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

Persistent vaginal bleeding during gender-affirming hormone therapy in transgender men

PURPOSE

While it is common for menstrual cycles to cease within the initial 6 months of treatment, there are instances where some transgender men may not experience this cessation. We analyzed transgender men undergoing gender-affirming hormone therapy (GAHT) with testosterone who experienced breakthrough bleeding in order to identify the factors associated with this condition.

METHODS

In this case-control study, 24 transgender men in the case group and 48 in the control group were assessed for clinical, sociodemographic, hormonal, and body composition variables using dual-energy X-ray absorptiometry. All participants had been on GATH for at least 6 months.

RESULTS

A few transgender men experienced persistent breakthrough bleeding, which was associated with decreased testosterone levels and free androgen index (FAI) compared with controls (p = 0.002 and p = 0.008, respectively). Among individuals with breakthrough bleeding, 50% had testosterone levels below the lowest tertile calculated for the sample, compared with 18.8% on controls (p = 0.007). After therapy adjustment, testosterone levels increased compared with the values obtained in the initial bleeding episode (p = 0.031). Eight transgender men required the addition of an oral progestogen to achieve amenorrhea, and these individuals had higher BMI than those in whom the adjustment of the parenteral testosterone dose was adequate (p = 0.026). A univariate prevalence ratio analysis revealed a negative association of persistent bleeding with testosterone levels (p = 0.028) and FAI levels (p = 0.019).

CONCLUSION

Higher BMI and lower levels of testosterone and FAI were the main factors associated with breakthrough bleeding in transgender men.

A Comprehensive Approach: Correlating Ultrasound Imaging with Endometrial Histopathological Analysis in Perimenopausal Women with Heavy Menstrual Bleeding

INTRODUCTION

Abnormal uterine bleeding (AUB) is a common troublesome symptom in the perimenopausal age group. The most common type of AUB in this age group is heavy menstrual bleeding. There is a risk of endometrial carcinoma and atypical endometrial hyperplasia in women with AUB in the age group of 40-50 years. Hence early evaluation is of paramount importance in managing women with perimenopausal heavy menstrual bleeding. The current study was undertaken to study the correlation between ultrasound findings and various benign and malignant endometrial histologies in perimenopausal women with heavy menstrual bleeding.

METHODOLOGY

Women aged 40-55 years presenting with heavy menstrual bleeding at the gynaecology outpatient department at Sree Balaji Medical College and Hospital, Chennai, India, were included in the study. Patients on anti-platelet and anti-coagulation therapy and patients already on hormonal treatment for heavy menstrual bleeding were excluded from the study. The demographic factors, symptom profiles, ultrasound findings, and histopathological reports were tabulated and analysed.

RESULTS

Of the 147 women included in the study, 75 (51%) were aged 45-50 years and 107 (73%) had two or more pregnancies. Fibroid was the common non-endometrial cause of heavy menstrual bleeding in 52 (35%) cases. The proliferative pattern was the most common non-pathological histology identified in 46 (31%) cases. Endometrial hyperplasia without atypia was the most common pathological histology observed in the study population. Endometrial thickness of more than 8 mm was strongly associated with premalignant or malignant endometrial lesions.

CONCLUSION

Our study has attempted to identify the correlation between ultrasound evaluation of perimenopausal women with heavy menstrual bleeding and endometrial pathology. Ultrasound, being cost-effective and widely available, is proven to be a tool for first-line investigation of perimenopausal women with heavy menstrual bleeding that guides further evaluation and management.

Development and Validation of a Nomogram Prediction Model for Endometrial Malignancy in Patients with Abnormal Uterine Bleeding

PURPOSE

This study aimed to identify the risk factors and sonographic variables that could be integrated into a predictive model for endometrial cancer (EC) and atypical endometrial hyperplasia (AEH) in women with abnormal uterine bleeding (AUB).

MATERIALS AND METHODS

This retrospective study included 1837 patients who presented with AUB and underwent endometrial sampling. Multivariable logistic regression was developed based on clinical and sonographic covariates [endometrial thickness (ET), resistance index (RI) of the endometrial vasculature] assessed for their association with EC/AEH in the development group (n=1369), and a predictive nomogram was proposed. The model was validated in 468 patients.

RESULTS

Histological examination revealed 167 patients (12.2%) with EC or AEH in the development group. Using multivariable logistic regression, the following variables were incorporated in the prediction of endometrial malignancy: metabolic diseases [odds ratio (OR)=7.764, 95% confidence intervals (CI) 5.042-11.955], family history (OR=3.555, 95% CI 1.055-11.971), age ≥40 years (OR=3.195, 95% CI 1.878-5.435), RI ≤0.5 (OR=8.733, 95% CI 4.311-17.692), and ET ≥10 mm (OR=8.479, 95% CI 5.440-13.216). A nomogram was created using these five variables with an area under the curve of 0.837 (95% CI 0.800-0.874). The calibration curve showed good agreement between the observed and predicted occurrences. For the validation group, the model provided acceptable discrimination and calibration.

CONCLUSION

The proposed nomogram model showed moderate prediction accuracy in the differentiation between benign and malignant endometrial lesions among women with AUB.

Assessment of paraclinical characteristics in peri- and postmenopausal bleeding women: is there a correlation between hemoglobin levels and ultrasonic indices?

Objectives

Vaginal bleeding is a common symptom of uterine intracavitary pathologies in perimenopausal and postmenopausal women, which leads to anemia. However, findings regarding the relationship between hemoglobin level and sonographic parameters remain limited. The aim of this study was (1) to investigate the histopathological findings of uterine intracavitary pathologies, hemoglobin concentrations and basic sonographic parameters, and (2) to evaluate their correlation among Vietnamese women with perimenopausal and postmenopausal bleeding.

Methods

This was a prospective study at Hue University Hospital and Hue Central Hospital from June 2016 to June 2019. The study enrolled 150 women older than 40 years with abnormal uterine bleeding. All patients underwent blood count testing and transvaginal ultrasound.

Results

Moderate to severe anemia was observed at a higher frequency in women with perimenopausal bleeding (58.1%) than postmenopausal bleeding (10.0%). The most common abnormality resulting in severe anemia was endometrial hyperplasia (70.8%), which was followed by endometrial cancer (4.2%). The uterine size, intrauterine mass, and endometrial thickness differed substantially between the benign and malignant groups. The study found significantly a weak negative correlation between hemoglobin concentration (g/L) and uterinelength, the anteroposterior diameter of uterine corpus in the overall study (r = -0.37, r = -0.32, respectively, P < 0.05); a moderate negativecorrelation between hemoglobin concentration and the largest diameter of intracavitary mass‑shaped lesion in the perimenopausal group (r = -0.4, P < 0.05).

Conclusion

Overall, histopathological results, hemoglobin concentration and basic sonographic parameters should be combined in evaluating intrauterine abnormalities in women with perimenopausal and postmenopausal bleeding. Ultrasonic indices of uterine size may be used to determine the prognosis of anemia in uterine intracavitary pathologies. However, further studies are needed to confirm these findings.

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

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.

Value of endometrial thickness and Doppler parameters of uterine artery in predicting endometrial cancer in postmenopausal women with abnormal uterine bleeding: a cross-sectional study in Vietnam

Objective

To determine the value of endometrial thickness (ET) and Doppler indices of uterine artery (UtA) as sonographic markers in predicting endometrial cancer (EC) among postmenopausal bleeding (PMB) women in low-resource settings as Vietnam.

Methods

This cross-sectional study was conducted at the Hue University Hospital and Hue Central Hospital between June 2016 and June 2019. The study enrolled all women who complained of PMB and were followed by transvaginal Doppler ultrasound. Their definitive histopathological examination was the gold standard for comparison.

Results

The UtA Doppler indices, including resistance index (RI), pulsatility index (PI), and peak systolic velocity (PSV), were significantly lower in the malignant group than in the benign group. The threshold values of the UtA, RI ≤0.73 and PI ≤1.42, were found with an area under receiver operating characteristic curve (AUC) of 0.85–0.88, and the sensitivity and specificity were 91.3% and 83.3%, respectively. Unlike PSV, the diagnostic value was the lowest, with an AUC of 0.72. ET was a good predictor for the diagnosis of EC, with an AUC of 0.89. In women with PMB, when using the cutoff value of EC more than 12.5 mm, the sensitivity and specificity were 93.8% and 77.8%, respectively. In addition, the higher the stage of EC, the lower the RI and PI and the greater the EC.

Conclusion

ET, and RI, PI, and PSV of the UtA could help in differentiating malignant from benign endometrial changes. Pulsed ultrasonic Doppler velocimetry seems to play a role in predicting the higher stages of EC. Further studies are needed to confirm these findings.