Abnormal uterine bleeding in perimenopause

Screening of prognostic factors and survival analysis based on histological type for perimenopausal endometrial carcinoma treated with hysterectomy

PURPOSE

This study aimed to explore the prognostic factors and survival patterns based on the histological type for the perimenopausal endometrial carcinoma (PIPEC) patients treated with hysterectomy.

METHODS

The PIPEC patients were selected from the Surveillance, Epidemiology, and End Results (SEER) database. Methods of random survival forest (RSF) and Cox regression were used to identify the possible prognostic factors of PIPEC patients. Then overall survival (OS) and cancer-specific survival (CSS) of PIPEC data were analyzed by histological types with regional lymph nodes status and SEER-stage to investigate the survival patterns of the PIPEC patients.

RESULTS

A total of 14,178 PIPEC patients were included in the study. We found tumor size, grade, histology, SEER-stage, AJCC-stage, AJCC-T stage, metastasis to distant organs and regional lymph nodes status had a significant survival outcome for PIPEC both for OS and CSS (all p < 0.05). Regardless of regional lymph nodes status and SEER-stage for OS and CSS, the low-grade endometrioid carcinoma had the best prognosis outcome, followed by the mix cell adenocarcinoma and high-grade endometrioid carcinoma, while the carcinosarcoma and undifferentiated carcinoma had relatively poor prognosis outcome. And the survival patterns of different histological types of PIPEC were diverse and changed along with the time.

CONCLUSION

We identified the possible prognostic factors of PIPEC patients treated with hysterectomy. And survival analysis based on the regional lymph nodes status and SEER-stage revealed the different histological types of PIPEC had diverse survival patterns, which will be helpful for guiding clinical practice.

Effect of norethisterone dose and duration in the management of abnormal uterine bleeding: a narrative review and case report

Abnormal uterine bleeding (AUB) is an acute/chronic variation in the normal menstrual cycle that affects adolescents, women of reproductive age and perimenopausal women. AUB affects approximately 3-30% of reproductive-aged women worldwide, and reduces their quality of life and productivity whilst increasing the overall healthcare burden. Its management requires thorough medical evaluation and individualized treatment. Depending on the severity and cause of AUB, its treatment ranges from lifestyle modifications and hormonal therapies to more invasive procedures or surgery. Although hormonal therapy is the preferred first-line measure in AUB, the available pharmacological options have various adverse effects. There exists a need for safer and more efficient treatment regimens with high patient compliance to effectively treat AUB. Norethisterone, also known as norethindrone, is a widely used synthetic analogue of progestogen. Controlled release formulations of norethisterone/ norethisterone acetate help maintain constant drug levels in the blood and exert minimal side-effects; therefore, they are promising therapeutic agents for effective AUB management. The present review summarizes the epidemiology and diagnosis of AUB, with a focus on the safety, efficacy and tolerability of norethisterone/ norethisterone acetate in AUB management. We also report a case of AUB in a 40-year-old woman, who was treated with NETA tablets. The treatment resulted in favourable outcomes, and patient satisfaction.

Analysis of clinical data of different endometrial pathological types in perimenopausal women with abnormal uterine bleeding

Objective

Early detection and diagnosis are important for improving the therapeutic effect and quality of life in patients with endometrial cancer (EC). This study aimed to analyze the clinical data of different endometrial pathological types in perimenopausal women with abnormal uterine bleeding (AUB) in order to provide evidence for the prevention and early diagnosis of EC.

Methods

A total of 462 perimenopausal women with AUB were enrolled in this prospective observational study. Endometrial biopsy was performed in patients with suspected endometrial lesions. According to the pathological examination results, the patients were divided into endometrial polyp group (EP) (n = 71), endometrial hyperplasia without atypia group (EH) (n = 59), atypical endometrial hyperplasia (AEH) (n = 36), and EC group (n = 27). The history risk factors and ultrasonic imaging characteristics of endometrium among the four groups were compared.

Results

Twenty-seven women were diagnosed with EC (5.84%). The prevalence rate of AEH and EC in the group of 51- to 55-year-old women was significantly higher than that in the groups of 40- to 45-year-old women and of 46- to 50-year-old women (P < 0.05). The age, body mass index, and history of diabetes gradually increased with the development of endometrial pathological types. In addition, the correlation index of endometrial blood flow increased gradually, and the proportion of uneven endometrial echo, unclear endometrial-myometrial junction (EMJ), and ovarian cyst also increased gradually. However, no statistically significant difference was found when comparing endometrial thickness (ET) and endometrial volume (EV) among endometrial pathological groups (P > 0.05). The ET, EV, endometrial vascularization index, endometrial flow index, and vascularization flow index in the ovarian cyst group were significantly higher (P < 0.05), and the proportion of uneven endometrium echo and unclear EMJ were significantly higher compared with that in the non-ovarian cyst group (P < 0.05).

Conclusions

The most common cause of perimenopausal women with AUB was benign endometrial lesions. However, women aged 51-55 years old with endometrial high risk factors and ovarian cyst should be alert to AEH and EC. Endometrial biopsy needs to be performed to determine endometrial malignancy in necessity.

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.

A retrospective analysis of the women hospitalized and treated due to anemia caused by gynecological pathologies: the role of intravenous iron (ferric carboxymaltose) and blood transfusion in clinical practice

BACKGROUND

Gynecological pathologies are an important cause of anemia in women. In this study, we aimed to evaluate women who had been hospitalized because of anemia (Hb level <10 g/dL) caused by gynecologic pathologies and treated with either intravenous iron (ferric carboxymaltose) or blood transfusion.

METHODS

This retrospective cross-sectional study was performed in a tertiary care center. Women who were hospitalized with the diagnosis of anemia with Hb level<10 g/dL and abnormal uterine bleeding between March 2015- September 2017 in the gynecology clinic were enrolled in the study. Hemoglobin levels, hemoglobin changes, uterine pathology and treatment of patients were recorded and compared.

RESULTS

One hundred and fifteen women received red blood cell transfusion and 100 women were treated with intravenous ferric carboxymaltose. The mean age of the women was 45.1±6.1 (22-57) years. Although the mean Hb levels were higher in the iv-iron replacement group at the end of the one month (P=0.001), the mean increase in Hb levels was similar between two treatment modalities (P=0.101). Among the anemic women who required surgery, iv iron replacement was the first choice in 75.9% of women; 34.1% received red blood cell transfusion in the preoperative period.

CONCLUSIONS

Gynecological pathologies are a common cause of anemia in reproductive age women and intravenous carboxymaltose treatment is a safe and cheaper alternative of blood-transfusion in appropriate cases to elevate the Hb levels in the preoperative period.

Hysteroscopy as a Therapeutic Tool: A Vision to Spare the Uterus in Premenopausal Abnormal Uterine Bleeding (AUB)/Heavy Menstrual Bleeding (HMB), an Update

Heavy menstrual bleeding (HMB) or abnormal uterine bleeding (AUB) is a common cause of gynecological complaints in perimenopausal women. The treatment chosen by most of the women having HMB/AUB in the perimenopausal age group when medical therapy fails is hysterectomy, which unfortunately has significant issues related to safety and long-term quality of life apart from being a burden on the health care system and cost to patients. Minimal access surgical techniques like hysteroscopic targeted therapies are available which are conservative and spare the uterus and major surgery and its complications and sequelae. Hysteroscopic management of HMB is a minimally invasive and targeted approach in diagnosing and treating the pathological lesions causing the symptoms and not radical like hysterectomy which has more chances of occurrence of adverse events both intra and postoperatively. In terms of health-related quality of life, women suffering from HMB who underwent a hysteroscopic conservative approach had better scores when compared to those with hysterectomy. The present review aims to review the evidence generated to compare the two surgical modalities, hysteroscopic targeted therapy and hysterectomy, in terms of their effectiveness, safety, and effect on the quality of life of these perimenopausal women having HMB/AUB.

Management of perimenopausal and menopausal symptoms

Most women worldwide experience menopausal symptoms during the menopause transition or postmenopause. Vasomotor symptoms are most pronounced during the first four to seven years but can persist for more than a decade, and genitourinary symptoms tend to be progressive. Although the hallmark symptoms are hot flashes, night sweats, disrupted sleep, and genitourinary discomfort, other common symptoms and conditions are mood fluctuations, cognitive changes, low sexual desire, bone loss, increase in abdominal fat, and adverse changes in metabolic health. These symptoms and signs can occur in any combination or sequence, and the link to menopause may even be elusive. Estrogen based hormonal therapies are the most effective treatments for many of the symptoms and, in the absence of contraindications to treatment, have a generally favorable benefit:risk ratio for women below age 60 and within 10 years of the onset of menopause. Non-hormonal treatment options are also available. Although a symptom driven treatment approach with individualized decision making can improve health and quality of life for midlife women, menopausal symptoms remain substantially undertreated by healthcare providers.

D-Chiro-Inositol in Endometrial Hyperplasia: A Pilot Study

Endometrial hyperplasia is a threatening pathology driven by unopposed estrogen stimulus. Moreover, insulin may act on the endometrium, prompting further growth. We aimed at assessing whether D-chiro-Inositol, an insulin sensitizer with estrogen-lowering properties, might improve the condition of patients with simple endometrial hyperplasia without atypia. We enrolled women with simple endometrial hyperplasia without atypia and related symptoms, including abnormal uterine bleeding. We treated the patients with one tablet per day, containing 600 mg of D-chiro-inositol for six months. Patients underwent ultrasound to assess the thickness of the endometrium at baseline, after three months, and at the end of this study. Endometrial thickness went from 10.82 ± 1.15 mm to 8.00 ± 0.81 mm after three months (p < 0.001) and to 6.9 ± 1.06 mm after six months (p < 0.001 versus baseline; p < 0.001 versus three months). D-chiro-inositol treatment also improved heavy menstrual bleeding and the length of menstruation. Despite the fact that our data should be validated in larger studies with appropriate control groups, our promising results support the hypothesis that D-chiro-inositol may represent a useful treatment in the case of endometrial hyperplasia without atypia.

Presidential reflections: how we got here, where we might go

Pieter van Keep was a founder and the third president of the International Menopause Society (IMS). He died, sadly, in 1991. Since then, every retiring president of the IMS has delivered the Pieter van Keep Memorial Lecture. This is an edited version of that lecture delivered at the 18th World Congress of the IMS in Lisbon, Portugal in 2022. In the article, President Steven R. Goldstein describes the path he followed that led him to the presidency of the IMS, including his original entry into transvaginal ultrasound, then gynecologic ultrasound and, ultimately, menopausal ultrasound. His was the first description of the benign nature of simple ovarian cysts, the ability of transvaginal ultrasound to exclude significant tissue in patients with postmenopausal bleeding and the significance of endometrial fluid collections in postmenopausal patients, just to name a few. However, it was his description of the unusual ultrasound appearance in the uterus of women receiving tamoxifen therapy that allowed his entry into the world of menopause. This, ultimately, led to leadership positions, and ultimately the presidency of the American Institute of Ultrasound in Medicine, the North American Menopause Society and, finally, the IMS, all chronicled in this article. In addition, the article describes in detail the activities of the IMS during the COVID pandemic.

Development of a brief menstrual quality of life measure for women with heavy menstrual bleeding

BACKGROUND

The National Institute for Health and Care Excellence advises that considerations around quality of life should be made when assessing and treating heavy menstrual bleeding. A quick and reliable method for women to assess the impact of HMB on their quality of life might encourage help-seeking. This research aimed to develop a new 10-item measure of menstrual quality of life (the PERIOD-QOL).

METHODS

Three pilot studies describe PERIOD-QOL development and a cross-sectional survey (N = 376) assessed PERIOD-QOL scores in women who reported HMB and those who did not. A population sample of women (mean age 30.29, SD = 9.06) completed the PERIOD-QOL and rated their menstrual bleeding as heavy/very heavy/extremely heavy (HMB group) or very light/light/moderate bleeding (LMMB) group. Data were analysed using independent samples Analysis of Variance and independent samples t-tests.

RESULTS

Cronbach's Alpha for the PERIOD-QOL = .88. A significant reduction in PERIOD-QOL scores was found across the 6 levels of bleeding from very light to extremely heavy, and significantly lower PERIOD-QOL scores were reported in the HMB than the LMMB group.

CONCLUSION

The results suggest that the PERIOD-QOL is a reliable measure and that women experiencing HMB reported significantly lower menstrual quality of life than those who did not. Further validation of the PERIOD-QOL is required to determine its relationships with existing measures of menstrual quality of life and to establish whether PERIOD-QOL scores are associated with decisions to seek help from health professionals and with verified diagnoses of conditions that cause HMB.

Diagnosis and medical management of abnormal premenopausal and postmenopausal bleeding

Abnormal uterine bleeding is a common reason for presentation to health-care providers: it is estimated that one woman in three will present to a care provider with abnormal uterine bleeding (AUB) during the reproductive years, and that at least one woman in 10 will experience postmenopausal bleeding. Although there are some variations in national guidelines for investigation, diagnosis and management of premenopausal AUB, there are far more areas of agreement than disagreement. A comprehensive literature search was undertaken to review national and international guidelines regarding investigation, diagnosis and management of AUB in both premenopausal and postmenopausal women. Areas of controversy are identified, and latest evidence reviewed. Although efforts to reduce hysterectomies for premenopausal AUB through medical management have largely been successful, there are areas where more research is necessary to guide optimal investigation and management. Many countries have well-defined guidelines for investigation and management of premenopausal AUB: there are fewer well-developed guidelines for investigation and management of postmenopausal bleeding. There is a paucity of evidence-based data on management of unscheduled bleeding on menopausal hormone therapy.

Oncological Safety of Diagnostic Hysteroscopy for Apparent Early-Stage Type II Endometrial Cancer: A Multicenter Retrospective Cohort Study

Objective

To study the oncological safety of diagnostic hysteroscopy for women with apparent early-stage type II endometrial cancer.

Patients and Methods

A total of 429 women with presumed early-stage type II endometrial cancer were included. The 5-year disease-free survival (DFS) and overall survival (OS) were estimated and compared using the Kaplan-Meier method and the log-rank test among patients diagnosed by Dilation &amp; Curettage (D&amp;C) or diagnostic hysteroscopy. The Cox proportional hazards regression model was employed to adjust for potential confounding factors.

Results

160 cases underwent D&amp;C and 269 cases were diagnosed by diagnostic hysteroscopy. The 5-year DFS rate was 72.17% in the diagnostic hysteroscopy group and 76.16% in the D&amp;C group, diagnostic hysteroscopy was not associated with deteriorated 5-year DFS rate (HR 1.25, 95% CI 0.84-1.86, P=0.281). The 5-year OS rate was 67.23% in the diagnostic hysteroscopy group and 70.71% in the D&amp;C group, diagnostic hysteroscopy did not increase the risk of all-cause death (HR 1.11, 95% CI 0.78-1.57, P=0.573). Multivariable analysis showed that the method of endometrial sampling was not independently associated with DFS (aHR 1.38, 95% CI 0.92-2.07, P=0.122) and OS (aHR 1.23, 95% CI 0.85-1.77, P=0.272).

Conclusion

For apparent early-stage type II endometrial cancer, endometrial sampling by diagnostic hysteroscopy was as safe as D&amp;C.

Subclinical Hypothyroidism in Perimenopausal Abnormal Uterine Bleeding Patients

Background 

Abnormal uterine bleeding (AUB) can be very troublesome and is common in women with thyroid dysfunction. The current study aimed to assess the incidence of subclinical hypothyroidism in women with perimenopausal AUB.

Methodology 

A cross-sectional study was conducted at Hayatabad Medical Complex (HMC), Peshawar, Pakistan, between September 2020 to February 2021. All outdoor female patients with complications in the obstetrics and gynecology department, aged between 40 to 55 years of age, and no obvious cervical and genital lesions were included in the study. Patients with a history of suspected inflammatory disease, use of oral contraceptives, and malignant lesions of the cervix were excluded from the study. All cases were evaluated for AUB and their thyroid profile was evaluated. Data regarding menstrual irregularities were recorded in a pre-defined proforma and clinical examination was performed.

Results

A total of 500 women were enrolled with a mean age of 47.2 ± 7.3 years. Of these, 234 (46.8%) women were overweight and the mean levels of the thyroid-stimulating hormone were 4.4 ± 2.5 mIU/L. The mean triiodothyronine and thyroxine were 3.2 ± 1.9 and 1.5 ± 0.7 pmol/L, respectively. The rate of subclinical hypothyroidism was 33%. It was shown that the body mass index was significantly correlated with subclinical hypothyroidism (p=0.03). Furthermore, the rate of oligomenorrhea was significantly higher in patients with subclinical hypothyroidism (p=0.05).

Conclusion 

This study highlights the association between thyroid dysfunction in women with menstrual disorders. Screening and surveillance of thyroid-related abnormalities are warranted in patients with menstrual irregularities to avoid complications of the disease.

Clinically Used Hormone Formulations Differentially Impact Memory, Anxiety-Like, and Depressive-Like Behaviors in a Rat Model of Transitional Menopause

A variety of U.S. Food and Drug Administration-approved hormone therapy options are currently used to successfully alleviate unwanted symptoms associated with the changing endogenous hormonal milieu that occurs in midlife with menopause. Depending on the primary indication for treatment, different hormone therapy formulations are utilized, including estrogen-only, progestogen-only, or combined estrogen plus progestogen options. There is little known about how these formulations, or their unique pharmacodynamics, impact neurobiological processes. Seemingly disparate pre-clinical and clinical findings regarding the cognitive effects of hormone therapies, such as the negative effects associated with conjugated equine estrogens and medroxyprogesterone acetate vs. naturally circulating 17β-estradiol (E2) and progesterone, signal a critical need to further investigate the neuro-cognitive impact of hormone therapy formulations. Here, utilizing a rat model of transitional menopause, we administered either E2, progesterone, levonorgestrel, or combinations of E2 with progesterone or with levonorgestrel daily to follicle-depleted, middle-aged rats. A battery of assessments, including spatial memory, anxiety-like behaviors, and depressive-like behaviors, as well as endocrine status and ovarian follicle complement, were evaluated. Results indicate divergent outcomes for memory, anxiety, and depression, as well as unique physiological profiles, that were dependent upon the hormone regimen administered. Overall, the combination hormone treatments had the most consistently favorable profile for the domains evaluated in rats that had undergone experimentally induced transitional menopause and remained ovary-intact. The collective results underscore the importance of investigating variations in hormone therapy formulation as well as the menopause background upon which these formulations are delivered.

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.

Effectiveness of different methods for polypectomy in the menopause: a retrospective study

Introduction: Most endometrial polyps represent focal hyperplasia of the endometrium. Endometrial polyps can be diagnosed by ultrasound, hysterocontrast sonography, hysterosalpingography, endometrial biopsy, and uterine curettage, but diagnostic hysteroscopy is considered the gold-standard method, with the greatest sensitivity and specificity and also with the opportunity for treatment at the same time.Study design: A retrospective study was conducted on 424 patients between 2006 and 2018. The polyps were verified during diagnostic hysteroscopy and were removed by resectoscopy or curettage. All samples underwent histological examination. The effectivity of the type of resection and the recurrence rate were evaluated.Results: The average age of the patients was 60.2 ± 9.3 years. Polyps were excised in 62.97% by resectoscopic polypectomy and in 37.03% by curettage. Malignancy was confirmed in 4.24% of cases. Histological verification of polyps was 79.4% in the resectoscopy group and 69.04% in the curettage group; the difference was significant (p < 0.01). The recurrence rate was 20.47% after resectoscopy and 27.12% following curettage.Conclusion: Hysteroscopy remains the best option and the gold-standard method among diagnostic procedures of endometrial pathology. In this study, there was a significant difference in matching hysteroscopic and histological findings in the two methods of polypectomy. The recurrence rate is also lower following resectoscopy.

Do fetuin-A/apha2-Heremans Schmid-glycoprotein levels have an association with recurrent pregnancy loss?

OBJECTIVE

Fetuin-A is a hepatokine which is previously found related to fertility and pregnancy outcomes. We aimed to investigate if recurrent pregnancy loss (RPL) is associated with increased fetuin-A levels.

MATERIALS AND METHODS

Serum fetuin-A concentrations were measured and compared in 30 non-pregnant women with a history of unexplained recurrent miscarriage, 29 women who had a history of unexplained recurrent miscarriage and were admitted to our clinic due to miscarriage during the study period and 30 fertile women who have no history of miscarriage or any other pregnancy complications with at least two previous healthy children.

RESULTS

The median serum fetuin-A levels of group I, II, and III were 59.45, 62.73, and 44.52, respectively (p=.065). Serum fetuin-A levels significantly increased in group II compared to group III (p=.011). No significant differences in the levels of fetuin-A of group I compared to either group II (p=.433) or group III (p=.268).

CONCLUSIONS

The etiology of RPL is still a subject that is not clarified. Fetuin-A levels may have a relationship with RPL.

Oral Desogestrel as Endometrial Preparation before Operative Hysteroscopy: A Systematic Review

The pharmacologic preparation of the endometrium before hysteroscopy may be achieved with the use of various drugs. This systematic review aims to summarize the available evidence regarding the use of desogestrel for endometrial preparation before hysteroscopic procedures. A literature search for suitable articles published in English language from inception of the database until August 2019 was performed using the following databases: PubMed/MEDLINE, EMBASE, the Cochrane Library, and Google Scholar. All original articles concerning desogestrel-only pretreatment before hysteroscopic surgery were considered eligible. Reviews, case reports/series, conference papers, studies including the use of combined hormonal preparation, and articles in languages other than English were excluded from the analysis. The literature search retrieved 3 studies that met all the inclusion criteria. The data demonstrated that desogestrel may be considered as a hormonal pretreatment drug before hysteroscopic procedures. The drug was distinctly effective and assessed as helpful by the operating surgeon in numerous patients who were administered the pretreatment of 75 μg daily. Oral desogestrel is a cheap, easily available, safe, and quite efficient alternative for endometrial preparation before hysteroscopic procedures.

Pathological spectrum of endometrial biopsies in Saudi women with abnormal uterine bleeding: A retrospective study of 13-years

OBJECTIVES

To assess and age stratify the types and frequencies of endometrial pathologies in Saudi women with abnormal uterine bleeding (AUB) that underwent endometrial biopsies, at our hospital over a 13-year period.

METHODS

In a retrospective study, from 2006 to 2018, all endometrial biopsies from Saudi women with AUB, reported at the laboratory of King Saud University-Medical City, Riyadh, Saudi Arabia, were revisited and analyzed. The women were categorized into <40, between 40-55 and >55 years of age.

RESULTS

We analyzed 6458 biopsies. In <40 and 40-55 years' groups cyclical endometrium was most common followed by endometrial polyps and disordered proliferative endometrium. In the >55 years' group, atrophic endometrium was most common followed by endometrial polyps. The hyperplasias and malignancies together accounted for 7.2% of the study, majority in the >55 years' group. Simple hyperplasia without atypia was the most common (3.9%), followed by malignancies (1.9%), complex atypical hyperplasia (0.7%), complex hyperplasia without atypia (0.4%), and simple atypical hyperplasia (0.3%).

CONCLUSION

Awareness of the probable spectrum of endometrial histopathologies in the various ages is useful in guiding management. Endometrial biopsies are valuable in early detection of precancerous and cancerous endometrial lesions especially in women over 40 years.

The levonorgestrel intrauterine system for prevention of endometrial cancer in women with obesity: A cost-effectiveness study

OBJECTIVE

To estimate the cost-effectiveness of the levonorgestrel intrauterine system (LNG-IUS) as an endometrial cancer prevention strategy in women with obesity.

METHODS

A Markov decision-analytic model was used to compare 5 strategies in women with a body mass index of 30 or greater: 1) Usual care 2) LNG-IUS for 5 years 3) LNG-IUS for 7 years 4) LNG-IUS for 5 years, replaced once for a total of 10 years 5) LNG-IUS for 7 years, replaced once for a total of 14 years. Obesity was presumed to be associated with a 3-fold relative risk of endometrial cancer incidence and a 2.65-fold disease-specific mortality. The LNG-IUS was assumed to confer a 50% reduction in cancer incidence over the period of the LNG-IUS insertion. Outcomes were incremental cost-effectiveness ratios, calculated in 2019 Canadian dollars (CAD) per year of life saved. One-way and two-way sensitivity analyses were performed.

RESULTS

The LNG-IUS strategy was considered cost-effective if the cost of the intervention is less than $66,400 CAD ($50,000 US dollars) per year of life saved. The strategy becomes cost-effective if the LNG-IUS is inserted at age 57 (strategy #2), at age 52 for strategy #3, at age 51 for strategy #4 and at age 45 for strategy #5, when compared to usual care. The results are stable to variations in cost but sensitive to the estimated risk reduction of the LNG-IUS and the impact of obesity on endometrial cancer incidence and disease-specific mortality.

CONCLUSION

The LNG-IUS is a cost-effective method of endometrial cancer prevention in women with obesity.

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.

Uterine fibroids in menopause and perimenopause

Uterine fibroids (UFs) are benign tumors that arise from a single genetically altered mesenchymal stem cell under the influence of gonadal hormones. UFs are the most common benign gynecologic tumors in premenopausal women worldwide. It is estimated that nearly 70% to 80% of women will develop UFs at some point during their lifetime. UFs often present with abnormal uterine bleeding (AUB), pelvic fullness, and may have deleterious effects on fertility. The natural regression of UFs begins in menopause. This is, however, a generality as this pathology may still be present in this age group. Many clinicians are concerned about hormone therapy (HT) because of UFs regrowth; nevertheless, research of this subject remains inconclusive. If UFs are present in perimenopause or menopause, they typically manifest as AUB, which represents up to 70% of all gynecological consultations in perimenopausal and postmenopausal women. As AUB is a broad symptom and may not be specific to UFs, a thorough evaluation is required for correct diagnosis and proper treatment accordingly. Understanding the unique characteristics of the available treatment modalities is crucial in deciding the appropriate treatment approach. Decision on treatment modality should be made based on selection of the least morbidity and lowest risk for each patient. Multiple modalities are available; however, surgery remains the method of choice, with the best cure rates. Various attempts to create an inexpensive, safe, and effective drug for the treatments of UFs are still in the early stages of the clinical trials with some showing great promise. Treatment options include tibolone, aromatase inhibitors, selective estrogen receptor modulators, uterine artery embolization, and selective progesterone receptor modulators.

Progesterone and abnormal uterine bleeding/menstrual disorders

This chapter explores the role of progesterone and progestogens in the management of abnormal uterine bleeding (AUB). Progestogens are used to regulate intermenstrual bleeding and decrease heavy menstrual bleeding (HMB) in women of reproductive age or who are perimenopausal. In menopausal women, progesterones and progestogens prevent endometrial hyperplasia and aim to reduce the development of endometrial cancer. We hope to make clear current best practice including preparation, specific benefits and risks. Progesterone also acts in concert with other hormones to affect breast, cardiovascular system, lipid profile and bone. We hope to explain how its unintended side effects may be used beneficially or may cause intended side effects.

Pharmacological and non-pharmacological pain relief for office hysteroscopy: an up-to-date review

In-office hysteroscopy is considered the standard technique for visualization of the uterine cavity and the diagnosis of intrauterine pathologies. Moreover, nowadays, it is possible to treat a vast number of intracavitary diseases in the office, without the need for the inpatient setting. However, in some cases, pain might occur, and this is the most common reason for not completing the procedure. Over the last 20 years, many efforts have been carried out to miniaturize the instrumentation and to improve the techniques in order to avoid discomfort. Nonetheless, hysteroscopy still provokes distress for many patients. For this reason, pharmacological and non-pharmacological treatments for intraoperative and postoperative pain relief have been widely used for in-office hysteroscopy, with different results in various groups of women. The purpose of this review was to analyze the current literature on pharmacological aids (non-steroidal anti inflammatory drugs, cyclooxygenase-2 inhibitors, antispasmodics, local anesthetics, prostaglandins, opioids) and non-pharmacological interventions (transcutaneous electrical nerve stimulation, uterine stretching, uterine pressure, warming of distension medium, hypnosis, music, vocal-local) and to evaluate their impact on the relief from pain experienced during in-office hysteroscopy.

Insights on Hysteroscopic Procedures and Their Place in Romanian Gynecologic Practice—The Experience of Two Medical Units

Hysteroscopy has known an increasing use in Romania over the last decade, succeeding to mark an impact on lowering the costs of medical services. The strategy of this study was to present the experience of two Romanian medical units with different experiences using inpatient regimen hysteroscopy, and to further compare it with current worldwide tendencies. Strong points in our practice were sought, as well as components that require improvement. Overall, abnormal uterine bleeding stands for most hospital case presentations in our study group; hysteroscopy had the highest accuracy and positive predictive value in identifying uterine myomas: 91.03% and 100%, respectively; for endometrial polyps, statistical analysis showed the highest sensitivity: 100%, with 83.89% specificity and a 77.64% positive predictive value. The applicability of hysteroscopy was further described for infertility cases and isthmocele repair.

BMI‑1 promotes invasion and metastasis in endometrial adenocarcinoma and is a poor prognostic factor

Endometrial adenocarcinoma is one of the most common types of gynecological malignancies and its incidence and mortality rates are increasing. Due to tumor recurrence and metastasis, the overall five-year survival rate of patients with endometrial adenocarcinoma is shortened. The aim of the present was to investigate the role of the polycomb group protein B-lymphoma Mo-MLV insertion region 1 (BMI-1) in the invasion, metastasis and the epithelial-mesenchymal transition (EMT) of endometrial adenocarcinoma cells, as well its effects on the prognosis of patients with endometrial adenocarcinoma. Immunohistochemistry was used to examine the expression profile of BMI-1 in normal and endometrial adenocarcinoma tissues. Western blotting was used to examine the expression levels of BMI-1 and EMT markers. Kaplan-Meier plots and a Cox proportional hazards model were used to assess the overall survival. MTT cell viability assays were used to detect the proliferation of endometrial cancer cells. Transwell assays were used to examine cell migration and invasion. Small interfering RNA was used to downregulate BMI-1 expression levels, to study its effect on EMT. Immunohistochemical and clinicopathological analyses showed that BMI-1 expression was increased in endometrial adenocarcinoma tissue compared with the normal endometrial tissue (P<0.05). The increased expression levels of BMI-1 were closely associated with stage, myometrial invasion and lymph node metastasis (P<0.05). Kaplan-Meier plots and a Cox proportional hazards model showed that increased BMI-1 expression was associated with a less favorable prognosis [P=0.040, hazards ratio (HR)=1.596] and was associated with late-stage adenocarcinoma (P=0.006, HR=1.670). Myometrial invasion (P=0.006, HR=1.509) and lymph node metastasis (P=0.004, HR=1.703) were determined to predict a less favorable prognosis. Downregulation of BMI-1 reduced migration and invasion in endometrial cancer cells in vivo. It was also found that downregulation of BMI-1 increased the expression levels of the epithelial markers E-cadherin and keratin, and decreased the expression levels of the mesenchymal markers N-cadherin, vimentin and the downstream transcription factor, Slug. In conclusion, BMI-1 expression was correlated with tumor invasion and metastasis, contributing to deep myometrial invasion and lymph node metastasis, and was a poor prognostic factor for endometrial adenocarcinoma.

Endometrium imaging using real-time rotational optical coherence tomography imaging system: A pilot, prospective and ex-vivo study

This study aimed to evaluate a novel real-time rotational optical coherence tomography (OCT) imaging system (OCTIS) with a fiber-optic probe to look at endometrium and to correlate the OCTIS images with standard histology. OCT could obtain real-time images resembling histological examination. With recent development of customized probes, it allows OCT to be used in the field of gynecology.This is a pilot, prospective, ex-vivo and observational study. Women underwent hysterectomy for various gynecological conditions were recruited and OCTIS images were obtained from endometrium of 15 fresh uterus specimens immediately after hysterectomy. The excised uterus was cut open and OCTIS imaging was obtained. The scanned region of endometrium was excised for histological examination and OCTIS images were precisely compared to corresponding histological images and ultrasound images. Blinded qualitative analysis on OCTIS images was performed by 2 assessors to determine inter-rating reliability on the histopathological diagnosis.Epithelium, glands, cysts, and stroma of endometrium were clearly seen by the OCTIS. Different phases of menstrual cycle of normal endometrium could be differentiated and pathological condition such as hyperplastic and dysplasic endometrium, which corresponded well with histological findings, could be identified. The inter-rater reliability between assessors on overall OCTIS endometrium and neoplastic OCTIS endometrium was moderate (Kendall τb of 0.58) and substantial (Kendall τb of 0.76), respectively.OCTIS can provide real-time, high-resolution and rotational imaging modality to view endometrial structure with high consistency with histological examination and satisfactory agreement between observers. It has a great potential to be developed in the clinical use of endometrial assessment for gynecological applications.

Application of 'no-touch' hysteroscopy (vaginoscopy) for the treatment of abnormal uterine bleeding in adolescence

AIM

This article retrospectively analyzed the efficacy and safety of vaginoscopy in the treatment of adolescent abnormal uterine bleeding (AUB) in 204 cases of AUB.

METHOD

From January 1, 2007 to December 31, 2017, 204 patients with intact hymen who were admitted to our hospital due to AUB received vaginoscopy, and vaginoscopy did not damage the hymen. In this study, 4.5 mm and 6.5 mm hysteroscopy were used with a pumping fluid pressure of 100-120 mm Hg and a flow rate of 400 mL/min. All 204 vaginoscopy was successfully completed in intravenous anesthesia.

RESULTS

Postoperative pathological examination confirmed that of the 204 patients, 53 patients had simple hyperplasia. There were 53 cases of polyps, 50 cases of endometrial gland hyperplasia and disordered arrangement, 35 cases of proliferative phase endometrium, five cases of bleeding phase endometrium, partial glandular secretion, three cases of complex hyperplasia and one case of decidua like change. Follow-up data from 64 patients showed that 34 patients were effective after treatment. Stepwise logistic regression analysis suggested that endometrial thickness was associated with treatment outcome (HR, 0.875, 95% CI, 0.786-0.974, P = 0.014). There was no significant difference in drug use between patients with effective and ineffective treatment.

CONCLUSION

'No-touch' vaginoscopy is feasible for the diagnosis and treatment of adolescent AUB without destroying the intact hymen.

Menstrual disorders and occupational exposures among female nurses: A nationwide cross-sectional study

BACKGROUND

The regularity of menstrual cycles is one of the important indicators of female reproductive health. However, the current evidence on the association of occupational exposures and menstrual disorders is scarce.

OBJECTIVES

This study aims to elucidate the relationship between occupational hazards and menstrual characteristics in female nurses and non-nurse health care workers in China.

DESIGN

We conducted a national cross-sectional study on the reproductive health of female nurses in China.

SETTINGS

A total of 1, 300 medical institutions in 15 provincial administrative regions in China participated in the study.

PARTICIPANTS

There were 8, 904 nurses and 3, 977 non-nurse health care workers who were selected using simple random sampling method.

METHODS

All participants were administered a face-to-face standardized questionnaire, including personal socio-demographic information, occupational activities, and self-reported menstrual characteristics. Univariate and multivariate logistic regressions were used for statistical analyses.

RESULTS

The results demonstrated that 41% of nurses experienced menstrual disorders. We found handling disinfectants was the most significant risk factor for menstrual disorders (OR = 1.53, 95% CI: 1.39-1.68), followed by abnormal workload (OR = 1.28, 95% CI: 1.19-1.39), and occupation as a nurse (OR = 1.28, 95% CI: 1.18-1.40). Noise, prolonged standing or frequent heavy lifting, night work, anti-cancer drug exposure, and overtime work were moderately associated with the occurrence of menstrual disorder (OR > 1).

CONCLUSIONS

This national-wide cross-sectional study has revealed the significant association between menstrual disorders and occupational hazards among female nurses in China.

Management of the Perimenopause

Perimenopause, or the menopausal transition, represents a period of time during which newly arising symptoms can present complex management decisions for providers. Many women present to care with complaints of hot flashes, vaginal and sexual changes, altered mood and sleep, and changing bleeding patterns. The effect of these symptoms on quality of life, even before a woman enters menopause, can be significant. The appropriate evaluation and evidence-based management of women in this transition is reviewed in this article. Two case vignettes are used to highlight certain evaluation and treatment challenges.