Definition of large niche after Cesarean section based on prediction of postmenstrual spotting: Chinese cohort study in non-pregnant women.

OBJECTIVE: A large niche after Cesarean section (CS) is associated with long-term complications, of which postmenstrual spotting is associated positively with the size of the niche. However, the diagnosis of a large niche in the literature is inconsistent and the definition is largely subjective. The aim of this study was to generate a definition for a large niche in non-pregnant women based on the presence of postmenstrual spotting. METHODS: Women who had undergone CS in our hospital between January 2012 and June 2017 were selected randomly from our database, contacted by telephone and subsequently examined between January 2016 and June 2020. Eligible for inclusion were non-pregnant women who had their last CS more than 1 year earlier and agreed to undergo transvaginal sonography (TVS). All participants underwent examination of their CS scar by TVS (two-dimensional color Doppler) during the midfollicular phase. Niche depth, length, width, residual myometrial thickness (RMT), adjacent myometrial thickness (AMT) and ratio of niche depth/AMT were recorded. Women diagnosed with a niche, defined as an indentation at the site of the CS with a depth of at least 2 mm, were classified into two groups (symptomatic or asymptomatic) according to whether they experienced postmenstrual spotting. Logistic regression analysis was used to establish the best cut-off values for the niche parameters to predict postmenstrual spotting. A new definition was generated based on the niche parameters with the highest area under the receiver-operating-characteristics (ROC) curve (AUC) for the prediction of postmenstrual spotting. RESULTS: A total of 727 women who had a CS > 1 year earlier underwent TVS examination, of whom 263 were diagnosed with a niche (prevalence of 36.2%). Of these, 160 women experienced postmenstrual spotting and 103 were asymptomatic. The three variables with the highest AUC for prediction of postmenstrual spotting were niche depth/AMT ratio (AUC, 0.798; 95% CI, 0.745-0.852), niche depth (AUC, 0.731; 95% CI, 0.668-0.795) and RMT (AUC, 0.683; 95% CI, 0.618-0.748). Based on the best cut-offs according to ROC-curve analysis, a large niche was defined as: niche depth ≥ 0.50 cm, RMT ≤ 0.21 cm or niche depth/AMT ratio ≥ 0.56. The prevalence of a large niche according to this definition was 22.4% (163/727). The new definition had a specificity of 61.17% (95% CI, 52.34-70.41%) and sensitivity of 76.87% (95% CI, 70.28-84.16%) for a large niche. CONCLUSION: This study has provided a new definition for a large niche after CS. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

[Prognosis of pregnant women with vaginal bleeding during the first trimester: about 239 cases at the Kamenge University Hospital in Bujumbura]. / Pronostic de la grossesse qui saigne au premier trimestre: à propos de 239 cas colligés au Centre Hospitalo-Universitaire de Kamenge, Bujumbura.

The purpose of this study is to evaluate the post-discharge prognosis of pregnant women with vaginal bleeding during the first trimester, admitted to the Emergency Maternity at the Kamenge University Hospital (CHUK), according to patients age, amount of bleeding and ultrasound results. We conducted a retrospective descriptive and analytical study of 239 medical records of patients hospitalized over a period of six years from January 2012 to December 2017. In this study, the prognosis of pregnant women with first-trimester metrorrhagia hospitalized at the CHUK was bad; the majority of them (65.7%) had miscarriage. Amount of bleeding, maternal age below 20 years, or well above or equal to 35 years, were significant risk factors but much more ultrasound detection of trophoblastic detachment. It would be interesting to perform a prospective study to detect the causes of these metrorrhagias and to determine late pregnancy complications.

Thyroid Dysfunction in Patients with Abnormal Uterine Bleeding in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Abnormal uterine bleeding is a common gynecological presentation, accounting for at least 20% of all new outpatient visits. It has been recognized that thyroid dysfunction may have profound effects on the female reproductive system. Both hypothyroidism and hyperthyroidism are associated with a variety of changes, including delayed onset of puberty, anovulatory cycles, and abnormally high fetal wastage. Hence, this study was conducted to know the thyroid status of the patient with abnormal uterine bleeding. METHODS: A descriptive cross-sectional study was conducted in all the patients with abnormal uterine bleeding in a tertiary care hospital from 2 August 2019 to 2 February 2020. Ethical clearance was received from the institutional review committee of KIST Medical College. Convenient sampling was done. Data was collected using a questionnaire which includes patients profile, the pattern of abnormal uterine bleeding, and thyroid profile. Statistical analysis was done using Statistical Package for the Social Sciences version 23. RESULTS: Out of 79 patients, it was found that 67 (84.8%) were euthyroid, 11 (13.9%) were hypothyroid,and 1 (1.2%) was hyperthyroidism. The most common type of abnormal uterine bleeding wasmenorrhagia 34 (43%), followed by polymenorrhoea 23 (29%), oligomenorrhoea 13 (16.5%), menometrorrhagia 6 (7.6%), metrorrhagia 2 (2.5%), and hypomenorrhea 1 (1.3%). The maximum number of patients was between 20-25 years with the mean age of 31 years. Among hypothyroid, 7(8.8%) had subclinical hypothyroidism and 4 (5%) had frank hypothyroidism. CONCLUSIONS: Most females with abnormal uterine bleeding were euthyroid. Menorrhagia was the most common pattern of abnormal uterine bleeding.

Evaluation of pre-malignant cervical lesions in females presenting with abnormal pelvic complaints.

OBJECTIVE: To evaluate premalignant cervical lesions by using Papanicolaou smears in females presenting with abnormal pelvic complaints. METHODS: The descriptive cross-sectional study was conducted from June to November 2013 at the Department of Histopathology, Mayo Hospital, Lahore, and comprised female patients aged 25-70 years presenting with abnormal pelvic complaints with no cause in the uterus checked through ultrasonography who were undergoing cervical Papanicolaou smear. The smears were spray-fixed and placed in 95% reagent alcohol and was then stained with haematoxylin and eosin stain. The cytological examination was carried out under light microscope. SPSS 16 was used for data analysis. RESULTS: There were 210 women with a mean age of 39.51±8.32 years. Vaginal discharge was present in 89(42.4%) women; postcoital bleeding in 12(5.7%), and intermenstrual bleeding was present in 21(10%) women. Dyspareunia was present in 33(15.7%) women, and pelvic pain in 60(28.6%). Overall, premalignant cervical cancer was noted in 17(8.1%) patients. Atypical squamous cells of unknown significance was present in 5(2.4%) women, low-grade squamous intraepithelial lesion (LSIL) in 8(3.8%), and high-grade squamous intraepithelial lesion in 4(1.9%) patients of cervical cancer. CONCLUSIONS: The frequency of premalignant cervical lesions in symptomatic patients was high enough to highlight the importance of early detection of cervical cancer.

Clinical Success Rate of Extensive Hysteroscopic Cesarean Scar Defect Excision and Correlation to Histologic Findings.

STUDY OBJECTIVE: Cesarean scar defect (CSD) is often associated with postmenstrual bleeding, infertility, and pain. Hysteroscopic CSD repair was described in the past, mainly as excision of the proximal edge of the defect to allow continuous blood flow during menstruation. In this study we aimed to evaluate the efficacy of extensive hysteroscopic cesarean scar niche excision in symptomatic patients. DESIGN: A retrospective cohort study. PATIENTS: Symptomatic patients treated with hysteroscopic CSD excision who were considered eligible for the procedure when myometrial thickness of 2 mm or more was observed on sonohysterography. SETTING: Tertiary referral center. INTERVENTIONS: Extensive CSD excision was performed using a cutting loop and pure cutting current. The proximal and distal edges of the defect were resected. This was followed by resection of tissue at the base of the niche, until underling muscular tissue was evident. Tissue sampled from the base of the CSD was collected for histologic examination. Patients were followed for a minimum of 1 year after hysteroscopic CSD excision. Clinical information obtained included detailed obstetric history and preoperative and postoperative menstruation pattern. MEASUREMENTS AND MAIN RESULTS: Between 2011 and 2016, 95 patients underwent extensive hysteroscopic niche excision; 67 were included in the study, whereas the remaining were lost to follow-up. Patient mean age at the time of the procedure was 38 ± 5.5 years. Twenty-nine patients (43%) had a history of high-order repeat cesarean surgeries. Sixty-six patients (98.5%) presented with postmenstrual bleeding, 26 with secondary infertility (38.8%), and 2 with pelvic pain (2.9%). After hysteroscopic niche excision, 63.4% of patients reported significant improvement or resolution of postmenstrual bleeding. A statistically significant reduction in number of bleeding days per cycle (15.5 ± 4.8 vs 9.8 ± 4.7, p < .001) was also noted. Histologic evidence for myometrial tissue within the obtained samples was associated with better outcomes. A histologic specimen from patients who experienced significant improvement or resolution of postmenstrual bleeding was more likely to reveal myometrial tissue (p = .04). Of the 26 patients who suffered from infertility, 19 attempted to conceive spontaneously after CSD excision. Of those, 10 patients (52.6%) conceived and 9 delivered at least once (47.36%). CONCLUSION: Extensive hysteroscopic surgical excision of cesarean scar niche should be considered in symptomatic patients suffering from irregular menstrual bleeding. The quality of the excision at the apex of the niche could be associated with a higher success rate. The role of niche excision to overcome secondary infertility should be further evaluated.

Four Surgical Strategies for the Treatment of Cesarean Scar Defect: A Systematic Review and Network Meta-analysis.

OBJECTIVE: This network meta-analysis compared treatment via laparoscopy, hysteroscopy (HP), combined laparoscopy with HP (LH), and vaginal repair (VR) for reducing intermittent abnormal uterine bleeding and cesarean scar defect (CSD) diverticulum depth in patients with CSD. DATA SOURCES: Electronic databases (PubMed, EMBASE, The Cochrane Central Register of Controlled Trials, MEDLINE, ClinicalTrials.gov, Chinese Biomedical Literature Database, and China National Knowledge Integrated) were searched for articles published through June 13, 2018. METHODS OF STUDY SELECTION: The search included randomized controlled trials (RCTs) and observational studies of surgical treatment for CSD. Standardized mean difference (SMD) and 95% confidence intervals (CIs) were reported. RCTs were evaluated by the Cochrane risk-of-bias tool, observational studies by Risk of Bias in Nonrandomized Studies of Intervention, and overall evidence quality by grade. Data were analyzed by STATA (version 15.0; StataCorp, College Station, TX) and R software for windows (version 3.5.0; R Core Team, 2018). TABULATION, INTEGRATION, AND RESULTS: Ten studies (n = 858; 4 RCTs and 6 observational studies) were included. Patients who underwent uterine diverticulum resection by LH had a shorter duration of abnormal uterine bleeding than those by HP (SMD = 1.36, 95% CI, 0.37-2.36; p = .007) and VR (SMD = 1.58, 95% CI, 0.97-2.19; p <.0001). LH reduced the CSD diverticulum depth more than VR (SMD = 1.57, 95% CI, 0.54-2.61; p = .003). There was no significant difference in efficacy among the surgical procedures. CONCLUSION: LH reduced intermittent abnormal uterine bleeding and scar depth more than the other surgical interventions. Larger clinical trials are warranted to verify this analysis.

A prospective clinical cohort study of women at increased risk for endometrial cancer.

OBJECTIVE: To evaluate endometrial cancer (EC) risk assessment and early detection strategies in high-risk populations, we designed a large, prospective cohort study of women undergoing endometrial evaluation to assess risk factors and collect novel biospecimens for future testing of emerging EC biomarkers. Here we report on the baseline findings of this study. METHODS: Women aged ≥45 years were enrolled at the Mayo Clinic from February 2013-June 2018. Risk factors included age, body mass index (BMI), smoking, oral contraceptive and hormone therapy use, and parity. We collected vaginal tampons, endometrial biopsies, and Tao brush samples. We estimated mutually-adjusted odds ratios (OR) and 95% confidence intervals (CI) using multinomial logistic regression; outcomes included EC, atypical hyperplasia, hyperplasia without atypia, disordered proliferative endometrium, and polyps, versus normal endometrium. RESULTS: Subjects included 1205 women with a mean age of 55 years; 55% were postmenopausal, and 90% had abnormal uterine bleeding. The prevalence of EC was 4.1% (n = 49), predominantly diagnosed in postmenopausal women (85.7%). Tampons and Tao brushings were obtained from 99% and 68% of women, respectively. Age (OR 1.14, 95% CI 1.1-1.2) and BMI (OR 1.39, 95% CI 1.1-1.7) were positively associated with EC; atypical hyperplasia (OR 1.07, 95% CI 1.0-1.1; OR 2.00, 95% CI 1.5-2.6, respectively), and polyps (OR 1.06, 95% CI 1.0-1.1; OR 1.17, 95% CI 1.0-1.3, respectively); hormone therapy use and smoking were inversely associated with EC (OR 0.42, 95%, 0.2-0.9; OR 0.43, 95% CI, 0.2-0.9, respectively). Parity and past oral contraception use were not associated with EC. CONCLUSIONS: Well-established EC risk factors may have less discriminatory accuracy in high-risk populations. Future analyses will integrate risk factor assessment with biomarker testing for EC detection.

Bleeding patterns with the 19.5 mg LNG-IUS, with special focus on the first year of use: implications for counselling.

Objective: The aim of the study was to provide an additional, detailed description of early bleeding patterns with the 19.5 mg levonorgestrel-releasing intrauterine system (LNG-IUS). Methods: We conducted a pooled analysis of the bleeding diaries of participants in a previously reported phase II randomised controlled study (n = 741) and a phase III study (n = 2904), with 2-year extension phase (n = 707), of the 19.5 mg LNG-IUS. Main outcome measures were the median number of bleeding and/or spotting days per 30-day reference period for 12 months and the influence of the previous contraceptive method and levonorgestrel dose on bleeding patterns. Results: The pooled analysis comprised 1697 women. There was a progressive decline in the number of bleeding and/or spotting days from month 1: the proportion of women with ≤4 bleeding and/or spotting days per month increased from 6.2% in month 1 to 15.8% in month 2, 26.0% in month 3, 39.3% in month 6 and 54.1% in month 12. The median number of bleeding and/or spotting days in month 1 was lowest in women who had previously been using an LNG-IUS. Conclusion: Analysis of bleeding diaries using 30-day reference periods provides detailed insight into bleeding changes in the first months following placement of the 19.5 mg LNG-IUS. This insight may prove useful when counselling women about contraceptive choice and method continuation.

Comparing bleeding patterns for the levonorgestrel 52 mg, 19.5 mg, and 13.5 mg intrauterine systems.

OBJECTIVE: Compare bleeding patterns for levonorgestrel 52 mg, 19.5 mg, and 13.5 mg intrauterine system (IUS) products using the World Health Organization Belsey definitions. STUDY DESIGN: We extracted available data on bleeding patterns from published sources. Lower dose products had published data at 1 and 3 years; the 52 mg IUS had available data for 1, 2 and 3 years for amenorrhea and 1 and 2 years for other bleeding patterns. We interpolated 2-year data for the lower dose products based on 1- and 3-year data and compared bleeding pattern rates using Fisher exact testing. RESULTS: The studies evaluated bleeding patterns in 1700, 1566 and 1531 women using levonorgestrel 52 mg, 19.5 mg and 13.5 mg products, respectively. Amenorrhea rates were greater by 180 days after insertion for 52 mg IUS users (11%) as compared to 19.5 mg (5%, p<.0001) and 13.5 mg (3%, p<.0001). Infrequent bleeding rates were higher for 52 mg users by the end of year 1 (31%) compared to 19.5 mg (26%, p=.01) and 13.5 mg (20%, p<.0001). Irregular bleeding rates were higher with the lower dose products by 90 days after insertion with continued lower rates at the end of year 1 for 52 mg users (6%) compared 19.5 mg (17%, p<.0001) and 13.5 mg (23%, p<.0001). Frequent and prolonged bleeding patterns were similar over the first 2 years for all products, although the rates were statistically higher for levonorgestrel 13.5 mg IUS users compared to 19.5 mg and 52 mg IUS users (p≤.03 for all time points after 90-days post-insertion). CONCLUSIONS: Levonorgestrel 52 mg IUS users have more amenorrhea and infrequent bleeding and less irregular bleeding compared to women using lower dose levonorgestrel IUS products. IMPLICATIONS STATEMENT: All women considering levonorgestrel IUS placement should receive counseling on the differences in bleeding patterns related to the various available doses. Women who are interested in maximizing the likelihood of favorable bleeding should consider a levonorgestrel 52 mg IUS over the lower dose alternatives.

Gynaecological and obstetrical bleeding in Caucasian women with congenital factor XI deficiency: Results from a twenty-year, retrospective, observational study.

INTRODUCTION: Factor XI (FXI) deficiency is a mild bleeding disorder, common among Ashkenazis, that may be underestimated in Caucasians. Management of FXI deficiency in women is a challenge, due to its unpredictable bleeding tendency and the little evidence available on this issue. OBJECTIVE: To describe gynaecological/obstetrical bleeding complications and to analyze the effectiveness and safety of the antihaemorrhagic treatment among women with FXI deficiency. MATERIAL AND METHODS: A retrospective, observational study of 214 Caucasian subjects with FXI deficiency collected during 20 years (1994-2014) without clinical selection. RESULTS: We identified 95 women with FXI deficiency. Any haemorrhagic event was communicated by 26/95 (27.4%), being abnormal uterine bleeding the most frequently found (12/95, 12.6%). Nine postpartum haemorrhages were recorded from 136 deliveries (6.6%) in 57 women. Four postsurgical bleeding complications were registered among 25 gynaecological surgeries (16%) in 20 women. Abnormal uterine bleeding, postpartum and postsurgical haemorrhages were related to both a positive bleeding history and FXI:C values ≤43.5%. Prophylaxis with fresh frozen plasma, used in 12/25 (48%) gynaecological surgeries, did not prevent from postoperative bleeding in three cases, but two developed severe adverse reactions. CONCLUSION: Women with FXI deficiency, especially those with a positive history of bleeding or FXI:C ≤43.5%, are at risk of developing gynaecological/obstetrical haemorrhages, most of them mild/moderate. Systematic prophylaxis has questionable effectiveness, but might cause severe side effects.

Associations of birth characteristics with perimenopausal disorders: a prospective cohort study.

Perimenopausal disorders (PDs) are prevalent and importantly affect quality of life among middle-aged women. Yet, very little is known about the developmental origins of these disorders. The objective of this study was to investigate the associations of birth characteristics with PDs. This cohort study is based on archived birth records for birth weight and gestational age, and followed prospectively in Swedish inpatient and outpatient registers for 8 years (n=3212). The main outcomes were menopausal and climacteric states (e.g. flushing, sleeplessness), perimenopausal bleeding and other PDs (e.g. atrophic vaginitis). Cox proportional hazards regression models were used to estimate the hazard ratios (HRs) for three subtypes of PDs separately. During the follow-up, 218 women had PDs, among whom 125 had menopausal and climacteric states, 61 had perimenopausal bleeding and 58 had other PDs as first recorded disorder. Birth weight was linearly associated with incidence rate of menopausal and climacteric states [HR=1.66 per 1 kg increase, 95% confidence interval (95% CI)=1.14-2.41]. Gestational age (rather than birth weight) was associated with incidence rate of other PDs (HR=0.87 per 1 week increase, 95% CI=0.79-0.95). Neither birth weight nor gestational age was associated with perimenopausal bleeding. Similar results were found after adjustment for other early-life and adult socio-demographic characteristics. This observational study provides, for the first time, evidence regarding the developmental origins of PDs. Future research is required to investigate the underlying causal mechanisms, which may shed further light on the etiology of this class of disorders.

Norethindrone acetate versus extended-cycle oral contraceptive (Seasonique®) in the treatment of endometriosis symptoms: A prospective open-label comparative study.

INTRODUCTION: This patient preference prospective study was designed to compare patients' satisfaction in women with endometriosis treated either by an extended-cycle oral contraception (OC) or by norethindrone acetate (NETA). METHODS: This patient preference prospective study included women of reproductive age with endometriosis. Patients were submitted to one of the following 12 months' treatments: Group A, continuous oral treatment with NETA (2.5 mg/day) and Group B, a 91-day extended-cycle OC (LNG/EE 150/30 mcg for 84 days and EE 10 mcg for 7 days). Patient satisfaction was the primary endpoint. RESULTS: There was no statistically significant difference in the rate of satisfied patients at 12-month follow up between the two study groups, 82.2% and 68.4% in Group A and Group B respectively (p = 0.143). At 6 and 12-months, there was a significant amelioration in the intensity of all pain in both groups. The median number of days of unscheduled bleeding during the first cycle was significantly higher in Group B compared to Group A. CONCLUSION: Both NETA and extended-cycle OC are effective in treating pain symptoms related to endometriosis. Extended-cycle OC may cause more unscheduled bleeding, but the rate of satisfaction for those who completed the treatment was similar in the two groups.

Long-term outcomes after elective sterilization procedures - a comparative retrospective cohort study of Medicaid patients.

OBJECTIVES: The objectives were to compare the long-term outcomes, including hysterectomy, chronic pelvic pain (CPP) and abnormal uterine bleeding (AUB), in women post hysteroscopic sterilization (HS) and laparoscopic tubal ligation (TL) in the Medicaid population. STUDY DESIGN: This was a retrospective observational cohort analysis using data from the US Medicaid Analytic Extracts Encounters database. Women aged 18 to 49years with at least one claim for HS (n=3929) or TL (n=10,875) between July 1, 2009, through December 31, 2010, were included. Main outcome measures were hysterectomy, CPP or AUB in the 24months poststerilization. Propensity score matching was used to control for patient demographics and baseline characteristics. Logistic regression analysis investigated the variables associated with a 24-month rate of each outcome in the HS versus laparoscopic TL cohorts. RESULTS: Postmatching analyses were performed at 6, 12 and 24months post index procedure. At 24months, hysterectomy was more common in the laparoscopic TL than the HS group (3.5% vs. 2.1%; p=.0023), as was diagnosis of CPP (26.8% vs. 23.5%; p=.0050). No significant differences in AUB diagnoses were observed. Logistic regression identified HS as being associated with lower risk of hysterectomy (odds ratio [OR] 0.77 [95% confidence interval {CI} 0.60-0.97]; p=.0274) and lower risk of CPP diagnosis (OR 0.91 [95% CI 0.83-0.99]; p=.0336) at 24months poststerilization. CONCLUSION: In Medicaid patients, HS is associated with a significantly lower risk of hysterectomy or CPP diagnosis 24months poststerilization versus laparoscopic TL. Incidence of AUB poststerilization is not significantly different. While some differences in outcomes were statistically significant, the effect sizes were small, and the conclusion is one of equivalence and not clinical superiority. IMPLICATIONS STATEMENT: This propensity score matching analysis confirms that pelvic pain and AUB are common in women before and after sterilization regardless of whether the procedure is performed hysteroscopically or laparoscopically. Moreover, HS is associated with a significantly lower risk of hysterectomy or a CPP diagnosis in the 24months poststerilization when compared to TL.

Efficacy of combined hormonal vaginal ring in comparison to combined hormonal pills in heavy menstrual bleeding.

OBJECTIVE: To compare the efficacy, acceptability and compliance of combined hormonal vaginal ring (CVR), with combined hormonal pills (CHP) in patients with heavy menstrual bleeding (HMB). STUDY DESIGN: This prospective study was conducted in 50 women with HMB in age group of 25-40 years. Patients were divided in two groups of 25 each and followed for six treatment cycles. In each group, cycle comprised of three weeks of CVR (releases 15µg of EE and 120µg of the etonogestrel per day) or CHP (containing 30µgm of EE and 150µgm of LNG) use, followed by one ring or pill free week. After each cycle, patients were evaluated about the amount of blood loss and duration of bleeding by the pictoral blood assessment chart (PBAC), early bleeding (EWB), continued bleeding (CWB), intermenstrual bleeding, intended bleeding, compliance, and user acceptability. The collected data were analyzed using the Chi square test, t-test and ANOVA test. RESULT: Reduction in PBAC score for CVR (70.73%) and CHP group (70.02%), duration of bleeding and incidence of EWB was comparable among the two groups. The incidence of intermenstrual bleeding was lower in CVR than in CHP group in cycle 3 and 4 with significant p value. The incidence of CWB was significantly lower and the incidence of intended bleeding pattern in CVR group was significantly higher in cycle 3, 4, 5 and 6, signifying better cycle control. Compliance was also higher in CVR (88%) than CHC (75.33% of all cycles). CONCLUSION: This trial suggests that both the CVR and CHP are very effective short-term treatments for HMB in reproductive age group. However, women had better cycle control and compliance with CVR. This may be an attractive option among the wide variety of medications used to treat HMB.

[Radiotherapy for endometrial cancer: experience of the national institute of oncology with 52 cases]. / La radiothérapie du cancer de l'endomètre: expérience de l'institut national d'oncologie à propos de 52 cas.

Endometrial cancer is the most common gynecological cancer in the Western world. It affects mainly postmenopausal women. The aim of our study is to report the experience of the radiotherapy department of the National Oncology Institute (INO) in the treatment of endometrial cancer. We retrospectively analyzed 52 cases of endometrial cancer treated in the INO radiotherapy department between 2007-2009. Data obtained from the patient medical records were related to the epidemiologic, clinical, therapeutic and evolutionary aspects of this cancer. The median age of the patients was 57 years, 87% were postmenopausal. The median of consultation time was six months. The main symptom was metrorrhagia (51 patients). Histological diagnosis was based on biopsic curettage of uterine endometrium in 51% of the cases. Anatomo-pathological examination showed an endometrioid adenocarcinoma in 92% of the cases. After the assessment, 27% of the patients were stage I, 30% stage II, 20% stage III and 1% stage IVA, according to the International Federation of Gynecological and Obstetrics (FIGO) stage classification. After surgery, 51% of the patients received postoperative external radiotherapy. The delivered dose was 46 Gray (Gy). All patients received internal vaginal brachytherapy. From an evolutionary perspective, 83% of the patients had no recurrences during the follow-up period, 8% of patients had a local recurrence and 4% of patients had distant metastases. Therefore, surgery is the main treatment for endometrial cancer. Radiotherapy is the primary adjuvant treatment.

Mood and anxiety disorders in patients with abnormal uterine bleeding.

OBJECTIVE: We aimed to investigate the prevalence of mood and anxiety disorders in patients with abnormal uterine bleeding (AUB) and the relationship between mood and anxiety disorders and AUB. METHOD: 96 consecutive patients with not yet classified AUB based on the PALM-COEIN classification and 94 volunteers were included in the study. Mood and anxiety disorders were ascertained by means of the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition/Clinical Version. RESULTS: Out of 96 patients, 55 (57.3%) met the criteria for at least one diagnosis of mood and anxiety disorder. The most common psychiatric disorders in patients with AUB were major depression (n=15, 15.6%), generalized anxiety disorder (n=18, 18.8%) and obsessive compulsive disorder (n=22, 22.9%), respectively. Compared with the control group, the prevalence of any psychiatric disorder (x(2)=43.52, p=0.000), any mood disorder (x(2)=10:37, p=0.001) and any anxiety disorder (Fisher's exact test, p=0.000) was higher in patients with AUB. The presence of any mood and anxiety disorder was an independent risk factor for AUB. CONCLUSION: Mood and anxiety disorders, particularly major depression, generalized anxiety disorder and obsessive-compulsive disorder were frequently observed in patients with AUB.

Comparison of classic terminology with the FIGO PALM-COEIN system for classification of the underlying causes of abnormal uterine bleeding.

OBJECTIVE: To compare classic terminology and the PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory disorders, endometrium, iatrogenic, and not classified) classification system among women who underwent surgery for abnormal uterine bleeding (AUB), and to subclassify the components of the PALM group for future studies. METHODS: In a retrospective study, data were obtained for nonpregnant women aged 18-55years who underwent hysterectomy, myomectomy, or polypectomy for AUB at a center in Turkey in 2014. The patients were retrospectively classified according to the PALM-COEIN system, and the two terminologies were compared. RESULTS: A total of 471 women were included. The term "hypermenorrhea" covered 15 different pathology combinations, "menorrhagia" nine, "metrorrhagia" 14, and "menometrorrhagia" 18. Of 92 patients with polyp, 5 (5.4%) had two polyps and 1 (1.1%) had three. Of 146 patients with adenomyosis, 131 (89.7%) had diffuse adenomyosis and 12 (8.2%) had adenomyoma. Of 309 patients with myoma uteri, 108 (34.9%) had submucous myoma and 201 (65.1%) had other types of myoma. CONCLUSION: Classic terminology for AUB is insufficient and confusing with respect to etiologic pathologies among nonpregnant women of reproductive age. Widespread adoption of the PALM-COEIN system for AUB classification will facilitate more meaningful communication among both clinicians and investigators, and clarify the populations that should be evaluated in clinical trials, thereby enhancing communication with patients.

Prospective evaluation of the impact of intermenstrual bleeding on natural fertility.

OBJECTIVE: To evaluate the impact of an episode of intermenstrual bleeding on the probability of conception in a menstrual cycle (fecundability). DESIGN: Prospective, time-to-pregnancy cohort study. SETTING: Community-based cohort. PATIENT(S): Women trying to conceive, ages 30 to 44 years, without known infertility. INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Current cycle and subsequent cycle fecundability. RESULT(S): A total of 549 women provided 1,552 complete cycles for analysis. Intermenstrual and luteal bleeding were reported in 36% and 34% of cycles, respectively. Ninety-three percent of all intermenstrual bleeding was luteal. Cycles in which women had intermenstrual bleeding or luteal bleeding were statistically significantly less likely to result in conception (fecundability ratio [FR] 0.23; 95% confidence interval [CI], 0.16-0.34; and FR 0.22; 95% CI, 0.14-0.33). Women with an episode of intermenstrual and luteal bleeding had a statistically significant increase in the probability of pregnancy in the subsequent cycle (FR 1.61; 95% CI, 1.15-2.25; and FR 2.01; 95% CI, 1.52-2.87, respectively). CONCLUSION(S): Intermenstrual bleeding statistically significantly decreases the odds of conceiving in that cycle but does not appear to negatively impact a woman's immediate future reproductive potential. CLINICAL TRIAL REGISTRATION NUMBER: NCT01028365.

Gynecologic follow up of 129 women on dialysis and after kidney transplantation: a retrospective cohort study.

OBJECTIVE: To describe the gynecologic issues and follow-up in our referral center of women on dialysis and after kidney transplantation. STUDY DESIGN: This retrospective cohort study included 129 dialysed women among whom 102 had had transplants. Data on menstrual pattern, pregnancies, contraception, and cervical cytology were retrieved from patients' files. RESULTS: The follow-up started at age 41.6±14.2 years and lasted for 9.5±10.2 years. Of the women, 78.7% had regular menses before dialysis, decreasing to 30.6% on dialysis (p<0.001), when 43.1% were amenorrheic (p<0.001). After transplantation, more patients had regular menstruation and fewer were amenorrheic (respectively 57.1% and 23.1%, p<0.001). On dialysis and after transplantation, 25% and 30.5% of patients suffered from metrorrhagia (compared to 17.1% before, p<0.01). Concerning pregnancies, rates of spontaneous abortions (33.3%, p=0.01), intrauterine growth retardation (28.5%, p<0.001) and prematurity (23.8%, p=0.008) were significantly higher after transplantation than before dialysis. Prescriptions for the combined contraceptive pill and intrauterine device decreased whereas chlormadinone acetate was widely used: it treated metrorrhagia and relieved mastodynia in 80% and 12% of the cases. Smear tests showed more inflammation (33% vs 0.8%, p<0.05), condylomas (13.6% vs 3.1%, p=0.005) and intraepithelial neoplasias (12.6% vs 2.3%, p=0.003) among patients after renal graft than before dialysis. CONCLUSION: Women on dialysis and after kidney transplantation suffered more from irregular menses and metrorrhagia which was improved by chlormadinone acetate. We noted high rates of obstetrical complications and abnormal smear tests. Consequently, this population must have close follow-up to identify and treat gynecologic issues.

Sonographic findings in postmenopausal women with a prior endometrial ablation: interpretation and management of women with endometrial thickening and bleeding.

OBJECTIVE: To understand the meaning of endometrial thickening and bleeding in postmenopausal women who had previously undergone endometrial ablation (EA). DESIGN: Retrospective observational study. Canadian Task Force III. SETTING: Obstetrics and Gynecology Unit, Magna Graecia University, Catanzaro, Italy. PATIENTS: Sixty-three postmenopausal women who had previously undergone EA. INTERVENTIONS: A retrospective evaluation of clinical charts of postmenopausal women who had a follow-up visit after EA between January 2000 and August 2014. MEASUREMENTS AND MAIN RESULTS: The rates of endometrial thickening (with or without bleeding), endometrial atrophy, and cancer were determined. Postmenopausal bleeding was reported in 9 patients (14.3%). Endometrial thickening was observed in 51 patients (80.9%; mean ± SD endometrial thickness, 7.7 ± 3.0 mm). A significantly (p < .05) greater number of patients with an endometrial thickness of 5 to 10 mm was observed compared with those with an endometrial thickness of <5 mm or >10 mm. A significant (p = .001) difference in increase in endometrial thickness was observed between patients with and without bleeding. Overall, hysteroscopy plus endometrial biopsy was scheduled in 24 patients. In all bleeding women, a histological diagnosis of endometrial atrophy was demonstrated. Concerning bleeding-free women, in 14 patients with endometrial thickening of >10 mm, mucosal atrophy was detected. The only bleeding-free patient in whom an endometrial echogenic fluid collection was detected had a histological diagnosis of endometrioid endometrial cancer. Thus, patients who underwent hysteroscopy had a 95.8% rate of mucosal atrophy and a 4.2% rate of endometrial cancer. The overall cancer rate in our global population (menopause with previous EA) was 1.6%. CONCLUSION: Postmenopausal bleeding and sonographic detection of endometrial thickening in patients with previous EA are not necessarily related to a malignant disease. Nonetheless, ultrasound visualization of endometrial thickening plus an echogenic endometrial fluid collection in these patients always warrants an invasive diagnostic procedure regardless of whether or not bleeding is reported.