Gallic acid ameliorates endometrial hyperplasia through the inhibition of the PI3K/AKT pathway and the down-regulation of cyclin D1 expression

BACKGROUND

Gallic acid (GA) is an organic compound with phenolic properties that occurs naturally and can be found in Guizhi Fuling capsules, showcasing a wide range of biological functionalities.

PURPOSE

The objective of this study was to examine the influence of GA on endometrial hyperplasia (EH) and elucidate its underlying mechanism.

METHODS

Initially, the induction of EH was achieved by administering estradiol to mice via continuous subcutaneous injection for a duration of 21 days. Concurrently, GA treatment was administered, and subsequently, the uterine tissue structure was assessed using hematoxylin and eosin (H&E) staining. Following this, the proliferation of human endometrial cells treated by GA was determined utilizing the CCK-8 method. Furthermore, network pharmacology and single-cell-RNA-seq data were employed to identify the target of GA action. In addition, we will employ immunofluorescence (IF), immunohistochemistry (IHC), flow cytometry, western blot and RT-qPCR methodologies to investigate the impact of GA on the expression level of cyclin D1, PI3K, p-PI3K, AKT, p-AKT.

RESULTS

GA treatment ameliorated histopathological alterations in the uterus and suppress proliferation. Estradiol stimulation can activate the PI3K/AKT pathway, leading to up-regulation of cyclin D1 expression, whereas GA treatment results in down-regulation of its expression.

CONCLUSIONS

The expression of cyclin D1 is down-regulated by GA through the inhibition of the PI3K/AKT pathway, effectively mitigating estradiol-induced EH in mice.

Increasing utilization of intrauterine device insertion at hysteroscopic endometrial evaluation for patients with endometrial hyperplasia

PURPOSE

To examine the utilization and characteristics related to the use of hysteroscopy at the time of endometrial evaluation for endometrial hyperplasia in the outpatient surgery setting.

METHODS

This cross-sectional study queried the Healthcare Cost and Utilization Project's Nationwide Ambulatory Surgery Sample. The study population was 3218 patients with endometrial hyperplasia who underwent endometrial evaluation from January 2016 to December 2019. Performance and clinical characteristics of hysteroscopic endometrial evaluation were assessed with multivariable binary logistic regression models.

RESULTS

A total of 2654 (82.5%) patients had hysteroscopic endometrial tissue evaluation. Patients with postmenopausal bleeding, heavy menstrual bleeding, and polycystic ovary syndrome were more likely to undergo hysteroscopic endometrial evaluation in multivariable analysis (all, adjusted-P < 0.001). Uterine injury occurred in 4.9 per 1000 hysteroscopic endometrial evaluations; none had uterine injury in the non-hysteroscopy cohort. Among the 2654 patients who had hysteroscopic endometrial evaluation, 106 (4.0%) patients had intrauterine device insertion at surgery, and the utilization increased from 2.9 to 5.8% during the study period (P-trend < 0.001). Younger age, more recent year surgery, and obesity were independently associated with increased utilization of intrauterine device insertion at hysteroscopic endometrial evaluation (all, adjusted-P < 0.05). Among 2023 reproductive-age patients with endometrial hyperplasia, 1666 (82.4%) patients underwent hysteroscopic endometrial evaluation. On multivariable analysis, patients with heavy menstrual bleeding were more likely to have hysteroscopic endometrial evaluation (adjusted-P < 0.05). Intrauterine device insertion increased from 3.7% in 2016 to 8.0% in 2019 (P-trend = 0.007).

CONCLUSION

This nationwide analysis suggests that the insertion of intrauterine devices at the time of hysteroscopic endometrial tissue evaluation for endometrial hyperplasia is increasing among reproductive-age population.

A comparative study of mono-exponential and advanced diffusion-weighted imaging in differentiating stage IA endometrial carcinoma from benign endometrial lesions

PURPOSE

The purpose of the current investigation is to compare the efficacy of different diffusion models and diffusion kurtosis imaging (DKI) in differentiating stage IA endometrial carcinoma (IAEC) from benign endometrial lesions (BELs).

METHODS

Patients with IAEC, endometrial hyperplasia (EH), or a thickened endometrium confirmed between May 2016 and August 2022 were retrospectively enrolled. All of the patients underwent a preoperative pelvic magnetic resonance imaging (MRI) examination. The apparent diffusion coefficient (ADC) from the mono-exponential model, pure diffusion coefficient (D), pseudo-diffusion coefficient (D*), perfusion fraction (f) from the bi-exponential model, distributed diffusion coefficient (DDC), water molecular diffusion heterogeneity index from the stretched-exponential model, diffusion coefficient (Dk) and diffusion kurtosis (K) from the DKI model were calculated. Receiver operating characteristic (ROC) analysis was used to evaluate the diagnostic efficiency.

RESULTS

A total of 90 patients with IAEC and 91 patients with BELs were enrolled. The values of ADC, D, DDC and Dk were significantly lower and D* and K were significantly higher in cases of IAEC (p < 0.05). Multivariate analysis showed that K was the only predictor. The area under the ROC curve of K was 0.864, significantly higher compared with the ADC (0.601), D (0.811), D* (0.638), DDC (0.743) and Dk (0.675). The sensitivity, specificity and accuracy of K were 78.89%, 85.71% and 80.66%, respectively.

CONCLUSION

Advanced diffusion-weighted imaging models have good performance for differentiating IAEC from EH and endometrial thickening. Among all of the diffusion parameters, K showed the best performance and was the only independent predictor. Diffusion kurtosis imaging was defined as the most valuable model in the current context.

Metformin and progestins in women with atypical hyperplasia or endometrial cancer: systematic review and meta-analysis

PURPOSE

To assess metformin's effectiveness in adding it to progestin-based hormone therapy for treating atypical endometrial hyperplasia (AEH) and early endometrial cancer (EEC).

METHODS

We conducted a systematic review and meta-analysis following PRISMA guidelines (registration number CRD42023399094). We searched databases for studies up to March 2023, including randomized and non-randomized clinical trials in English.

RESULTS

Out of 280 studies, 9 studies (1104 patients) were eligible. A total of 408 patients were allocated to receive metformin, and 696 patients entered the control group. Primary analysis focused on evaluating the CR showed a significant difference in patients with AEH treated with metformin (RR = 1.10, 95% CI 1.02-1.20, p = 0.02). Relapse rate (RR = 0.62, 95% CI 0.33-1.17, p = 0.14) was also evaluated. Secondary analysis indicated higher pregnancy rates (RR = 1.28, 95% CI 1.04-1.57, p = 0.02) with no significant difference in live birth rates (RR = 0.56, 95% CI 0.29-1.10, p = 0.09).

CONCLUSION

Combined therapy is effective. Metformin shows superiority to the standard regimen in achieving better CR rate in patients with AEH and benefits pregnancy rates but not recurrence or live birth rates. Therefore, the ideal fertility-sparing treatment for EC has not yet been determined and further clinical trials are needed.

Efficacy of Levonorgestrel Intrauterine System in the Management of Abnormal Uterine Bleeding: A Retrospective Analysis of a 100 Women

Aim

Abnormal uterine bleeding (AUB) is a common gynaecological complaint affecting around 10-30% women during reproductive years. It adversely affects a woman's life, leading to psychological, medical, social and sexual problems. We aim to study the efficacy of a levonorgestrel intrauterine system (LNG-IUS) in 100 women suffering from AUB.

Methodology

A retrospective study was carried out at a private nursing home in Mumbai over a period of 4 years. A total of 100 patients aged 30 years to 50 years (average age = 42.9 years) who underwent LNG-IUS insertion for abnormal uterine bleeding were studied. Cases were evaluated according to clinical findings, hemogram and transvaginal ultrasound. The women were called for follow-up at 1 week, 1 month, 6 months, 1 and 2 years to analyse type and amount of bleeding and development of amenorrhea.

Results

At the end of 6 months, 75% patients experienced decreased menstrual blood loss. Five patients underwent removal of the LNG-IUS at the end of 6 months as they experienced no relief of symptoms. At the end of 2 years, 95% patients were fully satisfied with the LNG-IUS insertion.

Conclusion

A levonorgestrel intrauterine system significantly reduces bleeding in menorrhagia due to benign causes and is found to be highly effective in the management of various gynaecological pathologies such as endometrial polyps, adenomyosis and endometrial hyperplasia when insertion perfomed after dilatation and curettage/polypectomy. It has proven to be superior to various surgical and other non-surgical treatment modalities.

Association between bacterial pathogenicity, endometrial histological changes and clinical prognosis in canine pyometra

Despite the high frequency and clinical relevance of canine pyometra, its pathogenesis remains poorly understood. In this study, the clinical data, histopathological alterations, and microbiological findings of 39 dogs with pyometra were analyzed to assess possible associations. The mean age of the affected animals was 9.6 ± 3.8 years; 76.3 % (29/38) had open cervix pyometra, 88 % (22/25) had tachypnea, 71 % (27/38) had anorexia, and 60.5 % (23/38) had leukocytosis. Histopathological analysis revealed that 66.5 % (26/39) of the uteri had a high degree of inflammation (score 4). Third-degree hyperplasia of the endometrial epithelium (72 %, 28/39) and intralesional or intrauterine bacteria (66.5 %, 26/39) were identified in most animals. Bacterial isolates were obtained from 82 % (32/39) of the uterine contents and five bacterial species were identified. Escherichia coli, classified in phylogroup B2, is associated with virulent adhesion genes (fimH, focG, and papC), and serum resistance (traT) was the most common isolate. There was an association between the detection of papC in E. coli isolates and higher necrosis scores. Additionally, the necrosis score was positively associated with the length of hospitalization, with each point increase in the necrosis score leading to two more days of hospitalization. These results suggest that papC-positive E. coli play an important role in the severity of pyometra in dogs. The present study revealed the possibility of using this virulence gene to better understand the prognosis of the disease in an affected animal.

Predictive value of body mass index (BMI) and determination of optimum cut-off point in the diagnosis of endometrial hyperplasia in pre-menopausal women with abnormal uterine bleeding

Background

The suitable BMI cut-off point in persons with endometrial cancer or hyperplasia with abnormal uterine bleeding was investigated in this study.

Methods

This case-control research was conducted on 1470 women with abnormal uterine bleeding in Ayatollah Rouhani Hospital,Babol between 2010 and 2012, with 312 participants included in the study. In terms of uterine biopsy results, patients were split into six groups: simple hyperplasia without atypia, simple hyperplasia with atypia, complicated hyperplasia with atypia, complex hyperplasia without atypia, endometrial cancer, and normal persons.

Results

The mean age and BMI of patients in these three groups were not significantly different (P equal to 0.081 and 0.435, respectively). The kind of disease exhibited a strong relationship with menstruation (P 0.001). The body mass index (BMI) values ​​did not have significant levels under the curve to determine the appropriate cut-off point in the diagnosis of hyperplasia plus endometrial cancer and endometrial cancer alone (P 0.380 and 0.124, respectively) and hyperplasia alone (P = 0.920). Based on logistic regression, age 50 years and older and irregular menstruation were significant with OR equal to 2.36 and 2.09 (P = 0.011) and HTN with OR equal to 0.44 (P = 0.026), respectively.

Conclusion

BMI has little predictive value in the detection of endometrial cancer or hyperplasia, according to the findings, and other diagnostic and screening modalities should be utilized instead. The findings backed up the theory that old age and irregular menstruation are linked to an increased risk of endometrial cancer.

Impact of abnormal uterine bleeding care in premenopausal patients prior to endometrial malignancy diagnosis

Background

Literature evaluating the management of abnormal uterine bleeding in premenopausal patients prior to endometrial malignancy diagnosis is lacking.

Objective

To evaluate predictors and consequences of inadequate evaluation and management of abnormal uterine bleeding and time to endometrial sampling in premenopausal patients prior to endometrial malignancy diagnosis.Study Design.This was a retrospective cohort study of premenopausal individuals with endometrioid endometrial cancer or atypical hyperplasia at a single institution from 2015 to 2020.. Complete noninvasive management encompassed pelvic exam, ultrasound, and progestin treatment before or in conjunction with the endometrial sampling of diagnosis. Multivariable logistic and ordinal odds models were used to evaluate predictors and outcomes.

Results

152 subjects were included, 80.3 % with cancer and 19.7 % with atypical hyperplasia. The majority of patients had anovulatory bleeding, obesityand recent health care. Only 20.4 % had complete nonvinvasive management, and only 12.5 % had complete noninvasive management or endometrial sampling within 2 months of presentation with abnormal bleeding. Class III obesity reduced the likelihood of complete assessment and increased time to sampling, while age 45 and up and parity reduced time to sampling. Most patients had partial workup but no progestin treatment and long intervals before endometrial sampling after presentation to a provider with abnormal bleeding. Incomplete workup correlated to worse cancer grade and stage.

Conclusion

Despite high clinical risk and health care contact, most patients had insufficient gynecologic management preceding a diagnosis of endometrial malignancy. Inadequate care correlated to worse oncologic outcomes and demonstrates missed opportunities for early detection and prevention of endometrial cancer.

Comparing endometrial biopsy results with hysteroscopic pathology in women presenting with abnormal and postmenopausal uterine bleeding

OBJECTIVE

To compare pathology results after office-based blind endometrial biopsy and pathology results from hysteroscopy in women presenting with abnormal uterine bleeding (AUB).

METHODS

A retrospective cohort study of biologic women presenting with AUB at a tertiary care referral care center. Patients were included if they underwent evaluation with blind endometrial biopsy performed in the office followed by hysteroscopy within one year. Hysteroscopic findings and pathology were correlated with index endometrial biopsy findings.

RESULTS

689 patients met inclusion criteria. The mean age and BMI were 49 (±10) years and 31 (±8) kg/m2. The median duration of bleeding leading up to presentation was of 3.5 (1.5-9) months. Of the patients who had operative hysteroscopic pathology demonstrating endometrial polyp, 30.6 % (81) had a polyp detected on office endometrial biopsy. Of the patients who had hysteroscopic pathology demonstrating intracavitary fibroids, 0 % (0) were detected on endometrial biopsy. Of the patients who had hyperplasia without atypia on hysteroscopy, 28.6 % (4) were detected or suspected on endometrial biopsy. Of the patients who had hyperplasia with atypia on hysteroscopy, 5.9 % (1) were detected or suspected on endometrial biopsy. There were 12 cases of confirmed or suspected malignancy on hysteroscopy, of which 8.3 % (1) were detected on endometrial biopsy.

CONCLUSION

Concordance between focal findings on office hysteroscopy and endometrial biopsy is low. Endometrial biopsy when malignancy is suspected has been shown to be of benefit, but in the setting of suspected benign focal pathology, blind assessment of the endometrial cavity for definitive diagnosis should be abandoned. In women with symptomatic uterine bleeding, hysteroscopic visualization is associated with increased sensitivity in identifying intrauterine pathology.

Risk-stratification machine learning model using demographic factors, gynaecological symptoms and β-catenin for endometrial hyperplasia and carcinoma: a cross-sectional study

BACKGROUND

Demographic features, suggestive gynaecological symptoms, and immunohistochemical expression of endometrial β-catenin have a prognostic capacity for endometrial hyperplasia and carcinoma. This study assessed the interaction of all variables and developed risk stratification for endometrial hyperplasia and carcinoma.

METHODS

This cross-sectional study was conducted from January 2023 to July 2023 at two teaching hospitals in Makassar Indonesia. Patients (< 70 years old) with suggestive symptoms of endometrial hyperplasia or carcinoma or being referred with disease code N.85 who underwent curettage and/or surgery for pathology assessment except those receiving radiotherapy, or chemotherapy, presence of another carcinoma, coagulation disorder, and history of anti-inflammatory drug use and unreadable samples. Demographic, and clinical symptoms were collected from medical records. Immunohistochemistry staining using mouse-monoclonal antibodies determined the β-catenin expression (percentage, intensity, and H-score) in endometrial tissues. Ordinal and Binary Logistic regression identified the potential predictors to be included in neural networks and decision tree models of histopathological grading according to the World Health Organization/WHO grading classification.

RESULTS

Abdominal enlargement was associated with worse pathological grading (adjusted odds ratio/aOR 6.7 95% CI 1.8-24.8). Increasing age (aOR 1.1 95% CI 1.03-1.2) and uterus bleeding (aOR 5.3 95% CI 1.3-21.6) were associated with carcinoma but not with %β-catenin and H-Score. However, adjusted by vaginal bleeding and body mass index, lower %β-catenin (aOR 1.03 95% 1.01-1.05) was associated with non-atypical hyperplasia, as well as H-Score (aOR 1.01 95% CI 1.01-1.02). Neural networks and Decision tree risk stratification showed a sensitivity of 80-94.8% and a specificity of 40.6-60% in differentiating non-atypical from atypical and carcinoma. A cutoff of 55% β-catenin area and H-Score of 110, along with other predictors could distinguish non-atypical samples from atypical and carcinoma.

CONCLUSION

Risk stratification based on demographics, clinical symptoms, and β-catenin possesses a good performance in differentiating non-atypical hyperplasia with later stages.

Modulatory effect of ciprofloxacin, a broad spectrum antibacterial drug, on mPT pore using rat model with estradiol benzoate-induced endometrial hyperplasia

Mitochondrial permeability transition (mPT) pore has become a motive for drug evolvement pertinent to dysregulated apoptosis situations. Some chemical compounds impede tumor/cancer via the inception of mPT pore opening. Ciprofloxacin has been demonstrated to hinder growth and effect apoptosis in some cancer cells. However, using a rat model, this study investigated its effect on mitochondrial-mediated cell death via mPT pore opening and estradiol benzoate (EB)-induced endometrial hyperplasia. Mitochondria were isolated using differential centrifugation. The opening of the pore, cytochrome c release (CCR), mitochondrial ATPase (mATPase) activity, mitochondrial lipid peroxidation (mLPO), caspases 3 and 9 levels, and hepatic DNA fragmentation were determined. Histological evaluation of hepatic and uterine sections and immunoexpression levels of Bax, caspase 3, and anti-apoptotic Bcl-2 levels were quantified. The results show that ciprofloxacin caused mPT pore opening, CCR, mATPase activity, effected mLPO, caspases 3 and 9 activations, and hepatic DNA fragmentation. The histology of the liver section showed moderate to marked disseminated congestion at 100 mg/kg, while higher doses showed severe hepatic damage. Severe EH was detected in the EB-treated rats which was attenuated by ciprofloxacin in the treatment group. The Bax and caspase expressions were upregulated by ciprofloxacin while anti-apoptotic Bcl-2 was downregulated. Ciprofloxacin induces mitochondrial-mediated cell death via mPT pore opening and mitigates EB-induced EH in rat models via Bax/caspase/Bcl-2 signaling pathway.

Association of Urinary Levels of Estrogens and Estrogen Metabolites with the Occurrence and Development of Endometrial Hyperplasia Among Premenopausal Women

Endometrial cancer is known to be an estrogen-dependent cancer, and it is believed that exposure to estrogens increases the risk of developing endometrial cancer in the absence of progesterone. Estrogens and estrogen metabolites may help to predict the risk of endometrial hyperplasia (EH) with atypia. Estrogens and estrogen metabolites were measured by high-performance liquid chromatography-mass spectrometry (HPLC-MS/MS) in the first morning urine sample collected from 150 patients with EH and 50 healthy premenopausal women in the study. In healthy premenopausal women, the level of 16α-hydroxyestrone (16α-OHE1) in the overweight group was significantly higher than that in the lean group (p < 0.05). The levels of 4-hydroxyestradiol (4-OHE2) and 16α-OHE1 were elevated in the AEH group as compared to that in the control group (p < 0.05). Overweight is related to EH incidence as it causes an imbalance of estrogen metabolites. This study provides identifies potential biomarkers for estrogen-induced AEH.

Robotic vNOTES Techniques for Hysterectomy in a Patient with a 16-week Sized Uterus and a Body Mass Index of 70

STUDY OBJECTIVE

To demonstrate the surgical techniques for robotic vNOTES hysterectomy with bilateral salpingo-oophorectomy (BSO) in a World Health Organization class 3 obesity patient (body mass index = 70) as well as large fibroid uterus (16 weeks sized).

DESIGN

Stepwise demonstration with narrated video footage.

SETTING

An academic tertiary care hospital. Our patient is a 50-year-old G0 with postmenopausal vaginal bleeding with an enlarged uterus; her endometrial biopsy showed complex endometrial hyperplasia with atypia.

INTERVENTIONS

The surgical exposure for extremely obese patients with a concomitantly large uterus can be very challenging transabdominally due to the patient being unable to tolerate the Trendelenburg position and abdominal gas pressure [1-5]. Therefore, transvaginal NOTES can be an alternative option for these types of challenging patients. However, although there are clear benefits of vNOTES surgery in obese patients, we still need to be thoughtful and deliberate in handling this kind of surgery [6]. Several key success factors that aid in the completion of the surgery include 1. Appropriate patient positioning (Trenguard Position) as tolerated. 2. Initial vaginal section of hysterectomy. 3. Successful port placement. 4. Trendelenburg, as far as tolerated. 5. Harnessing the robotic camera for anterior colpotomy. 6. Utilizing alternative surgical exposure techniques: air seal for maintaining gas pressure for optimizing exposure, lap pad for thermal isolation, and maintaining the uterus for safe exposure during BSO. 7. After identification of the bilateral ureters, the broad, round, and uterine ovarian ligaments were transected with vessel sealer (less thermal spread), and the cystectomy was completed. (Supplemental Video 1) 8. BSO was completed. 9. In-bag uterine tissue extraction. 10. Vaginal cuff closure with V-Loc barbed suture.

CONCLUSION

Robotic-assisted NOTES hysterectomy with BSO is feasible and safe in extremely obese patients with large uterus. The combination of all these strategies could aid in the feasibility and safety of patients with these challenging pathology and morbidity.

Does weight loss in women with obesity induce regression of endometrial hyperplasia? A systematic review

Obesity is a leading risk factor for endometrial cancer and its precursor, endometrial hyperplasia (EH). Currently, weight loss is recommended for people with EH and obesity, but evidence to guide weight management as primary or adjunctive therapy is limited. This systematic review aims to assess the role of weight loss in inducing histopathological regression of EH in women with obesity. A systematic search of Medline, PubMed, Embase and The Cochrane Library databases was conducted in January 2022. Studies reporting on participants with EH who underwent weight loss interventions, incorporating comparisons of pre- and post-intervention histology, were included. Studies were limited to those published in English with full text available. Six studies met the inclusion criteria, all of which reported outcomes after bariatric surgery. Three studies reported outcomes for the same group of participants, therefore only one outcome set was included. Pre-operative endometrial biopsy results were available for 167 women, and 81 had post-operative biopsies reported. Nineteen women (11.4% of those biopsied) had EH pre-operatively; 17 underwent repeat sampling post-operatively. Twelve (71%) had complete histological resolution, 1 (6%) had partial regression from complex hyperplasia to simple hyperplasia, 1 (6%) had persistent atypical hyperplasia, and 3 (18%) had persistent simple hyperplasia. One patient with a normal pre-intervention biopsy had simple hyperplasia post-operatively. Due to poor quality and overall scarcity of data, the role of weight loss in the primary or adjunctive treatment of EH is unknown. Future studies should prospectively assess weight loss modalities and targets, as well as use of concurrent therapies.

Rapid identification of endometrial hyperplasia and endometrial endometrioid cancer in young women

PURPOSE

We investigated endometrial hyperplasia (EH) and endometrial endometrioid cancer (EEC) and developed a nomogram model to predict the EH/EEC risk and improve patients' clinical prognosis.

METHODS

Data were collected from young females (age: ≤ 40 years) who complained of abnormal uterine bleeding (AUB) or abnormal ultrasound endometrial echoes. The patients were randomly divided into training and validation cohorts at a 7:3 ratio. The risk factors for EH/EEC were determined through the optimal subset regression analysis and a prediction model was developed. We used the concordance-index (C-index), and calibration plots in the training and validation sets to assess the prediction model. We drew the ROC curve in the validation set and calculated the area under the curve (AUC), as well as its accuracy, sensitivity, specificity, negative predictive value, and positive predictive value, and finally, converted the nomogram into a web page dynamic nomogram.

RESULTS

Predictors included in the nomogram model were body mass index (BMI), polycystic ovary syndrome (PCOS), anemia, infertility, menostaxis, AUB type, and endometrial thickness. The C-index of the model in the training and validation sets were 0.863 and 0.858. The nomogram model had good discriminatory power and was well-calibrated. According to the prediction model, the AUC of EH/EC, EH without atypia, and AH/EC were 0.889, 0.867, and 0.956, respectively.

CONCLUSIONS

The nomogram of EH/EC is significantly associated with risk factors, namely BMI, PCOS, anemia, infertility, menostaxis, AUB type, and endometrial thickness. The nomogram model can be used to predict the EH/EC risk and rapidly screen risk factors in a women population with high risk.

Endometrial telomerase activity in women with either endometrial cancer or hyperplasia: A systematic review and meta-analysis

AIM

We performed a systematic review and meta-analysis to assess whether endometrial telomerase activity is associated with endometrial cancer or hyperplasia.

METHODS

PubMed, Web of Science, Embase, Scielo, LILAC, and CNKI databases were searched to obtain relevant literature for articles published through June 2022, following PRISMA guidelines and a registered PROSPERO protocol. We included observational studies reporting endometrial telomerase activity in patients with either endometrial cancer or hyperplasia compared with benign endometrial tissue (control women). The Newcastle-Ottawa Scale was used to evaluate the quality of studies. Data were expressed as the odds ratios (OR) and 95 % confidence intervals (CI). Random effects and inverse variance methods were used to meta-analyze associations. The I² test was used to assess heterogeneity.

RESULTS

There were significant associations between endometrial telomerase activity and either endometrial cancer (20 studies, OR = 10.65, 95 % CI 6.39, 17.75, p = 0.00001, I² = 21 %) or endometrial hyperplasia (nine studies, OR = 3.62, 95 % CI 1.61, 8.13, p = 0.002, I² = 36 %) compared to women without endometrial cancer and hyperplasia. There was not a significant difference in telomerase activity in women with endometrial cancer compared to those with endometrial hyperplasia (seven studies, OR = 1.03; 95 % CI 0.31, 3.37, p = 0.96, I² = 49 %). In subgroup analyses, there were no significant differences in telomerase activity in patients with endometrial cancer by type of observational studies and by countries of the studies.

CONCLUSION

Endometrial telomerase activity is higher in women with either endometrial cancer or endometrial hyperplasia compared to control women without those lesions.

Yield of annual endometrial cancer surveillance in women with PTEN Hamartoma Tumor Syndrome

OBJECTIVE

Expert-opinion based guidelines state that endometrial cancer surveillance (ECS) might be considered for patients with PTEN Hamartoma Tumor Syndrome (PHTS) based on an elevated lifetime risk of endometrial cancer. We aimed to evaluate the yield of ECS by annual transvaginal ultrasound (TVUS) and endometrial biopsy (EMB) in PHTS patients.

METHODS

PHTS patients who visited our PHTS expert center between August 2012 and September 2020 and opted for annual ECS were included. Data on surveillance visits, diagnostics, reports of abnormal uterine bleeding and pathology results were retrospectively gathered and analyzed.

RESULTS

Surveillance was initiated in 25 women with a total of 93 gynecological surveillance visits during 76 surveillance years. The median age at first visit was 39 years (range 31-60) with a median follow-up duration of 38 months (range 6-96). Hyperplasia with and without atypia was detected six and three times, respectively, in seven (28%) women. The median age at hyperplasia detection was 40 years (range 31-50). In six asymptomatic women hyperplasia was detected during annual surveillance visits, while in one patient hyperplasia with atypia was detected during an additional visit due to abnormal uterine bleeding. In seven out of nine hyperplasias detected with EMB, TVUS beforehand showed no abnormalities. No (interval) carcinomas occurred.

CONCLUSIONS

ECS in women with PHTS enables detection of a substantial number of asymptomatic premalignancies, such as hyperplasia with and without atypia, suggesting that ECS may be beneficial with regard to cancer prevention. The addition of EMB to TVUS likely improves the detection of premalignancies.

Identifying women 45 years and younger at elevated risk for endometrial hyperplasia or cancer

OBJECTIVE

To estimate the prevalence of, and identify risk factors associated with, endometrial hyperplasia and/or cancer (EH/EC) in patients ≤45 years old undergoing endometrial sampling for abnormal uterine bleeding (AUB).

METHODS

We performed a retrospective cohort study of patients 18-45 years old with AUB who underwent endometrial sampling between 2016 and 2019 within a US-based multi-hospital system using billing code queries. We used multivariable Poisson regression to identify factors associated with EH/EC and calculated prevalence stratified by these factors. We estimated predicted probabilities within combinations of characteristics in order to examine the range of risk in this population.

RESULTS

Among 3175 patients, median age was 39 years (interquartile range [IQR]:35-43) and BMI was 29.7 kg/m² (IQR: 24.2-36.9). Thirty-nine percent were non-Hispanic White, 41% non-Hispanic Black, 9% Hispanic, and 11% Asian/Other/Unknown. BMI and polycystic ovarian syndrome (PCOS) were associated with higher EH/EC risk; non-Hispanic Black race was associated with lower risk. EH/EC prevalence ranged from 2% in BMI <25 to 16% in BMI ≥50 kg/m² (p-trend <0.001). These prevalence estimates differed by race/ethnicity with the lowest estimates in non-Hispanic Black patients (0.5% BMI <25 vs. 9% BMI ≥50) and highest in Hispanic patients (1.5% BMI <25 vs. 33% BMI ≥50). Accounting for combinations of risk factors, predicted probabilities were highest - 34-36% - among patients with PCOS, diabetes, BMI ≥50, and Hispanic or Asian/Other/Unknown race/ethnicity.

CONCLUSIONS

When accounting for combinations of key risk factors, risk of EH/EC in patients ≤45 years old with AUB ranges widely; the more nuanced estimates of risk presented here could help inform clinical decision-making about endometrial sampling in this population.

Lymph node evaluation for endometrial hyperplasia: a nationwide analysis of minimally invasive hysterectomy in the ambulatory setting

BACKGROUND

Given the possibility of occult endometrial cancer where nodal status confers important prognostic and therapeutic data, role of lymph node evaluation at hysterectomy for endometrial hyperplasia is currently under active investigation. The objective of the current study was to examine the characteristics related to lymph node evaluation at the time of minimally invasive hysterectomy when performed for endometrial hyperplasia in an ambulatory surgery setting.

METHODS

The Healthcare Cost and Utilization Project's Nationwide Ambulatory Surgery Sample was retrospectively queried to examine 49,698 patients with endometrial hyperplasia who underwent minimally invasive hysterectomy from 1/2016 to 12/2019. A multivariable binary logistic regression model was fitted to assess the characteristics related to lymph node evaluation at hysterectomy and a classification tree model with recursive partitioning analysis was constructed to examine the utilization pattern of lymph node evaluation.

RESULTS

Lymph node evaluation was performed in 2847 (5.7%) patients. In a multivariable analysis, (i) patient factors with older age, obesity, high census-level household income, and large fringe metropolitan, (ii) surgical factors with total laparoscopic hysterectomy and recent year surgery, (iii) hospital parameters with large bed capacity, urban setting, and Western U.S. region, and (iv) histology factor with presence of atypia were independently associated with increased utilization of lymph node evaluation at hysterectomy (all, P < 0.05). Among those independent factors, presence of atypia exhibited the largest association for lymph node evaluation (adjusted odds ratio 3.75, 95% confidence interval 3.39-4.16). There were 20 unique patterns of lymph node evaluation based on histology, hysterectomy type, patient age, year of surgery, and hospital bed capacity, ranging from 0 to 20.3% (absolute rate difference, 20.3%).

CONCLUSION

Lymph node evaluation at the time of minimally invasive hysterectomy for endometrial hyperplasia in the ambulatory surgery setting appears to be evolving with large variability based on histology type, hysterectomy modality, patient factors, and hospital parameters, warranting a consideration of developing clinical practice guidelines.

Evaluation of the Association of Endometrial Thickness, Insulin Resistance, and Menstrual Patterns in Adolescent Females with Polycystic Ovarian Syndrome

STUDY OBJECTIVE

To evaluate endometrial stripe (EMS) thickness and its association with menstrual pattern and insulin resistance in adolescent females with or at risk for polycystic ovarian syndrome (PCOS) METHODS: This was a retrospective case-control study of adolescent females ranging between 12 and 21 years old evaluated in the Adolescent Gynecology & Endocrinology Clinic (AGEC) at a tertiary children's hospital between 2017 and 2021. Transabdominal pelvic ultrasound (US) was obtained for evaluation of PCOS or acute pelvic pain. Unadjusted comparisons were performed between imaging measurements in the PCOS and control (girls without PCOS with acute pelvic pain) groups, as well as analysis of the PCOS group adjusted for age, body mass index, race, and biochemical values. This study was approved by the Institutional Review Board.

RESULTS

In our study, 54 subjects met the inclusion criteria for the PCOS group and 42 for the control group. EMS thickness was thinner in the PCOS group than in the control (0.55 ± 0.31 cm vs 0.70 ± 0.23 cm; P < .001). There was no difference in EMS thickness in the PCOS group when stratified by intermenstrual interval, insulin resistance, and other biochemical factors.

CONCLUSION

Our findings support recommendations by the 2018 International Guidelines to avoid use of US for the establishment of PCOS diagnosis in adolescents. These results highlight the unique pathophysiology of adolescent PCOS in contrast to PCOS in adult women. Further large-scale prospective studies are needed to understand the role of EMS thickness as a prognostic marker in adolescent PCOS.

Protective effect of eicosapentaenoic acid against estradiol valerate-induced endometrial hyperplasia via modulation of NF-κB/HIF-1α/VEGF signaling pathway in rats

BACKGROUND

Early diagnosis and treatment of endometrial hyperplasia (EH) remains mandatory for endometrial cancer (EC) prevention.

OBJECTIVE

To study the possible protective effect of eicosapentaenoic acid (EPA) in EH - induced by estradiol valerate (EV) in rats.

METHODS/MATERIALS

Adult female Wistar rats were given EV with or without EPA for 10 days. The uterine changes were evaluated by both physical (weight index) and histopathological methods. The markers of oxidative stress (Uterine malondialdehyde (MDA) and serum total antioxidant capacity (TAC) as well as serum estradiol and progesterone levels, and apoptosis (uterine caspase-3) were determined. Immunohistochemical estimations of nuclear factor kappa B (NF-κB) and vascular endothelial growth factor (VEGF) in addition to hypoxia-inducible factor 1 alpha (HIF-1α) immunoblotting were measured in uterine tissue.

KEY FINDINGS

EV showed significant increase in uterine weight index that is accompanied with histopatholigical evidences of EH. Such changes were associated with significant alterations in oxidative stress markers, modulation of estradiol and progesterone serum levels, an increase in HIF-1α, NF-κB and VEGF immuno-expressions and a significant decrease in caspase-3. EPA, in either dose, showed significant amelioration in uterine weight index as well as in histopathological changes. Such effect was accompanied with significant improvement in the measured hormonal levels, oxidative stress, apoptosis, and inflammatory parameters.

CONCLUSIONS

EPA in the used doses provided biochemical and histopathological improvement in EV-induced EH via modulation of NF-κB/HIF-1α/VEGF signaling pathway.

Chloroform Fraction of Drymaria Cordata Linn (CFDC) Suppresses Estradiol Benzoate-induced Endometrial Hyperplasia

BACKGROUND

The diagnosis of uterine dysfunction (endometrial hyperplasia) is on the rise. The available treatment is quite expensive and associated with some side effects. The therapeutic potential of natural products is now being explored, as they are easily available with little or no side effects. Drymaraia cordata is folklorically utilized in the treatment of diverse ailments including uterine fibroids. <P/> Objectives: This study aims to investigate the potential therapeutic effect of chloroform fraction of methanol extract of Drymaria cordata (CFDC) in estradiol benzoate (EB)-induced endometrial hyperplasia. <P/> Methods: Thirty-six rats were randomly divided equally into six groups. These included control group, CFDC:(100 mg/kg), CFDC:(200 mg/kg), EB:(2 mg/kg), EB+CFDC(100 mg/kg), and EB+CFDC(200 mg/kg). Endometrial hyperplasia (EH) was induced by intraperitoneal injection of EB. The levels of estrogen(E2), progesterone(PG), Follicle stimulating hormone(FSH), Luteinizing hormone(LH), Malondialdehyde(MDA), Superoxide dismutase(SOD), and Glutathione peroxidase(GSH-Px) activities were determined using ELISA technique. The uterine histological assessment and immunohistochemical expression levels of estrogen receptor, Ki-67, cytochrome c, and caspase 3 were carried out. <P/> Results: EH was severely expressed in the uterine section of EB-treated rats. However, CFDC administration improved the pathological features of the animal model. The sex hormones levels were increased in the EB-treated group, which were significantly reduced by CFDC. The antioxidant indices were also restored by CFDC. Immunoexpression levels of ERα and Ki-67 were downregulated while cytochrome c and caspase 3 were upregulated by CFDC. <P/> Conclusion: This study suggests that CFDC contains phytochemicals that can protect against EB-induced EH via modulation of hormonal signaling, apoptotic machinery, and oxidative indices.

Endometrial Thickness Measurement as Predictor of Endometrial Hyperplasia and Cancer in Perimenopausal Uterine Bleeding: Cross-Sectional Study

BACKGROUND

Endometrial thickness (ET) measurement was an alternative method for predicting abnormal endometrial pathology in postmenopausal bleeding. Cut-off value of ET measurement could not be use in perimenopausal bleeding.

OBJECTIVE

Aim of this study was to investigate appropriate ET cut-off value for perimenopause women with abnormal uterine bleeding (PEMB) and abnormal endometrial histopathology.

MATERIAL AND METHODS

This was a cross-sectional study. PEMB at Bhumibol Adulyadej Hospital between July 2018 and June 2022 were recruited. Subjects who met inclusion criteria underwent ET measurement and endometrial biopsy via endometrial aspirator. Participants who had histopathology report of endometrial hyperplasia and more were classified as the study group. The Control group were subjects with no endometrial hyperplasia or cancer. Demographic and clinical character data were included. Correlation of ET and endometrial histopathology were calculated for statistical significance.

RESULTS

A total of 304 cases were included. After exclusion, 254 subjects were recruited for this study. There were 22 and 232 cases in the study and control groups, respectively. The mean age and body mass index (BMI) of participants were 44.7 years old and 27.5 kg/m2, respectively. Prevalence of endometrial hyperplasia and cancer in perimenopausal uterine bleeding were 7.5 (19/254) and 1.2 (3/254) percent, respectively. Endometrial thickness equal to and more than 8 mm was associated with abnormal endometrial histopathology with statistical significance. Age, BMI, nulliparity, anovulatory bleeding history, hypothyroidism, diabetes mellitus and anovulation state of both groups were comparable.

CONCLUSIONS

Endometrial thickness equal or more than 8 mm were significantly associated with endometrial hyperplasia or more among perimenopausal women with abnormal uterine bleeding.

Does endometriosis increase the risks of endometrial hyperplasia and endometrial cancer?

OBJECTIVE

The risk of developing endometrial hyperplasia after diagnosis of endometriosis has not been determined. Moreover, the risk of endometrial cancer associated with endometriosis is unclear. This nationwide population-based study investigated the associations of endometrial hyperplasia and endometrial cancer with endometriosis, after adjusting for covariates.

METHODS

This population-based observational study analyzed data from the Korean National Health Insurance (NHI) database, including 147,869 women who were diagnosed with endometriosis from 2002 to 2017, with each patient matched to 20 control women without endometriosis. Cox proportional hazard regression analyses were performed to estimate the hazard ratios (HRs) of endometrial hyperplasia, endometrial cancer, and mortality from endometrial cancer.

RESULTS

Among three million women in this population, 16,377 women were diagnosed with endometrial hyperplasia, and 1795 women were diagnosed with endometrial cancer over 19,931,794 person-years of follow-up. Women with endometriosis were at significantly higher risks of endometrial hyperplasia (adjusted hazard ratio [aHR] 1.85, 95% confidence interval [CI] 1.75-1.95), and endometrial cancer (aHR 1.35, 95% CI 1.12-1.63) were compared with control women after adjustment for covariates. A diagnosis of endometriosis did not affect survival in patients with endometrial cancer.

CONCLUSION

The risks of endometrial hyperplasia and endometrial cancer were found to be significantly higher in women with than without endometriosis. The presence of endometriosis did not affect overall survival in women with endometrial cancer. Additional long-term prospective studies with adequate control of confounders are needed.

Sentinel lymph node mapping in patients with endometrial hyperplasia: A practice to preserve or abandon?

OBJECTIVES

To compare outcomes of patients with premalignant endometrial pathology undergoing hysterectomy with or without sentinel lymph node (SLN) removal. Outcomes of interest included surgical adverse events (AEs), cancer status on final pathology, postoperative treatment, and The Cancer Genome Atlas (TCGA) molecular risk profiles.

METHODS

We retrospectively identified patients with premalignant pathology on preoperative endometrial biopsy who underwent hysterectomy with or without SLN mapping/excision at our institution from 01/01/2017-12/31/2021. Clinical, pathologic, surgical, and TCGA profiling data were abstracted. Appropriate statistical tests were used.

RESULTS

Of 221 patients identified, 161 (73%) underwent hysterectomy with SLN excision and 60 (27%) underwent hysterectomy without SLN excision. Median age and body mass index were similar between groups. Median operative time was 130 min for those who underwent SLN mapping/excision versus 136 min for those who did not (p = 0.6). Thirty-day postoperative AE rates were 9% (n = 15/161) and 13% (n = 8/60), respectively (p = 0.9). Ninety-eight (44%) of 221 patients had grade 1-2 endometrioid endometrial cancer on final pathology (4 [4%] were stage IB or higher). Ten (10%) of 98 patients, all within the SLN group, received adjuvant treatment. Among all patients, of 33 (15%) with TCGA molecular classification data, 27 (82%) had copy number-low, 3 (9%) microsatellite instability-high, 2 (6%) POLE-ultramutated, and 1 (3%) copy number-high disease.

CONCLUSIONS

SLN assessment appears safe, detects a small number of occult nodal metastases for those upstaged, and provides additional staging information that can guide adjuvant treatment. SLN mapping should be discussed in preoperative counseling and offered using a shared decision-making approach.

Paeonol ameliorates endometrial hyperplasia in mice via inhibiting PI3K/AKT pathway-related ferroptosis

BACKGROUND

Paeonol (Pae) is one of the active ingredients from components of Guizhi Fuling Capsule, a traditional Chinese medicine widely used for the treatment of women's diseases, which exhibits various biological and pharmacological activities.

PURPOSE

The objective of this study was to investigate the molecular mechanism underlying the role of Pae in protecting against endometrial hyperplasia (EH).

METHODS

CCK-8 assay was performed to detect the effect of Pae on cell proliferation. Hematoxylin and eosin (H&E) staining was performed to evaluate uterine tissue structure. A network pharmacology study was performed to search the disease targets. Single-cell transcriptome analysis was performed with uterine tissues from 3 healthy donors and 3 EH patients on 10X Genomics platform. Changes in lipid peroxidation were detected by the MDA reaction. IHC assay, Western blot, immunofluorescence and RT-qPCR were used to study the effects of estradiol and Pae on the expression levels of GPX4, PI3K, AKT, p-PI3K, p-AKT in mice.

RESULTS

Pae treatment resulted in a decrease in cell viability of endometrial epithelial cells. Loss of uterus weight and morphology changes were observed in mice. In addition, Fe iron concentration and MDA levels increased, while the expression of GPX4, p-PI3K and p-AKT diminished.

CONCLUSIONS

Pae exhibited obvious alleviative activity in estradiol-induced mice via PI3K/AKT signaling pathway-regulated ferroptosis.

Comparison of the effectiveness of the levonorgestrel-intrauterine device and oral progestogens on regression of endometrial hyperplasia without atypia

Endometrial hyperplasia is caused by an excess of estrogen unopposed by progesterone. Oral progestogens are traditionally used for endometrial hyperplasia without atypia. However oral progestogen is not always successful at causing regression of endometrial hyperplasia. In addition, cyclic progestogens are less effective in delivering progestogen to the endometrium. Therefore, the levonorgestrel-intrauterine device (LNG-IUD), as an alternative option of delivery progestogen has been introduced in clinical practice. The effectiveness of LNG-IUD in causing regression of endometrial hyperplasia in the short-term had moderate-quality evidence, but the long-term (13 months to two years) effectiveness had low-quality evidence. In this study with relatively large sample size, we compared the effectiveness in the regression of endometrial hyperplasia without atypia for short-term and long-term between the treatment with LNG-IUD and oral progestogens or no treatment. Data on histology or ultrasound from 466 cases who received either LNG-IUD or oral progestogens or were untreated were collected. The primary treatment with LNG-IUD showed a 93% regression rate of endometrial hyperplasia, which was significantly higher than oral progestogens showing a 66% regression rate. The odds ratio of regression of endometrial hyperplasia in cases with LNG-IUD treatment was 7.128 (95%CI: 2.94, 16.76, p < 0.0001), compared to the cases with oral progestogen treatment. The regression rate in untreated cases was 16%. In addition, cases without regression by oral progestogens who then received the alternative treatment option by LNG-IUD also showed a 93% regression rate. While continuously receiving oral progestogens showed a 55% regression rate of endometrial hyperplasia, which was significantly lower than LNG-IUD treatment as an alternative option. Our data reports a significant response on regression of endometrial hyperplasia after LNG-IUD treatment in comparison with oral progestogen treatment.

Effects of isoflavone supplementation on endometrial thickness, endometrial hyperplasia, and cancer in ovariectomized cats

Ovariectomy is identified as a standard treatment in different European countries. Isoflavones, as nonsteroidal compounds in plants, are common constituents of soy and soy products. Some available cat diets contain different concentrations of soy products. This study aimed to examine the effects of isoflavone supplementation on endometrial hyperplasia and endometrial thickness in ovariectomized cats. Fifteen neutered adult cats were divided into control, estradiol, and isoflavone groups (five cats per group). Subcutaneous injection of estradiol (0.5 μg) in sesame oil (100 μL) was done for 30 days in estradiol-treated cats. Isoflavone-treated cats ingested a single oral tablet of soy extract for 30 days, while the controls received subcutaneous injections of the vehicle and oral placebo for 30 days. Histopathological findings of hematoxylin and eosin-stained sections revealed a significant difference between the estradiol group and other groups in terms of hyperplastic epithelium and simple hyperplasia. Thickness of myometrium was greater in the estradiol group compared to the isoflavone and control groups. Higher concentrations of estrogen can affect the endometrium and myometrium, while 30-day ingestion of isoflavone didn't have any uterine effect.

Diagnosis of endometrium hyperplasia and screening of endometrial intraepithelial neoplasia in histopathological images using a global-to-local multi-scale convolutional neural network

BACKGROUND AND OBJECTIVE

Endometrial hyperplasia (EH), a uterine pathology characterized by an increased gland-to-stroma ratio compared to normal endometrium (NE), may precede the development of endometrial cancer (EC). Particularly, atypical EH also known as endometrial intraepithelial neoplasia (EIN), has been proven to be a precursor of EC. Thus, diagnosing different EH (EIN, hyperplasia without atypia (HwA) and NE) and screening EIN from non-EIN are crucial for the health of female reproductive system. Computer-aided-diagnosis (CAD) was used to diagnose endometrial histological images based on machine learning and deep learning. However, these studies perform single-scale image analysis and thus can only characterize partial endometrial features. Empirically, both global (cytological changes relative to background) and local features (gland-to-stromal ratio and lesion dimension) are helpful in identifying endometrial lesions.

METHODS

We proposed a global-to-local multi-scale convolutional neural network (G2LNet) to diagnose different EH and to screen EIN in endometrial histological images stained by hematoxylin and eosin (H&E). The G2LNet first used a supervised model in the global part to extract contextual features of endometrial lesions, and simultaneously deployed multi-instance learning in the local part to obtain textural features from multiple image patches. The contextual and textural features were used together to diagnose different endometrial lesions after fusion by a convolutional block attention module. In addition, we visualized the salient regions on both the global image and local images to investigate the interpretability of the model in endometrial diagnosis.

RESULTS

In the five-fold cross validation on 7812 H&E images from 467 endometrial specimens, G2LNet achieved an accuracy of 97.01% for EH diagnosis and an area-under-the-curve (AUC) of 0.9902 for EIN screening, significantly higher than state-of-the-arts. In external validation on 1631 H&E images from 135 specimens, G2LNet achieved an accuracy of 95.34% for EH diagnosis, which was comparable to that of a mid-level pathologist (95.71%). Specifically, G2LNet had advantages in diagnosing EIN, while humans performed better in identifying NE and HwA.

CONCLUSIONS

The developed G2LNet that integrated both the global (contextual) and local (textural) features may help pathologists diagnose endometrial lesions in clinical practices, especially to improve the accuracy and efficiency of screening for precancerous lesions.

Endometrial hyperplasia as a risk factor of endometrial cancer

Endometrial hyperplasia (EH) is the precursor lesion for endometrioid adenocarcinoma of the endometrium (EC), which represents the most common malignancy of the female reproductive tract in industrialized countries. The most important risk factor for the development of EH is chronic exposure to unopposed estrogen. Histopathologically, EH can be classified into EH without atypia (benign EH) and atypical EH/endometrial intraepithelial neoplasia (EIN). Clinical management ranges from surveillance or progestin therapy through to hysterectomy, depending on the risk of progression to or concomitant EC and the patient´s desire to preserve fertility. Multiple studies support the efficacy of progestins in treating both benign and atypical EH. This review summarizes the evidence base regarding risk factors and management of EH. Additionally, we performed a systematic literature search of the databases PubMed and Cochrane Controlled Trials register for studies analyzing the efficacy of progestin treatment in women with EH.

Recurrent postmenopausal bleeding - just endometrial disease or ovarian sex cord-stromal tumor? A case report

BACKGROUND

Postmenopausal bleeding (PMB) is a common gynecologic complaint among elderly women, and endometrial hyperplasia is a common cause of this bleeding. Ovarian fibromas are the most common type of ovarian sex cord-stromal tumor (SCST). They arise from non-functioning stroma, rarely show estrogenic activity, and stimulate endometrial hyperplasia, causing abnormal vaginal bleeding.

CASE SUMMARY

We report herein the case of a 64-year-old Chinese woman who presented with recurrent PMB. A sex hormone test revealed that her estrogen level was significantly higher than normal, and other causes of hyperestrogenism had been excluded. The patient had undergone four curettage and hysteroscopy procedures in the past 7 years due to recurrent PMB and endometrial hyperplasia. The culprit behind the increase in estrogen level—an ovarian cellular fibroma with estrogenic activity—was eventually found during the fifth operation.

CONCLUSION

Ovarian cellular fibromas occur insidiously, and some may have endocrine functions. Postmenopausal patients with recurrent PMB and endometrial thickening observed on ultrasonography are recommended to undergo sex hormone testing while waiting for results regarding the pathology of the endometrium. If the estrogen level remains elevated, the clinician should consider the possibility of an ovarian SCST and follow-up the patient closely, even if the imaging results do not indicate ovarian tumors. Once the tumor is found, it should be removed as soon as possible no matter the size to avoid endometrial lesions due to long-term estrogen stimulation. More studies are needed to confirm whether preventive total hysterectomy with bilateral salpingo-oophorectomy should be recommended for women with recurrent PMB exhibiting elevated estrogen levels, despite the auxiliary examination results not indicating ovarian mass. The physical and psychological burden caused by repeated curettage could be prevented using this technique.

The relationship between oxidative stress markers and endometrial hyperplasia: A case-control study

Objective:

Endometrial hyperplasia (EH) is considered an endometrial cancer precursor. This study aimed to determine the role of oxidative stress and thiol groups with antioxidant properties in EH pathogenesis.

Materials and Methods:

In our prospective case-control study, participants were washed with 5 mL of saline before the endometrial biopsy. Endometrial washing fluid was taken into microtubules, and thiol and disulfide levels were analyzed using the Ellman reagent.

Results:

A total of 108 patients were in the EH group and 84 patients in the control group. The total and native thiol levels were higher values in the control group (p<0.001, for both). Disulfide levels were higher in the EH group (p<0.001). Native/total thiol ratio and disulfide/total thiol ratio were higher in the EH group (p<0.001, for both). The analysis performed in the control group revealed a significant positive correlation between estradiol and disulfide levels (r=0.322, p=0.033). No significant correlation was found between estradiol and disulfide in the EH group.

Conclusion:

Oxidative stress level was higher in the washing fluids of patients with EH and this stress plays a role in the EH etiology.

Effect of Nonionizing Radiation on Progesterone Treatment in Endometrial Hyperplasia: An Experimental Rat Study

OBJECTIVES

The aim of the study was to evaluate the negative effect of nonionizing radiation on the treatment of endometrial hyperplasia (EH) with oral progesterone.

DESIGN

Forty oophorectomized Wistar Albino female rats were included in this experimental rat study.

MATERIALS AND METHODS

The 4 groups were planned as follows: Group A; sham group; Group B; group receiving oral estradiol hemihydrate 4 mg/kg/day; Group C; 4 mg/kg/day oral estradiol hemihydrate followed with 1 mg/day medroxy progesterone acetate (MPA) and Group D; 4 mg/kg/day oral estradiol hemihydrate followed with 1 mg/day MPA with exposure to nonionizing radiation at 1800 mHz/3 h/day. After the experimental model, uterine horns were sampled and the preparations were evaluated for pathological parameters (glandular density, epithelial cell length, and luminal epithelial cell length) via light microscopy. Nonionizing radiation was created by a signal generator and a compatible mobile phone.

RESULTS

Estrogen was found to increase all parameters related to EH (p < 0.05). Progesterone treatment was found to decrease parameters related to EH (Group B vs. C; luminal epithelial cell length, glandular density, and epithelial length; 11.2 vs. 13.2 μm p = 0.007; 32.5 vs. 35.5, p = 0.068; and 219.9 μm vs. 285 µm, p < 0.001, respectively). Final analyses revealed reduced effectiveness of progesterone treatment in the rats exposed to nonionizing radiation (Group C vs. D); luminal epithelial cell length, glandular density, and epithelial length (11.2 μm vs. 13.5 μm, p = 0.179; 32.5 vs. 52, p < 0.001; and 219.9 μm vs. 374.1 μm, p = 0.001, respectively).

LIMITATIONS

The limitations of our study are that the results of animal experiments may not be appropriate for direct adaptation to humans and the relatively low number of rats included in the study.

CONCLUSION

Nonionizing radiation reduces the effect of progesterone in patients receiving treatment for EH.

Levonorgestrel-releasing intrauterine system versus oral medroxyprogesterone acetate in infertile women with endometrial hyperplasia without atypia

RESEARCH QUESTION

How does use of a levonorgestrel-releasing intrauterine system (LNG-IUS) in infertile women with endometrial hyperplasia without atypia affect endometrial hyperplasia regression and pregnancy rates compared with oral medroxyprogesterone acetate (MPA)?

DESIGN

This prospective cohort study included 215 infertile women with an indication for assisted reproductive technology (ART) and a diagnosis of endometrial hyperplasia without atypia. Endometrial hyperplasia was diagnosed by hysteroscopic endometrial biopsy. At the time of first- and second-line treatment, patients were offered therapy with either oral MPA 10 mg daily or LNG-IUS. Follow-up biopsies were scheduled after 90 days' treatment. After endometrial hyperplasia regression, patients were admitted to IVF/intracytoplasmic sperm injection (ICSI) cycles.

RESULTS

Baseline characteristics and confounders including age at diagnosis, body mass index and duration of infertility did not differ between LNG-IUS users and control participants and were accounted for using propensity score weighting. Endometrial hyperplasia regression rate at first follow-up was higher in the LNG-IUS group than the oral progestins group (28/28, 100% and 110/187, 58.8%; P < 0.001), while that after second-line treatment was comparable between the two groups (89/91, 97.8% and 122/124, 98.4%; P = 0.22). Clinical pregnancy rate, miscarriage rate and cumulative live birth rate following ART in patients ever receiving LNG-IUS were similar to those of patients receiving only MPA (34% versus 39.5%, 22.6% versus 34.7% and 26.4% versus 25.8%).

CONCLUSION

Endometrial hyperplasia regression is greater in women receiving LNG-IUS compared with oral MPA, while live birth rates following ART are comparable between the two groups. The use of LNG-IUS does not jeopardize the chances of pregnancy in women seeking fertility treatment.

Livin/BIRC7 gene expression as a possible diagnostic biomarker for endometrial hyperplasia and carcinoma

BACKGROUND

Livin/BIRC7 is a member of the inhibitors of apoptosis proteins family which are implicated in development of cancer through the inhibition of apoptosis process. This case-control study was intended to investigate livin/BIRC7 gene expression in endometrial hyperplasia and carcinoma and its correlation to some oxidative stress markers in addition to its possible diagnostic performance.

METHODS

This study included 90 participants [30 endometrial hyperplasia patients, 30 endometrial carcinoma patients, and 30 healthy controls]. Livin/BIRC7 gene expression was analyzed using quantitative reverse transcriptase-polymerase chain reaction (RT-PCR). Serum catalase activity was assessed by enzyme-linked immunosorbent assay (ELISA) and malondialdehyde level was measured by the colorimetric method.

RESULTS

Livin/BIRC7 gene expression was significantly (p < 0.001) higher in endometrial carcinoma from patients with endometrial hyperplasia when compared to controls. A positive correlation was found between livin/BIRC7 expression and serum catalase activity and malondialdehyde level in endometrial hyperplasia and carcinoma. The detection of livin/BIRC7 in endometrial carcinoma has excellent sensitivity and specificity.

CONCLUSIONS

Livin/BIRC7 was overexpressed in endometrial carcinoma with excellent power to differentiate endometrial carcinoma from endometrial hyperplasia or healthy subjects, suggesting that it might be a useful molecular marker for endometrial carcinoma diagnosis.

Rate of premalignant and malignant endometrial lesion in "low-risk" premenopausal women with abnormal uterine bleeding undergoing endometrial biopsy

Objective

To determine the incidence of endometrial hyperplasia and endometrial cancer (EH/EC) in low-risk premenopausal women with abnormal uterine bleeding (AUB) undergoing endometrial biopsy and to build a predictive model that includes clinical variables for predicting EH/EC in these women.

Methods

This retrospective study was conducted between January 2015 and March 2020. All premenopausal women aged <55 years with AUB who underwent endometrial sampling during a specified time period were included. Data regarding baseline characteristics, sonographic findings, and histological reports were collected from patient record sheets.

Results

During the specified time period, 1,089 premenopausal women underwent endometrial biopsy for AUB. Complete data analysis was done for 1,084 women. Of the endometrial samples, 95.3% revealed benign pathology, whereas 4.7% of the samples had major endometrial pathology EH/EC. On step-wise logistic regression analysis, intermenstrual bleeding (IMB) (OR, 3.15), body mass index (BMI) >25 kg/m² (odds ratio [OR], 4.4705), age >40 years (OR, 1.14), endometrial thickness (ET) >13 mm (OR, 2.59), and hypothyroidism (OR, 1.35) were significantly associated with EH/ EC. Considering the pretest probability for an EH/EC of 4.7%, this prediction model with a likelihood ratio of 14.2% demonstrated a post-test probability of 41% in the presence of the above-mentioned variables.

Conclusion

The risk of EH/EC was lower in low-risk premenopausal women with AUB. However, premenopausal women with IMB aged >40 years, hypothyroidism, BMI >25 kg/m², and thickened endometrium (ET >13 mm) are at high risk of EH/EC; therefore, endometrial biopsy should be considered early in their management plan.

Risk factors of endometrial cancer in patients with endometrial hyperplasia: implication for clinical treatments

Background

Endometrial hyperplasia (EH) is commonly-seen in the patients with endometrial cancer (EC), we aimed to evaluated the risk factors of EC in patients with EH, to provide evidence to the clinical prevention and treatment of EC.

Methods

This study was a retrospective study design. EH patients confirmed by pathological examinations and treated with hysterectomy in our hospital from June 1, 2018 to February 28, 2021 were included. The clinical characteristics of EC and no-EC patients were compared and analyzed. Logistics regression analyses were conducted to evaluate the risk factors of EC in patients with EH.

Results

A total of 228 EH patients were included, the incidence of EC in the EH patients was 31.58%. There were significant differences in the age, BMI, diabetes, hypertension and pathology of EH between EC and no EC groups (all P < 0.05), no significant differences in the hyperlipidemia, preoperative CA₁₂₅, number of deliveries, menopause and endometrial thickness between EC and no EC groups were found (all P > 0.05). Logistic regression analyses indicated that age > 50 y (OR 3.064, 95% CI 1.945–5.931), BMI ≥ 25 kg/m² (OR 2.705, 95% CI 1.121–3.889), diabetes (OR 3.049, 95% CI 1.781–5.114), hypertension (OR 2.725, 95% CI 1.108–3.431) and severe hyperplasia (OR 3.181, 95% CI 1.496–4.228) were the risk factors of EC in patients with EH (all P < 0.05).

Conclusions

The risk of EC in EH patients is high, especially for those patients with age > 50 y, BMI ≥ 25 kg/m², diabetes, hypertension and severe hyperplasia, special attentions should be paid for occurrence of EC and early diagnosis and early treatment are needed for those patients.

Comparison of endometrial cancer risk in patients with endometrial precancerous lesions: WHO 1994 vs EIN classification

Our aim was to investigate the frequency of concurrent endometrial cancer in patients with endometrial precancerous lesions (PCLs) using World Health Organization 1994 (WHO94) and endometrial intraepithelial neoplasia (EIN) systems. We retrospectively investigated patients that underwent surgery for endometrial PCLs according to WHO94 or EIN systems at Hacettepe University Gynecology Clinic between January 2002 and June 2014. Of the 267 patients, 189 (70.9%) were in the WHO94 group, 78 (29.2%) were in the EIN group. Mean age of patients was 50.2 years. Sixteen patients (8.5%) in WHO94 group and 15 (%19.2) patients in the EIN group had EC (p = 0.013). In WHO94 group, EC rate in patients with atypical EH (32.6%) was significantly more than patients with non-atypical EH (1.4%) (p < .001). Atypical EH and EIN are actual PCLs which could be accompanied by EC. Therefore, atypical EH and EIN should be treated surgically if there is no desire for fertility. IMPACT STATEMENTWhat is already known on this subject? Endometrial hyperplasias are precursors lesion in the pathogenesis of endometrium adenocarcinomas. There are two classification systems: World Health Organization System and endometrial intraepithelial neoplasia system (WHO and EIN).What do the results of this study add? In this paper, we report on endometrial precancerous lesions. Controversy continues over the endometrial precancerous lesion classification. We also share our experiences in this regard. We concluded that the EIN system was superior in determining concurrent cancer risk.What are the implications of these findings for clinical practice and / or further research? The paper should be of interest to readers in the areas of gynecology.It is important to clarify the classifications of precancerous lesions in order to guide clinicians in the treatment of patients with endometrial precancerous lesions. In this context, it could be suggested to use the EIN system more widely.

Pathology findings among women with alterations in uterine bleeding patterns in cameroon

PURPOSE

Endometrial cancer is on the rise in high-income countries but it has not been adequately studied in low-and-middle income countries especially in sub-Saharan Africa (SSA), likely due to scarce pathology facilities. The purpose of this study was to characterize and quantify the prevalence of endometrial hyperplasia or cancer in a cohort of women with abnormal uterine bleeding (AUB) who underwent endometrial biopsy in Cameroon.

METHODS

We designed a cross-sectional study using medical records to characterize women who underwent endometrial biopsy in the Cameroon Baptist Convention Health Services (CBCHS) from 2008 to 2019. Pathologic diagnoses were classified as either endometrial hyperplasia, endometrial cancer, or no endometrial hyperplasia/cancer. We reported the overall prevalence of endometrial hyperplasia or cancer. Bivariate analyses compared patient characteristics between women with endometrial cancer, endometrial hyperplasia, and neither.

RESULTS

The average age was 46.2 years and women had an average of 5.1 parity. We found that, 61 [(36.7% of 166 women; 95% CI (27.6-47.0%)] had endometrial hyperplasia or cancer. There were no cases of hyperplasia with atypia and 13 women had endometrial cancer. The remainder were comprised of benign or infectious pathologic findings. In bivariate analysis, mean ages were statistically different among the three groups (hyperplasia, cancer, and no hyperplasia/cancer), p < 0.001, and women with cancer had the highest age. Parity was statistically significantly different among the three groups (p = 0.002) and women with endometrial cancer had higher parity.

CONCLUSION

We found that just over 1 in 3 women with AUB who underwent endometrial biopsy at a health system in SSA were found to have pathologic findings of endometrial hyperplasia or cancer, with no cases of hyperplasia with atypia. Women with endometrial cancer had higher mean age and parity.

Evaluation of frozen section biopsy for fast track diagnosis of endometrial pathology in high-risk women with abnormal uterine bleeding

OBJECTIVE

To study the accuracy of frozen section biopsy for endometrial pathology in high-risk women with abnormal uterine bleeding (AUB).

STUDY DESIGN

A case-control study was conducted between November 2017 to April 2019, a total of 150 women with postmenopausal bleeding, perimenopausal AUB, and high-risk women of age < 40 years with AUB were recruited. All women underwent transvaginal sonography and Doppler, based on age-appropriate endometrial thickness cut-offs 80 women then underwent hysteroscopy. Based on hysteroscopy, women suspicious of malignancy were taken as cases (n = 40) and those with benign findings as controls (n = 40). All cases and controls underwent dilatation and curettage (D & C) with frozen section (FS) and routine histopathology.

RESULTS

The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR), negative LR, and overall test accuracy of FS were 90.9%, 93.19%, 83.33%, 96.19%, 13.8, 0.1 and 86.25% respectively for diagnosing endometrial hyperplasia and cancer taking histopathology as the gold standard. Correlation between frozen section biopsy and histopathology was highly significant (p < 0.001) on D & C specimens and the level of agreement was good (K = 0.778).

CONCLUSION

In women suspicious of malignancy on hysteroscopy, frozen section has high accuracy on D&C specimen and can be used to diagnose endometrial hyperplasia and cancer in an effort to fast-track investigations and work-up for definitive treatment while awaiting final histopathology.

Guizhi Fuling Capsule ameliorates endometrial hyperplasia through promoting p62-Keap1-NRF2-mediated ferroptosis

ETHNOPHARMACOLOGICAL RELEVANCE

Guizhi Fuling Capsule (GFC) is a classical traditional Chinese medicine officially recorded in Synopsis of the Golden Chamber and has long been used to treat gynecological diseases in China. However, scientific evidence for the anti-endometrial hyperplasia potential of GFC used in traditional medicine is lacking.

AIM OF THE STUDY

This study evaluated whether GFC protects against endometrial hyperplasia and its potential mechanism in mice.

METHODS AND MATERIALS

We used estrogen (estradiol) to induce endometrial hyperplasia in mice. C57BL/6 mice were treated with estradiol subcutaneously for 21 days, and GFC (75 mg/kg and 150 mg/kg) was given intragastric administration from the first day of the modeling. H&E staining is used to evaluate endometrial tissue structure change. Malondialdehyde was measured to explore lipid peroxidation. Western blot, immunohistochemistry and immunofluorescence were performed to observe the expressions of GPX4, p62, Keap1 and NRF2.

RESULTS

The degree of ferroptosis in endometrial tissue of patients with endometrial hyperplasia was lower than normal endometrial tissue. In addition, ferroptosis inducer imidazole ketone erastin could improve endometrial hyperplasia in mice. Interestingly, GFC significantly alleviated endometrial hyperplasia through triggering ferroptosis. Furthermore, GFC inhibited p62-Keap1-NRF2 pathway in estradiol-induced endometrial hyperplasia model.

CONCLUSIONS

GFC may attenuate estrogen-induced endometrial hyperplasia in mice through triggering ferroptosis via inhibiting p62-Keap1-NRF2 pathway. These findings suggest that GFC might act as a promising traditional Chinese medicine to treat endometrial hyperplasia.

Uterine anomalies in cell proliferation, energy homeostasis and oxidative stress in PCOS hamsters, M. auratus: Therapeutic potentials of melatonin

AIMS

Polycystic ovarian syndrome (PCOS) is a reproductive, endocrine and metabolic disorder. Less is known about the mechanism of its effect on uterine function and therapeutic potential of melatonin. Our aim was to evaluate uterine dysfunction(s) in letrozole induced PCOS and its possible rectification by melatonin.

MAIN METHODS

Adult female golden hamsters were divided into groups of Control (C), Melatonin (M; 1 mg/kg b.w.), Letrozole (L; 3 mg/kg b.w.) and combination of Letrozole+Melatonin (L + M; 3 mg/kg b.w. + 1 mg/kg b.w.) which were treated for 40 days. Analysis of serum testosterone/estradiol/progesterone/leptin/insulin, uterine histomorphometry, immunohistochemistry for proliferation cell nuclear antigen (PCNA), homeostatic assessment model of insulin resistance (HOMA-IR), western blotting for PCNA, androgen receptor (AR), insulin receptor (InsR), glucose tansporter-4 (GLUT-4), nuclear factor-kappa B (NFκB), cyclooxygenase-2 (COX-2) and biochemical analysis of superoxide dismutase (SOD)/catalase/lipid peroxidation (LPO) were done.

KEY FINDINGS

Serum testosterone, leptin and insulin increased while uterine InsR/GLUT-4 expression decreased in L group indicating metabolic abnormalities. Endometrial hyperplasia, increased expression of PCNA and AR indicated abnormal proliferation in L compared to C. Increased uterine oxidative load (SOD/catalase/LPO) and inflammatory markers NFκB/COX-2 expression in L was responsible for high tissue oxidative stress and inflammation. M administration normalized all the above parameters suggesting its ameliorative effect in L + M group.

SIGNIFICANCE

We report PCOS induced uterine dysfunction in Mesocricetus auratus for the first time. M administration restores uterine functions modulating cellular dynamicity, metabolic status, decreased oxidative and inflammatory load in PCOS hamsters. Therefore, we suggest the therapeutic potential of M against PCOS led uterine abnormalities to restore female fertility.

A Randomized Clinical Trial of Levonorgestrel Intrauterine System with or without Metformin for Treatment of Endometrial Hyperplasia without Atypia in Indian Women

Background:

Endometrial cancer is the second most frequent genital malignancy in women, which is showing a constant rise all over world. Endometrial hyperplasia is the precursor of endometrial cancer. Levonorgestrel intrauterine system is the first line management in patients with endometrial hyperplasia without atypia. Metformin has shown to reverse endometrial hyperplasia, but its effectiveness and safety in endometrial hyperplasia is uncertain.

Objective:

To compare the efficacy in terms of histopathological response, clinical response and safety at the end of 6 months in patients with endometrial hyperplasia without atypia managed with levonorgestrel intrauterine system alone versus patients managed with levonorgestrel intrauterine system plus metformin.

Methods:

The randomized control trial was conducted on 51 cases of endometrial hyperplasia without atypia. Twenty-five subjects were prescribed metformin 500mg twice daily with levonorgestrel intrauterine system and 26 subjects, with levonorgestrel intrauterine system only for 6 months. At the end of 6 months, endometrial sampling was performed for histopathological response.

Results:

Clinical response was observed in 23 of 25 subjects in metformin group and 22 of 24 in levonorgestrel only group. The metformin group responded significantly with amenorrhea (p= 0.0053), while levonorgestrel only group responded with regular cycles (p=0.027). At the end of study, of 46 subjects available for histopathological evaluation, 100% subjects in metformin group and 95.45% in levonorgestrel only group (p=0.47826) showed complete response. The metformin group had a significant reduction in body mass index at end of study [P = 0∙023, 95% confidence interval (-1.7802, -0.1418)].

Conclusion:

No significant difference in regression of endometrial hyperplasia was observed on adjunctive use of metformin but a significant reduction in BMI was observed. Use of metformin in obese patients may improve the treatment response.

Non-atypical endometrial hyperplasia: risk factors for occult endometrial atypia and malignancy in patients managed with hysterectomy

Objective

To determine the risk factors for occult endometrial atypia and malignancy in patients diagnosed with non-atypical endometrial hyperplasia (NEH) on endometrial biopsy.

Methods

All new cases of NEH diagnosed between April 2015 and March 2016 at KK Women’s and Children’s Hospital, who underwent hysterectomy as first-line treatment, were included in the study. Patients with a history of endometrial hyperplasia or malignancy were excluded from the study. Patient demographics (e.g., age, parity, body mass index [BMI]), medical history, and clinical presentation were obtained for analysis.

Results

In total, 262 patients were diagnosed with NEH, of which 18.3% (n=48) underwent hysterectomy as first-line management. The average time to surgery was 77.0±35.7 days. All cases were diagnosed by dilation and curettage, and hysteroscopy. The mean age was 51 years, and the mean BMI was 26.9±5.8 kg/m². Histology from the hysterectomy specimen showed 9 (18.8%) patients with atypical hyperplasia and 2 (4.2%) with grade 1, stage 1A endometrioid adenocarcinoma. Patients with higher grade final pathology had significantly lower median parity (1 vs. 2, P=0.039), higher mean BMI (30.1±6.5 vs. 25.9±5.3 kg/m², P=0.033), and BMI ≥30 kg/m² (54.5% vs. 13.5%, P=0.008, odds ratio 7.68), compared to patients whose final histology showed NEH or no residual hyperplasia.

Conclusion

Occult endometrial atypia and malignancy were found in 18.8% and 4.2% of patients with an initial diagnosis of NEH, respectively. High BMI and low parity were identified as significant risk factors for high-grade endometrial lesions in patients with NEH.

Impact of Bariatric Surgery on Endometrial Cancer Tumor Pathology

INTRODUCTION

Obesity is a well-established risk factor for endometrial cancer and is thought to adversely affect outcomes. The impact of significant and sustained weight loss as achieved by bariatric surgery for women with endometrial cancer is not well understood.

METHODS

We performed an institutional retrospective review of patients who underwent bariatric surgery and were diagnosed with premalignant or malignant uterine disease from 1989 to 2019 (n=171). We compared tumor characteristics and cancer-specific outcomes in patients diagnosed with uterine disease before ("PRE" group) or after ("POST" group) undergoing bariatric surgery and in a BMI- and age-matched cohort who did not undergo bariatric surgery.

RESULTS

Of the 171 patients, 120 were in the PRE group and 51 in the POST group. The POST group was more likely to have adenocarcinoma (68.6 vs 45.0%, p=0.012) and more likely to have a minimally invasive hysterectomy (80.9 vs 46.2%, p<0.001). Post-bariatric surgery weight loss was similar between the two groups. In women with malignant disease, tumor grade and pathology were similar in the PRE and POST groups. The 5-year overall survival was 98% in the PRE group and 77.8% in the POST group (p=0.016). However, 5-year overall survival was statistically similar in both PRE and POST groups compared to a matched cohort who did not undergo bariatric surgery.

CONCLUSIONS

In this study, we did not detect an impact of bariatric surgery on endometrial cancer pathology or disease survival. Larger, multi-center studies are needed to investigate the relationship between bariatric surgery status and cancer outcomes.

Aspiration biopsy versus dilatation and curettage for endometrial hyperplasia prior to hysterectomy

Background

To compare the diagnostic accuracy of aspiration biopsy and dilatation and curettage (D&C) in patients diagnosed with endometrial hyperplasia prior to hysterectomy.

Methods

We retrospectively reviewed medical records of 250 patients diagnosed with endometrial hyperplasia by endometrial sampling between July 2003 and March 2020. Endometrial sampling was performed by aspiration biopsy (n = 150) or D&C (n = 100), followed by hysterectomy within 6 months. Pathological findings of hysterectomy specimens of the two groups were compared to preoperative findings.

Results

The overall diagnostic concordance between endometrial sampling specimen including D&C and aspiration biopsy, and hysterectomy specimen was 51.0% (51/100) and 41.3% (62/150), respectively. Patients whose preoperative specimen was obtained by D&C were upgraded less significantly than those who underwent aspiration biopsy (21.0% vs 36.7%; P = 0.008). In particular, significantly fewer patients were upgraded after D&C than after aspiration biopsy in hyperplasia without atypia (12.5% vs 29.0%; P = 0.028). In addition, when the final pathological upgrade rate to endometrial carcinoma was evaluated between the two methods of endometrial sampling, significantly fewer cases were noted after D&C than after aspiration biopsy (15.0% vs 27.3%; P = 0.022).

Conclusions

In our study, D&C more accurately reflected the final diagnosis in patients with endometrial hyperplasia than aspiration biopsy based on the histological examination of hysterectomy specimens. When considering the management strategy for women with an endometrial hyperplasia diagnosis obtained by aspiration biopsy, physicians should consider the significant rate of upgraded diseases with this method of endometrial sampling.

[Analysis of pregnancy outcome after fertility-preserving treatment among women with atypical endometrial hyperplasia or endometrial carcinoma]

Objective: To analyze the pregnancy outcome, influencing factors and recurrence of fertility-preserving therapy for women with atypical endometrial hyperplasia (AEH) or endometrial carcinoma (EC). Methods: The multi-center retrospective study included 107 women with AEH or EC for fertility-preserving therapy in 10 hospitals from January 1st, 2009 to December 31st, 2018. The clinical pregnancy rate, live birth rate and recurrence of 66 patients with urgent child-bearing requirements after fertility-preserving treatment were analyzed. Results: (1) Among the 66 AEH and EC women with urgent child bearing requirements, 24 women chose spontaneous pregnancy, the clinical pregnancy rate was 54.2% (13/24) and the live birth rate was 41.7% (10/24), the median time from fertility-preserving therapy withdrawal to clinical pregnancy was 5.5 months. Forty-two women chose assisted reproductive technology (ART), the clinical pregnancy rate was 59.5% (25/42) and the live birth rate was 35.7% (15/42), the median time from fertility-preserving therapy withdrawal to clinical pregnancy was 19.5 months. The time from fertility-preserving therapy withdrawal to pregnancy in women receiving ART was significantly longer than that in women with spontaneous pregnancy (P=0.048). (2) Age and intrauterine adhesions were independent factors affecting the clinical pregnancy rate (P<0.05). (3) Among 107 patients with AEH or EC, the recurrence rate was 27.1% (29/107). Among the 42 cases who chose ART, 9 of them recurred before ART treatment, who received the fertility-preserving therapy again and then ART treatment, 8 women got clinical pregnancy,5 of them delivered at least a live birth. Conclusions: Women with AEH or EC could achieved satisfactory clinical pregnancy rate and live birth rate after fertility-preserving therapy. Age and intrauterine adhesions are independent factors affecting clinical pregnancy rate. The women with recurrent AEH or EC could be treated with fertility-preserving therapy again and get a satisfactory pregnancy outcome.

Type 2 diabetes mellitus facilitates endometrial hyperplasia progression by activating the proliferative function of mucin O-glycosylating enzyme GALNT2

OBJECTIVE

Type 2 diabetes mellitus (T2DM) is thought to be a risk factor for endometrial hyperplasia, but potential links between the two diseases are unknown. This study aims to evaluate the role of T2DM in the progression of endometrial hyperplasia.

METHODS

Female Sprague-Dawley rats were randomly divided into normal (N) group, endometrial hyperplasia (NH) group, T2DM (T) group, and endometrial hyperplasia with T2DM (TH) group. Proteomics analysis was performed to determine the protein profile of endometrial tissues. Proliferation, migration, and invasion of cells with/without GLANT2-knockdown were assessed. Immunohistochemical staining and ELISA were used to examine the expression of GALNT2 in endometrial tissues and serum of clinical samples.

RESULTS

The highest uterus index and endometrial thickness were observed in TH group, with the expression of proliferation marker PCNA increased significantly, indicating that T2DM facilitates the progress of endometrial hyperplasia. Proteomics analysis showed that there were significant differences in protein profiles among groups and differential proteins were mainly enriched in metabolic pathways. Further verification by molecular biology analysis indicated that GALNT2 is the key target for T2DM facilitating endometrial hyperplasia. The expression of GALNT2 was significantly decreased in high glucose environment. T2DM could synergize the proliferative function of GALNT2 aberration by activating EGFR/AKT/ERK pathway. The decreased expressions of GALNT2 in clinical samples were associated with worse subtypes of endometrial hyperplasia.

CONCLUSION

T2DM promoted the progression of endometrial hyperplasia by regulating the GALNT2-mediated phosphorylation of EGFR and enhancing cell proliferation. GALNT2 has the potential to be a novel biomarker in the treatment of endometrial hyperplasia.

Value of endometrial thickness in diagnosis of endometrial hyperplasia during selective estrogen receptor modulator therapy in premenopausal breast cancer patients

OBJECTIVE

The weak estrogenic-like effect of selective estrogen receptor modulator (SERM) may lead to series of endometrial lesions, including proliferation, hyperplasia, polyp formation, and even endometrial cancer. This study aimed to explore the effectiveness of different endometrial thickness in diagnosis of endometrial hyperplasia during SERM therapy in premenopausal patients.

METHODS

The clinical data of 115 patients receiving hysteroscopic endometrial biopsy during SERM therapy in Peking Union Medical College Hospital, China from January 2010 to December 2018 were retrospectively analyzed.

RESULTS

Average age at the beginning of SERM therapy was 43.4 ± 5.7 years old. Mean duration time of SERM therapy was 31.0 ± 22.1 months. The mean endometrial thickness was 14.3 ± 6.1 mm. 4 cases of atypical endometrial hyperplasia (3.5 %), and 4 cases of endometrial hyperplasia without atypia (3.5 %) were detected. Endometrial thickness was higher in endometrial hyperplasia patients than in no endometrial hyperplasia patients (18.8 vs 13.9 mm, p = 0.029). Endometrial thickness in 8 out of 8 endometrial hyperplasia patients and 38 out of 107 no endometrial hyperplasia patients were ≥ 15 mm (p = 0.002). The negative predictive value in the diagnosis of endometrial hyperplasia during SERM therapy in premenopausal patients was 100 % when endometrial thickness < 15 mm chosen as cutoff value.

CONCLUSION

Endometrial hyperplasia was less likely to occur in premenopausal patients during SERM therapy when endometrial thickness < 15 mm.

Fertility-Sparing Treatment in Young Women with Atypical Endometrial Hyperplasia and Low-Grade Endometrial Cancer: A Tertiary Center Experience

Objectives:

To evaluate the oncologic and reproductive outcomes of patients with atypical endometrial hyperplasia and low grade stage 1 endometrial cancer who received medical treatment.

Methods:

We carried out a retrospective study on all patients aged 20-42 years with complex, atypical endometrial hyperplasia, and low-grade stage 1 endometrial cancer, who wished to preserve fertility and were treated at the Royal Hospital. We held this study between January 2006 and December 2016. The patients received oral megestrol acetate with or without a levonorgestrel intrauterine system. We assessed their response to progestin treatment in terms of treatment duration, time to response, pregnancy, time of surgery, and oncological outcome. We performed the statistical analysis using the SPSS 20.0 software.

Results:

Twenty patients met the inclusion criteria, and among them 90% had complete remission. Among these 90%, 55% had complete remission within six months of treatment. The recurrence rate was recorded in 11 patients (55%) and it was more frequent in obese patients with body mass index (BMI) ≥30 (p=0.001), who had complete response in > 6 months of hormonal treatment. About 15% of the patients required hysterectomy, and 12 (60%) patients conceived after full treatment.

Conclusions:

Fertility-sparing treatment of atypical endometrial hyperplasia and grade 1 stage 1 endometrial cancer in reproductive-age women is feasible. However, obese patients (BMI ≥ 30) had a higher recurrence rate.