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Abnormal Uterine Bleeding as a Screening for Endometrial Cancer
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Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159
distention medium. Pipelle sampling of the endometrium was done if required for endometrial assessment. Biopsy for any evident focal lesions was done under direct vision, using the rigid hysteroscope and biopsy forceps. A five-point visual analogue score was used to determine the pain score on four occasions during the procedure e at entry in to the external and internal cervical os, while inside the uterus and during the Pipelle sampling. Measurements and Main Results: Outpatient hysteroscopy was successfully performed in all except 3 (9.6%) cases. Thirteen (41.9%) patients had atrophic endometrium and were discharged. Endometrial polyps were found and successfully removed at the same setting in 7 (22.6%) patients. Two patients (6.4%) had submucous fibroids. Thickened suspicious looking endometrium was found in 2 (6.4%) patients; histological examination confirmed endometrial carcinoma in these patients. All except 4 (12.9%) patients tolerated the procedure well, with an average visual analogue pain score of 2.8/5. Pipelle sampling was reported to be the most painful part of the entire procedure, with an average pain score of 3.3/5 compared to 2.5 during negotiation of the internal os. Overall, hospital admission was avoided in 28 (90.3%) cases. Conclusion: Outpatient hysteroscopy can be easily performed by adequately trained gynecologists. It is a well tolerated procedure and is effective in reducing the number of hospital visits per patient as well as hospital admissions for inpatient hysteroscopy.
445 Hysteroscopic Evaluation of Abnormal Uterine Bleeding Francisco AMC, Archangelo SCV. Materno Infantil, Universidade do Vale do Sapucai-UNIVAS, Pouso Alegre, MG, Brazil Study Objective: Evaluate the hysteroscopic findings in women presenting abnormal uterine bleeding. Design: Retrospective analysis of 634 consecutive hysteroscopy in women with abnormal uterine bleeding performed in the period from July 1996 to May 2008. Setting: Minimally invasive surgery department of Gynecology and Obstetritics Department of Universidade do Vale do Sapucai #8211; UNIVAS, Pouso Alegre-MG Brazil. Patients: 634 women with an indication for hysteroscopy in order to investigate abnormal uterine bleeding. Intervention: Hysteroscopy with oriented or guided endometrial biopsy.
Table 1 hysteroscopic findings of 638 women submitted to investigation of abnormal uterine bleeding
Polyp Normal Myoma Inconclusive Cancer Synechia Endometritis Hyperplasia Malformation Vascular dystrophy Hematometra Strange body Bone metaplasis Total
Menacme
Post-menopause
Total
143 135 48 19 1 12 6 12 5 2 2 0 0 385
115 84 16 29 40 18 18 5 4 0 0 1 0 330
258 219 64 48 41 24 24 17 9 2 2 1 0 715
Measurements and Main Results: Among the 634 women presenting abnormal uterine bleeding (289/638) 45% of them were in the post-
menopause period; (349/634) 55% of them were in the menacme. The most frequent affection in the women presenting abnormal uterine bleeding was polyp (258/638), followed by normal hysteroscopy (219/ 638); myoma (64/638); inconclusive hysteroscopies (48/638); endometrial cancer (41/638); synechiae (30/638); endometritis (24/638); endometrial hyperplasia (17/638); bad womb formation (9/638); vascular dystrophy (2/638); hematometra (2/638); strange body (1/638). Conclusion: The most frequent hysteroscopic finding in women presenting abnormal uterine bleeding is the endometrial polyp, followed by the absence of abnormality of endometrial cavity to hysteroscopy. The endometrial cancer was the third cause for abnormal uterine bleeding among women in the post-menopause period and the eleventh one among women in the menacme.
446 Abnormal Uterine Bleeding as a Screening for Endometrial Cancer Francisco AMC, Archangelo SCV. Materno Infantil, Universidade do Vale do Sapucaı´-UNIVA´S, Pouso Alegre, MG, Brazil Study Objective: To evaluate the absence of abnormal uterine bleeding efficacy as a marker for the absence of endometrial cancer. Design: Retrospective analysis of 2366 consecutive hysteroscopy performed in the period from July 1996 to May 2008. Setting: Minimally invasive surgery department of Gynecology and Obstetritics Department of Universidade do Vale do Sapucai #8211; UNIVAS, Pouso Alegre-MG Brazil. Patients: 2366 women with indication for hysteroscopy. 638 presenting abnormal uterine bleeding and 1728 with no abnormal uterine bleeding. Intervention: Hysteroscopy with oriented or guided endometrial biopsy. Measurements and Main Results: 2366 hysteroscopy were performed. 638 women presented an abnormal uterine bleeding and 1728 patients didn’t present the referred bleeding. There was no occurrence of endometrial cancer in the 1728 patients who did not present abnormal uterine bleeding (0/1728) 0%. However, among the 634 patients presenting abnormal uterine bleeding 41 presented endometrial cancer (41/638) 6, 4%. All the cases diagnosed as endometrial cancer presented abnormal uterine bleeding through the clinical history. In the 41 cases of endometrial cancer, 40 of them happened in the post-menopause and just one in the menacme. In spite of all the endometrial cancer cases happening in women with abnormal uterine bleeding, the benign affections were the most of the hysteroscopic findings in the women with abnormal uterine bleeding.
Table 1 Hysteroscopic findings of 2366 women submitted to hysteroscopy with or without abnormal uterine bleeding
Polyp Normal Synechia Myoma Inconclusive Cancer Malformation Hyperplasia Endometritis Strange body hematometra Vascular dystrophy Bone metaplasis Total
with AUB
without AUB
Total
258 211 30 74 48 40 9 17 9 1 2 3 0 702
804 447 212 125 116 0 28 10 15 21 4 2 2 1786
1062 658 242 199 164 40 37 27 24 22 6 5 2 2488
Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159 Table 2 hysteroscopic findings of 638 women submitted to investigation of abnormal uterine bleeding
Polyp Normal Myoma Inconclusive Cancer Synechia Endometritis Hyperplasia Malformation Vascular dystrophy Hematometra Strange body Bone metaplasis Total
Menacme
Post-menopause
Total
143 135 48 19 1 12 6 12 5 2 2 0 0 385
115 84 16 29 40 18 18 5 4 0 0 1 0 330
258 219 64 48 41 30 24 17 9 2 2 1 0 715
Conclusion: The abnormal uterine bleeding may be used as an event to indicate the investigation of endometrial cancer. The absence of abnormal uterine bleeding may be a strong marker for the absence of endometrial cancer.
447 Comparison of Histologic Finding from Dilatation and Currettage (D&C) with Hysteroscopic Biopsy in Postmenopausal Women with Vaginal Bleeding Lee DO,1 Choi JH,1 Lee KS,1 Park SY,1 Kim HY.2 1Center for Uterine Cancer, National Cancer Center, Goyang-si, Kyunggi-do, Republic of Korea; 2Department of Obstetrics & Gynecology, Kosin University College of Medicine, Busan, Republic of Korea Study Objective: To compare the histologic finding of hysteroscopic endometrial biopsy with that of dilatation and currettage (D&C) under anesthesia. In postmenopausal women who complain vaginal bleeding and show thickened endometrium by transvaginal ultrasound, hysteroscopic endometrial evaluation is a goldstandard for diagnosis. But because of inconvenience, many women want offical based endometrial currettage. So the aim of the study is to evaluated the concordance of histologic finding from D&C and hysteroscopic biopsy in postmenopausal women with vaginal bleeding and thickened endometrium by transvaginal ultrasonography. Design: A prospective study with 108 women. Setting: Tertially hosipital setting. Patients: Postmenopausal women with vaginal bleeding and thickened endometrial thickness over 5 mm by transvaginal ultrasound. Intervention: For all patients, preoperative laminaria insertion was done for cervical dilatation. Under general anesthesia, all women were examed by diagnostic hysteroscopy and several pictures were taken. After removal of hysteroscopy, blind D&C was performed for whole uterine cavity. Then hysteroscopy were re-inserted, and hysterocopic biopsy was performed. The histologic finding from D&C and hysteroscopic biopsy were compared. Measurements and Main Results: By hysteroscopy, one case of endometiral cancer, two cases of atypical endometrial hyperplasia, two cases of complex hyperplasia, and forty five cases of endometrial polyp were diagnosed. Through D&C, though it were performed under general anesthesia, endometrial cancer was diagnosed as normal proliferative endometrium, one case of atypical hyperplasia was diagnosed as complex hyperplasia, and over half of endometrial polyp were missed as normal or atrophic endometrium only. Conclusion: For endometrial evaluation in postmenopausal women with vaginal bleeding, D&C under general anesthesia often fails to find
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pathology of endometrium. Hysteroscopic endometrial biopsy is needed in these cases.
448 Hysteroscopic Exam and IUD Drainage for the Abnormal Uterine Bleeding Secondary to Cesarean Scar Defect Lin CP. Obs/Gyn, Chiayi Christian Hospital, Chiayi City, Taiwan Republic of China Study Objective: To access a new method to reduce the subsequent coffee ground discharge secondary to cesarean scar defect. Design: Case series. Setting: Chiayi Christian hospital. Patients: Six women with previous cesarean delivery history complained of subsequent flow with coffee ground discharge just after menstruation for many years. One had the history of simple endometrial hyperplasia. Another one had uterine masses. The remainders were robust. Intervention: They were all arranged for hysteroscopic exam to rule out endometrial pathology before insertion of drainage device. The intrauterine device(IUD) was plastic without copper threads. They were followed at outpatient service. Measurements and Main Results: The hysteroscopic exam revealed a fibrous defect over anterior uterine low segment at the site of the cesarean scar. The mean follow-up time was 8 months (from 3 to 14 months). Only one withdrew the IUD for persisted mucous discharge. The other women felt ‘‘drier’’ after menstruation post the method. The subsequent coffee ground was treated uneventfully. Conclusion: Previous cesarean section scar defect might form a pouch over anterior low uterine segment, which had been found as a cause of subsequent menstruation flow. Hysteroscopic resection of fibrotic tissue and oral contraceptive pills were two possible methods ever reported. Here we designed an alternative method, which never been described. IUD insertion designed as drainage of the bloody reservoir is a simple successful approach to the subsequent coffee ground flow secondary to cesarean scar pouch. However, it needed more clinical data to support this manner.
449 New Surgical Drape without Loss of Output Media in Operative Hysteroscop Murakami T,1 Yokomizo R,2 Funayama Y,3 Nabeshima H,4 Terada Y,1 Yuki H,1 Tachibana M, Hayasaka S,1 Ugajin T,1 Kikuchi MA.1 1Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan; 2Obstetrics and Gynecology, Sendai Social Insurance Hospital, Sendai, Miyagi, Japan; 3Obstetrics and Gynecology, Saka General Hospital, Shiogama, Miyagi, Japan; 4Obstetrics and Gynecology, Iwate Prefectural Iwai Hosrital, Ichinoseki, Iwate, Japan Study Objective: To develop and evaluate a new surgical drape preventing loss of perfusion fluid during hysteroscopic surgery to measure precisely fluid deficit during operations. Design: Clinical case series. Setting: A university hospital and affiliated hospitals. Patients: Women with endometrial polyps or submucous leiomyomas treated with hysteroresectoscopy. Intervention: Operative hysteroscopy using a novel single surgical draping system. Measurements and Main Results: We developed a surgical drape that allows funnel overflow during taranscervical resection into a drainable pouch. We used this drape for hysteroscopic operations in several hospitals. We measured fluid spillage by weighting the pads that had soaked up draining media underneath the patient’s bottom. Using the new drape, little fluid spilled out during hyseteroresectoscopy. None of
Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159
distention medium. Pipelle sampling of the endometrium was done if required for endometrial assessment. Biopsy for any evident focal lesions was done under direct vision, using the rigid hysteroscope and biopsy forceps. A five-point visual analogue score was used to determine the pain score on four occasions during the procedure e at entry in to the external and internal cervical os, while inside the uterus and during the Pipelle sampling. Measurements and Main Results: Outpatient hysteroscopy was successfully performed in all except 3 (9.6%) cases. Thirteen (41.9%) patients had atrophic endometrium and were discharged. Endometrial polyps were found and successfully removed at the same setting in 7 (22.6%) patients. Two patients (6.4%) had submucous fibroids. Thickened suspicious looking endometrium was found in 2 (6.4%) patients; histological examination confirmed endometrial carcinoma in these patients. All except 4 (12.9%) patients tolerated the procedure well, with an average visual analogue pain score of 2.8/5. Pipelle sampling was reported to be the most painful part of the entire procedure, with an average pain score of 3.3/5 compared to 2.5 during negotiation of the internal os. Overall, hospital admission was avoided in 28 (90.3%) cases. Conclusion: Outpatient hysteroscopy can be easily performed by adequately trained gynecologists. It is a well tolerated procedure and is effective in reducing the number of hospital visits per patient as well as hospital admissions for inpatient hysteroscopy.
445 Hysteroscopic Evaluation of Abnormal Uterine Bleeding Francisco AMC, Archangelo SCV. Materno Infantil, Universidade do Vale do Sapucai-UNIVAS, Pouso Alegre, MG, Brazil Study Objective: Evaluate the hysteroscopic findings in women presenting abnormal uterine bleeding. Design: Retrospective analysis of 634 consecutive hysteroscopy in women with abnormal uterine bleeding performed in the period from July 1996 to May 2008. Setting: Minimally invasive surgery department of Gynecology and Obstetritics Department of Universidade do Vale do Sapucai #8211; UNIVAS, Pouso Alegre-MG Brazil. Patients: 634 women with an indication for hysteroscopy in order to investigate abnormal uterine bleeding. Intervention: Hysteroscopy with oriented or guided endometrial biopsy.
Table 1 hysteroscopic findings of 638 women submitted to investigation of abnormal uterine bleeding
Polyp Normal Myoma Inconclusive Cancer Synechia Endometritis Hyperplasia Malformation Vascular dystrophy Hematometra Strange body Bone metaplasis Total
Menacme
Post-menopause
Total
143 135 48 19 1 12 6 12 5 2 2 0 0 385
115 84 16 29 40 18 18 5 4 0 0 1 0 330
258 219 64 48 41 24 24 17 9 2 2 1 0 715
Measurements and Main Results: Among the 634 women presenting abnormal uterine bleeding (289/638) 45% of them were in the post-
menopause period; (349/634) 55% of them were in the menacme. The most frequent affection in the women presenting abnormal uterine bleeding was polyp (258/638), followed by normal hysteroscopy (219/ 638); myoma (64/638); inconclusive hysteroscopies (48/638); endometrial cancer (41/638); synechiae (30/638); endometritis (24/638); endometrial hyperplasia (17/638); bad womb formation (9/638); vascular dystrophy (2/638); hematometra (2/638); strange body (1/638). Conclusion: The most frequent hysteroscopic finding in women presenting abnormal uterine bleeding is the endometrial polyp, followed by the absence of abnormality of endometrial cavity to hysteroscopy. The endometrial cancer was the third cause for abnormal uterine bleeding among women in the post-menopause period and the eleventh one among women in the menacme.
446 Abnormal Uterine Bleeding as a Screening for Endometrial Cancer Francisco AMC, Archangelo SCV. Materno Infantil, Universidade do Vale do Sapucaı´-UNIVA´S, Pouso Alegre, MG, Brazil Study Objective: To evaluate the absence of abnormal uterine bleeding efficacy as a marker for the absence of endometrial cancer. Design: Retrospective analysis of 2366 consecutive hysteroscopy performed in the period from July 1996 to May 2008. Setting: Minimally invasive surgery department of Gynecology and Obstetritics Department of Universidade do Vale do Sapucai #8211; UNIVAS, Pouso Alegre-MG Brazil. Patients: 2366 women with indication for hysteroscopy. 638 presenting abnormal uterine bleeding and 1728 with no abnormal uterine bleeding. Intervention: Hysteroscopy with oriented or guided endometrial biopsy. Measurements and Main Results: 2366 hysteroscopy were performed. 638 women presented an abnormal uterine bleeding and 1728 patients didn’t present the referred bleeding. There was no occurrence of endometrial cancer in the 1728 patients who did not present abnormal uterine bleeding (0/1728) 0%. However, among the 634 patients presenting abnormal uterine bleeding 41 presented endometrial cancer (41/638) 6, 4%. All the cases diagnosed as endometrial cancer presented abnormal uterine bleeding through the clinical history. In the 41 cases of endometrial cancer, 40 of them happened in the post-menopause and just one in the menacme. In spite of all the endometrial cancer cases happening in women with abnormal uterine bleeding, the benign affections were the most of the hysteroscopic findings in the women with abnormal uterine bleeding.
Table 1 Hysteroscopic findings of 2366 women submitted to hysteroscopy with or without abnormal uterine bleeding
Polyp Normal Synechia Myoma Inconclusive Cancer Malformation Hyperplasia Endometritis Strange body hematometra Vascular dystrophy Bone metaplasis Total
with AUB
without AUB
Total
258 211 30 74 48 40 9 17 9 1 2 3 0 702
804 447 212 125 116 0 28 10 15 21 4 2 2 1786
1062 658 242 199 164 40 37 27 24 22 6 5 2 2488
Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159 Table 2 hysteroscopic findings of 638 women submitted to investigation of abnormal uterine bleeding
Polyp Normal Myoma Inconclusive Cancer Synechia Endometritis Hyperplasia Malformation Vascular dystrophy Hematometra Strange body Bone metaplasis Total
Menacme
Post-menopause
Total
143 135 48 19 1 12 6 12 5 2 2 0 0 385
115 84 16 29 40 18 18 5 4 0 0 1 0 330
258 219 64 48 41 30 24 17 9 2 2 1 0 715
Conclusion: The abnormal uterine bleeding may be used as an event to indicate the investigation of endometrial cancer. The absence of abnormal uterine bleeding may be a strong marker for the absence of endometrial cancer.
447 Comparison of Histologic Finding from Dilatation and Currettage (D&C) with Hysteroscopic Biopsy in Postmenopausal Women with Vaginal Bleeding Lee DO,1 Choi JH,1 Lee KS,1 Park SY,1 Kim HY.2 1Center for Uterine Cancer, National Cancer Center, Goyang-si, Kyunggi-do, Republic of Korea; 2Department of Obstetrics & Gynecology, Kosin University College of Medicine, Busan, Republic of Korea Study Objective: To compare the histologic finding of hysteroscopic endometrial biopsy with that of dilatation and currettage (D&C) under anesthesia. In postmenopausal women who complain vaginal bleeding and show thickened endometrium by transvaginal ultrasound, hysteroscopic endometrial evaluation is a goldstandard for diagnosis. But because of inconvenience, many women want offical based endometrial currettage. So the aim of the study is to evaluated the concordance of histologic finding from D&C and hysteroscopic biopsy in postmenopausal women with vaginal bleeding and thickened endometrium by transvaginal ultrasonography. Design: A prospective study with 108 women. Setting: Tertially hosipital setting. Patients: Postmenopausal women with vaginal bleeding and thickened endometrial thickness over 5 mm by transvaginal ultrasound. Intervention: For all patients, preoperative laminaria insertion was done for cervical dilatation. Under general anesthesia, all women were examed by diagnostic hysteroscopy and several pictures were taken. After removal of hysteroscopy, blind D&C was performed for whole uterine cavity. Then hysteroscopy were re-inserted, and hysterocopic biopsy was performed. The histologic finding from D&C and hysteroscopic biopsy were compared. Measurements and Main Results: By hysteroscopy, one case of endometiral cancer, two cases of atypical endometrial hyperplasia, two cases of complex hyperplasia, and forty five cases of endometrial polyp were diagnosed. Through D&C, though it were performed under general anesthesia, endometrial cancer was diagnosed as normal proliferative endometrium, one case of atypical hyperplasia was diagnosed as complex hyperplasia, and over half of endometrial polyp were missed as normal or atrophic endometrium only. Conclusion: For endometrial evaluation in postmenopausal women with vaginal bleeding, D&C under general anesthesia often fails to find
S121
pathology of endometrium. Hysteroscopic endometrial biopsy is needed in these cases.
448 Hysteroscopic Exam and IUD Drainage for the Abnormal Uterine Bleeding Secondary to Cesarean Scar Defect Lin CP. Obs/Gyn, Chiayi Christian Hospital, Chiayi City, Taiwan Republic of China Study Objective: To access a new method to reduce the subsequent coffee ground discharge secondary to cesarean scar defect. Design: Case series. Setting: Chiayi Christian hospital. Patients: Six women with previous cesarean delivery history complained of subsequent flow with coffee ground discharge just after menstruation for many years. One had the history of simple endometrial hyperplasia. Another one had uterine masses. The remainders were robust. Intervention: They were all arranged for hysteroscopic exam to rule out endometrial pathology before insertion of drainage device. The intrauterine device(IUD) was plastic without copper threads. They were followed at outpatient service. Measurements and Main Results: The hysteroscopic exam revealed a fibrous defect over anterior uterine low segment at the site of the cesarean scar. The mean follow-up time was 8 months (from 3 to 14 months). Only one withdrew the IUD for persisted mucous discharge. The other women felt ‘‘drier’’ after menstruation post the method. The subsequent coffee ground was treated uneventfully. Conclusion: Previous cesarean section scar defect might form a pouch over anterior low uterine segment, which had been found as a cause of subsequent menstruation flow. Hysteroscopic resection of fibrotic tissue and oral contraceptive pills were two possible methods ever reported. Here we designed an alternative method, which never been described. IUD insertion designed as drainage of the bloody reservoir is a simple successful approach to the subsequent coffee ground flow secondary to cesarean scar pouch. However, it needed more clinical data to support this manner.
449 New Surgical Drape without Loss of Output Media in Operative Hysteroscop Murakami T,1 Yokomizo R,2 Funayama Y,3 Nabeshima H,4 Terada Y,1 Yuki H,1 Tachibana M, Hayasaka S,1 Ugajin T,1 Kikuchi MA.1 1Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan; 2Obstetrics and Gynecology, Sendai Social Insurance Hospital, Sendai, Miyagi, Japan; 3Obstetrics and Gynecology, Saka General Hospital, Shiogama, Miyagi, Japan; 4Obstetrics and Gynecology, Iwate Prefectural Iwai Hosrital, Ichinoseki, Iwate, Japan Study Objective: To develop and evaluate a new surgical drape preventing loss of perfusion fluid during hysteroscopic surgery to measure precisely fluid deficit during operations. Design: Clinical case series. Setting: A university hospital and affiliated hospitals. Patients: Women with endometrial polyps or submucous leiomyomas treated with hysteroresectoscopy. Intervention: Operative hysteroscopy using a novel single surgical draping system. Measurements and Main Results: We developed a surgical drape that allows funnel overflow during taranscervical resection into a drainable pouch. We used this drape for hysteroscopic operations in several hospitals. We measured fluid spillage by weighting the pads that had soaked up draining media underneath the patient’s bottom. Using the new drape, little fluid spilled out during hyseteroresectoscopy. None of