Congenital Uterine Malformation by Experts (CUME): diagnostic criteria for T-shaped uterus

OBJECTIVES

To identify uterine measurements that are reliable and accurate to distinguish between T-shaped and normal/arcuate uterus, and define T-shaped uterus, using Congenital Uterine Malformation by Experts (CUME) methodology, which uses as reference standard the decision made most often by several independent experts.

METHODS

This was a prospectively planned multirater reliability/agreement and diagnostic accuracy study, performed between November 2017 and December 2018, using a sample of 100 three-dimensional (3D) datasets of different uteri with lateral uterine cavity indentations, acquired from consecutive women between 2014 and 2016. Fifteen representative experts (five clinicians, five surgeons and five sonologists), blinded to each others' opinions, examined anonymized images of the coronal plane of each uterus and provided their independent opinion as to whether it was T-shaped or normal/arcuate; this formed the basis of the CUME reference standard, with the decision made most often (i.e. that chosen by eight or more of the 15 experts) for each uterus being considered the correct diagnosis for that uterus. Two other experienced observers, also blinded to the opinions of the other experts, then performed independently 15 sonographic measurements, using the original 3D datasets of each uterus. Agreement between the diagnoses made by the 15 experts was assessed using kappa and percent agreement. The interobserver reliability of measurements was assessed using the concordance correlation coefficient (CCC). The diagnostic test accuracy was assessed using the area under the receiver-operating-characteristics curve (AUC) and the best cut-off value was assessed by calculating Youden's index, according to the CUME reference standard. Sensitivity, specificity, negative and positive likelihood ratios (LR- and LR+) and post-test probability were calculated.

RESULTS

According to the CUME reference standard, there were 20 T-shaped and 80 normal/arcuate uteri. Individual experts recognized between 5 and 35 (median, 19) T-shaped uteri on subjective judgment. The agreement among experts was 82% (kappa = 0.43). Three of the 15 sonographic measurements were identified as having good diagnostic test accuracy, according to the CUME reference standard: lateral indentation angle (AUC = 0.95), lateral internal indentation depth (AUC = 0.92) and T-angle (AUC = 0.87). Of these, T-angle had the best interobserver reproducibility (CCC = 0.87 vs 0.82 vs 0.62 for T-angle vs lateral indentation depth vs lateral indentation angle). The best cut-off values for these measurements were: lateral indentation angle ≤ 130° (sensitivity, 80%; specificity, 96%; LR+, 21.3; LR-, 0.21), lateral indentation depth ≥ 7 mm (sensitivity, 95%; specificity, 77.5%; LR+, 4.2; LR-, 0.06) and T-angle ≤ 40° (sensitivity, 80%; specificity, 87.5%; LR+, 6.4; LR-, 0.23). Most of the experts diagnosed the uterus as being T-shaped in 0% (0/56) of cases when none of these three criteria was met, in 10% (2/20) of cases when only one criterion was met, in 50% (5/10) of cases when two of the three criteria were met, and in 93% (13/14) of cases when all three criteria were met.

CONCLUSIONS

The diagnosis of T-shaped uterus is not easy; the agreement among experts was only moderate and the judgement of individual experts was commonly insufficient for accurate diagnosis. The three sonographic measurements with cut-offs that we identified (lateral internal indentation depth ≥ 7 mm, lateral indentation angle ≤ 130° and T-angle ≤ 40°) had good diagnostic test accuracy and fair-to-moderate reliability and, when applied in combination, they provided high post-test probability for T-shaped uterus. In the absence of other anomalies, we suggest considering a uterus to be normal when none or only one criterion is met, borderline when two criteria are met, and T-shaped when all three criteria are met. These three CUME criteria for defining T-shaped uterus may aid in determination of its prevalence, clinical implications and best management and in the assessment of post-surgical morphologic outcome. The CUME definition of T-shaped uterus may help in the development of interventional randomized controlled trials and observational studies and in the diagnosis of uterine morphology in everyday practice, and could be adopted by guidelines on uterine anomalies to enrich their classification systems. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Diurnal variation of steroid hormones and their reference intervals using mass spectrometric analysis

OBJECTIVE

Accurate measurement of steroid hormones remains challenging. Mass spectrometry affords a reliable means for quantitating steroid profiles accurately. Our objective was to establish and define (1) the extent of diurnal fluctuations in steroid concentrations that potentially necessitate strict adherence to time of sample acquisition and (2) time-dependent steroid reference intervals.

DESIGN

Nine steroid markers were examined in couplets in males and females.

METHODS

Using isotope dilution high-performance liquid chromatography-tandem mass spectrometric (LC-MS/MS) analysis, we developed a multi-steroid profile requiring only a minimal volume of serum (0.1 mL). Couplet (AM and PM) measurements of steroid hormones for 120 healthy females (F) and 62 healthy males (M) were obtained. Patients were recruited from several participating centers.

RESULTS

The following diurnal values were noted to be significantly different in both females and males: cortisone, cortisol, corticosterone, 11 deoxycortisol (11 DOC), androstenedione, 17a-hydroxyprogesterone (17 OHP) and dehydroepiandrosterone (DHEA). Testosterone was only found to have significant diurnal variance in males. Progesterone showed no significant difference in AM and PM values for either groups and thus may provide an internal control.

CONCLUSIONS

When diagnosing endocrine disorders, it is imperative to acknowledge the 24-h diurnal variation of the biochemical steroid markers. We highlight the importance of standardization of collection times and appropriate implementation of reference intervals.

PRECIS

We identify diurnal fluctuations in steroid concentrations with time of day and emphasize the importance of adhering to firm time of sample acquisition.

Results of conventional and hysteroscopic surgery

Müllerian anomalies usually come to medical attention when they become problematic and require treatment. Most of these complications require surgical correction. The most commonly presenting anomaly is the double uterus which can be the source of recurrent abortion and preterm deliveries. The Strassman, Jones and Tompkins metroplasties have been shown to greatly improve the rate of successful deliveries in these patients. Hysteroscopic metroplasty, using either scissors, resectoscope or laser is now the recommended treatment for most septate uteri due to its relative simplicity, low morbidity and excellent reproductive outcome.

Bone-sparing properties of oral contraceptives

Postmenopausal osteoporosis is a major health care problem that affects 20 million women in the United States and accounts for > 1 million fractures per year. Hormone replacement therapy is effective for reducing bone loss in the postmenopausal women. However, intervention before menopause may delay or prevent the decline in bone mass that begins between ages 30 and 40 years. The effects of oral contraceptives on bone mass have been investigated, and a positive association between oral contraceptive use and bone mass that is directly related to the duration of oral contraceptive use was observed. The effects of oral contraceptives on bone mass may be related to the specific formation. The effect of estrogens is dose related, and the optimal dose appears to be 25 to 35 micrograms of ethinyl estradiol or its equivalent. Results from several studies show that norethindrone has a positive effect on bone mass. An oral contraceptive may offer optimal birth control for the older premenopausal woman who currently uses other forms of birth control.

Physiologic and pharmacologic effects of estrogen and progestins on bone

Estrogen deficiency has a primary role in the pathogenesis of osteoporosis, a major cause of morbidity and mortality in postmenopausal women. Estrogen therapy is associated with increased peak bone mass premenopausally and prevention of bone loss postmenopausally. The mechanisms by which estrogen exerts its effects on bone are not completely understood. Nonetheless, estrogen does affect calcium balance, and evidence suggests a direct mechanism via estrogen receptors on bone. The role of progestins in preventing bone loss is less well understood than that of estrogen. Studies in postmenopausal women and studies of add-back therapy in younger women have shown that norethindrone, but not medroxyprogesterone, treatment has a bone-sparing effect on cortical bone but not on trabecular bone. In addition, norethindrone, 5 or 10 mg daily, has effects on biochemical markers of bone turnover similar to those of estrogen, providing further evidence of a bone-sparing effect. The mechanisms for the effects of norethindrone on bone are unknown, although translocation of the estrogen receptor in an animal model and conversion in vivo to ethinyl estradiol have been postulated.