Preoperative Imaging in Patients with Deep Infiltrating Endometriosis: An Important Aid in Predicting Depth of Infiltration in Rectosigmoid Disease.

STUDY OBJECTIVE: To determine the diagnostic accuracy of specialist-performed transvaginal ultrasound (TVUS) and pelvic magnetic resonance imaging (MRI) modalities in predicting depth of deep infiltrating endometriosis (DIE) of the rectosigmoid by comparison with histologic specimens obtained at surgery. DESIGN: A retrospective analysis, which met the Standards for Reporting of Diagnostic Accuracy Studies (2015) guidelines for a diagnostic accuracy study. SETTING: Tertiary teaching hospital. PATIENTS: A total of 194 cases who underwent preoperative discussion at the gynecologic endosurgery unit multidisciplinary meeting between January 2012 and December 2019 were eligible for inclusion. INTERVENTIONS: Retrospective assessment of the accuracy of TVUS and MRI in predicting histologic depth of rectosigmoid DIE after operative management. MEASUREMENTS AND MAIN RESULTS: Al total of 135 surgeries were performed for DIE; 20 underwent a rectal shave, 14 had a disc/wedge resection, 38 an anterior/segmental resection, and 63 had no rectosigmoid surgery. Of the 52 patients with full-thickness rectal wall excision, all patients had at least one imaging modality available for review; 42 (81%) had both. At least one imaging modality was in agreement with histologic depth in 48 cases (92%) (sensitivity, 94%; specificity, 50%; positive predictive value [PPV], 97.9%; negative predictive value [NPV], 25.0%; area under the receiver operating curve, 0.720; 95% confidence interval, 0.229-1.000). When TVUS was assessed in isolation, the test remained sensitive for any rectal wall involvement (sensitivity, 93.6%; specificity, 50.0%; PPV, 97.8%; NPV, 25.0%; area under the receiver operating curve, 0.718; 95% confidence interval, 0.227-1.000). When only MRI was assessed, the test demonstrated both high sensitivity and specificity for rectal wall disease (sensitivity, 86.4%; specificity, 100%; PPV, 100%; NPV, 14.2). CONCLUSION: Specialist-performed TVUS and MRI are accurate in predicting depth of disease in rectosigmoid endometriosis. These modalities were similar in their diagnostic performance at assessing depth of rectal wall involvement, and their use is justified in the preoperative planning of these gynecologic surgeries.

Uptake of outpatient hysteroscopy in Australia using Medical Benefits Scheme data: Have we fallen behind?

BACKGROUND: Hysteroscopy is a safe procedure which allows both diagnosis and management of cervical and endometrial pathology. Improving Australian women's access to outpatient hysteroscopy would improve cost efficiency and allow women a quicker recovery, negating the need for a general anaesthetic. Increasing the Medicare renumeration for outpatient hysteroscopy could incentivise provision of outpatient hysteroscopy. AIM: We sought to review the trend and current uptake of outpatient diagnostic hysteroscopy in Medicare Benefits Scheme (MBS)-funded clinics within Australia. MATERIALS AND METHODS: A retrospective review of Australian MBS data from 1 January 1993 to 31 December 2020. RESULTS: Over the past 27 years, 1 319 909 hysteroscopies have been claimed from Medicare in Australia, with 39 958 (3.1%) claimed as an outpatient diagnostic procedure. Australian outpatient diagnostic hysteroscopy MBS item number use peaked in 1994 (5871 cases) representing 18.2% of all hysteroscopies claimed through the MBS that year. Uptake of the outpatient hysteroscopy item number rapidly declined after 1994 and in 2010, it represented 0.8% of all hysteroscopies claimed (426 of 49 618) and has remained below <0.5% from 2010 to 2020. CONCLUSIONS: The lower Medicare rebate and lack of recognition of the importance of outpatient hysteroscopy has likely been a driving factor in continuing inpatient hysteroscopy. Incentivised government funding has been successfully utilised in the UK to improve outpatient hysteroscopy access. This MBS data suggests that Australia has not progressed in outpatient hysteroscopy access and support a change in the current funding model to assist in supporting the uptake of outpatient access.

Virtual clinics in gynaecology - Can we shorten the wait? A randomised controlled trial implementing a novel care pathway for postmenopausal bleeding.

BACKGROUND: Postmenopausal bleeding (PMB), a common symptom of endometrial cancer, necessitates prompt clinical and sonographic assessment, often followed by hysteroscopy. Unfortunately, due to traditional gynaecology outpatient clinic paradigms, unnecessary patient-clinician encounters are common and may lead to delays in diagnosis. AIM: The aim was to assess a novel clinic model for the management of women with PMB based on virtual assessment and routine use of the outpatient hysteroscopy clinic. METHODS: An unblinded pragmatic randomised controlled trial was performed, comparing a 'virtual clinic' to routine outpatient clinical care. The primary outcome for assessment was time, measured as the interval (days) between referral triage and discharge for definitive management or to the general practitioner. Demographical and clinical data were collected. After discharge from the system, patients completed a satisfaction and feedback questionnaire. Log-rank tests were used to compare the equality of time-to-event functions across randomised groups. RESULTS: There were 96 participants, 46 in the intervention arm and 50 controls. The total time spent in the gynaecology system differed between groups (Χ2 (1) = 6.94, P = 0.008), with a median total time of 55 days (95% confidence interval (CI): 37-66 days) for the intervention group compared to a median of 84 days (95% CI: 54-101 days) for the control group. The number of in-person gynaecology encounters differed between those randomised to intervention (P < 0.001). Overall, 96% of respondents indicated a positive score for overall satisfaction. CONCLUSIONS: The proposed clinic model resulted in a significant reduction in the time between referral and discharge, without compromising patient satisfaction.

Determining a threshold measurement of endometrial thickness for asymptomatic postmenopausal women: A tertiary centre case series.

BACKGROUND: An incidental finding of a thickened endometrium on ultrasound in the postmenopausal patient without bleeding is a common presentation to gynaecological services; however there is limited evidence to guide clinical practice as to when hysteroscopic evaluation and endometrial sampling is required. AIMS: To determine the endometrial thickness at which endometrial sampling is indicated in asymptomatic postmenopausal women referred with thickened endometrium on ultrasound. MATERIALS AND METHODS: A single-centre retrospective case series of postmenopausal women without bleeding undergoing hysteroscopy was conducted. Logistic regression was used to examine the association between a range of variables and pre-malignant or malignant pathology and endometrial thickness. The optimal endometrial thickness threshold was identified to maximise model sensitivity. RESULTS: A total of 404 postmenopausal women were included in this study, having undergone a hysteroscopy at the study site between 1 July 2008 and 30 June 2018. The mean (SD) age of patients at presentation was 65 (9.09) years and the mean body mass index was 29.86 kg/m2 (6.52). Of these women, nine (2.2%) were diagnosed with endometrial carcinoma and seven (1.7%) had endometrial hyperplasia with atypia. The most common histopathological finding was of a benign endometrial polyp (153: 37.9%). When including hyperplasia with or without atypia in histopathology of interest, a cut-off of ≥9 mm provides the greatest sensitivity (83.3%) and specificity (63.8%) for a diagnosis of pre-malignant or malignant pathology (classification accuracy of 64.8%; area under the receiver operating characteristic: 0.7358, 95% CI: 0.6439, 0.8278) in this cohort. CONCLUSIONS: Using an endometrial thickness of ≥9 mm can be used as a cut-off for endometrial sampling in postmenopausal women without bleeding.

Telehealth for gynaecology outpatients during the COVID-19 pandemic: Patient and clinician experiences.

BACKGROUND: The COVID-19 pandemic has necessitated alterations in provision of health care and how patients access it. Telehealth has replaced traditional face-to-face outpatient clinics in an unprecedented manner. This study aimed to assess overall patient and clinician satisfaction with telehealth consultations, to establish acceptability of telehealth during pandemic and non-pandemic times, and document feedback. MATERIALS AND METHODS: A prospective observational study involving women presenting to a general gynaecology outpatient department was performed. Women who attended for consultation between 13 July and 4 September 2020 were invited to participate in a questionnaire following their telehealth appointment. Clinicians consulting in the outpatient department were invited to complete a questionnaire at the end of the eight-week study period. Satisfaction, utility and acceptability data were obtained using visual analogue scales (VAS). RESULTS: Twenty-six out of 56 (46.4%) clinicians and 124/870 (14.3%) patients completed the questionnaire. Patients who responded were older and more likely to have been born in Australia than women who did not (P = 0.0355 and P = 0.005, respectively). Overall patient satisfaction with telehealth was high (median VAS (interquartile range), 8.6 (5.6-9.8)). More women found telehealth to be acceptable during a pandemic than afterward (8.9 vs 6.6, P < 0.0001). Clinicians were less satisfied with telehealth than patients (7.1 vs 8.6, P = 0.02); however, most would be happy to continue using telehealth in non-pandemic times (7.0 (6.2-9.8)). CONCLUSION: Telehealth consultations allow provision of gynaecological care at a time when reducing risk of infection to patients and staff is paramount. Telehealth gynaecology consultations are efficient and convenient without significant detriment to patient or clinician satisfaction.

We live in a virtual world: Training the trainee using an integrated visual reality simulator curriculum.

BACKGROUND: Gynaecology trainees struggle to obtain adequate procedural experience. Training programs integrating virtual reality simulators (VRS) have been suggested as a solution. AIMS: The study aimed to assess if a VRS training program (LapSim® , Surgical Sciences, Göteborg, 2017) improved live operating performance at six months for novice and experienced trainees. Additional outcomes included the association between LapSim® logged time and live operating performance at six months, LapSim® scores and live operating performance at zero and sixmonths and the difference in benefit for novice and experienced gynaecology trainees. METHODS: A prospective intervention study was conducted. Novice and experienced trainees were enrolled, and comparisons made at zero- and six-month time points. The intervention groups were provided with a laparoscopic gynaecology curriculum incorporating VRS. Controls underwent routine training only. Assessment of live operating performance was conducted after six months training. RESULTS: Thirty-five trainees participated, and 25 had access to the VRS curriculum (17 novice and eight experienced trainees). Access to the VRS curriculum and time spent training on the LapSim® made no difference to live operating ability for either intervention group (P > 0.05). The median (interquartile range) hours of VRS usage were 7.9 (4.5-10.8) and 6.0 (4.0-6.8) for novice and experienced trainees respectively. The intervention group provided positive feedback on the utility of VRS in their laparoscopic skill development. CONCLUSION: Optimal utilisation of VRS in Australian training paradigms remains incompletely understood. Further research is required to establish the most effective integration of VRS into training models to ensure uptake and transferability to the operating theatre.

Tubal interruption and subsequent surgery for pain after endometrial ablation: A retrospective cohort study.

BACKGROUND: Endometrial ablation (EA) is an alternative to hysterectomy for abnormal uterine bleeding (AUB), with reduced recovery time and fewer operative risks. However, post-ablation pain may be associated with subsequent surgery, including hysterectomy. It is uncertain what factors affect surgery rates for post-ablation pain, particularly with respect to timing and technique of tubal interruption. AIM: To evaluate the relationship between tubal interruption and post-ablation pain and subsequent surgery. MATERIALS AND METHODS: We conducted a retrospective cohort study involving 324 patients at a Melbourne tertiary hospital from 2009 to 2020. The primary outcome was subsequent pelvic surgery for pain following EA. RESULTS: Pain following EA was reported by 29.7% of patients, with 10.5% of patients undergoing subsequent surgery for pain. Patients with tubal interruption were more likely to undergo subsequent surgery for pain than those with no tubal interruption (odds ratio (OR): 3.49, 95% CI: 1.59-7.66; P = 0.002). Tubal ligation was strongly associated with subsequent surgery for pain (OR: 3.12, 95% CI: 1.48-6.57; P = 0.003). In contrast, those with salpingectomy did not have an increased risk of subsequent surgery for pain, compared to those with no tubal interruption (OR: 1.5; 95% CI 0.32-7.13). Pre-ablation pain (adjusted OR: 2.98, 95% CI: 1.37-6.48; P = 0.006) and previous caesarean section (OR: 2.66; 95% CI: 1.13-6.25; P = 0.025) were also associated with subsequent surgery for pain. CONCLUSION: Our results suggest that tubal interruption, pre-ablation pain and previous caesarean section are associated with subsequent surgery for pain. These results can better inform preoperative counselling regarding the risk of subsequent surgery after EA.

Botulinum toxin A (Botox) injection into muscles of pelvic floor as a treatment for persistent pelvic pain secondary to pelvic floor muscular spasm: A pilot study.

BACKGROUND: Persistent pelvic pain (PPP) remains an important cause of morbidity. Pelvic floor muscle spasm is an important contributor to PPP. AIMS: The study's primary aim was to assess if botulinum toxin (BoNT) injection to pelvic floor muscles altered pain scores or quality of life (QoL) at six, 12 and 26 weeks. Secondary aims included investigating the impact of BoNT on opiate usage, examining the role of pain catastrophising, and assessing for complications. MATERIALS AND METHODS: A single-centre prospective cohort study enrolled 21 patients with PPP who had failed physiotherapy techniques. Each participant underwent BoNT injection to muscles of the pelvic floor and pudendal nerve block. Questionnaires and digital vaginal examinations were conducted at baseline, six, 12 and 26 weeks. Pain score quantification used visual analogue scales (VAS) and numerical rating scales (NRS). Other outcome assessments included The World Health Organization Quality of Life instrument (WHOQoL-BREF), Pain Catastrophising Scale (PCS), and modified Australian Pelvic Floor Questionnaire (APFQ). ACTRN12620000067976. RESULTS: Following BoNT injection, median VAS scores decreased for all domains at six and 12 weeks, with VAS for dyspareunia significant at six weeks (P = 0.026). Scores returned to baseline by 26 weeks. Opiate usage was significantly less following BoNT injection, with a percentage reduction of 23.8% (95% CI -48.3 to 0.7, P = 0.06). Sexual function improved significantly (P < 0.01), and at six months, four previously apareunic participants reported successful penetrative vaginal intercourse. Health-related QoL and PCS demonstrated sustained improvement (P = 0.02-0.05). NRS for muscle tenderness decreased for all assessed muscle groups (P < 0.001). CONCLUSIONS: BoNT requires further assessment as a treatment modality for select women with PPP.

Combination methotrexate and gefitinib: A potential medical treatment for inoperable nontubal ectopic pregnancy.

Nontubal ectopic pregnancies present as a therapeutic challenge. A 35-year-old primigravida at 7 weeks gestation had a live interstitial ectopic pregnancy and contraindications to surgery. The patient was treated with a multidose methotrexate regimen combined with oral gefitinib (250 mg daily for 7 days). The peak human chorionic gonadotropin (hCG) of the patient was recorded at 19 510 IU/L and began declining from day 4 of combination therapy (day 6 of initial treatment). Successful resolution of the ectopic was demonstrated by cessation of the fetal heart by day 15 and hCG falling to 23 IU/L by day 42. A 10-year review of all nontubal ectopic pregnancies treated with methotrexate identified 46 cases, which had a comparable time to resolution to combination therapy. However, for cases where cardiac activity was present, the median time to resolution following methotrexate treatment was 64 days (47-87 days), 22 days longer than combination therapy. Combination therapy may provide a safe medical treatment for inoperable nontubal ectopic pregnancy.

Introduction of the MyoSureLITE in an established outpatient hysteroscopy clinic.

BACKGROUND: Endometrial polyps are a common cause of abnormal uterine bleeding. The MyoSureLITE intrauterine morcellation device is effective at resecting endometrial polyps; however, its use in the outpatient setting requires appraisal. AIM: To assess the feasibility, utility, acceptability and costs associated with introduction of the MyoSureLITE into an established outpatient hysteroscopy (OPH) clinic. MATERIAL AND METHODS: A prospective clinical database from a tertiary Melbourne hospital was analysed from 1 July 2015 to 30 June 2018. Three 12-month time periods were compared: pre-introduction and trial phase, early use, and established use of the MyoSureLITE. Wait times, patient acceptability, second OPH bookings and procedure costs were measured. RESULTS: Eight hundred and seventy-one women underwent OPH during the study period, with 238 (27.3%) women presenting with endometrial polyp(s). At each timepoint, 78.5, 25 and 6.3% of women required rebooking for a subsequent hysteroscopy for pathology otherwise suitable for MyoSureLITE resection. Introduction of the MyoSureLITE avoided a subsequent procedure for 4, 60 and 69 women respectively for each year of use, with potentially reduced treatment costs for the institution. Median (IQR) wait time for definitive treatment of intrauterine pathology was 56 (24-84) days at time-period 1, decreasing to 0 (0-0) days during time-period 3, (P < 0.001); 87.6% would undergo OPH again. CONCLUSIONS: Routine use of the MyoSureLITE is effective, feasible, and acceptable to women. Provision of this device in outpatient service allows a 'see-and-treat' model, saving theatre time and treatment costs, facilitating a more direct throughput from presentation to treatment.

The Role of the Mirena Intrauterine Device in the Management of Endometrial Polyps: A Pilot Study.

STUDY OBJECTIVE: To study the hypothesis that the levonorgestrel intrauterine device (LNG-IUD) can have a role in the treatment of endometrial polyps confirmed at outpatient hysteroscopy in premenopausal women. DESIGN: Canadian Task Force classification level II1 (a controlled trial that is not randomised). SETTING: Outpatient hysteroscopy. PATIENTS: Premenopausal women who had a polyp diagnosed at outpatient hysteroscopy. INTERVENTIONS: Premenopausal women who had a polyp diagnosed at outpatient hysteroscopy and had a LNG-IUD inserted were booked for general anesthesia hysteroscopy and polypectomy through the standard booking process. A contemporaneous control was taken sequentially from the outpatient hysteroscopy database to match the case. MEASUREMENTS AND MAIN RESULTS: The presence of a polyp at hysteroscopy under general anesthesia. A total of 39 patients were included in the study, with 19 in the intervention group and 20 in the control group. The mean age was 43.6 (standard deviation = 5.6) and 43.2 (standard deviation = 8.1) years in the 2 groups, respectively. No difference was found in the time interval between the 2 procedures in the intervention and control groups (mean = 92 vs 84 days, p = .73). However, the proportion of polyps present at the second procedure was significantly higher in the control group (80% vs 37%; relative risk = 2.17; 95% confidence interval, 1.16-4.07; p = .0062). CONCLUSION: Our case-control study found that the LNG-IUD can have a role in the treatment of polyps for women who have heavy menstrual bleeding. This is the first study to show regression of endometrial polyps after treatment with LNG-IUD by direct visualisation at hysteroscopy.

Can Narrowband Imaging Improve the Laparoscopic Identification of Superficial Endometriosis? A Prospective Cohort Trial.

STUDY OBJECTIVE: To assess the usefulness of narrowband imaging (NBI) to detect additional areas of endometriosis not identified by standard white light in patients undergoing laparoscopy for the investigation of pelvic pain. DESIGN: A prospective cohort trial (Canadian Task Force classification II). Evidence obtained from a well-designed cohort study. SETTING: A tertiary laparoscopic subspecialty unit in Melbourne, Australia. PATIENTS: Fifty-seven patients undergoing laparoscopy for the investigation of pelvic pain were recruited. Fifty-three patients were eligible for analysis. INTERVENTIONS: Patients underwent standard white-light laparoscopy of the pelvis followed by NBI survey to assess for any additional areas suspicious for endometriosis. MEASUREMENTS AND MAIN RESULTS: All identified areas of possible endometriosis were resected and sent for blinded histopathological analysis. The additional predictive value of NBI was 0% if the preceding white-light survey was negative and 86% if the preceding white-light survey was positive. CONCLUSION: The use of NBI at laparoscopy for the investigation of pelvic pain is beneficial in finding additional areas of endometriosis if endometriosis is already suspected after white-light survey in a tertiary laparoscopic unit. Further research in nonspecialized units may show additional benefit and requires further research. NBI may also be useful as a diagnostic aid for trainees.

Multicentre retrospective study to assess diagnostic accuracy of ultrasound for superficial endometriosis-Are we any closer?

BACKGROUND: To establish whether the ultrasound findings of minimal endometriosis are confirmed at laparoscopy and that a correlation can be established as to the anatomical sites in this mild form of the disease. AIMS: Patients with pain and suspicion of endometriosis had an ultrasound scan by a sonologist with expertise in endometriosis as part of their pre-operative workup. MEASUREMENTS AND MAIN RESULTS: The clinical histories of 53 patients who had laparoscopy to investigate pelvic pain were reviewed. Ultrasounds were performed between 2012 and 2015 by a single sonologist with expertise in endometriosis assessments. The ultrasound findings were divided into subgroups as follows - presence of uterosacral ligament thickness, thickened pericolic fat, ovarian mobility and focal tenderness. These were compared with operative findings of those patients with superficial endometriosis. Evidence Level 3 - observational studies with controls and health services research that includes adjustment for likely confounding factors. RESULTS: Seventy-nine percent (42/53) of the patients had laparoscopic findings consistent with their ultrasound findings (95% CI 68-90%, P < 0.0001). Of the subgroups that we reviewed, uterosacral thickening (P < 0.05) and thickened pericolic fat (P < 0.05) were the most associated with superficial endometriosis at the time of laparoscopy. CONCLUSION: Markers on ultrasound that reliably demonstrated inflammation (thickened uterosacral ligaments and thickened pericolic fat) were shown to be significantly associated with the disease.

Clinical approach to vulvovaginal cysts and abscesses, a review.

Vulvovaginal cysts are a common problem for women, causing significant pain, discomfort and impact on quality of life. For clinicians, classifying and differentiating these cysts from each other and selecting appropriate management can be challenging, yet there is no integrated classification system and little literature that broadly summarises a clinical approach. We aimed to create a useful tool for clinicians by providing a detailed summary of various vulvovaginal cysts and abscesses with a clear novel classification system and hierarchy for diagnosis and management, to aid clinicians in this process.

Is outpatient hysteroscopy the new gold standard? Results from an 11 year prospective observational study.

BACKGROUND: In Australia, gynaecologists continue to investigate women with abnormal bleeding and suspected intrauterine pathology with inpatient hysteroscopy despite some evidence in the literature that that there is no difference in safety and outcome when compared to an outpatient procedure. AIMS: This prospective study assessed the safety, effectiveness and acceptability of outpatient hysteroscopy over 11 years at a tertiary hospital in Australia. Resource savings were then calculated. MATERIALS AND METHODS: A prospective database was analysed from March 2003 to January 2014 (130 months, 990 women). RESULTS: Successful hysteroscopic access was obtained in 94% of cases. Twenty-six percent of patients required a second procedure, including 132 for endometrial polyps and 33 for submucosal fibroids that were not able to be treated in the outpatient setting. On questioning, 88% of women would be happy to have the procedure again. Factors affecting success were pre-procedure pain, menopausal status and previous vaginal delivery. The difference between pain experienced versus pain expected was a major factor in patient acceptability. A vasovagal episode occurred in 5% of cases. CONCLUSION: Outpatient hysteroscopy was demonstrated to be safe, effective and acceptable to women. Provision of an outpatient hysteroscopy service saves theatre time and approximately $1000 per case. Improved techniques and technology will allow progression to a 'see and treat' service, providing further savings. With budget constraints, increasing wait times for major procedures and concerns about trainee surgical experience, an outpatient hysteroscopy service should be considered the 'gold standard' investigation over hysteroscopy in theatre.

Are endometrial nerve fibres unique to endometriosis? A prospective case-control study of endometrial biopsy as a diagnostic test for endometriosis in women with pelvic pain.

STUDY QUESTION: Can the presence of endometrial nerve fibres be used as a diagnostic test for endometriosis in women with pelvic pain? SUMMARY ANSWER: Endometrial fine nerve fibres were seen in the endometrium of women both with and without endometriosis, making their detection a poor diagnostic tool for endometriosis. WHAT IS KNOWN ALREADY: Laparoscopy and biopsy are currently the gold standard for making a diagnosis of endometriosis. It has been reported that small density nerve fibres in the functional layer of the endometrium are unique to women with endometriosis and hence nerve fibre detection could function as a less invasive diagnostic test of endometriosis. However, it may be that other painful conditions of the pelvis are also associated with these nerve fibres. We therefore focused this prospective study on women with pelvic pain to examine the efficacy of endometrial nerve fibre detection as a diagnostic test for endometriosis. STUDY DESIGN, SIZE, DURATION: This prospective case-control study conducted between July 2009 and July 2013 included 44 women with pelvic pain undergoing laparoscopic examination for the diagnosis of endometriosis. Immunohistochemical nerve fibre detection in endometrial curettings and biopsies using anti-protein gene product 9.5 was compared with surgical diagnosis. PARTICIPANTS/MATERIALS, SETTINGS, METHODS: Paired endometrial biopsies and curettings were taken from patients with (n = 22, study group) and without (n = 22, control group) endometriosis. Tissue was analysed by immunohistochemistry and nerve fibres were counted whenever they were present in the functional layer of the endometrium. MAIN RESULTS AND THE ROLE OF CHANCE: Fine nerve fibres were present in the eutopic endometrium of patients both with and without endometriosis. The presence of nerve fibres in curettings was not effective for either diagnosing or excluding endometriosis; sensitivity and specificity were 31.8 and 45.5% respectively, positive predictive value was 36.8% and negative predictive value was 40.0%. Few endometrial biopsy specimens were found to have nerve fibres present; sensitivity and specificity for endometrial biopsy were 13.6 and 68.2% respectively, positive predictive value was 30.0% and negative predictive value was 44.1%. LIMITATIONS, REASONS FOR CAUTION: This was a relatively small sample size and studies like this are subject to the heterogeneous nature of the patient population and tissue samples, despite our best efforts to regulate these parameters. WIDER IMPLICATIONS OF THE FINDINGS: Our results demonstrate that fine nerve fibres are present in women with and without endometriosis. Future work should focus on the function of endometrial nerves and whether these nerves are involved with the subfertility or pain that endometriosis sufferers experience. Our study does not support the detection of endometrial nerve fibres as a non-invasive diagnostic test of endometriosis in women with pelvic pain.

The effect of patient body mass index on surgical difficulty in gynaecological laparoscopy.

INTRODUCTION: Over the past three decades, rates of overweight and obesity internationally have risen to epidemic proportions. There are currently no published prospective studies examining the effect of obesity on gynaecologic laparoscopy for benign indications within a population with obesity rates comparable to Australian women. AIMS: To assess and quantify whether increasing patient body mass index negatively impacted upon the ability to successfully complete planned laparoscopic surgery. METHODS: From January 2009 until October 2012, 307 women undergoing laparoscopic gynaecological surgery for benign pathology were recruited. Intra-operative variables included the following: ease of identification of anatomical landmarks, entry technique and number of attempts, conversion to laparotomy and any complications encountered. Any post-operative complications were recorded at the six week post-operative review. RESULTS: 94.46% of operations were completed as planned. As BMI increased, the ease of identification of important anatomical landmarks significantly decreased. There was no correlation between increasing BMI and surgical complication rates. CONCLUSIONS: Planned gynaecological laparoscopy can be performed in obese patients with a high likelihood of completion. In this study, obesity was not associated with a significant increase in complication rates or failure to complete the surgery as planned.

Pain experience with outpatient hysteroscopy: A prospective cohort study.

BACKGROUND: Abnormal uterine bleeding (AUB) affects women of all ages and is one of the most common reasons for referral to a gynaecological clinic. Operative hysteroscopic procedures allow for a see-and-treat approach to AUB, and these techniques have been shown to be feasible and acceptable in the outpatient setting. OBJECTIVE: To assess if there is an increase in pain scores for women who are undergoing an operative hysteroscopic procedure with Myosure LITE® (Hologic; mechanical hysteroscopic tissue removal system) compared to outpatient diagnostic hysteroscopy alone. STUDY DESIGN: A prospective cohort study was performed. All participants attending the outpatient hysteroscopy clinic at Mercy Hospital for Women completed a pre-and post-procedure questionnaire. This included a visual analogue scale (VAS) for any pre-existing pain, anticipated pain, and actual pain experienced during procedure. Factors influencing overall satisfaction and willingness to attend again were also assessed. Data was entered into RedCap® for analysis. A difference in VAS of 10 mm or more was considered clinically significant. An alpha of p < 0.05 was assigned for statistical significance. RESULTS: Between February 2020 and November 2022, 208 women underwent outpatient diagnostic hysteroscopy followed by an operative hysteroscopy with MyoSure®. To allow for standardisation of analgesia, only participants who had a cervical block before their Myosure® procedure were included for analysis (n = 111). There was statistical evidence (t(111) = 2.36, p = 0.02) of a lower mean VAS pain score for operative Myosure (36.5 mm, 95 % CI: 31.1-41.8 mm) compared to outpatient diagnostic hysteroscopy (44.1 mm, 95 % CI: 39.0-49.2 mm). The mean difference in VAS pain score was estimated as 7.7 mm (95 % CI: 1.2-14.1 mm) lower for Myosure compared to hysteroscopy. Given the threshold for clinical significance was considered as 10 mm difference in VAS, the variance in pain scores is under the likely clinically significant range. There was no significant difference in pain scores for diagnostic hysteroscopy with or without paracervical block (mean difference = 1.42; 95 % CI: -6.35 to 9.20). There was no association between pre-existing pain, and actual pain for hysteroscopy, or Myosure (p = 0.997 and p = 0.065 respectively). The anticipated pain score was weakly associated with actual pain during the operative Myosure procedure (p = 0.02), and with outpatient diagnostic hysteroscopy (p = 0.019). CONCLUSION: Outpatient hysteroscopy procedures are generally well tolerated. The pain experience with operative Myosure was less than that reported during the diagnostic hysteroscopy by the same patient although this is unlikely of clinical significance. Importantly, Myosure was not more painful than the initial diagnostic procedure, and most patients were satisfied with the outcome and would choose to have the procedure again in an outpatient setting. This is in keeping with other studies which have shown a high degree of patient tolerance and satisfaction with this approach.