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.

Utilidad de la histeroscopia en el manejo del sangrado uterino anorma / Usefulness of hysteroscopy in the management of abnormal uterine bleeding

La histeroscopia se considera actualmente la prueba que posibilita no solo el diagnóstico, sino también el tratamiento de enfermedad intrauterina en paciente con clínica de sangrado uterino anormal causado por anomalías estructurales, como pólipos, adenomiosis, miomas submucosos, hiperplasia endometrial o cáncer de endometrio. La miniaturización del diámetro de los histeroscopios con canal de trabajo, del minirresector bipolar y de los sistemas de morcelación histeroscópica han permitido el tratamiento en régimen ambulatorio, en ocasiones en el mismo tiempo que el diagnóstico histeroscópico, aportando mayor satisfacción, reducción riesgos quirúrgicos o derivados de la anestesia y posibilitando una rápida resolución coste-efectiva de los síntomas. En este artículo se revisa la utilidad de la histeroscopia para el diagnóstico y el tratamiento de la enfermedad estructural intrauterina causante de sangrado uterino anormal.(AU)

Hysteroscopy is currently considered the test that enables not only the diagnosis but also the treatment of intrauterine pathology in patients with symptoms of abnormal uterine bleeding caused by structural abnormalities such as polyps, adenomyosis, submucosal fibroids, endometrial hyperplasia, or endometrial cancer. The miniaturization of the diameter of hysteroscopes with working channels, the bipolar mini-resector, and the hysteroscopic morcellation systems have allowed outpatient treatment, sometimes at the same time as hysteroscopic diagnosis, providing greater satisfaction, reducing surgical and/or anaesthesia risks and enabling rapid cost-effective resolution of symptoms. This article reviews the usefulness of hysteroscopy for the diagnosis and treatment of intrauterine structural pathology causing abnormal uterine bleeding.(AU)

Comparación entre las clasificaciones de hiperplasia endometrial. Revisión sistemática y evaluación de calidad / Comparison between endometrial hyperplasia classifications. Systematic review and quality evaluation

RESUMEN Antecedentes: La hiperplasia endometrial se clasifica actualmente en hiperplasia sin atipia o benigna y en lesión precancerosa, hiperplasia atípica / neoplasia intraepitelial endometrioide o EIN, según dos sistemas, el de la Organización Mundial de la Salud (OMS) que modificó sus anteriores clasificaciones en 2014 -aunque la de 1994 sigue siendo muy usaday el sistema de neoplasia intraepitelial endometrial (EIN). Aún no está claro qué sistema de clasificación de la hiperplasia endometrial debe utilizarse para el control y tratamiento de las pacientes. Objetivo: Revisar y evaluar metaanálisis que comparen los sistemas de clasificación para la hiperplasia endometrial de la Organización Mundial de la Salud y el sistema EIN. Métodos: Revisión sistemática de estudios de metaanálisis utilizando los términos de búsqueda 'hiperplasia endometrial' en las bases de datos PubMed, Embase y Lilacs. Los metaanálisis finalmente seleccionados se calificaron con la herramienta de evaluación AMSTAR 2. Resultados : Se encontraron 154 artículos de los cuales, después de selección y lectura completa, finalmente se extrajeron tres para análisis cualitativo. La calificación de los metaanálisis revisados con la herramienta de evaluación AMSTAR 2 encontró que la confianza general de sus resultados fue críticamente baja. Conclusiones : Los datos muestran que la morfometría objetiva en el sistema EIN es más confiable que los criterios de la OMS para evaluar el riesgo de progresión de la hiperplasia endometrial a cáncer. La comparación entre el sistema de la OMS y el sistema subjetivo de EIN dio como resultado valores pronósticos similares. Otro metaanálisis mostró una clara discrepancia entre el sistema de la OMS de 1994 y el sistema EIN. La evaluación mediante la herramienta de evaluación AMSTAR-2 mostró que la confianza general en los resultados de los estudios evaluados fue críticamente baja.

ABSTRACT Background : Endometrial hyperplasia is currently classified into non-atypical or benign hyperplasia and precancerous lesion, atypical hyperplasia/endometrioid intraepithelial neoplasia or EIN, according to two systems, the World Health Organization (WHO) which modified its previous classifications in 2014 -although the 1994 classification is still widely usedand the endometrial intraepithelial neoplasia (EIN) system. It is still unclear which classification system for endometrial hyperplasia should be used for patient management and treatment. Objective : To review and evaluate meta-analyses comparing the World Health Organization classification systems for endometrial hyperplasia and the EIN system. Methods : Systematic review of meta-analysis studies using the search terms "endometrial hyperplasia" in PubMed, Embase and Lilacs databases. The meta-analyses finally selected were scored using the AMSTAR 2 assessment tool. Results : We found 154 articles of which, after selection and complete reading, three were finally extracted for qualitative analysis. The rating of the meta-analyses reviewed with the AMSTAR 2 assessment tool found that the overall confidence of their results was critically low. Conclusions : The data show that objective morphometry in the EIN system is more reliable than the WHO criteria for assessing the risk of progression of endometrial hyperplasia to cancer. Comparison between the WHO system and the subjective EIN system resulted in similar prognostic values. Another meta-analysis showed a clear discrepancy between the 1994 WHO system and the EIN system. Evaluation using the AMSTAR-2 assessment tool showed that the overall confidence in the results of the evaluated studies was critically low.

Canine pyometra: interferences of age and type in blood count and serum biochemistry / Piometra canina: interferências da idade e tipo sobre o hemograma e a bioquímica sérica

Hematological and serum biochemical characteristics and prevalence of microorganisms in the uterine content of bitches with pyometra were described, according to type and age. This study was carried out at the Veterinary Medicine Hospital Renato Rodenburg de Medeiros Netto of the UFBA with 132 patients diagnosed with pyometra through imaging and laboratory tests, divided into two groups: Group 1 - less than eight years (n=72) and Group 2 - more than eight years (n=60). Both groups were submitted to Ovariohysterectomy (OH), in which blood and uterine lumen secretion samples were collected. The highest incidence of pyometra was found in bitches under 8 years (54.5%), Poodle breed (31.8%) and mixed-breed (27.3%). Open pyometra represented 80.3% of all cases. The death rate (6.0%) did not show significant difference between the types. Anemia (73.0%), thrombocytopenia (41.2%) and leukocytosis (77.0%) were observed. Urea and ALP were above the reference values in 41.8% and 52.2% of each group, respectively, while ALT (94.0%) and creatine (82%) remained normal in most animals. Serum biochemistry did not show significant differences (P<0.05). Escherichia coli and Klebsiella sp. grew in 33.3% and 16.7% of the samples, respectively. Therefore, no significant hematological and serum biochemical differences were observed in bitches with pyometra in both age categories.

Descreveu-se características hematológicas, bioquímicas séricas e prevalência de microrganismos no conteúdo uterino de cadelas com piometra, de acordo com o tipo e idade. Realizou-se este estudo no Hospital de Medicina Veterinária Renato Rodenburg de Medeiros Netto da UFBA com 132 pacientes diagnosticadas com piometra, por exames de imagem e laboratoriais, divididas em dois grupos: Grupo 1 – menos de oito anos (n=72) e Grupo 2 – mais de oito anos (n=60), submetidas a Ovariectomia (OH), quando se coletou amostras de sangue e secreção do lúmen uterino. A incidência maior deu-se em cadelas abaixo de 8 anos (54,5%), da raça Poodle (31,8%) e sem raça definida (SRD) (27,3%), sendo 80,3% de piometra aberta. A taxa de óbito (6,0%) não apresentou diferença significativa entre os tipos. Observou-se a ocorrência de anemia (73,0%), trombocitopenia (41,2%) e leucocitose (77,0%). Os valores de ureia e FA estiveram acima dos valores de referência em 41,8% e 52,2% das cadelas respectivamente, enquanto a ALT (94,0%) e a creatina (82%) mantiveram-se dentro dos valores de referência na maioria dos animais. A bioquímica sérica não apresentou diferenças significativas (P<0,05). Observou-se crescimento de Escherichia coli e Klebsiella sp. em 33,3% e 16,7% das amostras, respectivamente. Sendo assim, não se observou diferenças significativas hematológicas e na bioquímica sérica de cadelas com piometra nas categorias de idade.

Canine pyometra: interferences of age and type in blood count and serum biochemistry / Piometra canina: interferências da idade e tipo sobre o hemograma e a bioquímica sérica

Hematological and serum biochemical characteristics and prevalence of microorganisms in the uterine content of bitches with pyometra were described, according to type and age. This study was carried out at the Veterinary Medicine Hospital Renato Rodenburg de Medeiros Netto of the UFBA with 132 patients diagnosed with pyometra through imaging and laboratory tests, divided into two groups: Group 1 - less than eight years (n=72) and Group 2 - more than eight years (n=60). Both groups were submitted to Ovariohysterectomy (OH), in which blood and uterine lumen secretion samples were collected. The highest incidence of pyometra was found in bitches under 8 years (54.5%), Poodle breed (31.8%) and mixed-breed (27.3%). Open pyometra represented 80.3% of all cases. The death rate (6.0%) did not show significant difference between the types. Anemia (73.0%), thrombocytopenia (41.2%) and leukocytosis (77.0%) were observed. Urea and ALP were above the reference values in 41.8% and 52.2% of each group, respectively, while ALT (94.0%) and creatine (82%) remained normal in most animals. Serum biochemistry did not show significant differences (P<0.05). Escherichia coli and Klebsiella sp. grew in 33.3% and 16.7% of the samples, respectively. Therefore, no significant hematological and serum biochemical differences were observed in bitches with pyometra in both age categories.

Descreveu-se características hematológicas, bioquímicas séricas e prevalência de microrganismos no conteúdo uterino de cadelas com piometra, de acordo com o tipo e idade. Realizou-se este estudo no Hospital de Medicina Veterinária Renato Rodenburg de Medeiros Netto da UFBA com 132 pacientes diagnosticadas com piometra, por exames de imagem e laboratoriais, divididas em dois grupos: Grupo 1 ­ menos de oito anos (n=72) e Grupo 2 ­ mais de oito anos (n=60), submetidas a Ovariectomia (OH), quando se coletou amostras de sangue e secreção do lúmen uterino. A incidência maior deu-se em cadelas abaixo de 8 anos (54,5%), da raça Poodle (31,8%) e sem raça definida (SRD) (27,3%), sendo 80,3% de piometra aberta. A taxa de óbito (6,0%) não apresentou diferença significativa entre os tipos. Observou-se a ocorrência de anemia (73,0%), trombocitopenia (41,2%) e leucocitose (77,0%). Os valores de ureia e FA estiveram acima dos valores de referência em 41,8% e 52,2% das cadelas respectivamente, enquanto a ALT (94,0%) e a creatina (82%) mantiveram-se dentro dos valores de referência na maioria dos animais. A bioquímica sérica não apresentou diferenças significativas (P<0,05). Observou-se crescimento de Escherichia coli e Klebsiella sp. em 33,3% e 16,7% das amostras, respectivamente. Sendo assim, não se observou diferenças significativas hematológicas e na bioquímica sérica de cadelas com piometra nas categorias de idade.

Does a single application of contraceptive cause pathological changes in bitches? / [Uma única aplicação de anticoncepcional causa alterações patológicas em cadelas?]

O presente trabalho objetivou avaliar os efeitos da administração em dose única de progestágenos em fêmeas caninas hígidas, as quais nunca haviam recebido tais fármacos. Foram selecionadas 20 cadelas, que foram examinadas clinicamente e por meio de exames complementares. Nessas cadelas, foi aplicado medroxiprogesterona por via subcutânea. Noventa dias após, as fêmeas foram esterilizadas cirurgicamente, sendo os tecidos reprodutivos encaminhados para histopatologia. Foi possível verificar que, aos 30 dias, 12 animais (60%) apresentaram hiperplasia mamária. Aos 90 dias, 18 animais (90%) apresentavam sinais de hiperplasia endometrial cística, tendo cinco (27,77%) destes animais apresentado conteúdo purulento no lúmen uterino. No exame microscópico, apenas uma fêmea não demonstrou alterações patológicas, sendo a única que recebeu o contraceptivo na fase correta (anestro). As demais fêmeas apresentaram alterações que variaram entre alterações circulatórias a hiperplasia endometrial cística grave. Assim, foi possível concluir que uma única aplicação de anticoncepcional em fêmeas hígidas pode causar complicações leves a graves.(AU)

Hiperplasia endometrial asociada al uso del tamoxifeno en pacientes con cáncer de mama en Barranquilla / Endometrial hyperplasia associated with use of tamoxifen in patients with breast cancer in Barranquilla

Resumen Introducción: el tamoxifeno ha sido el medicamento de primera línea para el tratamiento del cáncer de mama; sin embargo, se han evidenciado serios eventos adversos con su uso. El objetivo de este trabajo fue determinar la hiperplasia endometrial asociada al uso de tamoxifeno en mujeres con cáncer de mama en una institución oncológica de la ciudad de Barranquilla- Colombia. Metodología: estudio de casos y controles retrospectivo. Se incluyeron 202 pacientes con cáncer de mamá tratadas entre 2012 y 2017. Fueron evaluadas variables antropométricas, sociodemográficas, personales, clínicas y patológicas. Se estimaron los Odds Ratios (OR) crudos y ajustados. Resultados: 68 participantes fueron diagnosticadas con hiperplasia endometrial secundaria al tratamiento antineoplásico. De éstas, 59 (86,7 %) usaron tamoxifeno, la mayoría (37,2 %) por un lapso de 6-11 meses. El análisis bivariado mostró asociación entre la hiperplasia endometrial y uso del tamoxifeno con un OR de 3,9 (IC95 %: 1,8-8,5) y 2,9 (IC95 %: 1,18-7,5) en los análisis crudos y ajustados, respectivamente. Conclusión: el uso de tamoxifeno se asocia con la presencia de hiperplasia endometrial.

Abstract Introduction: tamoxifen has been the first line drug for the treatment of breast cancer; however, serious adverse events have been evidenced with its use. The aim of this study was to determine endometrial hyperplasia associated with the use of tamoxifen in women with breast cancer in an oncological institution in the city of Barranquilla, Colombia. Methodology: retrospective case-control study. A total of 202 patients with breast cancer treated between 2012 and 2017 were included. Anthropometric, sociodemographic, personal, clinical and pathological variables were evaluated. Crude and adjusted Odds ratios (OR) were estimated. Results: 68 participants were diagnosed with endometrial hyperplasia secondary to antineoplastic treatment. Of these, 59 (86.7 %) used tamoxifen, the most of them (37.2 %) for a period of 6-11 months. Bivariate analysis showed an association between endometrial hyperplasia and tamoxifen use with an OR of 3.9 (95%CI: 1.8-8.5) and 2.9 (95%CI: 1.18-7.5) in the crude and adjusted analyses, respectively. Conclusion: tamoxifen use is associated with the presence of endometrial hyperplasia.

Técnica morfométrica en el diagnóstico diferencial de hiperplasia endometrial compleja y adenocarcinoma endometroide. Matanzas; 2014-2015 / Morphometric technique in the differential diagnosis of complex endometrial hyperplasia and endometroid adenocarcinoma. Matanzas; 2014-2015

RESUMEN Introducción: la función del endometrio está regida por el eje hipotálamo hipofisario mediante las hormonas sexuales por lo que es vulnerable a los desórdenes de este sistema los que provocan diferentes trastornos funcionales que se traducen en alteraciones morfológicas. Es fundamental su estudio para el diagnóstico de patologías que son un problema de salud en la población femenina. Objetivo: determinar las diferencias morfométricas para el diagnóstico histopatológico diferencial entre la hiperplasia endometrial compleja, el adenocarcinoma endometrioide y en el endometrio proliferativo normal, en el municipio Matanzas, enero2014 -2015. Material y Métodos: se realizó un estudio observacional descriptivo de corte transversal y se aplicó morfometría a una muestra de 30 biopsias endometriales, con el objetivo de determinar las diferencias morfométricas para el diagnóstico histopatológico diferencial entre la hiperplasia endometrial compleja, el adenocarcinoma endometrioide y en el endometrio proliferativo normal. Resultados: el área total de la glándula fue la variable analizada que mostró mayores valores y reflejó marcadas diferencias entre la hiperplasia endometrial compleja, el adenocarcinoma endometrioide y el endometrio proliferativo normal, seguida por la altura del epitelio por tanto existen diferencias cuando se estudian variables que tiene en cuenta la morfología glandular. Conclusiones: existen diferencias morfométricas entre la hiperplasia endometrial y el adenocarcioma endometroide cuando se estudian variables que tienen en cuenta la morfología y arquitectura glandular (AU).

SUMMARY Introduction: the endometrium function is ruled by the pituitary- hypothalamus axis by means of sexual hormones; therefore it is vulnerable to the disorders of this system provoking different functional disorders resulting in morphological alterations. It is very important to study them for the sake of the diagnosis of diseases that are a health problem in female population. Objective: to determine the morphometric differences for the differential histopathological diagnosis among the complex endometrial hyperplasia, the endometrioid adenocarcinoma and the normal proliferative endometrium e, in the municipality of Matanzas, in the period January 2014-2015. Methods: a cross-sectional descriptive observational study was carried out applying morphometry to a sample of 30 endometrial biopsies, with the objective of determining the morphometric differences for the differential histopathological diagnosis among the complex endometrial hyperplasia, endometrial adenocarcinoma and normal proliferative endometrium. Results: the gland total area was the used variable showing more values and revealed stark differences among complex endometrial hyperplasia, endometrioid adenocarcinoma and normal proliferative endometrium, followed by the epithelium height; hence there are differences when variables are studied taking into account glandular morphology. Conclusions: there are morphometric differences between endometrial hyperplasia and endometrioid adenocarcinoma when there are studied variables taking into account glandular morphology and architecture (AU).

Concordancia entre histeroscopía e histopatología en pacientes con sangrado uterino anormal / Concordance between hysteroscopy and histopathology in patients with abnormal uterine bleeding / Concordância entre histeroscopia e histopatología em pacientes com sangramento uterino anormal / Concordance entre l'hystéroscopie et l'histopathologie chez les patients présentant un saignement utérin anormal

Resumen Objetivo: Determinar la concordancia entre la histeroscopia e histopatología en pacientes con sangrado uterino anormal (SUA). Material y métodos: Estudio observacional, descriptivo y transversal de 36 pacientes con diagnóstico de SUA con realización de histeroscopia y biopsia endometrial en la clínica de mínima invasión. Resultados: La edad media fue de 39.1 años con un IMC medio de 33.3 kg/m2, la menarca media fue de 12.1 años, reportando pacientes núbiles pero en su mayoría mujeres multíparas con una media de 2.67 gestas. El patrón menstrual se reportó como frecuente 63.9% (n=23), regular 75% (n=27), prolongado 61.1% (n=22) y aumentado en volumen 80.6% (n=29). Se obtuvo un valor de 0.709 con una p= 0.000, representando una fuerza de concordancia buena. Con alto porcentaje para identificar hiperplasia endometrial de bajo riesgo con 90% (n=9/10) y para descartar patología estructural al identificar tejido endometrial normal con 88.2% (n=15/17). Conclusiones: Se observó de acuerdo con el coeficiente de kappa una fuerza de concordancia buena entre la histeroscopia e hiperplasia endometrial.

Abstract Object: To determine the concordance between hysteroscopy and histopathology in patients with abnormal uterine bleeding. Materials and methods: An observational, descriptive and cross-sectional study of 36 patients diagnosed with SUA with hysteroscopy and endometrial biopsy in the minimally invasive clinic. Results: The average age was 39.1 years with an average BMI of 33.3 kg / m2, the average menarca was 12.1 years, reporting nubile patients but mostly multiparous women with an average of 2.67 pregnancies. The menstrual pattern was reported as frequent 63.9% (n= 23), regular 75% (n= 27), prolonged 61.1% (n= 22) and increased in volume 80.6% (n= 29). A value of 0.709 was obtained with a p= 0.000, representing a good concordance force. With high percentage to identify low risk endometrial hyperplasia with 90% (n= 9/10) and to rule out structural pathology to normal endometrial tissue muscle with 88.2% (n= 15/17). Conclusions: An agreement has been established with the kappa coefficient of agreement between hysteroscopy and endometrial hyperplasia.

Resumo Objetivo: Determinar a concordancia entre histeroscopia e histopatologia em pacientes com sangramento uterino anormal. Materiais e métodos: Estudo observacional, descritivo e transversal de 36 pacientes diagnosticados com SUA com histeroscopia e biópsia endometrial na clínica minimamente invasiva. Resultados: A média de idade foi de 39,1 anos com IMC médio de 33,3 kg / m2, a menarca média foi de 12,1 anos, relatando pacientes nubileis, mas principalmente mulheres multíparas com média de 2,67 gestações. O padrâo menstrual foi relatado como freqüente 63,9% (n = 23), 75% regulares (n = 27), prolongado 61,1% (n = 22) e aumentou em volume 80,6% (n = 29). Um valor de 0,709 foi obtido com uma p = 0,000, representando uma boa força de concordância. Com alta porcentagem para identificar hiperplasia endometrial de baixo risco com 90% (n = 9/10) e para descartar patologia estrutural ao identificar tecido endometrial normal com 88,2% (n = 15/17). Conclusões: Uma boa força de concordância entre histeroscopia e hiperplasia endometrial foi observada de acordo com o coeficiente kappa.

Résumé Objectif: Déterminer la concordance entre l'hystéroscopie et l'histopathologie chez les patients présentant un saignement utérin anormal. Matériel et méthodes: Une étude observationnelle, descriptive et transversale de 36 patients diagnostiqués avec SUA avec hystéroscopie et biopsie de l'endométre dans la clinique mini-invasive. Résultats: L'age moyen était de 39,1 ans avec un IMC moyen de 33,3 kg / m2, la ménarche moyenne était de 12,1 ans, rapportant des patients nubiles mais surtout des femmes multipares avec une moyenne de 2,67 grossesses. Le profil menstruel a été signalé comme fréquent 63,9% (n = 23), régulier 75% (n = 27), prolongé 61,1% (n = 22) et a augmenté en volume 80,6% (n = 29). Une valeur de 0,709 a été obtenue avec p = 0,000, ce qui représente une bonne force de concordance. Avec un pourcentage élevé pour identifier l'hyperplasie de l'endométre á faible risque avec 90% (n = 9/10) et pour exclure la pathologie structurelle lors de l'identification du tissu endométrial normal avec 88,2% (n = 15/17). Conclusions: Une bonne force de concordance entre l'hystéroscopie et l'hyperplasie endométriale a été observée selon le coefficient kappa.

Protein-to-creatinine urinary in the early diagnosis of renal injury in canine pyometra / Relação proteína-creatinina-urinária no diagnóstico precoce de lesão renal em cadelas com piometra

Kidney disease that affects bitches with pyometra may lead patients to develop chronic renal failure even after pyometra treatment. Therefore, several studies have sought to clarify the gaps in the understanding of the pathogenesis of renal injury in pyometra. Identification of early detection markers for renal damage, which can predict and identify the prognosis of the disease, is very important. Proteinuria analysis can diagnose kidney damage, since proteins such as albumin are not filtered through the glomerulus and those that undergo glomerular filtration are almost completely reabsorbed by tubular cells. The objective of this study was to evaluate whether the urinary protein-to-creatinine ratio (UPC) can detect renal injury in bitches with pyometra before development of azotemia. For this, 44 bitches with pyometra were divided into two groups: bitches with azotemic piometra (A, n=15, creatinine >1.7) and bitches with non-azotemic pyometra (NA, n=29). The two groups were compared to the control group (CG, n=12), which had no signs of systemic disease. All animals underwent blood and urine tests. Leukocytosis was more evident in bitches in the A group than in the other groups. This shows that the inflammatory response may be associated with the pathogenesis of renal injury. The median UPC in bitches with pyometra was significantly higher than in the CG, with a median above the reference values. In conclusion, the UPC can be used in bitches with pyometra to detect renal damage before the development of azotemia. It has been suggested that the UPC of bitches with pyometra should be followed through during the postoperative period so that permanent renal lesions secondary to pyometra can be diagnosed and treated properly before the development of azotemia.(AU)

A doença renal que afeta cadelas com piometra pode levar a insuficiência renal crônica mesmo após o tratamento. Portanto, vários estudos procuraram esclarecer as lacunas na compreensão da patogênese da lesão renal na piometra. A identificação de marcadores de lesão renal precoce, que podem prever e identificar o prognóstico da doença é muito importante. A análise da proteinúria pode diagnosticar lesão renal, uma vez que proteínas como a albumina não são filtradas através do glomérulo e aquelas que sofrem filtração glomerular são quase completamente reabsorvidas pelas células tubulares. O objetivo deste estudo foi avaliar se a relação proteína-creatinina urinária (UPC) pode detectar lesão renal em cadelas com piometra antes do desenvolvimento de azotemia. Para isso, 44 cadelas com piometra foram divididas em dois grupos: cadelas com piometra azotêmica (A, n=15, creatinina >1,7) e cadelas com piometra não azotêmica (NA, n=29). Os dois grupos foram comparados ao grupo controle (CG, n=12), que não apresentaram sinais de doença sistêmica. Todos os animais foram submetidos a exames de sangue e urina. A leucocitose foi mais evidente nas cadelas do grupo A do que nos outros grupos. Isso mostra que a resposta inflamatória pode estar associada à patogênese da lesão renal. A mediana da UPC em cadelas com piometra foi significativamente maior que no CG, com uma mediana acima dos valores de referência. Em conclusão, a UPC pode ser usada em cadelas com piometra para detectar lesões renais antes do desenvolvimento de azotemia. Sugeriu-se que a UPC de cadelas com piometra deve ser acompanhada durante o pós-operatório, de modo que as lesões renais permanentes secundárias à piometra possam ser diagnosticadas e tratadas adequadamente antes do desenvolvimento de azotemia.(AU)

Sangrado y terapia hormonal en la menopausia (THM) / Bleeding during menopause hormone therapy (MHT)

La definición de sangrado ginecológico anormal durante terapia hormonal de la menopausia es aquel sangrado no programado durante el uso de la terapia. Este artículo es un pauteo que describe: 1) cuándo diagnosticar unsangrado anormal, ya que difiere según el tipo de esquema hormonal utilizado; 2) eldiagnóstico diferencial del origen del sangrado anormal; 3) los métodos de evaluación para diagnosticar el origen del sangrado. Se destacan los aspectos principales para el diagnóstico diferencial entre patología orgánica versus disrupción endometrial debida al tratamiento hormonal. Además, se describen los ajustes posibles para resolver el sangrado cuando éste se debe a disrupción del endometrio.

Abnormal bleeding related to menopausal hormone therapy is defined as unscheduled bleeding during the use of the therapy. This article outlines when to diagnose an abnormal bleeding -as this differs according to the type of hormonal scheme used-, the differential diagnosis of the origin of abnormal bleeding, and the methods of evaluation to assess the origin of the bleeding. The main aspects are highlighted on the differentiation of organic pathology versus disruption of the endometrium due to treatment. Also, treatment adjustments to resolve bleeding when it is due to disruption of the endometrium are outlined.

Hiperplasia endometrial simple con complejo focal y sin atipia, en una paciente de 23 años de edad. A propósito de un caso y revisión de la literatura / Simple endometrial hyperplasia with focal complex without atypia, in a patient of 23 years old. A case presentation and literature review

Resumen Se presenta el caso de una paciente de 23 años de edad, previamente sana, G1P0A1, con cuadro clínico de hemorragia uterina anormal, a quien se le realizó ecografía transvaginal que reportó embarazo molar, sin embargo tras realizar la medición sérica de B-HCG, fue de 0.00 mUI/ml, por lo que requirió realización de legrado y biopsia para establecer diagnóstico histológico. El resultado evidenció hiperplasia simple, con complejo focal y sin atipia. Se destaca la importancia de la comunicación de este caso, debido a que a esta edad, la presentación de esta patología es infrecuente. Se hace una revisión de los artículos publicados en los últimos 10 años en las bases de datos Medline vía PubMed, y en LILACS en español, inglés y francés. Se tuvo como referencia además textos clásicos. La hiperplasia endometrial simple en pacientes menores de 30 años es poco frecuente, se debe tener en cuenta la presencia de atipias en la histología pues de ser positivo, es mayor el riesgo de transformación maligna.

Abstract A case of a 23-year-old patient, previously healthy, G1P0A1, with clinical symptoms of abnormal uterine bleeding. The patient was underwent transvaginal ultrasound that reported molar pregnancy, however after making the measurement of serum B-HCG was 0.00 mIU/ml. It was necessary curettage and biopsy to establish histological diagnosis. The result showed simple hyperplasia endometrial with focal complex without atypia. The importance of communication in this case, because at this age, the presentation of this disease is uncommon. The literature published in English, Spanish and French during the last 10 years in the Medline database were reviewed via Pubmed and LILACS. Besides, classical texts was referenced in this article. Simple endometrial hyperplasia in patients under 30 years old is rare. It should be taken into account the presence of atypia on histology, because the risk is greater of malignant transformation.

Hiperplasia endometrial y criterios ecográficos: reporte de caso y revisión de la literatura / Endometrial hyperplasia and sonographic criteria: Case report and literature review / Hiperplasia endometrial e critérios ecográficos: relato de caso e revisão da literatura

El objetivo de este artículo es revisar los criterios ecográficos de hiperplasia endometrial y evaluar los puntos de corte para indicar la realización de biopsia endometrial. Se reporta el caso de una mujer de 47 años, con cuadro clínico de 4 años de evolución de sangrado vaginal anormal tipo menorragia, metrorragia e hipermenorrea, en manejo con anticonceptivos orales, sin mejoría, y con ecografía transvaginal con diagnóstico de hiperplasia endometrial. Para el diagnóstico de patología endometrial en las mujeres posmenopáusicas con sangrado vaginal, los autores recomiendan un valor de corte del grosor endometrial por ecografía transvaginal entre 4-5 mm con sensibilidad del 98% y valor predictivo negativo del 99% debido a que valores superiores están altamente relacionados con carcinoma endometrial.

The aim of this article is to review the sonographic criteria of endometrial hyperplasia and define the cutoff value to indicate the completion of the endometrial biopsy due to its relationship with the risk of endometrial carcinoma. We report the case of a woman aged 47 with four years of vaginal bleeding characterized by menorrhagia, metrorrhagia, and hypermenorrhea being treated with oral contraceptives without improvement, and transvaginal ultrasound diagnosis of endometrial hyperplasia. For the diagnosis of endometrial pathology in postmenopausal women with vaginal bleeding, the authors recommend a cutoff value of endometrial thickness by transvaginal ultrasound of 4-5 mm with sensitivity of 98% and negative predictive value of 99% since higher values are closely related to endometrial carcinoma.

O objetivo deste artigo é revisar os critérios ecográficos de hiperplasia endometrial e avaliar os pontos de corte para indicar a realização de biopsia endometrial. Se reporta o caso de uma mulher de 47 anos, com quadro clínico de 4 anos de evolução de sangrado vaginal anormal tipo menorragia, metrorragia e hipermenorreia, em manejo com anticonceptivos orais, sem melhora, com ecografia transvaginal com diagnóstico de hiperplasia endometrial. Para o diagnóstico de patologia endometrial nas mulheres pós-menopáusicas com sangrado vaginal, os autores recomendam um valor de corte do espessura endometrial por ecografia transvaginal entre 4-5 mmcom sensibilidade de 98% e valor preditivo negativo de 99% devido a que valores superiores estão altamente relacionados com carcinoma endometrial.

Recurso morfométrico para el diagnóstico de hiperplasia endometrial compleja y adenocarcinoma endometrioide. Matanzas 2014-2015 / Morphometric resource for the diagnosis of complex endometrial hyperplasia, and endometrial adenocarcinoma. Matanzas 2014-2015

Introducción: el endometrio es fundamental para el diagnóstico de entidades que constituyen problemas de salud para la población femenina. Resulta de vital importancia para el patólogo el hallazgo de diferencias entre la morfología del endometrio de la hiperplasia endometrial y el adenocarcinoma endometrioide que le permitan realizar el diagnóstico diferencial ente estas dos entidades. Objetivo: determinar las diferencias morfométricas para el diagnóstico histopatológico diferencial entre la hiperplasia endometrial compleja, el adenocarcinoma endometrioide y en el endometrio proliferativo normal. Materiales y métodos: se realizó un estudio observacional descriptivo de corte transversal y se aplicó morfometría a una muestra de 30 biopsias endometriales, con el objetivo de determinar las diferencias morfométricas para el diagnóstico histopatológico diferencial entre la hiperplasia endometrial compleja, el adenocarcinoma endometrioide y en el endometrio proliferativo normal. Se utilizó sistema morfométrico IMAGEN J 1.44p, se estudiaron las glándulas endometriales a las que se les halló la altura del epitelio glandular. Resultados: la altura del epitelio en las glándulas de tamaño menor, intermedio y mayor, expresaron estrechas diferencias entre la hiperplasia endometrial compleja, el adenocarcinoma endometrioide y en el endometrio proliferativo normal y que existen diferencias entre la hiperplasia endometrial y el adenocarcinoma endometrioide cuando se estudian variables que tiene en cuenta la morfología glandular. Conclusiones: se concluyó que existen diferencias entre la hiperplasia endometrial y el adenocarcinoma endometrioide cuando se estudian variables que tiene en cuenta la morfología glandular (AU).

Introduction: the endometrium is fundamental for the diagnosis of entities that are a health problem for female population. It is very important for the pathologist to find differences between the morphology of the endometrium of the endometrial hyperplasia and the endometrial adenocarcinoma allowing to perform the differential diagnosis between these two entities. Objective: to determine the morphometric differences for the differential histopathological diagnosis between the complex endometrial hyperplasia, the endometrial adenocarcinoma and the normal proliferative endometrium. Materials and methods: a cross-sectional, descriptive, observational study was applied and the morphometry was applied to a sample of 30 endometrial biopsies, with the objective of determining the morphometric differences for the histopathological differential diagnosis among complex endometrial hyperplasia, endometrial adenocarcinoma and normal proliferative endometrium. The morphometric system IMAGEN J 1.44p was used and the endometrial glands were studied and the height of their glandular epithelium was calculated. Results: the minor, intermediate and higher height of the epithelium in the glands expressed tight differences among complex endometrial hyperplasia, endometrial adenocarcinoma and normal proliferative endometrium, and showed that there are differences between endometrial hyperplasia and endometrial adenocarcinoma when the studied variables take into account the glandular morphology. Conclusions: there are differences between endometrial hyperplasia and endometrial adenocarcinoma when there are studied variables taking into account the glandular morphology (AU).

Recurso morfométrico para el diagnóstico de hiperplasia endometrial compleja y adenocarcinoma endometrioide. Matanzas 2014-2015 / Morphometric resource for the diagnosis of complex endometrial hyperplasia, and endometrial adenocarcinoma. Matanzas 2014-2015

Introducción: el endometrio es fundamental para el diagnóstico de entidades que constituyen problemas de salud para la población femenina. Resulta de vital importancia para el patólogo el hallazgo de diferencias entre la morfología del endometrio de la hiperplasia endometrial y el adenocarcinoma endometrioide que le permitan realizar el diagnóstico diferencial ente estas dos entidades. Objetivo: determinar las diferencias morfométricas para el diagnóstico histopatológico diferencial entre la hiperplasia endometrial compleja, el adenocarcinoma endometrioide y en el endometrio proliferativo normal. Materiales y métodos: se realizó un estudio observacional descriptivo de corte transversal y se aplicó morfometría a una muestra de 30 biopsias endometriales, con el objetivo de determinar las diferencias morfométricas para el diagnóstico histopatológico diferencial entre la hiperplasia endometrial compleja, el adenocarcinoma endometrioide y en el endometrio proliferativo normal. Se utilizó sistema morfométrico IMAGEN J 1.44p, se estudiaron las glándulas endometriales a las que se les halló la altura del epitelio glandular. Resultados: la altura del epitelio en las glándulas de tamaño menor, intermedio y mayor, expresaron estrechas diferencias entre la hiperplasia endometrial compleja, el adenocarcinoma endometrioide y en el endometrio proliferativo normal y que existen diferencias entre la hiperplasia endometrial y el adenocarcinoma endometrioide cuando se estudian variables que tiene en cuenta la morfología glandular. Conclusiones: se concluyó que existen diferencias entre la hiperplasia endometrial y el adenocarcinoma endometrioide cuando se estudian variables que tiene en cuenta la morfología glandular (AU).

Introduction: the endometrium is fundamental for the diagnosis of entities that are a health problem for female population. It is very important for the pathologist to find differences between the morphology of the endometrium of the endometrial hyperplasia and the endometrial adenocarcinoma allowing to perform the differential diagnosis between these two entities. Objective: to determine the morphometric differences for the differential histopathological diagnosis between the complex endometrial hyperplasia, the endometrial adenocarcinoma and the normal proliferative endometrium. Materials and methods: a cross-sectional, descriptive, observational study was applied and the morphometry was applied to a sample of 30 endometrial biopsies, with the objective of determining the morphometric differences for the histopathological differential diagnosis among complex endometrial hyperplasia, endometrial adenocarcinoma and normal proliferative endometrium. The morphometric system IMAGEN J 1.44p was used and the endometrial glands were studied and the height of their glandular epithelium was calculated. Results: the minor, intermediate and higher height of the epithelium in the glands expressed tight differences among complex endometrial hyperplasia, endometrial adenocarcinoma and normal proliferative endometrium, and showed that there are differences between endometrial hyperplasia and endometrial adenocarcinoma when the studied variables take into account the glandular morphology. Conclusions: there are differences between endometrial hyperplasia and endometrial adenocarcinoma when there are studied variables taking into account the glandular morphology (AU).

Detención de la hemorragia uterina anormal en pacientes a quienes se realizó histeroscopia operatoria / Resolution of abnormal uterine hemorrhage in patients submitted to operational histeroscopy in the University Hospital of Santander

Resumen OBJETIVO: Evaluar los factores sociodemográficos, clínicos, histopatológicos y del procedimiento quirúrgico asociados con el control (satisfactorio o inadecuado) de la hemorragia uterina anormal de pacientes a quienes se realizó histeroscopia operatoria. MATERIALES Y MÉTODOS: Estudio de casos y controles anidado en una cohorte retrospectiva al que se incluyeron pacientes que consultaron por hemorragia uterina anormal en el Hospital Universitario de Santander, Colombia (2008-2014). Variables independientes: factores demográficos, antecedentes clínicos, quirúrgicos y posquirúrgicos. RESULTADOS: Se encontraron registros de 180 procedimientos de histeroscopia; 124 de histeroscopias operatorias, de las que 114 se practicaron debido a síntomas de hemorragia uterina anormal; de estas últimas, 22 fueron reintervenciones para controlar la hemorragia uterina anormal (casos) y 92 controles. Los límites de edad se ubicaron en 19 y 66 años, con una mediana de 39 años; la mayoría eran menores de 45 años (66.7%), edad que se asoció como factor protector. El porcentaje de complicaciones durante el procedimiento fue de 1.75%, relacionadas con perforación uterina. Solo dos pacientes tuvieron complicaciones posquirúrgicas y la reintervención quirúrgica tuvo una incidencia de 19.3%; es decir, sucedió en 22 pacientes. CONCLUSIÓN: El riesgo de reintervención está relacionado con la hiperplasia endometrial, edad mayor de 45 años, antecedente de discrasia sanguínea y localización de la lesión en áreas diferentes al cuello uterino y como variable protectora el antecedente de paridad. Se hizo evidente la relación entre la falla del procedimiento histeroscópico, las variables de hiperplasia endometrial y la discrasia sanguínea.

Abstract OBJECTIVE: To evaluate the sociodemographic, clinical, histopathological and surgical procedure factors associated with the control (satisfactory or inadequate) of abnormal uterine hemorrhage in patients who underwent operative hysteroscopy. MATERIALS AND METHODS: Nested case-control study in a retrospective cohort that included women who consulted for abnormal uterine hemorrhage at the University Hospital of Santander, Colombia, from 2008 to 2014. Independent variables: demographic factors, clinical history, surgical and postsurgical. RESULTS: Records of 180 hysteroscopy procedures were found; 124 of operative hysteroscopies, of which 114 were performed due to symptoms of abnormal uterine hemorrhage; of the latter, 22 were reoperations to control abnormal uterine hemorrhage (cases) and 92 controls. The age limits were located in 19 and 66 years, with a median of 39 years; the majority were under 45 years old (66.7%), an age that was associated as a protective factor. The percentage of complications during the procedure was 1.75%, related to uterine perforation. Only two patients had postoperative complications and the surgical reoperation had an incidence of 19.3%; that is, it happened in 22 patients. CONCLUSION: The risk of reoperation is related to endometrial hyperplasia, age over 45 years, history of blood dyscrasia and location of the lesion in areas other than the cervix, and as a protective variable, the antecedent of parity. The relationship between the failure of the hysteroscopic procedure, the variables of endometrial hyperplasia and blood dyscrasia was evident.

Accuracy of Transvaginal Ultrasonography, Hysteroscopy and Uterine Curettage in Evaluating Endometrial Pathologies / Acurácia da ultrassonografia transvaginal, histeroscopia e curetagem uterina na avaliação de patologias endometriais

Abstract Objective To evaluate the accuracy of transvaginal ultrasonography, hysteroscopy and uterine curettage in the diagnosis of endometrial polyp, submucous myoma and endometrial hyperplasia, using as gold standard the histopathological analysis of biopsy samples obtained during hysteroscopy or uterine curettage. Methods Cross-sectional study performed at the Hospital Universitário de Brasília (HUB). Data were obtained from the charts of patients submitted to hysteroscopy or uterine curettage in the period from July 2007 to July 2012. Results One-hundred and ninety-one patients were evaluated, 134 of whom underwent hysteroscopy, and 57, uterine curettage. Hysteroscopy revealed a diagnostic accuracy higher than 90% for all the diseases evaluated, while transvaginal ultrasonography showed an accuracy of 65.9% for polyps, 78.1% for myoma and 63.2% for endometrial hyperplasia. Within the 57 patients submitted to uterine curettage, there was an accuracy of 56% for polyps and 54.6% for endometrial hyperplasia. Conclusion Ideally, after initial investigation with transvaginal ultrasonography, guided biopsy of the lesion should be performed by hysteroscopy, whenever necessary, in order to improve the diagnostic accuracy and subsequent clinical management.

Resumo Objetivo avaliar a acurácia da ultrassonografia transvaginal, da histeroscopia e da curetagem uterina no diagnóstico de pólipo endometrial, mioma submucoso e hiperplasia de endométrio, utilizando como padrão-ouro a análise histopatológica de amostras obtidas por biópsia realizada durante a histeroscopia ou a curetagem. Métodos estudo transversal realizado no Hospital Universitário de Brasília (HUB), cujas informações foram obtidas nos prontuários das pacientes que foram submetidas à histeroscopia ou curetagem uterina no período de julho de 2007 a julho de 2012. Resultados Foram avaliadas 191 pacientes, sendo que 134 foram submetidas à histeroscopia e 57 à curetagem uterina. Observou-se acurácia diagnóstica maior que 90% para todas as patologias avaliadas por histeroscopia, enquanto que por ultrassonografia transvaginal observou-se acurácia de 65,9% para pólipo, 78,1% para mioma e 63,2% para hiperplasia endometrial. Nas 57 pacientes submetidas a curetagem uterina, observou-se acurácia de 56% para pólipo e de 54,6% para hiperplasia endometrial. Conclusão Idealmente, após a investigação inicial com ultrassonografia transvaginal, deveria, sempre que necessário, ser realizada histeroscopia com biópsia guiada da lesão, o que melhoraria a acurácia diagnóstica e posterior conduta clínica.

Utilidad de la cromohisteroscopia en la evaluación del endometrio. Hospital de San José de Bogotá D.C, Colombia. Febrero-Octubre de 2014 / Evaluation of endometrium by chromohysteroscopy. Hospital de San José de Bogotá DC, Colombia Febrero-Octubre 2014

Determinar el rendimiento operativo de la cromohisteroscopia (CHC) en la evaluación del endometrio en el Hospital de San José de Bogotá DC, Colombia, entre febrero y octubre 2014. Metodología: se incluyeron 97 mujeres adultas a quienes se aplicaron 5 cc de azul de metileno al 1% en la cavidad endometrial y por histeroscopia se determinó la presencia de manchas oscuras de donde se tomaron biopsias dirigidas (estándar de oro). Mediante una hoja excel y base de datos stata13® se calcularon las características operativas por medio de tablas de contingencia, se compararon la CHC y la histeroscopia convencional (HC) por medio de la prueba de McNemar y se evaluó la concordancia entre evaluadores y técnicas por medio del coeficiente kappa. Resultados: la principal indicación fue hemorragia uterina anormal (80,41%) realizada en premenopáusicas (78,35%) con edad alrededor de 45 años que presentaban sobrepeso. La microscopía detectó un caso de cáncer endometrial, uno de hiperplasia endometrial y cuatro de endometritis crónica. La sensibilidad y valor predictivo negativo de la CHC fue 100%, la especificidad 39,8% y el VPP 1,7% para cáncer e hiperplasia. Para endometritis la sensibilidad fue 50%, especificidad 38,9%, VPP 3,5% y VPN 94,6%. No hubo diferencias estadísticas entre CHC y la HC. El acuerdo entre evaluadores fue de 79,12% y entre técnicas de 54,64%. Conclusión: la CHC en hemorragia uterina anormal puede aportar un mayor rendimiento para el diagnóstico de patologías malignas y premalignas que la HC por el alto valor predictivo negativo encontrado...

To assess the efficacy of chromohysteroscopy (CHC) for evaluation of endometrium at Hospital de San José de Bogotá DC, Colombia, between February and October 2014. Methodology: ninety-seven adult women were included. Five milliliters of 1% methylene blue dye was introduced into the uterine cavity through the hysteroscopic inlet. Biopsies were obtained from dark stained areas (gold standard) identified by hysteroscopy. Operating characteristics were based on contingency tables using Excel and Stata13® data bases. CHC and conventional hysteroscopy (CH) were compared using the McNemar test and inter-evaluator and techniques agreement was assessed using the kappa coefficient. Results: the main indication was abnormal uterine bleeding (80.41%) in premenopausal women (78.35%) with overweight aged around 45 years. Microscopic examination revealed one case of endometrial cancer, one case of endometrial hyperplasia and four cases of chronic endometritis. Sensitivity and negative predictive value (VPN) were 100% for CHC, specificity 39.8% and VPP 1.7% for cancer and hyperplasia, and sensitivity was 50%, specificity 38.9%, VPP 3.5% and VPN 94.6% for endometritis. There was no significant difference between CHC and CH. Agreement between evaluators was 79.12% and between techniques 54.64%. Conclusion: the high negative predictive value results obtained suggest that the performance of CHC may be superior to CH in diagnosing malignant and premalignant conditions in cases of abnormal uterine bleeding...