Hysteroscopic treatment of submucosal fibroids in perimenopausal women: when, why, and how?

Factors associated with dysmenorrhoea and menorrhagia improvement in patients with adenomyosis after uterine artery embolisation

BACKGROUND

This study examined the improvement of dysmenorrhoea and menorrhagia after uterine artery embolisation (UAE) in women with symptomatic adenomyosis and identified factors that could predict the improvement of dysmenorrhoea and menorrhagia.

METHODS

This retrospective study included women with adenomyosis who underwent bilateral UAE between December 2014 and December 2016. The percentage of the volume of the absence of contrast enhancement on T1-weighted images was evaluated 5-7 days after UAE. A receiver operating characteristic (ROC) analysis was used to determine a cut-off point and predict the improvement of dysmenorrhoea and menorrhagia.

RESULTS

Forty-eight patients were included. At 24 and 36 months after UAE, the improvement rates for dysmenorrhoea and menorrhagia were 60.4% (29/48) and 85.7% (30/35), and the recurrence rates were 19.4% (7/36) and 9.1% (3/33), respectively. Only the percentage of the volume of the absence of contrast enhancement on T1-weighted images was associated with the improvement of dysmenorrhoea (p = 0.001, OR = 1.051; 95% CI: 1.02-1.08) and menorrhagia (p = 0.006, OR = 1.077; 95% CI: 1.021-1.136). When the cut-off value of the ROC analysis was 73.1%, sensitivity, specificity, positive predictive value, and negative predictive value for the improvement of dysmenorrhoea were 58.6%, 94.7%, 94.4%, and 60%, while they were 58.9%, 80%, 100%, 100%, and 45.5% for the improvement of dysmenorrhoea.

CONCLUSION

Bilateral UAE for symptomatic adenomyosis led to good improvement of dysmenorrhoea and menorrhagia. The percentage of the volume of the absence of contrast enhancement on T1-weighted images of the uterus in postoperative magnetic resonance imaging might be associated with the improvement of dysmenorrhoea and menorrhagia.

Characteristic of Endometrial Stromal Sarcoma by Algorithm of Potential Biomarkers for Uterine Mesenchymal Tumor

The benign tumor uterine leiomyoma (UL) develops from the smooth muscle tissue that constitutes the uterus, whereas malignant tumor uterine sarcoma develops from either the smooth muscle tissue or stroma and is different from UL and endometrial cancer. Uterine sarcoma is broadly classified into three types: uterine leiomyosarcoma, endometrial stromal sarcoma (ESS), and carcinosarcoma. Although uterine leiomyosarcoma and ESS are both classified as uterine sarcoma, they significantly differ in terms of their sites of occurrence, symptoms, and treatment methods. Uterine leiomyosarcoma develops from the muscle tissue constituting the wall of the uterus and accounts for approximately 70% of all uterine sarcoma cases. In contrast, ESS develops from the stromal tissue beneath the endometrium and accounts for approximately 25% of all uterine sarcoma cases. ESS is classified as either low grade (LG) or high grade (HG). This case report aimed to highlight the importance of histopathologic examinations based on surgical specimens. Herein, we reported the case of a 45-year-old woman suspected of having submucosal leiomyoma of the uterus based on imaging results. Transvaginal ultrasonography and endometrial biopsy or partial dilation and curettage were performed. Contrast-enhanced magnetic resonance imaging (MRI) revealed a 32-mm mass projecting from the posterior wall of the uterus into the uterine cavity. T2-weighted imaging revealed a low signal within the mass; thus, submucosal UL was suspected. Histopathologic examination of surgical specimens obtained from a patient suspected of having submucosal UL after contrast-enhanced MRI indicated that the patient had ESS. Despite the remarkable advancements in medical imaging technology, the accuracy of contrast-enhanced MRI for detecting uterine mesenchymal tumors is limited. Therefore, histopathologic diagnosis based on surgical specimens should be performed when medical grounds for diagnosing a benign tumor on contrast-enhanced MRI are lacking.

Endometrial Biopsy: Indications, Techniques and Recommendations. An Evidence-Based Guideline for Clinical Practice

This practice guideline provides updated evidence for the gynecologist who performs endometrial biopsy (EB) in gynecologic clinical practice. An international committee of gynecology experts developed the recommendations according to AGREE Reporting Guideline. An adequate tissue sampling is mandatory when performing an EB. Blind methods should not be first choice in patients with suspected endometrial malignancy. Hysteroscopy is the targeted-biopsy method with highest diagnostic accuracy and cost-effectiveness. Blind suction techniques are not reliable for the diagnosis of endometrial polyps. In low resources settings, and in absence of the capacity to perform office hysteroscopy, blind techniques could be used for EB. Hysteroscopic punch biopsy allows to collect only limited amount of endometrial tissue. grasp biopsy technique should be considered first choice in reproductive aged women, bipolar electrode chip biopsy should be preferred with hypotrophic or atrophic endometrium. EB is required for the final diagnosis of chronic endometritis. There is no consensus regarding which endometrial thickness cut-off should be used for recommending EB in asymptomatic postmenopausal women. EB should be offered to young women with abnormal uterine bleeding and risk factors for endometrial carcinoma. Endometrial pathology should be excluded with EB in nonobese women with unopposed hyperestrogenism. Hysteroscopy with EB is useful in patients with abnormal bleeding even without sonographic evidence of pathology. EB has high sensitivity for detecting intrauterine pathologies. In postmenopausal women with uterine bleeding, EB is recommended. Women with sonographic endometrial thickness > 4mm using tamoxifen should undergo hysteroscopic EB.

Post treatment and 3 month contrast enhanced MRI findings following HIFU of submucosal fibroids: a retrospective study

PURPOSE

This study used contrast-enhanced MRI (CE-MRI) examination to assess the efficacy of high-intensity focused ultrasound (HIFU) for submucosal fibroids.

METHODS

A total of 81 submucosal fibroids, including 33 cases of type 1, 29 cases of type 2, and 19 cases of type 2-5, treated by HIFU were retrospectively reviewed. CE-MRI was performed in all cases immediately after HIFU, the non-perfused volume ratio (NPVR) and the degree of endometrial impairment were recorded. Thereafter, CE-MRI was repeated in all cases after three months, and the change of fibroid volume shrinkage rate (FVSR), NPVR and the degree of endometrial impairment were recorded.

RESULTS

The immediate NPVR was 86.4 ± 19.3% in type 1, 90.0 ± 13.3% in type 2 and 90.3 ± 7.2% in type 2-5. Among 81 fibroids, grades 0, 1, 2 and 3 endometrial impairments were observed in 38.3%, 16.1%, 14.8% and 30.9%, respectively. Three months later, NPVR was 68.0 ± 36.4% in type 1, 74.3 ± 27.7% in type 2 and 85.0 ± 16.1% in type 2-5. Grades 0, 1, 2 and 3 endometrial impairments were observed in 64.2%, 23.5%, 9.9% and 2.4%.FVSR was 49.0 ± 1.3% in type 1, 39.6 ± 1.7% in type 2 and 37.2 ± 2.1% in type 2-5. The FVSR in submucosal fibroid type 1 was superior to type 2 and type 2-5 (p < 0.05). The NPVR of submucosal fibroids in type 2-5 were higher than type 1 (p < 0.05) .There was no difference among different types of submucosal fibroids in endometrial impairment (p > 0.05) three months after HIFU.

CONCLUSIONS

At three months after HIFU, FVSR was better for submucosal fibroid type 1 than for type 2 and type 2-5. And there was no difference in endometrial impairment among the different types of submucosal fibroid groups.

Hysteroscopy Combined with Laser Vaporesection for Endometrial Polyps

OBJECTIVE

To compare the safety and efficiency of hysteroscopic laser vaporesection and hysteroscopic resection in the treatment of endometrial polyps.Methods: The literatures in databases were searched comprehensively, the literatures that met the inclusion criteria were screened out and the data were extracted. The data were combined with Stata12.0 statistical software.

RESULTS

4 literatures were included with a total sample size of 334. Meta-analysis showed that intraoperative blood loss in laser group was less than that in electrosurgical group [-3.043, 95% CI (-4.09, -2.00), P < 0.001]. Length of stay in the laser group was shorter than that in the electrotomy group [-1.013, 95% CI (-1.37, -0.65), P < 0.001]. The recurrence rate [0.275, 95%CI (0.135,0.563), P < 0.001] and complication rate [0.148, 95%CI (0.07,0.32), P < 0.001] in the laser group were lower than those in the electrotomy group. There was no significant difference in operative time between hysteroscopy combined with 2 μm laser and hysteroscopic electrotomy for endometrial polyps [-0.38, 95% CI (-1.34, 0.58), P = 0.441 > 0.05].

CONCLUSION

Hysteroscopic 2 μm laser vaporesection for the treatment of endometrial polyps has better safety and clinical efficacy. Compared with hysteroscopic electroresection, hysteroscopic laser vaporesection in the treatment of endometrial polyps may be safer and more effective. Given the potential limitations, we need larger, well-designed randomized controlled trials to verify our findings.

Abnormal Uterine Bleeding in Perimenopausal Women: The Role of Hysteroscopy and Its Impact on Quality of Life and Sexuality

Abnormal uterine bleeding (AUB) is a frequent symptom in perimenopausal women. It is defined as uterine bleeding in which the duration, frequency, or amount of bleeding is considered excessive and negatively affects the woman’s quality of life (QoL) and psychological well-being. In cases of structural uterine pathology, hysterectomy (usually performed via a minimally invasive approach) offers definitive symptom relief and is associated with long-lasting improvement of QoL and sexuality. However, over the past 30 years, uterus-preserving treatments have been introduced as alternatives to hysterectomy. Hysteroscopic polypectomy, myomectomy, or endometrial resection/endometrial ablation are minimally invasive techniques that can be used as an alternative to hysterectomy to treat AUB due to benign conditions. Although associated with high patient satisfaction and short-term improvement in their QoL, hysteroscopic treatments do not eliminate the risk of AUB recurrence or the need for further intervention. Therefore, considering the impact of different treatment options on QoL and sexuality during preoperative shared decision making could help identify the most appropriate and personalized treatment options for perimenopausal women suffering from AUB.

Diagnostic and prognostic role of TFF3, Romo-1, NF-кB and SFRP4 as biomarkers for endometrial and ovarian cancers: a prospective observational translational study

Purpose

This study aimed to evaluate trefoil factor 3 (TFF3), secreted frizzled-related protein 4 (sFRP4), reactive oxygen species modulator 1 (Romo1) and nuclear factor kappa B (NF-κB) as diagnostic and prognostic markers of endometrial cancer (EC) and ovarian cancer (OC).

Methods

Thirty-one patients with EC and 30 patients with OC undergone surgical treatment were enrolled together with 30 healthy controls in a prospective study. Commercial ELISA kits determined serum TFF-3, Romo-1, NF-кB and sFRP-4 concentrations.

Results

Serum TFF-3, Romo-1 and NF-кB levels were significantly higher in patients with EC and OC than those without cancer. Regarding EC, none of the serum biomarkers differs significantly between endometrial and non-endometrioid endometrial carcinomas. Mean serum TFF-3 and NF-кB levels were significantly higher in advanced stages. Increased serum levels of TFF-3 and NF-кB were found in those with a higher grade of the disease. Regarding OC, none of the serum biomarkers differed significantly among histological subtypes. Significantly increased serum levels of NF-кB were observed in patients with advanced-stage OC than those with stage I and II diseases. No difference in serum biomarker levels was found between those who had a recurrence and those who had not. The sensibility and specificity of these four biomarkers in discriminating EC and OC from the control group showed encouraging values, although no one reached 70%.

Conclusions

TFF-3, Romo-1, NF-кB and SFRP4 could represent new diagnostic and prognostic markers for OC and EC. Further studies are needed to validate our results.

Ultra-minimally invasive surgery in gynecological patients: a review of the literature

In the last decade, Ultra-minimally invasive surgery (UMIS) including both minilaparoscopic (MH) and percutaneous (PH) endoscopic surgery achieved widespread use around the world. Despite UMIS has been reported as safe and feasible surgical procedure, most of the available data are drawn from retrospective studies, with a limited number of cases and heterogeneous surgical procedures included in the analysis. This literature review aimed to analyze the most methodologically valid studies concerning major gynecological surgeries performed in UMIS. A literature review was performed double blind from January to April 2021. The keywords ‘minilaparoscopy’; ‘ultra minimally invasive surgery’; ‘3 mm’; ‘percutaneous’; and ‘Hysterectomy’ were selected in Pubmed, Medscape, Scopus, and Google scholar search engines. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were followed for the drafting of the systematic review. The systematic literature research provided 298 studies, of which 9 fell within the inclusion criteria. Two hundred ninety-six total patients were included, 148 for both PH and MH groups. Median age (48 years), BMI (24 kg/m²), OT (90 min), EBL (50 ml), time to discharge (1 day), self scar evaluation (10/10), and VAS (3/10) were reported. The most frequent intraoperative complication in both the PH and MH groups was surgical bleeding. The UMIS approaches were feasible and safe even for complex gynecological procedures. Operative times and complications were superimposable to the “classical” minimally invasive approaches reported in the literature. The reported results apply only to experienced surgeons.

Comparison of ultrasound-guided high-intensity focused ultrasound ablation and hysteroscopic myomectomy for submucosal fibroids: a retrospective study

OBJECTIVE

To compare the safety, reintervention and pregnancy outcomes between ultrasound-guided high intensity focused ultrasound (USgHIFU) and hysteroscopic myomectomy (HM) for submucosal fibroids.

MATERIALS AND METHODS

A total of 215 patients with a solitary submucosal fibroid treated by USgHIFU or HM at the third Xiangya Hospital were retrospectively reviewed. Among them, 58 treated with USgHIFU, 157 treated with HM.

RESULTS

A significant difference was observed in size, location and type of the fibroids, effective rate, and cumulative reintervention rate between the two groups (p < .05). The size of the fibroids was 57.9 ± 1.9 mm in the USgHIFU group, while it was 32.6 ± 1.2 mm in the HM group. The number of the fibroids at horn or fundus/uterine cavity was 16/42 in the USgHIFU group, while it was 21/136 in the HM group. The number of type I/II/2-5 was 16/17/25 in the USgHIFU group, while it was 133/24/0 in the HM group. In the USgHIFU group, the effective rate was 100% and the cumulative reintervention rate at 50 (17-97) months was 19.0%, while in the HM group, it was 94.3% and 7.6%, respectively. During the follow-up period, the pregnancy rate was 22.4% (13/58) and the reintervention rate due to invalid and recurrence was 15.5% (9/58) in the USgHIFU group, while they were 18.5% (29/157) and 7.0% (11/157) in the HM group. No significant difference was observed between the two groups (p > .05). Furthermore, the reintervention rate was positively correlated with age, treatment methods and parity and fertility requirements. No other significant difference was observed between the two groups.

CONCLUSIONS

Both USgHIFU and HM are safe and effective in treating submucosal fibroids. Compared with the HM group, the USgHIFU group had lower postoperative complications, but higher reintervention rate, with similar recurrence rate, pregnancy rate and reintervention rate due to invalid and recurrence. Reintervention was related to age, treatment methods, parity and fertility requirements.

Hysteroscopic endometrial biopsy: from indications to instrumentation and techniques. A call to action

During the last twenty years, the diagnostic approach to endometrial pathology has radically evolved. For over a century, intrauterine blind biopsy techniques were considered the gold standard procedure for the histopathological diagnosis of intrauterine diseases. The advent of hysteroscopy, which made it possible to directly visualize the uterine cavity, and the subsequent miniaturization of the instruments allowing its use in the office setting without anesthesia are considered game-changers. To date, it is feasible to retrieve a targeted eye specimen of endometrial tissue with little or no discomfort for the patient in the office setting. To pursue this aim, several technological upgrades have improved the diagnostic accuracy of hysteroscopic endometrial biopsy. In this paper we provide an up-to-date review of the latest evidence regarding indications, instrumentations, and techniques for hysteroscopic endometrial biopsy, to help the operator in providing an adequate endometrial sampling for histopathological analysis.

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.

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.

Novelties of ultrasound imaging for endometrial cancer preoperative workup

INTRODUCTION

Endometrial cancer (EC) is the most frequent gynecological cancer. Transvaginal ultrasound (TVU) plays a leading role in the preoperative workup and often is the first diagnostic instrumental examination. Despite expert hands' ultrasound is recommended to assess myometrial invasion in early stage EC, this method is a strictly operator-dependent examination, and varying degrees of sensitivity and specificity have been reported. The present review aims to provide an update of ultrasound imaging in the preoperative work-up for EC patients.

EVIDENCE ACQUISITION

A double-blind search was performed from May to September 2020. The following keywords: "ultrasound," "transvaginal ultrasound" and "endometrial cancer" were searched in Pubmed search engines, Scopus, and Web of Science. The Prisma statement was followed for the selection of the articles included.

EVIDENCE SYNTHESIS

The initial search provided 958 studies, of which 11 were included in the analysis. non-English articles, not relevant to the purposes of this study, case reports and articles with fewer than 40 cases were excluded.

CONCLUSIONS

TVU sensitivity and specificity in myometrial infiltration and cervical invasion is comparable to MRI but has lower costs, greater patient tolerability, and does not require contrast agents. An expert operator should perform the ultrasound examination in patients with suspected EC The presence of myometrial lesions, such as leiomyomas, could lower the diagnostic accuracy of ultrasound, so special attention should be paid to patients with concomitant uterine lesions.

Is Uterine Myomectomy a Real Contraindication to Vaginal Delivery? Results from a Prospective Study

OBJECTIVES

The main goal of our research was to explore correlations between a history of uterine myomectomy and maternal-fetal outcomes, throughout a comparison between vaginal deliveries in patients with or without a history of uterine myoma excision.

MATERIALS AND METHODS

A prospective study was carried out at two tertiary care hospitals between January 2019 and January 2020. Women were assigned into two groups according to the history of laparoscopic or laparotomic myomectomy (Group 1) or without myomectomy (Group 2).

RESULTS

80 women successfully delivered after myomectomy. Pregnancies with previous laparoscopic or laparotomic myomectomy were associated with a minor rate of spontaneous labor onset (RR 1.17; 95% CI 1.04 - 1.31) and with an increased rate of emergency cesarean section (RR 1.22; 95% CI 1.09 - 1.36). Moreover, myomectomy group had a significant number of indications to emergency cesarean section correlated to suspected uterine rupture (RR 1.19; 95% CI 1.02-1.39). There were no uterine ruptures or neonatal deaths recorded. First stage of labor was longer in the myomectomy group (316 vs 204 mins, p = 0.01). No differences in the rates of the prolonged first and second stage of labor, postpartum hemorrhage and vaginal laceration, and no neonatal adverse outcomes were found between groups.

CONCLUSIONS

Pregnancies after myomectomy might be associated with an elevated rate of emergency cesarean section only due to a higher percentage of suspected uterine rupture, without a real hazard of adverse obstetric or neonatal outcomes.

Quality of life and sexual functioning of patient affected by endometrial cancer

INTRODUCTION

Thanks to timely diagnosis and medical advancement the number of endometrial cancer (EC) patients achieving long term survival is constantly increasing and here comes the necessity to move forward with the understanding of post-treatment sexual adjustment and with the strategies to enhance sexual functioning (SF) and quality of life (QoL) in this population. In this scenario we designed this study aiming to summarize and analyze the available scientific evidence regarding QoL and especially SF in patients affected by EC who underwent surgical and adjuvant treatment.

EVIDENCE ACQUISITION

A preliminary research was conducted using Pubmed database with specific keywords combinations regarding SF, QoL and endometrial cancer. The main findings considered in the present review were: the study design, the number of patients included in each study, the information about pathology (histology and stage of disease), the questionnaires administered and the principal results concerning SF and QoL.

EVIDENCE SYNTHESIS

A total of thirteen studies, between 2009 and 2018, treating the aspects of SF and QoL in patients affected by EC were extracted. The principal findings of different studies were organized in the following sections: 1) overall SF in EC patients (reasons for sexual inactivity); 2) impact of EC on SF when compared to benign gynecological disease or healthy controls-focus on surgery; 3) minimally invasive surgery versus classical laparotomic approach and SF of EC patients; 4) surgery alone versus VBT versus EBRT and SF of EC patients; 5) focus on RT; 6) the mutual correlation between sociodemographic, relational, psychological, clinical/metabolic factors and the SF of EC patients.

CONCLUSIONS

Considering the widespread diffusion of female sexual dysfunction among EC patients and the relatively good prognosis, especially in early stage disease, it undoubtedly looms the need for proactive countermeasures to maximize the sexual well-being and QoL of these patients. A wide range of intervention in a multi-modal physical and mental perspective should be considered.

Hysteroscopic and ultrasonographic evaluation of ulipristal acetate treatment for symptomatic myomas in premenopausal women: a prospective study

OBJECTIVE

This study aimed to analyze the effects of a six-month therapy with ulipristal acetate (UPA) on myoma size and endometrial thickness in premenopausal women.

MATERIAL AND METHODS

Seventy-four women undergoing conservative therapy with UPA were enrolled for this study. All women underwent transvaginal ultrasound evaluation to assess the endometrial thickness, and the number and size of myomas at the beginning and after six months. Hysteroscopy and biopsy were performed after six months, if necessary.

RESULTS

After six months of treatment, sonographic examination showed a statistically significant (p < .05) reduction of the size of the largest myoma (56.3 ± 5.1 vs. 31.7 ± 10.1 mm) and a statistically significant (p < .05) increase in endometrial thickness (5.9 ± 2.1 vs. 9.7 ± 3.4 mm). Twenty-two patients with endometrial thickness >10 mm or nonhomogeneous pattern and ten patients with metrorrhagia underwent hysteroscopy: the most frequent finding was the combination of endometrial hypotrophy, floating surface, and chicken-wire vascular pattern aspect (14 cases, 43.7%). Histologic findings showed no case of complex hyperplasia.

CONCLUSION

UPA is a safe, effective and assured method to decrease symptoms, reduce the need for surgery in premenopausal women suitable for the treatment.