Transcriptional modulator ZBED6 affects cell cycle and growth of human colorectal cancer cells.
Akhtar Ali Muhammad,Younis Shady,Wallerman Ola,Gupta Rajesh,Andersson Leif,Sjöblom Tobias
Proceedings of the National Academy of Sciences of the United States of America
The transcription factor ZBED6 (zinc finger, BED-type containing 6) is a repressor of IGF2 whose action impacts development, cell proliferation, and growth in placental mammals. In human colorectal cancers, IGF2 overexpression is mutually exclusive with somatic mutations in PI3K signaling components, providing genetic evidence for a role in the PI3K pathway. To understand the role of ZBED6 in tumorigenesis, we engineered and validated somatic cell ZBED6 knock-outs in the human colorectal cancer cell lines RKO and HCT116. Ablation of ZBED6 affected the cell cycle and led to increased growth rate in RKO cells but reduced growth in HCT116 cells. This striking difference was reflected in the transcriptome analyses, which revealed enrichment of cell-cycle-related processes among differentially expressed genes in both cell lines, but the direction of change often differed between the cell lines. ChIP sequencing analyses displayed enrichment of ZBED6 binding at genes up-regulated in ZBED6-knockout clones, consistent with the view that ZBED6 modulates gene expression primarily by repressing transcription. Ten differentially expressed genes were identified as putative direct gene targets, and their down-regulation by ZBED6 was validated experimentally. Eight of these genes were linked to the Wnt, Hippo, TGF-β, EGF receptor, or PI3K pathways, all involved in colorectal cancer development. The results of this study show that the effect of ZBED6 on tumor development depends on the genetic background and the transcriptional state of its target genes.
Integrative genomics analysis reveals the multilevel dysregulation and oncogenic characteristics of TEAD4 in gastric cancer.
Lim Byungho,Park Jong-Lyul,Kim Hee-Jin,Park Young-Kyu,Kim Jeong-Hwan,Sohn Hyun Ahm,Noh Seung-Moo,Song Kyu-Sang,Kim Woo-Ho,Kim Yong Sung,Kim Seon-Young
Tumorigenesis is a consequence of failures of multistep defense mechanisms against deleterious perturbations that occur at the genomic, epigenomic, transcriptomic and proteomic levels. To uncover previously unrecognized genes that undergo multilevel perturbations in gastric cancer (GC), we integrated epigenomic and transcriptomic approaches using two recently developed tools: MENT and GENT. This integrative analysis revealed that nine Hippo pathway-related genes, including components [FAT, JUB, LATS2, TEA domain family member 4 (TEAD4) and Yes-associated protein 1 (YAP1)] and targets (CRIM1, CYR61, CTGF and ITGB2), are concurrently hypomethylated at promoter CpG sites and overexpressed in GC tissues. In particular, TEAD4, a link between Hippo pathway components and targets, was significantly hypomethylated at CpG site cg21637033 (P = 3.8 × 10(-) (20)) and overexpressed (P = 5.2 × 10(-) (10)) in 108 Korean GC tissues compared with the normal counterparts. A reduced level of methylation at the TEAD4 promoter was significantly associated with poor outcomes, including large tumor size, high-grade tumors and low survival rates. Compared with normal tissues, the TEAD4 protein was more frequently found in the nuclei of tumor cells along with YAP1 in 53 GC patients, demonstrating the posttranslational activation of this protein. Moreover, the knockdown of TEAD4 resulted in the reduced growth of GC cells both in vitro and in vivo. Finally, chromatin immunoprecipitation-sequencing and microarray analysis revealed the oncogenic properties of TEAD4 and its novel targets (ADM, ANG, ARID5B, CALD1, EDN2, FSCN1 and OSR2), which are involved in cell proliferation and migration. In conclusion, the multilevel perturbations of TEAD4 at epigenetic, transcriptional and posttranslational levels may contribute to GC development.
Frequency of endometrial cancer and atypical hyperplasia in infertile women undergoing hysteroscopic polypectomy.
Kuribayashi Yasushi,Nakagawa Koji,Sugiyama Rie,Motoyama Hiroshi,Sugiyama Rikikazu
The journal of obstetrics and gynaecology research
AIM:We aimed to determine the frequency of endometrial cancer in infertile women undergoing hysteroscopic endometrial polypectomy for endometrial polyps. METHODS:A total of 1035 infertile patients who underwent office-based hysteroscopic polypectomy at Sugiyama Clinic Marunouchi between July 2011 and October 2015 were eligible for this retrospective study. All patients had been diagnosed with endometrial polyps via hysterofiberscopy prior to operation, and they underwent hysteroscopic endometrial polypectomy using a resectoscope with monopolar resection. Surgical specimens were examined histopathologically. Characteristics of patients diagnosed with endometrial cancer on histopathological examination were evaluated retrospectively. RESULTS:The median age of patients was 32 years (range, 19-44 years). On histopathological examination, endometrial cancer was found in 10 patients (0.97%). Each histological type of endometrial cancer was represented as follows: three cases of endometrioid adenocarcinoma G1; one of endometrioid adenocarcinoma G2; two of endometrioid adenocarcinoma G3; and four of atypical endometrial hyperplasia. The median age of endometrial cancer patients was 34 years (range, 28-41 years), and the median body mass index was 21.2 kg/m (range, 16.7-29.9 kg/m ). Nine endometrial cancer patients were nulliparous, and all had undergone infertility treatment, with only one woman having delivered a healthy baby. An ovulation disorder was noted in four patients, with obesity (body mass index > 25 kg/m ) in just two. Polycystic ovary syndrome was concomitantly observed in one patient. However, abnormal vaginal bleeding was not noted in any of these patients. CONCLUSION:Hysteroscopic polypectomy should be performed when endometrial polyps are detected on investigational screening, and surgical specimens should be checked for the presence of malignancy.
Management of abnormal uterine bleeding - focus on ambulatory hysteroscopy.
International journal of women's health
The rapid evolution in ambulatory hysteroscopy (AH) has transformed the approach to diagnose and manage abnormal uterine bleeding (AUB). The medical management in primary care remains the mainstay for initial treatment of this common presentation; however, many women are referred to secondary care for further evaluation. To confirm the diagnosis of suspected intrauterine pathology, the traditional diagnostic tool of day case hysteroscopy and dilatation and curettage in a hospital setting under general anesthesia is now no longer required. The combination of ultrasound diagnostics and modern AH now allows thorough evaluation of uterine cavity in an outpatient setting. Advent of miniature hysteroscopic operative systems has revolutionized the ways in which clinicians can not only diagnose but also treat menstrual disorders such as heavy menstrual bleeding, intermenstrual bleeding and postmenopausal bleeding in most women predominantly in a one-stop clinic. This review discussed the approach to manage women presenting with AUB with a focus on the role of AH in the diagnosis and treatment of this common condition in an outpatient setting.
Is outpatient hysteroscopy accurate for the diagnosis of endometrial pathology among perimenopausal and postmenopausal women?
Bar-On Shikma,Ben-David Alon,Rattan Gilad,Grisaru Dan
Menopause (New York, N.Y.)
OBJECTIVE:To assess the histological and visual accuracy of outpatient hysteroscopy. METHODS:This was a retrospective analysis of all women referred to a tertiary center outpatient hysteroscopy clinic between March 2011 and October 2016 for the following indications: postmenopausal bleeding, suspected polyp, and/or thick endometrium. Histological accuracy was evaluated by comparing specimens obtained in hysteroscopy with those obtained by hysterectomy, and visual accuracy was evaluated by comparing visual findings with those obtained by biopsies. Sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio were calculated to assess visual accuracy. RESULTS:The mean age of participants was 54.14 (interquartile range 43.0-64.0). A total of 408 pathological specimens were obtained from outpatient hysteroscopies during the 712 visits recorded in the clinic log. Histological accuracy was evaluated in 15 participants who eventually underwent hysterectomy. Total percent of agreement between hysteroscopy biopsies and final pathology obtained by hysterectomy was 73% (kappa = 0.47). Overall visual accuracy was calculated with a 93.1% sensitivity, 52.1% specificity, 90.4% positive predictive value, and 61.0% negative predictive value. Visual accuracy for benign pathology was generally higher compared with that for pre and malignant lesions. Visual accuracy was satisfactory for the diagnosis of endometrial carcinoma with sensitivity and specificity of 71.4% and 98.9%, respectively, but poor for diagnosing hyperplasia with sensitivity and specificity of 25.0% and 96.6%, respectively. CONCLUSIONS:Outpatient hysteroscopy is an adequate and reliable tool for the evaluation of benign pathology in the uterine cavity. Visual findings may not suffice, and directed biopsies may be required to improve diagnostic accuracy.
Hysteroscopically guided transvaginal ultrasound tubal catheterization-a novel office procedure.
Cohen Shlomo B,Bouaziz Jerome,Jakobson-Setton Ariella,Goldenberg Motti,Schiff Eyal,Orvieto Raoul,Shulman Adrian
European journal of obstetrics, gynecology, and reproductive biology
OBJECTIVE:Investigate a novel office hysteroscopic tubal catheterization therapeutic method for proximal tubal occlusion. STUDY DESIGN:Prospective cohort study in a tertiary referral center. We evaluated the procedure on a group of 27 patients that were referred to our unit for proximal tubal occlusion demonstrated by hysterosalpingography, 9 (33.3%) of them with primary infertility and 18 of them (66.6%) with secondary infertility. The intervention included the usage of the modified Novy cornual cannulation set which was inserted through a 5F working cannel during an office operative hysteroscopy, followed by fallopian tube irrigation with saline-air mixture under ultrasonographic imaging. RESULTS:Our series revealed no complication during or after the procedure; anesthesia was not required. One patient lost from follow-up. Of the remaining 26, 10 patients (38.4%) conceived either spontaneously or with treatment by clomiphene or gonadotropine associated with intrauterine insemination. The median time to conception was 5 months (range 4-17). CONCLUSION:We therefore concluded that office hysteroscopic tubal catheterization is a simple (without anesthesia required) option for the treatment of patients suffering from proximal tubal occlusion. Fertility outcomes in our series are comparable to other treatments options for tubal catheterization. Therefore, tubal catheterization should not delay the assisted reproducted techniques if indicated but we propose to include it in a global integrated approach.
Misoprostol versus uterine straightening by bladder distension for pain relief in postmenopausal patients undergoing diagnostic office hysteroscopy: a randomised controlled non-inferiority trial.
Fouda Usama M,Elshaer Hesham S,Elsetohy Khaled A,Youssef Mohamed A
European journal of obstetrics, gynecology, and reproductive biology
OBJECTIVE:To compare the effectiveness of misoprostol with uterine straightening by bladder distension in minimising the pain experienced by postmenopausal patients during diagnostic office hysteroscopy. STUDY DESIGN:Seventy-six postmenopausal patients were randomly allocated in a 1:1 ratio to the misoprostol group or to the bladder distension group. Patients in the misoprostol group were instructed to insert two misoprostol tablets (400μg) in the vagina 12h before office hysteroscopy. Patients in the bladder distension group were instructed to drink one litre of water and to avoid urination during a period of 2h before office hysteroscopy. The severity of pain experienced by the patients during and at 30min after the procedure was measured using a 100-mm visual analogue scale (VAS). The ease of passing the hysteroscope through the cervical canal was assessed by the hysteroscopists using a 100-mm VAS. RESULTS:The passage of the hysteroscope through the cervical canal was easier in the misoprostol group [60.37±15.78 vs. 50.05±19.88, p=0.015]. The mean VAS pain score during the procedure was significantly lower in the misoprostol group [39.47±13.96 vs. 50.18±15.44, p=0.002]. The mean VAS pain score 30min post-procedure was comparable between both groups [11.82±3.71 vs. 12.61±4.06, p=0.379]. CONCLUSION:Vaginal misoprostol is more effective than uterine straightening by bladder distension in relieving the pain experienced by postmenopausal patients during office hysteroscopy. TRIAL REGISTRATION:Clinicaltrials.gov [NCT02328495]. https://clinicaltrials.gov/ct2/show/NCT02328495.
The value of hysteroscopic biopsy in the diagnosis of endometrial polyps.
Spadoto-Dias Daniel,Bueloni-Dias Flávia Neves,Elias Leonardo Vieira,Leite Nilton José,Modotti Waldir Pereira,Lasmar Ricardo Bassil,Dias Rogério
Women's health (London, England)
Several studies have demonstrated that the combination of hysteroscopy with endometrial biopsy is more accurate in differentiating endometrial polyps from endometrial hyperplasia and cancer. However, blind biopsy not always confirms hysteroscopic findings due to high rates of inadequate or insufficient material. The objective of this clinical, prospective, and comparative study was to establish a correlation between the histological results of office-based endometrial biopsies (hysteroscopically guided and blind) with the surgical polypectomy specimens. We evaluated 82 patients with hysteroscopic diagnosis of endometrial polyp, who randomly underwent hysteroscopically guided biopsy or blind biopsy, referred for surgical resection. A total of 36 women (43.9%) underwent hysteroscopically guided biopsy and 46 women (56.1%) underwent blind biopsy. The sensitivity of hysteroscopically guided biopsy for the diagnosis of endometrial polyps ranged between 35.3 and 36.8%, when carried out at the apex and base of the lesion, compared with 29.2% for blind biopsy. Specificity was 33.3, 50, and 60%, respectively, for each biopsy. The positive predictive values were 75, 77.8, and 87.5%, and negative predictive values were 8.3, 14.3, and 8.1% respectively, compared with surgical polypectomy specimens. The office-based endometrial biopsies had low diagnostic accuracy for endometrial polyps compared with surgical polypectomy specimens.
Endometrial injury for RIF patients undergoing IVF/ICSI: a prospective nonrandomized controlled trial.
Siristatidis Charalampos,Kreatsa Maria,Koutlaki Nikoleta,Galazios George,Pergialiotis Vasileios,Papantoniou Nikolaos
Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology
To evaluate the effect of endometrial injury on clinical outcomes in subfertile women with repeated implantation failures (RIF) undergoing assisted reproduction. In this prospective nonrandomized controlled trial, 103 subfertile women with RIF were included. Fifty-one underwent endometrial injury through hysteroscopy in the early follicular phase of the previous cycle and 52 underwent the standard protocol without any intervention. Live birth and miscarriage were the primary outcomes. Clinical and in vitro fertilization (IVF) cycle characteristics, were also compared between groups. Both groups were comparable in terms of baseline and cycle characteristics. Live birth rates were significantly higher in the study, compared with the control group (18/51 vs. 8/52, odds ratio (OR) = 0.25; 95% confidence interval (CI) = 0.10-0.64; p = 0.020), although miscarriage rates were similar (7/51 vs. 10/52, OR= 0.25; 95%CI= 0.12-0.66; p = 0.452). The rest of the outcomes parameters were comparable between groups. Logistic regression analysis revealed that endometrial injury and duration of subfertility were independent predictors of live birth after control of other variables (OR = 2.818; 95%CI = 1.044-7.605; p = 0.041 and OR = 0.674; 95%CI = 0.461-0.985, p = 0.042, respectively). Endometrial injury induced through office hysteroscopy in the preceding cycle in subfertile women with RIF improves live birth rates.
The REP-b (removal of endometrial pathologies-basket) in-office hysteroscopy.
Sudano Maria Chiara,Vitale Salvatore Giovanni,Rapisarda Agnese Maria Chiara,Carastro Denise,Tropea Alessandro,Zizza Gaetano
Updates in surgery
The aim of this study was to assess the safety, effectiveness and advantages of a new surgical technique for the extraction of endometrial polyps after in-office hysteroscopic polipectomy. Between November 2009 and September 2013, 140 pre- and post-menopausal women with a sonographic diagnosis of endometrial polyps underwent polypectomy in-office hysteroscopy, followed by lesion removal using classical surgical instruments or the new REP-b technique. A total of 70 women underwent endometrial polyp removal using the new surgical technique REP-b (GROUP A), and 70 women received endometrial polyp removal using classical surgical instruments (GROUP B). The extraction time Tr, calculated as the time from the introduction of the basket into the operative hysteroscopic sheath to the complete removal of the previously sectioned polyp, in GROUP A (REP-b technique) was significantly lower compared with GROUP B (control group). The median Tr for GROUP A was 29.50 s versus the median Tr for GROUP B of 54.00 s (P < 0.01). The use of the REP-b technique improves the outcome of the operation and reduces the extraction time for the removal of endocavitary uterine lesions.
The Value of Routine Hysteroscopy before the First Intracytoplasmic Sperm Injection Treatment Cycle.
Alleyassin Ashraf,Abiri Ameneh,Agha-Hosseini Marzieh,Sarvi Fatemeh
Gynecologic and obstetric investigation
BACKGROUND/AIMS:To assess uterine cavity with office hysteroscopy in order to diagnose and treat pathologies in patients who have started their first intracytoplasmic sperm injection (ICSI) cycles and evaluate its impact on pregnancy rate. METHODS:A number of 220 infertile women scheduled for ICSI participated in this prospective randomized study. They were randomly divided into 2 equal groups. Group I (intervention) underwent office hysteroscopy before starting assisted reproductive techniques (ART) cycle. Group II (control) started ART cycles without office hysteroscopy. All women had normal transvaginal ultrasonography and hysterosalpingography. The detected intrauterine abnormalities were treated during hysteroscopy. Four weeks after embryo transfer, ultrasonography was done for detecting clinical pregnancy. RESULTS:Abnormal findings were seen in hysteroscopy in 22.7% of the intervention group. The pregnancy rate in the intervention group (48.20%) was significantly higher than that in the control group (38.60%; p = 0.004). CONCLUSION:Routine office hysteroscopy before ICSI cycles provides direct evaluation of uterine cavity. Also, pregnancy rate improves after correction of endometrial cavity abnormalities.
Is outpatient hysteroscopy the new gold standard? Results from an 11 year prospective observational study.
Ma Tony,Readman Emma,Hicks Lauren,Porter Jenny,Cameron Melissa,Ellett Lenore,Mcilwaine Kate,Manwaring Janine,Maher Peter
The Australian & New Zealand journal of obstetrics & gynaecology
BACKGROUND:In Australia, gynaecologists continue to investigate women with abnormal bleeding and suspected intrauterine pathology with inpatient hysteroscopy despite some evidence in the literature that that there is no difference in safety and outcome when compared to an outpatient procedure. AIMS:This prospective study assessed the safety, effectiveness and acceptability of outpatient hysteroscopy over 11 years at a tertiary hospital in Australia. Resource savings were then calculated. MATERIALS AND METHODS:A prospective database was analysed from March 2003 to January 2014 (130 months, 990 women). RESULTS:Successful hysteroscopic access was obtained in 94% of cases. Twenty-six percent of patients required a second procedure, including 132 for endometrial polyps and 33 for submucosal fibroids that were not able to be treated in the outpatient setting. On questioning, 88% of women would be happy to have the procedure again. Factors affecting success were pre-procedure pain, menopausal status and previous vaginal delivery. The difference between pain experienced versus pain expected was a major factor in patient acceptability. A vasovagal episode occurred in 5% of cases. CONCLUSION:Outpatient hysteroscopy was demonstrated to be safe, effective and acceptable to women. Provision of an outpatient hysteroscopy service saves theatre time and approximately $1000 per case. Improved techniques and technology will allow progression to a 'see and treat' service, providing further savings. With budget constraints, increasing wait times for major procedures and concerns about trainee surgical experience, an outpatient hysteroscopy service should be considered the 'gold standard' investigation over hysteroscopy in theatre.
A novel hysteroscopic approach for ovarian cancer screening/early diagnosis.
Gizzo Salvatore,Noventa Marco,Quaranta Michela,Vitagliano Amerigo,Saccardi Carlo,Litta Pietro,Antona Donato
The lethality of epithelial ovarian cancer (EOC) may be due to common misconceptions regarding etiology and the absence of effective screening and early diagnostic tools. Reviews of histopathological surveys performed on the resected fallopian tubes of breast cancer (BRCA) mutation carriers, who underwent risk-reducing salpingo-oophorectomy, unexpectedly revealed the presence of occult carcinomas of the fallopian tubes. This finding prompted studies that demonstrated the most accredited theory of type II EOC development, which suggests that a large proportion of these tumors are derived from the fallopian tube. At present, no diagnostic tools or screening programs have been demonstrated to be effective or cost-effective in improving the outcome of EOC; it is therefore imperative that the scientific community unite its efforts in the identification of a valid screening and/or early diagnostic method for the treatment of this lethal gynecological malignancy. To this end, the present paper proposes a novel tool for the screening/early diagnosis of EOC: The 'Tuba-check'. This novel approach is based on the possibility of acquiring specimens for tubal lumen cytology via hysteroscopy in a minimally-invasive outpatient setting. The present study protocol aimed to validate the technical feasibility and oncological accuracy of the proposed approach, commencing with a cohort of patients with an expected increased oncological risk, including BRCA mutation carriers or those with a gene expression profile of 'BRCA-ness'. If the data collected by the present study protocol validates this approach, the 'Tuba-check' may, in the near future, be extended for the treatment of all women, therefore reducing the number of victims of epithelial ovarian carcinoma.
Abnormal uterine bleeding.
Whitaker Lucy,Critchley Hilary O D
Best practice & research. Clinical obstetrics & gynaecology
Abnormal uterine bleeding (AUB) is a common and debilitating condition with high direct and indirect costs. AUB frequently co-exists with fibroids, but the relationship between the two remains incompletely understood and in many women the identification of fibroids may be incidental to a menstrual bleeding complaint. A structured approach for establishing the cause using the Fédération International de Gynécologie et d'Obstétrique (FIGO) PALM-COEIN (Polyp, Adenomyosis, Leiomyoma, Malignancy (and hyperplasia), Coagulopathy, Ovulatory disorders, Endometrial, Iatrogenic and Not otherwise classified) classification system will facilitate accurate diagnosis and inform treatment options. Office hysteroscopy and increasing sophisticated imaging will assist provision of robust evidence for the underlying cause. Increased availability of medical options has expanded the choice for women and many will no longer need to recourse to potentially complicated surgery. Treatment must remain individualised and encompass the impact of pressure symptoms, desire for retention of fertility and contraceptive needs, as well as address the management of AUB in order to achieve improved quality of life.
The Challenging Intrauterine Contraceptive: In-office Hysteroscopic Approach.
Di Spiezio Sardo Attilio,da Cunha Vieira Mariana,Scognamiglio Marianna,Zizolfi Brunella,Nappi Carmine,de Angelis Carlo
Journal of minimally invasive gynecology
STUDY OBJECT:To describe 3 cases of misplaced or retained Intrauterine Contraceptive (IUC) that were successfully resolved by hysteroscopy performed in an ambulatory setting using miniaturized electrosurgical and mechanical operative instruments. DESIGN:Step-by-step description of the technique using slides, pictures, and video (educative video) (Canadian Task Force classification III). SETTING:Misplaced or retained IUC may be related to several causes; incorrect insertion is the leading cause. In these cases, patients may complain of abnormal bleeding, pelvic pain, or pregnancy or they may remain asymptomatic. When a displaced IUC is suspected, transvaginal ultrasonography is the primary investigation followed by radiography in cases in which the IUC is not seen within the uterus. Additional imaging such as computed tomographic scanning or magnetic resonance imaging may be needed. Hysteroscopy represents the gold standard for diagnostic clarification and management of a dislocated or embedded IUC. INTERVENTIONS:The hysteroscopic approach of the 3 cases was the following: removal of a partially perforating IUD in the cesarean scar pouch, repositioning of a dislocated IUS in the isthmocele, and removal of an embedded IUS in the cornual area. The procedures were performed in an ambulatory setting using a 5-mm continuous flow hysteroscope and vaginoscopic approach without any analgesia and/or anesthesia. The alternate use of mechanical and electrosurgical 5F instruments allowed us to separate the IUC from the myometrial uterine wall, respecting the healthy myometrium and without causing significant patient discomfort or complications. CONCLUSION:The possibility of using miniaturized electrosurgical and mechanical instruments with small-diameter hysteroscopes offers the possibility of an effective, safe, cost-efficient, and well-tolerated removal or repositioning of a misplaced or retained IUC. This minimally invasive approach can be performed in an office setting to avoid more invasive and traumatic approaches.
Hysteroscopic chasing for endometrial cancer in a low-risk population: risks of overinvestigation.
Scrimin Federica,Wiesenfeld Uri,Galati Emanuele F,Monasta Lorenzo,Ricci Giuseppe
Archives of gynecology and obstetrics
PURPOSE:To evaluate the appropriateness of the indications for hysteroscopy done, in fertile and postmenopausal women, for the detection of endometrial cancer. METHODS:A retrospective analysis of 2673 consecutive women who underwent office hysteroscopy chasing for endometrial cancer between January 2012 and June 2014. According to their medical history only low-risk women entered the study. RESULTS:A total of 1070 patients entered the study. The main outcome measure was the appropriateness of the indications for hysteroscopy. Appropriateness was assessed on the basis of guidelines of scientific societies and histologic report. According to the algorithm developed for appropriateness, 44 % of procedures resulted in being inappropriate. In reproductive-aged women 57 % of hysteroscopies were inappropriate. In postmenopausal women inappropriate hysteroscopies were 45 %. In reproductive-aged women, the reasons for inappropriateness were: absence of abnormal uterine bleeding (AUB) or AUB without a trial of progestin therapy. In postmenopausal women, the reasons for inappropriateness were: ultrasound report of endometrial thickening or polyp without bleeding. CONCLUSIONS:Hysteroscopy is often recommended for inappropriate indications. More evidence is needed to identify the risks of overinvestigation, overdiagnosis, and related overtreatment and to better identify the threshold beyond which benefits are likely to outweigh harms.
Accuracy of Hysteroscopic Endomyometrial Biopsy in Diagnosis of Adenomyosis.
Dakhly Dina M R,Abdel Moety Ghada A F,Saber Waleed,Gad Allah Sherine H,Hashem Ahmed T,Abdel Salam Lubna O E
Journal of minimally invasive gynecology
OBJECTIVES:To investigate the diagnostic accuracy of endomyometrial biopsy obtained via office hysteroscopy for the diagnosis of adenomyosis. STUDY DESIGN:Cross-sectional study. SETTING:Cairo University Teaching Hospital, Cairo, Egypt. PATIENTS:A total of 404 premenopausal women with symptoms clinically suggestive of having adenomyosis. INTERVENTIONS:All patients were subjected to 2-dimensional transvaginal sonography (TVS) in-office hysteroscopy examination with endomyometrial biopsy. Patients who subsequently underwent hysterectomy were included in the final analysis. MAIN MEASUREMENTS AND RESULTS:Accuracy of diagnostic modalities was represented using the terms sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy. A total of 292 patients were eligible for final analysis. Of these, 162 (55.47%) were diagnosed with adenomyosis based on hysterectomy specimens. TVS had a high sensitivity (83.95%) and a moderate specificity (60%). In contrast, endomyometrial biopsy was more specific (78.46%) than sensitive (54.32%). Hysteroscopic appearance of the endometrial cavity had low sensitivity (40.74%) and specificity (44.62%). Adding endomyometrial biopsy to TVS improved specificity (89.23%). CONCLUSION:Endomyometrial biopsy obtained via office hysteroscopy can diagnose adenomyosis with a high specificity and is recommended after TVS.
Effectiveness of Intrauterine Lignocaine in Addition to Paracervical Block for Pain Relief during Dilatation and Curettage, and Fractional Curettage.
Arora Aashima,Shukla Ajitabh,Saha Subhas Chander
Journal of obstetrics and gynaecology of India
PURPOSE OF STUDY:Dilatation and curettage (D&C) and fractional curettage (F/C) are commonly performed gynecological procedures. Randomized controlled trials have concluded that topical anesthesia effectively reduces pain in endometrial sampling and hysteroscopy. Our study was aimed at investigating this modality of pain relief in setting of a developing country where, due to lack of resources, successful completion of these procedures in an outpatient setting is a necessity. METHODS:This study was a prospective, randomized, placebo-controlled, double-blind study conducted in 84 patients. All patients received either intrauterine 2 % lignocaine or normal saline along with oral NSAID and paracervical block prior to the procedure. The pain was analyzed at three steps: at the time of curette, immediately post-procedure, and 30 min later using 10-cm visual analog score. RESULTS:The patients in the experimental and control groups were well matched for age, parity, body mass index, menopausal status, and the indications for intervention. At all the three stages, pain perceived in the lignocaine group was significantly less as compared to that in placebo group. As compared to lignocaine group (55 %), significantly higher number of women in placebo group (88 %) perceived severe pain during endometrial curettage (p = 0.001). CONCLUSIONS:The present study indicates that two percent intrauterine lignocaine significantly decreases the pain perception during intrauterine gynecological procedures such as D&C and F/C. This is a simple, effective, inexpensive, and low-risk intervention which can potentially increase the patient acceptability and compliance with such procedures.
Chronic endometritis in women with recurrent pregnancy loss and recurrent implantation failure: prevalence and role of office hysteroscopy and immunohistochemistry in diagnosis.
Bouet Pierre-Emmanuel,El Hachem Hady,Monceau Elise,Gariépy Gilles,Kadoch Isaac-Jacques,Sylvestre Camille
Fertility and sterility
OBJECTIVE:To determine the prevalence of chronic endometritis (CE) in patients with recurrent implantation failure (RIF) after IVF and unexplained recurrent pregnancy loss (RPL). DESIGN:Prospective observational study between November 2012 and March 2015. SETTING:University-affiliated private IVF clinic. PATIENT(S):Women with RIF after IVF (group 1) and unexplained RPL (group 2). INTERVENTION(S):Office hysteroscopy followed by an endometrial biopsy was performed as part of the workup for RIF and RPL. The diagnosis of CE was histologically confirmed using immunohistochemistry stains for syndecan-1 (CD138). MAIN OUTCOME MEASURE(S):The prevalence of CE in each group and the sensitivity/specificity of office hysteroscopy in the diagnosis of CE. RESULT(S):Ninety-nine patients were included (46 in group 1 and 53 in group 2). The mean age was 36.3 ± 4.9 years in group 1 and 34.5 ± 4.9 years in group 2. Five biopsies were uninterpretable (three in group 1 and two in group 2) because of insufficient specimen. The prevalence of CE was 14% (6/43) in group 1 and 27% (14/51) in group 2. The sensitivity and specificity of office hysteroscopy in the diagnosis of CE were 40% (8/20) and 80% (59/74), respectively. CONCLUSION(S):We found a high prevalence of immunohistochemically confirmed CE in women with RIF and RPL. Office hysteroscopy is a useful diagnostic tool but should be complemented by an endometrial biopsy for the diagnosis of CE. CLINICAL TRIAL REGISTRATION NO:NCT01762098.
An economic evaluation of outpatient versus inpatient polyp treatment for abnormal uterine bleeding.
Diwakar L,Roberts T E,Cooper N A M,Middleton L,Jowett S,Daniels J,Smith P,Clark T J,
BJOG : an international journal of obstetrics and gynaecology
OBJECTIVES:To undertake a cost-effectiveness analysis of outpatient uterine polypectomy compared with standard inpatient treatment under general anaesthesia. DESIGN:Economic evaluation carried out alongside the multi-centre, pragmatic, non-inferiority, randomised controlled Outpatient Polyp Treatment (OPT) trial. The UK National Health Service (NHS) perspective was used in the estimation of costs and the interpretation of results. SETTING:Thirty-one secondary care UK NHS hospitals between April 2008 and July 2011. PARTICIPANTS:Five hundred and seven women with abnormal uterine bleeding and hysteroscopically diagnosed endometrial polyps. INTERVENTIONS:Outpatient uterine polypectomy versus standard inpatient treatment. Clinicians were free to choose the technique for polypectomy within the allocated setting. MAIN OUTCOME MEASURES:Patient-reported effectiveness of the procedure determined by the women's self-assessment of bleeding at 6 months, and QALY gains at 6 and 12 months. RESULTS:Inpatient treatment was slightly more effective but more expensive than outpatient treatment, resulting in relatively high incremental cost-effectiveness ratios. Intention-to-treat analysis of the base case at 6 months revealed that it cost an additional £9421 per successfully treated patient in the inpatient group and £ 1,099,167 per additional QALY gained, when compared with outpatient treatment. At 12 months, these costs were £22,293 per additional effectively treated patient and £445,867 per additional QALY gained, respectively. CONCLUSIONS:Outpatient treatment of uterine polyps associated with abnormal uterine bleeding appears to be more cost-effective than inpatient treatment at willingness-to-pay thresholds acceptable to the NHS. TWEETABLE ABSTRACT:HTA-funded OPT trial concluded that outpatient uterine polypectomy is cost-effective compared with inpatient polypectomy.
Outpatient hysteroscopic polypectomy: bipolar energy system (Versapoint®) versus diode laser - randomized clinical trial.
Lara-Domínguez Maria D,Arjona-Berral Jose E,Dios-Palomares Rafaela,Castelo-Branco Camil
Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology
OBJECTIVE:To compare the resection of endometrial polyps with two different devices: the Versapoint biopolar electrode and the Diode Laser. METHODS:One hundred and two patients diagnosed with endometrial polyps were randomly assigned to undergo hysteroscopic polypectomy: one group (n = 52) performed with Versapoint bipolar electrode through a 5Fr working channel and the other group with Biolitec Diode Laser (n = 50) using a specific fiber for polyps in a 7Fr working channel. All cases were managed on an outpatient basis, without anesthesia and using a rigid 30(o) hysteroscope and saline solution as a distention medium. MAIN OUTCOME MEASURES:Complete resection rate, operative time, complications, intraoperative pain and relapse rate after three months. RESULTS:Intraoperative pain and polyp resection time was similar in both groups. Upon second look hysteroscopy at 3-month, a higher percentage of women of the Versapoint group presented polyp relapse (32.6 versus 2.2%, p = 0.001). Elimination of the polyp after incomplete resection was higher in the Laser group. A significantly higher number of patients in the Laser group considered the procedure to be highly recommendable (p = 0.02). CONCLUSION:Polypectomy with Diode Laser resulted in fewer relapses and a higher procedure satisfaction rate as compared to Versapoint.
Hysteroscopic Curettage Using the Lin Snare and Y Adaptor: A Review of 300 Cases.
Chin Hsuan,Lin Bao-liang
Journal of minimally invasive gynecology
STUDY:To present a de novo technique of endometrial sampling - hysteroscopic curettage. OBJECTIVE:Aim to describe this new procedure and study its effectiveness and accuracy. DESIGN:Prospective study (Canadian Task Force Classification II-2). SETTING:University-affiliated public hospital. PATIENTS:Two hundred and ninety-three consecutive patients who attended outpatient gynaecological endoscopic centre. INTERVENTION:A total of 300 hysteroscopic curettage was carried out using flexible hysteroscope and Lin snare system. MAIN RESULTS:The procedure failure rate is 2.67%. Out of 292 successful hysteroscopic curettages, hysteroscopy alone has a sensitivity of 99% and negative predictive value of 97.7%. The accuracy was further improved to near perfection with curettage histology. The negative predictive value is 99%. CONCLUSION:Hysteroscopic curettage is easy to perform, highly effective and accurate. It offers an excellent outpatient alternative for patients who require endometrial sampling and/or an evaluation of abnormal uterine bleeding.
Campo R,Santangelo F,Gordts S,Di Cesare C,Van Kerrebroeck H,De Angelis M C,Di Spiezio Sardo A
Facts, views & vision in ObGyn
Modern hysteroscopy represents a copernical revolution for the diagnosis and treatment of uterine pathology. Traditionally hysteroscopy was performed in a conventional operation room under general anaesthesia (in-patient hysteroscopy). Recent advances in technology and techniques made hysteroscopy less painful and invasive allowing it to be performed in an ambulatory setting (outpatient hysteroscopy). The so called "see & treat hysteroscopy", has reduced the distinction between diagnostic and operative procedure, thus, introducing the concept of a single procedure in which the operative part is perfectly integrated within the diagnostic work-up. The "digital hysteroscopic clinic" (DHC) on the other hand combines ultrasound with hysteroscopy, ideal for a one stop diagnostic procedure and surgical approach, outlasting laparoscopy with ultrasound, for increased surgical performance in outpatient settings. The aim of this paper is to describe the "state of the art" in an outpatient hysteroscopy setting.
Hysteroscopic Management of Retained Products of Conception.
Lin Yu-Hui,Cheng Yung-Yi,Ding Dah-Ching
Gynecology and minimally invasive therapy
We report a case with retained products of conception (RPOC) managed by hysteroscopic resection. A 45-year-old woman, G5P3SA1AA1, experienced spontaneous abortion on March 8, 2017, and had persistent vaginal bleeding since then. On May 12, 2017, she came to emergency room where endometrium biopsy was done and revealed degenerative gestational tissue with acute inflammation. On May 23, 2017, she followed up at outpatient department where ultrasonography showed no obvious intrauterine abnormalities with endometrial thickness of 6.5 mm. Office hysteroscopy was arranged and RPOC at the posterior uterine wall was suspected. She received hysteroscopic transcervical resection (TCR) of RPOC on May 26, 2017. After TCR, the vaginal bleeding discontinued. The pathology showed degenerative gestational products with acute inflammation. In conclusion, hysteroscopic TCR might be safe and feasible for RPOC.
Endophytic-Type Endometrial Cancer with Adenomyosis Successfully Diagnosed with Hysteroscopic Endometrial Biopsy Using an 8.3-mm Operative Resectoscope: A Case Report.
Honda Michiko,Tsuchiya Akira,Isono Wataru,Takahashi Mikiko,Fujimoto Akihisa,Kawamoto Masashi,Nishii Osamu
Case reports in oncology
In order to diagnose endometrial cancer preoperatively, outpatient endometrial biopsy with a curette is frequently performed owing to its convenience. However, in some cases, gynecologists fail to diagnose endometrial cancer via outpatient endometrial biopsy because of the cancer's distribution in the uterus and its consistency. A 57-year-old Japanese woman (gravida 4 para 4) presented with a 6-month history of light but intermittent postmenopausal vaginal bleeding. A malignant uterine tumor was strongly suspected after imaging using ultrasound examination and magnetic resonance imaging; however, a precise pathological diagnosis was not achieved despite multiple outpatient endometrial biopsies with the aid of office hysteroscopy. Based on an endometrial biopsy obtained using a cutting loop electrode on an 8.3-mm operative resectoscope, we reached a diagnosis of endophytic-type endometrial cancer, which is in accordance with the final pathological diagnosis after abdominal hysterectomy. Three months after her first visit to our hospital, total abdominal hysterectomy and bilateral salpingo-oophorectomy with pelvic/para-aortic lymph node dissection were performed. Macroscopically, the endometrium was atrophic, and there was no obvious mass in the uterine cavity; however, microscopically, the cancer cells mainly existed in the deep myometrium and the final diagnosis was International Federation of Gynecology and Obstetrics (FIGO) stage IB endometrial cancer. Operative biopsy of the uterine endometrium and deep myometrium using hysteroscopy confirmed an accurate preoperative diagnosis of uterine endometrial cancer specifically of the endophytic type.
Hysteroscopy after repeated implantation failure of assisted reproductive technology: A meta-analysis.
Cao Hanyu,You Di,Yuan Mingwei,Xi Mingrong
The journal of obstetrics and gynaecology research
We conducted this meta-analysis to explore the prognostic value of outpatient (or office) hysteroscopy (OH) preceding in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) cycles in women who had experienced repeated implantation failure (RIF), particularly in regard to the conflicting evidence reported by previous studies. Two reviewers independently searched Pubmed, MEDLINE, Web of Science, Cochrane Library and Embase to identify all publications of clinical trials of hysteroscopy with or without endometrial biopsy in RIF patients. The primary outcome measures were clinical pregnancy rate (CPR) and live birth rate (LBR). Pooled relative ratios (RRs) with 95% confidence intervals (CIs) were calculated. Publication bias was detected using funnel plots and Egger's regression tests. Six eligible studies comprising 4143 patients were included. The CPR and LBR were both significantly higher in RIF patients with OH than RIF patients without OH (CPR: RR 1.34, 95% CI 1.14-1.57, P < 0.05; LBR: RR 1.29, 95% CI 1.03-1.62, P < 0.05). Subgroup analysis revealed a significant association between OH and CPR in Asia (CPR: RR 1.49, 95% CI 1.31-1.69; P < 0.05) rather than in Europe (CPR: RR 1.08, 95% CI 0.93-1.26; P = 0.291). However, there was no evidence of a significant difference in either CPR or LBR between the normal and abnormal OH groups (CPR: RR 0.92, 95% CI 0.83-1.02, P = 0.12; LBR: RR 0.76, 95% CI 0.37-1.56, P = 0.450). Hysteroscopy may potentially improve pregnancy outcomes in patients with RIP.
Abnormal Uterine Bleeding- evaluation by Endometrial Aspiration.
Journal of mid-life health
Endometrial evaluation is generally indicated in cases presenting with abnormal uterine bleeding (AUB), especially in women more than 35 years of age. AUB encompasses a variety of presentation, for example, heavy menstrual bleeding, frequent bleeding, irregular vaginal bleeding, postcoital and postmenopausal bleeding to name a few. Many methods are used for the evaluation of such cases, with most common being sonography and endometrial biopsy with very few cases requiring more invasive approach like hysteroscopy. Endometrial aspiration is a simple and safe office procedure used for this purpose. Materials and Methods:We retrospectively analyzed cases of AUB where endometrial aspiration with Pipette (Medgyn) was done in outpatient department between January 2015 and April 2016. Case records (both paper and electronic) were used to retrieve data. Results:One hundred and fifteen cases were included in the study after applying inclusion and exclusion criteria. Most cases were between 46 and 50 years of age followed by 41-45 years. No cases were below 25 or more than 65 years of age. Heavy menstrual bleeding was the most common presentation of AUB. Adequate samples were obtained in 86% of cases while 13.9% of cases' sample was inadequate for opinion, many of which were later underwent hysteroscopy and/or dilatation and curettage (D and C) in operation theater; atrophic endometrium was the most common cause for inadequate sample. Uterine malignancy was diagnosed in three cases. Discussion:Endometrial aspiration has been compared with traditional D and C as well as postoperative histopathology in various studies with good results. Many such studies are done in India as well as in western countries confirming good correlation with histopathology and adequate tissue sample for the pathologist to give a confident diagnosis. No complication or side effect was noted with the use of this device. Conclusion:Endometrial aspiration is a simple, safe, and effective method to sample endometrium in cases of AUB avoiding risk of anesthesia and is less time-consuming. Many similar devices are also available in the market and need to be popularized in all parts of the country.
What should the optimal intrauterine pressure be during outpatient diagnostic hysteroscopy? A randomized comparative study.
Karaman Erbil,Kolusarı Ali,Çetin Orkun,Çim Numan,Alkış İsmet,Karaman Yasemin,Güler Seyithan
The journal of obstetrics and gynaecology research
AIM:The aim of this study was to evaluate and compare lower and higher uterine filling pressures during outpatient diagnostic hysteroscopy. METHODS:One hundred and seventy-five women eligible for outpatient diagnostic hysteroscopy were included in this randomized double blind comparative study. The subjects were randomized into two groups. Group 1 (n = 80) underwent surgery with lower intrauterine filling pressures (30, 40, and 50 mmHg) and group 2 (n = 81) underwent surgery with higher filling pressures (70, 80, and 100 mmHg). The primary outcome measure was adequate visibility during the procedure. The secondary outcome measure was pain perceived by the patient during and 30 min after the procedure. RESULTS:In total, 161 patients completed the trial. Group 2 had significantly higher adequate visibility than group 1 (71/80, 88.75% in group 1 and 79/81, 97.5% in group 2, P = 0.008). There was a trend toward increase in pain scores with higher pressures during the procedure. However, there were no significant differences between the two groups in terms of visual analog scale pain scores measured 30 min after the procedure. CONCLUSION:Lower uterine filling pressure was associated with lower pain scores with a higher trend towards inadequate visibility. It appears that higher filling pressure can be used for performing office hysteroscopy, but it is associated with higher pain scores.
[Comparison of current methods of tubal patency assessment].
Lőrincz Judit,Jakab Attila,Török Péter
Most common organic cause of infertility is the blockage of the Fallopian tubes. Several methods were introduced to evaluate tubal patency. Hysterosalpingography is a conventional radiology procedure using contrast medium, which gives an accurate image of the uterine cavity and the Fallopian tubes, but radiation exposure is necessary. Hystero-contrast-sonography similarly examines the uterine cavity and tubal patency by ultrasonography, and it enables to detect pelvic pathology, too. Transvaginal hydrolaparoscopy is a minimal invasive direct method using endoscope introduced into the abdominal cavity through the posterior vaginal fornix, both ovaries and tubal patency can be observed. Laparoscopy is the "gold standard" procedure in the tubal testing, however it is a more invasive procedure. A cost-effective testing method is the selective tubal pertubation performed via office hysteroscopy. Recent outpatient methods to detect tubal patency have high negative predictive values and recommended to be the first choice in infertility work-up. Orv. Hetil., 2017, 158(9), 324-330.
Structured imaging technique in the gynecologic office for the diagnosis of abnormal uterine bleeding.
Dueholm Margit,Hjorth Ina Marie D
Best practice & research. Clinical obstetrics & gynaecology
The aim in the diagnosis of abnormal uterine bleeding (AUB) is to identify the bleeding cause, which can be classified by the PALM-COEIN (Polyp, Adenomyosis, Leiomyoma, Malignancy (and hyperplasia), Coagulopathy, Ovulatory disorders, Endometrial, Iatrogenic and Not otherwise classified) classification system. In a gynecologic setting, the first step is most often to identify structural abnormalities (PALM causes). Common diagnostic options for the identification of the PALM include ultrasonography, endometrial sampling, and hysteroscopy. These options alone or in combination are sufficient for the diagnosis of most women with AUB. Contrast sonography with saline or gel infusion, three-dimensional ultrasonography, and magnetic resonance imaging may be included. AIM:The aim of this article is to describe how a simple structured transvaginal ultrasound can be performed and implemented in the common gynecologic practice to simplify the diagnosis of AUB and determine when additional invasive investigations are required. Structured transvaginal ultrasound for the identification of the most common endometrial and myometrial abnormalities and the most common ultrasound features are described. Moreover, situations where magnetic resonance imaging may be included are described. This article proposes a diagnostic setup in premenopausal women for the classification of AUB according to the PALM-COEIN system. Moreover, a future diagnostic setup for fast-track identification of endometrial cancer in postmenopausal women based on a structured evaluation of the endometrium is described.
Safety and Efficiency in a Canadian Outpatient Gynaecological Surgical Centre.
Lee Caroline E,Epp Annette
Journal of obstetrics and gynaecology Canada : JOGC = Journal d'obstetrique et gynecologie du Canada : JOGC
OBJECTIVE:This study sought to describe safety and efficiency outcomes for patients undergoing procedures at the Women's Health Centre, an outpatient gynaecological surgical centre in Saskatoon, SK. METHODS:A retrospective chart review of surgical outpatient health records was conducted for the period of July 2014 to June 2015. Data were abstracted using a standardized data form for patient admissions during the study period. Primary outcomes of interest included procedure time, lead time (registration to discharge), complication rates, readmission rates, and reoperation rates. Descriptive statistics were calculated using Microsoft Excel and were summarized using frequencies and percentages. The Kruskal-Wallis test was performed for lead time and procedural time by using IBM SPSS Statistics 24 software (IBM, Armonk, NY). RESULTS:During the study period, 1720 patients were seen by 21 providers. The mean number of patients seen per month was 144. The main services provided include hysteroscopic sterilization, non-resectoscopic endometrial ablation, loop electrosurgical excision procedure, hysteroscopy, and therapeutic abortion. Pain management was administered by local anaesthetic and/or conscious sedation. The mean procedure time was 10 ± 6 minutes, whereas the lead time was 171 ± 43 minutes. Immediate complications occurred in 3.9% of patients, the most common being vaginal bleeding (1.3%). The long-term complication rate was 5.1%, with the most common complication being reoperation in the main operating room, at 2.9%. CONCLUSION:Currently, many gynaecological procedures in Canada occur in a formal operating theatre setting. Our study demonstrates the safety and efficiency of an alternate setting where gynaecological procedures are performed on an outpatient basis by using local anaesthetic and conscious sedation.
Accuracy of Two-Dimensional Transvaginal Sonography and Office Hysteroscopy for Detection of Uterine Abnormalities in Patients with Repeated Implantation Failures or Recurrent Pregnancy Loss.
Shiva Marzieh,Ahmadi Firouzeh,Arabipoor Arezoo,Oromiehchi Mansoureh,Chehrazi Mohammad
International journal of fertility & sterility
Background:We sought to compare diagnostic values of two-dimensional transvaginal sonography (2D TVS) and office hysteroscopy (OH) for evaluation of endometrial pathologies in cases with repeated implantation failure (RIF) or recurrent pregnancy loss (RPL). MATERIALS AND METHODS:This prospective study was performed at Royan Institute from December 2013 to January 2015. TVS was performed before hysteroscopy as part of the routine diagnostic work-up in 789 patients with RIF or RPL. Uterine biopsy was performed in cases with abnormal diagnosis in TVS and/or hysteroscopy. We compared the diagnostic accuracy values of TVS in detection of uterine abnormalities with OH by receiver operating characteristic (ROC) curve analysis. RESULTS:TVS examination detected 545 (69%) normal cases and 244 (31%) pathologic cases, which included 84 (10.6%) endometrial polyps, 15 (1.6%) uterine fibroids, 10 (1.3%) Asherman's syndrome, 9 (1.1%) endometrial hypertrophy, and 126 (15.9%) septate and arcuate uterus. TVS and OH concurred in 163 pathologic cases, although TVS did not detect some pathology cases (n=120). OH had 94% sensitivity, 95% specificity, 62% positive predictive value (PPV), and 99% negative predictive value (NPV) for detection of endometrial polyps. In the diagnosis of myoma, sensitivity, specificity, PPV, and NPV were 100%. TVS had a sensitivity of 50% and specificity of 98% for the diagnosis of myoma. For polyps, TVS had a sensitivity of 54% and specificity of 80%. Area under the ROC curve (AUROC) was 70.69% for the accuracy of TVS compared to OH. CONCLUSION:TVS had high specificity and low sensitivity for detection of uterine pathologies in patients with RIF or RPL compared with OH. OH should be considered as a workup method prior to treatment in patients with normal TVS findings.
Office Operative Hysteroscopy: An Update.
Salazar Christina Alicia,Isaacson Keith B
Journal of minimally invasive gynecology
Hysteroscopy is considered the gold standard for the evaluation of intracavitary pathology in both premenopausal and postmenopausal patients associated with abnormal uterine bleeding, as well as for the evaluation of infertile patients with suspected cavity abnormalities. Office-based operative hysteroscopy allows patients to resume activities immediately and successfully integrates clinical practice into a "see and treat" modality, avoiding the added risks of anesthesia and the inconvenience of the operating room. For 2017, the Centers for Medicare and Medicaid Services has provided a substantial increase in reimbursement for a select number of office-based hysteroscopic procedures. This review provides an update on the indications, equipment, and procedures for office hysteroscopy, as well as the management of complications that may arise within an office-based practice.
Office hysteroscopic-guided selective tubal chromopertubation: acceptability, feasibility and diagnostic accuracy of this new diagnostic non-invasive technique in infertile women.
Carta Gaspare,Palermo Patrizia,Pasquale Chiara,Conte Valeria,Pulcinella Ruggero,Necozione Stefano,Cofini Vincenza,Patacchiola Felice
Human fertility (Cambridge, England)
The aim of this study was to evaluate accuracy, tolerability and side effects of office hysteroscopic-guided chromoperturbations in infertile women without anaesthesia. Forty-nine infertile women underwent the procedure to evaluate tubal patency and the uterine cavity. Women with unilateral or bilateral tubal stenosis at hysteroscopy with chromoperturbation, and women with bilateral tubal patency who did not conceive during the period of six months, underwent laparoscopy with chromoperturbation. The results obtained from hysteroscopy and laparoscopy in the assessment of tubal patency were compared. Sensitivity, specificity, accuracy, positive-predictive value and negative-predictive value were used to describe diagnostic performance. Pain and tolerance were assessed during procedure using a visual analogue scale (VAS). Side effects or late complications and pregnancy rate were also recorded three and six months after the procedure. The specificity was 87.8% (95% CI: 73.80-95.90), sensitivity was 85.7% (95% CI 57.20-98.20), positive and negative predictive values were 70.6% (95% CI: 44.00-89) and 94.7% (95% CI: 82.30-99.40), respectively. Pregnancy rate (PR) within six months after performance of hysteroscopy with chromoperturbation was 27%. Office hysteroscopy-guided selective chromoperturbation in infertile patients is a valid technique to evaluate tubal patency and uterine cavity.
Ambulatory management of heavy menstrual bleeding.
Di Spiezio Sardo Attilio,Spinelli Marialuigia,Zizolfi Brunella,Nappi Carmine
Women's health (London, England)
Heavy menstrual bleeding (HMB) has significant adverse effects on the quality of life of many women, placing an economic burden on both health services and society at large. Thus, it is essential that all women with HMB have easy access to the proper diagnostic and therapeutic work-up in an outpatient fashion, avoiding the more time-consuming inpatient management. This new outpatient approach for HMB is one of the latest development of gynecological practice and can offer both diagnostic and therapeutic procedures. This manuscript aims to show the current possibilities of the modern management of HMB, which can be safely and effectively accomplished in the outpatient setting: global and directed endometrial biopsy, levonorgestrel intrauterine system insertion as well as minimally invasive surgical procedures (encompassing a variety of operative hysteroscopic procedures and second-generation endometrial ablation) are described below.
Feasibility of hysteroscopic endometrial polypectomy using a new dual wavelengths laser system (DWLS): preliminary results of a pilot study.
Nappi Luigi,Sorrentino Felice,Angioni Stefano,Pontis Alessandro,Litta Pietro,Greco Pantaleo
Archives of gynecology and obstetrics
PURPOSE:Currently, endometrial polyps may be successfully treated in an outpatient setting with 5 Fr mechanical and bipolar instruments. Our aim is to evaluate the benefits of minimally invasive techniques in hysteroscopy, focusing on the use of a new dual wavelengths laser system in the treatment of endometrial polyps in an outpatient setting. METHODS:Between September 2012 and December 2014, all consecutive patients of reproductive and menopausal age with ultrasound diagnosis of endometrial polyp with maximum diameter ≤2.5 cm were eligible to participate in a prospective study. They underwent a hysteroscopic procedure with excision of the polyp using a new dual wavelengths laser system. All procedures were performed on an outpatient basis without anesthesia. RESULTS:Laser polypectomy was successfully performed in 219 out of 225 (97.3%). Success of surgery was not influenced by the initial location of polyp. No main complications were reported during or immediately after the procedure. 6 and 12 months follow-up with ultrasound scan did not show any persistence or recurrence of the pathology. CONCLUSIONS:Our preliminary findings seem to support the safety and the effectiveness of the laser hysteroscopic endometrial polypectomy. However, further studies are mandatory to validate its use in daily hysteroscopic practice.
Investigating vaginal bleeding in postmenopausal women found to have an endometrial thickness of equal to or greater than 10 mm on ultrasonography.
Turnbull Hilary L,Akrivos Nikolaos,Simpson Paul,Duncan Timothy J,Nieto Joaquin J,Burbos Nikolaos
Archives of gynecology and obstetrics
PURPOSE:This aim of this study is to determine the risk of endometrial cancer in symptomatic postmenopausal women, when endometrial thickness on transvaginal ultrasonography is equal to or greater than 10 mm, and subsequent office-based endometrial sampling histology is negative. METHODS:This is a prospective cross-sectional study, performed in a gynaecological oncology centre in the United Kingdom between February 2008 and July 2012. All postmenopausal women presenting with vaginal bleeding were investigated using transvaginal ultrasonography. Women with endometrial thickness measurements equal to or greater than 10 mm and negative office-based endometrial biopsy underwent hysteroscopy and endometrial biopsies. RESULTS:Over a 52-month period, 4148 women were investigated for postmenopausal vaginal bleeding. 588 (14.2%) women were found to have endometrial thickness measurements of equal to or greater than 10 mm on transvaginal ultrasonography. 170 (28.9%) cases of endometrial cancer were diagnosed in this group: 149 (87.6%) of the cancer cases were diagnosed in the outpatient setting with a Pipelle endometrial sampler, whilst 21 (12.4%) had a negative Pipelle sample and were diagnosed with hysteroscopy. The group diagnosed with hysteroscopy had lower BMI (32.7 kg/m versus 39.7 kg/m, p < 0.001) whilst the group diagnosed with Pipelle was more likely to have a history of hypertension and diabetes mellitus (p = 0.019 for both). The sensitivity of Pipelle was 87.65%. CONCLUSION:For women presenting with postmenopausal bleeding and where the endometrial thickness is equal to or greater than 10 mm and Pipelle sampling is negative, hysteroscopic evaluation with directed biopsy is strongly recommended.
Endometrial Polyps and Abnormal Uterine Bleeding (AUB-P): What is the relationship, how are they diagnosed and how are they treated?
Clark T Justin,Stevenson Helen
Best practice & research. Clinical obstetrics & gynaecology
The diagnosis and treatment of endometrial polyps will be familiar to most gynaecologists. However, the aetiology and natural history of these focal intrauterine lesions are yet to be elucidated. This lack of clarity is also true with regard to their clinical significance; whilst endometrial polyps are highly prevalent in all types of abnormal uterine bleeding (AUB), they are also commonly found in women without AUB. These controversies will be discussed along with current thoughts on the diagnosis and treatment of endometrial polyps. Criteria for diagnosis of uterine polyps vary according to the test used, but optimal testing is not yet solidified. Recent data from randomised trials evaluating new and established surgical technologies as well as comparing treatment protocols and settings will be examined.