Detection of endometrial cancer using tampon-based collection and methylated DNA markers

OBJECTIVE

Alterations in DNA methylation are early events in endometrial cancer (EC) development and may have utility in EC detection via tampon-collected vaginal fluid.

METHODS

For discovery, DNA from frozen EC, benign endometrium (BE), and benign cervicovaginal (BCV) tissues underwent reduced representation bisulfite sequencing (RRBS) to identify differentially methylated regions (DMRs). Candidate DMRs were selected based on receiver operating characteristic (ROC) discrimination, methylation level fold-change between cancers and controls, and absence of background CpG methylation. Methylated DNA marker (MDM) validation was performed using qMSP on DNA from independent EC and BE FFPE tissue sets. Women ≥45 years of age with abnormal uterine bleeding (AUB) or postmenopausal bleeding (PMB) or any age with biopsy-proven EC self-collected vaginal fluid using a tampon prior to clinically indicated endometrial sampling or hysterectomy. Vaginal fluid DNA was assayed by qMSP for EC-associated MDMs. Random forest modeling analysis was performed to generate predictive probability of underlying disease; results were 500-fold in-silico cross-validated.

RESULTS

Thirty-three candidate MDMs met performance criteria in tissue. For the tampon pilot, 100 EC cases were frequency matched by menopausal status and tampon collection date to 92 BE controls. A 28-MDM panel highly discriminated between EC and BE (96% (95%CI 89-99%) specificity; 76% (66-84%) sensitivity (AUC 0.88). In PBS/EDTA tampon buffer, the panel yielded 96% (95% CI 87-99%) specificity and 82% (70-91%) sensitivity (AUC 0.91).

CONCLUSION

Next generation methylome sequencing, stringent filtering criteria, and independent validation yielded excellent candidate MDMs for EC. EC-associated MDMs performed with promisingly high sensitivity and specificity in tampon-collected vaginal fluid; PBS-based tampon buffer with added EDTA improved sensitivity. Larger tampon-based EC MDM testing studies are warranted.

Quantifying procedural pain associated with office gynecologic tract sampling methods

OBJECTIVE

Emerging technologies may enable detection of endometrial cancer with methods that are less invasive than standard biopsy methods. This study compares patient pain scores among 3 office gynecologic tract sampling methods and explores their potential determinants.

METHODS

A prospective study including 3 sampling methods (tampon, Tao brush (TB), endometrial biopsy (EB)) was conducted between December 2015 and August 2017 and included women ≥45 years of age presenting with abnormal uterine bleeding, postmenopausal bleeding, or thickened endometrial stripe. Patients rated pain after each sampling procedure using a 100-point visual analog scale (VAS).

RESULTS

Of 428 enrolled, 190 (44.39%) patients underwent all 3 sampling methods and reported a VAS score for each. Nearly half were postmenopausal (n = 93, 48.9%); the majority were parous (172, 90.5%) of which 87.8% had at least one vaginal delivery. Among the 190 patients, the median (IQR) pain score was significantly lower for sampling via tampon (0 [0,2]) compared to TB (28 [12, 52]) or EB (32 [15, 60]) (both p < 0.001, Wilcoxon signed rank test). Among women who underwent tampon sampling, age and pain scores showed a weak positive correlation (Spearman rank correlation, r = 0.14; p = 0.006); EB sampling was associated with a weak inverse correlation between parity and pain scores (r = -0.14; p = 0.016).

CONCLUSION

Gynecologic tract sampling using a tampon had significantly lower pain than both EB and TB. Pain with tampon sampling was positively correlated with age and pain with EB sampling was inversely correlated with parity. Pain scores for TB and EB were not significantly related to age, menopausal status, or BMI.

Risk assessment of endometrial cancer and endometrial intraepithelial neoplasia in women with abnormal bleeding and implications for clinical management algorithms

BACKGROUND

Most endometrial cancer cases are preceded by abnormal uterine bleeding, offering a potential opportunity for early detection and cure of endometrial cancer. Although clinical guidelines exist for diagnostic workup of abnormal uterine bleeding, consensus is lacking regarding optimal management for women with abnormal bleeding to diagnose endometrial cancer.

OBJECTIVE

We report the baseline data from a prospective clinical cohort study of women referred for endometrial evaluation at the Mayo Clinic, designed to evaluate risk stratification in women at increased risk for endometrial cancer. Here, we introduce a risk-based approach to evaluate diagnostic tests and clinical management algorithms in a population of women with abnormal bleeding undergoing endometrial evaluation at the Mayo Clinic.

STUDY DESIGN

A total of 1163 women aged ≥45 years were enrolled from February 2013 to May 2019. We evaluated baseline absolute risks and 95% confidence intervals of endometrial cancer and endometrial intraepithelial neoplasia according to clinical algorithms for diagnostic workup of women with postmenopausal bleeding (assessment of initial vs recurrent bleeding episode and endometrial thickness measured through transvaginal ultrasound). We also evaluated risks among women with postmenopausal bleeding according to baseline age (<60 vs 60+ years) as an alternative example. For this approach, biopsy would be conducted for all women aged 60+ years and those aged <60 years with an endometrial thickness of >4 mm. We assessed the clinical efficiency of each strategy by estimating the percentage of women who would be referred for endometrial biopsy, the percentage of cases detected and missed, and the ratio of biopsies per case detected.

RESULTS

Among the 593 women with postmenopausal bleeding, 18 (3.0%) had endometrial intraepithelial neoplasia, and 47 (7.9%) had endometrial cancer, and among the 570 premenopausal women with abnormal bleeding, 8 (1.4%) had endometrial intraepithelial neoplasia, and 7 (1.2%) had endometrial cancer. Maximum risk was noted in women aged 60+ years (17.7%; 13.0%-22.3%), followed by those with recurrent bleeding (14.7%; 11.0%-18.3%). Among women with an initial bleeding episode for whom transvaginal ultrasound was recommended, endometrial thickness did not provide meaningful risk stratification: risks of endometrial cancer and endometrial intraepithelial neoplasia were nearly identical in women with an endometrial thickness of >4 mm (5.8%; 1.3%-10.3%) and ≤4 mm (3.6%; 0.9%-8.6%). In contrast, among those aged <60 years with an endometrial thickness of >4 mm, the risk of endometrial cancer and endometrial intraepithelial neoplasia was 8.4% (4.3%-12.5%), and in those with an endometrial thickness of ≤4 mm, the risk was 0% (0.0%-3.0%; P=.01). The most efficient strategy was to perform biopsy in all women aged 60+ years and among those aged <60 years with an endometrial thickness of >4 mm, with the lowest percentage referred to biopsy while still detecting all cases.

CONCLUSION

Existing clinical recommendations for endometrial cancer detection in women with abnormal bleeding are not consistent with the underlying risk. Endometrial cancer risk factors such as age can provide important risk stratification compared with the assessment of recurrent bleeding. Future research will include a formal assessment of clinical and epidemiologic risk prediction models in our study population as well as validation of our findings in other populations.

Medical therapy versus radiofrequency endometrial ablation in the initial treatment of heavy menstrual bleeding (iTOM Trial): A clinical and economic analysis

BACKGROUND

Radiofrequency endometrial ablation (REA) is currently a second line treatment in women with heavy menstrual bleeding (MHB) if medical therapy (MTP) is contraindicated or unsatisfactory. Our objective is to compare the effectiveness and cost burden of MTP and REA in the initial treatment of HMB.

METHODS

We performed a randomized trial at Mayo Clinic Rochester, Minnesota. The planned sample size was 60 patients per arm. A total of 67 women with HMB were randomly allocated to receive oral contraceptive pills (Nordette ®) or Naproxen (Naprosyn®) (n = 33) or REA (n = 34). Primary 12-month outcome measures included menstrual blood loss using pictorial blood loss assessment chart (PBLAC), patients' satisfaction, and Menorrhagia Multi-Attribute Scale (MMAS). Secondary outcomes were total costs including direct medical and indirect costs associated with healthcare use, patient out-of-pocket costs, and lost work days and activity limitations over 12 months.

RESULTS

Compared to MTP arm, women who received REA had a significantly lower PBLAC score (median [Interquartile range, IQR]: 0 [0-4] vs. 15 [0-131], p = 0.003), higher satisfaction rates (96.8%vs.63.2%, p = 0.003) and higher MMAS (median [IQR]: 100 [100-100] vs. 100 [87-100], p = 0.12) at 12 months. Direct medical costs were higher for REA ($5,331vs.$2,901, 95% confidence interval (CI) of mean difference:$727,$4,852), however, when indirect costs are included, the difference did not reach statistical significance ($5,469 vs. $3,869, 95% CI of mean difference:-$339, $4,089).

CONCLUSION

For women with heavy menstrual bleeding, initial radiofrequency endometrial ablation compared to medical therapy offered superior reduction in menstrual blood loss and improvement in quality of life without significant differences in total costs of care.

CLINICAL TRIAL REGISTRATION

NCT01165307.

Clinical limitations of the International Federation of Gynecology and Obstetrics (FIGO) classification of uterine fibroids

OBJECTIVE

To determine the reproducibility of classifying uterine fibroids using the 2011 International Federation of Gynecology and Obstetrics (FIGO) staging system.

METHODS

The present retrospective cohort study included patients presenting for the treatment of symptomatic uterine fibroids at the Gynecology Fibroid Clinic at Mayo Clinic, Rochester, USA, between April 1, 2013 and April 1, 2014. Magnetic resonance imaging of fibroid uteri was performed and the images were independently reviewed by two academic gynecologists and two radiologists specializing in fibroid care. Fibroid classifications assigned by each physician were compared and the significance of the variations was graded by whether they would affect surgical planning.

RESULTS

There were 42 fibroids from 23 patients; only 6 (14%) fibroids had unanimous classification agreement. The majority (36 [86%]) had at least two unique answers and 4 (10%) fibroids had four unique classifications. Variations in classification were not associated with physician specialty. More than one-third of the classification discrepancies would have impacted surgical planning.

CONCLUSION

FIGO fibroid classification was not consistent among four fibroid specialists. The variation was clinically significant for 36% of the fibroids. Additional validation of the FIGO fibroid classification system is needed.

Clinical Manifestations and Outcomes in Surgically Managed Gartner Duct Cysts

STUDY OBJECTIVE

Gartner duct cysts (GDCs) are rare embryological remnants of the mesonephric duct with the majority of cases discovered incidentally in asymptomatic patients. The largest prior published series evaluating the surgical management of GDCs included 4 patients. The present study aimed to determine the manifestations and outcomes of surgically managed patients with GDCs with important implications for surveillance, monitoring, and management.

DESIGN

A retrospective chart review (Canadian Task Force classification III).

SETTING

A tertiary care center.

PATIENTS

All women diagnosed with GDCs from January 1994 to April 2014 at our institution were identified. Patients were included if they underwent surgical management and had GDCs confirmed by pathology. One hundred twenty-four charts were manually reviewed, and 29 patients were included in the analysis.

INTERVENTIONS

All patients underwent surgical management, which included vaginal excision or marsupialization.

MEASUREMENTS AND MAIN RESULTS

A total of 29 patients met the inclusion criteria for this study. The median age of the patients included in the analysis was 36 years old. Eleven patients were asymptomatic at the time of diagnosis (37.9%). The reason for surgical intervention was not available in 9 of these patients. Surgical intervention was performed in 2 of the 11 asymptomatic patients because of an increasing size of the lesion during observation. Presenting symptoms included dyspareunia or pain with tampon placement (37.9%), pelvic pain or pressure (24.1%), pelvic mass or bulge (17.2%), and urinary incontinence (6.9%). Preoperative imaging studies were obtained in 62% of patients; ultrasound was used in 44.4%, computed tomographic scanning in 22.2%, magnetic resonance imaging in 16.7%, and multiple modalities in 16.7%. Approximately 10% were found to have other genitourinary anomalies, including a bladder cyst, urethral diverticulum, and a solitary right kidney with uterine didelphis and septate vagina. The average cyst size was 3.5 cm (±1.8 cm). Surgical excision of GDCs was performed in all except for 3 cases of marsupialization. No intraoperative complications occurred. The median follow-up was 82 months (range, 0-246 months). One patient had possible recurrence with dyspareunia and protruding tissue diagnosed 14 months postoperatively. There were no other postoperative complications in the follow-up period.

CONCLUSION

GDCs are rare pelvic masses that are often asymptomatic but may present with dyspareunia, pelvic pain or pressure, pelvic mass or bulge, or urinary symptoms. Excision or marsupialization is successful in the majority of cases without significant morbidity.

Risk Factors, Clinical Presentation, and Outcomes for Abdominal Wall Endometriosis

STUDY OBJECTIVE

To evaluate the risk factors, presentation, and outcomes in cases of abdominal wall endometriosis.

DESIGN

A case-control study (Canadian Task Force classification II-2).

SETTING

An academic medical center.

PATIENTS

A total of 102 (34 cases and 68 controls) were included.

INTERVENTIONS

Surgical resection of abdominal wall endometriosis.

MEASUREMENTS AND MAIN RESULTS

Cases underwent surgical excision for abdominal wall endometriosis at Mayo Clinic from January 1, 2000, through December 31, 2013. For each case, 2 controls were randomly selected from a list of women who had surgery in the same year with minimal (American Society for Reproductive Medicine stage I-II) endometriosis. A chart review was completed for variables of interest. Regression models were used to identify independent risk factors associated with abdominal wall endometriosis.

RESULTS

In 14 years, 2539 women had surgery for endometriosis at Mayo Clinic. Of these, only 34 (1.34%) had abdominal wall endometriosis. The mean age was 35.2 ± 5.9 years, and the median parity was 2 (range, 0-5). Clinical examination diagnosed abdominal wall endometriosis in 41% of cases, with the cesarean delivery scar being the most common site (59%). There was a strong correlation between the size of the lesion on clinical examination compared with the size of the pathology specimen (r² = 0.74, p < .001). When compared with controls, cases had significantly higher parity and body mass index, more cyclic localized abdominal pain, less dysmenorrhea, longer duration from the start of symptoms to surgery, and more gynecologic surgeries for symptoms without cure. In the final multivariable model, cyclic localized abdominal pain, absence of dysmenorrhea, and previous laparotomy were independently associated with abdominal wall endometriosis with adjusted odds ratios of 10.6 (95% CI 1.85-104.4, p < .001), 12.4 (95% CI 1.64-147.1, p < .001), and 70.1 (95% CI 14.8-597.7, p < .001), respectively, with an area under the curve for the receiver operating characteristic of 0.94 (95% CI, 0.87-0.98). After excision of the disease, repeat surgery was needed in 2 (5.9%) patients with a median time to recurrence of 50.5 (range, 36-65) months.

CONCLUSIONS

Abdominal wall endometriosis is a rare but unique form of endometriosis. Careful history and clinical examination can provide accurate diagnosis and avoid unnecessary delay before surgical intervention. Localized cyclic abdominal pain with the absence of dysmenorrhea and a history of prior laparotomy are independent risk factors with very high accuracy for diagnosis.

Correlation of Behavioral Interviewing Performance With Obstetrics and Gynecology Residency Applicant Characteristics☆?>

OBJECTIVE

To determine which individual residency applicant characteristics were associated with improved performance on standardized behavioral interviews. Behavioral interviewing has become a common technique for assessing resident applicants. Few data exist on factors that predict success during the behavioral interview component of the residency application process.

DESIGN

Interviewers were trained in behavioral interviewing techniques before each application season. Standardized questions were used. Behavioral interview scores and Electronic Residency Application Service data from residency applicants was collected prospectively for 3 years.

SETTING

It included the Accreditation Council for Graduate Medical Education-accredited obstetrics-gynecology residency program at a Midwestern academic medical center.

PARTICIPANTS

Medical students applying to a single obstetrics-gynecology residency program from 2012 to 2014 participated in the study.

RESULTS

Data were collected from 104 applicants during 3 successive interview seasons. Applicant's age was associated with higher overall scores on questions about leadership, coping, and conflict management (for applicants aged ≤25, 26-27, or ≥28y, mean scores were 15.2, 16.0, and 17.2, respectively; p = 0.03), as was a history of employment before medical school (16.8 vs 15.5; p = 0.03). Applicants who participated in collegiate team sports scored lower on questions asking influence/persuasion, initiative, and relationship management compared with those who did not (mean, 15.5 vs 17.1; p = 0.02).

CONCLUSIONS

Advanced applicant age and history of work experience before medical school may improve skills in dealing with difficult situations and offer opportunities in leadership. In the behavioral interview format, having relevant examples from life experience to share during the interviews may improve the quality of the applicant's responses. Increased awareness of the factors predicting interview performance helps inform the selection process and allows program directors to prioritize the most appropriate candidates for the match.

Abnormal Uterine Bleeding Is Associated With Increased BMP7 Expression in Human Endometrium

Abnormal uterine bleeding (AUB), a common health concern of women, is a heterogeneous clinical entity that is traditionally categorized into organic and nonorganic causes. Despite varied pharmacologic treatments, few offer sustained efficacy, as most are empiric, unfocused, and do not directly address underlying dysregulated molecular mechanisms. Characterization of such molecular derangements affords the opportunity to develop and use novel, more successful treatments for AUB. Given its implication in other organ systems, we hypothesized that bone morphogenetic protein (BMP) expression is altered in patients with AUB and hence comprehensively investigated dysregulation of BMP signaling pathways by systematically screening 489 samples from 365 patients for differences in the expression of BMP2, 4, 6, and 7 ligands, BMPR1A and B receptors, and downstream SMAD4, 6, and 7 proteins. Expression analysis was correlated clinically with data abstracted from medical records, including bleeding history, age at procedure, ethnicity, body mass index, hormone treatment, and histological diagnosis of fibroids, polyps, adenomyosis, hyperplasia, and cancer. Expression of BMP7 ligand was significantly increased in patients with AUB (H-score: 18.0 vs 26.7; P < .0001). Patients reporting heavy menstrual bleeding (menorrhagia) as their specific AUB pattern demonstrated significantly higher BMP7 expression. Significantly, no differences in the expression of any other BMP ligands, receptors, or SMAD proteins were observed in this large patient cohort. However, expression of BMPR1A, BMPR1B, and SMAD4 was significantly decreased in cancer compared to benign samples. Our study demonstrates that BMP7 is a promising target for future investigation and pharmacologic treatment of AUB.

Impact of Simple Ovarian Cysts on the Interpretation of Endometrial Thickness in Women with Postmenopausal Bleeding

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.

Laparoscopic appendectomy in women without identifiable pathology undergoing laparoscopy for chronic pelvic pain

Laparoscopic appendectomy is suggested to be effective therapy for women with chronic pelvic pain of unknown etiology.

Objectives:

To assess the effectiveness of appendectomy in women undergoing laparoscopy for chronic pelvic pain without identifiable pathology.

Methods:

This retrospective cohort study included women aged 15 to 50 years who underwent laparoscopic surgery for chronic pelvic pain without identifiable pathology. The cohort was divided into 2 groups: women who underwent appendectomy and women who had not undergone appendectomy at laparoscopic surgery. Postoperative pain was assessed at 6-week follow-up and by subsequent mailed questionnaire.

Results:

Women who underwent appendectomy (n = 19) were significantly more likely to report improvement in pain at 6-week follow-up than women who did not undergo appendectomy (n = 76) (93% vs 16%; P < .001). Thirty-six patients (38%) responded to the questionnaire at a median of 4.2 years after surgery, when the median change (improvement) in reported pain was greater in the appendectomy group than in the nonappendectomy group.

Conclusion:

Appendectomy is effective therapy for patients with chronic pelvic pain of unknown etiology who are undergoing laparoscopy.

Safety of culdotomy as a surgical approach: implications for natural orifice transluminal endoscopic surgery

OBJECTIVE

To evaluate the efficacy and safety of culdotomy as a surgical approach to access the peritoneal cavity and discuss its implications for natural orifice transluminal endoscopic surgery (NOTES).

METHODS

A retrospective chart review of women undergoing culdotomy for tubal sterilization (N 219) between January 1995 and December 2005 was performed. The Accordion Grading System was used for the severity of complications.

RESULTS

No intraoperative complications were noted. Postoperative complications occurred in 7 patients (3.2%): 6 infections (grade 2) and 1 case of hemorrhage (grade 3). Conversion to laparoscopy was necessary in 10 patients (2.2%) due to anatomical constraints or pelvic adhesions; however, culdotomy with entry into the abdominal cavity was nevertheless successful in all 10 cases. The difference in the proportion with a history of pelvic surgery between the conversion and nonconversion groups was not statistically significant (P = .068). Patients with BMI ≥30 had a higher conversion rate compared to patients with BMI <30 (11.4% versus 1.5%, P = .011). Tubal sterilization via culdotomy was successfully performed in all 11 women with no prior vaginal deliveries.

CONCLUSION

Culdotomy appears to be a safe surgical approach to access the peritoneal cavity and is associated with a low complication rate. These data support the feasibility and safety of utilizing the cul-de-sac as an access portal for natural orifice transluminal endoscopic surgery.

Endometrial ablation for the treatment of heavy menstrual bleeding in obese women

OBJECTIVE

To compare the efficacy and safety of endometrial ablation (EA) among obese versus non-obese women.

METHODS

A retrospective cohort study of 666 women who underwent EA at the Mayo Clinic, Rochester, USA, between January 1, 1998, and December 31, 2005, was conducted. Obesity was defined as a body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) of 30 or above. Outcome measures included treatment failure and amenorrhea. Regression models were used to compare outcomes and adjust for known confounders.

RESULTS

The mean BMI was 29.6±7.7; 263 women (39.5%) were classified as obese. No difference was observed in treatment failure at 5 years between the obese and non-obese cohorts (11.6% vs 9.7%) with an adjusted hazard ratio of 0.96 (95% confidence interval [CI], 0.60-1.53; P=0.878). The crude 12-month amenorrhea rate was higher among non-obese than obese women (24.3% vs 17.5%); however, this difference was not significant after adjusting for known predictors of amenorrhea. The odds ratio was 1.28 (95% CI, 0.75-2.19; P=0.366). Adverse events were rare and comparable between the cohorts.

CONCLUSION

The use of EA is a safe and effective option for women with obesity.

Efficacy and safety of global endometrial ablation after cesarean delivery: a cohort study

OBJECTIVE

The objective of the study was to evaluate the efficacy and safety of global endometrial ablation in women with a history of cesarean delivery.

STUDY DESIGN

We performed a historical cohort study of patients who underwent endometrial ablation for menorrhagia between 1998 and 2005. Outcome measures included amenorrhea, treatment failure, and operative complications. Time to treatment failure was compared using Kaplan-Meier analysis. Risk adjustments were performed using Cox and logistic regression models.

RESULTS

Of 704 patients meeting inclusion criteria, 162 (23%) had a history of 1 or more cesarean deliveries. Women with and without a history of cesarean delivery had comparable rates for 5 year cumulative endometrial ablation failure, amenorrhea, treatment failure, and operative complications. The type of ablation device and number of previous cesarean deliveries did not affect any outcomes.

CONCLUSION

The efficacy and safety of endometrial ablation are comparable in women with or without a history of cesarean delivery.

Efficacy, safety, and patient acceptability of the Essure™ procedure

The Essure™ system for permanent contraception was developed as a less invasive method of female sterilization. Placement of the Essure™ coil involves a hysteroscopic transcervical technique. This procedure can be done in a variety of settings and with a range of anesthetic options. More than eight years have passed since the US Food and Drug Administration approval of Essure™. Much research has been done to evaluate placement success, adverse outcomes, satisfaction, pain, and the contraceptive efficacy of the Essure™. The purpose of this review is to summarize the available literature regarding the efficacy, safety, and patient satisfaction with this new sterilization technique.

Efficacy of bipolar radiofrequency endometrial ablation vs thermal balloon ablation for management of menorrhagia: A population-based cohort

STUDY OBJECTIVE

To compare the efficacy of bipolar radiofrequency ablation (RFA) and thermal balloon ablation (TBA) using treatment failure and postprocedure amenorrhea as outcome measures.

DESIGN

Population-based cohort study (Canadian Task Force classification II-2).

SETTING

Two medical centers in the upper Midwest.

PATIENTS

Using the medical records linkage system of the Rochester Epidemiology Project, we identified 455 residents of Olmsted County, Minnesota, who underwent global endometrial ablation because of menorrhagia from January 1, 1998, through December 31, 2005. Amenorrhea was defined as complete cessation of menstruation that started immediately after ablation and lasted at least 12 months. Treatment failure was defined as necessity of repeat ablation or hysterectomy because of persistent bleeding or pain. Time to treatment failure for each procedure was compared using Kaplan-Meier plots. Relevant clinical data and complications were abstracted from medical records. Risk adjustments were performed using Cox and logistic regression models.

INTERVENTIONS

Radiofrequency ablation (n=255) and thermal balloon ablation (n=200).

MEASUREMENTS AND MAIN RESULTS

Mean (SD) patient age was 43.3 (5.5) years, and median follow-up was 2.2 years. The 3-year cumulative failure rate was 9% (95% confidence interval [CI], 5%-16%) for RFA and 12% (95% CI, 7%-16%) for TBA (p=.26). The difference remained nonsignificant after adjusting for known predictors of treatment failure such as age, parity, pretreatment dysmenorrhea, and tubal ligation (adjusted HR, 0.7; 95% CI, 0.4-1.4; p=.31). However, women had significantly higher rates of amenorrhea after RFA compared with TBA (32% vs 14%; p <.001). This difference remained significant after adjusting for known predictors of amenorrhea such as age, uterine length, and endometrial thickness (adjusted odds ratio, 2.9; 95% CI, 1.7-4.8; p <.001). Complications were infrequent and similar in the 2 groups.

CONCLUSION

Both RFA and TBA were equally effective treatments for menorrhagia in a population-based cohort. However, women who underwent RFA were 3 times more likely to have postprocedure amenorrhea.

Hysteroscopic sterilization in women with severe cardiac disease: experience at a tertiary center

OBJECTIVE

To determine the feasibility and effectiveness of hysteroscopic sterilization as a minimally invasive sterilization method for women with high-risk cardiac disease.

PARTICIPANTS AND METHODS

In a retrospective cohort study, 18 women with high-risk cardiac conditions that strictly contraindicated pregnancy were compared with a reference cohort of 157 women without cardiac disease. All underwent microinsert hysteroscopic sterilization at Mayo Clinic from January 2003 through February 2007. End points included successful placement, fallopian tube patency determined by hysterosalpingogram 3 months after the procedure, and pregnancy status.

RESULTS

Women in the cardiac cohort were younger than those in the reference cohort (median age, 25 vs 39 years; P<.001), had lower parity (median, 0 vs 2; P<.001), and had a higher proportion of patients categorized as American Society of Anesthesiologists' physical status 3 (severe systemic disease) and physical status 4 (systemic disease that is a constant threat to life) (83% vs 6%; P<.001). No significant differences were noted for use of general anesthesia (17% vs 27%; P=.41), successful bilateral device placement (100% vs 95%; P>.99), postoperative pain score (median, 0 for both groups; P=.87), or length of hospitalization (median, 6 vs 6 hours; P=.63). No intraoperative complications occurred. Follow-up hysterosalpingography showed high tubal occlusion rates in both cohorts (100% cardiac; 98% reference; P>.99). No pregnancies occurred during a median follow-up period of 20 months (interquartile range, 8-33 months).

CONCLUSION

For women with cardiac disease and strict contraindications for pregnancy, microinsert hysteroscopic sterilization provided minimally invasive, permanent, and reliable contraception.

Radiofrequency global endometrial ablation followed by hysteroscopic sterilization

STUDY OBJECTIVE

To describe the feasibility of performing Essure hysteroscopic sterilization immediately after NovaSure global endometrial ablation (GEA).

DESIGN

Descriptive feasibility study (Canadian Task Force classification III).

SETTING

Midwestern United States academic medical center.

PATIENTS

Twenty-five women (aged 35-49 years) with menorrhagia who elected GEA treatment and requested concurrent permanent sterilization.

INTERVENTIONS

NovaSure GEA followed immediately by Essure hysteroscopic sterilization. Patients returned 3 months after the procedure for hysterosalpingography (HSG) to document tubal occlusion.

MEASUREMENTS AND MAIN RESULTS

The inserts were placed successfully in all 25 patients; 21 returned for 3-month follow-up HSG, as recommended. Bilateral tubal occlusion was documented at 3 months in 19 patients (90%) and unilateral occlusion in 2 patients. Six-month postprocedural HSG in these 2 patients documented bilateral tubal occlusion. Hysterosalpingography was not performed in 4 patients. In all 21 patients with appropriate follow-up, complete occlusion was documented, and the ability to perform or interpret HSG was not affected by endometrial ablation.

CONCLUSION

Essure hysteroscopic sterilization can be safely performed after NovaSure GEA. Intrauterine synechiae do not appear to adversely affect the ability to perform HSG at 3 months or to document tubal occlusion.

Global Endometrial Ablation for Menorrhagia in Women With Bleeding Disorders

OBJECTIVE

To evaluate the efficacy of global endometrial ablation in women with bleeding disorders who presented with menorrhagia.

METHODS

A records-linkage system was used to construct a retrospective cohort of 41 women with bleeding disorders (coagulopathy) and a reference group of 111 randomly selected women without bleeding disorders from a pool of 943 women who underwent global endometrial ablation (with thermal balloon ablation technology or bipolar radiofrequency ablation technology) for menorrhagia at Mayo Clinic (Rochester, Minnesota) from January 1995 through December 2005. Demographic data, type of global endometrial ablation therapy and reablation, and hysterectomy data were extracted from the database.

RESULTS

There was no significant difference in baseline age, parity, body mass index, uterine size, type of global endometrial ablation therapy, or duration of follow-up between the groups. Two women (5%) in the coagulopathy group had hysterectomy or reablation, compared with 8 (7%) in the reference group (Fisher exact test, P=.728). A Kaplan-Meier plot showed no difference in the time to treatment failure between the groups (log-rank test, P=.534). Procedural-related complications were generally minor and infrequent (9 of 152 [6%]). Complications were equally distributed in the coagulopathy (4 of 41) and reference groups (6 of 111) (Fisher exact test, P=.267).

CONCLUSION

Global endometrial ablation is an effective treatment choice for women with coagulopathy presenting with menorrhagia.

Retrospective cost analysis comparing Essure hysteroscopic sterilization and laparoscopic bilateral tubal coagulation

STUDY OBJECTIVE

To compare the institutional cost of permanent female sterilization by Essure hysteroscopic sterilization and laparoscopic bilateral coagulation.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-2).

SETTING

Midwestern academic medical center.

PATIENTS

Women of reproductive age who elected for permanent contraception by the Essure method (n = 43) or by laparoscopic tubal coagulation (n = 44) during the time frame studied.

INTERVENTIONS

Placement of the Essure inserts according to the manufacturer's instructions or laparoscopic tubal sterilization using bipolar forceps according to standard techniques of open or closed laparoscopy.

MEASUREMENTS AND MAIN RESULTS

Cost-center data for the institutional cost of the procedure was abstracted for each patient included in the study. In addition, demographic data and procedural information were obtained and compared for the patient populations. The Essure system of hysteroscopic sterilization had a significantly decreased cost compared with laparoscopic tubal sterilization when both procedures were performed in an operating room setting. The decrease per patient in institutional cost was 180 dollars (p = .038). This included the cost of the confirmatory hysterosalpingogram 3 months after Essure placement and the cost of laparoscopic tubal occlusion by Filshie clip if the Essure micro-inserts could not be placed. The majority of the cost was related to hospital costs as opposed to physician costs. The Essure procedure had higher costs for disposable equipment (p <.0001), but this was offset by higher charges for operating room costs, which included the recovery room (p <.0001) and pharmacy costs (p <.0001) in the patients in the laparoscopy group.

CONCLUSION

In our setting, the Essure hysteroscopic sterilization had significant cost savings compared with laparoscopic tubal sterilization (p = .038). We believe that our data represent the minimum of potential savings using this approach, and future developments will only increase the cost difference found in our study.