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van Maldegem LDPR, van der Zande JA, van Werkhoven LA, Ewing‐Graham PC, Heemskerk‐Gerritsen BAM, van Doorn HC. Recurrent postmenopausal bleeding: Pathological findings and predictive factors. A multicenter, prospective, observational study. Acta Obstet Gynecol Scand 2024; 103:1283-1291. [PMID: 38695570 PMCID: PMC11168275 DOI: 10.1111/aogs.14851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 06/13/2024]
Abstract
INTRODUCTION Recurrent postmenopausal bleeding (PMB) occurs in 6%-25% of postmenopausal women who have experienced a previous episode of PMB. The question of whether recurrent PMB leads to a higher risk of endometrial cancer (EC) in comparison to a single episode of PMB is, however, controversial. Furthermore, little is known about predictive factors for recurrent PMB. MATERIAL AND METHODS A multicenter prospective cohort study was conducted over a 5-year period in four hospitals in the Netherlands. Women with PMB undergoing endometrial sampling and aged 40 years and older were included. Occurrence of recurrent PMB was retrospectively determined. Primary outcomes included (1) the incidence of recurrent PMB and (2) differences in pathological findings between patients with a single episode vs recurrent PMB. Secondary outcomes included (1) the association between diagnosis of benign polyps at first PMB and pathological findings at recurrent PMB and (2) factors predictive for recurrent PMB. RESULTS A total of 437 women with PMB were included, of whom 360 were at risk of recurrent PMB. With a median follow-up of 61 months (IQR (Interquartile range) 44-73), 26.4% experienced recurrent PMB. Patients with recurrent PMB were more often diagnosed with benign polyps (34.7% vs. 25.1%, p-value 0.015) and less frequently with a malignancy (5.3% vs. 17.8%, p-value 0.015), compared to patients with a single episode of PMB. Benign polyps at initial PMB were not associated with a (pre)malignancy at recurrence (OR 4.16, 95% CI 0.75-23.03). Predictive factors for recurrent PMB included use of hormone replacement therapy (HRT) (OR 3.32, 95% CI 1.64-6.72), and benign polyps at initial PMB (OR 1.80, 95% CI 1.07-3.04). CONCLUSIONS Recurrent PMB is common in women with a previous episode of PMB. Compared to patients with a single episode of PMB, patients with recurrent PMB and benign histological outcomes at accurate workup during their first episode were less often diagnosed with malignancies and more frequently with benign polyps. Benign polyps at first PMB are predictive for recurrent PMB, but not for a higher risk of (pre)malignancy.
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Affiliation(s)
- Laura D. P. R. van Maldegem
- Department of Gynecologic OncologyErasmus MC Cancer Institute, University Medical Center RotterdamRotterdamthe Netherlands
| | - Johanna A. van der Zande
- Department of Gynecologic OncologyErasmus MC Cancer Institute, University Medical Center RotterdamRotterdamthe Netherlands
| | - Lucy A. van Werkhoven
- Department of Gynecologic OncologyErasmus MC Cancer Institute, University Medical Center RotterdamRotterdamthe Netherlands
| | - Patricia C. Ewing‐Graham
- Department of PathologyErasmus MC Cancer Institute, University Medical Center RotterdamRotterdamthe Netherlands
| | | | - Helena C. van Doorn
- Department of Gynecologic OncologyErasmus MC Cancer Institute, University Medical Center RotterdamRotterdamthe Netherlands
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Manley K, Hillard T, Clark J, Kumar G, Morrison J, Hamoda H, Barber K, Holloway D, Middleton B, Oyston M, Pickering M, Sassarini J, Williams N. Management of unscheduled bleeding on HRT: A joint guideline on behalf of the British Menopause Society, Royal College Obstetricians and Gynaecologists, British Gynaecological Cancer Society, British Society for Gynaecological Endoscopy, Faculty of Sexual and Reproductive Health, Royal College of General Practitioners and Getting it Right First Time. Post Reprod Health 2024; 30:95-116. [PMID: 38743767 DOI: 10.1177/20533691241254413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Unscheduled bleeding on hormone replacement therapy (HRT) can affect up to 40% of users. In parallel with the increase in HRT prescribing in the UK, there has been an associated increase in referrals to the urgent suspicion of cancer pathway for unscheduled bleeding. On behalf of the British Menopause Society (BMS) an expert review panel was established, including primary and secondary care clinicians with expertise in the management of menopause, with representatives from key related organisations, including the Royal College of Obstetricians & Gynaecologists, the British Gynaecological Cancer Society, British Society for Gynaecological Endoscopy, Royal College of General Practitioners and Faculty of Sexual and Reproductive Health, and service development partners from NHS England and GIRFT (Getting it Right First Time). For each topic, a focused literature review was completed to develop evidence led recommendations, where available, which were ratified by consensus review within the panel and by guideline groups.
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Affiliation(s)
- Kristyn Manley
- Department of Gynaecology, University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, UK
| | - Timothy Hillard
- Department of Gynaecology, University Hospitals Dorset NHS Trust, Poole, UK
- British Menopause Society, Marlow, UK
| | - Justin Clark
- Department of Gynaecology, Birmingham Women's Hospital, Birmingham, UK
- British Gynaecological Endoscopy Society, London, UK
| | - Geeta Kumar
- Department of Gynaecology, Betsi Cadwaladr University Health Board, Wales, UK
- Royal College of Obstetricians and Gynaecologists, London, UK
| | - Jo Morrison
- Department of Gynaecological Oncology, Musgrove Park Hospital, Taunton, UK
- British Gynaecological Cancer Society, Bangor, UK
| | - Haitham Hamoda
- British Menopause Society, Marlow, UK
- Department of Gynaecology, King's College Hospital, London, UK
| | - Katie Barber
- British Menopause Society, Marlow, UK
- Primary Care Physician, Oxford, UK
| | - Debra Holloway
- Department of Gynaecology, Guys and St Thomas' Hospital, London, UK
| | - Bronwyn Middleton
- Department of Gynaecology, University Hospitals Sussex NHS Trust, Worthing, UK
| | - Maria Oyston
- NHS England Elective Recovery and Transformation Team, London, UK
| | - Mark Pickering
- Department of Gynaecology, University Hospitals Dorset NHS Trust, Poole, UK
| | - Jenifer Sassarini
- Department of Gynaecology, NHS Greater Glasgow and Clyde, Glasgow, UK
- Scottish Menopause Network, Glasgow, UK
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Talwar S, Kaur H, Tapasvi I, Nibhoria S, Tapasvi C. Clinical and Histopathological Characteristics in Women With Postmenopausal Bleeding: A Study of 120 Women in a Tertiary Care Hospital in Punjab. Cureus 2024; 16:e51690. [PMID: 38313886 PMCID: PMC10838394 DOI: 10.7759/cureus.51690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 02/06/2024] Open
Abstract
Background Postmenopausal bleeding (PMB) is defined as blood loss from the genital tract occurring 12 months or more after an individual's last menstrual period. It is important for women to recognize abnormal symptoms during menopause, with PMB being one of the most critical. PMB is a common clinical presentation and can be indicative of endometrial carcinoma. A thorough clinical assessment and endometrial histopathology can ensure early diagnosis and treatment of malignancy in high-risk patients. Materials and Methods This study included 120 women with PMB. Their clinical and histopathological characteristics were studied, and correlations between the characteristics were investigated. Patients were evaluated according to their age, parity, duration of menopause, and socioeconomic status. Various comorbidities such as diabetes mellitus, hypertension, and obesity were noted. Results The patients ranged in age from 45 to 80 years, with a mean age of 54.97 ± 5.86 years. Fifty-nine (49.16%) of the patients presented with PMB within 3 years of menopause. PMB was seen most commonly in patients with parity 3, accounting for 37 (30.83%) of the cases. Endometrial thickness was increased in 100 (83.33%) cases. The most common causes of PMB were simple hyperplasia without atypia (SHWOA) in 36 (36%) patients and atrophic endometrium in 14 (14%) patients. Twelve (10%) of the patients had endometrial carcinoma. Benign causes of PMB were present in 91 (75.3%) cases, whereas 29 (24.1%) had a malignant cause. Weakly positive, but significant correlations (P < 0.05) were seen between the development of malignancy and increasing age (Pearson correlation coefficient, r = 0.263) parity (r = 0.244), and body mass index (r = 0.272). Conclusions PMB is considered abnormal. Benign causes are more common, but malignant causes are possible. In the current study, endometrial carcinoma was the most common malignant cause of PMB. Endometrial carcinoma incidence increased with greater endometrial thickness and more years since menopause. Histopathological examination remains the criterion standard for the correct diagnosis. Initiatives are recommended for increasing awareness about PMB to support prompt medical attention for a better prognosis.
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Affiliation(s)
- Shailja Talwar
- Department of Obstetrics and Gynecology, Community Health Center, Khamanon, IND
| | - Harpreet Kaur
- Department of Obstetrics and Gynecology, Guru Gobind Singh Medical College and Hospital, Faridkot, IND
| | - Isha Tapasvi
- Department of Obstetrics and Gynecology, Guru Gobind Singh Medical College and Hospital, Faridkot, IND
| | - Sarita Nibhoria
- Department of Pathology, Guru Gobind Singh Medical College and Hospital, Faridkot, IND
| | - Chaitanya Tapasvi
- Department of Radiodiagnosis, Guru Gobind Singh Medical College and Hospital, Faridkot, IND
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Maruyama N, Fukunaga I, Kogo T, Endo T, Fujii W, Kanai-Azuma M, Naito K, Sugiura K. Accumulation of senescent cells in the stroma of aged mouse ovary. J Reprod Dev 2023; 69:328-336. [PMID: 37926520 PMCID: PMC10721854 DOI: 10.1262/jrd.2023-021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 10/05/2023] [Indexed: 11/07/2023] Open
Abstract
Senescent cells play a detrimental role in age-associated pathogenesis by producing factors involved in senescence-associated secretory phenotype (SASP). The present study was conducted to examine the possibility that senescent cells are present in aged ovaries and, if so, to determine the tissue region where senescent cells accumulate using a mouse model. Female mice at 2-4 and 8-10 months were used as reproductively young and aged models, respectively; the latter included mice with and without reproductive experience. Cells positive for senescence-associated β-galactosidase (SA-β-Gal) staining, one of the markers of cellular senescence, were detected in the stromal region of aged, but not young, ovaries regardless of reproductive experience. Likewise, the localization of cells expressing CDKN2A (cyclin dependent kinase inhibitor 2A), another senescence marker, in the stromal region of aged ovaries was detected with immunohistochemistry. CDKN2A expression detected by western blotting was significantly higher in the ovaries of aged mice with reproductive experience than in those without the experience. Moreover, cells positive for both γH2AX (a senescence marker) and fluorescent SA-β-Gal staining were present in those isolated from aged ovaries. In addition, the transcript levels of several SASP factors were significantly increased in aged ovaries. These results suggest that senescent cells accumulate in the ovarian stroma and may affect ovarian function in aged mice. Additionally, reproductive experience may promote accumulation.
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Affiliation(s)
- Natsumi Maruyama
- Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
| | - Isuzu Fukunaga
- Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
| | - Tomoaki Kogo
- Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
| | - Tsutomu Endo
- Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
- Department of Experimental Animal Model for Human Disease, Center for Experimental Animals, Tokyo Medical and Dental University, Tokyo, Japan
| | - Wataru Fujii
- Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
- Present address: Department of Veterinary Medical Science, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
| | - Masami Kanai-Azuma
- Department of Experimental Animal Model for Human Disease, Center for Experimental Animals, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kunihiko Naito
- Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
| | - Koji Sugiura
- Department of Animal Resource Sciences, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo, Japan
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Blix K, Laake I, Juvet L, Robertson AH, Caspersen IH, Mjaaland S, Skodvin SN, Magnus P, Feiring B, Trogstad L. Unexpected vaginal bleeding and COVID-19 vaccination in nonmenstruating women. SCIENCE ADVANCES 2023; 9:eadg1391. [PMID: 37738335 PMCID: PMC10516485 DOI: 10.1126/sciadv.adg1391] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 08/16/2023] [Indexed: 09/24/2023]
Abstract
The association between coronavirus disease 2019 (COVID-19) vaccination and vaginal bleeding among nonmenstruating women is not well studied. The Norwegian Institute of Public Health followed several cohorts throughout the pandemic and early performed a systematic data collection of self-reported unexpected vaginal bleeding in nonmenstruating women. Among 7725 postmenopausal women, 7148 perimenopausal women, and 7052 premenopausal women, 3.3, 14.1, and 13.1% experienced unexpected vaginal bleeding during a period of 8 to 9 months, respectively. In postmenopausal women, the risk of unexpected vaginal bleeding (i.e., postmenopausal bleeding) in the 4 weeks after COVID-19 vaccination was increased two- to threefold, compared to a prevaccination period. The corresponding risk of unexpected vaginal bleeding after vaccination was increased three- to fivefold in both nonmenstruating peri- and premenopausal women. In the premenopausal women, Spikevax was associated with at 32% increased risk as compared to Comirnaty. Our results must be confirmed in future studies.
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Affiliation(s)
- Kristine Blix
- Department of Method Development and Analytics, Norwegian Institute of Public Health, Oslo, Norway
| | - Ida Laake
- Department of Method Development and Analytics, Norwegian Institute of Public Health, Oslo, Norway
| | - Lene Juvet
- Department of Infection Control and Vaccines, Norwegian Institute of Public Health, Oslo, Norway
| | - Anna Hayman Robertson
- Department of Method Development and Analytics, Norwegian Institute of Public Health, Oslo, Norway
| | | | - Siri Mjaaland
- Department of Method Development and Analytics, Norwegian Institute of Public Health, Oslo, Norway
| | - Siri N. Skodvin
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Per Magnus
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Berit Feiring
- Department of Method Development and Analytics, Norwegian Institute of Public Health, Oslo, Norway
| | - Lill Trogstad
- Department of Method Development and Analytics, Norwegian Institute of Public Health, Oslo, Norway
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6
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Wang C, Li J, Liu W, Li S, Zhang Y, Jin Y, Cui J. Comprehensive analysis and experimental validation reveal elevated CLCN4 is a promising biomarker in endometrial cancer. Aging (Albany NY) 2023; 15:8744-8769. [PMID: 37671947 PMCID: PMC10522378 DOI: 10.18632/aging.204994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 07/25/2023] [Indexed: 09/07/2023]
Abstract
Several studies have reported the role of CLCN4 in tumor progression. However, its mechanism remains to be thoroughly studied. The objective of this study was to explore the potential pathogenic role of CLCN4 in endometrial carcinoma (UCEC) with a better understanding of the pathological mechanisms involved. The potential roles of CLCN4 in different tumors were explored based on The Cancer Genome Atlas (TCGA), the expression difference, mutation, survival, pathological stage, Immunity subtypes, Immune infiltration, tumor microenvironment (TME), tumor mutation burden (TMB), microsatellite instability (MSI), mismatch repair (MMR) related to CLCN4 were analyzed. Then, the expression, prognosis, mutation, and functional enrichment of CLCN4 in UCEC were analyzed. Immunohistochemical experiment was used to verify the expression of CLCN4 in endometrial cancer tissues and normal tissues. In vitro, we knocked down of CLCN4 in HEC-1-A cells and performed CCK8, WB, RT-PCR, wound-healing, transwell assays to further validation of the molecular function. Results revealed that high expression of CLCN4 was observed in 20 cancer types of TCGA. CLCN4 expression correlates with poor survival in MESO, BLCA, THCA, especially UCEC tumors. CLCN4 expression was significantly associated with CD4+ T-cell infiltration, especially CD4+ Th1-cell. Immunohistochemical experiment reveals that CLCN4 is high expressed in endometrial tumors, in vitro experiment reveals that knockdown of CLCN4 inhibits the cells proliferation, migration and invasion. Our study is the first to offer a comprehensive understanding of the oncogenic roles of CLCN4 on different tumors. CLCN4 may become a potential biomarker in UCEC.
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Affiliation(s)
- Chenyang Wang
- Department of Gynecology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, China
- Academy of Medical Sciences, Zhengzhou University, Zhengzhou 450000, China
| | - Jing Li
- Department of Gynecology, Qingdao Hospital, University of Health and Rehabilitation Sciences (Qingdao Municipal Hospital), Qingdao, Shandong 266000, China
| | - Weina Liu
- Department of Gynecology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, China
- Academy of Medical Sciences, Zhengzhou University, Zhengzhou 450000, China
| | - Shiya Li
- Department of Gynecology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, China
- Academy of Medical Sciences, Zhengzhou University, Zhengzhou 450000, China
| | - Yi Zhang
- Department of Gynecology, The University of Auckland, Grafton, Auckland 1023, New Zealand
| | - Yanbin Jin
- Department of Gynecology, Hainan Affiliated Hospital of Hainan Medical University (Hainan General Hospital), Haikou 570311, China
| | - Jinquan Cui
- Department of Gynecology, The Second Affiliated Hospital of Zhengzhou University, Zhengzhou 450000, China
- Academy of Medical Sciences, Zhengzhou University, Zhengzhou 450000, China
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Agnew HJ, Kitson SJ, Crosbie EJ. Gynecological malignancies and obesity. Best Pract Res Clin Obstet Gynaecol 2023:102337. [PMID: 37117071 DOI: 10.1016/j.bpobgyn.2023.102337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/24/2023] [Accepted: 03/31/2023] [Indexed: 04/30/2023]
Abstract
The global pandemic of obesity has had a significant impact on gynecological malignancies, most notably endometrial cancer. It has resulted in worldwide increases in the incidence of endometrial cancer and a change in patient demographics, resulting in more diagnoses than ever before being made in pre-menopausal women, who are often keen to pursue fertility-sparing treatments. Obesity increases the risk of gynecological cancers by creating a pro-carcinogenic environment of unopposed estrogen, hyperinsulinemia, and chronic inflammation. It can present both a diagnostic challenge and strongly influence management decisions, including the practicalities of performing surgery, increase anesthetic risks, and alter response rates to adjuvant and medical therapies. Obesity may also influence endometrial cancer mortality and certainly contributes to poorer overall survival due to an excess of deaths related to cardiovascular disease. Weight loss may well, therefore, be the key to the prevention of gynecological cancers and their recurrence.
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Affiliation(s)
- Heather J Agnew
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Department of Obstetrics and Gynaecology, Manchester University NHS Foundation Trust, St Mary's Hospital, Manchester, UK.
| | - Sarah J Kitson
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Emma J Crosbie
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK; Department of Obstetrics and Gynaecology, Manchester University NHS Foundation Trust, St Mary's Hospital, Manchester, UK.
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8
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Black D. Diagnosis and medical management of abnormal premenopausal and postmenopausal bleeding. Climacteric 2023; 26:222-228. [PMID: 36847215 DOI: 10.1080/13697137.2023.2178893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Abnormal uterine bleeding is a common reason for presentation to health-care providers: it is estimated that one woman in three will present to a care provider with abnormal uterine bleeding (AUB) during the reproductive years, and that at least one woman in 10 will experience postmenopausal bleeding. Although there are some variations in national guidelines for investigation, diagnosis and management of premenopausal AUB, there are far more areas of agreement than disagreement. A comprehensive literature search was undertaken to review national and international guidelines regarding investigation, diagnosis and management of AUB in both premenopausal and postmenopausal women. Areas of controversy are identified, and latest evidence reviewed. Although efforts to reduce hysterectomies for premenopausal AUB through medical management have largely been successful, there are areas where more research is necessary to guide optimal investigation and management. Many countries have well-defined guidelines for investigation and management of premenopausal AUB: there are fewer well-developed guidelines for investigation and management of postmenopausal bleeding. There is a paucity of evidence-based data on management of unscheduled bleeding on menopausal hormone therapy.
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Affiliation(s)
- D Black
- Department of Obstetrics, Gynecology and Reproductive Sciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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9
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On the use of spectroscopy, prediction machines and cybernetics for an affordable and proactive care approach for endometrial cancer. BIOMEDICAL ENGINEERING ADVANCES 2022. [DOI: 10.1016/j.bea.2022.100057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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10
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Crosbie EJ, Kitson SJ, McAlpine JN, Mukhopadhyay A, Powell ME, Singh N. Endometrial cancer. Lancet 2022; 399:1412-1428. [PMID: 35397864 DOI: 10.1016/s0140-6736(22)00323-3] [Citation(s) in RCA: 346] [Impact Index Per Article: 173.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/26/2022] [Accepted: 02/03/2022] [Indexed: 12/21/2022]
Abstract
Endometrial cancer is the most common gynaecological cancer in high income countries and its incidence is rising globally. Although an ageing population and fewer benign hysterectomies have contributed to this trend, the growing prevalence of obesity is the major underlying cause. Obesity poses challenges for diagnosis and treatment and more research is needed to offer primary prevention to high-risk women and to optimise endometrial cancer survivorship. Early presentation with postmenopausal bleeding ensures most endometrial cancers are cured by hysterectomy but those with advanced disease have a poor prognosis. Minimally invasive surgical staging and sentinel-lymph-node biopsy provides a low morbidity alternative to historical surgical management without compromising oncological outcomes. Adjuvant radiotherapy reduces loco-regional recurrence in intermediate-risk and high-risk cases. Advances in our understanding of the molecular biology of endometrial cancer have paved the way for targeted chemotherapeutic strategies, and clinical trials will establish their benefit in adjuvant, advanced, and recurrent disease settings in the coming years.
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Affiliation(s)
- Emma J Crosbie
- Gynaecological Oncology Research Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary's Hospital, Manchester, UK; Department of Obstetrics and Gynaecology, St Mary's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
| | - Sarah J Kitson
- Gynaecological Oncology Research Group, Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary's Hospital, Manchester, UK
| | - Jessica N McAlpine
- Department of Obstetrics and Gynaecology, Division of Gynecologic Oncology, University of British Columbia and BC Cancer, Vancouver, BC, Canada
| | - Asima Mukhopadhyay
- Kolkata Gynecological Oncology Trials and Translational Research Group, Chittaranjan National Cancer Institute, Kolkata, India; Department of Gynaecological Oncology, James Cook University Hospital, Middlesbrough, UK; Department of Gynaecological Oncology, Newcastle University, Newcastle upon Tyne, UK
| | - Melanie E Powell
- Department of Clinical Oncology, Barts and The London NHS Trust, London, UK
| | - Naveena Singh
- Department of Anatomic Pathology, Vancouver General Hospital, Vancouver, BC, Canada
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11
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Rotenberg O, Goldberg GL. The significance of "atrophic endometrium" in women with postmenopausal bleeding. Arch Gynecol Obstet 2022; 306:579-583. [PMID: 35318501 DOI: 10.1007/s00404-022-06540-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We evaluated the interpretation of atrophic endometrium (AE) histology as the most common cause for postmenopausal bleeding (PMB). This theory has been accepted for several generations by gynecologists and gynecologic oncologists and has been published in past and current major gynecology textbooks. In our review of the literature, we did not find sufficient histological or clinical proof for this concept. In our view, AE is not a cause of PMB and we back this up with a review of old and current medical literature. The old studies are based on information which was obtained prior to the existence of transvaginal sonogram, sonohysterogram and hysteroscopy. Focal lesions are notorious for being missed by endometrial sampling and curettage. Recent studies show that focal endometrial lesions are a crucial cause for PMB and some of those lesions can harbor cancer. In our opinion, AE is the most common histology found because it is physiologic and a ubiquitous finding in postmenopausal women, but it is not a cause of PMB. Referring to AE as a cause of PMB may result in misdiagnosis of cancer, management delay and unnecessary intervention. To avoid misdiagnosis of cancer, transvaginal sonogram should be considered in all women with PMB and AE on pathology. If endometrial thickness is found, AE is unlikely to be the cause of the PMB and further workup is warranted to reveal the true etiology for the bleeding.
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Affiliation(s)
- Ohad Rotenberg
- Department of Obstetrics and Gynecology and Women's Health Montefiore Medical Center, Albert Einstein College of Medicine, 3332 Rochambeau Avenue, Bronx, NY, 10467-2836, USA.
| | - Gary L Goldberg
- Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Morrison J, Balega J, Buckley L, Clamp A, Crosbie E, Drew Y, Durrant L, Forrest J, Fotopoulou C, Gajjar K, Ganesan R, Gupta J, Hughes J, Miles T, Moss E, Nanthakumar M, Newton C, Ryan N, Walther A, Taylor A. British Gynaecological Cancer Society (BGCS) uterine cancer guidelines: Recommendations for practice. Eur J Obstet Gynecol Reprod Biol 2022; 270:50-89. [DOI: 10.1016/j.ejogrb.2021.11.423] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 11/19/2021] [Indexed: 12/24/2022]
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13
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Histopathological Findings in Iranian Patients with Postmenopausal Uterine Bleeding. INDIAN JOURNAL OF GYNECOLOGIC ONCOLOGY 2021. [DOI: 10.1007/s40944-021-00515-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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14
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Njoku K, O'Flynn H, Jones E, Ramchander NC, White H, Macey R, Crosbie EJ. Screening tests for endometrial cancer in the general population. Hippokratia 2021. [DOI: 10.1002/14651858.cd013859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Kelechi Njoku
- Division of Cancer Sciences; Faculty of Biology, Medicine and Health, The University of Manchester; Manchester UK
| | - Helena O'Flynn
- Division of Cancer Sciences; Faculty of Biology, Medicine and Health, The University of Manchester; Manchester UK
| | - Eleanor Jones
- Division of Cancer Sciences; Faculty of Biology, Medicine and Health, The University of Manchester; Manchester UK
| | - Neal C Ramchander
- Division of Cancer Sciences; Faculty of Biology, Medicine and Health, The University of Manchester; Manchester UK
| | - Helen White
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health; The University of Manchester ; Manchester UK
| | - Richard Macey
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS); University of Oxford; Oxford UK
| | - Emma J Crosbie
- Division of Cancer Sciences; Faculty of Biology, Medicine and Health, The University of Manchester; Manchester UK
- Manchester Academic Health Science Centre; Manchester University NHS Foundation Trust; Manchester UK
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15
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Boeckstaens S, Dewalheyns S, Heremans R, Vikram R, Timmerman D, Van den Bosch T, Verbakel JY. Signs and symptoms associated with uterine cancer in pre- and postmenopausal women. Heliyon 2020; 6:e05372. [PMID: 33204876 PMCID: PMC7649270 DOI: 10.1016/j.heliyon.2020.e05372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/09/2020] [Accepted: 10/26/2020] [Indexed: 10/31/2022] Open
Abstract
Uterine cancer is the most and second most common gynecological malignancy in developed and developing countries, respectively. The majority of endometrial cancers are diagnosed early due to the presence of abnormal uterine bleeding. The existing literature however contains only little data regarding the prevalence of such symptoms compared to patients with no or benign pathology. Therefore, a systematic review was conducted in order to determine the significance of various clinical signs and symptoms predicting uterine cancer. Embase, Web of Science and Medline databases were searched from inception until 18 June 2019. Studies eligible for selection inclusion assessed the diagnostic accuracy of clinical signs and symptoms in pre- and postmenopausal women aged 18-99 years old with uterine malignancy. Case reports, case series and studies of which full text was not available, were excluded. The risk of bias was assessed using the QUADAS-2 tool by two independent reviewers. Results were visualized by forest plots using RevMan(5.3). Forty-one studies were eventually included in this systematic review. Abnormal uterine bleeding occurring in pre-, post- and perimenopausal women was proven to be the most widely investigated symptom in relation to cancer of the uterus. Thirty-two articles examined patients with postmenopausal bleeding of which sensitivity and specificity varied between 0.28 to 0.86 and 0.63 to 0.84, respectively. Abnormal bleeding in pre- and perimenopausal women on the other hand showed a sensitivity ranging from 0.63 to 0.81. Its specificity could not be calculated due to missing data. Other symptoms appeared not sufficiently examined to assess their diagnostic accuracy range. This review highlights the current lack of knowledge regarding the diagnostic accuracy of several signs and symptoms for uterine cancer. After a thorough in-depth review of the literature, meta-analysis could not be performed due to the absence of control populations in the majority of articles. Further research is needed to establish the rule-in or rule-out value of specific clinical signs to identify patients at risk for uterine malignancy prompting further clinical assessment.
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Affiliation(s)
- Shari Boeckstaens
- Department of Obstetrics and Gynaecology, KU Leuven, Belgium
- Department of Obstetric Ultrasound and Fetal Medicine, University College London Hospital, United Kingdom
| | | | - Ruben Heremans
- Department of Obstetrics and Gynaecology, KU Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Belgium
| | - Radhika Vikram
- Department of Obstetrics and Gynaecology, West Hertfordshire Hospitals, Watford, United Kingdom
| | - Dirk Timmerman
- Department of Obstetrics and Gynaecology, KU Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Belgium
| | - Thierry Van den Bosch
- Department of Obstetrics and Gynaecology, KU Leuven, Belgium
- Laboratory for Tumor Immunology and Immunotherapy, KU Leuven, Belgium
| | - Jan Y. Verbakel
- Department of Public Health and Primary Care, KU Leuven, Belgium
- Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom
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16
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Umehara T, Urabe N, Obata T, Yamaguchi T, Tanaka A, Shimada M. Cutting the ovarian surface improves the responsiveness to exogenous hormonal treatment in aged mice. Reprod Med Biol 2020; 19:415-424. [PMID: 33071644 PMCID: PMC7542011 DOI: 10.1002/rmb2.12345] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/22/2020] [Accepted: 08/06/2020] [Indexed: 12/17/2022] Open
Abstract
Purpose Ovarian vascular abnormality and ovarian fibrosis are observed in the low responder patients and aging mice. Vascularization and fibrosis are regulated by injury‐repair system, such as wound. Thus, in this study, the authors tried to investigate the effect of the surgical treatment to ovarian surface with cutting on the functions of ovary in aging mouse model, gcNrg1KO. Method The ovarian surface of gcNrg1KO was surgically cut, and then the ovary was returned inside of bursa ovarica. To assess the effect of cutting on fertility, mating test, smear analysis, and exogenous hormonal treatment were done. Additionally, the histological analysis was used for observing the remodeling of ovarian stroma after the surgical approach. Result Ovarian fibrosis disappeared at 7 days after surgery. With the abrogation of fibrosis, the blood vessels were fluently observed around the follicles, and the follicular development was re‐started. The responses against exogenous hormone were recovered at 21 days after the surgery, and estrous cycle and delivery were also recovered by the surgery and the fertility was maintained for 3 months. Conclusion This cutting method of ovarian surface becomes a good option against low responder patients.
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Affiliation(s)
- Takashi Umehara
- Graduate School of Integrated Sciences for Life Hiroshima University Higashi-Hiroshima Japan
| | - Nao Urabe
- Saint Mother Obstetrics and Gynecology Clinic Institute for ART Fukuoka Japan
| | - Toshiki Obata
- Saint Mother Obstetrics and Gynecology Clinic Institute for ART Fukuoka Japan
| | - Takashi Yamaguchi
- Saint Mother Obstetrics and Gynecology Clinic Institute for ART Fukuoka Japan
| | - Atsushi Tanaka
- Saint Mother Obstetrics and Gynecology Clinic Institute for ART Fukuoka Japan
| | - Masayuki Shimada
- Graduate School of Integrated Sciences for Life Hiroshima University Higashi-Hiroshima Japan
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17
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Dana PM, Sadoughi F, Mobini M, Shafabakhsh R, Chaichian S, Moazzami B, Chamani M, Asemi Z. Molecular and Biological Functions of Melatonin in Endometrial Cancer. Curr Drug Targets 2020; 21:519-526. [DOI: 10.2174/1389450120666190927123746] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 09/01/2019] [Accepted: 09/12/2019] [Indexed: 12/15/2022]
Abstract
Endometrial cancer is the fifth leading cancer among women. This rate is higher in developed countries and its incidence is increasing worldwide. Diabetes mellitus, obesity, hypertension and arteriosclerosis are major risk factors for endometrial cancer. Melatonin is a hormone synthesized in the pineal and extra-pineal organs such as the digestive tract, bone marrow, retina and more. Evidence shows the potential effects of melatonin in endometrial cancer inhibition. Therefore, the focus of this paper is to review this outstanding evidence and to summarize the molecular and biological mechanisms of melatonin for the inhibition of endometrial cancer.
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Affiliation(s)
- Parisa Maleki Dana
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
| | - Fatemeh Sadoughi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
| | - Moein Mobini
- Faculty of Kinesiology, University of Calgary, Calgary, AB, Canada
| | - Rana Shafabakhsh
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
| | - Shala Chaichian
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Bahram Moazzami
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Chamani
- Department of Gynecology and Obstetrics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Zatollah Asemi
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
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18
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Cheewakriangkrai C, Kietpeerakool C, Charoenkwan K, Pattanittum P, John D, Aue‐aungkul A, Lumbiganon P. Health education interventions to promote early presentation and referral for women with symptoms of endometrial cancer. Cochrane Database Syst Rev 2020; 3:CD013253. [PMID: 32168393 PMCID: PMC7069600 DOI: 10.1002/14651858.cd013253.pub2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Diagnosis of endometrial (womb) cancer is normally made at an early stage, as most women with the disease experience abnormal vaginal bleeding, which prompts them to seek medical advice. However, delays in presentation and referral can result in delay in diagnosis and management, which can lead to unfavourable treatment outcomes. This is particularly a problem for pre- and peri-menopausal women. Providing educational information to women and healthcare providers regarding symptoms relating to endometrial cancer may raise awareness of the disease and reduce delayed treatment. OBJECTIVES To assess the effectiveness of health education interventions targeting healthcare providers, or individuals, or both, to promote early presentation and referral for women with endometrial cancer symptoms. SEARCH METHODS We searched CENTRAL, MEDLINE and Embase. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of review articles. SELECTION CRITERIA We planned to include randomised controlled trials (RCTs), both individually randomised and cluster-RCTs. In the absence of RCTs we planned to include well-designed non-randomised studies (NRS) with a parallel comparison assessing the benefits of any type of health education interventions. DATA COLLECTION AND ANALYSIS Two review authors independently evaluated whether potentially relevant studies met the inclusion criteria for the review, but none were found. MAIN RESULTS A comprehensive search of the literature yielded the following results: CENTRAL (1022 references), MEDLINE (2874 references), and Embase (2820 references). After de-duplication, we screened titles and abstracts of 4880 references and excluded 4864 that did not meet the review inclusion criteria. Of the 16 references that potentially met the review inclusion, we excluded all 16 reports after reviewing the full texts. We did not identify any ongoing trials. AUTHORS' CONCLUSIONS There is currently an absence of evidence to indicate the effectiveness of health education interventions involving healthcare providers or individuals or both to promote early presentation and referral for women with endometrial cancer symptoms. High-quality RCTs are needed to assess whether health education interventions enhance early presentation and referral. If health education interventions can be shown to reduce treatment delays in endometrial cancer, further studies would be required to determine which interventions are most effective.
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Affiliation(s)
- Chalong Cheewakriangkrai
- Faculty of Medicine, Chiang Mai UniversityDepartment of Obstetrics and Gynecology110 Intawaroros RoadMuangChiang MaiThailand50200
| | - Chumnan Kietpeerakool
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Kittipat Charoenkwan
- Faculty of Medicine, Chiang Mai UniversityDepartment of Obstetrics and Gynecology110 Intawaroros RoadMuangChiang MaiThailand50200
| | - Porjai Pattanittum
- Khon Kaen UniversityDepartment of Epidemiology and Biostatistics, Public Health FacultyMitraparp RoadMueng DistrictKhon KaenKhon KaenThailand40002
| | | | - Apiwat Aue‐aungkul
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
| | - Pisake Lumbiganon
- Khon Kaen UniversityDepartment of Obstetrics and Gynaecology, Faculty of Medicine123 Mitraparb RoadAmphur MuangKhon KaenThailand40002
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19
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First-time postmenopausal bleeding as a clinical marker of long-term cancer risk: A Danish Nationwide Cohort Study. Br J Cancer 2019; 122:445-451. [PMID: 31806879 PMCID: PMC7000815 DOI: 10.1038/s41416-019-0668-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 11/04/2019] [Accepted: 11/15/2019] [Indexed: 11/22/2022] Open
Abstract
Background Data on long-term risk of cancer after a postmenopausal bleeding diagnosis are sparse. Methods We used Danish medical registries to conduct a population-based cohort study of women with a first hospital-diagnosed postmenopausal bleeding during 1995–2013. We computed the absolute risk of cancer and the standardised incidence ratio (SIR) comparing the observed cancer incidence with that expected in the general population. Results Among 43,756 women with postmenopausal bleeding, the absolute 1- and 5-year risk of endometrial cancer were 4.66% and 5.18%, respectively. The SIR of endometrial cancer was elevated during 0–3 months (SIR = 330.36 (95% CI: 315.43–345.81)), 3–12 months (SIR = 11.39 (95% CI: 9.79–13.17)), 1–5 years (SIR = 2.55 (95% CI: 2.19–2.94)) and >5 years of follow-up (SIR = 1.63 (95% CI: 1.40–1.90)). All selected gynaecological and urological, gastrointestinal and haematological cancers had elevated 0–3 months SIRs. Beyond 1 year of follow-up the SIRs of ovarian and bladder cancer remained elevated with a 1–5-year SIR of 2.15 (95% CI: 1.71–2.65) and 1.45 (95% CI: 1.14–1.80), respectively. Conclusions In the Danish population, women with a first hospital-diagnosed postmenopausal bleeding have an increased 0–3 months risk of gynaecological, urological, gastrointestinal and haematological cancers. The SIR of endometrial, ovarian and bladder cancer remained elevated for several years.
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20
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Wiggans A, Coleridge S, Bryant A, Morrison J. Relationship between vulvar symptoms and incidence of vulvar cancer in women referred to a rapid access clinic. Int J Gynaecol Obstet 2019; 145:283-286. [DOI: 10.1002/ijgo.12818] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 11/04/2018] [Accepted: 03/29/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Alison Wiggans
- Department of Gynaecological OncologyGRACE CentreMusgrove Park Hospital Taunton UK
| | - Sarah Coleridge
- Department of Gynaecological OncologyGRACE CentreMusgrove Park Hospital Taunton UK
| | - Andrew Bryant
- Institute of Health and SocietyNewcastle University Newcastle upon Tyne UK
| | - Jo Morrison
- Department of Gynaecological OncologyGRACE CentreMusgrove Park Hospital Taunton UK
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21
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Cheewakriangkrai C, Kietpeerakool C, Aue-aungkul A, Charoenkwan K, Pattanittum P, John D, Lumbiganon P. Health education interventions to promote early presentation and referral for women with symptoms of endometrial cancer. Hippokratia 2019. [DOI: 10.1002/14651858.cd013253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Chalong Cheewakriangkrai
- Faculty of Medicine, Chiang Mai University; Department of Obstetrics and Gynecology; 110 Intawaroros Road Muang Chiang Mai Thailand 50200
| | - Chumnan Kietpeerakool
- Khon Kaen University; Department of Obstetrics and Gynaecology, Faculty of Medicine; 123 Mitraparb Road Amphur Muang Khon Kaen Thailand 40002
| | - Apiwat Aue-aungkul
- Khon Kaen University; Department of Obstetrics and Gynaecology, Faculty of Medicine; 123 Mitraparb Road Amphur Muang Khon Kaen Thailand 40002
| | - Kittipat Charoenkwan
- Faculty of Medicine, Chiang Mai University; Department of Obstetrics and Gynecology; 110 Intawaroros Road Muang Chiang Mai Thailand 50200
| | - Porjai Pattanittum
- Khon Kaen University; Department of Epidemiology and Biostatistics, Public Health Faculty; Mitraparp Road Mueng District Khon Kaen Khon Kaen Thailand 40002
| | | | - Pisake Lumbiganon
- Khon Kaen University; Department of Obstetrics and Gynaecology, Faculty of Medicine; 123 Mitraparb Road Amphur Muang Khon Kaen Thailand 40002
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22
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Sauvan M, Pourcelot AG, Fournet S, Fernandez H, Capmas P. Office hysteroscopy for postmenopausal women: Feasibility and correlation with transvaginal ultrasound. J Gynecol Obstet Hum Reprod 2018; 47:505-510. [DOI: 10.1016/j.jogoh.2018.08.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 08/13/2018] [Accepted: 08/29/2018] [Indexed: 12/22/2022]
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23
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Comparison of Three Clinical Models for Estimating the Risk of Endometrial Cancer in Post-Menopausal Women with Abnormal Vaginal Bleeding. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2018. [DOI: 10.5812/ijcm.55934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kansal Y, Bahadur A, Chaturvedi J, Rao S, Arora H, Kumari O, Pandey H, Rupendra K. Spectrum of Abnormal Uterine Bleeding: Clinical Pattern and Endometrial Pathology Aspects. J Gynecol Surg 2018. [DOI: 10.1089/gyn.2017.0077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Yamini Kansal
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Anupama Bahadur
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Jaya Chaturvedi
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Shalinee Rao
- Department of Pathology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Hitanshi Arora
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Om Kumari
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Harshita Pandey
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - K. Rupendra
- Department of Obstetrics and Gynaecology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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25
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Umehara T, Kawai T, Kawashima I, Tanaka K, Okuda S, Kitasaka H, Richards JS, Shimada M. The acceleration of reproductive aging in Nrg1 flox/flox ;Cyp19-Cre female mice. Aging Cell 2017; 16:1288-1299. [PMID: 28857490 PMCID: PMC5676068 DOI: 10.1111/acel.12662] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2017] [Indexed: 11/30/2022] Open
Abstract
Irregular menstrual cycles, reduced responses to exogenous hormonal treatments, and altered endocrine profiles (high FSH/high LH/low AMH) are observed in women with increasing age before menopause. In this study, because the granulosa cell‐specific Nrg1 knockout mice (gcNrg1KO) presented ovarian and endocrine phenotypes similar to older women, we sought to understand the mechanisms of ovarian aging and to develop a new strategy for improving fertility in older women prior to menopause. In the ovary of 6‐month‐old gcNrg1KO mice, follicular development was blocked in bilayer secondary follicles and heterogeneous cells accumulated in ovarian stroma. The heterogeneous cells in ovarian stroma were distinguished as two different types: (i) the LH receptor‐positive endocrine cells and (ii) actin‐rich fibrotic cells expressing collagen. Both the endocrine and fibrotic cells disappeared following long‐term treatment with a GnRH antagonist, indicating that the high levels of serum LH induced the survival of both cell types and the abnormal endocrine profile to reduce fertility. Moreover, follicular development to the antral stages was observed with reduced LH and the disappearance of the abnormal stromal cells. Mice treated with the GnRH antagonist regained normal, recurrent estrous cycles and continuously delivered pups for at least for 3 months. We conclude that endocrine and matrix alternations occur within the ovarian stroma with increasing age and that abolishing these alternations resets the cyclical release of LH. Thus, GnRH antagonist treatments might provide a new, noninvasive strategy for improving fertility in a subset of aging women before menopause.
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Affiliation(s)
- Takashi Umehara
- Graduate School of Biosphere Science Hiroshima University Higashi‐Hiroshima Japan
| | - Tomoko Kawai
- Graduate School of Biosphere Science Hiroshima University Higashi‐Hiroshima Japan
| | - Ikko Kawashima
- Graduate School of Biosphere Science Hiroshima University Higashi‐Hiroshima Japan
| | - Katsuhiro Tanaka
- Graduate School of Biosphere Science Hiroshima University Higashi‐Hiroshima Japan
| | - Satoshi Okuda
- Graduate School of Biosphere Science Hiroshima University Higashi‐Hiroshima Japan
| | - Hiroya Kitasaka
- Graduate School of Biosphere Science Hiroshima University Higashi‐Hiroshima Japan
| | - JoAnne S. Richards
- Department of Molecular & Cellular Biology Baylor College of Medicine Houston TX USA
| | - Masayuki Shimada
- Graduate School of Biosphere Science Hiroshima University Higashi‐Hiroshima Japan
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26
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Martinez-Garcia E, Lesur A, Devis L, Cabrera S, Matias-Guiu X, Hirschfeld M, Asberger J, van Oostrum J, Casares de Cal MDLÁ, Gómez-Tato A, Reventos J, Domon B, Colas E, Gil-Moreno A. Targeted Proteomics Identifies Proteomic Signatures in Liquid Biopsies of the Endometrium to Diagnose Endometrial Cancer and Assist in the Prediction of the Optimal Surgical Treatment. Clin Cancer Res 2017; 23:6458-6467. [PMID: 28790116 DOI: 10.1158/1078-0432.ccr-17-0474] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 04/05/2017] [Accepted: 08/03/2017] [Indexed: 11/16/2022]
Abstract
Purpose: Endometrial cancer (EC) diagnosis relies on the observation of tumor cells in endometrial biopsies obtained by aspiration (i.e., uterine aspirates), but it is associated with 22% undiagnosed patients and up to 50% of incorrectly assigned EC histotype and grade. We aimed to identify biomarker signatures in the fluid fraction of these biopsies to overcome these limitations.Experimental Design: The levels of 52 proteins were measured in the fluid fraction of uterine aspirates from 116 patients by LC-PRM, the latest generation of targeted mass-spectrometry acquisition. A logistic regression model was used to assess the power of protein panels to differentiate between EC and non-EC patients and between EC histologic subtypes. The robustness of the panels was assessed by the "leave-one-out" cross-validation procedure performed within the same cohort of patients and an independent cohort of 38 patients.Results: The levels of 28 proteins were significantly higher in patients with EC (n = 69) compared with controls (n = 47). The combination of MMP9 and KPYM exhibited 94% sensitivity and 87% specificity for detecting EC cases. This panel perfectly complemented the standard diagnosis, achieving 100% of correct diagnosis in this dataset. Nine proteins were significantly increased in endometrioid EC (n = 49) compared with serous EC (n = 20). The combination of CTNB1, XPO2, and CAPG achieved 95% sensitivity and 96% specificity for the discrimination of these subtypes.Conclusions: We developed two uterine aspirate-based signatures to diagnose EC and classify tumors in the most prevalent histologic subtypes. This will improve diagnosis and assist in the prediction of the optimal surgical treatment. Clin Cancer Res; 23(21); 6458-67. ©2017 AACR.
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Affiliation(s)
- Elena Martinez-Garcia
- Biomedical Research Group in Gynecology, Vall Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, CIBERONC, Barcelona, Spain
| | - Antoine Lesur
- Luxembourg Clinical Proteomics Center (LCP), Luxembourg Institute of Health (LIH), Strassen, Luxembourg
| | - Laura Devis
- Biomedical Research Group in Gynecology, Vall Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, CIBERONC, Barcelona, Spain
| | - Silvia Cabrera
- Gynecology Department, Vall Hebron University Hospital, Barcelona, Spain
| | - Xavier Matias-Guiu
- Pathological Oncology Group and Pathology Department, University Hospital Arnau de Vilanova, and University Hospital Bellvitge, IRBLLEIDA and Idibell, University of Lleida, CIBERONC, Barcelona, Spain
| | - Marc Hirschfeld
- Department of Obstetrics and Gynecology, University Medical Center, Albert-Ludwigs-University, Freiburg, Germany
- Institute of Veterinary Medicine, Georg-August-University Goettingen, Germany
| | - Jasmin Asberger
- Department of Obstetrics and Gynecology, University Medical Center, Albert-Ludwigs-University, Freiburg, Germany
| | - Jan van Oostrum
- Luxembourg Clinical Proteomics Center (LCP), Luxembourg Institute of Health (LIH), Strassen, Luxembourg
| | | | - Antonio Gómez-Tato
- Faculty of Mathematics, University of Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - Jaume Reventos
- Biomedical Research Group in Gynecology, Vall Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, CIBERONC, Barcelona, Spain
- Basic Sciences Department, International University of Catalonia, CIBERONC, Barcelona, Spain
| | - Bruno Domon
- Luxembourg Clinical Proteomics Center (LCP), Luxembourg Institute of Health (LIH), Strassen, Luxembourg
| | - Eva Colas
- Biomedical Research Group in Gynecology, Vall Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, CIBERONC, Barcelona, Spain.
| | - Antonio Gil-Moreno
- Biomedical Research Group in Gynecology, Vall Hebron Research Institute (VHIR), Universitat Autònoma de Barcelona, CIBERONC, Barcelona, Spain.
- Gynecology Department, Vall Hebron University Hospital, Barcelona, Spain
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Abdelraheim AR, Khairy M, Mohammed M, Lawrence A. Two week waits: What are we waiting for? Eur J Obstet Gynecol Reprod Biol 2017; 215:112-117. [PMID: 28609712 DOI: 10.1016/j.ejogrb.2017.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/04/2017] [Accepted: 06/06/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To evaluate the two-week referral system by analysing the 2-week wait (2WW) referrals to the rapid access gynaecology clinic over one year. We have also sought to identify the risk factors for endometrial cancer to help setting criteria that can be used to prioritise urgent appointments, refine subsequent management strategies. STUDY DESIGN Retrospective review of the data of all women referred for suspected gynaecological cancers over one year via the 2 WW office at Queen's Hospital, Romford, UK. Data of all other women in whom a diagnosis of a gynaecological malignancy was made during the same period following non-urgent (non-2WW) referrals were also collected. RESULTS Over one year, a total of 1105 women were referred under the 2WW for suspected gynaecological malignancy. A total of 765 patients (69.23%) were referred with suspected endometrial cancer and the main indication for referral was postmenopausal bleeding. Hundred-seventy nine women (16.20%) were referred with suspected ovarian cancer. A pelvic mass found in 62 of these women and this was the main indication of referral. The number of women referred with suspected cervical cancer was 117 (10.59%) and the main indication for referral was postcoital bleeding. Forty-four women (3.98%) referred with suspected vulvo-vaginal cancer and the main presentation was vulval lesion. The positive predictive value of referrals for diagnosing endometrial, ovarian, cervical and vulvo-vaginal malignancy was 8.1%, 9.5%, 5.98% and 13.64% and the overall predictive value for diagnosing gynaecological malignancy was 8.33%. The predictive values of the 2WW referrals for diagnosing different types of gynaecological cancers in premenopausal women are low compared to postmenopausal women (1.86% and 9.89% respectively, p<0.001). The number of cancers diagnosed through non-urgent system was higher than the number diagnosed through urgent system (95 vs. 92). Presence of diabetes mellitus, increased endometrial thickness, prolonged bleeding and advancing age represent the best model for predicting endometrial cancer. CONCLUSION The overall predictive value of the 2WW system for suspected gynaecological malignancies is low particularly in premenopausal women. The current referral criteria need to be modified with a view to incorporating risk factors to prioritise urgent appointments and refine subsequent management plans.
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Affiliation(s)
- Ahmed R Abdelraheim
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Minia University, Egypt; Gynaecological Oncology unit, Queen's Hospital, Romford, UK.
| | - Mohammed Khairy
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Minia University, Egypt
| | - Mo'men Mohammed
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Minia University, Egypt
| | - Alexandra Lawrence
- Gynaecological Oncology unit, Queen's Hospital, Romford, UK; Gynaecological Cancer center, St. Bart's Hospital, London, UK
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Bakour S, Emovon E, Nevin J, Ewies AAA. Is routine adnexal scanning for postmenopausal bleeding of value? Observational study of 2101 women. J OBSTET GYNAECOL 2017; 37:779-782. [PMID: 28485195 DOI: 10.1080/01443615.2017.1306031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Our objective is to assess the merits of adnexal scanning during the investigation of women with postmenopausal bleeding (PMB) in terms of adnexal cancer diagnosis. This observational study was designed utilising an institutional PMB database in a teaching hospital, analysing a sample of 2101 consecutive women with PMB seen between 16th February 2012 and 12th August 2014 looking at the prevalence of cancer in adnexal masses identified on Trans-vaginal ultrasound scanning (TVS) in these PMB women. This study suggests that routine adnexal scanning in women with PMB may provide no benefit. It could be exposing women to unnecessary surgery or surveillance with the associated risks and cost implications. Most of the women who underwent surgery presented with palpable masses. Those with negative clinical examination had either benign masses which may have remained inconsequential or non-suspicious scan findings. A well-designed randomised controlled trial is needed to confirm the findings. Impact statement Trans-vaginal ultrasound scanning (TVS) is the standard first line investigation for women presenting with postmenopausal bleeding (PMB) primarily to assess the endometrial thickness. This has led to a widespread practice of opportunistic adnexal scanning, which generated a debate amongst gynaecologists about the value of such practice. This observational study, assessing the merits of routine adnexal scanning in these women in terms of adnexal cancer diagnosis, suggests that this practice may provide no benefit to women with isolated self-limiting PMB and unremarkable bimanual examination. It could be exposing women to unnecessary surgery or surveillance with the associated risks and cost implications when insignificant adnexal masses are identified on the scan. A well-designed randomised controlled trial is needed to elucidate if clinical examination in combination with endometrial scanning only is more effective and cost-effective than clinical examination followed by systematic pelvic scanning to detect cases of ovarian cancer in women with PMB.
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Affiliation(s)
- Shagaf Bakour
- a Sandwell and West Birmingham Hospitals NHS Teaching Trust , Birmingham , UK.,b Aston Medical School, Aston Medical Research Institute, Aston University , Birmingham , UK
| | - Emmanuel Emovon
- a Sandwell and West Birmingham Hospitals NHS Teaching Trust , Birmingham , UK
| | - James Nevin
- a Sandwell and West Birmingham Hospitals NHS Teaching Trust , Birmingham , UK
| | - Ayman A A Ewies
- a Sandwell and West Birmingham Hospitals NHS Teaching Trust , Birmingham , UK.,c The College of Medical & Dental Sciences, University of Birmingham , Birmingham , UK
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Walker S, Hamilton W. Risk of cervical cancer in symptomatic women aged ≥40 in primary care: A case-control study using electronic records. Eur J Cancer Care (Engl) 2017; 26. [PMID: 28474381 DOI: 10.1111/ecc.12706] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2017] [Indexed: 11/28/2022]
Abstract
There are approximately 3,000 new UK diagnoses of cervical cancer annually, with many women presenting symptomatically. We aimed to identify and quantify features of cervical cancer in primary care in a case-control study in the UK. Putative features of cervical cancer were identified, and odd ratios and positive predictive values (PPVs) were calculated. About 1,006 women aged ≥40 years diagnosed with cervical cancer and 4,992 age-, sex- and practice-matched controls were selected from the Clinical Practice Research Datalink. Median age at diagnosis was 61 years (interquartile range 51-75). Seven symptoms and two abnormal investigations were associated with cervical cancer: post-menopausal bleeding, odds ratio 43 (95% confidence interval 25, 75); vaginal discharge or vaginitis 8.8 (5.2, 15), intermenstrual bleeding 4.7 (1.6, 14); haematuria 4.6 (2.1, 10); irregular menstruation 3.8 (1.6, 9.0); urinary tract infection 1.9 (1.3, 2.8); abdominal pain 1.8 (1.4, 2.5); high white cell count 5.1 (2.9, 8.8) and low haemoglobin 2.6 (1.8, 3.8): all p < .005. The PPV of cervical cancer in women aged ≥55 with post-menopausal bleeding was 4.6% (2.5, 8.3). Other than for post-menopausal bleeding no symptom is high risk. Some symptoms, particularly haematuria, may be helpful. The primary care clinician must consider the unlikely diagnosis when the likely diagnosis does not settle with treatment.
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Affiliation(s)
- S Walker
- University of Exeter Medical School, Exeter, UK
| | - W Hamilton
- University of Exeter Medical School, Exeter, UK
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Sundar S, Balega J, Crosbie E, Drake A, Edmondson R, Fotopoulou C, Gallos I, Ganesan R, Gupta J, Johnson N, Kitson S, Mackintosh M, Martin-Hirsch P, Miles T, Rafii S, Reed N, Rolland P, Singh K, Sivalingam V, Walther A. BGCS uterine cancer guidelines: Recommendations for practice. Eur J Obstet Gynecol Reprod Biol 2017; 213:71-97. [PMID: 28437632 DOI: 10.1016/j.ejogrb.2017.04.015] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 04/05/2017] [Indexed: 10/19/2022]
Abstract
The British Gynaecological Cancer Society has issued the first Endometrial (Uterine) Cancer guidelines as recommendation for practice for the UK.
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Affiliation(s)
- Sudha Sundar
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Janos Balega
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Emma Crosbie
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Alasdair Drake
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Richard Edmondson
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Christina Fotopoulou
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom.
| | - Ioannis Gallos
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Raji Ganesan
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Janesh Gupta
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Nick Johnson
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Sarah Kitson
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Michelle Mackintosh
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Pierre Martin-Hirsch
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Tracie Miles
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Saeed Rafii
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Nick Reed
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Phil Rolland
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Kavita Singh
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Vanitha Sivalingam
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
| | - Axel Walther
- British Gynaecological Cancer Society, C/O Williams Denton CYF, Bangor LL57 4FE, United Kingdom
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Reijnen C, Visser NCM, Bulten J, Massuger LFAG, van der Putten LJM, Pijnenborg JMA. Diagnostic accuracy of endometrial biopsy in relation to the amount of tissue. J Clin Pathol 2017; 70:941-946. [PMID: 28389441 DOI: 10.1136/jclinpath-2017-204338] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 03/18/2017] [Accepted: 03/27/2017] [Indexed: 11/04/2022]
Abstract
AIMS For the diagnostic workup of postmenopausal bleeding, histological examination of the endometrium is frequently performed. Failure of endometrial sampling due to insufficient material is often reported but objective criteria for quality assessment of endometrial biopsies are lacking. The aim of the present study is to evaluate the association between the amount of tissue obtained by endometrial sampling and the diagnostic accuracy, and to establish a cut-off level for a minimal amount of tissue required for a conclusive diagnosis. METHODS For this retrospective cohort study, clinicopathological data and Pipelle endometrial sampling slides of 139 patients who were treated with hysterectomy were collected. The surface of evaluable endometrial tissue was measured by means of structured digital assessment. The correlation between the predictive values in relation to the endometrial tissue surface was calculated for different cut-off values. RESULTS The median endometrial tissue surface was 4.7 mm2 (range 0.4-156.4) for benign endometrium, 27.8 mm2 (range 0.0-208.4) for premalignant endometrium and 43.8 mm2 (range 0.0-223.6) for malignant endometrium. There was a significant association between the endometrial tissue surface and the correctness of diagnosis. A minimal endometrial tissue surface of 35 mm2 could be defined, for positive and negative predictive values of 92.6% and 85.7%, respectively. CONCLUSIONS The diagnostic accuracy of Pipelle endometrial sampling is associated with the amount of endometrial tissue surface, with a minimal cut-off value of 35 mm2 required to classify an endometrial sample as conclusive. Quantification of endometrial tissue can contribute to standardisation of quality assessment of endometrial samplings.
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Affiliation(s)
- Casper Reijnen
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Nicole C M Visser
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johan Bulten
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Leon F A G Massuger
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Louis J M van der Putten
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johanna M A Pijnenborg
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, The Netherlands
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Visser NCM, Sparidaens EM, van den Brink JW, Breijer MC, Boss EA, Veersema S, Siebers AG, Bulten J, Pijnenborg JMA, Bekkers RLM. Long-term risk of endometrial cancer following postmenopausal bleeding and reassuring endometrial biopsy. Acta Obstet Gynecol Scand 2016; 95:1418-1424. [PMID: 27633936 PMCID: PMC5132156 DOI: 10.1111/aogs.13022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 08/31/2016] [Indexed: 12/03/2022]
Abstract
Introduction Women with postmenopausal bleeding and endometrial thickness >4 mm undergo endometrial sampling to exclude endometrial cancer. The aim of this study is to investigate the relative risk of developing endometrial cancer in a prospective cohort after initial work‐up for postmenopausal bleeding showing reassuring histology or insufficient sampling. Material and methods All women presenting with postmenopausal bleeding were prospectively included from January 2009 to April 2011. Follow‐up data were collected from patient charts and PALGA (Dutch Pathology Registry). Hazard ratios for endometrial cancer were determined by calculating standardized incidence ratios. Results A total of 668 women were included and 568 women were available for follow‐up [median follow‐up time 47 (range 7–63) months]. Women who presented with postmenopausal bleeding, endometrial thickness >4 mm and hyperplasia without atypia on biopsy at the first presentation showed a significantly increased risk (standardized incidence ratio 17.15, 95% confidence interval 1.96–61.93) of being diagnosed with endometrial cancer during the first four years of follow up compared with the age‐specific population. All women that developed endometrial cancer after initial reassuring histology presented with recurrent postmenopausal bleeding. None of the women with endometrial thickness >4 mm and no or insufficient sample for histology at the first presentation developed endometrial cancer during the follow up. Conclusions Although in general, women with endometrial hyperplasia without atypia are considered to have a low risk for cancer, we observed a significant long‐term risk of endometrial cancer after postmenopausal bleeding. Whether additional diagnostics or a more stringent follow‐up regimen would be cost‐effective, needs to be studied.
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Affiliation(s)
- Nicole C M Visser
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ellen M Sparidaens
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Maria C Breijer
- Department of Obstetrics and Gynecology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Erik A Boss
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands
| | - Sebastiaan Veersema
- Department of Obstetrics and Gynecology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Albert G Siebers
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johan Bulten
- Department of Pathology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johanna M A Pijnenborg
- Department of Obstetrics and Gynecology, Elisabeth-TweeSteden Hospital, Tilburg, The Netherlands
| | - Ruud L M Bekkers
- Department of Obstetrics and Gynecology, Radboud University Medical Center, Nijmegen, The Netherlands
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Edey KA, Rundle S, Hickey M. Hormone replacement therapy for women previously treated for endometrial cancer. Hippokratia 2016. [DOI: 10.1002/14651858.cd008830.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | - Stuart Rundle
- Northern Gynaecological Oncology Centre; Gynaecological Oncology; Queen Elizabeth Hospital Sheriff Hill Gateshead UK NE9 6SX
| | - Martha Hickey
- The Royal Women's Hospital; The University of Melbourne; Level 7, Research Precinct Melbourne Victoria Australia Parkville 3052
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Seckin B, Cicek MN, Dikmen AU, Bostancı EI, Muftuoglu KH. Diagnostic value of sonography for detecting endometrial pathologies in postmenopausal women with and without bleeding. JOURNAL OF CLINICAL ULTRASOUND : JCU 2016; 44:339-346. [PMID: 26857098 DOI: 10.1002/jcu.22329] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 12/07/2015] [Indexed: 06/05/2023]
Abstract
PURPOSE To investigate the diagnostic value of endometrial thickness measurement on sonography in predicting endometrial pathologies in postmenopausal women with vaginal bleeding and in those with asymptomatic thickened endometrium. METHODS Six hundred two postmenopausal women with vaginal bleeding or asymptomatic thickened endometrium were evaluated in this study. Two hundred seventy-four women with postmenopausal bleeding regardless of endometrial thickness (group 1: symptomatic) and 328 women with an incidental finding of thickened endometrium (≥5 mm) without bleeding (group 2: asymptomatic) underwent endometrial biopsy for histopathologic examination. The receiver operating characteristics curves of endometrial thickness measurement for prediction of endometrial pathologies were analyzed. RESULTS Endometrial carcinoma was detected in eight women (2.9%) in group 1 and in three (0.9%) in group 2. The best cutoff point for endometrial thickness in predicting endometrial carcinoma in group 1 was 8.2 mm, which provided 75% sensitivity (95% confidence interval [CI], 40.9-92.9%) and 74% specificity (95% CI, 68-78.5%); area under the receiver operating characteristics curve (AUC), 0.88; 95% CI, 0.76-1.00%; p = 0.0001. In group 2, the AUC was 0.76 (95% CI, 0.46-1.00; p = 0.114); the evidence was inconclusive as to the relationship between endometrial thickness and malignancy. For the prediction of polyps, the AUCs of endometrial thickness were 0.77 for group 1 (95% CI, 0.71-0.83%; p = 0.0001) and 0.61 for group 2 (95% CI, 0.54-0.67%; p = 0.002). CONCLUSIONS Sonographically determined endometrial thickness measurement shows high diagnostic performance for detection of endometrial cancer in symptomatic postmenopausal women at the optimal cutoff thickness of approximately 8 mm, although the evidence supporting the use of sonography for predicting malignancy in asymptomatic women is inconclusive. For polyp detection, this technique shows moderate diagnostic ability in symptomatic women, but its predictive value is low in asymptomatic women. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:339-346, 2016.
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Affiliation(s)
- Berna Seckin
- Department of Reproductive Endocrinology, Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey
| | - Mahmut Nedim Cicek
- Department of Reproductive Endocrinology, Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey
| | | | - Esra Isci Bostancı
- Department of Reproductive Endocrinology, Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey
| | - Kamil Hakan Muftuoglu
- Department of Pathology, Zekai Tahir Burak Women's Health Education and Research Hospital, Ankara, Turkey
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Pakish JB, Lu KH, Sun CC, Burzawa JK, Greisinger A, Smith FA, Fellman B, Urbauer DL, Soliman PT. Endometrial Cancer Associated Symptoms: A Case-Control Study. J Womens Health (Larchmt) 2016; 25:1187-1192. [PMID: 27254529 DOI: 10.1089/jwh.2015.5657] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The majority of women with endometrial cancer (EC) present at an early stage with an associated 5-year survival rate of >90%. High rates of early detection are attributed to warning symptoms; however, the prevalence of such symptoms has not been well defined. METHODS A case-control study was conducted assessing the prevalence of symptoms in EC patients at a large cancer center compared with healthy controls. Controls included patients seen for an annual gynecologic care visit (AV) or for a gynecological problem-based visit (PV). A self-administered questionnaire was given to all participants addressing EC-associated symptoms, at the time of initial clinic visit. Odds ratios (ORs) were used to compare prevalence of symptoms between EC cases and controls. Logistic regression was used to determine the impact of menopausal status and obesity on symptom prevalence. RESULTS The cases (n = 75) were significantly older than the AV (n = 203) and PV (n = 151) controls (59.7 vs. 49.8 vs. 51.0 years, p < 0.01), had a higher body mass index (35.5 vs. 29.4 vs. 30.9 kg/m2, p < 0.01), and were more likely to be postmenopausal (76% vs. 53.7% vs. 52.0%, p < 0.01). The cases were more likely to report postmenopausal bleeding (OR = 32.99 and 5.83, p < 0.01) and abnormal vaginal discharge (OR = 8.8 and 3.3, p < 0.01) compared with the AV and PV groups. Overall, 55.4% of cases reported abnormal vaginal discharge. CONCLUSIONS Symptoms of both postmenopausal bleeding and abnormal vaginal discharge were significantly higher in EC compared with controls. The presence of such symptoms should raise concern for malignant disease and prompt immediate gynecological evaluation.
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Affiliation(s)
- Janelle B Pakish
- 1 Department of Gynecologic Oncology and Reproductive Medicine, University of Texas M.D. Anderson Cancer Center , Houston, Texas
| | - Karen H Lu
- 1 Department of Gynecologic Oncology and Reproductive Medicine, University of Texas M.D. Anderson Cancer Center , Houston, Texas
| | - Charlotte C Sun
- 1 Department of Gynecologic Oncology and Reproductive Medicine, University of Texas M.D. Anderson Cancer Center , Houston, Texas
| | - Jennifer K Burzawa
- 1 Department of Gynecologic Oncology and Reproductive Medicine, University of Texas M.D. Anderson Cancer Center , Houston, Texas
| | | | | | - Bryan Fellman
- 4 Department of Biostatistics, University of Texas M.D. Anderson Cancer Center , Houston, Texas
| | - Diana L Urbauer
- 4 Department of Biostatistics, University of Texas M.D. Anderson Cancer Center , Houston, Texas
| | - Pamela T Soliman
- 1 Department of Gynecologic Oncology and Reproductive Medicine, University of Texas M.D. Anderson Cancer Center , Houston, Texas
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Clinical outcomes of patients with insufficient sample from endometrial biopsy or curettage. Int J Gynecol Pathol 2015; 33:500-6. [PMID: 25083966 DOI: 10.1097/pgp.0000000000000085] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Endometrial biopsy and curettage are widely used uterine sampling procedures. Occasionally, the amount of tissue obtained is so minimal that diagnosis cannot be reached. In published studies, insufficient samples comprise 2% to 60% of endometrial samples and are influenced by multiple contributory factors. To date, specific quantitative criteria for an adequate endometrial sample have not been established in the pathology community. The decision to classify a sample as nondiagnostic is subject to great interobserver variability, especially where elderly patients are concerned. Meanwhile, whether or not to repeat the procedure is the dilemma for clinical management. Herein we studied the clinicopathologic features of 1120 endometrial samples designated as insufficient for diagnosis. Such samples were more commonly encountered in elderly patients than younger ones (14.6% vs. 5.8%). Our pathologists generally required one intact tissue fragment containing both glands and stroma for premenopausal patients and 5 to 10 strips of atrophic endometrial epithelium for postmenopausal patients. By the 12-mo follow-up, 38% of patients with nondiagnostic samples had second sampling procedures and 7% underwent hysterectomy. The second sample was adequate in 75% of patients, 10% of which showed malignant tumor. If any worrisome histologic findings were present in the initial nondiagnostic sample, a high percentage of these patients were found to have uterine malignancy on second procedures (43%). Aims of this study are to bring awareness to this commonly overlooked topic, to validate our diagnostic criteria, and to outline important clinical implications.
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Hardarson HA, Heidemann LN, dePont Christensen R, Mogensen O, Jochumsen KM. Vaginal vault recurrences of endometrial cancer in non-irradiated patients - Radiotherapy or surgery. Gynecol Oncol Rep 2015; 11:26-30. [PMID: 26076091 PMCID: PMC4434165 DOI: 10.1016/j.gore.2015.01.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Accepted: 01/08/2015] [Indexed: 11/18/2022] Open
Abstract
Background The treatment of locally recurrent endometrial cancer is based on limited evidence. The standard treatment is radiotherapy (RT) which is effective for local control and the effect has been documented in prospective studies. Investigations of surgical treatment (ST) of recurrences are few and limited to previously irradiated patients or patients with advanced disease. Investigation of surgical treatment for isolated vaginal vault recurrence is practically nonexistent. The aim of this study is to evaluate the efficacy of RT and ST in a non-irradiated group with recurrent endometrial cancer limited to the vaginal vault. Methods Patients treated for recurrent endometrial cancer at Odense University Hospital, Denmark between 2003 and 2012 were identified, n = 118. Thirty-three patients had an isolated vaginal vault recurrence and were treated with either RT, ST or both. Re-recurrence rates and survival rates were calculated at 2 year follow-up using Fishers exact test. Results Twenty-six patients were treated with RT, 5 with ST, 2 with both. The mean (SD) follow-up-time was 4.4 years (2.99) (RT) and 3.9 years (0.90) (ST). Two year re-recurrence rates were 40% (RT) (95 CI 9.2–48%) and 0% (ST) (95 CI 0–60%). Two-year survival rates were 83% (RT) (95 CI 71–100%) and 100% (ST) (95 CI 40–100%) ST had one re-recurrence at 2.3 years. Conclusion This study indicates that ST is an appropriate treatment for locally recurrent endometrial cancer. Our study involves a limited number of patients and is made retrospectively, therefore prospective and ideally randomized trials evaluating both survival and complications are warranted. Investigate radiotherapy and surgical treatment of vaginal vault recurrences of endometrial cancer. All patients were naïve to radiotherapy and 5 were treated with surgery and 26 with radiotherapy. Rates of survival and re-recurrence were equivalent though in favor of surgery.
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Affiliation(s)
- Hordur Alexander Hardarson
- Department of Obstetrics and Gynecology, Odense University Hospital, Denmark
- Corresponding author at: Department of Obstetrics and Gynecology, Odense University Hospital, Sdr. Boulevard 29, DK-5000 Odense C, Denmark.
| | | | - René dePont Christensen
- Research Unit of General Practice, Institute of Public Health, University of Southern Denmark, Denmark
| | - Ole Mogensen
- Department of Obstetrics and Gynecology, Odense University Hospital, Denmark
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Brown JC, Lin LL, Segal S, Chu CS, Haggerty AE, Ko EM, Schmitz KH. Physical activity, daily walking, and lower limb lymphedema associate with physical function among uterine cancer survivors. Support Care Cancer 2014; 22:3017-25. [PMID: 24906839 DOI: 10.1007/s00520-014-2306-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 05/27/2014] [Indexed: 01/13/2023]
Abstract
PURPOSE We sought to quantify the proportion of uterine cancer survivors who self-report poor physical function. We then sought to quantify the association of poor physical function with physical activity (PA), walking, and lower limb lymphedema (LLL), among women with a history of uterine cancer. METHODS Physical function was quantified using the Medical Outcomes Study 12-Item Short-Form Health Survey (SF-12) questionnaire. PA, walking, and LLL were measured using self-report questionnaire. PA was calculated using metabolic equivalent hours per week (MET-h week(-1)), and walking was calculated using blocks per day (blocks day(-1)). Logistic regression estimated odds ratios (OR) and 95 % confidence intervals (95 % CI). RESULTS Among the 213 uterine cancer survivors in our survey (43 % response rate), 35 % self-reported poor physical function. Compared to participants who reported <3.0 MET-h week(-1) of PA, participants who reported ≥18.0 MET-h week(-1) of PA were less likely to have poor physical function (OR 0.03, 95 % CI 0.01-0.10; P trend < 0.0001). Compared to participants who reported <4.0 blocks day(-1) of walking, participants who reported ≥12.0 blocks day(-1) of walking were less likely to have poor physical function (OR 0.07, 95 % CI 0.03-0.19; P trend < 0.0001). Compared to participants who did not have LLL, participants with LLL were more likely to have poor physical function (OR 5.25, 95 % CI 2.41-11.41; P < 0.0001). CONCLUSION Higher levels of PA and walking associate with a lower likelihood of reporting poor physical function. The presence of LLL associates with a higher likelihood of reporting poor physical function. These findings are hypothesis-generating and should be evaluated in future prospective studies.
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Affiliation(s)
- Justin C Brown
- Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, 8th Floor, Blockley Hall, Philadelphia, PA, 19104, USA
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Mitchell AL, Gajjar KB, Theophilou G, Martin FL, Martin-Hirsch PL. Vibrational spectroscopy of biofluids for disease screening or diagnosis: translation from the laboratory to a clinical setting. JOURNAL OF BIOPHOTONICS 2014; 7:153-165. [PMID: 24648213 DOI: 10.1002/jbio.201400018] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 02/21/2014] [Accepted: 02/22/2014] [Indexed: 06/03/2023]
Abstract
There remains a need for objective and cost-effective approaches capable of diagnosing early-stage disease in point-of-care clinical settings. Given an increasingly ageing population resulting in a rising prevalence of chronic diseases, the need for screening to facilitate the personalising of therapies to prevent or slow down pathology development will increase. Such a tool needs to be robust but simple enough to be implemented into clinical practice. There is interest in extracting biomarkers from biofluids (e.g., plasma or serum); techniques based on vibrational spectroscopy provide an option. Sample preparation is minimal, techniques involved are relatively low-cost, and data frameworks are available. This review explores the evidence supporting the applicability of vibrational spectroscopy to generate spectral biomarkers of disease in biofluids. We extend the inter-disciplinary nature of this approach to hypothesise a microfluidic platform that could allow such measurements. With an appropriate lightsource, such engineering could revolutionize screening in the 21(st) century.
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Affiliation(s)
- Alana L Mitchell
- Centre for Biophotonics, Lancaster Environment Centre, Lancaster University, Lancaster LA1 4YQ, UK
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Munro MG. Investigation of women with postmenopausal uterine bleeding: clinical practice recommendations. Perm J 2013; 18:55-70. [PMID: 24377427 DOI: 10.7812/tpp/13-072] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Postmenopausal uterine bleeding is defined as uterine bleeding after permanent cessation of menstruation resulting from loss of ovarian follicular activity. Bleeding can be spontaneous or related to ovarian hormone replacement therapy or to use of selective estrogen receptor modulators (eg, tamoxifen adjuvant therapy for breast carcinoma). Because anovulatory "cycles" with episodes of multimonth amenorrhea frequently precede menopause, no consensus exists regarding the appropriate interval of amenorrhea before an episode of bleeding that allows for the definition of postmenopausal bleeding. The clinician faces the possibility that an underlying malignancy exists, knowing that most often the bleeding comes from a benign source. Formerly, the gold-standard clinical investigation of postmenopausal uterine bleeding was institution-based dilation and curettage, but there now exist office-based methods for the evaluation of women with this complaint. Strategies designed to implement these diagnostic methods must be applied in a balanced way considering the resource utilization issues of overinvestigation and the risk of missing a malignancy with underinvestigation. Consequently, guidelines and recommendations were developed to consider these issues and the diverse spectrum of practitioners who evaluate women with postmenopausal bleeding. The guideline development group determined that, for initial management of spontaneous postmenopausal bleeding, primary assessment may be with either endometrial sampling or transvaginal ultrasonography, allowing patients with an endometrial echo complex thickness of 4 mm or less to be managed expectantly. Guidelines are also provided for patients receiving selective estrogen receptor modulators or hormone replacement therapy, and for an endometrial echo complex with findings consistent with fluid in the endometrial cavity.�
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Affiliation(s)
- Malcolm G Munro
- Chair of the Southern California Permanente Medical Group's Abnormal Uterine Bleeding Working Group, Director of Gynecological Services for the Los Angeles Medical Center in California, and a Professor in the Department of Obstetrics and Gynecology at the David Geffen School of Medicine at the University of California Los Angeles.
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Abstract
Abnormal peri-menopausal bleeding is a common clinical problem. Decisions to investigate if the menstrual disorders are related to an underlying pathology or represent physiologic changes are often complex especially as no clear guidance is available. The aim of this review is to present a summary of the current available evidence regarding the investigation tools used to evaluate women with abnormal uterine bleeding during menopausal transition and in the post-menopausal period. In this article, we focus mainly on the investigation and exclusion of endometrial carcinoma, as this represents the most common malignancy diagnosed.
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Dreisler E, Poulsen LG, Antonsen SL, Ceausu I, Depypere H, Erel CT, Lambrinoudaki I, Pérez-López FR, Simoncini T, Tremollieres F, Rees M, Ulrich LG. EMAS clinical guide: Assessment of the endometrium in peri and postmenopausal women. Maturitas 2013; 75:181-90. [DOI: 10.1016/j.maturitas.2013.03.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Klomp H, van der Linden PJ. Postmenopausal Bleeding and Corticosteroids. Gynecol Obstet Invest 2013; 76:260. [DOI: 10.1159/000351105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 04/03/2013] [Indexed: 11/19/2022]
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van Hanegem N, Breijer MC, Opmeer BC, Mol BWJ, Timmermans A. Prediction models in women with postmenopausal bleeding: a systematic review. ACTA ACUST UNITED AC 2012; 8:251-62. [PMID: 22554173 DOI: 10.2217/whe.12.10] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Postmenopausal bleeding is associated with an elevated risk of having endometrial cancer. The aim of this review is to give an overview of existing prediction models on endometrial cancer in women with postmenopausal bleeding. In a systematic search of the literature, we identified nine prognostic studies, of which we assessed the quality, the different phases of development and their performance. From these data, we identified the most important predictor variables. None of the detected models completed external validation or impact analysis. Models including power Doppler showed best performance in internal validation, but Doppler in general gynecological practice is not easily accessible. We can conclude that we have indications that the first step in the approach of women with postmenopausal bleeding should be to distinguish between women with low risk versus high risk of having endometrial carcinoma and the next step would be to refer patients for further (invasive) testing.
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Affiliation(s)
- Nehalennia van Hanegem
- Department of Obstetrics & Gynecology, Academic Medical Center, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, the Netherlands.
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Burbos N, Musonda P, Duncan TJ, Crocker SG, Nieto JJ, Morris EP. Postmenopausal vaginal bleeding in women using hormone replacement therapy. ACTA ACUST UNITED AC 2012; 18:5-9. [DOI: 10.1258/mi.2011.011111] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Objective To estimate the risk of endometrial cancer in postmenopausal women presenting with vaginal bleeding using estrogen–progestogen hormone replacement therapy (HRT) regimens and to assess if the duration of HRT use has an effect on the risk of diagnosing endometrial cancer. Study design Cross-sectional study of consecutive women presenting with postmenopausal vaginal bleeding at a gynaecological oncology centre in the UK. Main outcome measures Endometrial cancer diagnosis. Results Over a 62-month period, 4847 women were investigated for postmenopausal vaginal bleeding. The majority of women (4097, 84.5%) did not use any HRT preparation at the time of initial referral and 750 (15.5%) women were using combined HRT preparations. A total of 298 (6.1%) women were diagnosed with endometrial carcinoma. Women using HRT preparations were significantly less likely to be diagnosed with endometrial cancer compared with women not using HRT (adjusted odds ratio = 0.229, 95% CI 0.116–0.452; P < 0.0001). The longer duration of HRT use did increase the risk of diagnosing endometrial cancer in women presenting with postmenopausal vaginal bleeding, but this was not statistically significant. Conclusions Postmenopausal women presenting with vaginal bleeding and using combined HRT preparations have significantly lower risk of being diagnosed with endometrial cancer when compared with women not using HRT.
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Affiliation(s)
- Nikolaos Burbos
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Patrick Musonda
- School of Medicine, Health Policy & Practice, University of East Anglia, Norwich, UK
| | - Timothy J Duncan
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Simon G Crocker
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Joaquin J Nieto
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - Edward P Morris
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
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Zaki A, Gaber A, Ghanem E, Moemen M, Shehata G. Abdominal obesity and endometrial cancer in egyptian females with postmenopausal bleeding. Nutr Cancer 2011; 63:1272-8. [PMID: 22043928 DOI: 10.1080/01635581.2011.615973] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Endometrial cancer is the most common type of female genital tract malignancies. We intended to assess the relation between different measures of obesity and the risk to develop endometrial cancer in Egyptian females with postmenopausal bleeding (PMB). The study was conducted in Alexandria, Egypt and included all postmenopausal females presenting to the University Hospital of Gynecology and Obstetrics with PMB within the study period (from January 1 to September 30). A questionnaire was completed, and data about anthropometric measurements including weight, height, and waist circumference were collected. Vaginal sonography, dilatation and curettage, and pathological examination were done by experts for all participants. Endometrial cancer was diagnosed in 38% of females presenting with PMB. Using ROC curve analysis, only the measure of abdominal obesity (waist circumference) showed significant accuracy in predicting endometrial cancer (area = 0.63, P < .05). The best cutoff point that maximizes accuracy was 88 cm. Body mass index (≥30 vs. ≤30) showed no significant relation (OR = 1.1, 95%CI 0.5-2.3), and the ratio between upper and lower body obesity (W/H ratio) showed border line significant relation (OR = 2, 95% CI 1-4.1), whereas waist circumference (≥88 vs. ≤88 cm) showed strikingly high OR (OR = 13.6, 95%CI 4-46.6). The risk of abdominal obesity on endometrial cancer remains very high (OR = 15.8, 95%CI 4.1-60.9) even after adjustment, in a logistic model, for other risk factors such as age at presentation, age at menarche, age at menopause, family history of malignancy, and gravidity. Abdominal obesity (waist circumference >88 cm) is the best measure of obesity to be used in predicting the risk of endometrial cancer in Egyptian females with PMB.
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Affiliation(s)
- Adel Zaki
- Biomedical Informatics and Medical Statistics Department, Medical Research Institute, Alexandria University, Egypt.
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Musonda P, Burbos N, Duncan TJ, Crocker SG, Morris EP, Nieto JJ. Comparing the performance of two clinical models in estimating the risk of endometrial cancer in symptomatic postmenopausal women. Eur J Obstet Gynecol Reprod Biol 2011; 159:433-8. [PMID: 21975177 DOI: 10.1016/j.ejogrb.2011.09.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Revised: 06/29/2011] [Accepted: 09/01/2011] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The aim of this study was to internally evaluate the accuracy measures of the two newly developed predictive models, called DEFAB and DFAB, used to estimate the risk of endometrial cancer in postmenopausal women presenting with vaginal bleeding. STUDY DESIGN Prospective study including postmenopausal women presenting with vaginal bleeding. RESULTS Over a 46-month-period, 3795 postmenopausal women presented with vaginal bleeding and were included in the study. A total of 221 (6%) women were diagnosed with endometrial carcinoma. The DEFAB predictive model incorporates known risk factors such as presence of Diabetes, Endometrial thickness measurement on transvaginal ultrasonography, Frequency of bleeding, Age, and Body mass index. The DFAB model is based on the above clinical characteristics excluding the ultrasonography result. For the recommended cut-off values, there was no evidence (p-value=0.221) of a difference in the diagnostic ability with respect to sensitivity, specificity, area under receiver operating curve, positive predictive value and negative predictive value. There was strong evidence (p-value<0.0001) to suggest that the diagnostic ability of DEFAB and DFAB agree as evidenced by the excellent Kappa statistic 0.950 (95% CI 0.940-0.960). We found strong evidence (p-value<0.0001) that the variables incorporated in both predictive models simultaneously correctly classify an individual to either having cancer or not having cancer with respect to logistic discriminant analysis. CONCLUSION We recommend that these two predictive models can be used interchangeably.
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Affiliation(s)
- Patrick Musonda
- Medical Statistician, School of Medicine, Health Policy & Practice, University of East Anglia, Norwich NR4 7TJ, United Kingdom.
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Doraiswami S, Johnson T, Rao S, Rajkumar A, Vijayaraghavan J, Panicker VK. Study of endometrial pathology in abnormal uterine bleeding. J Obstet Gynaecol India 2011; 61:426-30. [PMID: 22851826 DOI: 10.1007/s13224-011-0047-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Accepted: 06/23/2011] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Abnormal uterine bleeding (AUB) is the commonest presenting symptom in gynaecology out-patient department. Endometrial sampling could be effectively used as the first diagnostic step in AUB, although at times, its interpretation could be quite challenging to the practicing pathologists. This study was done to evaluate histopathology of endometrium for identifying the endometrial causes of AUB. We also tried to observe the incidence of various pathology in different age groups presenting with abnormal uterine bleeding. MATERIAL AND METHODS This was a study done at Sri Ramachandra Medical College and Research Institute, Chennai, India on 620 patients who presented with AUB from June 2005-June 2006. Out of which 409 cases of isolated endometrial lesions diagnosed on histopathology were selected for the final analyses. A statistical analysis between age of presentation and specific endometrial causes was done using χ(2) test. RESULTS The most common age group presenting with AUB was 41-50 years (33.5%). The commonest pattern in these patients was normal cycling endometrium (28.4%). The commonest pathology irrespective of the age group was disordered proliferative pattern (20.5%). Other causes identified were complications of pregnancy (22.7%), benign endometrial polyp (11.2%), endometrial hyperplasias (6.1%), carcinomas (4.4%) and chronic endometritis (4.2%). Endometrial causes of AUB and age pattern was statistically significant with P value <0.05. CONCLUSION There is an age specific association of endometrial lesions. In perimenopausal women AUB is most commonly dysfunctional in origin and in reproductive age group, one should first rule out complications of pregnancy. The incidence of disordered proliferative pattern was significantly high in this study, suggesting an early presentation of these patients.
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Estimating the Risk of Endometrial Cancer in Symptomatic Postmenopausal Women: A Novel Clinical Prediction Model Based on Patients' Characteristics. Int J Gynecol Cancer 2011; 21:500-6. [DOI: 10.1097/igc.0b013e31820c4cd6] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
IntroductionThe aim of this study was to develop a multivariable model to predict the risk of endometrial carcinoma in postmenopausal women with vaginal bleeding using individuals' clinical characteristics.Patients and MethodsThis prospective study of consecutive postmenopausal women presenting with vaginal bleeding was conducted at a gynecological oncology center in the United Kingdom for a 46-month period. All women underwent transvaginal ultrasound scanning as the initial investigation tool to evaluate the endometrium. Women found to have an endometrial thickness 5 mm or more had endometrial sampling performed.ResultsOf a total of 3548 women presenting with vaginal bleeding during the study period, 201 (6%) women had a diagnosis of endometrial carcinoma. An investigator-led best model selection approach used to select the best predictors of cancer in the multiple logistic regression model showed that patient's age (odds ratio [OR], 1.06), body mass index (OR, 1.07), recurrent episodes of bleeding (OR, 3.64), and a history of diabetes (OR, 1.48) increased the risk of endometrial malignancy when corrected for other characteristics. The mentioned clinical variables satisfied the criteria for inclusion in our predictive model called FAD 31 (F for the frequency of bleeding episodes, A for the age of the patient, D for diabetes, and the number 31 represents the BMI cut-off value). The total score for the model varies from 0 to 8. The area under the receiver operating characteristics curve for the developed model was 0.73 (95% confidence interval, 0.70-0.77).DiscussionWe have developed a simple model based on patients' clinical characteristics in estimating the risk of endometrial cancer for postmenopausal women presenting with vaginal bleeding. The model shows reasonable discriminatory ability for women with cancer and without, with an area under the receiver operating characteristics curve of 0.73. This will allow clinicians to individualize the diagnostic pathway for women with postmenopausal vaginal bleeding.
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Abstract
Endometrial cancer covers several different types, the most prevalent in the developed world being endometrioid adenocarcinoma, which is estrogen-dependent and has a better prognosis compared to the non-estrogen-dependent types, e.g. papillary serous adenocarcinoma and clear cell carcinomas. Prognosis is also dependent on tumor differentiation and stage, and treatment should be adjusted accordingly. In this paper, the different types of endometrial cancer, staging, prognosis, diagnosis, prevention, treatment and their relationship to estrogen and other female hormones are reviewed.
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Affiliation(s)
- L S G Ulrich
- Department of Gynecology and Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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