Comparison of the long-term histopathologic and morphologic changes after endometrial rollerball ablation and resection: a prospective randomized trial

STUDY OBJECTIVE: To compare long-term histologic features of endometrial rollerball ablation versus resection. DESIGN: Randomized clinical trial (Canadian Task Force classification I). SETTING: Akdeniz University School of Medicine. PATIENTS: Women with menorrhagia undergoing endometrial ablation. INTERVENTION: Comparison of patients with menorrhagia undergoing endometrial resection and ablation. MEASUREMENTS AND MAIN RESULTS: Endometrial rollerball ablation (n = 23 women) and resection (n = 25) were followed by second-look office hysteroscopy with endometrial biopsy. Mean follow-up to second look hysteroscopy after rollerball ablation and loop resection was 33.4 +/- 2.1 and 31.1 +/- 2.6 months, respectively. Complete atrophy and partial adhesion or obliteration of the cavity and fibrosis were observed at second-look hysteroscopy and were similar in both groups. Whereas all random biopsy specimens after both ablation and resection revealed diminished endometrial glands with varied necrosis and scarring, the number of endometrial glands per field was not correlated with amount of bleeding or menstrual pattern. Bleeding patterns were similar between the groups. No precancerous or malignant lesion was found after the procedures. CONCLUSION: Although efficacy of both endometrial ablation and resection is related to initial thermal destruction and correlated with postablation hysteroscopic and histologic findings, endometrial regrowth may be expected and is not a failure of ablation. Both procedures revealed histopathologically and clinically similar results.     

Rollerball Endometrial Ablation: A Histological Study in Danazol Pretreated Patients

Summary: Endomyometrial biopsies were taken from danazol pretreated patients about to undergo rollerball endometrial ablation for menorrhagia. The biopsies were taken with a loop electrode at hysteroscopy before and after 1, 2, 3 passes of a rollerball electrode over the endometrium using powers of electrocoagulation diathermy varying from 30 to 100 watts. The biopsies were then assessed histologically. Nineteen biopsies from the perceived endocervical canal, 25 posttreatment curettings and 3 hysterectomy specimens were also assessed. Biopsies taken after danazol pretreatment but before diathermy showed a thinned inactive endometrium. A histological classification of the effect of electrocoagulation diathermy on the endometrium was developed describing increasing endometrial damage. The degree of endometrial damage was directly related to the number of rolls of the ball over the endometrium and to the power of electrocoagulation diathermy. Endometrium was found in 84% of biopsies from the perceived endocervical canal and endometrium was found in curettings from 3 of 11 patients who were amenorrhoeic following ablation.     

Endometrial thickness in tamoxifen-treated patients: an independent predictor of endometrial disease.

OBJECTIVE: To assess the independent contribution of transvaginal ultrasound in identifying women at risk for endometrial disorders, and determine whether a cutoff value identifies women who need endometrial histologic assessment. METHODS: Postmenopausal women with breast cancer who were receiving tamoxifen, with ultrasonographic endometrial thickness greater than 4 mm or vaginal bleeding, had hysteroscopy with selective endometrial biopsies. Endometrial thickness, duration of tamoxifen therapy, and endometrial histology were studied. Parametric and nonparametric tests and logistic regression and receiver operating characteristic curves were used for statistical analysis. RESULTS: The study population consisted of 163 women, 46 with vaginal bleeding. The proportion of women with abnormal histologic findings was greater among those with endometrial thicknesses exceeding 9 mm compared with those with endometrial thicknesses 9 mm or less (60% versus 6.1%, P < .001) and among women who received tamoxifen for more than 27 months than those who received it for less time (46% versus 16%, P < .005). Logistic regression showed that endometrial thickness greater than 9 mm and vaginal bleeding were independent predictors of abnormal findings at hysteroscopy. CONCLUSION: In women taking tamoxifen, sonographic endometrial thickness exceeding 9 mm and the presence of vaginal bleeding are independent predictors of endometrial disease. If either exists, hysteroscopy and biopsy should be done.     

Discrepancy between ultrasonography and hysteroscopy and histology of endometrium in postmenopausal breast cancer patients using tamoxifen

BACKGROUND: The increased risk of endometrial carcinoma following the use of tamoxifen has stimulated studies on endometrial diagnostic screening methods. In tamoxifen users the endometrial thickening observed with transvaginal ultrasonography (TVU) frequently cannot be confirmed by hysteroscopy or histology. OBJECTIVE: The aim was to investigate the relationship between TVU and hysteroscopic and histologic endometrial findings in postmenopausal patients using tamoxifen. METHODS: Fifty-three asymptomatic postmenopausal tamoxifen-using breast cancer patients underwent a gynecological examination combined with TVU. Patients with an endometrial thickness of >5 mm were offered hysteroscopy and endometrial biopsy. FINDINGS: Thirty-one patients (58%) had an endometrial thickness of >5 mm with enhanced, inhomogeneous echogenicity. Hysteroscopy was performed in 22 patients and 3 underwent hysterectomy. Seven of 22 patients had endometrial polyps, histologically characterized by cystically dilated glands lined with atrophic epithelium and periglandular stromal condensation. Histology of the three hysterectomy specimens showed a similar picture of atrophic luminal epithelium, covering dilated glands lined with atrophic epithelium and surrounded by dense stroma, which resembled the histology of the endometrial polyps. In all three specimens the histologically measured endometrial thickness corresponded with that on TVU. INTERPRETATION: Tamoxifen can induce specific endometrial changes consisting of cystically dilated glands with periglandular stromal condensation while the overlying epithelium remains atrophic. The changes occur either in the endometrium itself or as a protrusion of the endometrium, i.e., as endometrial polyps. These findings explain the discrepancy between ultrasound, hysteroscopy, and histology. Due to the high number of false-positive findings, TVU is not an effective screening instrument in these patients.     

Depth of endometrial penetration in adenomyosis helps determine outcome of rollerball ablation

OBJECTIVE: Our purpose was to determine whether the depth of endometrial penetration into the myometrium correlates with outcome of rollerball endometrial ablation. STUDY DESIGN: Fifty consecutive patients with hysteroscopically normal-appearing cavities (without gross polyps or submucous fibroids) had endometrial ablations for menorrhagia and were subsequently studied for ≥3.5 years. A posterior myometrial biopsy to determine the amount of endometrial penetration was performed and correlated with outcome. RESULTS: Patients with deep endometrial penetration into the myometrium (deep adenomyosis) had poor outcomes after ablation. Those with no or minimal endometrial penetration (superficial adenomyosis) had good results with few exceptions. CONCLUSION: A myometrial biopsy specimen at the time of operative hysteroscopy can diagnose adenomyosis and help predict outcome after rollerball endometrial ablation. Superficial adenomyosis can be treated definitively with ablation. Deep adenomyosis responds poorly to ablation. Hysterectomy should be considered when myometrial biopsy, preoperative ultrasonography, or magnetic resonance imaging demonstrates deep adenomyosis. (Am J Obstet Gynecol 1996;174:1786-94.)     

Risk of discovering endometrial carcinoma or atypical hyperplasia during hysteroscopic surgery in postmenopausal women.

STUDY OBJECTIVE: To assess the risk of diagnosing endometrial carcinoma or atypical hyperplasia in tissue resected during hysteroscopy performed for intrauterine pathology presumed benign in postmenopausal women. DESIGN: A single-center prospective study (Canadian Task Force classification II-2). SETTING: Department of Gynecology, La Conception Hospital, Marseille, France. PATIENTS: Three hundred twenty-five women with intrauterine pathology, presumed benign, causing postmenopausal bleeding or bleeding related to hormone replacement therapy. INTERVENTION: All women had an endometrial biopsy after diagnostic hysteroscopy to exclude endometrial carcinoma or atypical hyperplasia. Then they underwent hysteroscopic surgical resection (203, 62.5%) or endometrial ablation (122, 37.5%). MEASUREMENTS AND MAIN RESULTS: Two cases each (0.6%) of endometrial carcinoma and endometrial atypical hyperplasia were discovered that were missed by preoperative evaluations. CONCLUSION: Outpatient hysteroscopy and endometrial biopsy do not eliminate the finding of carcinoma or endometrial atypical hyperplasia, as these disorders may be discovered during hysteroscopic surgery.     

Endouterine Eingriffe – Abrasio, Hysteroskopie und Endometriumablation

Uterine bleeding disorders may cause diagnostic intrauterine interventions such as hysteroscopy and curettage or therapeutic procedures such as hysteroscopic polypectomy, myomectomy, or endometrial ablation. Hysteroscopic myoma resection has excellent results, as the bleeding pathology is directly correlated with the submucous location of uterine leiomyomata. Endometrial ablation is an established procedure; nevertheless, it is still not performed often in German-speaking countries. The long-term results of three prospective randomized trials comparing endometrial ablation with hysterectomy show a decrease in the advantages of endometrial ablation over time. Currently, several new techniques for endometrial ablation are under investigation, which are standardized, easy to perform, and avoid the hysterocopic mode of access.     

Hysteroscopic Appearance of Endometrial Cavity after Microwave Endometrial Ablation

Study ObjectiveTo assess the appearance of the endometrial cavity after microwave endometrial ablation.DesignProspective observational study.SettingGuangDong Women's and Children's Hospital, GuangDong, China.PatientsA total of 349 patients who underwent microwave endometrial ablation from January 2000 through August 2008 were followed up for 1 month to 8 years. At follow-up in 2007 and 2008, patients were advised of this clinical study and were randomly selected for participation if they agreed to undergo outpatient hysteroscopy to assess the uterine cavity during follow-up visits. Fifty three patients (median [range] age, 43.1 [33–53] years) were recruited into the study at the time of endometrial ablation.InterventionOutpatient hysteroscopy.Main ResultsWithin the first 3 months after ablation, outpatient hysteroscopy revealed varying amounts of necrotic tissue from the endometrium and superficial myometrium of the uterus. Six months postablation, a granulomatous reaction and fibrosis were present. A fibrotic cavity was also evident, and menstrual flow was reduced or had ceased. One year after ablation, hysteroscopy demonstrated a fibrotic cavity with myofibrous scars. Most patients developed amenorrhea at this time. Two years or more postablation, a second hysteroscopy demonstrated various types of intrauterine adhesions in 28 of the 53 women (52.8%). A cervical adhesion was observed in 1 patient (1.9%), focal adhesions in the fundal area in 12 (22.6%), a narrowed and scarred uterine cavity with bilateral stenotic tubal ostia in 11 (20.7%), and complete obliteration of the cavity in 4 (7.5%). Of these 28 women, 22 had amenorrhea, 3 had vaginal spotting during menstruation, and 2 had hypomenorrhea. Of those without intrauterine adhesions, only 5 had amenorrhea, 10 had vaginal spotting, and 8 had hypomenorrhea.ConclusionThe hysteroscopic appearance of the uterine cavity after microwave endometrial ablation varies considerably. In this study, the menstrual outcome was correlated with postablation uterine cavity appearance.     

Detection of kappa- and lambda-expressing cells in the endometrium by in situ hybridization.

The detection of kappa- and lambda-expressing cells in endometrial biopsies using in situ hybridization was correlated with the histologic findings. Forty endometrial biopsies were examined in conjunction with kappa and lambda expression in serial sections, recorded as the number of positive cells per 10 x100 fields. Cells expressing kappa or lambda were found in 39/40 (98%) biopsies with the average total number per 10 x100 fields as follows: proliferative (n = 13) 13; secretory (n = 6) 16; endometritis (n = 6) 623; polyp (n = 4) 72; adenocarcinoma (n = 6) 677; oral contraceptive effect (n = 5) 8. Many of the B lymphocytes expressing kappa and lambda did not have the cytologic features of plasma cells. The diagnosis of chronic endometritis can be made when the histologic findings of out-of-phase endometrial glands and focal fibrosis are seen with increased plasma cells; in cases where the latter is equivocal, in situ hybridization testing for light chain expression can be useful. Cells expressing kappa and lambda mRNA are relatively common in normally cycling endometrium, implying that mild chronic antigenic stimulation is present in most endometrial tissues. In situ hybridization for light chain expression can be helpful in endometria where only very rare plasma cells are seen; a baseline result would rule out chronic endometritis.     

Endometrial intraepithelial neoplasia diagnosed at endometrial resection

The literature has no reported cases of isolated endometrial intraepithelial neoplasia found at endometrial resection. If endometrial cancer is occult it might not be detected at diagnostic hysteroscopy or during resection, especially if destructive techniques are used. A 51-year-old woman had history of menorrhagia, with diagnostic hysteroscopy showing benign functional endometrium and diagnosed as dysfunctional uterine bleeding. Endometrial resection was performed and the pathologic examination in one stripe of resected tissue found focal, isolated endometrial intraepithelial neoplasia. This case reinforces the importance of pathologic tissue examination after endometrial ablation. Care must be taken when performing second-generation nonhysteroscopic ablation techniques, as even with direct visualization a premalignant lesion can be missed.     

Hysteroscopic vs histologic diagnosis. Study of 222 cases of abnormal uterine hemorrhage]

BACKGROUND: AUB (abnormal uterine bleeding) is one of the most common pathologies. It is therefore important to use a method that is easy to carry out in order to ensure a rapid and reliable diagnosis. Hysteroscopy may represent the elective method for the study of the uterine cavity. METHODS: A total of 222 women suffering from AUB were studied between January 1996 and June 1997 at the Department of Surgery, Gynecology Clinic of L'Aquila University. Their age ranged between 30 and 74 years old. The exclusion criteria for the study were as follows: presence of a genital infection in active or latent phase, pregnancy in progress or abortion. All patients underwent operative hysteroscopy with targeted biopsy accompanied, when necessary, by endometrial ablation. All biopsies underwent histological analysis and the results of hysteroscopic diagnosis and histological diagnosis were then compared. RESULTS: There was a 85% correspondence between results. The main difficulties were encountered in the identification and selection of the characteristics of hyperplasia. Moreover, during the study it was found that hysteroscopy was both diagnostic and also therapeutic since it enabled the removal of polyps and intracavitary fibroma or endometrial ablation if required. CONCLUSIONS: Hysteroscopy was therefore found to be a totally reliable method for the study of abnormal uterine bleeding compared to the histological tests carried out.     

Second-look laparotomy in ovarian cancer: evaluation of pathologic variables

From 1977 through 1982, 135 patients with ovarian cancer, having a mean age of 53.7 years and no clinical evidence of disease after approximately 1 year of treatment, underwent a "second-look" laparotomy. Of the 135 patients, 58 (43%) had histologic confirmation of disease at the second-look procedure. Persistent disease was positively correlated with the original stage and negatively correlated with the extent of the original reductive surgery. The original histologic grade or cellular subtype did not significantly influence the findings at reexploration. Patient survival, as judged by percentage of patients alive 3 years after the second-look laparotomy, was dependent on the following surgical/pathologic parameters: tumor size at reexploration, peritoneal cytologic features, residual tumor after reexploration, and histologic grade.     

Balloon endometrial ablation under hysteroscopic control of septate uterus complicated by postcesarean scar defect

Use of second-generation endometrial ablation devices has largely supplanted hysteroscopic resection and rollerball ablation for treatment of menorrhagia. Pathology of the uterus may be diagnosed immediately before endometrial ablation procedure using these newer instruments, making the chosen device inappropriate and requiring a change in planned procedure. Preprocedural assessment with 1 or a combination of transvaginal ultrasound (TVS), saline-infusion sonography, and hysteroscopy is necessary to identify suitability for preferred technique. TVS is frequently used as the only investigation to assess uterine cavity, and undiagnosed or missed pathology on TVS may render chosen endometrial ablation procedure inappropriate. Previously undiagnosed septate uterus and postcesarean scar defect were diagnosed at hysteroscopy immediately before endometrial ablation, but missed by routine TVS. Balloon endometrial ablation in the septate uterus was used.     

Second-look hysteroscopy after antitubercular treatment in infertile women with genital tuberculosis undergoing in vitro fertilization

Objectives

To assess the efficacy of antitubercular treatment on the uterine cavity in infertile women diagnosed with genital tuberculosis using second-look hysteroscopy.

Methods

A total of 70 women with genital tuberculosis who underwent second-look hysteroscopy were enrolled in the study. They were started on antitubercular drugs and followed up after 6 months of therapy with second-look hysteroscopy. McNemar's χ² test was used to compare the hysteroscopy findings before and after antitubercular treatment.

Results

Antitubercular treatment improved hysteroscopy findings in women with thin or flimsy adhesions (grade I), singular dense adhesions (grade II), and occluding adhesions at the internal os (grade IIa) (P < 0.01). Patients with extensive adhesions, extensive endometrial scarring, fibrosis, and a tubular cavity showed no improvement after antitubercular treatment. Mean endometrial thickness of the 70 patients on day 21 prior to starting drug therapy was 6.8 mm, which increased to 8.1 mm after 6 months of treatment.

Conclusion

Considering the exorbitant cost of assisted reproductive technology in low-resource countries, it is necessary to consider reassessment of the uterine cavity prior to beginning such treatment.     

Hysteroscopic appearance of the endometrial cavity following thermal balloon endometrial ablation

OBJECTIVE: To assess the appearance of the endometrial cavity after thermal balloon endometrial ablation. DESIGN: Observational study. SETTING: University teaching hospital. PATIENT(S): Twenty-two women who had undergone thermal balloon endometrial ablation and who were followed up for at least 6 months. INTERVENTION(S): Outpatient diagnostic hysteroscopy. MAIN OUTCOME MEASURE(S): Appearance of the endometrial cavity and presence of intrauterine adhesions on hysteroscopy. RESULT(S): Postablation intrauterine adhesions were found in eight women (36.4%); six had focal adhesions in the fundal area and two had complete obliteration of the cavity. Of these eight women, three had spotting during menstruation, three had hypomenorrhea, one had eumenorrhea, and one had amenorrhea. The uterine cavity was fibrotic in four (18%) women; all reported spotting during menstruation. Ten women had a normal uterine cavity; eight had hypomenorrhea, one had spotting, and one had eumenorrhea. CONCLUSION(S): The hysteroscopic appearance of the uterine cavity after thermal balloon endometrial ablation varies considerably. Menstrual outcome is associated with postablation appearance.     

Could endometrial cytology be helpful in detecting endometrial malignancies?

This short communication assesses the concordance indexes between hysteroscopic biopsies and endometrial cytology for each endometrial pattern found in a sample of 37 women. Patients underwent endometrial cytology under sonographic guidance. The specimens were obtained with an endocervical brush and were fixed on slides (no liquid-based methods). After endometrial cytology, hysteroscopy with biopsy was performed. The best concordance index was found for endometrial malignancies, suggesting that endometrial cytology is able to detect cancers but not other endometrial diseases, as compared with endometrial hysteroscopic biopsies. Therefore, the overall concordance index suggests a fair concordance between histological and cytological findings. This leads us to conclude that usual endometrial cytology should not be recommended to screen endometrial diseases, but it may be used as an alternative diagnostic tool when hysteroscopic biopsies or other blinded procedures for endometrial sampling are unwanted, because it allows malignancies to be detected as well as hysteroscopic-guided biopsies.     

A New Hysteroscopic Scoring System for Diagnosing Chronic Endometritis

Study ObjectiveTo develop a new hysteroscopic morphologic scoring system to diagnose chronic endometritis (CE).DesignProspective study.SettingMedical hysteroscopy office.PatientsIn total, 320 patients underwent hysteroscopy, dilation and curettage, and endometrial biopsies from February 2017 to June 2018 with the intention of undergoing assisted reproductive technology treatment because of infertility or recurrent miscarriage.InterventionsAll patients underwent hysteroscopy, dilation and curettage, and endometrial biopsies for histologic examination and were classified according to the new hysteroscopic morphologic scoring system.Measurements and Main ResultsOf the 320 patients, 164 received a diagnosis of CE by histology (group A), whereas 156 patients were found not to have CE (group B). A total of 116 patients were diagnosed by our hysteroscopy scoring system to have CE, and 204 patients did not have CE. The scoring system showed a sensitivity and specificity of 62.8% and 91.7%, respectively. The positive predictive values and negative predictive values were 88.8% and 70.1%, respectively. Receiver operating characteristic analysis showed a cutoff value of >2 and an area under the curve of 0.823. Hysteroscopic and histologic grading showed moderate agreement (κ index = 0.529).ConclusionOur hysteroscopic scoring system has a high sensitivity and specificity for CE; it is hoped that its use can reduce interobserver variability. Future clinical studies are warranted to confirm the validity and clinical applicability of the proposed hysteroscopic morphologic scoring system for CE.     

Comparison of hysteroscopic and hysterectomy findings to assess the diagnostic accuracy of office hysteroscopy in tamoxifen-treated patients with breast cancer

STUDY OBJECTIVE: To assess the diagnostic accuracy of office hysteroscopy by comparing hysteroscopic findings with histologic findings on hysterectomy specimens in postmenopausal women with breast cancer treated with tamoxifen. DESIGN: Retrospective clinical study (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Thirty-three women. INTERVENTION: Record review. MEASUREMENTS AND MAIN RESULTS: Compared with histologic diagnoses of uteri, hysteroscopic findings showed diagnostic sensitivity of 97%, specificity of 100%, positive predictive value of 100% and negative predictive value of 96%. The diagnostic accuracy of hysteroscopy is the same in patients taking tamoxifen as in the general population. CONCLUSION: Hysteroscopy is a powerful method for diagnosing endometrial disease because it provides a direct view of the uterine cavity, reveals focal lesions, and enables targeted biopsies to be performed at the same time.     

Hysteroscopic evaluation of menopausal patients with sonographically atrophic endometrium

STUDY OBJECTIVE: To assess the diagnostic and operative potential of hysteroscopy in postmenopausal patients selected by ultrasound criteria. DESIGN: Prospective evaluation (Canadian Task Force classification II-2). SETTING: Outpatient ultrasound and hysteroscopy department of a university-affiliated hospital. PATIENTS: Two hundred twelve women with an endometrial thickness less than 4 mm on ultrasound and in menopause for at least 1 year. INTERVENTIONS: Transvaginal ultrasound and office hysteroscopy, with eye-directed biopsy specimens obtained with a 5-mm, continuous-flow operative hysteroscope, and performed without anesthesia. MEASUREMENTS AND MAIN RESULTS: Only 13 (6%) patients were symptomatic (irregular bleeding). Hysteroscopic diagnosis of endometrial polyps in three women (23%) was confirmed by histology. In the remaining 199 (94%) asymptomatic patients with atrophic endometrium on ultrasound, hysteroscopy showed an endometrial pathology in 10% (16 polyps, 4 submucous myomas); in one patient histologic evaluation disclosed focal adenocarcinoma in an endometrial polyp. CONCLUSION: Hysteroscopy allows a proper histologic diagnosis, even in asymptomatic postmenopausal women with atrophic endometrium on ultrasound.