Evaluation of endometrial thickness with transvaginal ultrasonography and histopathology in premenopausal women with abnormal vaginal bleeding

Diagnosis of abnormal uterine bleeding based on the FIGO classification: A systematic review and expert opinions

AIM

To present evidence- and consensus-based recommendations for the diagnosis abnormal uterine bleeding.

METHODS

A literature search for the diagnosis of abnormal uterine bleeding was systematically conducted in PubMed from its inception to May 2024 to identify meta-analyses, reviews, randomized controlled trials, and clinical trials, followed by an additional systematic search using keywords. Based on this evidence, an expert panel developed background, clinical, and future research questions.

RESULTS

Based on a systematic search and the collected evidence, we developed five background questions, three clinical questions, and one future research question, with recommendations and/or statements. Evidence and recommendations are provided for clinical questions. Additionally, we developed a flowchart for diagnosis showing the steps of the examinations to be performed.

CONCLUSION

The flowchart and nine recommendations/statements specify an efficient diagnostic procedure to differentiate abnormal causative diseases of uterine bleeding optimized for actual Japanese situations.

A Comprehensive Approach: Correlating Ultrasound Imaging with Endometrial Histopathological Analysis in Perimenopausal Women with Heavy Menstrual Bleeding

INTRODUCTION

Abnormal uterine bleeding (AUB) is a common troublesome symptom in the perimenopausal age group. The most common type of AUB in this age group is heavy menstrual bleeding. There is a risk of endometrial carcinoma and atypical endometrial hyperplasia in women with AUB in the age group of 40-50 years. Hence early evaluation is of paramount importance in managing women with perimenopausal heavy menstrual bleeding. The current study was undertaken to study the correlation between ultrasound findings and various benign and malignant endometrial histologies in perimenopausal women with heavy menstrual bleeding.

METHODOLOGY

Women aged 40-55 years presenting with heavy menstrual bleeding at the gynaecology outpatient department at Sree Balaji Medical College and Hospital, Chennai, India, were included in the study. Patients on anti-platelet and anti-coagulation therapy and patients already on hormonal treatment for heavy menstrual bleeding were excluded from the study. The demographic factors, symptom profiles, ultrasound findings, and histopathological reports were tabulated and analysed.

RESULTS

Of the 147 women included in the study, 75 (51%) were aged 45-50 years and 107 (73%) had two or more pregnancies. Fibroid was the common non-endometrial cause of heavy menstrual bleeding in 52 (35%) cases. The proliferative pattern was the most common non-pathological histology identified in 46 (31%) cases. Endometrial hyperplasia without atypia was the most common pathological histology observed in the study population. Endometrial thickness of more than 8 mm was strongly associated with premalignant or malignant endometrial lesions.

CONCLUSION

Our study has attempted to identify the correlation between ultrasound evaluation of perimenopausal women with heavy menstrual bleeding and endometrial pathology. Ultrasound, being cost-effective and widely available, is proven to be a tool for first-line investigation of perimenopausal women with heavy menstrual bleeding that guides further evaluation and management.

Successful in vitro fertilization following conservative surgery for synchronous endometrioid tumor of ovary and uterus

BACKGROUND

Successful pregnancy outcome in women with synchronous ovarian and endometrial cancers is very rare. We report successful pregnancy outcome in a young woman managed conservatively for synchronous endometrial and ovarian cancer.

CASE PRESENTATION

Thirty years old nulliparous lady presented following exploratory laparotomy, left salpingo-oophorectomy and hysteroscopic polypectomy for left adnexal mass. Histology revealed endometrioid carcinoma of left ovary and moderately differentiated adenocarcinoma in the resected polyp. She underwent staging laparotomy along with hysteroscopy which confirmed above findings without any evidence of further tumor spread. She was treated conservatively with high dose oral progestin (megestrol acetate, 160 mg) and leuprolide acetate 3.75 mg monthly injections for three months along with four cycles of carboplatin and paclitaxel based chemotherapy followed by monthly injection of leuprolide for further three months. After failure of spontaneous conception, she underwent ovulation induction for six cycles along with intrauterine insemination which failed. She underwent in vitro fertilization with donor egg followed by elective cesarean section at 37 weeks of gestation. She delivered a healthy baby of weight 2.7 kg. Intraoperatively 5 × 6 cm right ovarian cyst was found which drained chocolate coloured fluid on puncture and cystectomy was carried out. Histological examination revealed endometrioid cyst of right ovary. Uterus was spared as she wanted to preserve her fertility. She is being followed periodically and is normal nine months following delivery. She is on injection Depot medroxy progesterone acetate once every three months.

Multimodal MRI-Based Radiomics-Clinical Model for Preoperatively Differentiating Concurrent Endometrial Carcinoma From Atypical Endometrial Hyperplasia

Objectives

To develop and validate a radiomics model based on multimodal MRI combining clinical information for preoperative distinguishing concurrent endometrial carcinoma (CEC) from atypical endometrial hyperplasia (AEH).

Materials and Methods

A total of 122 patients (78 AEH and 44 CEC) who underwent preoperative MRI were enrolled in this retrospective study. Radiomics features were extracted based on T2-weighted imaging (T2WI), diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) maps. After feature reduction by minimum redundancy maximum relevance and least absolute shrinkage and selection operator algorithm, single-modal and multimodal radiomics signatures, clinical model, and radiomics-clinical model were constructed using logistic regression. Receiver operating characteristic (ROC) analysis, calibration curves, and decision curve analysis were used to assess the models.

Results

The combined radiomics signature of T2WI, DWI, and ADC maps showed better discrimination ability than either alone. The radiomics-clinical model consisting of multimodal radiomics features, endometrial thickness >11mm, and nulliparity status achieved the highest area under the ROC curve (AUC) of 0.932 (95% confidential interval [CI]: 0.880-0.984), bootstrap corrected AUC of 0.922 in the training set, and AUC of 0.942 (95% CI: 0.852-1.000) in the validation set. Subgroup analysis further revealed that this model performed well for patients with preoperative endometrial biopsy consistent and inconsistent with postoperative pathologic data (consistent group, F1-score = 0.865; inconsistent group, F1-score = 0.900).

Conclusions

The radiomics model, which incorporates multimodal MRI and clinical information, might be used to preoperatively differentiate CEC from AEH, especially for patients with under- or over-estimated preoperative endometrial biopsy.

New Light on Endometrial Thickness as a Risk Factor of Cancer: What Do Clinicians Need to Know?

Transvaginal ultrasound (TVUS) represents an accurate and noninvasive technique to investigate endometrial thickness (ET) in the early diagnosis of endometrial cancer (EC). In the literature, for maximum ET there is no consensus on the cutoff value for normal ET in postmenopause for either symptomatic or asymptomatic women. Most patients with EC present with postmenopausal bleeding (PMB) and in these patients is necessary to perform TVUS to evaluate ET as an indicator for endometrial biopsy. On the contrary, if ET is incidentally detected in postmenopausal patients without bleeding, endometrial sampling for a postmenopausal woman without bleeding should not be routinely performed, although it is estimated that up to 15% of EC occurs in women without vaginal bleeding. The aim of our review was to give clinicians necessary and useful knowledge on the role of TVUS and ET for early detection of EC in their daily routine practice. Based on the most important studies in the literature, we summarized that in premenopausal woman with abnormal uterine bleeding, an optimal cutoff for ET has not yet been established. For postmenopausal women with PMB, at low risk, and ET <4 mm, a follow-up scan could be offered, and for women with ET ≥4 mm, office hysteroscopy-guided endometrial sampling is recommended independently of ET results. On the other hand, in postmenopausal women with PMB and at high risk of EC, office hysteroscopy-guided endometrial sampling is necessary. In postmenopausal women without PMB and ET ≥4 mm, arbitrary endometrial sampling is not recommended, but evaluated case by case based on risk factors. In conclusion, there is broad consensus on the importance of TVUS and the need for further investigation based on risk factors of EC.

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.

ACR Appropriateness Criteria® Abnormal Uterine Bleeding

This publication summarizes the relevant literature for the imaging of patients with symptoms of abnormal uterine bleeding, including initial imaging, follow-up imaging when the original ultrasound is inconclusive, and follow-up imaging when surveillance is appropriate. For patients with abnormal uterine bleeding, combined transabdominal and transvaginal ultrasound of the pelvis with Doppler is the most appropriate initial imaging study. If the uterus is incompletely visualized with the initial ultrasou2nd, MRI of the pelvis without and with contrast is the next appropriate imaging study, unless a polyp is suspected on the original ultrasound, then sonohysterography can be performed. If the patient continues to experience abnormal uterine bleeding, assessment with ultrasound of the pelvis, sonohysterography, and MRI of the pelvis without and with contrast would be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

A Novel Risk-Scoring Model for Prediction of Premalignant and Malignant Lesions of Uterine Endometrium Among Symptomatic Premenopausal Women

PURPOSE

Uterine cancer is the second most prevalent cancer of the female genital tract, with 90% of it being of endometrial origin. The aim of this research was to create and validate a risk-scoring model using patients' clinical variables in predicting premalignant and malignant lesions of the uterine endometrium among premenopausal women with abnormal uterine bleeding (AUB).

METHODS

This is a retrospective cohort study conducted at a tertiary hospital of Southern India for a period of 5 years from July 2014 to August 2019, including women aged ≤55 years who had AUB and underwent endometrial biopsy. The incidence of atypical endometrial hyperplasia (AEH) and endometrial cancer (EC) was determined, and clinical and demographic variables were compared among cases (AEH/EC) and controls (no AEH/EC) using simple logistic regression. A risk-scoring model was derived and validated with a split-sample internal validation method.

RESULTS

A total of 472 premenopausal women presenting with AUB were included in the study. There were 20 women (4.2%) with AEH and eight (1.7%) with EC. We found a statistically significant positive correlation of an anovulatory pattern of bleeding (odds ratio [OR]=3.4; p=0.009), age ≥45 years (OR=1.12; p=0.01), body mass index (BMI) ≥30 kg/m2 (OR=2.46; p=0.04) and diabetes mellitus (OR=3.00; p=0.02) with a higher risk of AEH/EC diagnosis upon histopathological examination of endometrial biopsy specimens of the study population. A risk-scoring model (PAD30) was created using these variables to predict premalignant and malignant endometrial lesions. The best cutoff score derived by the receiver operating characteristics (ROC) curve, of ≥5, had a sensitivity of 85.7% and specificity of 87.6% with an area under the curve (AUC) of 0.84 (95% CI 0.75-0.93; p=0.04). With a positive likelihood ratio of 6.91, our prediction model increases the post-test probability of AEH/EC to 30.6% from 6% of the pre-test probability.

CONCLUSION

The proposed model demonstrated a moderate diagnostic accuracy in predicting premalignant and malignant lesions of the uterine endometrium among symptomatic premenopausal women.

Comparison of diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography, and hysteroscopy in evaluating the endometrial polyps in women with abnormal uterine bleeding: a systematic review and meta-analysis

Introduction

In women with abnormal uterine bleeding (AUB), endometrial polyps are a frequent finding, and the risk of a focal (pre)malignancy in a polyp is up to 6%. Because of this reported risk, the detection of polyps in these women is important.

Aim

To evaluate and compare the diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography, and hysteroscopy in detecting endometrial polyps in women with AUB.

Material and methods

The searches were conducted by two independent researchers to find the relevant studies published from 1/1/2009 until the end of 30/06/2019. We searched for published literature in English language in MEDLINE, EMBASETM, The Cochrane Library, and Trip database. For literature published in other languages, we searched national databases (Magiran and SID), KoreaMed, and LILACS. The risk of bias of every article was evaluated by using QUADAS-2.

Results

After selection and quality assessment, 11 studies were included. Based on the random effect model the total prevalence of endometrial polyps in women with abnormal uterine bleeding was 38%. The sensitivity and specificity of saline infusion sonohysterography in diagnosis of endometrial polyps were 0.87 and 0.86, respectively. The sensitivity and specificity of transvaginal ultrasonography were 0.62 and 0.73 and the sensitivity and specificity of hysteroscopy were 0.92 and 0.85, respectively.

Conclusions

Although that sonohysterography is a safe and relatively cheap method, which allows ruling out or confirming endometrial polyps, it cannot be replaced with hysteroscopy due to the fact that hysteroscopy combined with biopsy is the gold standard for ruling out malignancies in an endometrial polyp.

Prediction of Endometrial Hyperplasia and Cancer among Premenopausal Women with Abnormal Uterine Bleeding

Objective

To create a prediction model including clinical variables for the prediction of premalignant/malignant endometrial pathology in premenopausal women with abnormal uterine bleeding (AUB).

Methods

This is an observational retrospective study including 240 premenopausal women with AUB referred to diagnostic hysteroscopy. Based on the presence of endometrial hyperplasia (EH) or cancer (EC), the women were divided into cases (EH/EC) and controls (no EH/EC). Univariate, stepwise logistic regression and ROC curve analysis were performed.

Results

12 women had EH/EC (5%). Stepwise logistic regression analysis showed that EH/EC associated significantly with BMI ≥ 30 (OR=7.70, 95% CI 1.90 to 31.17), diabetes (OR=9.71, 95% CI 1.63 to 57.81), and a thickened endometrium (OR=1.20, 95% CI 1.08 to 1.34, criterion > 11 mm). The AUC was 0.854 (95% confidence intervals 0.803 to 0.896, p<0.0001). Considering the pretest probability for EH/EC of 5%, the prediction model with a positive likelihood ratio of 8.14 showed a posttest probability of 30%. The simultaneous presence of two or three risk factors was significantly more common in women with EH/EC than controls (50% vs. 6.6 and 25% vs. 0%, respectively, p<0.0001).

Conclusion

When premenopausal vaginal bleeding occurs in diabetic obese women with ET > 11 mm, the percentage of premalignant/malignant endometrial pathology increases by 25%. It is likely that the simultaneous presence of several risk factors is necessary to significantly increase the probability of endometrial pathology.

Risk of synchronous endometrial disorders in women with endometrioid borderline tumors of the ovary

Background

Synchronous endometrial disorders have been poorly studied in women with endometrioid borderline ovarian tumors (EBOT). The aims of this study were to investigate the risk of endometrial disorders among women with EBOT and associated factors, as well as their oncological and fertility outcomes.

Results

This retrospective study included 33 women with EBOT. Their mean age was 41.9 years, and endometria were evaluated in 25 of these patients. The prevalence of synchronous endometrial disorders was 52.0% (n = 13/25) and this incidence was 41.4% (n = 46/111) after systematic analysis. Univariable analysis showed that EBOT patients who were younger, nulliparous, and had experienced abnormal vaginal bleeding were more likely to have synchronous endometrial disorders. The median follow-up was 54 months (range: 14-250 months), and three patients (10.3%) developed recurrences. No deaths due to EBOT were recorded. Among the nine nulliparous women treated conservatively who were attempting to conceive, only one (11.1%) pregnancy resulted in a live birth.

Conclusions

Synchronous endometrial disorders are common in women with EBOT, especially in those who are younger, nulliparous, and have experienced abnormal vaginal bleeding. Thus, endometrial sampling should be performed in women with EBOT undergoing conservative surgery, and a hysterectomy should be performed in cases requiring radical treatment.

Identification and functional analyses of differentially expressed metabolites in early stage endometrial carcinoma

Diagnosis of endometrial cancer is primarily based on symptoms and imaging, with early-stage disease being difficult to diagnose. Therefore, development of potential diagnostic biomarkers is required. Metabolomics, a quantitative measurement of the dynamic metabolism in living systems, can be applied to determine metabolite profiles in different disease states. Here, serum metabolomics was performed in 46 early stage endometrial cancer patients and 46 healthy volunteers. In addition, the effect of identified metabolites on tumor cell behavior (invasion, migration, proliferation, apoptosis and autophagy) was examined in endometrial cancer cell lines. Compared with controls, phenylalanine, indoleacrylic acid (IAA), phosphocholine and lyso-platelet-activating factor-16 (lyso-PAF) were differentially detected in patients. Functional analyses demonstrated that IAA, PAF and phenylalanine all dose-dependently inhibited tumor cell invasion and migration, and suppressed cell proliferation. PAF also induced tumor cell apoptosis and autophagy, while phenylalanine had no effect on apoptosis or autophagy. IAA triggered apoptosis and had a biphasic effect on autophagy: inhibiting autophagy with doses <1 mmol/L but inducing at 1 mmol/L. Interestingly, the alterations in proliferation, apoptosis and autophagy caused by 1 mmol/L IAA, were all reversed by the concomitant treatment of tryptophan (100 μmol/L). Phosphocholine inhibited tumor cell invasion and migration, and promoted cell proliferation and autophagy, all in a dose-dependent manner. Phosphocholine also protected cells from TNF-α-induced apoptosis. In conclusion, 4 serum metabolites were identified by serum metabolomics in endometrial cancer patients and functional analyses suggested that they may play roles in modulation of tumor cell behavior, although their exact mode of action still needs to be determined.

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.

Targeted Proteomics Identifies Proteomic Signatures in Liquid Biopsies of the Endometrium to Diagnose Endometrial Cancer and Assist in the Prediction of the Optimal Surgical Treatment

Purpose: Endometrial cancer (EC) diagnosis relies on the observation of tumor cells in endometrial biopsies obtained by aspiration (i.e., uterine aspirates), but it is associated with 22% undiagnosed patients and up to 50% of incorrectly assigned EC histotype and grade. We aimed to identify biomarker signatures in the fluid fraction of these biopsies to overcome these limitations.Experimental Design: The levels of 52 proteins were measured in the fluid fraction of uterine aspirates from 116 patients by LC-PRM, the latest generation of targeted mass-spectrometry acquisition. A logistic regression model was used to assess the power of protein panels to differentiate between EC and non-EC patients and between EC histologic subtypes. The robustness of the panels was assessed by the "leave-one-out" cross-validation procedure performed within the same cohort of patients and an independent cohort of 38 patients.Results: The levels of 28 proteins were significantly higher in patients with EC (n = 69) compared with controls (n = 47). The combination of MMP9 and KPYM exhibited 94% sensitivity and 87% specificity for detecting EC cases. This panel perfectly complemented the standard diagnosis, achieving 100% of correct diagnosis in this dataset. Nine proteins were significantly increased in endometrioid EC (n = 49) compared with serous EC (n = 20). The combination of CTNB1, XPO2, and CAPG achieved 95% sensitivity and 96% specificity for the discrimination of these subtypes.Conclusions: We developed two uterine aspirate-based signatures to diagnose EC and classify tumors in the most prevalent histologic subtypes. This will improve diagnosis and assist in the prediction of the optimal surgical treatment. Clin Cancer Res; 23(21); 6458-67. ©2017 AACR.

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

BACKGROUND AND AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

Objective

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

Methods

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

Results

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

Conclusion

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

Special considerations in early-stage breast cancer patients and survivors

Long-term outcomes for early-stage breast cancer have continued to improve, and more patients are becoming long-term survivors. In addition to patients' concern about risk of developing recurrent disease, they are also concerned about potential toxicities of treatment. Current guidelines for long-term follow-up are reviewed. Potential toxicities of tamoxifen and aromatase inhibitors are reviewed. Management of menopausal symptoms, cancer-related fatigue, and cognitive function is discussed.

Treatment of symptomatic uterine fibroids with green tea extract: a pilot randomized controlled clinical study

Background

Uterine fibroids (UFs, also known as leiomyoma) affect 70% of reproductive-age women. Imposing a major burden on health-related quality-of-life (HRQL) of premenopausal women, UF is a public health concern. There are no effective medicinal treatment options currently available for women with symptomatic UF.

Objectives

To evaluate the efficacy and safety of green tea extract (epigallocatechin gallate [EGCG]) on UF burden and quality of life in women with symptomatic UF, in a double-blinded, placebo-controlled randomized clinical trial.

Methods

A total of 39 reproductive-age women (age 18–50 years, day 3 serum follicle-stimulating hormone <10 \U/mL) with symptomatic UF were recruited for this study. All subjects had at least one fibroid lesion 2 cm³ or larger, as confirmed by transvaginal ultrasonography. The subjects were randomized to oral daily treatment with either 800 mg of green tea extract (45% EGCG) or placebo (800 mg of brown rice) for 4 months, and UF volumes were measured at the end, also by transvaginal ultrasonography. The fibroid-specific symptom severity and HRQL of these UF patients were scored at each monthly visit, using the symptom severity and quality-of-life questionnaires. Student’s t-test was used to evaluate statistical significance of treatment effect between the two groups.

Results

Of the final 39 women recruited for the study, 33 were compliant and completed all five visits of the study. In the placebo group (n = 11), fibroid volume increased (24.3%) over the study period; however, patients randomized to green tea extract (n = 22, 800 mg/day) treatment showed significant reduction (32.6%, P = 0.0001) in total UF volume. In addition, EGCG treatment significantly reduced fibroid-specific symptom severity (32.4%, P = 0.0001) and induced significant improvement in HRQL (18.53%, P = 0.01) compared to the placebo group. Anemia also significantly improved by 0.7 g/dL (P = 0.02) in the EGCG treatment group, while average blood loss significantly decreased from 71 mL/month to 45 mL/month (P = 0.001). No adverse effects, endometrial hyperplasia, or other endometrial pathology were observed in either group.

Conclusion

EGCG shows promise as a safe and effective therapeutic agent for women with symptomatic UFs. Such a simple, inexpensive, and orally administered therapy can improve women’s health globally.

ACR appropriateness criteria(®) on abnormal vaginal bleeding

In evaluating a woman with abnormal vaginal bleeding, imaging cannot replace definitive histologic diagnosis but often plays an important role in screening, characterization of structural abnormalities, and directing appropriate patient care. Transvaginal ultrasound (TVUS) is generally the initial imaging modality of choice, with endometrial thickness a well-established predictor of endometrial disease in postmenopausal women. Endometrial thickness measurements of ≤5 mm and ≤4 mm have been advocated as appropriate upper threshold values to reasonably exclude endometrial carcinoma in postmenopausal women with vaginal bleeding; however, the best upper threshold endometrial thickness in the asymptomatic postmenopausal patient remains a subject of debate. Endometrial thickness in a premenopausal patient is a less reliable indicator of endometrial pathology since this may vary widely depending on the phase of menstrual cycle, and an upper threshold value for normal has not been well-established. Transabdominal ultrasound is generally an adjunct to TVUS and is most helpful when TVUS is not feasible or there is poor visualization of the endometrium. Hysterosonography may also allow for better delineation of both the endometrium and focal abnormalities in the endometrial cavity, leading to hysteroscopically directed biopsy or resection. Color and pulsed Doppler may provide additional characterization of a focal endometrial abnormality by demonstrating vascularity. MRI may also serve as an important problem-solving tool if the endometrium cannot be visualized on TVUS and hysterosonography is not possible, as well as for pretreatment planning of patients with suspected endometrial carcinoma. CT is generally not warranted for the evaluation of patients with abnormal bleeding, and an abnormal endometrium incidentally detected on CT should be further evaluated with TVUS.

Challenges in the gynecologic care of premenopausal women with breast cancer

Premenopausal women with a new diagnosis of breast cancer are faced with many challenges. Providing health care for issues such as gynecologic comorbidities, reproductive health concerns, and vasomotor symptom control can be complicated because of the risks of hormone treatments and the adverse effects of adjuvant therapies. It is paramount that health care professionals understand and be knowledgeable about hormonal and nonhormonal treatments and their pharmacological parameters so they can offer appropriate care to women who have breast cancer, with the goal of improving quality of life. Articles for this review were identified by searching the PubMed database with no date limitations. The following search terms were used: abnormal uterine bleeding, physiologic sex steroids, endometrial ablation, hysteroscopic sterilization, fertility preservation in endometrial cancer, tranexamic acid and breast cancer, menorrhagia treatment and breast cancer, abnormal uterine bleeding and premenopausal breast cancer, levonorgestrel IUD and breast cancer, tamoxifen and gynecologic abnormalities, tamoxifen metabolism, hormones and breast cancer risk, contraception and breast cancer, pregnancy and breast cancer, and breast cancer and infertility treatment.