.62%). The presence of a feeding vessel, the interrupted mucosa sign, or both detected 48 (82.76%) of the polyps. In the multivariate analysis, only the interrupted mucosa sign was a statistically significant predictor of pathologic diagnosis of a polyp (P= .035), with an odds ratio of 3.83 (95% confidence interval, 1.10-13.29). Other sonographic findings were not independent predictors of a polyp: mass (P = .35), single feeding vessel (P = .31), endometrial thickness (P = .88), and endometrial echogenicity (P = .45). The sensitivity, specificity, and positive predictive value of the interrupted mucosa sign were 59%, 75%, and 85%, respectively.

CONCLUSIONS

The interrupted mucosa sign is a promising sonographic sign for identification of endometrial polyps, with greater predictive power than previously described signs. It has the potential to improve the diagnostic performance of sonography, especially when used in combination with other described signs.

Endometrial evaluation with transvaginal ultrasonography for the screening of endometrial hyperplasia or cancer in premenopausal and perimenopausal women

Objective

The aim of our study is to determine clinical factors and sonographic findings associated with endometrial hyperplasia or cancer (EH+) in premenopausal and perimenopausal women.

Methods

A total of 14,340 transvaginal ultrasonography examinations of 9,888 healthy premenopausal and perimenopausal women were included in this retrospective study. One hundred sixty-two subjects underwent endometrial biopsy based on abnormal uterine bleeding (AUB), sonographic endometrial abnormalities (thickened endometrium, endometrial mass, or endometrial stripe abnormality), or both. The clinical factors and sonographic endometrial abnormalities were evaluated with regard to EH+.

Results

Histologically verified EH+ was found in fourteen subjects (8.6%); ten cases of endometrial hyperplasia (EH) without atypia, three cases of EH with atypia (AEH), and one case of endometrial cancer. Neither clinical factors nor AUB were associated with EH+ (P=0.32) or AEH+ (P=0.72). Of sonographic findings, endometrial stripe abnormality was significantly associated with EH+ (P=0.003) and marginally associated with AEH+ (P=0.05), but a thickened endometrium was not associated with EH+ (P=0.43).

Conclusion

Endometrial stripe abnormality is a significant factor to predict EH+ in healthy premenopausal and perimenopausal women with and without AUB. However, simple measurement of endometrial thickness has a limited role in this capacity.

The role of sonographic endometrial patterns and endometrial thickness in the differential diagnosis of ectopic pregnancy

OBJECTIVE

The purpose of this study was to examine the usefulness of the endometrial trilaminar pattern and thickness in the diagnosis of ectopic pregnancy.

STUDY DESIGN

We reviewed patient records for clinical and ultrasonographic data for patients with the suspicion of ectopic pregnancy. The trilaminar pattern and endometrial thickness were tested as predictors for the diagnosis of ectopic pregnancy.

RESULTS

The trilaminar pattern had a specificity of 94% and sensitivity of 38% (n = 403 women). The mean endometrial thickness was thinner in patients with ectopic, compared with normal pregnancy (9.5 +/- 5.7 mm vs 12.4 +/- 5.9 mm; P = .035). Patients with normal pregnancy or first-trimester losses had comparable thicknesses (12.4 +/- 5.9 mm vs 12.5 +/- 8.0 mm). The receiver operator curve showed that there was no thickness value useful for the diagnosis of ectopic pregnancy.

CONCLUSION

The trilaminar pattern is specific for the diagnosis of ectopic pregnancy, but it is associated with low sensitivity. The endometrial thickness tends to be thinner in patients with an ectopic pregnancy.

Radiological error: analysis, standard setting, targeted instruction and teamworking

Diagnostic radiology does not have objective benchmarks for acceptable levels of missed diagnoses. Until now, data collection of radiological discrepancies has been very time consuming. The culture within the specialty did not encourage it. However, public concern about patient safety is increasing. There have been recent innovations in compiling radiological interpretive discrepancy rates which may facilitate radiological standard setting. However standard setting alone will not optimise radiologists' performance or patient safety. We must use these new techniques in radiological discrepancy detection to stimulate greater knowledge sharing, targeted instruction and teamworking among radiologists. Not all radiological discrepancies are errors. Radiological discrepancy programmes must not be abused as an instrument for discrediting individual radiologists. Discrepancy rates must not be distorted as a weapon in turf battles. Radiological errors may be due to many causes and are often multifactorial. A systems approach to radiological error is required. Meaningful analysis of radiological discrepancies and errors is challenging. Valid standard setting will take time. Meanwhile, we need to develop top-up training, mentoring and rehabilitation programmes.

Radiological error: analysis, standard setting, targeted instruction and teamworking

Diagnostic radiology does not have objective benchmarks for acceptable levels of missed diagnoses. Until now, data collection of radiological discrepancies has been very time consuming. The culture within the specialty did not encourage it. However, public concern about patient safety is increasing. There have been recent innovations in compiling radiological interpretive discrepancy rates which may facilitate radiological standard setting. However standard setting alone will not optimise radiologists' performance or patient safety. We must use these new techniques in radiological discrepancy detection to stimulate greater knowledge sharing, targeted instruction and teamworking among radiologists. Not all radiological discrepancies are errors. Radiological discrepancy programmes must not be abused as an instrument for discrediting individual radiologists. Discrepancy rates must not be distorted as a weapon in turf battles. Radiological errors may be due to many causes and are often multifactorial. A systems approach to radiological error is required. Meaningful analysis of radiological discrepancies and errors is challenging. Valid standard setting will take time. Meanwhile, we need to develop top-up training, mentoring and rehabilitation programmes.