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1.
PLoS One ; 15(4): e0232231, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32343732

RESUMO

BACKGROUND: To inform treatment decisions in women diagnosed with endometrial hyperplasia, quantification of the potential for concurrent endometrial cancer and the future risk of progression to cancer is required. METHODS: We identified studies up to September 2018 that reported on the prevalence of concurrent cancer (within three months of endometrial hyperplasia diagnosis), or the incidence of cancer, identified at least three months after hyperplasia diagnosis. Random-effects meta-analyses produced pooled estimates and 95% confidence intervals (CIs). RESULTS: A total of 36 articles were identified; 15 investigating concurrent and 21 progression to cancer. In pooled analysis of 11 studies of atypical hyperplasia, the pooled prevalence of concurrent endometrial cancer was 32.6% (95% CI: 24.1%, 42.4%) while no studies evaluated concurrent cancer in non-atypical hyperplasia. The risk of progression to cancer was high in atypical hyperplasia (n = 5 studies, annual incidence rate = 8.2%, 95% CI 3.9%, 17.3%) and only one study reported on non-atypical hyperplasia (annual incidence rate = 2.6%, 95% CI: 0.6%, 10.6%). CONCLUSIONS: Overall, a third of women with atypical hyperplasia had concurrent endometrial cancer, although the number of studies, especially population-based, is small. Progression to cancer in atypical hyperplasia was high, but few studies were identified. Population-based estimates are required, in both atypical and non-atypical hyperplasia patients to better inform treatment strategies.


Assuntos
Hiperplasia Endometrial/complicações , Neoplasias do Endométrio/etiologia , Progressão da Doença , Hiperplasia Endometrial/diagnóstico , Hiperplasia Endometrial/epidemiologia , Neoplasias do Endométrio/diagnóstico , Neoplasias do Endométrio/epidemiologia , Endométrio/patologia , Feminino , Humanos , Incidência , Lesões Pré-Cancerosas/complicações , Lesões Pré-Cancerosas/diagnóstico , Lesões Pré-Cancerosas/epidemiologia , Prevalência , Fatores de Risco
2.
Am J Obstet Gynecol ; 223(4): 549.e1-549.e13, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32268124

RESUMO

BACKGROUND: Most endometrial cancer cases are preceded by abnormal uterine bleeding, offering a potential opportunity for early detection and cure of endometrial cancer. Although clinical guidelines exist for diagnostic workup of abnormal uterine bleeding, consensus is lacking regarding optimal management for women with abnormal bleeding to diagnose endometrial cancer. OBJECTIVE: We report the baseline data from a prospective clinical cohort study of women referred for endometrial evaluation at the Mayo Clinic, designed to evaluate risk stratification in women at increased risk for endometrial cancer. Here, we introduce a risk-based approach to evaluate diagnostic tests and clinical management algorithms in a population of women with abnormal bleeding undergoing endometrial evaluation at the Mayo Clinic. STUDY DESIGN: A total of 1163 women aged ≥45 years were enrolled from February 2013 to May 2019. We evaluated baseline absolute risks and 95% confidence intervals of endometrial cancer and endometrial intraepithelial neoplasia according to clinical algorithms for diagnostic workup of women with postmenopausal bleeding (assessment of initial vs recurrent bleeding episode and endometrial thickness measured through transvaginal ultrasound). We also evaluated risks among women with postmenopausal bleeding according to baseline age (<60 vs 60+ years) as an alternative example. For this approach, biopsy would be conducted for all women aged 60+ years and those aged <60 years with an endometrial thickness of >4 mm. We assessed the clinical efficiency of each strategy by estimating the percentage of women who would be referred for endometrial biopsy, the percentage of cases detected and missed, and the ratio of biopsies per case detected. RESULTS: Among the 593 women with postmenopausal bleeding, 18 (3.0%) had endometrial intraepithelial neoplasia, and 47 (7.9%) had endometrial cancer, and among the 570 premenopausal women with abnormal bleeding, 8 (1.4%) had endometrial intraepithelial neoplasia, and 7 (1.2%) had endometrial cancer. Maximum risk was noted in women aged 60+ years (17.7%; 13.0%-22.3%), followed by those with recurrent bleeding (14.7%; 11.0%-18.3%). Among women with an initial bleeding episode for whom transvaginal ultrasound was recommended, endometrial thickness did not provide meaningful risk stratification: risks of endometrial cancer and endometrial intraepithelial neoplasia were nearly identical in women with an endometrial thickness of >4 mm (5.8%; 1.3%-10.3%) and ≤4 mm (3.6%; 0.9%-8.6%). In contrast, among those aged <60 years with an endometrial thickness of >4 mm, the risk of endometrial cancer and endometrial intraepithelial neoplasia was 8.4% (4.3%-12.5%), and in those with an endometrial thickness of ≤4 mm, the risk was 0% (0.0%-3.0%; P=.01). The most efficient strategy was to perform biopsy in all women aged 60+ years and among those aged <60 years with an endometrial thickness of >4 mm, with the lowest percentage referred to biopsy while still detecting all cases. CONCLUSION: Existing clinical recommendations for endometrial cancer detection in women with abnormal bleeding are not consistent with the underlying risk. Endometrial cancer risk factors such as age can provide important risk stratification compared with the assessment of recurrent bleeding. Future research will include a formal assessment of clinical and epidemiologic risk prediction models in our study population as well as validation of our findings in other populations.


Assuntos
Algoritmos , Carcinoma in Situ/diagnóstico , Hiperplasia Endometrial/diagnóstico , Neoplasias do Endométrio/diagnóstico , Metrorragia/diagnóstico , Idoso , Biópsia , Carcinoma in Situ/complicações , Hiperplasia Endometrial/complicações , Neoplasias do Endométrio/complicações , Endométrio/diagnóstico por imagem , Endométrio/patologia , Feminino , Humanos , Histeroscopia , Metrorragia/etiologia , Pessoa de Meia-Idade , Tamanho do Órgão , Pós-Menopausa , Recidiva , Medição de Risco , Ultrassonografia , Hemorragia Uterina/diagnóstico , Hemorragia Uterina/etiologia
3.
Am J Obstet Gynecol ; 223(1): 103.e1-103.e13, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-31978437

RESUMO

BACKGROUND: Though hysterectomy remains the standard treatment for complex atypical hyperplasia, patients who desire fertility or who are poor surgical candidates may opt for progestin therapy. However, the effectiveness of the levonorgestrel-releasing intrauterine device compared to systemic therapy in the treatment of complex atypical hyperplasia has not been well studied. OBJECTIVE: We sought to examine differences in treatment response between local progestin therapy with the levonorgestrel-releasing intrauterine device and systemic progestin therapy in women with complex atypical hyperplasia. METHODS: This single-institution retrospective study examined women with complex atypical hyperplasia who received progestin therapy between 2003 and 2018. Treatment response was assessed by histopathology on subsequent biopsies. Time-dependent analyses of complete response and progression to cancer were performed comparing the levonorgestrel-releasing intrauterine device and systemic therapy. A propensity score inverse probability of treatment weighting model was used to create a weighted cohort that differed based on treatment type but was similar with respect to other characteristics. An interaction-term analysis was performed to examine the impact of body habitus on treatment response, and an interrupted time-series analysis was employed to assess if changes in treatment patterns correlated with outcomes over time. RESULTS: A total of 245 women with complex atypical hyperplasia received progestin therapy (levonorgestrel-releasing intrauterine device n = 69 and systemic therapy n = 176). The mean age and body mass index were 36.9 years and 40.0 kg/m2, respectively. In the patient-level analysis, women who received the levonorgestrel-releasing intrauterine device had higher rates of complete response (78.7% vs 46.7%; adjusted hazard ratio, 3.32; 95% confidence interval, 2.39-4.62) and a lower likelihood of progression to cancer (4.5% vs 15.7%; adjusted hazard ratio, 0.28; 95% confidence interval, 0.11-0.73) compared to those who received systemic therapy. In particular, women with class III obesity derived a higher relative benefit from levonorgestrel-releasing intrauterine device therapy in achieving complete response compared to systemic therapy: class III obesity, adjusted hazard ratio 4.72, 95% confidence interval 2.83-7.89; class I-II obesity, adjusted hazard ratio 1.83, 95% confidence interval 1.09-3.09; and nonobese, adjusted hazard ratio 1.26, 95% confidence interval 0.40-3.95. In the cohort-level analysis, the obesity rate increased during the study period (77.8% to 88.2%, 13.4% relative increase, P = .033) and levonorgestrel-releasing intrauterine device use significantly increased after 2007 (6.3% to 82.7%, 13.2-fold increase, P < .001), both concomitant with a higher proportion of women achieving complete response (32.9% to 81.4%, 2.5-fold increase, P = .005). CONCLUSION: Our study suggests that local therapy with the levonorgestrel-releasing intrauterine device may be more effective than systemic therapy for women with complex atypical hyperplasia who opt for nonsurgical treatment, particularly in morbidly obese women. Shifts in treatment paradigm during the study period toward increased levonorgestrel-releasing intrauterine device use also led to improved complete response rates despite increasing rates of obesity.


Assuntos
Hiperplasia Endometrial/complicações , Hiperplasia Endometrial/tratamento farmacológico , Dispositivos Intrauterinos Medicados , Levanogestrel/administração & dosagem , Obesidade Mórbida/congênito , Progestinas/administração & dosagem , Adulto , Feminino , Humanos , Progestinas/uso terapêutico , Estudos Retrospectivos , Resultado do Tratamento
4.
BJOG ; 127(7): 848-857, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-31961463

RESUMO

OBJECTIVE: To assess the efficacy of metformin in megestrol acetate (MA)-based fertility-sparing treatment for patients with atypical endometrial hyperplasia (AEH) and endometrioid endometrial cancer (EEC). DESIGN: A randomised, single-centre, open-label, controlled trial conducted between October 2013 and December 2017. SETTING: Shanghai OBGYN Hospital of Fudan University, China. POPULATION: A total of 150 patients (18-45 years old) with primary AEH or well-differentiated EEC were randomised into an MA group (n = 74) and an MA plus metformin group (n = 76). METHODS: Patients with AEH or EEC were firstly stratified, then randomised to receive MA (160 mg orally, daily) or MA (160 mg orally, daily) plus metformin (500 mg orally, three times a day). MAIN OUTCOMES AND MEASURES: The primary efficacy parameter was the cumulate complete response (CR) rate within 16 weeks of treatment (16w-CR rate); the secondary efficacy parameters were 30w-CR rate and adverse events. RESULTS: The 16w-CR rate was higher in the metformin plus MA group than in the MA-only group (34.3 versus 20.7%, odds ratio [OR] 2.0, 95% confidence interval [CI] 0.89-4.51, P = 0.09) but the difference was more significant in 102 AEH patients (39.6 versus 20.4%, OR 2.56, 95% CI 1.06-6.21, P = 0.04). This effect of metformin was also significant in non-obese (51.4 versus 24.3%, OR 3.28, 95% CI 1.22-8.84, P = 0.02) and insulin-sensitive (54.8 versus 28.6%, OR 3.04, 95% CI 1.03-8.97, P = 0.04) subgroups of AEH women. No significant result was found in secondary endpoints. CONCLUSION: As a fertility-sparing treatment, metformin plus MA was associated with a higher early CR rate compared with MA alone in AEH patients. TWEETABLE ABSTRACT: For AEH patients, metformin plus MA might be a better fertility-sparing treatment to achieve a higher early CR rate compared with MA alone.


Assuntos
Antineoplásicos Hormonais/administração & dosagem , Hiperplasia Endometrial/tratamento farmacológico , Neoplasias do Endométrio/tratamento farmacológico , Preservação da Fertilidade/métodos , Acetato de Megestrol/administração & dosagem , Metformina/administração & dosagem , Adolescente , Adulto , China , Quimioterapia Combinada , Hiperplasia Endometrial/complicações , Neoplasias do Endométrio/complicações , Feminino , Humanos , Pessoa de Meia-Idade , Resultado do Tratamento , Adulto Jovem
5.
Menopause ; 26(9): 1068-1070, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31453972

RESUMO

OBJECTIVE: The aim of the study was to review the management of endometrial hyperplasia in a woman undergoing liver transplantation for alcoholic cirrhosis. METHODS: This is a case presentation on a postmenopausal woman with a tissue diagnosis of endometrial intraepithelial neoplasia managed with a levonorgestrel intrauterine device, before and after liver transplantation. Full written informed consent was obtained from the patient to present her case. RESULTS: The patient experienced resolution of her endometrial intraepithelial neoplasia with conversion to atrophic endometrium after management with levonorgestrel intrauterine device. CONCLUSIONS: A large percentage of women with cirrhosis experience abnormal uterine bleeding, which may be due to the coagulopathy that accompanies liver disease, or endometrial hyperplasia or carcinoma. Although hysterectomy is the criterion standard of treatment for atypical endometrial hyperplasia in a postmenopausal woman, patients with cirrhosis severe enough to require transplant are usually poor surgical candidates. Multiple studies have shown success with conservative management of atypical hyperplasia. There is a paucity of literature on managing patients undergoing transplant with abnormal uterine bleeding and it is therefore important to highlight conservative management options for this patient population.


Assuntos
Hiperplasia Endometrial/complicações , Cirrose Hepática/cirurgia , Transplante de Fígado , Tratamento Conservador , Hiperplasia Endometrial/terapia , Feminino , Humanos , Cirrose Hepática/complicações , Pessoa de Meia-Idade , Pós-Menopausa
6.
Saudi Med J ; 40(8): 815-819, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31423519

RESUMO

OBJECTIVES: Abnormal uterine bleeding (AUB) is a leading cause of hysterectomies, the cause of which is usually diagnosed with preoperative endometrial sampling. We planned this study to assess the accuracy of diagnosing the histologic patterns of endometrium in the preoperative sample in reference to the final histologic diagnosis in hysterectomy. METHODS: We retrospectively reviewed medical charts between January 2011 and December 2015 at a tertiary hospital in Saudi Arabia and identified 43 cases of AUB with complete documentation. The histologic diagnoses were classified into normal and benign pathology group (N/B), or carcinoma and hyperplasia category (Ca/H). Measures of validity were used to compare endometrial sampling histological diagnoses to diagnoses following hysterectomy and Cohen's kappa to assess for agreement between the 2 modalities. Results: The median age of all patients was 49 years. Preoperative histologic examination showed 53.8% sensitivity, 90% specificity, 70% positive predictive values and 81.8% negative predictive values, 30.1%  false positive rates and 18.2% false negative rates. The agreement between preoperative and postoperative histologic diagnoses was moderate (79.1%, k=0.469). Conclusion: The accuracy of preoperative histologic examination was moderate. Our findings recommend cautious clinical decision making and limiting hysterectomy to women who do not respond to other therapeutic measures.


Assuntos
Carcinoma/patologia , Hiperplasia Endometrial/patologia , Neoplasias do Endométrio/patologia , Endométrio/patologia , Menorragia/patologia , Metrorragia/patologia , Adulto , Idoso , Carcinoma/complicações , Carcinoma/diagnóstico , Carcinoma/cirurgia , Tomada de Decisão Clínica , Hiperplasia Endometrial/complicações , Hiperplasia Endometrial/diagnóstico , Hiperplasia Endometrial/cirurgia , Neoplasias do Endométrio/complicações , Neoplasias do Endométrio/diagnóstico , Neoplasias do Endométrio/cirurgia , Endometrite/complicações , Endometrite/diagnóstico , Endometrite/patologia , Endometrite/terapia , Reações Falso-Positivas , Feminino , Humanos , Histerectomia , Menorragia/etiologia , Menorragia/terapia , Metrorragia/etiologia , Metrorragia/terapia , Pessoa de Meia-Idade , Pólipos/complicações , Pólipos/diagnóstico , Pólipos/patologia , Pólipos/terapia , Valor Preditivo dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade
7.
Gynecol Endocrinol ; 35(11): 932-937, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31165649

RESUMO

Objective: The conservative treatment of endometrial hyperplasia without atypia (HWA), atypical endometrial hyperplasia (AH/EIN) and early endometrioid carcinoma (EEC) is based on progestins. We aimed to assess whether diabetes mellitus affects the responsiveness of HWA, AH/EIN and EEC to conservative treatment, through a systematic review and meta-analysis. Study design: Electronic databases were searched for studies assessing the outcome of conservative treatment in HWA, AH/EIN and EEC, stratified based on the diagnosis of diabetes mellitus. The association of diabetes mellitus with treatment failure was assessed by using odds ratio (OR). A p-value < .05 was considered significant. The risk of publication bias was assessed by using a funnel plot. A subgroups analyses was performed based on histologic diagnosis of benignity (HWA) or premalignancy/malignancy (AH/EIN or EEC). Results: Six studies with 876 patients (383 HWA, 365 AH/EIN and 128 EEC) were included. Overall, diabetes mellitus was not associated with outcome of treatment (OR = 1.20; p = .62). The association was not significant in both the HWA subgroup (OR = 0.95; p = .93) and in AH/EIN and EEC subgroup (OR = 1.43; p = .46). There was no significant risk of publication bias. Conclusions: Diabetes mellitus does not affect the outcome of conservative treatment in HWA, AH/EIN and EEC.


Assuntos
Tratamento Conservador , Complicações do Diabetes/terapia , Hiperplasia Endometrial/terapia , Neoplasias do Endométrio/terapia , Hiperplasia Endometrial/complicações , Neoplasias do Endométrio/complicações , Feminino , Humanos
8.
Virchows Arch ; 475(2): 201-209, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31079233

RESUMO

Papillary proliferation of the endometrium (PPE) is an uncommon lesion that frequently shows mucinous metaplasia. PPE occasionally has concurrent or preceding endometrial hyperplasia and carcinomas, but there is little molecular evidence to support the relationships between PPEs and endometrial neoplasia. In this study, we analyzed the clinicopathological and immunohistochemical features in 30 PPEs (22 simple PPEs and 8 complex papillary hyperplasia (CPH)). Hotspot mutations of KRAS, PI3KCA, AKT1, PTEN (exons 3, 5, and 7), and ARID1A (exons 1 and 14) were detected by pyrosequencing or bidirectional Sanger sequencing. We found that endometrial hyperplasia and carcinoma were more common in CPHs (4/6, 66.7%) than in simple PPEs (4/21, 19.0%) (p < 0.05). Compared with the adjacent normal endometrium, PPEs frequently showed loss of PAX2 (56.7%) and PTEN (10%) expression, diffuse p16 expression (36.7%), decreased PR expression (84.3%), and lower Ki67 labeling index (median 1%, range 1-15%). Simple PPEs and CPHs had similar immunohistochemical features (p > 0.05). KRAS mutations were identified in 14 PPEs and 1 concurrent endometrial carcinoma. The prevalence of KRAS mutations was not statistically different between simple PPEs (10/21, 45.5%) and CPHs (4/8, 50%) (p > 0.05), but was higher in PPEs displaying mucinous metaplasia (12/24, 50%) than in those without (2/6, 33.3%) (p < 0.05). One simple PPE with a KRAS mutation had an AKT1 mutation. No PPEs demonstrated mutations in PI3KCA, PTEN, and ARID1A. In conclusion, both simple PPE and CPH share some common molecular alterations with endometrial neoplasia, in which, KRAS mutations might be a driver.


Assuntos
Hiperplasia Endometrial/complicações , Hiperplasia Endometrial/patologia , Neoplasias do Endométrio/complicações , Neoplasias do Endométrio/patologia , Endométrio/patologia , Adulto , Idoso , Análise Mutacional de DNA , Hiperplasia Endometrial/genética , Neoplasias do Endométrio/genética , Feminino , Humanos , Imuno-Histoquímica , Metaplasia/genética , Metaplasia/patologia , Pessoa de Meia-Idade
9.
Maturitas ; 123: 15-24, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31027672

RESUMO

OBJECTIVES: To derive and validate a practical scoring system for identification of endometrial cancer (EC) or atypical hyperplasia (AH) using transvaginal ultrasonography (TVS) and gel infusion sonography (GIS) in women with postmenopausal bleeding (PMB). STUDY DESIGN: Endometrial pattern was correlated with endometrial pathology in consecutive women with PMB in both a derivation study (N = 164) and a validation study (N = 711). Logistic regression was used to derive and validate two scoring systems (A and B) for prediction of EC/AH: scoring system A was Doppler score + interrupted endo-myometrial junction (IEJ) (2 points); and scoring system B was Doppler score + IEJ (1 point) + Irregular Endometrial Outline (IESO) by GIS (1 point); the Doppler score was based on the presence of more than one single or double vessel (1 point) + multiple vessels (1 point) + large vessels (1 point). OUTCOME MEASURES: Diagnostic performance and calibration curves for identification of EC/AH. RESULTS: Both scoring systems had good observer agreement. VALIDATION DATA: Scoring was most effective with endometrial thickness (ET) ≥ 8 mm. Both scoring systems were well calibrated and performed satisfactorily in women with ET ≥ 8 mm. The sensitivity and specificity of a score of ≥ 2 points in system A were 92% and 84%; the respective values were 89% and 88% in system B. CONCLUSIONS: Scoring was highly efficient in identifying EC/AH. Four risk groups of EC/AH may guide the management of women with PMB: very low (ET < 4 mm), low (ET 4-7.9 mm), intermediate (ET ≥ 8 mm and score < 2 points) and high risk (ET ≥ 8 mm and score ≥ 2 points).


Assuntos
Carcinoma Endometrioide/diagnóstico por imagem , Hiperplasia Endometrial/diagnóstico por imagem , Neoplasias do Endométrio/diagnóstico por imagem , Endométrio/diagnóstico por imagem , Pós-Menopausa , Idoso , Carcinoma Endometrioide/complicações , Carcinoma Endometrioide/patologia , Carcinossarcoma/complicações , Carcinossarcoma/diagnóstico por imagem , Carcinossarcoma/patologia , Hiperplasia Endometrial/complicações , Hiperplasia Endometrial/patologia , Neoplasias do Endométrio/complicações , Neoplasias do Endométrio/patologia , Feminino , Humanos , Histeroscopia , Modelos Logísticos , Pessoa de Meia-Idade , Miométrio/diagnóstico por imagem , Neoplasias Císticas, Mucinosas e Serosas/complicações , Neoplasias Císticas, Mucinosas e Serosas/diagnóstico por imagem , Neoplasias Císticas, Mucinosas e Serosas/patologia , Sensibilidade e Especificidade , Ultrassonografia , Ultrassonografia Doppler , Hemorragia Uterina/etiologia
10.
Eur J Obstet Gynecol Reprod Biol ; 236: 14-21, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30875539

RESUMO

The aim of this study is to investigate clinical behavior of Atypical Polypoid Adenomyomas (APAs) and to describe the rates of (i) recurrences, (ii) their association with endometrial hyperplasia and (iii) with endometrial cancer. All studies that reported the outcome of the clinical management of patients with histologically proven APAs were included. A review of the English literature since 1970 was systematically performed (PROSPERO No CRD42018080003). A quality assessment tool was used to assess the scientific value of all the studies. Main contribution of this review is the proposal of new definitions regarding the clinical behaviour of APAs: Cure, Residual or persistent APA, Recurrent APA, Synchronous endometrial hypeprasia, Subsequent endometrial hyperplasia, Synchronous endometrial cancer, and Subsequent endometrial cancer, are terms elucidated in the context of this review. Their rates after initial diagnosis and treatment of APAs are presented as the main outcome measures. 63 studies and 350 patients were included in the systematic review. Fifteen studies that reported 208 patients who did not have hysterectomy as initial treatment were included for further quantitative assessment. The cure rate of APAs in cases where uterus was preserved was 51.0% (106/208), the residual rate of APA was 20.2% (42/208), the recurrence rate of APA was 35.1% (73/208), the concurrent endometrial hyperplasia rate was 7.2% (15/208), the concurrent endometrial cancer rate was 4.8% (10/208), the subsequent endometrial hyperplasia rate of was 6.7% (14/208), and the subsequent endometrial cancer rate of was 10.1% (21/208). Moreover, 56.4% of the patients with APA who opted for uterine sparing treatment and wished to conceive they had a viable pregnancy. The use of hysteroscopic techniques at the initial management of APAs is related with significantly decreased residual rate, and signicantly increased cure rates. In this review, the recurrence rate and the association of APAs with cancer appeared to be higher compared to the previously reported in the literature rates. APAs comprise an intriguing clinical entity that needs individualized treatment, considering the increased association to serious gynecological diseases. Hysterectomy is the appropriate treatment, however uterus-sparing surgery can be offered to selected patients.


Assuntos
Adenomioma/epidemiologia , Hiperplasia Endometrial/complicações , Neoplasias do Endométrio/complicações , Recidiva Local de Neoplasia/epidemiologia , Adenomioma/complicações , Adenomioma/diagnóstico , Adenomioma/terapia , Algoritmos , Feminino , Humanos , Gravidez , Resultado da Gravidez
12.
BJOG ; 126(7): 936-943, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30548528

RESUMO

OBJECTIVE: After successful progestin therapy for endometrial hyperplasia (EH), the risk of relapse remains. We aimed to assess if immunohistochemical (IHC) expression of progesterone receptor isoforms, PR-A and PR-B, in endometrial glands and stroma in pre-treatment endometrial biopsies was related to relapse of EH. DESIGN AND SETTING: Biopsy material originated from women with low-risk and medium-risk EH recruited to a recent Norwegian multicentre randomised trial. Participants (n = 153) had been treated for 6 months with three different progestin regimens. POPULATION: One hundred and thirty-five of the 153 women achieved therapy response and underwent follow up for 24 months after therapy withdrawal. Fifty-five women relapsed during follow up. Pre-treatment endometrial biopsies from 94 of the 135 responding women were available for IHC staining. METHODS: Immunohistochemical staining was performed separately for PR-A and PR-B and IHC expression was evaluated in endometrial glands and stroma by a histological score (H-score) using light microscopy. MAIN OUTCOME MEASURE: Immunohistochemical expression of PR-A and PR-B in endometrial glands and stroma in women with or without relapse of EH. RESULTS: Low PR-A in endometrial glands (P = 0.013) and stroma (P < 0.001), and high PR-B in endometrial glands (P = 0.001) in pre-treatment endometrial biopsy have a statistically significant association with relapse of EH. Women with a pre-treatment ratio of PR-A:PR-B ≤ 1 have a higher risk of relapse (71%) compared with women with a ratio of PR-A:PR-B > 1 (19%; P < 0.001). CONCLUSION: Immunohistochemical expression of PR-A and PR-B in pre-treatment endometrial biopsy proves valuable as a predictor of relapse in EH. TWEETABLE ABSTRACT: Pre-treatment endometrial expression of PR-A and PR-B is a valuable predictor of relapse in endometrial hyperplasia.


Assuntos
Hiperplasia Endometrial/complicações , Hiperplasia Endometrial/tratamento farmacológico , Receptores de Progesterona/metabolismo , Adulto , Idoso , Biomarcadores/metabolismo , Feminino , Humanos , Pessoa de Meia-Idade , Progestinas/uso terapêutico , Recidiva , Estudos Retrospectivos
13.
Rev. chil. endocrinol. diabetes ; 12(1): 26-28, 2019. ilus
Artigo em Espanhol | LILACS | ID: biblio-982035

RESUMO

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.


Assuntos
Humanos , Feminino , Hemorragia Uterina/etiologia , Menopausa , Terapia de Reposição de Estrogênios/efeitos adversos , Moduladores de Receptor Estrogênico/efeitos adversos , Norpregnenos/efeitos adversos , Pólipos/complicações , Pólipos/diagnóstico , Neoplasias do Endométrio/complicações , Neoplasias do Endométrio/diagnóstico , Moduladores de Receptor Estrogênico/uso terapêutico , Diagnóstico Diferencial , Hiperplasia Endometrial/complicações , Hiperplasia Endometrial/diagnóstico , Endométrio/diagnóstico por imagem , Metrorragia/etiologia , Norpregnenos/uso terapêutico
14.
BMC Fam Pract ; 19(1): 135, 2018 07 30.
Artigo em Inglês | MEDLINE | ID: mdl-30060741

RESUMO

BACKGROUND: One million women per year seek medical advice for abnormal uterine bleeding (AUB) in the United Kingdom. Many low-risk patients who could be managed exclusively in primary care are referred to hospital based gynaecology services. Performing endometrial sampling (ES) in the community may improve care, reduce the rate of referrals and minimise costs. We aimed to search and synthesise the literature on the effectiveness of ES (Pipelle versus other devices) in managing AUB in low-risk patients. METHODS: We undertook an electronic literature search in MEDLINE via OvidSP, Scopus, and Web of Science for relevant English-language articles from 1984 to 2016 using a combination of MeSH and keywords. Two reviewers independently pre-selected 317 articles and agreed on 60 articles reporting data from over 7300 patients. Five themes were identified: sample adequacy, test performance, pain and discomfort, cost-effectiveness, and barriers and complications of office ES. RESULTS: Pipelle seems to perform as well as dilation and curettage and, as well or better than other ES devices in terms of sampling adequacy and sensitivity. It also seems to be better regarding pain/discomfort and costs. However, Pipelle can disrupt the sonographic appearance of the endometrium and may be limited by cervical stenosis, pelvic organ prolapse and endometrial atrophy. CONCLUSIONS: The current evidence supports the use of Pipelle in the management of low-risk women presenting in the outpatient setting with symptomatic AUB when combined with clinical assessment and ultrasound scanning. However, the implications of its widespread use in primary care are uncertain and more research is required.


Assuntos
Biópsia/métodos , Assistência à Saúde/métodos , Hiperplasia Endometrial/patologia , Neoplasias do Endométrio/patologia , Endométrio/patologia , Ginecologia , Metrorragia/patologia , Atenção Primária à Saúde , Análise Custo-Benefício , Hiperplasia Endometrial/complicações , Hiperplasia Endometrial/diagnóstico , Neoplasias do Endométrio/complicações , Neoplasias do Endométrio/diagnóstico , Feminino , Humanos , Metrorragia/etiologia , Dor Processual , Medição de Risco , Hemorragia Uterina/diagnóstico , Hemorragia Uterina/etiologia , Hemorragia Uterina/patologia
15.
Gynecol Oncol ; 148(3): 485-490, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29290489

RESUMO

OBJECTIVES: To determine the risk of endometrial cancer (EC) and lymph node involvement in patients with a preoperative diagnosis of "AH-only" versus "AH - cannot rule out carcinoma" and to study the value of SLN mapping. METHODS: We reviewed all patients with a preoperative diagnosis of atypical hyperplasia, who underwent primary surgery with SLN mapping followed by pelvic lymphadenectomy. Sensitivity and negative predictive value (NPV) of SLN and rates of endometrial cancer were calculated. RESULTS: Overall, 64/120 (53.3%) patients were found to have EC on final pathology: 58 stage IA, 3 IB, and 3 IIIC1. In patients with preoperative diagnosis of "AH", 44.3% (31/70) had EC on final pathology compared to 66% (33/50) in patients with "AH - cannot rule out cancer" (p=0.02). Overall, 3.3% of the patients (4/120) had lymph node involvement. In patients with EC with a pre-operative diagnosis of "AH", none had lymph node metastasis (0/31), compared to 12.1% (4/33) in patients with "AH - cannot rule out cancer" (p=0.06). Elevated preoperative CA125 levels (>25U/mL) were statistically associated with the risk of lymph node metastasis on final pathology (p=0.024). Unilateral and bilateral SLN detection occurred in 93.7% and 78.1% respectively. In patients with EC and bilateral SLN mapping, sensitivity and NPV were respectively 66.6% and 97.9%. There was one false negative (ITCs in non-SLN). CONCLUSION: Our data indicate that the risk of lymph node involvement in patients with a preoperative diagnosis of "AH-only" is null. Lymph node assessment could be omitted in those patients. Conversely this risk is significant in patients with "AH - cannot rule out cancer". SLN mapping could be a valuable staging procedure in these patients.


Assuntos
Carcinoma Endometrioide/patologia , Hiperplasia Endometrial/patologia , Neoplasias do Endométrio/patologia , Biópsia de Linfonodo Sentinela/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Antígeno Ca-125/sangue , Carcinoma Endometrioide/sangue , Carcinoma Endometrioide/complicações , Carcinoma Endometrioide/diagnóstico , Hiperplasia Endometrial/sangue , Hiperplasia Endometrial/complicações , Hiperplasia Endometrial/cirurgia , Neoplasias do Endométrio/sangue , Neoplasias do Endométrio/complicações , Neoplasias do Endométrio/diagnóstico , Feminino , Humanos , Excisão de Linfonodo , Metástase Linfática , Proteínas de Membrana/sangue , Pessoa de Meia-Idade , Miométrio/patologia , Gradação de Tumores , Invasividade Neoplásica , Estadiamento de Neoplasias , Pelve , Valor Preditivo dos Testes , Sensibilidade e Especificidade
16.
Reprod Sci ; 25(8): 1286-1291, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29153060

RESUMO

OBJECTIVES: To explore whether the metabolic switches proceed or succeed the histological changes in precancerous lesions. To validate pyruvate kinase isoform 1 (PKM1) and pyruvate kinase isoform 2 (PKM2) as a histological biomarker to predict the progression of endometrial hyperplasia into invasive cancer status. METHODS: The records of 56 patients with a primary diagnosis of complex hyperplasia with atypia after endometrial biopsy were selected and analyzed retrospectively. A set of 3 consecutive sections at 4-µm thickness were cut and studied with immunohistochemical stains. From each case, 2 to 3 fields with a diagnosis of complex hyperplasia with atypia were selected and compared. A single pathologist blinded to the final diagnosis assigned the scoring. RESULTS: Positive immunostaining for PKM1 was observed in 31.25% (10 out of 32) of initial endometrial biopsy with the diagnosis of complex hyperplasia with atypia and final diagnosis of endometrial cancer, while 91.67% (out of 24) of patients with final diagnosis of negative endometrial cancer had endometrial biopsy with positive PKM1 staining ( P < .001). Positive immunostaining for PKM2 was observed in 100% of patient with endometrial biopsy result of endometrial hyperplasia with atypia (56 of 56). CONCLUSIONS: Lack of staining with PKM1 expression may help to predict the fate of endometrial hyperplasia. The disappearance of this marker is associated with the progression of hyperplasia toward cancer phenotype. Further studies are needed to understand the causes and potential mechanisms for suppressing Pyruvate Kinase Isoform 1 expression in endometrial hyperplasia.


Assuntos
Hiperplasia Endometrial/metabolismo , Neoplasias do Endométrio/diagnóstico , Neoplasias do Endométrio/metabolismo , Histerectomia , Infertilidade Feminina/prevenção & controle , Piruvato Quinase/metabolismo , Biomarcadores Tumorais/metabolismo , Proteínas de Transporte/metabolismo , Hiperplasia Endometrial/complicações , Neoplasias do Endométrio/etiologia , Neoplasias do Endométrio/cirurgia , Endométrio/metabolismo , Endométrio/patologia , Feminino , Humanos , Proteínas de Membrana/metabolismo , Prognóstico , Estudos Retrospectivos , Sensibilidade e Especificidade , Hormônios Tireóideos/metabolismo
17.
J Zhejiang Univ Sci B ; 18(11): 1022-1025, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29119739

RESUMO

This study aimed to evaluate fertility and oncologic outcomes in women with complex hyperplasia (CH) or complex atypical hyperplasia (CAH) who received fertility-sparing therapy and in vitro fertilization (IVF). Endometrial carcinoma is the most common carcinoma of the female genital tract, and is associated with endometrial hyperplasia (EH) resulting from long-term unopposed estrogenic stimulation of the endometrium. EH is characterized by non-physiological proliferation of endometrium that results in glands with irregular shapes and varying sizes. The World Health Organization (WHO) classified it into four types: simple or complex hyperplasia with or without atypia. CH is characterized by glands with irregular outlines that demonstrate marked structural complexity and back-to-back crowding. Atypical hyperplasia designates a proliferation of glands exhibiting cytologic atypia, in which varying degrees of nuclear atypia and loss of polarity are present. It has been reported that high-dose progestin is safe and efficient for CAH or early-stage low-grade carcinoma for young women who desire fertility-preserving treatment. However, few studies have reported the differences of pregnancy outcomes between patients with CAH and CH, while those patients take a great proportion in people suffered from infertility. More studies about the outcome of IVF are needed. Our aim is to evaluate fertility and oncological outcomes in women with CH or CAH who received fertility-sparing therapy.


Assuntos
Carcinoma/terapia , Hiperplasia Endometrial/terapia , Neoplasias do Endométrio/terapia , Preservação da Fertilidade , Fertilização In Vitro , Infertilidade Feminina/terapia , Progestinas/uso terapêutico , Adulto , Carcinoma/complicações , Hiperplasia Endometrial/complicações , Neoplasias do Endométrio/complicações , Endométrio , Feminino , Humanos , Infertilidade Feminina/complicações , Gravidez , Resultado da Gravidez , Progestinas/efeitos adversos
18.
J Exp Ther Oncol ; 11(2): 159-160, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28976140

RESUMO

OBJECTIVE: Primary tumors of round ligament are rare, and when found are typically leiomyomas. Endometrioma, and mesothelial cysts are the benign lesions recognized as involving the round ligament. We report a case of lipoma of the round ligament in a 48-year-old premenopausal woman. Round ligament lipoma on the intraperitoneal portion (abdominal site) is very rare and it should be kept in the differential diagnosis of ovarian and abdominal masses.


Assuntos
Doenças dos Anexos/diagnóstico por imagem , Hiperplasia Endometrial/diagnóstico por imagem , Lipoma/diagnóstico por imagem , Ligamento Redondo do Útero/diagnóstico por imagem , Doenças dos Anexos/patologia , Doenças dos Anexos/cirurgia , Dilatação e Curetagem , Hiperplasia Endometrial/complicações , Hiperplasia Endometrial/patologia , Hiperplasia Endometrial/cirurgia , Feminino , Humanos , Lipoma/patologia , Lipoma/cirurgia , Menorragia/etiologia , Menorragia/cirurgia , Pessoa de Meia-Idade , Ligamento Redondo do Útero/patologia , Ligamento Redondo do Útero/cirurgia , Ultrassonografia
19.
Climacteric ; 20(5): 414-420, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-28780893

RESUMO

Abnormal uterine bleeding is one of the commonest presenting complaints encountered in a gynecologist's office or primary-care setting. The wider availability of diagnostic tools has allowed prompt diagnosis and treatment of an increasing number of menstrual disorders in an office setting. This White Paper reviews the advantages and disadvantages of transvaginal ultrasound, blind endometrial sampling and diagnostic hysteroscopy. Once a proper diagnosis has been established, appropriate therapy may be embarked upon. Fortunately, only a minority of such patients will have premalignant or malignant disease. When bleeding is sufficient to cause severe anemia or even hypovolemia, prompt intervention is called for. In most of the cases, however, the abnormal uterine bleeding will be disquieting to the patient and significantly affect her 'quality of life'. Sometimes, reassurance and expectant management will be sufficient in such patients. Overall, however, in cases of benign disease, some intervention will be required. The use of oral contraceptive pills especially those with a short hormone-free interval, the insertion of the levonorgestrel intrauterine system, the incorporation of newer medical therapies including antifibrinolytic drugs and selective progesterone receptor modulators and minimally invasive treatments have made outpatient therapy increasingly effective. For others, operative hysteroscopy and endometrial ablation are proven therapeutic tools to provide both long- and short-term relief of abnormal uterine bleeding, thus avoiding, or deferring, hysterectomy.


Assuntos
Perimenopausa , Hemorragia Uterina/diagnóstico , Hemorragia Uterina/terapia , Anti-Inflamatórios não Esteroides/uso terapêutico , Biópsia , Anticoncepcionais Orais Combinados/uso terapêutico , Diagnóstico por Imagem/métodos , Hiperplasia Endometrial/complicações , Hiperplasia Endometrial/terapia , Endométrio/patologia , Feminino , Neoplasias dos Genitais Femininos/complicações , Neoplasias dos Genitais Femininos/terapia , Humanos , Histeroscopia , Leiomioma/complicações , Leiomioma/terapia , Levanogestrel/uso terapêutico , Pessoa de Meia-Idade , Gravidez , Qualidade de Vida , Hemorragia Uterina/etiologia
20.
J Midwifery Womens Health ; 62(4): 502-506, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28719132

RESUMO

Endometrial biopsy can be used to diagnose endometrial hyperplasia, endometrial cancer, and uterine infections. This cost-effective procedure has minimal side effects, and complications are rare. The purpose of this clinical bulletin is to provide clinicians with guidance about endometrial biopsy including the procedure's advantages and disadvantages, indications and contraindications, and side effects. In addition, step-by-step instructions for performing endometrial biopsy, the equipment required, selection of sampling devices, and care before and after the procedure are discussed.


Assuntos
Biópsia/métodos , Hiperplasia Endometrial/diagnóstico , Neoplasias do Endométrio/diagnóstico , Endométrio/cirurgia , Ginecologia/métodos , Hemorragia Uterina , Biópsia/efeitos adversos , Contraindicações de Procedimentos , Hiperplasia Endometrial/complicações , Neoplasias do Endométrio/complicações , Endometrite/diagnóstico , Endométrio/patologia , Feminino , Humanos , Tocologia , Enfermeiras Obstétricas , Gravidez , Complicações na Gravidez , Sociedades Médicas , Estados Unidos , Hemorragia Uterina/diagnóstico , Hemorragia Uterina/etiologia
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