Abnormal uterine and post-menopausal bleeding in the acute gynaecology unit

Detection and Classification of Hysteroscopic Images Using Deep Learning

BACKGROUND

Although hysteroscopy with endometrial biopsy is the gold standard in the diagnosis of endometrial pathology, the gynecologist experience is crucial for a correct diagnosis. Deep learning (DL), as an artificial intelligence method, might help to overcome this limitation. Unfortunately, only preliminary findings are available, with the absence of studies evaluating the performance of DL models in identifying intrauterine lesions and the possible aid related to the inclusion of clinical factors in the model.

AIM

To develop a DL model as an automated tool for detecting and classifying endometrial pathologies from hysteroscopic images.

METHODS

A monocentric observational retrospective cohort study was performed by reviewing clinical records, electronic databases, and stored videos of hysteroscopies from consecutive patients with pathologically confirmed intrauterine lesions at our Center from January 2021 to May 2021. Retrieved hysteroscopic images were used to build a DL model for the classification and identification of intracavitary uterine lesions with or without the aid of clinical factors. Study outcomes were DL model diagnostic metrics in the classification and identification of intracavitary uterine lesions with and without the aid of clinical factors.

RESULTS

We reviewed 1500 images from 266 patients: 186 patients had benign focal lesions, 25 benign diffuse lesions, and 55 preneoplastic/neoplastic lesions. For both the classification and identification tasks, the best performance was achieved with the aid of clinical factors, with an overall precision of 80.11%, recall of 80.11%, specificity of 90.06%, F1 score of 80.11%, and accuracy of 86.74 for the classification task, and overall detection of 85.82%, precision of 93.12%, recall of 91.63%, and an F1 score of 92.37% for the identification task.

CONCLUSION

Our DL model achieved a low diagnostic performance in the detection and classification of intracavitary uterine lesions from hysteroscopic images. Although the best diagnostic performance was obtained with the aid of clinical data, such an improvement was slight.

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.

Minimally invasive approaches for the early detection of endometrial cancer

Endometrial cancer (EC) is one of the most common gynecologic cancers and its incidence is rising globally. Although advanced EC has a poor prognosis; diagnosing EC at an earlier stage could improve long-term patient outcomes. However, there is no consensus on the early detection strategies for EC and the current diagnostic practices such as transvaginal ultrasound, hysteroscopy and endometrial biopsy are invasive, costly and low in specificity. Thus, accurate and less invasive screening tests that detect EC in women with early stages of the disease are needed. Current research has revolutionized novel EC early detection methodologies in many aspects. This review aims to comprehensively characterizes minimally invasive screening techniques that can be applied to EC in the future, and fully demonstrate their potential in the early detection of EC.

A risk prediction nomogram of endometrial carcinoma and precancerous lesions in postmenopausal women: A retrospective study

This study aimed to develop a risk prediction nomogram for endometrial carcinoma and precancerous lesions in postmenopausal women to provide postmenopausal patients with more information on disease probability, work out personalized medical plans, and reduce unnecessary invasive clinical examinations. We enrolled 340 patients who underwent hysteroscopy at Beijing Maternity Hospital between March 2016 and July 2018. The patients were divided into the low-risk (275 patients) and high-risk (65 patients) groups, according to the results of the pathological examinations. Binary logistic analysis was performed to evaluate the 20 potential risk factors for endometrial cancer and precancerous lesions in postmenopausal women and to screen for certain risk factors using the Statistical Package for the Social Sciences version 26.0. Using R 4.0.3, we built a prediction nomogram that incorporated the selected factors. The discrimination, calibration, and clinical usefulness of the prediction model were assessed using the concordance (C)-index, calibration plot, and decision curve analysis. Internal validation was assessed using bootstrapping validation. Predictors included in the prediction nomogram included obesity, vaginal bleeding, family history of gynecological malignancies, endometrial thickness ≥ 1.15 cm, and color Doppler flow imaging blood flow. The model displayed good discrimination, with a C-index of 0.853, and good calibration. Decision curve analysis showed that the model was clinically useful, with a benefit range of 2% to 93%. A high C-index value of 0.844 could still be reached in the interval validation. Obesity, vaginal bleeding, family history of gynecological malignancies, endometrial thickness ≥ 1.15 cm, and color Doppler flow imaging blood flow were independent risk factors for endometrial cancer and precancerous lesions. Thus, the prediction nomogram can be conveniently used to facilitate individual risk prediction in patients with endometrial cancer and precancerous lesions.

Vibrational Biospectroscopy: An Alternative Approach to Endometrial Cancer Diagnosis and Screening

Endometrial cancer (EC) is the sixth most common cancer and the fourth leading cause of death among women worldwide. Early detection and treatment are associated with a favourable prognosis and reduction in mortality. Unlike other common cancers, however, screening strategies lack the required sensitivity, specificity and accuracy to be successfully implemented in clinical practice and current diagnostic approaches are invasive, costly and time consuming. Such limitations highlight the unmet need to develop diagnostic and screening alternatives for EC, which should be accurate, rapid, minimally invasive and cost-effective. Vibrational spectroscopic techniques, Mid-Infrared Absorption Spectroscopy and Raman, exploit the atomic vibrational absorption induced by interaction of light and a biological sample, to generate a unique spectral response: a “biochemical fingerprint”. These are non-destructive techniques and, combined with multivariate statistical analysis, have been shown over the last decade to provide discrimination between cancerous and healthy samples, demonstrating a promising role in both cancer screening and diagnosis. The aim of this review is to collate available evidence, in order to provide insight into the present status of the application of vibrational biospectroscopy in endometrial cancer diagnosis and screening, and to assess future prospects.

The cost of diagnosing endometrial cancer: Quantifying the healthcare cost of an abnormal uterine bleeding workup

OBJECTIVE

The evaluation of women with perimenopausal abnormal uterine bleeding (AUB) and postmenopausal bleeding (PMB) to detect endometrial cancer (EC) and its precursors is not standardized and can vary widely. Consequently, costs associated with the workup and management undoubtedly vary. This study aimed to quantify costs of AUB/PMB evaluation to understand the healthcare burden associated with securing a pathologic diagnosis.

METHODS

Women ≥45 years of age presenting to a single institution gynecology clinic with AUB/PMB for diagnostic workup were prospectively enrolled February 2013-October 2017 for a lower genital tract biospecimen research study. Clinical workup of AUB/PMB was determined by individual provider discretion. Costs of care were collected from administrative billing systems from enrollment to 90 days post enrollment. Costs were standardized and inflation-adjusted to 2017 US Dollars (USD).

RESULTS

In total, there were 1017 women enrolled with 5.6% diagnosed with atypical hyperplasia or endometrial cancer (EC). Within the full cohort, 90-day median cost for AUB/PMB workup and management was $2279 (IQR $512-4828). Among patients with a diagnostic biopsy, median 90-day costs ranged from $2203 (IQR $499-3604) for benign or disordered proliferative endometrium (DPE) diagnosis to $21,039 (IQR $19,084-24,536) for a diagnosis of EC.

CONCLUSIONS

The costs for diagnostic evaluation of perimenopausal AUB and PMB vary greatly according to ultimate tissue-based diagnosis. Even reassuring benign findings that do not require further intervention-the most common in this study's cohort-yield substantial costs. The development of sensitive, specific, and more cost-effective diagnostic strategies is warranted.

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.

Quality of life and sexuality of postmenopausal women with intrauterine pathologies: a recommended three-step multidisciplinary approach focusing on the role of hysteroscopy

Intrauterine pathologies are common in postmenopausal women and clinicians must identify signs and symptoms accurately to provide the adequate diagnosis and treatment. The quality of life (QoL) and sexuality of women are important outcomes to be considered to provide adequate clinical management of the postmenopausal patient with gynecologic pathologies. The aim of this paper is to propose a simple and replicable three-step multidisciplinary approach to evaluate the psychological outcomes of postmenopausal women with intrauterine pathologies, focusing on the role of hysteroscopy. In particular, the article describes three evaluation steps of those psychological outcomes corresponding to three fundamental moments of the patient's diagnostic and therapeutic path: the initial symptoms, diagnosis, and treatment. In our viewpoint, the standard use of such a protocol might considerably improve the QoL of postmenopausal patients undergoing hysteroscopic procedures due to intrauterine pathologies.

Typical ultrasound features of various endometrial pathologies described using International Endometrial Tumor Analysis (IETA) terminology in women with abnormal uterine bleeding

OBJECTIVE

To describe the ultrasound features of different endometrial and other intracavitary pathologies inpre- and postmenopausal women presenting with abnormal uterine bleeding, using the International Endometrial Tumor Analysis (IETA) terminology.

METHODS

This was a prospective observational multicenter study of consecutive women presenting with abnormal uterine bleeding. Unenhanced sonography with color Doppler and fluid-instillation sonography were performed. Endometrial sampling was performed according to each center's local protocol. The histological endpoints were cancer, atypical endometrial hyperplasia/endometrioid intraepithelial neoplasia (EIN), endometrial atrophy, proliferative or secretory endometrium, endometrial hyperplasia without atypia, endometrial polyp, intracavitary leiomyoma and other. For fluid-instillation sonography, the histological endpoints were endometrial polyp, intracavitary leiomyoma and cancer. For each histological endpoint, we report typical ultrasound features using the IETA terminology.

RESULTS

The database consisted of 2856 consecutive women presenting with abnormal uterine bleeding. Unenhanced sonography with color Doppler was performed in all cases and fluid-instillation sonography in 1857. In 2216 women, endometrial histology was available, and these comprised the study population. Median age was 49 years (range, 19-92 years), median parity was 2 (range, 0-10) and median body mass index was 24.9 kg/m² (range, 16.0-72.1 kg/m² ). Of the study population, 843 (38.0%) women were postmenopausal. Endometrial polyps were diagnosed in 751 (33.9%) women, intracavitary leiomyomas in 223 (10.1%) and endometrial cancer in 137 (6.2%). None (0% (95% CI, 0.0-5.5%)) of the 66 women with endometrial thickness < 3 mm had endometrial cancer or atypical hyperplasia/EIN. Endometrial cancer or atypical hyperplasia/EIN was found in three of 283 (1.1% (95% CI, 0.4-3.1%)) endometria with a three-layer pattern, in three of 459 (0.7% (95% CI, 0.2-1.9%)) endometria with a linear endometrial midline and in five of 337 (1.5% (95% CI, 0.6-3.4%)) cases with a single vessel without branching on unenhanced ultrasound.

CONCLUSIONS

The typical ultrasound features of endometrial cancer, polyps, hyperplasia and atrophy and intracavitary leiomyomas, are described using the IETA terminology. The detection of some easy-to-assess IETA features (i.e. endometrial thickness < 3 mm, three-layer pattern, linear midline and single vessel without branching) makes endometrial cancer unlikely. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Cross-sectional imaging of acute gynaecologic disorders: CT and MRI findings with differential diagnosis-part II: uterine emergencies and pelvic inflammatory disease

Due to the growing use of cross-sectional imaging in emergency departments, acute gynaecologic disorders are increasingly diagnosed on urgent multidetector computed tomography (CT) studies, often requested under alternative presumptive diagnoses in reproductive-age women. If clinical conditions and state-of-the-art scanner availability permit, magnetic resonance imaging (MRI) is superior to CT due to its more in-depth characterisationof abnormal or inconclusive gynaecological findings, owing to excellent soft-tissue contrast, intrinsic multiplanar capabilities and lack of ionising radiation.

This pictorial review aims to provide radiologists with a thorough familiarity with gynaecologic emergencies by illustrating their CT and MRI appearances, in order to provide a timely and correct imaging diagnosis. Specifically, this second instalment reviews with examples and emphasis on differential diagnosis the main non-pregnancy-related uterine emergencies (including endometrial polyps, degenerated leiomyomas and uterine inversion) and the spectrum of pelvic inflammatory disease.

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.

Endometrial sampling in low-risk patients with abnormal uterine bleeding: a systematic review and meta-synthesis

BACKGROUND

One million women per year seek medical advice for abnormal uterine bleeding (AUB) in the United Kingdom. Many low-risk patients who could be managed exclusively in primary care are referred to hospital based gynaecology services. Performing endometrial sampling (ES) in the community may improve care, reduce the rate of referrals and minimise costs. We aimed to search and synthesise the literature on the effectiveness of ES (Pipelle versus other devices) in managing AUB in low-risk patients.

METHODS

We undertook an electronic literature search in MEDLINE via OvidSP, Scopus, and Web of Science for relevant English-language articles from 1984 to 2016 using a combination of MeSH and keywords. Two reviewers independently pre-selected 317 articles and agreed on 60 articles reporting data from over 7300 patients. Five themes were identified: sample adequacy, test performance, pain and discomfort, cost-effectiveness, and barriers and complications of office ES.

RESULTS

Pipelle seems to perform as well as dilation and curettage and, as well or better than other ES devices in terms of sampling adequacy and sensitivity. It also seems to be better regarding pain/discomfort and costs. However, Pipelle can disrupt the sonographic appearance of the endometrium and may be limited by cervical stenosis, pelvic organ prolapse and endometrial atrophy.

CONCLUSIONS

The current evidence supports the use of Pipelle in the management of low-risk women presenting in the outpatient setting with symptomatic AUB when combined with clinical assessment and ultrasound scanning. However, the implications of its widespread use in primary care are uncertain and more research is required.

Post-menopausal bleeding - Is transvaginal ultrasound a useful first-line investigation in tamoxifen users?

Objective To evaluate the role of transvaginal ultrasound triage in women with a history of tamoxifen treatment who present with post-menopausal bleeding. Study design A retrospective review was undertaken of patients who presented with symptoms of post-menopausal bleeding and underwent ultrasound triage. Endometrial thickness and ultrasonographic features were then correlated with hysteroscopic and histopathological outcome data. The findings and outcomes for women with a history of tamoxifen use (tamoxifen group) were compared to those who had not taken tamoxifen (non-tamoxifen group). Results A total of 614 women with post-menopausal bleeding underwent transvaginal ultrasound triage, of whom 53 had a history of current or previous tamoxifen treatment. An endometrial thickness of ≥5 mm or the presence of other abnormal features was used to triage women to further investigation by hysteroscopy and biopsy. Endometrial thickness was significantly greater in the tamoxifen group (11 mm vs. 6 mm). Nearly all of the tamoxifen group were triaged to further investigation (98.1%), compared with significantly fewer in the non-tamoxifen group (68.3%) Overall, the incidence of endometrial pathology was also significantly higher in tamoxifen patients (43.4% vs. 31.7%). Conclusion For women presenting with post-menopausal bleeding, the use of transvaginal ultrasound as a triage tool is rarely helpful in evaluating women who have a history as tamoxifen use, as most will require further investigation with hysteroscopy and biopsy. A post-menopausal bleeding protocol that omits transvaginal ultrasound for women with a history of tamoxifen use may be an appropriate and effective pathway for managing these patients.

MRI appearances of benign uterine disease

Benign uterine disease is a common entity affecting women of all ages. Ultrasound has historically been the predominant imaging method used in the evaluation of benign gynaecological disease, magnetic resonance imaging (MRI) being reserved for use in the staging of malignant uterine and cervical disease. MRI is now increasingly used in the diagnosis of benign uterine disease as well as a tool for problem-solving in cases of diagnostic dilemma. It allows detailed assessment of benign conditions, such as endometrial lesions, leiomyomas, and adenomyosis, and can be helpful in the stratification of patients to different treatment modalities, including surgical resection, uterine artery embolization, and medical therapies. In this article, we review the MRI findings in the common benign uterine diseases.

A risk-scoring model for the prediction of endometrial cancer among symptomatic postmenopausal women with endometrial thickness > 4 mm

Objective. To develop and test a risk-scoring model for the prediction of endometrial cancer among symptomatic postmenopausal women at risk of intrauterine malignancy. Methods. We prospectively studied 624 postmenopausal women with vaginal bleeding and endometrial thickness > 4 mm undergoing diagnostic hysteroscopy. Patient characteristics and endometrial assessment of women with or without endometrial cancer were compared. Then, a risk-scoring model, including the best predictors of endometrial cancer, was tested. Univariate, multivariate, and ROC curve analysis were performed. Finally, a split-sampling internal validation was also performed. Results. The best predictors of endometrial cancer were recurrent vaginal bleeding (odds ratio (OR) = 2.96), the presence of hypertension (OR = 2.01) endometrial thickness > 8 mm (OR = 1.31), and age > 65 years (OR = 1.11). These variables were used to create a risk-scoring model (RHEA risk-model) for the prediction of intrauterine malignancy, with an area under the curve of 0.878 (95% CI 0.842 to 0.908; P < 0.0001). At the best cut-off value (score ≥ 4), sensitivity and specificity were 87.5% and 80.1%, respectively. Conclusion. Among symptomatic postmenopausal women with endometrial thickness > 4 mm, a risk-scoring model including patient characteristics and endometrial thickness showed a moderate diagnostic accuracy in discriminating women with or without endometrial cancer. Based on this model, a decision algorithm was developed for the management of such a population.

Diagnostic accuracy of endometrial thickness for the detection of intra-uterine pathologies and appropriateness of performed hysteroscopies among asymptomatic postmenopausal women

OBJECTIVE

To measure the diagnostic accuracy of endometrial thickness for the detection of intra-uterine pathologies among asymptomatic postmenopausal women, and to test the diagnostic accuracy and appropriateness of performed hysteroscopies.

STUDY DESIGN

Prospective study of 268 asymptomatic postmenopausal women with endometrial thickness ≥4 mm referred to diagnostic hysteroscopy. The diagnostic accuracy of various endometrial thickness cut-off values was tested. Histological and hysteroscopic results were compared to measure the diagnostic accuracy of outpatient hysteroscopies.

RESULTS

No endometrial thickness cut-off values had optimal diagnostic accuracy [positive likelihood ratio (LR+) >10 and negative likelihood ratio (LR-) <0.1]. The best endometrial thickness cut-off value for the detection of all intra-uterine pathologies was ≥8 mm (LR+ 10.05 and LR- 0.22). An endometrial thickness cut-off value ≥10 mm did not miss any cases of endometrial cancer. The success rate of diagnostic hysteroscopy was 89%, but 97% of these revealed a benign intra-uterine pathology. The diagnostic accuracy of hysteroscopy was optimal for all intra-uterine pathologies, except endometrial hyperplasia (LR- 0.52).

CONCLUSION

Using an endometrial thickness cut-off value ≥4 mm, only 3% of performed hysteroscopies were useful for the detection of pre-malignant or malignant lesions. Despite the finding that endometrial thickness did not show optimal diagnostic accuracy, using the best cut-off value (≥8 mm) may be helpful to decrease the number of false-positive results. No cases of endometrial cancer were diagnosed in asymptomatic postmenopausal women with endometrial thickness <10mm.

Ultrasound in the diagnosis of endometrial and intracavitary pathology: an update

Over the last two decades, ultrasound evaluation of the endometrium and uterine cavity evolved from 2D grayscale evaluation of the endometrial thickness to a much more comprehensive examination including colour imaging, fluid instillation and 3D ultrasound. The International Endometrial Tumor Analysis (IETA) group recently published a consensus opinion paper on terms, definitions and measurements to describe the sonographic features on the endometrium and intrauterine lesions.

Screening for uterine tumours

The most prevalent uterine tumours are leiomyomas, which are benign and have a prevalence of about 50% at menopause. The incidence of endometrial cancer and uterine sarcomas is about 25 per 100,000 and 0.7 per 100,000, respectively. Reported risk factors for endometrial cancer are advanced age, unopposed oestrogen stimulation, late menopause, obesity, diabetes mellitus, nulliparity, feminising ovarian tumours, polycystic ovarian syndrome, tamoxifen and belonging to a hereditary non-polyposis colorectal cancer family. Unopposed oestrogen stimulation and tamoxifen have also been confirmed to induce uterine sarcomas. Cervical cytology, endometrial sampling and ultrasound have been proposed in the early diagnosis of endometrial cancer. No pathognomonic ultrasound, magnetic resonance imaging or computed tomography features are able to differentiate between a leiomyoma and a uterine sarcoma, and reliable serum markers for sarcomas are lacking. To date, mass screening for uterine malignancies is not feasible or effective.

Comparison of diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography and hysteroscopy in postmenopausal bleeding

OBJECTIVE

To compare the diagnostic accuracy of transvaginal sonography (TVS), saline infusion sonohysterography (SIS) and hysteroscopy (HS) with respect to pathological diagnosis in the detection of uterine cavity abnormalities associated with abnormal uterine bleeding among postmenopausal women.

METHODS

Being a prospective, investigator-blind trial, the present study was conducted on 137 postmenopausal women, with abnormal uterine bleeding, admitted to the Department of Obstetrics and Gynecology of Istanbul Bilim University, Florence Nightingale Hospital and Fertigyn Woman Health and IVF Center. After TVS, all patients underwent SIS using Cook Soft 500 IVF transfer catheter and HS, consecutively. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated to compare the diagnostic accuracy of TVS, SIS and HS.

RESULTS

Most commonly encountered endometrial lesions were polypoid lesion (38.0%) and hyperplasia (28.4%) among our study population consisting of 137 women (mean age 61.6 ± 9.6 years) in their postmenopausal stage. Overall sensitivity rates were 70.0% for TVS, 89.6% for SIS and 92.3% for HS, while the overall specificity rates were 50.0, 77.3 and 80.7%, respectively. HS had PPV of 96.2% and NPV of 65.3%, whereas PPV was determined to be 80.9 versus 95.3% and NPV was 35.4 versus 58.3% for TVS and SIS, respectively.

CONCLUSIONS

As an easy to perform, safe and well-tolerated procedure yielding high diagnostic accuracy, saline infusion SIS via this catheter seems to be superior to TVS and very close to HS. It may be used as the primary method for the detection of uterine abnormalities among postmenopausal women with abnormal uterine bleeding.

Review of new office-based hysteroscopic procedures 2003-2009

Office operative hysteroscopy is a recent technique that enables treatment of uterine pathologic disorders in the ambulatory setting using miniaturized hysteroscopes with mechanical or electric instruments. The available international literature from 1990 to 2002 has clearly demonstrated that such technique enables performance of hysteroscopically directed endometrial biopsy and treatment of uterine adhesions, anatomic disorders, polyps, and small myomas safely and successfully without cervical dilation and the need for anesthesia. This review provides a comprehensive survey of further advancements of office operative hysteroscopy in the treatment of other gynecologic pathologic conditions that have not been included in the schema of treatment indications for office procedures proposed in 2002. A search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews identified articles published from 2003 to 2009. Eighteen articles were identified: 9 on hysteroscopic sterilization; 1 on office-based metroplasty, 8 on office-based treatment of some uncommon gynecologic pathologic conditions (e.g., hematometra, diagnosis and treatment of vaginal lesions, treatment of uterine cystic neoformations, bleeding from the cervical stump, diagnosis and treatment of endocervical ossification, and removal of uterovaginal packing). All performed procedures were carried out safely and successfully in the office setting, with high patient tolerance and minimal discomfort. The success of the procedures has been confirmed by resolution of symptoms and at follow-up ultrasonographic and hysteroscopic examinations. Currently, as a result of technologic advancements and increased operator experience, an increasing number of gynecologic pathologic conditions traditionally treated in the operating room may be treated safely and effectively using office operative hysteroscopy.