Risk assessment for endometrial cancer in women with abnormal vaginal bleeding: Results from the prospective IETA-1 cohort study.

OBJECTIVE: To investigate the association between personal history, anthropometric features and lifestyle characteristics and endometrial malignancy in women with abnormal vaginal bleeding. METHODS: Prospective observational cohort assessed by descriptive and multivariable logistic regression analyses. Three features-age, body mass index (BMI; calculated as weight in kilograms divided by the square of height in meters), and nulliparity-were defined a priori for baseline risk assessment of endometrial malignancy. The following variables were tested for added value: intrauterine contraceptive device, bleeding pattern, age at menopause, coexisting diabetes/hypertension, physical exercise, fat distribution, bra size, waist circumference, smoking/drinking habits, family history, use of hormonal/anticoagulant therapy, and sonographic endometrial thickness. We calculated adjusted odds ratio, optimism-corrected area under the receiver operating characteristic curve (AUC), R2 , and Akaike's information criterion. RESULTS: Of 2417 women, 155 (6%) had endometrial malignancy or endometrial intraepithelial neoplasia. In women with endometrial cancer median age was 67 years (interquartile range [IQR] 56-75 years), median parity was 2 (IQR 0-10), and median BMI was 28 (IQR 25-32). Age, BMI, and parity produced an AUC of 0.82. Other variables marginally affected the AUC, adding endometrial thickness substantially increased the AUC in postmenopausal women. CONCLUSION: Age, parity, and BMI help in the assessment of endometrial cancer risk in women with abnormal uterine bleeding. Other patient information adds little, whereas sonographic endometrial thickness substantially improves assessment.

The cost-effectiveness of progesterone in preventing miscarriages in women with early pregnancy bleeding: an economic evaluation based on the PRISM trial.

OBJECTIVES: To assess the cost-effectiveness of progesterone compared with placebo in preventing pregnancy loss in women with early pregnancy vaginal bleeding. DESIGN: Economic evaluation alongside a large multi-centre randomised placebo-controlled trial. SETTING: Forty-eight UK NHS early pregnancy units. POPULATION: Four thousand one hundred and fifty-three women aged 16-39 years with bleeding in early pregnancy and ultrasound evidence of an intrauterine sac. METHODS: An incremental cost-effectiveness analysis was performed from National Health Service (NHS) and NHS and Personal Social Services perspectives. Subgroup analyses were carried out on women with one or more and three or more previous miscarriages. MAIN OUTCOME MEASURES: Cost per additional live birth at ≥34 weeks of gestation. RESULTS: Progesterone intervention led to an effect difference of 0.022 (95% CI -0.004 to 0.050) in the trial. The mean cost per woman in the progesterone group was £76 (95% CI -£559 to £711) more than the mean cost in the placebo group. The incremental cost-effectiveness ratio for progesterone compared with placebo was £3305 per additional live birth. For women with at least one previous miscarriage, progesterone was more effective than placebo with an effect difference of 0.055 (95% CI 0.014-0.096) and this was associated with a cost saving of £322 (95% CI -£1318 to £673). CONCLUSIONS: The results suggest that progesterone is associated with a small positive impact and a small additional cost. Both subgroup analyses were more favourable, especially for women who had one or more previous miscarriages. Given available evidence, progesterone is likely to be a cost-effective intervention, particularly for women with previous miscarriage(s). TWEETABLE ABSTRACT: Progesterone treatment is likely to be cost-effective in women with early pregnancy bleeding and a history of miscarriage.

Modelling risk assessment for cervical cancer in symptomatic Saudi women.

OBJECTIVES: To assess whether the utility of cervical cancer screening could be improved by combining multiple factors in addition to the pap test. Methods: A retrospective cohort study of 300 symptomatic women who were suspected to have cervical cancer and referred for biopsy examination at King Abdulaziz Medical City, Riyadh, Saudi Arabia between February 2017 and December 2017. Results: A high risk of cervical cancer in Saudi women was associated with 4 risk factors: family history (adjusted odds ratio [aOR], 4.216; 95% confidence intervals [CI], 1.433-12.400), vaginal bleeding (aOR, 3.959; 95% CI, 1.272-12.318), hypertension (aOR, 4.554; 95% CI, 1.606-12.912), and an abnormal pap smear test (aOR, 13.985; 95% CI, 5.108-38.284). The model yields an adequate utility (area under the curve, 87.5%, 95% CI, 80.9-94.0%) with acceptable goodness-of-fit (p=0.6915). Conclusion: The pap smear test alone is inadequate to assess high risk for cervical cancer in our center. Early detection of cervical cancer may require consideration of a combination of factors including the pap test. This study has shown that using a combination of abnormal family history, vaginal bleeding, hypertension, and the pap smear test improved the effectiveness of cervical cancer screening.

Can risk factors, clinical history and symptoms be used to predict risk of ectopic pregnancy in women attending an early pregnancy assessment unit?

OBJECTIVE: To examine whether risk factors and symptoms may be used to predict the likelihood of ectopic pregnancy (EP) in women attending early pregnancy assessment units in the UK. METHODS: This was an observational cohort study of pregnant women under 12 weeks' gestation who were recruited from three London university hospitals between August 2012 and April 2013. One hospital continued recruitment between January and June 2015. A standardized information sheet incorporating patient demographics, medical history and symptoms was completed by patients and confirmed by examining clinicians. The outcome measure was final pregnancy location. RESULTS: There were 1320 eligible patients included in the analysis, with a total of 72 EPs (rate of 6%). Pelvic pain and diarrhea > three times in the previous 24 h were independent symptoms that increased the risk of EP, with relative risks of 2.4 (95% CI, 1.4-4.0; P = 0.002) and 2.2 (95% CI, 1.08-4.5; P = 0.03), respectively. The only other independent marker of risk of EP was duration of vaginal bleeding; the risk of EP increased by 20% (95% CI, 14%-27%) for every 1-day increment in duration (P < 0.001). A logistic regression model incorporating these factors demonstrated an area under the receiver-operating characteristics curve of 0.73 (95% CI, 0.67-0.79). The prevalence of EP was low when there was no pelvic pain, no diarrhea and the duration of bleeding was ≤ 3 days, with an EP rate of 2% (6/391). In the presence of a single risk factor, the EP rate increased to 5% (29/631) when only pelvic pain was present, 8% (1/12) when only diarrhea > three times in the previous 24 h was reported and 9% (9/103) when there was only vaginal bleeding with a duration > 3 days. Women with pelvic pain and vaginal bleeding of any severity for > 3 days had a high EP rate of 16% (23/146). In the nine women who also reported diarrhea > three times in the previous 24 h, two had EP. CONCLUSIONS: Only the presence of pelvic pain, diarrhea > three times in the previous 24 h and duration of bleeding were symptoms that significantly increased the risk for EP in women attending early pregnancy assessment units. Risk factors and symptoms alone could not be used to predict reliably an EP. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Características clínico-epidemiológicas y manejo del cáncer endometrial (2010-2013) / Clinical-epidemiological characteristics and management of endometrial cancer (2010-2013)

Introducción: el cáncer de endometrio ha incrementado su incidencia y se asocia a factores de riesgo presentes en muchas mujeres en la perimenopausia. El síntoma más común es el sangramiento y la modalidad de tratamiento más empleada es la cirugía. Objetivo: caracterizar el cáncer endometrial en el Hospital América Arias desde enero de 2010 hasta junio de 2013. Métodos: se realizó un estudio descriptivo en el Hospital América Arias, desde 1ro de enero de 2010 hasta el 30 de junio de 2013. Se incluyó el total las pacientes con sangramiento uterino anormal en la etapa peri y posmenopáusico a partir de 40 años de edad. Las pacientes con diagnóstico histopatológico de cáncer endometrial constituyeron la muestra (n= 49). Resultados: la edad promedio de las pacientes fue de 60,8 ± 9,9 años. Presentaban sobrepeso 30,6 por ciento, y 44,9 por ciento eran obesas. El examen histopatológico posquirúrgico muestra que la lesión estuvo limitada al endometrio en 14,3 por ciento de las pacientes; pero hubo invasión de los dos tercios externos del miometrio en 61,2 por ciento de ellas. La extensión al cuello y a los anejos uterinos fue de 38,8 por ciento y 22,4 por ciento respectivamente. Conclusiones: existe una tendencia a la aparición del adenocarcinoma endometrial en edades cada vez más avanzadas. Se asocia a factores de riesgo como obesidad, infertilidad y el uso de terapia hormonal de remplazo. Además de la cirugía, algunas pacientes requirieron tratamiento oncológico específico(AU)

Introduction: The incidence of endometrial cancer has increased and it is associated with risk factors present in many perimenopausewomen. The most common symptom is bleeding and the most widely used treatment modality is surgery. Objective: Characterize endometrial cancer at America Arias Hospital from January 2010 to June 2013. Methods: A descriptive study was conductedat America Arias Hospital, from 1 January 2010 to 30 June 2013. The total included over 40 year patients with abnormal uterine bleeding in perimenopausal and postmenopausal. Patients with histopathologic diagnosis of endometrial cancer constituted the sample (n= 49). Results: The mean age of patients was 60.8 ± 9.9 years. 30.6 percent were overweight and 44.9 percent were obese. Postoperative histopathologic examination shows that the lesion was limited to the endometrium in 14.3 percent of patients, but there was invasion of the two outer thirds of the myometrium in 61.2 percent. The extension cervix and adnexa was 38.8 percent and 22.4 percent, respectively. Conclusions: There is a tendency to the appearance of endometrial adenocarcinoma at increasingly advanced ages. It is associated with risk factors such as obesity, infertility, and the use of hormone replacement therapy. In addition to surgery, some patients required specific cancer treatment(AU)

Individualized assessment of preterm birth risk using two modified prediction models.

OBJECTIVES: To construct two prediction models for individualized assessment of preterm delivery risk within 48h and before completed 32 weeks of gestation and to test the validity of modified and previously published models. STUDY DESIGN: Data on 617 consecutive women with preterm labor transferred to a tertiary care center for threatened preterm delivery between 22 and 32 weeks of gestation were analysed. Variables predicting the risk of delivery within 48h and before completed 32 weeks of gestation were assessed and applied to previously published prediction models. Multivariate analyses identified variables that were incorporated into two modified models that were subsequently validated. RESULTS: Two modified prediction models were developed and internally validated, incorporating four and six of the following variables to predict the risk of delivery within 48h and before completed 32 weeks of gestation, respectively: presence of preterm premature rupture of membranes and/or vaginal bleeding, sonographic cervical length, week of gestation, fetal fibronectin, and serum C-reactive protein. The correspondence between the actual and the predicted preterm birth rates suggests excellent calibration of the models. Internal validation analyses for the modified 48h and 32 week prediction models revealed considerably high concordance-indices of 0.8 (95%CI: [0.70-0.81]) and 0.85 (95%CI: [0.82-0.90]), respectively. CONCLUSIONS: Two modified prediction models to assess the risk of preterm birth were constructed and validated. The models can be used for individualized prediction of preterm birth and allow more accurate risk assessment than based upon a single risk factor. An online-based risk-calculator was constructed and can be assessed through: http://cemsiis.meduniwien.ac.at/en/kb/science-research/software/clinical-software/prematurebirth/.

Immediate postabortion intrauterine device insertion: continuation and satisfaction.

BACKGROUND: The provision of intrauterine devices (IUDs) immediately postabortion has the potential to decrease unintended pregnancy in the United States. Studies have demonstrated safety and efficacy; however, there are limited data about continuation, satisfaction, and bleeding patterns among women receiving immediate postabortion IUDs. STUDY DESIGN: We performed a retrospective cohort study of women undergoing immediate postabortion IUD insertion. Demographics and clinical data were collected from intake forms and procedure notes. We attempted to contact women by telephone to administer a short questionnaire to assess continuation, satisfaction, and bleeding patterns. RESULTS: We were able to contact 77 of 225 (34%). Women lost to follow-up were more likely to have higher parity or a pregnancy of greater gestational age at the time of abortion compared with women who were successfully contacted. Continuation and satisfaction rates were high (80.5% and 80.6%, respectively). Reported bleeding patterns with IUD use were similar to previously reported patterns. CONCLUSION: Follow-up of women undergoing immediate postabortion IUD insertion is challenging. However, we found that women choosing immediate postabortion IUD had high rates of continuation and satisfaction.

Medicine or Surgery (Ms): a randomized clinical trial comparing hysterectomy and medical treatment in premenopausal women with abnormal uterine bleeding.

Hysterectomy may be overused as treatment for abnormal uterine bleeding due to benign causes in reproductive women. Medical therapies are an alternative, and there is a need for randomized trials comparing the outcomes of these approaches. Women of reproductive age who continued to have bothersome abnormal uterine bleeding after cyclic hormonal treatment with medroxyprogesterone acetate (MPA; 10-20 mg for 10-14 days/month) for 3-5 months were invited to participate in a randomized trial of hysterectomy versus other medical therapies. Participating gynecologists were free to choose the particular surgical (transabdominal or transvaginal) or medical (generally oral contraceptives and/or a prostaglandin synthetase inhibitor) approaches. Outcomes during 2 years of follow-up include quality of life (primary), sexual function, clinical effectiveness and cost. We screened 1557 women to find 413 who began 3-5 months of MPA; 215 completed this treatment, of whom 102 still had bothersome symptoms, and of these 38 consented to be randomized. Another 25 women with bothersome symptoms after a documented history of 3 months of cyclic MPA were also randomized, for a total of 63. The average age of randomized women was 41; 54% were African-American, and they reported uterine bleeding 12 days/month on average, heavy bleeding 6 days/month. Anemia (hematocrit<32) was present in 38% of African-Americans and 15% of Caucasians (p=0.05). Two thirds of the women had fibroids and 80% reported pelvic pain. Obesity was common (45% had a body mass index (BMI)>30), and associated with a longer duration of symptoms (12 vs. 4 years for BMI<25; p=0.02) and a greater prevalence of incontinence (44% vs. 16%; p=0.046). Although recruitment was difficult, we have completed enrollment in a randomized clinical trial comparing surgical and medical treatments for abnormal uterine bleeding.

Hysterectomy rates in the United States 1990-1997.

OBJECTIVE: To assess hysterectomy rates, type of hysterectomy, and other factors associated within the United States from 1990-1997. METHODS: A descriptive statistical analysis of national discharge data was undertaken. Data from the nationwide Inpatient Sample of the Healthcare Cost and Utilization Project (from which national estimates are generated based on a 20% stratified sample of US community hospitals) were used for the years 1990-1997. All women who underwent hysterectomy were identified using International Classification of Diseases, 9th Revision, Clinical Modification, procedure codes. Outcome measures included rate, type of hysterectomy, age of patients, length of stay, total hospital charges, and diagnostic categories. RESULTS: Rates of hysterectomy have not changed significantly over the years from 1990-1997. Rates for hysterectomy in 1990 were 5.5 per 1000 women and increased slightly by 1997 to 5.6 per 1000 women. The type of hysterectomy has changed, with laparoscopic hysterectomy accounting for 9.9% of cases by 1997, with a concomitant decline in abdominal hysterectomy but no substantial change in vaginal hysterectomy rates. Length of stay decreased and total charges increased for all types of hysterectomy. Vaginal hysterectomy and laparoscopic hysterectomy are associated with shorter length of stay than abdominal hysterectomy. Abdominal hysterectomy is the most common procedure (63.0% in 1997). CONCLUSION: The majority of hysterectomies are abdominal, and the most common indication is uterine fibroids. The introduction of alternative techniques for controlling abnormal uterine bleeding such as endometrial ablation has not had an impact on hysterectomy rates, and there has only been a limited uptake of laparoscopic approaches.

[The assessment of the prognostic factors for the development of cancer in patients with hemorrhages in the presence of endometrial atrophy]. / Otsenka prognosticheskikh faktorov razvitiia raka u bol'nykh s krovotecheniiami na fone atrofii éndometriia.

A total of 95 women aged 47 to 72 were examined with a history of bloody discharge in the postmenopause. Sex hormones, hydrocortisone, thyroid hormones, blood lipids and serotonin, noradrenaline and adrenalin excretion were assessed. Histologic examinations of endometrial scrapings off were carried out in all the cases. A table for prediction of endometrial diseases has been created on the basis of the findings. Cancer development risk factors were singled out.

Assessment of in utero hypoxia and risk of sudden infant death syndrome.

Few data are available on the role of hypoxia in sudden infant death syndrome (SIDS). The purpose of this study was to assess whether 10 antenatal factors consistent with in utero hypoxia were associated with an increased risk of SIDS. Cases and two sets of controls were chosen from the Upstate New York Live Birth Cohort for 1974 (n = 132,948). One hundred and forty-eight SIDS cases were identified, along with 114 dead controls made up of all other sudden deaths. Randomly selected live controls were frequency-matched to cases on mother's age, race, residence, parity, and infant's birthdate (n = 355). Data were collected from vital certificates (97% response), hospital delivery records (89%), and autopsy reports (100%). Odds ratios and 95% confidence intervals were calculated using Mantel-Haenszel techniques and logistic regression. Abnormal uterine bleeding was the only statistically significant (P less than 0.05) risk factor observed when dead controls were used (OR = 5.4). When live controls were used, statistically significant increases in risk were found for: placenta praevia (OR = 21.8), abruptio placentae (OR = 3.7), multiple birth (OR = 29.6), pregnancy interval less than or equal to 12 months (OR = 3.8), sexually transmitted disease (OR = 6.4), and eclampsia (OR = 17.7). These results lend support to a possible hypoxic aetiology of SIDS; however, differences by control group suggest that some factors are not specific to SIDS alone but may be risk factors for infant mortality in general.

Maternal mortality in the American University of Beirut Medical Center (AUBMC) 1971-1982.

Maternal deaths were reviewed at the American University of Beirut Medical Center (AUBMC) during an 11-year period, 1971-1982. There were 35,058 live births and 45 deaths making a maternal mortality rate of 128 per 100,000 live births. Hemorrhage, sepsis and toxemia were the main direct obstetric causes of death. The most important indirect causes were cerebrovascular accidents and heart disease. In this review, an analytic discussion of the direct and indirect causes of maternal death in Lebanon are presented and preventive measures are discussed.

PIP: Maternal deaths were reviewed at the American University of Beirut Medical Center during an 11 year period, 1971-82. There were 35,058 livebirths and 45 deaths, making a maternal mortality rate of 128/100,000 livebirths. Hemorrhage, sepsis, and toxemia were the main direct causes of obstetric death. The most important indirect causes were cerebrovascular accidents and heart disease. In this, review, an analytic discussion of the direct and indirect causes of maternal death in Lebanon are presented and preventive measures are discussed.