Severe metrorrhagia in patients with advanced gynecologic cancer: endovascular treatment benefits in acute and chronic setting.

PURPOSE: Interventional radiology plays an established role in the management of many conditions of the female reproductive tract. Since in benign gynecological and obstetric pathologies, as myomas and postpartum hemorrhages, uterine arteries embolization has been already evaluated, this manuscript aims to report on a single-center experience concerning the endovascular management of metrorrhagia caused by gynecological malignancies. MATERIALS AND METHODS: Single-center retrospective analysis of thirty patients affected by gynecologic cancer treated with endovascular embolization between January 2016 and December 2018 for acute or chronic metrorrhagia. RESULTS: All patients were in advanced oncological stage (III or IV) with loco-regional spread of the tumor or invasion of pelvic structures, with a poor performance status. They were not suitable for surgery. On initial CT angiography, contrast media extravasation was confirmed in two patients (6.6%), while on DSA examination, tumor stain was displayed in 28 patients (93.4%). In two patients (6.6%) a pseudoaneurysm was reported. CONCLUSIONS: Endovascular treatment of metrorrhagia in oncologic patients could be a valid therapeutic alternative, especially when in elderly patients with poor clinical conditions not suitable for surgery. A bilateral and superselective embolization using non-resorbable embolic agents should be performed, except for those cases in which there is infiltration of major vessels causing pseudoaneurysms or fistulas that require embolization.

Unusual case of a small bowel leiomyoma presenting as an adnexal mass.

This case report will discuss an interesting case of a premenopausal woman who presented with an adnexal mass consistent with a leiomyoma on imaging. However, intraoperatively, the mass was thought to be a gastrointestinal stromal tumour but histological diagnosis subsequently confirmed a leiomyoma arising from the small bowel.

[The contribution of ultrasonography in the exploration of postmenopausal metrorrhagias]. / L'apport de l'échographie dans l'exploration des métrorragies post-ménopausiques.

Post-menopausal metrorrhagias represent a frequent reason for consultation in gynecology. Our study aims to evaluate the contribution of pelvic ultrasonography in the exploration of endocavitary lesions in people experiencing this symptom and to compare the results found with those of hysteroscopy and histology. This was an analytic retrospective study of 33 cases referred for evaluation of postmenopausal metrorrhagias at the department of gynecology and obstetrics «A¼ in the Center of Maternity and Neonatology of Tunis in 2012. All patients underwent pelvic ultrasonography and diagnostic hysteroscopy. We analyzed and compare the data obtained with pelvic ultrasonography, hysteroscopy and histological examination. The average age of our patients was 57.78 years and the average age of menopause was 48.36 years. The confrontation between ultrasonographic and histological data showed that ultrasonography has a sensitivity of 80.6%, a specificity of 79.38%, positive predictive value (PPV) of 67.03% and negative predictive value (NPV) of 91.54%. With respect to hysteroscopy these values were 84,44%, 82,72%, 69,93% and 92,65% respectively. Performance level for each exploratory diagnostic tool varied according to the lesion which caused metrorrhagias and generally hysteroscopy was more reliable in the exploration of metrorrhagias than ultrasonography: Youden index 0.67 against 0.59. Our results confirmed data published in the literature that assigns to hysteroscopy a greater reliability compared to pelvic ultrasonography in the diagnosis of endocavitary lesions causing postmenopausal metrorrhagias.

[Feasibility and diagnostic value of hysterosonography performed in bleeding time in the exploration of abnormal uterine bleeding]. / Faisabilité et valeur diagnostique de l'hystérosonographie réalisée en période de saignement dans l'exploration des saignements utérins anormaux.

OBJECTIVES: The aim of our study is to evaluate the feasibility, safety and diagnostic value of hysterosonography performed in an emergency setting among patients consulting for active abnormal uterine bleeding. MATERIALS AND METHODS: In this prospective study, we included 216 patients visiting our emergency department for abnormal uterine bleeding. All patients had a transvaginal ultrasound with doppler study and an hysterosonography. Secondly, the patients, in whom we diagnosed a suspected organic lesion, were addressed to an endoscopic or surgical procedure with pathological examination. Initially, we evaluated the feasibility and the safety of hysterosonography and secondly, we compared the two techniques (EEV and hysterosonography), sensitivity, specificity, LHR+and LHR-. RESULTS: The hysterosonography was performed in 98.1 % of patients and its realization has resulted in an additional period of 1.2minutes on average (extreme: 6-12) compared to ultrasound. The tolerance of the hysterosonographic examination was very good in 73.5 % of patients and good in 23.1 % of them. For the 167 patients who had been diagnosed with presumed organic lesions, pathological examination found an endometrial hyperplasia in 34.7 % of cases, polyps in 40.1 % of cases, sub-mucosal fibroids in 11.3 % of cases, endometrial cancer in 0.7 % of cases and other lesions in 13.2 % of cases. The diagnostic value of hysterosonography was superior to ultrasound in the detection of polyps (AUC: 0.894 vs 0.778, P=0.003) and fibromas (AUC: 1.000 vs 0.716, P=0.001) while the two methods showed no significant difference in the detection of hyperplasia. CONCLUSION: The purpose of our study was to focus on a particular context of use of the hysterosonography consisting on hemorrhagic period and on its realization in the emergency room. We were able to demonstrate that hysterosonography is compatible with the emergency situation as to its feasibility and its diagnostic value and that its realization would contribute to the sorting of patients to guide them immediately to a surgical or endoscopic procedure if necessary.

Correlation between transvaginal ultrasound measured endometrial thickness and histopathological findings in Turkish women with abnormal uterine bleeding.

AIM: The present study aims to determine how transvaginal ultrasonography and histopathological examination findings are correlated in a cohort of premenopausal and postmenopausal Turkish women with abnormal uterine bleeding. METHODS: This is a retrospective review of 350 Turkish women who underwent transvaginal ultrasonography and suction curettage as a result of abnormal uterine bleeding. RESULTS: Sonographic appearance of the endometrium was normal in 244 patients (69.7%), while homogeneous thickening was detected in 47 patients (13.4%) and cystic thickening in 21 patients (6.0%). A sonographic diagnosis of endometrial polyp was made in 38 patients (10.9%). Histopathological analysis of endometrial samplings revealed proliferative endometrium (36%), secretory endometrium (24.6%), decidualization (10.9%), endometrial polyp (8.3%), endometritis (6.8%), endometrial hyperplasia (4.6%), irregular shedding (3.7%), atrophic endometrium (3.1%), endometrial cancer (1.1%) and placental retention (0.9%). The sonographic and histopathological findings correlated significantly (χ(2) = 122 768, P = 0.001; r = 0.215, P = 0.001). Approximately 51% of the women with homogeneous endometrial thickening had proliferative endometrium. Only 44.7% of the women with ultrasonographically visualized endometrial polyps had histopathologically diagnosed endometrial polyps. Nearly 57% of the women with cystic endometrial thickening had proliferative endometrium. CONCLUSION: If there is no facility for hysteroscopy or hysteroscopy-guided endometrial biopsy for women with abnormal uterine bleeding, transvaginal ultrasonography findings can be efficiently used to make a preliminary diagnosis and, thus, notify the pathologists.

Sangramento uterino anormal: proposta de abordagem do Grupo Heavy Menstrual Bleeding: Evidence-Based Learning for Best Practice (HELP) / Heavy menstrual bleeding: management proposal of the Heavy Menstrual Bleeding: Evidence-Based Learning for Best Practice Group (HELP)

O Sangramento Uterino Anormal (SUA) representa um problema de saúde pública complexo que pode acometer 1/3 das mulheres em todo o mundo. Apresenta um impacto negativo importante na qualidade de vida de mulheres e associa-se a elevados custos econômicos diretos e indiretos. Trata-se de uma condição desafiadora tanto para as mulheres afetadas quanto para os profissionais de saúde. A nomenclatura atribuída ao SUA é confusa e faltam ainda recomendações diagnósticas e terapêuticas padronizadas. Foi criado o grupo Heavy Menstrual Bleeding: Evidence-based Learning for Best Practice (HELP) com proposta abordar os aspectos inconclusivos do SUA. Foram avaliados 134 documentos, incluindo 121 artigos científicos e 14 revisões de medicamentos, para desenvolvimento dos protocolos HELP. Foram elaborados protocolos simplificados referentes ao diagnóstico e tratamento do SUA, visando contribuir de forma mais eficaz com os médicos em seus diferentes cenários de atuação. O roteiro diagnóstico sugerido, compreendendo perguntas chaves e ações específicas, sinaliza para indicação de métodos propedêuticos adicionais. O tratamento proposto visa reduzir a perda do sangue menstrual e melhorar de a qualidade de vida das pacientes.(AU)

Abnormal uterine bleeding (AUB) is a complex public health problem that can affect one third of women worldwide. It has a significant negative impact on quality of life of women and is associated with high direct and indirect economic costs. It is a challenging condition for both the women affected and for the health professionals. The nomenclature assigned to the AUB is confusing and still miss diagnostic and therapeutic recommendations standardized. The Heavy Menstrual Bleeding: Evidence-based Learning for Best Practice Group (HELP) was created with the proposal to address the inconclusive aspects of AUB. The group evaluated 134 documents, including 121 scientific articles and 14 reviews of drugs for the development of protocols HELP. Simplified protocols were drawn up relating to the diagnosis and treatment of AUB, to contribute more effectively with doctors at different scenarios of operation. The script diagnostic suggested, comprising keys questions and specific actions, can indicate additional diagnostic methods. The proposed treatment aims to reduce the loss of menstrual blood and improve the quality of life of patients.(AU)

Transvaginal ultrasonography and hysteroscopy as predictors of endometrial polyps in postmenopause.

The study compared ultrasound and ambulatorial hysteroscopy as diagnostic methods detecting endometrial polyps in postmenopause women. 281 women aged 41-82 years who underwent ambulatorial hysteroscopy were analyzed for presence of uterine bleeding and/or altered transvaginal ultrasound (endometrial thickness ≥5 mm). Ultrasonography detected endometrial polyps in 22.8% of patients and endometrial thickening in the other 59.8%. Hysteroscopy diagnosed endometrial polyps in 80.8%. Ultrasonography showed sensitivity of 88.7%, specificity of 25.4%, positive predictive value of 81.7%, negative predictive value of 37.5% and accuracy of 75.4% in diagnosing endometrial polyps. Hysteroscopy showed 96.4% sensitivity, 74.6% specificity, 93.4% positive predictive value, 84.6% negative predictive value and 91.8% accuracy. Hysteroscopy demonstrated more accuracy than ultrasonography, which is not sufficient for accurate diagnosis.

[Role of imaging in cases of bleeding after spontaneous or induced abortion]. / Rôle de l'imagerie en cas de métrorragies après fausse couche spontanée ou interruption volontaire de grossesse.

Post-abortum hemorrhage is a common clinical situation and etiological diagnosis has to be made early to avoid further complications such as persistent bleeding, infection or adhesions that may compromise fertility. Retained products of conception are the most common cause of bleeding. The diagnosis is based on endovaginal color doppler ultrasound showing a thickened and hypervascular endometrial echo-complex extending partly to the myometrium. The main differential diagnosis is uterine arteriovenous malformation, mostly iatrogenic. Diagnosis is based on the presence of myometrial confluent cystic lesions filled with turbulent and high velocity arterial flow on endovaginal color doppler ultrasound. The distinction between these two etiologies of post-abortion bleeding is mandatory because of totally different treatment: typically medical and/or surgical in case of retained products of conception and by selective arterial embolization in case of vascular malformation.

Comparison of transvaginal 3D sonohysterography with outpatient hysteroscopy in the evaluation of abnormal uterine bleeding.

OBJECTIVE: To compare transvaginal three-dimensional sonohysterography (3D SHSG) and outpatient hysteroscopy with regards to diagnostic accuracy, procedure time, and patient discomfort with a prospective randomized controlled cohort study in a teaching hospital in London. The study included a population group of 49 women with abnormal uterine bleeding from varied ethnic backgrounds, of which 44 completed the study. Subjects with pregnancies, pelvic infections, large uteruses, suspicious or diagnosed pelvic malignancies, and who did not meet the criteria for day surgery, were excluded. MATERIALS AND METHODS: Patients were randomized into two groups: group 1 had hysteroscopy followed by SHSG while group 2 had SHSG followed by hysteroscopy. Diagnostic accuracy, procedure time, and patient discomfort of SHSG in comparison to hysteroscopy were studied. RESULTS: A total of 44 patients completed the study. The average age of the study population was 44.8 years and the mean parity was 1.8. Nulliparas represented 34.03% of the study population and the average duration of symptoms was 14.8 months. CONCLUSION: In the investigation of women with abnormal bleeding in an outpatient setting, both hysteroscopy and SHSG are comparable in the diagnosis of intracavity lesions, pain rating, and procedure time. However patient acceptability of SHSG was significantly more when compared to outpatient hysteroscopy.

Diagnostic accuracy of sonohysterography and transvaginal sonography as compared with hysteroscopy and endometrial biopsy: a prospective study.

AIM: The aim of the study was to compare the diagnostic accuracy between transvaginal sonography (TVS) and sonohysterography (SHG) versus hysteroscopy (Hys) plus endometrial biopsy (EB) to evaluate uterine cavity. METHODS: One hundred and sixteen patients were enrolled. These presented with infertility and/or abnormal uterine bleeding and/or suspicious uterine cavity pathology. Women consecutively underwent during the same day, to TVS, SHG and Hys plus EB by three different operators. RESULTS: TVS shows excellent specificity (95.7%) in uterine polyps detection, good sensitivity (85,7%) and specificity (89.2%) in investigating endometrial hyperplasia, and excellent NPV (92.2%) in the diagnosis of submucous myomas. Diagnostic accuracy of TVS for synechiae is not evaluable. SHG demonstrates high specificity (92.8%) in the detection of uterine polyps, and high sensitivity (92.9%) and specificity (96.8%) in the diagnosis of endometrial hyperplasia. In addition it shows high sensitivity (90%), specificity (99%), PPV (92.2%), and NPV (99%) for detection of submucous myomas. Finally, SHG shows high PPV (100%) and NPV (100%) for synechiae assessment. CONCLUSION: TVS could be used as first step investigation to exclude uterine pathologies. TVS could reduce the number of diagnostic Hys normally performed in women with normal uterine cavity. Furthermore SHG should be useful to diagnose the pathologies and to decide between operative Hys in-office or resectoscopic treatment.

Fertility preservation in heterotopic cervical pregnancy: what is the best procedure?

We describe a patient who underwent assisted reproduction techniques and was diagnosed with heterotopic cervical pregnancy, and then discuss the management of this entity, which is rare and has no standard protocols. Treatment consisted of intra-arterial methotrexate (50 mg/m(2) body surface area) and simultaneous selective embolization of uterine arteries. The literature is also reviewed to identify other approaches and outcomes.

Diagnosis of abnormal uterine bleeding with imaging.

The major role of ultrasound in the evaluation of abnormal uterine bleeding, other than that occurring during pregnancy, is in postmenopausal women. Because postmenopausal bleeding can be the presenting symptom of endometrial cancer, any woman with this symptom should be evaluated to diagnose or exclude carcinoma. Over the last two decades, the role of ultrasound in the evaluation of postmenopausal bleeding has changed markedly, from little or no role in 1990 to a major role today. In the intervening years, numerous studies have shown that ultrasound is at least as sensitive as endometrial biopsy for endometrial cancer and that ultrasound can reliably exclude cancer without the need for biopsy in some women with postmenopausal bleeding. In particular, numerous studies have shown that women with an endometrial thickness of 4 mm or less have an extremely low likelihood of endometrial cancer and thus do not need to undergo endometrial biopsy. Ultrasound can also help in the selection of an appropriate biopsy technique. In a woman with postmenopausal bleeding and a thick endometrium, a sonohysterogram can determine whether the endometrium is diffusely thick or has focal areas of thickening. With diffuse thickening, a blind endometrial biopsy is appropriate. When there are one or more focal areas of thickening, hysteroscopic biopsy is likely to be the better choice. We present two clinical algorithms, either of which is an acceptable approach to the use of ultrasound and/or endometrial biopsy in women with postmenopausal bleeding: the "ultrasound-first" approach and the "biopsy-first" approach.

Significance of incidentally thick endometrial echo on transvaginal ultrasound in postmenopausal women.

Postmenopausal bleeding is "cancer until proven otherwise." A thin distinct endometrial echo on transvaginal ultrasound has a risk of malignancy of 1 in 917 and does not require an endometrial biopsy. If the endometrial echo is poorly visualized, then in such women, saline infusion sonohysterography is an appropriate next step. The prevalence of asymptomatic endometrial thickening (mostly due to inactive polyps) is high, approximately 10% to 17% of postmenopausal women. The risk of malignancy in such polyps is low (approximately 0.1%), and in structures that mimic polyps, it is also low (0.3%). The incidence of serious complications from an operative intervention in such postmenopausal women is not insignificant (1.3%-3.6%). Thus, automatic intervention in such women, without any high-risk status, is not warranted.

Transvaginal Doppler sonography for evaluation of irregular uterine bleeding with DMPA.

BACKGROUND: The main cause for discontinuation of depot medroxyprogesterone acetate (DMPA) use is irregular menstrual bleeding. The exact pathophysiological mechanisms of irregular bleeding have remained unclear. Transvaginal Doppler is a non-invasive method for studying changes in blood flow which may highlight the underlying pathology in those cases with irregular uterine bleeding. The aim of this study was to quantify the uterine and subendometrial microvasculature in DMPA users with irregular bleeding pattern in comparison to DMPA users with amenorrhea. STUDY DESIGN: This is a case control study. Forty users of DMPA were divided into two groups: one group included 20 users with irregular uterine bleeding and the second group included 20 amenorrheic users. Pulsatility index (PI) and resistance index (RI) of uterine and subendometrial blood vessels were determined. Power Doppler Energy was used to quantify the signal percentage of the subendometrial area. RESULTS: There is significant reduction of PI and RI in the uterine artery and subendometrial microvasculature in cases of irregular uterine bleeding. CONCLUSION: Irregular uterine bleeding with DMPA associated with increased perfusion of uterine and subendometrial blood vessels.

Presenting features of women with uterine arteriovenous malformations.

OBJECTIVE: To describe the outcome of patients with uterine arteriovenous malformations (AVMs) after uterine artery embolization (UAE). DESIGN: Retrospective case series. SETTING: Tertiary center of a university hospital. PATIENT(S): Thirteen patients were referred to a tertiary medical center from primary care facilities with profuse uterine bleeding. INTERVENTION(S): Uterine artery embolization. MAIN OUTCOME MEASURE(S): Thirteen patients underwent UAE. Eleven patients had no additional vaginal bleeding, whereas two patients underwent hysterectomy after embolization. RESULT(S): Twelve patients developed AVMs after induced abortions. One patient had a congenital uterine AVM. Based on the transfer notes, eight cases had incomplete abortions, three cases had dysfunctional uterine bleeding, one case had a molar pregnancy, and one case had a uterine AVM. Two cases underwent hysterectomy after UAE. One patient delivered a healthy baby after bilateral UAE. CONCLUSION(S): Uterine AVMs should be suspected in patients with abrupt, profuse vaginal bleeding and a medical history of an induced abortion. Primary physicians should consider uterine AVMs with such a medical history. A prompt diagnosis and therapy are essential for favorable outcomes in patients with uterine AVMs.

Saline infusion sonohysterography - an effective tool for evaluation of the endometrial cavity in women with abnormal uterine bleeding.

We evaluated the diagnostic accuracy of saline infusion sonohysterography (SISH) over transvaginal sonography (TVS) for the detection of intrauterine abnormalities using hysteroscopy as the gold standard in a retrospective study of 70 women mostly presenting with abnormal uterine bleeding. TVS was normal in 32 women, while in the others polyps or fibroids projecting into the cavity (n = 19) or a thick endometrium (n = 19) were suspected. On performing SISH the uterine cavity was found to be normal in 29 women, while 35 had suspected polyps/fibroids and 6 had other abnormalities. Hysteroscopy proved to be normal in 28 women, 35 had polyps/fibroids and 7 had other abnormalities. The sensitivity, specificity, positive and negative predictive values for TVS were 72.4%, 100%, 100% and 74%, respectively, while for SISH the corresponding figures were 91.4%, 92.6%, 89.3% and 94.1%. SISH is a simple, minimally invasive and cost-effective investigative tool enhancing the diagnostic accuracy of TVS and can be an effective screening test prior to hysteroscopy.

Accuracy of endometrial thickness in detecting benign endometrial pathology in postmenopausal women.

OBJECTIVE: The aim of this study was to determine whether an endometrial thickness less than 5 mm on transvaginal ultrasound (TVUS) is sufficient to exclude benign endometrial lesions in postmenopausal women with bleeding and to determine a cutoff value below which benign endometrial pathology could be ruled out. METHODS: Electronic medical records of consecutive postmenopausal women presenting with vaginal bleeding suspicious for benign pathology were reviewed between September 2002 and December 2007. All women underwent TVUS with endometrial stripe measurement followed by saline infusion sonography (SIS). Accuracy of endometrial echo thickness for detecting intracavitary masses was compared with the reference standard of SIS. A receiver operating characteristic curve was constructed to calculate whether other cutoff values would be more accurate than 5 mm in detecting benign endometrial masses. RESULTS: A total of 1,097 women were referred during the study period; 135 met the inclusion criteria and underwent TVUS followed by SIS. The endometrial echo was less than 5 mm in 43% and 5 mm or greater in 57%. The overall prevalence of polyps or fibroids was 50%. Using an endometrial echo cutoff less than 5 mm, sensitivity was 76% (95% CI, 65-85), specificity was 63% (95% CI, 51-73), positive predictive value was 67%, and negative predictive value was 72%. The area under the receiver operating characteristic curve for detection of benign masses was 0.79 (95% CI, 0.72-0.87). We were unable to determine a cutoff value below which benign endometrial pathology could be excluded. CONCLUSIONS: With an endometrial thickness cutoff of 5 mm a considerable amount of benign endometrial pathology in postmenopausal women with bleeding is missed, and SIS or hysteroscopy may be warranted.

A pilot evaluation of saline sonohysterography for postmenopausal bleeding with thickened endometrium.

The aim of this study was to assess the clinical and cost implications of pilot introduction of saline sonohysterography for postmenopausal bleeding with thickened endometrium (>or= 5 mm), at the Royal Glamorgan Hospital. The investigation was attempted in 48 patients who were found to have a thickened endometrium (>or= 5 mm) on transvaginal ultrasound scanning. The attempt was successful in 45 patients (93.8%). Failures were due to (1) cervical stenosis and (2) leakage of saline from the cervix. Difficult catheterisation of the cervix causing pain was encountered in a minority of cases. Two-thirds of patients were found have focal lesions and were booked for hysteroscopic resection. These patients included 30 with polyps, which were precisely described in all of them. In view of this low complication rate and high accuracy, the technique was integrated as a standard method of investigation for postmenopausal bleeding at the hospital.