Detection of Benign Endometrial Masses by Endometrial Stripe Measurement in Premenopausal Women

Endometrial Cancer in Reproductive-Aged Females: Etiology and Pathogenesis

Endometrial cancer is the most common gynecologic malignancy in developed countries, and the incidence is rising in premenopausal females. Type I EC is more common than Type II EC (80% vs. 20%) and is associated with a hyperestrogenic state. Estrogen unopposed by progesterone is considered to be the main driving factor in the pathogenesis of EC. Studies show that BMI > 30 kg/m2, prolonged duration of menses, nulliparity, presence of polycystic ovarian syndrome, and Lynch syndrome are the most common causes of EC in premenopausal women. Currently, there are no guidelines established to indicate premenopausal patients who should be screened. This review aims to synthesize current data on the etiology, risk factors, presentation, evaluation, and prognosis of endometrial cancer in this population.

The Utility of Pelvic Ultrasounds in Adolescents Presenting to the Emergency Department with Abnormal Uterine Bleeding

STUDY OBJECTIVE

To analyze what factors influence a provider's decision to order a pelvic ultrasound (PUS) in the emergency department (ED) for adolescents with abnormal uterine bleeding (AUB), to determine if endometrial stripe (EMS) measurements are used in treatment decisions, and to evaluate if treatment outcomes differ based on EMS thicknesses.

METHODS

Retrospective chart review of patients aged 11-19 presenting to the ED with AUB from 2006 to 2018. Those receiving a PUS were divided into three EMS groups: ≤5 mm, 6-9 mm, and ≥10 mm. Outcomes were evaluated in admitted patients by progress notes indicating resolution of bleeding. Cross-tab, χ2, and logistic and linear regression analysis were performed.

RESULTS

Of 258 adolescents meeting study criteria, 113 (43.8%) had a PUS. None had an abnormality. A PUS was more likely to be performed in patients with lower hemoglobin values (P < .003). Provider decision to order a PUS did not differ by age or bleeding duration (P > .1). Among those with a PUS, 67 (59%) received hormonal therapy (pill, progestin-only, IV estrogen). There were no significant differences in treatment choices based on EMS (P < .061) or, among the 44 admitted patients (17%), in the time it took bleeding to stop after initiating treatment (pill: P = .227, progestin-only: P = .211, IV estrogen: P = .229).

CONCLUSION

In adolescents with AUB in the ED, performing a PUS was more common in those with low hemoglobin. EMS thickness did not appear to affect treatment decisions or inpatient outcomes. Larger studies are needed to confirm the current findings and determine if PUS is needed in the evaluation of AUB.

Investigation and management of abnormal uterine bleeding in reproductive-aged women: a descriptive review of national and international recommendations

PURPOSE

To review and compare the most recently published recommendations on the investigation and management of abnormal uterine bleeding (AUB).

MATERIALS AND METHODS

A descriptive review of recommendations from the American College of Obstetricians and Gynaecologists (ACOG), the National Institute for Health and Care Excellence (NICE), the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), the Society of Obstetricians and Gynaecologists of Canada (SOGC) and the International Federation of Gynaecology and Obstetrics (FIGO) on AUB in reproductive-aged women was carried out.

RESULTS

There is a consensus that detailed personal and family history along with physical examination are essential in the investigation of menstrual, intermenstrual or postcoital AUB. All the medical societies recommend transvaginal ultrasound as the first-line imaging modality to determine the AUB cause. Moreover, they agree (except for RANZCOG) that, in women with AUB, endometrial biopsy should only be performed if additional risk factors for endometrial cancer are present. Laboratory tests may be helpful in the AUB investigation; however, there are several discrepancies among the recommendations. Regarding AUB management, NICE, ACOG and SOGC agree that the administration of hormonal or non-hormonal medications should be the first-line treatment modality in bleeding disorders and absent or minor structural pelvic pathology. Surgical management should be preferred in cases of identified polyps, large fibroids or unsuccessful pharmacological treatment.

CONCLUSIONS

Since AUB affects a significant proportion of reproductive-aged women, the main objective is to improve the quality of life of these patients without missing cases of malignancy.

Implementation of Office Hysteroscopy for the Evaluation and Treatment of Intrauterine Pathology

Hysteroscopy provides a minimally invasive strategy to evaluate intrauterine pathology and manage conditions such as abnormal uterine bleeding, infertility, intrauterine adhesions, müllerian anomalies, and intrauterine foreign bodies. Increasing access to hysteroscopy procedures in the office has the potential to improve patient care by minimizing financial and logistical barriers, aiding in streamlined diagnosis and treatment planning, and potentially averting unnecessary operative procedures and anesthesia. Office hysteroscopy refers to procedures performed in outpatient settings where pain management involves no medications, oral nonsedating medications, local anesthetic agents, or oral or inhaled conscious sedation. We present best practices for the implementation of hysteroscopy in an office setting. These include appropriate patient selection, optimal procedural timing, cervical preparation for patients at highest risk of cervical stenosis or pain with dilation, individualized pain-management strategies, use of distension media, and video monitoring to engage patients in the procedure. We describe miniaturized equipment for use in the office setting and "no-touch" vaginoscopic approaches to limit patient discomfort. With appropriate training and experience, office hysteroscopy presents a simple and cost-effective modality for optimizing gynecologic care for our patients.

Endometrial Cut Off Thickness as Predictor of Endometrial Pathology in Perimenopausal Women with Abnormal Uterine Bleeding: A Cross-Sectional Study

Purpose

We aim to determine the predictive value of endometrial thickness by transvaginal ultrasonography (TVS) in diagnosing endometrial pathology and to evaluate whether Doppler complements its diagnostic efficacy in perimenopausal women with abnormal uterine bleeding.

Methods

This cross-sectional observational study was conducted among 70 perimenopausal women with AUB who underwent TVS measurement of endometrial thickness (ET) and Doppler flow indices followed by endometrial sampling and histopathological examination (HPE).

Results

In HPE, 51 (73%) women had normal diagnosis while 19 (27%) women had neoplastic histology either benign or malignant. They were categorised into group I and group II, respectively. There was a significant difference in age (P=0.001) and incidence of obesity (P=0.01) between the two groups. The ETs measured in group I and group II were 7.89 ± 2.62 mm and 14.07 ± 3.96 mm, respectively, with significant difference (P < 0.001). A TVS-ET of 10.5 mm had the highest sensitivity and specificity of 89.5% and 86.3%, respectively, PPV of 70.68%, NPV of 95.68%, LR+ of 6.52, and LR- of 0.12. Doppler flow velocimetric study of endometrial and uterine vessels did not demonstrate a significant difference.

Conclusions

Women in perimenopause with AUB should be offered to undergo endometrial sampling for histopathological examination if TVS ET ≥10.5 mm. The coexisting risk factors especially higher age (>45 years) and obesity (BMI>30) significantly escalate the chances of developing endometrial pathology.

The role of transvaginal color doppler indices to predict malignancy in abnormal uterine bleeding according to PALM-COEIN classification

INTRODUCTION

The objective of this study is to analyze the differences in transvaginal color Doppler parameters in premenopasual women with abnormal uterine bleeding (AUB) among PALM-COEIN groups.

MATERIALS AND METHOD

This cross-sectional study was performed in a training and educational hospital, included 147 premenopausal women with AUB. Patients were divided into four groups according to PALM-COEIN. All subjects were evaluated by transvaginal Doppler sonography and uterine artery (UA) pulsatility and resistive indexes (PI, RI) were calculated then compared.

RESULTS

Four groups named AUB-P, AUB-E, AUB-M and AUB-O included 39, 30, 32 and 46 patients, respectively. The mean age of patients was 44.82 (35-55 years), EC rate was 3.4 %. UA-PI was lower in the AUB-M group compared with AUB-P and AUB-O (p < 0.001). UA-RI was different among gruops (p < 0.001). UA-RI was lowest in the AUB-M, and highest in the AUB-O (0.60 ± 0.15; 0.85 ± 0.05 respectively). The cut-off values of ET, UA-PI and UA-RI for detecting AUB-M were 13.5, 1.55 and 0.71 respectively.

CONCLUSION

Transvaginal color Doppler sonography may be beneficial in detecting the etiology of AUB in premenopausal women.

ACR Appropriateness Criteria® Abnormal Uterine Bleeding

This publication summarizes the relevant literature for the imaging of patients with symptoms of abnormal uterine bleeding, including initial imaging, follow-up imaging when the original ultrasound is inconclusive, and follow-up imaging when surveillance is appropriate. For patients with abnormal uterine bleeding, combined transabdominal and transvaginal ultrasound of the pelvis with Doppler is the most appropriate initial imaging study. If the uterus is incompletely visualized with the initial ultrasou2nd, MRI of the pelvis without and with contrast is the next appropriate imaging study, unless a polyp is suspected on the original ultrasound, then sonohysterography can be performed. If the patient continues to experience abnormal uterine bleeding, assessment with ultrasound of the pelvis, sonohysterography, and MRI of the pelvis without and with contrast would be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The two FIGO systems for normal and abnormal uterine bleeding symptoms and classification of causes of abnormal uterine bleeding in the reproductive years: 2018 revisions

BACKGROUND

The International Federation of Gynecology and Obstetrics (FIGO) systems for nomenclature of symptoms of normal and abnormal uterine bleeding (AUB) in the reproductive years (FIGO AUB System 1) and for classification of causes of AUB (FIGO AUB System 2; PALM-COEIN) were first published together in 2011. The purpose was to harmonize the definitions of normal and abnormal bleeding symptoms and to classify and subclassify underlying potential causes of AUB in the reproductive years to facilitate research, education, and clinical care. The systems were designed to be flexible and to be periodically reviewed and modified as appropriate.

OBJECTIVES

To review, clarify, and, where appropriate, revise the previously published systems.

METHODOLOGY AND OUTCOME

To a large extent, the process has been an iterative one involving the FIGO Menstrual Disorders Committee, as well as a number of invited contributions from epidemiologists, gynecologists, and other experts in the field from around the world between 2012 and 2017. Face-to-face meetings have been held in Rome, Vancouver, and Singapore, and have been augmented by a number of teleconferences and other communications designed to evaluate various aspects of the systems. Where substantial change was considered, anonymous voting, in some instances using a modified RAND Delphi technique, was utilized.

Management of abnormal uterine bleeding - focus on ambulatory hysteroscopy

The rapid evolution in ambulatory hysteroscopy (AH) has transformed the approach to diagnose and manage abnormal uterine bleeding (AUB). The medical management in primary care remains the mainstay for initial treatment of this common presentation; however, many women are referred to secondary care for further evaluation. To confirm the diagnosis of suspected intrauterine pathology, the traditional diagnostic tool of day case hysteroscopy and dilatation and curettage in a hospital setting under general anesthesia is now no longer required. The combination of ultrasound diagnostics and modern AH now allows thorough evaluation of uterine cavity in an outpatient setting. Advent of miniature hysteroscopic operative systems has revolutionized the ways in which clinicians can not only diagnose but also treat menstrual disorders such as heavy menstrual bleeding, intermenstrual bleeding and postmenopausal bleeding in most women predominantly in a one-stop clinic. This review discussed the approach to manage women presenting with AUB with a focus on the role of AH in the diagnosis and treatment of this common condition in an outpatient setting.

Endometrial Ablation

The destruction of the endometrium in women with heavy menstrual bleeding has been used for well over a century, and the various techniques of delivering forms of thermal energy have been modified over the years to ensure a safe and effective treatment approach. Today, 6 nonresectoscopic devices are approved for use in the United States in addition to resectoscopic techniques that rely on the skillful use of the operative hysteroscope. Regardless of the technique used, endometrial ablation uniformly reduces menstrual blood loss, improves general and menstrual-related quality of life, and prevents hysterectomy in 4 of 5 women who undergo the procedure. When patients are appropriately selected, outcomes are optimized, and risks of serious complications are minimized. This article reviews the literature with singular reference to nonresectoscopic endometrial ablation procedures including historical background, appropriate patient selection, clinical outcomes data, complications, and special or unique considerations.

Endometrial evaluation with transvaginal ultrasonography for the screening of endometrial hyperplasia or cancer in premenopausal and perimenopausal women

Objective

The aim of our study is to determine clinical factors and sonographic findings associated with endometrial hyperplasia or cancer (EH+) in premenopausal and perimenopausal women.

Methods

A total of 14,340 transvaginal ultrasonography examinations of 9,888 healthy premenopausal and perimenopausal women were included in this retrospective study. One hundred sixty-two subjects underwent endometrial biopsy based on abnormal uterine bleeding (AUB), sonographic endometrial abnormalities (thickened endometrium, endometrial mass, or endometrial stripe abnormality), or both. The clinical factors and sonographic endometrial abnormalities were evaluated with regard to EH+.

Results

Histologically verified EH+ was found in fourteen subjects (8.6%); ten cases of endometrial hyperplasia (EH) without atypia, three cases of EH with atypia (AEH), and one case of endometrial cancer. Neither clinical factors nor AUB were associated with EH+ (P=0.32) or AEH+ (P=0.72). Of sonographic findings, endometrial stripe abnormality was significantly associated with EH+ (P=0.003) and marginally associated with AEH+ (P=0.05), but a thickened endometrium was not associated with EH+ (P=0.43).

Conclusion

Endometrial stripe abnormality is a significant factor to predict EH+ in healthy premenopausal and perimenopausal women with and without AUB. However, simple measurement of endometrial thickness has a limited role in this capacity.

The medical management of abnormal uterine bleeding in reproductive-aged women

In the treatment of women with abnormal uterine bleeding, once a thorough history, physical examination, and indicated imaging studies are performed and all significant structural causes are excluded, medical management is the first-line approach. Determining the acuity of the bleeding, the patient's medical history, assessing risk factors, and establishing a diagnosis will individualize their medical regimen. In acute abnormal uterine bleeding with a normal uterus, parenteral estrogen, a multidose combined oral contraceptive regimen, a multidose progestin-only regimen, and tranexamic acid are all viable options, given the appropriate clinical scenario. Heavy menstrual bleeding can be treated with a levonorgestrel-releasing intrauterine system, combined oral contraceptives, continuous oral progestins, and tranexamic acid with high efficacy. Nonsteroidal antiinflammatory drugs may be utilized with hormonal methods and tranexamic acid to decrease menstrual bleeding. Gonadotropin-releasing hormone agonists are indicated in patients with leiomyoma and abnormal uterine bleeding in preparation for surgical interventions. In women with inherited bleeding disorders all hormonal methods as well as tranexamic acid can be used to treat abnormal uterine bleeding. Women on anticoagulation therapy should consider using progestin-only methods as well as a gonadotropin-releasing hormone agonist to treat their heavy menstrual bleeding. Given these myriad options for medical treatment of abnormal uterine bleeding, many patients may avoid surgical intervention.

FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age

There is general inconsistency in the nomenclature used to describe abnormal uterine bleeding (AUB), in addition to a plethora of potential causes-several of which may coexist in a given individual. It seems clear that the development of consistent and universally accepted nomenclature is a step toward rectifying this unsatisfactory circumstance. Another requirement is the development of a classification system, on several levels, for the causes of AUB, which can be used by clinicians, investigators, and even patients to facilitate communication, clinical care, and research. This manuscript describes an ongoing process designed to achieve these goals, and presents for consideration the PALM-COEIN (polyp; adenomyosis; leiomyoma; malignancy and hyperplasia; coagulopathy; ovulatory dysfunction; endometrial; iatrogenic; and not yet classified) classification system for AUB, which has been approved by the International Federation of Gynecology and Obstetrics (FIGO) Executive Board as a FIGO classification system.

Accuracy of endometrial thickness in detecting benign endometrial pathology in postmenopausal women

OBJECTIVE

The aim of this study was to determine whether an endometrial thickness less than 5 mm on transvaginal ultrasound (TVUS) is sufficient to exclude benign endometrial lesions in postmenopausal women with bleeding and to determine a cutoff value below which benign endometrial pathology could be ruled out.

METHODS

Electronic medical records of consecutive postmenopausal women presenting with vaginal bleeding suspicious for benign pathology were reviewed between September 2002 and December 2007. All women underwent TVUS with endometrial stripe measurement followed by saline infusion sonography (SIS). Accuracy of endometrial echo thickness for detecting intracavitary masses was compared with the reference standard of SIS. A receiver operating characteristic curve was constructed to calculate whether other cutoff values would be more accurate than 5 mm in detecting benign endometrial masses.

RESULTS

A total of 1,097 women were referred during the study period; 135 met the inclusion criteria and underwent TVUS followed by SIS. The endometrial echo was less than 5 mm in 43% and 5 mm or greater in 57%. The overall prevalence of polyps or fibroids was 50%. Using an endometrial echo cutoff less than 5 mm, sensitivity was 76% (95% CI, 65-85), specificity was 63% (95% CI, 51-73), positive predictive value was 67%, and negative predictive value was 72%. The area under the receiver operating characteristic curve for detection of benign masses was 0.79 (95% CI, 0.72-0.87). We were unable to determine a cutoff value below which benign endometrial pathology could be excluded.

CONCLUSIONS

With an endometrial thickness cutoff of 5 mm a considerable amount of benign endometrial pathology in postmenopausal women with bleeding is missed, and SIS or hysteroscopy may be warranted.

Primary Care in Obstetrics and Gynecology — A Place for Advanced Ultrasound?

The evaluation of adnexal masses based on transvaginal sonography (TVS) and when their size is too big- transabdominal US can be facilitated and refined by using color Doppler (CD), power Doppler (PD), and pulsed Doppler(PW), including three-dimensional ultrasound (3D US). With these modes, we obtain information about vascularity and flow indices, and their distribution within a mass. Considering the fact that neoangiogenesis is a main feature of malignancy, this is essential information. Thus, we are able to assume the benign or malignant character of an adnexal mass, make the right choice of additional imaging or biochemical tests, and then channel the treatment appropriately. This is subsequently demonstrated for simple cyst, hemorrhagic cysts, endometrioma, dermoid, serous papillary cystoma, ectopic pregnancy, and ovarian carcinoma.

Abnormal uterine bleeding (AUB) is a common problem in primary care. Compared to transabdominal approach, TVS improves the detection rate of underlying uterine pathology. In conditions like endometrial hyperplasia, polyps, submucous leiomyoma, and endometrial cancer, CD, PD, PW and contrast enhanced transvaginal ultrasound may optimize sonographic evaluation. Saline infusion sonohysterography (SISH) in out patient department (OPD) is an alternative to invasive diagnostic hysteroscopy in patients with AUB.

Care for maternal and fetal well-being during pregnancy is a main task in OPD. The assessment of fetal pathology is almost entirely based on Ultrasound. Several illustrations of fetal anomalies detected during 1st trimester and 2nd trimester screening, of abnormal findings in feto-maternal Doppler ultrasound, and fetal pathology demonstrated in 3D/4D ultrasound mode, conclude this review of advanced ultrasound in primary care.

Management of Heavy Menstrual Bleeding: Is Hysterectomy the Radical Mastectomy of Gynecology?

Both hysterectomy for heavy menstrual bleeding and radical mastectomy for breast cancer are steeped in the history of surgery and have recently been challenged as being too radical for the disorder at hand. Radical mastectomy has largely been replaced with local removal of the tumor with subsequent radiation and/or chemotherapy. Alternatives to hysterectomy include a number of medical interventions, most notably intrauterine progestin-releasing systems, and endometrial ablation, a procedure that has a relatively high success rate and one that is now feasible for many women in an office or procedure room setting. However, although radical mastectomy rates have dropped precipitously, hysterectomy rates, at least in the United States remain relatively stable. Determining the proportion of hysterectomies that are done for heavy menstrual bleeding is difficult, largely because of coding issues, so it is difficult to measure the impact of new medical and minimally invasive surgical procedures. Nevertheless, it seems clear that many women are not exposed to the plethora of options to hysterectomy, a fact that may reflect a number of issues that may include training, skill, and financial incentives or disincentives. Clearly, options to hysterectomy are not a panacea, but if women are empowered to select from all of the options available, the rate of hysterectomy for bleeding should decrease while maintaining, or even enhancing the patient's satisfaction with care.