Clinicopathological Pattern of Endometrial Specimens in Women with Abnormal Uterine Bleeding and Ultrasonography Correlation.

BACKGROUND: Abnormal uterine bleeding (AUB) refers to any symptomatic deviation from normal menstruation. AUB is a common gynecological disorder in non-pregnant women of reproductive age, accounting for approximately 33% of gynecological outpatient visits. The early diagnosis and management cause of AUB is important because of increased incidence of endometrial carcinoma with rapid growth. Transvaginal ultrasound is non-invasive imaging technique used to find endometrial carcinoma before referring patients for invasive techniques. Dilatation and curettage (D&C) and endometrial biopsy are surgical procedures that scrape the endometrial lining of the uterus for diagnosis and treatment. The aim of this study is to describe the clinicopathologic pattern of endometrial specimens in women with AUB and ultrasonographic correlation. METHODS: Tissues from endometrial biopsy and curettage of 411 patients with AUB who referred to Shahid Mohammadi hospital were prospectively selected from 2021 to 2023. Patients were divided into three groups based on age and menstrual status including: premenopausal (18-39 years), perimenopausal (40-49 years) and postmenopausal (≥50 years). The results were correlated to patient's age and other data and evaluated with statistical analysis. RESULTS: During the two-year study period, a total of 411 endometrial specimens with clinical diagnosis of AUB were submitted and the results were analyzed. The youngest patient presenting with AUB was 21 years old, while the oldest was 77 years old. The most common complaint was menorrhagia in 201 (48.0%) out of 411 patients. The most common pathology finding in three groups was polyp in 100 (24.3%) cases. Hormonal effect was the next commonly observed pattern seen in 70 (17.0%) cases. P value was calculated as 0.003 which was significant using chi-square for the trend seen in age. CONCLUSION: Endometrial sampling is a useful tool for evaluation of women with AUB and referring patients for treatment. Histopathological evaluation of the endometrium is very useful in detecting the etiology of AUB. Transvaginal sonography has high sensitivity in detecting polyps.

Correlation Between the Clinical Diagnosis and Sonographic Diagnosis in Women with First-Trimester Vaginal Bleeding.

BACKGROUND: Vaginal bleeding is the most common cause of presentation at the emergency department in the first trimester. Clinical presentation helps determine the likely cause of first-trimester vaginal bleeding. However, ultrasound imaging is required to reach a definitive diagnosis. OBJECTIVE: To determine the relationship between clinical diagnosis and ultrasonographic findings in women with first-trimester vaginal bleeding. METHODS: A prospective longitudinal study was conducted on 94 pregnant patients with a history of bleeding per vagina (PV) in the first trimester by using transvaginal ultrasound. RESULTS: PV spotting was noted in 64.9% and heavy bleeding in 35.1%. The most common clinically associated symptom was abdominal pain (68, 72.3%), and the least common clinically associated symptom was vesicle expulsion (2.1%). The most common predisposing factor was fever (31, 33.0%). The most frequent clinical diagnosis was threatened abortion (48, 51.1%), and the least common clinical diagnosis was gestational trophoblastic disease (GTD) and inevitable abortion (1, 1.1%). The most common ultrasound diagnosis at the initial scan was incomplete abortion (19.2%), while at follow-up scans, it was threatened abortion (48, 51.1%). The overall concordance between clinical diagnosis and ultrasound was 38.8%, with both complete abortion and GTD showing a concordance of 100%. The least concordance was seen in missed abortions (25%). CONCLUSION: Clinical assessment is insufficient in the identification of the cause of vaginal bleeding due to the overall low concordance rate. A combination of clinical assessment and ultrasonography is required for decision-making in every case.

The role of shear wave elastography in predicting endometrial cancer in patients presenting with abnormal uterine bleeding.

OBJECTIVE: Shear Wave Elastography (SWE) is an objective quantitative ultrasound elastography technique that can demonstrate the stiffness of anatomical structures to aid in their detection and characterization. We aimed to evaluate the role of shear wave elastography in differentiating endometrial carcinoma from benign uterine pathologies in women with abnormal uterine bleeding. PATIENTS AND METHODS: This prospective study was conducted at our institution from January 2020 to April 2020. A hundred patients with endometrial sampling planned and SWE due to abnormal uterine bleeding were included in the study. According to the histopathological results of the patients, those with normal and atrophic endometrium results were defined as group I (control group), those with benign results such as polyps and endometrial hyperplasia were defined as group II, and those with endometrial cancers were defined as group III. RESULTS: After adjustment for age, a statistically significant difference was found in Emean (mean and adjusted mean) value between the study groups (F2.96=86.37, p<.001, η2=0.64). The post-hoc analysis was performed with a Bonferroni adjustment. The mean Emean value was found to be statistically significantly higher in group III (17.14±0.40) compared to group I (10.39±0.26) and group II (11.49±0.32) (p<0.001). In addition, a statistically significant difference was found between the benign and normal groups. CONCLUSIONS: As a new diagnostic technique in gynecology, elastography appears to be a valuable tool in differentiating malign endometrial pathologies from normal or benign endometrial pathologies in females with abnormal uterine bleeding.

Estimating risk of endometrial malignancy and other intracavitary uterine pathology in women without abnormal uterine bleeding using IETA-1 multinomial regression model: validation study.

OBJECTIVES: To assess the ability of the International Endometrial Tumor Analysis (IETA)-1 polynomial regression model to estimate the risk of endometrial cancer (EC) and other intracavitary uterine pathology in women without abnormal uterine bleeding. METHODS: This was a retrospective study, in which we validated the IETA-1 model on the IETA-3 study cohort (n = 1745). The IETA-3 study is a prospective observational multicenter study. It includes women without vaginal bleeding who underwent a standardized transvaginal ultrasound examination in one of seven ultrasound centers between January 2011 and December 2018. The ultrasonography was performed either as part of a routine gynecological examination, during follow-up of non-endometrial pathology, in the work-up before fertility treatment or before treatment for uterine prolapse or ovarian pathology. Ultrasonographic findings were described using IETA terminology and were compared with histology, or with results of clinical and ultrasound follow-up of at least 1 year if endometrial sampling was not performed. The IETA-1 model, which was created using data from patients with abnormal uterine bleeding, predicts four histological outcomes: (1) EC or endometrial intraepithelial neoplasia (EIN); (2) endometrial polyp or intracavitary myoma; (3) proliferative or secretory endometrium, endometritis, or endometrial hyperplasia without atypia; and (4) endometrial atrophy. The predictors in the model are age, body mass index and seven ultrasound variables (visibility of the endometrium, endometrial thickness, color score, cysts in the endometrium, non-uniform echogenicity of the endometrium, presence of a bright edge, presence of a single dominant vessel). We analyzed the discriminative ability of the model (area under the receiver-operating-characteristics curve (AUC); polytomous discrimination index (PDI)) and evaluated calibration of its risk estimates (observed/expected ratio). RESULTS: The median age of the women in the IETA-3 cohort was 51 (range, 20-85) years and 51% (887/1745) of the women were postmenopausal. Histology showed EC or EIN in 29 (2%) women, endometrial polyps or intracavitary myomas in 1094 (63%), proliferative or secretory endometrium, endometritis, or hyperplasia without atypia in 144 (8%) and endometrial atrophy in 265 (15%) women. The endometrial sample had insufficient material in five (0.3%) cases. In 208 (12%) women who did not undergo endometrial sampling but were followed up for at least 1 year without clinical or ultrasound signs of endometrial malignancy, the outcome was classified as benign. The IETA-1 model had an AUC of 0.81 (95% CI, 0.73-0.89, n = 1745) for discrimination between malignant (EC or EIN) and benign endometrium, and the observed/expected ratio for EC or EIN was 0.51 (95% CI, 0.32-0.82). The model was able to categorize the four histological outcomes with considerable accuracy: the PDI of the model was 0.68 (95% CI, 0.62-0.73) (n = 1532). The IETA-1 model discriminated very well between endometrial atrophy and all other intracavitary uterine conditions, with an AUC of 0.96 (95% CI, 0.95-0.98). Including only patients in whom the endometrium was measurable (n = 1689), the model's AUC was 0.83 (95% CI, 0.75-0.91), compared with 0.62 (95% CI, 0.52-0.73) when using endometrial thickness alone to predict malignancy (difference in AUC, 0.21; 95% CI, 0.08-0.32). In postmenopausal women with measurable endometrial thickness (n = 848), the IETA-1 model gave an AUC of 0.81 (95% CI, 0.71-0.91), while endometrial thickness alone gave an AUC of 0.70 (95% CI, 0.60-0.81) (difference in AUC, 0.11; 95% CI, 0.01-0.20). CONCLUSION: The IETA-1 model discriminates well between benign and malignant conditions in the uterine cavity in patients without abnormal bleeding, but it overestimates the risk of malignancy. It also discriminates well between the four histological outcome categories. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Adenomyosis in women undergoing hysterectomy for abnormal uterine bleeding associated with uterine leiomyomas.

BACKGROUND: Uterine leiomyomas and adenomyosis are both common and often associated with abnormal uterine bleeding (AUB), including the symptom of heavy menstrual bleeding (HMB). Understanding the prevalence of adenomyosis in women with uterine leiomyomas could inform clinicians and patients in a way that may improve therapeutic approaches. OBJECTIVE: To explore the prevalence of adenomyosis in a group of women who underwent hysterectomy for AUB-L, to determine the prevalence of submucous leiomyomas, and to examine the utility of preoperative ultrasound to detect the presence of adenomyosis. METHODS: The Kaiser Permanente Hysterectomy Database (KPHD) was searched for women aged 18-52 undergoing hysterectomy for leiomyoma-associated chronic AUB (AUB-L) in 2018 and 2019. A target sample of 400 comprised those with at least 3 years in the Health System. Radiologists evaluated preoperative pelvic ultrasound images to determine leiomyoma size and level 2 FIGO type (submucous or other), and the linked electronic medical record abstracted for clinical features, including histopathological evidence of adenomyosis. RESULTS: Of the 370 subjects that met the study criteria, adenomyosis was identified via histopathology in 170 (45.9%). There was no difference in the adenomyosis prevalence with (47.1%) and without (43.0%) at least one submucous leiomyoma. Subgroup analysis of ultrasound images by an expert radiologist for the presence of adenomyosis demonstrated a positive predictive value of 54.0% and a negative predictive value of 43.4%. CONCLUSIONS: Adenomyosis was present in almost half of this AUB-L cohort undergoing hysterectomy and was equally prevalent in those with and without submucous leiomyomas as determined by sonographic evaluation. The imaging findings are in accord with prior investigators and demonstrate that 2-D ultrasound is insensitive to the presence of adenomyosis when the uterus is affected by leiomyomas. Further research is necessary to determine the impact of various adenomyosis phenotypes on the presence and severity of the symptom of HMB.

Performance of the WID-qEC test versus sonography to detect uterine cancers in women with abnormal uterine bleeding (EPI-SURE): a prospective, consecutive observational cohort study in the UK.

BACKGROUND: To detect uterine cancer, simpler and more specific index tests are needed to triage women with abnormal uterine bleeding to a reference histology test. We aimed to compare the performance of conventional index imaging tests with the novel WID-qEC DNA methylation test in terms of detecting the presence or absence of uterine cancers in women with abnormal uterine bleeding. METHODS: EPI-SURE was a prospective, observational study that invited all women aged 45 years and older with abnormal uterine bleeding attending a tertiary gynaecological diagnostic referral centre at University College London Hospital (London, UK) to participate. Women meeting these inclusion criteria who consented to participate were included. Pregnant women and those with previous hysterectomy were excluded. A cervicovaginal sample for the WID-qEC test was obtained before standard assessment using index imaging tests (ie, ultrasound) and, where applicable, reference histology (ie, biopsy, hysteroscopy, or both) was performed. Technicians performing the WID-qEC test were masked to the final clinical outcome. The result of the WID-qEC test is defined as the sum of the percentage of fully methylated reference (ΣPMR) of the ZSCAN12 and GYPC regions. Patients were followed until diagnostic resolution or until June 12, 2023. The primary outcome was to assess the real-world performance of the WID-qEC test in comparison with ultrasound with regard to the area under the receiver-operating-characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values. EPI-SURE is registered with ISRCTN (16815568). FINDINGS: From June 1, 2022, to Nov 24, 2022, 474 women were deemed eligible to participate. 74 did not accept the invitation to participate, and one woman withdrew after providing consent. 399 women were included in the primary analysis cohort. Based on 603 index imaging tests, 186 (47%) women were recommended for a reference histology test (ie, biopsy, hysteroscopy, or both). 12 women were diagnosed with cancer, 375 were not diagnosed with cancer, and 12 had inconclusive clinical outcomes and were considered study dropouts. 198 reference histology test procedures detected nine cases of cancer and missed two; one further cancer was directly diagnosed at hysterectomy without a previous reference test. The AUC for detection of uterine cancer based on endometrial thickness in mm was 87·2% (95% CI 71·1-100·0) versus 94·3% (84·7-100·0) based on WID-qEC (p=0·48). Endometrial thickness assessment on ultrasound scan was possible in 379 (95%) of the 399 women and a prespecified cut-off of 4·5 mm or more showed a sensitivity of 90·9% (95% CI 62·3-98·4), a specificity of 79·1% (74·5-82·9), a positive predictive value of 11·8% (6·5-20·3), and a negative predictive value of 99·6% (98·0-99·9). The WID-qEC test was possible in 390 (98%) of the 399 patients with a sensitivity of 90·9% (95% CI 62·3-98·4), a specificity of 92·1% (88·9-94·4), a positive predictive value of 25·6% (14·6-41·1), and a negative predictive value of 99·7% (98·3-99·9), when the prespecified threshold of 0·03 ΣPMR or more was applied. When a higher threshold (≥0·3 ΣPMR) was applied the specificity increased to 97·3% (95% CI 95·1-98·5) without a change in sensitivity. INTERPRETATION: The WID-qEC test delivers fast results and shows improved performance compared with a combination of imaging index tests. Triage of women with abnormal uterine bleeding using the WID-qEC test could reduce the number of women requiring histological assessments for identification of potential malignancy and specifically reduce the false positive rate. FUNDING: The Eve Appeal, Land Tirol, and the European Research Council under the European Union's Horizon 2020 Research and Innovation Programme.

Triage method for endometrial biopsy in postmenopausal women: a multicenter retrospective cohort study.

OBJECTIVE: To identify the optimal triage procedure for endometrial biopsies in postmenopausal women. METHODS: The clinical information of 470 postmenopausal women with endometrial biopsy results and postmenopausal bleeding (PMB) and/or transvaginal ultrasonography (TVU) abnormalities were collected at the gynecology departments of four general hospitals from March 2021 to March 2022. In the validation cohort, 112 women with TVU abnormalities who underwent endometrial biopsy at Xiangya hospital between May 2022 and May 2023 were enrolled. The endpoint was the final diagnosis based on hysteroscopy reports and biopsy pathology results. The sensitivity, specificity, positive predictive value, and negative predictive value were compared among the three triage methods. A nomogram prediction model was developed and validated. RESULTS: Referring women with TVU abnormalities for endometrial biopsy identified 100% malignant/premalignant lesions despite low specificity (19.7%). Among women with measurable endometrial thickness (ET), we suggest that the ET cutoff value for biopsy referral should be ≥4 mm. The PMB (odds ratio [OR], 3.241; 95% confidence interval [CI], 1.073-9.789), diabetes (OR, 10.915; 95% CI, 3.389-35.156), and endometrial thickness (OR, 1.277; 95% CI, 1.156-1.409) were independent predictive factors for endometrial (pre)malignancy. A nomogram prediction model was constructed (area under curve [AUC] = 0.802, 95% CI: 0.715 to 0.889). The ideal cutoff point was 22.5, with a sensitivity of 100.0% and a specificity of 15.7%. The external validation achieved an AUC of 0.798 (95% CI, 0.685-0.911). CONCLUSIONS: It was possible to refer all postmenopausal women with TVU abnormity (ET ≥ 4 mm or other abnormal findings) for endometrial biopsy. Among women with TVU abnormalities, a nomogram was constructed, and a score greater than 22.5 suggested the need for referral for endometrial biopsy, while a score less than 22.5 suggested that regular follow-up was required, further improving the triage procedure.

Post-Menopausal Bleeding: Role of Imaging.

Post-menopausal bleeding (PMB) accounts for 5% of gynecologic office visits and is the presenting symptom in 90% of women with endometrial cancer, which requires prompt evaluation. The most common etiology of PMB is vaginal or endometrial atrophy and endometrial polyps, while endometrial hyperplasia and carcinoma account for less than 10% of PMB. Transvaginal ultrasonography measurement of an endometrial thickness (EMT) less than or equal to 4 mm has a 99% negative predictive value for endometrial carcinoma. Endometrial sampling is required if EMT >4 mm or persistent bleeding occurs. Further evaluation can be accomplished with saline infusion sonography, magnetic resonance imaging, and hysteroscopy.

Abnormal Uterine Bleeding in Reproductive Age Women: Role of Imaging in the Diagnosis and Management.

Abnormal uterine bleeding (AUB) is defined by the International Federation of Gynecology and Obstetrics as bleeding from the uterine corpus that is abnormal in regularity, volume, frequency, or duration and occurs in the absence of pregnancy. AUB is a common condition that affects about a third of women in their lifetime. Abnormal bleeding in duration, quantity, or timing consists of 2 categories, predictable cyclical heavy menstrual bleeding (HMB) and irregular non-cyclical intermenstrual bleeding (IMB). The most common causes of HMB include fibroids and adenomyosis and IMB is commonly caused by ovulatory dysfunction such as in polycystic ovaries, endometrial polyp, or an IUD. A pelvic ultrasound is the initial and often only imaging modality needed in the imaging evaluation of abnormal uterine bleeding and can accurately identify the common causes of abnormal uterine bleeding in the reproductive age group.

Correlation of Endometrial Thicknessby Transvaginal Sonography with Histopathological Examination in Abnormal Uterine Bleeding in Perimenopausal Age Group.

BACKGROUND: Transvaginal sonography and endometrial biopsy are the two diagnostic tests, most frequently used to investigate the cause of abnormal uterine bleeding.The aim of this study is to correlate the findings between transvaginal sonography and histopathology for diagnostic evaluation in perimenopausal women with abnormal uterine bleeding. METHODS: A descriptive observational study was carried out at Paropakar Maternity and Women's Hospital, Thapathali, Kathmandu, Nepal during the period of one year (1st January 2019 to 30th December 2019) in 70perimenopausal women with abnormal uterine bleeding. Transvaginal sonography wasdone and endometrial thickness was noted. Endometrial biopsy was done under intravenous anaesthesia. Histopathological reports reviewed and analysis done. RESULTS: The most common age group of women presenting with abnormal uterine bleeding was 40 to 43 years(42.9%) and the commonest clinical feature was menorrhagia (50%) followed by menometrorrhagia (27.1%). The transvaginal sonography showed that majority of women had endometrial thickness of 10-12mm(35.7%) followed by 7-9mm(27.1%). Proliferative endometrium (37.1%) was most common histopathologicalfinding followed by secretory endometrium (30%). 10 cases of proliferative endometrium was seen at ET 7-9mm and 1 case of endometrial carcinoma was seen at ET 13-15 mm with P-value <0.13. CONCLUSIONS: Transvaginal sonography and histopathological examination are the standard diagnostic procedures for the assessment of abnormal uterine bleeding and for early detection of precancerous lesion like endometrial hyperplasiaand endometrial cancer.

Uterine Metastasis Presenting as Abnormal Uterine Bleeding in a Case of Primary Breast Cancer Identified on 18F-FDG PET/CT.

Metastases to the female genital tract are rare, especially from extragenital primaries. The most common extragenital sites associated with genital metastasis are the gastrointestinal tract (37.6%) followed by the breast (34.9%). It is crucial to differentiate primary from metastatic involvement of the uterus for appropriate patient management. We present one such case of endometrial metastasis in a patient who presented clinically with abnormal uterine bleeding and was diagnosed with primary breast cancer via 18F-FDG PET/CT.

Importância do diagnóstico por imagem em pacientes com sangramento uterino anormal / Importance of diagnostic imaging in patients with abnormal uterine bleeding

O sangramento uterino anormal é diagnóstico sindrômico comum no consultório do ginecologista e pode comprometer substancialmente a qualidade de vida. O objetivo no diagnóstico de sangramento uterino anormal é distinguir pacientes com causas estruturais (anatômicas), como pólipo, adenomiose, leiomioma, malignidade e hiperplasia, de pacientes que apresentam anatomia normal, nas quais o sangramento pode ser devido a alteração dos mecanismos de coagulação, distúrbios ovulatórios, distúrbios primários do endométrio, iatrogenia, ou ter outra causa não classificada. O diagnóstico se inicia a partir de anamnese detalhada e exame físico geral e ginecológico completos, seguidos da solicitação de exames complementares (laboratoriais e de imagem), conforme indicado. O exame de imagem de primeira linha para identificação das causas estruturais inclui a ultrassonografia pélvica. Histerossonografia, histeroscopia, ressonância magnética e amostragem endometrial para exame de anatomia patológica são opções que podem ser incluídas no diagnóstico a depender da necessidade. O objetivo deste artigo é apresentar a relevância dos exames de imagem na investigação das causas de sangramento uterino anormal.

Abnormal uterine bleeding is one of the commonest presenting complaints encountered in a gynecologist's office and may substantially affect quality of life. The aim in the diagnosis of abnormal uterine bleeding is to distinguish women with anatomic causes such as polyp, adenomyosis, leiomyoma, malignancy and hyperplasia from women with normal anatomy where the cause may be coagulopathy, ovulatory disorders, endometrial, iatrogenic and not otherwise classified. Diagnosis begins with a thorough history and physical examination followed by appropriate laboratory and imaging tests as indicated. The primary imaging test for the identification of anatomic causes include ultrasonography. Saline infusion sonohysterography, magnetic resonance, hysteroscopy, endometrial sampling are options that can be included in the diagnosis depending on the need. The aim of this article is to present the relevance of imaging exams in the investigation of the causes of abnormal uterine bleeding.

Ultrasonographic evaluation of endometrial stripe thickness is insufficient to rule out uterine serous carcinoma.

PURPOSE: Uterine serous carcinoma (USC) is a rare endometrial cancer representing less than 10% of uterine cancers but contributing to up to 50% of the mortality. Delay in diagnosis with this high-grade histology can have significant clinical impact. USC is known to arise in a background of endometrial atrophy. We investigated endometrial stripe (EMS) thickness in USC to evaluate current guidelines for postmenopausal bleeding in the context of this histology. METHODS: Retrospective chart review was conducted using ICD-9 and ICD-10 codes over an 18-year period. We included 139 patients with USC and compared characteristics of patients with EMS ≤ 4 mm and EMS > 4 mm. Chi-square or Fisher's exact tests were used to compare proportions and two-tailed t-tests to compare means. A p-value of < 0.05 was considered statistically significant. RESULTS: Most patients were white, obese, and multiparous. Thirty-two (23%) had an EMS ≤ 4 mm; 107 (77%) had an EMS > 4 mm. There were no statistically significant differences in age at diagnosis or presenting symptoms between groups, and postmenopausal bleeding was the most common symptom in each group. CONCLUSION: Nearly 25% of patients with USC initially evaluated with transvaginal ultrasound were found to have an EMS ≤ 4 mm. If transvaginal ultrasound is used to triage these patients, one in four women will potentially experience a delay in diagnosis that may impact their prognosis.

The Utility of Pelvic Ultrasounds in Adolescents Presenting to the Emergency Department with Abnormal Uterine Bleeding.

STUDY OBJECTIVE: To analyze what factors influence a provider's decision to order a pelvic ultrasound (PUS) in the emergency department (ED) for adolescents with abnormal uterine bleeding (AUB), to determine if endometrial stripe (EMS) measurements are used in treatment decisions, and to evaluate if treatment outcomes differ based on EMS thicknesses. METHODS: Retrospective chart review of patients aged 11-19 presenting to the ED with AUB from 2006 to 2018. Those receiving a PUS were divided into three EMS groups: ≤5 mm, 6-9 mm, and ≥10 mm. Outcomes were evaluated in admitted patients by progress notes indicating resolution of bleeding. Cross-tab, χ2, and logistic and linear regression analysis were performed. RESULTS: Of 258 adolescents meeting study criteria, 113 (43.8%) had a PUS. None had an abnormality. A PUS was more likely to be performed in patients with lower hemoglobin values (P < .003). Provider decision to order a PUS did not differ by age or bleeding duration (P > .1). Among those with a PUS, 67 (59%) received hormonal therapy (pill, progestin-only, IV estrogen). There were no significant differences in treatment choices based on EMS (P < .061) or, among the 44 admitted patients (17%), in the time it took bleeding to stop after initiating treatment (pill: P = .227, progestin-only: P = .211, IV estrogen: P = .229). CONCLUSION: In adolescents with AUB in the ED, performing a PUS was more common in those with low hemoglobin. EMS thickness did not appear to affect treatment decisions or inpatient outcomes. Larger studies are needed to confirm the current findings and determine if PUS is needed in the evaluation of AUB.

The effects of Saline Infusion Sonography on the histological quality of endometrial sampling in women with postmenopausal bleeding.

BACKGROUND: The aim of this study is to analyze the histopathological features of endometrial samples obtained by aspiration when performed before or after the saline contrast sonohysterography in women with postmenopausal bleeding and a thickened endometrium. Hypothetically, the saline infusion could disrupt the tissue and therefore affect the quality of the sample. Furthermore, we want to determine which histological features have impact on the quality of the endometrial sample. METHODS: We performed a randomized controlled trial (ESPRESSO trial) in which we analyzed the aspiration samples in two groups. Women were allocated either to saline contrast sonohysterography and subsequent endometrial sampling (SCSH-Sampling group) or to the opposite order (Sampling-SCSH group). Dedicated gyneco-pathologists retrospectively assessed the specimens and recorded the type (blood, mucus, epithelium, intact glands, stroma and tissue context) and quantity (on a scale of 0-3) of material that was found in the specimens. RESULTS: This analysis consisted of 197 samples, with 101 women in the SCSH-Sampling group and 96 women in the Sampling-SCSH group. No significant differences were found in the histological features between the two groups. All significant histological features differed significantly in the sufficient samples compared to the insufficient samples: higher amounts of blood, more endometrial epithelium, presence of intact endometrial glands, better stroma and tissue context. Oppositely, a significantly higher amount of mucus was found in the insufficient samples. CONCLUSION: This study shows that the histological features of the endometrial sample were not affected by the saline contrast sonohysterography, when performed prior to the tissue sampling. Trial registration ESPRESSO TRIAL, NTR5690, registered 16 February 2016, https://trialsearch.who.int/Trial2.aspx?TrialID=NTR5690 .

Additional value of Doppler ultrasound to B-mode ultrasound in assessing for uterine intracavitary pathologies among perimenopausal and postmenopausal bleeding women: a multicentre prospective observational study in Vietnam.

PURPOSE: To determine the role of Doppler ultrasonography when combined with B-mode ultrasonography in diagnosing uterine intracavitary pathologies (UIPs) in perimenopausal and postmenopausal bleeding women. METHODS: This multicentre prospective observational study included 150 women aged > 40 years with abnormal uterine bleeding (AUB), who were hospitalised at Hospital X and Hospital Y between June 2016 and June 2019. All participants underwent transvaginal B-mode ultrasound and transvaginal Doppler ultrasound, and the results of sonography were compared to histopathological endpoint. RESULTS: The morphological features, structure, margin, border line of the endometrial-mass lesion, intracavitary uterine fluid, and Doppler signal clearly differed between benign and malignant intracavitary pathologies (p < 0.0001). However, echogenicity had a limited value in differentiating among UIPs (p = 0.1). The sensitivity and specificity of the pedicle sign in diagnosing endometrial polyps were 50.0% and 97.6%; for the circular pattern in endometrial fibroids were 46.2% and 100.0%; for the multiple vessel pattern in endometrial cancer were 64.0% and 96.0%; and for the scattered vessel pattern in endometrial hyperplasia were 43.96% and 56.43%, respectively. The additional value of Doppler ultrasound was greater than that of separate B-mode ultrasound in assessing UIPs in our study. CONCLUSIONS: B-mode ultrasound used in combination with Doppler as a noninvasive tool was significantly valuable in the diagnostic procedures for UIPs in perimenopausal and postmenopausal bleeding women. Doppler ultrasound and B-mode transvaginal ultrasound should be used together routinely for discrimination between malignant diseases and benign endometrial changes. Further studies are needed to better understand the benefits of combining Doppler ultrasound and B-mode ultrasound in routine sonographic practice.

Accuracy of office hysteroscopy in diagnosis of endometrial pathologies compared to ultrasound and histopathology in Baghdad Teaching Hospital.

BACKGROUND: Menstrual problems with all manifestations ranging from life-threatening bleeding to amenorrhea are considered patterns of abnormal uterine bleeding (AUB), which is until now a popular reason for referral to the gynaecologic clinic and requires a special diagnostic tool. OBJECTIVE: To assess the accuracy of hysteroscopy in diagnosing endometrial pathologies and to compare it with sonographic and histopathologic reports. PATIENTS AND METHODS: A prospective study conducted in the Baghdad Teaching Hospital on 60 Iraqi females having varying complaints from abnormal uterine bleeding in pre- and post-menopausal women, infertility, and chronic pelvic pain with normal or abnormal ultrasound findings. Office hysteroscopy was done and an endometrial biopsy was obtained for histopathology for a period of 10 months between September 2020 and June 2021. RESULTS: The current study showed that hysteroscopy was more accurate in diagnosing sensitivity of endometrial poly (100%), fibroids (83%), hyperplasia (84.2%), and cancer (50%) whereas ultrasounds were more accurate in diagnosing sensitivity to endometrial myoma (90%). Hysteroscopy and ultrasound showed low sensitivity in detecting endometrial cancer (50% and 34%, respectively). CONCLUSION: Although a transvaginal ultrasound was considered an integral part in the diagnosis of endometrial pathologies, it can be used for initial investigation, however, when suspecting endometrial pathology, hysteroscopy can be more advanced for evaluation, immediate treatment of endometrial masses, and obtaining targeted biopsies. Hysteroscopy showed high sensitivity in detecting endometrial polyps.

Comparison of 3D ultrasound, 2D ultrasound and 3D Doppler in the diagnosis of endometrial carcinoma in patients with uterine bleeding: A systematic review and meta-analysis.

Endometrial cancer is a common malignancy affecting women worldwide. Usually, it clinically manifests with uterine bleeding, although identical clinical manifestations occur in benign conditions as well, with several endometrial biopsies being conducted unnecessarily. Therefore, an accurate, non-invasive diagnostic test is needed for first-line assessment, so as unnecessary biopsies are limited as much as possible. This systematic review aims to assess the diagnostic accuracy of three-dimensional ultrasound, a relatively novel method in gynecologic assessment, compared to two-dimensional ultrasound and three-dimensional Doppler in the prediction of uterine malignancy in women with abnormal uterine bleeding. The accuracy of endometrial volume, as a diagnostic parameter assessed by three-dimensional ultrasound is compared to diagnostic parameters from the other two methods, namely endometrial thickness and 3D Doppler indices (vascularization index, flow index and vascularization flow index). Articles relevant to our research question were systematically sought in the Web of Science, Scopus and MEDLINE/PubMed databases and underwent rigorous evaluation for inclusion according to the PRISMA 2020 guidelines. Eligible studies were thoroughly assessed for risk of bias and relevant data was extracted and analyzed. Studies were heterogenous and extracted data varied from study to study. Data on endometrial volume was compared to other diagnostic parameters. Forest plots with pooled percentages and hierarchical summary receiver operating characteristic curves were constructed for each comparison. Relative sensitivity and specificity ratios were calculated for each comparison to test for statistical significance. Endometrial volume and thickness comparison showed sensitivity 83% for both parameters and specificity 75% and 69% respectively, with volume being more specific than thickness (p < 0.05). Endometrial volume and Doppler indices comparison showed that sensitivity was 73%, 82%, 81% and 82%, while specificity was 72%, 76%, 75% and 76% for endometrial volume, vascularization index, flow index and vascularization-flow index respectively. All three Doppler indices were significantly more sensitive in the diagnosis of malignancy compared to endometrial volume (p < 0.05) While endometrial thickness remains a reliable predictor of uterine malignancy, endometrial volume appears promising as a method with higher specificity and more reliable measurements. Similarly, vascular indices seem as competent and even more sensitive than endometrial volume as predictors, with the added advantage of semi-automated and reproducible measurements that reflect the whole organ. More comparative studies with standardized protocols should be established, so as reliable cut-off values can be determined and thus standardize and streamline the diagnostic algorithm via the implementation of the three-dimensional modalities in the settings that they are available.

Etiology distribution of abnormal uterine bleeding according to FIGO classification system: A combined study of ultrasound and histopathology.

AIM: To classify the FIGO's PALM-COEIN etiology for abnormal uterine bleeding (AUB) patients according to the ultrasound and histopathology and to evaluate the etiology prevalence distribution for AUB patients. METHODS: A total of 1065 women with AUB in the Second Hospital of Shandong University between January 2019 and March 2021. The intrauterine histopathological and ultrasound results were reviewed retrospectively.PALM-COEIN etiology classification was performed according to histopathology and ultrasound. The classification system was stratified into nine basic categories: Polyp (AUB-P), adenomyosis (AUB-A), leiomyoma (AUB-L), malignancy and hyperplasia (AUB-M), coagulopathy (AUB-C), ovulatory disorders (AUB-O), endometrium (AUB-E), Iatrogenic(AUB-I), and not classified (AUB-N). The number of cases and composition ratio were also calculated. RESULTS: According to the FIGO's classification system, the PALM group (656,61.60%), which were defined as structural entities that can be measured visually with ultrasound and/or histopathology. 176 (16.53%) patients were classified as AUB-P,102 (9.58%) patients were classified as AUB-A, 487(45.73%) patients were classified as AUB-L, 31 (2.91%) patients were classified as AUB-M. The COEIN group (409,38.40%), which were defined as nonstructural entities that cannot be measured by ultrasound and/or histopathology. Nobody were classified as AUB-C in our group, and 383 (35.96%) patients were classified as AUB-O, 4 (0.38%) patients were classified as AUB-E,14 (1.31%) patients were classified as AUB-I,8 (0.75%) patients were classified as AUB-N. CONCLUSION: In our study, AUB-L was the most common cause, followed by AUB-O, AUB-P, AUB-A, AUB-M, AUB-I, AUB-N, and AUB-E.PALM-COEIN etiology classification system played an important role in the epidemic and management standardization of AUB patients, provided an effective communication between physicians and researchers also. Ultrasonography was the preferred examination for AUB patients, especially with structural abnormalities.

Diagnostic Value of Vaginal Ultrasound under Improved Clustering Algorithm Combined with Hysteroscopy in Abnormal Uterine Bleeding.

In order to explore the diagnostic value of the improved clustering algorithm of vaginal ultrasound combined with hysteroscopy in abnormal uterine bleeding (AUB), 128 patients diagnosed with AUB in the hospital were selected as the research objects. A K-means improved clustering color image segmentation algorithm was designed and applied to AUB vaginal ultrasound image processing. The running time, mean square error (MSE), and peak to signal noise ratio (PSNR) were calculated to evaluate the algorithm, and the sensitivity, specificity, negative likelihood ratio, and positive likelihood ratio were used to evaluate the diagnostic accuracy of the detection method. In addition, combined with hysteroscopy, a comprehensive evaluation of the diagnostic value of abnormal uterine bleeding diseases was implemented. The results showed that compared with the traditional K-means clustering algorithm, the running time of the improved K-means clustering color image segmentation algorithm in the training set was significantly shortened, the MSE was significantly decreased, and the PSNR was significantly increased (P < 0.05). The sensitivity, specificity, negative likelihood ratio, and positive likelihood ratio (90.5%, 93.2%, 84.3, and 96.3%) of AUB diagnosis were significantly improved in the algorithm of vaginal ultrasound combined with hysteroscopy (P < 0.05). In summary, the combination of vaginal ultrasound and hysteroscopy based on K-means improved clustering color image segmentation algorithm can significantly improve the clinical diagnostic accuracy of AUB patients.