Measurement of endometrial thickness in premenopausal women in office gynecology

Sonographic, Demographic, and Clinical Characteristics of Pre- and Postmenopausal Women with Endometrial Cancer; Results from a Post Hoc Analysis of the IETA4 (International Endometrial Tumor Analysis) Multicenter Cohort

In this study, we conducted a comparative analysis of demographic, histopathological, and sonographic characteristics between pre- and postmenopausal women diagnosed with endometrial cancer, while also examining sonographic and anthropometric features in 'low' and 'intermediate/high-risk' cases, stratified by menopausal status. Our analysis, based on data from the International Endometrial Tumor Analysis (IETA) 4 cohort comprising 1538 women (161 premenopausal, 1377 postmenopausal) with biopsy-confirmed endometrial cancer, revealed that premenopausal women, compared to their postmenopausal counterparts, exhibited lower parity (median 1, IQR 0-2 vs. 1, IQR 1-2, p = 0.001), a higher family history of colon cancer (16% vs. 7%, p = 0.001), and smaller waist circumferences (median 92 cm, IQR 82-108 cm vs. 98 cm, IQR 87-112 cm, p = 0.002). Premenopausal women more often had a regular endometrial-myometrial border (39% vs. 23%, p < 0.001), a visible endometrial midline (23% vs. 11%, p < 0.001), and undefined tumor (73% vs. 84%, p = 0.001). Notably, despite experiencing a longer duration of abnormal uterine bleeding (median 5 months, IQR 3-12 vs. 3 months, 2-6, p < 0.001), premenopausal women more often had 'low' risk disease (78% vs. 46%, p < 0.001). Among sonographic and anthropometric features, only an irregular endometrial-myometrial border was associated with 'intermediate/high' risk in premenopausal women. Conversely, in postmenopausal women, multiple features correlated with 'intermediate/high' risk disease. Our findings emphasize the importance of considering menopausal status when evaluating sonographic features in women with endometrial cancer.

Predictive factors of endometrial lesions in patients with abnormal uterine bleeding

PURPOSE

To explore the risk factors of endometrial lesions in patients with abnormal uterine bleeding(AUB) and establish prediction models which can discriminate between different endometrial etiologies of AUB.

MATERIAL AND METHODS

We conducted this cross-sectional study in consecutive 778 women with AUB who received ultrasound examination and endometrial histopathological examination. Models were developed to distinguish between normal endometrium and (1) endometrial lesions, (2) endometrial polyps, (3) endometrial hyperplasia without atypia, (4) endometrial atypical hyperplasia and endometrial carcinoma.

RESULTS

274 (35.2%) women had normal endometrium; 504 (64.8%) had endometrial lesions, including 337(43.3%) endometrial polyps, 139(17.9%) endometrial hyperplasia without atypia, 28(3.6%) endometrial atypical hyperplasia and endometrial carcinoma. Age (OR = 1.122, 95%CI 1.002-1.257, P < 0.001), ET (endometrial thickness, OR = 2.702, 95%CI 1.629-4.402, P < 0.001), and CA125(U/ml) (OR = 1.007, 95%CI 1.003-1.021, P < 0.001) are independent risk factors of endometrial lesions in women with AUB. BMI(OR = 1.109, 95%CI 1.067-1.433,P = 0.038), ET(OR = 20.741, 95%CI 16.136-98.842, P < 0.001), age(OR = 1.182, 95%CI1.031-1.433,P = 0.016)、CA125(U/ml) (OR = 1.690, 95%CI 1.506-1.929,P = 0.001), prevalence of hypertension(OR = 1.350, 95%CI 1.051-67.82, P = 0.014) and diabetes(OR = 1.108, 95%CI 1.008-20.194,P = 0.001) were independent risk factors for atypical hyperplasia and endometrial carcinoma in patients with AUB. The model we built could predict atypical hyperplasia and endometrial carcinoma with the sensitivity of 87.5%, specificity of 80.7% and the AUC of 0.921.

CONCLUSION

In women with AUB, the new-built model based on age, BMI, endometrial thickness, hypertension, diabetes and CA125 could discriminate reliable between atypical hyperplasia, endometrial carcinoma and normal women. The model may be useful for management of AUB.

Treatment with Myo-Inositol Does Not Improve the Clinical Features in All PCOS Phenotypes

BACKGROUND

The aim of the present study is to investigate the effects produced by a treatment with myo-Inositol (myo-Ins) in women presenting polycystic ovary syndrome (PCOS) of different phenotypes.

METHODS

We performed a retrospective study to evaluate whether patients presenting different PCOS phenotypes, treated for 6 months with myo-Ins, might exhibit a differential response to the treatment. On this premise, we clustered women with PCOS phenotypes A, B, and C in the first study group (hyperandrogenic PCOS or H-PCOS), and women presenting PCOS phenotype D in a separate study group (non-hyperandrogenic PCOS or NH-PCOS) to evaluate if the presence of hyperandrogenism, shared by H-PCOS, might imply a metabolic/endocrine condition rather than a gynecological issue.

RESULTS

The administration of myo-Ins induced a significant improvement in metabolic and endocrine parameters in H-PCOS, while the effects on NH-PCOS were negligible. Additionally, myo-Ins treatment improved the endometrial thickness of H-PCOS.

CONCLUSIONS

Subjects selected for the study exhibited a differential response to myo-Ins therapy according to their PCOS phenotypes. The data suggest that the same treatment might not equally improve the parameters of the PCOS condition in each sub-group of patients. It is crucial to distinguish the various phenotypes to properly select the therapeutical approach.

D-Chiro-Inositol in Endometrial Hyperplasia: A Pilot Study

Endometrial hyperplasia is a threatening pathology driven by unopposed estrogen stimulus. Moreover, insulin may act on the endometrium, prompting further growth. We aimed at assessing whether D-chiro-Inositol, an insulin sensitizer with estrogen-lowering properties, might improve the condition of patients with simple endometrial hyperplasia without atypia. We enrolled women with simple endometrial hyperplasia without atypia and related symptoms, including abnormal uterine bleeding. We treated the patients with one tablet per day, containing 600 mg of D-chiro-inositol for six months. Patients underwent ultrasound to assess the thickness of the endometrium at baseline, after three months, and at the end of this study. Endometrial thickness went from 10.82 ± 1.15 mm to 8.00 ± 0.81 mm after three months (p < 0.001) and to 6.9 ± 1.06 mm after six months (p < 0.001 versus baseline; p < 0.001 versus three months). D-chiro-inositol treatment also improved heavy menstrual bleeding and the length of menstruation. Despite the fact that our data should be validated in larger studies with appropriate control groups, our promising results support the hypothesis that D-chiro-inositol may represent a useful treatment in the case of endometrial hyperplasia without atypia.

The incidence of unexpected uterine malignancies in hysterectomies carried out for benign indications

PURPOSE

The aim of the present study was to evaluate the incidence of unexpected uterine malignancies in patients undergoing hysterectomy for benign indications and to evaluate their clinical characteristics.

METHODS

We conducted a retrospective review of patients who underwent benign hysterectomy in the Department of Gynecology, the First Hospital of Shanxi Medical University from January 2015 to December 2020. The clinical data of these patients were retrieved and collected.

RESULTS

Their median age was 49.8 years (31-82 years). The mean parity was 1.86 ± 2.54. Their mean BMI was 27.5 ± 7.6 kg/m2. 42.90% were (2438/5683) postmenopausal. The benign indications of procedure were as follows: symptomatic uterine leiomyomas 2218/5683 (39.02%), pelvic organ prolapse 1406/5683 (24.74%), symptomatic endometriosis or adenomyosis 1132/5683 (19.91%), and 927/5683 (16.31%) to treat other benign conditions such as abnormal uterine bleeding, infection, polyps, and endometrial hyperplasia without atypia. In minimally invasive surgery subgroups, 1560/2621 (59.52%) specimens were removed by in-bag manual morcellation through vaginal cuff. The mean operative time of minimally invasive surgery with in-bag morcellation was shorter than abdominal hysterectomy (96.75 ± 35.7 vs. 140 ± 32.6, P < .001), and the estimated blood loss was also less than abdominal hysterectomy (47.35 ± 42.3 vs. 170 ± 60.4, P < .001). A total of 19/5683 (0.33%) unexpected uterine malignancies were recorded, of which 14/5683 (0.26%) were unexpected endometrial carcinomas and 5/5683 (0.08%) were unexpected uterine sarcomas.

CONCLUSION

Preoperative examination in the context of benign hysterectomy must be undertaken with care, and patients should be educated about the very slight possibility of a malignant diagnosis.

The fate of human SUSD2+ endometrial mesenchymal stem cells during decidualization

Regeneration of the endometrial stromal compartment in premenopausal women is likely maintained by the perivascular endometrial mesenchymal stem/stromal cells (eMSC) expressing sushi domain containing 2 (SUSD2). The fate of SUSD2+ eMSC during pregnancy and their role in decidualization is not fully known. The aim of our study was to determine the effect of progesterone on the stemness of the SUSD2+ eMSC isolated from non-pregnant uterine samples. Secondary objectives were to characterize the functional capacity including differentiation and clonogenicity assays of SUSD2+ eMSC isolated from decidua at full term and compare it to the capacity of those isolated from non-pregnant uterine samples. Progesterone treatment induced changes in the decidual gene expression profile in non-pregnant SUSD2+ eMSC. Data analysis of a publicly available single cell RNA-seq data set revealed differential expression of several mesenchymal and epithelial signature genes between the SUSD2+ eMSC and the decidual stromal cells, suggesting mesenchymal-to-epithelial transition occurs during decidualization. Histological analysis revealed a significantly lower abundance of SUSD2+ eMSC in 1st trimester and full term samples compared to non-pregnant samples, p = 0.0296 and 0.005, respectively. The differentiation and the colony forming capacity did not differ significantly between the cells isolated from non-pregnant and pregnant uterine samples. Our results suggest that SUSD2+ eMSC undergo decidualization in vitro, while maintaining MSC plasma membrane phenotype. Human eMSC seem to play an important role in the course of endometrial decidualization and embryo implantation. Pregnancy reduced the abundance of SUSD2+ eMSC, however eMSC function remains intact.

The influence of biological and lifestyle factors on circulating cell-free DNA in blood plasma

Research and clinical use of circulating cell-free DNA (cirDNA) is expanding rapidly; however, there remain large gaps in our understanding of the influence of lifestyle and biological factors on the amount of cirDNA present in blood. Here, we review 66 individual studies of cirDNA levels and lifestyle and biological factors, including exercise (acute and chronic), alcohol consumption, occupational hazard exposure, smoking, body mass index, menstruation, hypertension, circadian rhythm, stress, biological sex and age. Despite technical and methodological inconsistences across studies, we identify acute exercise as a significant influence on cirDNA levels. Given the large increase in cirDNA induced by acute exercise, we recommend that controlling for physical activity prior to blood collection is routinely incorporated into study design when total cirDNA levels are of interest. We also highlight appropriate selection and complete reporting of laboratory protocols as important for improving the reproducibility cirDNA studies and ability to critically evaluate the results.

Clinical and biochemical discriminants between functional hypothalamic amenorrhoea (FHA) and polycystic ovary syndrome (PCOS)

BACKGROUND

Secondary oligo/amenorrhoea occurs in 3%-5% of women of reproductive age. The two most common causes are polycystic ovary syndrome (PCOS) (2%-13%) and functional hypothalamic amenorrhoea (FHA) (1%-2%). Whilst both conditions have distinct pathophysiology and their diagnosis is supported by guidelines, in practice, differentiating these two common causes of menstrual disturbance is challenging. Moreover, both diagnoses are qualified by the need to first exclude other causes of menstrual disturbance.

AIM

To review clinical, biochemical and radiological parameters that could aid the clinician in distinguishing PCOS and FHA as a cause of menstrual disturbance.

RESULTS

FHA is uncommon in women with BMI > 24 kg/m2 , whereas both PCOS and FHA can occur in women with lower BMIs. AMH levels are markedly elevated in PCOS; however, milder increases may also be observed in FHA. Likewise, polycystic ovarian morphology (PCOM) is more frequently observed in FHA than in healthy women. Features that are differentially altered between PCOS and FHA include LH, androgen, insulin, AMH and SHBG levels, endometrial thickness and cortisol response to CRH. Other promising diagnostic tests with the potential to distinguish these two conditions pending further study include assessment of 5-alpha-reductase activity, leptin, INSL3, kisspeptin and inhibin B levels.

CONCLUSION

Further data directly comparing the discriminatory potential of these markers to differentiate PCOS and FHA in women with secondary amenorrhoea would be of value in defining an objective probability for PCOS or FHA diagnosis.

MRI of the endometrium - from normal appearances to rare pathology

MRI was recently included as a standard pre-operative diagnostic tool for patients with endometrial cancer. MR findings allow a better risk assessment and ultimately guides the surgical planning. Therefore, it is vital that the radiological interpretation is as accurate as possible. This requires essential knowledge regarding the appropriate MRI protocol, as well as different appearances of the endometrium, ranging from normal peri- and post-menopausal changes, benign findings (e.g. endometrial hyperplasia, polyp, changes due to exogenous hormones) to common and rare endometrium-related malignancies. Furthermore, this review will emphasize the role of MRI in staging endometrial cancer patients and highlight pitfalls that could result in the underestimation or overestimation of the disease extent.

Ultrasound features help identify patients who can undergo noninvasive management for suspected retained products of conception: a single institutional experience

OBJECTIVES

To evaluate ultrasound (US) features associated with successful noninvasive management for suspected retained products of conception (RPOC).

METHODS

In this IRB-approved retrospective study, the radiology report database was queried for pelvic US with keywords of postpartum hemorrhage (PPH) and/or RPOC over a 2-year period. Follow-up exams, US exams without clinical follow-up, suboptimal image quality, and > 1 year from delivery or pregnancy termination were excluded. Charts were reviewed for clinical presentation and management. Two radiologists reviewed images for endometrial thickness, endometrial echogenicity, endometrial vascularity, and enhanced myometrial vascularity (EMV), as well as inner myometrial peak systolic velocity (PSV) and resistive index (RI) where available. Features were assessed for associations with management approach, and test characteristics were calculated.

RESULTS

Initial query yielded 196 exams, and 48 were excluded. A total of 148 patients were included. Mean age was 34.2 years (21-47), and mean time from delivery or pregnancy termination was 40.4 days (0-223). 81 (55%) underwent noninvasive management: 72 (48%) expectant and 9 (6%) medical. 67 (45%) underwent invasive management: 60 (41%) surgical and 7 (5%) uterine artery embolization. There was substantial inter-reader agreement for assessment of EMV (K = 0.78) and endometrial vascularity (K = 0.72). Thin endometrial stripe, avascular endometrium, and absence of EMV were associated with successful noninvasive management (p < 0.05). Thin endometrium (< 10 mm) had specificity (90%), PPV (88%), and likelihood ratio (5.91) in predicting successful noninvasive management.

CONCLUSION

Endometrial thickness < 10 mm, avascular endometrium, and absence of EMV are the sonographic features associated with successful noninvasive management for PPH or suspected RPOC.

Thickened Endometrium: When to Intervene? A Clinical Conundrum

The endometrium is a dynamic target organ in a woman's reproductive life. It undergoes cyclical change regulated by the fine balance between oestrogen and progesterone. The endometrial thickness (ET) varies according to the phases of the menstrual cycle. Endometrium contains both oestrogen and progesterone receptors, which respond to above hormones, irrespective of whether the woman is in reproductive or menopausal phase. Abundance of oestrogen leads to endometrial hyperplasia, and paucity causes endometrial atrophy. The initial best modality of assessing ET or aberration is high resolution transvaginal ultrasonogram. Thickened endometrium is always a clinical conundrum. Dilemma does remain as to the thickness of endometrium which requires intervention, mostly in symptomatic pre and perimenopausal women. In post-menopausal women with bleeding, the cut-off of ET that warrants investigation is almost defined. However, the cut-off value of ET in asymptomatic postmenopausal women; beyond which intervention is required, is still debated. Dilemma also exists about the cut-off of ET in both symptomatic and asymptomatic women on HRT and Tamoxifen. This article will discuss the above issues and reach at some consensus about the cut-off of ET after critical analysis of evidence and experience and will help clinicians in arriving at a proper decision in dealing with such clinically confounding situations.

Total and endothelial cell-derived cell-free DNA in blood plasma does not change during menstruation

Assays measuring cell-free DNA (cfDNA) in blood have widespread potential in modern medicine. However, a comprehensive understanding of cfDNA dynamics in healthy individuals is required to assist in the design of assays that maximise the signal driven by pathological changes, while excluding fluctuations that are part of healthy physiological processes. The menstrual cycle involves major remodelling of endometrial tissue and associated apoptosis, yet there has been little investigation of the impact of the menstrual cycle on cfDNA levels. Paired plasma samples were collected from 40 healthy women on menstruating (M) and non-menstruating (NM) days of their cycle. We measured total cfDNA by targeting ALU repetitive sequences and measured endothelial-derived cfDNA by methylation-specific qPCR targeting an endothelium-unique unmethylated CDH5 DNA region. CfDNA integrity and endothelial cfDNA concentration, but not total cfDNA, are consistent across time between NM and M. No significant changes in total (ALU-115 p = 0.273; ALU-247 p = 0.385) or endothelial cell specific (p = 0.301) cfDNA were observed, leading to the conclusion that menstrual status at the time of diagnostic blood collection should not have a significant impact on the quantitation of total cfDNA and methylation-based cancer assays.

A prospective, randomized study of Toremifene vs. tamoxifen for the treatment of premenopausal breast cancer: safety and genital symptom analysis

BACKGROUND

Toremifene (TOR) is a selective oestrogen receptor modulator (SERM) and has comparable efficacy to that of tamoxifen (TAM) in breast cancer patients. Herein, we compared the safety of TOR to that of TAM in the adjuvant treatment of premenopausal breast cancer.

METHODS

This was a prospective randomized and open-label clinical study. Premenopausal patients with hormonal receptor (HR)-positive early breast cancer were randomly assigned (1:1) to receive TOR) or TAM treatment. The follow-up period was 1 year. The primary end point was the incidence of ovarian cysts, and secondary end points were the incidence of endometrial thickening, changes in female hormones, the incidence of fatty liver, changes in the modified Kupperman index (mKMI) and changes in quality of life.

RESULTS

There were 92 patients in the final analysis. The incidences of ovarian cysts were 42.6% in the TOR group and 51.1% in the TAM group (p = 0.441). Forty-one patients (87.2%) in the TOR group and 36 patients (80.0%) in the TAM group experienced endometrial thickening (p = 0.348). The proportions of patients with fatty liver were 31.9% in the TOR group and 26.7% in the TAM group (p = 0.581). No significant differences in the mKMI or quality of life were observed between the two groups.

CONCLUSIONS

TOR and TAM have similar side effects on the female genital system and quality of life in premenopausal early breast cancer patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02344940. Registered 26 January 2015 (retrospectively registered).

Measurement of endometrial thickness in premenopausal women in office gynecology

Purpose

To define the median endometrial thickness (ET) in office gynecology is thought to be important for clinical practice. However, there are few reports about ET that have included the general female population on a large scale. The median ET was determined prospectively in premenopausal women who attended office gynecology for cervical cancer screening.

Methods

In total, 849 women were enrolled. The median ET was determined by using transvaginal ultrasound and the relationships between the ET and various clinical factors were analyzed.

Results

The participants' median age was 38.5 years. The median ET was 8.6 mm (90% and 95% quantiles: 13.8 and 15.8 mm). The ET was not related to their age, symptoms, obstetric history, geographical location, or risk factors for endometrial cancer. In the women with a menstrual cycle length of 28-30 days, the ET was 7 mm on days 1-6, but it increased from 5.4 mm immediately after menstruation (day 7 or 8) to 9.2 mm on days 13-14. Subsequently, the ET increased further to 11.1 mm on day 18.

Conclusion

In all the women, the upper limit of the ET was 13.8 mm and 15.8 mm in the 90% and 95% quantile, respectively, in office gynecology.