- Email: [email protected]
Vabra aspiration in office gynecology
GYNECOLOGIC
ONCOLOGY
10, 329-336 (1980)
Vabra Aspiration in Office Gynecology I. DELKE,
M.D., N. P. VERIDIANO,
M.D.,’ AND B. DIAMOND,
M.D.
Department of Obstetrics and Gynecology, The Brookdale Hospital Medical Center, Linden Boulevard at Brookdale Plaza, Brooklyn, New York 11212 Received May 13, 1980 Four years of clinical experience with 320 vabra aspirations in 271 patients, aged 2 1 to 84 years, has confirmed our expectation of the procedure, as a quick and easy method, affording reliable diagnosis, causing few complications, and acceptable to patients as a routine method. The procedure was suitable for approximately 80% of patients with menstrual disorders or postmenopausal bleeding. It was also valuable in the follow-up of patients with previous adenomatous hyperplasia of the endometrium and those on long-term estrogen therapy for postmenopausal symptoms. The initial VA specimen was adequate in 95.2% of cases and the quality was excellent. VA supplemented with ECC and uterine size measurement enabled the diagnosis, grading, and staging of all adenocarcinomas accurately. Adenomatous hyperplasia of the endometrium was correctly diagnosed in 96.5% instances but two patients with mild to moderate adenomatous hyperplasia were missed. Endometrial polyps were diagnosed in only 50% of patients. The therapeutic or hemostatic efficacy of VA was just over 50% in this series. The five pregnancy complications (two ectopic pregnancies and three incomplete abortions) in our experience, warrant consideration in all premenopausal females presenting with a menstrual disorder before VA is carried out. Undoubtedly, hospitalization can be avoided, with attendant cost saving, by more widespread use of this technique. We recommend that all obstetric and gynecologic residents be familiar with the procedure.
Although outpatient procedures for diagnosing endometrial cancer have been advocated for 50 years [lo] dilatation and curettage (D&C) in the hospital under general anesthesia remains the prime diagnostic procedure [3]. Increasing demand for early diagnosis, espeically of malignant disease, has resulted in a marked increase in the frequency of diagnostic uterine curettage by the gynecologist. The development of vacuum aspiration for evacuating the pregnant uterus led naturally to the use of this method as a diagnostic and therapeutic procedure in nonpregnant women [8]. The use of the vabra aspiration (VA) has been reported in extensive clinical trials from Europe and many advantages have been claimed for the method [1,6-9,l l-131. Recently, this instrument became available in the U.S. It has attained widespread clinical use in a short time and preliminary reports have confirmed its usefulness [2-14,151. To date, most reports [l-4,6-9,1 l-151 have looked at the accuracy of the material obtained from VA in comparison to the D&C specimen and have found a very high correlation. ’ Address reprint requests to N. P. Veridiano, M. D., Department of Obstetrics and Gynecology, The Brookdale Hospital Medical Center, Linden Boulevard at Brookdale Plaza, Brooklyn, N.Y. 11212. 329 0090~8258/80/060329-08$01.00/O Copyright Q 1980 by Academic Press, Inc. All rights of reproduction in any form reserved.
330
DELKE,
VERIDIANO,
AND
DIAMOND
The purpose of the present report is to evaluate endocervical curettage (ECC), uterine sounding, and VA in the (1) management of patients with menstrual disorders and postmenopausal bleeding (PMB), (2) periodic follow-up of patients on long-term estrogen therapy for postmenopausal symptoms or patients with previous adenomatous hyperplasia of the endometrium, and (3) clinical staging and grading of endometrial cancer. MATERIALS
AND METHODS
The material comprises 320 vabra aspirations done in 271 patients, aged 2 1 to 84 years (Table l), by two gynecologists in their private practice over a four-year period, January 1, 1976 to December 31, 1979. The various indications for the procedure are shown in Table 2. Patients with (1) previous surgery on the cervix, (2) cervical stenosis, (3) possible adnexal mass, (4) debilitating medical conditions, and (5) very apprehensive patients were excluded. This amounted to 20% of patients requiring endometrial sampling. The instrument and technique used were as described elsewhere [ 1,2,14,151. All 27 1 patients had a pelvic examination and a Papanicolaou smear. Endocervical curettage with the Kevorkian curette (ECC) followed by uterine cavity sounding was performed in 96.7 and 91. I%, respectively. VA was performed in all patients without premeditation, anesthesia, or cervical dilatation. The patients were observed for lo-15 min on the examining table and the vital signs were checked. Patients returned to work the day of the procedure and coitus resumed after 5-7 days. Tissue collected was fixed immediately in 4% formaldehyde solution, the chamber being filled to capacity and closed with the extra cap provided. Patients with persistent or recurrent bleeding had fractional D&C in hospital or second VA in the office. Those patients on long-term estrogen therapy had VA every 6 months. All tissues from the VA, fractional D&C, and hysterectomy specimen were histologically reviewed. During the same I-year period, there were 2368 diagnostic uterine curettages performed for various menstrual disorders and postmenopausal bleeding (PMB) at the Brookdale Hospital Medical Center as an inpatient procedure under general anesthesia with a minimum hospital stay of 48 hr. Nearly 70% of these were done for menstrual disorders and three quarters of the patients were 40-59 years of age. RESULTS
The age distribution is widespread (Table 1) but the majority of patients, 212 (78.2%), were 40-59 years of age. There were 257 (94.8%) white patients. The indications for VA (Table 2) included menstrual disorders in 188(69.4%), PMB in 59 (21.8%), previous adenomatous hyperplasia of the endometrium in 11 (4.1%), and 9 (3.3%) patients on estrogen therapy for postmenopausal symptoms. Only 2 out of 188premenopausal patients with menstrual disorders, both over 50 years of age, had adenocarcinoma of the endometrium, while 8 out of 59 (57-84 years old) with PMB had this disease. One of these eight patients was on premarin for several years without any endometrial sampling. ECC performed in 262 cases was satisfactory in all and positive in only two instances. Uterine cavity length was
VABRA ASPIRATION
331
IN OFFICE GYNECOLOGY
TABLE 1 AGE DISTRIBUTIONOF 271 PATIENTS
Age
No. of patients
Percentage
30-39 40-49 m-59 Over 60
7 26 113 99 26
2.6 9.6 41.7 36.5 9.6
Total
271
100.0
Less than 30
measured and documented in 247 instances: 5% were less than 6 cm, 58.3% 6-8 cm, and 27.3% over 8 cm. The initial VA specimen was adequate for tissue study in 258 cases (95.2%) and the histologic diagnosis is shown in Table 3. Adenocarcinoma was diagnosed, staged, and graded accurately in 10 cases, as confirmed by hysterectomy specimen review. Adenomatous hyperplasia of the endometrium was found in 55 patients. There were 37 patients with mild focal adenomatous hyperplasia, 13 with moderate degree, 2 with severe hyperplasia without atypia, and 3 with atypical severe adenomatous hyperplasia. In five patients (ages 21-40 years), all presenting with “mennorrhagia,” the endometrium showed pregnancy changes: decidual reaction without chorionic villi (two ectopic pregnancies), decidual reaction with chorionic villi (two incomplete abortions), and one placental tissue (incomplete abortion). Tissue was insufficient for review in 13 cases (4.8%) at initial VA. Nine were postmenopausal females and subsequent D&C showed atrophic endometrium in seven and endometrial polyp in two. Of the four premenopausal females with menstrual disorders three had an endometrial polyp on D&C and one had proliferative endometrium with mild adenomatous hyperplasia of the endometrium. The accuracy of VA, as reviewed in 119 cases with subsequent D&C (44), second VA (33), and hysterectomy (42) showed the same histologic diagnosis as the initial VA in 104 cases (87.4%) and different tissue diagnosis in 15 instances (12.6%): two adenomatous hyperplasia of the endometrium, five endometrial TABLE 2 INDICATIONSFORVABRA ASPIRATION Indications Menstrual disorders (Menometrorrhagia) Postmenopausal bleeding Previous endometrial hyperplasia Estrogen series Postcoital bleeding Suspicious Pap smear Oral contraceptive pills for 7 years Total
No. of patients
Percentage
188
69.4
59 9 2 1 I
21.8 4.1 3.3 0.1 0.4 0.4
271
100. I
11
332
DELKE, VERIDIANO,
AND DIAMOND
TABLE 3 HISTOLOGIC DIAGNOSIS OF INITIAL VABRA ASPIRATION SPECIMEN IN 271 PATIENTS
Histologic diagnosis Proliferative endometrium Adenomatous hyperplasia of endometrium Secretory endometrium Atrophic endometrium Insufficient tissue Adenocarcinoma of endometrium Benign cystic changes of endometrium Endometrial polyp Pregnancy changes of endometrium Mixed endometrium Menstrual endometrium Chronic endometritis Total
No. of patients
Percentage
102 55 53 IS 13 IO 6 5 5 4 2 I
37.6 20.3 19.6 5.5 4.8 3.7 2.2 1.8 1.8 1.5 0.7 0.4
271
99.9
polyps, seven atrophic endometrium, and one insufficient tissue on D&C following VA (Table 4). The difference was important in only seven instances (5.9%). Two patients had adenomatous hyperplasia and five had endometrial polyps. Hence, the accuracy rate of VA approaches 94%. Therapeutic Efficacy One hundred fifty-four patients (56.8%) were asymptomatic after the initial VA and did not require a second VA or conventional D&C for 3 to 6 months. Estrogen Series There were nine patients on long-term estrogen therapy for postmenopausal symptoms (Table 5). There were two groups of patients in this series. The first group consisted of five patients who had VA before estrogen maintenance was started. Two of these five developed atypicai adenomatous hyperplasia of the endometrium and all reverted to normal on discontinuation of the estrogen. The second group comprised of four patients who already were on long-term estrogen therapy without initial endometrial sampling. One of these four patients presented with PMB and was found to have grade 3 adenocarcinoma of the endometrium. One patient had moderate adenomatous hyperplasia on VA, confirmed by review of the hysterectomy specimen. The hysterectomy was done for uterine prolapse. The two remaining patients in this group had atypical adenomatous hyperplasia which reverted to normal on withdrawal of the drug. Complication Rate Two patients had syncope immediately following the procedure but both recovered within 5 min. One instance of pelvic infection and a suspected uterine perforation on one occasion, requiring no surgical repair, were observed. Subjective pain was absent in 10 (3.4%), mild in 174(64.2%), moderate in 74 (27.3%), and severe in 13 patients (4.8%).
TABLE 4
Proliferative endometrium (1) Atrophic endometrium (I)
Insufficient tissue (13)
Initial VA diagnosis
Insufficient tissue (1)
Second VA Atrophic endometrium (7) Endometrial polyp (5) Mild endometrial hyperplasia (I)
D&C
Moderate endometrial hyperplasia (I)
Hysterectomy
DISCORDANCE BETWEEN FINDINGS BY INITIAL VABRA ASPIRATION AND D&C, SECOND VA, OR HYSTERECTOMY SPECIMEN IN I5 PATIENTS
202 Estinyl, 0.02
2002 Premarin, 0.625
2002 Premarin, 1.25.
0 Premarin, 0.625 2002 Premarin, 0.625
3003 Estinyl, 0.02
1011 Estinyi, 0.02
2022 Premarin, 0.625
50
56
58*
60
62*
64*
74*
Mild adenomatous hyperplasia of endometrium Focal atypical adenomatous hyperplasia of endometrium Adenocarcinoma, grade 3
Moderate adenomatous hyperplasia of endometrium Proliferative endometrium Scanty benign endometrium
Scanty benign endometrium Scanty benign endonetrium Proliferative endometrium
I
Atypical adenomatous hyperplasia of endometrium D/C estinyl proliferative endometrium
Proliferative endometrium proliferative endometrium
Proliferative endometrium
Proliferative endometrium
Proliferative endometrium
2
Proliferative endometrium
Severe atypical adenomaous hyperplasia of endometrium D/C estinyl proliferative endometrium
Atypical adenomatous hyperplasia of endometrium
3
4
Benign cystic endometrium
D/C Premarin benign cystic endometrium
D/C” Premarin proliferative endometrium
Vabra follow-up
Benign cystic endometrium
5
*These patients have been started on estrogen therapy by other physician! without an initial endometrial sampling.
61
1001 Premarin, 0.625
49
Age
Estrogen and Para dosage (mg)
TABLE 5 ESTROGENSERVES
Adenocarcinoma grade 1
Focal moderate adenomatous hyperplasia of endometrium
Hysterectomy
w E
VABBA
ASPIRATION
IN
OFFICE
GYNECOLOGY
335
DISCUSSION At the present time, increasing demand for medical care, associated with few hospital beds and rising cost, have made the conversion of diagnostic and therapeutic procedures to outpatient status more important. This report confirms the experience of others [2,6,14,15] that D&C with the use of general anesthesia in hospital is unnecessary if the purpose is to evaluate endocervical and/or endometrial tissue. The VA specimens were of excellent quality for histopathologic interpretation as shown by several authors [6,9,12] and the diagnostic accuracy agreed with other series [2,6,12,14,15]. All adenocarcinomas, 96.5% of the endometrial hyperplasias, but only 50% of endometrial polyps were correctly diagnosed by VA. The therapeutic or hemostatic efficacy of VA was just over 50% in this series, much lower than the reported 80-95% [6,9,121. The complication rate in our material, as in the literature [6,12], was modest. Vasovagal reaction occurred in only two patients, far less than might be expected. There was one patient with clinical signs of pelvic infection and one case of questionable uterine perforation requiring no surgical repair. Subjective pain or lower abdominal discomfort was the most common complaint. In the great majority of cases the pain was mild to moderate and brief, restricted to the procedure itself. Others [9] have observed that the pain associated with VA was comparable to that caused by insertion of an intrauterine device and less than that caused by hysterosalpingography. Thus the method does not require anesthesia and the patient can return to her usual work immediately. VA is well suited for 75-90% of patients requiring endometrial sampling [9, 141. We agree with others [9,14,15] that patients with cervical stenosis, possible adnexal mass, marked obesity, or debilitating medical conditions should be excluded. In this series two patients were found to have ruptured ectopic pregnancy following VA and three others had incomplete abortion. The age range of these five patients was 21-40 years. One should consider the possibility of a pregnancy complication in all premenopausal females presenting with menstrual disorders before VA. The method is also very useful in cases where endometrial sampling must be done periodically as in patients on long-term estrogen therapy or those with previous adenomatous hyperplasia of the endometrium. The findings here confirm the experience of others that adenomatous hyperplasia induced by long-term estrogen administration will usually respond to withdrawal of the drug 151. Four years of clinical experience with VA has confirmed our expectation of the procedure as a quick and easy method, affording reliable diagnosis, causing few complications, and acceptable to patients as a routine method. Furthermore, when supplemented with ECC and uterine size measurement it enables clinical staging and grading of endometrial cancer. Undoubtedly, many hospitalizations can be avoided, with attendant cost saving, by more widespread use of this technique. We recommend that all obstetric and gynecologic residency programs institute VA in their training so that their residents are familiar with the procedure. REFERENCES 1. Bjerre, B. A., Gardmark, S. A., and Sjoberg, N. Aspiration curettage-A J. Reprod. Med. 7, 221-223 (1971).
new diagnostic method,
336
DELKE,
VERIDIANO,
AND
DIAMOND
2. Cohen, C. J. Gusberg, S. B., and Koftler, D. Histologic screening for endometrial cancer, Cynecol. Oncol. 2, 279-286 (1974). 3. Creasman, W. T., and Weed, J. C. Screening techniques in endometrial cancer, Cancer 38, 438-440 (1976). 4. Denis, R. Jr., Bamett, J. M., and Forbes, S. E. Diagnostic suction curettage, Obstet. Gynecol. 42,
301-303 (1973). 5. Gusberg, S. B. Current concepts: The changing nature of endometrial cancer, N. Engl. J. Med. 302, 729-731 (1980). 6. Haack-Sorensen, P. E., Starklint H., Aronsen, A., Hansen, M. K., and Kristoffersen, K. Diagnos-
tic vabra (aspiration) curettage, Dun. Med. Bull. 26, l-6 (1979). 7. Holt, E. M. Out-patient diagnostic curettage, J. Obstet. Gynaecol. Brit. Commonw. 77, 10431046 (1970). 8. Jensen, J. A., and Jensen, 3. G. Abrasio mucosae uterie aspiratione, Ugeskr. Laeg. 130, 21242127 (I%@. 9. Jensen, J. G. Vacuum curettage. Out-patient curettage without anesthesia, A report of 350 cases, Dan. Med. Bull. 17, 199-2020 (1970).
10. Kelly, H. A. Curettage without anesthesia on the office table. Amer. .I. Obstet. Gynecol. 9,78-80 (1925).
Il. Mathews, D. D., Kakani, A., and Bhattacharya, A. A comparison of vacuum aspiration of the uterus and conventional curettage in the management of abnormal uterine bleeding, J. Obstet. Gynaecol. Brit. Commonw. 80, 176-180 (1973). 12. Nussler, E., Thomsen, P. B., and Weeth, R. Vacuum curettage of the uterus,Dan. Med. Bull. 22, 165-168 (1975). 13. Saunders, P., and Rowland, R. Vacuum Curettage of the uterus without anesthesia, J. Obstet.
Gynaecol. Brif. Commonw. 79, 168-174 (1972). 14. Walters, D., Robinson, D., Park, R. C., and Paton, W. E. Diagnostic outpatient aspiration curettage, Obstet. Gynecol. 46, 160-164 (1975). 15. Webb, M. J., and Gaffey, T. A. Outpatient diagnostic aspiration curettage, Obstet. Gynecol. 47, 239-242 ( 1976).
ONCOLOGY
10, 329-336 (1980)
Vabra Aspiration in Office Gynecology I. DELKE,
M.D., N. P. VERIDIANO,
M.D.,’ AND B. DIAMOND,
M.D.
Department of Obstetrics and Gynecology, The Brookdale Hospital Medical Center, Linden Boulevard at Brookdale Plaza, Brooklyn, New York 11212 Received May 13, 1980 Four years of clinical experience with 320 vabra aspirations in 271 patients, aged 2 1 to 84 years, has confirmed our expectation of the procedure, as a quick and easy method, affording reliable diagnosis, causing few complications, and acceptable to patients as a routine method. The procedure was suitable for approximately 80% of patients with menstrual disorders or postmenopausal bleeding. It was also valuable in the follow-up of patients with previous adenomatous hyperplasia of the endometrium and those on long-term estrogen therapy for postmenopausal symptoms. The initial VA specimen was adequate in 95.2% of cases and the quality was excellent. VA supplemented with ECC and uterine size measurement enabled the diagnosis, grading, and staging of all adenocarcinomas accurately. Adenomatous hyperplasia of the endometrium was correctly diagnosed in 96.5% instances but two patients with mild to moderate adenomatous hyperplasia were missed. Endometrial polyps were diagnosed in only 50% of patients. The therapeutic or hemostatic efficacy of VA was just over 50% in this series. The five pregnancy complications (two ectopic pregnancies and three incomplete abortions) in our experience, warrant consideration in all premenopausal females presenting with a menstrual disorder before VA is carried out. Undoubtedly, hospitalization can be avoided, with attendant cost saving, by more widespread use of this technique. We recommend that all obstetric and gynecologic residents be familiar with the procedure.
Although outpatient procedures for diagnosing endometrial cancer have been advocated for 50 years [lo] dilatation and curettage (D&C) in the hospital under general anesthesia remains the prime diagnostic procedure [3]. Increasing demand for early diagnosis, espeically of malignant disease, has resulted in a marked increase in the frequency of diagnostic uterine curettage by the gynecologist. The development of vacuum aspiration for evacuating the pregnant uterus led naturally to the use of this method as a diagnostic and therapeutic procedure in nonpregnant women [8]. The use of the vabra aspiration (VA) has been reported in extensive clinical trials from Europe and many advantages have been claimed for the method [1,6-9,l l-131. Recently, this instrument became available in the U.S. It has attained widespread clinical use in a short time and preliminary reports have confirmed its usefulness [2-14,151. To date, most reports [l-4,6-9,1 l-151 have looked at the accuracy of the material obtained from VA in comparison to the D&C specimen and have found a very high correlation. ’ Address reprint requests to N. P. Veridiano, M. D., Department of Obstetrics and Gynecology, The Brookdale Hospital Medical Center, Linden Boulevard at Brookdale Plaza, Brooklyn, N.Y. 11212. 329 0090~8258/80/060329-08$01.00/O Copyright Q 1980 by Academic Press, Inc. All rights of reproduction in any form reserved.
330
DELKE,
VERIDIANO,
AND
DIAMOND
The purpose of the present report is to evaluate endocervical curettage (ECC), uterine sounding, and VA in the (1) management of patients with menstrual disorders and postmenopausal bleeding (PMB), (2) periodic follow-up of patients on long-term estrogen therapy for postmenopausal symptoms or patients with previous adenomatous hyperplasia of the endometrium, and (3) clinical staging and grading of endometrial cancer. MATERIALS
AND METHODS
The material comprises 320 vabra aspirations done in 271 patients, aged 2 1 to 84 years (Table l), by two gynecologists in their private practice over a four-year period, January 1, 1976 to December 31, 1979. The various indications for the procedure are shown in Table 2. Patients with (1) previous surgery on the cervix, (2) cervical stenosis, (3) possible adnexal mass, (4) debilitating medical conditions, and (5) very apprehensive patients were excluded. This amounted to 20% of patients requiring endometrial sampling. The instrument and technique used were as described elsewhere [ 1,2,14,151. All 27 1 patients had a pelvic examination and a Papanicolaou smear. Endocervical curettage with the Kevorkian curette (ECC) followed by uterine cavity sounding was performed in 96.7 and 91. I%, respectively. VA was performed in all patients without premeditation, anesthesia, or cervical dilatation. The patients were observed for lo-15 min on the examining table and the vital signs were checked. Patients returned to work the day of the procedure and coitus resumed after 5-7 days. Tissue collected was fixed immediately in 4% formaldehyde solution, the chamber being filled to capacity and closed with the extra cap provided. Patients with persistent or recurrent bleeding had fractional D&C in hospital or second VA in the office. Those patients on long-term estrogen therapy had VA every 6 months. All tissues from the VA, fractional D&C, and hysterectomy specimen were histologically reviewed. During the same I-year period, there were 2368 diagnostic uterine curettages performed for various menstrual disorders and postmenopausal bleeding (PMB) at the Brookdale Hospital Medical Center as an inpatient procedure under general anesthesia with a minimum hospital stay of 48 hr. Nearly 70% of these were done for menstrual disorders and three quarters of the patients were 40-59 years of age. RESULTS
The age distribution is widespread (Table 1) but the majority of patients, 212 (78.2%), were 40-59 years of age. There were 257 (94.8%) white patients. The indications for VA (Table 2) included menstrual disorders in 188(69.4%), PMB in 59 (21.8%), previous adenomatous hyperplasia of the endometrium in 11 (4.1%), and 9 (3.3%) patients on estrogen therapy for postmenopausal symptoms. Only 2 out of 188premenopausal patients with menstrual disorders, both over 50 years of age, had adenocarcinoma of the endometrium, while 8 out of 59 (57-84 years old) with PMB had this disease. One of these eight patients was on premarin for several years without any endometrial sampling. ECC performed in 262 cases was satisfactory in all and positive in only two instances. Uterine cavity length was
VABRA ASPIRATION
331
IN OFFICE GYNECOLOGY
TABLE 1 AGE DISTRIBUTIONOF 271 PATIENTS
Age
No. of patients
Percentage
30-39 40-49 m-59 Over 60
7 26 113 99 26
2.6 9.6 41.7 36.5 9.6
Total
271
100.0
Less than 30
measured and documented in 247 instances: 5% were less than 6 cm, 58.3% 6-8 cm, and 27.3% over 8 cm. The initial VA specimen was adequate for tissue study in 258 cases (95.2%) and the histologic diagnosis is shown in Table 3. Adenocarcinoma was diagnosed, staged, and graded accurately in 10 cases, as confirmed by hysterectomy specimen review. Adenomatous hyperplasia of the endometrium was found in 55 patients. There were 37 patients with mild focal adenomatous hyperplasia, 13 with moderate degree, 2 with severe hyperplasia without atypia, and 3 with atypical severe adenomatous hyperplasia. In five patients (ages 21-40 years), all presenting with “mennorrhagia,” the endometrium showed pregnancy changes: decidual reaction without chorionic villi (two ectopic pregnancies), decidual reaction with chorionic villi (two incomplete abortions), and one placental tissue (incomplete abortion). Tissue was insufficient for review in 13 cases (4.8%) at initial VA. Nine were postmenopausal females and subsequent D&C showed atrophic endometrium in seven and endometrial polyp in two. Of the four premenopausal females with menstrual disorders three had an endometrial polyp on D&C and one had proliferative endometrium with mild adenomatous hyperplasia of the endometrium. The accuracy of VA, as reviewed in 119 cases with subsequent D&C (44), second VA (33), and hysterectomy (42) showed the same histologic diagnosis as the initial VA in 104 cases (87.4%) and different tissue diagnosis in 15 instances (12.6%): two adenomatous hyperplasia of the endometrium, five endometrial TABLE 2 INDICATIONSFORVABRA ASPIRATION Indications Menstrual disorders (Menometrorrhagia) Postmenopausal bleeding Previous endometrial hyperplasia Estrogen series Postcoital bleeding Suspicious Pap smear Oral contraceptive pills for 7 years Total
No. of patients
Percentage
188
69.4
59 9 2 1 I
21.8 4.1 3.3 0.1 0.4 0.4
271
100. I
11
332
DELKE, VERIDIANO,
AND DIAMOND
TABLE 3 HISTOLOGIC DIAGNOSIS OF INITIAL VABRA ASPIRATION SPECIMEN IN 271 PATIENTS
Histologic diagnosis Proliferative endometrium Adenomatous hyperplasia of endometrium Secretory endometrium Atrophic endometrium Insufficient tissue Adenocarcinoma of endometrium Benign cystic changes of endometrium Endometrial polyp Pregnancy changes of endometrium Mixed endometrium Menstrual endometrium Chronic endometritis Total
No. of patients
Percentage
102 55 53 IS 13 IO 6 5 5 4 2 I
37.6 20.3 19.6 5.5 4.8 3.7 2.2 1.8 1.8 1.5 0.7 0.4
271
99.9
polyps, seven atrophic endometrium, and one insufficient tissue on D&C following VA (Table 4). The difference was important in only seven instances (5.9%). Two patients had adenomatous hyperplasia and five had endometrial polyps. Hence, the accuracy rate of VA approaches 94%. Therapeutic Efficacy One hundred fifty-four patients (56.8%) were asymptomatic after the initial VA and did not require a second VA or conventional D&C for 3 to 6 months. Estrogen Series There were nine patients on long-term estrogen therapy for postmenopausal symptoms (Table 5). There were two groups of patients in this series. The first group consisted of five patients who had VA before estrogen maintenance was started. Two of these five developed atypicai adenomatous hyperplasia of the endometrium and all reverted to normal on discontinuation of the estrogen. The second group comprised of four patients who already were on long-term estrogen therapy without initial endometrial sampling. One of these four patients presented with PMB and was found to have grade 3 adenocarcinoma of the endometrium. One patient had moderate adenomatous hyperplasia on VA, confirmed by review of the hysterectomy specimen. The hysterectomy was done for uterine prolapse. The two remaining patients in this group had atypical adenomatous hyperplasia which reverted to normal on withdrawal of the drug. Complication Rate Two patients had syncope immediately following the procedure but both recovered within 5 min. One instance of pelvic infection and a suspected uterine perforation on one occasion, requiring no surgical repair, were observed. Subjective pain was absent in 10 (3.4%), mild in 174(64.2%), moderate in 74 (27.3%), and severe in 13 patients (4.8%).
TABLE 4
Proliferative endometrium (1) Atrophic endometrium (I)
Insufficient tissue (13)
Initial VA diagnosis
Insufficient tissue (1)
Second VA Atrophic endometrium (7) Endometrial polyp (5) Mild endometrial hyperplasia (I)
D&C
Moderate endometrial hyperplasia (I)
Hysterectomy
DISCORDANCE BETWEEN FINDINGS BY INITIAL VABRA ASPIRATION AND D&C, SECOND VA, OR HYSTERECTOMY SPECIMEN IN I5 PATIENTS
202 Estinyl, 0.02
2002 Premarin, 0.625
2002 Premarin, 1.25.
0 Premarin, 0.625 2002 Premarin, 0.625
3003 Estinyl, 0.02
1011 Estinyi, 0.02
2022 Premarin, 0.625
50
56
58*
60
62*
64*
74*
Mild adenomatous hyperplasia of endometrium Focal atypical adenomatous hyperplasia of endometrium Adenocarcinoma, grade 3
Moderate adenomatous hyperplasia of endometrium Proliferative endometrium Scanty benign endometrium
Scanty benign endometrium Scanty benign endonetrium Proliferative endometrium
I
Atypical adenomatous hyperplasia of endometrium D/C estinyl proliferative endometrium
Proliferative endometrium proliferative endometrium
Proliferative endometrium
Proliferative endometrium
Proliferative endometrium
2
Proliferative endometrium
Severe atypical adenomaous hyperplasia of endometrium D/C estinyl proliferative endometrium
Atypical adenomatous hyperplasia of endometrium
3
4
Benign cystic endometrium
D/C Premarin benign cystic endometrium
D/C” Premarin proliferative endometrium
Vabra follow-up
Benign cystic endometrium
5
*These patients have been started on estrogen therapy by other physician! without an initial endometrial sampling.
61
1001 Premarin, 0.625
49
Age
Estrogen and Para dosage (mg)
TABLE 5 ESTROGENSERVES
Adenocarcinoma grade 1
Focal moderate adenomatous hyperplasia of endometrium
Hysterectomy
w E
VABBA
ASPIRATION
IN
OFFICE
GYNECOLOGY
335
DISCUSSION At the present time, increasing demand for medical care, associated with few hospital beds and rising cost, have made the conversion of diagnostic and therapeutic procedures to outpatient status more important. This report confirms the experience of others [2,6,14,15] that D&C with the use of general anesthesia in hospital is unnecessary if the purpose is to evaluate endocervical and/or endometrial tissue. The VA specimens were of excellent quality for histopathologic interpretation as shown by several authors [6,9,12] and the diagnostic accuracy agreed with other series [2,6,12,14,15]. All adenocarcinomas, 96.5% of the endometrial hyperplasias, but only 50% of endometrial polyps were correctly diagnosed by VA. The therapeutic or hemostatic efficacy of VA was just over 50% in this series, much lower than the reported 80-95% [6,9,121. The complication rate in our material, as in the literature [6,12], was modest. Vasovagal reaction occurred in only two patients, far less than might be expected. There was one patient with clinical signs of pelvic infection and one case of questionable uterine perforation requiring no surgical repair. Subjective pain or lower abdominal discomfort was the most common complaint. In the great majority of cases the pain was mild to moderate and brief, restricted to the procedure itself. Others [9] have observed that the pain associated with VA was comparable to that caused by insertion of an intrauterine device and less than that caused by hysterosalpingography. Thus the method does not require anesthesia and the patient can return to her usual work immediately. VA is well suited for 75-90% of patients requiring endometrial sampling [9, 141. We agree with others [9,14,15] that patients with cervical stenosis, possible adnexal mass, marked obesity, or debilitating medical conditions should be excluded. In this series two patients were found to have ruptured ectopic pregnancy following VA and three others had incomplete abortion. The age range of these five patients was 21-40 years. One should consider the possibility of a pregnancy complication in all premenopausal females presenting with menstrual disorders before VA. The method is also very useful in cases where endometrial sampling must be done periodically as in patients on long-term estrogen therapy or those with previous adenomatous hyperplasia of the endometrium. The findings here confirm the experience of others that adenomatous hyperplasia induced by long-term estrogen administration will usually respond to withdrawal of the drug 151. Four years of clinical experience with VA has confirmed our expectation of the procedure as a quick and easy method, affording reliable diagnosis, causing few complications, and acceptable to patients as a routine method. Furthermore, when supplemented with ECC and uterine size measurement it enables clinical staging and grading of endometrial cancer. Undoubtedly, many hospitalizations can be avoided, with attendant cost saving, by more widespread use of this technique. We recommend that all obstetric and gynecologic residency programs institute VA in their training so that their residents are familiar with the procedure. REFERENCES 1. Bjerre, B. A., Gardmark, S. A., and Sjoberg, N. Aspiration curettage-A J. Reprod. Med. 7, 221-223 (1971).
new diagnostic method,
336
DELKE,
VERIDIANO,
AND
DIAMOND
2. Cohen, C. J. Gusberg, S. B., and Koftler, D. Histologic screening for endometrial cancer, Cynecol. Oncol. 2, 279-286 (1974). 3. Creasman, W. T., and Weed, J. C. Screening techniques in endometrial cancer, Cancer 38, 438-440 (1976). 4. Denis, R. Jr., Bamett, J. M., and Forbes, S. E. Diagnostic suction curettage, Obstet. Gynecol. 42,
301-303 (1973). 5. Gusberg, S. B. Current concepts: The changing nature of endometrial cancer, N. Engl. J. Med. 302, 729-731 (1980). 6. Haack-Sorensen, P. E., Starklint H., Aronsen, A., Hansen, M. K., and Kristoffersen, K. Diagnos-
tic vabra (aspiration) curettage, Dun. Med. Bull. 26, l-6 (1979). 7. Holt, E. M. Out-patient diagnostic curettage, J. Obstet. Gynaecol. Brit. Commonw. 77, 10431046 (1970). 8. Jensen, J. A., and Jensen, 3. G. Abrasio mucosae uterie aspiratione, Ugeskr. Laeg. 130, 21242127 (I%@. 9. Jensen, J. G. Vacuum curettage. Out-patient curettage without anesthesia, A report of 350 cases, Dan. Med. Bull. 17, 199-2020 (1970).
10. Kelly, H. A. Curettage without anesthesia on the office table. Amer. .I. Obstet. Gynecol. 9,78-80 (1925).
Il. Mathews, D. D., Kakani, A., and Bhattacharya, A. A comparison of vacuum aspiration of the uterus and conventional curettage in the management of abnormal uterine bleeding, J. Obstet. Gynaecol. Brit. Commonw. 80, 176-180 (1973). 12. Nussler, E., Thomsen, P. B., and Weeth, R. Vacuum curettage of the uterus,Dan. Med. Bull. 22, 165-168 (1975). 13. Saunders, P., and Rowland, R. Vacuum Curettage of the uterus without anesthesia, J. Obstet.
Gynaecol. Brif. Commonw. 79, 168-174 (1972). 14. Walters, D., Robinson, D., Park, R. C., and Paton, W. E. Diagnostic outpatient aspiration curettage, Obstet. Gynecol. 46, 160-164 (1975). 15. Webb, M. J., and Gaffey, T. A. Outpatient diagnostic aspiration curettage, Obstet. Gynecol. 47, 239-242 ( 1976).