Outpatient hysteroscopy and ultrasonography in the management of endometrial disease

Quality of Life, Anxiety and Depression in Women Treated with Hysteroscopic Endometrial Resection or Ablation for Heavy Menstrual Bleeding: Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background and Objectives: Hysteroscopic endometrial resection (ER) or global endometrial ablation (GEA) are feasible methods to treat heavy menstrual bleeding (HMB). The aim of this systematic review and meta-analysis of randomized controlled trials (RCTs) was to assess patient's quality of life (QoL) in women treated with ER/GEA compared to hysterectomy. Materials and Methods: Electronic searches in MEDLINE Scopus, ClinicalTrials.gov, EMBASE, PROSPERO and Cochrane CENTRAL were conducted from their inception to July 2022. Inclusion criteria were RCTs of premenopausal women with HMB randomized to conservative surgical treatment (ER/GEA) or hysterectomy. The primary outcome was the evaluation of QoL using the SF-36 score. Results: Twelve RCTs (2773 women) were included in the analysis. Women treated with hysteroscopic ER/GEA showed significantly lower scores for the SF-36 general health perception (mean difference (MD) -8.56 [95% CI -11.75 to -5.36]; I2 = 0%), social function (MD -12.90 [95% CI -23.90 to -1.68]; I2 = 91%), emotional role limitation (MD -4.64 [95% CI -8.43 to -0.85]; I2 = 0%) and vitality (MD -8.01 [95% CI -14.73 to -1.30]; I2 = 74%) domains relative to hysterectomy. Anxiety, depression scores and complication rates were similar between treatments. Relative to uterine balloon therapy, amenorrhea was more common with EA/GER (relative risk 1.51 [95% CI 1.03 to 1.20] I2 = 28%), but posttreatment satisfaction was similar. Conclusions: Women's perception of QoL might be seen to be less improved after hysteroscopic ER/GEA rather than hysterectomy. However, such findings need to be confirmed by additional trials due to the high number of outdated studies and recent improvements in hysteroscopic instrumentation and techniques.

Management of abnormal uterine bleeding - focus on ambulatory hysteroscopy

The rapid evolution in ambulatory hysteroscopy (AH) has transformed the approach to diagnose and manage abnormal uterine bleeding (AUB). The medical management in primary care remains the mainstay for initial treatment of this common presentation; however, many women are referred to secondary care for further evaluation. To confirm the diagnosis of suspected intrauterine pathology, the traditional diagnostic tool of day case hysteroscopy and dilatation and curettage in a hospital setting under general anesthesia is now no longer required. The combination of ultrasound diagnostics and modern AH now allows thorough evaluation of uterine cavity in an outpatient setting. Advent of miniature hysteroscopic operative systems has revolutionized the ways in which clinicians can not only diagnose but also treat menstrual disorders such as heavy menstrual bleeding, intermenstrual bleeding and postmenopausal bleeding in most women predominantly in a one-stop clinic. This review discussed the approach to manage women presenting with AUB with a focus on the role of AH in the diagnosis and treatment of this common condition in an outpatient setting.

Accuracy of transvaginal ultrasonography compared to endometrial biopsy for the etiological diagnosis of abnormal perimenopausal bleeding

BACKGROUND AND AIMS

Perimenopause is marked by clinical manifestations which disturb everyday life and which may also hide a pathomorphological, more precisely endometrial, substrate. An accurate early diagnosis established by accessible, non-invasive methods is very important for the therapeutic management.

METHOD

The study included 103 patients aged between 41.5-55.11 years, divided into 3 age groups: 40-44 years (n=10), 45-49 years (n=54) and ≥50 years (n=39).

RESULTS

Certain risk factors of endometrial neoplasm or premalignant conditions were evidenced, their accurate identification being useful in limiting the number of patients with abnormal uterine bleeding (AUB) submitted to diagnostic screening. The most common cause of AUB in our study was fibroma, followed by functional causes.

CONCLUSIONS

Transvaginal ultrasound (TVUS) represents a minimally invasive method for the screening of perimenopausal patients with AUB, especially to rule out endometrial adenocarcinoma (EAC). TVUS sensitivity was higher than clinical diagnosis in case of leiomioma, polypi and EAC. TVUS was more accurate in the diagnosis of EAC, polypi and leiomioma.

A Comparative Observational Study of the Use of Saline Uterine Hydrosonography for the Diagnosis and Assessment of Uterine Cavity Lesions in Women

Aim of this study was to evaluate the performance of saline hydrosonography (HSGM) (also known as saline infusion sonography (SIS)) against transvaginal ultrasound scan (TVS) and hysteroscopy in the diagnosis of uterine cavity lesions. Diagnostic hysteroscopy with biopsy is considered as the “gold standard” to diagnose intrauterine abnormalities. The introduction of HSGM has improved the diagnostic capability of ultrasound. It is important to establish the efficacy and safety of HSGM before it is widely recommended for use. This retrospective observational data was collected from all 223 patients who underwent TVS, HSGM, and hysteroscopy as part of their gynaecological investigations from 1 January 2008 to 31 December 2010 at Central Middlesex Hospital, London. Endometrial Polyps. TVS: sensitivity 60.53%, specificity 97.06%, positive predictive value (PPV) 95.83%, and negative predictive value (NPV) 68.75% and HSGM: sensitivity 95%, specificity 97.14%, PPV 97.44%, and NPV 94.44%. Submucous Leiomyoma. TVS: sensitivity 57.14%, specificity 93.48%, PPV 84.21%, and NPV 78.18% and HSGM: sensitivity 96.55%, specificity 100.00%, PPV 100.00%, and NPV 97.92%. Diagnostic efficacy of HSGM is superior to TVS for the diagnosis of endometrial polyps and submucous fibroids. HSGM should be considered as an intermediate investigation after TVS to assess intracavity pathology and to confirm the diagnosis; hysteroscopy should become a therapeutic intervention.

Endometrial study in patients with postmenopausal metrorrhagia

INTRODUCTION

The aim of the study was to devise a strategy to diagnose malign endometrial pathologies (adenocarcinoma or atypical hyperplasia) that minimizes the number of invasive tests done (hysteroscopy, aspiration biopsy or curettage) with no loss of its detection efficiency.

MATERIAL AND METHODS

We retrospectively studied the clinical histories of 779 postmenopausal women at the University Hospital Complex of Albacete, for whom an endometrial study had been done (hysteroscopy, aspiration biopsy or curettage) with a 1-year follow-up between 1 March 2006 and 31 March 2008.

RESULTS

There were 77 cases of a malignant pathology (66 adenocarcinomas and 11 hyperplasias with atypia); 96.1% had metrorrhagia, and there were only 3 cases of asymptomatic patients (all 3 presented endometrial thickness of > 5 mm: 10, 12 and 15 mm). The sensitivity and specificity of the transvaginal ultrasound, with a 5 mm cut-off point to diagnose a malignant pathology, were 98.4% and 30.1%, respectively; 89.1% and 99.6%, respectively, for aspiration biopsy; 83.9% and 99.1%, respectively, for hysteroscopy without biopsy; and both were 100% for biopsy. Statistical significance was considered at p < 0.05 and confidence intervals were calculated at 95%.

CONCLUSIONS

In postmenopausal women with metrorrhagia, the first action to take is to do a transvaginal ultrasound, followed by en endometrial study, but only if the endometrium is irregular or endometrial thickness is ≥ 5 mm; in asymptomatic women, the cut-off point should be set at 10 mm. The immediate method of choice is an ambulatory biopsy.

A randomised controlled trial of Outpatient versus inpatient Polyp Treatment (OPT) for abnormal uterine bleeding

BACKGROUND

Uterine polyps cause abnormal bleeding in women and conventional practice is to remove them in hospital under general anaesthetic. Advances in technology make it possible to perform polypectomy in an outpatient setting, yet evidence of effectiveness is limited.

OBJECTIVES

To test the hypothesis that in women with abnormal uterine bleeding (AUB) associated with benign uterine polyp(s), outpatient polyp treatment achieved as good, or no more than 25% worse, alleviation of bleeding symptoms at 6 months compared with standard inpatient treatment. The hypothesis that response to uterine polyp treatment differed according to the pattern of AUB, menopausal status and longer-term follow-up was tested. The cost-effectiveness and acceptability of outpatient polypectomy was examined.

DESIGN

A multicentre, non-inferiority, randomised controlled trial, incorporating a cost-effectiveness analysis and supplemented by a parallel patient preference study. Patient acceptability was evaluated by interview in a qualitative study.

SETTING

Outpatient hysteroscopy clinics and inpatient gynaecology departments within UK NHS hospitals.

PARTICIPANTS

Women with AUB - defined as heavy menstrual bleeding (formerly known as menorrhagia) (HMB), intermenstrual bleeding or postmenopausal bleeding - and hysteroscopically diagnosed uterine polyps.

INTERVENTIONS

We randomly assigned 507 women, using a minimisation algorithm, to outpatient polypectomy compared with conventional inpatient polypectomy as a day case in hospital under general anaesthesia.

MAIN OUTCOME MEASURES

The primary outcome was successful treatment at 6 months, determined by the woman's assessment of her bleeding. Secondary outcomes included quality of life, procedure feasibility, acceptability and cost per quality-adjusted life-year (QALY) gained.

RESULTS

At 6 months, 73% (166/228) of women who underwent outpatient polypectomy were successfully treated compared with 80% (168/211) following inpatient polypectomy [relative risk (RR) 0.91, 95% confidence interval (CI) 0.82 to 1.02]. The lower end of the CIs showed that outpatient polypectomy was at most 18% worse, in relative terms, than inpatient treatment, within the 25% margin of non-inferiority set at the outset of the study. By 1 and 2 years the corresponding proportions were similar producing RRs close to unity. There was no evidence that the treatment effect differed according to any of the predefined subgroups when treatments by variable interaction parameters were examined. Failure to completely remove polyps was higher (19% vs. 7%; RR 2.5, 95% CI 1.5 to 4.1) with outpatient polypectomy. Procedure acceptability was reduced with outpatient compared with inpatient polyp treatment (83% vs. 92%; RR 0.90, 95% CI 0.84 to 0.97). There were no significant differences in quality of life. The incremental cost-effectiveness ratios at 6 and 12 months for inpatient treatment were £1,099,167 and £668,800 per additional QALY, respectively.

CONCLUSIONS

When treating women with AUB associated with uterine polyps, outpatient polypectomy was non-inferior to inpatient polypectomy at 6 and 12 months, and relatively cost-effective. However, patients need to be aware that failure to remove a polyp is more likely with outpatient polypectomy and procedure acceptability lower.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 65868569.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 61. See the NIHR Journals Library website for further project information.

Endometrial thickness measured by ultrasonography in postmenopausal patients with endometrial carcinoma has significance, irrespective of histological subtype

OBJECTIVE

The criterion standard of practice for gynecologists is to measure the endometrial thickness with ultrasonography in women presenting with postmenopausal bleeding. A recent study reported that a thin endometrial stripe upon ultrasonography did not reliably exclude type II endometrial carcinoma. The aim of the present study was to reevaluate the reliability of ultrasonographic measurement of the endometrium for prediction of endometrial carcinomas of both types I and II in postmenopausal women.

METHODS

We collected clinical data from patients with endometrial carcinoma who underwent surgical treatment at the Department of Obstetrics and Gynecology of the Osaka University Hospital, Osaka, Japan, during our study period from 2010 to 2012. Only the postmenopausal cases were included in our study. We excluded cases with insufficient clinical data.

RESULTS

Preoperative measurement of the endometrium by transvaginal ultrasonography revealed that the endometrium was greater than 4 mm in 80 (89%) of the 90 type I cases and in 41 (93%) of the 44 type II cases. The median of the endometrial thickness measured with transvaginal ultrasonography preoperatively in type I cases, including both patients with myometrial invasion less than 1/2 and those with myometrial invasion greater than 1/2, was 13 mm (range, 1-78 mm). That of type II cases was 15 mm (range, 1-54 mm). This difference was not statistically significant (P = 0.46 by Mann-Whitney U test). These results implied that endometrial thickness was not significantly associated with the type of tumors.

CONCLUSIONS

Ultrasonographic measurements of the endometrium for prediction of endometrial carcinomas in postmenopausal women are reliable for both type I and type II tumors. These results encourage us to continue to use the "4-mm (5-mm) rule" to evaluate endometrial thickness in postmenopausal women, in opposition to a previous report.

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.

How often are endometrial polyps malignant in asymptomatic postmenopausal women? A multicenter study

OBJECTIVE

The objective of the study was to evaluate the prevalence of cancer and premalignant lesions in polyps on atrophic endometrium in asymptomatic postmenopausal women to compare these findings with a similar cohort of patients with abnormal uterine bleeding.

STUDY DESIGN

One thousand one hundred fifty-two asymptomatic and 770 consecutive postmenopausal women with abnormal uterine bleeding were included in a retrospective multicenter study. Recruited patients underwent hysteroscopic polypectomy based on a sonohysterographic or hysteroscopic diagnosis. The pathologic report was the main outcome measure.

RESULTS

One single case of stage 1 grade 1 endometrial carcinoma on a polyp with a mean diameter of 40 mm (0.1%) was observed in asymptomatic women. This prevalence was 10 times lower than in symptomatic patients (P < .0001). The prevalence of atypical hyperplastic polyps was 1.2% in asymptomatic women (2.2% in symptomatic patients; P < .005). At multivariate analysis, polyps' diameter was the only variable significantly associated to an abnormal histology (cancer, polypoid cancer, and atypical hyperplasia) in asymptomatic women (odds ratio for polyps with mean diameter > 18 mm, 6.9; confidence interval, 2.2-21.4).

CONCLUSION

Follow-up and/or treatment of endometrial polyps incidentally diagnosed in asymptomatic postmenopausal patients could be safely restricted to few selected cases based on polyp diameter.

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.

Hysteroscopic myomectomy for menorrhagia using Versascope bipolar system: efficacy and prognostic factors at a minimum of one year follow up

OBJECTIVE

To evaluate the effectiveness of hysteroscopic submucous myomectomy for women with heavy menstrual bleeding (HMB) over a minimum 1-year period and assess prognostic factors associated with treatment success.

STUDY DESIGN

Prospective observational study set in a university teaching hospital in UK involving 92 women symptomatic of HMB with submucous myomas consecutively recruited between June 2003 and November 2006. Hysteroscopic myomectomy was performed under outpatient local anaesthetic (n=35, 38%) or daycase general anaesthesia (n=57, 62%) using Gynecare Versascope bipolar system. The main outcome measures were: the need for secondary surgical or medical re-intervention, menstrual improvement and patient satisfaction. Other outcome measures include: successful completion of primary resection, type of secondary treatment.

RESULT

Mean follow up was 2.6 years (95% CI 2.3-2.9). Complete fibroid excision was achieved in 66%. Secondary surgical re-intervention was required in 27 (29%) of which 11 (12%) were repeat hysteroscopic myomectomy and 10 (11%) were hysterectomy procedures. Multiple uterine fibroids and adenomyosis were identified in 80% of hysterectomies. At follow up, improved menstrual symptoms and patient satisfaction were reported by 91% and 86%, respectively. Irregular cycle HMB and incomplete fibroid excision were associated with secondary retreatment. Size of the submucous fibroid resected, presence of intramural and subserosal fibroids, or LA vs. GA setting were unrelated to treatment success.

CONCLUSION

HMB with submucous myomas may be successfully treated by completely removing the intracavity myoma component, irrespective of co-existent intramural or subserosal fibroids or size of fibroid resected. This effect remains sustained over at least a 1-2 year period.

Endometrial directed biopsy during sonohysterography using the NiGo device: prospective study in women with abnormal uterine bleeding

OBJECTIVE

To determine the accuracy of sonohysterography (SHG), combined with sonography-guided biopsies that are performed by using the NiGo device, in the diagnosis of endometrial pathologies in women with abnormal uterine bleeding (AUB).

DESIGN

Prospective study.

SETTING

Outpatient clinic.

PATIENT(S)

One hundred sixteen women with AUB (55 postmenopausal and 61 premenopausal).

INTERVENTION(S)

Patients underwent transvaginal sonography and SHG; when an endometrial condition needing a biopsy was diagnosed, the biopsy was performed both by using the NiGo device (ASL 1, Imperia, Italy) and by using Pipelle.

MAIN OUTCOME MEASURE(S)

Feasibility of SHG and endometrial biopsy by NiGo.

RESULT(S)

Sonohysterography was successfully performed by using the NiGo device in 87.4% of the cases (92.6% of premenopausal women and 81.5% of postmenopausal women). Seventy-eight (86.7%) women were judged to require endometrial biopsy; the NiGo device allowed obtaining an adequate biopsy for histological evaluation in 74 cases (94.9%). There was no statistically significant difference in efficacy between the NiGo and Pipelle in providing a specimen that was adequate for histological evaluation. Although no significant difference was observed in the histological diagnosis performed on the specimens obtained by the two techniques, NiGo allowed diagnosis of more focal lesions (simple hyperplasia, endometrial polyps, and myomas).

CONCLUSION(S)

The NiGo device allows an adequate biopsy for histological evaluation to be obtained during SHG in an outpatient setting.

Management of abnormal uterine bleeding and the pathology of endometrial hyperplasia

There are no screening tests for endometrial carcinoma, and patients typically present with abnormal uterine bleeding. This article discusses the pathophysiology and clinical work-up of abnormal uterine bleeding, and risk factors for endometrial carcinoma. Atypical complex hyperplasia and the more recently defined endometrial intraepithelial neoplasia are well recognized as precancers. Evolving knowledge of their genetic alterations provides the opportunity to develop molecular markers, so that endometrial diseases may be diagnosed at the precancerous or early invasive stage. Emerging molecular markers also provide the opportunity to develop clinically useful screening tests for the most common malignancy of the female genital tract.

Diagnosis of abnormal uterine bleeding

Abnormal uterine bleeding is an extremely common indication for referral to a gynaecologist. This chapter examines the modes of presentation and the causes of such symptoms, which range from physiological variations to more sinister underlying pathology. A thorough understanding of these causes is required to direct investigation in an appropriate manner. The full range of possible investigations is discussed with emphasis on how to choose the most appropriate tests for a particular patient. This is fundamental to ensure that tests are pertinent and streamlined, and to prevent unnecessary anxiety and delay. Once the underlying causes have been clarified, a suitable management plan can be made.

Comparison of transvaginal ultrasonography and saline infusion sonohysterography in evaluating the endometrial cavity in pre- and postmenopausal women with abnormal uterine bleeding

OBJECTIVE

To compare the diagnostic accuracy of transvaginal ultrasonography (TVUS) and saline infusion sonohysterography (SIS) of the endometrial cavity in pre- and postmenopausal women with abnormal uterine bleeding.

DESIGN

In a prospective study, TVUS and concurrent SIS findings of 100 pre- and 33 postmenopausal women were recorded. The pathological diagnoses of the specimens, obtained by means of dilatation and curettage, hysteroscopy, and hysterectomy, were taken as reference and compared with the results of TVUS and SIS.

RESULTS

When TVUS and SIS findings were compared with pathological results, the sensitivity and specificity of TVUS in diagnosing endometrial pathologies were 83% and 70.6%, respectively, whereas the sensitivity and specificity of SIS were 97.7% and 82.4%, respectively. The sensitivity and specificity of SIS in the diagnosis of endometrial polyps were 100% and 91.8%, respectively, and in the diagnosis of fibroids were 95% and 100%, respectively.

CONCLUSION

SIS is more accurate than TVUS alone in the evaluation of the endometrial cavity in women with abnormal uterine bleeding.

Saline infusion sonography in women with abnormal uterine bleeding: an update of recent findings

PURPOSE OF REVIEW

To inform about new developments concerning saline infusion sonography, especially in women suffering from abnormal uterine bleeding.

RECENT FINDINGS

The diagnostic accuracy of saline infusion sonography has been established before the period of this review; however, recent papers support the high diagnostic accuracy and conclude saline infusion sonography is able to replace diagnostic hysteroscopy in the evaluation of the uterine cavity. The use of gel instead of saline as distension medium and the introduction of new three-dimensional inversion rendering techniques enhances the visualization of the endometrium which may improve the diagnostic accuracy of saline infusion sonography. A simple, feasible and seemingly cost-effective method of saline infusion sonography-based guided endometrial biopsy has been developed. The technique may allow saline infusion sonography based polypectomy. A classification of submucous fibroids has been proposed in order to allow more accurate, saline infusion sonography-based, preoperative selection of fibroids suitable for hysteroscopic resection.

SUMMARY

The development of saline infusion sonography-based guided biopsies allows saline infusion sonography to compete with vaginoscopic operative hysteroscopy. Additional comparative trials are needed in order to finalize the decision about the proper method of the assessment of the uterine cavity.

Endometrial cancer

Each year, endometrial cancer develops in about 142,000 women worldwide, and an estimated 42,000 women die from this cancer. The typical age-incidence curve for endometrial cancer shows that most cases are diagnosed after the menopause, with the highest incidence around the seventh decade of life. The appearance of symptoms early in the course explains why most women with endometrial cancer have early-stage disease at presentation. For all stages taken together, the overall 5-year survival is around 80%. There is a substantial prognostic difference between the histological types of endometrial cancers. The most common lesions (type 1) are typically hormone sensitive and low stage and have an excellent prognosis, whereas tumours of type 2 are high grade with a tendency to recur, even in early stage. The cornerstone of treatment for endometrial cancer is surgery, which not only is important for staging purposes but also enables appropriate tailoring of adjuvant treatment modalities that benefit high-risk patients only. We review current concepts about epidemiology, pathology, pathogenesis, risk factors and prevention, diagnosis, staging, prognostic factors, treatment, and follow-up of endometrial cancer.