The Use of Hysteroscopy for the Diagnosis and Treatment of Intrauterine Pathology: ACOG Committee Opinion, Number 800

Enhancing precision in hysteroscopic surgery: The role of intraoperative ultrasound

Hysteroscopy stands as the gold-standard approach for managing intrauterine pathology. However, in complex clinical cases, hysteroscopic evaluation alone may prove insufficient for the safest and successful patient management. Intraoperative ultrasound (IOUS) has emerged as a valuable adjunct to hysteroscopic surgery, offering real-time visualization of endometrial cavity, uterine walls and instruments within the uterine cavity, enabling precise delineation of anatomical structures, and helping to assess the extent of pathology during intricate interventions. This review aims to comprehensively assess the applications, efficacy and utility of IOUS in hysteroscopic surgery. Available evidence indicates that in hysteroscopic myomectomy, IOUS significantly reduces the risk of uterine perforation, particularly in submucosal FIGO 2 myomas, and enhances the likelihood of a single-step procedure. During hysteroscopic metroplasty, ultrasound guidance decreases the chance of incomplete uterine septum resection. In the hysteroscopic management of severe Asherman syndrome, IOUS reduces the risk of uterine perforation or false passage. For cesarean scar pregnancy (CSP), ultrasound is crucial in defining the most appropriate surgical approach and is effective in guiding the hysteroscopic treatment of endogenic CSP. The use of IOUS in hysteroscopy proves valuable in complex cases where the risk of uterine perforation or incomplete procedure is increased.

Effect of esketamine on haemodynamic fluctuations in patients undergoing hysteroscopic surgery: A prospective, double-blind randomized clinical trial

AIMS

We explored whether esketamine anesthesia during hysteroscopic surgery can reduce intraoperative hemodynamic fluctuations and improve patient benefit.

METHODS

A total of 170 patients undergoing hysteroscopic surgery were enrolled, and 151 patients were finally included in the analysis, among which 19 used vasoactive drugs during surgery. Patients were randomly assigned to either the esketamine anesthesia group (E group) or the sufentanil anesthesia group (S group). The primary outcomes were blood pressure and heart rate during the surgery. Secondary outcomes included resistance to laryngeal mask insertion, demand for propofol and remifentanil, nausea and vomiting, Richmond Agitation and Sedation Scale (RASS), dizziness and pain intensity after resuscitation, vasoactive medication treatment, hospitalization time and expenses.

RESULTS

E group had a more stable heart rate, systolic blood pressure, diastolic blood pressure and mean blood pressure than the S group (p < 0.001). Patients in E group had a higher demand for propofol (p < 0.001) but better RASS scores (p < 0.001) after resuscitation. The incidence of intraoperative vasoactive medication use was higher in the S group (18.4% vs. 6.7%, p = 0.029). There were no statistically significant differences in terms of resistance to laryngeal mask insertion, remifentanil demand, time required for resuscitation, postoperative pain, dizziness, nausea or vomiting.

CONCLUSIONS

Compared with sufentanil, esketamine-induced anesthesia during hysteroscopic surgery can reduce intraoperative hemodynamic fluctuations and the incidence of intraoperative vasoactive medication. Although esketamine-induced anesthesia may increase the demand for propofol during surgery, it does not affect the anesthesia recovery time and the quality of patient recovery is better.

A Deeper Look at Office Hysteroscopy in Asymptomatic Postmenopausal Patients: indications and outcomes of 822 Cases

STUDY OBJECTIVE

This study aims to assess the prevalence of malignancy and other endometrial pathologies in asymptomatic postmenopausal women referred for office hysteroscopy, identify main referral indications, and assess their relationship with the risk of malignancy. Secondary objectives included evaluating the association between ultrasound variables and malignancy risk and assessing procedure validity, which encompasses duration, feasibility and patient comfort during office hysteroscopy.

DESIGN

Retrospective analysis.

SETTING

The study was conducted at the Department of Gynecology, Division of Gynaecology and Obstetrics, University Medical Centre Ljubljana, Slovenia's largest tertiary care center.

PARTICIPANTS

The cohort consisted of 822 asymptomatic postmenopausal women referred for office hysteroscopy, excluding those with postmenopausal bleeding within the last year.

INTERVENTIONS

Participants underwent office hysteroscopy with or without biopsy.

MEASUREMENTS AND MAIN RESULTS

The main indication for hysteroscopy was ultrasound abnormalities alone, with remaining indications including a combination of ultrasound and clinical findings. Among the cohort, 97.4% exhibited benign findings, while 2.6% were diagnosed with cancer or precancerous lesions. The analysis revealed that patients with indications based on ultrasound and clinical findings suggestive of malignancy had a higher risk of malignancy compared to those with ultrasound alone. In 387 patients with documented ultrasound variables, inhomogeneous endometrial appearance (OR: 8.2, 95% CI: 2.4-27.9, p<0.001) and significant liquid content within the uterine cavity (OR: 10.2, 95% CI: 3.6-28.9, p<0.001) exhibited strong associations with malignancy. Analysis of the procedure revealed a high feasibility rate (87.8%), with a median duration of 13,7 minutes and a median VAS pain score after the procedure of 3/10.

CONCLUSIONS

The prevalence of endometrial cancer and precancerous lesions in asymptomatic postmenopausal patients is likely low, with most intrauterine pathologies being benign. Our study demises the utility of routine endometrial surveillance for this population in the absence of specific risk factors. A holistic approach, considering individualized assessments and factors beyond endometrial thickness, is crucial in interpreting ultrasonic findings.

Combining Ultrasonography and Endometrial Aspiration as a One-Stop Screening for Endometrial Neoplasia

OBJECTIVE

To assess the performance of simultaneous endometrial aspiration and sonohysterography to screen for endometrial cancer or hyperplasia in women aged 50 years or older.

METHODS

We conducted a prospective study from February 2014 to October 2020 at the ultrasound unit of a large urban academic medical center. The study included 1,635 women aged 50 years or older referred for endometrial evaluation, with follow-up through January 2021. Participants underwent saline infusion sonohysterography combined with ultrasound-guided endometrial aspiration. The primary outcome measured was a diagnosis of endometrial cancer or hyperplasia within 1 year from screening. The diagnostic accuracy of the combined evaluation method, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), was assessed.

RESULTS

Of 1,170 women who completed the study protocol, 82 (7.0%) had endometrial cancer and 42 (3.6%) had endometrial hyperplasia. Of all patients who developed cancer during the follow-up period, 85.5% were diagnosed within 1 year after evaluation. The application of simultaneous endometrial aspiration and sonohysterography together demonstrated a sensitivity of 99.1%, specificity of 24.9%, PPV of 11.8%, and NPV of 99.6%. Using a theoretical sequential approach, assuming an endometrial aspiration is performed only in patients determined to be high risk by sonohysterography, demonstrated a sensitivity of 93.4%, specificity of 99.9%, PPV of 99.0%, and NPV of 99.3%.

CONCLUSION

Simultaneous endometrial aspiration and sonohysterography is an effective one-stop outpatient screening tool for detecting endometrial cancer and hyperplasia in women aged 50 years or older. With the integration of two screening modalities into a single procedure, simultaneous endometrial aspiration and sonohysterography may overcome the limitations inherent in each of the currently recommended methods individually, potentially improving patient prognosis and streamlining the diagnostic process.

Incidence and risks of excessive distension absorption in hysteroscopic surgery using 5% mannitol solution: a retrospective descriptive study

OBJECTIVE

To clarify the incidence of excessive distension absorption in hysteroscopic surgery using 5% mannitol solution, evaluate the associated risks, and help to establish a safe fluid deficit threshold for such complication.

DESIGN

Retrospective descriptive study.

SETTING

Academic medical center.

PATIENTS

Ten thousand six hundred ninety-three patients underwent inpatient hysteroscopic surgery with 5% mannitol perfusion using a monopolar electrosurgical instrument from Jan. 2015 to Sep. 2020.

INTERVENTION(S)

None. This study has been approved by the Ethics Committee of Sun Yat-sen Memorial Hospital.

MEASUREMENTS AND MAIN RESULTS

A fluid deficit of more than 1000 mL was defined as the diagnostic criteria for excessive distension absorption. The overall incidence of excessive distension absorption in this study was 0.46% (49/10693). The incidence was 2.57% (16/623) for transcervical resection of fibroid (TCRF), 2.36% (9/381) for retained products of conception (RPOC) removal, 1.20% (6/501) for hysteroscopic uterine septum resection (HSR), 0.48% (4/828) for transcervical resection of the endometrium (TCRE), and 0.53% (14/2621) for transcervical resections of adhesion (TCRA). Excessive distension absorption could occur within seven minutes in HSR. Among the patients diagnosed with excessive distension absorption, 30.77% (12/39) exhibited signs or symptoms related to circulation overload with a fluid deficit under 2500 mL, and 10.26% (4/39) developed pulmonary edema.

CONCLUSION

Excessive distension absorption could happen in all kinds hysteroscopic surgical treatment including RPOC removal and TCRA which were rarely reported. The overall incidence of excessive distension absorption could be low. But it would be five times higher in certain procedures such as TCRF, RPOC removal and TCRA. Resection using a needle electrode in HSR and TCRA may contribute to the short time development of excessive distension absorption. 30.77% of the patients could not tolerate the fluid deficit of less than 2500 mL which was set as a threshold for isotonic distending media and presented with circulation overload related signs or symptoms.

Hysteroscopy: where did we start, and where are we now? The compelling story of what many considered the "Cinderella" of gynecological endoscopy

Hysteroscopy has truly revolutionized the field of diagnostic and operative gynecology. It is presently regarded as the gold standard method for both the diagnosis and treatment of intrauterine diseases and it has fundamentally altered the way gynecologists treat patients with such conditions. These pathologies can now be diagnosed and treated in an outpatient setting, thanks to technological advancements and instrument downsizing. Two hundred years of development and notable innovation are now reflected in the present hysteroscopic practice. This review attempts to trace the boundaries-pushing history of hysteroscopy by highlighting the advancements in technology and the therapeutic and diagnostic benefits offered by this groundbreaking approach.

Guideline No. 453: Endometrial Ablation in the Management of Abnormal Uterine Bleeding

OBJECTIVE

To provide an update of the current evidence-based guideline on the techniques and technologies used in endometrial ablation, a minimally invasive technique for the management of abnormal uterine bleeding of benign origin.

TARGET POPULATION

Women of reproductive age with abnormal uterine bleeding and benign pathology with or without structural abnormalities.

BENEFITS, HARMS, AND COSTS

Implementation of the guideline recommendations will improve the provision of endometrial ablation as an effective treatment for abnormal uterine bleeding. Following these recommendations would allow the surgical procedure to be performed safely and maximize success for patients.

EVIDENCE

The guideline was updated with published literature retrieved through searches of Medline and the Cochrane Library from January 2014 to April 2023, using appropriate controlled vocabulary and keywords (endometrial ablation, hysteroscopy, menorrhagia, heavy menstrual bleeding, abnormal uterine bleeding, hysterectomy). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English. Grey (unpublished) literature was retrieved from the Association of Obstetricians and Gynecologists of Quebec (AOGQ) in 2023.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

Obstetricians, gynaecologists, and primary care providers.

SOCIAL MEDIA ABSTRACT

This is an updated version of the 2015 SOGC Endometrial Ablation guideline. The authors discuss special considerations, update evidence, and make new fluid deficit recommendations.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Feasibility of Office-Based Operative Hysteroscopy by a Tissue Removal System Without Anesthesia

STUDY OBJECTIVE

To investigate the feasibility of operative hysteroscopy by a hysteroscopic tissue removal system (HTRS) without anesthesia in women with endometrial polyps (EP) or retained products of conception (RPOC).

DESIGN

Prospective observational cohort study.

SETTING

University-affiliated Department of Obstetrics and Gynecology.

PATIENTS

Consenting women aged >18 years diagnosed with EP or RPOC from 9/2022 to 8/2023 confirmed by a prior office hysteroscopy.

INTERVENTIONS

Office-based vaginoscopic operative hysteroscopy without anesthesia using the Mini-Elite Truclear HTRS. Oral misoprostol was prescribed for cervical ripening. The patients rated intraoperative and 5-minute postoperative pain levels on a visual analog scale, with mild pain defined as a score of 0 to 4, moderate as 5 to 7, and severe as 8 to 10. A successful procedure was defined as complete removal of the pathology.

MEASUREMENTS AND MAIN RESULTS

Fifty patients were included in this pilot study, and 47 (94.0%) procedures were completed successfully, including 21/24 (87.5%) cases of EP and all cases of RPOC (26/26, p = .06). No intra- or postoperative complications occurred. The intraoperative pain levels were rated as mild, moderate, and severe by 26 (52.0%), 16 (32.0%) and 8 (16.0%) patients, respectively. Severe intraoperative pain was more common in nulliparous women and those >10 years from their last vaginal delivery and was not associated with patient age, menopausal status, presence of abnormal uterine bleeding, or pathology size. Severe postoperative pain, reported by 5 (10.0%) patients, was significantly associated with removal of EP compared with RPOC, longer operative time, and nulliparity or >10 years from the last vaginal delivery. The procedure was considered acceptable by 46 (92.0%) patients, and 45 (90.0%) would recommend it to a friend/relative.

CONCLUSIONS

Office-based operative hysteroscopy by the HTRS is successful and well tolerated by most women, especially for RPOC removal.

Association Between the Blood Glucose Value at PACU Discharge and Postoperative Hypoglycemia in Nondiabetic Patients With Hyperglycemia After Hysteroscopic Surgery: A Retrospective Cohort Study

PURPOSE

The target glycemic control for nondiabetic patients in the postanesthesia care unit (PACU) after hysteroscopic surgery remains unclear. Our goal is to determine the optimal level of glycemic control by finding the relationship between blood glucose level (BGL) leaving the PACU and postoperative hypoglycemia in nondiabetic patients.

DESIGN

This retrospective cohort study was conducted at a comprehensive tertiary hospital in Chongqing, China between June 2018 and December 2020.

METHODS

The target independent and dependent variables were BGL leaving the PACU and postoperative hypoglycemia, respectively. The primary outcome was the incidence of hypoglycemia. Logistic regression was used to explore the association between discharge BGL and hypoglycemia. The optimal glycemic control range was determined by using the receiver operating characteristic (ROC) curve.

FINDINGS

Prior to insulin use, BGL in the insulin-using subgroup might be as high as 20 mmol/L. Hypoglycemia was related to the BGL while leaving the PACU (odds ratio (OR) 0.37 [95% confidence interval (CI) 0.22 to 0.65]). The best cut-off value (12.95 mmol/L) was determined by fitting the ROC curve.

CONCLUSIONS

If severe hyperglycemia develops during hysteroscopic surgery in individuals with 5% glucose as the mediator of uterine distention, the recommendation is to maintain blood glucose above 12.95 mmol/L when treated with insulin.

Increasing utilization of intrauterine device insertion at hysteroscopic endometrial evaluation for patients with endometrial hyperplasia

PURPOSE

To examine the utilization and characteristics related to the use of hysteroscopy at the time of endometrial evaluation for endometrial hyperplasia in the outpatient surgery setting.

METHODS

This cross-sectional study queried the Healthcare Cost and Utilization Project's Nationwide Ambulatory Surgery Sample. The study population was 3218 patients with endometrial hyperplasia who underwent endometrial evaluation from January 2016 to December 2019. Performance and clinical characteristics of hysteroscopic endometrial evaluation were assessed with multivariable binary logistic regression models.

RESULTS

A total of 2654 (82.5%) patients had hysteroscopic endometrial tissue evaluation. Patients with postmenopausal bleeding, heavy menstrual bleeding, and polycystic ovary syndrome were more likely to undergo hysteroscopic endometrial evaluation in multivariable analysis (all, adjusted-P < 0.001). Uterine injury occurred in 4.9 per 1000 hysteroscopic endometrial evaluations; none had uterine injury in the non-hysteroscopy cohort. Among the 2654 patients who had hysteroscopic endometrial evaluation, 106 (4.0%) patients had intrauterine device insertion at surgery, and the utilization increased from 2.9 to 5.8% during the study period (P-trend < 0.001). Younger age, more recent year surgery, and obesity were independently associated with increased utilization of intrauterine device insertion at hysteroscopic endometrial evaluation (all, adjusted-P < 0.05). Among 2023 reproductive-age patients with endometrial hyperplasia, 1666 (82.4%) patients underwent hysteroscopic endometrial evaluation. On multivariable analysis, patients with heavy menstrual bleeding were more likely to have hysteroscopic endometrial evaluation (adjusted-P < 0.05). Intrauterine device insertion increased from 3.7% in 2016 to 8.0% in 2019 (P-trend = 0.007).

CONCLUSION

This nationwide analysis suggests that the insertion of intrauterine devices at the time of hysteroscopic endometrial tissue evaluation for endometrial hyperplasia is increasing among reproductive-age population.

Effectiveness of Manual Hysteroscopic Tissue Removal Device for Intrauterine Polyps in Infertile Women in Both Operating and Office Settings

Background: Mechanical hysteroscopic tissue removal (mHTR) systems are widely used for removing intrauterine pathology. Given the startup and procedural costs for electrically powered mechanical units, disposable manual mHTR systems have been developed. Methods: With little published, we describe its effectiveness for hysteroscopic intrauterine polypectomy. Results: One-hundred fifty-seven infertile women underwent hysteroscopic polypectomy with the manual mHTR device. Complete removal was accomplished in all but three cases, with blood loss being <10 mL and all specimens deemed sufficient for histopathologic diagnosis. Conclusions: These results suggest that the disposable manual mHTR system is effective in removing endometrial polyps. Head-to-head comparisons with other alternative technologies are needed.

Pain and anxiety management with virtual reality for office hysteroscopy: systemic review and meta-analysis

PURPOSE

Office hysteroscopy (OH) is a commonly performed procedure, although it might be associated with some degree of pain and anxiety. Our aim was to determine the effects of virtual reality on pain and anxiety levels felt by patients undergoing OH.

METHODS

MEDLINE, Embase, Google Scholar, Cochrane Library, clinicaltrials.gov, ProQuest, Grey literature, and manual searching of references within studies found in the initial search were systematically searched using the terms 'Virtual Reality' and 'Hysteroscopy' without time or language limitations. The review considered all studies assessing the impact of virtual reality (VR) over OH outcomes, and prospective randomized trials were included in the meta-analysis. Retrospective and case - control studies were excluded from the meta-analysis.

RESULTS

We identified 17 studies, of which four randomized controlled studies were included in the meta-analysis (327 participants, 168 in the VR group and 159 in the control group). On a 0-10 scale, pain sensation and maximal pain sensation during the operation were not statistically different between study and control groups (relative risk (RR) =  -0.64, 95% C.I (-1.57)0.29) and (RR = -0.93, 95% C.I (-3.33) - 1.47), respectively. Anxiety measurement was statistically lower in the study group (RR = -1.73, 95% C.I (-2.79) - ( -0.67)).

CONCLUSIONS

The available data suggest that VR techniques do not decrease the pain sensation during OH however, they do contribute to a reduction in the anxiety levels experienced by patients. PROSPERO registration number CRD42023432819.

Detection and Classification of Hysteroscopic Images Using Deep Learning

BACKGROUND

Although hysteroscopy with endometrial biopsy is the gold standard in the diagnosis of endometrial pathology, the gynecologist experience is crucial for a correct diagnosis. Deep learning (DL), as an artificial intelligence method, might help to overcome this limitation. Unfortunately, only preliminary findings are available, with the absence of studies evaluating the performance of DL models in identifying intrauterine lesions and the possible aid related to the inclusion of clinical factors in the model.

AIM

To develop a DL model as an automated tool for detecting and classifying endometrial pathologies from hysteroscopic images.

METHODS

A monocentric observational retrospective cohort study was performed by reviewing clinical records, electronic databases, and stored videos of hysteroscopies from consecutive patients with pathologically confirmed intrauterine lesions at our Center from January 2021 to May 2021. Retrieved hysteroscopic images were used to build a DL model for the classification and identification of intracavitary uterine lesions with or without the aid of clinical factors. Study outcomes were DL model diagnostic metrics in the classification and identification of intracavitary uterine lesions with and without the aid of clinical factors.

RESULTS

We reviewed 1500 images from 266 patients: 186 patients had benign focal lesions, 25 benign diffuse lesions, and 55 preneoplastic/neoplastic lesions. For both the classification and identification tasks, the best performance was achieved with the aid of clinical factors, with an overall precision of 80.11%, recall of 80.11%, specificity of 90.06%, F1 score of 80.11%, and accuracy of 86.74 for the classification task, and overall detection of 85.82%, precision of 93.12%, recall of 91.63%, and an F1 score of 92.37% for the identification task.

CONCLUSION

Our DL model achieved a low diagnostic performance in the detection and classification of intracavitary uterine lesions from hysteroscopic images. Although the best diagnostic performance was obtained with the aid of clinical data, such an improvement was slight.

Effect of Remimazolam Supplementation on Propofol Requirements During Hysteroscopy: A Double-Blind, Dose-Response Study

BACKGROUND

Propofol is commonly used for procedural sedation but may increase side effects in a dose-dependent manner. Remimazolam, an ultrashort-acting benzodiazepine, has been approved for procedural sedation but may delay awakening. This study tested the hypothesis that remimazolam as a supplement reduces effect-site propofol concentration (Ceprop) required to suppress response to cervical dilation in patients undergoing hysteroscopy.

METHODS

One hundred and fifty patients who were scheduled for hysteroscopy were randomized to receive 0, 0.05, 0.1, 0.15, or 0.2 mg·kg-1 intravenous remimazolam, followed by a bolus of sufentanil 0.15 μg⋅kg-1, and a target-controlled propofol infusion. The initial target Ceprop was 3.5 μg·mL-1 and was increased or decreased in subsequent patients by steps of 0.5 μg·mL-1 according to whether there was loss of response to cervical dilation in the previous patient. We used up-down sequential analysis to determine values of Ceprop that suppressed response to cervical dilation in 50% of patients (EC50).

RESULTS

The EC50 of propofol for suppressing response to cervical dilation was lower in patients given 0.1 mg·kg-1 (2.08 [95% confidence interval, CI, 1.88-2.28] μg·mL-1), 0.15 mg⋅kg-1 (1.83 [1.56-2.10] μg·mL-1), and 0.2 mg⋅kg-1 (1.43 [1.27-1.58] μg·mL-1) remimazolam than those given 0 mg⋅kg-1 (3.67 [3.49-3.86] μg·mL-1) or 0.05 mg⋅kg-1 (3.47 [3.28-3.67] μg·mL-1) remimazolam (all were P < .005). Remimazolam at doses of 0.1, 0.15, and 0.2 mg·kg-1 decreased EC50 of propofol by 43.3% (95% CI, 41.3%-45.5%), 50.3% (48.0%-52.8%), and 61.2% (58.7%-63.8%), respectively, from baseline (remimazolam 0 mg⋅kg-1). Propofol consumption was lower in patients given 0.1 mg⋅kg-1 (4.15 [3.51-5.44] mg·kg-1), 0.15 mg⋅kg-1 (3.54 [3.16-4.46] mg·kg-1), and 0.2 mg⋅kg-1 (2.74 [1.73-4.01] mg·kg-1) remimazolam than those given 0 mg⋅kg-1 (6.09 [4.99-7.35] mg·kg-1) remimazolam (all were P < .005). Time to anesthesia emergence did not differ significantly among the 5 groups.

CONCLUSIONS

For women undergoing hysteroscopic procedures, remimazolam at doses from 0.1 to 0.2 mg·kg-1 reduced the EC50 of propofol inhibiting response to cervical dilation and the total propofol requirement. Whether the combination could improve perioperative outcomes deserves further investigation.

Developing a Nomogram for Prioritizing Hysteroscopy in Endometrial Cancer Diagnosis: A Case-Control Study

(1) Background: The pandemic led to significant healthcare disruptions, resulting in postponed surgeries and extended waiting times for non-urgent treatments, including hysteroscopies essential for diagnosing endometrial cancer. This study aims to formulate a risk stratification model to enhance the prioritization of hysteroscopy procedures in Brazil; (2) Methods: A case-control study was conducted at Vila Santa Catarina Hospital in São Paulo, analyzing the medical records of 2103 women who underwent hysteroscopy between March 2019 and March 2022. We used bivariate analysis and multivariate linear regression to identify risk factors associated with endometrial cancer and formulate a nomogram; (3) Results: The findings revealed a 5.5% incidence of pre-invasive and invasive endometrial disease in the study population, with an average waiting time of 120 days for hysteroscopy procedures. The main risk factors identified were hypertension, diabetes, postmenopausal bleeding, and obesity; (4) Conclusions: This research highlights the urgent need for efficient prioritization of hysteroscopy procedures in the wake of the pandemic. The developed nomogram is an innovative tool for identifying patients at higher risk of endometrial cancer, thus facilitating timely diagnosis and treatment and improving overall patient outcomes in a strained healthcare system.

Does vaginal cleansing with iodine decreases infection rate in office hysteroscopy?

PURPOSE

To determine whether preoperative vaginal cleansing with iodine-based solution prior to hysteroscopy, reduces postoperative infection rate compared to no vaginal cleansing.

METHODS

A retrospective study at a single tertiary, university affiliated hospital of all individuals who have had an office hysteroscopy. Study group consisted of patients who have had preoperative vaginal cleansing with iodine-based solution and were compared to those who have not. Any procedural related complaints at the 30 days following the hysteroscopy were recorded.

RESULTS

A total of 505 were available for analysis, 183 in the study group and 322 in the control group. The most common indications for operation were infertility evaluation (33.9% vs. 28.6%) and retained products of conception (33.3% vs. 29.2%), and most common procedures were diagnostic only (49.7% vs. 42.5%) followed by adhesiolysis (12% vs. 14.3%). No statistical differences were noted with regards to postoperative infections, as only one case of pelvic inflammatory disease was noted, in the iodine cleansing group (0.19% for postoperative infection).

CONCLUSION

Our comparative study may suggest that the use of preoperative iodine solution prior to office hysteroscopy does not decrease the postoperative infection rate up to 30 days, thus can be avoided.

Post-Menopausal Bleeding: Role of Imaging

Post-menopausal bleeding (PMB) accounts for 5% of gynecologic office visits and is the presenting symptom in 90% of women with endometrial cancer, which requires prompt evaluation. The most common etiology of PMB is vaginal or endometrial atrophy and endometrial polyps, while endometrial hyperplasia and carcinoma account for less than 10% of PMB. Transvaginal ultrasonography measurement of an endometrial thickness (EMT) less than or equal to 4 mm has a 99% negative predictive value for endometrial carcinoma. Endometrial sampling is required if EMT >4 mm or persistent bleeding occurs. Further evaluation can be accomplished with saline infusion sonography, magnetic resonance imaging, and hysteroscopy.

FIGO best practice guidance in surgical consent

Obtaining medical consent preoperatively is one of the key steps in preparing for surgery, and is an important step in informed decision making with the patient. According to good medical practice guidelines, doctors are required to have the knowledge and skills to treat patients as well as inform them, respect their wishes, and establish trust between themselves and their patients. Valid consent includes elements of competence, disclosure, understanding, and voluntariness. Documentation of these elements is also very important. The International Federation of Gynecology and Obstetrics (FIGO) Education Communication and Advocacy Consortium (ECAC) has realized that the quality of consent varies considerably across the world and has developed simple guidelines regarding consent and procedure-specific checklists for the most common obstetric and gynecological procedures.

The Current Situation of Anaesthesia for Hysteroscopy in Mainland China: A National Survey

Purpose: The need for anaesthesia or analgesia for performing hysteroscopy remains debatable. This study aimed to conduct an overview of the situation of anaesthesia for hysteroscopy in mainland China. Methods: Two questionnaires were separately designed for anaesthesiologists and gynaecologists and distributed to every medical institution that performed hysteroscopic procedures on patients with infertility in mainland China. Electronic questionnaires were distributed via WeChat, and data on anaesthesia regimen, monitoring parameters, procedure number, and other information were collected. Results: Reproductive technology is conducted by 536 institutions in mainland China. The survey received 491 responses from anaesthetists (91.6%) and 436 from gynaecologists (81.3%). In 2021, 552,225 hysteroscopies were conducted in 268 medical centres. The average percentage of hysteroscopy under anaesthesia is 63.8% in 2021, wherein 47.3% of institutions have an anaesthesia percentage of >75%. Propofol and opioid analgesics, such as fentanyl and sufentanil, were the most commonly used intravenous anaesthetics. All sedations were performed by anaesthesiologists. Monitoring parameters included pulse oxygen saturation (98.9%), electrocardiogram (91.6%) and noninvasive blood pressure (91.3%). An anaesthesiologist-to-operating room ratio of <1 was observed in 31.3% of medical institutions. Surprisingly, 52.4% of medical institutions performing hysteroscopy had no postanaesthesia care unit (PACU). Most institutions with PACU were equipped with independent oxygen sources, suction and monitors. Both rigid and flexible hysteroscopes (rigid hysteroscope, 45.1%; flexible hysteroscope, 4.5%; both types, 50.4%) were used, and the hysteroscopic diameter was ≤5 mm in 60.3% of medical centres. Conclusions: China performs a large number of hysteroscopies, and sedation is the most frequently used anesthesia regimen. However, issues such as inadequate emergency support devices, insufficient personnel and weak resuscitation management after anaesthesia, have been observed.

Nurse support for pain and anxiety control in women undergoing diagnostic hysteroscopy: a randomized clinical trial

OBJECTIVE

The aim of the study is to evaluate the effectiveness of nurse support for controlling pain and anxiety in women undergoing diagnostic hysteroscopy.

METHODS

This randomized clinical trial included 192 women who underwent diagnostic hysteroscopy at an academic hospital. Women were divided into two groups: those who received nurse support (n = 95) as the intervention group and those who did not (n = 97) as the control group.

RESULTS

The mean age of women was 54.24 ± 13.91 years and 53.47 ± 13.24 years ( P = 0.670) in the intervention and control groups, respectively. There were no differences in clinical and sociodemographic variables between the groups. The mean pain score during examination was 6.62 ± 2.60 and 7.05 ± 2.30 ( P = 0.327) for the intervention and control groups, respectively. Most women in both groups were satisfied with the examination ( P = 0.777). There was a significant reduction in systolic blood pressure and heart rate during the examination in the intervention group ( P = 0.029 and P < 0.001, respectively) and an increase in anxiety scores in the control group ( P = 0.009).

CONCLUSIONS

There was no reduction in pain scores during hysteroscopy with nurse support. However, the control group showed an increase in anxiety scores after the hysteroscopy.

Nonsteroidal anti-inflammatory drug with a local anesthetic compared to nonsteroidal anti-inflammatory drug alone significantly reduce the pain associated with vaginoscopic office hysteroscopy

INTRODUCTION AND OBJECTIVES

Pain is the most common cause of office hysteroscopy (OH) failure. There is no consensus on alleviation of pain during OH. The aim was to compare the effectiveness of pain-relieving methods during OH.

STUDY DESIGN

A prospective randomized open-label trial included women subjected to OH. All women received 100 mg of ketoprofen intravenously pre-procedure. Women were randomly assigned to 3 arms: A) no local anesthesia, B) infiltration anesthesia with 20 ml of 1% lidocaine solution, C) paracervical block with 20 ml of 1% lidocaine solution. Karl Storz Bettocchi® rigid hysteroscope with a 5 mm operative sheath was used. Intensity of pain in numeric rating scale (NRS), intensity of cervical bleeding, frequency of vasovagal episodes, and failure rate were compared.

RESULTS

The study involved 201 women, 67 in each arm. NRS value during OH was higher in arm A than in B and C (6.3 vs. 5.1 vs. 5.0; p = 0.01). NRS value after OH did not differ and in all arms pain was imperceptible (p = 0.007). Cervical bleeding was more frequent in arm B than in A and C (76.1% vs. 33.4% vs. 35.9%; p < 0.0001), but its intensity did not differ from the other arms (p = 0.3). Vasovagal episode was most common in arm B (p = 0.048). There was no difference in the failure rate between the arms (p = 0.08).

CONCLUSIONS

The paracervical block, albeit technically the most laborious, has proven to be the most beneficial for the patient in terms of overall comfort and for the surgeon regarding feasibility.

Clinical outcomes in women with endometrial polyps underwent conservative management

OBJECTIVE

To evaluate the regression rate of endometrial polyps (EPs) in a cohort of asymmetric women after conservative follow-up.

MATERIALS AND METHODS

In this retrospective cohort study, a total of 1006 women with asymptomatic EPs were treated with expectant management or hormonal drugs between June 1999 and May 2018. Four hundred forty-eight women (44.5%) were administered with hormonal medications and 558 women were managed expectantly (55.5%). Office hysteroscopy was performed to confirm the diagnosis and regression of EPs. Hormonal administration included oral contraceptives, progestin and cyclic estrogen/progestin regimen according to physicians' preferences. Clinical characteristics, including the patient's age, body mass index, parity, and type of conservative management were collected.

RESULTS

The mean observation time was 14.1 ± 18.5 months (range, 1-162 months). The overall regression rate of EPs in this cohort was 33.5%, 24.6% occurred after medication and 8.9% after expectant management. Patient age (<50 years) (p < 0.001), follow-up period (p = 0.005) and hormonal drugs used (p < 0.001) were significantly associated with EP regression. Twenty-four (7.1%) of the 337 EP regression patients later developed recurrent disease. Follow-up period (p < 0.001) and hormonal drugs used (p = 0.032) were closely related to polyp recurrence after initial regression. Nevertheless, multivariate logistic regression analysis revealed that hormonal drugs used was significantly associated with the regression (p < 0.001) and recurrence (p = 0.016) of EPs.

CONCLUSION

Women aged 50 or less are more suitable for conservative treatment for EPs. Hormonal drugs used could increase the incidence of EP regression.

Is endometrial sampler SAP-1 a good way to diagnose the common intrauterine occupying lesions?-A diagnostic study

Background

Intrauterine occupying lesion is clinically common in the female reproductive organs. Endometrial cancer is the most critical one among intrauterine occupying lesions, which accordingly is considered as the main indication for endometrial cancer screening, for which endometrial sampler SAP-1 was recommended as an effective sampling tool.

Objective

This study aimed to evaluate the diagnostic efficacy of SAP-1 for endometrial polyp and uterine submucous myoma.

Materials and Methods

From August 2018 to June 2022, patients who were hospitalized for undergoing hysteroscopy examination were enrolled in this study. Before the procedure, endometrial samples were collected by the method of SAP-1. The histological results were compared with those by hysteroscopy sampling to analyze the diagnostic efficacy of SAP-1.

Results

The qualified rate for the SAP-1 sampling was 92.1%, which is a bit lower than that by method of hysteroscopy (95.3%). And the difference was not statistically significant (P > 0.05). Endometrial polyp (47.5%) and uterine submucous myoma (7.1%) accounted for the majority of endometrial lesions, while only 11.3% endometrial polyps (17/151) and 0% submucous myomas (0/23) were detected by SAP-1 sampling.

Conclusion

Endometrial sampler SAP-1 is not effective in detection of solid intrauterine lesions indicated by the imaging examination. Hysteroscopy is recommended for definite diagnosis.

Outpatient Hysteroscopic Polypectomy-A Retrospective Study Comparing Rigid and Semirigid Office Hysteroscopes

Endometrial polyps are one of the most common pathological conditions in gynecology. Hysteroscopy is the gold standard for the diagnosis and treatment of endometrial polyps. The purpose of this multicenter, retrospective study was to compare patients' pain perception during an operative hysteroscopic endometrial polypectomy in an outpatient setting with two different hysteroscopes (rigid and semirigid) and to identify some clinical and intraoperative characteristics that are related to worsening pain during the procedure. We included women that underwent, at the same time as an diagnostic hysteroscopy, the complete removal of an endometrial polyp (using the see-and-treat strategy) without any kind of analgesia. A total of 166 patients were enrolled, of which 102 patients underwent a polypectomy with a semirigid hysteroscope and 64 patients underwent the procedure with a rigid hysteroscope. No differences were found during the diagnostic step; on the contrary, after the operative procedure, a statistically significant greater degree of pain was reported when the semirigid hysteroscope was used. Cervical stenosis and menopausal status were risk factors for pain both in the diagnostic step and in the operative one. Our results confirm that operative hysteroscopic endometrial polypectomy in an outpatient setting is an effective, safe, and well-tolerated procedure and indicate that it might be better tolerated if a rigid rather than semirigid instrument is used.

Comparison of the effects of spinal anesthesia, paracervical block and general anesthesia on pain, nausea and vomiting, and analgesic requirements in diagnostic hysteroscopy: A non-randomized clinical trial

Background

The aim of this study was to compare the effect of spinal anesthesia (SPA), paracervical block (PB), and general anesthesia (GA), on pain, the frequency of nausea and vomiting and analgesic requirements in diagnostic hysteroscopy.

Methods

This single-center, non-randomized, parallel-group, clinical trial was conducted on 66 diagnostic hysteroscopy candidates who were selected by convenience sampling at Fatemieh Hospital, in Hamadan, Iran, in 2021.

Results

The mean pain score during recovery and the need for analgesic injections was found to be significantly higher in the GA group compared to that in the SPA group (pain: 3.77 ± 2.25 vs. 0.10 ± 0.30, P < 0.001), (analgesic: 50 vs. 0%, P < 0.001) and PB group (pain: 3.77 ± 2.25 vs. 0.90 ± 1.37, P < 0.001), (analgesic 50 vs. 10%, P < 0.001), respectively. However, no statistically significant difference was observed between the mean pain score between SPA and PB groups (0.10 ± 0.30 vs. 0.90 ± 1.3, P = 0.661). In addition, there were no significant differences between groups on nausea/vomiting after operation (P = 0.382). In adjusted regression analysis (adjusting for age, weight, gravid, abortion, and cause of hysteroscopy), the odds ratio (OR) of pain score during recovery was increased in PB (OR: 4.471, 95% CI: 1.527-6.156, P = 0.018) and GA (OR: 8.406, 95% CI: 2.421-9.195, P = 0.001) groups compared with the SPA group. However, in adjusting based on times of surgery duration, anesthesia duration, recovery and return of motor function, the ORs of pain score between groups was not statistically significant.

Conclusion

Despite reduced pain during recovery in patients receiving SPA, duration of anesthesia, recovery period, and return of motor function were significantly prolonged compared to those receiving PB or GA. It seems that PB with less recovery time and faster return of motor function than SPA and also mild pain during recovery compared to GA can be a good option for hysteroscopy.

Clinical trial registration

http://www.irct.ir, identifier IRCT20120915010841N26.

Fluorescence in situ hybridization test for detection of endometrial carcinoma cells by non-invasive vaginal swab

Endometrial cancer (EC) is the most common gynaecological malignancy with increasing incidence in developed countries. As gold standard, hysteroscopy confirms only 30% of suspected ECs. The detection of EC cells in the vagina by fluorescence in situ hybridization (FISH) after a smear test could reduce invasive procedures in the future. Using array-based comparative genome hybridization (aCGH) on 65 endometrial carcinomas, most frequently imbalanced regions of the tumour genome were identified. Bacterial artificial chromosomes were used to generate FISH-probes homologue to these human regions. The FISH test was hybridized on swabs specimens collected from the vaginal cavity. Samples from six patients without EC were selected as a negative control and on 13 patients with known EC as a positive control. To distinguish between benign and EC cases, the cut-off value has been defined. A first validation of this EC-FISH Test was performed with swabs from 41 patients with suspected EC. The most common genomic imbalances in EC are around the CTNNB1, FBXW7 and APC genes. The cut-off is defined at 32% of analysed cells without diploid signal pattern. This differs significantly between the positive and negative controls (p < 0.001). In a first validation cohort of 41 patients with suspected EC, the EC-FISH Test distinguishes patients with and without EC with a sensitivity of 91% and a specificity of 83%. The negative predictive value is 96%. This is the first report of a non-invasive EC-FISH Test to predict EC in women with suspected EC.

Massively parallel sequencing of endometrial lavage specimens for the detection of cancer-associated mutations in atypical and non-atypical endometrial hyperplasia

Background

Endometrial hyperplasia (EH), particularly with atypia, is considered an antecedent of endometrial adenocarcinoma. In this study, we aimed to apply massively parallel sequencing of endometrial lavage specimens for the detection of cancer-associated mutations in atypical (AEH) and non-atypical endometrial hyperplasia (NEH). The identified alterations were compared with those detected in tissue samples.

Materials and methods

Endometrial lavage specimens and parallel biopsy samples (n = 11 for AEH and n = 9 for NEH) were obtained from 18 women (9 with AEH and 9 with NEH) who received an office hysteroscopy for suspected endometrial lesions. All samples were tested for somatic mutations in hotspot regions of 72 cancer-associated genes by massively parallel sequencing.

Results

On analyzing sequencing data, the presence of at least one cancer-associated gene mutation was identified in 72.7 and 44.4% of endometrial lavage specimens obtained from women with AEH and NEH, respectively (p = 0.362, 95% confidence interval = 0.72-3.70). The concordance rates between mutations identified in endometrial lavage specimens and endometrial biopsies were 54.5 and 0% from women with AEH and NEH, respectively (p = 0.014). A patient with NEH harbored mutations in endometrial lavage with the same mutations found in the tissue specimen at low allele frequency below detection cutoff, raising the suspicion of missed focal atypia.

Conclusion

Endometrial hyperplasia is characterized by a high burden of cancer-associated mutations, particularly in the presence of atypia. Our study, albeit performed with a relatively small number of samples, indicates that their detection by massively parallel sequencing of endometrial lavage is feasible. Our findings may allow tailoring of endometrial biopsies to the individual risk of AEH; additionally, they can pave the way toward less invasive surveillance protocols in patients with known EH.

Vasovagal Syncope during Office Hysteroscopy—A Frequently Overlooked Unpleasant Complication

Due to technological advancements in miniaturization of instruments and improved optics, the number of office hysteroscopic procedures has increased over time. Office hysteroscopy is preferred due to avoidance of general anesthesia and decreased overall cost. Vasovagal syncope has been implied as the most common complication. Vasovagal syncope is associated with inappropriate reflex vasodilation and bradycardia in the setting of an acute malfunction between the autonomic nervous system and the cardiovascular system; however, there is no mortality associated with vasovagal syncope. A management strategy for acute vasovagal reflex during office hysteroscopy is proposed in order to manage this common complication.

Prospective Study Investigating Change in Carboxyhemoglobin Blood Level During Operative Hysteroscopy

STUDY OBJECTIVES

To evaluate whether the use of radiofrequency energy during resectoscopy leads to increases in patient blood levels of carboxyhemoglobin (COHb) and investigate procedural variables associated with these elevations.

DESIGN

A prospective cross-sectional study of 40 subjects undergoing a hysteroscopic procedure using bipolar radiofrequency energy.

SETTING, PATIENTS, AND INTERVENTIONS

The study was conducted at an ambulatory surgery center. Procedures for uterine leiomyoma, septa, products of conception, or a combination of these pathologies were included. We measured blood COHb levels before and immediately after the surgery. Abnormal postoperative COHb level was defined as an increase of plasma COHb ≥3.0%. All patients with abnormal postoperative levels were contacted and screened for carbon monoxide toxicity symptoms. Summary statistics included frequency for categorical variables and averages for continuous variables. p values were reported without modification.

MEASUREMENTS AND MAIN RESULTS

A total of 17.5% of subjects met the criteria for abnormal postoperative COHb levels. None of these subjects reported symptoms of carbon monoxide toxicity. One subject with an elevated postoperative COHb level had intraoperative hemodynamic changes possibly related to COHb elevation. An abnormal postoperative COHb level was associated with a higher fluid deficit (p = .024) and greater myoma volume (p = .04).

CONCLUSION

This study demonstrates that systemic absorption of carbon monoxide is a reproducible phenomenon in hysteroscopic resections using bipolar diathermy. Greater absorption is associated with a higher fluid deficit and greater myoma volume. Although none of the subjects with an abnormal increase screened positive for symptoms in the postoperative setting and only 1 experienced hemodynamic changes intraoperatively, our study looked at a healthy and young patient population. More research is needed on the safety of this COHb exposure in patients with medical comorbidities. Special consideration should be given to the possibility of carbon monoxide absorption and the uncertain long-term effects when planning extensive hysteroscopic resections.

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.

Towards less invasive molecular diagnostics for endometrial cancer: massively parallel sequencing of endometrial lavage specimens in women attending for an office hysteroscopy

We aimed to detect endometrial cancer (EC)-associated mutations in endometrial lavage specimens collected in an office setting and to compare the detected mutations with those identified in tissue samples. Participants included 16 women attending for an office hysteroscopy because of suspected EC between July 2020 and October 2021. Massively parallel sequencing was conducted using the targeted 72 cancer-associated genes. Endometrial lavage specimens, endometrial tissue samples, and blood samples were simultaneously sequenced to establish the concordance of genetic alterations. In this study, the vast majority of EC-associated mutations identified in lavage samples (R² = 0.948) were identical to those detected in endometrial tissues. Of the 13 patients with EC, 12 (92.3%) had at least one mutation identified in endometrial lavage samples. Notably, no mutations in lavage samples were identified in the two patients with a previous history of EC but no actual endometrial lesions, supporting a high negative predictive value of the test. A patient previously diagnosed with EC and with current evidence of atypical hyperplasia showed persisting PTEN, PIK3R1, and KRAS mutations in her endometrial lavage specimen. PTEN was the most commonly mutated gene, followed by PIK3R1, ARID1A, PIK3CA, CTNNB1, and KRAS. In conclusions, our study provides pilot evidence on the actionability of uterine lavage samples sequencing to detect EC-associated mutations in women with suspected endometrial lesions. In a precision medicine framework, the high mutational concordance between uterine lavage samples and tissue specimens may help inform less invasive diagnostic protocols and the need for ongoing surveillance in patients with EC who wished for fertility-preserving treatment. KEY MESSAGES: • Sequencing of uterine lavage samples collected by office hysteroscopy is feasible. • Most EC mutations identified in lavage were identical to endometrial tissues. • Sequencing of uterine lavage samples may help inform diagnostic protocols for EC. • This approach can be used for recurrence surveillance in patients with EC.

Symptom-related Ki-67 expression in endometrial polyps

OBJECTIVE

The aim of this study was to compare Ki-67 expression in endometrial polyps that present with different abnormal uterine bleeding patterns.

STUDY DESIGN

A total of 120 women diagnosed with endometrial polyps were included in the study. In this prospective study, tissue samples taken by hysteroscopic polypectomy method between September 2019 and September 2020 at Bursa City Hospital were examined. The main study groups were determined as premenopausal and postmenopausal patients. The patients' complaints at first admission to the hospital, demographic, histopathological and immunohistochemical features were recorded.

RESULTS

Ki-67 glandular and stromal expressions were higher in the premenopausal patient group (p = 0.016 and p = 0.005 respectively). Median Ki-67 gland and stroma measurements; was higher in patients with heavy menstrual bleeding (HMB) than in patients with intermenstrual bleeding (IMB), patients with postmenopausal bleeding (PMB), and patients who were asymptomatic [(p = 0.012, p = 0.011 and p = 0.009 respectively); (p < 0.001, p < 0.001 and p = 0.004 respectively)]. The median Ki-67 stroma measurement was found to be higher in the patient group whose complaint persisted after polypectomy (p = 0.034). In the estimation of response to treatment, the cut-off value for Ki-67 stromal expression was determined as ≤ 6%.

CONCLUSION

High Ki-67 expression in endometrial polyps is associated with HMB and may predict the continuation of abnormal uterine bleeding after polypectomy.

Endometrial Cancer Management in Young Women

Endometrial cancer (EC) rarely develops in young women. Most cases are associated with known risk factors: BMI > 30, history of Polycystic Ovary Syndrome (PCOs), and race differentiation. The molecular EC classification based on The Cancer Genome Atlas Research Network divides these heterogeneous cancers into four types: Polymerase Epsilon Mutation (POLE), Microsatellite Instability (MSI), Copy Number Low (CNL), and Copy Number High (CNH). This division was introduced to allow for early assessment of neoplastic changes and clinical management, including targeted therapies. The basic technique for imaging endometrium changes is transvaginal sonography. Hysteroscopy is the standard for obtaining endometrial material for histological evaluation. The MRI result permits assessment of the extent of EC cancer infiltration. In young women who want to preserve fertility, apart from surgery, conservative management is often implemented after strict selection based on clinical and pathological data. This pharmacological treatment involves the administration of progestogens MPA (medroxyprogesterone acetate) and MA (megestrol acetate). The use of metformin may increase the effectiveness of such treatment. An alternative option is to apply progestogens locally—via the levonorgestrel-releasing intrauterine device. In addition to pharmacological treatment, hysteroscopic resection may be used—part of the uterine muscle adjacent to the pathologically changed endometrium may also undergo resection. An alternative is the administration of estrogen receptor modulators (e.g., SERMs) or aromatase inhibitors, or GnRH agonists.

Executive Summary of the Uterine Cancer Evidence Review Conference

Evidence for uterine cancer prevention, diagnosis, and special issues from the Uterine Cancer Evidence Review Conference is summarized.

The Centers for Disease Control and Prevention recognized the need for educational materials for clinicians on the prevention and early diagnosis of gynecologic cancers. The American College of Obstetricians and Gynecologists convened a panel of experts in evidence review from the Society for Academic Specialists in General Obstetrics and Gynecology and content experts from the Society of Gynecologic Oncology to review relevant literature, best practices, and existing practice guidelines as a first step toward developing evidence-based educational materials for women's health care clinicians about uterine cancer. Panel members conducted structured literature reviews, which were then reviewed by other panel members and discussed at a virtual meeting of stakeholder professional and patient advocacy organizations in January 2021. This article is the evidence summary of the relevant literature and existing recommendations to guide clinicians in the prevention, early diagnosis, and special considerations of uterine cancer. Substantive knowledge gaps are noted and summarized to provide guidance for future research.

Diagnostic office hysteroscopy; why is it still painful procedure despite the surgical experience and mini-hysteroscope?

AIM

To evaluate the effect of cervical canal features on pain during outpatient hysteroscopy performed by experienced surgeons using mini-hysteroscope.

METHODS

A prospective observational study was conducted on 303 women undergoing diagnostic hysteroscopy without anesthesia. Pain intensity was evaluated using the visual analog scale (VAS) when the cervical canal was passed. The patients were divided into two groups according to the VAS score: painless or mild pain (VAS <4) and moderate or severe pain (VAS ≥ 4). The relationship between cervical canal characteristics (length, version, and flexion positions, history of cervical intervention, stenosis, synechiae), obstetric and gynecological history, preoperative anxiety level, procedure duration, and pain intensity was examined.

RESULTS

Moderate pain (4 ≤ VAS < 7) was observed in 38% of patients (n = 117) and 14 patients (5%) experienced severe pain (VAS ≥ 7). In multivariate analysis, nulliparity (p = 0.01; OR, 4.6; 95% CI, 1.7-13.2), postmenopausal state (p = 0.02; OR, 2.2; 95% CI, 1.2-4.3), excessive flexion of the cervix and retroverted uterus (p <0.001; OR, 4.1; 95% CI, 2.0-8.5) were identified as risk factors for a painful procedure. Diagnostic hysteroscopy was successful in 98% of the patients. The pain was the primary cause of the failed hysteroscopy.

CONCLUSION

In addition to nulliparity and postmenopausal status, unfavorable features of the cervical canal, such as the excessive flexion position of the cervix and uterine retroversion are significant causes of pain during outpatient hysteroscopy.

Endometrial Sampling for Preoperative Diagnosis of Uterine Leiomyosarcoma

STUDY OBJECTIVES

To examine the effectiveness of endometrial sampling for preoperative detection of uterine leiomyosarcoma in women undergoing hysterectomy, identify factors associated with missed diagnosis, and compare the outcomes of patients who had a preoperative diagnosis with those of patients who had a missed diagnosis.

DESIGN

Retrospective cohort study using linked data from the New York Statewide Planning and Research Cooperative System and New York State Cancer Registry from 2003 to 2015.

SETTING

Inpatient and outpatient encounters at civilian hospitals and ambulatory surgery centers in New York State.

PATIENTS

Women with uterine leiomyosarcoma who underwent a hysterectomy and a preoperative endometrial sampling within 90 days before the hysterectomy.

INTERVENTIONS

Endometrial sampling.

MEASUREMENTS AND MAIN RESULTS

A total of 79 patients with uterine leiomyosarcoma met the sample eligibility criteria. Of these patients, 46 (58.2%) were diagnosed preoperatively, and 33 (41.8%) were diagnosed postoperatively. Patients in the 2 groups did not differ significantly in age, race/ethnicity, bleeding symptoms, or comorbidities assessed. In multivariable regression analysis, women who had endometrial sampling performed with hysteroscopy (compared with women who had endeometrial sampling performed without hysteroscopy) had a higher likelihood of preoperative diagnosis (adjusted risk ratio [aRR] 3.03; 95% confidence interval [CI], 1.43-6.42). Patients with localized stage (vs distant stage) or tumor size >11 cm (vs <8 cm) were less likely to be diagnosed preoperatively (aRR 0.50; 95% CI, 0.28-0.89, and aRR 0.54; 95% CI, 0.30-0.99, respectively). Supracervical hysterectomy was not performed in any of the patients whose leiomyosarcoma was diagnosed preoperatively compared with 21.2% of the patients who were diagnosed postoperatively (p = .002).

CONCLUSION

Endometrial sampling detected leiomyosarcoma preoperatively in 58.2% of the patients. The use of hysteroscopy with endometrial sampling improved preoperative detection of leiomyosarcoma by threefold. Patients with a missed diagnosis had a higher risk of undergoing suboptimal surgical management at the time of their index surgery.

Office Versus Institutional Operative Hysteroscopy: An economic model

STUDY OBJECTIVE

Model and compare estimated health system costs and gynecologic practice revenues when hysteroscopic surgery is performed in the office or institutional setting, either an ambulatory surgical center (ASC) or a traditional operating room (OR) Design: Economic modeling exercise Setting, Patients and Interventions: Non-clinical Measurements and Main Results: An economic model was developed that included US reimbursement rates for the office and institutional settings as well as the inherent expenses required for office hysteroscopic surgery. For CPT Code 58558, hysteroscopic biopsy and/or polypectomy, total health system costs were estimated as follows: Office, $1,382.48; ASC, $1,655.31; OR $2,918.10. In the modeled office setting, costs for the same procedure were estimated from instrumentation and supply list prices obtained from vendors and staffing costs from national databases. Revenue and cost modeling were performed and compared both for one to ten monthly procedure volumes and by hysteroscopic systems, while other elements of the procedure were standardized, including technique, staffing, generic supplies, and the use of local anesthesia. Four vendors provided system price information; one purpose built, one electromechanical, and two traditional. The projected office-based, per-case net revenue with the purpose-built system was always greater than in the ASC or OR, and relatively independent of monthly procedure volume (1 per month $743.59; 10 per month $876.17). For the traditional and electromechanical systems, it took from 2 to 5 monthly procedures to realize a net revenue greater than $239.39. Using 3 sets of vendor matched instruments, at 10 cases per month, the per case net revenue for the electromechanical system was $514.00, and for the two traditional systems $564.02 and $693.72.

CONCLUSION

Performance of office-based hysteroscopic surgery is associated with reduced health system costs when compared to the institutional environment. The net revenue for the practice was dependent on both the volume of procedures performed and the hysteroscopic system and technique selected.

Diagnostic Accuracy of Hysteroscopic Scoring System in Predicting Endometrial Malignancy and Atypical Endometrial Hyperplasia

Aims and Objectives:

The aim of this study was to determine the diagnostic accuracy of a hysteroscopic scoring system in predicting endometrial cancer and endometrial hyperplasia with atypia.

Materials and Methods:

This is a prospective study involving 95 peri and postmenopausal women with abnormal uterine bleeding who underwent hysteroscopic-guided endometrial biopsy. After the calculation of hysteroscopic score, biopsy was obtained and sent for histopathological examination. Hysteroscopic diagnosis of carcinoma endometrium was made when the total score was ≥16 and a score ≥7 supported a diagnosis of endometrial hyperplasia with atypia.

Results:

Out of the 95 women, 46 (48.4%) women had postmenopausal bleeding. The mean age of women was 50.4 ± 10.3 years. Eight women were diagnosed to have endometrial cancer and eight had endometrial hyperplasia with atypia on histopathological examination. Using a hysteroscopy score ≥16, the sensitivity and specificity were found to be 62.5% and 90.8%, respectively, for diagnosing endometrial cancer. Hysteroscopy score ≥9 was found to be a better cutoff for diagnosing endometrial cancer using Youden index. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for diagnosing endometrial cancer with score ≥9 was 100%, 67.8%, 22.2%, and 100%, respectively. The sensitivity, specificity, PPV, and NPV for diagnosing endometrial hyperplasia with atypia with score ≥7 was found to be 75%, 58.6%, 14.3%, and 96.2%, respectively.

Conclusion:

The hysteroscopic scoring system has a good diagnostic performance when a cutoff score ≥9 is used in predicting endometrial cancer. However, the scoring system has lower diagnostic accuracy in predicting endometrial hyperplasia with atypia.

Correlation of Metabolic Factors with Endometrial Atypical Hyperplasia and Endometrial Cancer: Development and Assessment of a New Predictive Nomogram

Purpose

This study aimed to investigate the association of metabolic factors with endometrial atypical hyperplasia and endometrial cancer, and to develop a nomogram model to predict the risk of developing endometrial cancer.

Patients and Methods

We collected data of patients with endometrial atypical hyperplasia and endometrial cancer as the case group and then selected patients with simple hyperplasia or polypoid hyperplasia of the endometrium during the same period as the control group using the age-matched method. Laboratory results of metabolic factors were retrieved from the clinical data of the two groups of patients. Multivariable logistic regression analysis was used to determine the risk factors associated with endometrial malignant hyperplasia and to develop a nomogram prediction model of risk factors associated with endometrial malignant hyperplasia. Discrimination, calibration, and clinical usefulness of the prediction model were assessed using the C-index, calibration plot, and decision curve analysis.

Results

Predictors included in the column line graph model were age, hypertension, diabetes, BMI, uric acid, and hyperlipidemia. We calculated the C-index of the model and performed bootstrap validation. Our nomogram model had good discriminatory power and was well calibrated. Decision curve analysis was also used to guide the practical application of this column line graph model.

Conclusion

The development of endometrial malignant hyperplasia is significantly associated with metabolic factors: BMI > 25, hyperuricemia, and hyperlipidemia are the main risk factors. Hypertension, hyperglycemia and elevated CA199 were also associated with the development of endometrial malignant hyperplasia. The nomogram prediction model based on physical examination and laboratory testing developed in this study can be used as a rapid method for predicting the risk of endometrial malignancy development and screening for risk factors in a population of women with metabolism-related high-risk factors.

Comparison between 200 μg and 800 μg of vaginal misoprostol for cervical ripening before operative hysteroscopy: A randomized controlled trial

OBJECTIVE

To compare between 200 and 800 μg of vaginal misoprostol for cervical ripening before operative hysteroscopy.

METHODS

Quadruple-blind randomized clinical trial conducted between November 2019 and September 2020 involving 76 patients undergoing cervical dilatation before surgical hysteroscopy at teaching hospitals in Pernambuco, Brazil. Women received the vaginal misoprostol dosage of 200 or 800 μg,10-12 h before operative hysteroscopy. The cervical width was the primary outcome, and secondary outcomes were patient satisfaction, adverse effects, surgical complications, and duration of cervical dilatation. Chi-square tests of association, Fisher's exact and Mann-Whitney U tests were used with an α error of <5%.

RESULTS

There was no statistical difference between the groups in the mean of the cervical width (800 μg: 6.5 ± 1.6 mm vs 200 μg: 5.8 ± 1.8 mm, P = 0.055), patient satisfaction, and surgical findings, but the duration of cervical dilatation was lower in the 800-μg group (28.16 ± 28.5 s vs 41.97 ± 31.0 s, P = 0.035). Among the adverse effects, diarrhea was more frequent in the 800-μg group with statistical difference (100% vs 0%; P = 0.01).

CONCLUSION

For cervical ripening, 200 μg misoprostol is equally effective with fewer adverse effects than 800 μg before operative hysteroscopy. ClinicalTrials.gov: NCT04152317. https://clinicaltrials.gov/ct2/show/NCT04152317.

Simplification of Vaginoscopic Surgery Using a Self-Retaining External Vulvar Sheet (Darwish sheet)

Objective

One of the main difficulties of vaginoscopy is continuous leakage of distension medium from the introitus hindering proper visualization. This study evaluates the effectiveness and success of performing diagnostic or operative vaginoscopic surgery via a tight self-retaining external vulvar sheet (Darwish sheet) expressed as tight vaginoscopy (TV) compared with conventional vaginoscopy (CV).

Patients and Methods

Females referred for vaginoscopy were initially examined by diagnostic CV followed by TV, and whenever indicated, operative TV via Darwish sheet was performed.

Results

Diagnostic TV was more feasible with excellent visualization if compared with CV. The mean infused distension fluid volume was 325 ml versus 485 ml, and the mean leaked fluid volume was 37 ml versus 94 ml in diagnostic TV versus CV, respectively. Operative TV via Darwish sheet was done in 21 cases (56.7%) that required surgery with 100% success rate without any reported complications.

Conclusions

Accomplishing vulvar tightness using a cheap self-retaining external vulvar sheet (Darwish sheet) during vaginoscopy (TV) is associated with a clearer visualization of vagina or cervix, a lesser amount of irrigating fluid and lesser leakage as compared with CV.

Postoperative Streptococcus constellatus Bacteremia in a 75-Year-Old Patient with Pyometra: A Case Report

Patient: Female, 75-year-old

Final Diagnosis: Bacteremia • pyometra

Symptoms: Fever • vaginal discharge

Medication: —

Clinical Procedure: Curettage • drainage

Specialty: Infectious Diseases • Obstetrics and Gynecology

Atypical vessels in hysteroscopy: Usefulness in prediction of malignant diseases in patients treated with tamoxifen

AIM

Tamoxifen (TAM) is widely used in adjuvant endocrine therapy for invasive breast cancer as a selective estrogen modulator, but this treatment has a risk of developing endometrial malignancy. However, hysteroscopic findings during or after TAM treatment are unclear. The aim of this study is to examine the association between hysteroscopic patterns and malignant histological findings during or after treatment with TAM.

METHODS

The subjects were patients who received TAM after surgery for breast cancer and underwent hysteroscopy at our institution from January 2016 to December 2019. Clinicopathological factors and hysteroscopic findings were collected from medical records and investigated retrospectively. Histologically, atypical endometrial hyperplasia, endometrial cancer, and carcinosarcoma were classified as malignant diseases.

RESULTS

A total of 26 patients were eligible for the study. Hysteroscopic findings included an irregular surface of the endometrium (n = 3, 11.5%), atypical vessels (n = 10, 38.5%), papillary structure (n = 3, 11.5%), and polypoid structure (n = 18, 69.2%). Histological examination revealed malignancy in six patients (23.0%). The percentage of atypical vessels in patients with malignancies was significantly higher than that in patients with a normal endometrium or benign lesion (100% vs. 20%, p = 0.0009). The sensitivity and specificity of atypical vessels in hysteroscopy for diagnosis of malignant diseases were 100% and 80%, respectively.

CONCLUSIONS

Hysteroscopic findings of atypical vessels may be useful for prediction of malignant diseases in patients treated with TAM.

Sepsis following hysteroscopic myomectomy

Hysteroscopy and hysteroscopic myomectomy in general have low complication rates. Two patients underwent hysteroscopic myomectomy for prolapsing submucous myomas after UAE. The onset of prolapsing myoma occurred at varying times between completion of UAE and myomectomy, resulting in bacteremia for both patients. In Case 1, the patient recovered with intravenous antibiotic treatment. However, the patient in Case 2 had status improvement after undergoing an abdominal myomectomy, explorative laparotomy for removal of a necrotic myoma. Our two patient cases serve as a caution to clinicians regarding the rare incidence of septicemia occurring in patients undergoing hysteroscopic myomectomy with prior UAE treatment for prolapsing myomas.