A randomized prospective study of the use of endometrial ablation for prevention of recurrent endometrial polyps in breast cancer patients receiving tamoxifen

Objective: To assess the roles of endometrial ablation in prevention of recurrence of tamoxifen-associated endometrial polyps in breast cancer patients.Design: A randomized prospective study of tamoxifen-treated patients who underwent hysteroscopic removal of endometrial polyps with or without simultaneous resection of the endometrium.Materials and Methods: Twenty consecutive women (aged 43–61 years) undergoing hysteroscopic removal of tamoxifen-associated endometrial polyps were randomized via a computer-generated random table to undergo or not to undergo concomitant endometrial ablation. All patients had undergone endometrial sampling prior to the procedure. The patients were followed for at least 18 months (range 18–24 months). The follow-up included transvaginal ultrasonography every 6 months and hysteroscopy when endometrial irregularity was noted. The main outcome variable was recurrence of endometrial polyps while the occurrence of uterine bleeding was noted.Results: In the 10 study group women, who underwent endometrial ablation, only 1 patient had a 1 × 1 cm endometrial polyp diagnosed and removed during the follow-up period. Seven of the study women remained amenorrheic, and 3 experienced spotting a few days every month. In the control group, a recurrent endometrial polyp, necessitating hysteroscopic removal, was diagnosed postoperatively in 6 women (two-tailed Fisher’s Exact test; P < .06).Conclusion: Recurrence of endometrial polyps, one of the most common problems in breast cancer patients receiving long-term treatment with tamoxifen, can be significantly reduced by performing endometrial ablation at the time of hysteroscopic removal of the polyp. The possible risk of occult endometrial cancer is yet to be determined.     

Three-year follow-up results of polypectomy with endometrial ablation in the management of endometrial polyps associated with tamoxifen in Chinese women

Objective

The aim of this study was to investigate the role of hysteroscopic polypectomy with endometrial ablation in the management of tamoxifen-associated endometrial polyps in postmenopausal women with a more than 3-year follow-up period.

Study design

The medical records of 76 postmenopausal patients on tamoxifen who were performed hysteroscopic polypectomy with endometrial ablation were evaluated more than 3 years after the procedure with recurrence of polyps, recurrent abnormal uterine bleeding and surgical re-intervention.

Results

Average follow-up period was 74.91 ± 20.84 months. No patient underwent hysterectomy, 7 of 76 patients had a surgical re-intervention representing a total of 90.8% avoidance of additional surgery during the follow-up period, and 4 patients had a recurrent endometrial polyp representing the recurrence rate was 5.3%. 3 of 41 patients with postmenopausal bleeding had a recurrent abnormal uterine bleeding representing symptomatic relief rate is 92.7%. The treatment failed in 7 patients who requested surgical re-intervention: 4 patients requested a repeat polypectomy and ablation, 1 patient requested a repeat ablation and 2 patients requested a repeat hysteroscopy with uterine adhesion. No malignant endometrial pathological result was found.

Conclusions

For postmenopausal patients suffering from endometrial polyps associated with tamoxifen, hysteroscopic polypectomy with endometrial ablation continues to be proven as a safe and effective minimally invasive treatment method. The high rate of surgical re-intervention avoidance, great symptomatic relief and low recurrence rate are very encouraging for this technology.     

Hysteroscopic endomyometrial resection of three uterine sarcomas.

STUDY OBJECTIVE: To describe our experience with three uterine sarcomas associated with hysteroscopic endometrial ablation. DESIGN: Cohort study (Canadian Task Force classification II-2). SETTING: University-affiliated teaching hospitals. PATIENTS: Three of 2402 women undergoing hysteroscopic endometrial ablation who had uterine sarcomas. INTERVENTION: Hysteroscopic endomyometrial resection. MEASUREMENTS AND MAIN RESULTS: One low-grade endometrial stromal sarcoma and two carcinosarcomas were resected. After hysterectomy in two patients, no residual cancer was identified in one of them. The third patient was an 82-year-old woman with moderate menorrhagia who refused hysterectomy. After endomyometrial resection she remained amenorrheic for the last 14 months of her life. CONCLUSION: From our experience the incidence of uterine sarcomas is approximately 1/800 women undergoing hysteroscopic ablation for abnormal uterine bleeding. Complete endomyometrial resection is feasible and may be offered as diagnostic and palliative therapy in women at high risk for hysterectomy.     

Endometrial stromal sarcoma diagnosed after hysteroscopic endometrial resection

Endometrial ablation and resection is now common therapy for dysfunctional uterine bleeding that is unresponsive to conservative management. Opponents argue that it may predispose patients to potentially hazardous malignancies of the uterus. In our patient, endometrial resection was performed to treat menorrhagia after a negative workup. Pathologic interpretation of the resected tissue showed a low-grade stromal sarcoma of the endometrium. The woman underwent definitive treatment, which included total abdominal hysterectomy, and has remained recurrence free over the past 3 years. Although rare, uterine malignancies have been documented after hysteroscopic management of menorrhagia. It is suggested that intraoperative endometrial resection or tissue sampling be done to prevent or diagnose endometrial hyperplasia and uterine malignancies.     

Hysteroscopic and nonhysteroscopic endometrial ablation

Endometrial ablation is defined as the elimination of the endometrium by thermal energy or resection. It was introduced in the 1980s as an alternative to hysterectomy to those patients with abnormal uterine bleeding and benign pathology who are unable or unwilling to tolerate traditional therapies. This article explores various endometrial ablation techniques.     

Hysteroscopic resection of endometrial polyps: a study of 195 cases

OBJECTIVE: To ascertain the therapeutic efficiency of hysteroscopic resection for the treatment of endometrial polyps in women with abnormal uterine bleeding and postmenopausal metrorrhagia. SETTING: University hospital. DESIGN: Retrospective consecutive patient follow-up. MATERIAL AND METHODS: From 1987 to 1997, 195 patients with haemorrhagic endometrial polyps were treated with hysteroscopic resection in our department. RESULTS: Five complications occurred, but no major complications were noted. A total of 89.2% of the patients remained in contact after hospitalization. After long term follow-up (5.2 years), successful results were obtained in 80% of the patients with polyp resection without associated endometrial ablation. Further surgery (hysterectomy) was required in only five women. CONCLUSION: Transcervical resection is the gold standard for treatment of endometrial polyps.     

Hysteroscopic resection of endometrial hyperplasia

STUDY OBJECTIVE: To evaluate the efficacy and safety of hysteroscopic resection of endometrial hyperplasia without atypia. DESIGN: Pilot feasibility study (Canadian Task Force classification II-1). SETTING: Department of gynecology at a general hospital. PATIENTS: Seventy-three women. Intervention. Transcervical hysteroscopic endometrial resection under general or spinal anesthesia. MEASUREMENTS AND MAIN RESULTS: Efficacy of treatment was based on hysteroscopic and histologic regression of endometrial hyperplasia and subjectively assessed uterine bleeding. Safety was evaluated by adverse events. Forty-four cycling women experienced complete remission of uterine bleeding and none had persistence of endometrial hyperplasia during follow-up; four underwent hysterectomy. Atrophic endometrium was present in 24 menopausal women, one of whom underwent hysterectomy. CONCLUSION: Endometrial resection was effective in achieving regression of endometrial hyperplasia and preventing its recurrence. (J Am Assoc Gynecol Laparosc 6(2):151-154, 1999)     

Pregnancy rates after hysteroscopic polypectomy depending on the size or number of the polyps

Objective To assess the reproductive benefits of hysteroscopic polypectomy in previous infertile women depending on the size or number of the polyps. Design and methods In this retrospective study, from February 2000 to September 2005, totally 83 selected women were included with: a) diagnoses of primary or secondary infertility, endometrial polyp/polyps and abnormal uterine bleeding. Endometrial polyps were diagnosed by transvaginal ultrasound followed by diagnostic hysteroscopy, to confirm diagnosis, and hysteroscopic polypectomy. All 83 subjects who consisted the study group, met inclusion criteria: age under 35 years, at least 12 months of infertility, from 3 to 8 months menstrual disorders (intermenstrual bleeding or spotting, menometrorrhagia or menorrhagia) and from 3 to 18 months of follow-up with attempts to conceive after hysteroscopic polypectomy. The endometrial polyp/polyps appeared to be the only reason to explain their infertility after infertility workup of the couples. There was a comparison of fertility rates after hysteroscopic polypectomy between patients having endometrial polyp ≤ 1 cm and patients with bigger or multiple polyps. Results Of the 83 subjects, all were found to have endometrial polyps in diagnostic hysteroscopy, confirmed at histologic examination after hysteroscopic polypectomy. Among patients of the study group, there were no significant differences in age, type or length of infertility, or follow-up period after the procedure. The mean size of the endometrial polyps was 1.9 ± 1.4.cm. Thirty-one patients had endometrial polyp ≤ 1 cm and 52 patients had bigger or multiple endometrial polyps. Following polypectomy, menstrual pattern was normalized in 91.6% of patients. Spontaneous pregnancy and delivery at term rates, in the total population of the study, increased after the procedure and were 61.4% and 54.2% respectively. There was no statistical difference in fertility rates between patients having polyps ≤ 1 cm and patients having >1 cm polyps or multiple polyps. Spontaneous abortion rate in the first trimester of pregnancy was 6% of the total number of patients and there was no statistical difference between patients with small or bigger/multiple polyps. Type of infertility did not affect fertility rates after hysteroscopic polypectomy. Complication rate after hysteroscopic polypectomy was as low as 2.4%, while recurrence rate of the procedure reached 4.9% of patients. Conclusion Hysteroscopic polypectomy of endometrial polyps appeared to improve fertility and increase pregnancy rates in previous infertile women with no other reason to explain their infertility, irrespective of the size or number of the polyps. Type of infertility of patients seems not to affect fertility rates after hysteroscopic polypectomy. Menstrual pattern was normalized in the majority of patients after hysteroscopic polypectomy. In addition, hysteroscopic polypectomy is a safe procedure with low complication rate.     

Asymptomatic Thickened Endometrium in Postmenopausal Women: Malignancy Risk

Study ObjectiveTo assess the diagnostic findings and determine the frequency of malignancy in postmenopausal women evaluated by office hysteroscopy for a thickened endometrium without bleeding.DesignRetrospective cohort (Canadian Task Force classification II-B).SettingAcademic medical center in the Midwestern United States.PatientsOver 3600 women underwent an office hysteroscopy between January 1, 2007, and October 20, 2011, for abnormal uterine bleeding or an abnormal ultrasound. Of these, 154 postmenopausal women had a thickened endometrium (>4 mm) and no bleeding.InterventionsFlexible office hysteroscopy using a 3.1-mm scope with saline as the distending media was performed for clinical reasons, and results were captured within a research database.Measurements and Main ResultsFor the 154 women, the range of endometrial measurements was 4.2 to 28 mm (mean = 10.0 mm). Hysteroscopy diagnoses included 93 patients with polyps, 19 with myomas or uterine synechiae, and 34 with benign-appearing endometrium. Nine hysteroscopies were inadequate because of poor visualization (n = 1), cervical stenosis (n = 6), or patient discomfort (n = 2). Endometrial biopsies (EMBs) were performed in 109 patients, and none were found to have cancer or an atypical endometrium. Six had simple hyperplasia without atypia, and their endometrial measurements were within the range of the patients in our study who had a benign endometrium (5–15 mm, mean = 10.3). Of the women with a polyp, 73 (78.4%) subsequently underwent polypectomy. On final pathology, 1 had cancer (endometrial measurement = 24 mm), and 1 had complex hyperplasia with atypia (endometrial measurement = 17 mm). EMBs performed in the office for these 2 patients showed an insufficient endometrium and inactive endometrium, respectively.ConclusionCancer and atypia can occur in asymptomatic women. Endometrial thickness was 17 mm or greater in 2 cases, and EMBs performed in the office were inconsistent with the final diagnosis. Hysteroscopy is important when ultrasound and EMB do not agree. Polypectomy may be indicated even in asymptomatic women, but further studies regarding an endometrial measurement threshold or polyp size are warranted.     

The clinical significance of small endometrial polyps

Objective

Small endometrial polyps are relatively common in asymptomatic women and may regress spontaneously. In symptomatic women, the finding of a small polyp (<1 cm diameter) raises the question of the clinical pertinence and necessity of excision. Sparse data are available on the effectiveness of hysteroscopic excision of small polyps to manage abnormal uterine bleeding. The aim of this study was to assess outcome after hysteroscopic excision of small endometrial polyps in symptomatic patients.

Study design

This was an observational cohort study enrolling 255 premenopausal women presenting with abnormal uterine bleeding and a small endometrial polyp on office hysteroscopy, undertaken between January 2004 and February 2007. The study group was referred for polypectomy by operative hysteroscopy. The outcome of the procedure was reviewed 6–12 months later by a telephone interview to assess the pattern of uterine bleeding after the procedure and overall satisfaction.

Results

Significant improvement in the magnitude of bleeding was experienced by 70% of participants, but only 30% of them reported return to regular menses. Satisfaction with the procedure was reported by 80%. Younger patients reported a less favorable bleeding pattern and were found to be less satisfied with the outcome of the procedure.

Conclusions

Symptomatic women with small endometrial polyps can be treated safely and efficiently with hysteroscopic excision. In the younger age group of patients, however, the outcome of the procedure may be less favorable and may necessitate the addition of endometrial ablation to improve outcome and increase patient satisfaction.     

A randomized, prospective study of endometrial resection to prevent recurrent endometrial polyps in women with breast cancer receiving tamoxifen.

STUDY OBJECTIVE: To assess the role of endometrial resection in preventing recurrence of tamoxifen-associated endometrial polyps in women with breast cancer. DESIGN: Randomized, prospective study (Canadian Task Force classification I). SETTING: Tertiary university-affiliated medical center. PATIENTS: Twenty consecutive women (age range 43-61 yrs). INTERVENTIONS: Hysteroscopic removal of tamoxifen-associated endometrial polyps with or without simultaneous resection of the endometrium. MEASUREMENTS AND MAIN RESULTS: Patients were randomized to undergo (10 women) or not undergo (10) concomitant endometrial resection. They were followed for at least 18 months (range 18-24 mo), including transvaginal ultrasonography every 6 months and hysteroscopy when endometrial irregularity was noted. The main outcome variable was recurrence of endometrial polyps; occurrence of uterine bleeding was also noted. In women who underwent endometrial resection, only one had a 1 x 1-cm endometrial polyp diagnosed and removed during follow-up. Seven women remained amenorrheic, and three experienced spotting for a few days every month. In the control group, six women had recurrent endometrial polyps requiring hysteroscopic removal (two-tail Fisher's exact test p <0.06). CONCLUSION: Recurrence of endometrial polyps, one of the most common problems in patients with breast cancer receiving long-term treatment with tamoxifen, may be reduced by performing endometrial resection at the time of hysteroscopic removal of polyps. The possible risk of occult endometrial cancer is yet to be determined. (J Am Assoc Gynecol Laparosc 6(3):285-288, 1999)     

Utilidad de la histeroscopia en el manejo del sangrado uterino anormal

Hysteroscopy is currently considered the test that enables not only the diagnosis but also the treatment of intrauterine pathology in patients with symptoms of abnormal uterine bleeding caused by structural abnormalities such as polyps, adenomyosis, submucosal fibroids, endometrial hyperplasia, or endometrial cancer. The miniaturization of the diameter of hysteroscopes with working channels, the bipolar mini-resector, and the hysteroscopic morcellation systems have allowed outpatient treatment, sometimes at the same time as hysteroscopic diagnosis, providing greater satisfaction, reducing surgical and/or anaesthesia risks and enabling rapid cost-effective resolution of symptoms. This article reviews the usefulness of hysteroscopy for the diagnosis and treatment of intrauterine structural pathology causing abnormal uterine bleeding.     

Endometrial ablation by rollerball electrocoagulation compared to uterine balloon thermal ablation. Technical and safety aspects

Objective: To compare two methods of endometrial ablation, hysteroscopic rollerball electrocoagulation (RBE) and non-hysteroscopic uterine balloon thermal (UBT) ablation (Thermachoice™), regarding intra- and post-operative technical complications and safety aspects. Study design: A randomised controlled study in a teaching hospital, 139 pre-menopausal women with dysfunctional uterine bleeding proved by a validated menstrual score list were enclosed. Endometrial ablation by a hysteroscopic or non-hysteroscopic method was performed. Results: Rollerball electrocoagulation carries a significantly higher risk of intra-operative complications compared to uterine balloon thermal ablation and is a significantly more time consuming procedure. Post-operative complication rates in both groups were low, but post-operative analgesics were prescribed significantly more in the uterine balloon group. Conclusion: Endometrial ablation by uterine balloon thermal ablation (Thermachoice™) is a safe and simple non-hysteroscopic procedure.     

Accuracy of hysteroscopy in predicting histopathology of endometrium in 1500 women

STUDY OBJECTIVE: To estimate the accuracy of hysteroscopy in predicting endometrial histopathology. DESIGN: Retrospective analysis (Canadian Task Force classification II-2). SETTING: Public hospital. PATIENTS: One thousand five hundred women undergoing diagnostic hysteroscopy for suspected endometrial pathology, mostly because of abnormal uterine bleeding. INTERVENTIONS: Hysteroscopy and endometrial biopsy. MEASUREMENTS AND MAIN RESULTS: Hysteroscopy imaging was matched with histology. Functional, dysfunctional, and atrophic endometrium were considered normal findings; endometritis, endometrial polyps, hyperplasia, and carcinomas were considered abnormal. Sensitivity, specificity, and negative (NPV) and positive (PPV) predictive values of hysteroscopy in detecting normal or abnormal endometrium were calculated. These figures were defined to assess hysteroscopic accuracy in estimating pathologic conditions. Histology showed normal endometrium in 927 patients. Endometritis, polyps, hyperplasia, and malignancies were found in 21, 265, 185, and 102 patients, respectively. Hysteroscopy showed sensitivity, specificity, NPV, and PPV of 94.2%, 88.8%, 96.3%, and 83.1%, respectively, in predicting normal or abnormal histopathology of endometrium. Highest accuracy was in diagnosing endometrial polyps, with sensitivity, specificity, NPV, and PPV of 95.3%, 95.4%, 98.9%, and 81.7%, respectively; the worst result was in estimating hyperplasia, with respective figures of 70%, 91.6%, 94.3%, and 60.6%. All failures of hysteroscopic assessment resulted from poor visualization of the uterine cavity or from underestimation or overestimation of irregularly shaped endometrium. CONCLUSION: Hysteroscopy was accurate in distinguishing between normal and abnormal endometrium. Nevertheless, better knowledge of relationship between hysteroscopic imaging and pathophysiologic states of endometrium is necessary to improve its accuracy. Endometrial sampling is recommended in all hysteroscopies showing unevenly shaped and thick endometrial mucosa or an anatomically distorted uterine cavity, and when endouterine visualization is less than optimal.     

Sonographic, hysteroscopic, and histologic evaluation of the endometrium in postmenopausal women with breast cancer receiving tamoxifen

STUDY OBJECTIVE: To evaluate the estrogenic effects of tamoxifen on the endometrium in postmenopausal women with breast cancer. DESIGN: Consecutive study (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Thirty-three women. Interventions. All patients underwent transvaginal sonography (TVS) and color flow Doppler of endometrial vessels, hysteroscopy, and, if necessary, endometrial biopsy or other operative hysteroscopic procedures. MEASUREMENTS AND MAIN RESULTS: In four women the endometrium was thin on TVS and atrophic at hysteroscopic assessment. In 29 women with thick endometrium on TVS, hysteroscopy and endometrial biopsy showed atrophy (11 patients), hyperplasia (5), polyps (11), and well-differentiated adenocarcinoma (2). The two endometrial cancers were present in women with uterine bleeding. In women with positive histologic findings, the endometrium was significantly thicker (p = 0.04) and duration of tamoxifen therapy longer than in those with negative findings, although this was not statistically significant (p = 0.067). CONCLUSION: We believe regular assessment of the endometrium by TVS should be performed in postmenopausal patients at the start of the tamoxifen therapy, and hysteroscopy in women with a thick endometrium or postmenopausal bleeding. We believe that patients with thin endometrium on TVS at the beginning of tamoxifen therapy, who have no abnormal uterine bleeding should be screened with these examinations for 2 years.     

Efficacy and satisfaction rate comparing endometrial ablation by rollerball electrocoagulation to uterine balloon thermal ablation in a randomised controlled trial

OBJECTIVE: To compare two methods of endometrial ablation, hysteroscopic rollerball electrocoagulation (RBE) and non-hysteroscopic uterine balloon thermal ablation (Thermachoice trade mark ), regarding efficacy for reducing dysfunctional uterine bleeding and patients satisfaction rate. METHODS: A randomised controlled study was performed in a teaching hospital at the department of gynaecology. One hundred and thirty-seven premenopausal women with dysfunctional uterine bleeding proved by validated menstrual score list were included. Endometrial ablation by a hysteroscopic or non-hysteroscopic method was performed by one gynaecologist. RESULTS: Reduction of menstrual blood loss was significantly more successful at 24 months for thermal ablation with uterine balloon. Success rate measured by menstrual score < 185 for rollerball and thermal balloon ablation are equivalent at 12 and 24 months post-operatively. Satisfaction of the patients for both methods at 24 months post-operatively is not significantly different (respective 75% for rollerball and 80% for uterine balloon). CONCLUSIONS: Endometrial ablation by uterine balloon thermal ablation (Thermachoice trade mark ) is equally effective as hysteroscopic RBE of the endometrium.     

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.     

Dysfunctional uterine bleeding: advances in diagnosis and treatment

Dysfunctional uterine bleeding occurs during the reproductive years unrelated to structural uterine abnormalities. Ovulatory dysfunctional uterine bleeding occurs secondary to defects in local endometrial hemostasis; while anovulatory dysfunctional uterine bleeding is a systemic disorder, occurring secondary to endocrinologic, neurochemical, or pharmacologic mechanisms. Evaluation of patients with abnormal uterine bleeding and identifying those with dysfunctional uterine bleeding is achieved with a combination of the following: history; physical examination; and judicious use of laboratory evaluation, endometrial sampling and uterine imaging, with sonographic techniques and/or hysteroscopy. Coagulopathies should be considered as should the notion that intramural and subserosal myomas are unlikely to contribute to AUB. High-quality evidence suggests that medical therapy is frequently successful, and newer approaches, such as local delivery of progestins via intrauterine devices, appear to be particularly promising and devoid of systemic side effects. For those intolerant of medical therapy, and/or for whom fertility is no longer desired, a number of minimally invasive surgical options for hysterectomy now exist and are collectively termed endometrial ablation. Endometrial ablation may be performed with or without hysteroscopic guidance. There is an increasing body of evidence that suggests that nonhysteroscopic endometrial ablation may be at least as effective as hysteroscopic endometrial ablation, even when the hysteroscopic procedure is performed by experts.     

Long-term results of hysteroscopic myomectomy in 235 patients

OBJECTIVE: To assess the efficacy of transcervical resection of submucous fibroids according to type and size. MATERIALS AND METHODS: Retrospective follow-up of 235 women with submucous fibroids at outpatient hysteroscopy who underwent a hysteroscopic transcervical resection. The main indications were the abnormal uterine bleeding and fertility problems. Thirty-seven percent of patients had an associated endometrial ablation and 32% had a polyp resection. Fifty-one percent of women were menopausal. In cases of incomplete resection a repeat procedure was offered. RESULTS: Intra-operative complications were rare (2.6%) and there was no major complication. Eighty-four percent of cases were followed-up. The median follow-up was 40 months (range 18-66 months). The procedure was classed as a success in 94.4% of patients. Among the cases that were classed as a failure, four patients had a repeated hysteroscopic procedure, three patients had a subsequent hysterectomy and four patients presented with abnormal uterine bleeding at follow-up. CONCLUSION: The hysteroscopic transcervical resection of submucous fibroids is a safe and highly effective long-term therapy for carefully selected women presenting with abnormal uterine bleeding and fertility problems. It produces satisfactory long-term results with few complications.