The risk of malignancy in uterine polyps: A systematic review and meta-analysis

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.

Analysis of ultrasonic imaging changes and factors related to malignant transformation in postmenopausal patients with endometrial polyps

OBJECTIVE

To examine the ultrasonic changes in postmenopausal endometrial polyps and analyze factors related to their malignant transformation.

METHODS

This retrospective study analyzed clinical data from 200 postmenopausal patients with endometrial polyps treated at Jinan Maternity and Child Care Hospital and Pingyin Hospital of Traditional Chinese Medicine from December 2020 to December 2023. All patients underwent pathological biopsies to diagnose the nature of the endometrial polyps. This study compared the clinical and ultrasonic imaging features of these patients and analyzed factors influencing the malignant transformation of postmenopausal endometrial polyps.

RESULTS

Pathological findings classified 160 patients (80.00%) into the benign group and 40 patients (20.00%) into the malignant group. Significant differences were noted in endometrial thickness, polyp diameter, heterogeneity of lesion echogenicity, and vascularization between the groups (all P<0.05). The malignant group exhibited notably higher blood flow (Grade II+III constituted 70.00% compared to 29.38% in the benign group, P<0.05). The time average velocity (TAV), pulse index (PI), and resistance index (RI) were significantly lower in the malignant group (all P<0.05). The area under curve (AUC) values for TAV, PI, and RI in diagnosing malignant endometrial polyps were 0.754, 0.713, and 0.771, respectively. Increased body mass index (BMI), irregular premenopausal menstruation, and ≥2 occurrences of postmenopausal bleeding were identified as risk factors for malignant transformation (all P<0.05). These six indicators were used to create a predictive model for malignant transformation, achieving an AUC of 0.942.

CONCLUSION

Malignancy in postmenopausal endometrial polyps is uncommon, yet distinct differences exist in the transvaginal color Doppler ultrasound characteristics between benign and malignant cases. Factors such as increased BMI, irregular premenopausal menstruation, and ≥2 occurrences of postmenopausal bleeding significantly contribute to the risk of malignant transformation. These findings, combined with ultrasound features, provide a robust basis for screening and monitoring these patients.

Abnormal Uterine Bleeding: A Pictorial Review on Differential Diagnosis and Not-So-Common Cases of Interventional Radiology Management

Abnormal uterine bleeding (AUB) poses a multifaceted challenge in women's health, necessitating an integrated approach that addresses its diverse etiologies and clinical presentations. The International Federation of Gynecology and Obstetrics PALM-COEIN classification system provides a systematic approach to the diagnosis of AUB in non-pregnant women, based on clinical and imaging-based categorization of causes into structural (Polyps, Adenomyosis, Leiomyomas and Malignancy; PALM), and non-structural causes (Coagulopathies, Ovulatory disorders, primary Endometrial disorders, Iatrogenic and Not otherwise classified; COEIN). On the other hand, placental disorders, uterine rupture, ectopic pregnancy and retained products of conceptions are the main causes of uterine bleeding during pregnancy and in the peripartum period. Ultrasound is usually the first-line imaging technique for the differential diagnosis of causes of AUB. Computed Tomography may be useful if ultrasound findings are unclear, especially in emergency settings. Magnetic resonance imaging, when indicated, is an excellent second-line diagnostic tool for a better non-invasive characterization of the underlying cause of AUB. This pictorial review aims to illustrate the main causes of AUB from the point of view of diagnostic imaging and to show not-so-common cases that can be treated by means of interventional radiology.

The risk factors for premalignant and malignant endometrial polyps in premenopausal and postmenopausal women and trends over the past decade: A retrospective study in a single center, South Korea

OBJECTIVES

To assess the prevalence and risk factors for premalignancy and malignancy in endometrial polyps and to evaluate trends over the past decade.

STUDY DESIGN

This was a retrospective study of patients who underwent hysteroscopic polypectomy at Inha University Hospital, South Korea between January 2013 and June 2023. The demographic and clinical characteristics of the patients reviewed to identify risk factors for premalignancy and malignancy in endometrial polyps included the following: age, parity, body mass index, menopausal status, abnormal uterine bleeding symptoms, diabetes mellitus, hypertension, polycystic ovarian syndrome, use of menopausal hormonal therapy or oral contraceptives, tamoxifen treatment in patients with breast cancer, and the number of polyps.

RESULTS

In total, 725 patients were enrolled, among whom 52 (7.2 %) had premalignant and malignant lesions. In logistic regression analysis, menopause (OR: 8.37, 95 % CI [3.33-21.04]), abnormal uterine bleeding (OR: 7.42, 95 % CI [2.13-25.86]), obesity (OR: 3.22, 95 % CI [1.53-6.77]), multiple polyps (OR: 2.86, 95 % CI [1.39-5.88]) and nulliparity (OR: 2.64, 95 % CI [1.13-6.19]) were significantly associated with premalignancy and malignancy in polyps. Annual trends during the study period showed an increase in the number of patients with three of the five risk factors (obesity, multiple polyps, and nulliparity) and an increase in the prevalence of premalignancy and malignancy in polyps.

CONCLUSIONS

Menopause, abnormal uterine bleeding, obesity, multiple polyps, and nulliparity increase the risk of premalignancy and malignancy in endometrial polyps. The prevalence of premalignant and malignant polyps has been increasing over the past decade. The risk factors that have contributed to this trend were obesity, nulliparity, and multiple polyps.

Should outpatient hysteroscopy be used in preference to transvaginal ultrasound to identify endometrial pathology in premenopausal women with heavy menstrual bleeding? Revisiting NICE Guideline 88

Introduction

National Institute for Health and Care Excellence Guideline 88 advocates outpatient hysteroscopy in preference to transvaginal ultrasound for premenopausal women with heavy menstrual bleeding, who are suspected of having submucosal fibroids, polyps or endometrial pathology. The guideline, however, analysed outdated studies that provided low-quality evidence. This study aimed to assess the diagnostic accuracy of transvaginal ultrasound in detecting endometrial pathology; and to evaluate the cost-effectiveness of outpatient hysteroscopy if it were to be used in preference to transvaginal ultrasound.

Methods

A health service evaluation was conducted at a district general foundation trust between 1 January 2019 and 31 March 2019 of all premenopausal women with heavy menstrual bleeding. A cost-effectiveness analysis was also performed to evaluate the financial implication of outpatient hysteroscopy being used in preference to transvaginal ultrasound.

Results

100 patients were included in the study. For the detection of endometrial pathology, transvaginal ultrasound had a positive predictive value of 65.2%; negative predictive value of 98.5%; sensitivity of 93.75%; specificity of 88.89% and an accuracy of 89.77%. For identifying endometrial polyps, submucosal fibroids and endometrial thickening, transvaginal ultrasound had a positive predictive value of 33.3%, 85.7% and 50%, respectively. It would have cost the Trust 78.7% more if National Institute for Health and Care Excellence's recommendation was carried out, with a 23.4% increase in workload in the hysteroscopy department, and a decrease of 7.8% transvaginal scans performed.

Conclusion

Outpatient hysteroscopy is costly and would increase the workload burden in the hysteroscopy department. Transvaginal ultrasound has a high sensitivity, specificity and accuracy in detecting endometrial pathology therefore it should remain as the initial diagnostic investigation.

Preoperative Haematologic Markers for the Differentiation of Endometrial Cancer from Benign Endometrial Lesions in Postmenopausal Patients with Endometrial Masses

Purpose

The diagnostic value of preoperative hematological changes in endometrial cancer (EC) remains unclear. This study aimed to assess the role of preoperative hematologic parameters in differentiating EC from benign endometrial lesions in postmenopausal women with endometrial masses.

Methods

Preoperative laboratory variables were retrospectively reviewed in patients with malignant or benign endometrial lesions, and the significance of intergroup differences was assessed. Receiver operating characteristic curves were used to analyze the optimal cut-off values for each variable. Logistic regression analysis was used to identify the variables predicting the presence of endometrial malignancy.

Results

Preoperative laboratory variables of 176 patients (84 EC and 92 benign lesions) with endometrial masses were analyzed. Significant differences were observed between malignant and benign lesions in terms of WBC count, ANC, MCV, MPV, PDW, CA125, NLR, PMR, LMR, and SII (P < 0.05). Multivariate analyses showed that a high WBC count, high ANC, low MCV, low MPV, low PDW, high CA125, high NLR, high PMR, high LMR, and high SII independently predicted the presence of endometrial malignancy.

Conclusion

The combination markers, MPV+PDW+NLR, had good discriminatory power for the presence of malignancy (AUC 0.797). Our results suggest that hematologic markers could be useful for the differentiation of malignant and benign endometrial lesions.

Clinical evaluation of a new hand-driven hysteroscopic tissue removal device, Resectr™ 5fr, for the resection of endometrial polyps in an office setting

PURPOSE

A first clinical evaluation of a new hand-driven hysteroscopic tissue removal device, Resectr™ 5fr, for office polypectomy without any anesthesia.

METHODS

Women with at least one small endometrial polyp were eligible. Hysteroscopic polypectomy was performed using the Resectr™ 5fr in an office setting, without any anesthesia.

RESULTS

One hundred and two hysteroscopic polypectomies were included in the analysis. The median installation time was 1.9 min (95% confidence interval (CI) 1.6-2.1). The median time to complete polyp removal was 1.2 min (95% CI 0.8-1.6). The median surgeon's safety, practical, and comfort scores on a 5-point Likert scale were high (5 (5-5), 5 (4-5), and 5 (4-5), respectively). Women's pain score was low (median 1 (0-3)), whereas the satisfaction rate was high (median 5 (5-5)), both on a 5-point Likert scale. There were two conversions (hysteroscopic scissors (n = 1), a new Resectr™ 5fr device (n = 1)). There was one incomplete procedure (tissue hardness).

CONCLUSION

Hysteroscopic removal of small polyps, using the [Formula: see text] 5fr in an office setting is feasible in terms of installation and resection time. Surgeon's practical, comfort, and safety scores are high, whereas women report low pain scores and high satisfaction rates.  TRIAL REGISTRATION: Dutch Clinical Trial Registry (NTR 7119, NL6923): https://www.trialregister.nl/trial/6923 . Date of registration: 27/03/2018.

Analysis of factors related to endometrial cancer in postmenopausal women with endometrial thickening

OBJECTIVE

To investigate the factors related to endometrial cancer (EC) in postmenopausal women with endometrial thickening and the value of endometrial thickness (ET) in predicting EC.

METHODS

A retrospective study of 385 referrals to our department for hysteroscopic diagnostic curettage assessment was carried out. Univariate analysis and multiple logistic regression analysis were used to identify the independent contributors to the development of EC. The ability of ET to predict EC was evaluated by receiver operating characteristic curve analysis.

RESULTS

The follow-up period from the identification of endometrial thickening to pathological confirmation of EC was from 2 weeks to 3 months. In the postmenopausal bleeding (PMB) group, a total of 47 participants' specimens were pathologically malignant. Older age and polypoid mass-like lesions ( P < 0.001) were independent factors associated with EC. The optimal critical value of ET in predicting EC was 9.5 mm, with a sensitivity and specificity of 70.21% and 70.67%, respectively. In the non-PMB group, six participants had evidence of malignant pathology, and only polypoid mass-like lesions were an independent factor associated with EC ( P < 0.001).

CONCLUSIONS

For postmenopausal women with increased ET and PMB, older age, thicker ET, and polypoid mass-like lesions on transvaginal ultrasound were independent associated factors for EC. An ET greater than 9.5 mm is a threshold for predicting EC. For postmenopausal women with increased ET without PMB, the incidence of endometrial malignancy is low. If the woman has polypoid mass-like lesions on transvaginal ultrasound, she should receive further attention.

Contemporary evaluation of women and girls with abnormal uterine bleeding: FIGO Systems 1 and 2

Abnormal uterine bleeding (AUB) is common, often debilitating, and may affect over 50% of reproductive-aged women and girls. Whereas AUB is a collection of symptoms that include intermenstrual bleeding and abnormalities in period duration, cycle length, and regularity, it is heavy menstrual bleeding (HMB) that is most contributory to iron deficiency and related anemia. It is apparent that AUB, in general, and HMB, in particular, remain underrecognized and underreported. FIGO created two systems for assessing and classifying AUB. FIGO System 1 defines the bleeding pattern using four primary descriptors: frequency, duration, regularity, and flow volume. FIGO System 2 provides a structured classification system of possible causes of AUB, using the acronym PALM-COEIN. "PALM" refers to structural causes of AUB (Polyp, Adenomyosis, Leiomyoma, Malignancy), and "COEI" refers to nonstructural causes (Coagulopathy, Ovulatory dysfunction, Endometrial, and Iatrogenic). The "N" is reserved for those entities that are currently not otherwise classified. Using FIGO System 1 as a gateway to FIGO System 2 streamlines the investigation of reproductive-aged women and girls with AUB. Understanding the pathogenesis of the FIGO System 2 "PALM-COEIN" causes helps interpret investigations and the onward management of AUB. Numerous evidence gaps exist concerning AUB; however, if researchers and trialists universally adopt FIGO Systems 1 and 2 for the assessment and diagnosis of AUB, clear translatable research findings can be applied globally.

Therapeutic options for the management of abnormal uterine bleeding

Just as the investigation of abnormal uterine bleeding (AUB) is approached systematically using the two FIGO systems for AUB in the reproductive years, treatment options can be considered similarly. Therapeutic options fall into two categories-medical and surgical-and while medical management is typically regarded as first-line therapy, there are several exceptions defined by the presenting cause or causes, mainly when infertility is a concurrent issue. In the early 1990s, up to 60% of women underwent a hysterectomy for the symptom of heavy menstrual bleeding (HMB), but this figure has decreased. The number of women undergoing a hysterectomy for benign disorders continues to decline, along with an increase in hysterectomies performed using minimally invasive techniques. Discussions about therapeutic options are tailored to the individual patient, and we include the risks and benefits of each option, including no management, to enable the patient to make an informed choice. The different types of treatment options and the factors affecting decision-making are considered in this article.

Polycystic ovary syndrome is associated with a higher risk of premalignant and malignant endometrial polyps in premenopausal women: a retrospective study in a tertiary teaching hospital

Background

Polycystic ovary syndrome (PCOS) is characterized by anovulation, insufficient progesterone, hyperandrogenism, and insulin resistance. These factors can disrupt the endometrium of PCOS patients and can lead to chronic low-grade inflammation in the endometrium, endometrial hyperplasia, or even endometrial cancer.

Objective

The aim of this study was to investigate the prevalence of premalignant and malignant endometrial polyps in premenopausal women and to further explore whether PCOS is associated with premalignant and malignant changes in endometrial polyps.

Methods

This study was conducted by retrieving the medical data of 4236 premenopausal women who underwent hysteroscopic polypectomies between January 2015 and December 2021. Demographic and clinical data regarding age, height, weight, parity, hormone replacement therapy, oral contraceptives, abnormal uterine bleeding, hypertension, diabetes mellitus, PCOS, number of polyps, and size of polyps were collected, and their associations with premalignant and malignant changes in endometrial polyps were analysed.

Result

Among the endometrial polyps removed by hysteroscopic polypectomy in premenopausal women, the prevalence of premalignant and malignant polyps was 2.15%, which comprised hyperplasia with atypia at 1.13% and endometrial carcinoma at 1.02%. PCOS was associated with a higher risk of premalignant and malignant endometrial polyps in premenopausal women after adjustment for potential confounding factors.

Conclusion

PCOS is associated with a higher risk of premalignant and malignant endometrial polyps in premenopausal women. Therefore, it is important to evaluate the endometrium in PCOS patients with ultrasonography or hysteroscopy, and active management involving hysteroscopic polypectomy should be offered to PCOS patients diagnosed with endometrial polyps regardless of symptoms.

Incidence of endometrial carcinoma in patients with endometrial intraepithelial neoplasia versus atypical endometrial polyp

ObjectiveOur study's primary aim was to compare the incidence of endometrial carcinoma in patients with a presurgical diagnosis of endometrial intraepithelial neoplasia confined to the endometrium (EIN-E) versus endometrial intraepithelial neoplasia confined to a polyp (EIN-P). Our secondary aim was to examine the difference in pathological features, prognostic risk groups and sentinel lymph node involvement between the two groups.

METHODS

We conducted a retrospective cohort study between January 2014 and December 2020 in a tertiary university-affiliated medical center. The study considered the characteristics of women who underwent hysterectomy with sentinel lymph node dissection for endometrial intraepithelial neoplasia (EIN). We compared EIN-E diagnosed by endometrial sampling via dilatation curettage or hysteroscopic curettage vs EIN-P. A multivariate logistic regression analysis was used to assess risk factors for endometrial cancer.

RESULTS

Eighty-eight women were included in the study, of those, 50 were women with EIN-P (EIN-P group) and 38 were women with EIN following an endometrial biopsy (EIN-E group).The median age was 57.5 years (range; 52-68) in the EIN-P group as compared with 63 years (range; 53-71) in the EIN-E group (p=0.47). Eighty-nine percent of the women in the EIN-E group presented with abnormal uterine bleeding whereas 46% of the women in the EIN-P group were asymptomatic (p=0.001). Pathology results following hysterectomy revealed concurrent endometrial carcinoma in 26% of women in the EIN-P group compared with 47% of women in the EIN-E group (p=0.038). Multivariate analysis showed that endometrial cancer was significantly less common in the EIN-P group (overall response (OR)=0.3 95% confidence interval (CI)=0.1-0.9, p=0.03). Eighty-four percent of cancers were grade one in the EIN-P group compared with 50% in the EIN-E group (p=0.048).

CONCLUSIONS

Concurrent endometrial cancer is less frequent with EIN-P than with EIN-E. The high incidence of endometrial carcinoma in both groups supports the current advice to perform hysterectomy for post-menopausal women. Our data does not support performing sentinel lymph node dissection for EIN-P that was completely resected. The benefit of sentinel lymph node dissection for women with pre-operative EIN-E is yet to be determined.

PET/MR imaging in gynecologic cancer: tips for differentiating normal gynecologic anatomy and benign pathology versus cancer

Positron emission tomography/magnetic resonance imaging (PET/MR) is used in the pre-treatment and surveillance settings to evaluate women with gynecologic malignancies, including uterine, cervical, vaginal and vulvar cancers. PET/MR combines the excellent spatial and contrast resolution of MR imaging for gynecologic tissues, with the functional metabolic information of PET, to aid in a more accurate assessment of local disease extent and distant metastatic disease. In this review, the optimal protocol and utility of whole-body PET/MR imaging in patients with gynecologic malignancies will be discussed, with an emphasis on the advantages of PET/MR over PET/CT and how to differentiate normal or benign gynecologic tissues from cancer in the pelvis.

Estimated costs of preoperative evaluation of postmenopausal hysterectomy for prolapse at a safety-net hospital: an observational descriptive study

BACKGROUND

In practice, preoperative evaluation prior to hysterectomy varies. Unnecessary preoperative evaluation may add cost and risk with little benefit to the patient.

OBJECTIVE

This study aimed to describe practice patterns and the associated costs related to preoperative evaluations before hysterectomy for prolapse at a safety-net hospital.

STUDY DESIGN

This was a retrospective cohort study of postmenopausal women who underwent a hysterectomy for prolapse. Nonfacility-associated cost data were obtained from the Centers for Medicare Services. The biopsy cost was estimated to be $172.55 and $125.23 for ultrasounds.

RESULTS

A total of 505 postmenopausal cases were identified. Of those, 155 (31%) underwent a preoperative biopsy, 305 (60%) had an ultrasound, and 124 (25%) had both. Of those, 72.9% had an indication for a biopsy. A total of 64 biopsies and 216 ultrasounds lacked clear indication. Of those, 56 biopsies were performed for bleeding in cases with an endometrial thickness of <4 mm. The total cost of nonvalue-added testing was $42,576.

CONCLUSION

Adherence to a strict preoperative algorithm would have saved $38,092 over the study period, although 0.50% of these biopsies would potentially have detected endometrial cancer preoperatively. These results underscore the value of clinical algorithms at teaching institutions.

Executive Summary of the Uterine Cancer Evidence Review Conference

Evidence for uterine cancer prevention, diagnosis, and special issues from the Uterine Cancer Evidence Review Conference is summarized.

The Centers for Disease Control and Prevention recognized the need for educational materials for clinicians on the prevention and early diagnosis of gynecologic cancers. The American College of Obstetricians and Gynecologists convened a panel of experts in evidence review from the Society for Academic Specialists in General Obstetrics and Gynecology and content experts from the Society of Gynecologic Oncology to review relevant literature, best practices, and existing practice guidelines as a first step toward developing evidence-based educational materials for women's health care clinicians about uterine cancer. Panel members conducted structured literature reviews, which were then reviewed by other panel members and discussed at a virtual meeting of stakeholder professional and patient advocacy organizations in January 2021. This article is the evidence summary of the relevant literature and existing recommendations to guide clinicians in the prevention, early diagnosis, and special considerations of uterine cancer. Substantive knowledge gaps are noted and summarized to provide guidance for future research.

Noninvasive Predictor for Premalignant and Cancerous Lesions in Endometrial Polyps Diagnosed by Ultrasound

Background

There was no consensus for management of asymptomatic endometrial polyps (EPs) up to date.

Objective

The aim of present study was to determine the risk factors of malignant lesions in EPs diagnosed by ultrasound and establish a noninvasive predictor to decrease unnecessary hysteroscopy for EPs.

Study Design

We reviewed the records of all consecutive patients who underwent hysteroscopy for EPs in the Women’s Hospital School of Medicine Zhejiang University between January 1, 2001 and December 31, 2018. The patients with histological diagnoses of atypical hyperplasia or cancer were defined as malignancy, while the patients with histological diagnoses of benign lesions were randomly selected as benign group according to the ratio of 1:4 (malignancy:benign), matching by age and year of hospitalization. Logistic regression analysis was used to analyze the clinical parameters for predicting malignancy of EPs. A Chi-squared automatic interaction detection (CHAID) decision tree analysis was performed to find a noninvasive predictor. The sensitivity, specificity, and the receiver operating characteristic curve (ROC) were used for assess the efficacy of the noninvasive predictor. New diagnosed EPs patients received in 2019 were used for verifying the accuracy of the noninvasive predictor.

Results

The age in 15,790 cases of benign lesions was significantly younger than that in 230 malignancy cases (41.97 ± 11.53 year vs 53.31 ± 11.61 years, p <0.001). AUB (OR 7.306, 95%CI 4.927–10.835), large EPs (OR 2.595, 95%CI 1.662–4.052), and blood flow signal in EPs (OR 2.690, 95%CI 1.872–3.866) were independent predictive factors of malignancy in all enrolled patients. A noninvasive predictor for malignancy of EPs was established, through combining with AUB, large polyps and blood flow signal. This predictor presented excellent sensitivity and NPV (91.3 and 95.8%), with acceptable specificity and AUC (0.801). Further validation in new diagnosed EPs also suggested excellent sensitivity and reasonable specificity (100 and 58.5%) of the predictor. Factors such as thickened endometrial thickness, menopause shorter than 10 years, hypertension, obesity and nulliparous were also validated as independent predictors of malignancy in different subgroup analysis.

Conclusions

The noninvasive predictor combined with other risk factors from subgroup analysis would be reliable to distinguish the benign lesions from malignancy for EPs diagnosed by ultrasound.

Clinicopathologic characteristics and risk factors for endometrial malignancy in postmenopausal women with endometrial thickening

OBJECTIVE

To evaluate the clinicopathological characteristics and risk factors for endometrial malignancy in postmenopausal women with endometrial thickening.

METHODS

This was a retrospective study. Postmenopausal women with endometrial thickening (defined as the thickest endometrial portion in the sagittal uterine plane was greater than or equal to 5 mm) through transvaginal ultrasound in our outpatient department, and further referred to the gynecology department at Xuanwu Hospital for hysteroscopic diagnostic curettage assessment between January 2018 and March 2021 were included. According to the histopathological results, participants were divided into the benign group and malignant group. Univariate analysis was used to compare the differences in various factors, including demographics, clinical characteristics, medical complications, and ultrasound characteristics, between the two groups. Multiple logistic regression analysis was used to identify the factors that were independent contributors to the development of endometrial malignancy. Receiver operating characteristic analysis of endometrial thickness (ET) to predict endometrial malignancy was performed.

RESULTS

In total, 385 eligible cases were included in the analysis. The results suggested that older age (odds ratio [OR] 1.061, 95% confidence interval [CI] 1.008-1.116, P = 0.023), thicker ET (OR 5.032, 95% CI 2.453-10.322, P < 0.001), irregular menstruation in the past (OR 19.203, 95% CI 1.936-190.431, P = 0.012), postmenopausal bleeding (OR 12.341, 95% CI 4.440-34.302, P < 0.001), and polypoid mass-like lesions (OR 30.330, 95% CI 8.974-102.509, P < 0.001) were risk factors that were independently associated with the development of endometrial malignancy in postmenopausal women with increased ET. The optimal critical value of ET in predicting malignancy was 9.5 mm, and the sensitivity and specificity were 71.70% and 71.69%, respectively.

CONCLUSIONS

For postmenopausal women with endometrial thickening, our results suggested that women who are older, have a thicker ET, had irregular menstruation in the past, have postmenopausal bleeding, and have polypoid mass-like lesions should seek medical attention as soon as possible and undergo further invasive examination. The use of 9.5 mm as the ET value to prompt investigations may be acceptable since it is unlikely to miss any atypical endometrial hyperplasia or endometrial cancer.

Endometrial polyps are non-neoplastic but harbor epithelial mutations in endometrial cancer drivers at low allelic frequencies

Endometrial polyps (EMPs) are common exophytic masses associated with abnormal uterine bleeding and infertility. Unlike normal endometrium, which is cyclically shed, EMPs persist over ovulatory cycles and after the menopause. Despite their usual classification as benign entities, EMPs are paradoxically associated with endometrial carcinomas of diverse histologic subtypes, which frequently arise within EMPs. The etiology and potential origins of EMPs as clonally-derived neoplasms are uncertain, but previous investigations suggested that EMPs are neoplasms of stromal origin driven by recurring chromosomal rearrangements. To better define benign EMPs at the molecular genetic level, we analyzed individual EMPs from 31 women who underwent hysterectomy for benign indications. The 31 EMPs were subjected to comprehensive genomic profiling by exome sequencing of a large panel of tumor-related genes including oncogenes, tumor suppressors, and chromosomal translocation partners. There were no recurring chromosomal rearrangements, and copy-number analyses did not reveal evidence of significant chromosome-level events. Surprisingly, there was a high incidence of single nucleotide variants corresponding to classic oncogenic drivers (i.e., definitive cancer drivers). The spectrum of known oncogenic driver events matched that of endometrial cancers more closely than any other common cancer. Further analyses including laser-capture microdissection showed that these mutations were present in the epithelial compartment at low allelic frequencies. These results establish a link between EMPs and the acquisition of endometrial cancer driver mutations. Based on these findings, we propose a model where the association between EMPs and endometrial cancer is explained by the age-related accumulation of endometrial cancer drivers in a protected environment that-unlike normal endometrium-is not subject to cyclical shedding.

Hysteroscopic Endometrial Resection in Symptomatic Tamoxifen Treated Women for Breast Cancer Can Provide Both Definitive Diagnosis and Effective Long-term Therapy

We evaluated resectoscopic surgery for definitive diagnosis and long-term therapy in 16 symptomatic tamoxifen-treated women with breast cancer who presented with abnormal uterine bleeding and/or intrauterine anomalies. Seven pre-menopausal women had benign pre- and post-operative endometrial biopsy, and 4 had benign polyps. At a median of 7 years of follow-up (range 2-8), all remained amenorrheic. Of 9 post-menopausal women, pre-operative biopsy was inadequate in 4, benign endometrium was found in 4, and non-atypical endometrial hyperplasia was found in 1. Post-operatively, all had benign pathology, 8 having polyp and 1 leiomyoma. At a median follow-up of 7 years (range 2-13), all were amenorrheic, with no recurrence of breast cancer or uterine pathology.

Does an Endometrial Cancer Diagnosis among Asymptomatic Patients Improve Prognosis?

BACKGROUND

Endometrial cancer is the most common gynecological malignancy in developed countries with no screening available. There is still a tendency to provide invasive bioptic verification in asymptomatic women with abnormal ultrasound findings to diagnose carcinoma in a preclinical phase; even though, it is not supported by European guidelines. Our goal was to determine DFS (disease-free survival), OS (overall survival), and DSS (disease-specific survival) differences between symptom-free and symptomatic (bleeding, or spotting) endometrial cancer patients with similar stage and tumor/clinical characteristics.

METHODS

All of our patients with endometrial cancer following surgical treatment between 2006 and 2019 were assessed, evaluating risk factors for recurrence and death while focusing on bleeding using univariable and multivariable analysis.

RESULTS

625 patients meeting the inclusion criteria were divided into asymptomatic (n = 144, 23%) and symptomatic (n = 481, 77%) groups. The median follow-up was 3.6 years. Using univariable analysis, symptomatic patients had a three times higher risk of recurrence (HR 3.1 (95% Cl 1.24-7.77), p = 0.016). OS (HR 1.35 (0.84-2.19), p = 0.219) and DSS (HR 1.66 (0.64-4.28), p = 0.3) were slightly worse without reaching statistical significance. In our multivariable analysis, symptomatology was deemed completely insignificant in all monitored parameters (DFS: HR 2.03 (0.79-5.24), p = 0.144; OS: HR 0.72 (0.43-1.21), p = 0.216).

CONCLUSIONS

The symptomatic endometrial cancer patients risk factor of earlier recurrence and death is insignificantly higher when compared with the asymptomatic cohort. However, multivariable analysis verifies that prognosis worsens with other clinically relevant parameters, not by symptomatology itself. In terms of survival outcome in EC patients, we recognized symptomatology as a non-significant marker for the patient's prognosis.

Prevalence and risk factors for malignancy in hysteroscopy-resected endometrial polyps

INTRODUCTION

To determine the prevalence of malignant lesions in endometrial polyps by hysteroscopic polypectomy, and risk factors for malignant transformation. The secondary aim was to evaluate background endometrium of atypical hyperplasia in endometrial polyps, and the risk of coexisting endometrial carcinoma after hysterectomy.

METHODS

This retrospective study included women who underwent hysteroscopic polypectomy between January 2015 and December 2019. Demographic characteristics, hysteroscopic findings, and histopathology results of the polyp and the uterus, in the case of a hysterectomy, were collected.

RESULTS

In all, 946 women were included in the study. Endometrial carcinoma in a polyp was found in 10 women (1.06%), and atypical hyperplasia was found in 11 women (1.16%). At the multivariate logistic regression model of risk factors, old age (P = 0.022) and obesity (P = 0.011) were significantly associated with (pre-)malignant polyp. Five of the ten women (50%) with atypical hyperplasia confined to a polyp had coexisting endometrial carcinoma in the hysterectomy specimen.

CONCLUSION

Women with risk factors should be offered hysteroscopic polypectomy to allow a reliable histologic evaluation. Furthermore, hysterectomy is recommended in women with atypical hyperplasia in endometrial polyps even after complete resection.

microRNAs in female infertility: An overview

Infertility impacts a considerable number of women worldwide, and it affects different aspects of family life and society. Although female infertility is known as a multifactorial disorder, there are strong genetic and epigenetic bases. Studies revealed that miRNAs play critical roles in initiation and development of female infertility related disorders. Early diagnosis and control of these diseases is an essential key for improving disease prognosis and reducing the possibility of infertility and other side effects. Investigating the possible use of miRNAs as biomarkers and therapeutic options is valuable, and it merits attention. Thus, in this article, we reviewed research associated with female diseases and highlighted microRNAs that are related to the polycystic ovary syndrome (up to 30 miRNAs), premature ovarian failure (10 miRNAs), endometriosis (up to 15 miRNAs), uterine fibroids (up to 15 miRNAs), endometrial polyp (3 miRNAs), and pelvic inflammatory (6 miRNAs), which are involved in one or more ovarian or uterine disease-causing processes.

"What you see is what you get" abnormal endometrial sonographic findings are sufficient for direct surgical hysteroscopy: Retrospective cohort study

OBJECTIVE

To evaluate the possibility of referring women with uterine polyps larger than 1.5 cm directly to surgical hysteroscopy.

METHODS

This retrospective cohort study included all women referred to a university-affiliated tertiary medical center for hysteroscopy, with the diagnosis of endometrial polyp, from 01/2013 to 05/2016. Women were referred for surgical hysteroscopy based on TVUS findings. PPV of TVUS for detecting intrauterine polyps was evaluated relating to pathology as gold standard, with sub-group analysis relating to polyp size and other parameters.

RESULTS

We selected 1.5 cm as a cutoff size for subgroup analysis of endometrial polyps. PPV of TVUS for the entire cohort of 295 cases eligible for analysis, was 79.3%. TVUS describing polyps ≥1.5 cm had PPV of 92.1%, higher than the PPV for smaller polyps. Among post-menopausal women in this group, PPV was as high as 96.2%. Use of doppler or saline was found to improve PPV in the entire cohort. Indication for performing TVUS did not affect the PPV.

CONCLUSION

TVUS describing polyps ≥1.5 cm may suffice for direct referral of women to surgical hysteroscopy. A personalized approach based on the initial diagnosis may avoid unnecessary invasive procedures for patients.

Tumor Characteristic Variations between Symptomatic and Asymptomatic Endometrial Cancer

Endometrial cancer is the most common gynecologic malignancy in Europe and usually diagnosed in its initial stage owing to early symptoms of abnormal bleeding. There is no population screening for this disease, although it can sometimes be accidentally diagnosed in asymptomatic patients. Our study aims to determine differences in clinical and tumor characteristics between an asymptomatic and symptomatic group of patients. This unicentric prospective observational study took place in University Hospital Brno between January 2016 and December 2019. A total of 264 patients met inclusion criteria (26% asymptomatic, 74% with reported symptoms). We did not find a statistically significant difference in clinical characteristics (menopausal status, parity, age, BMI, and serum level of CA 125) between groups. According to ultrasound examination, bleeding tumors were larger (19.5 vs. 12.7 mm, p ≤ 0.001). Definitive histology results indicated more frequent lymphovascular space invasion (p < 0.001), along with deep myometrial (p = 0.001) and cervical (p = 0.002) invasion. There was no difference in advanced stages of the tumor. We did not substantiate statistically significant difference in immunohistochemical profile (estrogen and progesterone receptors, L1 cell adhesion molecule, tumor protein p53), which is relevant for tumor recurrence risk and survival capacity. Our conclusions affirmed that bleeding occurs more often among patients with local tumor invasion into the myometrium and cervical stroma. Final International Federation of Gynecology and Obstetrics (FIGO) stage, histology, and immunohistochemical characteristics do not significantly affect symptom appearance.

The use of hysteroscopy in endometrial cancer: old questions and novel challenges

Endometrial cancer is the most common gynecological malignancy with a relatively good overall prognosis. It traditionally has two subtypes: type 1 (endometrioid carcinoma) and type 2 (non-endometrioid carcinoma). The prognosis is excellent for stage I endometrioid cancer, with a 5-year survival rate of 96%. However, the prognosis is much worse for women with high-risk endometrial cancer. Effective preoperative staging is important in order to tailor treatment and achieve optimal long-term survival. The majority of asymptomatic polyps detected by ultrasound are treated surgically. Conventionally, dilatation and curettage was performed to obtain a histological diagnosis, but nowadays hysteroscopy with biopsy is starting to be considered as the gold standard. Hysteroscopic resection seems to reduce the risk of underdiagnosed (atypical endometrial hyperplasia) endometrial cancer. To avoid the spread of malignant cells, hysteroscopy should be performed with concern to keep intrauterine pressure low. In comparison with cervical injection, the hysteroscopic method has a better detection rate in the para-aortic area during sentinel lymph node mapping. In the assessment of cervical involvement, the accuracy of magnetic resonance imaging is significantly higher than the accuracy of hysteroscopy. In fertility-sparing cases, hysteroscopic endometrium resection with progesterone therapy is an acceptable option.

Removal of uterine polyps: clinical management and surgical approach

Endometrial polyps have a reported prevalence from 7.8% up to 30% and are one of the most cost-consuming gynecological conditions for our specialty. There are strong practitioner beliefs that surgical removal of endometrial polyps is highly beneficial, particularly for those with abnormal uterine bleeding and infertility. Additionally, polypectomy is indicated to reduce the risk of malignancy. Transvaginal ultrasound is the first-line diagnostic option for detection of endometrial polyps, while sonohysterography has similar accuracy as hysteroscopy in the diagnostic confirmation. Blind dilatation and curettage is not recommended for polyp removal; rather, hysteroscopy in the operating room and office setting using small-diameter hysteroscopic equipment is the standard approach. This can be performed without anesthesia in most women. While hysteroscopy is an effective method for polypectomy with a low complication rate, it is unknown whether this is truly beneficial for reproductive-age women with infertility and prior assisted reproduction therapy. The risk of malignancy in women with postmenopausal bleeding justifies the necessity of polypectomy with histologic tissue examination. In asymptomatic women, the risk of malignancy is low, and there are no known benefits of polyp removal in the prevention of malignant transformation. Cost-effective studies remain to be done to provide us with the optimal approach to endometrial polyps including the management of asymptomatic and/or infertile women, ideal location including office-based or the operating room setting, complication prevention including intrauterine adhesions, and recurrence issues.

Risk of Pre-Malignancy or Malignancy in Postmenopausal Endometrial Polyps: A CHAID Decision Tree Analysis

BACKGROUND AND AIMS

Postmenopausal endometrial polyps are commonly managed by surgical resection; however, expectant management may be considered for some women due to the presence of medical co-morbidities, failed hysteroscopies or patient's preference. This study aimed to identify patient characteristics and ultrasound morphological features of polyps that could aid in the prediction of underlying pre-malignancy or malignancy in postmenopausal polyps.

METHODS

Women with consecutive postmenopausal polyps diagnosed on ultrasound and removed surgically were recruited between October 2015 to October 2018 prospectively. Polyps were defined on ultrasound as focal lesions with a regular outline, surrounded by normal endometrium. On Doppler examination, there was either a single feeder vessel or no detectable vascularity. Polyps were classified histologically as benign (including hyperplasia without atypia), pre-malignant (atypical hyperplasia), or malignant. A Chi-squared automatic interaction detection (CHAID) decision tree analysis was performed with a range of demographic, clinical, and ultrasound variables as independent, and the presence of pre-malignancy or malignancy in polyps as dependent variables. A 10-fold cross-validation method was used to estimate the model's misclassification risk.

RESULTS

There were 240 women included, 181 of whom presented with postmenopausal bleeding. Their median age was 60 (range of 45-94); 18/240 (7.5%) women were diagnosed with pre-malignant or malignant polyps. In our decision tree model, the polyp mean diameter (≤13 mm or >13 mm) on ultrasound was the most important predictor of pre-malignancy or malignancy. If the tree was allowed to grow, the patient's body mass index (BMI) and cystic/solid appearance of the polyp classified women further into low-risk (≤5%), intermediate-risk (>5%-≤20%), or high-risk (>20%) groups.

CONCLUSIONS

Our decision tree model may serve as a guide to counsel women on the benefits and risks of surgery for postmenopausal endometrial polyps. It may also assist clinicians in prioritizing women for surgery according to their risk of malignancy.

The diagnosis of endometrial cancer in women with asymptomatic endometrial polyp does not increase survival rates: an israel gynecologic oncology group study

OBJECTIVE

To compare outcomes of symptomatic and asymptomatic women with endometrial cancer and a preoperative diagnosis of an endometrial polyp.

DESIGN

An Israel Gynecologic Oncology Group multi-center retrospective cohort study.

METHODS

Of 635 patients with endometrial cancer and a preoperative diagnosis of an endometrial polyp who underwent surgery between 2002 and 2014 in one of 11 centers in Israel were divided into two groups according to the presence of bleeding symptoms. Outcome measures included recurrence-free survival, disease-specific survival and overall survival. Survival data were plotted according to the method of Kaplan and Meier and compared using the log-rank test.

RESULTS

There were 513 symptomatic and 122 asymptomatic women with endometrial cancer and a preoperative diagnosis of an endometrial polyp. The median follow-up was 52 months (range 12-120 months). There were no differences between patients who experienced bleeding and those who did not in 5-year recurrence-free survival (85.2 % vs. 85.7 %; p=0.83, respectively), disease-specific survival (88.2 % vs. 89.2 %; p=0.71, respectively), or overall survival (80.2% vs. 78.4 %; p=0.97, respectively).

CONCLUSION

The diagnosis of endometrial cancer in patients with asymptomatic endometrial polyps is not associated with improved outcomes as compared with patients with bleeding. In the absence of factors indicating a high risk of endometrial cancer, clinical and sonographic follow-up is the advised management strategy for these patients.

Endometrial polyps. An evidence-based diagnosis and management guide

OBJECTIVE

To provide an updated practice guideline for the management of patients with endometrial polyps.

MATERIALS AND METHODS

A committee of six expert researchers draw the recommendations according to AGREE II Reporting Guideline. An electronic search was performed querying the following databases MEDLINE (accessed through PubMed), Scopus, PROSPERO, EMBASE, CINAHL, Cochrane Library (including the Cochrane Database of Systematic Reviews), Scielo.br, Google Scholar, from inception to May 2020. A combination of text-words and Medical Subject Headings (MeSH) regarding endometrial polyps, diagnosis, management and treatment was used. Trials were assessed for methodologic rigor and graded using the United States Preventive Services Task Force classification system.

RECOMMENDATIONS

Transvaginal ultrasonography (TVUS) should be the imaging modality of choice for the detection of endometrial polyps in woman of fertile age (level B). Its accuracy increases when color-doppler, 3D investigation and contrast are used (level B). Dilation and Curettage (D&C) should be avoided for the diagnosis and management of polyps (level A). In office hysteroscopy showed the highest diagnostic accuracy in infertile patients with suspected endometrial polyps (level B). Polyps might alter endometrial receptivity, and embryo implantation reducing pregnancy rates (level C). Hysteroscopic polypectomy is feasible and safe with negligeble risk of intrauterine adhesion formation (level B). Polypectomy does not compromise reproductive outcomes from subsequent IVF procedures but the removal of polyps as a routine practice in sub-fertile women is not currently supported by the evidence (level B). Cost-effectiveness analysis suggest performing office polypectomy in women desiring to conceive (level B). Saline infused sonohysterography is highly accurate in detecting polyps in asymptomatic postmenopausal women (level B). Postmenopausal women with vaginal bleeding and suspected endometrial polyp should be offered diagnostic hysteroscopy with hysteroscopic polypectomy if endometrial polyps are present (level B). In-office hysteroscopy has the highest diagnostic accuracy with high cost-benefits ratio for premalignant and malignant pathologies of the uterine cavity (level B). Due to risk of malignancy, histopathological analysis of the polyp is mandatory (level B). Blind D&C should be avoided due to inaccuracy for the diagnosis of focal endometrial pathology (level A). Expectant management is not recommended in symptomatic patients especially in postmenopausal women (level B). In case of atypical hyperplasia or carcinoma on a polyp, hysterectomy is recommended in all post-menopausal patients and in premenopausal patients without desire of future fertility (level B). Asymptomatic endometrial polyps in postmenopausal women should be removed in case of large diameter (> 2 cm) or in patients with risk factors for endometrial carcinoma (level B). Excision of polyps smaller than 2 cm in asymptomatic postmenopausal patients has no impact on cost-effectiveness or survival (level B). Removal of asymptomatic polyps in premenopausal women should be considered in patients with risk factors for endometrial cancer (level B).

A body shape index (ABSI) and endometrial pathology

A body shape index (ABSI) is an anthropometric measure that allows evaluating abdominal adiposity. Obesity is considered a risk factor for endometrial cancer (EC). Due to the increase in EC's incidence, identifying risk factors for endometrial pathology is essential in women's health. The study aimed to identify an association between EC/endometrial pathology and ABSI. We identified well-known risk factors for endometrial cancer and calculated ABSI in 408 women who were admitted to the Polish Mother's Memorial Hospital Research Institute between January 2016 and December 2017. Patients were divided into four subgroups: no endometrial pathology, endometrial polyps, hyperplasia without atypia, and hyperplasia with atypia/cancer. Statistical analysis showed a correlation between ABSI and the presence of cancer/atypical hyperplasia (Kruskal-Wallis test, p = .042). Additional multivariate analysis revealed that both ABSI and body mass index (BMI) z scores might potentially be associated with EC presence (ABSI z score quintiles Q1, Q2, Q3 vs. Q4, Q5: p = .039; BMI z score quintiles Q1, Q2, Q3 vs. Q4, Q5: p = .038). We found an association between cancer/atypical hyperplasia and ABSI. Further studies on ABSI are needed to establish ABSI as a risk factor for EC fully.

Endometrial polyps: Is the prediction of spontaneous regression possible?

Objective

Endometrial polyps have been considered as a hyperplastic growth of endometrial stromal and glandular tissues. Even asymptomatic polyps in premenopausal women are usually removed as soon as they are diagnosed, although it is still unknown how often endometrial polyps disappear spontaneously. The aim of this study was to investigate the regression rate of endometrial polyps and the possible factors related to their spontaneous regression.

Methods

A total of 197 women with endometrial polyps were treated with operative hysteroscopy between January 2017 and April 2019 at our tertiary center. Of these, 123 patients who preferred conservative follow-up were enrolled in the study. Clinical and pathological data were obtained from electronic medical records.

Results

Patients with endometrial polyps were followed up for a median period of 62 days (range 30–360 days). Most women with endometrial polyps (84%) were reported to have gynecologic symptoms. Spontaneous polyp regression was observed in 28 (23%) patients who underwent surgery reevaluation. Patient age (<45 years), premenopausal period, and polyp size (<2 cm) were found to be associated with spontaneous endometrial polyp regression (P<0.05). We also observed more polyp regression in women with abnormal uterine bleeding (P=0.05). Second-look hysteroscopy showed that all postmenopausal women had persistent endometrial polyps.

Conclusion

Patient age (<45 years), premenopausal period, polyp size (<2 cm), and abnormal uterine bleeding may be associated with spontaneous endometrial polyp regression.

The Use of Hysteroscopy for the Diagnosis and Treatment of Intrauterine Pathology: ACOG Committee Opinion, Number 800

This Committee Opinion provides guidance on the current uses of hysteroscopy in the office and the operating room for the diagnosis and treatment of intrauterine pathology and the potential associated complications. General considerations for the use of diagnostic and operative hysteroscopy include managing distending media, timing for optimal visualization, and cervical preparations. In premenopausal women with regular menstrual cycles, the optimal timing for diagnostic hysteroscopy is during the follicular phase of the menstrual cycle after menstruation. Pregnancy should be reasonably excluded before performing hysteroscopy. There is insufficient evidence to recommend routine cervical ripening before diagnostic or operative hysteroscopy, but it may be considered for those patients at higher risk of cervical stenosis or increased pain with the surgical procedure. In randomized trials, patients reported a preference for office-based hysteroscopy, and office-based procedures are associated with higher patient satisfaction and faster recovery when compared with hospital-based operative hysteroscopy. Other potential benefits of office hysteroscopy include patient and physician convenience, avoidance of general anesthesia, less patient anxiety related to familiarity with the office setting, cost effectiveness, and more efficient use of the operating room for more complex hysteroscopic cases. Appropriate patient selection for office-based hysteroscopic procedures for women with known uterine pathology relies on thorough knowledge and understanding of the target pathology, size of the lesion, depth of penetration of the lesion, patient willingness to undergo an office-based procedure, physician skills and expertise, assessment of patient comorbidities, and availability of proper equipment and patient support. Both the American College of Obstetricians and Gynecologists (ACOG) and the American Association of Gynecologic Laparoscopists (AAGL) agree that vaginoscopy may be considered when performing office hysteroscopy because studies have shown that it can significantly reduce procedural pain with similar efficacy. The office hysteroscopy analgesia regimens commonly described in the literature include a single agent or a combination of multiple agents, including a topical anesthetic, a nonsteroidal antiinflammatory drug, acetaminophen, a benzodiazepine, an opiate, and an intracervical or paracervical block, or both. Based on the currently available evidence, there is no clinically significant difference in safety or effectiveness of these regimens for pain management when compared to each other or placebo. Patient safety and comfort must be prioritized when performing office hysteroscopic procedures. Patients have the right to expect the same level of patient safety as is present in the hospital or ambulatory surgery setting.

Current Resources for Evidence-Based Practice, May 2020

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of a new National Academy of Medicine report on planned place of birth and implications during the SARS-CoV-2 pandemic and commentaries on reviews focused on anorectal sexually transmitted infections and feeding methods following cleft lip repair in infants.

Clinical management of vaginal bleeding in postmenopausal women

Menopause is characterized by permanent cessation of menstrual periods and is clinically diagnosed after 12 months of complete amenorrhea. It occurs at a median age of 51 years alongside the physiological process of aging, although it can happen at an earlier age for other medical conditions or after surgery (surgical menopause). Due to reduced circulating estrogens and progesterone, the reproductive organs undergo progressive atrophy. This physiologic process of aging is also present at an endometrial level; without the cyclic hormonal actions of the menstrual cycle, the endometrium during menopause becomes atrophic. Postmenopausal bleeding (PMB) is a common gynecologic complaint encountered by the clinician. Endometrial cancer is present in about 10% of patients with PMB. Nevertheless, many other conditions, such as endometrial or cervical polyps, genital atrophy, or non-gynecologic conditions, may also be present. Historically, dilation and curettage (D&C) was the main diagnostic procedure in patients with PMB; however, newer methods of investigation have replaced D&C. The aim of this review is to present an up-to-date analysis of the current evidence for the clinical management of vaginal bleeding in postmenopausal women.