Hysteroscopic Findings Research Articles

Can we rely on blind endometrial biopsy for detection of focal intrauterine pathology?

To compare the diagnostic power of random endometrial biopsy with hysteroscopy for intrauterine lesions. A retrospective cohort study of 639 women evaluated by diagnostic office hysteroscopy and endometrial biopsy (Novak curette) was carried out between 10/1997-6/2000. Reasons for evaluation were postmenopausal bleeding, abnormal uterine bleeding, ultrasound or hystero-salpingography findings, intrauterine device removal, suspected retained products of conception, infertility, late abortions and recurrent abortions. The women's mean age was 43.4+/-13.3 years (range, 18-88). The most prevalent indication for investigation was abnormal uterine bleeding (n=218, 34.1%), followed by sonographic or hystero-salpingographic findings (n=167, 26.1%). Hysteroscopy revealed a normal uterine cavity in 367 (57.4%) women. Endometrial polyps and submucosal fibroids were the most common hysteroscopic findings (in 151 [23.6%] and 72 [11.3%], respectively). The hysteroscopic findings were compared with the pathology results in 558 cases. The sensitivity of the Novak curette for detection of endometrial polyps and submucosal fibroids was only 8.4% and 1.4%, respectively. The positive predictive value (30.9%) and the negative predictive value (57.9%) for both lesions were likewise low. On the other hand, hysteroscopy was not effective in diagnosing the 27 cases of hyperplasia (26 simple and one complex) all without atypia. Random endometrial sampling alone is not effective for diagnosing focal lesions of the uterine cavity and should be combined with other modalities, preferably diagnostic hysteroscopy.

Office hysteroscopy in an in vitro fertilization program

Objective. In the present paper we evaluate the incidence of intrauterine pathologies in a population undergoing in vitro fertilization (IVF) treatment. Moreover, we compare the IVF outcome between patients with normal and abnormal uterine findings to determine if office hysteroscopy (OH) is of any clinical significance.Methods. The hysteroscopic findings in 866 consecutive patients were analyzed. The study group included 555 patients at the first IVF attempt and 311 patients with two or more failed IVF cycles.Results. All hysteroscopic parameters were considered normal in 514 cases (59.4%); in 352 cases (40.6%) various pathological conditions were found. Patients were divided into two groups according to the hysteroscopic findings. The implantation and pregnancy rates were similar between the groups. Comparing the clinical outcomes in patients with repeated IVF failure who had hysteroscopy with no pathology and with pathology, we did not find any statistical differences.Conclusions. This study suggests that hysteroscopy as a routine infertility examination should be performed in all patients, owing to the elevated incidence of hysteroscopic pathological findings (59.4%); hysteroscopy also seems to be the best way to repair the uterine cavity when pathological conditions are present. However, performing OH before IVF–embryo transfer is of no significant value in improving pregnancy outcomes.

Prevalence of hysteroscopic findings and histologic diagnoses in patients with abnormal uterine bleeding

To describe the prevalence of hysteroscopic findings and histologic diagnoses in patients with abnormal uterine bleeding (AUB). Retrospective series of consecutive patients. Tertiary care university hospital and private office. Four thousand fifty-four hysteroscopies with biopsy in patients with AUB evaluated between June 1993 and December 2004. Hysteroscopies were performed using 2.9-mm or 4-mm telescopes with CO(2) or saline as the distension media. Biopsies were done with a 5-mm grasper or with a Novak's curette. Prevalence of hysteroscopic findings and histologic analysis of biopsies. Endometrial polyp was the most frequent hysteroscopic finding, accounting for 1,374 (33.9%) cases. Normal uterine cavity and cervical canal were found in 814 (20.1%) patients. Submucous fibroids were diagnosed in 302 (7.5%) women. Normal endometrium was the most frequent histologic diagnosis, accounting for 1,888 (46.6%) cases. Endometrial polyp was found in 1,115 (27.5%) patients. Endometrial hyperplasia was diagnosed in 613 (15.1%) and endometrial cancer in 105 (2.6%) women. Endometrial polyps are the most frequent hysteroscopic findings in patients with AUB, whereas normal endometrium is the most frequent histologic diagnosis.

The Sonohysterographic Difference in Submucosal Uterine Fibroids and Endometrial Polyps Treated by Hysteroscopic Surgery

The purpose of this study was to clarify the differences in sonohysterographic (SHG) findings between submucosal uterine fibroids and endometrial polyps treated by surgical hysteroscopy. Eighty patients with intrauterine benign masses without any endometrial cytologic atypia were examined by SHG before undergoing surgical hysteroscopy. The SHG images in these masses were assessed for the following characteristics: size, number, location, echogenicity, and degree of projection into the uterine cavity. The SHG findings were then compared with their hysteroscopic findings. The feeding vessels into these masses were also assessed by transvaginal color Doppler sonography in 26 of the 80 patients. In all 80 patients, 47 histopathologically had submucosal fibroids, whereas the remaining 33 had endometrial polyps. Masses measuring greater than 20 mm were significantly more frequently fibroids than polyps (P < .01). Homogeneous hyperechoic masses were significantly seen in polyps (93.9% [31/33]; P < .01) but not in any fibroids except for 1 case. Multiple feeding vessels were significantly found in fibroids (12/15; P < .01), whereas they were not found in any of the 11 polyps examined. The location and degree of projection into the uterine cavity of these masses as assessed by SHG were consistent with their hysteroscopic findings in 78 (97.5%) of 80 patients. The foci of endometrial hyperplasia were significantly found in 5 (15.2%) of 33 polyps (P < .01), whereas no such tissues were obtained in any fibroids. Intracavitary fibroids tend to be larger than the polyps, and homogeneous hyperechoic masses in the uterine cavity observed by SHG are highly suggestive of endometrial polyps.

Hysteroscopy after uterine fibroid embolization in women of fertile age

Uterine artery embolization for fibroids is a controversial issue for women with incomplete reproductive plans. Ovarian failure and uterine infection are the most dreaded complications of this procedure. The purpose of the present study was to assess the types and the frequency of intrauterine abnormalities and the histological features of the endometrium after embolization. Uterine artery embolization was performed on 51 women (average age 34.5 years) with intramural fibroid/s larger than 4 cm. Hysteroscopy and endometrial biopsy was performed from 3 to 9 months later in the luteal phase of the cycle. Despite all women having no major symptoms prior to hysteroscopy, only 19 (37%) had completely normal hysteroscopic findings. There was intrauterine protrusion of fibroid/s in 19 cases (37%), yellowish coloration of the endometrium in 14 (28%), intrauterine or cervical adhesions in seven (14%), and communication between the myoma and the uterine cavity in five cases (10%). A normal, functional endometrium was histologically verified in 44 women of 49 (90%) who could be evaluated. Regressive changes (necrosis or hyalinization) of leiomyoma or of indefinite origin were found in 17 patients and embolization particles in five, including one patient with microspheres inside the endometrial vessel. No case of Asherman syndrome or endometrial atrophy was observed. The frequency of abnormal hysteroscopic findings after embolization is surprisingly high. The clinical significance, reversibility, and impact on fertility of abnormal hysteroscopic findings after embolization remain unclear. Regardless, hysteroscopy should be strongly recommended to all patients after uterine fibroid embolization, prior to conception.

Hysteroscopic findings in women at risk of HNPCC. Results of a prospective observational study

To report the feasibility and results of diagnostic hysteroscopy in women at risk of HNPCC. Fifty-seven women with mismatch repair gene mutations (n = 11) or Amsterdam II criteria (n = 46) were followed-up prospectively from January 1999 to March 2005. Flexible hysteroscopy was performed once a year. The endometrium was sampled routinely. Of 91 attempted hysteroscopies, 10 failed. The endometrial mucosa appeared normal in 34 cases. Polyps were seen in 12 cases, atrophy in 11, hypertrophy in 10, and fibroids in 7; two hysteroscopies suspected malignancy. A micropolypoid appearance was visualized during five hysteroscopies (5/81, 6%). Of the 86 endometrial biopsy attempts, 64 were successful and showed atrophy (n = 14), proliferation (n = 12), secretion (n = 27), polyps (n = 6), simple hyperplasia without atypia (n = 3), or cancer (n = 2). Micropolypoid appearance was not associated with a specific histological pattern. Operative hysteroscopy was done in 24 cases; in two patients with apparently benign focal lesions the results showed simple hyperplasia without atypias. Five patients underwent hysterectomy (simple hyperplasia without atypias, n = 2; endometrioid adenocarcinoma, n = 2; or secretory mucosa, n = 1). This study led to diagnosis of endometrial simple hyperplasia in 6% of cases and of cancer in 3%. In patients at risk of HNPCC, hysteroscopy appears feasible to screen endometrial pathology. Two cancers have been diagnosed over 91 patient-years at risk. Hysteroscopy should be compared to sonography as a screening tool in women at risk of HNPCC.

Uso do spray de lidocaína em histeroscopia diagnóstica

OBJETIVO: determinar a eficácia do spray de lidocaína a 10% aplicado no colo uterino antes da execução da histeroscopia diagnóstica para reduzir a dor e o desconforto causados pelo exame. MÉTODOS: Participaram do estudo 261 pacientes atendidas consecutivamente, entre março de 2004 e março de 2005. As pacientes foram randomizadas para dois grupos: um grupo recebendo aplicação tópica do spray de lidocaína (grupo lidocaína) e outro não recebendo nenhuma medicação antes do procedimento (grupo controle). Trinta miligramas de lidocaína spray a 10% foram aplicados na superfície do colo uterino, sendo a histeroscopia iniciada cinco minutos depois. Imediatamente após o final do procedimento a paciente respondeu um questionário sobre dor e quantificou a intensidade da dor, em centímetros, usando uma escala analógica visual não graduada. Os testes t não pareado, Mann-Whitney e chi2 foram aplicados na análise estatística, com nível de significância de 0,05. RESULTADOS: não houve diferença entre os grupos quanto à idade, paridade ou porcentagem de pacientes na menacme ou menopausa, ou quanto à indicação do procedimento e os achados histeroscópicos. Uma biópsia foi realizada em 57 das 132 pacientes no grupo lidocaína, e em 48 das 129 do grupo controle (p=0,96). O escore médio de dor foi 4,3±2,9 no grupo lidocaína, e 3,9±2,5 no grupo controle (p=0,2). Diferença no escore médio de dor foi observada somente na comparação entre pacientes na menacme e menopausa recebendo ou não a lidocaína spray, com p=0,01 e 0,04, respectivamente. CONCLUSÕES: o uso da lidocaína spray durante a histeroscopia diagnóstica não minimiza o desconforto e a dor das pacientes, e não deve ser utilizada.

Value Of The MRI In The Preoperative Staging Of Endometrial Cancer

Aims: This is a retrospective observational study aimed to assess accuracy of the MRI as a predictive tool for histopathological staging, correlation between MRI, transvaginal scan (TVS) and hysteroscopy, in relation to the histopathological (H/P) staging and the compliance to the NHS fast track guidelines. Material and methods: The study population comprises 66 patients diagnosed and treated from endometrial cancer either locally or through referral to tertiary centre between January 1999 and May 2006. Data were collected regarding following parameters: hysteroscopic findings, TVS findings, MRI findings, management outcome, H/P staging, agreement between MRI and H/P. Data analysis was conducted with regards to significant correlation between different diagnostic modalities, correlation between MRI and H/P and degree of compliance with NHS rules. Results A significant positive correlation was found between endometrial histopathological (H/P) staging and preoperative hysteroscopic findings (p=0.04). Considering the pathological staging, significant correlations were found between transvaginal scan (TVS) and hysteroscopy (P=0.03) and also MRI (P=0.04). Sensitivity of the MRI as a predictive tool for the pathological staging was (79%). This was higher in early stage I endometrial cancer in than stages II and more (35%) with a NPV for stage I EC of 93%. The unit was found to be compliant in 89.5% of cases to the 31 day decision /treatment interval and in 95.5% to the referral/treatment interval Conclusion MRI scans offer clinical benefit in terms of triaging the patients for referral to tertiary centre. There is benefit associated with the use of the TVS as a primary screening tool owing to the significant correlation between the TVS and MRI,and significant correlation between the TVS and the outpatient hysteroscopy. The interesting association between polypoid lesion and early stage EC would encourage the set up of RCT to show the clinical effectiveness of local hysteroscopic resection, and the subtotal hysterectomy versus the current management of TAH+BSO.

The role of Pipelle ® Mark II sampling in endometrial disease diagnosis

Objective To evaluate the feasibility and accuracy of Pipelle ® Mark II sampling (designed for combined cytology and histology testing) in the diagnosis of endometrial disease. Materials and methods A 97 women with abnormal uterine bleeding or intrauterine lesions on ultrasound examination underwent Pipelle ® Mark II endometrial sampling, followed by diagnostic hysteroscopy. The adequacy of endometrial samples obtained for cytological and histological analysis was assessed. A correlation was established between endometrial cytology, histology and diagnostic hysteroscopy results. Where discrepancies were found, they were compared with the histological results obtained from operative hysteroscopy. Results The tissue samples obtained for cytological and histological diagnoses were insufficient in 14.4% and 11.3% of patients, respectively. The opposite was found in the group of postmenopausal women ( N = 52): the tissue samples for cytological and histological diagnoses were insufficient in only 3.8% and 15.4% of cases, respectively. The cytological results corroborated diagnostic hysteroscopy findings and histological results in all cases but 3 (3.6%). Only two cases of endometrial carcinoma were reported in this group of patients, and they were both detected by all three methods. The rate of false positives with endometrial cytological sampling was 3.6%. There were no false negatives. Conclusion Pipelle ® Mark II endometrial sampling is feasible. It provides adequate samples for histological and/or cytological analysis and reliable results. It reduces the rate of false negative results for endometrial cancer. Pipelle ® Mark II sampling is particularly useful in postmenopausal women and in women with endometrial atrophy. Other larger studies are necessary to evaluate the efficiency of Pipelle Mark II.

P-61: Effects of endometrial evaluation with office hysteroscopy in IVF-ET patients with repeated failures

One of the most consistent factors for the success of in vitro fertilization and embryo transfer (IVF-ET) is known to be the quality of the embryos. However, the significance of embryo quality in determining pregnancy rates should not be considered apart from endometrial receptivity. Failure of conception despite repeated transfers of apparently good-quality embryos is a significant clinical problem in practice. This study was conducted to evaluate the efficacy of office hysteroscopy in IVF-ET patients who repeatedly failed to conceive despite transfer of good-quality embryos. Retrospective comparative study. Fifty-six patients who failed to conceive in at least two previous IVF-ET cycles with a normal uterine cavity on hysterosalpingography were included in this study. They were divided into two groups: group A (n=28) had office hysteroscopy and group B (n=28) did not. The main outcome measures were cumulative pregnancy and live birth rates of two IVF-ET cycles following the office hysterosocpy. Total duration between hysteroscopy and following IVF-ET cycles was less than 1 year. The statistical analyses were carried out using SPSS software package and Fisher’s exact or Mann-Whitney U tests were used where appropriate. There were no differences in baseline characteristics and controlled ovarian hyperstimulation (COH) outcomes between the two groups. Pregnancy rate (28.6% vs. 17.9%) and live birth rate (17.6% vs. 10.7%) tended to be higher in group A in the first following cycle after office hysteroscopy. Cumulative pregnancy and live birth rates after two following cycles showed similar results (39.3% vs. 21.4%; 21.4% vs. 14.3%). In group A, abnormal hysteroscopic findings did not have significant effects on the pregnancy rates.View Large Image Figure ViewerDownload (PPT)View Large Image Figure ViewerDownload (PPT)View Large Image Figure ViewerDownload (PPT) Endometrial evaluation with office hysteroscopy in patients who repeatedly failed to conceive seems to improve pregnancy and live birth rates. These results seem to be independent of hysteroscopic uterine findings. Further prospective randomized studies in a larger scale will be necessary to confirm these findings.

Validation of hysteroscopic view in cases of endometrial hyperplasia and cancer in patients with abnormal uterine bleeding

Study objective To validate hysteroscopic view with histology in cases of endometrial hyperplasia and cancer in patients with abnormal uterine bleeding (AUB) Design Retrospective study (Canadian Task Force classification II-3). Setting University teaching hospitals in Rio de Janeiro and São Paulo, and private office in Rio de Janeiro. Patients Four thousand and fifty-four patients with AUB in whom hysteroscopic views were complete and the histologic result was conclusive. Intervention Four thousand and fifty-four office hysteroscopies with complete views and conclusive histologic results. The material for histologic examination was obtained through biopsy of the lesion in an outpatient unit or through the resection of the entire lesion in patients who underwent surgery. Histology was considered the “gold standard” and compared with the hysteroscopic view. Measurements and main results In the histology of the 4054 examinations, 613 (15.2%) were endometrial hyperplasia, and 105 (2.6%) were endometrial cancer. The most frequent hysteroscopic finding was endometrial polyps (31.2%). In endometrial hyperplasia, the sensitivity of the hysteroscopic view was 56.3% (95% CI 52.2%–60.2%), specificity was 89.1% (95% CI 88.0%–90.1%), positive predictive value (PPV) was 48.0% (95% CI 44.3%–51.7%), negative predictive value (NPV) was 92.0% (95% CI 90.1%–92.9%), and accuracy was 72.7% (95% CI 70.7%–74.7%). Accuracy was defined as the proportion of correct results among the hysteroscopic examinations. In endometrial cancer, the sensitivity of the hysteroscopic view was 80.0% (95% CI 71.1%–87.2%), specificity was 99.5% (95% CI 99.2%–99.7%), PPV was 81.5% (95% CI 72.7%–88.5%), NPV was 99.5% (95% CI 99.2%–99.7%), and accuracy was 89.8% (95% CI, 85.9%–93.6%). In the 814 patients (20.0%) in whom the hysteroscopic view was normal, there were no false negatives for endometrial cancer; however, there were 37 (4.5%) false negatives for endometrial hyperplasia. In the histologic cases of endometrial cancer, 101 (96.2%) hysteroscopic views were compatible with cancer or hyperplasia (80.0% and 16.2%, respectively). Ninety-seven out of 103 hysteroscopic views with cancer findings (94.2%) had histologic diagnosis of cancer or hyperplasia (81.5% and 12.6%, respectively). Conclusion It seems that even in face of good validity of hysteroscopic view for endometrial hyperplasia and cancer, histologic study is mandatory in the presence of any lesion as the hysteroscopic view cannot completely replace the histologic study in patients with AUB.

OC117: Transvaginal ultrasound (TVUS) and sonohysterography (SHG) in the preoperative staging of submucous fibroids

Objectives: To assess the diagnostic accuracy of TVUS and SHG in the preoperative staging of submucous fibroids. Methods: Forty-eight women with submucous fibroids diagnosed on TVUS were assessed with SHG within 30 days from surgical treatment. Fibroids were staged according to the angle between the fibroid margins and the endometrium: G0, 90◦. Results were compared with findings at operative hysteroscopy or on pathological examination of the uterus. Results: TVUS allowed staging of the fibroid in 18/48 cases (38%). SHG changed staging in 3 out of these 18 cases (17%). In those 30 women where TVUS did not allow staging of the fibroid, SHG was successful in 26. Overall, SHG was considered diagnostic in 44/48 cases (92%). In all of these 44, the accuracy of staging was confirmed. In 4 cases, SHG was considered non diagnostic due to technical difficulties in obtaining sufficient distension of the endometrial cavity. No patient experienced severe pain, vasovagal reactions or infection. Conclusion: SHG performs better than simple TVUS in the preoperative staging of submucous fibroids. SHG showed complete concordance with hysteroscopic and pathological findings.

Hysteroscopic appearance of malignant and benign endometrial lesions: a case–control study

To analyze hysteroscopic appearance of benign and malignant endometrial lesions in order to identify patterns to estimate the risk of malignance. Matched case-control study; two controls per case. The cases were 21 women (age range 40-90 years, median 63) with histologically confirmed endometrial malignancy, and the control group 42 women submitted to diagnostic hysteroscopy for benign lesions (age range 37-81 years, median 57). Hysteroscopic findings associated with malignancy were papillary aspect (OR 26.0, 95%CI 6.4-105.3), size>1/2 uterine cavity (OR 22.0, 95%CI 5.1-95.8), irregular surface (OR 8.0, 95%CI 2.7-23.2), mixed color (OR 10.0, 95%CI 3.6-28.0), diffuse vascular arrangement (OR 5.3, 95%CI 1.3-21.5), little branched vessels (OR 15.0, 95%CI 3.0-74.9), and discordance between the main vascular axe and the direction of the lesion growth (OR 37.0; 95% CI 10.7-128.3). Ulcerated surface and anarchic vascular aspect were present only in malignant cases. The analyzes of general aspect, size, surface, color, vascular arrangement and vascular aspect allowed the estimation of the risk of malignancy, and the identification of points for targeted sampling.

Assessment of uterine cavity by hysteroscopy in assisted reproduction programme and its influence on pregnancy outcome

The aim of the study was to evaluate if the diagnosis and treatment of uterine cavity abnormalities by hysteroscopy in patients undergoing IVF programme is of any value in improving clinical pregnancy outcome. 520 patients participated in this prospective randomized study and were classified into two groups. Group I (n = 265) without office hysteroscopy. Group II (n = 255) had office hysteroscopy and was sub classified into Group II a and Group II b. Group II a (n = 160) had normal hysteroscopic findings whereas Group II b (n = 95) had abnormal office hysteroscopy findings, which were corrected at the same time. There was no difference in the mean number of oocytes retrieved, fertilization rate, and number of embryos transferred among the patients in different groups. Statistically significant difference was observed in terms of clinical pregnancy rates between Group I and Group II a (26.2 and 44.44%, P < 0.05), and Group I and Group II b (26.2 and 39.55%, P < 0.05), respectively. Patients with recurrent IVF embryo transfer failures after normal hysterosalpingography findings should also be reevaluated using hysteroscopy prior to further commencing IVF-embryo transfer cycles in order to enhance the clinical pregnancy rates.

3275: The diagnostic accuracy of transvaginal sonography in uterine pathology

Objectives: The purpose of this study is to evaluate the diagnostic accuracy in uterine pathology between transvaginal ultrasound and hysteroscopy. Methods: During the period from January 1995 to May 2005, 277 women underwent hysteroscopy combined with transvaginal ultrasound due to evaluate the cause of infertility and endometrial pathology at Department of Obstetrics and Gynecology in Korea University Hospital. Results: Mean age of the study group was 37.3 and mean parity was 1.13. According to pathologic reports, final diagnosis were normal finding (43.5%), polyp (20.8%), submucosal myoma (11.1%), endometritis (9.7%), endometrial hyperplasia (2.8%) and endometrial cancer (1.4%) etc. The transvaginal ultrasound showed 57.89% sensitivity, 65.26% specificity and 75.0% positive predictive value in detecting endometrial lesions. The sensitivity, specificity and positive predictive value of hysteroscopy were 92.61%, 69.66% and 85.5%, respectively. Overall agreement of transvaginal ultrasound and hysteroscopic finding was 58.7%. Hysteroscopy showed much higher detection rate in case of synechiae and endometritis compared with transvaginal ultrasound. Conclusions: Hysteroscopy was significantly better diagnostic procedure than transvaginal ultrasound. But transvaginal ultrasound also helpful in diagnosis of polyp, submucosal myoma and in evaluation of myometrium and adnexa. So, we concluded that both hysteroscopy and transvaginal ultrasound are useful methods in detection of endometrial lesion.

77: Hysteroscopic Findings and Histopathologic Results in Women with Postmenopausal Bleeding

To evaluate the endometrial cavity and its histopathologic results in women with postmenopausal bleeding. The following histopathology was found in 26 cases under study: normal endometrium 35.2%, polyps 22.3%, myoma 13.1%, myoma and polyp 11.4%, endometrial hyperplasia 14.8%, adenocarcinoma 2.2%. Abdominal hysterectomy was done in patients with hyperplasia and adenocarcinoma. Endometrial ablation and resection was done in other patients, with no bleeding until the days of follow-up. Amenorrhea was achieved in 88% of patients. Hysteroscopy in women with postmenopausal bleeding not only results in better understanding of intrauterine pathology, and its histology, it can also prevent from unnecessary hysterectomies in women desire to preserve their uterus.

Tamoxifen therapy for breast cancer and endometrial pathology

Background: Tamoxifen, used as adjuvant therapy for carcinoma breast in postmenopausal women to prevent relapse has estrogenic effect on the endometrium. Methods: 104 patients on tamoxifen for more than six months were subjected to a clinical examination and transvaginal sonography. Patients with endometrial thickness > 8 mm were further evaluated by hysteroscopy and endometrial biopsy. Results: 35(34%) patients were symptomatic. The average endometrial thickness was 11.2 mm which correlated with duration of tamoxifen use. 27(48%) patients had abnormal hysteroscopic findings. 35 (63%) of endometrial biopsies revealed abnormal endometrium. One case of endometrial carcinoma was diagnosed. The results were statistically analysed. There is a significant association between symptomatic status and endometrial thickness and duration of tamoxifen use. Conclusion: All patients on long term tamoxifen should be annually screened for endometrial pathology.

Hysteroscopic Findings in Women With a History of Very Thin Endometrium During Assisted Conception Treatments

Hysteroscopic Findings in Women With a History of Very Thin Endometrium During Assisted Conception Treatments

The Association Between Uterine Septum and Infertility

The association between uterine septum and recurrent pregnancy loss (rpl) is well established. However, the relationship between uterine septum and infertility remained unclear. Whenever assisted reproductive technology (ART) is considered, the female patient is scrutinized for uterine factors in order to enhance pregnancy outcome. However, subtle uterine factors may be missed or ignored in infertile patients who are not undergoing ART. The purpose of this study is to report the incidence of short uterine septum in infertility patients based on hysteroscopic findings as well as to report the pregnancy outcome after assisted conception. A historical cohort study. The study included 1011 patients who underwent laparoscopic and hysteroscopic surgery for treatment of infertility over a 12 year period of time ending February 2005. Group 1 included 661 patients who were found to have endometriosis; Group 2 included 350 patients who had no endometriosis. All patients underwent both a diagnostic hysteroscopy and laparoscopy. Surgical correction was done if any pathology was found. The majority of surgeries were performed by the same surgeon. If a uterine septum was detected, the type was determined (short <2cm or long >2cm), and hysteroscopic division was performed. The incidence of uterine septum in both groups was determined. Following surgery 33 patients underwent ART, while 35 patients underwent intrauterine insemination (IUI) after controlled ovarian hyperstimulation (COH). Pregnancy outcome was calculated. The mean age and duration of infertility of the women with uterine septum was 31.0± 5.1 and 3.6± 3.4 years respectively while 51.7% had primary infertility. Uterine septum was found in 117 patients (17.7%) in Group1 and in 61 patients (17.4%) in Group 2. The majority of septa were of the short type, 15.6% in Group1 and 14.3% in Group 2. Of 178 patients who were found to have uterine septum, 117 (65.7%) had endometriosis and 61 patients (34.3%) had no endometriosis. Of those patients who attempted ART, 81.8% conceived while the pregnancy rate per cycle was 51.9%. Of those patients who attempted IUI, 68.6% conceived while the pregnancy rate per cycle was 38.1%. Seven patients who had initially undergone IUI and did not conceive, had ART, 6 of the 7 conceived. Our data suggest that the incidence of short uterine septum in infertile patients is much higher than what has previously been reported. After hysteroscopic surgical correction, high pregnancy rates can be achieved after assisted conception. Thorough evaluation of the endometrial cavity to detect subtle uterine anomalies should be advocated for all infertility patients. If a uterine septum is found in infertile patients, the possibility of endometriosis should be considered.

Accuracy of hysteroscopic diagnosis of endometrial hyperplasia: A retrospective study of 323 patients

Study objective To evaluate the diagnostic accuracy of hysteroscopic view in endometrial hyperplasia. Design Retrospective study (Canadian Task Force classification II-2). Setting Public hospital in northern Italy. Patients Three hundred twenty-three patients suffering from endometrial hyperplasia out of 2251 women (1119 premenopausal and 1132 postmenopausal) who underwent office-based hysteroscopy from January 1996 through May 2004. Intervention Review of 2251 outpatient hysteroscopies carried out with 5- to 6-mm sheathed hysteroscopes and accomplished with blind or hysteroscopically targeted endometrial biopsies. Measurements and main results The pathologic report was considered the reference test. Hysteroscopic detection of focal or extensive endometrial thickening, irregular vascular network, architectural distortion and crowding of gland openings, and gland cyst formation were considered endoscopic features consistent with hyperplasia. Overall sensitivity, specificity, negative predictive values (NPV), and positive predictive values (PPV) of hysteroscopy in order to foresee a diagnosis of hyperplasia were calculated. These figures were calculated both in premenopausal and postmenopausal patients. Histopathology yielded a diagnosis of simple, complex, and atypical hyperplasia in 247, 51, and 25 patients, respectively. Hysteroscopy foresaw hyperplasia in 38.4% of patients with simple hyperplasia and in 58.9% of patients with complex or atypical hyperplasia. Normal hysteroscopic findings underestimated simple hyperplasia in 34 patients (13.7%) and complex or atypical hyperplasias in 1 patient (1.3%) (p <.01). To predict the diagnosis of hyperplasia, hysteroscopy showed an overall sensitivity, specificity, NPV, and PPV of 63.7%, 91.7%, 91.3%, and 64.7%, respectively. Among premenopausal patients, hyperplasia was diagnosed in 134 women (11.9%); in this group, hysteroscopy showed sensitivity, specificity, NPV, and PPV of 65.6%, 88.5%%, 93.5%, and 50.5%, respectively. In postmenopausal patients, we found endometrial hyperplasia in 189 women (16.6%); sensitivity, specificity, NPV, and PPV of hysteroscopic view to anticipate hyperplasia were 61.6%, 95.2%, 89.3%, and 79.4%, respectively. A significantly better PPV to foresee hyperplasia was found in postmenopausal women compared with premenopausal patients (p <.01). Conclusions Current hysteroscopic criteria suggesting endometrial hyperplasia are inaccurate; in order to exclude hyperplasia, a pathologic assessment is warranted in all hysteroscopies showing an irregularly lined or thick endometrium.