Resectoscopic surgery in 10 women with abnormal uterine bleeding and atypical endometrial hyperplasia

STUDY OBJECTIVE: To evaluate the role of the resectoscope in the diagnosis and treatment of women with abnormal uterine bleeding (AUB) and atypical endometrial hyperplasia. DESIGN: Retrospective case series (Canadian Task Force classification III-3). SETTING: University-affiliated teaching hospital. PATIENTS: Ten women. Intervention. Hysteroscopic evaluation after preoperative endometrial biopsy indicated simple hyperplasia without atypia, complex hyperplasia with atypia, or inadequate specimen. MEASUREMENTS AND MAIN RESULTS: Atypical hyperplasia was confirmed in eight patients after total endomyometrial resection. Hysterectomy was offered to all patients but accepted by only two: one for bilateral ovarian serous cystadenomas and the second for a granulosa cell ovarian tumor. No residual endometrium was found in hysterectomy specimens. Seven women were amenorrheic and well 1 to 9 years after resection. An additional patient with amenorrhea died from colon cancer 2 years after resection. CONCLUSION: Resectoscopic surgery confirmed or detected atypical endometrial hyperplasia in eight women and excluded it in two patients with AUB and a previous diagnosis of simple hyperplasia, atypical hyperplasia, or inadequate specimen. Skillful resectoscopic surgery may be an alternative to hysterectomy in selected patients with atypical hyperplasia 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.     

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

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

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.     

Miscellaneous Uterine Malignant Neoplasms Detected during Hysteroscopic Surgery

Study ObjectivesTo estimate the incidence of incidental miscellaneous uterine malignant neoplasms other than endometrioid adenocarcinoma detected during routine resectoscopic surgery in women with abnormal uterine bleeding (AUB) and to examine the effect of hysteroscopic surgery on long-term clinical outcome.DesignProspective cohort study (Canadian Task Force classification II-3).SettingUniversity-affiliated teaching hospital.PatientsWomen with AUB.InterventionFrom January 1, 1990, through December 31, 2008, one of the authors (G.A.V.) and several fellows performed primary hysteroscopic surgery at St. Joseph's Health Care in 3892 women with AUB. Of the 7 with malignant disease, one underwent hysteroscopic partial (n = 1) or complete (n = 6) rollerball electrocoagulation or endomyometrial resection. After diagnosis of uterine cancer, the women were counseled about the disease and management in accord with established clinical practice guidelines. Follow-up with office visits and telephone interviews ranged from 2 to 8 years (median, 6 years).Measurements and Main ResultsOf the 3892 women, 4 had undiagnosed and 3 had suspected miscellaneous uterine malignant neoplasms including 1 endometrial stromal sarcoma, 2 carcinosarcomas, 2 atypical polypoid adenomyomas of the endometrium, 1 minimal deviation adenocarcinoma of the cervix, and 1 smooth-muscle tumor of uncertain malignant potential. At 2 to 8 years of follow-up, 1 patient died accidentally after 1 year, 1 died of carcinomatosis of either coexisting breast cancer or a carcinosarcoma (postmortem examination was declined) after 1 year, and 5 were alive and well.ConclusionResectoscopic surgery in women with miscellaneous uterine malignant lesions not adversely affect 5-year survival and long-term prognosis.     

Validation of hysteroscopic view in cases of endometrial hyperplasia and cancer in patients with abnormal uterine bleeding

STUDY OBJECTIVE: To validate hysteroscopic view with histology in cases of endometrial hyperplasia and cancer in patients with abnormal uterine bleeding (AUB) DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: University teaching hospitals in Rio de Janeiro and S?o Paulo, and private office in Rio de Janeiro. PATIENTS: Four thousand and fifty-four patients with AUB in whom hysteroscopic views were complete and the histologic result was conclusive. INTERVENTION: Four thousand and fifty-four office hysteroscopies with complete views and conclusive histologic results. The material for histologic examination was obtained through biopsy of the lesion in an outpatient unit or through the resection of the entire lesion in patients who underwent surgery. Histology was considered the "gold standard" and compared with the hysteroscopic view. MEASUREMENTS AND MAIN RESULTS: In the histology of the 4054 examinations, 613 (15.2%) were endometrial hyperplasia, and 105 (2.6%) were endometrial cancer. The most frequent hysteroscopic finding was endometrial polyps (31.2%). In endometrial hyperplasia, the sensitivity of the hysteroscopic view was 56.3% (95% CI 52.2%-60.2%), specificity was 89.1% (95% CI 88.0%-90.1%), positive predictive value (PPV) was 48.0% (95% CI 44.3%-51.7%), negative predictive value (NPV) was 92.0% (95% CI 90.1%-92.9%), and accuracy was 72.7% (95% CI 70.7%-74.7%). Accuracy was defined as the proportion of correct results among the hysteroscopic examinations. In endometrial cancer, the sensitivity of the hysteroscopic view was 80.0% (95% CI 71.1%-87.2%), specificity was 99.5% (95% CI 99.2%-99.7%), PPV was 81.5% (95% CI 72.7%-88.5%), NPV was 99.5% (95% CI 99.2%-99.7%), and accuracy was 89.8% (95% CI, 85.9%-93.6%). In the 814 patients (20.0%) in whom the hysteroscopic view was normal, there were no false negatives for endometrial cancer; however, there were 37 (4.5%) false negatives for endometrial hyperplasia. In the histologic cases of endometrial cancer, 101 (96.2%) hysteroscopic views were compatible with cancer or hyperplasia (80.0% and 16.2%, respectively). Ninety-seven out of 103 hysteroscopic views with cancer findings (94.2%) had histologic diagnosis of cancer or hyperplasia (81.5% and 12.6%, respectively). CONCLUSION: It seems that even in face of good validity of hysteroscopic view for endometrial hyperplasia and cancer, histologic study is mandatory in the presence of any lesion as the hysteroscopic view cannot completely replace the histologic study in patients with AUB.     

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.     

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.     

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.     

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.     

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.     

Endometrioid adenocarcinoma treated by hysteroscopic endomyometrial resection

A 53-year-old multiparous woman, with no identifiable risk factor for endometrial cancer, presented with menorrhagia. She had been treated with oral contraceptives for 3 years. Office endometrial biopsy indicated well-differentiated villoglandular adenocarcinoma of the endometrium. The patient refused hysterectomy and would consent only to hysteroscopic resection. She remains alive and well, with no clinical evidence of recurrence 5 years after resection. We propose that skillful resectoscopic surgery, under specific circumstance, may be an appropriate alternative treatment to hysterectomy for some early uterine malignancies.     

Hysteroscopy in perimenopausal and postmenopausal women with abnormal uterine bleeding

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

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.     

Endometrial cancer in patients with preoperative diagnosis of atypical endometrial hyperplasia

OBJECTIVE: Atypical endometrial hyperplasia (AEH) has been associated with the presence of concomitant endometrial carcinoma (EC). The aim of this study is to examine the frequency of coexisting endometrial carcinoma when atypical endometrium hyperplasia was found upon biopsy. We also evaluated the influence of preoperative diagnostic techniques (pipelle and dilation and curettage (D&C)), and the value of transvaginal ultrasound in detecting unexpected tumor invasion. STUDY DESIGN: Between January 1992 and December 2003, at the Department of Obstetrics and Gynecology, University of Parma, and Policlinico S. Matteo, Pavia, 70 consecutive patients subjected to total hysterectomy with a histological diagnosis of AEH were retrospectively selected. 52/70 patients underwent vaginal hysterectomy, with bilateral salpingo-oophorectomy (BSO) whereas 18/70 had abdominal hysterectomy with BSO within 8 weeks since the diagnosis of AEH. RESULTS: We found in 30 of the 70 patients with atypical endometrial hyperplasia in the biopsy coexisting endometrial carcinoma (43%). No differences in diagnostic accuracy between the pipelle method and D&C were found. CONCLUSION: Transvaginal ultrasound was not a feasible method for predicting EC. After a follow-up of an average of 5 years there was, neither in the abdominal operated patients nor in the vaginal operated patients, a recurrence of disease.     

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.     

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)     

Hysteroscopic evaluation of endometrial polyps.

OBJECTIVE: To establish the validity of hysteroscopy for predicting cancer in endometrial polyps based on their number, size and hysteroscopic appearance. METHOD: Retrospective observational study of 653 women diagnosed hysteroscopically as having endometrial polyps. After outpatient or surgical hysteroscopic resection or resection following hysterectomy, the diagnosis was confirmed by histological examination. The incidence of cancer in women who had polyps was determined in the light of menopausal status, symptoms, size, number and appearance of the polyps. RESULT: Carcinoma was found in only 3.9% of the women who consulted for menopausal metrorrhagia and were diagnosed as having a polyp. Hysteroscopy had a sensitivity of 36% and a specificity of 98% for a diagnosis of cancerous polyp or atypical hyperplasia. CONCLUSION: The appearance and number of endometrial polyps seen by hysteroscopy may be useful in predicting cancer in the polyps, although resection and histological examination will still be necessary to confirm the diagnosis.     

Long-term impact and risk factors for hysterectomy after hysteroscopic surgery for menorrhagia

The objective of this study was to assess the long-term impact of management and establish the incidence of hysterectomy, and to identify factors predictive of failure of the procedure among women who had undergone hysteroscopic endometrial resection with or without myomectomy for menorrhagia. Clinical history and data on additional treatment and follow-up status were obtained by medical record review and postal questionnaire for 279 women who had undergone hysteroscopic surgery. Follow-up data were available for 259 (93%) cases, and the mean follow-up was 6.0 years. Subsequent hysterectomy was the primary endpoint, and its incidence was calculated by survival analysis. Univariant analysis and Cox regression model were used to identify predictors of failure. Myomas, polyps, adenomyosis, or endometrial hyperplasia were found in 40.9% of hysteroscopic procedures. Perioperative complications occurred in 5.7% and late complications in 7.7%. During the follow-up period, 97 (37.5%) of 259 women underwent at least one gynecological procedure. The incidence of hysterectomy was 23.6% (95% confidence interval: 18.8–29.1%). Positive predictive factors for hysterectomy were long uterine cavity (≥9 cm) and tubal ligation. Most (82.8%) of the 198 women who did not undergo hysterectomy had postoperative oligo- or amenorrhea. Hormone replacement therapy was common (67%) among postmenopausal women after endometrial resection. Hysteroscopic resection of the endometrium and concomitant hysteroscopic resection of fibroids for the treatment of menorrhagia is a suitable alternative to hysterectomy and offers lasting results. A large uterine cavity indicating possible uterine pathology and tubal ligation associated with hematometra increase the risk of hysterectomy.     

Efficacy of the levonorgestrel intrauterine system (LNG-IUS) in the prevention of the atypical endometrial hyperplasia and endometrial cancer: retrospective data from selected obese menopausal symptomatic women

The aim of this retrospective study was to evaluate the efficacy of levonorgestrel intrauterine system-releasing (LNG-IUS) insertion in preventing atypical endometrial hyperplasia (AH) and endometrial cancer (EC) in symptomatic postmenopausal overweight/obese women. A total of 34 overweight/obese postmenopausal women, presenting abnormal uterine bleeding (AUB) and endometrial hyperplasia (EH), and who were submitted to LNG-IUS insertion, were identified from registry data. Endometrial histology at LNG-IUS insertion showed simple EH in 20 cases (58.8%), complex EH in 14 cases (41.2%). At 36 months, 91% of patients showed no recurrence of AUB and a significant reduction in the mean endometrial thickness (from 8.2?±?2.2 to 3.2?±?1.5?mm, p < 0.05) was observed. Histologic regression of EH was observed in 27 (79.4%) and 33 (97.5%) cases at 12 and 36 months, respectively. None of the women in which EH persisted, reported cellular atypia or cancer progression at 12 and 36 months of follow-up. LNG-IUS represents an effective treatment option to manage postmenopausal obese women affected by AUB and EH. The device seems to be able to prevent the onset of AH and EC in women at high risk. Further prospective controlled studies in a well selected group of women are needed.