Could body mass index be an indicator for endometrial biopsy in premenopausal women with heavy menstrual bleeding?

Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynaecologists and Obstetricians (CNGOF)

OBJECTIVE

To provide French guidelines for the management of women with abnormal uterine bleeding (AUB).

DESIGN

A consensus committee of 26 experts was formed. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding (i.e. pharmaceutical or medical device companies). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The last guidelines from the Collège National des Gynécologues et Obstétriciens Français on the management of women with AUB were published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescents; idiopathic AUB; endometrial hyperplasia and polyps; type 0-2 fibroids; type 3 or higher fibroids; and adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and evidence profiles were compiled. The GRADE® methodology was applied to the literature review and the formulation of recommendations.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 are strong and 17 weak. No response was found in the literature for 14 questions. We chose to abstain from recommendations rather than providing advice based solely on expert clinical experience.

CONCLUSIONS

The 36 recommendations make it possible to specify the diagnostic and therapeutic strategies for various clinical situations practitioners encounter, from the simplest to the most complex.

Should body mass index replace age to drive the decision for endometrial sampling in premenopausal women with abnormal uterine bleeding?

OBJECTIVE

This study aimed to evaluate risk factors for endometrial intraepithelial neoplasia/malignancy in premenopausal women with abnormal uterine bleeding or oligomenorrhea. Specifically, we aimed to elucidate whether body mass index (BMI) or age confers a higher risk.

STUDY DESIGN

A retrospective cohort study was performed at a large academic center examining risk factors for endometrial hyperplasia/malignancy in premenopausal women undergoing endometrial sampling.

RESULTS

Of the 4170 women ages 18-51 who underwent endometrial sampling from 1987 to 2019, 77 (1.85%) were found to have endometrial intraepithelial neoplasia or malignancy. Clinical predictors of EIN/malignancy in this population included obesity (OR: 3.84, 95%, p < .001), Body mass index [(OR30 vs. 25:2.11, p < .001) and OR35 vs. 30: 1.65, p < .001], Diabetes (OR: 3.6, p-value <.001), hormonal therapy use (OR: 2.93, p < .001), personal history of colon cancer (OR: 9.90, p = .003), family history of breast cancer (OR: 2.65, p < .001), family history of colon cancer (OR: 3.81, p < .001), and family history of endometrial cancer (OR: 4.92, p = .033). Age was not significantly associated with an increased risk of disease. Adjusting for other factors, a model using BMI to predict the risk of EIN/malignancy was more discriminative than a model based on age.

CONCLUSIONS

Increased BMI, may be more predictive of endometrial hyperplasia/malignancy than age in premenopausal women with abnormal uterine bleeding. Modification of evaluation guidelines in a contemporary demographic setting could be considered.

[Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynecologists and Obstetricians (CNGOF)]

OBJECTIVE

To provide French guidelines for the management of women with abnormal uterine bleeding (AUB).

DESIGN

A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, or medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The last guidelines from the Collège national des gynécologues et obstétriciens français (CNGOF) on the management of women with AUB was published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescent; idiopathic AUB; endometrial hyperplasia and polyps; fibroids type 0 to 2; fibroids type 3 and more; adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 present a strong agreement and 17 a weak agreement. Fourteen questions did not find any response in the literature. We preferred to abstain from recommending instead of providing expert advice.

CONCLUSIONS

The 36 recommendations made it possible to specify the diagnostic and therapeutic strategies of various clinical situations managed by the practitioner, from the simplest to the most complex.

Rate of premalignant and malignant endometrial lesion in "low-risk" premenopausal women with abnormal uterine bleeding undergoing endometrial biopsy

Objective

To determine the incidence of endometrial hyperplasia and endometrial cancer (EH/EC) in low-risk premenopausal women with abnormal uterine bleeding (AUB) undergoing endometrial biopsy and to build a predictive model that includes clinical variables for predicting EH/EC in these women.

Methods

This retrospective study was conducted between January 2015 and March 2020. All premenopausal women aged <55 years with AUB who underwent endometrial sampling during a specified time period were included. Data regarding baseline characteristics, sonographic findings, and histological reports were collected from patient record sheets.

Results

During the specified time period, 1,089 premenopausal women underwent endometrial biopsy for AUB. Complete data analysis was done for 1,084 women. Of the endometrial samples, 95.3% revealed benign pathology, whereas 4.7% of the samples had major endometrial pathology EH/EC. On step-wise logistic regression analysis, intermenstrual bleeding (IMB) (OR, 3.15), body mass index (BMI) >25 kg/m² (odds ratio [OR], 4.4705), age >40 years (OR, 1.14), endometrial thickness (ET) >13 mm (OR, 2.59), and hypothyroidism (OR, 1.35) were significantly associated with EH/ EC. Considering the pretest probability for an EH/EC of 4.7%, this prediction model with a likelihood ratio of 14.2% demonstrated a post-test probability of 41% in the presence of the above-mentioned variables.

Conclusion

The risk of EH/EC was lower in low-risk premenopausal women with AUB. However, premenopausal women with IMB aged >40 years, hypothyroidism, BMI >25 kg/m², and thickened endometrium (ET >13 mm) are at high risk of EH/EC; therefore, endometrial biopsy should be considered early in their management plan.

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.

Rate of Significant Endometrial Pathology in Women at Low Risk for Endometrial Hyperplasia or Cancer Presenting with Abnormal Uterine Bleeding

Background and Objectives

To determine the rate of significant endometrial abnormalities in premenopausal women at low risk for endometrial hyperplasia and cancer presenting with abnormal uterine bleeding (AUB).

Patients and Methods

This descriptive study was conducted from January 1, 2016 to March 31, 2019. The inclusion criteria were premenopausal women, 35-50 years, presenting with AUB, low risk for endometrial hyperplasia or endometrial cancer, and having undergone endometrial sampling or uterine curettage. Nulliparous, obesity, diabetes mellitus, polycystic ovary syndrome, chronic anovulation, infertility, tamoxifen therapy and/or a family history of uterine, ovarian, breast and colon cancer were excluded. Data regarding baseline characteristics were collected, and histopathology reports were reviewed.

Results

During the study period, 644 subjects were recruited, 557 of whom had adequate endometrial tissue for histopathology study. The pathology demonstrated benign in most cases (96%). The rate of significant abnormal endometrial pathology was 4% (23 cases) including 19 cases of endometrial hyperplasia without atypia (3.3%), and 4 cases of endometrial cancer (0.7%).

Conclusion

The rate of significant abnormal endometrial pathology in premenopausal women at low risk for endometrial hyperplasia or endometrial cancer presenting with AUB was very low. This information should be incorporated into the counseling process regarding the risks and benefits of endometrial sampling.

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.