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.     

Resectoscopic surgery in women with abnormal uterine bleeding and nonatypical endometrial hyperplasia

STUDY OBJECTIVE: To evaluate the role of resectoscopic surgery in the diagnosis and treatment of women with abnormal uterine bleeding and endometrial hyperplasia without atypia. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: University-affiliated teaching hospital. PATIENTS: Twenty-five women with simple and seven with complex hyperplasia. INTERVENTION: Hysteroscopic endometrial ablation. MEASUREMENTS AND MAIN RESULTS: In patients with simple hyperplasia, average age, parity, body mass index, and mean arterial pressure were 53.2 years, 2.4 pregnancies, 30 kg/m2, and 99.5 mm Hg, respectively; in those with complex hyperplasia corresponding figures were 48 years, 2 pregnancies, 36 kg/m2, and 100 mm Hg. Nineteen of 32 women had postmenopausal bleeding, 9 of whom were taking combined hormone replacement therapy. Two had subsequent hysterectomies, one for pain and the other for incomplete resection due to an enlarged uterus. Resection could not be completed in one morbidly obese woman. One patient died from heart disease. During the follow-up of 1 to 8 years (mean 4 yrs) all patients remained amenorrheic with no evidence of recurrent disease or progression to cancer. CONCLUSION: Resectoscopic surgery by experienced hysteroscopists may be effective therapy for endometrial hyperplasia without atypia, especially in women at high risk for medical therapy or hysterectomy. Patient surveillance is mandatory for early detection and management of recurrent disease and progression to cancer.     

Histopathologic behavior of endometrial hyperplasia during tamoxifen therapy for breast cancer

OBJECTIVE: The purpose of the present study is to prospectively evaluate the effects of tamoxifen on the pathological behavior of endometrial hyperplasias without atypia, diagnosed before the start of adjuvant endocrine therapy, in menopausal patients suffering from breast cancer. METHODS: Twenty-six patients suffering from estrogen-receptor positive breast cancer and candidate to receive adjuvant tamoxifen, were found to be affected by endometrial hyperplasias before the start of endocrine therapy. All women showed a baseline endometrial stripe, measured by transvaginal ultrasonography, thicker than 4 mm and the diagnosis of endometrial hyperplasia was made by hysteroscopy and endometrial biopsy. Two patients showing complex atypical hyperplasia underwent vaginal hysterectomy, whereas the remaining 24 patients, suffering from endometrial hyperplasia without atypia, were followed on a yearly basis during the period of tamoxifen intake, by hysteroscopy and endometrial biopsy. RESULTS: Baseline histopathology showed simple and complex hyperplasia in 20 and in 4 patients, respectively. The median follow-up period was 38 months; in particular, all patients underwent endometrial assessment after 12 months, while 22, 16, 10 and 4 patients were followed-up after 24, 36, 48 and 60 months of tamoxifen therapy, respectively. Progression from complex hyperplasia to complex atypical hyperplasia (1 patient) and from complex and simple hyperplasia to adenocarcinomas (2 patients) was found within 24 months of tamoxifen intake in 3 patients (12.5%). In 2 patients (8.3%), a progression from simple to complex hyperplasia was detected within 36 months of tamoxifen treatment. In 13 patients (54.1%), stable histology of simple or complex hyperplasia was found, whereas 6 patients (25.0%), with focal hyperplasia harbored in an endometrial polyp, showed a normalization of endometrial histology after polyp resection. CONCLUSIONS: Endometrial hyperplasias without atypia diagnosed before endocrine therapy for breast cancer in menopausal patients show an early and high progression-rate to atypical lesions under tamoxifen influence.     

Endometrial hyperplasia and the risk of carcinoma

Recent reports suggest that atypical endometrial hyperplasia diagnosed by biopsy or curettage is accompanied by a higher than expected risk of coexistent invasive cancer. In order to test this hypothesis we reviewed the pathology and clinical history of all patients at our institution who underwent hysterectomy for endometrial hyperplasia with or without cytologic atypia. We found 24 patients of 45 with a preoperative diagnosis of hyperplasia with cytologic atypia, and 21 with simple or complex hyperplasia without atypia. No cancers were found at surgery in the latter group nor were any significant historical differences found between the two groups. Of the patients with atypia, 12/24 (50%) had an endometrial carcinoma and nine patients (37.5%) were stage IB or greater. This is a significantly greater risk than previously reported in the literature. Endometrial hyperplasia with cytologic atypia may carry a higher risk of coexistent invasive endometrial carcinoma than previously believed. Methods to identify those patients at highest risk should be determined.     

Histopathologic correlation of dilatation and currettage and hysterectomy specimens in patients with postmenopausal bleeding

PURPOSE OF INVESTIGATION: To evaluate the consistency of preoperative and postoperative histopathological findings in postmenopausal patients with abnormal bleeding. METHODS: Pathologic diagnoses of 42 postmenopausal women with abnormal bleeding or increased endometrial thickness who underwent both dilatation and curettage (D and C), and hysterectomy for proper indications were retrospectively examined. RESULTS: The most common diagnosis was irregular proliferative endometrium in both the pre- and postoperative groups with 16 patients each (38%). After subgroup analysis, 50% of the patients with a preoperative diagnosis of complex hyperplasia without atypia, had complex atypical hyperplasia, and two-thirds of the patients with a preoperative diagnosis of complex atypical hyperplasia had endometrial cancer as the final diagnoses. CONCLUSION: Preoperative D and C endometrial pathology findings positively correlated with postoperative hysterectomy pathology results. However, as the real pathology gets worse , D and C seems to under-diagnose the real pathology. In cases with complex hyperplasia with or without atypia , a second D and C or hysteroscopic evaluation may be recommended.     

The management of endometrial hyperplasia: an evaluation of current practice

OBJECTIVE: To identify current management practices and evaluate subsequent outcomes of treatment for women diagnosed with endometrial hyperplasia. STUDY DESIGN: All women with a histological diagnosis of endometrial hyperplasia at the Birmingham Women's Hospital were identified between October 1998 and September 2000. A retrospective case note review was performed for each woman using a standardised data abstraction sheet. Baseline characteristics including clinical presentation and treatment strategy were obtained. Results of subsequent endometrial tissue examinations were used to assess histological response to treatment and the need and indication for hysterectomy was used to assess clinical response. RESULTS: There were 351 women diagnosed with endometrial hyperplasia during the study period of which 84% presented with symptoms of abnormal uterine bleeding and 54% were postmenopausal. Complex endometrial hyperplasia was the most common diagnosis accounting for 60% of all cases. Eighty percent of women with atypical endometrial hyperplasia were treated by hysterectomy compared with 30% without evidence of cytological atypia (relative hysterectomy rate of 2.6, 95% CI 2.0-3.3). Hysterectomy was avoided in 138/172 (80%, 95% CI 74-86%) women managed conservatively during the study period. Overall 35/108 (36%, 95% CI 27-46%) of women managed conservatively had persistent or progressive disease identified (mean follow up 36 months). 20/143 (14%) women initially diagnosed with endometrial hyperplasia who subsequently underwent hysterectomy were found to have endometrial cancer, the majority of whom had been diagnosed with atypical disease (14/20, 70%). CONCLUSION(S): The majority of women with atypical endometrial hyperplasia were managed by hysterectomy and the substantial risk of diagnostic under-call supports this approach to treatment. In contrast, there is no consensus regarding the initial management of women with endometrial hyperplasia without cytological atypia.     

Endometrial Biopsy in Low-Risk Women: Are We Over-Investigating?

The appropriate age at which to perform endometrial biopsy for abnormal uterine bleeding (AUB) is controversial. This study aimed to determine the prevalence of malignant and premalignant pathologies in women aged 41–49 years with AUB and without risk factors for endometrial cancer. Records of women who had undergone a biopsy at the gynaecology clinic of the Centre hospitalier de l'Université de Montréal between 2014 and 2018 were reviewed. Of the 209 women included in the study, 2 had atypical hyperplasia, which resolved without treatment, and 3 had hyperplasia without atypia. The remaining women had benign results, showing that the prevalence of malignant and premalignant endometrial pathologies is low in this subgroup of patients.     

Endometrial hyperplasia: a review

Endometrial hyperplasia is a precursor to the most common gynecologic cancer diagnosed in women: endometrial cancer of endometrioid histology. It is most often diagnosed in postmenopausal women, but women at any age with unopposed estrogen from any source are at an increased risk for developing endometrial hyperplasia. Hyperplasia with cytologic atypia represents the greatest risk for progression to endometrial carcinoma and the presence of concomitant carcinoma in women with endometrial hyperplasia. Abnormal uterine bleeding is the most common presenting symptom of endometrial hyperplasia. Specific Pap smear findings and endometrial thickness per ultrasound could also suggest the diagnosis. Unopposed estrogen in women taking hormone replacement therapy increases the risk of endometrial hyperplasia. Tamoxifen has demonstrated its efficacy in treating women at risk for breast cancer, but it increases the risk of endometrial hyperplasia. The choice of treatment for endometrial hyperplasia is dependent on patient age, the presence of cytologic atypia, the desire for future childbearing, and surgical risk. Endometrial hyperplasia without atypia responds well to progestins. However, women with atypical hyperplasia should be treated with hysterectomy unless other factors preclude surgery. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to describe the definition and classification of endometrial hyperplasia, to outline the clinical features of a patient with endometrial hyperplasia, to point out the natural history of endometrial hyperplasia, and to summarize the diagnostic options for patients with endometrial hyperplasia.     

Hiperplasia endometrial atípica en biopsia preoperatoria y resultado de la pieza de histerectomía

Objectives

The purpose of this study was to examine the relationship between diagnosis of atypical endometrial hyperplasia in a curettage sample and the final pathological result after hysterectomy.

Material and methods

There were 33 patients who fulfilled the criteria for inclusion in this study. Clinical records were reviewed to identify clinical, histopathological and treatment data.

Results

Adenocarcinoma was found in four (12.12%) of the 33 surgical specimens from hysterectomy. Endometrial hyperplasia was found in 28 specimens, although 12 (36.3%) of these specimens showed no atypia. No endometrial hyperplasia or signs of any other tumor were found in one specimen.

Conclusions

After pathological findings of atypical endometrial hyperplasia, the next step should be to perform hysterectomy. Given the major risks of delaying or not performing surgery for a possible concomitant endometrial cancer, which can be treated and cured, the risk of overtreating some patients is acceptable.     

Clinical over- and under-estimation in patients who underwent hysterectomy for atypical endometrial hyperplasia diagnosed by endometrial biopsy: the predictive value of clinical parameters and diagnostic imaging

OBJECTIVE: The aim of this study was to analyze the clinical and imaging characteristics in patients diagnosed with atypical endometrial hyperplasia based on endometrial biopsy in comparison with the final diagnosis from resected uteri; i.e. to determine the rates of underestimation (endometrial cancer), equivalent diagnosis (atypical hyperplasia), and overestimation (hyperplasia without atypia or non-hyperplastic lesion). MATERIALS AND METHODS: We reviewed 33 patients who were diagnosed with atypical endometrial hyperplasia by endometrial biopsy using a small curette and then underwent total abdominal hysterectomy between September 1992 and May 2002. Clinical parameters obtained from patients' charts, and imaging analyses using transvaginal ultrasonography (TUS) and magnetic resonance (MR) imaging were retrospectively re-examined. RESULTS: Among 33 patients who underwent hysterectomy due to a diagnosis of atypical hyperplasia, nine cases (27.2%) were underestimated (cancer), nine cases (27.2%) were equivalent and 15 cases (45.6%) were overestimated as indicated by examination of the endometrium of the resected uterus. There was no difference among these groups in either clinical parameters or diagnostic images obtained by TUS or MR. CONCLUSION: Diagnosis of atypical endometrial hyperplasia by endometrial biopsy often resulted in under- or over-estimation, as shown by examination after hysterectomy. As there is neither a reliable clinical parameter nor imaging feature to distinguish between these groups, hysterectomy is still the best treatment for these patients if they are willing to give up their fertility.     

The value of curettage in diagnosis of endometrial hyperplasia.

OBJECTIVES: The aim of this study was to assess the value of diagnosis of endometrial hyperplasia by curettage and to determine the results of proliferating cell nuclear antigen (PCNA) immunostaining in differentiating endometrial carcinoma from endometrial hyperplasia. METHODS: According to Kurman's criteria, we treated 150 patients with endometrial hyperplasia detected by curettage and compared retrospectively the diagnosis by curettage with that by hysterectomy. PCNA expression was examined using immunohistochemostaining on 60 patients with complex atypical hyperplasia detected by curettage. RESULTS: Simple hyperplasia was found by curettage in 53 patients, complex hyperplasia in 11, simple atypical hyperplasia in 26, and complex atypical hyperplasia in 60. All patients were rediagnosed after hysterectomy. As a result, 65 were found to have simple hyperplasia, 7 complex hyperplasia, 15 simple atypical hyperplasia, 29 complex atypical hyperplasia, and 34 endometrial carcinoma. The accuracy of histological diagnosis by curettage was 76.7-92.0% and was dependent on different types of hyperplasia. Simple atypical hyperplasia and complex atypical hyperplasia were more likely to coexist with endometrial carcinoma than both simple hyperplasia and complex hyperplasia (chi2 = 26.3, P < 0.001), and complex atypical hyperplasia was more likely to coexist with endometrial carcinoma than simple atypical hyperplasia (chi2 = 9.78, P < 0.005). In complex atypical hyperplasia patients, coexistence with endometrial carcinoma was more common after menopause than before menopause (chi2 = 3.93, P < 0.05). In complex atypical hyperplasia patients, the expression of PCNA in cases associated with endometrial carcinoma was higher or stronger than in cases associated without endometrial carcinoma (chi2 = 7.68, P < 0.01, or U = 252.00, P < 0.01). Conclusions. Curettage tends to be more highly accurate in diagnosing simple hyperplasia than complex atypical hyperplasia, which is often found by hysterectomy to be associated with endometrial carcinoma. The expression of PCNA may be helpful in differentiating complex atypical hyperplasia from endometrial carcinoma.     

Preoperative and postoperative correlation of histopathological findings in cases of endometrial hyperplasia

OBJECTIVES: To determine the preoperative and postoperative correlation of histopathological findings in cases of endometrial hyperplasia. MATERIAL AND METHODS: One hundred and three patients with endometrial hyperplasia detected by surgical curettage performed due to various gynecologic pathologies were treated by hysterectomy. We compared retrospectively the histopathological diagnoses found on curettage with those found on hysterectomy specimens. The classification scheme endorsed by the International Society of Gynecological Pathologists was used to classify the endometrial hyperplasia. The histologic findings found on the endometrial tissue of curettage specimens were correlated with those from hysterectomy specimens. Histopathologic evaluation was performed by a single skilled gynecologic pathologist. RESULTS: A total number of 103 women--76 (73.8%) premenopausal and 27 (26.2%) postmenopausal--were determined to have endometrial hyperplasia on histopathological evaluation of endometrial tissues obtained by endometrial curettage performed for evaluation of various bleeding abnormalities. These included 94 patients with simple hyperplasia without atypia (91.3%), two patients with simple hyperplasia with atypia (1.9%), five patients with complex hyperplasia without atypia (4.9%), and two patients with complex hyperplasia with atypia (1.9%). Histopathological evaluation of endometrial tissue obtained from hysterectomy specimens (of patients diagnosed with hyperplasia on curettage) revealed a total number of 65 cases (63.1%) with endometrial hyperplasia, and 38 cases (36.9%) with various histopathological findings. The correlation between preoperative and postoperative endometrial histologic findings was found to be statistically insignificant (r = 0.105, p = 0.29). Among 94 patients who were found to have simple hyperplasia without atypia on curettage specimens, 55.3%, were found to have simple hyperplasia without atypia, 1.1% simple hyperplasia with atypia, 5.3% complex hyperplasia without atypia, 9.6% secretory endometrium, 4.3% proliferative endometrium, 21.3% disorganized proliferative endometrium, 1.1% corpus luteum persistency, 1.1% basal endometrium, and 1.1% endometrium cancer on final hysterectomy specimens. CONCLUSION: Postoperative diagnosis of endometrial pathology might be different from that of preoperative especially in cases with simple endometrial hyperplasia without atypia.     

Hysteroscopic view in atypical endometrial hyperplasias: A correlation with pathologic findings on hysterectomy specimens

STUDY OBJECTIVE: To evaluate whether hysteroscopic imaging can contribute to decrease the rate of undetected endometrial carcinomas concurrent with atypical hyperplasia diagnosed by endometrial biopsy. DESIGN: Retrospective study. DESIGN CLASSIFICATION: Canadian Task Force Classification II-3. SETTING: Public hospital. PATIENTS: Hysteroscopic reports of 25 menopausal patients undergoing endometrial biopsy yielding a diagnosis of atypical hyperplasia were reviewed. On the basis of this diagnosis, all patients were treated by hysterectomy, and the pathologic findings on the uterine specimen were correlated with the diagnoses obtained by hysteroscopic view. INTERVENTIONS: Hysteroscopy was video-assisted and carried out with normal saline solution used as liquid distension medium; a 5-mm sheathed hysteroscope, with a working channel, was used for each examination. After hysteroscopic inspection, an endometrial sampling targeted under vision was performed by mechanical or electrosurgical instrumentation. When extensive features of hyperplastic or neoplastic growth were observed, we combined a blind sampling procedure with Vabra-curettage. We calculated the sensitivity, specificity, and negative and positive predictive values of hysteroscopic inspection to foresee the diagnosis of endometrial cancer incidentally detected on hysterectomy specimen. MEASUREMENTS AND MAIN RESULTS: On the basis of histopathologic study of uterine specimens, non atypical hyperplasias were detected in 3 patients, the diagnosis of complex atypical hyperplasia was confirmed in 11 patients, whereas a concurrent infiltrating endometrial adenocarcinoma was detected in 11 patients (44.0%). In the 14 patients with diagnosis of endometrial hyperplasia, no feature suggesting endometrial malignancy was reported by hysteroscopic inspection. In the 11 cases showing infiltrating carcinomas, hysteroscopic view was consistent with endometrial malignancy in 9 patients and with endometrial hyperplasia in 2 patients. An intramucous endometrial carcinoma without evidence of myometrial invasion was found on hysterectomy specimens of these two latter patients. From these figures, sensitivity, specificity, and negative and positive predictive values of hysteroscopy to foresee a diagnosis of infiltrating carcinoma were 84.6%, 100%, 87.5%, and 100%, respectively. CONCLUSIONS: Hysteroscopic view is a sensitive and specific method to identify among patients with a diagnosis of atypical hyperplasia on endometrial biopsy those with a coexisting infiltrating carcinoma.     

Concurrent endometrial carcinoma following hysterectomy for atypical endometrial hyperplasia

Objective

To evaluate the prevalence of concurrent endometrial carcinoma in women diagnosed with atypical endometrial hyperplasia (AEH) by endometrial biopsy.

Study design

We retrospectively analyzed the medical records of 126 patients who underwent hysterectomies for AEH diagnosed by endometrial biopsy from 1999 to 2008. AEH was initially diagnosed by dilatation and curettage (98 cases) or endometrial biopsy with a Z-sampler (24 cases). The remaining four cases were diagnosed by hysteroscopic polypectomy. The results of the endometrial biopsies were graded on an ordinal scale and were compared with pathologic features obtained at the hysterectomy.

Results

In patients preoperatively diagnosed with AEH by biopsy, hysterectomy specimens revealed a rate of simple or complex endometrial hyperplasia without atypia of 27% with AEH and normal proliferative phases found in 54.7 and 7.9% of specimens, respectively. The incidence of endometrial carcinoma was considerably high (13/126, 10.3%). Eleven of 13 cases were confined to the endometrium and the remaining two were located at the adenomyosis without myometrial invasion. All patients with endometrial carcinoma displayed coexisting atypical complex hyperplasia following hysterectomy.

Conclusions

Biopsy specimens showing AEH, particularly atypical complex hyperplasia, are associated with a risk of coexisting endometrial carcinoma. When considering management strategies for women with a biopsy diagnosis of AEH, clinicians should take into account the considerable rate of concurrent endometrial cancer and the discrepancy with pathologic diagnosis. Treatment modalities may differ depending on population as the rates of concurrent endometrial cancer with AEH and myometrial invasion vary by geographical location.     

Atypical hyperplasia of endometrium and hysteroscopy

OBJECTIVE: To evaluate the risk of discovering an endometrial cancer when atypical hyperplasia was diagnosed by either endometrial samples using the pipelle device or hysteroscopic resection products. PATIENTS AND METHODS: A retrospective monocentric study from january 1990 to july 2000. Twenty-three patients with atypical hyperplasia were included. Initial endometrial status was provided by endometrial biopsyduring diagnosis hysteroscopy (12 cases) or by operative hysteroscopic resection products (11 cases). For 23 patients, operative hysteroscopy and analyse of products resected were performed. For all patients, there was no hysteroscopical aspect evocative of adenocarcinoma. For 23 patients, histopathological analysis of the hysterectomy piece precised the final diagnosis. RESULTS: Among the 23 hysterectomy pieces, 7 adenocarcinomas were diagnosed (30.4%). Risk for discovering adenocarcinoma when atypical hyperplasia was diagnosed by means of the pipelle biopsy device was 50% (6/12). Risk for discovering adenocarcinoma when atypical hyperplasia was diagnosed by means of operative hysteroscopy resection products was 5.9 % (1/17). DISCUSSION AND CONCLUSION: Atypical endometrial hyperplasia evidenced by pipelle biopsy device is often associated with adenocarcinoma. Diagnosis hysteroscopy however does not show evident pathological aspect of adenocarcinoma in such cases. Operative hysteroscopy allows in most cases correction of endometrial status. Risk of omitting adenocarcinoma when atypical hyperplasia is discovered on hysteroscopic resection pieces is low.     

Descriptive epidemiology of endometrial hyperplasia in patients with abnormal uterine bleeding

PURPOSE OF INVESTIGATION: To evaluate the prevalence and epidemiologic characteristics of endometrial hyperplasias in women with abnormal uterine bleeding. METHODS: We performed a retrospective analysis on data gained from 294 patients with histologically documented endometrial hyperplasia (with or without atypia), detected among 1,469 women who underwent fractional dilatation and curettage in our department due to abnormal uterine bleeding from 1986 to 1998. Epidemiologic characteristics were abstracted from the patients' medical charts. RESULTS: 294/1469 women were found with endometrial hyperplasia (258 without atypia and 36 atypical hyperplasias). Thirty-six of them were under 40 years of age. Four of the detected endometrial hyperplasias progressed to endometrial carcinoma (one with simple hyperplasia, two with complex and one with atypical hyperplasia). Obesity and hypertension were justified as risk factors in our study population. CONCLUSIONS: The prevalence of endometrial hyperplasia according to our data was 20%. There were statistically significant differences in most epidemiologic parameters between the two types of hyperplasia. The progression of four endometrial hyperplasias to endometrial adenocarcinoma indicates the need for intense follow-up even in cases where patients undergo conservative therapy.     

Risk of finding an endometrial cancer when atypical hyperplasia was incidentally diagnosed on hysteroscopic resection products

OBJECTIVE: To evaluate the risk of discovering an endometrial cancer when atypical hyperplasia was diagnosed by histologic examination of hysteroscopic resection products. STUDY DESIGN: A retrospective monocentric study from January 1994 to January 2001. Seventeen patients with atypical hyperplasia were included. Initial endometrial status was provided by operative hysteroscopy resection products. For all patients, there was no hysteroscopical aspect evocative of adenocarcinoma. Histopathological analysis of the hysterectomy pieces precised the final diagnosis. RESULTS: Among the 17 hysterectomy pieces, one adenocarcinoma was diagnosed. Risk for discovering adenocarcinoma when atypical hyperplasia was diagnosed by operative hysteroscopy resection products was 5.9% (1/17). CONCLUSION: Risk of omitting adenocarcinoma when atypical hyperplasia is discovered by hysteroscopy resection pieces is low.     

Hysterectomy in women with cervical stenosis. Surgical indications and pathology

OBJECTIVE: To evaluate indications for surgery and final pathology results in patients who underwent hysterectomy with a concurrent diagnosis of cervical stenosis. STUDY DESIGN: Retrospective chart review of 25 women who underwent hysterectomy after diagnosis of cervical stenosis. RESULTS: The average age was 59 years (range, 38-80). Indications for surgery included postmenopausal bleeding in 10 patients, previous dysplasia with inadequate Papanicolaou test follow-up in 4, recurrent high grade squamous intraepithelial lesion in 1, chronic pelvic pain in 5, acute pain in 2, dysfunctional uterine bleeding in 2 and thickened endometrial stripe in 1 patient on tamoxifen. An attempt to obtain an endometrial sample was unsuccessful in 14 patients. Twenty patients had undergone prior gynecologic surgery. The results of final cervical pathologic examination revealed severe cervical dysplasia or carcinoma in situ in 3. Final uterine pathology revealed 1 patient with uterine adenocarcinoma and 19 patients with benign pathology, including endometritis, fibroids, adenomyosis and endometrial hyperplasia. CONCLUSION: The majority of patients with cervical stenosis resulting in inadequate cancer screening and/or symptoms resulting from stenosis will have significant benign pathology (64%), cervical dysplasia (12%) or uterine cancer (4%). For these patients, hysterectomy is a reasonable option.     

Cytological diagnosis of endometrial cancer and preinvasive endometrial lesions. A comparison of the Endo-Pap sampler with fractional curettage

The value of the Endo-Pap endometrial cell sampling device in the cytological assessment of the endometrium was compared with fractional curettage. 318 symptomatic women were studied consecutively, among whom were 42 with malignant tumors of the uterus. Satisfactory material for cytological diagnosis of the endometrial state was obtained in 96%, whereas only 91% of the histopathological material was suitable for interpretation. 35 of 36 women with primary cancers of the corpus uteri had atypical endometrial cytology (sensitivity 0.97). Of 42 uterine cancers, including one metastatic ovarian carcinoma, two adenocarcinomas and three squamous carcinomas of the cervix, 40 were detected by endometrial cytology (sensitivity 0.95). All 5 cases of high grade cytological atypia in endometrial polyps or endometrial hyperplasia could be diagnosed by abnormal endometrial cytology and 4 of 5 patients with adenomatous endometrial hyperplasia were diagnosed correctly. Endometrial cytology obtained with the Endo-Pap sampler is a simple and cheap diagnostic method with which to detect endometrial cancer. It is also effective for diagnosis of preinvasive endometrial lesions with highgrade cytological atypia. Clinicians should recognize that out-patient investigation of the endometrial state by endometrial cell sampling with the Endo-Pap is reliable and can usually replace fractional curettage.