Office hysteroscopy and adenomyosis

Junctional zone thickening: an endo-myometrial unit disorder

Adenomyosis is a disease defined by histopathology, mostly of hysterectomy specimens, and classification is challenged by the disagreement of the histologic definition. With the introduction of Magnetic Resonance Imaging (MRI) and two- and three-dimensional ultrasound, the diagnosis of adenomyosis became a clinical entity. In MRI and US, adenomyosis ranges from thickening of the inner myometrium or junctional zone to nodular, cystic, or diffuse lesions involving the entire uterine wall, up to a well-circumscribed adenomyoma or a polypoid adenomyoma. The absence of an accepted classification and the vague and inconsistent terminology hamper basic and clinical research. The sub-endometrial halo seen at US and MRI is a distinct entity, differing from the outer myometrium by its increased nuclear density and vascular structure. The endometrium and the sub-endometrial muscularis or archimetra are of Müllarian origin, while the outer myometrium is non-Mullerian mesenchymal. The junctional zone (JZ) is important for uterine contractions, conception, implantation, and placentation. Thickening of the JZ can be considered inner myometrium adenomyosis, with or without endometrial invasion. Changes in the JZ should be considered a different entity than myometrial clinically associated with impaired conception, implantation, abnormal uterine bleeding, pelvic pain and obstetrical outcome. Pathology of the basal endometrium and JZ is a separate entity and should be identified as an endo-myometrial unit disorder (EMUD).

Diagnosis and Treatment of Adenomyosis with Office Hysteroscopy-A Narrative Review of Literature

INTRODUCTION

Adenomyosis is a common chronic disease in women of reproductive age, characterised by the presence of ectopic endometrial tissue within myometrium. Even though adenomyosis presents with chronic pelvic pain, menorrhagia or abnormal uterine bleeding, dysmenorrhoea, and dyspareunia and is often recognised after hysterectomies. However, the development of ultrasonography and magnetic resonance imaging has improved the pre-operative diagnosis of the disease. Hysteroscopy provides information in real time from the uterine cavity and the offers the possibility of obtaining direct biopsies.

MATERIAL AND METHODS

The literature was searched via Pubmed and Embase with the following headings: diagnosis of adenomyosis or adenomyoma and office hysteroscopy, hysteroscopy findings of adenomyosis or adenomyoma, treatment of adenomyosis or adenomyoma with office hysteroscopy.

RESULTS

The literature showed that hysteroscopy can identify superficial adenomyosis. There are a variety of hysteroscopic images that can be connected with the disease. New equipment like the spirotome has been used to access deeper layers of myometrium and obtain biopsies under direct vision from the adenomyotic areas. Different methods of treatment have been also described, like enucleation of focal superficial adenomyoma, coagulation, evacuation of cystic adenomyosis when the lesion is smaller than 1.5 cm, and resection of adenomyotic nodules in case of bigger lesions (>1.5 cm). Diffuse superficial adenomyosis is also managed by resection.

CONCLUSIONS

Hysteroscopy has revolutionised the approach to adenomyosis. It is a useful tool in assessing mainly superficial adenomyosis. The role of hysteroscopy in surgical management of adenomyosis need to be confirmed with further studies.

Diagnostic Value of Ultrasonography Combined with Hysteroscopy in Intrauterine Space-Occupying Abnormalities

The aim of this study was to analyze the diagnostic significance of ultrasonography combined with hysteroscopy for intrauterine space-occupying abnormalities. A total of 99 patients with uterine space-occupying abnormalities treated in hospitals were enrolled. The patients were divided into three groups according to different disease types: the submucosal myoma group, endometrial polyp group, and placenta residue group, with 33 patients in each group. The differences and diagnostic effects in intrauterine ultrasound, hysteroscopic findings, and surgical histopathology were observed in each group. Outcome measures: it was to compare the sensitivity, specificity, and accuracy of intrauterine ultrasound and angiography for intrauterine space-occupying lesions using surgical and pathological examination methods as the gold standard; the relationship between the location, number, size, appearance, and serosal layer of intrauterine lesions was clearly shown; the location, number, appearance, and echogenicity of space-occupying abnormalities under hysteroscopy were observed. The results showed that the diagnostic rates of endometrial polyps, submucous myoma, and residual placenta were 90.9%, 80.8%, and 72.7%, respectively. However, the sensitivity, specificity, and accuracy of ultrasonography in the diagnosis of endometrial polyps were 90.0%, 66.7%, and 87.9%, respectively; those of hysteroscopy in the diagnosis of endometrial polyps were 96.7%, 66.7%, and 93.9%, respectively; and combined diagnosis was 96.7%, 100.0%, 97.0%, 100.0%, and 75.0%. The sensitivity, specificity, and accuracy of ultrasonography in the diagnosis of submucous myoma of the uterus were 88.9%, 50.0%, and 81.8%, respectively; those of hysteroscopy in the diagnosis of submucous myoma of the uterus were 96.3%, 83.3%, and 93.9%, respectively; and combined diagnosis was 100.0%, 83.3%, 97.0%, 96.4%, and 100.0%. The sensitivity, specificity, and accuracy of ultrasonography in the diagnosis of uteroplacental remnants were 87.5%, 66.7%, and 81.8%, respectively; those of hysteroscopy in the diagnosis of uteroplacental remnants were 91.7%, 77.8%, and 87.9%, respectively; and combined diagnosis was 95.8%, 88.9%, 93.9%, 95.8%, and 88.9%. In summary, ultrasonography combined with hysteroscopy can improve the diagnostic sensitivity and accuracy for intrauterine space-occupying abnormalities.

Opinion paper: gynecological surgery in local anesthesia?

Purpuse

The paracervical block (PCB) is a local anesthesia procedure that can be used to perform gynecological surgeries without the need for further anesthesia. With the PCB, surgeries can be moved from the central operating room to outpatient operating rooms, where they can be performed without the presence of an anesthesia team.

Methods

In this paper, the indications, implementation and limitations of the procedure are discussed.

Conclusion

Especially in times of scarce staff and OR resources during the Corona pandemic, OR capacity can be expanded in this way.

Hysteroscopy and female infertility: a fresh look to a busy corner

Hysteroscopy has evolved from the traditional art of examining the uterine cavity for diagnostic purposes to an invaluable modality to concomitantly diagnose and (see and) treat a multitude of intrauterine pathologies, especially in the field and clinics specialising in female reproduction. This article reviews the literature on the most common cervical, endometrial, uterine and tubal pathologies such as chronic endometritis, endometrial polyps, adenomyosis, endometriosis, endometrial atrophy, adhesions, endometrial hyperplasia, cancer, and uterine malformations. The aim is to determine the efficiency of hysteroscopy compared with other available techniques as a diagnostic and treatment tool and its association with the success of in vitro fertilisation procedures. Although hysteroscopy requires an experienced operator for optimal results and is still an invasive procedure, it has the unique advantage of combining great diagnostic and treatment opportunities before and after ART procedures. In conclusion, hysteroscopy should be recommended as a first-line procedure in all cases with female infertility, and a special effort should be made for its implementation in the development of new high-tech procedures for identification and treatment infertility-associated conditions.

Diagnosing adenomyosis: an integrated clinical and imaging approach

BACKGROUND

Adenomyosis is a benign uterine disorder where endometrial glands and stroma are pathologically demonstrated within the uterine myometrium. The pathogenesis involves sex steroid hormone abnormalities, inflammation, fibrosis and neuroangiogenesis, even though the proposed mechanisms are not fully understood. For many years, adenomyosis has been considered a histopathological diagnosis made after hysterectomy, classically performed in perimenopausal women with abnormal uterine bleeding (AUB) or pelvic pain. Until recently, adenomyosis was a clinically neglected condition. Nowadays, adenomyosis may also be diagnosed by non-invasive techniques, because of imaging advancements. Thus, a new epidemiological scenario has developed with an increasing number of women of reproductive age with ultrasound (US) or magnetic resonance imaging (MRI) diagnosis of adenomyosis. This condition is associated with a wide variety of symptoms (pelvic pain, AUB and/or infertility), but it is also recognised that some women are asymptomatic. Furthermore, adenomyosis often coexists with other gynecological comorbidities, such as endometriosis and uterine fibroids, and the diagnostic criteria are still not universally agreed. Therefore, the diagnostic process for adenomyosis is challenging.

OBJECTIVE AND RATIONALE

We present a comprehensive review on the diagnostic criteria of adenomyosis, including clinical signs and symptoms, ultrasound and MRI features and histopathological aspects of adenomyotic lesions. We also briefly summarise the relevant theories on adenomyosis pathogenesis, in order to provide the pathophysiological background to understand the different phenotypes and clinical presentation. The review highlights the controversies of multiple existing criteria, summarising all of the available evidences on adenomyosis diagnosis. The review aims also to underline the future perspective for diagnosis, stressing the importance of an integrated clinical and imaging approach, in order to identify this gynecological disease, so often underdiagnosed.

SEARCH METHODS

PubMed and Google Scholar were searched for all original and review articles related to diagnosis of adenomyosis published in English until October 2018.

OUTCOMES

The challenge in diagnosing adenomyosis starts with the controversies in the available pathogenic theories. The difficulties in understanding the way the disease arises and progresses have an impact also on the specific diagnostic criteria to use for a correct identification. Currently, the diagnosis of adenomyosis may be performed by non-invasive methods and the clinical signs and symptoms, despite their heterogeneity and poor specificity, may guide the clinician for a suspicion of the disease. Imaging techniques, including 2D and 3D US as well as MRI, allow the proper identification of the different phenotypes of adenomyosis (diffuse and/or focal). From a histological point of view, if the diagnosis of diffuse adenomyosis is straightforward, in more limited disease, the diagnosis has poor inter-observer reproducibility, leading to extreme variations in the prevalence of disease. Therefore, an integrated non-invasive diagnostic approach, considering risk factors profile, clinical symptoms, clinical examination and imaging, is proposed to adequately identify and characterise adenomyosis.

WIDER IMPLICATIONS

The development of the diagnostic tools allows the physicians to make an accurate diagnosis of adenomyosis by means of non-invasive techniques, representing a major breakthrough, in the light of the clinical consequences of this disease. Furthermore, this technological improvement will open a new epidemiological scenario, identifying different groups of women, with a dissimilar clinical and/or imaging phenotypes of adenomyosis, and this should be object of future research.

Symptoms and classification of uterine adenomyosis, including the place of hysteroscopy in diagnosis

Where histology used the presence of glands and/or stroma in the myometrium as pathognomonic for adenomyosis, imaging uses the appearance of the myometrium, the presence of striations, related to the presence of endometrial tissue within the myometrium, the presence of intramyometrial cystic structures and the size and asymmetry of the uterus to identify adenomyosis. Preliminary reports show a good correlation between the features detected by imaging and the histological findings. Symptoms associated with adenomyosis are abnormal uterine bleeding, pelvic pain (dysmenorrhea, chronic pelvic pain, dyspareunia), and impaired reproduction. However a high incidence of existing comorbidity like fibroids and endometriosis makes it difficult to attribute a specific pathognomonic symptom to adenomyosis. Heterogeneity in the reported pregnancy rates after assisted reproduction is due to the use of different ovarian stimulation protocols and absence of a correct description of the adenomyotic pathology. Current efforts to classify the disease contributed a lot in elucidated the potential characteristics that a classification system should be relied on. The need for a comprehensive, user friendly, and clear categorization of adenomyosis including the pattern, location, histological variants, and the myometrial zone seems to be an urgent need. With the uterus as a possible unifying link between adenomyosis and endometriosis, exploration of the uterus should not only be restricted to the hysteroscopic exploration of the uterine cavity but in a fusion with ultrasound.

The Investigation and Management of Adenomyosis in Women Who Wish to Improve or Preserve Fertility

The management of adenomyosis remains a great challenge to practicing gynaecologists. Until recently, hysterectomy has been the only definitive treatment in women who have completed child bearing. A number of nonsurgical and minimally invasive, fertility-sparing surgical treatment options have recently been developed. This review focuses on three aspects of management, namely, (1) newly introduced nonsurgical treatments; (2) management strategies of reproductive failures associated with adenomyosis; and (3) surgical approaches to the management of cystic adenomyoma.

From Clinical Symptoms to MR Imaging: Diagnostic Steps in Adenomyosis

Adenomyosis or endometriosis genitalis interna is a frequent benign disease of women in fertile age. It causes symptoms like bleeding disorders and dysmenorrhea and seems to have a negative effect on fertility. Adenomyosis can be part of a complex genital and extragenital endometriosis but also can be found as a solitary uterine disease. While peritoneal endometriosis can be easily diagnosed by laparoscopy with subsequent biopsy, the determination of adenomyosis is difficult. In the following literature review, the diagnostic methods clinical history and symptoms, gynecological examination, 2D and 3D transvaginal ultrasound, MRI, hysteroscopy, and laparoscopy will be discussed step by step in order to evaluate their predictive value in the diagnosis of adenomyosis.

The Role of Hysteroscopy in the Diagnosis and Treatment of Adenomyosis

Uterine adenomyosis is a common gynecologic disorder in women of reproductive age, characterized by the presence of ectopic endometrial glands and stroma within the myometrium. Dysmenorrhea, abnormal uterine bleeding, chronic pelvic pain, and deep dyspareunia are common symptoms of this pathological condition. However, adenomyosis is often an incidental finding in specimens obtained from hysterectomy or uterine biopsies. The recent evolution of diagnostic imaging techniques, such as transvaginal sonography, hysterosalpingography, and magnetic resonance imaging, has contributed to improving accuracy in the identification of this pathology. Hysteroscopy offers the advantage of direct visualization of the uterine cavity while giving the option of collecting histological biopsy samples under visual control. Hysteroscopy is not a first-line treatment approach for adenomyosis and it represents a viable option only in selected cases of focal or diffuse “superficial” forms. During office hysteroscopy, it is possible to enucleate superficial focal adenomyomas or to evacuate cystic haemorrhagic lesions of less than 1.5 cm in diameter. Instead, resectoscopic treatment is indicated in cases of superficial adenomyotic nodules > 1.5 cm in size and for diffuse superficial adenomyosis. Finally, endometrial ablation may be performed with the additional removal of the underlying myometrium.

Value of ultrasound shear wave elastography in the diagnosis of adenomyosis

BACKGROUND

The aim of the study was to assess the accuracy of ultrasound shear wave elastography in the diagnosis of adenomyosis.

METHODS

One hundred and fifty three patients were examined. Ninety-seven patients were with suspected adenomyosis and 56 patients were with unremarkable myometrium. Adenomyosis was confirmed in 39 cases (A subgroup) and excluded in 14 cases (B subgroup) in the main group based on morphological examination. All patients underwent ultrasound examination using an Aixplorer (Supersonic Imagine, France) scanner with application of shear wave elastography during transvaginal scanning. Retrospective analysis of the elastography criteria against the findings from morphological/histological examination was performed.

RESULTS

The following values of Young's modulus were found in subgroup A (adenomyosis): Emean - 72.7 (22.6-274.2) kPa (median, 5-95th percentiles), Emax - 94.8 (29.3-300.0) kPa, SD - 9.9 (2.6-26.3) kPa; in subgroup B (non adenomyosis) - 28.3 (12.7-59.5) kPa, 33.6 (16.0-80.8) kPa, 3.0 (1.4-15.6) kPa; in the control group - 24.4 (17.9-32.4) kPa, 29.8 (21.6-40.8) kPa, 2.3 (1.3-6.1) kPa, respectively (P < 0.05 for all comparison with subgroup В and the control group). The Emean cut-off value for adenomyosis diagnosis was 34.6 kPa. The sensitivity, specificity, positive predictive value, negative predictive value and area under curve (AUC) were 89.7%, 92.9%, 97.2%, 76.5% and 0.908. The Emax cut-off value was 45.4 kPa (89.7%, 92.9%, 97.2%, 76.5% and 0.907, respectively).

CONCLUSION

This study showed a significant increase of the myometrial stiffness estimated with shear wave elastography use in patients with adenomyosis.

Adenomyosis: a systematic review of medical treatment

Adenomyosis is a heterogeneous gynaecologic condition with a range of clinical presentations, the most common being heavy menstrual bleeding and dysmenorrhoea; however, patients can also be asymptomatic. Several studies support the theory that adenomyosis results from invasion of the endometrium into the myometrium, causing alterations in the junctional zone. These changes are commonly seen on imaging studies, such as transvaginal ultrasound and magnetic resonance imaging. The aim of this review is to discuss the medical approach to the management of adenomyosis symptoms, including pain and abnormal uterine bleeding. The standard treatment of adenomyosis is hysterectomy, but there is no medical therapy to treat the symptoms of adenomyosis while still allowing patients to conceive. Medical therapies using suppressive hormonal treatments, such as continuous use of oral contraceptive pills, high-dose progestins, selective oestrogen receptor modulators, selective progesterone receptor modulators, the levonorgestrel-releasing intrauterine device, aromatase inhibitors, danazol, and gonadotrophin receptor hormone agonists can temporarily induce regression of adenomyosis and improve the symptoms.

Is Hysteroscopy Better than Ultrasonography for Uterine Cavity Evaluation? An Evidence-Based and Patient-Oriented Approach

Evaluation of the uterine cavity is an important part of the gynecological check, especially in symptomatic women and, over the last few decades, a number of technical and technological advancements has allowed a superb investigation of this organ. Traditionally, transvaginal ultrasound (TVUS) has been the first-line diagnostic tool for evaluating uterine diseases, also considering that gynecologists are familiar with the technique since it is included in the basic training in obstetrics and gynecology. Nevertheless, to date “office hysteroscopy” received growing attention since the development of smaller-diameter hysteroscopes which has made it possible to easily perform the hysteroscopy in ambulatory settings, obviating the need for anesthesia and dilatation of the cervical canal.

According to our overview, none of the available methods for endometrial evaluation are ideal and each one has pros and cons. TVUS allows assessment of both the myometrium and the endometrium and typically offers greater patient comfort, but it has a higher false-negative rate in diagnosing focal intrauterine pathology. On the other hand, office hysteroscopy has the advantage of providing (most of the time) a real-time diagnosis avoiding anxiety, inconvenience and costs associated with follow-up appointments. The main advantage of the office hysteroscopy on the TVUS is the possibility to perform an operative phase if necessary during the examination itself. In fact, the modern smaller-diameter hysteroscopes have a working channel through which operative miniaturized instruments (mechanical instruments or bipolar electrodes) can be introduced, allowing the performance of target-eye biopsies and the “instant” treatment of most of uterine diseases in outpatient settings.

Comparison of uterine and tubal pathology identified by transvaginal sonography, hysterosalpingography, and hysteroscopy in female patients with infertility

Background

The causes of female infertility are multifactorial and necessitate comprehensive evaluation including physical examination, hormonal testing, and imaging. Given the associated psychological and financial stress that imaging can cause, infertility patients benefit from a structured and streamlined evaluation. The goal of such a work up is to evaluate the uterus, endometrium, and fallopian tubes for anomalies or abnormalities potentially preventing normal conception. To date, the standard method for assessing these structures typically involves some combination of transvaginal sonography (TVS), hysterosalpingography (HSG), and hysteroscopy (HSC). The goal of this review is to compare the diagnostic accuracy of TVS, HSG, and HSC for diagnosing abnormalities in infertility patients to determine if all studies are necessary for pre-treatment evaluation.

Results

We identified infertility patients prior to initiation of assisted reproductive technology who had baseline TVS, HSG, and HSC within 180 days of each other. From medical record review, we compared frequencies of each finding between modalities. Of the 1274 patients who received a baseline TVS over 2 years, 327 had TVS and HSG within 180 days and 55 patients had TVS, HSG and HSC. Of the 327, TVS detected fibroids more often than HSG (74 vs. 5, p < .0001), and adenomyosis more often than HSG (7 vs. 2, p = .02). HSG detected tubal obstruction more often than TVS (56 vs. 8, p = .002). Four (1.2 %) patients had endometrial polyps on both HSG and TVS.

In the 55 patients with HSG, TVS, and HSC, HSC identified endometrial polyps more often than TVS (10 vs. 1, p = .0001) and HSG (10 vs. 2, p = .0007). TVS detected more fibroids than HSC (17 vs. 5, p < .0001). Tubal obstruction was identified more often by HSG than HSC (19 vs. 5, p < .0001).

Conclusions

TVS is superior for evaluation of myometrial pathology. HSG is superior for evaluation of tubal pathologies. Endometrial pathologies are best identified with HSC.

Pregnancy Outcome after Office Microhysteroscopy in Women with Unexplained Infertility

Background

Hysteroscopy offers diagnostic accuracy and the ability to treat uterine pathology. The current study aimed to review the findings and feasibility of the proposed office-based diagnostic and operative microhysteroscopy in previously diagnosed wom- en with unexplained infertility and to evaluate the post-microhysteroscopic pregnancy outcome in a-year follow-up period.

Materials and Methods

This prospective controlled study was conducted between 2006 and 2013. Two hundreds women with unexplained infertility were randomized into two groups: A. study group including 100 women recruited for office micohysteroscopic session and B. control group including 100 without the proposed microhysteroscopic intervention. A malleable fiberoptic 2-mm, 0 and 30 degrees angled hysteroscopy along with an operative channel for grasping forceps, scissors, or coaxial bipolar electrode were used for both diagnostic and operative indications. The findings, complications, and patient tolerance were recorded. A-year follow-up of pregnancy outcome for both groups was also performed.

Results

Seventy cases (70%) of patients had a normal uterine cavity. Twenty wom- en (20%) had endometrial polyps. Other pathology included submucous myomas in 3 cases (3%), intrauterine adhesions in 3 cases (3%), polypoid endometrium in 3 cases (3%), and bicornuate uterus in one case (1%). The pathological findings were treated in all patients without complication. Also a-year follow-up of the to- tal developing cumulative pregnancy rate (CPR) was evaluated in groups A and B (control). Group A revealed the total CPR of 28.5%, among which 25% in women without pathology, 40% in women with endometrial polyps, 23% in women with adhesions, 33% in women with polypoid endometrium, and 21% in those with bi- cornuate uterus. However, A-year follow-up of spontaneous pregnancy outcome in group B showed a total CPR of 15%.

Conclusion

Women tolerance, safety, and feasibility of simultaneous operative correc- tion make the proposed office microhysteroscopy an ideal and routine procedure in order to diagnose and to treat missed intrauterine abnormalities, especially in cases with un- explained infertility, with additional improvement of the pregnancy outcome after the procedure.

Rare case of giant cystic adenomyoma mimicking a uterine malformation, diagnosed and treated by hysteroscopy

We describe a case of giant cystic uterine adenomyoma that was diagnosed and treated by hysteroscopy. In a 27-year-old woman with menometrorrhagia, severe dysmenorrhea, and chronic pelvic pain, pelvic ultrasonography revealed an enlarged uterine cavity filled with homogeneous low echogenic fluid content. A large cornual hematometra of 8.0 cm in diameter in a bicornuate uterus was suspected, and this hypothesis was also supported by magnetic resonance imaging findings. On the contrary, hysteroscopy revealed a bilocular huge cystic lesion of the posterior uterine wall that was removed by means of monopolar loop resection. The operative finding and the histopathologic examination confirmed the diagnosis of cystic adenomyoma of the uterus. Hysteroscopy may represent a valid tool for diagnosis and minimally invasive treatment of cystic adenomyoma, including those of large volume. Its use is helpful in differential diagnosis between cystic adenomyoma and uterine malformations as a possible cause of pelvic pain.

Hysteroscopic diagnosis and excision of myometrial cystic adenomyosis

In 1908, Cullen described the first cases of cystic adenomyosis in his textbook on adenomyomata. Although not very common, with the introduction of noninvasive imaging techniques such as magnetic resonance imaging (MRI) and 3-D transvaginal ultrasound, an increasing number of cases have been reported. Patients primarily complain of severe dysmenorrhea, chronic pelvic pain, and dysfunctional uterine bleeding. Currently, it is unclear whether adenomyosis and, more specifically, cystic adenomyosis can be an underlying reason for impaired fertility and reproductive outcome. With the postponement of childbearing, the number of patients with adenomyosis and cystic adenomyosis seeking fertility treatment is increasing. Therefore, in these patients, uterine exploration should include not only the evaluation of the endometrial cavity but also the exploration of the sub-endometrial zone. Indirect imaging techniques, combined with office mini-hysteroscopy, offer the possibility of complete uterine exploration. Two patients with cystic adenomyosis are described in this paper: one had the chief complaint of menorrhagia and the other was referred for evaluation of infertility and severe dysmenorrhea. The aim of these case reports is to present hysteroscopic dissection and ablation of adenomyotic cysts as an alternative procedure for the surgical management of this condition.

Coexistence of adenomyosis in women operated for benign gynecological diseases

BACKGROUND

To compare demographic, clinical and histopathological characteristics of women diagnosed with adenomyosis (AG) after hysterectomy to those of women diagnosed with leiomyoma (LG) and to investigate the predisposing factors for AG.

METHODS

This study was carried out on 204 patients who underwent gynecologic surgery for various indications except for gynecologic malignancy between January 2005 and December 2009 and whose histopathological analysis of hysterectomy/myomectomy specimen revealed either AG or LG. Women with AG and those with LG were compared with respect to age, parity, menstrual pattern, history of induced abortion, history of prior uterine surgery, smoking, dysmenorrhea, dyspareunia, chronic pelvic pain and coexisting endometrial and ovarian pathologies.

RESULTS

The mean age of our patients was 51 ± 8 years (range 28-85), 40% of them were postmenopausal, and 64% had a history of uterine surgery. The mean age (p = 0.014), gravida (p = 0.018), parity (p = 0.017) and previous endometrial sampling (p < 0.01) were significantly higher in AG. Main symptoms were abnormal uterine bleeding (39%), dysmenorrhea (63%) and nonmenstrual pelvic pain (62%). Age (p = 0.01), menometrorrhagia (p = 0.02) and endometrial sampling (p < 0.01) were the significant covariants in binary logistic regression for AG.

CONCLUSION

AG is an enigmatic disease frequently causing gynecologic complaints and endomyometrial junction deterioration during endometrial sampling may be a trigger point for developing AG.

Relationship between adenomyosis and uterine polyps

OBJECTIVE

To evaluate whether adenomyosis is associated with uterine polyps.

STUDY DESIGN

To perform an ethical human study, we planned a large retrospective observational study covering the entire patient population of the ULSS 17-Veneto district who underwent resectoscopy in 2007 and 2008 (959 patients). We enrolled all the patients underwent resectoscopy with resection of uterine polyps, with resection of myomas, with endometrial ablations by slicing, and with endometrial biopsies in both the presence and absence of hysteroscopically visible lesions. The diagnosis of adenomyosis was made by pathological examination of tissue specimens obtained using a resectoscope loop. Multivariate logistic regression was performed to determine if adenomyosis was one of the various risk factors for the presence and number of uterine polyps. Statistical Package for the Social Sciences (SPSS 16.0) was employed, and p≤0.05 was the minimum for significance.

RESULTS

Age (p=0.005), adenomyosis (p=0.013), high fasting glucose levels (p=0.004), and hypertension (p=0.045) were significantly associated with endometrial polyps. The presence of multiple endometrial polyps seemed to be associated with the presence of adenomyosis (p=0.016). The presence of cervical polyps was significantly associated only with presence of adenomyosis (p=0.002). The presence of multiple cervical polyps did not seem to be influenced by any of the variables considered.

CONCLUSIONS

The results clearly demonstrate an association between adenomyosis and uterine polyps. The pathogenetic role of adenomyosis in the development of polyps should therefore be investigated further.

Feasibility of office hysteroscopy through the "see and treat technique" in private practice: a prospective observational study

PURPOSE

The purpose of the study was to examine the feasibility of office hysteroscopy through the no-touch "see and treat technique" in a routine basis in private practice.

METHODS

In the private practice of two trained gynecologists, women with an indication for further investigation of the uterine cavity were treated with the technique. A total of 112 consecutive women were prospectively allocated to a "no-touch" and "see and treat" technique of hysteroscopy. Neither anaesthesia nor analgesia was used as soon as criteria were met. Hysteroscopy was performed using a rigid 3.4-mm hysteroscope and a medium of 0.9% saline.

RESULTS

Treatment efficacy and patient compliance were evaluated through scores on a visual analogue scale (VAS) for pain, complications and success rates, along with the symphony between hysteroscopic findings and histology. The patients' pain score on the VAS was low and only in 2 out of 112 cases there was a marked discomfort. In four cases suggested treatment was not successful, because of the fear of the patient. In 60.71% of cases that hysteroscopy was indicated, the uterine cavity was normal. No complications or adverse effects were noted. Apart from one case, there was a full agreement between hysteroscopic findings and histology.

CONCLUSION

Office hysteroscopy is a successful and well-tolerated procedure. Through adequate expertise it should be considered the method of choice in private basis, at the same time when exploration of the uterine cavity is needed.

Office hysteroscopy: current trends and potential applications: a critical review

Office hysteroscopy is an excellent method of identifying and treating intracavitary uterine lesions. It has become easy to learn and perform; as an aid of modern technological applications, it is safe, accurate, provides immediate results under direct visualisation, and offers the additional benefit of histological confirmation and the discomfort of patients is minimal. We applied an extended literature search to explore the special features and details of the technique itself, as it evolved since it first appeared 30 years back. Our initial goal was to examine potential changes/improvements of the modality, in terms of the instrumentation used and the technique itself, the indications of use, its incorporation in daily practice, and patients' and clinicians' acceptability.

Role of hysteroscopy in evaluating chronic pelvic pain

OBJECTIVE

To provide a survey of various gynecological conditions causing chronic pelvic pain (CPP) that might be diagnosed by hysteroscopy.

DESIGN

Review article.

SETTING

Departments of obstetrics and gynecology and pathophysiology of human reproduction at a university in Italy.

PATIENT(S)

Women affected by CPP.

INTERVENTION(S)

Hysteroscopy.

MAIN OUTCOME MEASURE(S)

Effectiveness in diagnosing intrauterine pathologies that cause CPP.

RESULT(S)

Hysteroscopy is highly effective in diagnosing various gynecological causes of CPP, including adenomyosis, chronic endometritis, Müllerian anomalies, retained fetal bones, endocervical ossification, and intrauterine abnormalities. Furthermore, hysteroscopy may play a primary role in the resolution of some of these conditions.

CONCLUSION(S)

Because it can be executed safely in an office setting without anesthesia, hysteroscopy may be indicated, together with the other noninvasive procedures such as transvaginal ultrasonography, as a first-level investigation in women who are affected by CPP.