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Ghafarzadeh M, Marzban-Rad S, Sattari P, Taheri HR. Uterine artery embolization technique for treatment of a huge multi myomatous uterus in a virgin woman. Ann Med Surg (Lond) 2022; 77:103722. [PMID: 35638039 PMCID: PMC9142713 DOI: 10.1016/j.amsu.2022.103722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 04/29/2022] [Accepted: 05/01/2022] [Indexed: 11/10/2022] Open
Abstract
Introduction Uterine artery embolization is a non-surgical method performed for large and numerous fibroids to preserve the fertility. Case presentation The patient is a 36-year-old virgin woman with menometrorrhagia, abdominal pressure, constipation, bilateral abdominal pain, frequent urination and a compressive effect on the intestines was reported to our center. She was diagnosed with uterine fibroids. Discussion Because the type of uterine masses and possibility of uncontrollable bleeding during myomectomy and hysterectomy, uterine vascular embolization by supra selective angiography to preserve the uterus was performed. Due to fever, pain and vaginal discharge, she was hospitalized again and hysterotomy was performed without any reported complications. Conclusion Uterine artery embolization is a safe method, however reduction and loss in ovarian function can be seen with the treatment. Measurement of follicle stimulating hormone and anti-Müllerian hormone before and after the treatment is important. Fibroids are very common, occur individually or in multiple myometrial smooth muscle cells. The patient is a 36-year-old virgin woman with menometrorrhagia, abdominal pressure. she was hospitalized again and hysterotomy was performed without any reported complications. It is also recommended to use egg storage with existing methods if possible, to maintain future fertility.
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Affiliation(s)
- Masoumeh Ghafarzadeh
- Department of Obstetrics and Gynecology, School of Medicine, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Saeid Marzban-Rad
- Department of Surgery, Imam-Reza Hospital, Aja University of Tehran Medical Sciences, Tehran, Iran
| | - Parastesh Sattari
- General Practitioner, Institute of Health Education and Research, Chamran Hospital, Tehran, Iran
| | - Hamid Reza Taheri
- Department of Surgery, School of Medicine, Shahed University, Tehran, Iran
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Lam JY, Voyvodic F, Jenkins M, Knox S. Transient uterine contractions as a potential pathology mimic on premenopausal pelvic MRI and the role of routine repeat T2 sagittal images to improve observer confidence. J Med Imaging Radiat Oncol 2018; 62:649-653. [PMID: 29917321 DOI: 10.1111/1754-9485.12760] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 05/21/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Pelvic MRI has an increasingly important role in the evaluation of non-malignant uterine pathology including uterine leiomyomas, adenomyosis and endometriosis. Normal physiological myometrial junctional zone transient contractions can also be identified on MRI and have the potential to act as pathology mimics. This study aims to evaluate both the incidence of visible physiological contractions in premenopausal female pelvic MRI and also to support the routine acquisition of a repeat T2 sagittal sequence to differentiate transient physiological contractions from true underlying pathology and therefore improve observer confidence. METHODS A total of 279 female patients of child-bearing age who had undergone a pelvic MRI over a 16 month period met the inclusion criteria. All patients underwent a standard examination protocol on the same hardware. This included performing two separate T2-weighted sagittal sequences as part of the protocol firstly as the initial and then as the final series for the examination. The sagittal series were reviewed separately by four readers and conclusions made for each case with regards to the presence of identifiable contractions on one or both series and their potential to act as pathology mimics. RESULTS Of the 279 cases, there were 34 cases (12.2%) that were found to have transient junctional zone contractions acting as pathology mimics, resembling either leiomyomata or adenomyosis. CONCLUSIONS Standard MRI sequences need to be able to distinguish normal transient physiological uterine contractions from true pathology to avoid diagnostic error. The routine utility of a repeat T2-weighted sagittal sequence performed at the conclusion of a patient's examination was shown to improve reader confidence in distinguishing transient contractions from true uterine pathology while adding minimal time penalty to the overall examination. It is therefore advocated that all premenopausal female pelvic MRI cases have a T2 sagittal series as the initial and then the final series as part of a routine protocol.
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Affiliation(s)
- John Ym Lam
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | | | | | - Steven Knox
- Benson Radiology, Adelaide, South Australia, Australia
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Martinho MSL, da Costa Santos CMN, Silva Carvalho JLM, Bernardes JFMAL. Effect of clinical information and previous exam execution on observer agreement and reliability in the analysis of hysteroscopic video-recordings. Arch Gynecol Obstet 2017; 297:393-400. [PMID: 29218411 DOI: 10.1007/s00404-017-4614-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 12/01/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Inter-observer agreement and reliability in hysteroscopic image assessment remain uncertain and the type of factors that may influence it has only been studied in relation to the experience of hysteroscopists. We aim to assess the effect of clinical information and previous exam execution on observer agreement and reliability in the analysis of hysteroscopic video-recordings. MATERIALS AND METHODS Ninety hysteroscopies were video-recorded and randomized into a group without (Group 1) and with clinical information (Group 2). The videos were independently analyzed by three hysteroscopists, regarding lesion location, dimension, and type, as well as decision to perform a biopsy. One of the hysteroscopists had executed all the exams before. Proportions of agreement (PA) and kappa statistics (κ) with 95% confidence intervals (95% CI) were used. RESULTS In Group 2, there was a higher proportion of a normal diagnosis (p < 0.001) and a lower proportion of biopsies recommended (p = 0.027). Observer agreement and reliability were better in Group 2, with the PA and κ ranging, respectively, from 0.73 (95% CI 0.62, 0.83) and 0.44 (95% CI 0.26, 0.63), for image quality, to 0.94 (95% CI 0.88, 0.99) and 0.85 (95% CI 0.65, 0.95), for the decision to perform a biopsy. Execution of the exams before the analysis of the video-recordings did not significantly affect the results. CONCLUSION With clinical information, agreement and reliability in the overall analysis of hysteroscopic video-recordings may reach almost perfect results and this was not significantly affected by the execution of the exams before the analysis. However, there is still uncertainty in the analysis of specific endometrial cavity abnormalities.
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Affiliation(s)
- Margarida Suzel Lopes Martinho
- S. João Hospital Centre, Porto, Portugal.,Department of Obstetrics and Gynecology, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Cristina Maria Nogueira da Costa Santos
- MEDCIDS, Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Rua Dr. Plácido da Costa, 4200-319, Porto, Portugal. .,CINTESIS, Centre for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal.
| | | | - João Francisco Montenegro Andrade Lima Bernardes
- S. João Hospital Centre, Porto, Portugal.,Department of Obstetrics and Gynecology, Faculty of Medicine, University of Porto, Porto, Portugal.,CINTESIS, Centre for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal.,Pedro Hispano Hospital, Local Health Unit of Matosinhos, Matosinhos, Portugal
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Dvorská D, Braný D, Danková Z, Halašová E, Višňovský J. Molecular and clinical attributes of uterine leiomyomas. Tumour Biol 2017; 39:1010428317710226. [DOI: 10.1177/1010428317710226] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Dana Dvorská
- Division of Molecular Medicine, Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
- Clinic of Gynecology and Obstetrics, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Dušan Braný
- Division of Molecular Medicine, Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
- Clinic of Gynecology and Obstetrics, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Zuzana Danková
- Division of Oncology, Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Erika Halašová
- Division of Molecular Medicine, Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Jozef Višňovský
- Clinic of Gynecology and Obstetrics, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
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Dueholm M, Hjorth IMD. Structured imaging technique in the gynecologic office for the diagnosis of abnormal uterine bleeding. Best Pract Res Clin Obstet Gynaecol 2016; 40:23-43. [PMID: 27818130 DOI: 10.1016/j.bpobgyn.2016.09.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 09/23/2016] [Indexed: 12/11/2022]
Abstract
The aim in the diagnosis of abnormal uterine bleeding (AUB) is to identify the bleeding cause, which can be classified by the PALM-COEIN (Polyp, Adenomyosis, Leiomyoma, Malignancy (and hyperplasia), Coagulopathy, Ovulatory disorders, Endometrial, Iatrogenic and Not otherwise classified) classification system. In a gynecologic setting, the first step is most often to identify structural abnormalities (PALM causes). Common diagnostic options for the identification of the PALM include ultrasonography, endometrial sampling, and hysteroscopy. These options alone or in combination are sufficient for the diagnosis of most women with AUB. Contrast sonography with saline or gel infusion, three-dimensional ultrasonography, and magnetic resonance imaging may be included. AIM The aim of this article is to describe how a simple structured transvaginal ultrasound can be performed and implemented in the common gynecologic practice to simplify the diagnosis of AUB and determine when additional invasive investigations are required. Structured transvaginal ultrasound for the identification of the most common endometrial and myometrial abnormalities and the most common ultrasound features are described. Moreover, situations where magnetic resonance imaging may be included are described. This article proposes a diagnostic setup in premenopausal women for the classification of AUB according to the PALM-COEIN system. Moreover, a future diagnostic setup for fast-track identification of endometrial cancer in postmenopausal women based on a structured evaluation of the endometrium is described.
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Affiliation(s)
- Margit Dueholm
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Denmark.
| | - Ina Marie D Hjorth
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Denmark
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Testa AC, Di Legge A, Bonatti M, Manfredi R, Scambia G. Imaging techniques for evaluation of uterine myomas. Best Pract Res Clin Obstet Gynaecol 2015; 34:37-53. [PMID: 26803557 DOI: 10.1016/j.bpobgyn.2015.11.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 11/18/2015] [Indexed: 12/11/2022]
Abstract
Due to their high prevalence and related morbidity, uterine myomas constitute a group of gynecological pathologies largely studied in all clinical, diagnostic, and therapeutic aspects. They have been widely evaluated with a large series of imaging techniques. In fact, ultrasound (also saline infusion sonohysterography) and magnetic resonance imaging (MRI) are considered the optimal methods to assess uterine fibroids in terms of number, volume, echostructure, location, relation with endometrial cavity and uterine layers, vascularization, and differential diagnosis with other benign (adenomyosis) and malignant myometrial pathologies. Nevertheless, further studies are required to fill some gaps such as the absence of a common and sharable sonographic terminology and methodology to scan the myometrium, as well as imaging parameters for differentiation of typical myomas from smooth tumors of unknown malignant potential (STUMP) and leiomyosarcomas.
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Affiliation(s)
- Antonia Carla Testa
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
| | - Alessia Di Legge
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy.
| | - Matteo Bonatti
- Department of Radiology, Bolzano Central Hospital, Bolzano, Italy
| | | | - Giovanni Scambia
- Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart, Rome, Italy
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Value of magnetic resonance imaging in diagnosis of adenomyosis and myomas of the uterus. J Minim Invasive Gynecol 2013; 19:620-6. [PMID: 22935303 DOI: 10.1016/j.jmig.2012.06.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2012] [Revised: 06/14/2012] [Accepted: 06/21/2012] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To estimate the diagnostic performance of magnetic resonance imaging (MRI) in detection of myomas and adenomyosis of the uterus. DESIGN Prospective cohort observational study (Canadian Task Force classification II-2). SETTING Department of obstetrics and gynecology, tertiary academic hospital. PATIENTS One hundred fifty-three consecutive women with an enlarged uterus accompanied by gynecologic symptoms and/or with an asymptomatic pelvic mass. INTERVENTION Total abdominal hysterectomy. All patients underwent MRI before the operation. MEASUREMENTS AND MAIN RESULTS The sensitivity, specificity, positive, and negative predictive value of MRI for the diagnosis of uterine pathology was calculated using histologic findings as the standard criterion for final diagnosis. Receiver operating characteristics curves were constructed to describe the diagnostic performance of MRI. In the diagnosis of myomas, MRI demonstrated sensitivity of 94.1%, specificity of 68.7%, PPV of 95.7%, and NPV of 61.1%. In the diagnosis of adenomyosis, MRI demonstrated sensitivity of 46.1%, specificity of 99.1%, PPV of 92.3%, and NPV of 88.5%. The area under the curve (AUC) for the diagnostic performance of MRI in the detection of myomas and adenomyosis was 0.81 and 0.73, respectively. Uterine sarcoma was diagnosed in 5 patients; in these cases, MRI demonstrated sensitivity of 60.0%, specificity of 99.2%, PPV of 75.0%, and NPV of 98.4%. The AUC for MRI in the diagnosis of uterine sarcomas was 0.80. CONCLUSIONS MRI exhibits a high AUC for the diagnosis of both adenomyosis and myomas. The PPV of MRI in the diagnosis of adenomyosis and myomas of the uterus is high as well. MRI seems to be a useful technique in everyday clinical practice in the diagnostic approach of these common conditions, enabling clinicians to select the most appropriate management.
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Cirilli AR, Cipot SJ. Emergency Evaluation and Management of Vaginal Bleeding in the Nonpregnant Patient. Emerg Med Clin North Am 2012; 30:991-1006. [DOI: 10.1016/j.emc.2012.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Omari EA, Varghese T, Kliewer MA. A novel saline infusion sonohysterography-based strain imaging approach for evaluation of uterine abnormalities in vivo: preliminary results. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2012; 31:609-615. [PMID: 22441918 PMCID: PMC3659397 DOI: 10.7863/jum.2012.31.4.609] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
In this article, we demonstrate the feasibility of saline infusion sonohysterography-based strain imaging for the determination of stiffness variations in uterine masses in vivo. Strain images are estimated using a 2-dimensional multilevel hybrid algorithm developed for sector array ultrasound transducers. Coarse displacements are initially estimated using envelope echo signals, followed by a guided finer displacement estimation using window lengths on the order of 6 wavelengths and 7 A-lines on radiofrequency data. Strain images are obtained by estimating displacement slopes using least squares estimation. In this prospective study, we show that stiffer masses such as fibroids appear darker or as regions with low strain on strain images and are thus clearly differentiated when compared to normal uterine tissue. A high strain boundary around stiffer masses referred to as a "halo" due to increased slipping or sliding of the mass during the applied deformation is also visualized. Uterine polyps, on the other hand, are visualized as masses that are brighter or regions with high strain when compared to the background myometrium, indicating the presence of a softer mass. Axial strain images provide additional new information that may supplement current clinical B-mode imaging used for the diagnosis of uterine abnormalities. Our results show the feasibility of improving clinical diagnosis based on strain imaging.
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Affiliation(s)
- Eenas A Omari
- Department of Medical Physics, University of Wisconsin-Madison, 1111 Highland Ave, Madison, WI 53705, USA
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Bennett GL, Andreotti RF, Lee SI, Dejesus Allison SO, Brown DL, Dubinsky T, Glanc P, Mitchell DG, Podrasky AE, Shipp TD, Siegel CL, Wong-You-Cheong JJ, Zelop CM. ACR appropriateness criteria(®) on abnormal vaginal bleeding. J Am Coll Radiol 2011; 8:460-8. [PMID: 21723482 DOI: 10.1016/j.jacr.2011.03.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Accepted: 03/25/2011] [Indexed: 10/17/2022]
Abstract
In evaluating a woman with abnormal vaginal bleeding, imaging cannot replace definitive histologic diagnosis but often plays an important role in screening, characterization of structural abnormalities, and directing appropriate patient care. Transvaginal ultrasound (TVUS) is generally the initial imaging modality of choice, with endometrial thickness a well-established predictor of endometrial disease in postmenopausal women. Endometrial thickness measurements of ≤5 mm and ≤4 mm have been advocated as appropriate upper threshold values to reasonably exclude endometrial carcinoma in postmenopausal women with vaginal bleeding; however, the best upper threshold endometrial thickness in the asymptomatic postmenopausal patient remains a subject of debate. Endometrial thickness in a premenopausal patient is a less reliable indicator of endometrial pathology since this may vary widely depending on the phase of menstrual cycle, and an upper threshold value for normal has not been well-established. Transabdominal ultrasound is generally an adjunct to TVUS and is most helpful when TVUS is not feasible or there is poor visualization of the endometrium. Hysterosonography may also allow for better delineation of both the endometrium and focal abnormalities in the endometrial cavity, leading to hysteroscopically directed biopsy or resection. Color and pulsed Doppler may provide additional characterization of a focal endometrial abnormality by demonstrating vascularity. MRI may also serve as an important problem-solving tool if the endometrium cannot be visualized on TVUS and hysterosonography is not possible, as well as for pretreatment planning of patients with suspected endometrial carcinoma. CT is generally not warranted for the evaluation of patients with abnormal bleeding, and an abnormal endometrium incidentally detected on CT should be further evaluated with TVUS.
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Kiss MZ, Varghese T, Kliewer M. Exvivo ultrasound attenuation coefficient for human cervical and uterine tissue from 5 to 10 MHz. ULTRASONICS 2011; 51:467-71. [PMID: 21163508 PMCID: PMC3056396 DOI: 10.1016/j.ultras.2010.11.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2010] [Revised: 11/23/2010] [Accepted: 11/23/2010] [Indexed: 05/07/2023]
Abstract
Attenuation estimation and imaging in the cervix has been utilized to evaluate the onset of cervical ripening during pregnancy. This feature has also been utilized for the acoustic characterization of leiomyomas and myometrial tissue. In this paper, we present direct narrowband substitution measurement values of the variation in the ultrasonic attenuation coefficient in ex vivo human uterine and cervical tissue, in the 5-10 MHz frequency range. At 5 MHz, the attenuation coefficient values are similar for the different orientations of uterine tissue with values of 4.1-4.2 dB/cm, 5.1 dB/cm for the leiomyoma, and 6.3 dB/cm for the cervix. As the frequency increases, the attenuation coefficient values increase and are also spread out, with a value of approximately 12.6 dB/cm for the uterus (both parallel and perpendicular), 16.0 for the leiomyoma, and 26.8 dB/cm for the cervix at 10 MHz. The attenuation coefficient measured increases monotonically over the frequency range measured following a power law.
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Affiliation(s)
- Miklos Z. Kiss
- Applied Physics Laboratory, Johns Hopkins University, 11100 Johns Hopkins Road, Laurel, MD 20723-6099
- Department of Medical Physics, University of Wisconsin-Madison, 1111 Highland Avenue, Madison, WI 53706, USA
| | - Tomy Varghese
- Department of Medical Physics, University of Wisconsin-Madison, 1111 Highland Avenue, Madison, WI 53706, USA
| | - M.A. Kliewer
- Department of Radiology, University of Wisconsin-Madison, 1111 Highland Avenue, Madison, WI 53706, USA
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Kasius JC, Broekmans FJM, Veersema S, Eijkemans MJC, van Santbrink EJP, Devroey P, Fauser BCJM, Fatemi HM. Observer agreement in the evaluation of the uterine cavity by hysteroscopy prior to in vitro fertilization. Hum Reprod 2011; 26:801-7. [DOI: 10.1093/humrep/der003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Bignardi T, Van den Bosch T, Condous G. Abnormal uterine and post-menopausal bleeding in the acute gynaecology unit. Best Pract Res Clin Obstet Gynaecol 2009; 23:595-607. [DOI: 10.1016/j.bpobgyn.2009.05.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2009] [Accepted: 05/04/2009] [Indexed: 10/20/2022]
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[Hierarchy for diagnostic and etiological management in menometrorrhagia]. ACTA ACUST UNITED AC 2009; 37 Suppl 8:S349-55. [PMID: 19268213 DOI: 10.1016/s0368-2315(08)74775-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A strategy to establish the diagnosis and the etiology of menorrhagia is necessary for an adaptated therapeutic care. The cross-examination must endeavour to assess bleedings and their clinical impact, and concentrate on specific pathology (such as hemostasis disorders). Clinical examination may eliminate cervical vaginal pathologies and estimate uterine volume. The diagnosis of pregnancy should always be considered and eliminated and that of iron deficiency anemia will be helpful. Explorations of hemostasis balance will be recommended according to clinical and biological features. Hormonal measurement are not contributive, except in diagnosis of SOPK. Endometrium biopsy with the Pipelle will be systematically performed after 40 years of age or in case of risk factors of endometrial cancer. Transvaginal ultrasonography is the first line exam to recommend in case of proved menorrhagia. Hysteroscopy and hysterosonography will be recommended if ultrasonography is not informative enough, or in case of medical treatment failure. MRI is recommended in an second intention (in case of multiple uterine fibroids, or suspected adenomyosis, and if an arterial embolization is required).
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Endometrial changes from short-term therapy with CDB-4124, a selective progesterone receptor modulator. Mod Pathol 2009; 22:450-9. [PMID: 19136935 DOI: 10.1038/modpathol.2008.204] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Selective progesterone receptor modulators are a class of drugs with progesterone antagonist activity that may confer therapeutic benefit for reproductive disorders in premenopausal women. Endometrial structure, which is dynamically controlled by circulating sex hormones, is likely to be perturbed by progesterone receptor modulators through their progesterone antagonist properties. We examined endometrial histology in 58 premenopausal women treated with the progesterone receptor modulator CDB-4124 (also known as Proellex) for endometriosis or uterine leiomyomata in two clinical trials. Endometrial biopsies obtained after 3 or 6 months with doses of 12.5, 25, or 50 mg daily oral CDB-4124 were reviewed independently by three pathologists. Consensus diagnoses using the World Health Organization hyperplasia scoring system, comments on specific histologic features, and clinical annotation were collected and analyzed. The majority of the endometrial biopsies (103 of 174 biopsies) contained histologic changes that are not seen during normal menstrual cycles. The histology of CDB-4124-treated patients was generally inactive or atrophic, and less frequently, proliferative or secretory, superimposed upon which were novel changes including formation of cystically dilated glands, and secretory changes coexisting with mitoses and apoptotic bodies. With increasing treatment dose and duration, the cysts became predominant and their lining inactive or atrophic. Cystic glands in the CDB-4124-treated subjects correlated with increased endometrial thickness by ultrasound. None of the CDB-4124-treated patients developed endometrial carcinoma or hyperplasia while on therapy. CDB-4124 therapy for 3-6 months produces histologic changes that are sufficiently novel that they might easily be misinterpreted by pathologists, particularly as disordered proliferative or hyperplastic endometrium. Knowledge of the constellation of endometrial changes associated with this agent and other progesterone receptor modulators, including cystic architecture and mixed non-physiologic epithelial changes will prevent misdiagnosis.
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McLucas B. Diagnosis, imaging and anatomical classification of uterine fibroids. Best Pract Res Clin Obstet Gynaecol 2008; 22:627-42. [DOI: 10.1016/j.bpobgyn.2008.01.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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18
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Thurkow AL, Admiraal CF, Emanuel MH, van Kesteren PJM, Veersema S. Submucous myomas: diagnosis and therapy. ACTA ACUST UNITED AC 2007. [DOI: 10.1007/s10397-007-0340-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Horne FM, Blithe DL. Progesterone receptor modulators and the endometrium: changes and consequences. Hum Reprod Update 2007; 13:567-80. [PMID: 17630398 DOI: 10.1093/humupd/dmm023] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Progesterone receptor modulators (PRMs) have been used for contraceptive research, as well as for treatment of fibroids, endometriosis and heavy or irregular menstrual bleeding. Long-term treatment with these compounds results in changes to the endometrium resulting in potential confusion in trying to characterize endometrial biopsies. A meeting was held to discuss the properties of PRMs, the effects of perturbed hormonal control of the endometrium and the need for further understanding of the biology of progesterone receptor action to facilitate the development of new PRMs. A panel of pathologists was convened to evaluate endometrial changes associated with a minimum of three months of chronic treatment with PRMs. Four different agents were used in the treatment regimens but the pathologists were blinded to treatment regimen or agent. The panel agreed that the endometrial biopsies did not fit into a classification of either proliferative or secretory endometrium but exhibited an unusual architecture that could be characterized as glandular dilatation. There was little evidence of mitosis, consistent with a proposed anti-proliferative effect of PRMs. The panel concluded that the biopsies did not reveal evidence of safety concern and that pathologists and investigators familiar with endometrial effects of chronic PRM exposure should consider working with pharmaceutical companies and regulatory agencies to develop standard descriptions of PRM-associated endometrial changes as well as the types of histologic changes that would signal a need for intervention.
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Etiology, symptomatology, and diagnosis of uterine myomas. Fertil Steril 2007; 87:725-36. [PMID: 17430732 DOI: 10.1016/j.fertnstert.2007.01.093] [Citation(s) in RCA: 379] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2006] [Revised: 01/11/2007] [Accepted: 01/11/2007] [Indexed: 11/18/2022]
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Batzer FR. Abnormal uterine bleeding: imaging techniques for evaluation of the uterine cavity and endometrium before minimally invasive surgery--the case for transvaginal ultrasonography. J Minim Invasive Gynecol 2007; 14:9-11. [PMID: 17218222 DOI: 10.1016/j.jmig.2006.08.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2006] [Accepted: 08/24/2006] [Indexed: 11/23/2022]
Abstract
Transvaginal ultrasound has been utilized for first line evaluation of abnormal uterine bleeding since its development in the early 1980's. The benefits and diagnostic effectiveness of transvaginal ultrasound in assessing the uterus, unlike hysteroscopy, extends to the complete pelvis. The ease of application, patient acceptance, and immediacy of results are rapidly apparent. Comparisons with hysteroscopic evaluation are discussed. While tissue diagnosis is still the gold standard, transvaginal sonography lets one know what surgical procedure to plan for from hysteroscopy to Endoscopy or laparotomy, including when no further surgical evaluation is necessary.
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Abstract
This chapter summarizes the diagnostic performance (sensitivity, specificity, positive and negative likelihood ratios) of ultrasound, computer tomography, and magnetic resonance imaging in the diagnosis of various gynecological diseases and tumors. Positron emission tomography is not discussed. Imaging in infertility, in the diagnosis of Mullerian duct anomalies and in gynecological oncology (staging of gynecological cancers, diagnosis of recurrence of gynecological cancer, diagnosis of trophoblastic tumors) is not dealt with. Ultrasound is the first-line imaging method for discrimination between viable intrauterine pregnancy, miscarriage and tubal pregnancy in women with bleeding and/or pain in early pregnancy, for discrimination between benign and malignant adnexal masses and for making a specific diagnosis in adnexal tumors (e.g. dermoid cyst, endometrioma, hemorrhagic corpus luteum, etc.), for diagnosing intracavitary uterine pathology in women with bleeding problems, and for confirming or refuting pelvic pathology in women with pelvic pain. Magnetic resonance imaging can have a role as a secondary test in the diagnosis of adenomyosis, 'deep endometriosis' (e.g. endometriosis in the rectovaginal septum or in the uterosacral ligaments), and in the diagnosis of extremely rare types of ectopic pregnancy (e.g. in the spleen, liver or retroperitoneum).
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Affiliation(s)
- Lil Valentin
- Department of Clinical Sciences Malmö, Lund University, Sweden.
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Jansen FW, de Kroon CD, van Dongen H, Grooters C, Louwé L, Trimbos-Kemper T. Diagnostic hysteroscopy and saline infusion sonography: prediction of intrauterine polyps and myomas. J Minim Invasive Gynecol 2006; 13:320-4. [PMID: 16825074 DOI: 10.1016/j.jmig.2006.03.018] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2006] [Revised: 03/22/2006] [Accepted: 03/19/2006] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To compare the positive predictive value (PPV) of diagnostic hysteroscopy (DH) and saline infusion sonography (SIS) for the detection of myomas and polyps in patients with abnormal uterine bleeding. DESIGN All consecutive women referred to our University Hospital diagnosed with an intrauterine polyp or myoma by office DH or SIS were included in the study. Patients referred to our clinic from 1993 through 2000 underwent DH. From 2001 through 2004 SIS was performed. After hysteroscopic removal in an inpatient setting, histopathologic results were used as a gold standard to calculate PPV of SIS and DH. (Canadian Task Force classification II-3) SETTING Tertiary referral center. INTERVENTION Diagnostic hysteroscopy and saline infusion sonography. PATIENTS Women in whom an intrauterine polyp or myoma was diagnosed either by DH or SIS MEASUREMENTS AND MAIN RESULTS: The PPVs of SIS and DH in the evaluation of intrauterine polyps and fibroids did not significantly differ. However, p = 0.3 is the significant difference for the PPV of SIS in premenopausal women comparing the PPV of SIS for fibroids (0.95) with the PPV of SIS for polyps (0.81). CONCLUSIONS Diagnostic hysteroscopy and saline infusion sonography are equivalent diagnostic tools for the detection of intrauterine myomas and polyps.
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Affiliation(s)
- Frank Willem Jansen
- Department of Gynaecology, Leiden University Medical Center, Leiden, The Netherlands
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Cepni I, Ocal P, Erkan S, Saricali FS, Akbas H, Demirkiran F, Idil M, Bese T. Comparison of transvaginal sonography, saline infusion sonography and hysteroscopy in the evaluation of uterine cavity pathologies. Aust N Z J Obstet Gynaecol 2005; 45:30-5. [PMID: 15730362 DOI: 10.1111/j.1479-828x.2005.00336.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIMS To determine whether performing transvaginal sonography (TVS) and saline infusion sonography (SIS) before hysteroscopy could reduce the number of diagnostic hysteroscopies performed for the evaluation of uterine cavity abnormalities. METHODS Two hundred and twenty three women with suspected uterine cavity abnormalities were prospectively evaluated by TVS, SIS and hysteroscopy, and had histological evaluation of the endometrium with hysteroscopic biopsy or dilatation and curettage (D&C). One hundred and sixty five patients (74%) were premenopausal and 58 patients (26%) were postmenopausal. RESULTS The positive predictive value (PPV) for endometrial polyps was 69% for TVS, 78% for SIS and 81% for hysteroscopy in premenopausal patients. In the postmenopausal group, TVS and SIS could detect only 24% of endometrial polyps, whereas 70% were diagnosed by hysteroscopy. The PPV for submucous fibroids was 47% for TVS, 81% for SIS and 77% for hysteroscopy in the premenopausal group. CONCLUSIONS In premenopausal patients, SIS and hysteroscopy are equally accurate in the diagnosis of endometrial polyps and submucous fibroids. Hysteroscopy is the most accurate test for polypoid lesions in the postmenopausal group. Performing TVS, SIS and D&C could reduce the number of diagnostic hysteroscopies performed for the evaluation of uterine cavity abnormalities by 71.5% in premenopausal patients. However, this rate decreases to 40% in the postmenopausal group.
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Affiliation(s)
- Ismail Cepni
- Department of Obstetrics and Gynaecology, Istanbul University, Turkey.
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Akande VA, Vyas SK. Questioning the ubiquity of outpatient endometrial sampling in the management of menstrual disorders. BJOG 2003. [DOI: 10.1111/j.1471-0528.2003.02011.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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