Isthmocele and Infertility

Isthmocele is a gynecological condition characterized by a disruption in the uterine scar, often associated with prior cesarean sections. This anatomical anomaly can be attributed to inadequate or insufficient healing of the uterine wall following a cesarean incision. It appears that isthmocele may impact a woman's quality of life as well as her reproductive capacity. The incidence of isthmocele can range from 20% to 70% in women who have undergone a cesarean section. This review aims to sum up the current knowledge about the effect of isthmocele on fertility and the possible therapeutic strategies to achieve pregnancy. However, currently, there is not sufficiently robust evidence to indicate the need for surgical correction in all asymptomatic patients seeking fertility. In cases where surgical correction of isthmocele is deemed necessary, it is advisable to evaluate residual myometrial thickness (RMT). For patients with RMT >2.5-3 mm, hysteroscopy appears to be the technique of choice. In cases where the residual tissue is lower, recourse to laparotomic, laparoscopic, or vaginal approaches is warranted.

Recurrent postmenopausal bleeding: a survey of practice among gynecologists in Scotland

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.

The yield of endometrial aspiration in women with various risk factors and bleeding abnormalities

Background

Even in the face of a substantial increase in the numbers of endometrial cancer cases and in the numbers of women who have risk factors, there is no clear agreement about the indications for assessing the endometria of women with abnormal bleeding or about the tools to use in that assessment. This study sought to determine in a group of high risk women with abnormal uterine bleeding, the probability that an outpatient endometrial aspiration would identify significant pathology.

Methods

Retrospective cohort study of the histology from endometrial aspirations performed from 2001 to 2008 for abnormal uterine bleeding at Harbor-UCLA Medical Center and its satellite public health clinics. Medical records were reviewed in detail to assess risk factors, descriptions of bleeding abnormalities and histologic results.

Results

The charts of 1601 women who underwent 1636 endometrial biopsies for a wide variety of abnormal uterine bleeding patterns yielded 73 (4.6 %) cases of endometrial carcinoma, 43 cases of atypical endometrial hyperplasia (2.7 %), for an overall yield of significant pathology of 7.2 %. Hyperplasia without atypia was found in another 83 cases (5.2 %). Obesity, diabetes and postmenopausal age are associated with an increased risk of significant pathology. Bleeding patterns were so poorly documented that analysis of yield by this factor should be viewed with caution.

Conclusions

The probability of detecting significant uterine pathology is greatest among obese, diabetic postmenopausal women with diabetes (26.3 %). Conversely, the probability of identifying significant pathology in younger women without risk factors is less than 2 %. For women who perceive their individualized risk estimate to be too small to justify an endometrial biopsy, it may be possible to offer oral higher dose progestin therapy on the condition that persistent abnormal bleeding will require more intensive evaluation. These estimates of absolute risk of being diagnosed with significant pathology on endometrial biopsy may be helpful to patients as they consider giving informed consent for the procedure.

Experiences of women referred for urgent assessment of postmenopausal bleeding (PMB)

Women with postmenopausal bleeding (PMB) are referred for specialist assessment within 2 weeks of presentation to their GP. No research has previously examined women's experiences of expedited referral. This was investigated in the present study using questionnaires (6-item State Anxiety Inventory (6-STAI)) and focus groups. A total of 55 women completed questionnaires. Results showed high levels of anxiety at first hospital visit (mean 47.0 (SD 14.27); 95% CI 43.14-50.93). Scores declined by 90 days, but were higher in those not undergoing hysteroscopy. Fifteen women who underwent hysteroscopy attended focus groups. Women recalled fear of cancer from symptom onset until receipt of results. Anxiety was exacerbated by poor knowledge of PMB and lack of awareness of expedited referral. Post-discharge, those with unexplained or recurrent symptoms expressed frustration and upset. Effective strategies to raise awareness of PMB and its causes are needed, including reasons for expedited referral. Women without cancer may also need more support.

Geriatric gynecology

Most postmenopausal vaginal bleeding is benign; however, it merits diagnostic evaluation by transvaginal ultrasound or endometrial biopsy after emergency department evaluation. Patients and physicians may treat menopausal symptoms with hormone replacement therapy or other agents, such as venlafaxine or gabapentin. Hormone replacement therapy, when initiated close to the start of menopause and continued at the lowest possible dose for the shortest possible duration, carries less risk than previously believed. Pelvic organ prolapse affects millions of women and may contribute to poor body image and difficulty with urinary, gastrointestinal, and sexual function. Treatment options include Kegel exercises, pessaries, and surgery.

Current practice in the removal of benign endometrial polyps: a Dutch survey

The purpose of this study is to evaluate the current practice of Dutch gynecologists in the removal of benign endometrial polyps and compare these results with the results of a previous study from 2003. In 2009 Dutch gynecologists were surveyed by a mailed questionnaire about polypectomy. Gynecologists answered questions about their individual performance of polypectomy: setting, form of anesthesia, method, and instrument use. The results were compared with the results from the previous survey. The response rate was 70% (585 of 837 gynecologists). Among the respondents, 455 (78%) stated to remove endometrial polyps themselves. Polyps were mostly removed in an inpatient setting (337; 74%) under general or regional anesthesia (247; 54%) and under direct hysteroscopic vision (411; 91%). Gynecologists working in a teaching hospital removed polyps more often in an outpatient setting compared with gynecologists working in a nonteaching hospital [118 (43%) vs. 35 (19%) p < 0.001]. These results are in accordance with the results from 2003. Compared to 2003 there was an increase in the number of gynecologists performing polypectomies with local or no anesthesia [211 (46%) vs. 98 (22%), p < 0.001]. An increase was also noted in the number of gynecologists using direct hysteroscopic vision [411 (91%) vs. 290 (64%), p < 0.001] and 5 Fr electrosurgical instruments [181 (44%) vs. 56 (19%), p < 0.001]. Compared to the situation in 2003, there is an increase in removal under direct hysteroscopic vision, with 5 Fr electrosurgical instruments, using local or no anesthesia. This implies there is progress in outpatient hysteroscopic polypectomy in the Netherlands.