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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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Xydias EM, Kalantzi S, Tsakos E, Ntanika A, Beis N, Prior M, Daponte A, Ziogas AC. Comparison of 3D ultrasound, 2D ultrasound and 3D Doppler in the diagnosis of endometrial carcinoma in patients with uterine bleeding: A systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2022; 277:42-52. [PMID: 35988462 DOI: 10.1016/j.ejogrb.2022.08.005] [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: 04/28/2022] [Revised: 07/21/2022] [Accepted: 08/06/2022] [Indexed: 11/04/2022]
Abstract
Endometrial cancer is a common malignancy affecting women worldwide. Usually, it clinically manifests with uterine bleeding, although identical clinical manifestations occur in benign conditions as well, with several endometrial biopsies being conducted unnecessarily. Therefore, an accurate, non-invasive diagnostic test is needed for first-line assessment, so as unnecessary biopsies are limited as much as possible. This systematic review aims to assess the diagnostic accuracy of three-dimensional ultrasound, a relatively novel method in gynecologic assessment, compared to two-dimensional ultrasound and three-dimensional Doppler in the prediction of uterine malignancy in women with abnormal uterine bleeding. The accuracy of endometrial volume, as a diagnostic parameter assessed by three-dimensional ultrasound is compared to diagnostic parameters from the other two methods, namely endometrial thickness and 3D Doppler indices (vascularization index, flow index and vascularization flow index). Articles relevant to our research question were systematically sought in the Web of Science, Scopus and MEDLINE/PubMed databases and underwent rigorous evaluation for inclusion according to the PRISMA 2020 guidelines. Eligible studies were thoroughly assessed for risk of bias and relevant data was extracted and analyzed. Studies were heterogenous and extracted data varied from study to study. Data on endometrial volume was compared to other diagnostic parameters. Forest plots with pooled percentages and hierarchical summary receiver operating characteristic curves were constructed for each comparison. Relative sensitivity and specificity ratios were calculated for each comparison to test for statistical significance. Endometrial volume and thickness comparison showed sensitivity 83% for both parameters and specificity 75% and 69% respectively, with volume being more specific than thickness (p < 0.05). Endometrial volume and Doppler indices comparison showed that sensitivity was 73%, 82%, 81% and 82%, while specificity was 72%, 76%, 75% and 76% for endometrial volume, vascularization index, flow index and vascularization-flow index respectively. All three Doppler indices were significantly more sensitive in the diagnosis of malignancy compared to endometrial volume (p < 0.05) While endometrial thickness remains a reliable predictor of uterine malignancy, endometrial volume appears promising as a method with higher specificity and more reliable measurements. Similarly, vascular indices seem as competent and even more sensitive than endometrial volume as predictors, with the added advantage of semi-automated and reproducible measurements that reflect the whole organ. More comparative studies with standardized protocols should be established, so as reliable cut-off values can be determined and thus standardize and streamline the diagnostic algorithm via the implementation of the three-dimensional modalities in the settings that they are available.
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Affiliation(s)
- Emmanouil M Xydias
- University of Thessaly, School of Health Sciences, Faculty of Medicine, Biopolis 41334, Larissa, Greece
| | - Sofia Kalantzi
- University of Thessaly, School of Health Sciences, Faculty of Medicine, Biopolis 41334, Larissa, Greece
| | - Elias Tsakos
- EmbryoClinic, Adrianoupoleos 6, 55133 Thessaloniki, Greece
| | - Anna Ntanika
- University of Ioannina, School of Health Sciences, Faculty of Medicine, Kourmanio Campus, 45100 Ioannina, Greece
| | - Nikolaos Beis
- University of Thessaly, School of Health Sciences, Faculty of Medicine, Biopolis 41334, Larissa, Greece
| | - Matthew Prior
- Consultant and Subspecialist in Reproductive Medicine, Head of Department, Newcastle Fertility Centre, International Centre for Life, Newcastle NE1 4EP, UK
| | - Alexandros Daponte
- University of Thessaly, School of Health Sciences, Faculty of Medicine, Biopolis 41334, Larissa, Greece; University of Thessaly, Department of Obstetrics and Gynecology, Larissa General University Hospital, Biopolis 41334, Larissa, Greece
| | - Apostolos C Ziogas
- University of Thessaly, School of Health Sciences, Faculty of Medicine, Biopolis 41334, Larissa, Greece.
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Kulaksiz D, Erin R. Direct hysteroscopic endometrial sampling and pipelle sampling in perimenopausal women. Minerva Obstet Gynecol 2022; 74:343-347. [PMID: 35920358 DOI: 10.23736/s2724-606x.21.04971-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Abnormal uterine bleeding is a common cause of hospital admission in perimenopausal women. It can be the first sign of many diseases such as endometrial cancer and endometrial hyperplasia. Endometrial sampling is valuable in early diagnosis and treatment. Although hysterectomy is the gold standard in the diagnosis of endometrial pathology, it is not considered an acceptable method for diagnosis. With the principle of "see and treat, hysteroscopy seems to be the most successful method. METHODS After obtaining the necessary ethics committee approval, we obtained liquid-based cytology samples of our perimenopausal patients who frequently applied to our outpatient clinic with abnormal uterine bleeding. To conduct endometrial sampling of our patients, we used pipelle aspiration method in our 75-disease group and direct hysteroscopic sampling method in our other 75 disease group. We then compared the pre- and postoperative pathology results. RESULTS There was no statistically significant difference between preoperative and postoperative pathological results in both pipelle and hysteroscopic sampling groups. CONCLUSIONS Evaluation of endometrial pathologies by hysteroscopic method and pipelle method has high sensitivity and specificity. Gynecologists may determine the method preference according to the status of the health system together with their patients.
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Affiliation(s)
- Deniz Kulaksiz
- Department of Obstetrics and Gynecology, Trabzon Kanuni Training and Research Hospital, Health Sciences University, Trabzon, Turkey -
| | - Recep Erin
- Department of Obstetrics and Gynecology, Trabzon Kanuni Training and Research Hospital, Health Sciences University, Trabzon, Turkey
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Schiemer R, Furniss D, Phang S, Seddon AB, Atiomo W, Gajjar KB. Vibrational Biospectroscopy: An Alternative Approach to Endometrial Cancer Diagnosis and Screening. Int J Mol Sci 2022; 23:ijms23094859. [PMID: 35563249 PMCID: PMC9102412 DOI: 10.3390/ijms23094859] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 01/27/2023] Open
Abstract
Endometrial cancer (EC) is the sixth most common cancer and the fourth leading cause of death among women worldwide. Early detection and treatment are associated with a favourable prognosis and reduction in mortality. Unlike other common cancers, however, screening strategies lack the required sensitivity, specificity and accuracy to be successfully implemented in clinical practice and current diagnostic approaches are invasive, costly and time consuming. Such limitations highlight the unmet need to develop diagnostic and screening alternatives for EC, which should be accurate, rapid, minimally invasive and cost-effective. Vibrational spectroscopic techniques, Mid-Infrared Absorption Spectroscopy and Raman, exploit the atomic vibrational absorption induced by interaction of light and a biological sample, to generate a unique spectral response: a “biochemical fingerprint”. These are non-destructive techniques and, combined with multivariate statistical analysis, have been shown over the last decade to provide discrimination between cancerous and healthy samples, demonstrating a promising role in both cancer screening and diagnosis. The aim of this review is to collate available evidence, in order to provide insight into the present status of the application of vibrational biospectroscopy in endometrial cancer diagnosis and screening, and to assess future prospects.
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Affiliation(s)
- Roberta Schiemer
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham NG5 1PB, UK;
- Correspondence:
| | - David Furniss
- Mid-Infrared Photonics Group, George Green Institute for Electromagnetics Research, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, UK; (D.F.); (S.P.); (A.B.S.)
| | - Sendy Phang
- Mid-Infrared Photonics Group, George Green Institute for Electromagnetics Research, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, UK; (D.F.); (S.P.); (A.B.S.)
| | - Angela B. Seddon
- Mid-Infrared Photonics Group, George Green Institute for Electromagnetics Research, Faculty of Engineering, University of Nottingham, Nottingham NG7 2RD, UK; (D.F.); (S.P.); (A.B.S.)
| | - William Atiomo
- College of Medicine, Mohammed Bin Rashid University of Medicine and Health Sciences (MBRU), Dubai P.O. Box 505055, United Arab Emirates;
| | - Ketankumar B. Gajjar
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham NG5 1PB, UK;
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Executive Summary of the Uterine Cancer Evidence Review Conference. Obstet Gynecol 2022; 139:626-643. [PMID: 35272316 PMCID: PMC8936160 DOI: 10.1097/aog.0000000000004711] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 11/18/2021] [Indexed: 01/21/2023]
Abstract
Evidence for uterine cancer prevention, diagnosis, and special issues from the Uterine Cancer Evidence Review Conference is summarized. The Centers for Disease Control and Prevention recognized the need for educational materials for clinicians on the prevention and early diagnosis of gynecologic cancers. The American College of Obstetricians and Gynecologists convened a panel of experts in evidence review from the Society for Academic Specialists in General Obstetrics and Gynecology and content experts from the Society of Gynecologic Oncology to review relevant literature, best practices, and existing practice guidelines as a first step toward developing evidence-based educational materials for women's health care clinicians about uterine cancer. Panel members conducted structured literature reviews, which were then reviewed by other panel members and discussed at a virtual meeting of stakeholder professional and patient advocacy organizations in January 2021. This article is the evidence summary of the relevant literature and existing recommendations to guide clinicians in the prevention, early diagnosis, and special considerations of uterine cancer. Substantive knowledge gaps are noted and summarized to provide guidance for future research.
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Allam MM, Allam MS, Mehasseb MK. Recurrent postmenopausal bleeding: a survey of practice among gynecologists in Scotland. ACTA ACUST UNITED AC 2020; 72:64-69. [PMID: 32403905 DOI: 10.23736/s0026-4784.20.04432-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The definition and management of recurrent postmenopausal bleeding (PMB) are not well described in the literature, with no consensus among the clinicians and no available contemporary UK evidence-based guidelines. We conducted this survey to examine the practice of gynecologists based in Scotland in relation to recurrent postmenopausal bleeding. METHODS A web-based questionnaire was sent to 200 non-training grade gynecologists in Scotland exploring their views on the definition, investigation and management of recurrent PMB. Data were extracted from the 61 responses received. RESULTS Seventy-seven percent of responders defined recurrent PMB as two or more episodes of PMB, while 21% defined it after three episodes. A bleed-free interval of 3 and 6 months was needed to identify a recurrence by 46% and 44% of responders, respectively. 70% would investigate recurrent PMB with a combination of transvaginal sonography, hysteroscopy and biopsy. Only 19% would arrange a pelvic MRI routinely, while 43% would never offer one. 72% would consider a hysterectomy at some stage, with 22% of responders offering it after 3 episodes of PMB with negative investigation. 18% would never offer a hysterectomy without an identified pathology. 32% of responders felt that the management of recurrent PMB required an individualized case-by-case approach. CONCLUSIONS This survey highlights the need for a clinical guideline to address the wide variation in the management of recurrent PMB.
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Affiliation(s)
- Marwa M Allam
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Mohammed S Allam
- Department of Obstetrics and Gynecology, University Hospital of Wishaw, Wishaw, UK
| | - Mohamed K Mehasseb
- Department of Gynecological Oncology, Glasgow Royal Infirmary, NHS Greater Glasgow and Clyde, Glasgow, UK -
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Abstract
Menopause is characterized by permanent cessation of menstrual periods and is clinically diagnosed after 12 months of complete amenorrhea. It occurs at a median age of 51 years alongside the physiological process of aging, although it can happen at an earlier age for other medical conditions or after surgery (surgical menopause). Due to reduced circulating estrogens and progesterone, the reproductive organs undergo progressive atrophy. This physiologic process of aging is also present at an endometrial level; without the cyclic hormonal actions of the menstrual cycle, the endometrium during menopause becomes atrophic. Postmenopausal bleeding (PMB) is a common gynecologic complaint encountered by the clinician. Endometrial cancer is present in about 10% of patients with PMB. Nevertheless, many other conditions, such as endometrial or cervical polyps, genital atrophy, or non-gynecologic conditions, may also be present. Historically, dilation and curettage (D&C) was the main diagnostic procedure in patients with PMB; however, newer methods of investigation have replaced D&C. The aim of this review is to present an up-to-date analysis of the current evidence for the clinical management of vaginal bleeding in postmenopausal women.
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Affiliation(s)
- J Carugno
- Obstetrics, Gynecology and Reproductive Sciences Department, Minimally Invasive Gynecology Unit, Miller School of Medicine, University of Miami, Miami, FL, USA
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Javadian P, Nezhat F. Endometrial Carcinoma and its Precursors. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1242:59-72. [PMID: 32406028 DOI: 10.1007/978-3-030-38474-6_4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
This chapter focuses on premalignant and malignant diseases of the endometrium (lining of the uterus). Endometrial carcinoma is the most common gynecologic cancer in the United States. Women have a 1 in 40 lifetime risk of being diagnosed with endometrial cancer, the fourth most common malignancy among women. An estimated 61,880 new diagnoses of uterine cancer and 12,160 deaths from the disease occurred in 2019 in the United States (American Cancer Society, Facts & Figures, https://www.cdc.gov/cancer/uterine/statistics/index.htm , 2019).
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Affiliation(s)
- Pouya Javadian
- Robert Wood Johnson Barnabas Health Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Farr Nezhat
- Nezhat Surgery for Gynecology/Oncology, New York, NY, USA. .,Weill Cornell Medical College of Cornell University, New York, NY, USA. .,Stony Brook University School of Medicine, Stony Brook, NY, USA. .,Department of Minimally Invasive Gynecologic Surgery and Robotics, NYU Winthrop University Hospital, Mineola, NY, USA.
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Histopathology and Clinical Outcomes of 151 Women with Postmenopausal Bleeding Treated with Resectoscopic Surgery. J Minim Invasive Gynecol 2019; 27:763-773. [PMID: 31202823 DOI: 10.1016/j.jmig.2019.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/22/2019] [Accepted: 06/05/2019] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Because postmenopausal bleeding (PMB) is associated with up to 10% of endometrial neoplasia and office endometrial sampling fails in approximately 10% and is inadequate in 30% of cases, the objective was to determine the role of hysteroscopic endometrial resection (HER) for the diagnosis and treatment of women with PMB. DESIGN A retrospective cohort. SETTING A university-affiliated teaching hospital. PATIENTS One hundred fifty-one women with PMB (September 1990-December 2010). INTERVENTION HER in the operating room. MEASUREMENTS AND MAIN RESULTS The median (range) age and body mass index were 58 (50-87) years and 29 (21-52) kg/m2, respectively. Office endometrial biopsy failed in 30 (19.8%), was inadequate in 20 (13.2%), identified nonatypical endometrial hyperplasia (NAH) in 21 (14%), atypical hyperplasia (AH) in 4 (2.6%), and endometrial cancer (EC) in 2 (1.3%) women. HER in 151 women identified 7 new cases of AH (3 from failed/inadequate office biopsy and 4 from NAH) and 9 EC (5 from failed/inadequate office biopsy, 1 from proliferative endometrium, 2 from NAH, and 1 from AH). All 27 women with NAH were treated by HER alone. Of 8 women with AH, 6 were treated with HER and 2 with hysterectomy; no residual endometrium was found in hysterectomy specimens. Of the 11 women with EC, 2 refused hysterectomy and are well 10 and 15 years after HER. Hysterectomy was performed for 9 of 11 EC cases, 2 of 8 AH cases, and 1 for abnormal uterine bleeding. Six women had repeat HER for persistent abnormal uterine bleeding, and 10 were lost to follow-up. At a median follow-up of 11.5 years (range, 7-20 years), 132 (12 hysterectomies + 10 lost) of 151 (87.4%) women were satisfied with no further bleeding. CONCLUSION In women with PMB, hysteroscopic endometrial resection concomitantly with resection of intrauterine pathology by experienced surgeons is feasible, safe, and effective for diagnosis in all cases and treatment of the majority of intrauterine pathology including NAH and selected cases of AH and EC.
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The thin red line - postmenopausal abnormal uterine bleeding with endometrial thickness less than 4 mm. Contemp Oncol (Pozn) 2019; 23:43-46. [PMID: 31061636 PMCID: PMC6500390 DOI: 10.5114/wo.2019.83816] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 01/31/2019] [Indexed: 11/17/2022] Open
Abstract
Aim of the study To evaluate the risk of endometrial malignancy in postmenopausal women with abnormal uterine bleeding (AUB) with endometrial thickness ≤ 4 mm. Material and methods Histological assessment of endometrial samples obtained via hysteroscopy or curettage was performed in 57 women. Results Women with premalignancy or malignancy (24.6%) had higher endometrial thickness (by 9.7%, p = 0.01) compared to women with benign condition. Out of 12 women with atypical hyperplasia (21.1%), 5 women (8.8%) were diagnosed with simple and 7 women (12.3%) had complex hyperplasia, whereas 2 (3.5%) were diagnosed with malignancy. Conclusions Postmenopausal women with AUB and endometrial echo ≤ 4 mm are less likely to have a malignant condition. However, the role of histological evaluation cannot be undermined, especially in women at high risk of endometrial cancer, and routine endometrial biopsy should be considered. We recommend a change in the cut-off to 2 mm in routine practice.
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Alcázar JL, Bonilla L, Marucco J, Padilla AI, Chacón E, Manzour N, Salas A. Risk of endometrial cancer and endometrial hyperplasia with atypia in asymptomatic postmenopausal women with endometrial thickness ≥11 mm: A systematic review and meta-analysis. JOURNAL OF CLINICAL ULTRASOUND : JCU 2018; 46:565-570. [PMID: 30113073 DOI: 10.1002/jcu.22631] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 06/22/2018] [Accepted: 07/09/2018] [Indexed: 06/08/2023]
Abstract
PURPOSE To evaluate the risk of endometrial cancer and/or endometrial hyperplasia with atypia in asymptomatic postmenopausal women with endometrial thickness ≥ 11 mm. METHODS Systematic review of literature using database search (PubMed and Web of Science) of articles published between January 1990 and December 2016 evaluating the correlation between endometrial thickness as measured by transvaginal ultrasound (double layer) and histopathological findings in asymptomatic postmenopausal women, using the following terms: "endometrial thickness," "postmenopausal," "postmenopause," and "asymptomatic." Inclusion criteria were prospective or retrospective studies of more than 150 cases that provided information on endometrial thickness and its correlation with histopathological data. Studies that included patients with hormone replacement therapy, tamoxifen, or aromatase inhibitors were excluded. The overall relative risk (RR) for EC/EHA was calculated, stratifying the patients into two groups according to endometrial thickness (<11 mm and ≥11 mm). Heterogeneity was assessed by calculating I2 . RESULTS The search identified 289 studies. After exclusions, nine articles that met all the inclusion criteria were included, comprising data from 4751 women. The prevalence of endometrial cancer and/or endometrial hyperplasia with atypia was 2.4%. The relative risk of endometrial cancer and/or endometrial hyperplasia with atypia in the ≥11 mm group was 2.59 (95% CI: 1.66-4.05). High heterogeneity was observed between studies (I2 : 57.3%, P = .016). CONCLUSIONS Overall the risk for EC/EHA was 2.6 times greater in women with ET ≥11 mm vs women with ET 5-10 mm, although there was significant heterogeneity in estimates across studies.
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Affiliation(s)
- Juan Luis Alcázar
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain
| | - Laura Bonilla
- Department of Obstetrics and Gynecology, University Hospital Virgen de las Nieves, Granada, Spain
| | | | - Ana Isabel Padilla
- Department of Obstetrics and Gynecology, Canaty Islands University Hospital, Tenerife, Spain
| | - Enrique Chacón
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain
| | - Nabil Manzour
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain
| | - Aina Salas
- Department of Obstetrics and Gynecology, Clínica Universidad de Navarra, School of Medicine, University of Navarra, Pamplona, Spain
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Gnanachandran C, Zielinski E, Penketh R. Survey on Selection Criteria Indication for Patients with Postmenopausal Bleeding for Hysteroscopy: Variation in Current Practice and Implications for Clinical Effectiveness. J Gynecol Surg 2018. [DOI: 10.1089/gyn.2018.0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Evelyn Zielinski
- Department of Obstetrics and Gynaecology, University Hospital of Leicester, Leicester, UK
| | - Richard Penketh
- Department of Gynaecology, Cardiff and Vale University Health Board, Cardiff, UK
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13
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Chen TC, Wanniarachige D, Murphy S, Lockhart K, O'Mahony J. Surveying the Cost-Effectiveness of the 20 Procedures with the Largest Public Health Services Waiting Lists in Ireland: Implications for Ireland's Cost-Effectiveness Threshold. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:897-904. [PMID: 30098666 DOI: 10.1016/j.jval.2018.02.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 02/21/2018] [Accepted: 02/25/2018] [Indexed: 05/21/2023]
Abstract
OBJECTIVES To survey the cost effectiveness of procedures with the largest waiting lists in the Irish public health system to inform a reconsideration of Ireland's current cost-effectiveness threshold of €45,000/quality-adjusted life-year (QALY). METHODS Waiting list data for inpatient and day case procedures in the Irish public health system were obtained from the National Treatment Purchase Fund. The 20 interventions with the largest number of individuals waiting for inpatient and day case care were identified. The academic literature was searched to obtain cost-effectiveness estimates from Ireland and other high-income countries. Cost-effectiveness estimates from foreign studies were adjusted for differences in currency, purchasing power parity, and inflation. RESULTS Of the top 20 waiting list procedures, 17 had incremental cost-effectiveness ratios (ICERs) lower than €45,000/QALY, 14 fell below €20,000/QALY, and 10 fell below €10,000/QALY. Only one procedure had an ICER higher than the current threshold. Two procedures had ICERs reported for different patient and indication groups that lay on either side of the threshold. CONCLUSIONS Some cost-effective interventions that have large waiting lists may indicate resource misallocation and the threshold may be too high. An evidence-informed revision of the threshold may require a reduction to ensure it is consistent with its theoretical basis in the opportunity cost of other interventions foregone. A limitation of this study was the difficulty in matching specific procedures from waiting lists with ICER estimates from the literature. Nevertheless, our study represents a useful demonstration of a novel concept of using waiting list data to inform cost-effectiveness thresholds.
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Affiliation(s)
| | | | - Síofra Murphy
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Katie Lockhart
- School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - James O'Mahony
- Centre for Health Policy and Management, Trinity College Dublin, Dublin, Ireland.
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14
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Abdaal A, Mushtaq Y, Khasati L, Moneim J, Khan F, Ahmed H, Bolton H. Post-menopausal bleeding - Is transvaginal ultrasound a useful first-line investigation in tamoxifen users? Post Reprod Health 2018; 24:72-78. [PMID: 29402191 DOI: 10.1177/2053369118755190] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Objective To evaluate the role of transvaginal ultrasound triage in women with a history of tamoxifen treatment who present with post-menopausal bleeding. Study design A retrospective review was undertaken of patients who presented with symptoms of post-menopausal bleeding and underwent ultrasound triage. Endometrial thickness and ultrasonographic features were then correlated with hysteroscopic and histopathological outcome data. The findings and outcomes for women with a history of tamoxifen use (tamoxifen group) were compared to those who had not taken tamoxifen (non-tamoxifen group). Results A total of 614 women with post-menopausal bleeding underwent transvaginal ultrasound triage, of whom 53 had a history of current or previous tamoxifen treatment. An endometrial thickness of ≥5 mm or the presence of other abnormal features was used to triage women to further investigation by hysteroscopy and biopsy. Endometrial thickness was significantly greater in the tamoxifen group (11 mm vs. 6 mm). Nearly all of the tamoxifen group were triaged to further investigation (98.1%), compared with significantly fewer in the non-tamoxifen group (68.3%) Overall, the incidence of endometrial pathology was also significantly higher in tamoxifen patients (43.4% vs. 31.7%). Conclusion For women presenting with post-menopausal bleeding, the use of transvaginal ultrasound as a triage tool is rarely helpful in evaluating women who have a history as tamoxifen use, as most will require further investigation with hysteroscopy and biopsy. A post-menopausal bleeding protocol that omits transvaginal ultrasound for women with a history of tamoxifen use may be an appropriate and effective pathway for managing these patients.
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Affiliation(s)
- A Abdaal
- 1 School of Clinical Medicine, Ringgold Standard Institution, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Y Mushtaq
- 1 School of Clinical Medicine, Ringgold Standard Institution, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - L Khasati
- 1 School of Clinical Medicine, Ringgold Standard Institution, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - J Moneim
- 1 School of Clinical Medicine, Ringgold Standard Institution, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - F Khan
- 1 School of Clinical Medicine, Ringgold Standard Institution, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - H Ahmed
- 1 School of Clinical Medicine, Ringgold Standard Institution, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - H Bolton
- 2 Department of Gynaecological Oncology, Ringgold Standard Institution, Addenbrooke's Hospital, Cambridge, UK
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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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16
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Ghoubara A, Sundar S, Ewies AAA. Endometrial pathology in recurrent postmenopausal bleeding: observational study of 385 women. Climacteric 2018; 21:391-396. [PMID: 29741102 DOI: 10.1080/13697137.2018.1461825] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- A. Ghoubara
- University of Birmingham, Birmingham, UK
- Department of Obstetrics and Gynecology, Aswan University, Aswan, Egypt
- Gynaecology Department, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - S. Sundar
- University of Birmingham, Birmingham, UK
- Gynaecology Department, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - A. A. A. Ewies
- University of Birmingham, Birmingham, UK
- Gynaecology Department, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
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Yi Y, Bryce CL, Adambekov S, Edwards RP, Goughnour SL, Linkov F. Cost-effectiveness analysis of biopsy strategies for endometrial cancer diagnosis in women with postmenopausal bleeding: Pipelle sampling curette versus dilatation & curettage. Gynecol Oncol 2018; 150:112-118. [PMID: 29747864 DOI: 10.1016/j.ygyno.2018.04.565] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 04/18/2018] [Accepted: 04/20/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endometrial sampling is widely used for accurate diagnosis of endometrial cancer (EC), which is the most common gynecologic cancer in US women. The objective of this study was to explore the cost-effectiveness of two endometrial sampling procedures for diagnosing EC: (1) Pipelle endometrial sampling (Pipelle), and (2) dilatation & curettage (D&C), while accounting for sampling procedure failure rates and diagnostic accuracy in women with postmenopausal bleeding (PMB). METHOD The decision analytic model was built to compare the cost-effectiveness of Pipelle and D&C strategies in a hypothetical cohort of PMB women. The analysis was performed from the perspective of a public healthcare payer (Medicare, US). We used 2017 Medicare reimbursement data for cost estimation. The effectiveness of these two diagnostic strategies was measured by analyzing the remaining life expectancy after EC diagnosis and subsequent treatment. RESULTS The base case analysis suggested that Pipelle was not only equally effective (32.11 vs. 32.11 years of life), but also less costly ($1897.80 vs. $2999.11) based on Medicare reimbursement when compared to D&C. In one-way sensitivity analyses and Monte Carlo probabilistic sensitivity analysis, the Pipelle remained the more cost-effective sampling strategy even after accounting for sampling failure rate associated with each sampling strategy. CONCLUSION The Pipelle is the more cost-effective sampling strategy compared to D&C for EC diagnosis in women with PMB. From the cost-effectiveness perspective, the higher sampling failure rate of Pipelle should not be regarded as a limitation in its clinical application.
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Affiliation(s)
- Yan Yi
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 130 De Soto St, Pittsburgh, PA 15261, United States.
| | - Cindy L Bryce
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, 130 De Soto St, Pittsburgh, PA 15261, United States
| | - Shalkar Adambekov
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, 130 De Soto St, Pittsburgh, PA 15261, United States
| | - Robert P Edwards
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, 3380 Boulevard of the Allies, 300 Halket Street, Pittsburgh, PA 15213, United States
| | - Sharon L Goughnour
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, 3380 Boulevard of the Allies, 300 Halket Street, Pittsburgh, PA 15213, United States
| | - Faina Linkov
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, 3380 Boulevard of the Allies, 300 Halket Street, Pittsburgh, PA 15213, United States
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Salazar CA, Isaacson KB. Office Operative Hysteroscopy: An Update. J Minim Invasive Gynecol 2017; 25:199-208. [PMID: 28803811 DOI: 10.1016/j.jmig.2017.08.009] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 08/02/2017] [Accepted: 08/05/2017] [Indexed: 02/06/2023]
Abstract
Hysteroscopy is considered the gold standard for the evaluation of intracavitary pathology in both premenopausal and postmenopausal patients associated with abnormal uterine bleeding, as well as for the evaluation of infertile patients with suspected cavity abnormalities. Office-based operative hysteroscopy allows patients to resume activities immediately and successfully integrates clinical practice into a "see and treat" modality, avoiding the added risks of anesthesia and the inconvenience of the operating room. For 2017, the Centers for Medicare and Medicaid Services has provided a substantial increase in reimbursement for a select number of office-based hysteroscopic procedures. This review provides an update on the indications, equipment, and procedures for office hysteroscopy, as well as the management of complications that may arise within an office-based practice.
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Affiliation(s)
| | - Keith B Isaacson
- Newton Wellesley Hospital, Harvard Medical School, Newton, Massachusetts.
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Patient and provider factors associated with endometrial Pipelle sampling failure. Gynecol Oncol 2016; 144:324-328. [PMID: 27912906 DOI: 10.1016/j.ygyno.2016.11.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 11/21/2016] [Accepted: 11/22/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To explore risk factors associated with sampling failure in women who underwent Pipelle biopsy. METHODS A consecutive sample of 201 patient records was selected from women who underwent Pipelle biopsy procedures for suspected uterine pathology in a large healthcare system over a 6-month period (January 2013 through June 2013). Personal and medical data including age, BMI, gravidity and parity, and previous history of Pipelle biopsy were abstracted from medical records for each patient. Logistic regression analyses were used to determine factors associated with biopsy sampling failure. RESULTS Pipelle biopsy sampling failed in 46 out 201 women (22.89%), where 8 (17.39%) were due to inability to access the endometrium, 37 (80.43%) were inadequate samples, and 1 (2.18%) was due to unknown reasons. Personal and medical factors found to be related to sampling failure included: postmenopausal bleeding as biopsy indication (OR 7.41, 95% CI 2.27-24.14); history of prior biopsy failure (OR 23.87, 95% CI 3.76-151.61); and provider type (physician vs. midlevel provider) (OR 9.152, 95% CI 2.49-33.69). CONCLUSION We identified several risk factors for biopsy failure that suggest the need for particular care with Pipelle sampling procedures among women with certain characteristics, including postmenopausal bleeding and a history of prior failed Pipelle biopsy. Our finding of a significantly higher risk of sampling failure based on personal and clinical data suggests that providers must take into account additional considerations to improve sampling success.
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Millet I, Badat N, Petit É, Cayrac M, Pages-Bouic E, Taourel P. Cancer de l’endomètre induit : quelle place pour l’échographie ? IMAGERIE DE LA FEMME 2016. [DOI: 10.1016/j.femme.2016.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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21
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Torrijos MCS, de Merlo GG, Mirasol EG, García MTG, Parra CÁ, Goy EI. Endometrial study in patients with postmenopausal metrorrhagia. Arch Med Sci 2016; 12:597-602. [PMID: 27279854 PMCID: PMC4889695 DOI: 10.5114/aoms.2016.59934] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 11/16/2014] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION The aim of the study was to devise a strategy to diagnose malign endometrial pathologies (adenocarcinoma or atypical hyperplasia) that minimizes the number of invasive tests done (hysteroscopy, aspiration biopsy or curettage) with no loss of its detection efficiency. MATERIAL AND METHODS We retrospectively studied the clinical histories of 779 postmenopausal women at the University Hospital Complex of Albacete, for whom an endometrial study had been done (hysteroscopy, aspiration biopsy or curettage) with a 1-year follow-up between 1 March 2006 and 31 March 2008. RESULTS There were 77 cases of a malignant pathology (66 adenocarcinomas and 11 hyperplasias with atypia); 96.1% had metrorrhagia, and there were only 3 cases of asymptomatic patients (all 3 presented endometrial thickness of > 5 mm: 10, 12 and 15 mm). The sensitivity and specificity of the transvaginal ultrasound, with a 5 mm cut-off point to diagnose a malignant pathology, were 98.4% and 30.1%, respectively; 89.1% and 99.6%, respectively, for aspiration biopsy; 83.9% and 99.1%, respectively, for hysteroscopy without biopsy; and both were 100% for biopsy. Statistical significance was considered at p < 0.05 and confidence intervals were calculated at 95%. CONCLUSIONS In postmenopausal women with metrorrhagia, the first action to take is to do a transvaginal ultrasound, followed by en endometrial study, but only if the endometrium is irregular or endometrial thickness is ≥ 5 mm; in asymptomatic women, the cut-off point should be set at 10 mm. The immediate method of choice is an ambulatory biopsy.
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Affiliation(s)
- María C. Serna Torrijos
- Obstetrics and Gynecology Department, Hospital and University Complex of Albacete (SESCAM), Albacete, Spain
| | - Gaspar González de Merlo
- Obstetrics and Gynecology Department, Hospital and University Complex of Albacete (SESCAM), Albacete, Spain
| | - Esteban González Mirasol
- Obstetrics and Gynecology Department, Hospital and University Complex of Albacete (SESCAM), Albacete, Spain
| | - María Teresa Gómez García
- Obstetrics and Gynecology Department, Hospital and University Complex of Albacete (SESCAM), Albacete, Spain
| | - Carmen Ángel Parra
- Obstetrics and Gynecology Department, Hospital and University Complex of Albacete (SESCAM), Albacete, Spain
| | - Enrique Iglesias Goy
- Department of Medical Sciences, School of Medicine, University Autonóma, Madrid, Spain
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Clark TJ, Middleton LJ, Cooper NA, Diwakar L, Denny E, Smith P, Gennard L, Stobert L, Roberts TE, Cheed V, Bingham T, Jowett S, Brettell E, Connor M, Jones SE, Daniels JP. A randomised controlled trial of Outpatient versus inpatient Polyp Treatment (OPT) for abnormal uterine bleeding. Health Technol Assess 2016; 19:1-194. [PMID: 26240949 DOI: 10.3310/hta19610] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Uterine polyps cause abnormal bleeding in women and conventional practice is to remove them in hospital under general anaesthetic. Advances in technology make it possible to perform polypectomy in an outpatient setting, yet evidence of effectiveness is limited. OBJECTIVES To test the hypothesis that in women with abnormal uterine bleeding (AUB) associated with benign uterine polyp(s), outpatient polyp treatment achieved as good, or no more than 25% worse, alleviation of bleeding symptoms at 6 months compared with standard inpatient treatment. The hypothesis that response to uterine polyp treatment differed according to the pattern of AUB, menopausal status and longer-term follow-up was tested. The cost-effectiveness and acceptability of outpatient polypectomy was examined. DESIGN A multicentre, non-inferiority, randomised controlled trial, incorporating a cost-effectiveness analysis and supplemented by a parallel patient preference study. Patient acceptability was evaluated by interview in a qualitative study. SETTING Outpatient hysteroscopy clinics and inpatient gynaecology departments within UK NHS hospitals. PARTICIPANTS Women with AUB - defined as heavy menstrual bleeding (formerly known as menorrhagia) (HMB), intermenstrual bleeding or postmenopausal bleeding - and hysteroscopically diagnosed uterine polyps. INTERVENTIONS We randomly assigned 507 women, using a minimisation algorithm, to outpatient polypectomy compared with conventional inpatient polypectomy as a day case in hospital under general anaesthesia. MAIN OUTCOME MEASURES The primary outcome was successful treatment at 6 months, determined by the woman's assessment of her bleeding. Secondary outcomes included quality of life, procedure feasibility, acceptability and cost per quality-adjusted life-year (QALY) gained. RESULTS At 6 months, 73% (166/228) of women who underwent outpatient polypectomy were successfully treated compared with 80% (168/211) following inpatient polypectomy [relative risk (RR) 0.91, 95% confidence interval (CI) 0.82 to 1.02]. The lower end of the CIs showed that outpatient polypectomy was at most 18% worse, in relative terms, than inpatient treatment, within the 25% margin of non-inferiority set at the outset of the study. By 1 and 2 years the corresponding proportions were similar producing RRs close to unity. There was no evidence that the treatment effect differed according to any of the predefined subgroups when treatments by variable interaction parameters were examined. Failure to completely remove polyps was higher (19% vs. 7%; RR 2.5, 95% CI 1.5 to 4.1) with outpatient polypectomy. Procedure acceptability was reduced with outpatient compared with inpatient polyp treatment (83% vs. 92%; RR 0.90, 95% CI 0.84 to 0.97). There were no significant differences in quality of life. The incremental cost-effectiveness ratios at 6 and 12 months for inpatient treatment were £1,099,167 and £668,800 per additional QALY, respectively. CONCLUSIONS When treating women with AUB associated with uterine polyps, outpatient polypectomy was non-inferior to inpatient polypectomy at 6 and 12 months, and relatively cost-effective. However, patients need to be aware that failure to remove a polyp is more likely with outpatient polypectomy and procedure acceptability lower. TRIAL REGISTRATION Current Controlled Trials ISRCTN 65868569. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 61. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- T Justin Clark
- Birmingham Women's Hospital NHS Foundation Trust, Edgbaston, Birmingham, UK.,School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Lee J Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Natalie Am Cooper
- Women's Health Research Unit, The Blizard Institute, Queen Mary University of London, London, UK
| | - Lavanya Diwakar
- Health Economics Unit, School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Elaine Denny
- Centre for Health and Social Care Research, Faculty of Health, Birmingham City University, Edgbaston, Birmingham, UK
| | - Paul Smith
- Birmingham Women's Hospital NHS Foundation Trust, Edgbaston, Birmingham, UK.,School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Laura Gennard
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Lynda Stobert
- Centre for Health and Social Care Research, Faculty of Health, Birmingham City University, Edgbaston, Birmingham, UK
| | - Tracy E Roberts
- Health Economics Unit, School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Versha Cheed
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Tracey Bingham
- Birmingham Women's Hospital NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - Sue Jowett
- Health Economics Unit, School of Health and Population Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Elizabeth Brettell
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Mary Connor
- Jessop Wing, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Sian E Jones
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Jane P Daniels
- School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
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Famuyide AO, Shazly SAM, Makdisi PB, El-Nashar SA, Breitkopf DM, Hopkins MR, Laughlin-Tommaso SK. Impact of Simple Ovarian Cysts on the Interpretation of Endometrial Thickness in Women with Postmenopausal Bleeding. J Womens Health (Larchmt) 2016; 25:889-96. [PMID: 27064534 DOI: 10.1089/jwh.2015.5644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There is evidence that premenopausal hormones may persist for variable time after menopause. Histological specimens from postmenopausal women support the presence of follicular growth at that age. Residual ovarian function may explain postmenopausal bleeding (PMB), which is not associated with endometrial pathology. Our objective was to evaluate the effect of sonographic diagnosis of simple ovarian cysts on the association between thickened endometrium and endometrial pathology in women with PMB. MATERIALS AND METHODS Data were retrospectively collected from medical records of women who underwent office hysteroscopy for PMB between January 2007 and October 2011. Women with sonographic reports within 3 months of presentation were included. Endometrial thickness and the presence of a simple ovarian cyst (≤5 cm) were documented by reviewing sonographic reports. Diagnosis of endometrial pathology was abstracted according to pathology reports or hysteroscopic impression. Endometria with hyperplasia, cancer, or polyps were considered pathological. RESULTS Of 836 women with PMB, 356 had recent transvaginal sonography and were included in the analysis. Pathological endometrium was documented in 129 (36.2%) women, including 29 (8.2%) with endometrial cancer. In women with PMB and no evidence of a simple ovarian cyst, endometrial thickness was an independent predictor of endometrial pathology and endometrial cancer with adjusted OR = 1.13 (95% CI = 1.07-1.19) and 1.16 (95% CI = 1.07-1.25), respectively. In the presence of simple ovarian cysts, the adjusted ORs for endometrial thickness as a predictor of endometrial pathology were 1.06 (95% CI = 0.90-1.25) and 0.84 (95% CI = 0.62-1.14), respectively. CONCLUSION The presence of simple ovarian cysts (≤5 cm) tempers the value of endometrial thickness in predicting endometrial pathology in women with PMB.
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Affiliation(s)
- Abimbola O Famuyide
- 1 Department of Obstetrics and Gynecology, Mayo Clinic , Rochester, Minnesota
| | - Sherif A M Shazly
- 1 Department of Obstetrics and Gynecology, Mayo Clinic , Rochester, Minnesota.,2 Department of Obstetrics and Gynecology, Assiut University , Asyut, Egypt
| | - Peter B Makdisi
- 1 Department of Obstetrics and Gynecology, Mayo Clinic , Rochester, Minnesota
| | - Sherif A El-Nashar
- 1 Department of Obstetrics and Gynecology, Mayo Clinic , Rochester, Minnesota
| | - Daniel M Breitkopf
- 1 Department of Obstetrics and Gynecology, Mayo Clinic , Rochester, Minnesota
| | - Matthew R Hopkins
- 1 Department of Obstetrics and Gynecology, Mayo Clinic , Rochester, Minnesota
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A Structured Assessment to Decrease the Amount of Inconclusive Endometrial Biopsies in Women with Postmenopausal Bleeding. Int J Surg Oncol 2016; 2016:3039261. [PMID: 27034826 PMCID: PMC4808545 DOI: 10.1155/2016/3039261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 01/19/2016] [Accepted: 02/08/2016] [Indexed: 11/17/2022] Open
Abstract
Objective. To determine whether structured assessment of outpatient endometrial biopsies decreases the number of inconclusive samples. Design. Retrospective cohort study. Setting. Single hospital pathology laboratory. Population. Endometrial biopsy samples of 66 women with postmenopausal bleeding, collected during the usual diagnostic work-up and assessed as insufficient for a reliable histological diagnosis. Methods. Endometrial biopsy samples were requested from the pathology laboratories. The retrieved samples were systematically reassessed by a single pathologist specialized in gynecology. Main Outcome Measure. Disagreement between initial assessment and conclusion after structured reassessment. Results. We retrieved 36 of 66 endometrial biopsy samples from six different pathology laboratories. Structured reassessment of the retrieved samples by a single pathologist specialized in gynecology did not change the conclusion in 35 of the 36 samples. The remaining sample contained a large amount of endometrial tissue and the diagnosis at reassessment was endometrial hyperplasia without atypia. All other samples contained insufficient material for a reliable diagnosis. Conclusion. A structured reassessment of endometrial biopsies samples, which were classified as inconclusive due to insufficient material, did not change the conclusion. Although it might be helpful for pathologists to have diagnostic criteria for adequacy and/or inadequacy of an endometrial biopsy sample, the gain in efficiency is likely to be small.
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25
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El-Sharkawy M, El-Mazny A, Ramadan W, Hatem D, Abdel-Hafiz A, Hammam M, Nada A. Three-dimensional ultrasonography and power Doppler for discrimination between benign and malignant endometrium in premenopausal women with abnormal uterine bleeding. BMC WOMENS HEALTH 2016; 16:18. [PMID: 26980265 PMCID: PMC4793544 DOI: 10.1186/s12905-016-0297-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 03/09/2016] [Indexed: 08/30/2023]
Abstract
BACKGROUND Ultrasonography has been extensively used in women suspected of having a gynecological malignancy. The aim of this study is to evaluate the efficacy of 3D ultrasonography and power Doppler for discrimination between benign and malignant endometrium in premenopausal women with abnormal uterine bleeding. METHODS This cross-sectional study included 78 premenopausal women with abnormal uterine bleeding scheduled for hysteroscopy and endometrial curettage. The endometrial thickness (ET), uterine artery pulsatility index (PI) and resistance index (RI), and endometrial volume (EV) and 3D power Doppler vascularization index (VI), flow index (FI), and vascularization flow index (VFI) were measured and compared with hysteroscopic and histopathologic findings. RESULTS The ET (P <0.001), EV (P <0.001), and endometrial VI (P <0.001) and VFI (P = 0.043) were significantly increased in patients with atypical endometrial hyperplasia and endometrial carcinoma (n = 10) than those with benign endometrium (n = 68); whereas, the uterine artery PI and RI and endometrial FI were not significantly different between the two groups. The best marker for discrimination between benign and malignant endometrium was the VI with an area under the ROC curve of 0.88 at a cutoff value of 0.81%. CONCLUSION 3D ultrasonography and power Doppler, especially endometrial VI, may be useful for discrimination between benign and malignant endometrium in premenopausal women with abnormal uterine bleeding.
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Affiliation(s)
- Mohamed El-Sharkawy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Akmal El-Mazny
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Wafaa Ramadan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Dina Hatem
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Aly Abdel-Hafiz
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Hammam
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Adel Nada
- Department of Obstetrics and Gynecology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Dueholm M, Marinovskij E, Hansen ES, Møller C, Ørtoft G. Diagnostic methods for fast-track identification of endometrial cancer in women with postmenopausal bleeding and endometrial thickness greater than 5 mm. Menopause 2016; 22:616-26. [PMID: 25535964 DOI: 10.1097/gme.0000000000000358] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aims to evaluate the diagnostic efficiency of pattern recognition by transvaginal ultrasonography (TVS) and gel infusion sonography (GIS) for identifying endometrial pathology and to compare this setup with a standard setup of endometrial sampling (ES), hysteroscopy with pattern evaluation (HY(pattern)), or magnetic resonance imaging (MRI). METHODS This study used a prospective cohort of 174 women with postmenopausal bleeding and endometrial thickness of 5 mm or greater. Resectoscopic biopsy (hysteroscopy with biopsy) samples or hysterectomy served as reference standard. Malignant and benign endometrial patterns were evaluated with TVS, GIS and HY(pattern) were then added. The efficiency of each diagnostic strategy, including ES and MRI findings (n = 83), was compared and evaluated against the reference standard. RESULTS ES, TVS, GIS, and HY(pattern) had high diagnostic efficiency (area under the curve) for malignancy diagnosis (ES, 0.90; TVS, 0.88; GIS, 0.92; HY(pattern), 0.91). When insufficient samples were incorporated, ES was less efficient than the other techniques. ES was not more efficient in the subgroup of women without localized lesions than in the subgroup of women with localized lesions. MRI and HY(pattern) added limited efficiency, whereas hysteroscopy with biopsy was most efficient. CONCLUSIONS As a first-line technique, pattern recognition on TVS, GIS, and HY(pattern) correctly identifies 9 of 10 women with malignancy and is superior to pattern recognition on ES when insufficient samples are included. Endometrial pattern evaluated with TVS and GIS is a fast and efficient first-line diagnostic tool that outperforms ES in women with or without localized lesions. Malignant patterns on TVS/GIS should warrant fast-track evaluation, whereas women with benign patterns may be selected for office or operative hysteroscopy. A fast-track diagnostic setup based on pattern recognition is presented.
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Affiliation(s)
- Margit Dueholm
- From the 1Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus N, Denmark; 2Department of Diagnostic Imaging, Aarhus University Hospital, Aarhus N, Denmark; and 3Department of Pathology, Aarhus University Hospital, Aarhus N, Denmark
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27
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The accuracy of endometrial sampling in women with postmenopausal bleeding: a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol 2016; 197:147-55. [DOI: 10.1016/j.ejogrb.2015.12.008] [Citation(s) in RCA: 116] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 11/28/2015] [Accepted: 12/10/2015] [Indexed: 11/23/2022]
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Dueholm M, Hjorth IMD, Secher P, Jørgensen A, Ørtoft G. Structured Hysteroscopic Evaluation of Endometrium in Women With Postmenopausal Bleeding. J Minim Invasive Gynecol 2015; 22:1215-24. [DOI: 10.1016/j.jmig.2015.06.018] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 06/13/2015] [Accepted: 06/17/2015] [Indexed: 11/25/2022]
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Cooper NAM, Robinson LLL, Clark TJ. Ambulatory hysteroscopy and its role in the management of abnormal uterine bleeding. JOURNAL OF FAMILY PLANNING AND REPRODUCTIVE HEALTH CARE 2015; 41:284-91. [DOI: 10.1136/jfprhc-2014-100872] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Reproducibility of Endometrial Pathologic Findings Obtained on Hysteroscopy, Transvaginal Sonography, and Gel Infusion Sonography in Women With Postmenopausal Bleeding. J Minim Invasive Gynecol 2015; 22:1036-44. [PMID: 26044592 DOI: 10.1016/j.jmig.2015.05.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Revised: 05/26/2015] [Accepted: 05/27/2015] [Indexed: 12/26/2022]
Abstract
STUDY OBJECTIVE To evaluate and compare interobserver variation in endometrial pattern recognition with hysteroscopy (HY) and transvaginal sonography (TVS) and gel infusion sonography (GIS) with regard to the diagnosis of endometrial pathology. DESIGN Prospective study (Canadian Task Force II-1). SETTING University clinic. PATIENTS One hundred twenty-two consecutive women with postmenopausal bleeding and an endometrium thickness ≥ 5 mm. INTERVENTION Two observers using HY and 2 others using TVS and GIS evaluated the endometrial pattern in recorded video clips. Interobserver agreement regarding findings obtained with TVS, GIS, and HY for a diagnosis of cancer, hyperplasia, polyps, and no endometrial pathology was expressed by κ coefficients and compared. MEASUREMENT AND MAIN RESULTS Interobserver agreement (κ) was as follows: identification of normal endometrium: HY (.74), TVS (.68), and GIS (.48); diagnosis of cancer: HY (.56), TVS (.59), and GIS (.34); classification in all categories of endometrial pathology: HY (.70), TVS (.47), and GIS (.41) (p < .05 HY vs GIS). The presence of additional endometrial polyps decreased agreement on HY in patients with hyperplasia or cancer. Observer agreement was poor regarding the diagnosis of hyperplasia by all techniques. CONCLUSION Observer agreement regarding both HY and TVS was reliable for the diagnosis of a normal endometrium but poor with HY, TVS, and especially GIS for a diagnosis of cancer. In patients with hyperplasia or cancer, agreement between observers was especially low in the presence of additional polyps when HY was used. These findings call attention to the need for systematic methods to improve reliability in endometrial pattern recognition.
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Diagnostic utility of three-dimensional power Doppler ultrasound for postmenopausal bleeding. Taiwan J Obstet Gynecol 2015; 54:221-6. [DOI: 10.1016/j.tjog.2013.10.043] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2013] [Indexed: 11/22/2022] Open
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Dueholm M, Christensen JW, Rydbjerg S, Hansen ES, Ørtoft G. Two- and three-dimensional transvaginal ultrasound with power Doppler angiography and gel infusion sonography for diagnosis of endometrial malignancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:734-743. [PMID: 24862861 DOI: 10.1002/uog.13421] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 05/14/2014] [Accepted: 05/16/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To evaluate the diagnostic efficiency of two-dimensional (2D) and three-dimensional (3D) transvaginal ultrasonography, power Doppler angiography (PDA) and gel infusion sonography (GIS) at offline analysis for recognition of malignant endometrium compared with real-time evaluation during scanning, and to determine optimal image parameters at 3D analysis. METHODS One hundred and sixty-nine consecutive women with postmenopausal bleeding and endometrial thickness ≥ 5 mm underwent systematic evaluation of endometrial pattern on 2D imaging, and 2D videoclips and 3D volumes were later analyzed offline. Histopathological findings at hysteroscopy or hysterectomy were used as the reference standard. The efficiency of the different techniques for diagnosis of malignancy was calculated and compared. 3D image parameters, endometrial volume and 3D vascular indices were assessed. Optimal 3D image parameters were transformed by logistic regression into a risk of endometrial cancer (REC) score, including scores for body mass index, endometrial thickness and endometrial morphology at gray-scale and PDA and GIS. RESULTS Offline 2D and 3D analysis were equivalent, but had lower diagnostic performance compared with real-time evaluation during scanning. Their diagnostic performance was not markedly improved by the addition of PDA or GIS, but their efficiency was comparable with that of real-time 2D-GIS in offline examinations of good image quality. On logistic regression, the 3D parameters from the REC-score system had the highest diagnostic efficiency. The area under the curve of the REC-score system at 3D-GIS (0.89) was not improved by inclusion of vascular indices or endometrial volume calculations. CONCLUSION Real-time evaluation during scanning is most efficient, but offline 2D and 3D analysis is useful for prediction of endometrial cancer when good image quality can be obtained. The diagnostic efficiency at 3D analysis may be improved by use of REC-scoring systems, without the need for calculation of vascular indices or endometrial volume. The optimal imaging modality appears to be real-time 2D-GIS.
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Affiliation(s)
- M Dueholm
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - J W Christensen
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - S Rydbjerg
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - E S Hansen
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark
| | - G Ørtoft
- Department of Obstetrics and Gynecology, Aarhus University Hospital, Aarhus, Denmark
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Wong ASW, Lao TTH, Cheung CW, Yeung SW, Fan HL, Ng PS, Yuen PM, Sahota DS. Reappraisal of endometrial thickness for the detection of endometrial cancer in postmenopausal bleeding: a retrospective cohort study. BJOG 2015; 123:439-46. [PMID: 25800522 DOI: 10.1111/1471-0528.13342] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2015] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To estimate the accuracy of transvaginal ultrasound (TVS) measurement of endometrial thickness (ET) in diagnosing endometrial cancer in postmenopausal women with vaginal bleeding (PMB). DESIGN Retrospective cohort study. SETTING One-stop PMB clinic in a Hong Kong teaching hospital. POPULATION A cohort of 4383 women with PMB. METHODS Transvaginal ultrasonic measurement of ET and endometrial biopsies were obtained in women presenting with PMB between 2002 and 2013. Endometrial histology was used as the reference standard to calculate accuracy estimates. MAIN OUTCOME MEASURES Accuracy data for TVS ET presented as sensitivity, specificity, and area under the receiver operator characteristic (ROC) curve. RESULTS Endometrial cancer was diagnosed in 3.8% of women. The median ET in those with endometrial cancer was significantly higher than those with benign conditions (15.7 versus 3.2 mm, P < 0.001). The area under the ROC curve was 0.92 (95% CI 0.89-0.94). The sensitivity for the detection of endometrial cancer at 3-, 4-, and 5-mm cut-offs were 97.0% (95% CI 94.5-99.6%), 94.1% (95% CI 90.5-97.6%), and 93.5% (95% CI 89.7-97.2%), respectively. The corresponding estimates of specificity at these thresholds were 45.3% (95% CI 43.8-46.8%), 66.8% (65.4-68.2%), and 74.0% (72.7-75.4%). CONCLUSIONS Transvaginal ultrasound using a 3-mm cut-off has high sensitivity for detecting endometrial cancer and can identify women with PMB who are highly unlikely to have endometrial cancer, thereby avoiding more invasive endometrial biopsy.
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Affiliation(s)
- A S-W Wong
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong City, Hong Kong
| | - T T-H Lao
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong City, Hong Kong
| | - C W Cheung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong City, Hong Kong
| | - S W Yeung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong City, Hong Kong
| | - H L Fan
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong City, Hong Kong
| | - P S Ng
- Department of Obstetrics and Gynaecology, Union Hospital, Hong Kong City, Hong Kong
| | - P M Yuen
- Department of Obstetrics and Gynaecology, Hong Kong Sanatorium & Hospital, Hong Kong City, Hong Kong
| | - D S Sahota
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong City, Hong Kong
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Does probability guided hysteroscopy reduce costs in women investigated for postmenopausal bleeding? ScientificWorldJournal 2015; 2015:605312. [PMID: 25785283 PMCID: PMC4345274 DOI: 10.1155/2015/605312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 12/11/2014] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To evaluate whether a model to predict a failed endometrial biopsy in women with postmenopausal bleeding (PMB) and a thickened endometrium can reduce costs without compromising diagnostic accuracy. DESIGN, SETTING, AND POPULATION Model based cost-minimization analysis. METHODS A decision analytic model was designed to compare two diagnostic strategies for women with PMB: (I) attempting office endometrial biopsy and performing outpatient hysteroscopy after failed biopsy and (II) predicted probability of a failed endometrial biopsy based on patient characteristics to guide the decision for endometrial biopsy or immediate hysteroscopy. Robustness of assumptions regarding costs was evaluated in sensitivity analyses. MAIN OUTCOME MEASURES Costs for the different strategies. RESULTS At different cut-offs for the predicted probability of failure of an endometrial biopsy, strategy I was generally less expensive than strategy II. The costs for strategy I were always € 460; the costs for strategy II varied between € 457 and € 475. At a 65% cut-off, a possible saving of € 3 per woman could be achieved. CONCLUSIONS Individualizing the decision to perform an endometrial biopsy or immediate hysteroscopy in women presenting with postmenopausal bleeding based on patient characteristics does not increase the efficiency of the diagnostic work-up.
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Seshadri S, Khalil M, Osman A, Clough A, Jayaprakasan K, Khalaf Y. The evolving role of saline infusion sonography (SIS) in infertility. Eur J Obstet Gynecol Reprod Biol 2014; 185:66-73. [PMID: 25528732 DOI: 10.1016/j.ejogrb.2014.11.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 11/19/2014] [Accepted: 11/27/2014] [Indexed: 10/24/2022]
Abstract
Saline infusion sonography (SIS) has become a valuable diagnostic modality in gynaecology over the last three decades. SIS is now commonly employed for detailed evaluation of the uterine cavity as part of pre-treatment assessment in infertile women. The objective of this paper is review the scientific literature on SIS in infertility. Medline, Ovid and Cochrane databases were searched for relevant articles. The indications, technical aspects and the potential advantages of SIS are discussed. The efficacy and sensitivity of SIS are compared to hysteroscopy in the evaluation of uterine polyps, fibroids, intrauterine adhesions and uterine anomalies. Increasing evidence suggests the use of SIS prior to an in-vitro fertilization (IVF) cycle as it has increased sensitivity in the detection of intrauterine pathology. SIS is cost-effective and results in better patient satisfaction scores than hysteroscopy.
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Affiliation(s)
- S Seshadri
- Assisted Conception Unit, Guys Hospital, 11th Floor, Tower Wing, Great Maze Pond, London SE1 9RT, United Kingdom.
| | - M Khalil
- Assisted Conception Unit, Guys Hospital, 11th Floor, Tower Wing, Great Maze Pond, London SE1 9RT, United Kingdom
| | - A Osman
- Assisted Conception Unit, Guys Hospital, 11th Floor, Tower Wing, Great Maze Pond, London SE1 9RT, United Kingdom
| | - A Clough
- Assisted Conception Unit, Guys Hospital, 11th Floor, Tower Wing, Great Maze Pond, London SE1 9RT, United Kingdom
| | - K Jayaprakasan
- Royal Derby Hospital, Derby & NURTURE, University of Nottingham, Nottingham NG7 2UH, United Kingdom
| | - Y Khalaf
- Assisted Conception Unit, Guys Hospital, 11th Floor, Tower Wing, Great Maze Pond, London SE1 9RT, United Kingdom
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Smith PP, O'Connor S, Gupta J, Clark TJ. Recurrent Postmenopausal Bleeding: a Prospective Cohort Study. J Minim Invasive Gynecol 2014; 21:799-803. [DOI: 10.1016/j.jmig.2014.03.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 03/04/2014] [Accepted: 03/06/2014] [Indexed: 11/27/2022]
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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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Salman MC, Bozdag G, Dogan S, Yuce K. Role of postmenopausal bleeding pattern and women's age in the prediction of endometrial cancer. Aust N Z J Obstet Gynaecol 2013; 53:484-8. [PMID: 23909869 DOI: 10.1111/ajo.12113] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 06/04/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Women with postmenopausal bleeding should be evaluated efficiently to exclude endometrial carcinoma. AIMS To estimate the risk of endometrial cancer using individual case characteristics among women with postmenopausal bleeding in whom the endometrial thickness is >4 mm. METHODS Women with postmenopausal bleeding underwent clinical evaluation followed by transvaginal ultrasonography and endometrial biopsy. Clinical evaluation included age, body mass index, duration of menopause, number of bleeding episodes and amount of bleeding. RESULTS This study included 142 women, and endometrial carcinoma was found in 18 (12.7%). Older age, higher body mass index, longer duration of menopause, longer lasting bleeding episodes, higher amount of bleeding and recurrent bleeding episodes were the clinical characteristics associated with endometrial cancer. However, multivariate analysis revealed >55 years of age during postmenopausal bleeding, history of recurrent bleeding episodes and bleeding exceeding 5 pads per day in each episode as significant parameters, which predicted the presence of endometrial cancer among women with postmenopausal bleeding. CONCLUSIONS Prompt evaluation is required in women with postmenopausal bleeding to exclude endometrial cancer. Transvaginal ultrasonography is a reasonable first-line approach, and invasive sampling is required when ultrasonographic endometrial thickness is above 4 mm. However, about 90% of women with postmenopausal bleeding will finally be found to have a nonmalignant condition. Therefore, women who are at increased cancer risk should further be distinguished. This may be achieved using individual patient characteristics that result in a more accurate evaluation strategy with lower rates of unnecessary invasive procedures.
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Affiliation(s)
- Mehmet C Salman
- Department of Obstetrics and Gynaecology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Visser NC, Breijer MC, Herman MC, Bekkers RL, Veersema S, Opmeer BC, Mol BW, Timmermans A, Pijnenborg JM. Factors attributing to the failure of endometrial sampling in women with postmenopausal bleeding. Acta Obstet Gynecol Scand 2013; 92:1216-22. [DOI: 10.1111/aogs.12212] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 06/24/2013] [Indexed: 12/01/2022]
Affiliation(s)
| | | | - Malou C. Herman
- Department of Obstetrics and Gynecology; Maxima Medical Center; Veldhoven
| | - Ruud L.M. Bekkers
- Department of Obstetrics and Gynecology; Radboud University Nijmegen Medical Center; Nijmegen
| | | | - Brent C. Opmeer
- Clinical Research Unit; Academic Medical Center; Amsterdam; the Netherlands
| | | | - Anne Timmermans
- Department of Obstetrics and Gynecology; Academic Medical Center; Amsterdam
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McPencow AM, Erekson EA, Guess MK, Martin DK, Patel DA, Xu X. Cost-effectiveness of endometrial evaluation prior to morcellation in surgical procedures for prolapse. Am J Obstet Gynecol 2013; 209:22.e1-9. [PMID: 23545164 DOI: 10.1016/j.ajog.2013.03.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 03/13/2013] [Accepted: 03/27/2013] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of the study was to compare the cost-effectiveness of 3 screening options for endometrial cancer in asymptomatic, postmenopausal women prior to undergoing morcellation in minimally invasive supracervical hysterectomy and minimally invasive sacral colpopexy for the treatment of pelvic organ prolapse. STUDY DESIGN A decision tree model was constructed to compare no screening, endometrial biopsy, and transvaginal ultrasound for asymptomatic, postmenopausal women prior to surgery. Effectiveness was measured by life-years. The incremental cost-effectiveness ratio, defined as the difference in cost between 2 screening options divided by the difference in life-years between the 2 options, was calculated in 2012 US dollars for endometrial biopsy and transvaginal ultrasound, in comparison with no screening. RESULTS Using an endometrial cancer prevalence of 0.6% and a 40% risk of upstaging after morcellation, the expected per-patient cost was $8800, $9023, and $9112 over 5 years for no screening, endometrial biopsy, and transvaginal ultrasound, respectively. The expected life-years saved compared with no screening were 0.00108 for endometrial biopsy and 0.00105 for transvaginal ultrasound, ie, 0.39 and 0.38 days, respectively. The estimated incremental cost-effectiveness ratio was $207,348 for endometrial biopsy and $298,038 for transvaginal ultrasound compared with no screening. A sensitivity analysis showed that the prevalence of endometrial cancer and the risk of endometrial cancer upstaging after morcellation had the greatest impact on the cost-effectiveness of screening. CONCLUSION For asymptomatic, postmenopausal women, preoperative endometrial evaluation via endometrial biopsy or transvaginal ultrasound helps improve the preoperative detection of endometrial cancer, but universal screening is not cost effective.
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Affiliation(s)
- Alexandra M McPencow
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale School of Medicine, New Haven, CT.
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Steiner E, Juhasz-Bösz I, Emons G, Kölbl H, Kimmig R, Mallmann P. Transvaginal Ultrasound for Endometrial Carcinoma Screening - Current Evidence-based Data. Geburtshilfe Frauenheilkd 2012; 72:1088-1091. [PMID: 25278620 DOI: 10.1055/s-0032-1328070] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
The value of transvaginal ultrasound in gynaecological examinations is beyond dispute. But it is of particular forensic importance that the validity of this type of imaging with regard to the reliable detection of early-stage malignancy is properly understood. Vaginal ultrasound screening in asymptomatic patients for the early detection of endometrial carcinoma is not useful from a medical point of view, nor is it cost-efficient. However, even though the validity of transvaginal ultrasound for screening has currently not been proven, the method should still be an integral part of gynaecological examinations.
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Affiliation(s)
- E Steiner
- Department of Obstetrics and Gynaecology, GPR Clinical Centre Ruesselsheim
| | - I Juhasz-Bösz
- Department of Obstetrics and Gynaecology, University of Saarland
| | - G Emons
- Department of Obstetrics and Gynaecology, Georg-August-University of Goettingen
| | - H Kölbl
- Department of Obstetrics and Gynaecology, Medical University of Vienna
| | - R Kimmig
- Department of Obstetrics and Gynaecology, University of Duisburg-Essen
| | - P Mallmann
- Department of Obstetrics and Gynaecology, Cologne University
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Elfayomy AK, El Tarhouny SA. Ovarian volume assessment in relation to histologic findings and sex hormone levels in women with postmenopausal bleeding and thickened endometrium. Ann Saudi Med 2012; 32:588-92. [PMID: 23396021 PMCID: PMC6081122 DOI: 10.5144/0256-4947.2012.588] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In postmenopausal women, ovarian stromal hyperplasia and endometrial cancer are often identified concurrently. The aim of the present study was to verify the association of ovarian volume with histologic findings and sex hormones levels in women with postmenopausal bleeding and thickened endometrium. DESIGN AND SETTING Prospective observational study conducted in a teaching hospital between March 2008 and February 2010 PATIENTS AND METHODS Ninety women with postmenopausal bleeding and thickened endometrium (>=5 mm) were enrolled. They underwent vaginal sonography for ovarian volume measurement. Blood samples were collected for sex steroid hormones assay. In addition, endometrial sampling was done for definitive histologic diagnosis. RESULTS According to histologic results, 18 cases (20%) had endometrial adenocarcinoma, 24 cases (26.7%) had endometrial hyperplasia with or without atypia and 48 cases (53.3%) had benign histologic findings. Large ovaries were significantly associated with higher body mass index (BMI>=30) (P=.002) and endometrial adenocarcinoma (P < .001). After adjustment for age and BMI, increased ovarian volume in adenocarcinoma was associated with high serum level of estradiol (P < .001), serum total testosterone (P=.04) and serum free testosterone (P < .01) compared with other histologic findings. CONCLUSIONS Large ovaries among women with postmenopausal bleeding and thick endometrium were associated with elevated serum sex steroid hormones and represent a marker of risk for endometrial adenocarcinoma.
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Affiliation(s)
- Amr K Elfayomy
- Department of Obstetrics and Gynecology, Faculty of Medicine, Taibah University, Al Madinah 30001, Saudi Arabia.
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Breijer MC, Van Doorn HC, Clark TJ, Khan KS, Timmermans A, Mol BW, Opmeer BC. Diagnostic strategies for endometrial cancer in women with postmenopausal bleeding: cost-effectiveness of individualized strategies. Eur J Obstet Gynecol Reprod Biol 2012; 163:91-6. [DOI: 10.1016/j.ejogrb.2012.03.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Revised: 02/16/2012] [Accepted: 03/17/2012] [Indexed: 11/25/2022]
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Burbos N, Musonda P, Crocker SG, Morris EP, Nieto JJ, Duncan TJ. Management of postmenopausal women with vaginal bleeding when the endometrium can not be visualized. Acta Obstet Gynecol Scand 2012; 91:686-91. [PMID: 22443120 DOI: 10.1111/j.1600-0412.2012.01407.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the risk of endometrial cancer when endometrial thickness is not visualized using ultrasonography. DESIGN Cross-sectional study. SETTING Gynecological oncology center in the United Kingdom. POPULATION All postmenopausal women referred with vaginal bleeding. METHODS All women were investigated using gray-scale transvaginal ultrasonography. Women were arbitrarily stratified into four groups according to the endometrial thickness measurement. Women with endometrial thickness that was not adequately visualized on ultrasonography were included in a separate group. MAIN OUTCOME MEASURES Endometrial cancer diagnosis. RESULTS Over a 50-month period, 4454 women were investigated for postmenopausal vaginal bleeding. A total of 259 (6%) of women were diagnosed with endometrial carcinoma. Endometrial thickness measured 5-9.9 mm in 1201 (27%), 10-14.9 mm in 468 (11%), 15-19.9 mm in 209 (5%), and equal to or greater than 20mm in 197 (4%) of women. In 174 (4%) of women, the endometrial thickness was not visualized on transvaginal ultrasonography. For women where the endometrial thickness was not adequately visualized, the final histology included benign endometrium (124), endometrial cancer (26), endometrial polyps (11), endometritis (7), and other pathology (7). The odds of endometrial cancer in women where the endometrial thickness was not visualized were found to be significantly higher than the odds of cancer for women with an endometrial thickness of 5-9.9 mm (OR = 5.23, 95%CI 3.10-8.85, p-value <0.0001). CONCLUSIONS For women presenting with postmenopausal bleeding and where the endometrial thickness cannot be adequately visualized on ultrasonography, hysteroscopic evaluation is recommended.
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Affiliation(s)
- Nikolaos Burbos
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospital NHS Foundation Trust, Colney Lane, Norwich, United Kingdom.
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Ambeba E, Linkov F. Advancements in the use of blood tests for cancer screening in women at high risk for endometrial and breast cancer. Future Oncol 2011; 7:1399-414. [DOI: 10.2217/fon.11.127] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Several years ago, it was argued that the identification of serum biomarkers is one of the most promising approaches for the detection of early-stage malignant or even premalignant lesions. In this review, the need to establish better monitoring protocols is described for obese women who are at higher risk for the development of malignancies commonly associated with excess weight; specifically endometrial and postmenopausal breast cancer. These cancers have been chosen for this review article as our aim was to focus on female cancers that have been linked with obesity. Cancer screening is essential in detecting disease in its earliest stage in order to reduce morbidity and mortality; however, effective screening is not available for many cancer types. Even for cancers that have effective screening protocols available, there are barriers to screening in obese individuals, such as reduced mobility and embarrassment. These barriers often delay screening in these vulnerable population groups, leading to detection of the disease at a more advanced stage and ultimately leading to a poorer prognosis. As of today, biomarkers do not replace but augment imaging and other existing screening approaches. Future development of blood- or urine-based biomarkers as a way to screen individuals at high risk for certain cancers may prove to be an excellent method for overcoming the barriers that individuals at high risk are facing today. The overall purpose of this manuscript is to provide an overview of screening techniques and to identified barriers and alternate biomarker-based approaches for improvement of endometrial and breast cancer screening in obese women.
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Affiliation(s)
- Erica Ambeba
- Department of Epidemiology, University of Pittsburgh
| | - Faina Linkov
- Department of Obstetrics, Gynecology & Reproductive Science, Magee-Womens Research Institute, University of Pittsburgh 3380 Blvd of Allies, Room 323, Pittsburgh, PA 15213 USA
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Van den Bosch T, Coosemans A, Morina M, Timmerman D, Amant F. Screening for uterine tumours. Best Pract Res Clin Obstet Gynaecol 2011; 26:257-66. [PMID: 22078749 DOI: 10.1016/j.bpobgyn.2011.08.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 08/16/2011] [Indexed: 11/25/2022]
Abstract
The most prevalent uterine tumours are leiomyomas, which are benign and have a prevalence of about 50% at menopause. The incidence of endometrial cancer and uterine sarcomas is about 25 per 100,000 and 0.7 per 100,000, respectively. Reported risk factors for endometrial cancer are advanced age, unopposed oestrogen stimulation, late menopause, obesity, diabetes mellitus, nulliparity, feminising ovarian tumours, polycystic ovarian syndrome, tamoxifen and belonging to a hereditary non-polyposis colorectal cancer family. Unopposed oestrogen stimulation and tamoxifen have also been confirmed to induce uterine sarcomas. Cervical cytology, endometrial sampling and ultrasound have been proposed in the early diagnosis of endometrial cancer. No pathognomonic ultrasound, magnetic resonance imaging or computed tomography features are able to differentiate between a leiomyoma and a uterine sarcoma, and reliable serum markers for sarcomas are lacking. To date, mass screening for uterine malignancies is not feasible or effective.
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Affiliation(s)
- Thierry Van den Bosch
- Department of Obstetrics and Gynecology, University Hospitals, Herestraat 49, 3000 Leuven, Belgium
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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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Alcázar JL, Jurado M. Three-dimensional ultrasound for assessing women with gynecological cancer: A systematic review. Gynecol Oncol 2011; 120:340-6. [DOI: 10.1016/j.ygyno.2010.10.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2010] [Accepted: 10/19/2010] [Indexed: 12/26/2022]
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van Hanegem N, Breijer MC, Khan KS, Clark TJ, Burger MPM, Mol BWJ, Timmermans A. Diagnostic evaluation of the endometrium in postmenopausal bleeding: an evidence-based approach. Maturitas 2010; 68:155-64. [PMID: 21145186 DOI: 10.1016/j.maturitas.2010.11.010] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 11/07/2010] [Accepted: 11/08/2010] [Indexed: 11/28/2022]
Abstract
Postmenopausal bleeding (PMB) is a common complaint in general gynecological practice. Women with PMB have around a 10% chance of having endometrial carcinoma and therefore PMB always needs further evaluation. This article summarizes the reviews on the subject and provides an overview of the use of diagnostic tools in patients with PMB. Four types of diagnostic test are described: sonographic measurement of endometrial thickness, endometrial sampling, hysteroscopy and saline infusion sonography. All four have been independently shown to be accurate in excluding endometrial cancer. However, neither in systematic reviews nor in international guidelines is consensus found regarding the sequence in which these methods should be employed in women with PMB. For measurement of endometrial thickness in symptomatic women, a cut-off value of 3mm is recommended, but the cost-effectiveness of this strategy has yet to be shown. Research should now focus on the incorporation of individual patient characteristics and pre-test probabilities for cancer in algorithms for the investigation of PMB, and the most cost-effective sequenced combination of the four types of test.
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Affiliation(s)
- N van Hanegem
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands.
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