Management of abnormal uterine bleeding and the pathology of endometrial hyperplasia

Analysis of the results of invasive diagnostic procedures in patients referred to gynecologic department due to abnormal uterine bleeding

Introduction

Abnormal uterine bleeding (AUB) is one of the most common reason for visits to gynecologists. Endometrial biopsy is a routine procedure in gynecological practice to detect the etiology of AUB and to exclude precancerous and cancerous lesions of the endometrium. The aim of this study was to assess the causes of AUB among women, who had undergone invasive diagnostics due to AUB.

Material and methods

This study was carried among 531 women, who had undergone invasive diagnostics due to AUB between January 2018 and December 2018. Women were divided into premenopausal (with perimenopausal) and postmenopausal groups. Transvaginal ultrasound was performed. Endometrial thickness was compared with histopathological results in each subgroup and statistically analyzed. The incidence of histopathological findings and rate of anemia were also analyzed.

Results

In our series of patients the most common cause of AUB based on histopathological results was endometrial polyp, both before and after menopause. The most frequent pathologies at ultrasound findings were leiomyomas and endometrial polyps. The incidence of taken together: atypical hyperplasia and endometrial cancer was significantly higher in postmenopausal group (8.58%) than in pre- and perimenopausal (1.35%, p = 0.0001). The median endometrial thickness, both before and after menopause, was significantly greater in patients with pathological than with nonpathological endometrium. 31% of women with abnormal uterine bleeding before menopause and 10% after menopause had anemia.

Conclusions

Measurements of endometrial thickness seems to be acceptable initial diagnostic tool to distinguish between benign and pathological endometrial changes both before and after menopause.

Comparing the Administration of Letrozole and Megestrol Acetate in the Treatment of Women with Simple Endometrial Hyperplasia without Atypia: A Randomized Clinical Trial

INTRODUCTION

The present study was conducted as a pilot to compare the therapeutic effects and the potential side effects of oral Megestrol acetate and Letrozole in the treatment of simple hyperplasia in perimenopausal women.

METHODS

The participants of this randomized clinical trial consisted of two groups of 25 women aged 44-50 presenting with abnormal uterine bleeding diagnosed with simple endometrial hyperplasia without cytologic atypia confirmed by transvaginal ultrasonography and biopsy. The first group received 40-mg doses of Megestrol acetate for 2 weeks per month for a total period of 2 months. The second group received 2.5-mg daily doses of Letrozole for a total period of 2 months. The differences in terms of quantitative measurements were analyzed using the independent two-sample t test and the paired t test. To compare the two groups in terms of the distribution of the categorical variables, Pearson's Chi square and Fisher's Exact tests were used at the significance level of 0.05 by Stata-9.2.

RESULTS

Although the intervention led to significant improvements in both groups (P < .001), there was no difference between the groups in terms of accomplishing resolution (P = .74) [seven (28%) patients in the Letrozole group and five (20%) in the Megestrol group], while two patients in the Letrozole group and nine in the Megestrol group suffered from side effects, suggesting significantly lower side effects in the Letrozole group (P = .02).

CONCLUSION

Letrozole and Megestrol acetate seem to have similar effects on the treatment of simple endometrial hyperplasia, the only difference being that Letrozole presents fewer side effects than Megestrol acetate in patients with this condition.

FUNDING

Abnormal Uterine Bleeding Research Center of Semnan University of Medical Sciences, Semnan, Iran.

TRIAL REGISTRATION

IRCT2015031011504N5.

Role of transvaginal ultrasonography in diagnosing endometrial hyperplasia in pre- and post-menopause women

Background:

Abnormal uterine bleeding (AUB) is the most common presenting symptom of endometrial hyperplasia (EH). Transvaginal ultrasonography (TVS) is a diagnostic tool in the evaluation of AUB and EH with various sensitivity and specificity. However, the exact accuracy of TVS in diagnosing EH had not been evaluated. In this study, we aim to evaluate the accuracy of TVS in detecting EH.

Materials and Methods:

In this retrospective study, 120 women (mean age of 48.64 ± 6.74 years) with AUB with suspicious/or possible EH were evaluated. TVS and pathology findings of possible EH were recorded. Sensitivity, specificity, positive, and negative predictive value (PPV and NPV) was calculated.

Results:

Sixty-eight patients were premenopause, and 52 were postmenopause. TVS reported EH in 85 cases (70.83%). Pathology results showed EH in 85 cases (70.83%) including simple cystic hyperplasia in 82 cases, atypical, simple hyperplasia in one case and complex hyperplasia in two cases. Among these 85 cases, EH was confirmed by pathology in 81 cases. The accuracy, sensitivity, specificity, PPV, and NPV were 88.25%, 90.7%, 84%, 97.7%, and 84% in premenopause and 100% in postmenopause women.

Conclusion:

TVS is an appropriate diagnostic tool in premenopause and postmenopause women presenting with AUB, especially in detecting EH. However, further studies are needed to determine the exact accuracy of TVS in diagnosing TVS.

Short- and Long-Term Effects of Prenatal Exposure to Iron Oxide Nanoparticles: Influence of Surface Charge and Dose on Developmental and Reproductive Toxicity

Iron oxide nanoparticles (NPs) are commonly utilized for biomedical, industrial, and commercial applications due to their unique properties and potential biocompatibility. However, little is known about how exposure to iron oxide NPs may affect susceptible populations such as pregnant women and developing fetuses. To examine the influence of NP surface-charge and dose on the developmental toxicity of iron oxide NPs, Crl:CD1(ICR) (CD-1) mice were exposed to a single, low (10 mg/kg) or high (100 mg/kg) dose of positively-charged polyethyleneimine-Fe₂O₃-NPs (PEI-NPs), or negatively-charged poly(acrylic acid)-Fe₂O₃-NPs (PAA-NPs) during critical windows of organogenesis (gestation day (GD) 8, 9, or 10). A low dose of NPs, regardless of charge, did not induce toxicity. However, a high exposure led to charge-dependent fetal loss as well as morphological alterations of the uteri (both charges) and testes (positive only) of surviving offspring. Positively-charged PEI-NPs given later in organogenesis resulted in a combination of short-term fetal loss (42%) and long-term alterations in reproduction, including increased fetal loss for second generation matings (mice exposed in utero). Alternatively, negatively-charged PAA-NPs induced fetal loss (22%) earlier in organogenesis to a lesser degree than PEI-NPs with only mild alterations in offspring uterine histology observed in the long-term.

Levonorgestrel-releasing intrauterine system vs oral progestins for non-atypical endometrial hyperplasia: a systematic review and metaanalysis of randomized trials

We sought to evaluate the therapeutic efficacy of levonorgestrel-releasing intrauterine system (LNG-IUS) with oral progestins for treatment of non-atypical endometrial hyperplasia (EH). Searches were conducted on PubMed, SCOPUS, and CENTRAL databases to August 2014, and reference lists of relevant articles were screened. The search was limited to articles conducted on human beings and females. The PRISMA Statement was followed. Seven randomized controlled trials (n = 766 women) were included. Main outcome measures were the therapeutic effect rate (histological response) after 3, 6, 12, and 24 months of treatment; rate of irregular vaginal bleeding; and the hysterectomy rate per woman randomized. The Cochrane Collaboration risk of bias tool was used for quality assessment. Metaanalysis was performed with fixed effects model. LNG-IUS achieved a highly significant therapeutic response rate compared with oral progestins after 3 months of treatment (odds ratio [OR], 2.30; 95% confidence interval [CI], 1.39-3.82; P = .001, 5 trials, I(2) = 0%, n = 376), after 6 months of treatment (OR, 3.16; 95% CI, 1.84-5.45; P < .00001, 4 trials, I(2) = 0%, n = 397), after 12 months of treatment (OR, 5.73; 95% CI, 2.67-12.33; P < .00001, 2 trials, I(2) = 0%, n = 224), and after 24 months of treatment (OR, 7.46; 95% CI, 2.55-21.78; P = .0002, 1 trial, n = 104). Subgroup analysis showed evidence of highly significant therapeutic response following LNG-IUS compared with oral progestins for non-atypical simple as well as complex EH (OR, 2.51; 95% CI, 1.14-5.53; P = .02, 6 trials, I(2) = 0%, n = 290; and OR, 3.31; 95% CI, 1.62-6.74; P = .001, 4 trials, I(2) = 0%, n = 216, respectively). Compared with oral progestins, LNG-IUS achieved significantly fewer hysterectomies (OR, 0.26; 95% CI, 0.15-0.45; P < .00001, 3 trials, n = 362, I² = 42%). No difference was observed in the rate of irregular vaginal bleeding between both groups (OR, 1.12; 95% CI, 0.54-2.32; P = .76, 2 trials, n = 207, I² = 77%). Funnel plot analysis was not performed because of the relatively small number of included studies. For treatment of non-atypical EH, LNG-IUS achieves higher therapeutic effect rates and lower hysterectomy rates than oral progestins and should be offered as an alternative to oral progestins in these cases.

Menopause and Cancers

Cancer is a disease of aging, and therefore is more prevalent after menopause. Menopausal symptoms resulting from cancer treatments are an important survivorship issue in cancer care. This article reviews the preventive strategies, utilization of health resources, and management of menopausal symptoms after cancer treatment. Preventive screening as informed by genetic and lifestyle risk, and lifestyle modification, may mitigate the risk of cancer and cancer mortality. Despite potential benefits to quality of life, hormone replacement is rarely prescribed to survivors of gynecologic malignancies. Special considerations are needed for the treatment and supportive care of menopausal symptoms in cancer survivors.

Efficacy of the Levonorgestrel-Releasing Intrauterine System on IVF-ET Outcomes in PCOS With Simple Endometrial Hyperplasia

OBJECTIVE

This study investigated the in vitro fertilization (IVF) outcome of levonorgestrel-releasing intrauterine system (LNG-IUS) pretreatment for simple endometrial hyperplasia (EH) in patients with polycystic ovary syndrome (PCOS) undergoing IVF embryo transfer (IVF-ET).

METHODS

One hundred ninety patients with PCOS and simple EH without cytologic atypia were allocated randomly to 2 independent arms, that is, the LNG-IUS group (90 patients) and the non-LNG-IUS group (100 patients). Four hundred fourteen patients with PCOS without endometrial disease comprised the control group. Each patient was reevaluated by transvaginal ultrasonography (TVS) and endometrial biopsy after 6 months. For each patient, IVF outcome measures, such as number of recombinant follicle-stimulating hormone, endometrial thickness on human chorionic gonadotropin (HCG) day, hormone levels (progesterone, luetinizing hormone, and serum estradiol) on HCG day, number of oocytes, fertilization rate, clinical pregnancy rate, and miscarriage rate were compared among the 3 groups.

RESULTS

In general, the 3 groups did not differ with respect to the main clinical and biochemical data. After 6 months, patients in LNG-IUS group had an EH resolution rate of 87.77%. In the non-LNG-IUS group, the resolution rate was 15.00%, and 3% of these patients showed progression of EH. The clinical pregnancy rates in the non-LNG-IUS group were significantly lower (28.04%) than that in the LNG-IUS group (46.06%) and the control group (44.65%). The miscarriage rate was highest in the non-LNG-IUS group, but no significant difference in miscarriage rate existed among the 3 groups.

CONCLUSION

The study illustrates that the LNG-IUS can be safely used for 6 months as a treatment for patients with PCOS and simple EH. Additionally, use of the LNG-IUS can increase the clinical pregnancy rates and implantation rates of patients with PCOS and simple EH who undergo gonadotropin-releasing hormone agonist IVF-ET protocols.

LNG-IUS treatment of non-atypical endometrial hyperplasia in perimenopausal women: a randomized controlled trial

OBJECTIVE

To compare the efficacy of the levonorgestrel-releasing intrauterine system (LNG-IUS) and oral norethisterone acetate (NET) for treatment of non-atypical endometrial hyperplasia in perimenopausal women.

METHODS

One hundred and twenty perimenopausal women with non-atypical endometrial hyperplasia were selected in this randomized controlled trial. Patients received LNG-IUS (n=59) or NET (n=61; 15 mg/day for 3 weeks/cycle) for 3-6 months. Outpatient follow-up with endometrial biopsies were undertaken at 3, 6, and 12 months intervals after treatment. Outcome measures were; the regression rate, the time to regression and hysterectomy rate.

RESULTS

A significantly higher regression rate was noted in the LNG-IUS group than in NET group at the 3rd, 6th and 12th month follow-up visits using intention-to-treat analysis (67.8% vs. 47.5%, relative risk [RR], 1.42; 79.7% vs. 60.7%, RR, 1.31; and 88.1% vs. 55.7%, RR, 1.58, respectively). However, no significant difference was found regarding the median time to regression (3 months). The hysterectomy rate during the follow-up period was significantly higher in the NET group (57.4% vs.22%, p<0.001).

CONCLUSION

LNG-IUS treatment of non-atypical endometrial hyperplasia in perimenopausal women is more effective than NET for achieving disease regression for the majority within 1 year. Moreover, it can reduce the number of hysterectomies performed.

Adenomyosis among samples from hysterectomy due to abnormal uterine bleeding in Ahwaz, southern Iran

Introduction:

Adenomyosis is one of the most common, yet underdiagnosed, underlying causes of abnormal uterine bleeding (AUB). We aimed to evaluate the prevalence of adenomyosis among subjects who underwent hysterectomy due to AUB.

Materials and Methods:

We studied the pathological specimens from 100 cases of AUB who underwent hysterectomy and were referred to Jundishapur University of Medical Sciences, Ahwaz (Iran) from 2007 to 2010. All specimens were reviewed by the same pathologist.

Results:

Pathological findings included adenomyosis 21%, leiomyoma 30%, adenomyosis and leiomyoma 21%, adenomyosis and other pathological causes 7%, and other pathological causes 21%. The overall prevalence of adenomyosis was 49%. Mean age of the patients was 46.9 ± 7.8 years and the highest frequency of adenomyosis was observed in the age group 30–60 years.

Conclusions:

Overall prevalence of adenomyosis in the population with AUB (49%) that we studied was higher than that in the reports from other populations. Occurrence of isolated adenomyosis in those aged less than 30 years was rare, and adenomyosis was usually accompanied by other lesions.

Sonohysterography: the utility of diagnostic criteria sets

OBJECTIVE

The objective of our study was to determine whether applying specific diagnostic criteria to the interpretation of sonohysterography would improve the diagnostic accuracy of the interpretation.

MATERIALS AND METHODS

This retrospective study included 200 consecutive patients who underwent both sonohysterography and a procedure that resulted in a positive pathologic diagnosis. The initial interpretation (reader 1) was performed at the time of the examination. Subsequently, a reviewer with limited expertise (reader 2) interpreted the sonohysterograms masked to both the original medical imaging report and the final pathologic diagnosis. Reader 2 used a set of standardized diagnostic criteria to aid in arriving at one of the following diagnoses: normal, endometrial polyp, endometrial hyperplasia, endometrial carcinoma, submucosal fibroid, adenomyosis, adhesions, or clots. These results were compared with the initial diagnostic report (reader 1) and the final pathologic findings.

RESULTS

Overall agreement with pathology findings was 76.7% for reader 1 and 84.9% for reader 2. Comparison of the readers' interpretations using the pathologic diagnosis as the reference standard showed that reader 2's interpretations, which were established using the diagnostic criteria set, were uniformly better than those of reader 2.

CONCLUSION

The application of standardized diagnostic criteria may enhance the diagnostic accuracy of sonohysterography.

Pharmacological therapy for abnormal uterine bleeding

Pharmacological therapies for the treatment of abnormal uterine bleeding are effective and generally well tolerated. This review presents an evidence-based approach to medical therapy. Selection depends on the etiology and amount of bleeding, need for contraception or preservation of fertility, perimenopause status, and medication efficacy and adverse effects.Available nonhormonal agents include nonsteroidal anti-inflammatory agents, which reduce bleeding by 25% to 35% and improve dysmenorrhea through reduced prostaglandin levels; tranexamic acid, which inhibits plasminogen activator with a 40% to 60% reduction in menstrual blood loss; and intranasal desmopressin, which is an antifibrinolytic for women with an underlying bleeding disorder (eg, von Willebrand disease).Hormonal regimens cause the inhibition of endometrial growth. Cyclic progestogen therapy for 21 days results in a significant reduction in menstrual blood loss. Limited data suggest that oral contraceptives reduce menstrual blood loss by 40% to 50% with decreased breast tenderness and dysmenorrhea and a reduction in risk of uterine and ovarian cancer. The progestin-releasing intrauterine devices are effective up to 97% by 6 months and provide relief of dysmenorrhea and contraception. Long-acting progestogen injections produce amenorrhea and provide contraception but are associated with irregular spotting and reversible bone loss. Danazol leads to endometrial atrophy with a reduced menstrual loss; androgenic adverse effects may be lessened with lower doses or vaginal use. Gonadotrophin agonists lead to ovarian suppression and are used to shrink fibroids or the endometrium preoperatively but are limited by hypoestrogenic adverse events. Emergency use of parenteral conjugated estrogens has a 70% chance of stopping abnormal bleeding but an increased risk of thrombosis.

Epithelial membrane protein-2 expression is an early predictor of endometrial cancer development

BACKGROUND

Endometrial cancer (EC) is a common malignancy worldwide. It is often preceded by endometrial hyperplasia, whose management and risk of neoplastic progression vary. Previously, the authors have shown that the tetraspan protein epithelial membrane protein-2 (EMP2) is a prognostic indicator for EC aggressiveness and survival. Here the authors validate the expression of EMP2 in EC, and further examine whether EMP2 expression within preneoplastic lesions is an early prognostic biomarker for EC development.

METHODS

A tissue microarray (TMA) was constructed with a wide representation of benign and malignant endometrial samples. The TMA contains a metachronous cohort of cases from individuals who either developed or did not develop EC. Intensity and frequency of EMP2 expression were assessed using immunohistochemistry.

RESULTS

There was a stepwise, statistically significant increase in the average EMP2 expression from benign to hyperplasia to atypia to EC. Furthermore, detailed analysis of EMP2 expression in potentially premalignant cases demonstrated that EMP2 positivity was a strong predictor for EC development.

CONCLUSIONS

EMP2 is an early predictor of EC development in preneoplastic lesions. In addition, combined with our previous findings, these results validate EMP2 as a novel biomarker for EC development.

Strategies in the histologic diagnosis of low-grade glandular endometrial neoplasm

PURPOSE OF REVIEW

Histological diagnosis of well differentiated endometrioid adenocarcinoma (WDA) has been challenging over the years. Considering the impact of this diagnosis on treatment and follow-up of the patient, in this review, we have discussed and evaluated the most useful of the proposed histological criteria for diagnosis of WDA and its distinction from mimic lesions.

RECENT FINDINGS

Diagnostic criteria for WDA are proposed regarding histologic features predicting the presence of myometrial or endometrial stromal invasion by proliferating glands, or aggressive behavior.

SUMMARY

Most useful diagnostic histological features in WDA, such as cribriform, labyrinthine, and confluent glandular patterns, and stromal desmoplasia are highlighted. Presence of these features differentiates WDA from mimics and justifies aggressive treatment.

Transdermal estradiol for postpartum depression: a promising treatment option

Postpartum depression (PPD) is the most common unrecognized complication of childbirth and affects 1 out of 7 childbearing women. Although conventional pharmacologic and psychotherapeutic antidepressant treatments are effective for PPD, a natural alternative may be preferred by postpartum women, especially those who breastfeed their infants. The treatment of PPD with synthetic forms of naturally occurring estrogen is mechanistically appealing because PPD occurs in the context of estrogen withdrawal at parturition. Preliminary evidence suggests that PPD is a disorder of hormone-related mood dysregulation (similar to perimenopausal depression) that can be effectively treated with estrogen. This review provides the basic science and clinical background as well as safety considerations to support the application of transdermal estradiol as a treatment for PPD. We conclude that estradiol treatment for PPD requires confirmation of efficacy in a randomized clinical trial before routine clinical use as monotherapy. Additional data regarding maternal tolerability of cyclic progestins, long-term safety of estradiol treatment, estradiol passage into breast milk and infants, and interdisciplinary collaboration among psychiatrists and gynecologists is also needed before estradiol is used in women who decline or fail to respond to first-line antidepressant treatments, or as an augmentation of conventional antidepressant treatment.

Endometrial hyperplasia and the risk of progression to carcinoma

The primary presenting symptom of endometrial neoplasia is abnormal uterine bleeding, which typically prompts an endometrial biopsy to rule out carcinoma. Approximately 70% of women with abnormal uterine bleeding are diagnosed with benign findings and 15% are diagnosed with carcinoma. The remaining 15% receive a diagnosis of endometrial hyperplasia (EH), which includes a broad range of lesions, from mild, reversible proliferations to the immediate precursors of carcinoma. The widely used World Health Organization (WHO) system classifies EH according to four combinations of glandular crowding and nuclear atypia: simple (SH), complex (CH), simple atypical (SAH), or complex atypical hyperplasia (CAH), although the two forms of atypical hyperplasia (AH) are often collapsed into one category. Diagnoses of EH raise three issues. First, the low interobserver reproducibility-less than 50% in almost all studies-hinders the ability of WHO-based classification to effectively guide clinical management. Second, approximately 50% of women diagnosed with AH have concurrent carcinoma. Not surprisingly, most women with AH undergo hysterectomy as primary treatment, but non-surgical management can be effective. Third, data on progression risks for women with EH who retain their uterus are extremely limited. Emerging data indicate the long-term risk among women with SH or CH is less than 5%, but the risk among women with AH is approximately 30%. These data highlight priority areas for future research, such as increasing the diagnostic reproducibility of EH, improving the discrimination between AH and carcinoma, and identifying biomarkers to stratify risks or serve as indicators of response to clinical treatment.