Frequency of endometrial cancer and atypical hyperplasia in infertile women undergoing hysteroscopic polypectomy

Correlation of Hysteroscopy With Histopathological Findings of the Endometrium in Women With Polycystic Ovary Syndrome (PCOS)-Related Infertility

Introduction There have been numerous studies on the anovulatory factor, leading to infertility in women with polycystic ovary syndrome (PCOS); however, studies on the endometrium factor causing infertility in PCOS women are scarce. While hysteroscopy can accurately diagnose endometrial disorders such as endometrial polyps, it may be ineffective in detecting probable endometrial pathologies due to different hormonal habitats in these patients. Materials and methods Sixty patients with PCOS-related infertility were included in the study. All participants underwent hysteroscopic examination followed by endometrial biopsy and histopathological examination. The clinical and hormonal profiles of two main subgroups, that is, (a) normal endometrium (N), which included proliferative endometrium and secretory endometrium on histology, and (b) disordered endometrium (D), which included disordered endometrium on histology, were compared. Results There was no correlation between hysteroscopic and histopathological findings of PCOS infertile women. In the subgroup analysis of the two main histological types, that is, normal (proliferative and secretory) and disordered (disordered endometrium), age (28.70±4.66 vs. 32.9±5.61, p=0.012) and duration of amenorrhea (5.49±2.43 vs. 7.82±2.93, p=0.008) were significantly higher in the disordered group. There was a statistically nonsignificant higher BMI in the patients of the disordered endometrium group. Conclusion These findings suggest that endometrial biopsy and histopathological evaluation along with hysteroscopy should be desired in women with PCOS-related infertility, especially if they are in the late reproductive age group and have a longer duration of amenorrhea, regardless of endometrial thickening. This approach is essential to diagnose and treat endometrial disorder, which can be an additional cause of infertility, recurrent implantation failure, and recurrent pregnancy loss, in addition to ovulatory dysfunction.

Prevalence of and risk factors for chronic endometritis in patients with intrauterine disorders after hysteroscopic surgery

OBJECTIVE

To identify the prevalence of and risk factors for chronic endometritis (CE) in patients with intrauterine disorders and the therapeutic efficacy of hysteroscopic surgery in the treatment of CE without antibiotic therapy.

DESIGN

Prospective cohort study.

SETTING

Hospital specializing in reproductive medicine.

PATIENT(S)

The study population consisted of 350 women with infertility, of whom 337 were recruited, who underwent hysteroscopic surgery between November 2018 and June 2021. Eighty-nine consecutive patients without intrauterine disorders were also recruited as controls.

INTERVENTION(S)

Endometrial samples were collected during the surgery for CD138 immunostaining for the diagnosis of CE. In women diagnosed with CE, endometrial biopsy was performed without antibiotic use in the subsequent menstrual cycle.

MAIN OUTCOME MEASURE(S)

Prevalence of and risk factors for CE in intrauterine disorders and therapeutic effects of hysteroscopic surgery on CE.

RESULT(S)

The prevalence of CE with ≥5 CD138-positive cells in women with no intrauterine disorder and with endometrial polyps, myomas, intrauterine adhesions (IUAs), and septate uterus was 15.7%, 85.7%, 69.0%, 78.9%, and 46.2%, respectively. A multivariate analysis revealed that CE was diagnosed significantly more often in the endometrial polyp (odds ratio, 27.69; 95% confidence interval, 15.01-51.08) and IUA groups (odds ratio, 8.85; 95% confidence interval, 3.26-24.05). The rate of recovery from CE with surgery in women with endometrial polyps, myomas, IUA, and septate uterus was 89.7%, 100%, 92.8%, and 83.3%, respectively.

CONCLUSION(S)

Endometrial polyp and IUA were risk factors for CE. Most CE cases with intrauterine disorders were cured with hysteroscopic surgery without antibiotic therapy, regardless of the type of intrauterine abnormalities.

Noninvasive Predictor for Premalignant and Cancerous Lesions in Endometrial Polyps Diagnosed by Ultrasound

Background

There was no consensus for management of asymptomatic endometrial polyps (EPs) up to date.

Objective

The aim of present study was to determine the risk factors of malignant lesions in EPs diagnosed by ultrasound and establish a noninvasive predictor to decrease unnecessary hysteroscopy for EPs.

Study Design

We reviewed the records of all consecutive patients who underwent hysteroscopy for EPs in the Women’s Hospital School of Medicine Zhejiang University between January 1, 2001 and December 31, 2018. The patients with histological diagnoses of atypical hyperplasia or cancer were defined as malignancy, while the patients with histological diagnoses of benign lesions were randomly selected as benign group according to the ratio of 1:4 (malignancy:benign), matching by age and year of hospitalization. Logistic regression analysis was used to analyze the clinical parameters for predicting malignancy of EPs. A Chi-squared automatic interaction detection (CHAID) decision tree analysis was performed to find a noninvasive predictor. The sensitivity, specificity, and the receiver operating characteristic curve (ROC) were used for assess the efficacy of the noninvasive predictor. New diagnosed EPs patients received in 2019 were used for verifying the accuracy of the noninvasive predictor.

Results

The age in 15,790 cases of benign lesions was significantly younger than that in 230 malignancy cases (41.97 ± 11.53 year vs 53.31 ± 11.61 years, p <0.001). AUB (OR 7.306, 95%CI 4.927–10.835), large EPs (OR 2.595, 95%CI 1.662–4.052), and blood flow signal in EPs (OR 2.690, 95%CI 1.872–3.866) were independent predictive factors of malignancy in all enrolled patients. A noninvasive predictor for malignancy of EPs was established, through combining with AUB, large polyps and blood flow signal. This predictor presented excellent sensitivity and NPV (91.3 and 95.8%), with acceptable specificity and AUC (0.801). Further validation in new diagnosed EPs also suggested excellent sensitivity and reasonable specificity (100 and 58.5%) of the predictor. Factors such as thickened endometrial thickness, menopause shorter than 10 years, hypertension, obesity and nulliparous were also validated as independent predictors of malignancy in different subgroup analysis.

Conclusions

The noninvasive predictor combined with other risk factors from subgroup analysis would be reliable to distinguish the benign lesions from malignancy for EPs diagnosed by ultrasound.

Analysis of the therapeutic effects of hysteroscopic polypectomy with and without doxycycline treatment on chronic endometritis with endometrial polyps

PROBLEM

We aimed to compare the therapeutic effects of hysteroscopic polypectomy with and without doxycycline treatment on chronic endometritis (CE) with endometrial polyps.

METHOD OF STUDY

DESIGN: A cross-sectional study was conducted on 267 infertile patients, of whom 243 were recruited, who underwent hysteroscopic polypectomy between March 2019 and March 2020. During surgery, the endometrial specimens for the immunohistochemistry analysis of the plasma cell marker CD138 and for the intrauterine bacterial culture were obtained to diagnose CE, and the prevalence of CE was analyzed. Of the 222 women who were diagnosed with CE after polypectomy, we treated 62 women with doxycycline (antibiotic group) and did not provide antibiotics in 160 women (non-antibiotic group).

RESULTS

Most of the infertile patients with endometrial polyps had CE (92.6%). The recovery rate from CE by hysteroscopic polypectomy was significantly higher in the non-antibiotic group than in the antibiotic group (88.8% and 58.1%, respectively, p < 0.0001). The duration of recovery from CE in the non-antibiotic group was shorter than that in the antibiotic group (42.6 ± 41.0 and 56.5 ± 32.3 days, respectively, p < 0.0001). The clinical pregnancy rate within 6 months in non-antibiotic group was higher than that in the antibiotic group (63.2% and 43.8%, respectively, p = 0.034).

CONCLUSION

Endometrial polyps are significantly associated with CE. Most CE patients with endometrial polyps had been cured by polypectomy without doxycycline. Inappropriate antibiotic therapy may delay recovery from CE and decrease the efficacy of polypectomy on CE and pregnancy rates.

New development on hysteroscopy for endometrial cancer diagnosis: state of the art

Endometrial cancer (EC) is the most common gynecologic cancer diagnosed in developed countries and represents the second most frequent gynecologic cancer-related cause of death following ovarian cancer. There are 2 subtypes of EC. Type I tumors (endometrioid adenocarcinoma) representing 85-90% of the cases. They are likely to be low-grade tumors and are thought to have a link to estrogen exposure. Type II tumors represent 10-15% of EC. They are characterized as high-grade carcinomas, with serous or clear cell histology type, and carry poor prognoses. The benefits of hysteroscopy in achieving a targeted endometrial biopsy under direct visualization over blind biopsy techniques are widely accepted. Hysteroscopic endometrial biopsy is performed under direct visualization and is the only technique that allows for the selective biopsy of targeted areas of the endometrium. There is no screening protocol for the early detection of EC. Among the general population, advanced age, obesity, nulliparity and the use of exogenous hormones are known as risk factors for EC. There are additional situations that portend an increased risk of EC that deserve special consideration such as in patients diagnosed with Lynch Syndrome, using tamoxifen, obese, or the young patient with a desire for future fertility. We presented a narrative review of the current role of hysteroscopy for the diagnosis of endometrial cancer.

Introduction of Female Reproductive Processes and Reproductive Diseases

The female reproductive process is very complicated, including multiple processes. Each process is different and plays a vital role in reproduction. If some reproductive diseases occur, these processes will be abnormal, causing infertility problem. In this Chapter, we will describe the female reproductive process and their corresponding reproductive diseases.

Comparing endometrial hysteroscopic and histological findings of infertile women with polycystic ovary syndrome and unexplained infertility: A cross-sectional study

Background

Infertility is a critical condition in women with polycystic ovary syndrome (PCOS), caused not only by anovulation but also by endometrial abnormality.

Objective

This study aimed to evaluate and compare the hysteroscopic and histological findings of endometrial biopsies in infertile women with PCOS and normal endometrial thickness and women with unexplained infertility (UI).

Materials and Methods

This cross-sectional study compared the initial hysteroscopy and endometrial histological findings of 70 infertile women with PCOS and normal endometrial thickness with those of 35 women with UI. The relationship between endometrial histology and clinical parameters such as including luteinizing hormone, follicle-stimulating hormone, thyroid-stimulating hormone, testosterone, prolactin, fasting blood sugar, body mass index (BMI), and infertility duration was analyzed.

Results

The mean age of women with PCOS was significantly lower than that of women with UI (27.5 ± 4.1 vs. 30 ± 4.5 years, respectively) (p < 0.001). The mean BMI was higher in women with PCOS than in women with UI (28.7 ± 4.4 vs. 25.1 ± 3 kg/m2) (p < 0.001). The hysteroscopic findings of all women with PCOS were normal, whereas 91.4% of women with UI had normal hysteroscopic findings, 2.9% had a polyp, and 5.7% had endometrial thickening. The histological findings of women with PCOS revealed proliferative endometrium in 54.3%, disordered proliferative endometrium in 17.1%, secretory endometrium in 8.6%, and endometrial polyp in 17.1%, whereas these percentages in women with UI were 28.6%, 0%, 54.3%, and 20%, respectively.

Conclusion

The hysteroscopic evaluation alone of infertile women might not detect all probable endometrial pathologies in women with PCOS.

The risk of malignancy in uterine polyps: A systematic review and meta-analysis

BACKGROUND

Endometrial polyps are a common condition. The risk of malignancy has often led to an overtreatment with high health care costs and huge psychological distress.

OBJECTIVE

We conducted a systematic review and a meta-analysis in order to estimate the prevalence of premalignant and malignant lesions in women undergoing hysteroscopic polypectomy.

DATA SOURCE

We developed the search using PubMed/MEDLINE and EMBASE databases to identify papers published between 2000- January 2019. The research strategy used on Pubmed was: ("polyps" (MESH) OR "endometrial polyp*") AND ("malignancy" OR "cancer" OR "histopathology" OR "hysteroscopy" OR "ultrasound", OR "sonohysterography"). The same search was modified for EMBASE.

STUDY ELIGIBILITY

We included all observational retrospective and prospective studies and studies were selected for the review if they met following inclusion criteria: pre-operative diagnosis of benign-looking endometrial polyps at ultrasound examination or at hysteroscopy, excision of endometrial polyps via surgical hysteroscopy, histopathological diagnosis of benign polyps, or hyperplasia without atypia, or premalignancy (atypical hyperplasia) or malignancy (endometrial cancer). Moreover, studies were included if number or percentage of subjects with and without malignancy was provided and if they reported data about menopausal and/or bleeding status. We excluded data presented exclusively as abstracts in national and international meetings, or case report or review articles that did not include original data and papers published in other than English language. Our primary outcome was the prevalence of endometrial premalignant or malignant polyps in the total series, among premenopausal and postmenopausal women and among women with or without abnormal bleeding and then in subgroup analysis according to study design, diagnostic method, study region and calendar year of publication.

RESULTS

A total of 51 studies reporting data on 35,345 women were included in this review. The prevalence of malignant polyps was 2.73% (95% CI 2.57-2.91) with very high heterogeneity among studies. The rates were lower for premenopausal women (1.12%) than post-menopausal ones (4.93%) and the difference was statistically significant (chi-square = 397.21. p < .0001). The risk of malignancy was higher among symptomatic (5.14%) than asymptomatic ones (1.89%) (chi-square = 133.13 p < .001). We observed higher rate of malignant polyps in prospective studies. In the meta-analysis selecting 10 prospective studies the random pooled estimate was 5.88 (95% CI: 4.06-7.97) with heterogeneity among studies (heterogeneity chi square = 17.55 P = .025) whereas in retrospective studies the random pooled estimate was 2.94 (95% CI:2.24-3.71) with high heterogeneity among studies (P < .001). This finding can be due to more strict diagnostic criteria in prospective studies.

CONCLUSION

Symptomatic vaginal bleeding and postmenopausal status in women with endometrial polyps increased the risk of malignancy. This finding could be an useful evidence to select patients who need to undergo hysteroscopic resection of endometrial polyps and women to whom, instead, an expectant management can be offer.