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Slaager FC, van der Zande JA, van Werkhoven LA, van Maldegem LDPR, Breijer MC, Dorman MZ, Vencken PMLH, de Waard J, Hofhuis W, Nieuwenhuyzen-De Boer GM, van Beekhuizen HJ, Hoogduin K, Makkus ALCF, van Es N, Ewing-Graham PC, van Doorn HC. Diagnostic workup of patients with benign or inconclusive reports on office endometrial biopsy after first episode of postmenopausal blood loss. Eur J Obstet Gynecol Reprod Biol 2025; 310:113991. [PMID: 40294513 DOI: 10.1016/j.ejogrb.2025.113991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2024] [Revised: 04/17/2025] [Accepted: 04/19/2025] [Indexed: 04/30/2025]
Abstract
BACKGROUND Postmenopausal bleeding carries a risk of endometrial cancer, and office endometrial sampling (OES) is often the first diagnostic approach. Whether further diagnostic procedures such as hysteroscopy or saline infusion sonography (SIS) are required to rule out polyps and malignancies is uncertain. The objective of this study is to evaluate whether clinicians perform further diagnostic tests when OES is benign or inconclusive. Secondary outcomes include the patient characteristics associated with the likelihood of performing further diagnostic tests and the incidence of endometrial intraepithelial neoplasia and endometrial malignancy. METHODS We performed a multicenter, prospective cohort study, evaluating patients with a first episode of postmenopausal bleeding, with an endometrial thickness of >4 mm on 2D vaginal sonography and a benign or inconclusive result of an OES. Patients who underwent further diagnostic or therapeutic procedures (hysteroscopy or SIS) were compared to patients who did not. Univariate and multivariate analyses were performed to identify predictive factors for additional diagnostic procedures and the diagnosis of endometrial malignancy. RESULTS Of the 350 eligible patients, 197 (56 %) underwent further diagnostic procedures. These patients had a thicker endometrium (median 8.6 mm vs. 6.0 mm; p < 0.001), more frequent suspicion of intracavitary abnormalities (34.0 % vs. 14.4 %; p < 0.001), and more frequent insufficient aspiration samples (20.8 % vs. 11.8 %; p = 0.025) compared to patients who received expectant management. Multivariate regression analysis confirmed these findings. The underlying risk of malignancy was 2.7 % with benign samples and 6.8 % with insufficient samples. Overall, malignancy incidence was higher in those who underwent further diagnostic workup (p = 0.04). CONCLUSION In this prospective study, just over half of patients underwent further diagnostic procedures. Endometrial thickness, suspicion of intracavitary abnormality or an insufficient endometrial sample were predictive for further diagnostic workup. The incidence of malignancy was higher in patients who underwent diagnostic workup, which argues for a risk-based strategy in clinical decision-making. REGISTRATION Central study approval was obtained at the Erasmus MC (MEC 2015-740). The study was registered in the Dutch trial register (www.onderzoekmetmensen.nl, NL7608).
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Affiliation(s)
- F Ciska Slaager
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Netherlands (the).
| | - Johanna A van der Zande
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Netherlands (the)
| | - Lucy A van Werkhoven
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Netherlands (the)
| | | | - Maria C Breijer
- Department of Obstetrics and Gynecology, Admiraal de Ruyter Hospital, 's-Gravenpolderseweg 114, 4462 RA Goes, Netherlands (the)
| | - Manja Z Dorman
- Department of Gynecology, Bravis Hospital, Boerhaaveplein 1, 4624 VT Bergen op Zoom, Netherlands (the)
| | - Peggy M L H Vencken
- Department of Gynecology, Bravis Hospital, Boerhaaveplein 1, 4624 VT Bergen op Zoom, Netherlands (the)
| | - Judith de Waard
- Department of Gynecology, Franciscus Gasthuis & Vlietland, Kleiweg 500, 3045 PM Rotterdam, Netherlands (the)
| | - Ward Hofhuis
- Department of Gynecology, Franciscus Gasthuis & Vlietland, Kleiweg 500, 3045 PM Rotterdam, Netherlands (the)
| | | | - Heleen J van Beekhuizen
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Netherlands (the)
| | - Klaas Hoogduin
- Department of Pathology, Pathan B.V. Kleiweg 500, 3045 PM Rotterdam, Netherlands (the)
| | | | - Nicole van Es
- Department of Pathology, Bravis Hospital, Boerhaaveplein 1, 4624 VT Bergen op Zoom, Netherlands (the)
| | - Patricia C Ewing-Graham
- Department of Pathology, Erasmus MC Cancer Institute, University Medical Center, Doctor molewaterplein 40, 3015 GD Rotterdam, Netherlands (the)
| | - Helena C van Doorn
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, Netherlands (the)
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Pathare ADS, Džigurski J, Pujol-Gualdo N, Rukins V, Peters M, Mägi R, Salumets A, Saare M, Laisk T. A large-scale genome-wide association study on female genital tract polyps highlights role of DNA repair, cell proliferation, and cell growth. Hum Reprod 2025; 40:750-763. [PMID: 39986329 DOI: 10.1093/humrep/deaf025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 01/05/2025] [Indexed: 02/24/2025] Open
Abstract
STUDY QUESTION Can a large-scale genome-wide association study (GWAS) meta-analysis identify genomic risk loci and likely involved genes for female genital tract (FGT) polyps, provide insights into the biological mechanism underlying their development, and inform of potential overlap with other traits, including endometrial cancer? SUMMARY ANSWER GWAS meta-analysis of FGT polyps highlights potentially shared mechanisms between polyp development and cancerous processes. WHAT IS KNOWN ALREADY Small-scale candidate gene studies have focused on biological processes such as oestrogen stimulation and inflammation to clarify the biology behind FGT polyps. However, the exact mechanism for the development of polyps is still elusive. At the same time, a genome-wide approach, which has become the gold standard in complex disease genetics, has never been used to uncover the genetics of the FGT polyps. STUDY DESIGN, SIZE, DURATION We performed a GWAS meta-analysis including a total of 36 984 women with FGT polyps (International Classification of Diseases (ICD-10) diagnosis code N84) and 420 993 female controls (without N84 code) of European ancestry from the FinnGen study (11 092 cases and 94 394 controls), Estonian Biobank (EstBB, 14 008 cases and 112 799 controls), and the Pan-UKBB study (11 884 cases and 213 800 controls). PARTICIPANTS/MATERIALS, SETTING, METHODS GWAS meta-analysis and functional annotation of GWAS signals were performed to identify genetic risk loci and prioritize genes in associated loci. To explore associations with other traits, we performed a look-up of associated variants across multiple traits and health conditions, genetic correlation analysis, and phenome-wide association study (PheWAS) with ICD-10 diagnosis codes. MAIN RESULTS AND THE ROLE OF CHANCE Our GWAS meta-analysis revealed 16 significant (P < 5 × 10-8) genomic risk loci. Based on exonic variants in GWAS signals, we prioritized EEFSEC, ODF3, PRIM1, PLCE1, LRRC34/MYNN, EXO1, and CHEK2 which are involved in DNA repair, cell proliferation, and cell growth. Several of the identified genomic loci have previously been linked to endometrial cancer and/or uterine fibroids, highlighting the potentially shared mechanisms underlying tissue overgrowth and cancerous processes. Genetic correlation analysis revealed a positive correlation with body mass index and reproductive traits, that can be classified as symptoms or risk factors of endometrial polyps (EPs), whereas a negative correlation was observed between FGT polyps and both menopause (genetic correlation estimate (rg) = -0.29, SE = 0.08, P = 8.8×10-4) and sex hormone-binding globulin (SHBG) (rg = -0.22, SE = 0.04, P = 2.4×10-8). On the phenotypic level, the strongest associations were observed with endometriosis, uterine fibroids, and excessive, frequent, and irregular menstruation. LARGE SCALE DATA The complete GWAS summary statistics will be made available after publication through the GWAS Catalog (https://www.ebi.ac.uk/gwas/). LIMITATIONS, REASONS FOR CAUTION In this study, we focused broadly on FGT polyps and did not differentiate between the polyp subtypes. Considering the prevalence of FGT polyp subtypes, we assumed that most women included in the study had EPs. Further research on the expression profile of FGT polyps could complement the GWAS study to substantiate the functional importance of the identified variants. WIDER IMPLICATIONS OF THE FINDINGS The study findings have the potential to significantly enhance our understanding of the genetic mechanisms involved, paving the way for future functional follow-up, which in turn could improve the diagnosis, risk assessment, and targeted treatment options, since surgery is the only line of treatment available for diagnosed polyps. STUDY FUNDING/COMPETING INTEREST(S) This study was funded by European Union through the European Regional Development Fund Project No. 2014-2020.4.01.15-0012 GENTRANSMED. Computations were performed in the High-Performance Computing Center of the University of Tartu. The study was also supported by the Estonian Research Council (grant no. PRG1076 and MOBJD1056) and Horizon 2020 innovation grant (ERIN, grant no. EU952516). All the authors declared no conflict of interest.
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Affiliation(s)
- Amruta D S Pathare
- Celvia CC, Tartu, Estonia
- Department of Obstetrics and Gynecology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Jelisaveta Džigurski
- Estonian Genome Centre, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Natàlia Pujol-Gualdo
- Estonian Genome Centre, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Valentina Rukins
- Estonian Genome Centre, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Maire Peters
- Celvia CC, Tartu, Estonia
- Department of Obstetrics and Gynecology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Reedik Mägi
- Estonian Genome Centre, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Andres Salumets
- Celvia CC, Tartu, Estonia
- Department of Obstetrics and Gynecology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
- Division of Obstetrics and Gynecology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Merli Saare
- Celvia CC, Tartu, Estonia
- Department of Obstetrics and Gynecology, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Triin Laisk
- Estonian Genome Centre, Institute of Genomics, University of Tartu, Tartu, Estonia
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Weigel GM, Baison GN, Mihalov L, Mupombwa T. Prevalence of and risk factors for endometrial polyps among asymptomatic postmenopausal women with uterovaginal prolapse. Am J Obstet Gynecol 2025; 232:196.e1-196.e6. [PMID: 39127165 DOI: 10.1016/j.ajog.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 07/14/2024] [Accepted: 08/05/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND The prevalence of endometrial polyps among asymptomatic, postmenopausal women is not well defined. There is no clear clinical consensus on how to manage endometrial polyps in this population and whether these polyps truly are a cause for clinical concern. OBJECTIVE This study aimed to estimate the prevalence of endometrial polyps among asymptomatic (without bleeding), postmenopausal women and to evaluate risk factors associated with their presence. STUDY DESIGN This cross-sectional study assessed the prevalence of endometrial polyps among asymptomatic, postmenopausal women who underwent a hysterectomy for uterovaginal prolapse. Patients were excluded if they underwent a hysterectomy for other indications, including postmenopausal bleeding. Following chart review, eligible patients who received care at a single site in Washington state from 2009 to 2018 were included. The primary outcome was the presence of endometrial polyps on pathology. Risk factors associated with polyp prevalence were subsequently assessed using univariate analysis and multivariate regression. RESULTS Of the 317 eligible women identified, endometrial polyps were identified in 106 women (33.4%). The average polyp size and endometrial thickness was 13±10 mm and 1.4±1.5 mm, respectively. Most cases (78%) had solitary polyps. Premalignant and malignant lesions were found in 2 cases (1.89%); 1 had endometrial carcinoma and 1 had endometrial intraepithelial neoplasia. Baseline clinical and demographic characteristics were similar between patients with and those without endometrial polyps, including the presence of fibroids, endometriosis, and adenomyosis. A multivariate logistic regression showed that the presence of polyps was independently associated with a high body mass index (odds ratio, 1.06; 95% confidence interval, 1.01-1.12; P=.02) and use of menopausal hormone therapy (odds ratio, 1.67; 95% confidence interval, 1.02-2.72; P=.04). CONCLUSION Asymptomatic postmenopausal women who underwent hysterectomy for uterovaginal prolapse exhibited a high prevalence of endometrial polyps. Those who used menopausal hormone therapy and who had a high body mass index were at a higher risk for developing endometrial polyps. Although the risk for malignancy seems to be low, more investigation is warranted to truly quantify the lifetime risk. For now, expectant management may be a reasonable approach for incidentally found, asymptomatic polyps.
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Affiliation(s)
- Gabriela M Weigel
- Department of Obstetrics and Gynecology, Brown University, Women and Infants Hospital, Providence, RI.
| | - George N Baison
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Linda Mihalov
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Tariro Mupombwa
- Department of Obstetrics and Gynecology, Brown University, Women and Infants Hospital, Providence, RI
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Bensouda S, Cromack SC, Komorowski AS, HogenEsch E, Schipma MJ, Wang X, Fowler H, Pavone M, Green SJ, Bernardi LA, Bakkensen JB. Uterine pathology and microbiome among patients with endometrial polyps and fibroids. F&S SCIENCE 2025; 6:107-116. [PMID: 39710357 DOI: 10.1016/j.xfss.2024.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2024] [Revised: 12/16/2024] [Accepted: 12/17/2024] [Indexed: 12/24/2024]
Abstract
OBJECTIVE To evaluate the uterine microbiome among women with endometrial polyps and submucosal fibroids and to compare results between endometrial sampling techniques. DESIGN Patients with polyps or fibroids were prospectively recruited before hysteroscopy, whereas patients undergoing retrieval for planned oocyte cryopreservation were recruited prospectively as controls. Three specimen types obtained for each patient were the distal 5 mm of an embryo catheter passed to the uterine fundus (C), endometrial tissue from an endometrial biopsy (T), and formalin-fixed paraffin-embedded (FFPE) endometrial tissue from the same endometrial biopsy. 16S ribosomal RNA gene amplicon sequencing was performed to analyze the structure of the endometrial microbiome. SUBJECTS Thirty-seven participants including 28 women with polyps and/or fibroids and 9 controls. EXPOSURE None. MAIN OUTCOME MEASURES Microbial taxonomic alpha and beta diversity; differential abundance of taxa. RESULTS Across all sample types, participants with polyps had higher microbial alpha diversity than controls (4.3 vs. 5.1, q = 0.049), and microbial communities were significantly different (pairwise Permutational Multivariate Analysis of Variance (PERMANOVA) pseudo-F = 2.1, q = 0.003). These differences were observed when examining C specimens alone (5.4 vs. 6.4, q = 0.001; pairwise PERMANOVA pseudo-F = 2.5, q = 0.003), although they did not reach significance when examining either T or FFPE specimens alone. Participants with fibroids had similar alpha diversity yet significant differences in beta diversity compared with controls in analyses combining all specimens (pairwise PERMANOVA pseudo-F = 1.475, q = 0.030); however, these differences did not achieve significance when analyzing C, T, or FFPE specimens alone. When comparing C and T specimens vs. FFPE specimens overall, alpha diversity was significantly higher (q < 0.001 and q < 0.001, respectively) and there were significant differences in beta diversity (q < 0.003 and q < 0.003, respectively). Analyses of C specimens generated a larger number of significantly differentially abundant taxa compared with other sampling methods. Although not statistically significant, relative abundance of putative pathogens was higher in participants with polyps than controls regardless of sampling technique. CONCLUSIONS Results of this exploratory study suggest that significant microbial differences exist among patients with endometrial polyps vs. healthy controls. However, results varied by sampling technique, highlighting a need to identify optimal sampling methods before validating findings in larger prospective cohort studies.
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Affiliation(s)
- Sabrine Bensouda
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Sarah C Cromack
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Allison S Komorowski
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Elena HogenEsch
- Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Matthew J Schipma
- NUSeq Core Facility, Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Xinkun Wang
- NUSeq Core Facility, Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hailie Fowler
- NUSeq Core Facility, Center for Genetic Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - MaryEllen Pavone
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stefan J Green
- Department of Internal Medicine, Division of Infectious Diseases, Rush University, Chicago, Illinois
| | - Lia A Bernardi
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jennifer B Bakkensen
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Al-Rayes S, Mohamed M, Suarthana E, Kigloo HN, Raina J, Tulandi T. Risks of Malignancy among 11,204 Patients with Endometrial Polyp: A Systematic Review and Meta-analysis. Gynecol Minim Invasive Ther 2025; 14:40-50. [PMID: 40143979 PMCID: PMC11936404 DOI: 10.4103/gmit.gmit-d-24-00056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2024] [Revised: 11/26/2024] [Accepted: 12/03/2024] [Indexed: 03/28/2025] Open
Abstract
Objectives To evaluate factors associated with malignancy in patients with endometrial polyps. Materials and Methods We conducted electronic database research on PubMed, MEDLINE, EMBASE, COCHRANE, and Google Scholar from inception for all studies on endometrial polyp. After removing duplicates, and title and abstract screening, we had a total of 121 articles and 151 others from screening the reference list. Inclusion criteria included peri and postmenopausal women > 45 years diagnosed histopathologically with endometrial polyp(s). We excluded women with a history of endometrial cancer or hysterectomy. Results Twenty studies were analyzed. Of 11204 patients with endometrial polyp, 287 had malignant polyps (2.75%), 182 (1.8%) had concomitant endometrial hyperplasia with atypia, and 520 (5.2%) had hyperplasia without atypia within the polyp. Menopausal women had a higher risk of pre-malignancy/malignancy than non-menopausal women (OR 5.63 (95CI 3.87, 8.20, I 2 = 0%, P < 0.001). Endometrial thickness on ultrasound in pre-malignancy/malignancy cases was significantly thicker than in the benign polyp (mean difference 4.2 mm, 95% CI 0.8 to 7.6 mm, I 2 = 18%, P = 0.02). Women who used tamoxifen or hormone replacement therapy (HRT) had a lower likelihood of endometrial pre-malignancy/malignancy, while women with abnormal uterine bleeding (AUB) had a higher probability of pre-malignancy/malignancy. The odd ratio of having pre-malignancy/malignancy among those who used tamoxifen was 0.50 (95% CI 0.26-0.94: I 2 12%, p = 0.03). Conclusion In women with endometrial polyp, menopausal age and thickened endometrium might increase the probability while tamoxifen or HRT use might lower the likelihood of endometrial pre-malignancy/malignancy; and the presence of AUB might signal endometrial pre-malignancy/malignancy.
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Affiliation(s)
- Sarah Al-Rayes
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
- Department of Obstetrics and Gynecology, McGill University, Montreal, Canada
| | - Mariam Mohamed
- Faculty of Medicine, University of Montreal, Montreal, Canada
| | - Eva Suarthana
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
- Department of Obstetrics and Gynecology, McGill University, Montreal, Canada
| | - Hormoz Nassiri Kigloo
- Department of Obstetrics and Gynecology, McGill University, Montreal, Canada
- Faculty of Medicine, University of Laval, Quebec, Canada
| | - Jason Raina
- Department of Family Medicine, University of Manitoba, Manitoba, Winnipeg, Canada
| | - Togas Tulandi
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
- Department of Obstetrics and Gynecology, McGill University, Montreal, Canada
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Yao X, Ye X, Chen L, Zheng J. An Atypical Sonographic Presentation of an Endometrial Polyp in a Postmenopausal Woman: A Case Report. Cureus 2024; 16:e73107. [PMID: 39524159 PMCID: PMC11543380 DOI: 10.7759/cureus.73107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2024] [Indexed: 11/16/2024] Open
Abstract
Endometrial polyps, a common gynecological finding, may be symptomatic or asymptomatic, with age and postmenopausal bleeding identified as significant risk factors. While typically identifiable on ultrasound, atypical presentations can pose diagnostic challenges. We report a case of a postmenopausal woman initially misdiagnosed with endometrial cavity fluid due to the polyp's almost entirely cystic appearance on ultrasound. Hysteroscopy revealed hyperplastic endometrium with a 3.5-cm endometrial polyp. A polypectomy was performed, and the specimen was sent for histopathological evaluation, which revealed an endometrial polyp and cystic hyperplasia without atypia. This case highlights the importance of considering atypical sonographic presentations of endometrial polyps, particularly in postmenopausal women, to avoid diagnostic delays and guide appropriate management.
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Affiliation(s)
- Xiaohong Yao
- Radiology, Guangdong Medical University, Zhanjiang, CHN
- Ultrasound, The Third People's Hospital of Longgang District, Shenzhen, CHN
| | - Xuandan Ye
- Gynecology, The Third People's Hospital of Longgang District, Shenzhen, CHN
| | - Lixia Chen
- Gynecology, The Third People's Hospital of Longgang District, Shenzhen, CHN
| | - Jian Zheng
- Radiology, Guangdong Medical University, Zhanjiang, CHN
- Ultrasound, The Second Affiliated Hospital, School of Medicine, The Chinese University of Hong Kong, Shenzhen & Longgang District People's Hospital, Shenzhen, CHN
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Jang S, Hwang SO. Risk factors for atypical hyperplasia or endometrial cancer in premenopausal women aged ≤ 45 years with abnormal uterine bleeding. Eur J Obstet Gynecol Reprod Biol 2024; 302:288-293. [PMID: 39348761 DOI: 10.1016/j.ejogrb.2024.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 09/15/2024] [Accepted: 09/17/2024] [Indexed: 10/02/2024]
Abstract
OBJECTIVES To assess the prevalence and risk factors for atypical hyperplasia (AH) or endometrial cancer (EC) in premenopausal women aged ≤ 45 years with abnormal uterine bleeding (AUB). METHODS This was a retrospective study of premenopausal patients aged 18 to 45 years who underwent hysteroscopy, dilation and curettage, or pipelle sampling at Inha University Hospital, South Korea, from 2014 to 2023. We used multivariable logistic regression analysis to identify risk factors and calculate the predicted probabilities of AH or EC with various combinations of these factors. RESULTS Of 821 patients included in the study, 6.0 % were diagnosed with AH or EC. The significant risk factors identified were nulliparity (odds ratio (OR): 4.75, 95 % confidence interval (CI): 2.11-10.70), PCOS (OR: 2.72, 95 % CI: 1.34-5.52), and multiple polyps (OR: 2.33, 95 % CI: 1.23-4.41). The predicted probabilities of developing AH or EC increased with the number of risk factors present, ranging from 1 % to 33.6 %. CONCLUSIONS The predicted probabilities within combinations of risk factors may be considered helpful in making better clinical decisions regarding endometrial sampling for patients ≤ 45 years with AUB.
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Affiliation(s)
- Shina Jang
- Department of Obstetrics and Gynecology, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea.
| | - Sung-Ook Hwang
- Department of Obstetrics and Gynecology, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea
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Viganò S, Smedile A, Cazzella C, Marra P, Bonaffini PA, Sironi S. Abnormal Uterine Bleeding: A Pictorial Review on Differential Diagnosis and Not-So-Common Cases of Interventional Radiology Management. Diagnostics (Basel) 2024; 14:798. [PMID: 38667444 PMCID: PMC11049404 DOI: 10.3390/diagnostics14080798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 04/05/2024] [Accepted: 04/07/2024] [Indexed: 04/28/2024] Open
Abstract
Abnormal uterine bleeding (AUB) poses a multifaceted challenge in women's health, necessitating an integrated approach that addresses its diverse etiologies and clinical presentations. The International Federation of Gynecology and Obstetrics PALM-COEIN classification system provides a systematic approach to the diagnosis of AUB in non-pregnant women, based on clinical and imaging-based categorization of causes into structural (Polyps, Adenomyosis, Leiomyomas and Malignancy; PALM), and non-structural causes (Coagulopathies, Ovulatory disorders, primary Endometrial disorders, Iatrogenic and Not otherwise classified; COEIN). On the other hand, placental disorders, uterine rupture, ectopic pregnancy and retained products of conceptions are the main causes of uterine bleeding during pregnancy and in the peripartum period. Ultrasound is usually the first-line imaging technique for the differential diagnosis of causes of AUB. Computed Tomography may be useful if ultrasound findings are unclear, especially in emergency settings. Magnetic resonance imaging, when indicated, is an excellent second-line diagnostic tool for a better non-invasive characterization of the underlying cause of AUB. This pictorial review aims to illustrate the main causes of AUB from the point of view of diagnostic imaging and to show not-so-common cases that can be treated by means of interventional radiology.
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Affiliation(s)
- Sara Viganò
- Department of Radiology, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy; (A.S.); (C.C.); (P.M.); (P.A.B.); (S.S.)
| | - Antonella Smedile
- Department of Radiology, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy; (A.S.); (C.C.); (P.M.); (P.A.B.); (S.S.)
| | - Caterina Cazzella
- Department of Radiology, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy; (A.S.); (C.C.); (P.M.); (P.A.B.); (S.S.)
| | - Paolo Marra
- Department of Radiology, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy; (A.S.); (C.C.); (P.M.); (P.A.B.); (S.S.)
- School of Medicine, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo 1, 20126 Milano, Italy
| | - Pietro Andrea Bonaffini
- Department of Radiology, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy; (A.S.); (C.C.); (P.M.); (P.A.B.); (S.S.)
- School of Medicine, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo 1, 20126 Milano, Italy
| | - Sandro Sironi
- Department of Radiology, Papa Giovanni XXIII Hospital, Piazza OMS 1, 24127 Bergamo, Italy; (A.S.); (C.C.); (P.M.); (P.A.B.); (S.S.)
- School of Medicine, University of Milano-Bicocca, Piazza dell’Ateneo Nuovo 1, 20126 Milano, Italy
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Jang S, Hwang SO. The risk factors for premalignant and malignant endometrial polyps in premenopausal and postmenopausal women and trends over the past decade: A retrospective study in a single center, South Korea. Eur J Obstet Gynecol Reprod Biol 2024; 295:118-123. [PMID: 38354603 DOI: 10.1016/j.ejogrb.2024.01.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/09/2024] [Accepted: 01/24/2024] [Indexed: 02/16/2024]
Abstract
OBJECTIVES To assess the prevalence and risk factors for premalignancy and malignancy in endometrial polyps and to evaluate trends over the past decade. STUDY DESIGN This was a retrospective study of patients who underwent hysteroscopic polypectomy at Inha University Hospital, South Korea between January 2013 and June 2023. The demographic and clinical characteristics of the patients reviewed to identify risk factors for premalignancy and malignancy in endometrial polyps included the following: age, parity, body mass index, menopausal status, abnormal uterine bleeding symptoms, diabetes mellitus, hypertension, polycystic ovarian syndrome, use of menopausal hormonal therapy or oral contraceptives, tamoxifen treatment in patients with breast cancer, and the number of polyps. RESULTS In total, 725 patients were enrolled, among whom 52 (7.2 %) had premalignant and malignant lesions. In logistic regression analysis, menopause (OR: 8.37, 95 % CI [3.33-21.04]), abnormal uterine bleeding (OR: 7.42, 95 % CI [2.13-25.86]), obesity (OR: 3.22, 95 % CI [1.53-6.77]), multiple polyps (OR: 2.86, 95 % CI [1.39-5.88]) and nulliparity (OR: 2.64, 95 % CI [1.13-6.19]) were significantly associated with premalignancy and malignancy in polyps. Annual trends during the study period showed an increase in the number of patients with three of the five risk factors (obesity, multiple polyps, and nulliparity) and an increase in the prevalence of premalignancy and malignancy in polyps. CONCLUSIONS Menopause, abnormal uterine bleeding, obesity, multiple polyps, and nulliparity increase the risk of premalignancy and malignancy in endometrial polyps. The prevalence of premalignant and malignant polyps has been increasing over the past decade. The risk factors that have contributed to this trend were obesity, nulliparity, and multiple polyps.
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Affiliation(s)
- Shina Jang
- Department of Obstetrics and Gynecology, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea.
| | - Sung Ook Hwang
- Department of Obstetrics and Gynecology, Inha University Hospital, Inha University College of Medicine, Incheon, South Korea.
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Bougie O, Randle E, Thurston J, Magee B, Warshafsky C, Rittenberg D. Directive clinique n o 447 : Diagnostic et prise en charge des polypes endométriaux. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102403. [PMID: 38331092 DOI: 10.1016/j.jogc.2024.102403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
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Bougie O, Randle E, Thurston J, Magee B, Warshafsky C, Rittenberg D. Guideline No. 447: Diagnosis and Management of Endometrial Polyps. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102402. [PMID: 38325734 DOI: 10.1016/j.jogc.2024.102402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
OBJECTIVE The primary objective of this clinical practice guideline is to provide gynaecologists with an algorithm and evidence to guide the diagnosis and management of endometrial polyps. TARGET POPULATION All patients with symptomatic or asymptomatic endometrial polyps. OPTIONS Options for management of endometrial polyps include expectant, medical, and surgical management. These will depend on symptoms, risks for malignancy, and patient choice. OUTCOMES Outcomes include resolution of symptoms, histopathological diagnosis, and complete removal of the polyp. BENEFITS, HARMS, AND COSTS The implementation of this guideline aims to benefit patients with symptomatic or asymptomatic endometrial polyps and provide physicians with an evidence-based approach toward diagnosis and management (including expectant, medical, and surgical management) of polyps. EVIDENCE The following search terms were entered into PubMed/Medline and Cochrane: endometrial polyps, polyps, endometrial thickening, abnormal uterine bleeding, postmenopausal bleeding, endometrial hyperplasia, endometrial cancer, hormonal therapy, female infertility. All articles were included in the literature search up to 2021 and the following study types were included: randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE Gynaecologists, family physicians, registered nurses, nurse practitioners, medical students, and residents and fellows. TWEETABLE ABSTRACT Uterine polyps are common and can cause abnormal bleeding, infertility, or bleeding after menopause. If patients don't experience symptoms, treatment is often not necessary. Polyps can be treated with medication but often a surgery will be necessary. SUMMARY STATEMENTS RECOMMENDATIONS.
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Conforti RA, Delsouc MB, Zorychta E, Telleria CM, Casais M. Copper in Gynecological Diseases. Int J Mol Sci 2023; 24:17578. [PMID: 38139406 PMCID: PMC10743751 DOI: 10.3390/ijms242417578] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 12/24/2023] Open
Abstract
Copper (Cu) is an essential micronutrient for the correct development of eukaryotic organisms. This metal plays a key role in many cellular and physiological activities, including enzymatic activity, oxygen transport, and cell signaling. Although the redox activity of Cu is crucial for enzymatic reactions, this property also makes it potentially toxic when found at high levels. Due to this dual action of Cu, highly regulated mechanisms are necessary to prevent both the deficiency and the accumulation of this metal since its dyshomeostasis may favor the development of multiple diseases, such as Menkes' and Wilson's diseases, neurodegenerative diseases, diabetes mellitus, and cancer. As the relationship between Cu and cancer has been the most studied, we analyze how this metal can affect three fundamental processes for tumor progression: cell proliferation, angiogenesis, and metastasis. Gynecological diseases are characterized by high prevalence, morbidity, and mortality, depending on the case, and mainly include benign and malignant tumors. The cellular processes that promote their progression are affected by Cu, and the mechanisms that occur may be similar. We analyze the crosstalk between Cu deregulation and gynecological diseases, focusing on therapeutic strategies derived from this metal.
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Affiliation(s)
- Rocío A. Conforti
- Facultad de Química, Bioquímica y Farmacia, Universidad Nacional de San Luis (UNSL), Instituto Multidisciplinario de Investigaciones Biológicas de San Luis (IMIBIO-SL-CONICET), San Luis CP D5700HHW, Argentina; (R.A.C.); (M.B.D.)
| | - María B. Delsouc
- Facultad de Química, Bioquímica y Farmacia, Universidad Nacional de San Luis (UNSL), Instituto Multidisciplinario de Investigaciones Biológicas de San Luis (IMIBIO-SL-CONICET), San Luis CP D5700HHW, Argentina; (R.A.C.); (M.B.D.)
| | - Edith Zorychta
- Experimental Pathology Unit, Department of Pathology, Faculty of Medicine and Health Sciences, McGill University, 3775 University Street, Montreal, QC H3A 2B4, Canada;
| | - Carlos M. Telleria
- Experimental Pathology Unit, Department of Pathology, Faculty of Medicine and Health Sciences, McGill University, 3775 University Street, Montreal, QC H3A 2B4, Canada;
- Cancer Research Program, Research Institute, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | - Marilina Casais
- Facultad de Química, Bioquímica y Farmacia, Universidad Nacional de San Luis (UNSL), Instituto Multidisciplinario de Investigaciones Biológicas de San Luis (IMIBIO-SL-CONICET), San Luis CP D5700HHW, Argentina; (R.A.C.); (M.B.D.)
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13
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Hurtado S, Shetty MK. Post-Menopausal Bleeding: Role of Imaging. Semin Ultrasound CT MR 2023; 44:519-527. [PMID: 37832697 DOI: 10.1053/j.sult.2023.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
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.
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Ai F, Qin X, Zhou L, Wang S. Analysis of factors related to endometrial cancer in postmenopausal women with endometrial thickening. Menopause 2023; 30:920-926. [PMID: 37555714 DOI: 10.1097/gme.0000000000002232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
OBJECTIVE To investigate the factors related to endometrial cancer (EC) in postmenopausal women with endometrial thickening and the value of endometrial thickness (ET) in predicting EC. METHODS A retrospective study of 385 referrals to our department for hysteroscopic diagnostic curettage assessment was carried out. Univariate analysis and multiple logistic regression analysis were used to identify the independent contributors to the development of EC. The ability of ET to predict EC was evaluated by receiver operating characteristic curve analysis. RESULTS The follow-up period from the identification of endometrial thickening to pathological confirmation of EC was from 2 weeks to 3 months. In the postmenopausal bleeding (PMB) group, a total of 47 participants' specimens were pathologically malignant. Older age and polypoid mass-like lesions ( P < 0.001) were independent factors associated with EC. The optimal critical value of ET in predicting EC was 9.5 mm, with a sensitivity and specificity of 70.21% and 70.67%, respectively. In the non-PMB group, six participants had evidence of malignant pathology, and only polypoid mass-like lesions were an independent factor associated with EC ( P < 0.001). CONCLUSIONS For postmenopausal women with increased ET and PMB, older age, thicker ET, and polypoid mass-like lesions on transvaginal ultrasound were independent associated factors for EC. An ET greater than 9.5 mm is a threshold for predicting EC. For postmenopausal women with increased ET without PMB, the incidence of endometrial malignancy is low. If the woman has polypoid mass-like lesions on transvaginal ultrasound, she should receive further attention.
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Affiliation(s)
- Fangfang Ai
- From the Department of Obstetrics and Gynecology, Xuanwu Hospital, Capital Medical University, Beijing, People's Republic of China
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Jain V, Munro MG, Critchley HOD. Contemporary evaluation of women and girls with abnormal uterine bleeding: FIGO Systems 1 and 2. Int J Gynaecol Obstet 2023; 162 Suppl 2:29-42. [PMID: 37538019 PMCID: PMC10952771 DOI: 10.1002/ijgo.14946] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Abnormal uterine bleeding (AUB) is common, often debilitating, and may affect over 50% of reproductive-aged women and girls. Whereas AUB is a collection of symptoms that include intermenstrual bleeding and abnormalities in period duration, cycle length, and regularity, it is heavy menstrual bleeding (HMB) that is most contributory to iron deficiency and related anemia. It is apparent that AUB, in general, and HMB, in particular, remain underrecognized and underreported. FIGO created two systems for assessing and classifying AUB. FIGO System 1 defines the bleeding pattern using four primary descriptors: frequency, duration, regularity, and flow volume. FIGO System 2 provides a structured classification system of possible causes of AUB, using the acronym PALM-COEIN. "PALM" refers to structural causes of AUB (Polyp, Adenomyosis, Leiomyoma, Malignancy), and "COEI" refers to nonstructural causes (Coagulopathy, Ovulatory dysfunction, Endometrial, and Iatrogenic). The "N" is reserved for those entities that are currently not otherwise classified. Using FIGO System 1 as a gateway to FIGO System 2 streamlines the investigation of reproductive-aged women and girls with AUB. Understanding the pathogenesis of the FIGO System 2 "PALM-COEIN" causes helps interpret investigations and the onward management of AUB. Numerous evidence gaps exist concerning AUB; however, if researchers and trialists universally adopt FIGO Systems 1 and 2 for the assessment and diagnosis of AUB, clear translatable research findings can be applied globally.
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Affiliation(s)
- Varsha Jain
- Centre for Reproductive HealthUniversity of EdinburghEdinburgh, ScotlandUK
| | - Malcolm G. Munro
- Department of Obstetrics and GynecologyDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
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Lebduska E, Beshear D, Spataro BM. Abnormal Uterine Bleeding. Med Clin North Am 2023; 107:235-246. [PMID: 36759094 DOI: 10.1016/j.mcna.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Abnormal uterine bleeding is a common problem in premenopausal women and refers to uterine bleeding that is abnormal in frequency, duration, volume, and/or regularity. Etiologies can be classified using the PALM-COIEN system. Patients should receive a comprehensive history and physical with special attention to menstrual, sexual, and family history. Physical examination needs to include a pelvic examination with speculum and bimanual components. All patients need to have a pregnancy test and CBC with platelets. Treatments vary by etiology. Medical treatments include levonorgestrel intrauterine devices, oral contraceptive pills, and tranexamic acid. Surgical treatment options include endometrial ablation and hysterectomy.
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Affiliation(s)
- Elena Lebduska
- University of Colorado, UC Heath Internal Medicine - Lowry, 8111 E. Lowry boulevard, Denver, CO 80230, USA
| | - Deidra Beshear
- University of Kentucky, 1000 S. Limestone, Lexington, KY 40536, USA
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17
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Black D. Diagnosis and medical management of abnormal premenopausal and postmenopausal bleeding. Climacteric 2023; 26:222-228. [PMID: 36847215 DOI: 10.1080/13697137.2023.2178893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Abnormal uterine bleeding is a common reason for presentation to health-care providers: it is estimated that one woman in three will present to a care provider with abnormal uterine bleeding (AUB) during the reproductive years, and that at least one woman in 10 will experience postmenopausal bleeding. Although there are some variations in national guidelines for investigation, diagnosis and management of premenopausal AUB, there are far more areas of agreement than disagreement. A comprehensive literature search was undertaken to review national and international guidelines regarding investigation, diagnosis and management of AUB in both premenopausal and postmenopausal women. Areas of controversy are identified, and latest evidence reviewed. Although efforts to reduce hysterectomies for premenopausal AUB through medical management have largely been successful, there are areas where more research is necessary to guide optimal investigation and management. Many countries have well-defined guidelines for investigation and management of premenopausal AUB: there are fewer well-developed guidelines for investigation and management of postmenopausal bleeding. There is a paucity of evidence-based data on management of unscheduled bleeding on menopausal hormone therapy.
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Affiliation(s)
- D Black
- Department of Obstetrics, Gynecology and Reproductive Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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Vroom AJ, Bongarts S, Bongers MY, Kooreman LFS, Bosch SL, Geomini PMAJ, van Hanegem N. The effects of Saline Infusion Sonography on the histological quality of endometrial sampling in women with postmenopausal bleeding. BMC Womens Health 2023; 23:46. [PMID: 36739405 PMCID: PMC9899370 DOI: 10.1186/s12905-023-02178-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 01/13/2023] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The aim of this study is to analyze the histopathological features of endometrial samples obtained by aspiration when performed before or after the saline contrast sonohysterography in women with postmenopausal bleeding and a thickened endometrium. Hypothetically, the saline infusion could disrupt the tissue and therefore affect the quality of the sample. Furthermore, we want to determine which histological features have impact on the quality of the endometrial sample. METHODS We performed a randomized controlled trial (ESPRESSO trial) in which we analyzed the aspiration samples in two groups. Women were allocated either to saline contrast sonohysterography and subsequent endometrial sampling (SCSH-Sampling group) or to the opposite order (Sampling-SCSH group). Dedicated gyneco-pathologists retrospectively assessed the specimens and recorded the type (blood, mucus, epithelium, intact glands, stroma and tissue context) and quantity (on a scale of 0-3) of material that was found in the specimens. RESULTS This analysis consisted of 197 samples, with 101 women in the SCSH-Sampling group and 96 women in the Sampling-SCSH group. No significant differences were found in the histological features between the two groups. All significant histological features differed significantly in the sufficient samples compared to the insufficient samples: higher amounts of blood, more endometrial epithelium, presence of intact endometrial glands, better stroma and tissue context. Oppositely, a significantly higher amount of mucus was found in the insufficient samples. CONCLUSION This study shows that the histological features of the endometrial sample were not affected by the saline contrast sonohysterography, when performed prior to the tissue sampling. Trial registration ESPRESSO TRIAL, NTR5690, registered 16 February 2016, https://trialsearch.who.int/Trial2.aspx?TrialID=NTR5690 .
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Affiliation(s)
- Albertine J. Vroom
- grid.414711.60000 0004 0477 4812Department of Gynecology and Obstetrics, Máxima Medisch Centrum, Veldhoven, The Netherlands ,Department of Obstetrics and Gynecology, GROW- School for Oncology and Reproduction, GMaastricht UMC+, P. Debyelaan 25, HX 6229 Maastricht, The Netherlands
| | - Simone Bongarts
- grid.414711.60000 0004 0477 4812Department of Gynecology and Obstetrics, Máxima Medisch Centrum, Veldhoven, The Netherlands
| | - Marlies Y. Bongers
- grid.414711.60000 0004 0477 4812Department of Gynecology and Obstetrics, Máxima Medisch Centrum, Veldhoven, The Netherlands ,Department of Obstetrics and Gynecology, GROW- School for Oncology and Reproduction, GMaastricht UMC+, P. Debyelaan 25, HX 6229 Maastricht, The Netherlands
| | | | - Steven L. Bosch
- grid.511956.f0000 0004 0477 488XLaboratory for Pathology and Medical Microbiology (Stichting PAMM), Eindhoven, The Netherlands
| | - Peggy M. A. J. Geomini
- grid.414711.60000 0004 0477 4812Department of Gynecology and Obstetrics, Máxima Medisch Centrum, Veldhoven, The Netherlands
| | - Nehalennia van Hanegem
- grid.7692.a0000000090126352Department of Reproductive Medicine and Gynecology, University Medical Center, Utrecht, The Netherlands
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Zhang L, Guo Y, Qian G, Su T, Xu H. Value of endometrial thickness for the detection of endometrial cancer and atypical hyperplasia in asymptomatic postmenopausal women. BMC Womens Health 2022; 22:517. [PMID: 36510213 PMCID: PMC9743752 DOI: 10.1186/s12905-022-02089-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/21/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The role of transvaginal sonography (TVS) in screening endometrial cancer and hyperplasia is significant in postmenopausal women. The objective of this study is to determine the endometrium thickness (ET) cut-off to distinguish premalignancy and malignancy in asymptomatic postmenopausal women. METHODS We retrospectively evaluated data of 968 eligible patients among 2537 asymptomatic postmenopausal women with ET ≥ 5 mm examined by TVS who were subjected to hysteroscopy and endometrial biopsy between January 1, 2017, and June 30, 2020 in an urban tertiary specialized hospital in China. The patients were divided into two groups according to the pathology outcomes: benign, and atypical hyperplasia (AH) and endometrial carcinoma (EC). The risk factors and the optimal cut-off of ET for detecting AH and EC were determined by logistic regression analysis and receiver operating characteristic curve. RESULTS 2537 patients were offered hysteroscopy during a 42-month period. Finally, 968 patients were included for further analysis. Of these, 8 (0.8%) women were diagnosed with EC and 5 (0.5%) women with AH. The mean ET of AH and EC group was substantially higher than that in benign group (10.4 mm vs. 7.7 mm, P < 0.05). ET was significantly correlated with AH and EC shown by logistic regression analysis with an odds ratio (OR) of 1.252 (95% confidence interval [CI] 1.107-1.416, P < 0.001). The optimal cut-off value for AH and EC was found to be 8 mm with the maximum AUC of 0.715 (95% CI 0.686-0.743, P < 0.001), with a sensitivity of 0.846, a specificity of 0.609, positive likelihood ratio (LR+) of 2.164 and negative likelihood ratio (LR-) of 0.253. CONCLUSION An ET cut-off of ≥ 8 mm shows a reasonable performance to detect AH and EC in asymptomatic postmenopausal women, thereby avoiding more invasive endometrial biopsy.
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Affiliation(s)
- Linna Zhang
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, 200030, China
- Shanghai Municipal Key Clinical Speciality, Shanghai, 200030, China
| | - Ying Guo
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, 200030, China
- Shanghai Municipal Key Clinical Speciality, Shanghai, 200030, China
| | - Guxia Qian
- Putuo District Maternity and Child Care Center, Shanghai, 200062, China
| | - Tao Su
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China.
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, 200030, China.
- Shanghai Municipal Key Clinical Speciality, Shanghai, 200030, China.
| | - Hong Xu
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, 200030, China.
- Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, 200030, China.
- Shanghai Municipal Key Clinical Speciality, Shanghai, 200030, China.
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Daley D, Padwick M, Mistry S, Malhotra V, Vikram RS, Stanciu P. Case report: Spontaneous remission of synchronous endometrial and ovarian cancers following pregnancy. Front Oncol 2022; 12:1001677. [DOI: 10.3389/fonc.2022.1001677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 11/01/2022] [Indexed: 12/03/2022] Open
Abstract
IntroductionEndometrial cancer is one of the most common malignancies affecting women. It is uncommonly diagnosed in young women, particularly in the absence of abnormal vaginal bleeding symptoms.Case presentationA 28-year-old woman was referred to our department with lower abdominal pain. Transvaginal ultrasound showed a complex right adnexal mass with mixed echogenicity. Magnetic resonance imaging (MRI) identified a right-sided, torted, cystic solid ovarian mass, and a polypoid lesion in the uterine cavity.DiagnosisFollowing multidisciplinary team advice, hysteroscopic transcervical resection of endometrial polypoid mass and laparoscopic right salpingo-oophorectomy was performed. Histopathologic assessment of the endometrial tissue showed changes consistent with grade 1 endometrioid endometrial carcinoma, while the right ovarian mass showed a well-differentiated endometrioid carcinoma.InterventionThe patient underwent hormonal treatment and surveillance whilst making a final decision regarding further surgical management. However, the patient stopped hormonal treatment after 2 weeks, went abroad and absconded from treatment for 8 months. On her return, she had conceived naturally and was in the first trimester of pregnancy. Further management was postponed until the patient was 7 weeks postnatal. The patient was not keen on any further surgical management and opted for close surveillance with ultrasound scans and hysteroscopies with endometrial biopsies. All subsequent endometrial biopsies showed normal endometrium, with no evidence of hyperplasia or malignancy.OutcomeTo date, the patient remains on a 6-monthly surveillance plan and is considered to have had complete natural remission of her endometrial and ovarian cancers following pregnancy.ConclusionThis unique case demonstrates a natural phenomenon, in which the complete, natural remission of endometrial and ovarian cancers occurred following pregnancy and childbirth. The aetiology may be related to the high progesterone levels occurring in pregnancy.
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Uterine disorders and iron deficiency anemia. Fertil Steril 2022; 118:615-624. [PMID: 36182260 DOI: 10.1016/j.fertnstert.2022.08.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/18/2022] [Accepted: 08/08/2022] [Indexed: 02/07/2023]
Abstract
Abnormal uterine bleeding (AUB) is a clinical entity which can lead to iron deficiency anemia. Classification according to the acronym PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy, and hyperplasia; coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not otherwise classified) provides a structured approach to establish the cause of AUB. The goal of this review is to discuss the different mechanisms and the relationship between uterine disorders and AUB. Heavy menstrual bleeding, a subgroup of AUB, is more closely related to the presence of uterine fibroids. The relationship between heavy menstrual bleeding and uterine fibroids remains poorly characterized, particularly the understanding of endometrial function in women with structural myometrial features such as leiomyomas. A number of theories have been proposed in the literature and are discussed in this review. Uterine adenomyosis is also a frequent cause of AUB, and its pathogenesis is still far from being fully elucidated. The mechanisms contributing to its development are multifactorial. Many theories lean toward invasion of the myometrium by endometrial cells. Both clinical and basic studies favor the theory of direct invasion, although de novo development of adenomyosis from Müllerian rests or stem cells has not been ruled out. Development of adenomyotic lesions involves repeated tissue injury and repair. In addition, this review describes the other causes of AUB such as endometrial polyps, cesarean scar defects, and uterine vascular abnormalities. Endometrial polyps are often asymptomatic, but approximately 68% of women have concomitant AUB. Histologic alterations in the lower uterine segment in patients who had undergone cesarean sections were identified and may explain the cause of AUB.
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Ren H, Duan H, Wang S, Chang Y. Hysteroscopy Combined with Laser Vaporesection for Endometrial Polyps. J INVEST SURG 2022; 35:1772-1778. [PMID: 36062372 DOI: 10.1080/08941939.2022.2116134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To compare the safety and efficiency of hysteroscopic laser vaporesection and hysteroscopic resection in the treatment of endometrial polyps.Methods: The literatures in databases were searched comprehensively, the literatures that met the inclusion criteria were screened out and the data were extracted. The data were combined with Stata12.0 statistical software. RESULTS 4 literatures were included with a total sample size of 334. Meta-analysis showed that intraoperative blood loss in laser group was less than that in electrosurgical group [-3.043, 95% CI (-4.09, -2.00), P < 0.001]. Length of stay in the laser group was shorter than that in the electrotomy group [-1.013, 95% CI (-1.37, -0.65), P < 0.001]. The recurrence rate [0.275, 95%CI (0.135,0.563), P < 0.001] and complication rate [0.148, 95%CI (0.07,0.32), P < 0.001] in the laser group were lower than those in the electrotomy group. There was no significant difference in operative time between hysteroscopy combined with 2 μm laser and hysteroscopic electrotomy for endometrial polyps [-0.38, 95% CI (-1.34, 0.58), P = 0.441 > 0.05]. CONCLUSION Hysteroscopic 2 μm laser vaporesection for the treatment of endometrial polyps has better safety and clinical efficacy. Compared with hysteroscopic electroresection, hysteroscopic laser vaporesection in the treatment of endometrial polyps may be safer and more effective. Given the potential limitations, we need larger, well-designed randomized controlled trials to verify our findings.
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Affiliation(s)
- Hongyan Ren
- Department of Minimally Invasive Gynecologic Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Hua Duan
- Department of Minimally Invasive Gynecologic Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Sha Wang
- Department of Minimally Invasive Gynecologic Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Yanan Chang
- Department of Minimally Invasive Gynecologic Center, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
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van Gemert J, Herman M, Beelen P, Geomini P, Bongers M. Endometrial polypectomy using tissue removal device or electrosurgical snare: a randomised controlled trial. Facts Views Vis Obgyn 2022; 14:235-243. [DOI: 10.52054/fvvo.14.3.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Hysteroscopic transcervical resection of endometrial polyps is a widely used method and is increasingly performed in office or outpatient care. To ensure patient comfort is key, smaller instruments are preferred while also achieving a complete resection of the pathology.
Objectives: To evaluate the effectiveness of the electrosurgical polyp snare (DPS) in comparison with a tissue removal device (TRD).
Materials and Methods: This was a randomised controlled non-inferiority trial which included 66 women with symptomatic endometrial polyps who had been referred to the gynaecological outpatient clinic at the Máxima Medical Centre, Veldhoven, the Netherlands. The patients were randomly allocated by using sealed envelopes to treatment with either the DPS (Duckbill®, Cook) or the TRD (Truclear™, Medtronic). Clinicians and patients were not blinded to the treatment performed. An independent observer blindly assessed the results.
Main outcome measures: The primary outcome was the complete removal of the endometrial polyp. Secondary outcomes were woman acceptability and pain during the procedure, operating time, peri-operative and immediate postoperative complications.
Results: 57% of the polyps in the DPS group and 95% in the TRD group were completely removed (risk difference -0.39; 95% CI: -0.60 to -0.15). Average operating time was longer with DPS compared to the TRD (11.7 min. vs. 6.8 min., p = 0.018). The number of insertions of the hysteroscope was higher with the DPS compared to the TRD (3.9 vs. 1.7, p <0.001). One serious adverse event, a uterine perforation, occurred in the DPS group.
Conclusion: The TRD was superior to the DPS in completeness of polyp removal.
What is new? TRD has a higher rate of complete polyp resection, overall safety and higher patient satisfaction, this instrument should be considered as the preferred option in outpatient and office gynaecology.
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Heremans R, Van Den Bosch T, Valentin L, Wynants L, Pascual MA, Fruscio R, Testa AC, Buonomo F, Guerriero S, Epstein E, Bourne T, Timmerman D, Leone FPG. Ultrasound features of endometrial pathology in women without abnormal uterine bleeding: results from the International Endometrial Tumor Analysis study (IETA3). ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:243-255. [PMID: 35385178 DOI: 10.1002/uog.24910] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/14/2022] [Accepted: 03/23/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The primary aim of this study was to describe the ultrasound features of various endometrial and other intracavitary pathologies in women without abnormal uterine bleeding (AUB) using the International Endometrial Tumor Analysis (IETA) terminology. The secondary aim was to compare our findings with published data on women with AUB. METHODS This was a prospective observational study of women presenting at one of seven centers specialized in gynecological ultrasonography, from 2011 until 2018, for indications unrelated to AUB. All patients underwent transvaginal ultrasound using the IETA examination and measurement techniques. Ultrasonography was performed as part of routine gynecological examination or follow-up of non-endometrial pathology, or as part of the work-up before undergoing treatment for infertility, uterine prolapse or ovarian pathology. Ultrasound findings were described using the IETA terminology. Endometrial sampling was performed after the ultrasound scan. The histological endpoints were endometrial atrophy, proliferative or secretory endometrium, endometrial hyperplasia without atypia, endometrial polyp, intracavitary leiomyoma, endometrial intraepithelial neoplasia (EIN), endometrial cancer (EC) and insufficient tissue. The findings in our cohort of women without AUB were compared with those in a published cohort of women with AUB who were examined with transvaginal ultrasound between 2012 and 2015 using the same IETA examination technique and terminology. RESULTS In this study (IETA3), we included 1745 women without AUB who underwent a standardized transvaginal ultrasound examination followed by either endometrial sampling with histological diagnosis (n = 1537) or at least 1 year of clinical and ultrasound follow-up (n = 208). Of these, 858 (49.2%) women were premenopausal and 887 (50.8%) were postmenopausal. Histology showed the presence of EC and/or EIN in 29 (1.7%) women, endometrial polyps in 1028 (58.9%), intracavitary myomas in 66 (3.8%), proliferative or secretory changes or hyperplasia without atypia in 144 (8.3%), endometrial atrophy in 265 (15.2%) and insufficient tissue in five (0.3%). Most cases of EC or EIN (25/29 (86.2%)) were diagnosed after menopause. The mean endometrial thickness in women with EC or EIN was 11.2 mm (95% CI, 8.9-13.6 mm), being on average 2.4 mm (95% CI, 0.3-4.6 mm) thicker than their benign counterparts. Women with malignant endometrial pathology manifested more frequently non-uniform echogenicity (22/29 (75.9%)) than did those with benign endometrial pathology (929/1716 (54.1%)) (difference, +21.8% (95% CI, +4.2% to +39.2%)). Moderate to abundant vascularization (color score 3-4) was seen in 31.0% (9/29) of cases with EC or EIN compared with 12.8% (220/1716) of those with a benign outcome (difference, +18.2% (95% CI, -0.5% to +36.9%)). Multiple multifocal vessels were recorded in 24.1% (7/29) women with EC or EIN vs 4.0% (68/1716) of those with a benign outcome (difference, +20.2% (95% CI, +4.6% to +35.7%)). A regular endometrial-myometrial junction was seen less frequently in women with EC or EIN (19/29 (65.5%)) vs those with a benign outcome (1412/1716 (82.3%)) (difference, -16.8% (95% CI, -34.2% to +0.6%)). In women with endometrial polyps without AUB, a single dominant vessel was the most frequent vascular pattern (666/1028 (64.8%)). In women with EC, both in those with and those without AUB, the endometrium usually manifested heterogeneous echogenicity, but the endometrium was on average 8.6 mm (95% CI, 5.2-12.0 mm) thinner and less intensely vascularized (color score 3-4: difference, -26.8% (95% CI, -52.2% to -1.3%)) in women without compared to those with AUB. In both pre- and postmenopausal women, asymptomatic endometrial polyps were associated with a thinner endometrium, and they manifested more frequently a bright edge, a regular endometrial-myometrial junction and a single dominant vessel than did polyps in symptomatic women, and they were less intensely vascularized. CONCLUSIONS We describe the typical ultrasound features of EC, polyps and other intracavitary histologies using IETA terminology in women without AUB. Our findings suggest that the presence of asymptomatic polyps or endometrial malignancy may be accompanied by thinner and less intensely vascularized endometria than their symptomatic counterparts. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R Heremans
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - T Van Den Bosch
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - L Valentin
- Department of Obstetrics and Gynecology, Skåne University Hospital Malmö and Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - L Wynants
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Epidemiology, CAPHRI Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands
| | - M A Pascual
- Department of Obstetrics, Gynecology and Reproduction, Hospital Universitario Dexeus, Barcelona, Spain
| | - R Fruscio
- Clinic of Obstetrics and Gynecology, Department of Medicine and Surgery, San Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | - A C Testa
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitatio A. Gemelli, IRCCS, Rome, Italy
| | - F Buonomo
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - S Guerriero
- Department of Obstetrics and Gynecology, University of Cagliari, Policlinico Universitario Duilio Casula, Monserrato, Cagliari, Italy
| | - E Epstein
- Department of Clinical Science and Education, Karolinska Institutet, and Department of Obstetrics and Gynecology, Södersjukhuset, Stockholm, Sweden
| | - T Bourne
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynaecology, Queen Charlotte's and Chelsea Hospital, Imperial College London, London, UK
| | - D Timmerman
- Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - F P G Leone
- Department of Obstetrics and Gynecology, Clinical Sciences Institute Luigi Sacco, Milan, Italy
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Shen Y, Feng W, Yang J, Yi J. Effect of Hysteroscopic Polypectomy Combined with Mirena Placement on Postoperative Adverse Reactions and Recurrence Rate of Endometrial Polyps: Based on a Large-Sample, Single-Center, Retrospective Cohort Study. BIOMED RESEARCH INTERNATIONAL 2022; 2022:1232495. [PMID: 35528176 PMCID: PMC9071880 DOI: 10.1155/2022/1232495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 11/17/2022]
Abstract
Objective To investigate the effect of hysteroscopy surgery combined with Mirena on postoperative adverse reactions and recurrence rate of endometrial polyps (EP). Methods A total of 312 patients who underwent hysteroscopic polypectomy of EP in our hospital from June 2017 to November 2020 were enrolled retrospectively. Among them, 42 patients did not take any treatment after the operation (control group), 156 patients were treated with levonorgestrel intrauterine birth control system (Mirena group), and 114 patients were treated with oral spironolone ethinylestradiol tablets (oral group). The clinical data of 312 patients were recorded and followed up regularly. All patients were followed up through an outpatient clinic or telephone to 12 months after the operation. The patients' age, disease course, number of pregnancies, clinical manifestations, endometrial thickness before the operation, duration of operation, amount of bleeding during the operation, and number and size of polyps were analyzed. The recurrence and postoperative side effects of EP in the three groups were followed up within 12 months after the operation. Results There was no significant difference in endometrial thickness among the three groups before treatment (P > 0.05). After 3 months, 6 months, and 12 months of treatment, the endometrial thickness of the three groups decreased, while the decrease in the Mirena group and the oral group was better compared to the control (P < 0.05). The decrease in the Mirena group was better than that in the oral group (P < 0.05). There was no significant difference in hemoglobin levels among the three groups before treatment (P > 0.05). After 3, 6, and 12 months of treatment, the hemoglobin levels of the three groups increased to varying degrees, while the levels of the Mirena group and oral group were better compared to the control (P < 0.05). Three months after the operation, the improvement of clinical symptoms was similar in the three groups, and there was no significant difference among the three groups (P > 0.05). At 6 and 12 months after the operation, the improvement of clinical symptoms in the oral group and Mirena group was better compared to the control group (P < 0.05), but there was no significant difference between the oral group and Mirena group (P > 0.05). After the operation, some patients had complications such as lower abdominal pain, breast distension pain, irregular vaginal bleeding, and abnormal liver function. There was no significant difference in the number of complications among the three groups (P > 0.05). During the follow-up to 12 months after the operation, the recurrence rate in the oral group and Mirena group was lower compared to the control (P < 0.05), and the recurrence rate in the Mirena group was lower than that in the oral group (P < 0.05). Conclusion Placing Mirena immediately after hysteroscopic polypectomy of EP can reduce the recurrence rate of endometrial polyps, increase the level of hemoglobin, and reduce the thickness of the endometrium, which can be employed and popularized according to the condition of patients in clinical work.
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Affiliation(s)
- Yanli Shen
- The Fifth Affiliated Hospital of Xinjiang Medical University, 830011, China
| | - Wenguang Feng
- The Fifth Affiliated Hospital of Xinjiang Medical University, 830011, China
| | - Jing Yang
- The Fifth Affiliated Hospital of Xinjiang Medical University, 830011, China
| | - Jinling Yi
- The Fifth Affiliated Hospital of Xinjiang Medical University, 830011, China
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Xue H, Shen WJ, Zhang Y. Pathological pattern of endometrial abnormalities in postmenopausal women with bleeding or thickened endometrium. World J Clin Cases 2022; 10:2159-2165. [PMID: 35321190 PMCID: PMC8895164 DOI: 10.12998/wjcc.v10.i7.2159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/11/2021] [Accepted: 01/17/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Hui Xue
- Department of Gynecology, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Wen-Jing Shen
- Department of Gynecology, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Yi Zhang
- Department of Gynecology, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
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Keller CA, Antil N, Jeffrey RB, Kamaya A. Color Doppler Imaging of Vascular Abnormalities of the Uterus. Ultrasound Q 2022; 38:72-82. [PMID: 35239631 DOI: 10.1097/ruq.0000000000000578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Many uterine abnormalities present clinically with bleeding encompassing a broad spectrum of patients from postmenopausal spotting to life-threatening hemorrhage. Color and spectral Doppler imaging of the pelvis is often the first crucial investigation used to quickly establish the correct etiology of the uterine bleeding and guide clinical decision making and patient management.
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Affiliation(s)
- Cody A Keller
- Department of Radiology, Stanford University School of Medicine, Stanford, CA
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Essentiality of Trace Elements in Pregnancy, Fertility, and Gynecologic Cancers-A State-of-the-Art Review. Nutrients 2021; 14:nu14010185. [PMID: 35011060 PMCID: PMC8746721 DOI: 10.3390/nu14010185] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/23/2021] [Accepted: 12/28/2021] [Indexed: 12/18/2022] Open
Abstract
Gynecological neoplasms pose a serious threat to women's health. It is estimated that in 2020, there were nearly 1.3 million new cases worldwide, from which almost 50% ended in death. The most commonly diagnosed are cervical and endometrial cancers; when it comes to infertility, it affects ~48.5 million couples worldwide and the number is continually rising. Ageing of the population, environmental factors such as dietary habits, environmental pollutants and increasing prevalence of risk factors may affect the reproductive potential in women. Therefore, in order to identify potential risk factors for these issues, attention has been drawn to trace elements. Trace mineral imbalances can be caused by a variety of causes, starting with hereditary diseases, finishing with an incorrect diet or exposure to polluted air or water. In this review, we aimed to summarize the current knowledge regarding trace elements imbalances in the case of gynecologic cancers as well as female fertility and during pregnancy.
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Wong CLH, So PL. Prevalence and risk factors for malignancy in hysteroscopy-resected endometrial polyps. Int J Gynaecol Obstet 2021; 155:433-441. [PMID: 33621356 DOI: 10.1002/ijgo.13656] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/15/2021] [Accepted: 02/22/2021] [Indexed: 01/31/2023]
Abstract
INTRODUCTION To determine the prevalence of malignant lesions in endometrial polyps by hysteroscopic polypectomy, and risk factors for malignant transformation. The secondary aim was to evaluate background endometrium of atypical hyperplasia in endometrial polyps, and the risk of coexisting endometrial carcinoma after hysterectomy. METHODS This retrospective study included women who underwent hysteroscopic polypectomy between January 2015 and December 2019. Demographic characteristics, hysteroscopic findings, and histopathology results of the polyp and the uterus, in the case of a hysterectomy, were collected. RESULTS In all, 946 women were included in the study. Endometrial carcinoma in a polyp was found in 10 women (1.06%), and atypical hyperplasia was found in 11 women (1.16%). At the multivariate logistic regression model of risk factors, old age (P = 0.022) and obesity (P = 0.011) were significantly associated with (pre-)malignant polyp. Five of the ten women (50%) with atypical hyperplasia confined to a polyp had coexisting endometrial carcinoma in the hysterectomy specimen. CONCLUSION Women with risk factors should be offered hysteroscopic polypectomy to allow a reliable histologic evaluation. Furthermore, hysterectomy is recommended in women with atypical hyperplasia in endometrial polyps even after complete resection.
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Affiliation(s)
| | - Po Lam So
- Department of Obstetrics and Gynaecology, Tuen Mun Hospital, Hong Kong
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30
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Papakonstantinou E, Adonakis G. Management of pre-, peri-, and post-menopausal abnormal uterine bleeding: When to perform endometrial sampling? Int J Gynaecol Obstet 2021; 158:252-259. [PMID: 34669187 DOI: 10.1002/ijgo.13988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/17/2021] [Accepted: 10/19/2021] [Indexed: 12/24/2022]
Abstract
Abnormal uterine bleeding (AUB) is defined as abnormal volume, duration, or frequency of menstrual period and is a common symptom in women of all ages (premenopausal, perimenopausal, and postmenopausal). The acronym PALM-COEIN, introduced by the International Federation of Gynecology and Obstetrics (FIGO), facilitates the evaluation and differential diagnosis of AUB, mostly in premenopausal women with AUB. Endometrial evaluation (including ultrasound or hysteroscopic imaging and tissue sampling) for subtle pathology is proposed in patients who are at high risk for endometrial cancer and in patients at low risk who present with AUB and who present poor correspondence in medical treatment. Many new diagnostic modalities are available in clinicians in order to help the assessment of women presenting with abnormalities in their menstrual pattern. The present study reviews the optimal management of women presenting with AUB, taking into consideration the actual need for invasive management in these women, who of them require it, and who can be diagnosed without histological verification. The importance of endometrial tissue sampling in women who present with AUB as well as the best timing for a clinician to conduct a biopsy are two axons analyzed below, according to the latest worldwide guidelines and major publications about this subject.
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Affiliation(s)
- Efthymia Papakonstantinou
- Department of Obstetrics-Gynecology, University Hospital, University of Patras School of Medicine, Patras, Greece
| | - Georgios Adonakis
- Department of Obstetrics-Gynecology, University Hospital, University of Patras School of Medicine, Patras, Greece
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Pomeranz M, Klein Z, Mulla D, Ovadia M, Sharvit M, Schonman R, Daykan Y, Arbib N. "What you see is what you get" abnormal endometrial sonographic findings are sufficient for direct surgical hysteroscopy: Retrospective cohort study. Int J Gynaecol Obstet 2021; 158:295-300. [PMID: 34606087 DOI: 10.1002/ijgo.13964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 08/25/2021] [Accepted: 09/30/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate the possibility of referring women with uterine polyps larger than 1.5 cm directly to surgical hysteroscopy. METHODS This retrospective cohort study included all women referred to a university-affiliated tertiary medical center for hysteroscopy, with the diagnosis of endometrial polyp, from 01/2013 to 05/2016. Women were referred for surgical hysteroscopy based on TVUS findings. PPV of TVUS for detecting intrauterine polyps was evaluated relating to pathology as gold standard, with sub-group analysis relating to polyp size and other parameters. RESULTS We selected 1.5 cm as a cutoff size for subgroup analysis of endometrial polyps. PPV of TVUS for the entire cohort of 295 cases eligible for analysis, was 79.3%. TVUS describing polyps ≥1.5 cm had PPV of 92.1%, higher than the PPV for smaller polyps. Among post-menopausal women in this group, PPV was as high as 96.2%. Use of doppler or saline was found to improve PPV in the entire cohort. Indication for performing TVUS did not affect the PPV. CONCLUSION TVUS describing polyps ≥1.5 cm may suffice for direct referral of women to surgical hysteroscopy. A personalized approach based on the initial diagnosis may avoid unnecessary invasive procedures for patients.
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Affiliation(s)
- Meir Pomeranz
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zvi Klein
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Doron Mulla
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Michal Ovadia
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel
| | - Merav Sharvit
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Schonman
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yair Daykan
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nissim Arbib
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Akış S, Kıran G, Göçmen A. The clinical importance of polyp size measurement through two-dimensional saline infusion sonohysterography prior to hysteroscopic resection in predicting premalignant and malignant endometrial lesions. Int J Gynaecol Obstet 2021; 157:582-587. [PMID: 34510415 DOI: 10.1002/ijgo.13925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/26/2021] [Accepted: 09/08/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate the clinical importance of endometrial polyp size measured using saline infusion sonohysterography (SIS) before performing a hysteroscopic resection in predicting premalignant/malignant lesions. METHODS A retrospective observational study analysis was conducted of 365 patients, who underwent SIS, in a reference hospital. The longest plane of the polyp size was taken as base. Polyps were classified as benign, premalignant, or malignant. RESULTS The rates of premalignant and malignant lesions were 7.4% and 0.9%, respectively. The mean polyp size was 17.7 ± 0.5 mm in benign patients and 23.7 ± 1.8 mm in premalignant/malignant individuals (P < 0.001). In the group of polyps that were 0-10, 10-20, 20-30, and >30 mm, premalignancy/malignancy rates were 0.0%, 4.8%, 13.3%, and 18.8%, respectively. The cut-off value for polyp size to be able to predict lesions was calculated as 22.5 mm (sensitivity: 63%, specificity: 80%) on receiver operating characteristics curve analysis (P = 0.001, area under the curve 0.732). The power of the study was calculated as 90.86%. CONCLUSION During the female reproductive years, endometrial polyps smaller than 10 mm, as measured in SIS, can be followed. However, when the polyp size is 22.5 mm or more, especially in postmenopausal women, treatment should be planned.
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Affiliation(s)
- Serkan Akış
- Department of Gynecologic Oncology, University of Health Sciences, Zeynep Kamil Women and Children Diseases Education and Research Hospital, Istanbul, Turkey
| | - Gürkan Kıran
- Department of Obstetrics and Gynecology, Faculty of Medicine, Bezmialem Vakıf University, Istanbul, Turkey
| | - Ahmet Göçmen
- Department of Obstetrics and Gynecology, Medicana Ataşehir Hospital, Istanbul, Turkey
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Minimal uterine serous carcinoma and endometrial polyp: a close clinicopathological relationship. Hum Pathol 2021; 118:1-8. [PMID: 34508766 DOI: 10.1016/j.humpath.2021.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 11/24/2022]
Abstract
Frequently involving an endometrial polyp, minimal uterine serous carcinoma (MUSC) represents the earliest recognizable forms of endometrial serous carcinoma. The aim of this study was to provide a comprehensive morphological and clinical outcome assessment of MUSC involving endometrial polyp. A total of 77 fully staged MUSCs involving endometrial polyp were identified, including 53 MUSCs confined to polyp and 24 nonpolyp confined tumors. Extrauterine disease was found in 17% (9/53) of polyp-confined MUSCs compared to 41.7% (10/24) of nonpolyp confined tumors (p = 0.02). Lymphovascular invasion was observed in 3.8% (2/53) of polyp-confined cases compared to 25% (6/24) of nonpolyp confined cases (p = 0.047). Lymph node metastasis was observed in 11.3% (6/53) of polyp-confined cases, compared to 29.2% (7/24) of nonpolyp confined cases (p = 0.058). Positive pelvic washing cytology was seen in 18.9% (10/53) of polyp-confined versus 37.5% (9/24) of nonpolyp confined tumors (p = 0.078). Overall, 58 of 77 (75.3%) patients had low tumor stage (57 stage I cases and 1 stage II case) and only two patients (3.5%) had a recurrence. In contrast, 19 of 77 (24.7%) patients had advanced stage (stage III or IV) disease and 17 (89.5%) patients had recurrence (p < 0.0001). Only one of 57 low-stage patient (1.7%) versus 11 of 19 high-stage patients (57.8%) died of the tumor (p < 0.0001). Five of 53 (9.4%) patients with polyp-confined MUSC and 7 of 24 (29.2%) patients with nonpolyp confined MUSC died of the disease (p = 0.03). In conclusion, while a small percentage of MUSCs exist without the involvement of an endometrial polyp, a close topographic relationship between MUSC and the endometrial polyp is confirmed in this largest series, supporting the theory that most if not all MUSCs arise in an EMP. Patients with MUSC without extrauterine spread have an excellent prognosis. Compared to patients with MUSC confined to an endometrial polyp, patients with MUSC extending to the background endometrium have a significantly higher risk for high-stage disease at presentation.
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Raz N, Feinmesser L, Moore O, Haimovich S. Endometrial polyps: diagnosis and treatment options - a review of literature. MINIM INVASIV THER 2021; 30:278-287. [PMID: 34355659 DOI: 10.1080/13645706.2021.1948867] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION AND AIM Endometrial polyps (EPs) are a common gynecologic condition, associated with abnormal uterine bleeding (AUB), infertility, and premalignant and malignant conditions. Technologies for diagnosis and treatment of EPs are constantly evolving. We aim to provide an updated review on diagnosis and management options for patients with EPs. MATERIAL AND METHODS We conducted an electronic search in databases including MEDLINE, PubMed, Cochrane Central Register and others. We included 68 publications regarding EPs, their clinical burden, diagnostic modalities, treatment options and new technologies. RESULTS Transvaginal ultrasound (TVS) is the common modality for EP detection and color doppler increases its diagnostic accuracy. Dilation and curettage (D&C) should be avoided for diagnosis and treatment of EPs. Hysteroscopy shows high diagnostic value in EPs and allows for both histological diagnosis and effective treatment. Office hysteroscopy and see and treat hysteroscopy without anesthesia is feasible and safe for EP diagnosis and treatment, gaining more trained surgeons globally. Effective and safe technological tools for EP resection include Laser, resectoscopes, morcellators, MyoSure, Truclear and scissors\graspers. CONCLUSIONS EPs are safely and effectively diagnosed and treated with the hysteroscopic tools reviewed in this article. More research is needed to define the best treatment modality.
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Affiliation(s)
- Nili Raz
- Gynecology Ambulatory Surgery Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel.,Technion Israel Institute of Technology, Haifa, Israel
| | - Larissa Feinmesser
- Gynecology Ambulatory Surgery Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel.,Technion Israel Institute of Technology, Haifa, Israel
| | - Omer Moore
- Gynecology Ambulatory Surgery Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel.,Technion Israel Institute of Technology, Haifa, Israel
| | - Sergio Haimovich
- Gynecology Ambulatory Surgery Unit, Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel.,Technion Israel Institute of Technology, Haifa, Israel
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Török P, Molnár S, Lampé R, Jakab A. The use of hysteroscopy in endometrial cancer: old questions and novel challenges. Climacteric 2021; 23:330-335. [PMID: 32648827 DOI: 10.1080/13697137.2020.1732914] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Endometrial cancer is the most common gynecological malignancy with a relatively good overall prognosis. It traditionally has two subtypes: type 1 (endometrioid carcinoma) and type 2 (non-endometrioid carcinoma). The prognosis is excellent for stage I endometrioid cancer, with a 5-year survival rate of 96%. However, the prognosis is much worse for women with high-risk endometrial cancer. Effective preoperative staging is important in order to tailor treatment and achieve optimal long-term survival. The majority of asymptomatic polyps detected by ultrasound are treated surgically. Conventionally, dilatation and curettage was performed to obtain a histological diagnosis, but nowadays hysteroscopy with biopsy is starting to be considered as the gold standard. Hysteroscopic resection seems to reduce the risk of underdiagnosed (atypical endometrial hyperplasia) endometrial cancer. To avoid the spread of malignant cells, hysteroscopy should be performed with concern to keep intrauterine pressure low. In comparison with cervical injection, the hysteroscopic method has a better detection rate in the para-aortic area during sentinel lymph node mapping. In the assessment of cervical involvement, the accuracy of magnetic resonance imaging is significantly higher than the accuracy of hysteroscopy. In fertility-sparing cases, hysteroscopic endometrium resection with progesterone therapy is an acceptable option.
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Affiliation(s)
- P Török
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - S Molnár
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - R Lampé
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - A Jakab
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Ludwin A, Lindheim SR, Booth R, Ludwin I. Removal of uterine polyps: clinical management and surgical approach. Climacteric 2021; 23:388-396. [PMID: 32648824 DOI: 10.1080/13697137.2020.1784870] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Endometrial polyps have a reported prevalence from 7.8% up to 30% and are one of the most cost-consuming gynecological conditions for our specialty. There are strong practitioner beliefs that surgical removal of endometrial polyps is highly beneficial, particularly for those with abnormal uterine bleeding and infertility. Additionally, polypectomy is indicated to reduce the risk of malignancy. Transvaginal ultrasound is the first-line diagnostic option for detection of endometrial polyps, while sonohysterography has similar accuracy as hysteroscopy in the diagnostic confirmation. Blind dilatation and curettage is not recommended for polyp removal; rather, hysteroscopy in the operating room and office setting using small-diameter hysteroscopic equipment is the standard approach. This can be performed without anesthesia in most women. While hysteroscopy is an effective method for polypectomy with a low complication rate, it is unknown whether this is truly beneficial for reproductive-age women with infertility and prior assisted reproduction therapy. The risk of malignancy in women with postmenopausal bleeding justifies the necessity of polypectomy with histologic tissue examination. In asymptomatic women, the risk of malignancy is low, and there are no known benefits of polyp removal in the prevention of malignant transformation. Cost-effective studies remain to be done to provide us with the optimal approach to endometrial polyps including the management of asymptomatic and/or infertile women, ideal location including office-based or the operating room setting, complication prevention including intrauterine adhesions, and recurrence issues.
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Affiliation(s)
- A Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland.,Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland.,Centermed - Private Hospital and Clinic, Krakow, Poland
| | - S R Lindheim
- Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, Ohio, USA
| | - R Booth
- Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, Ohio, USA
| | - I Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland.,Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland.,Centermed - Private Hospital and Clinic, Krakow, Poland
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Wong M, Thanatsis N, Nardelli F, Amin T, Jurkovic D. Risk of Pre-Malignancy or Malignancy in Postmenopausal Endometrial Polyps: A CHAID Decision Tree Analysis. Diagnostics (Basel) 2021; 11:diagnostics11061094. [PMID: 34203810 PMCID: PMC8232598 DOI: 10.3390/diagnostics11061094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 06/06/2021] [Accepted: 06/08/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND AIMS Postmenopausal endometrial polyps are commonly managed by surgical resection; however, expectant management may be considered for some women due to the presence of medical co-morbidities, failed hysteroscopies or patient's preference. This study aimed to identify patient characteristics and ultrasound morphological features of polyps that could aid in the prediction of underlying pre-malignancy or malignancy in postmenopausal polyps. METHODS Women with consecutive postmenopausal polyps diagnosed on ultrasound and removed surgically were recruited between October 2015 to October 2018 prospectively. Polyps were defined on ultrasound as focal lesions with a regular outline, surrounded by normal endometrium. On Doppler examination, there was either a single feeder vessel or no detectable vascularity. Polyps were classified histologically as benign (including hyperplasia without atypia), pre-malignant (atypical hyperplasia), or malignant. A Chi-squared automatic interaction detection (CHAID) decision tree analysis was performed with a range of demographic, clinical, and ultrasound variables as independent, and the presence of pre-malignancy or malignancy in polyps as dependent variables. A 10-fold cross-validation method was used to estimate the model's misclassification risk. RESULTS There were 240 women included, 181 of whom presented with postmenopausal bleeding. Their median age was 60 (range of 45-94); 18/240 (7.5%) women were diagnosed with pre-malignant or malignant polyps. In our decision tree model, the polyp mean diameter (≤13 mm or >13 mm) on ultrasound was the most important predictor of pre-malignancy or malignancy. If the tree was allowed to grow, the patient's body mass index (BMI) and cystic/solid appearance of the polyp classified women further into low-risk (≤5%), intermediate-risk (>5%-≤20%), or high-risk (>20%) groups. CONCLUSIONS Our decision tree model may serve as a guide to counsel women on the benefits and risks of surgery for postmenopausal endometrial polyps. It may also assist clinicians in prioritizing women for surgery according to their risk of malignancy.
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Affiliation(s)
- Michael Wong
- Institute for Women’s Health, University College London Hospitals, London NW1 2BU, UK; (M.W.); (N.T.); (T.A.)
| | - Nikolaos Thanatsis
- Institute for Women’s Health, University College London Hospitals, London NW1 2BU, UK; (M.W.); (N.T.); (T.A.)
| | - Federica Nardelli
- Department of Women’s and Children’s Health, Catholic University of Sacred Heart, 1, 00168 Rome, Italy;
| | - Tejal Amin
- Institute for Women’s Health, University College London Hospitals, London NW1 2BU, UK; (M.W.); (N.T.); (T.A.)
| | - Davor Jurkovic
- Institute for Women’s Health, University College London Hospitals, London NW1 2BU, UK; (M.W.); (N.T.); (T.A.)
- Correspondence: ; Tel.: +44-20-3447-9411
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Vitale SG, Haimovich S, Laganà AS, Alonso L, Di Spiezio Sardo A, Carugno J. Endometrial polyps. An evidence-based diagnosis and management guide. Eur J Obstet Gynecol Reprod Biol 2021; 260:70-77. [PMID: 33756339 DOI: 10.1016/j.ejogrb.2021.03.017] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 03/02/2021] [Accepted: 03/08/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To provide an updated practice guideline for the management of patients with endometrial polyps. MATERIALS AND METHODS A committee of six expert researchers draw the recommendations according to AGREE II Reporting Guideline. An electronic search was performed querying the following databases MEDLINE (accessed through PubMed), Scopus, PROSPERO, EMBASE, CINAHL, Cochrane Library (including the Cochrane Database of Systematic Reviews), Scielo.br, Google Scholar, from inception to May 2020. A combination of text-words and Medical Subject Headings (MeSH) regarding endometrial polyps, diagnosis, management and treatment was used. Trials were assessed for methodologic rigor and graded using the United States Preventive Services Task Force classification system. RECOMMENDATIONS Transvaginal ultrasonography (TVUS) should be the imaging modality of choice for the detection of endometrial polyps in woman of fertile age (level B). Its accuracy increases when color-doppler, 3D investigation and contrast are used (level B). Dilation and Curettage (D&C) should be avoided for the diagnosis and management of polyps (level A). In office hysteroscopy showed the highest diagnostic accuracy in infertile patients with suspected endometrial polyps (level B). Polyps might alter endometrial receptivity, and embryo implantation reducing pregnancy rates (level C). Hysteroscopic polypectomy is feasible and safe with negligeble risk of intrauterine adhesion formation (level B). Polypectomy does not compromise reproductive outcomes from subsequent IVF procedures but the removal of polyps as a routine practice in sub-fertile women is not currently supported by the evidence (level B). Cost-effectiveness analysis suggest performing office polypectomy in women desiring to conceive (level B). Saline infused sonohysterography is highly accurate in detecting polyps in asymptomatic postmenopausal women (level B). Postmenopausal women with vaginal bleeding and suspected endometrial polyp should be offered diagnostic hysteroscopy with hysteroscopic polypectomy if endometrial polyps are present (level B). In-office hysteroscopy has the highest diagnostic accuracy with high cost-benefits ratio for premalignant and malignant pathologies of the uterine cavity (level B). Due to risk of malignancy, histopathological analysis of the polyp is mandatory (level B). Blind D&C should be avoided due to inaccuracy for the diagnosis of focal endometrial pathology (level A). Expectant management is not recommended in symptomatic patients especially in postmenopausal women (level B). In case of atypical hyperplasia or carcinoma on a polyp, hysterectomy is recommended in all post-menopausal patients and in premenopausal patients without desire of future fertility (level B). Asymptomatic endometrial polyps in postmenopausal women should be removed in case of large diameter (> 2 cm) or in patients with risk factors for endometrial carcinoma (level B). Excision of polyps smaller than 2 cm in asymptomatic postmenopausal patients has no impact on cost-effectiveness or survival (level B). Removal of asymptomatic polyps in premenopausal women should be considered in patients with risk factors for endometrial cancer (level B).
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Affiliation(s)
- Salvatore Giovanni Vitale
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Sergio Haimovich
- Hillel Yaffe Medical Center, Technion-Israel Technology Institute, Hadera, Israel
| | - Antonio Simone Laganà
- Department of Obstetrics and Gynecology, "Filippo Del Ponte" Hospital, University of Insubria, Varese, Italy
| | - Luis Alonso
- Centro Gutenberg, Endoscopy Unit, Malaga, Spain
| | | | - Jose Carugno
- Department of Obstetrics, Gynecology and Reproductive Sciences, Minimally Invasive Gynecology Division, University of Miami, Miller School of Medicine, 1321 NW 14(th) Street Suite 201, Miami, FL 33136, USA.
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Nakai Y, Maeda E, Kanda T, Ikemura M, Ushiku T, Sasajima Y, Isshiki S, Abe O. Uterine adenomyosis with extensive glandular proliferation: case series of a rare imaging variant. ACTA ACUST UNITED AC 2021; 26:153-159. [PMID: 32209513 DOI: 10.5152/dir.2019.19252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE We aimed to investigate the clinical and magnetic resonance imaging (MRI) characteristics of uterine adenomyosis, in which there is an extensive area of high signal intensity in the myometrium on T2-weighted MRI. METHODS This retrospective radiographic study reviewed a case series of six patients (mean age, 36 years) with adenomyosis. These patients were selected because, unlike in classical adenomyosis, T2-weighted images showed a larger area of high signal intensity than that of low signal intensity in the myometrium. The morphology of the myometrial lesions, patterns of contrast enhancement (n=4), intramyometrial hemorrhaging, diffusion restriction (n=5), endometrial lesions, and imaging findings after treatment (n=3) were evaluated on MRI. RESULTS The patients' clinical symptoms included vaginal bleeding and severe anemia. Four were administered hormonal therapy, one underwent hysterectomy, and one underwent enucleation. On T2-weighted images, all showed endometrial thickening and a high signal intensity area in the myometrium that was divided up by a mesh of low signal intensity bands, with an appearance reminiscent of a fish caught in a net. Other findings included gradual centripetal enhancement with contrast defects in multicystic areas (4/4), an intramyometrial hemorrhage (1/6), and increased diffusion (5/5). Following hormonal therapy, the uteruses decreased in size and were similar to those of classical adenomyosis on MRI (3/3). The lesions were diagnosed as adenomyosis with a proliferation of adenomyotic glandular tissue and a proliferative endometrial polyp. CONCLUSION This case series suggests that there is a subgroup of uterine adenomyosis that shows a characteristic "fish-in-a-net" appearance on T2-weighted images.
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Affiliation(s)
- Yudai Nakai
- Department of Radiology, The University of Tokyo School of Medicine, Tokyo, Japan;Department of Radiology, Teikyo University School of Medicine, Tokyo, Japan
| | - Eriko Maeda
- Department of Radiology, The University of Tokyo School of Medicine, Tokyo, Japan
| | - Tomonori Kanda
- Department of Radiology, Kobe University School of Medicine, Hyogo, Japan
| | - Masako Ikemura
- Department of Pathology, The University of Tokyo School of Medicine, Tokyo, Japan
| | - Tetsuo Ushiku
- Department of Pathology, The University of Tokyo School of Medicine, Tokyo, Japan
| | - Yuko Sasajima
- Department of Pathology, Teikyo University School of Medicine, Tokyo, Japan
| | - Saiko Isshiki
- Department of Radiology, Nippon Medical School Musashikosugi Hospital, Kanagawa, Japan
| | - Osamu Abe
- Department of Radiology, The University of Tokyo School of Medicine, Tokyo, Japan
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Vroom AJ, Aerts L, Bongers MY, Lim AC, Pielkenrood BJ, Geomini PMAJ, van Hanegem N. Endometrial sampling before or after saline contrast sonohysterography in women with postmenopausal bleeding (ESPRESSO trial): A multicenter randomized controlled trial. Acta Obstet Gynecol Scand 2021; 100:1258-1264. [PMID: 33454970 PMCID: PMC8359187 DOI: 10.1111/aogs.14086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 01/07/2021] [Accepted: 01/08/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The aim of this study is to evaluate the quality of the endometrial sample obtained by office endometrial aspiration when performed before or after saline contrast sonohysterography (SCSH) in women with postmenopausal bleeding and a thickened endometrium. To conduct a complete, minimally invasive and cost-effective diagnostic workup in women with postmenopausal bleeding and a thickened endometrium, ideally both the office endometrial sampling and SCSH are performed. However, it is not known whether both tests affect each other when performed one after another. MATERIAL AND METHODS Women with postmenopausal bleeding and an endometrial thickness >4 mm were eligible. Women were randomized into two groups: one group received endometrial aspiration before SCSH, the other group received SCSH before endometrial aspiration. The primary outcome was the proportion of sufficient endometrial samples. Reliability of the SCSH images and pain during procedures were secondary outcomes. RESULTS During the inclusion period, 513 eligible women with postmenopausal bleeding visited the participating hospitals, 293 of whom received information about the study. Of these women, 232 (79%) agreed to participate. In the SCSH-aspiration group, 65 women (59%) had a sufficient endometrial sample compared with 70 (67%) in the aspiration-SCSH group (odds ratio 1.46, 95% CI 0.83-2.54, P = .19). The proportion of reliable sonographic images was significantly higher in the SCSH-aspiration group (n = 88, 87%) compared with the aspiration-SCSH group (n = 71, 74%) (OR 2.38, 95% CI 1.38-4.99, P = .02) in the per protocol analysis. CONCLUSIONS This study shows that the quality of an endometrial sample in women with postmenopausal bleeding is not affected by SCSH. Both procedures can be performed in one outpatient visit to perform an optimal diagnostic workup.
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Affiliation(s)
- Albertine J Vroom
- Department of Gynecology and Obstetrics, Maxima Medisch Centrum, Veldhoven, The Netherlands.,Department of Obstetrics and Gynecology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Luca Aerts
- Department of Obstetrics and Gynecology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Marlies Y Bongers
- Department of Gynecology and Obstetrics, Maxima Medisch Centrum, Veldhoven, The Netherlands.,Department of Obstetrics and Gynecology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Arianne C Lim
- Department of Obstetrics and Gynecology, GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bart J Pielkenrood
- Department of Imaging and Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Peggy M A J Geomini
- Department of Gynecology and Obstetrics, Maxima Medisch Centrum, Veldhoven, The Netherlands
| | - Nehalennia van Hanegem
- Department of Reproductive Medicine and Gynecology, University Medical Center Utrecht, Utrecht, The Netherlands
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Török P, Krasznai Z, Molnár S, Lampé R, Jakab A. Preoperative assessment of endometrial cancer. Transl Cancer Res 2020; 9:7746-7758. [PMID: 35117377 PMCID: PMC8797972 DOI: 10.21037/tcr-20-2068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/06/2020] [Indexed: 11/06/2022]
Abstract
Endometrial cancer (EC), the most common among gynaecological malignancies occurs predominantly after the menopause. The diagnosis is most commonly (in about 75-80%) set up at early stage when surgical therapy and if necessary postoperative radiotherapy results in an excellent prognosis, with a 90-95% 5-year overall survival (OS) and a locoregional recurrence rates of 4-8%. Accurate preoperative assessment of the lymph nodes would ideally identify those patients with advanced stage disease, who might benefit from more extensive surgical procedures and adjuvant therapies. magnetic resonance imaging (MRI), hysteroscopic excisional biopsy (HEB) and high resolution 2D or 3D ultrasound performed by expert operator are considered to add valuable information for preoperative staging of EC. The use of biomarkers could be beneficial in decreasing inter-observer variability between the histology of the diagnostic specimen and the final operative sample, as well as to avoid overtreatment in a part of the high-grade tumors with excellent prognosis. The goal of surgical management of EC is to remove the primary tumor and to identify definite prognostic factors to determine whether adjuvant therapy is required. Extended surgery, including para-aortic lymphadenectomy has a significant morbidity, and with the future selection of cases it can be safely avoided, we can decrease complications without compromising oncological safety. In the future, the importance of hysteroscopy guided sampling may increase to gain a representative sample for biomarker detection.
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Affiliation(s)
- Péter Török
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zoárd Krasznai
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Szabolcs Molnár
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Rudolf Lampé
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Attila Jakab
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Sun H, Chang Q, Liu YS, Jiang YT, Gong TT, Ma XX, Zhao YH, Wu QJ. Adherence to Cancer Prevention Guidelines and Endometrial Cancer Risk: Evidence from a Systematic Review and Dose-Response Meta-analysis of Prospective Studies. Cancer Res Treat 2020; 53:223-232. [PMID: 32972048 PMCID: PMC7811997 DOI: 10.4143/crt.2020.546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 09/09/2020] [Indexed: 12/20/2022] Open
Abstract
Purpose The evidence of adherence to cancer prevention guidelines and endometrial cancer (EC) risk has been limited and controversial. This study summarizes and quantifies the relationship between adherence to cancer prevention guidelines and EC risk. Materials and Methods The online databases PubMed, Web of Science, and EMBASE were searched for relevant publications up to June 2, 2020. This study had been registered at PROSPERO. The registration number is CRD42020149966. Study quality evaluation was performed based on the Newcastle-Ottawa Scale. The I2 statistic was used to estimate heterogeneity among studies. Egger’s and Begg’s tests assessed potential publication bias. Summary hazard ratios (HRs) and 95% confidence intervals (CIs) for the relationship between adherence to cancer prevention guidelines score was assigned to participants by summarizing individual scores for each lifestyle-related factor. The scores ranged from least healthy (0) to most healthy (20) and the EC risk was calculated using a random-effects model. Results Five prospective studies (four cohort studies and one case-cohort study) consisted of 4,470 EC cases, where 597,047 participants were included. Four studies had a low bias risk and one study had a high bias risk. Summary EC HR for the highest vs. lowest score of adherence to cancer prevention guidelines was 0.54 (95% CI, 0.40 to 0.73) and had a high heterogeneity (I2=86.1%). For the dose-response analysis, an increment of 1 significantly reduced the risk of EC by 6%. No significant publication bias was detected. Conclusion This study suggested that adherence to cancer prevention guidelines was negatively related to EC risk.
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Affiliation(s)
- Hui Sun
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China.,Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China
| | - Qing Chang
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China.,Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ya-Shu Liu
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China.,Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yu-Ting Jiang
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China.,Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ting-Ting Gong
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xiao-Xin Ma
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yu-Hong Zhao
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China.,Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China
| | - Qi-Jun Wu
- Department of Clinical Epidemiology, Shengjing Hospital of China Medical University, Shenyang, China.,Clinical Research Center, Shengjing Hospital of China Medical University, Shenyang, China
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Ashktorab H, Sherif Z, Tarjoman T, Azam S, Lee E, Shokrani B, Okereke I, Soleimani A, Carethers JM, Laiyemo AO, Aduli F, Nouraie M, Habtezion A, Brim H. Elevated Risk for Sessile Serrated Polyps in African Americans with Endometrial Polyps. Dig Dis Sci 2020; 65:2686-2690. [PMID: 31832971 PMCID: PMC7289663 DOI: 10.1007/s10620-019-05991-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Accepted: 12/03/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Colorectal and endometrial lesions increase with age. It is not known if these two precursor lesions in sporadic cases associate with each other. AIM To determine the association between colorectal polyps and endometrial polyps (EP) in African Americans. METHODS We reviewed records of patients referred to gynecology clinics and had colonoscopy at Howard University Hospital from January 2004 to December 2015. We defined cases as all patients who had EP and underwent colonoscopy. For controls, we used EP-free patients who underwent colonoscopy. Logistic regression analysis was used to assess the association between colon polyps and EP. RESULTS The median age was 60 years in 118 Cases and 57 years in 664 Controls. The overall colorectal polyps prevalence in the two groups was not statistically different (54% in controls vs. 52% in cases, P = 0.60). Sessile serrated adenoma/polyps (SSPs) were more frequent in cases (8% vs. 2% in controls, P = 0.003). Sigmoid and rectal locations were more prevalent in controls than cases. In multivariate analysis and after adjusting for age, diabetes mellitus (DM), and BMI, SSPs were associated with EP occurrence with an odds ratio of 4.6 (CI 1.2-16.7, P = 0.022). CONCLUSION Colorectal polyp prevalence was similar in EP patients compared to EP-free controls. However, we observed a significant association between higher-risk SSPs in patients with EP. The prevalence of smoking and DM was higher in these patients. Females with EP might benefit from a screening for colonic lesions in an age-independent manner.
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Affiliation(s)
- Hassan Ashktorab
- Department of Medicine and Cancer Research Center, Howard University College of Medicine, 2041 Georgia Avenue, N.W., Washington, DC, 20060, USA.
| | - Zaki Sherif
- Department of Medicine and Cancer Research Center, Howard University College of Medicine, 2041 Georgia Avenue, N.W., Washington, DC, 20060, USA
| | - Taraneh Tarjoman
- Department of Medicine and Cancer Research Center, Howard University College of Medicine, 2041 Georgia Avenue, N.W., Washington, DC, 20060, USA
| | - Saman Azam
- Department of Medicine and Cancer Research Center, Howard University College of Medicine, 2041 Georgia Avenue, N.W., Washington, DC, 20060, USA
| | - Edward Lee
- Pathology Department and Cancer Research Center, Howard University College of Medicine, Washington, DC, USA
| | - Babak Shokrani
- Pathology Department and Cancer Research Center, Howard University College of Medicine, Washington, DC, USA
| | - Ifeanyichukwu Okereke
- Department of Medicine and Cancer Research Center, Howard University College of Medicine, 2041 Georgia Avenue, N.W., Washington, DC, 20060, USA
| | - Akbar Soleimani
- Department of Medicine and Cancer Research Center, Howard University College of Medicine, 2041 Georgia Avenue, N.W., Washington, DC, 20060, USA
| | - John M Carethers
- Departments of Internal Medicine and Human Genetics and Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48109-5368, USA
| | - Adeyinka O Laiyemo
- Department of Medicine and Cancer Research Center, Howard University College of Medicine, 2041 Georgia Avenue, N.W., Washington, DC, 20060, USA
| | - Farshad Aduli
- Department of Medicine and Cancer Research Center, Howard University College of Medicine, 2041 Georgia Avenue, N.W., Washington, DC, 20060, USA
| | - Mehdi Nouraie
- Division of Pulmonary, Department of Medicine, University of Pittsburg, Pittsburg, PA, USA
| | - Aida Habtezion
- Gastroenterology Division, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Hassan Brim
- Pathology Department and Cancer Research Center, Howard University College of Medicine, Washington, DC, USA
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Manchanda R, Thapa S. An overview of the main intrauterine pathologies in the postmenopausal period. Climacteric 2020; 23:384-387. [PMID: 32520598 DOI: 10.1080/13697137.2020.1776694] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Hysteroscopy is the gold standard for evaluating the uterine cavity, diagnosing intrauterine pathology, and operative intervention for some causes of abnormal uterine bleeding. The American College of Obstetricians and Gynecologists concluded that, when the endometrium measures ≤4 mm with transvaginal ultrasonography, the likelihood that bleeding is secondary to endometrial carcinoma is less than 1% (negative predictive value 99%), and endometrial biopsy is not recommended. Endometrial sampling in this clinical scenario will likely result in insufficient tissue for evaluation and it is reasonable to consider initial management for atrophy. A thickened endometrium on transvaginal ultrasonography (>4 mm in a postmenopausal woman with postmenopausal bleeding) warrants additional evaluation with endometrial sampling. A negative tissue biopsy following 'blind' endometrial sampling in women with postmenopausal bleeding is not considered to be an endpoint, and further evaluation of the endometrial cavity with hysteroscopy to exclude focal disease is imperative.
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Affiliation(s)
- R Manchanda
- Gynaecological Endoscopy Unit, Manchanda's Endoscopic Centre and PSRI Hospital, Delhi, India
| | - S Thapa
- Gynaecological Endoscopy, Rosewalk Hospital, New Delhi, India
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Sheng KK, Lyons SD. To treat or not to treat? An evidence-based practice guide for the management of endometrial polyps. Climacteric 2020; 23:336-342. [DOI: 10.1080/13697137.2020.1742107] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- K. K. Sheng
- Department of Obstetrics and Gynaecology, Mater Clinic, Sydney, Australia
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Sydney, Australia
- Faculty of Medicine, University of Sydney, Sydney, Australia
| | - S. D. Lyons
- Department of Obstetrics and Gynaecology, Mater Clinic, Sydney, Australia
- Department of Obstetrics and Gynaecology, Royal North Shore Hospital, Sydney, Australia
- Faculty of Medicine, University of Sydney, Sydney, Australia
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Allam MM, Allam MS, Mehasseb MK. Recurrent postmenopausal bleeding: a survey of practice among gynecologists in Scotland. ACTA ACUST UNITED AC 2020; 72:64-69. [PMID: 32403905 DOI: 10.23736/s0026-4784.20.04432-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The definition and management of recurrent postmenopausal bleeding (PMB) are not well described in the literature, with no consensus among the clinicians and no available contemporary UK evidence-based guidelines. We conducted this survey to examine the practice of gynecologists based in Scotland in relation to recurrent postmenopausal bleeding. METHODS A web-based questionnaire was sent to 200 non-training grade gynecologists in Scotland exploring their views on the definition, investigation and management of recurrent PMB. Data were extracted from the 61 responses received. RESULTS Seventy-seven percent of responders defined recurrent PMB as two or more episodes of PMB, while 21% defined it after three episodes. A bleed-free interval of 3 and 6 months was needed to identify a recurrence by 46% and 44% of responders, respectively. 70% would investigate recurrent PMB with a combination of transvaginal sonography, hysteroscopy and biopsy. Only 19% would arrange a pelvic MRI routinely, while 43% would never offer one. 72% would consider a hysterectomy at some stage, with 22% of responders offering it after 3 episodes of PMB with negative investigation. 18% would never offer a hysterectomy without an identified pathology. 32% of responders felt that the management of recurrent PMB required an individualized case-by-case approach. CONCLUSIONS This survey highlights the need for a clinical guideline to address the wide variation in the management of recurrent PMB.
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Affiliation(s)
- Marwa M Allam
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Mohammed S Allam
- Department of Obstetrics and Gynecology, University Hospital of Wishaw, Wishaw, UK
| | - Mohamed K Mehasseb
- Department of Gynecological Oncology, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK -
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47
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Yılmaz BK, Evliyaoğlu Ö, Yorgancı A, Özyer Ş, Üstün YE. Serum concentrations of heavy metals in women with endometrial polyps. J OBSTET GYNAECOL 2020; 40:541-545. [PMID: 31478412 DOI: 10.1080/01443615.2019.1634022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Endometrial polyps are one of the common reasons of abnormal uterine bleeding in women. Industrialisation, urbanisation and increased air pollution cause increased heavy metal exposure. Heavy metals that have oestrogenic effects in human body are named as metalloestrogens. The aim of this study was to investigate the serum metalloestrogen levels such as copper (Cu), zinc (Zn), aluminium (Al), lead (Pb), nickel (Ni) and Cu/Zn ratio and their possible relationship with the occurrence of endometrial polyps. Eighty women with abnormal uterine bleeding were divided into two groups: 40 women diagnosed with endometrial polyp (study group) and 40 women without endometrial polyp (control group). Ages, body mass indices, smoking behaviours, drinking water choices, chronic diseases and intrauterine device histories were noted for all patients. Blood levels of Cu, Zn, Al, Pb, Ni and Cu/Zn ratio were analysed by inductively coupled plasma-mass spectrometry method for both groups. No statistically significant differences were observed in terms of serum median levels of Cu and Pb between the study and the control groups. The serum median levels of Zn, Ni and Al were found to be statistically lower in the study group when compared with the control group. The Cu/Zn ratio was statistically higher in the study group. High Cu/Zn ratio, as a biomarker of oxidative stress, suggests the role of oxidative stress in etiopathogenesis of endometrial polyps.IMPACT STATEMENTWhat is already known on this subject? Studies demonstrate that oestrogen and progesterone play an important role in pathogenesis of endometrial polyps. Inorganic heavy metal ions that bind and activate oestrogen receptors are referred to as 'metalloestrogens'. Apart from toxic effects, metalloestrogens have been linked to the aetiology of oestrogen-dependent diseases such as breast and endometrium cancer and endometriosis. However, serum levels of heavy metals were not investigated in a large group of endometrial polyp patients.What do the results of this study add? This is the first study investigating the serum levels of heavy metals in a large group of endometrial polyp patients. We did not observe any increased serum levels of heavy metals in endometrial polyp patients. Our results might suggest that oestrogenic heavy metal exposure has no role in the appearance of endometrial polyps. However, increased Cu/Zn ratio due to low serum levels zinc suggests oxidative stress might play a role in endometrial polyps.What are the implications of these findings for clinical practice and/or further research? Further research of heavy metals in endometrial polyps with simultaneous blood and tissue samples could show the precise effect of environmental exposure of metalloestrogens in aetiopathogenesis of endometrial polyps.
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Affiliation(s)
- Betül Kalkan Yılmaz
- Zekai Tahir Burak Women's Health Education and Research Center, Department of Obstetrics and Gynecology, University of Health Sciences, Ankara, Turkey
| | - Özlem Evliyaoğlu
- Zekai Tahir Burak Women's Health Education and Research Center, Department of Obstetrics and Gynecology, University of Health Sciences, Ankara, Turkey
| | - Ayçağ Yorgancı
- Zekai Tahir Burak Women's Health Education and Research Center, Department of Obstetrics and Gynecology, University of Health Sciences, Ankara, Turkey
| | - Şebnem Özyer
- Zekai Tahir Burak Women's Health Education and Research Center, Department of Obstetrics and Gynecology, University of Health Sciences, Ankara, Turkey
| | - Yaprak Engin Üstün
- Zekai Tahir Burak Women's Health Education and Research Center, Department of Obstetrics and Gynecology, University of Health Sciences, Ankara, Turkey
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Ciscato A, Zare SY, Fadare O. The significance of recurrence in endometrial polyps: a clinicopathologic analysis. Hum Pathol 2020; 100:38-44. [PMID: 32334830 DOI: 10.1016/j.humpath.2020.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 11/30/2022]
Abstract
A subset of endometrial polyps recurs after resection. The clinicopathologic significance of the phenomenon is evaluated herein. Consecutive cases of recurrent polyps (index polyp removed by hysteroscopy-directed polypectomy or by curettage; at least one more polyp diagnosed ≤12 months after) were compared with an age-matched control group of nonrecurrent polyps regarding 15 clinicopathologic features. A total of 107 (5.6%) of the 1908 polyps diagnosed in a sampling specimen during the study period was a recurrence, and 102 (6.9%) of the 1478 patients who were diagnosed with an endometrial polyp in a sampling specimen had at least 1 recurrence. Eighty-six percent of patients with any recurrences had only one recurrence, with a mean duration between the index polyp and the first recurrence of 4.36 months. On univariate analyses, the recurrent polyps were, compared with controls, significantly larger, had a higher stromal mitotic index, and more frequently displayed prominent thick-walled vessels in most fragments of the polyp. However, on Cox regression multivariate analyses, no single clinicopathologic feature was significantly associated with a recurrence. No malignancies were diagnosed during the follow-up of the study and control group patients at median follow-up durations of 23 and 34 months, respectively. In conclusion, the recurrence of an endometrial polyp is relatively uncommon (5.6% of polyps) and does not portend an increased risk of malignancy. We could not identify any clinicopathologic features that conclusively predict a recurrence.
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Affiliation(s)
- Andreas Ciscato
- Department of Pathology, University of California San Diego, La Jolla, CA, USA
| | - Somaye Y Zare
- Department of Pathology, University of California San Diego, La Jolla, CA, USA
| | - Oluwole Fadare
- Department of Pathology, University of California San Diego, La Jolla, CA, USA.
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Ergenoglu AM, Hortu I, Taylan E, Yeniel AO, Akdemir A, Sahin C, Karadadas N. Can we rely on blind endometrial curettage for complete removal of focal intrauterine lesion? A prospective clinical study. J Gynecol Obstet Hum Reprod 2020; 49:101696. [PMID: 32018046 DOI: 10.1016/j.jogoh.2020.101696] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/17/2020] [Accepted: 01/24/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To investigate the diagnostic and therapeutic efficiency of dilatation-curettage (D&C) combined with aspiration curettage for endometrial pathology compared to hysteroscopy alone in this study. MATERIAL AND METHODS A total of 143 patients who have suspicion of endometrial mass like lesion, increased endometrial thickness (>5-mm at menopause and/or endometrial thickness upper than 5-mm in patients under tamoxifen treatment due to breast cancer during 2-D transvaginal ultrasonography examination) were enrolled. All patients underwent procedures in order of hysteroscopy, D&C plus aspiration and second look hysteroscopy. Data for age, menopausal status, tamoxifen treatment, endometrial histology, hysteroscopy and D&C findings were recorded and statistically analyzed. RESULTS Initial hysteroscopy revealed focally growing endometrial lesion in 96 patients. Second look hysteroscopy showed persistent focal lesion in 77 patients (80 %) after D&C plus aspiration. Endometrial blind curettage failed to diagnose 42 % (25/60) of endometrial polyps, none of submucous myomas as well as 27 % (3/11) of premalignant and malignant endometrial lesions. The sensitivity, specificity, overall accuracy, positive predictive value and negative predictive value of hysteroscopy were found as 84.1 %, 83.3 %, 83.9 %, 93.8 %, and 63.8 %, respectively. CONCLUSIONS Hysteroscopy showed significant superiority in the diagnosis and definitive treatment of endometrial pathologies specifically in focally growing endometrial lesions compared to D&C plus aspiration.
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Affiliation(s)
- Ahmet Mete Ergenoglu
- Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey
| | - Ismet Hortu
- Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey.
| | - Enes Taylan
- Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey; Women's Cancer Program, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ahmet Ozgur Yeniel
- Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey
| | - Ali Akdemir
- Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey
| | - Cagdas Sahin
- Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey
| | - Nedim Karadadas
- Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey
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50
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Abstract
Menopause is characterized by permanent cessation of menstrual periods and is clinically diagnosed after 12 months of complete amenorrhea. It occurs at a median age of 51 years alongside the physiological process of aging, although it can happen at an earlier age for other medical conditions or after surgery (surgical menopause). Due to reduced circulating estrogens and progesterone, the reproductive organs undergo progressive atrophy. This physiologic process of aging is also present at an endometrial level; without the cyclic hormonal actions of the menstrual cycle, the endometrium during menopause becomes atrophic. Postmenopausal bleeding (PMB) is a common gynecologic complaint encountered by the clinician. Endometrial cancer is present in about 10% of patients with PMB. Nevertheless, many other conditions, such as endometrial or cervical polyps, genital atrophy, or non-gynecologic conditions, may also be present. Historically, dilation and curettage (D&C) was the main diagnostic procedure in patients with PMB; however, newer methods of investigation have replaced D&C. The aim of this review is to present an up-to-date analysis of the current evidence for the clinical management of vaginal bleeding in postmenopausal women.
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Affiliation(s)
- J Carugno
- Obstetrics, Gynecology and Reproductive Sciences Department, Minimally Invasive Gynecology Unit, Miller School of Medicine, University of Miami, Miami, FL, USA
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