Hysteroscopy In Diagnosis Research Articles

301: The Value of Hysteroscopic Diagnosis of Adenomyosis

301: The Value of Hysteroscopic Diagnosis of Adenomyosis

Office hysteroscopic metroplasty: Three “diagnostic criteria” to differentiate between septate and bicornuate uteri

Study objective To evaluate the benefits of adopting 3 simple “diagnostic criteria” in the differential diagnosis between septate and bicornuate uteri, and the relative treatment by hysteroscopy in an office setting. Design Prospective clinical study (Canadian Task Force classification III). Setting University-affiliated hospital. Patients Two hundred-sixty patients with a hysteroscopic diagnosis of a double uterine cavity were enrolled. Interventions Office hysteroscopic metroplasty was performed without analgesia or anesthesia using 5F scissors. Measurements and Main Results The presence of vascularized tissue, sensitive innervation, and the appearance of the tissue at the incision of a supposed septum during an office hysteroscopic procedure were the criteria used to differentiate a septate from a bicornuate uterus. In 93.1% of the cases, office hysteroscopic metroplasty was successfully performed during the same diagnostic procedure. In 15 of 18 patients scheduled for laparoscopic control of the uterine anatomy, the suspicion of a bicornuate uterus was confirmed. Hysteroscopic follow-up at 3 months showed a regular uterine cavity with a fundal notch less than 1 cm. Conclusion The study demonstrates the possibility of obtaining complete, safe removal of uterine septae in most cases by office hysteroscopy confirmation, using mechanical instruments, in an office setting. This was achieved by relating the diagnosis and treatment to simple anatomic and physiologic diagnostic criteria.

Resectoscopic surgery may be an alternative to hysterectomy in high-risk women with atypical endometrial hyperplasia

Study objective Endometrial hyperplasia is found in 2% to 10% of women with abnormal uterine bleeding (AUB). Up to 43% of patients with cytologic atypia harbor coexisting adenocarcinoma, and approximately 20% to 52% of atypical hyperplasias, if untreated, progress to cancer. The objective of this study was to estimate the incidence of atypical endometrial hyperplasia encountered during routine resectoscopic surgery in women with AUB and to evaluate the role of resectoscopic surgery in the management of women with AUB and atypical endometrial hyperplasia who refused and/or were at high risk for hysterectomy. Design Prospective cohort study (Canadian Task Force classification II-3). Setting University-affiliated teaching hospital. Patients From January 1990 through December 2005, the senior author (GAV) performed primary resectoscopic surgery in 3401 women with AUB. Among these, there were 22 women with atypical (17 complex, 5 simple) endometrial hyperplasia. Interventions All women underwent hysteroscopic evaluation and partial (n = 3) or complete (n = 19) endometrial electrocoagulation and/or resection. Subsequently, 6 women had hysterectomy and bilateral salpingo-oophorectomy (BSO). Measurements and main results The median (range) for age, parity, and body mass index were 55 years (24–78 years), 2 (0–4), and 30.1 kg/m 2 (22.5–52.2 kg/m 2), respectively. Among the 3401 women, there were 22 cases of atypical endometrial hyperplasia, 12 of which were incidentally diagnosed at the time of hysteroscopy (complex 10, simple 2, incidence 0.35%). After hysteroscopic diagnosis or confirmation of diagnosis, 6 women underwent hysterectomy and BSO. Of the remaining 16 women, followed for a median of 5 years (range 1.5–12 years), 1 was lost to follow-up, 1 had only a biopsy to preserve fertility, 1 died from lung cancer after 4 years, and 1 died from colon cancer after 5 years. One patient developed endometrial cancer after 10.5 years with postmenopausal bleeding. She remains alive and well 3.5 years after hysterectomy and BSO. The remaining 11 patients are amenorrheic at a median follow-up of 6 years (range 1.5–12 years). Conclusions Resectoscopic surgery in 3391 women with AUB detected 12 incidental cases of atypical endometrial hyperplasia (incidence 0.35%). Skillful resectoscopic surgery may be an alternative to hysterectomy in women with AUB and atypical endometrial hyperplasia, who refuse or are at high-risk for hysterectomy and who are compliant with regular and long-term follow-up.

The exploration of the value of hysteroscopy in diagnosis and treatment for the hypomenorrhea and amenorrhea

目的 评价宫腔镜在月经减少及闭经中的诊断价值及治疗情况;方法回顾性分析102例月经减少及闭经患者宫腔镜检查情况及治疗情况,与其他诊断方法作对比.结果 月经减少及闭经者,多由于内膜有不同程度的损伤,宫腔镜在诊断方面较其他诊断方法有明显的优势.结论 宫腔镜可作为月经减少及闭经患者的常规检查方法。

Zastosowanie histeroskopii w diagnostyce i leczeniu niepłodności

Zastosowanie histeroskopii w diagnostyce i leczeniu niepłodności

182: Mini-Hysteroscopy Findings in Women Complaining of AUB and with No Abnormality at TVE

Abnormal uterine bleeding (AUB) is the most frequent indication for specialist consultations worldwide. Transvaginal echography (TVE) and SHG are considered first line diagnostic investigation in patients with AUB. This study aimed at evaluating the value of fluid mini-hysteroscopy (MiniHys) in women in whom TVE found no abnormality. We therefore compared findings at MiniHys with that at histology, endocervical and endometrial cultures in a group of women complaining of AUB and with no evidence of pathology at TVE. Prospective study. Clinical research and academic environment. Hundred pre-menopausal patients (age range 20–46 yrs) complaining of AUB with normal uterine cavity on TVE performed in the mid proliferative phase. Women in their follicular phase underwent diagnostic fluid MiniHys using speculum, endocervical swabs and endometrial biopsy. Main outcome measures: Endometrial findings at hysteroscopy, endometrial histology, endocervical and endometrial cultures (common bacteria, mycoplasma, chlamidya). At hysteroscopy 21 cases of endocervical polyps and 12 cases of endometrial polyps were detected. All endometrial polyps were smaller than 0.5 cm. However, in 71 cases hysteroscopic signs of chronic endometritis and/or endocervicitis were found. More in detail, hyperhemia, easy bleeding, mucosal adhesions, isolated or diffuse micropolyps, stromal edema were considered as sign of inflammation. Histology confirmed the diagnosis of CE in 40 (56.3%) cases; accordingly, endometrial culture was positive in 44 (62.0%) cases whereas positive cases at endocervical culture were significantly lower (n=29, 40.8%) (Fisher exact test: P<0.05 and P<0.01, vs. histology and endometrial culture, respectively). In 29 women with no signs of CE at MiniHys histology was positive in only 1 case, endometrial and endocervical cultures in 2 and 5 cases, respectively. In about two-thirds of women complaining of AUB but with no evidence of abnormality at TVE, direct inspection of endometrial cavity by means of hysteroscopy demonstrated signs of CE. Results of histology and endometrial cultures but not endocervical cultures showed high concordance and confirmed the hysteroscopic diagnosis in about 60% of cases. The nature of remaining 40% of cases of hysteroscopic CE remains unknown. On the basis of these results and of the advantages of MiniHys with respect to conventional hysteroscopy, MiniHys should be performed in all patients complaining of AUB whatever is TVE and SHG result.

OC7.03: Symptomatic postmenopausal women with endometrial polyps removed by hysteroscopy: prevalence of atypical hyperplasia, and cancer in a multicentre Italian study

Objective: To determine the prevalence of atypical hyperplasia, and endometrial cancer in asymptomatic postmenopausal women with endometrial polyps on atrophic endometrium, removed by hysteroscopic polypectomy. Methods: Asymptomatic postmenopausal women with standardized sonographic (endometrial thickness ≤4 mm), and/or hysteroscopic (visual diagnosis) diagnosis of endometrial polyp on atrophic endometrium, were retrospectively reviewed from 2000 to 2004. Patients on HRT and/or TMX treatment were excluded. All women underwent transvaginal sonography (TVS) with colorand/or powerDoppler evaluation, sonohysterography in selected cases, and/or diagnostic hysteroscopy (HYS). Hysteroscopic polypectomy was performed by using office operative hysteroscope or by resectoscope. Demographic, sonographic and hysteroscopic data were recorded. Histology of the removed polyp was the main outcome. Results: 637 consecutive patients were analysed among those so far included. Mean age (± sd) was 62 years ±8. Mean years after menopause were 13 ± 13. Mean BMI was 26 ± 5. Mean diameter of endometrial polyp at TVS and/or HYS was 18 ± 15 mm. Typical, atypical hyperplasia, and cancer were 4.9%, 1.6%, and 0.2%, respectively. One polypoid cancer was found. Conclusions: This first ad interim analysis of a larger multicentre study observed one case of endometrial cancer in asymptomatic postmenopausal women with endometrial polyp on atrophic endometrium. This confirmed the reliability of endometrial thickness ≤4 mm and hysteroscopic visual diagnosis for the exclusion of endometrial disease. This retrospective study adds evidence to the feasibility of a conservative management of asymptomatic polyps. Monitoring criteria need to be established.

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.

Practice patterns of SGO members for stage IIIA endometrial cancer

The purpose of surgical staging is to better determine prognosis and treatment. The International Federation of Gynecology and Obstetrics (FIGO) stage IIIA endometrial cancer is a heterogenous disease, and adjuvant therapy is not well-defined. The aim of this study was to survey the Society of Gynecologic Oncologists (SGO) members and fellows about their approach to the treatment of patients with stage IIIA endometrial cancer. All 850 members of the SGO were mailed surveys that asked how they would manage various case scenarios of stage IIIA endometrial cancer. Data were collected using an Internet survey database. Frequency distributions were determined, and nonparametric tests were performed. Fifty-three percent of SGO members and fellows responded. For the treatment of stage IIIA disease with malignant cytology only, adjuvant therapy was recommended 46%, 62%, and 98% of the time for women with grades 1, 2, and UPSC, respectively. Sixty-six percent of respondents would not remove malignant cytology from the current staging criteria. Ninety-nine percent of respondents recommended adjuvant therapy for patients with adnexal or serosal involvement. Eighty-six percent indicated that a hysteroscopy for diagnosis would not alter their treatment recommendations. While most gynecologic oncologists in our survey recommend adjuvant therapy for stage IIIA endometrial carcinoma, our results showed that patients with malignant cytology only would receive different treatments than patients with adenxal or serosal involvement. Histology and grade of the tumor are predictors of therapy recommendations over malignant cytology. Most respondents agreed that patients with malignant cytology should remain in stage IIIA.

Hysteroscopic diagnosis and treatment of endocervical ossification: A case report

We describe a case of osseous metaplasia into the cervical canal in a 41-year-old woman. The patient had a history of primary infertility, pelvic pain, chronic endocervicitis, and bone formation in the upper third of the cervical canal. After antibiotic therapy, we removed bone fragments by operative hysteroscopy using grasping forceps. The fragments were completely removed with no evidence of recurrence at 1-year follow-up. Chronic endocervicitis may cause endocervical ossification and should be ruled out before surgical removal of bone fragments in order to ensure definitive resolution and prevent recurrence.

Diagnostic Hysteroscopy in Endometrial Hyperplasia

Objectives: To assess the reproducibility of hysteroscopic diagnosis in the various types of endometrial hyperplasias and to compare different classifications of endometrial hyperplasia from this point of view. Study Design: 109 endometrial hyperplasias, diagnosed in the last 5 years with hysteroscopy, were all biopsied and had a pathological examination. We tried to estimate the accuracy of hysteroscopy comparing the various classifications of endometrial hyperplasia to the final pathologic diagnosis. Results: Using older endometrial hyperplasia classification, the overall diagnostic accuracy of hysteroscopy was 76% as for the correct type of hyperplasia. Classifying them at hysteroscopy into two categories only, i.e. hyperplasias and neoplasias, gave a more accurate result (90.26%). Conclusions: The newer classification is better from the hysteroscopist’s point of view.

Diagnosis of malignant mesenchymal uterine tumors by hysteroscopic excisional biopsy

To emphasize the need for histologic evaluation of intrauterine lesions. Six cases of unexpected mesenchymal uterine tumors were diagnosed following pathologic review of specimens obtained during hysteroscopy to evaluate intrauterine lesions. Retrospective chart review (Canadian Task Force classification II-3). Large tertiary care medical center. Four postmenopausal and two perimenopausal women with uterine mesenchymal tumors. Hysteroscopy and staging laparotomy. Mean age of the patients was 57.5 +/- 19.5 years (mean +/- 2SD). Four women (67%) were postmenopausal. Three patients had abnormal uterine bleeding, one had a cervical mass, and the other two were asymptomatic and referred for evaluation of thick endometrium detected by routine ultrasound, which had been preformed as part of their annual check-up. In all cases, the initial hysteroscopic diagnosis was endometrial polyp or submucous myoma. Following the pathologic review, all six women underwent complete staging laparotomy. In two women, there was no residual disease in the surgical specimen. None of the patients had extrauterine spread of the disease. At mean follow-up of 21.5 +/- 9.7 months (mean +/- 2SD), all women were asymptomatic. Intrauterine lesions erroneously considered to be benign endometrial polyps or myomas can turn out to be malignant mesenchymal uterine tumors. Hysteroscopic evaluation and biopsy might offer early diagnosis and treatment to these patients.

Office hysteroscopic evaluation of endometrium: can we hit the target?

The objective was to determine the value of office hysteroscopy in the diagnosis of endometrial hyperplasia by comparing the patients who had hysteroscopic diagnosis of hyperplasia with the results of histopathologic examinations, and to try to describe the visual criteria. Two hundred and sixteen premenopausal and 114 postmenopausal patients who were admitted to the endoscopic surgery department between January 2000 and March 2001 were enrolled. Visual diagnoses of endometrial hyperplasia with office hysteroscopy were compared with the histopathological results of the endometrial specimen. Pathology confirmed 50 of the 70 hysteroscopically-diagnosed hyperplasia patients. The positive predictive value of office hysteroscopy was 71.4% and the negative predictive value was 95.4% in the diagnosis of endometrial hyperplasia. The accuracy of hysteroscopic evaluation of the uterine cavity is extremely encouraging. Office hysteroscopy, which has a high diagnostic reliability and minimal discomfort, appears to be an ideal method of diagnosis and follow-up of patients with endometrial hyperplasia.

Hysteroscopic diagnosis and surgery in patients with intrauterine diseases

Hysteroscopic diagnosis and surgery in patients with intrauterine diseases

The malignant potential of endometrial polyps

Objectives: To determine the pre-malignant and malignant potential of endometrial polyps and to assess whether different clinical parameters are associated with malignancy in the polyps. Study design: Four hundred and thirty consecutive cases of hysteroscopic diagnosis of endometrial polyp were retrieved. The medical records, preoperative vaginal sonography results and histopathology findings were reviewed. Statistical analysis was performed. Results: Hysteroscopy truly identified endometrial polyps in 95.7% of the cases. In 11.4% cases, hyperplasia without atypia was found in the endometrial polyp. In 3.3 and 3.0% of women pre-malignant or malignant conditions were found in the polyp. Older age, menopause status and polyps larger than 1.5 cm were associated with significant pre-malignant or malignant changes, although the positive predictive value for malignancy was low. All the malignant polyps were diagnosed only in postmenopausal women. The presence of postmenopausal or irregular vaginal bleeding, was not a predictor of malignancy in the polyp. Conclusions: Postmenopausal women with endometrial polyps are at increased risk of malignancy in the polyp. Those patients, whether symptomatic or not should be evaluated by hysteroscopic resection of the polyps. Asymptomatic premenopausal patients with polyps smaller than 1.5 cm can be observed.

Hysteroscopically Targeted Biopsies Compared with Blind Samplings in Endometrial Assessment of Menopausal Women Taking Tamoxifen for Breast Cancer

Study Objective To determine the validity of tissue sampling accomplished by hysteroscopically targeted or blind biopsies in the assessment of endometrial morbidity associated with tamoxifen treatment. Design Retrospective, unrandomized study (Canadian Task Force classification II-2). Setting Public hospital. Patients One hundred seventy-six menopausal women who had an endometrial stripe of more than 4 mm on transvaginal ultrasonography. Intervention Review of histopathologic reports of patients undergoing hysteroscopy followed by targeted (94 samplings) or blind (82 samplings) endometrial biopsies. Measurements and Main Results Histopathology was considered the reference test to assess endometrial morbidity, and correlates with hysteroscopic findings were made to evaluate the validity of the two sampling procedures. Overall, in 23 women (13.0%) tissue samples were insufficient for pathologic evaluation. Functional or atrophic endometrium and cystic atrophy were found in 51 (28.8%) and 37 patients (21.0%), respectively. Polyps, hyperplasias, and carcinomas were found in 38 (21.5%), 19 (10.7%), and 6 (3.3%), respectively. Blind biopsies failed to detect 5 of 5 polyps and 33 of 37 cystic atrophies, and in 34.1% of cases provided insufficient tissue for diagnosis; however, no hyperplasias or carcinomas were undetected. All specimens collected under vision were pathologically evaluable; 34 of 38 hysteroscopic reports of cystic atrophy were confirmed, and neither endometrial polyps nor hyperplasias and carcinomas were undetected. In distinguishing between normal and abnormal endometrium, hysteroscopy showed sensitivity and negative predictive value of 100% regardless of sampling modality. We found better specificity (80.0% vs 68.9%) and positive predictive value (68.9% vs 43.7%) for hysteroscopic diagnosis when tissue was collected under vision compared with blind sampling. Conclusion In women taking tamoxifen, endometrial evaluation performed by blind sampling is safe in excluding hyperplasias or carcinomas. For complete understanding of tamoxifen-associated morbidity, hysteroscopy with sampling under vision has better diagnostic compliance.

Non-Oral Poster 62: Hysteroscopic Diagnosis and Treatment in Premenopausal versus Postmenopausal Women

Non-Oral Presentations: AUGS-SGS Abstracts: 2004 Joint Scientific Meeting The American Urogynecologic Society and The Society of Gynecologic Surgeons

Classification of Microhysteroscopic Images and their Correlation with Histologic Diagnoses

Study Objective To confirm that images observed at hysteroscopy correlate with histopathologic diagnoses. Design Double-blind study (Canadian Task Force classification II-2). Setting Gynecologic cancer center, private institute. Subjects One thousand four hundred thirty-six uterine cavities. Intervention Hysteroscopy. Measurements and Main Results Images were classified as normal hysteroscopy, benign lesion, low-risk hyperplasia, high-risk hyperplasia, and carcinoma. A hysteroscopic diagnosis was made and biopsy specimens were obtained with Kevorkian-type curettes or Sims curettes. Tissues were studied by a pathologist, after which we compared endoscopic diagnoses with anatopathologic diagnoses. Significant correlation was found between suspicion based on images and histologic confirmation (p = 0.001). The Cramer V coefficient, which measures the relationship between both methods, was high: 0.925. The Cramer V coefficient takes values ranging from zero, to indicate lack of correlation, to 1, to indicate perfect correlation. A λ symmetry coefficient of 0.96 is interpreted as probable improvement in the prediction of histologic diagnosis based on images. Conclusion This classification system can be useful for a systematic approach to hysteroscopic findings and to improve communication among specialists. It is based on the degree of hysteroscopic suspicion aimed at early detection of endometrial cancer and its precursor lesions.

Use of strict sonohysterographic methods for preoperative assessment of submucous myomas

Objective To assess the diagnostic accuracy of sonohysterography (SHG) and transvaginal sonography versus diagnostic hysteroscopy in preoperative assessment of submucous myomas. Design Prospective pilot study. Setting University hospital outpatient center. Patient(s) Forty-eight symptomatic (bleeding, infertility) premenopausal patients with submucous myomas. Intervention(s) Preoperative grading of submucous myomas with a strict SHG methodology and standard transvaginal sonography compared with hysteroscopic grading of submucous myoma before hysteroscopic myomectomy. Main outcome measure(s) SHG and sonographic agreement with hysteroscopic findings. Result(s) Forty-eight patients were enrolled (mean age ± SD = 41 years ± 10.2). The median duration of SHG was 12 minutes (interquartile range, 9–16). The mean number of submucous myomas was 1 (range, 1–3) per woman. In all cases, a successful SHG was performed, with no, mild, or moderate pain in 38 (79%), 8 (17%), and 2 (4%) patients, respectively. No patients experienced severe pain or vasovagal reaction. All cases were correctly diagnosed by SHG compared with the final hysteroscopic diagnosis (κ = 1.0; SE = 0.105). Simple transvaginal ultrasound was inaccurate in six cases (κ = 0.81; SE = 0.103). Conclusion(s) Strict and reproducible SHG diagnostic procedures proved to be as effective as hysteroscopy and well tolerated in preoperative grading of submucous myomas.

P127: Sonohysterography and endometrial sampling in the pre-operative assessment of submucous myomas

To determine the role of sonohysterography (SHG), associated with endometrial sampling, in the pre-operative assessment of submucous myomas and associated endometrial abnormalities. 64 symptomatic (bleeding) pre-menopausal patients with submucous myomas were recruited. All patients underwent transvaginal sonography (TVS) and SHG (Technos MP, Esaote). Number, volume and site of myomas and the myoma-perimetrium distance were considered at TVS. SHG with endometrial sampling was performed with a 4.7 mm (14F) intrauterine catheter. Patient compliance to SHG was evaluated by a subjective pain scale. Submucous myoma were classified at SHG as G0, G1 and G2 and compared to final hysteroscopic finding. Depending on hystologic findings at endometrial sampling, selected patients received pre-operative medical treatment. Hysteroscopic myomectomy was the standard surgical approach. Mean age (± sd) of the enrolled patients was 41 years ± 6.6. Median myoma volume was 4 cc (interquartile range 2–10). Overall 74 submucous myomas were examined. Twenty-five (39%) patients had additional intramural and or subserous myomas. Moderate or severe pain was experienced in 5 patients (8%). At hysteroscopy, submucous myomas were classified as G0, G1 and G2 in 17, 35 and 22 cases, respectively. All 72 cases with one submucous myoma were correctly diagnosed by sonohysterography compared to the final hysteroscopic diagnosis. In two patients with large (> 5 cc) and multiple submucous SHG misclassified one G1 and one G2 cases. Simple endometrial hyperplasia at endometrial sampling was found in nine patients. This finding allowed for completing surgical with medical treatment. Sonohysterography proved to be effective and well tolerated and in pre-operative assessment of submucous myomas. Endometrial sampling performed during SHG could help to identify coexisting endometrial abnormalities and the need for medical treatment.