The expression of corticotropin-releasing hormone family peptides in premalignant and malignant vulvar lesions

Objectives To examine the relation of corticotropin-releasing hormone (CRH) family peptides with inflammatory processes and oncogenesis, emphasizing in vulvar inflammatory, premalignant and malignant lesions, as well as to investigate the possibility of lesion cells immunoescaping, utilizing FAS/FAS-L complex. Methods Immunohistochemical expression of CRH, urocortin (UCN), FasL and their receptors CRHR1, CRHR2 and Fas was studied in vulvar tissue sections obtained from patients with histologically confirmed diagnosis of lichen, vulvar intraepithelial neoplasia (VIN) and vulvar squamous cell carcinoma (VSCC). The patient cohort was selected from a tertiary teaching Hospital in Greece, between 2005 and 2015. For each of the disease categories, immunohistochemical staining was evaluated and the results were statistically compared. Results A progressive increase of the cytoplasmic immunohistochemical expression of CRH and UCN, from precancerous lesions to VSCC was observed. A similar increase was detected for Fas and FasL expression. Nuclear localization of UCN was demonstrated in both premalignant and VSCC lesions, with staining being significantly intensified in carcinomas, particularly in the less differentiated tumor areas or in the areas at invasive tumor front. Conclusions Stress response system and CRH family peptides seem to have a role in inflammation maintenance and progression of vulvar premalignant lesions to malignancy. It seems that stress peptides may locally modulate the stroma through Fas/FasL upregulation, possibly contributing to vulvar cancer development (AU)

The expression of corticotropin-releasing hormone family peptides in premalignant and malignant vulvar lesions.

OBJECTIVES: To examine the relation of corticotropin-releasing hormone (CRH) family peptides with inflammatory processes and oncogenesis, emphasizing in vulvar inflammatory, premalignant and malignant lesions, as well as to investigate the possibility of lesion cells immunoescaping, utilizing FAS/FAS-L complex. METHODS: Immunohistochemical expression of CRH, urocortin (UCN), FasL and their receptors CRHR1, CRHR2 and Fas was studied in vulvar tissue sections obtained from patients with histologically confirmed diagnosis of lichen, vulvar intraepithelial neoplasia (VIN) and vulvar squamous cell carcinoma (VSCC). The patient cohort was selected from a tertiary teaching Hospital in Greece, between 2005 and 2015. For each of the disease categories, immunohistochemical staining was evaluated and the results were statistically compared. RESULTS: A progressive increase of the cytoplasmic immunohistochemical expression of CRH and UCN, from precancerous lesions to VSCC was observed. A similar increase was detected for Fas and FasL expression. Nuclear localization of UCN was demonstrated in both premalignant and VSCC lesions, with staining being significantly intensified in carcinomas, particularly in the less differentiated tumor areas or in the areas at invasive tumor front. CONCLUSIONS: Stress response system and CRH family peptides seem to have a role in inflammation maintenance and progression of vulvar premalignant lesions to malignancy. It seems that stress peptides may locally modulate the stroma through Fas/FasL upregulation, possibly contributing to vulvar cancer development.

Title: Repeated implantation failure is associated with increased Th17/Treg cell ratio, during the secretory phase of the human endometrium.

Repeated implantation failure (RIF) is a significant limiting factor in assisted reproduction. Chronic endometrial inflammation has been noted in RIF women, therefore we sought to investigate the potential association of endometrial Th17/Treg ratio and endometrial inflammation in these cases. Endometrial pipelle biopsies were obtained from volunteers, 29 women with RIF (failure to achieve pregnancy following at least 3 transfers of high-grade embryos in IVF-cycles) and 27 fertile women (at least one child) in total, at the secretory phase of the menstrual cycle. Using tissues from 17 fertile and 18 RIF endometrial samples, stromal and immune cells were isolated and flow cytometry analysis was performed to determine Th17 and CD4+ CD25high FOXP3+ cell populations in endometrial stromal cell suspensions. Another group of tissues from 10 fertile and 11 RIF samples were used for mRNA expression levels of Treg and Th17-cell transcription factors, FOXP3 and RORγt respectively. Endometrial inflammatory mediators' mRNA expression was also analyzed. A statistically significant increase in protein flow cytometry analysis of Th17/Treg ratio (p ≤ 0.05) as well as a reduction in absolute Treg cells in the endometrium (p ≤ 0.05) was noted in women with RIF. Additionally, RNA analysis on the same set of women indicated RORγt/FOXP3 significantly increased in women with RIF compared to fertile ones (p ≤ 0.05). Finally, women with RIF exhibited significantly (p ≤ 0.05) elevated mRNA levels of pro-inflammatory mediators (ΤΝF-a, ΙL-6, IL-8 and CCl2). Women with RIF exhibit elevated Th17/Treg ratio, mostly due to endometrial Treg depletion, as well as a pro-inflammatory state in the endometrium.

Conservative treatment of endometrial cancer in women of reproductive age (Review).

Endometrial cancer is the fifth most common female cancer worldwide and the third leading female cancer in the Western world. The marked surge in endometrial cancer incidence is alarming. The aim of the present review is to focus on endometrial cancer affecting young women of reproductive age. Surgery, namely abdominal or laparoscopic hysterectomy, with or without salpingo-oophorectomy, and sentinel lymph node detection has become the standard surgical strategy for early stage endometrioid endometrial cancer. However, premenopausal women might want to preserve their fertility, especially if they are nulliparous or have not reached their desired number of children at the time of diagnosis. Conservative, uterus-sparing treatment, based on progestin products, may be an advantageous option for patients meeting the necessary criteria. Potential candidates have to be committed to following a rigorous protocol of treatment, investigations and follow-up. The evidence in favor of this approach, although limited, is encouraging and patients who have achieved a histologically documented disease complete remission could attempt to conceive spontaneously or with the immediate use of assisted reproductive technology techniques. The risk of partial or negative response to progestin treatment or cancer recurrence is well documented, thus patients have to be aware of the possible need for interruption of conservative treatment and hysterectomy.

Diffusion Weighted Imaging in the Assessment of Tumor Grade in Endometrial Cancer Based on Intravoxel Incoherent Motion MRI.

The aim of this study is to investigate the possibility of predicting histological grade in patients with endometrial cancer on the basis of intravoxel incoherent motion (IVIM)-related histogram analysis parameters. This prospective study included 52 women with endometrial cancer (EC) who underwent MR imaging as initial staging in our hospital, allocated into low-grade (G1 and G2) and high-grade (G3) tumors according to the pathology reports. Regions of interest (ROIs) were drawn on the diffusion weighted images and apparent diffusion coefficient (ADC), true diffusivity (D), and perfusion fraction (f) using diffusion models were computed. Mean, median, skewness, kurtosis, and interquartile range (IQR) were calculated from the whole-tumor histogram. The IQR of the diffusion coefficient (D) was significantly lower in the low-grade tumors from that of the high-grade group with an adjusted p-value of less than 5% (0.048). The ROC curve analysis results of the statistically significant IQR of the D yielded an accuracy, sensitivity, and specificity of 74.5%, 70.1%, and 76.5% respectively, for discriminating low from high-grade tumors, with an optimal cutoff of 0.206 (×10-3 mm2/s) and an AUC of 75.4% (95% CI: 62.1 to 88.8). The IVIM modeling coupled with histogram analysis techniques is promising for preoperative differentiation between low- and high-grade EC tumors.

Approaches to Improve Endometrial Receptivity in Case of Repeated Implantation Failures.

Repeated implantation failures are a constant challenge in reproductive medicine with a significant impact both on health providers and on infertile couples. Several approaches have been proposed so far as effective; however, accumulative data have clarified that most of the treatment options do not have the evidence base for a generalized application to be suggested by the relevant societies. Implantation failures are attributed to either poor quality embryos or to defected endometrial receptivity. The current review aims to summarize in a systematic way all the new trends in managing RIF via interference with endometrial receptivity. The authors focus mainly, but not exclusively, on endometrial injury prior to embryo transfer and endometrial priming with autologous cells or biological agents. To this direction, a systematic search of the Pubmed database has been conducted taking into account the emerged evidence of the last two decades. All the suggested interventions are herein presented and analyzed in terms of reproductive outcomes. It is evident that properly powered and designed randomized trials are needed to support a new standard approach in RIF treatment that will safely be incorporated in national and international guidelines.

Splenic pregnancy treated with transcatheter embolization and methotrexate.

BACKGROUND: Primary splenic pregnancy is a rare entity, usually treated with splenectomy. CASE PRESENTATION AND REVIEW OF THE LITERATURE: We report the first case of conservative management of splenic pregnancy with selective embolization and intramuscular methotrexate administration. Postoperative treatment was uneventful. We have further systematically reviewed the literature upon the treatment options in case of splenic pregnancy. It has been evident that most cases were treated with spleenectomy, especially in case of active hemorrhage. Spleen preservation is rarely achieved, only in cases of hemodynamically stable, uncomplicated patients. CONCLUSION: Splenic selective embolization could be a treatment option in case of uncomplicated splenic pregnancy with the benefit of splenic preservation.

Acceptability of Self-Sampling for Human Papillomavirus-Based Cervical Cancer Screening.

Background: Human papillomavirus (HPV)-DNA testing combined with self-sampling could increase cervical cancer screening effectiveness, utilizing a sensitive screening modality and an easy sampling method with minimal pain or discomfort. Self-sampling acceptability, though, is pivotal. Materials and Methods: This study is a nested cross-sectional survey within GRECOSELF, a cross-sectional study on HPV-based screening with self-sampling, aiming at investigating self-sampling acceptability among Greek women residing in rural areas, and the factors affecting it. Women between 25 and 60 years old were recruited by midwives participating in a nationwide midwifery network. Participants, after self-sampling, filled out a questionnaire with three sections, one regarding demographic characteristics, a second with questions pertaining to the participants' cervical cancer screening history, and a third with questions regarding the self-sampling process per se. Results: The sample included 13,111 women. Most participants (67.9%), including those screened or not in the past, would prefer self-sampling if assured that the results are not inferior to standard testing. Discomfort or pain during self-sampling was absent or minimal in 97.1% and 96.5% of the cases, respectively, and 74.4% of the women felt adequately confident that they followed the instructions correctly. Women mostly preferred self-sampling at home compared with health care facilities. Pain and discomfort during the procedure, although rare, were significant factors against acceptance. Most of the women reporting a negative impression had a negative experience with conventional sampling in the past. Conclusion: Self-sampling is highly acceptable. Acceptance can be further improved with proper communication of the process and its noninferiority compared with conventional screening.

Cancer pain who cares? International and national patterns of evidence-based global guidelines recommendations for physicians on the Web (2011 vs. 2018).

PURPOSE: Although pain is a common event during treatment of cancer, its assessment and management remains suboptimal in everyday clinical practice at global level. METHODS: Considering both the important role of internet in daily life and that clinical guidelines are important for translating evidence in clinical practice, we performed a prospective study to scrutinize the magnitude of updated evidence-based cancer-pain guideline recommendation for physicians on the web. Changes over-time at a global level were scrutinized at two time points: 2011 for baseline and 2018 at first follow-up. Both anesthesiology and oncology societies were analyzed. RESULTS: In 2011 we scrutinized 181,00 WebPages and 370 eligible societies were identified; 364 of these were eligible for analyses both in 2011 and 2018. The magnitude of cancer pain updated and evidence-based guideline recommendations on the web for health care providers was extremely low at global level and at any time point considered: 1.1% (4/364) in 2011 and 4.7% (17/364) in 2018. Continental and intercontinental patterns, National's highest developmental index, oncology tradition and economic-geographic areas were not found to influence cancer pain web-guideline provision. In 2018, pain & supportive care societies provided the highest rate of updated evidence-based cancer-pain guidelines for clinicians. Only 3/25 medical oncology societies and 1/34 radiation oncology societies, provided own or e-link (to other societies') evidence-based guidelines in their websites. CONCLUSIONS: Major medical oncology and radiation oncology societies - at global level - fail to produce updated cancer pain recommendations for their physicians, with most of these providing no or inconsistent or outdated guidelines.

Implementation of HPV-based Cervical Cancer Screening Combined with Self-sampling Using a Midwifery Network Across Rural Greece: The GRECOSELF Study.

Self-sampling for human papillomavirus (HPV) testing is an alternative to physician sampling particularly for cervical cancer screening nonattenders. The GRECOSELF study is a nationwide observational cross-sectional study aiming to suggest a way to implement HPV-DNA testing in conjunction with self-sampling for cervical cancer screening in Greece, utilizing a midwifery network. Women residing in remote areas of Greece were approached by midwives, of a nationwide network, and were provided with a self-collection kit (dry swab) for cervicovaginal sampling and asked to answer a questionnaire about their cervical cancer screening history. Each sample was tested for high-risk (hr) HPV with the Cobas HPV test. HrHPV-Positive women were referred to undergo colposcopy and, if needed, treatment according to colposcopy/biopsy results. Between May 2016 and November 2018, 13,111 women were recruited. Of these, 12,787 women gave valid answers in the study questionnaire and had valid HPV-DNA results; hrHPV prevalence was 8.3%; high-grade cervical/vaginal disease or cancer prevalence was 0.6%. HrHPV positivity rate decreased with age from 20.7% for women aged 25-29 years to 5.1% for women aged 50-60 years. Positive predictive value for hrHPV testing and for HPV16/18 genotyping ranged from 5.0% to 11.6% and from 11.8% to 27.0%, respectively, in different age groups. Compliance to colposcopy referral rate ranged from 68.6% (for women 25-29) to 76.3% (for women 40-49). For women residing in remote areas of Greece, the detection of hrHPV DNA with the Cobas HPV test, on self-collected cervicovaginal samples using dry cotton swabs, which are provided by visiting midwives, is a promising method for cervical cancer secondary prevention.

Intrauterine CRH-treated PBMC in repeated implantation failure.

BACKGROUND: The intrauterine administration of activated autologous peripheral blood monocytes (PBMC) prior to embryo transfer seems to improve reproductive outcomes in women with repeated implantation failure (RIF). We have previously shown that the intrauterine administration of PBMC treated with corticotropin-releasing hormone (CRH) prior to blastocyst transfer (day 5) improves significantly the clinical pregnancy rate of women with RIF. In the present crossover pilot study, we have investigated whether CRH-PBMC treatment could be of benefit in case of fresh early cleavage stage embryo transfer (day 3) in women with RIF. METHODS: Twenty-six (n = 26) women with at least three previous failed IVF attempts and no history of clinical pregnancy in the past were recruited in this study. Ovarian stimulation was performed following either the long or the short protocol. PBMC were collected during the oocyte retrieval, were treated with CRH, and transferred in the uterine cavity 2 days later. Good quality cleavage stage embryos were transferred at day 3, following oocyte retrieval. RESULTS: Following the intrauterine administration of CRH-treated autologous PBMC, 15/26 clinical pregnancies occurred (57.69%). Compared to the null result of the same women prior to recruitment, this observation was considered significant (P < 10-2 ). CONCLUSION: Our findings further support the role of the intrauterine administration of CRH-treated PBMC as an effective approach when transferring cleavage stage embryos in women with RIF. Prospective randomized studies are needed to clarify whether such intervention could be of benefit in clinical practice.

Endometrial CRH and implantation: from bench to bedside.

Endometrial corticotropin-releasing hormone (CRH) has been described as a mediator of decidualisation and as a contributor of maternal-fetal immunotolerance. Deregulation of the CRH expression pattern has been associated with unfavourable reproductive outcomes as well as chronic endometrium-derived inflammatory disorders, such as endometriosis and adenomyosis. The current review summarises the evidence produced regarding the role of CRH in endometrial physiology and pathophysiology and highlights recent clinical data regarding the role of CRH in improving clinical pregnancy rates in women with repeated implantation failures following in vitro fertilisation and embryo transfer.

CRH Receptors in Human Reproduction.

BACKGROUND: Corticotropin releasing hormone (CRH), the main peptide-mediator of stress, has been found in the female reproductive system. OBJECTIVE: Herein, the role of CRH receptors in the female reproductive system is presented. RESULTS: It is clear that CRH receptors are involved in the regulation of the hypothalamic-pituitaryovarian axis, while locally are associated with decidualization, embryonic implantation, early fetal development and triggering of parturition. CONCLUSION: Abnormal CRH signaling may contribute to obstetrical pathophysiology, such as preeclampsia, abnormal placenta invasion, endometrial growth retardation and preterm delivery.

The Role of HCG in Implantation: A Mini-Review of Molecular and Clinical Evidence.

Embryo implantation is a complex process involving continuous molecular cross-talk between the embryo and the decidua. One of the key molecules during this process is human chorionic gonadotropin (HCG). HCG effectively modulates several metabolic pathways within the decidua contributing to endometrial receptivity. Herein, a brief overview of the molecular mechanisms regulated by HCG is presented. Furthermore, we summarize the existing evidence regarding the clinical impact on reproductive outcomes after endometrial priming with HCG prior to embryo transfer. Although promising, further evidence is needed to clarify the protocol that would lead to beneficial outcomes.

Alpha tocopherol transfer protein (αTTP) is expressed in endometrial carcinoma and is correlated with FIGO stage and 5-year survival.

BACKGROUND: Increased oxidative stress plays an important role in cancer development. Vitamin E is considered a potent anti-oxidant and its transfer protein αTTP facilitates its cellular delivery. We hypothesize that αTTP could be present in and have an impact on endometrial cancer. MATERIALS AND METHODS: Ishikawa endometrial cancer cells were treated with BSO and AAPH to mimick oxidative stress conditions. αTTP was detected by immunocytochemistry and western blot. αΤΤP expression was then assessed in 191 endometrioid endometrial carcinomas. Immunopositivity was correlated with grade, FIGO stage, and 5-year survival. Immuno-reactivity was assessed with a semi-quantitative score. RESULTS: AAPH- and BSO-induced αTTP expression in Ishikawa cells. Immunohistochemical assessment of the 191 endometrial cancer cases showed that αTTP expression correlated with FIGO stage (p = 0.014) but not with grade. Five-year survival was significantly better in cases of lower αTTP expression compared to cases with higher expression (p = 0.041). CONCLUSIONS: The current results show that αTTP plays a role in endometrial carcinoma. Possibly endometrial cancer cells attempt to protect themselves from increasing oxidative stress by up-regulating αTTP. Selective molecular interventions targeting oxidative stress escape strategies, e.g., by overexpression of αTTP, could, therefore, allow oxidative stress to damage cancer cell membranes and thus restrict cancer progression.

Prevalence of HPV genotypes in cervical adenocarcinoma: a study in Greek women.

PURPOSE: To study the prevalence of human papillomavirus (HPV) genotypes among cervical adenocarcinomas in Greek women. METHODS: The study group comprised 78 adenocarcinoma cases (20 in situ and 58 invasive). HPV DNA was amplified using polymerase chain reaction (PCR) and HPV genotypes were identified by reverse hybridization. RESULTS: There was a high prevalence of HPV infection both for in situ (95%) or invasive (94.83%) adenocarcinomas, comprising also cancers of unusual morphology. HPV 16 was the commonest strain (N=57, 73.08%) followed by HPV 18 (N=28, 35.90%). Interestingly, 13 cases (16.67%) were also HPV 52 positive (as co-infection with HPV 16 or 18). All other strains with the exception of HPV 66 were found only as co-infections. No significant age difference was noted in terms of any HPV strain positivity. CONCLUSIONS: HPV DNA was found in the large majority of cervical adenocarcinomas. As opposed to other studies, HPV 52 was the third most commonly encountered strain after HPV 16 and HPV 18. The above findings would probably be of help in decision making concerning vaccination policy for the prevention of HPV infection in Greece.

Repeated implantation failure: a new potential treatment option.

BACKGROUND: Previous studies have shown that the intrauterine administration of peripheral blood mononuclear cells (PBMC) may improve pregnancy outcome of women with repeated implantation failure (RIF). We have demonstrated that, during implantation, corticotropin-releasing hormone (CRH) plays a key role in facilitating endometrial decidualization and maternal-foetal immunotolerance. In the present preliminary study, we investigated whether the intrauterine administration of autologous CRH-treated PBMC can improve clinical pregnancy rates of women with RIF. METHODS: Forty-five (n = 45) women with at least three failed in vitro fertilization (IVF) attempts and no previously reported clinical pregnancy were included in this crossover study. All women underwent controlled ovarian stimulation using the long GnRH agonist protocol. PBMC were isolated at day of oocyte retrieval, treated with CRH and administered in the uterine cavity at day 2, following oocyte retrieval. Blastocyst transfer was performed on day 5. RESULTS: Following the CRH-PBMC intrauterine administration, a significant increase was observed in the clinical pregnancy rate of this cohort of women with RIF (20/45 women had a clinical pregnancy; 44.44%, P < 10(-3)) compared to the previous null clinical pregnancy rate prior to the intervention. CONCLUSION: The current findings support a possible role for the intrauterine administration of autologous CRH-treated PBMC in treating women with RIF. Further randomized controlled trials are needed to investigate the efficacy of this intervention.

Hysteroscopy in women with abnormal uterine bleeding: a meta-analysis on four major endometrial pathologies.

PURPOSE: To determine the accuracy of hysteroscopy in diagnosing endometrial cancer, hyperplasia, polyps and submucous myomas. METHODS: Relevant articles were retrieved from the MEDLINE and the Cochrane Library (1986-2011). Studies were selected blindly. Results for diagnostic accuracy were extracted to form separate 2 × 2 tables (for endometrial cancer, hyperplasia, polyps and submucous myomas). A summary sensitivity and specificity point reflected the average accuracy observed. Summary ROCs (SROCs) were also calculated according to the HSROC model. RESULTS: For endometrial cancer, the estimated sensitivity was 82.6% (95% CR 66.9-91.8%) and the specificity was 99.7% (95% CR 98.1-99.9%). For endometrial hyperplasia, sensitivity was 75.2% (95% CR 55.4-88.1 %), while specificity was 91.5% (95% CR 85.7-95.0%). For endometrial polyps, sensitivity was 95.4% (95% CR 87.4-98.4%) and specificity was 96.4% (95% CR 93.7-98.0%). Finally, for submucous myomas, sensitivity was estimated to 97.0% (95% CR 89.8-99.2%) and specificity to 98.9% (95% CR 93.3-99.8%). CONCLUSIONS: Diagnostic accuracy for hysteroscopy is high for endometrial cancer, polyps and submucous myomas, but only moderate for endometrial hyperplasia.

Galectin-1 overexpression in endometriosis and its regulation by neuropeptides (CRH, UCN) indicating its important role in reproduction and inflammation.

Endometriosis is an inflammatory disease of women of reproductive age featured by the presence of ectopic endometrium and is strongly related to infertility. Galectins, carbonhydrate-binding proteins, have been found to have pro- or anti-inflammatory roles in the reproductive tract and in pathological conditions concerning infertility. Galectin-1, which is expressed at endometrium and decidua, plays a major role in implantation and trophoblast invasion. Also, the neuropeptides, corticotropin releasing hormone (CRH) and urocortin (UCN) and their receptors are expressed in eutopic and ectopic endometrium showing a differential expression pattern in endometriotic women compared to healthy ones. The aim of this study was to examine the galectin-1 expression in endometriotic lesions and compare its expression in eutopic endometrium of endometriotic and healthy women. Furthermore, we examined the effect of CRH and UCN in galectin-1 expression in Ishikawa cell line and macrophages and investigated the implication of CRHR1 in these responses. Eutopic and ectopic endometrium specimens, Ishikawa cell line and mice macrophages were used. Immunohistochemistry and western blot analysis were performed in order to identify galectin-1 expression in ectopic and eutopic endometrium of women with and without endometriosis and the regulatory effect of CRH and UCN on galectin-1 expression. This study presents for the first time that galectin-1 is overexpressed in endometriotic lesions compared to eutopic endometrium of endometriotic women and is more abundantly expressed in eutopic endometrium of disease women compared to healthy ones. Furthermore, it is shown that CRH and UCN upregulate galectin-1 expression in Ishikawa cell line and macrophages and this effect is mediated through CRHR1. These results suggest that galectin-1 might play an important role in endometriosis pathology and infertility profile of women suffering from endometriosis by being at the same time regulated by CRH and UCN interfering in the immune disequilibrium which characterizes this pathological condition.

Methylene blue: how to visualize the endometrium in uterine morcellation material.

The aim of the study was to evaluate whether the preoperative intrauterine injection of methylene blue could help in visualizing the endometrium of uterine morcellation specimens. A total of 48 laparoscopic subtotal hysterectomies using the uterine morcellation technique were used for the study. In 19 of these cases, a preoperative intrauterine administration of methylene blue had been performed (study group). The total number of slides for each group, without and with methylene blue, was counted. Moreover, the number of slides comprising endometrial tissue was evaluated. The number of sections included in the control group to adequately assess the endometrium ranged from 6 to 95 (mean 27.24±4.01), whereas the respective number for the study group ranged from 4 to 10 (mean 7.21±0.44). The efficacy of recognizing adequate endometrial tissue (defined by the percentage of slides with adequate endometrial tissue over the overall slides requested to evaluate complete uterine histology) was significantly higher in the study group compared with that in the control group (67.05%±2.36% vs. 17.46%±2.66%, respectively; P<10(-3)). The preoperative intrauterine methylene blue administration when programming a uterine morcellation is an easy, cheap, harmless, and quick procedure that has many advantages. It reduces the time of gross handling and the number of tissue blocks submitted for examination without harming the morphologic appearance of the endometrial tissue. Moreover, it helps pathologists in identifying areas with endometrial pathology that would have probably escaped from attention in conventionally handled material.