Transvaginal sonography combined with saline contrast sonohysterography in evaluating the uterine cavity in premenopausal patients with abnormal uterine bleeding

OBJECTIVES

To evaluate whether saline contrast sonohysterography (SCSH) adds additional information to that obtained by transvaginal sonography (TVS) for predicting endometrial abnormality in premenopausal patients with abnormal uterine bleeding.

PATIENTS AND METHODS

This was a two-center prospective study at a university clinic and a central hospital in Denmark. The uterine cavity was evaluated with TVS and SCSH in 470 premenopausal patients with abnormal uterine bleeding. One hundred and eighty-nine of the patients had operative hysteroscopy or hysterectomy within 4 months which provided a detailed description of the uterine cavity and was used as the true value for exclusion of polyps and submucous myomas.

RESULTS

Based on normal endometrial morphology alone, the results for detection of an abnormal uterine cavity were as follows: sensitivities of TVS 0.92, SCSH 0.99; specificities of TVS 0.62, SCSH 0.72; positive predictive values of TVS 0.80, SCSH 0.85; negative predictive values of TVS 0.82, SCSH 0.98. Transvaginal sonography combined with SCSH was superior to TVS for detection of intracavitary abnormalities (McNemar test, P = 0.008). The post-test probability of there being an abnormal cavity after normal findings on TVS alone was 0.18 (0.10-0.32) and after TVS and SCSH it was 0.02 (0.01-0.11). When normal endometrial morphology was combined with an endometrial thickness of < 12 mm for evaluation of all abnormalities including hyperplasia, the diagnostic potential of TVS or SCSH was almost unchanged except for specificities, which were markedly lower (TVS 0.54; SCSH 0.57). In all the patients referred, TVS had a negative predictive value of 0.94 for identification of polyps and myomas when findings at subsequent SCSH were accepted as the true value. Transvaginal sonography reduced the pretest probability of polyps or submucous myomas from 0.35 to a post-test probability of 0.06, but missed 21% of the polyps.

CONCLUSIONS

Sonohysterography was a sensitive tool and was superior to TVS used alone for evaluation of the uterine cavity in patients who underwent operative surgery for abnormal uterine bleeding. All abnormalities except one were found at SCSH, while TVS alone missed polyps and had almost one in four equivocal findings. The use of TVS, without saline contrast, left one in five of the polyps undiagnosed in referred patients with abnormal bleeding.

Effects of oophorectomy on functional properties of resistance arteries isolated from the cancellous bone of the rabbit femur

Information is sparse concerning the effect of oophorectomy (OOX) on bone vascularization and blood flow of possible significance for altered remodeling. Whether OOX affects functional characteristics of isolated bone resistance arteries was investigated. Ring preparations (diameter approximately 250 microm) of small femoral bone arteries from oophorectomized and sham-operated rabbits were mounted on a myograph six weeks postoperatively. Cumulative concentration response curves were obtained for various agonists at a normalized lumen diameter. Oophorectomy did not significantly influence lumen diameter, maximal response to high potassium, or maximal response to high potassium and 10(-5) M noradrenaline. However, OOX significantly increased the maximal response to noradrenaline (OOX 2.14 +/- 0.36 N/m, Sham 1.25 +/- 0.14 N/m) and endothelin-1 (OOX 1.76 +/- 0.32, Sham 0.95 +/- 0.15) in metaphyseal arteries. Moreover, the corresponding maximal active pressure for the agonists was significantly increased. OOX did not influence endothelial function assessed by the effects of acetylcholine or substance P. The functional responses of diaphyseal arteries were unaffected by OOX. The study demonstrates regional differences in the effects of OOX on small arteries of importance for control of vascular resistance in bone which suggests a relation between altered vascular function after ovarian hormonal withdrawal and the changes in bone turnover associated with osteoporosis.

Progressive multifocal leukoencephalopathy with concurrent Richter's syndrome

Progressive multifocal leukoencephalopathy (PML) is a demyelinating infectious disease caused by the JC virus. It was originally described in patients with chronic lymphocytic leukemia (CLL). Richter's syndrome, or transformation to large cell Lymphoma, occurs in approximately 3% of patients with CLL, and carries a poor prognosis. We report a patient with documented PML and concurrent Richter's transformation outside the central nervous system. Before establishing a definitive diagnosis of PML, radiation therapy to the presumed lymphomatous brain lesion had been considered, raising the issue of whether stereotactic brain biopsy should be considered in every patient in a similar situation. Although this is likely a rare occurrence, patients with Richter's transformation documented at an extra-neural site and a brain lesion may benefit from the establishment of an infectious diagnosis which would influence therapy.

Transient neonatal cyanosis: unusual presentation of right-sided cardiac masses

We report a case of a neonate with multiple cardiac masses, cyanosis, and a heart murmur. Arterial desaturation was the result of right-to-left shunting at the foramen ovale level caused by tricuspid regurgitation. Three right-sided cardiac masses were detected by echocardiography. By 2 weeks of age the patient had complete resolution of his cyanosis and improved tricuspid regurgitation following the normal decrease in pulmonary vascular resistance. At 2 years of age, he has no cardiovascular symptoms and the masses are calcified and have no hemodynamic consequences.

Differing effects of supplemental KCl and KHCO3: pathophysiological and clinical implications

Compared to the prehistoric diet, the modern human diet contains not only excessive NaCl and deficient K+, but also deficient precursors of HCO3- and sometimes excessive precursors of nonvolatile acid. The mismatch between the modern diet and the still ancient biological machinery of humans subtly but chronically disorders their internal milieu, giving rise to a prolonged state of low-grade potassium deficiency and low-grade metabolic acidosis whose severity increases with age. Supplemental KCI cannot redress this mismatch and correct this state. However, the mismatch is redressed and the state corrected by restoring intakes of K+ and HCO3- to levels approaching those in the diet of our prehistoric forebearers, with either fruits and vegetables or with supplemental KHCO3. So restored, KHCO3 can: 1) attenuate hypertension and possibly prevent its occurrence by suppressing the phenomenon of normotensive NaCl-sensitivity, in part by its natriuretic effect; (2) prevent kidney stones by reducing urinary excretion of calcium and increasing urinary excretion of citrate; (3) ameliorate and protect against the occurrence of osteoporosis by increasing the renal retention of calcium and phosphorus, and by suppressing bone resorption and enhancing bone formation; and (4) likely prevent stroke.

NaCl-induced renal vasoconstriction in salt-sensitive African Americans: antipressor and hemodynamic effects of potassium bicarbonate

In 16 African Americans (blacks, 14 men, 2 women) with average admission mean arterial pressure (MAP, mm Hg) 99.9+/-3.5 (mean+/-SEM), we investigated whether NaCl-induced renal vasoconstriction attends salt sensitivity and, if so, whether supplemental KHCO3 ameliorates both conditions. Throughout a 3-week period under controlled metabolic conditions, all subjects ate diets containing 15 mmol NaCl and 30 mmol potassium (K+) (per 70 kg body wt [BW] per day). Throughout weeks 2 and 3, NaCl was loaded to 250 mmol/d; throughout week 3, dietary K+ was supplemented to 170 mmol/d (KHCO3). On the last day of each study week, we measured renal blood flow (RBF) and glomerular filtration rate (GFR) using renal clearances of PAH and inulin. Ten subjects were salt sensitive (SS) (DeltaMAP >+5%) and 6 salt resistant (SR). In NaCl-loaded SS but not SR subjects, RBF (mL/min/1.73 m2) decreased from 920+/-75 to 828+/-46 (P<0.05); filtration fraction (FF, %) increased from 19. 4+/- to 21.4 (P<0.001); and renal vascular resistance (RVR) (10(3)xmm Hg/[mL/min]) increased from 101+/-8 to 131+/-10 (P<0.001). In all subjects combined, DeltaMAP varied inversely with DeltaRBF (r =-0.57, P=0.02) and directly with DeltaRVR (r = 0.65, P=0.006) and DeltaFF (r = 0.59, P=0.03), but not with MAP before NaCl loading. When supplemental KHCO3 abolished the pressor effect of NaCl in SS subjects, RBF was unaffected but GFR and FF decreased. The results show that in marginally K+-deficient blacks (1) NaCl-induced renal vasoconstrictive dysfunction attends salt sensitivity; (2) the dysfunction varies in extent directly with the NaCl-induced increase in blood pressure (BP); and (3) is complexly affected by supplemented KHCO3, GFR and FF decreasing but RBF not changing. In blacks, NaCl-induced renal vasoconstriction may be a pathogenetic event in salt sensitivity.

Normotensive salt sensitivity: effects of race and dietary potassium

-Normotensive salt sensitivity, a putative precursor of hypertension, might be quite frequent in African Americans (blacks) and less frequent in Caucasian Americans (whites), but only when dietary potassium is deficient and not when maintained well within the normal range. We tested this hypothesis in 41 metabolically controlled studies of 38 healthy normotensive men (24 blacks, 14 whites) who ate a basal diet low in sodium (15 mmol/d) and marginally deficient in potassium (30 mmol/d) for 6 weeks. Throughout the last 4 weeks, NaCl was loaded (250 mmol/d); throughout the last 3, potassium was supplemented (as potassium bicarbonate) to either mid- or high-normal levels, 70 and 120 mmol/d. Salt sensitivity, defined as an increase in mean arterial blood pressure >/=3 mm Hg with salt loading, was deemed "moderate" if increasing </=10 mm Hg and "severe" if increasing more. When dietary potassium was 30 mmol/d, salt loading induced a mean increase in blood pressure only in blacks (P<0.001), and salt sensitivity occurred in most blacks but not whites (79% vs 36% (P<0.02). Supplementing potassium only to 70 mmol/d attenuated moderate salt sensitivity similarly in blacks and whites; 120 mmol/d abolished it, attenuated severe salt sensitivity, which occurred in a quarter of affected blacks, and suppressed the frequency and severity of salt sensitivity in blacks to levels similar to those observed in whites. These observations demonstrate that in most normotensive black men but not white men, salt sensitivity occurs when dietary potassium is even marginally deficient but is dose-dependently suppressed when dietary potassium is increased within its normal range. Such suppression might prevent or delay the occurrence of hypertension, particularly in the many blacks, in whom dietary potassium is deficient.

Long-term results and pharmacokinetics of high-dose paclitaxel in patients with refractory epithelial ovarian carcinoma

The purpose of this study was to analyze the efficacy and toxicity of a high dose of paclitaxel in patients with ovarian cancer refractory to platinum chemotherapy. Another phase II study of hydroxyurea was run in the same patient population. Fifty patients with measurable ovarian cancer were entered on this phase II study at The University of Texas M. D. Anderson Cancer Center. Treatment consisted of 250 mg/m2 of paclitaxel given by continuous intravenous infusion over 24 h every 3 weeks. Patients with disease unresponsive to paclitaxel could then be crossed over to hydroxyurea, and vice versa. Twenty-five (53%) out of 47 evaluable patients had a response (two complete responses and 23 partial responses). Twelve (26%) patients had stable disease. The median survival was 11.3 months. The main toxic effect was neutropenia (98% of patients) with 28 (9%) episodes of neutropenic fever. Neutropenia required therapy with granulocyte colony-stimulating factor. Other side effects were alopecia (100%), anemia (98%), gastrointestinal problems (57%), stomatitis (27%), and neurotoxicity (55%). Paclitaxel administered at a high dose as a single agent proved to be very active in patients who had platinum-refractory ovarian cancer and was well tolerated. Further studies of high-dose paclitaxel in patients with ovarian carcinoma are indicated.

Phase II study of i.v. CI-980 in patients with advanced platinum refractory epithelial ovarian carcinoma

CI-980 is a synthetic mitotic inhibitor that binds to tubulin at the colchicine site, inhibiting the polymerization of microtubules and arresting cellular division in metaphase. Myelosuppression and neurotoxicity were dose-limiting in phase I studies. Sixteen patients with stage III and IV platinum-refractory ovarian cancer received 4.5 mg/m2/day of CI-980 as a continuous i.v. infusion for 72 h, repeated every 3 weeks. Eleven patients had progression and four patients had stable disease. One patient (6%; 95% CI 0-25%) achieved a partial response after 9 months of treatment which lasted for 27 months. The overall median survival was 7 months. Grade 4 granulocytopenia occurred in five patients, with two episodes of neutropenic fever. Neurological toxicity was mild with 12 episodes of transient subclinical recent memory loss documented in four patients by specialized neuropsychological evaluations. One patient each had hallucinations and mild truncal ataxia, and four patients had mild, reversible neurosensory toxicity. One episode of severe hypoxemia and dyspnea occurred in a patient with chronic obstructive pulmonary disease. CI-980 has minimal activity and is tolerable in a population of heavily pretreated patients with platinum refractory ovarian cancer.

Effects of ouabain on the isolated human uteroplacental vasculature

OBJECTIVE

We sought to describe the effects of ouabain on the human uteroplacental vasculature.

STUDY DESIGN

Stem villous vessels and intramyometrial arteries isolated from placental and myometrial biopsy specimens at term were mounted in organ baths. Moreover, isolated human placental cotyledons were perfused.

RESULTS

Contractions induced by the thromboxane A2 analog U46619 were unaffected by pretreatment with ouabain 10(-10) to 10(-6) mol/L. In fetal vessels nitric oxide (10(-8) to 3 x 10(-5) mol/L) induced relaxation of vascular tonus induced by U46619 and potassium. This relaxation was inhibited by pretreatment with ouabain 10(-7) to 10(-6) mol/L. These associations were unaffected by removal of the endothelium. In maternal arteries ouabain (10(-6) mol/L) failed to significantly affect nitric oxide-induced relaxation. Ouabain (10(-9) mol/L) significantly affected pressure-flow relationships in perfused cotyledons.

CONCLUSIONS

Ouabain impairs nitric oxide-induced relaxation of human stem villous arteries and veins, which may explain the changes induced by therapeutically relevant concentrations of the drug on pressure-flow relationships in the perfused cotyledon. Thus treatment with cardiac glycosides in pregnancy may impair uteroplacental blood flow.

Length tension relationships in the nonpregnant and pregnant rat uterus and the effect of antiprogestin

Length-tension relationships and the tissue composition of the corpus and the cervix uteri were investigated in a rat model. Four groups of rats were used: nonpregnant (n = 12); day 18 of pregnancy treated with vehicle (n = 8); day 18 of pregnancy treated with the antiprogestin ZK 98 299 (Onapristone) for 19 h (n = 8); and day 22 of pregnancy during spontaneous labour (n = 8). Increased extensibility and maximal contractility in both corpus and cervix uteri were demonstrated with increased gestational age. The collagen concentration was reduced significantly in corporal preparations from pregnant rats compared with those from nonpregnant rats but not in specimens from the cervix. Antiprogestin treatment tended to increase the contractile ability.

Risk factors, treatment, and outcome of central nervous system recurrence in adults with intermediate-grade and immunoblastic lymphoma

To evaluate the incidence, risk factors, and outcome of central nervous system (CNS) recurrence in adult patients with non-Hodgkin's lymphoma, we evaluated 605 newly diagnosed patients with large-cell and immunoblastic lymphoma who participated in prospective chemotherapy studies. The Kaplan-Meier estimate of probability of CNS recurrence at 1 year after diagnosis was 4.5% (95% confidence interval [CI], 4.4 to 4.6). Twenty-four patients developed CNS recurrence after a median of 6 months from diagnosis (range, 0 to 44 months). In univariate analysis, an increased risk for CNS recurrence was associated with an advanced disease stage (P = .0014), an increased LDH (P = .0000), the presence of B-symptoms (P = . 0037), involvement of more than one extranodal site (P = .0000), poor performance status (P = .0005), and B-cell phenotype (P = .008). Bone marrow involvement (P = .005), involvement of parenchymal organs (P = .03), and involvement of skin, subcutaneous tissue, and muscle (P = .002) were also associated with an increased risk for CNS disease. Multivariate logistic regression analysis identified only involvement of more than one extranodal site (P = .0005) and an increased LDH (P = .0008) as independent predictors of CNS recurrence. Established CNS recurrence had a poor prognosis. Only 1 of 24 patients remains alive and the Kaplan-Meier estimate of probability of survival at 1 year after the diagnosis of CNS recurrence is only 25.3% (95% CI, 6.9 to 43.7). Intrathecal treatment provided symptomatic benefit in only 1 of 6 patients. Radiation treatment provided symptomatic improvement in 6 of 9 patients treated. However, remissions were short and followed by systemic or CNS recurrence. Serum LDH and involvement of more than one extranodal site are independent risk factors for CNS recurrence in patients with large-cell lymphoma. The presence of both risk factors identifies a patient group at high risk for CNS recurrence. Established CNS recurrence can be rapidly fatal. Transient responses occur after radiation treatment.

Potassium intake and cardiovascular reactivity in children with risk factors for essential hypertension

OBJECTIVES

Our study objectives were as follows: (1) to determine whether urinary excretion of potassium is lower in black than in white children, (2) to determine whether cardiovascular reactivity (CVR) varies inversely with dietary intake of potassium, and (3) to confirm that CVR is greater in black than in white children, and in children with a family history of hypertension than in those without such a history.

STUDY DESIGN

Baseline measurements included 24-hour urinary sodium, potassium, and creatinine levels and food intake (by questionnaire). Resting and stress blood pressure were measured during blood sampling, cold water foot immersion, and a video game before and after 1 week each of supplementation with potassium citrate, 1.5 mmol/kg per day, and placebo administered in random order.

RESULTS

Thirty-nine children aged 7 to 15 years were studied. White subjects had higher baseline excretion of potassium than black subjects (p < 0.001) and higher vegetable intake (p < 0.01), which were positively correlated (r = 0.53, p < 0.001). At baseline, the 24-hour urinary potassium/creatinine ratio varied inversely with diastolic CVR to the video game stressor in white children (r = -0.55, p = 0.02). Cardiovascular reactivity was not attenuated measurably by potassium supplementation compared with placebo. The CVR was greater in children with a family history of hypertension than in those without, but was not greater in black children than in white children.

CONCLUSIONS

The urinary potassium/creatinine ratio is higher in white than black children because their intake of vegetables is greater; dietary potassium intake may modulate CVR, particularly in white children with a family history of hypertension, but may need to be supplemented for more than 1 week to demonstrate attenuation of CVR; and a family history of hypertension may be a stronger predictor of enhanced CVR than is race.

No effects of human relaxin on the active and passive biomechanical properties of isolated cervical specimens from nonpregnant women

OBJECTIVE

To evaluate the effect of human relaxin (hRLX-2) on the active and passive biomechanical properties of cervical tissue in vitro.

MATERIAL

Cervical samples were obtained from the middle part of the cervix in 22 nonpregnant women undergoing hysterectomy.

METHODS

The effect of hRLX-2 (10(-7) M) on the active biomechanical properties was studied on vasopressin (10(-8) M) induced smooth muscle contractions in an organ bath model. The effect on the passive biomechanical properties were studied after incubation of the strips for 48 h with hRLX-2 (10(-8) M and 10(-9) M). Subsequently, the specimens were stretched in a material testing machine until they broke. The load applied and the elongation were simultaneously recorded and the results translated into stress-strain curves.

RESULTS

hRLX-2 did not influence the vasopressin-induced contractility of cervical strips from nonpregnant women in this study. No synergistic effect of progesterone could be demonstrated. The passive biomechanical properties (tensile strength, extensibility, stiffness of failure energy) did not change significantly after relaxin incubation. The results obtained in vitro do not suggest an important physiological effect of relaxin on the human nonpregnant cervix.

Central nervous system relapse of lymphoid malignancies in adults: the role of high-dose chemotherapy

Adults with CNS recurrence of lymphoid malignancies generally have a very poor prognosis. Although recent reports indicate that a proportion of patients may obtain prolonged remission after bone marrow transplantation, the role of high-dose chemotherapy in the management of this complication remains controversial. We reviewed the literature in order to better evaluate the relative contribution of high-dose chemotherapy to the outcome of patients with CNS recurrence. We focused mainly on results in adults, but included results on pediatric patients when relevant. Our review of the data indicates that 20% to 40% of adults with a history of CNS involvement by lymphoma or lymphoid leukemia can be cured by high-dose chemotherapy. A small fraction of patients with active CNS involvement can be cured as well. No data is available to determine superiority of a particular conditioning regimen or of allogeneic vs. autologous BMT. There is no conclusive benefit to post-transplant intrathecal therapy and the role of cranial or cranio-spinal radiation treatment and its optimal timing remains to be determined. Prospective studies are needed to resolve many of the issues regarding the treatment, and to improve the outcome of patients with CNS recurrence of lymphoid malignancies.

Effects of transmural field stimulation in isolated smooth muscle of human rectum and internal anal sphincter

Smooth muscle preparations from the circular muscle layer of the most distal rectum and the proximal and distal human internal anal sphincter (IAS) mounted in organ baths to record isometric tension developed spontaneous tension. Transmural electrical field stimulation (TMS) induced frequency- and impulse duration-dependent relaxations sensitive to tetrodotoxin in the stimulation range of 0.5-40 Hz and 0.04-0.6 ms. Poststimulus contractions were most frequent and prominent in rectal preparations. Maximal relaxations were comparable in the three locations and were achieved at 10 Hz and 0.4 ms. The frequency inducing half-maximal response was lower in rectal strips compared with IAS. Phentolamine (10-(6) M) enhanced relaxations and diminished off-contractions at 40 Hz in distal IAS. N omega-nitro-L-arginine (L-NNA) concentration dependently inhibited both relaxations and off-contractions (10 Hz, 0.4 ms). The pD2 values (-log EC50) of L-NNA were lower in rectal muscle compared with those in IAS. L-Arginine (10-(4) M) inhibited the blocking effect of L-NNA. In one-half of the preparations, L-NNA reversed the relaxations to duration contractions (15-40 Hz), which were inhibited by atropine in rectal preparations and by phentolamine in IAS. In conclusion, excitatory innervation of the IAS is alpha-adrenergic and cholinergic in the rectum. A product of the L-arginine-nitric oxide pathway mediates the TMS-induced inhibition of the muscle and is also involved in poststimulus contractions.

Reduced dietary potassium reversibly enhances vasopressor response to stress in African Americans

Acute vasopressor responses to stress are adrenergically mediated and hence potentially subject to differential modulation by dietary potassium and sodium. The greater vasopressor responsiveness in blacks compared with whites might then be consequent not only to a high dietary salt intake but also to a marginally reduced dietary potassium intake. Under controlled metabolic conditions, we compared acute vasopressor responses to cold and mental stress in black and white normotensive men during three successive dietary periods: (1) while dietary potassium was reduced (30 mmol K+/70 kg per day) and salt was restricted (10 to 14 days); (2) while salt was loaded (15 to 250 mmol Na+/70 kg per day) (7 days); and (3) while salt loading was continued and potassium was either supplemented (70 mmol K+/70 kg per day) (7 to 21 days) in 9 blacks and 6 whites or continued reduced (30 mmol K+/70 kg per day) (28 days) in 4 blacks (time controls). At the lower potassium intake, cold-induced increase in forearm vascular resistance in blacks was twice that in whites during both salt restriction and salt loading. Normalization of dietary potassium attenuated cold-induced increases in both forearm vascular resistance and systolic and diastolic blood pressures in blacks but only in systolic pressure in whites. In blacks but not in whites, normalization of dietary potassium attenuated mental stress-induced increases in systolic and diastolic pressures. In normotensive blacks but not whites, a marginally reduced dietary intake of potassium reversibly enhances adrenergically mediated vasopressor responsiveness to stress. That responsiveness so enhanced over time might contribute to the pathogenesis of hypertension in blacks.

The relationship between preoperative endometrial thickness, the anteroposterior diameter of the uterus and clinical outcome following transcervical resection of the endometrium

The objective of this study was to identify whether the endometrial thickness, or the anteroposterior diameter of the uterus as assessed by transvaginal ultrasonography (TVS), could be used to predict the clinical outcome following transcervical resection of the endometrium (TCRE). An open observational trial was carried out, involving 195 consecutive patients undergoing TCRE, 188 of whom completed follow-up. The patients were examined by TVS preoperatively, and then 6 weeks, 6 months and 1 year following TCRE. In all examinations, endometrial thickness, the anteroposterior diameter and residual endometrium, uterine morphology and the clinical outcome as measured by pain reduction, bleeding index and amenorrhea were assessed. Patients with a preoperative endometrial thickness of 8 mm or less had a higher rate of amenorrhea after 1 year than patients with an endometrial thickness exceeding 8 mm. Outcome did not relate to the histological phase of the endometrium obtained during resection. Neither the uterine anteroposterior diameter, or the presence of submucous fibroids, had any influence on the clinical outcome. Cavity fluid was observed in some cases but was not always associated with symptoms. Residual endometrium could be detected by TVS in 38% of the women after 1 year, but the vast majority of these patients reported a satisfactory outcome from the procedure. We conclude that the size of the anteroposterior diameter does not affect the clinical outcome of TCRE, whilst the preoperative endometrial thickness does have a significant impact on the likelihood of achieving amenorrhea after 1 year. The data suggest that TCRE should preferably be performed when the endometrium is at its thinnest and that there may be a useful role for agents that produce endometrial atrophy prior to surgery.