- Email: [email protected]
Evaluation of Abnormal Uterine Bleeding as a Predictor of Pre-Malignant or Malignant Lesions Present in Endometrial Polyps
S54
Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159
groups: Misoprostol group 106 cases in which Misoprostol tablet (0.2 mg) was put into vaginal fornix at night before the surgery. Dilating stent group 108 cases in which the dilating stent was put into the cervical canal at night before the surgery. Intervention: Transcervical resection of myoma, polyp, adhesion and removal of intrauterine foreign bodies were preformed in both group under intravenous general anesthesia or epidural anesthesia. Measurements and Main Results: During operation there were 96 cases (90.6%) which breadth of cervical canal O7.5 mm in Misoprostol group and 82 cases (75.9%) in dilating stent group. P!0.05. The mean operating time was 18 .94 6.45 min in Misoprostol group and 24.41 7.54 min in dilating stent group, P!0.05. The blood loss was 13.81 5.69 ml in Misoprostol group and 17 .64 5.48 ml in dilating group. P!0.05. The incidence of intraoperative complications was 0.9% in Misoprostol group and 1.8% in dilating group. PO0.05. Conclusion: Misoprostol dilatation effect for cervical pretreatment of hysteroscopic surgery was efficacy. Its operating time was shorter, blood loss was less compared with dilating stent group Complications in both group was low.
210
Open Communication Session 6dHysteroscopy (4:29 PM d 4:34 PM)
Minimally Invasive Management of Mislocated Levonorgestrel Intrauterine System: Case Series and a Systematic Review of the Literature Hopkins MR, El-Nashar SA, Agudelo-Suarez P, Creedon DJ, Famuyide AO. Obstetrics and Gynecology, Mayo Clinic Rochester, Rochester, Minnesota
Study Objective: To report on the presentation and management of mislocated levonorgestrel intrauterine system (LNG-IUS) and to summarize the available literature. Design: Case series and a systematic review of the literature. Setting: A teaching hospital in the Upper Midwest. Patients: Utilizing the record-linkage system of Mayo Clinic, 10 women who were diagnosed with intraabdominal mislocated LNG-IUS from January 2000 through March 2008 were identified. Clinical presentation, management and follow up data were recorded. In addition, a systematic review was performed on the MEDLINE, EMBASE, Cochrane Systematic Reviews, CENTRAL, Web of Science, and Scopus databases up to March, 2007 on the management of intra-abdominal mislocated LNG-IUS was performed. Intervention: LNG-IUS (Mirena, Bayer HealthCare Pharmaceuticals Inc., Wayne, NJ). Measurements and Main Results: The median age at insertion was 25 years (range, 21e30), median parity 2 (range,1-4), median body mass index 23.9 kg/m2 (range,18.3-30.5). At insertion, 5 women were within 8 weeks postpartum and 5 were lactating. The median time from insertion to diagnosis of perforation was 18 days (range 7- 737 days). In one woman pregnancy was diagnosed and retrieval during elective cesarean section was decided. In the remaining 9, successful laparoscopic retrieval was performed. In 50% of the cases LNG-IUS was found in the omentum. The systematic review identified 11 reports including 39 cases of intra-abdominal LNG-IUS including one previous case of full term delivery with intra-abdominal LNG-IUS. Conclusion: Postpartum insertion is an important risk factor for perforation. Laparoscopic retrieval of intraabdominal LNG-IUS is feasible as LNG-IUS mostly is found in the omentum with minimal adhesion.
Table 1 Minimally Invasive Management of Mislocated Levonorgestrel Intrauterine System Study
Time from last Number Age) delivery
Ng Kee Kwong, 2002 Selo-Ojeme, 2003 HaimovKochman, 2003 Margarit, 2004 Nitka, 2004
1 9
Kalu, 2005 Khan, 2006
1 1
Van Houdenhoven, 2006 Budiman, 2007 Current Study
Presentation
Retrieval
Place of the LNG-IUS
1
39
NA
Ectopic pregnancy
Laparoscopy
Omentum
1
44
Not post partum
Omentum
4
33 (3237) 36 33 (2739)
Yes in all
Pelvic pain and recurrence of Laparoscopy menstruation Bleeding and pelvic pain, one Laparoscopy patient had no symptoms
21
1 10
NA NA
Left hypochondrium pain Laparoscopy Irregular pain, abdominal pain, Laparoscopy pregnancy in 2, and 4 asymptomatic
34 28
Yes Yes
30 (2147)
Only one
39
Yes
Recurrence of bleeding Urgency and suprapubic discomfort 13 were asymptomatic, 6 abdominal pain and 2 pregnancy Intrauterine Pregnancy
25 (2328)
5 women (6 weeks), 6 had abdominal pain, one Laparoscopy (n 5 9) and 3 women (520 shoulder pain and one during CS (n 5 1) weeks), and in 2 NA hypochondrium pain, one with Intrauterine pregnancy
N.A., not available; D.P., Douglas Pouch; Rt, right; lt, left.) Age presented as median (range)
Omentum (n 5 2), D.P (n 5 1), Rt. Gutter (n 5 1)
Laparoscopy Laparoscopy
Omentum Omentum (n 5 6), imbedded in the transverse colon (n 5 1), imbedded in sigmoid (n 5 1), and imbedded in appendix (n 5 1) Rt ovarian fossa In the bladder
Laparoscopy (n 5 15), laparotomy (n 5 1), not clear (n 5 4) and one left intraabdominal During CS
Omentum (n 5 10), partially embedded into the uterine fundus (n 5 4), and not clear (n 5 7) Omentum Omentum (n 5 5), D.P (n 5 2), lt ovarian fossa (n 5 1), Broad ligament (N 5 1) and partially attached to the left fallopian tube (n 5 1)
Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159 211
Open Communication Session 6dHysteroscopy (4:35 PM d 4:40 PM)
Evaluation of Abnormal Uterine Bleeding as a Predictor of Pre-Malignant or Malignant Lesions Present in Endometrial Polyps Siedhoff M, Arslan AA, Day B, Marshall S, Phillips K, Arunamata A, Tsai MC. Obstetrics and Gynecology, New York University School of Medicine, New York, New York Study Objective: To evaluate if abnormal uterine bleeding is a good independent predictor of pre-malignant or malignant lesions present in endometrial polyps. Design: Retrospective analysis of 183 consecutive cases of hysteroscopic polypectomy. Setting: University-based tertiary teaching hospital, department of Obstetrics and Gynecology. Patients: One hundred eighty three women (age 21e81 years) with diagnosis of endometrial polyps by saline infusion sonogram who subsequently underwent surgical excision. Intervention: Hysteroscopic polypectomy, dilation and curettage. Measurements and Main Results: Of the 183 patients who underwent hysteroscopic polypectomy, 149 (81%) reported history of abnormal uterine bleeding and in 34 (19%), the diagnosis was attributed to an incidental finding during routine pelvic sonogram. One hundred and two (56%) were pre-menopausal and 81 (44%) post-menopausal. Benign pathology, endometrial hyperplasia without atypia, atypical endometrial hyperplasia and endometrial cancer were found in the endometrial polyps in 162 (89%), 13 (7%), 4 (2%) and 4 (2%) patients, respectively. In logistic regression analysis, patients’ complaint of abnormal uterine bleeding was associated with the presence of pre-malignant or malignant lesions in endometrial polyps: OR 5 1.42 (95% CI 5 0.39-5.12). Conclusion: Our preliminary data showed that abnormal uterine bleeding is associated with increased risk of pre-malignant or malignant condition confined to endometrial polyps. Larger studies are needed to confirm these findings.
212
Open Communication Session 6dHysteroscopy (4:41 PM d 4:46 PM)
The Value of Pipelle Endometrial Biopsy for the Detection of Pre-Malignant or Malignant Lesions Confined to Endometrial Polyps Day B, Arslan AA, Siedhoff M, Phillips K, Marshall S, Lerner V, Tsai MC. Obstetrics and Gynecology, New York University School of Medicine, New York, New York Study Objective: To evaluate the value of office pipelle endometrial biopsy in predicting the presence of pre-malignant or malignant lesions confined to endometrial polyps. Design: Retrospective analysis of consecutive cases of symptomatic endometrial polyps with their respective pre-operative office endometrial biopsy. Setting: University-based tertiary teaching hospital, department of Obstetrics and Gynecology. Patients: One hundred fourteen women (age 21e81 years) who presented with abnormal uterine bleeding and co-existing endometrial polyps diagnosed by saline infusion sonogram, and who had a pre-operative office endometrial biopsy. Intervention: Hysteroscopic polypectomy, dilation and curettage, endometrial biopsy. Measurements and Main Results: Of the 114 patients eligible for this study, 61 (54%) were pre-menopausal and 53 (46%) post-menopausal. Benign pathology, endometrial hyperplasia without atypia, atypical endometrial hyperplasia and endometrial cancer were found in endometrial polyp specimens in 97 (85%), 11 (10%), 4 (3.5%) and 2 (2%) patients, respectively, and in the endometrial biopsy specimens in 107 (94%), 6 (5%), 1 (1%) and 0 (0%) patients, respectively. There was 98% (95/97) concordance between the histological diagnosis of endometrial biopsy and endometrial polyp samples for benign conditions. However, only 5 out of 17 pre-malignant and malignant conditions
S55
diagnosed after polypectomy had been identified by endometrial biopsy preoperatively (29% concordance, p 5 0.004). Nineteen percent (22/114) of the endometrial sampling returned as insufficient tissue.. Conclusion: There is poor concordance of histological diagnosis between pre-operative office pipelle endometrial biopsy and endometrial polyps. Office endometrial biopsy is not a reliable method to predict the pre-malignant or malignant lesions confined to endometrial polyps.
213
Open Communication Session 6dHysteroscopy (4:47 PM d 4:52 PM)
The Use of Bipolar Energy and Saline in Hysteroscopic Surgery: A Series of 75 Patients Chandakas S,2 Erian J.1 1Iaso Maternity Hospital; 2Attikon University Hospital, Athens, Greece Study Objective: To evaluate operative hysteroscopy using bipolar energy and saline electrode excision for the treatment of endometrial polyps or fibroids. Design: Prospective, randomized study. Setting: A University Hospital and a major Gynecological Hospital in Athens, Greece. Patients: Seventy-five consecutive patients with endometrial polyps or fibroids, up to 5 cm, in need for hysteroscopic resection. Intervention: Patients underwent diagnostic hysteroscopy, followed by operative resectoscopy using the bipolar/saline electrode system by Olympus passed through the operating sheath of a small-caliber hysteroscope. Measurements and Main Results: Operating times, difficulty of the operation, surgeon satisfaction with the procedure, intra- and postoperative complications, postoperative pain, and patient satisfaction were recorded. The majority of women were premenopausal (82%).Main reasons for surgery included infertility (39%), Disfunctional Uterine Bleeding (31%) and Post Menopausal Bleeding (17%) Operative hysteroscopy was performed with a bipolar electrosurgical device to cut, vaporize and coagulate. Main outcome measures were pain control during the procedure, the post-operative pain score at 15 and 60 min, and at 24 h after the procedure, and patients’ satisfaction rate. All procedures were completed within 45 min, the amount of saline used varied from 500e2550 m. Conclusion: Operative resectoscopy with bipolar energy and the use of saline appears to be the technique of choice for endometrial polyps or fibroids up to 5 cm. The length of the procedures is similar to existing techniques and the safety and satisfaction rate both for the surgeon and for the patient is better.
214
Open Communication Session 6dHysteroscopy (4:53 PM d 4:58 PM)
Correspondence between Hysteroscopic Findings and Severity of Endometrial Chronic Inflammation Colafiglio G,1 Saliani N,1 Donatis S De,1 Pinto V,1 Pastore A,1 Resta L,2 Cicinelli E.1 1Obstetrics and Gynecology, University of Bari, Bari, Italy; 2 Pathology, University of Bari, Bari, Italy Study Objective: To investigate the correlation between hysteroscopic and histological findings in women with CE (chronic endometritis). The ultimate aim is the possibility to have information about grade of inflammation by means of the presence of different hysteroscopic aspects. Design: Records from 94 women in whom CE was diagnosed at both fluid hysteroscopy and histology on specimens collected by means of Novak’s curette were reviewed. Setting: University centre. Patients: 94 woman with chronic endometritis. Intervention: The patients underwent at fluid hysteroscopy and histology with Novak’s curette. Measurements and Main Results: The grading of inflammation at both investigations was scored with an arbitrary scale and compared. More in detail, at hysteroscopy: Grade 1 (mild): focal or diffuse hyperhemia or periglandular hyperhemia associated or not to stromal edema; Grade 2
Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159
groups: Misoprostol group 106 cases in which Misoprostol tablet (0.2 mg) was put into vaginal fornix at night before the surgery. Dilating stent group 108 cases in which the dilating stent was put into the cervical canal at night before the surgery. Intervention: Transcervical resection of myoma, polyp, adhesion and removal of intrauterine foreign bodies were preformed in both group under intravenous general anesthesia or epidural anesthesia. Measurements and Main Results: During operation there were 96 cases (90.6%) which breadth of cervical canal O7.5 mm in Misoprostol group and 82 cases (75.9%) in dilating stent group. P!0.05. The mean operating time was 18 .94 6.45 min in Misoprostol group and 24.41 7.54 min in dilating stent group, P!0.05. The blood loss was 13.81 5.69 ml in Misoprostol group and 17 .64 5.48 ml in dilating group. P!0.05. The incidence of intraoperative complications was 0.9% in Misoprostol group and 1.8% in dilating group. PO0.05. Conclusion: Misoprostol dilatation effect for cervical pretreatment of hysteroscopic surgery was efficacy. Its operating time was shorter, blood loss was less compared with dilating stent group Complications in both group was low.
210
Open Communication Session 6dHysteroscopy (4:29 PM d 4:34 PM)
Minimally Invasive Management of Mislocated Levonorgestrel Intrauterine System: Case Series and a Systematic Review of the Literature Hopkins MR, El-Nashar SA, Agudelo-Suarez P, Creedon DJ, Famuyide AO. Obstetrics and Gynecology, Mayo Clinic Rochester, Rochester, Minnesota
Study Objective: To report on the presentation and management of mislocated levonorgestrel intrauterine system (LNG-IUS) and to summarize the available literature. Design: Case series and a systematic review of the literature. Setting: A teaching hospital in the Upper Midwest. Patients: Utilizing the record-linkage system of Mayo Clinic, 10 women who were diagnosed with intraabdominal mislocated LNG-IUS from January 2000 through March 2008 were identified. Clinical presentation, management and follow up data were recorded. In addition, a systematic review was performed on the MEDLINE, EMBASE, Cochrane Systematic Reviews, CENTRAL, Web of Science, and Scopus databases up to March, 2007 on the management of intra-abdominal mislocated LNG-IUS was performed. Intervention: LNG-IUS (Mirena, Bayer HealthCare Pharmaceuticals Inc., Wayne, NJ). Measurements and Main Results: The median age at insertion was 25 years (range, 21e30), median parity 2 (range,1-4), median body mass index 23.9 kg/m2 (range,18.3-30.5). At insertion, 5 women were within 8 weeks postpartum and 5 were lactating. The median time from insertion to diagnosis of perforation was 18 days (range 7- 737 days). In one woman pregnancy was diagnosed and retrieval during elective cesarean section was decided. In the remaining 9, successful laparoscopic retrieval was performed. In 50% of the cases LNG-IUS was found in the omentum. The systematic review identified 11 reports including 39 cases of intra-abdominal LNG-IUS including one previous case of full term delivery with intra-abdominal LNG-IUS. Conclusion: Postpartum insertion is an important risk factor for perforation. Laparoscopic retrieval of intraabdominal LNG-IUS is feasible as LNG-IUS mostly is found in the omentum with minimal adhesion.
Table 1 Minimally Invasive Management of Mislocated Levonorgestrel Intrauterine System Study
Time from last Number Age) delivery
Ng Kee Kwong, 2002 Selo-Ojeme, 2003 HaimovKochman, 2003 Margarit, 2004 Nitka, 2004
1 9
Kalu, 2005 Khan, 2006
1 1
Van Houdenhoven, 2006 Budiman, 2007 Current Study
Presentation
Retrieval
Place of the LNG-IUS
1
39
NA
Ectopic pregnancy
Laparoscopy
Omentum
1
44
Not post partum
Omentum
4
33 (3237) 36 33 (2739)
Yes in all
Pelvic pain and recurrence of Laparoscopy menstruation Bleeding and pelvic pain, one Laparoscopy patient had no symptoms
21
1 10
NA NA
Left hypochondrium pain Laparoscopy Irregular pain, abdominal pain, Laparoscopy pregnancy in 2, and 4 asymptomatic
34 28
Yes Yes
30 (2147)
Only one
39
Yes
Recurrence of bleeding Urgency and suprapubic discomfort 13 were asymptomatic, 6 abdominal pain and 2 pregnancy Intrauterine Pregnancy
25 (2328)
5 women (6 weeks), 6 had abdominal pain, one Laparoscopy (n 5 9) and 3 women (520 shoulder pain and one during CS (n 5 1) weeks), and in 2 NA hypochondrium pain, one with Intrauterine pregnancy
N.A., not available; D.P., Douglas Pouch; Rt, right; lt, left.) Age presented as median (range)
Omentum (n 5 2), D.P (n 5 1), Rt. Gutter (n 5 1)
Laparoscopy Laparoscopy
Omentum Omentum (n 5 6), imbedded in the transverse colon (n 5 1), imbedded in sigmoid (n 5 1), and imbedded in appendix (n 5 1) Rt ovarian fossa In the bladder
Laparoscopy (n 5 15), laparotomy (n 5 1), not clear (n 5 4) and one left intraabdominal During CS
Omentum (n 5 10), partially embedded into the uterine fundus (n 5 4), and not clear (n 5 7) Omentum Omentum (n 5 5), D.P (n 5 2), lt ovarian fossa (n 5 1), Broad ligament (N 5 1) and partially attached to the left fallopian tube (n 5 1)
Abstracts / Journal of Minimally Invasive Gynecology 15 (2008) S1eS159 211
Open Communication Session 6dHysteroscopy (4:35 PM d 4:40 PM)
Evaluation of Abnormal Uterine Bleeding as a Predictor of Pre-Malignant or Malignant Lesions Present in Endometrial Polyps Siedhoff M, Arslan AA, Day B, Marshall S, Phillips K, Arunamata A, Tsai MC. Obstetrics and Gynecology, New York University School of Medicine, New York, New York Study Objective: To evaluate if abnormal uterine bleeding is a good independent predictor of pre-malignant or malignant lesions present in endometrial polyps. Design: Retrospective analysis of 183 consecutive cases of hysteroscopic polypectomy. Setting: University-based tertiary teaching hospital, department of Obstetrics and Gynecology. Patients: One hundred eighty three women (age 21e81 years) with diagnosis of endometrial polyps by saline infusion sonogram who subsequently underwent surgical excision. Intervention: Hysteroscopic polypectomy, dilation and curettage. Measurements and Main Results: Of the 183 patients who underwent hysteroscopic polypectomy, 149 (81%) reported history of abnormal uterine bleeding and in 34 (19%), the diagnosis was attributed to an incidental finding during routine pelvic sonogram. One hundred and two (56%) were pre-menopausal and 81 (44%) post-menopausal. Benign pathology, endometrial hyperplasia without atypia, atypical endometrial hyperplasia and endometrial cancer were found in the endometrial polyps in 162 (89%), 13 (7%), 4 (2%) and 4 (2%) patients, respectively. In logistic regression analysis, patients’ complaint of abnormal uterine bleeding was associated with the presence of pre-malignant or malignant lesions in endometrial polyps: OR 5 1.42 (95% CI 5 0.39-5.12). Conclusion: Our preliminary data showed that abnormal uterine bleeding is associated with increased risk of pre-malignant or malignant condition confined to endometrial polyps. Larger studies are needed to confirm these findings.
212
Open Communication Session 6dHysteroscopy (4:41 PM d 4:46 PM)
The Value of Pipelle Endometrial Biopsy for the Detection of Pre-Malignant or Malignant Lesions Confined to Endometrial Polyps Day B, Arslan AA, Siedhoff M, Phillips K, Marshall S, Lerner V, Tsai MC. Obstetrics and Gynecology, New York University School of Medicine, New York, New York Study Objective: To evaluate the value of office pipelle endometrial biopsy in predicting the presence of pre-malignant or malignant lesions confined to endometrial polyps. Design: Retrospective analysis of consecutive cases of symptomatic endometrial polyps with their respective pre-operative office endometrial biopsy. Setting: University-based tertiary teaching hospital, department of Obstetrics and Gynecology. Patients: One hundred fourteen women (age 21e81 years) who presented with abnormal uterine bleeding and co-existing endometrial polyps diagnosed by saline infusion sonogram, and who had a pre-operative office endometrial biopsy. Intervention: Hysteroscopic polypectomy, dilation and curettage, endometrial biopsy. Measurements and Main Results: Of the 114 patients eligible for this study, 61 (54%) were pre-menopausal and 53 (46%) post-menopausal. Benign pathology, endometrial hyperplasia without atypia, atypical endometrial hyperplasia and endometrial cancer were found in endometrial polyp specimens in 97 (85%), 11 (10%), 4 (3.5%) and 2 (2%) patients, respectively, and in the endometrial biopsy specimens in 107 (94%), 6 (5%), 1 (1%) and 0 (0%) patients, respectively. There was 98% (95/97) concordance between the histological diagnosis of endometrial biopsy and endometrial polyp samples for benign conditions. However, only 5 out of 17 pre-malignant and malignant conditions
S55
diagnosed after polypectomy had been identified by endometrial biopsy preoperatively (29% concordance, p 5 0.004). Nineteen percent (22/114) of the endometrial sampling returned as insufficient tissue.. Conclusion: There is poor concordance of histological diagnosis between pre-operative office pipelle endometrial biopsy and endometrial polyps. Office endometrial biopsy is not a reliable method to predict the pre-malignant or malignant lesions confined to endometrial polyps.
213
Open Communication Session 6dHysteroscopy (4:47 PM d 4:52 PM)
The Use of Bipolar Energy and Saline in Hysteroscopic Surgery: A Series of 75 Patients Chandakas S,2 Erian J.1 1Iaso Maternity Hospital; 2Attikon University Hospital, Athens, Greece Study Objective: To evaluate operative hysteroscopy using bipolar energy and saline electrode excision for the treatment of endometrial polyps or fibroids. Design: Prospective, randomized study. Setting: A University Hospital and a major Gynecological Hospital in Athens, Greece. Patients: Seventy-five consecutive patients with endometrial polyps or fibroids, up to 5 cm, in need for hysteroscopic resection. Intervention: Patients underwent diagnostic hysteroscopy, followed by operative resectoscopy using the bipolar/saline electrode system by Olympus passed through the operating sheath of a small-caliber hysteroscope. Measurements and Main Results: Operating times, difficulty of the operation, surgeon satisfaction with the procedure, intra- and postoperative complications, postoperative pain, and patient satisfaction were recorded. The majority of women were premenopausal (82%).Main reasons for surgery included infertility (39%), Disfunctional Uterine Bleeding (31%) and Post Menopausal Bleeding (17%) Operative hysteroscopy was performed with a bipolar electrosurgical device to cut, vaporize and coagulate. Main outcome measures were pain control during the procedure, the post-operative pain score at 15 and 60 min, and at 24 h after the procedure, and patients’ satisfaction rate. All procedures were completed within 45 min, the amount of saline used varied from 500e2550 m. Conclusion: Operative resectoscopy with bipolar energy and the use of saline appears to be the technique of choice for endometrial polyps or fibroids up to 5 cm. The length of the procedures is similar to existing techniques and the safety and satisfaction rate both for the surgeon and for the patient is better.
214
Open Communication Session 6dHysteroscopy (4:53 PM d 4:58 PM)
Correspondence between Hysteroscopic Findings and Severity of Endometrial Chronic Inflammation Colafiglio G,1 Saliani N,1 Donatis S De,1 Pinto V,1 Pastore A,1 Resta L,2 Cicinelli E.1 1Obstetrics and Gynecology, University of Bari, Bari, Italy; 2 Pathology, University of Bari, Bari, Italy Study Objective: To investigate the correlation between hysteroscopic and histological findings in women with CE (chronic endometritis). The ultimate aim is the possibility to have information about grade of inflammation by means of the presence of different hysteroscopic aspects. Design: Records from 94 women in whom CE was diagnosed at both fluid hysteroscopy and histology on specimens collected by means of Novak’s curette were reviewed. Setting: University centre. Patients: 94 woman with chronic endometritis. Intervention: The patients underwent at fluid hysteroscopy and histology with Novak’s curette. Measurements and Main Results: The grading of inflammation at both investigations was scored with an arbitrary scale and compared. More in detail, at hysteroscopy: Grade 1 (mild): focal or diffuse hyperhemia or periglandular hyperhemia associated or not to stromal edema; Grade 2