What is the recurrence rate of postmenopausal bleeding in women who have a thin endometrium during a first episode of postmenopausal bleeding?

OBJECTIVE: To determine the incidence and significance of recurrent postmenopausal bleeding among women diagnosed with an endometrial thickness < or =4 mm after a first episode of postmenopausal bleeding. METHODS: Consecutive patients not using hormone replacement therapy (HRT) presenting with a first episode of postmenopausal bleeding and an endometrial thickness < or =4 mm at transvaginal ultrasonography (TVU) were managed expectantly. In case of recurrent bleeding, the patient was evaluated according to the hospital's local policy with TVU, office endometrial sampling, hysteroscopy or dilatation and curettage (D&C) or a combination of these tests. We evaluated the incidence of recurrent bleeding, potential risk factors for recurrent bleeding, and the diagnosis made after recurrent bleeding. RESULTS: A total of 607 patients were registered with a first episode of postmenopausal bleeding, of whom 249 had an endometrial thickness < or =4 mm. Follow-up took place with a median of 174 weeks (range: 4-250 weeks). During follow-up, 25 of the 249 patients (10%; 95% CI: 6.6-14%) had recurrent bleeding. Median time until recurrence of bleeding was 49 weeks (range: 9-186 weeks). Two patients with recurrent bleeding turned out to have an endometrial carcinoma (8%; 95% CI: 2.2-25%), and 1 patient had a malignant melanoma. Time since menopause, age, body mass index, hypertension, diabetes and anticoagulants were not predictive for recurrent bleeding. CONCLUSION: The recurrence rate after a first episode of postmenopausal bleeding managed expectantly is low and cannot be predicted by patient characteristics. Patients with recurrent bleeding should be re-evaluated, as they bear a considerable risk of carcinoma.

Perioperative surgical outcome of conventional and robot-assisted total laparoscopic hysterectomy.

BACKGROUND: To evaluate surgical outcome in a consecutive series of patients with conventional and robot assisted total laparoscopic hysterectomy. METHODS: A retrospective cohort study was performed among patients with benign and malignant indications for a laparoscopic hysterectomy. Main surgical outcomes were operation room time and skin to skin operating time, complications, conversions, rehospitalisation and reoperation, estimated blood loss and length of hospital stay. RESULTS: A total of 294 patients were evaluated: 123 in the conventional total laparoscopic hysterectomy (TLH) group and 171 in the robot TLH group. After correction for differences in basic demographics with a multivariate linear regression analysis, the skin to skin operating time was a significant 18 minutes shorter in robot assisted TLH compared to conventional TLH (robot assisted TLH 92m, conventional TLH 110m, p0.001). The presence or absence of previous abdominal surgery had a significant influence on the skin to skin operating time as did the body mass index and the weight of the uterus. Complications were not significantly different. The robot TLH group had significantly less blood loss and lower rehospitalisation and reoperation rates. CONCLUSIONS: This study compares conventional TLH with robot assisted TLH and shows shorter operating times, less blood loss and lower rehospitalisation and reoperation rates in the robot TLH group.

The accuracy of transvaginal ultrasonography in the diagnosis of endometrial abnormalities.

OBJECTIVE: To evaluate the diagnostic accuracy of transvaginal ultrasonography for endometrial abnormalities in women with abnormal uterine bleeding. METHODS: In a prospective study, 136 consecutive patients underwent transvaginal ultrasonography, hysteroscopy, and endometrial sampling through suction curettage or directed biopsy. The ultrasonographic findings were evaluated on the basis of the final diagnosis established by hysteroscopy and histologic examination. Receiver operating characteristic curve analysis and likelihood ratios were used. Likelihood ratios algebraically combine sensitivity and specificity to describe more than the independent values themselves, specifically the change in odds favoring disease given a particular test result. RESULTS: In 21 of the 136 patients, hysteroscopy detected polyps or submucous myomas, which curettage failed to detect. In 67 premenopausal women, ultrasonography demonstrated a sensitivity in diagnosing endometrial abnormalities of 88% and a specificity of 68%, using a cutoff point of 5 mm of single-layer endometrial thickness. The positive likelihood ratio was 2.8 (95% confidence interval [CI] 1.66-4.55) and negative likelihood ratio 0.18 (95% CI 0.07-0.46). In 69 postmenopausal women, using a cutoff point of 3 mm, the sensitivity, specificity, positive likelihood ratio and negative likelihood ratio were 97%, 74%, 3.7 (95% CI 2.18-6.38), and 0.04 (95% CI 0.01-0.28) respectively. CONCLUSIONS: Transvaginal ultrasonography is an excellent first-step diagnostic method of excluding the endometrial abnormalities in women with postmenopausal bleeding but is of limited use in premenopausal women with irregular bleeding. Ultrasonography may reduce the number of invasive endometrial investigations by approximately 40%.

Transvaginal ultrasonography and endometrial changes in postmenopausal breast cancer patients receiving tamoxifen.

OBJECTIVES: To assess an estrogenic effect of tamoxifen on the uterus and to evaluate the usefulness of transvaginal ultrasonography for identifying tamoxifen-induced endometrial pathology. METHODS: One hundred and two postmenopausal breast cancer patients without gynecological symptoms were examined by transvaginal ultrasonography. Forty-eight patients were treated with tamoxifen and 54 patients served as reference. An endometrial thickness of > or = 6 mm (double-layer) was used as cut-off point for further hysteroscopic and histologic examination. RESULTS: Thirty percent of the women taking tamoxifen had evidence of an abnormal postmenopausal endometrium compared with 6% in the reference group (P = 0.005). Those patients receiving tamoxifen had a significantly thicker endometrium (median 6.0 mm versus 2.0 mm; P < 0.001), a larger uterine volume (median 93 cm3 versus 72 cm3; P = 0.03) and more uterine fluid (12% versus 2%; P = 0.005). Furthermore, an ultrasonographic suspect 'Swiss-cheese' endometrial pattern was noted in almost a quarter of the patients treated with tamoxifen, but this was clearly not associated with intracavitary pathology. CONCLUSIONS: Our data indicate that tamoxifen stimulates the uterine body and endometrium. The data also indicate that the ultrasonographic endometrial appearance during tamoxifen therapy may be misleading and that a high percentage (46%) of false-positive results occur. Therefore, in asymptomatic postmenopausal breast cancer patients taking tamoxifen, the findings on ultrasonography should be interpreted with caution.

Cost-effectiveness of transvaginal sonography and saline infused sonography in the evaluation of menorrhagia.

OBJECTIVES: To assess the cost-effectiveness of transvaginal sonography (TVS) and saline infused sonography (SIS) in the diagnostic work-up of women with menorrhagia. METHODS: We performed a decision analysis in which we compared the percentage of patients treated successfully and cost of six strategies for the evaluation of menorrhagia: (0) hormonal treatment, (I) treatment of all patients with balloon ablation, (II) TVS and therapeutic hysteroscopy, (III) TVS, SIS and therapeutic hysteroscopy, (IV) SIS and therapeutic hysteroscopy, and (V) diagnostic hysteroscopy and therapeutic hysteroscopy. Hormonal treatment was considered to be the reference strategy to which the five strategies were compared. Data were obtained from the published literature. In order to evaluate the robustness of our results, we performed extensive sensitivity analyses, in which we varied sensitivity and specificity of TVS and hysteroscopy, the prevalence of intracavitary abnormalities, as well as costs of TVS and SIS. RESULTS: We found that the strategy starting with SIS (IV) and the strategy with diagnostic hysteroscopy (V) revealed the highest number of patients treated successfully for menorrhagia. In terms of cost-effectiveness, SIS for all patients was superior over immediate diagnostic hysteroscopy for all patients. Strategies starting with TVS were less effective than the strategy starting with SIS. CONCLUSIONS: We recommend SIS as the procedure of first choice in the work-up for women with menorrhagia.

Is balloon ablation as effective as endometrial electroresection in the treatment of menorrhagia?

BACKGROUND: Hot-fluid balloon therapy is a recently introduced, relatively simple endometrial ablation procedure for menorrhagia. Because it is thought to be safer than other ablation procedures, it would be superior to other types of ablation if it is equally effective. The purpose of the present study was therefore to compare the safety and effectiveness of balloon ablation and transcervical resection of the endometrium (TCRE) for the treatment of menorrhagia. PATIENTS AND METHODS: We performed a prospective cohort study comparing TCRE and hot-fluid balloon ablation in consecutive patients suffering from menorrhagia and not responding to medical treatment. Between 1992 and 1994, all patients had TCRE, whereas from 1995 onward, all patients had balloon therapy. Outcome measures were surgical reintervention, menstrual pattern, and patient satisfaction. Assuming a 9% reintervention rate after TCRE, a series of 150 patients was required to show balloon ablation to be equally effective. RESULTS: Of the 152 patients who were included, 75 underwent TCRE and 77 had balloon ablation. The procedure had to be abandoned in 13 patients in the TCRE group (17%) and in 8 patients in the balloon ablation group (10%). In the TCRE group, four patients underwent a second resection, whereas hysterectomy was performed in 15 patients (3-year cumulative reintervention rate 26%). In the balloon-ablation group, there were no reresections, whereas hysterectomy was performed in 9 patients (3-year cumulative reintervention rate 13%) (log-rank test P = 0.11). The relative risk for any reintervention was 0.36 (95% confidence interval 0.05-2.5). At 3 months' follow-up the duration of menstruation was significantly shorter after TCRE than after balloon ablation, but at 6, 12, and 24 months, the duration of menstruation in the two groups appeared to be equal. No difference in patient satisfaction could be detected between the two groups, but there appeared to be a statistically significant decline in patient satisfaction over time for both therapies. This decline was stronger after TCRE than after balloon ablation. CONCLUSIONS: Because endometrial ablation with a hot-fluid balloon seems to be as effective as endometrial resection, with a lower complication rate, balloon ablation might become the procedure of choice for endometrial ablation.

[Carcinoma of the fallopian tube after prophylactic laparoscopic ovariectomy in a patient with a BRCAI mutation]. / Tubacarcinoom na profylactische laparoscopische ovariëctomie bij een patiënte met een BRCAI-genmutatie.

A 48-year-old woman with a distended abdomen appeared to have ascites and was admitted to the gynaecological ward. At the age of 31 years she had been diagnosed with breast cancer and had undergone surgical breast conservation of the right breast. There was a history of both ovarian cancer and breast cancer in her family. Genetic evaluation showed that she was carrying a BRCAI germline mutation. At the age of 42 years she underwent a prophylactic bilateral laparoscopic ovariectomy and 5 years later she underwent a complete mastectomy due to breast carcinoma of the left breast. Two months later she developed ascites, a raised CA125 level and on a CT scan carcinoma of the peritoneum. During the laparotomy a fallopian tube carcinoma was found. After the uterus, fallopian tubes and omentum had been surgically removed, chemotherapy took place. The patient tolerated this well and the CA125 value decreased. Recently, the first molecular evidence was found that linked fallopian tube cancer to germline mutations in BRCAI patients. Patients harbouring a BRCA germline mutation not only have an increased risk of ovarian carcinoma but also of fallopian tube carcinoma. Therefore, in patients with a BRCA mutation, prophylactic surgery should take the form of an adnexectomy, not an oophorectomy.

[Transvaginal contrast sonography of the uterus in the diagnosis of abnormal uterine blood loss: less hysteroscopies needed]. / Transvaginale contrastechoscopie van de uterus in de diagnostiek van abnormaal uterien bloedverlies: minder hysteroscopieën nodig.

OBJECTIVE: To determine the value of transvaginal saline-infusion sonography of the uterus in patients with abnormal uterine blood loss in terms of avoiding hysteroscopy. DESIGN: Prospective. METHOD: According to the protocol, transvaginal saline-infusion sonography was carried out on all consecutive patients with abnormal uterine blood loss (post-menopausal patients with an endometrial thickness of > or = 5 mm and all pre-menopausal patients with menorrhagia or metrorrhagia) in the St. Joseph hospital in Veldhoven, the Netherlands, during the period 1999-2001. If sonography did not provide an image suitable for assessment, or if intracavitary (pedunculated) lesions such as polyps or myomas were suspected, a planned therapeutic hysteroscopy was carried out. Patients indicated their perception of pain on a visual analogue scale. RESULTS: Saline-infusion sonography of the uterus was performed in 457 patients (age: 40-69 years). In 32 patients (7%) it did not result in a representative image. In 138 (32%) of the remaining 425 patients, a pedunculated lesion was suspected. In 262 (59%) of the 457 patients, diagnostic efforts were restricted to ultrasonic examination. This was combined with endometrial aspiration in 161 (61%) of these patients. In total, hysteroscopy was carried out in 195 of the 457 patients (43%). There were no complications. Pain was scored as 'none-little' by 292 patients (64%), 'moderate' by 76 (17%) and 'a great deal' by 48 (10%) patients. CONCLUSION: Saline-infusion sonography of the uterus is a safe diagnostic method in patients with abnormal uterine blood loss, which, in more than half the cases, can replace less well-tolerated diagnostic procedures.

Improvement of sexual function after transobturator tape procedure in women with stress urinary incontinence.

Sling procedures are a widely proven treatment for stress urinary incontinence. The aim of this prospective study was to evaluate the effect of the transobturator tape on female sexual functioning. Fifty-four women treated for stress urinary incontinence with transobturator tape filled out self-administered questionnaires on quality of life, urinary incontinence, and sexual function prior to surgery and 6 weeks and 12 months postoperatively. Preoperatively, 40 women (78%) were sexually active. There were no significant postoperative changes regarding frequency of sexual activity, sexual desire, and problems with lubrication or orgasm. Preoperatively, 55% reported urinary leakage during sexual activity and after surgery 6.5%. Sexual satisfaction was significantly improved 6 weeks (p = 0.05) and 12 months (p = 0.03) postoperatively. Pain during or after sexual activity was declined, only one patient reported worsening of pain. The transobturator tape procedure has a positive effect on female sexual functioning by reducing urinary leakage and pain during or after sexual activity. It seems to improve the overall sexual satisfaction. Further research is warranted to support these preliminary findings.

Laparoscopic subtotal hysterectomy versus laparoscopic total hysterectomy: a decade of experience.

At present, there are only few data on the surgical outcomes of laparoscopic hysterectomy (LH). Up till now, it has been unclear whether there is a difference in number of complications among the subcategories of laparoscopic total hysterectomy and laparoscopic subtotal hysterectomy (LSH). Therefore, we have performed a retrospective analysis to evaluate the peri- and postoperative outcomes in women undergoing LSH versus LH. This multi-centre retrospective cohort study (Canadian Task Force classification II-2) was conducted in multi-centres (two teaching hospitals and one university medical centre) in the Netherlands, all experienced in minimally invasive gynaecology. In a multi-centre retrospective cohort study we compared the long-term outcomes of laparoscopic subtotal hysterectomy and laparoscopic total hysterectomy (including laparoscopic assisted vaginal hysterectomy, laparoscopic hysterectomy and total laparoscopic hysterectomy). All laparoscopic hysterectomies from the last 10 years (January 1998 till December 2007) were included. Patient characteristics, intra- and postoperative complications, operating time and duration of hospital stay were recorded. The minimum follow-up was 6 months. A total of 390 cases of laparoscopic hysterectomies were included in the analysis: 192 laparoscopic subtotal hysterectomies and 198 laparoscopic total hysterectomies. Patient characteristics such as age and parity were equal in the groups. The overall number of short-term and long-term complications was comparable in both groups: 17% and 15%. Short-term complications (bleeding, fever) were 3% in the LSH group and 12% in the LH group. Long-term complications were (tubal prolapse and cervical stump reoperations) 15% in the LSH group and 3% in the LH group. Laparoscopic subtotal hysterectomy as compared with the different types of laparoscopic total hysterectomy is associated with more long-term postoperative complications, whereas laparoscopic total hysterectomy is associated with more short-term complications.

The relation between age, time since menopause, and endometrial cancer in women with postmenopausal bleeding.

The objective is to assess among women with postmenopausal bleeding the relationship of age and time since menopause on one hand and the presence of endometrial cancer and atypical hyperplasia on the other hand. In a multicenter prospective cohort study, 614 women presenting with postmenopausal bleeding were included. Women underwent transvaginal sonography and, in cases where the endometrial thickness was >4 mm, endometrial sampling. Splines were used to assess the association between each of the continuous variables and (pre)malignancy of the endometrium. Subsequently, univariate and multivariate analysis were performed. The average age for women without (pre)malignancy was 61.7 years (SD 9.8). As malignant and premalignant cases were found to have similar age, these subgroups were merged in the analyses. Age was an independent predictor of (pre)malignancy. In women younger than 55 years, the odds ratio was 1.9 (95% CI: 1.1-3.3) for each year under 55 years of age and 1.03 (95% CI: 1.00-1.06) for each year over 55 years of age. The risk of (pre)malignancy of the endometrium was 4.9% in women less than 3 years postmenopausal versus 19.7% in women more than 20 years postmenopausal. However, in a multivariate analysis only age contributed to the prediction of risk. This study demonstrates that, in postmenopausal women with vaginal bleeding, the risk of (pre)malignancy of the endometrium is low in women under 50 years of age, increases considerably until 55 years of age, and rises only modestly with further advancing age. Future studies should explore whether these findings can be incorporated in the diagnostic work-up of women with postmenopausal bleeding.

The accuracy of endometrial sampling in the diagnosis of patients with endometrial carcinoma and hyperplasia: a meta-analysis.

BACKGROUND: Endometrial assessment by means of biopsy or sampling of endometrial cells is a minimally invasive alternative for dilatation and curettage (D&C) or hysteroscopy. The use of this technique is believed to reduce the cost of the diagnostic work-up for abnormal uterine bleeding without reducing accuracy. Because the authors were not aware of any systematic review of this test, they performed a meta-analysis to assess the accuracy of endometrial sampling devices in the detection of endometrial carcinoma and atypical hyperplasia. METHODS: The authors searched the literature for studies published between 1966 and 1999 comparing the results of endometrial sampling with findings at D&C, hysteroscopy, and/or hysterectomy. They found 39 studies that included 7914 women. For each study, the fraction of patients was calculated in which endometrial sampling failed. Furthermore, the authors calculated the fraction of cases of endometrial carcinoma and atypical hyperplasia that were identified correctly as well as the fraction of women in whom these diseases were diagnosed false positively. RESULTS: The detection rate for endometrial carcinoma was higher in postmenopausal women compared with premenopausal women. In both postmenopausal and premenopausal women, the Pipelle was the best device, with detection rates of 99. 6% and 91%, respectively. For the detection of atypical hyperplasia, there was only one study that reported explicitly on postmenopausal women, thereby hampering the possibility of subgroup analysis. Again, the Pipelle was the most sensitive technique with a sensitivity of 81%. The specificity of all devices was > 98%. CONCLUSIONS: Endometrial biopsy with the Pipelle is superior to other endometrial techniques in the detection of endometrial carcinoma and atypical hyperplasia. The accuracy of the Pipelle is higher in postmenopausal women compared with premenopausal women.

Comparison of transvaginal sonography, saline infusion sonography, and hysteroscopy in premenopausal women with abnormal uterine bleeding.

PURPOSE: Saline infusion sonography (SIS) is a relatively new technique in the evaluation of abnormal uterine bleeding. We compared the diagnostic accuracy of SIS with that of transvaginal sonography (TVS) in the detection of intracavitary abnormalities in premenopausal women with abnormal uterine bleeding. METHODS: In this prospective study, consecutive premenopausal women who underwent a hysteroscopy for abnormal uterine bleeding also underwent TVS and SIS. The findings at TVS and SIS were compared with the hysteroscopic and histologic findings. Sensitivity, specificity, and likelihood ratios were calculated. Receiver operating characteristic curves were constructed to assess the performance of endometrial thickness measured using TVS. RESULTS: Sixty-two patients were included in the study. TVS demonstrated 60% sensitivity in directly visualizing intracavitary abnormalities and 93% specificity. The likelihood ratio of the presence of an intracavitary abnormality was 8, and the likelihood ratio of the absence of an intracavitary abnormality was 0.43. Defining an abnormality at TVS as direct visualization of an intracavitary abnormality or an endometrial thickness greater than 5 mm, TVS had an 85% sensitivity and a 21% specificity, with corresponding likelihood ratios of 1.1 and 0.71, respectively. For SIS, the sensitivity, specificity, and likelihood ratios of the presence and absence of intracavitary abnormalities were 88%, 95%, 10, and 0.13, respectively. CONCLUSIONS: SIS is more accurate in the diagnosis of intracavitary abnormalities in premenopausal women than is TVS. An approach using endometrial thickness measurement by TVS and reserving SIS for patients who have an endometrial thickness greater than 5 mm or an intracavitary abnormality visualized by TVS would be the most effective method to reduce the number of hysteroscopies.

Comparison of transvaginal ultrasonography and saline infusion sonography for the detection of intracavitary abnormalities in premenopausal women.

OBJECTIVE: To compare the diagnostic accuracy of transvaginal sonography (TVS) and saline infusion sonography (SIS) for detecting intracavitary abnormalities in premenopausal women with abnormal uterine bleeding. METHOD: Consecutive premenopausal women who underwent hysterectomy for abnormal uterine bleeding were included. All women underwent TVS and SIS before their hysterectomy. The findings at TVS and SIS were compared with the findings of the hysterectomy specimen. Sensitivity, specificity, and likelihood ratios were calculated. RESULTS: The results of 50 patients with abnormal uterine bleeding were evaluated. Histological examination revealed normal endometrial histology in 27 patients, submucous myomas in 13 patients and intracavitary polyps in 10 patients. The sensitivity of TVS in directly visualizing intracavitary abnormalities was 61% for a specificity of 96%. The likelihood ratio of presence of an intracavitary abnormality was 16 and the likelihood ratio of absence of such a finding was 0.41. When defining abnormality at TVS as direct visualization of an intracavitary abnormality or an increased endometrial thickness (cut-off level 5 mm), the sensitivity of TVS was 87% for a specificity of 56%, with corresponding likelihood ratios of 2 and 0.23, respectively. The sensitivity and specificity of SIS was 100% and 85% with likelihood ratios of 6 and 0.0, respectively. No intracavitary abnormality was missed by SIS. CONCLUSION: The diagnostic accuracy of SIS is higher than the accuracy of TVS. A combined approach using endometrial thickness measurement by TVS and, reserving SIS for patients with increased (> 5 mm) endometrial thickness, or endometrium inadequately visualized on TVS, is the optimal method of reducing the hysteroscopy rate.