Can "chromohysteroscopy" help target endometrial biopsy in postmenopausal bleeding?

A preliminary study was conducted to evaluate the value of endometrial dying during diagnostic hysteroscopy. Twenty-two postmenopausal bleeding cases without hysteroscopic findings were included in the study. Before the random endometrial biopsy 5 ml of methylene blue (1%) was instilled into the uterine cavity. Staining was observed in 19 of the cases. Tissues were obtained from both stained and non-stained areas with grasping forceps. "Chromohysteroscopy" led the diagnosis of three more endometrial pathologies; two more cases of endometritis and one more case of endometrial hyperplasia. In conclusion, chromohysteroscopy seems like a new avenue worth pursuing for better diagnoses of unexplained endometrial pathologies.     

Percutaneous administration of testosterone gel in postmenopausal women – a pharmacological study

We wished to investigate if a testosterone gel administered percutaneously to postmenopausal women could result in stable serum levels of the hormone and which dose was required to produce levels within the normal premenopausal range. Fifteen postmenopausal women, mean age 55.3 years (range 45–70 years), volunteered to participate in the study and were divided into three groups. They received 10, 20 or 30?mg of testosterone as a 1% testosterone hydroalcoholic gel at 09.00?hours daily for 14 days. The gel was applied in a thin layer on the outside of the thigh each morning, over an area of approximately 15?cm². Blood samples were collected hourly between 09.00 and 17.00?hours on days 1 and 14, and also at 08.00?hours on days 3, 5, 11, 12, 13 and finally day 16, i.e. 2 days after termination of treatment. The mean basal serum level of testosterone was 1.1?±?0.9?nmol/l and for 5α-dihydrotestosterone 208?±?143?pmol/l. There was a clear increase from the 10?mg to the 20?mg treatment (mean testosterone level during treatment 3.2 and 7.2?nmol/l, respectively) while serum testosterone values after 30?mg showed very little further increase (mean 7.5?nmol/l). Values for days 3–5 were quite similar to those for days 13–14. The present study suggests that adequate and acceptable serum levels of testosterone can be achieved with 10?mg testosterone applied transdermally.     

Is an endometrial thickness of ≥4 mm on transvaginal ultrasound scan an appropriate threshold for investigation of postmenopausal bleeding?

Uterine cancer is the fourth most common cancer in the UK. Transvaginal ultrasound (TVS) provides a reliable means of determining endometrial thickness. There is little consensus as to the optimum endometrial thickness threshold for investigation of endometrial cancer. The aim of our study was to ascertain an appropriate endometrial thickness (ET) while limiting unnecessary investigation. A prospective study of women with postmenopausal bleeding (PMB) referred to the rapid access clinic over a 2-year period was undertaken. The primary investigation was TVS and if the ET was ≥4 mm, an endometrial sampling (Pipelle®) or a hysteroscopy was undertaken. Endometrial cancers were identified from the pathology reporting system and a search of the Northern and Yorkshire Cancer Registry Information Service (NYCRIS). Pre-test/post-test risks of endometrial cancer and numbers needed to test were calculated to determine optimum ET threshold. There were 1045 referrals to the rapid access clinic with a history of PMB. Pre-test risk of endometrial cancer was 6.5 %. Post-test risk was stratified according to ET measurement. The probability of an endometrial cancer at an ET < 4 mm was 0.3 %. Binary logistic regression analysis confirmed a statistically significant linear correlation between ET and the risk of developing endometrial cancer (p < 0.0001). The numbers needed to test in order to diagnose one case of endometrial cancer at 3 mm is 11 when compared with 4 at 10 mm. The authors conclude a threshold of ET ≥ 4 mm ensures the majority of cancers are detected with minimal unnecessary invasive investigation.     

Should endometrial polyps be removed in patients with postmenopausal bleeding?—an assessment of study designs and report of a failed randomised controlled trial (ISRCTN73825127)

We describe the design of a randomised controlled trial to evaluate the efficacy of endometrial polyp removal in women with postmenopausal bleeding. We designed a trial in which patients with postmenopausal bleeding and endometrial thickness >4 mm undergo hysteroscopy. If during hysteroscopy an endometrial polyp was diagnosed, patients were asked to participate in this trial and after informed consent allocated to immediate removal of the polyp or expectant management. This trial suffered from lack of recruitment related both to doctors seeking for informed consent as well as to patients' unwillingness to participate in this trial. However, a randomised controlled trial on this subject is still necessary to evaluate the efficacy of uterine cavity evaluation in the diagnostic work-up of women with postmenopausal bleeding, focussing on benign pathology. Therefore, we propose an alternative design, which might be more feasible.     

Can ultrasound replace dilation and curettage? A longitudinal evaluation of postmenopausal bleeding and transvaginal sonographic measurement of the endometrium as predictors of endometrial cancer

OBJECTIVE: The purpose of this study was to evaluate postmenopausal bleeding and transvaginal sonographic measurement of endometrial thickness as predictors of endometrial cancer and atypical hyperplasia in women whose cases were followed for > or =10 years after referral for postmenopausal bleeding. STUDY DESIGN: Women (n = 394) who had postmenopausal bleeding from November 1987 to October 1990 underwent transvaginal sonographic measurement of endometrial thickness and curettage. It was possible to assess the medical records (regarding recurrence of a postmenopausal bleeding, development of endometrial cancer, and death) in 339 of the 394 women (86%) > or =10 years after referral for postmenopausal bleeding. RESULTS: Thirty-nine of the 339 women (11.5%) had endometrial cancer, and 5 women (1.5%) had atypical hyperplasia. The relative risk of endometrial cancer in women who were referred for postmenopausal bleeding was 63.9 (95% CI, 46.0-88.8); the corresponding relative risk for endometrial cancer and atypical hyperplasia together was 72.1 (95% CI, 52.8-98.5) compared with women of the same age from the general population of the same region of Sweden. No woman with an endometrial thickness of < or =4 mm was diagnosed as having endometrial cancer. The relative risk of the development of endometrial cancer in women with an endometrial thickness of >4 mm was 44.5 (95% CI, 6.5-320.1) compared with women with an endometrial thickness of < or =4 mm. The reliability of endometrial thickness (cutoff value, < or =4 mm) as a diagnostic test for endometrial cancer was assessed: Sensitivity, 100%; specificity, 60%; positive predictive value, 25%; and negative predictive value, 100%. The incidence of endometrial cancer or atypical hyperplasia in women with an intact uterus whose cases had been followed for > or =10 years was 5.8% (15/257 women) compared with 22.7% (15/66 women) in women who had < or =1 episode of recurrent bleeding. No endometrial cancer was diagnosed in women with a recurrent postmenopausal bleeding who had an endometrial thickness of < or =4 mm at the initial scan. CONCLUSION: Postmenopausal bleeding incurs a 64-fold increase risk for endometrial cancer. There was no increased risk of endometrial cancer or atypia in women who did not have recurrent bleeding, whereas women with recurrent bleeding were a high-risk group. No endometrial cancer was missed when endometrial thickness measurement (cutoff value, < or =4 mm) was used, even if the women were followed up for < or =10 years. We conclude that transvaginal sonographic scanning is an excellent tool for the determination of whether further investigation with curettage or some form of endometrial biopsy is necessary     

Heavy menstrual bleeding: a global survey of health care practitioners’ perceptions

Abstract

Objectives: This study sought to assess the perceptions of health care practitioners (HCPs) regarding heavy menstrual bleeding (HMB).

Methods: We developed an online survey for HCPs administered in 10 countries (Brazil, Canada, China, France, Germany, Korea, Russia, Spain, UK and USA), in order to assess their perceptions regarding HMB.

Results: We received 1032 responses. Most HCPs considered more than 7 days of bleeding abnormal. There was a significant difference in the definition of HMB between countries (p?<?.001). Most HCPs measured menstrual blood loss by the number of sanitary pads or tampons needed, followed by the impact on patients’ daily activities. The majority of HMB patients (61%) were diagnosed as having a non-structural disorder with no causative identifiable coagulopathy. Patient acceptance and compliance were each relevant for the treatment decisions of half of the HCPs. Treatment options for idiopathic HMB featured mainly oral contraceptives and the levonorgestrel-releasing intrauterine system. Surgery was mentioned as a treatment option for idiopathic HMB by 44% of HCPs.

Conclusion: The definition of HMB and HCP perceptions of HMB regarding diagnostic and therapeutic issues varied between countries. Surgery was mentioned as a treatment for idiopathic HMB by nearly half of HCPs. Clinician education is greatly needed to improve the management of women with HMB.     

Transvaginal ultrasonography of the endometrium in women with postmenopausal bleeding: is it always necessary to perform an endometrial biopsy?

OBJECTIVE: This study was undertaken to evaluate whether it was possible to abstain from performing an endometrial biopsy when endometrial thickness according to transvaginal ultrasonography was /=50 years who were referred because of postmenopausal bleeding or irregular bleeding during hormone replacement therapy. If endometrial thickness was /=5 mm underwent either curettage or endometrial biopsy. RESULTS: One hundred sixty-three women had an endometrial thickness /=5 mm. The corresponding figure when atypical hyperplasia and endometrial metastases were included was 20. 2%. CONCLUSION: If the false-negative rate of endometrial biopsy techniques is taken into account, then the combination of transvaginal ultrasonography and cervical cytologic examination is an adequate form of management for women with postmenopausal bleeding or irregular bleeding during hormone replacement therapy as long as endometrial thickness is 相似文献   

Adenoid cystic carcinoma of the Bartholin’s gland: a rare tumor unmarked by persistent vulvar pain in a postmenopausal women

INTRODUCTION: Adenoid cystic carcinoma (ACC) of the Bartholin's gland is a rare malignancy characterized by slow growth, local invasion and perineural infiltration. CASE: A 64-year-old postmenopausal woman presented with persistent vulvar pain. Local examination revealed a 2 x 2 cm painful vulvar nodule. Nodule was excised and ACC originating in the Bartholin's gland with positive resection margin was determined in pathological examination. We performed hemivulvectomy and ipsilateral inguinal lymph node dissection. Pathology showed that the resection margins were free of tumor and there was no lymph node metastasis. DISCUSSION: In cases of persistent vulvar pain without swelling, complete vulvovaginal evaluation should be done to prevent delay in diagnosis of Bartholin's gland cancer. Treatment modality must be tailored to each patient, though there is no consensus on the treatment.     

Managing postmenopausal bleeding revisited: what is the best first line investigation and who should be seen within 2 weeks? A cross-sectional study of 326 women

Objectives

The management strategies of postmenopausal bleeding (PMB) vary between different centres. This study was conducted to (1) evaluate the performance of a “One Stop PMB Clinic” that uses trans-vaginal ultrasound scanning (TVS) ± Pipelle^® endometrial biopsy (EB) as the first line investigation, and (2) identify the risk factors for endometrial cancer to help setting criteria to prioritize clinic slots.

Study design

A retrospective data review of 326 women seen in the period from 1 August 2005 until 31 August 2009 at Ipswich Hospital, UK.

Results

The median primary referral interval was 30 days. The prevalence of endometrial cancer and atypical hyperplasia was 5.5% (n = 18) and 1.8% (n = 6), respectively. One case with endometrial thickness (ET) of <5 mm and negative Pipelle^® EB was found to have cancer on a curettage specimen taken for persistent bleeding. Statistical analysis revealed an association between endometrial cancer and increased ET (p < 0.0001), increased age (p = 0.004) and multiple episodes of bleeding (p = 0.04). There was no evidence of an association with parity (p = 0.64) or severity of bleeding (p = 0.46). There was no case of endometrial cancer in HRT users.

Conclusion

TVS ± Pipelle^® EB may be a safe first line investigation in managing PMB. Accepting that all investigations have a false negative rate, women with persistent bleeding should be re-investigated. Given the ever-increasing workload, the priority for urgent appointments may be given to the older women, non-users of HRT and those with multiple episodes rather than heavy bleeding.     

Management of heavy menstrual bleeding: is hysterectomy the radical mastectomy of gynecology?

Both hysterectomy for heavy menstrual bleeding and radical mastectomy for breast cancer are steeped in the history of surgery and have recently been challenged as being too radical for the disorder at hand. Radical mastectomy has largely been replaced with local removal of the tumor with subsequent radiation and/or chemotherapy. Alternatives to hysterectomy include a number of medical interventions, most notably intrauterine progestin-releasing systems, and endometrial ablation, a procedure that has a relatively high success rate and one that is now feasible for many women in an office or procedure room setting. However, although radical mastectomy rates have dropped precipitously, hysterectomy rates, at least in the United States remain relatively stable. Determining the proportion of hysterectomies that are done for heavy menstrual bleeding is difficult, largely because of coding issues, so it is difficult to measure the impact of new medical and minimally invasive surgical procedures. Nevertheless, it seems clear that many women are not exposed to the plethora of options to hysterectomy, a fact that may reflect a number of issues that may include training, skill, and financial incentives or disincentives. Clearly, options to hysterectomy are not a panacea, but if women are empowered to select from all of the options available, the rate of hysterectomy for bleeding should decrease while maintaining, or even enhancing the patient's satisfaction with care.     

Safety and comfort of long-term continuous combined transdermal estrogen and intrauterine levonorgestrel administration for postmenopausal hormone substitution – a review

Objective: To review the endometrial safety and patient acceptability of long-term use of continuous transdermal estrogen substitution combined with intrauterine release of levonorgestrel (LNG) in postmenopausal women.

Design: One-hundred and fifty-three women who utilized the regimen for 2 IUD cycles were followed-up for a period of 10 years. Histology of the endometrium was evaluated at the end of this period to assess endometrial safety and the acceptability of the method was assessed based on the replacement rate of the LNG-IUS and continuation of ET.

Results: The regimen, administered over a 10-year period, was very well tolerated and the IUD was retained well and no expulsions occurred. The dominant endometrial histologic picture was that of inactive endometrium characterized by glandular atrophy and stroma decidualization (Kurman classification 5b). No cases of endometrial hyperplasia were found.

Conclusion: The low systemic absorption of LNG could be desirable, thus allowing for maximization of the beneficial effects of ET on organ tissues (e.g. cardiovascular tissues and breast). Repeat LNG-IUS is associated with high patient satisfaction. If started before the age of 60, this regimen could be advised for lifelong prevention of cardiovascular disease and other prevention measures. The LNG-IUS was shown to effectively oppose the secondary effects of systemic estrogen on the endometrium tissue resulting in strong suppression during the entire period of EPT.     

Sertoli–Leydig cell tumor presenting hyperestrogenism in a postmenopausal woman: A case report and review of the literature

ObjectiveSertoli–Leydig cell tumor (SLCT) accounts for <0.5% of all ovarian tumors, which is unusual in postmenopausal women. Postmenopausal women with SLCT usually become virilized. We report a postmenopausal woman with SLCT presenting with hyperestrogenism.Case ReportWe report a rare case of SLCT in a postmenopausal woman aged 61 years, who presented with postmenopausal bleeding, endometrial hyperplasia and mucous polyp, elevated estradiol, and decreased follicle-stimulating hormone (FSH) and luteinizing hormone (LH) values, all suggesting hyperestrogenism. Transvaginal ultrasound revealed several small cyst locules, detected inside the right ovary, with a maximum diameter of 7 mm. The diagnosis was delayed because of the atypical clinical manifestation and negative serum tumor markers. The frozen section investigation revealed SLCT intraoperatively, which was confirmed by histopathological and immunocytochemical examination. The tumor was positive for inhibin-alpha, pancytokeratin, and p53 and in isolated tumor cells, positive for Ki-67.ConclusionThis case of SLCT suggests the existence of a new specific type of endocrine complex disease.     

Is postmenopausal hormone replacement therapy suitable after a cardio- or cerebrovascular event?

Purpose

Vascular disease is the leading cause of death in women. One-third of acute events affect women below age 60, when the prevalence of menopausal symptoms is high. This raises the question if hormone replacement therapy (HRT) may be an appropriate treatment for individual women although vascular disease is generally considered a contraindication.

Methods

Selective literature search was used for this study.

Results

In healthy women, HRT increases risks for venous thromboembolism and ischemic stroke, but for cardiovascular disease apparently only beyond 10 years after menopause or 60 years of age. Limited data in women with cardio or cerebrovascular disease have not demonstrated an increased risk for a vascular recurrent event, but for the first year after initiation. In HRT users affected by a cardiovascular event continuation of HRT has not been found to be associated with adverse outcome. Low dose estradiol––preferentially as transdermal patches, if necessary combined with metabolically neutral progestins––appears to convey lower risk.

Conclusions

Safety data on HRT in survivors of cardiovascular events or ischemic stroke are limited, but exceptionally increased risk appears to be excluded. If off-label use of HRT is considered to be initiated or continued in women with cardio- or cerebrovascular disease, extensive counseling on the pros and cons of HRT is mandatory.

     

Acceptability of the levonorgestrel intrauterine system in the long-term treatment of heavy menstrual bleeding: how many women choose to use a second device?

Objective

To assess the acceptability of the levonorgestrel-releasing intrauterine system (LNG-IUS, Mirena^®) in the long-term treatment of heavy menstrual bleeding.

Study design

Retrospective study of all consecutive women who had a LNG-IUS inserted for control of idiopathic heavy menstrual bleeding between January 2000 and December 2003. Duration of use, reasons for early removal, number of devices removed after 5 years of use, and number of women who decided to use a second LNG-IUS were assessed.

Results

Of a total of 216 devices inserted, 129 (59.7%) were removed after 5 years of use, 68 (31.5%) were removed anytime before the completion of 5 years, and the remaining 19 (8.8%) patients were lost to follow-up. In 32 of the 68 cases (47.1%) with early removal of the LNG-IUS, the main reason for discontinuation was the appearance of the menopause. After the 5-year effective lifetime of the LNG-IUS, 51 of the 129 women (39.5%) chose to have a second device inserted. Of the 78 women who completed the 5-year treatment period and did not decide to use the LNG-IUS again, 71 (91%) had reached the menopause.

Conclusion

The LNG-IUS was well accepted by women with idiopathic heavy menstrual bleeding as shown by 39.5% of users (or 87.9% if menopausal women are excluded) deciding to use a second device when the first LNG-IUS expired after 5 years of use.     

Menstrual bleeding -- must that be? Extended use of oral hormonal contraceptives

More and more women request less menstruation and would refuse temporarily or completely gladly onto the menstruation and the accompanying symptoms. Through the continuous conquest of the oral hormonal contraceptive pills in the long-cycle treatment can the loss of blood reduced, breakthrough bleeding and spotting can be decreased or prevented and the complaints occurring with menstruation as well as menstruation conditional provocations for cycle dependent illnesses can be reduced or prevented. The long cycle is a genuine alternative for these women to the improvement in living quality and hygiene even if for this purpose extensive great studies are not yet available.     

Is the incidence of fetal-to-maternal hemorrhage increased in patients with third-trimester bleeding?

OBJECTIVE: If a pregnancy is complicated by third-trimester bleeding, is there a higher risk of fetal-to-maternal hemorrhage that might necessitate the administration of additional anti-D immune globulin to prevent alloimmunization in the patient who is Rh D-negative? The study objective was to analyze prospectively the incidence of fetal-to-maternal hemorrhage in pregnancies that were complicated by third trimester bleeding compared with three control groups. STUDY DESIGN: Pregnancies that were complicated by third-trimester bleeding, preterm premature rupture of the membranes, and preterm labor were identified prospectively on admission. A group of preterm patients with no complications was also collected prospectively. Patients with any history and/or clinical evidence of trauma were excluded. Kleihauer-Betke tests were performed with all patients, and the results were blinded until study completion. Sample size calculations were performed to determine the minimum number of cases needed in each group. RESULTS: A total of 403 patients were collected during the study period: 91 patients had third-trimester bleeding, 101 patients had preterm premature rupture of the membranes, 116 patients had preterm labor, and 95 patients were in the no complication group. There was no statistical difference identified in the Kleihauer-Betke test results between any of the study groups. CONCLUSION: The incidence of fetal-to-maternal hemorrhage does not appear to be increased in pregnancies that are complicated by third-trimester bleeding when compared to noncomplicated control subjects or to other obstetrically complicated pregnancies. This information would suggest that the routine administration of additional anti-D immune globulin (beyond the current recommended protocol) to women who are Rh D-negative whose pregnancies are complicated by third-trimester bleeding is not indicated.     

The inconvenience due to women’s monthly bleeding (ISY) survey: a study of premenstrual symptoms among 5728 women in Europe

Objectives: The aim of the ISY study was to investigate the prevalence of menstrual-related symptoms prior to and/or during menstrual or withdrawal bleeding among women from 12 European countries.

Methods: A 15-min quantitative online survey was conducted in two waves from February to September 2015 among 5728 women aged between 18 and 45 years, with an equal distribution of women using a combined hormonal contraceptive, including regular combined oral contraceptives (COCs) (CHC group, n?=?2739) and women using a non-hormonal contraceptive or no contraceptive (non-HC group, n?=?2989).

Results: The prevalence of at least one menstrual-related symptom was high in CHC users (93%) and in non-HC users (95%) (p?p?Conclusions: Premenstrual and menstrual symptomatology was less frequent, less numerous and less severe (except for headache) in women using CHCs; however, it remains a common concern. Reducing the frequency of menstrual periods could reduce withdrawal-related symptoms.