Resolution of Uterine Arteriovenous Malformation and Maintenance of Reproduction in 20 Women Treated with a GnRH Agonist Concomitantly with an Aromatase Inhibitor and Tranexamic Acid

ObjectiveThis study investigated the efficacy of GnRH agonists concomitantly with transient aromatase inhibitor and tranexamic acid to treat women with uterine arteriovenous malformations (AVMs) associated with abnormal uterine bleeding (AUB) to preserve fertility and determine reproductive outcome.MethodsThis was a prospective cohort study in a tertiary centre. Doppler ultrasound demonstrated AVM in 19 women with AUB 1–28 weeks following spontaneous or therapeutic abortion and in one woman 4 years after normal pregnancy while taking an oral contraceptive. On the basis of experience from the first three cases, 17 women were treated with tranexamic acid (1 g three times daily orally for 5 days), a GnRH agonist (3.75–11.25 mg, for 1–3 months), plus an aromatase inhibitor (letrozole 2.5 mg once daily for 5days) with the initial injection of GnRH agonist. Two women required blood transfusion, and one required uterine tamponade with Foley catheter balloon in the first 48 hours to control heavy bleeding (Canadian Task Force Classification II-2).ResultsAll 20 AVMs resolved within 1–3 months of treatment. Of 16 women who attempted pregnancy, all (100%), including two who had uterine artery embolization (one after hysteroscopic septoplasty), conceived spontaneously with 18 live births. Two women are using contraception (one taking an oral contraceptive, one using a levonorgestrel intrauterine system), and one 40-year-old is not using contraception. One woman had hysteroscopic endometrial ablation followed by vaginal hysterectomy for AUB at 1 and 2 years later.ConclusionA GnRH agonist in combination with transient aromatase inhibitor and tranexamic acid is an effective management strategy to treat and maintain reproduction in women with AVMs associated with AUB.     

Resectoscopic surgery may be an alternative to hysterectomy in high-risk women with atypical endometrial hyperplasia

STUDY OBJECTIVE: Endometrial hyperplasia is found in 2% to 10% of women with abnormal uterine bleeding (AUB). Up to 43% of patients with cytologic atypia harbor coexisting adenocarcinoma, and approximately 20% to 52% of atypical hyperplasias, if untreated, progress to cancer. The objective of this study was to estimate the incidence of atypical endometrial hyperplasia encountered during routine resectoscopic surgery in women with AUB and to evaluate the role of resectoscopic surgery in the management of women with AUB and atypical endometrial hyperplasia who refused and/or were at high risk for hysterectomy. DESIGN: Prospective cohort study (Canadian Task Force classification II-3). SETTING: University-affiliated teaching hospital. PATIENTS: From January 1990 through December 2005, the senior author (GAV) performed primary resectoscopic surgery in 3401 women with AUB. Among these, there were 22 women with atypical (17 complex, 5 simple) endometrial hyperplasia. INTERVENTIONS: All women underwent hysteroscopic evaluation and partial (n = 3) or complete (n = 19) endometrial electrocoagulation and/or resection. Subsequently, 6 women had hysterectomy and bilateral salpingo-oophorectomy (BSO). MEASUREMENTS AND MAIN RESULTS: The median (range) for age, parity, and body mass index were 55 years (24-78 years), 2 (0-4), and 30.1 kg/m2 (22.5-52.2 kg/m2), respectively. Among the 3401 women, there were 22 cases of atypical endometrial hyperplasia, 12 of which were incidentally diagnosed at the time of hysteroscopy (complex 10, simple 2, incidence 0.35%). After hysteroscopic diagnosis or confirmation of diagnosis, 6 women underwent hysterectomy and BSO. Of the remaining 16 women, followed for a median of 5 years (range 1.5-12 years), 1 was lost to follow-up, 1 had only a biopsy to preserve fertility, 1 died from lung cancer after 4 years, and 1 died from colon cancer after 5 years. One patient developed endometrial cancer after 10.5 years with postmenopausal bleeding. She remains alive and well 3.5 years after hysterectomy and BSO. The remaining 11 patients are amenorrheic at a median follow-up of 6 years (range 1.5-12 years). CONCLUSIONS: Resectoscopic surgery in 3391 women with AUB detected 12 incidental cases of atypical endometrial hyperplasia (incidence 0.35%). Skillful resectoscopic surgery may be an alternative to hysterectomy in women with AUB and atypical endometrial hyperplasia, who refuse or are at high-risk for hysterectomy and who are compliant with regular and long-term follow-up.     

Endometrial adenocarcinoma encountered at the time of hysteroscopic endometrial ablation

STUDY OBJECTIVE: To determine the diagnostic accuracy and possible role of treatment of hysteroscopic endometrial resection in women with abnormal uterine bleeding (AUB) diagnosed with endometrial adenocarcinoma. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: University-affiliated center. PATIENTS: Thirteen women with AUB and eight with postmenopausal bleeding. INTERVENTION: Preablation endometrial office biopsy and hysteroscopic evaluation. MEASUREMENTS AND MAIN RESULTS: Preablation endometrial biopsy was inadequate, inconclusive, or difficult to obtain in these women, and endometrial cancer was found at the time of resectoscopic surgery. Total endomyometrial resection including the tubal ostia was completed in eight women (group 1) and partial resection in five (group 2). Endometrial adenocarcinoma was confirmed histologically in all patients. A small focus of cancer was found in only two women in group 1 after total resection; in one the procedure was performed 9 years earlier and in the other it was completed hastily after absorption of 800 ml of 1.5% glycine irrigation solution. In women in group 2 malignancy was highly suspected and total resection was considered unwise. CONCLUSION: All patients were alive and well 0.5 to 9 years after hysterectomy, with no evidence of recurrent cancer.     

Long-Term Outcomes After Intrauterine Morcellation vs Hysteroscopic Resection of Endometrial Polyps

Study ObjectiveTo compare the long-term outcomes of intrauterine morcellation (IUM) of endometrial polyps vs a traditional operative polypectomy technique, hysteroscopic resection (HSR), and to identify factors predictive of recurrent abnormal uterine bleeding (AUB) after operative polypectomy.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingMinimally invasive gynecologic surgery practice in a tertiary care center.PatientsWomen who underwent operative hysteroscopic polypectomy between January 1, 2004 and December 31, 2009.InterventionsIntrauterine morcellation or HSR with evaluation and/or treatment of recurrent AUB after operative polypectomy.Measurements and Main ResultsOf 311 patients (IUM group, 139; HSR group, 172), 167 (53.7%) had at least 1 gynecologic follow-up visit and 57 (18.4%) had recurrent AUB. Subsequent gynecologic clinic visit rates were similar between the 2 groups (HSR, 58.1%, vs IUM, 48.2%; p = .08). Recurrence of AUB within the first 4 years of follow-up was similar between the IUM and HSR groups (hazard ratio for HSR vs IUM, 1.12; 95% confidence interval, 0.64–1.98; p = .59). However, recurrence of endometrial polyps approached statistical significance (hazard ratio, 3.3; 95% confidence interval, 0.94–11.49; p = .06). Premenopausal status, history of hormone replacement therapy, multiparity, and polycystic ovarian syndrome were independently associated with AUB recurrence. There were no reports of inability to establish a histopathologic diagnosis among all pathology specimens evaluated.ConclusionCompared with HSR, intrauterine morcellation may be associated with lower recurrence of endometrial polyps. However, the incidence of recurrent AUB is independent of polypectomy method.     

The impact of alternative treatment for abnormal uterine bleeding on hysterectomy rates in a tertiary referral center

Study ObjectiveThe purpose of this study was to estimate the influence of alternatives to hysterectomy for abnormal uterine bleeding (AUB) on hysterectomy rates.DesignRetrospective cohort study. Canadian Task Force II-2.SettingUniversity hospital.PatientsPremenopausal patients with AUB.InterventionsMedical records of all premenopausal patients treated for AUB in our university clinic between January 1, 1995, and December 31, 2004, were reviewed. Patients were identified based on (specific) diagnostic and therapy codes used in the registry system of the hospital. The total number of placements of levonorgestrel-releasing intrauterine device (LNG-IUD), hysteroscopic surgery, and hysterectomies performed/year was estimated. In addition, the course of treatment of each patient was assessed.Measurements and Main ResultsA total of 640 patients received surgery and 246 LNG-IUDs were placed. The proportion of endometrial ablations decreased significantly over time (p <.001), whereas hysteroscopic polyp or myoma removal (p =.030) and insertion of LNG-IUD (p <.001) both increased. The proportion of patients receiving hysterectomy for AUB as their first therapy decreased significantly (p =.005) from 40.6% to 31.4%, although the total number of patients receiving hysterectomy remained similar (p =.449). The 5-year intervention-free percentage for LNG-IUD was 70.6% (SD = 3.3%), for hysteroscopic polyp or myoma removal 75.5% (SD = 3.3%), and for endometrial ablation 78.0% (SD = 4.3%; p =.067).ConclusionDespite the introduction of alternative therapies, the total hysterectomy rate in the management of AUB did not decrease in our clinic.     

The Levonorgestrel Intrauterine System is an Effective Treatment in Women with Abnormal Uterine Bleeding and Anticoagulant Therapy

ObjectiveTo evaluate the efficacy of levonorgestrel intrauterine systems (LNG-IUS) in obese women with AUB on anticoagulant therapy.DesignProspective observational case series (Canadian Task Force Classification II-3).SettingUniversity affiliated teaching hospital.PatientsPremenopausal women on Warfarin therapy.InterventionsFrom January 2002 through January 2007, 10 women were identified from the senior author's clinical practice (G.A.V.). After clinical assessment, including Papanicolaou smear, endometrial biopsy, and pelvic sonography, the LNG-IUS was placed to treat their AUB.Measurements and Main ResultsThe median and range of age, parity, and body mass index were 45 years (34-49), 1 (0-4), and 38 kg/m² (26-52), respectively. All women were receiving warfarin therapy (4-12.5 mg/d) for previous venous thromboembolism. Some patients had additional comorbid conditions and were at high risk for traditional medical or surgical therapies. After placement of the LNG-IUS, all women reported menstrual reduction at 3 and 6 months. By 12 months, 1 woman with large fibroids expelled the LNG-IUS and was treated with transfemoral uterine artery embolization. Two women had amenorrhea, and 7 had hypomenorrhea. At 2 to 5 years, 1 woman expelled the LNG-IUS and hysterectomy indicated extensive adenomyosis in a 195-g uterus, and 1 woman had hysteroscopic endometrial ablation, 4 were menopausal, 2 had amenorrhea, and 1 had hypomenorrhea. In the 5 women with uterine fibroids measuring 4.2 to 147 cm³, the fibroids were reduced in volume by approximately 75% in 2, were no longer detectable in 1, were subsequently shown to be adenomyoma in 1, and required uterine artery embolization in 1.ConclusionIn properly assessed and selected obese, premenopausal women with AUB receiving warfarin therapy and at high risk for traditional therapies, the LNG-IUS was an effective treatment in 70% of patients.     

Findings in Patients with Postmenstrual Spotting with Prior Cesarean Section

Study ObjectiveThroughout the years, patients previously submitted to C-sections may have abnormal uterine bleeding (AUB) of the post-menstrual spotting type. This symptom has been correlated to an anatomical defect on the anterior uterine wall. The objective of the present investigation was to assess the hysteroscopy findings of women at reproductive age, previously submitted to cesarean sections and complaining of post-menstrual spotting, stressing the diagnosis of isthmocele.DesignProspective study (Canadian Task Force II).SettingState public hospital—Department of Gynecological Endoscopy.PatientsForty-three patients at reproductive age previously submitted to one or more cesarean sections, complaining of AUB of the post-menstrual spotting type, were submitted to diagnostic hysteroscopy in order to assess the presence of anterior uterine wall isthmocele.InterventionsHysteroscopic diagnoses.Measurements and Main ResultsThe mean number of previous C-sections was 2, the average time of post-menstrual spotting observation was 6 years and the mean duration of each episode was 6 days. The hysteroscopic diagnosis of isthmocele was conclusive in 38 patients (88.37%).ConclusionPatients with previous C-sections complaining of postmenstrual spotting type of AUB have a high prevalence of isthmocele, and this condition is likely diagnosed through diagnostic hysteroscopy.     

Hysteroscopy in Evaluation of Abnormal Uterine Bleeding

Abstract

One-third of all gynaecological consultations are because of abnormal uterine bleeding (AUB). This proportion rises to more than 2/3rd when peri & post menopausal women are considered. In normal to 12 week size uteri, the cause of abnormal bleeding often remains obscure.

Objectives (S)

Clinical and hysteroscopic evaluation of the cervical canal & uterine cavity of 100 women with AUB to evaluate various causes of AUB in the study population.

Method (S)

100 women with AUB and uterine size normal to 12 weeks pregnancy were subjected to clinical & hysteroscopic examination. The cause of bleeding was evaluated.

Results

Menorrhagia (30%), menometrorrhagia (16%), oligomenorrhea (16%) and postmenopausal bleeding (2%) were some of the indications for hysteroscopy. Intrauterine pathology was diagnosed in 74% of cases. Hyperplastic endometrium (30%) and mucus polypi (28%) were the most frequent findings. 13% of the cases had multiple finding. A surprising 7% had IUCD in their uteri without their knowledge, while bony spicules was found in 1 patient. Both patients with post menopausal bleeding had atrophic endometrium.

Conclusion (S)

Hysteroscopy can be easily learnt. It gives a clue to diagnosis in AUB and can reduce the burden of hysterectomy in many cases which can be treated by simple procedures.     

Incidence of Leiomyosarcoma at Surgery for Presumed Uterine Myomas in Different Age Groups

Study ObjectiveTo evaluate the incidence of leiomyosarcoma (LMS) at surgery for presumed uterine myomas according to different age groups.DesignA retrospective cohort study.SettingA tertiary referral hospital.PatientsAll women undergoing surgery for presumed uterine myomas between January 1, 2006, and December 31, 2016.InterventionsLaparoscopic myomectomy, laparotomic myomectomy, total hysterectomy, or hysteroscopic myomectomy.Measurements and Main ResultsA total of 1398 patients underwent surgery for presumed uterine myomas. The incidence of LMS was 2.15 per 1000 surgeries (n = 3, 1/466, 0.2%). In women under 40 years old, the incidence of occult LMS was 0 (0/561). In women between 40 and 49 years old, 190 myomectomies were performed (28% of the surgeries), and the rate of LMS was 1.49 per 1000 (n = 1, 1/673, 0.15%). In women over 49 years old, a total hysterectomy was performed in 82.3% of the cases, and the incidence of LMS was 12.2 per 1000 surgeries (n = 2, 1/82, 1.2%).ConclusionThe incidence of occult LMS in patients under 40 years old undergoing surgery for presumed uterine myomas was 0. These findings are suggestive that the use of power morcellation in this population may be safe.     

Assessment of endometrial volume and vascularization using transvaginal 3D power Doppler angiography in women with postmenopausal bleeding

ObjectiveTo compare the usefulness of 3D power Doppler angiography (3D-PDA) and endometrial thickness measurement by 2D Doppler ultrasound in the distinction of benign from malignant disease in postmenopausal women with abnormal uterine bleeding (AUB) and an endometrial thickness greater than 4.5 mm.MethodsForty-eight women with AUB and an endometrial thickness greater than 4.5 mm on 2D ultrasound underwent 3D-PDA. The endometrium and a 5-mm subendometrial “shell” were evaluated at rotation angles of 9° and 30°. Endometrial volume, vascularity index, flow index, and vascularization flow index were obtained.ResultsThe histologic findings were normal or benign for 38 women (79%) and malignant for 10 (21%). All vascular indices were significantly higher in the group with malignancies except for the vascularization flow index. There were no differences in the values obtained using the 9° or the 30° angle. Receiver-operating characteristics curves were traced for all indices. The vascularity index had the best area under the curve (0.78), 77.8% sensitivity, and 82.6% specificity. The areas under the curve were smaller for the shell than for the endometrium.Conclusion3D-PDA was not found better than 2D ultrasound at distinguishing benign from malignant disease in women with AUB and an endometrial thickness greater than 4.5 mm.     

Hysteroscopic surgery does not adversely affect the long-term prognosis of women with endometrial adenocarcinoma

STUDY OBJECTIVE: To determine the effect of hysteroscopic surgery on the long-term clinical outcome of women diagnosed with endometrial cancer. DESIGN: Prospective cohort study (Canadian Task Force classification II-3). SETTING: University-affiliated teaching hospital. PATIENTS: From January 1990 through December 2005, the principal author (GAV) performed primary hysteroscopic surgery in 3401 women with abnormal uterine bleeding. Among these women, there were 16 occult and 3 known endometrial cancers. INTERVENTIONS: All women underwent hysteroscopic evaluation and partial (n = 8) or complete (n = 11) rollerball electrocoagulation and/or endomyometrial resection. After diagnosis of endometrial malignancy, women were counseled regarding their disease and management, in accordance with established clinical practice guidelines. Follow-up ranged from 1 to 14 years and was conducted by office visits and telephone interviews. MEASUREMENTS AND MAIN RESULTS: Among the 3401 women, there were 19 women with endometrial adenocarcinoma, 3 of whom were known to harbor cancer before hysteroscopic surgery. One woman refused hysterectomy and remains alive and well 5 years after total hysteroscopic endomyometrial resection. Two women wished to maintain fertility; 1 consented to hysterectomy after incomplete resection of her lesion. The other was treated with progestins. Her cancer reverted to complex hyperplasia, and she requested hysterectomy 4 years later. No residual cancer was found. After 5 years of follow-up, 1 patient died from carcinoma of the gallbladder (2 years), and 2 died at 4 years; 1 at the age of 87 years of natural causes and the other at the age of 86 years from acute renal failure unrelated to her cancer. Fourteen women remain alive and well at 5 to 14 years of follow-up. Two additional women remain alive and well at 1 and 4 years of follow-up. CONCLUSION: Resectoscopic surgery did not adversely affect the 5-year survival and the long-term prognosis in 14 women with endometrial cancer.     

Hysteroscopy in perimenopausal and postmenopausal women with abnormal uterine bleeding

From February 1983 to January 1985, we performed outpatient microhysteroscopic examinations on 618 women 45 years of age or older with abnormal uterine bleeding (AUB). Three hundred thirty-four (54%) had normal and functional or hypoatrophic endometrium, 78 (12.6%) had low-risk hyperplasia, 8 (1.3%) had high-risk hyperplasia, and 66 (10.6%) had adenocarcinoma. Correlation with histologic findings revealed the considerable diagnostic accuracy of the technique: its reliability approaches 100% when one deals with endometrial neoplasia, 87.5% with high-risk hyperplasia and 65.2% with low-risk hyperplasia. The diagnosis cannot rely on hysteroscopic examination only. A biopsy can be performed during the examination or immediately thereafter. In 54.1% of AUB patients, no endometrial changes could be detected on hysteroscopy and biopsy. Curettage, therefore, would have resulted in overtreatment of these patients. Moreover, the usefulness of dilatation and curettage in about half of AUB patients over 45 should be questioned seriously.     

Case-Control Study of Complications Associated With Bipolar and Monopolar Hysteroscopic Operations

Study ObjectiveTo examine whether all hysteroscopic operations can be performed using bipolar technology and to compare the complication rates of hysteroscopic surgery performed using monopolar and bipolar technology.DesignCase-control study (Canadian Task Force classification II-2).SettingEndoscopic gynecology unit at a tertiary-care university hospital.PatientsWomen aged 17 to 88 years (median, 43.9 years) who underwent operative hysteroscopy to treat uterine disease.InterventionsOperative hysteroscopy using bipolar technology and normal saline solution as irrigation medium. The control group was composed of women who underwent the procedure using monopolar technology, with glycine as irrigation medium, before adoption of bipolar technology.Measurements and Main ResultsData regarding short-term complications were prospectively obtained during surgery and at 2-week follow-up. More than 1800 procedures were investigated (1318 in the study group and 524 in the control group). The complication rate was 4.1% in the study group and 2.8% in the control group (p = .08).ConclusionBoth monopolar and bipolar hysteroscopic techniques are safe and feasible. The bipolar hysteroscopic system has eliminated the need to use hypotonic solutions as irrigation medium, with its life-threatening complications. When limiting normal saline solution to 2 L, no serious complications associated with irrigation medium are expected. Therefore, we believe that when available, the bipolar system should be preferred.     

Diagnostic hysteroscopy in abnormal uterine bleeding. Five-years' experience

BACKGROUND: Hysteroscopy has acquired a central role in the clinical diagnosis of intrauterine pathologies. This study evaluated the feasibility, procedure modality, tolerability, complications and diagnostic accuracy of hysteroscopy in the management of patients with abnormal uterine bleeding (AUB). METHODS: This retrospective study was carried out on 512 women (age range: 38-80 years, mean age: 63) with AUB who attended our hysteroscopy outpatient service from January 1996 to December 2001. After undergoing transvaginal sonography, the patients were referred for further diagnostic studies. Ambulatory hysteroscopy without premedication was performed using a Hamou hysteroscope and physiological solution or CO(2) as distension medium. Guided biopsy with a Novak cannula completed the examination. When focal lesions were found, the patients were referred for surgical treatment (hysteroscopic resection, hysterectomy, etc.). Hysteroscopic and histologic findings were then compared. RESULTS: Locoregional or general anaesthesia was required in only 9.3% of cases to complete the examination. Overall, the examination was well tolerated; one case of serious complications (vagal syndrome which resolved rapidly) and 18 cases of shoulder blade pain were recorded. The hysteroscopic picture was normal in 25% of cases, benign pathology was diagnosed in 58.6% and suspected malignant neoplasia in 16.4%. Correlation rates between hysteroscopic and histologic diagnoses are reported for the various hysteroscopic pictures. CONCLUSIONS: Ambulatory hysteroscopy was shown to be a simple, safe, well tolerated and reliable procedure in the diagnosis of AUB across all age groups. Its widespread use can drastically reduce the need for conventional curettage, thereby increasing patient satisfaction and lowering costs.     

Global Endometrial Ablation in the Presence of Essure? Microinserts

Abnormal uterine bleeding (AUB) affects 30% of women at some time during their reproductive years and is one of the most common reasons a woman sees a gynecologist. Many women are turning to endometrial ablation to manage their AUB. This article reviews the data relating to the available endometrial ablation techniques performed with hysteroscopic sterilization, and focuses on data from patients who had Essure® (Conceptus, San Carlos, CA) coils placed prior to performance of endometrial ablation. Reviewed specifically are data regarding safety and efficacy of these two procedures when combined. Data submitted to the US Food and Drug Administration for the three devices currently approved are reviewed, as well as all published case series. Articles included were selected based on a PubMed search for endometrial ablation (also using the brand names of the different techniques currently available), hysteroscopic sterilization, and Essure.Key words: Abnormal uterine bleeding, Endometrial ablation, Hysteroscopic sterilizationAbnormal uterine bleeding (AUB) affects 30% of women at some time during their reproductive years and is one of the most common reasons a woman sees a gynecologist.¹ AUB tends to occur more frequently as patients get older, and women typically present between the ages of 30 and 55 years with this problem. After appropriate evaluation, medical management is often the first line of treatment. However, many women are turning to endometrial ablation to manage their AUB. Patients are counseled to avoid pregnancy after endometrial ablation due to the increased risks for pregnancy after ablation. Problems such as premature rupture of membranes, preterm labor, intrauterine growth restriction, abnormal placentation, and higher cesarean delivery rates are reported.² Practitioners must offer a reliable contraceptive method after endometrial ablation has been performed.²There is a higher prevalence of women choosing permanent sterilization for their contraception as they age. According to the 2006–2008 National Survey of Family Growth, 28.2% of women aged 35 to 39 years and 39.1% of women aged 40 to 44 years use female sterilization as their choice of birth control.³ Ideally, women requiring endometrial ablation could benefit from concomitant procedures providing relief of their menorrhagia as well as permanent birth control. The transcervical approach of endometrial ablation and hysteroscopic sterilization makes the two methods well suited to be performed simultaneously, providing both menorrhagia relief and permanent sterilization. Furthermore, the second-generation endometrial ablation methods and hysteroscopic sterilization can both be performed in an office setting with local anesthetics and minimal anesthesia.Currently the NovaSure® (Hologic, Bedford, MA), hydrothermal ablation (HTA), and Gynecare ThermaChoice® (Ethicon, Somerville, NJ) are third-generation methods of global endometrial ablation (GEA) that are approved by the US Food and Drug Administration (FDA) for use with Essure® (Conceptus, San Carlos, CA) coils in situ. In consideration of performing a concomitant endometrial ablation with Essure coils in situ, several concerns regarding safety and efficacy need to be addressed.Hysteroscopic sterilization requires placement of a microinsert that spans the uterotubal junction. This coil is made up of stainless steel, nitinol, and polyethyl terpathalate material. Proper placement of the Essure coils requires 3 to 8 coils to be in the endometrial cavity,⁴ which puts the microinsert in direct or indirect contact with the ablation device. Some concerns that need to be evaluated include

1. Thermal and/or Electrical Conductivity
   • Given that the coils used in hysteroscopic sterilization are made out of metal, does the microinsert transmit the heat or conduct energy that is generated during endometrial ablation distally to the tube or outside the uterus?
   • What is the extent of damage that may occur due to this increase in temperature or energy transmission?
   • Most importantly, is the ability of the microinsert to yield tubal occlusion affected by its exposure to these conditions?
2. Tubal Occlusion Confirmation Testing
   • A confirmation of tubal occlusion prior to proceeding with endometrial ablation is currently recommended by the FDA.⁴ Although concomitant use of Gynecare ThermaChoice with Essure coils was granted by the FDA in 2006, this was rescinded after several patients had inadequate hysterosalpingogram (HSG) procedures due to Asherman syndrome. Therefore, how does ablation affect the ability to perform the confirmation test?
   • If the ability to perform HSG is compromised, are there alternatives to this confirmatory test that are acceptable?

     

Prevalence of Hemostatic Disorders in Adolescents with Abnormal Uterine Bleeding

Study ObjectiveTo evaluate the incidence of hemostatic disorders in a population of adolescents with various patterns of abnormal uterine bleeding (AUB).DesignRetrospective observational study.SettingUniversity hospital.ParticipantsOne hundred thirteen adolescents with AUB; mean age at menarche and mean age at the onset of symptoms 12 ± 1.2 years and 13.5 ± 2.8 years, respectively.Main Outcome MeasuresData on menstrual history, bleeding symptoms, co-existing medical conditions, and medical therapies were assessed. All patients were screened for hemostatic disorders with laboratory testing. The incidence of the disorders was calculated. Subjects were further divided in 2 groups based on whether the AUB started in the first 2 years from menarche (group 1) or later (group 2). A statistical analysis was performed using a chi-square test to compare incidence of hemostatic disorders between the groups.ResultsOne hundred thirteen adolescents with AUB were identified. Overall, 54 (47.8%) patients had some underlying hemostatic disorder, of which a platelet dysfunction was the most common (17.7%). Von Willebrand disease was detected in 13.3% of cases and a deficiency of a coagulation factor in 12.4%. In 7.1% of patients an isolated increase of bleeding time was observed. When divided in 2 groups, 44.2% of patients in group 1 and 59.2% in group 2 had a coagulation disorders, with no statistically significant difference between the 2 groups (P = .17).ConclusionAUB in adolescents is frequently associated with an underlying disorder of hemostasis, most commonly a platelet function disorder. The results highlight the importance of screening for coagulation disorders in adolescents with AUB, independently from the gynecologic age at onset.     

Safety and Efficacy of a Novel Barrier Film to Prevent Intrauterine Adhesion Formation after Hysteroscopic Myomectomy: The PREG1 Clinical Trial

Study ObjectiveTo evaluate the safety and potential efficacy of a novel degradable polymer film (DPF) designed to act as a 7-day barrier to prevent intrauterine adhesions (IUAs) after hysteroscopic myomectomy.DesignA prospective single-arm, first-in-human clinical study.SettingMulticenter study involving 6 centers in France, Belgium, and the Netherlands.PatientsWomen aged 40 years or older with no plans to conceive who qualified for hysteroscopic myomectomy (at least 1 10-mm type 0, 1, or 2 myoma) and had a sounded length of the uterine cavity (fundus to exocervix) ranging between 6 cm and 9 cm were considered eligible for the study.InterventionsThe DPF was inserted after hysteroscopic transcervical myoma resection. The women were followed up by a telephone call at 30 days and second-look hysteroscopy 4 to 8 weeks after the procedure.Measurements and Main ResultsThe chosen safety outcome measures were uterine perforation or cervical trauma at the time of the DPF insertion and unexpected fever, pain, or bleeding beyond 48 hours and up to 30 days after insertion, whereas the outcome measure for efficacy was the absence of IUAs on second-look hysteroscopy. A total of 23 women participated in the study. There were no incidents of uterine perforation or cervical trauma at the time of the DPF insertion. There were no reported adverse effects attributable to the DPF. On second-look hysteroscopy, 20 (87%) of the 23 women had no IUAs.ConclusionThe DPF is a novel, easy-to-apply, and acceptable device to prevent IUAs, with very promising initial safety and efficacy data.     

Hormonal replacement therapy and evaluation of intrauterine pathology in postmenopausal women: a ten-year study

BACKGROUND: To evaluate the role of hormonal replacement therapy (HRT) in determining: a) abnormal uterine bleeding (AUB); b) increased endometrial thickness at transvaginal sonography (TVS); c) the correct indication for outpatient hysteroscopy (HS) and biopsy in diagnosing intrauterine pathology. METHODS: Between April 1991 and April 2001 a group of 3,400 postmenopausal women was referred to the Department of Obstetrics and Gynecology of Rome University "La Sapienza"; 16.7% of them had received HRT. 587 out of the 3,400 women were recruited for a comparative study, including four groups. To assess statistical significance of HRT in determining AUB, and/or endometrial thickness related to malignant disease the chi-square test was used; p < 0.05 was considered significant. Histology was considered the true result (control). RESULTS: An increase in the endometrial thickness occurred significantly more often in women on HRT (p < 0.03); as well as the percentage of AUB (p < 0.0001). No difference in the incidence of endometrial adenocarcinoma was reported between the HRT and the non HRT groups. CONCLUSIONS: In postmenopausal women using HRT we can confirm that a higher incidence of signs (AUB, endometrial thickness > or = 5 mm) does not coincide with a higher incidence of malignant pathology. The data obtained from the recruited patients was arranged and evaluated by the most suitable methods for screening endometrial adenocarcinoma. According to our experience, we believe a cut-off point of 8 mm to be significant (p < 0.001) to perform an hysteroscopy and biopsy except for asymptomatic patients on HRT.     

Hysteroscopic Photodynamic Diagnosis Using 5-Aminolevulinic Acid: A High-Sensitivity Diagnostic Method for Uterine Endometrial Malignant Diseases

Study ObjectiveTo examine the diagnostic accuracy of hysteroscopic photodynamic diagnosis (PDD) using 5-aminolevulinic acid (5ALA) in patients with endometrial cancer and premalignant atypical endometrial hyperplasia.DesignA single-center, open-label, exploratory intervention study.SettingUniversity Hospital in Japan.PatientsThirty-four patients who underwent hysteroscopic resection in the Department of Obstetrics and Gynecology at Keio University Hospital.InterventionsPatients were given 5ALA orally approximately 3 hours before surgery and underwent observation of the uterine cavity and endometrial biopsy using 5ALA-PDD during hysteroscopic resection. Specimens were diagnosed histopathologically and the diagnostic sensitivity and specificity of hysteroscopic 5ALA-PDD for malignancy in the uterine cavity was determined. Red (R), blue (B), and green (G) intensity values were determined from PDD images, and the relationships of histopathological diagnosis with these values were used to develop a model for objective diagnosis of uterine malignancy.Measurements and Main ResultsThree patients were excluded from the study because of failure of the endoscope system. A total of 113 specimens were collected endoscopically. The sensitivity and specificity of 5ALA-PDD for diagnosis of malignancy in the uterine cavity were 93.8% and 51.9%, respectively. The R/B ratio in imaging analysis was highest in malignant lesions, followed by benign lesions and normal uterine tissue, with significant differences among these groups (p <.05). The R/B and G/B ratios were used in a formula for prediction of malignancy based on logistic regression and the area under the receiver operating characteristic curve for this formula was 0.838. At a formula cutoff value of 0.220, the sensitivity and specificity for diagnosis of malignant disease were 90.6% and 65.4%, respectively.ConclusionTo our knowledge, this is the first study of the diagnostic accuracy of 5ALA-PDD for malignancies in the uterine cavity. Hysteroscopic 5ALA-PDD had higher sensitivity and identifiability of lesions. These findings suggest that hysteroscopic 5ALA-PDD may be useful for diagnosis of minute lesions.     

宫腔镜电切术治疗异常子宫出血36例临床分析

目的 探讨宫腔镜电工术治疗异常子宫出血手术的疗效及影响因素。方法 应用连续灌流式宫腔镜,对３６例异常子宫出血患者进行宫腔镜电切手术治疗,其中９例为子宫内膜切除、、１６例为肌瘤及部分内膜切除、９例为肌瘤切除、２例为息肉及部分内膜切除。结果 术中、术后并发症发生率为８．３％。术后随访４～１２月者３２例,月经改善率８２．４％,其中闭经５．９％,月经量减少５８．８％,月经量正常１７．６％,８例痛经中６例改