- Email: [email protected]
Excerpts from the World Medical Literature
WORLD MEDICAL LITERATURE
Excerpts from the World Medical Literature Cleve Ziegler, MD Department of Obstetrics and Gynecology, the Jewish General Hospital and McGill University, Montréal, QC
Premenopausal abnormal uterine bleeding and risk of endometrial cancer; Pennant et al., BJOG 2017;124:404e11. Abstract: A systematic review to establish the risk of endometrial cancer and atypical hyperplasia in premenopausal women with abnormal uterine bleeding. Sixty-five of 2736 articles retrieved qualified for analysis. Overall risk of endometrial cancer was 0.33%, and atypical hyperplasia was 1.3%. Risk of cancer was very low (0.11%) in women with heavy menstrual bleeding compared with women with intermenstrual bleeding (0.52%). No cases of atypical hyperplasia were identified in women with heavy menstrual bleeding. Age (>50 years) was also associated with a higher risk of cancer (14.1% vs. 0.8% for women <40 years). Comments: Almost all professional societies recommend endometrial sampling in the investigation of abnormal uterine bleeding in premenopausal women (SOGC, American College of Obstetricians and Gynecologists, and National Institute for Health and Care Excellence). However, endometrial biopsies can be unpleasant for the patient, technically difficult for the provider, and a barrier to initiating medical management by either family physician or specialist. This article serves to reassure us that rates of atypical hyperplasia or cancer are very low in women with regular, heavy periods and women under 50 years old. Where barriers to specialist consultation exist, family physicians should be reassured that they can initiate medical management while awaiting a gynecologist’s opinion. Clinicians should be more cautious in treating older women with irregular bleeding without an endometrial biopsy. Patient and provider factors associated with endometrial Pipelle sampling failure; Adambekov et al., Gynecol Oncol 2017;144:324e8. Abstract: To explore the risk factors associated with sampling failure in women who underwent Pipelle biopsy. Medical records were reviewed in 200 patients who underwent Pipelle biopsies for suspected uterine pathology. Pipelle biopsy sampling failed in 23% of women; reasons
included inability to access the endometrium, inadequate samples, and “unknown.” Factors related to failed sampling included postmenopausal status (OR 7.41), history of prior biopsy failure (OR 23.87), and type of provider (OR 9.15). Comments: Over the past two decades, office sampling with Pipelle or similar devices has replaced formal curettage as the first-line step in evaluation of abnormal uterine bleeding in premenopausal and postmenopausal women. Pipelle has been consistently demonstrated to have a high sensitivity for the detection of endometrial cancer. However, there remains a number of women in whom office biopsy is not technically feasible. Identifying these patients and arranging for formal hysteroscopy/curettage may be preferable instead of futile attempts at office sampling. Personally, I will attempt a repeat office endometrial biopsy if the referring clinician is a low-volume provider but will avoid traumatizing a patient if it is clear from her clinical examination that failure is the likely outcome again. Hysteroscopic proximal tubal occlusion versus laparoscopic salpingectomy as a treatment for hydrosalpinges prior to IVF or ICSI; Dreyer et al., Hum Reprod 2016;31:2005e16. Abstract: This was a randomized trial to determine whether hysteroscopic proximal tubal occlusion with Essure had comparable results to laparoscopic salpingectomy for women undergoing IVF/ICSI for tubal factor infertility. A two-centre RCT of 85 women with ultrasound-documented hydrosalpinx and infertility who were scheduled for IVF/ ICSI was performed; half were randomly assigned to insertion of Essure devices, and the other half were randomly assigned to laparoscopic surgical removal of the fallopian tubes. Ongoing pregnancy rates were 26% in the Essure group and 55% in the laparoscopic surgery group. J Obstet Gynaecol Can 2017;39(4):213e214 https://doi.org/10.1016/j.jogc.2017.02.010 Copyright ª 2017 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
APRIL JOGC AVRIL 2017
l
213
WORLD MEDICAL LITERATURE
The conclusion was that Essure was inferior to laparoscopic salpingectomy for pregnancy rate in these patients. Comments: It has been a difficult few years for the much heralded Essure implant. The concept of a less invasive method of outpatient/office hysteroscopic sterilization was appealing. Yet, recent evidence from a large database in New York state showed that women who had undergone this procedure were much more likely to have repeat surgery within the year after placement than those who had undergone laparoscopic tubal sterilization. In this article, which involved the use of Essure as an alternative to the riskier laparoscopic surgery for treating hydrosalpinges, the authors demonstrated that the use of Essure was associated with a significantly lower chance of successful ongoing pregnancy. The evidence that “treating” hydrosalpinges in women with tubal factor infertility contributes to improved success with IVF/ICSI is clear; the question remains whether there are possibly safer alternatives to surgical removal of the fallopian tubes in these patients. Small lesion size measured by colposcopy may predict absence of cervical intraepithelial neoplasia in a large loop excision of the transformation zone specimen; Munmany et al., BJOG 2017;124:495e502. Abstract: A cohort of 116 women who underwent a loop electrosurgical excision procedure (LEEP) for persistent
214
l
APRIL JOGC AVRIL 2017
cervical intraepithelial neoplasia was classified into the following two groups: those with and without residual cervical intraepithelial neoplasia in the LEEP specimen. The outcome measure was to determine whether the size of the initial lesion and HPV genotype could be used to predict which women would have a negative LEEP specimen. Size of initial lesion of <12 mm using digital colposcopy and non-HPV 16 and 18 genotypes had a negative predictive value of 86% in predicting a negative LEEP specimen. Comments: There is an extensive body of literature linking prior cervical excision (LEEP or cold knife cone) and preterm birth. These procedures, and HPV infection itself, are associated with an increased relative risk of preterm birth in the range of 1.6 to 1.8. Changing guidelines for both the management and triage of squamous intraepithelial lesions of the cervix promotes a more conservative approach with regards to excision in young women. Nevertheless, there is still an unacceptably high rate of negative LEEP specimens of 20% to 25% (as in this article). The implications on future pregnancy in these women are not trivial. Developing better predictors of negative histology at LEEP would help clinicians avoid ultimately unnecessary procedures, with all the short- and long-term risk they incur. Digital colposcopy and the incorporation of HPV genotype testing in evaluation of these patients look promising.
Excerpts from the World Medical Literature Cleve Ziegler, MD Department of Obstetrics and Gynecology, the Jewish General Hospital and McGill University, Montréal, QC
Premenopausal abnormal uterine bleeding and risk of endometrial cancer; Pennant et al., BJOG 2017;124:404e11. Abstract: A systematic review to establish the risk of endometrial cancer and atypical hyperplasia in premenopausal women with abnormal uterine bleeding. Sixty-five of 2736 articles retrieved qualified for analysis. Overall risk of endometrial cancer was 0.33%, and atypical hyperplasia was 1.3%. Risk of cancer was very low (0.11%) in women with heavy menstrual bleeding compared with women with intermenstrual bleeding (0.52%). No cases of atypical hyperplasia were identified in women with heavy menstrual bleeding. Age (>50 years) was also associated with a higher risk of cancer (14.1% vs. 0.8% for women <40 years). Comments: Almost all professional societies recommend endometrial sampling in the investigation of abnormal uterine bleeding in premenopausal women (SOGC, American College of Obstetricians and Gynecologists, and National Institute for Health and Care Excellence). However, endometrial biopsies can be unpleasant for the patient, technically difficult for the provider, and a barrier to initiating medical management by either family physician or specialist. This article serves to reassure us that rates of atypical hyperplasia or cancer are very low in women with regular, heavy periods and women under 50 years old. Where barriers to specialist consultation exist, family physicians should be reassured that they can initiate medical management while awaiting a gynecologist’s opinion. Clinicians should be more cautious in treating older women with irregular bleeding without an endometrial biopsy. Patient and provider factors associated with endometrial Pipelle sampling failure; Adambekov et al., Gynecol Oncol 2017;144:324e8. Abstract: To explore the risk factors associated with sampling failure in women who underwent Pipelle biopsy. Medical records were reviewed in 200 patients who underwent Pipelle biopsies for suspected uterine pathology. Pipelle biopsy sampling failed in 23% of women; reasons
included inability to access the endometrium, inadequate samples, and “unknown.” Factors related to failed sampling included postmenopausal status (OR 7.41), history of prior biopsy failure (OR 23.87), and type of provider (OR 9.15). Comments: Over the past two decades, office sampling with Pipelle or similar devices has replaced formal curettage as the first-line step in evaluation of abnormal uterine bleeding in premenopausal and postmenopausal women. Pipelle has been consistently demonstrated to have a high sensitivity for the detection of endometrial cancer. However, there remains a number of women in whom office biopsy is not technically feasible. Identifying these patients and arranging for formal hysteroscopy/curettage may be preferable instead of futile attempts at office sampling. Personally, I will attempt a repeat office endometrial biopsy if the referring clinician is a low-volume provider but will avoid traumatizing a patient if it is clear from her clinical examination that failure is the likely outcome again. Hysteroscopic proximal tubal occlusion versus laparoscopic salpingectomy as a treatment for hydrosalpinges prior to IVF or ICSI; Dreyer et al., Hum Reprod 2016;31:2005e16. Abstract: This was a randomized trial to determine whether hysteroscopic proximal tubal occlusion with Essure had comparable results to laparoscopic salpingectomy for women undergoing IVF/ICSI for tubal factor infertility. A two-centre RCT of 85 women with ultrasound-documented hydrosalpinx and infertility who were scheduled for IVF/ ICSI was performed; half were randomly assigned to insertion of Essure devices, and the other half were randomly assigned to laparoscopic surgical removal of the fallopian tubes. Ongoing pregnancy rates were 26% in the Essure group and 55% in the laparoscopic surgery group. J Obstet Gynaecol Can 2017;39(4):213e214 https://doi.org/10.1016/j.jogc.2017.02.010 Copyright ª 2017 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.
APRIL JOGC AVRIL 2017
l
213
WORLD MEDICAL LITERATURE
The conclusion was that Essure was inferior to laparoscopic salpingectomy for pregnancy rate in these patients. Comments: It has been a difficult few years for the much heralded Essure implant. The concept of a less invasive method of outpatient/office hysteroscopic sterilization was appealing. Yet, recent evidence from a large database in New York state showed that women who had undergone this procedure were much more likely to have repeat surgery within the year after placement than those who had undergone laparoscopic tubal sterilization. In this article, which involved the use of Essure as an alternative to the riskier laparoscopic surgery for treating hydrosalpinges, the authors demonstrated that the use of Essure was associated with a significantly lower chance of successful ongoing pregnancy. The evidence that “treating” hydrosalpinges in women with tubal factor infertility contributes to improved success with IVF/ICSI is clear; the question remains whether there are possibly safer alternatives to surgical removal of the fallopian tubes in these patients. Small lesion size measured by colposcopy may predict absence of cervical intraepithelial neoplasia in a large loop excision of the transformation zone specimen; Munmany et al., BJOG 2017;124:495e502. Abstract: A cohort of 116 women who underwent a loop electrosurgical excision procedure (LEEP) for persistent
214
l
APRIL JOGC AVRIL 2017
cervical intraepithelial neoplasia was classified into the following two groups: those with and without residual cervical intraepithelial neoplasia in the LEEP specimen. The outcome measure was to determine whether the size of the initial lesion and HPV genotype could be used to predict which women would have a negative LEEP specimen. Size of initial lesion of <12 mm using digital colposcopy and non-HPV 16 and 18 genotypes had a negative predictive value of 86% in predicting a negative LEEP specimen. Comments: There is an extensive body of literature linking prior cervical excision (LEEP or cold knife cone) and preterm birth. These procedures, and HPV infection itself, are associated with an increased relative risk of preterm birth in the range of 1.6 to 1.8. Changing guidelines for both the management and triage of squamous intraepithelial lesions of the cervix promotes a more conservative approach with regards to excision in young women. Nevertheless, there is still an unacceptably high rate of negative LEEP specimens of 20% to 25% (as in this article). The implications on future pregnancy in these women are not trivial. Developing better predictors of negative histology at LEEP would help clinicians avoid ultimately unnecessary procedures, with all the short- and long-term risk they incur. Digital colposcopy and the incorporation of HPV genotype testing in evaluation of these patients look promising.