Isthmocele: an overview of diagnosis and treatment

SUMMARY An isthmocele, a cesarean scar defect or uterine niche, is any indentation representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity, at the site of a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.

RESUMO A istmocele ou nicho uterino é representada por uma descontinuidade miometrial ou um defeito anecoico triangular na parede uterina anterior, com a base se comunicando com a cavidade uterina no local de uma cicatriz anterior de cesárea. O defeito pode ser classificado como pequeno ou grande, dependendo da espessura da parede miometrial deficiente. Embora geralmente assintomático, seu principal sintoma é o sangramento uterino anormal ou pós-menstrual; a dor pélvica crônica também pode ocorrer. Infertilidade, placenta acreta ou prévia, deiscência de cicatriz, ruptura uterina e gravidez ectópica em cicatriz de cesárea prévia também podem aparecer como complicações dessa condição. Os fatores de risco para desenvolvimento da istmocele comprovados até o momento incluem útero retroverso e múltiplas cesarianas. No entanto, fatores como localização mais inferior de uma cesárea prévia, fechamento incompleto da histerotomia, aderências precoces na parede uterina e predisposição genética também podem contribuir para o desenvolvimento de um nicho. Como não existem critérios definitivos para o diagnóstico de uma istmocele, vários métodos de imagem podem ser usados para avaliar a integridade da parede uterina e, assim, diagnosticar uma istmocele. Entretanto, ultrassonografia transvaginal e sono-histerografia com infusão salina surgem como métodos específicos, sensíveis e custo-efetivos para o diagnóstico de istmocele. O tratamento inclui manejo clínico ou cirúrgico, dependendo do tamanho do defeito, da presença de sintomas, da presença de infertilidade secundária e de planos de gravidez. O manejo cirúrgico inclui abordagens minimamente invasivas como histeroscopia, laparoscopia ou transvaginal, de acordo com o tamanho do defeito.

Sangramento uterino anormal: proposta de abordagem do Grupo Heavy Menstrual Bleeding: Evidence-Based Learning for Best Practice (HELP) / Heavy menstrual bleeding: management proposal of the Heavy Menstrual Bleeding: Evidence-Based Learning for Best Practice Group (HELP)

O Sangramento Uterino Anormal (SUA) representa um problema de saúde pública complexo que pode acometer 1/3 das mulheres em todo o mundo. Apresenta um impacto negativo importante na qualidade de vida de mulheres e associa-se a elevados custos econômicos diretos e indiretos. Trata-se de uma condição desafiadora tanto para as mulheres afetadas quanto para os profissionais de saúde. A nomenclatura atribuída ao SUA é confusa e faltam ainda recomendações diagnósticas e terapêuticas padronizadas. Foi criado o grupo Heavy Menstrual Bleeding: Evidence-based Learning for Best Practice (HELP) com proposta abordar os aspectos inconclusivos do SUA. Foram avaliados 134 documentos, incluindo 121 artigos científicos e 14 revisões de medicamentos, para desenvolvimento dos protocolos HELP. Foram elaborados protocolos simplificados referentes ao diagnóstico e tratamento do SUA, visando contribuir de forma mais eficaz com os médicos em seus diferentes cenários de atuação. O roteiro diagnóstico sugerido, compreendendo perguntas chaves e ações específicas, sinaliza para indicação de métodos propedêuticos adicionais. O tratamento proposto visa reduzir a perda do sangue menstrual e melhorar de a qualidade de vida das pacientes.(AU)

Abnormal uterine bleeding (AUB) is a complex public health problem that can affect one third of women worldwide. It has a significant negative impact on quality of life of women and is associated with high direct and indirect economic costs. It is a challenging condition for both the women affected and for the health professionals. The nomenclature assigned to the AUB is confusing and still miss diagnostic and therapeutic recommendations standardized. The Heavy Menstrual Bleeding: Evidence-based Learning for Best Practice Group (HELP) was created with the proposal to address the inconclusive aspects of AUB. The group evaluated 134 documents, including 121 scientific articles and 14 reviews of drugs for the development of protocols HELP. Simplified protocols were drawn up relating to the diagnosis and treatment of AUB, to contribute more effectively with doctors at different scenarios of operation. The script diagnostic suggested, comprising keys questions and specific actions, can indicate additional diagnostic methods. The proposed treatment aims to reduce the loss of menstrual blood and improve the quality of life of patients.(AU)

Diagnostic accuracy of endometrial curettage in endometrial pathology

Abnormal uterine bleeding is one of the most frequent problems in life of an adult female. Uterine curettage or biopsy remains a preferred sampling procedure for diagnosis of the endometrial pathology. The objective of this study was to compare the sensitivity, specificity, positive and negative predictive value of endometrial curettage. This validation study was carried out at the Department of Histopathology, Army Medical College Rawalpindi in collaboration with Military Hospital, Rawalpindi from January to December 2010. The study included 50 curettage and subsequent hysterectomy specimen of the same patients. Non-probability sampling technique was used to divide patients into two groups with 50 patients in each group. One group was of endometrial curettage having endometrial pathology [group A]. Second group was of subsequent hysterectomy specimen of the same patients [group B]. Endometrial curettage was found most accurate in diagnosing endometrial carcinoma. Sensitivity of endometrial curettage was found to be 33% whereas specificity and positive predictive value was found to be 100% each. Negative predictive value was found to be 93.1%. Endometrial biopsy is a sensitive and a specific test in and is accurate in diagnosing endometrial pathology. It is found most accurate in diagnosing endometrial carcinoma

Location, size and clinical symptoms of uterine polyps

In this study we tried to find relationship between location, size and clinical symptoms of uterine polyps. Our cross sectional study was performed during the year 2008 in Ahwaz Imam Khomayni Hospital. Patients who underwent office hysteroscopy were evaluated and those with hysteroscopic diagnosis of polyp were entered in the study. Hysteroscopic findings of location and size of polyps and clinical presentations of Abnormal Uterine Bleeding [AUB] dysmenorrhea, infertility, discharge, spotting plus discharge were evaluated. One hundred and twenty four patients were evaluated. The most common location of polyp and clinical presentation were cervical canal and AUB, respectively. Polyp sizes of equal or less than 1 cm are commonly seen in cervical canal and cornea and more than 1 cm polyps are commonly found in uterine cavity and near internal os. In this study we showed that location of polyp is important in clinical presentation. Patients presented with AUB had polyps more common in uterine cavity, patients with spotting plus discharge had polyps more in cervical canal

Sangramento uterino anormal / Abnormal uterine bleeding

O sangramento uterino anormal é um distúrbio frequente que pode ocorrer em qualquer idade entre a menarca e a menopausa, mas concentra-se principalmente em seus extremos, logo após a menarca e no período perimenopausa, quando ocorrem alterações no eixo hipotálamo-hipófise-ovário, que levam com muita frequência à anovulação. O sangramento uterino disfuncional, considerado diagnóstico de exclusão, pode ser ovulatório ou anovulatório. O manejo do quadro pressupõe que o sangramento agudo seja coibido e que se evite a recidiva; para tanto, é fundamental que se estabeleça o diagnóstico etiológico. Os autores fazem uma revisão objetiva sobre o assunto, dando ênfase ao diagnóstico e tratamento da doença.

Abnormal uterine bleeding is a clinical problem wich may occur at any time during the reproductive years; however, it is most prevalent during perimenarche and perimenopause, when women tend to have anovularoty cycles. Disfunctional uterine bleeding is a prevalent disease that affects women from adolescence to menopause. The treatment should control the acute bleeding and avoid the recidive. The etiological diagnosis is fundamental for this purpose. The authors make an objective review about dysfunctional uterine bleeding herein, focusing on the diagnosis and treatment of the disease.

Alteraciones hemostáticas en pacientes con sangrado uterino anormal / Hemostatic alterations in patients with abnormal uterine bleeding

Conocer la frecuencia de defectos hemostáticos en mujeres con sangrado uterino anormal. Se estudiaron 55 mujeres de edades comprendidas entre 17 y 55 años, que presentaban sangrado uterino anormal. En cada paciente se realizó un estudio que comprendió: Historia clínica, examen físico (incluido examen ginecológico), biopsia endometrial, ultrasonograma transvaginal y pélvico y estudio hemostático a través de la determinación de los tiempos de protrombina y de tromboplastina parcial, concentraciones de factor VIII (FVIII), factor von Willebrand (FvW) y IX y agregación plaquetaria con epinefrina, ADP, colágeno y ristocetina. Hospital Nuestra Señora de Chiquinquirá, e Instituto de Investigaciones Clínicas “Dr. Américo Negrette”, Facultad de Medicina. Universidad del Zulia, Maracaibo, Venezuela. En todas las mujeres se halló una alteración orgánica, funcional o mixta en el área genital. Los tiempos de coagulación y las concentraciones de los factores estudiados fueron normales con excepción de una paciente cuya concentración de FVIII fue de 0,47U/μL. La agregación plaquetaria mostró alteraciones en el 51,1 por ciento de los casos. La frecuencia de alteraciones de la coagulación en mujeres con sangrado uterino anormal, fue similar a la de la población general, por esta razón no se justifica que todas las pacientes con sangrado uterino anormal, se sometan a un estudio de coagulación; sin embargo, la alta frecuencia de agregación plaquetaria anormal, se debe tomar en cuenta antes de decidir una conducta quirúrgica.

Eficiencia de los métodos diagnósticos en el estudio del sangrado uterino anormal en la peri y postmenopausia / Diagnostic methods in peri and potmenopausal women with abnormal uterine bleeding

El sangrado uterino anormal es un importante síntoma que puede indicar la presencia de cáncer o hiperplasia endometrial. El objetivo de este estudio es evaluar la eficiencia de los diversos métodos diagnósticos en pacientes peri y postmenopáusicas con sangrado uterino anormal y proponer una vía de manejo en estas pacientes. Diferentes métodos diagnósticos serán evaluados, incluyendo ecografía transvaginal, sonohisterografía, Doppler, resonancia magnética nuclear, biopsia por Pipelle, dilatación y curetage e histeroscopia. Está demostrado que la ecografía transvaginal tiene una alta eficiencia para el reconocimiento de lesiones difusas, mientras que sonohisterografía tiene una alta eficiencia para identificar lesiones focales. Por otro lado, la biopsia por Pipelle ha demostrado descartar patología difusa con una alta eficiencia. Se concluye que la mejor vía para el estudio de pacientes con sangrado uterino anormal es realizar una ecografía transvaginal y una histerosonografía en el mismo momento, seguido por una biopsia mediante Pipelle. Finalmente, puede ser sugerido que por esta vía es altamente probable que todos los casos de cáncer e hiperplasia endometrial puedan ser identificados.

Abnormal uterine bleeding is an important symptom that can mean presence of endometrial cancer or endometrial hyperplasia. The aim of this study is to assess the effectiveness of selected diagnostic methods in peri and potmenopausal women with abnormal uterine bleeding, and to propose a way to manage in these patients. Different diagnostic methods are assessed, which include transvaginal ultrasonography, sonohysterography, Doppler technique, magnetic resonance images, biopsy by Pipelle, dilatation and curettage, and hysteroscopy. It is founded that ultrasonography has a high efficiency when it comes for identifying diffuse lesions, while sonohysterography has a high efficiency for identify focal lesions. On the other hand biopsy by Pipelle has demonstrated to rule out diffuse pathology with a high efficiency. It is concluded that the best way to manage patients with abnormal uterine bleeding by performing ultrasonography and sonohysterography at the same time followed by a Pipelle biopsy. Finally, it can be suggested that by this way it is highly probable that all cases with endometrial carcinoma and endometrial hyperplasia can be identified.

Vaginal bleeding with multicystic ovaries and a pituitary mass in a child with severe hypothyroidism.

A seven year and ten months old girl presented with cyclic vaginal bleeding and a huge abdominopelvic mass. She had clinical features of hypothyroidism. The investigation results were consistent with the diagnosis of primary hypothyroidism with precocious puberty. She also had bilaterally enlarged cystic ovaries on CT scan of abdomen and CT scan of brain showed pituitary macroadenoma. After starting treatment with thyroxine, patient became euthyroid and her general condition improved. Treatment with thyroxine alone halted the cyclic vaginal bleeding, led to rapid resolution of the ovarian cysts and regression of the pituitary mass.

Evaluation of adjunctive tests for cervical cancer screening in low resource settings.

BACKGROUND: Visual inspection of cervix after application of acetic acid (VIA) is an effective screening tool for cervical cancer in low resource settings, but its low specificity leads to high referral rates. Adjunctive testing may overcome this drawback. AIMS: This pilot study was aimed to assess test performances of VIA, human papillomavirus (HPV) testing and Pap smear, individually and in simulated combinations, to determine the probable best screening option. SETTING AND DESIGN: Gynecology outpatient department (OPD); cross-sectional study. MATERIALS AND METHODS: One hundred women with complaints of irregular vaginal bleeding or discharge, post coital bleeding or unhealthy cervix on examination underwent Pap smear, HPV testing, VIA, colposcopy and biopsy, if indicated, in this screening order. STATISTICAL ANALYSIS: Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each of the tests with a biopsy result of > or =HSIL taken as the gold standard. Simulated parallel and sequential combinations for VIA/Pap, VIA/HPV and HPV/Pap were calculated and compared with individual test performance. RESULTS: Prevalence of abnormal Pap smears was 5%, VIA positive 51% and HPV positive 16%. Sensitivity and specificity of VIA were 100% and 53.3% respectively. For HPV and Pap tests corresponding figures were 85.7%, 89.7% and 50%, 98.9% respectively. The best simulated combination with a balance of sensitivity and specificity was of VIA followed by HPV testing (sensitivity 85.7%, specificity 95.4%). CONCLUSION: Addition of HPV testing to VIA can increase the specificity of VIA, thereby reducing the referral rates without compromising the sensitivity of the test.

Histerescopía diagnóstica: rendimiento en el estudio de la metrorragia e inocuidad ante un eventual cáncer de endometrio, revisión de la literatura / Diagnostic hysteroscopy in postmenopausal metrorrhagia and safety in endometrial cancer patients: literature review

Objetivo: Evaluar la precisión diagnóstica de la histeroscopia en el estudio del endometrio en pacientes con metrorragia y determinar los riesgos derivados de efectuar el examen en pacientes portadoras de un cáncer de endometrio. Método: Revisión no sistemática de la literatura basada en MEDLINE y rastreo de referencias de artículos relevantes. Resultados: Se identificaron 7 metaanálisis, los cuales incluyen 43.757 pacientes sometidas a diferentes procedimientos para el estudio del endometrio. Se compara el rendimiento de la histeroscopia diagnóstica contra biopsia aspirativa endometrial, ecografía transvaginal e histerosonografía en su correlación con la histología. La histeroscopia resultó ser un examen de muy alta especificidad al igual que la biopsia espirativa, que los hace útiles en el estudio de casos con endometrio anormal seleccionados por ecografía transvaginal. Se examinó las recomendaciones autorizadas, la evidencia a favor y en contra de realizar histeroscopia en pacientes con cáncer de endometrio. Conclusiones: No existe evidencia suficiente para sostener la inocuidad de la histeroscopia diagnóstica en este tipo de pacientes, pero tampoco para afirmar que empeore su pronóstico. Se propone un esquema de estudio de la metrorragia en diferentes situaciones clínicas en base a la evidencia disponible, teniendo en cuenta la sugerencia de evitar en lo posible la histeroscopia en pacientes con riesgo alto de cáncer de endometrio.

Efficacy of pipelle as a tool for endometrial biopsy

This study was carried out to determine the accuracy of Pipelle sampling in the diagnosis of abnormal uterine bleeding by comparing it with histopathology of the hysterectomy specimens taken as gold standard. One hundred patients with abnormal uterine bleeding in perimenopausal or postmenopausal age group scheduled for hysterectomy had endometrial sampling with Pipelle, in the department of Obstetrics and Gynaecology Unit I, Sir Ganga Ram Hospital, Lahore, from Dec. 2003 to Dec. 2004. The specimens were sent for histopathology. Among 100 patients, 66 underwent hysterectomy. In the remaining 34 patients, 6 had inadequate specimen on Pipelle sampling and in 28 patients hysterectomy was planned but postponed because of medical problems. Among the 66 patients the results of Pipelle Endometrial Sampling [PES] were compared with histological results of hysterectomy specimen. Among the 66 patients the results of PES were compared with the histological results of hysterectomy specimen. In 61 cases the histopathological results were identical indicating a correlation of 92.42%. In 5 cases results were different, 4 having slight variation and in one case PES reported complex hyperplasia and on hysterectomy it turned out to be a case of carcinoma cervix. It is concluded that Pipelle biopsy is definitely a useful and cost effective method. It can reduce the number of D and C performed in the theatre. Moreover it has an advantage of taking biopsy on the first visit of patient thereby time taken for the diagnosis of malignancy can be reduced

Accuracy of pipelle endometrial sampler in evaluation of endometrium

The purpose of this study was to compare the use of pipelle endometrial sampling device based on the quality of material obtained and diagnostic accuracy with conventional dilation and curettage [Dand C] or hysterectomy specimens. This cross sectional study was done on 50 patients who referred to gynecology ward of Imam Reza hospital with abnormal uterine bleeding [AUB] or infertility for endometrial dating. Thirty-eight patients underwent two endometrial samplings [pipelle and conventional D and C] on the same occasion while 12 cases underwent hysterectomy. The procedure of sampling by pipelle was done by one person and the specimens were submitted to a pathologist. The adequacy of the specimen and histoiogical diagnosis were compared. Pipelle obtained adequate sample in 47 of 50 cases [94%]. The histoiogical diagnosis was the same in 85% of cases [40 out of 47]. The sensitivity for endometrial dating and endometrial polyp was 100% and 40%, respectively. Among 7 cases of inconsistent diagnosis, there was one missed malignancy [squamous cell carcinoma of cervix with extension to isthmus and lower segment]. In this case the histoiogical diagnosis of pipelle was inactive endometrium surrounded by pieces of clot. Pipelle endometrial sampling is an easy method for diagnosis of endometrial pathology. Its diagnostic accuracy for endometrial dating is very high, but in management of AUB, replacing conventional D and C with pipelle should be done with caution and preferably completed by other diagnostic techniques

[Postmenopausal uterine bleeding. Analytic study about 65 cases]

Postmenopausal uterine bleeding is frequent in gynecology. This symptom can reveal benign causes as well as cancers. So it's essential to rule out organic pathology. We propose a retrospective study of 65 postmenopausal women who had uterine bleeding for two years. To study the relative frequency of different causes of post-menopausal uterine bleeding.- To evaluate the different investigation procedures. In 65 cases of postmenopausal bleeding, we found:- 6 cases of cancer [9.2%]: 4 cases of cancer of uterine corpus and 2 cases of cancer of uterine cervix.- Benign pathology was more frequent [59 cases: 90.8%], essentially represented by endometrial atrophy [37 cases] and hyperplasia [11 cases].- Hysteroscopic aspect in the 4 cases of endometrial cancer:- Polypoid hypertrophy: 2 cases.- Simple hyperplasia: 2 cases. Despite the fact that benign pathology is more frequent than malignancy as a cause postmenopausal uterine bleeding, we must always rule out a cancer by oriented biopsy

Valor de la histeroscopía en el diagnóstico de las metrorragias / Hysteroscopy value in metrorrhage diagnosis

El sangrado uterino anormal es una de las principales causas de consulta en ginecología. Por muchos años el principal método diagnóstico, sino el único, correspondió a la dilatación y legrado de la cavidad uterina para obtener una muestra representativa del endometrio y luego su estudio histológico. Actualmente se ha establecido que este procedimiento da cuenta sólo del 70-80 por ciento del material de la cavidad uterina y los resultados son insatisfactorios para lograr un diagnóstico definitivo, que permita explicar la causa del sangrado uterino. La histeroscopía ha ocupado un importante papel en el diagnóstico, pues permite una visión completa de la cavidad, puede visualizar las alteraciones anatómicas y aquellas del endometrio que puedan explicar la causa de la metrorragia. Además permite realizar biopsias dirigidas o bajo visión directa. El presente trabajo muestra la experiencia acumulada durante 33 meses en el Hospital Regional Temuco, luego de haber incorporado el estudio histeroscópico en las pacientes con diagnóstico de metrorragia, entre otras indicaciones. Se presentan los principales diagnósticos obtenidos y la sensibilidad y especificidad frente a diagnósticos específicos

Correlación entre escobillado y biopsia endometriales: propuesta del escobillado como screening para detección del carcinoma de endometrio / Correlation between endometrials endobrushings and biopsies: proposal of the endobrushings as screening for detection of the endometrium carcinoma

Durante un lapso de 19 meses se estudiaron 47 pacientes con metrorragias de la peri y posmenopausia, a 37 de ellas se les efectuaron escobillados y biopsias de endometrio con fines diagnósticos. Se procede a realizar una correlación citoanatomopatológica deducida de las dos modalidades diagnósticas. De los 37 casos a los que se les efectuó escobillado y raspado biópsico, se obtuvo correlación positiva en 94,60 por ciento de los casos. Se enfatiza en la sencillez de la realización del escobillado, su alta confiabilidad, su bajo costo, la posible difusión del método en centros de baja complejidad y la generalización del mismo como método de pesquisa del carcinoma de endometrio en mujeres climatéricas asintomáticas, asi mismo como metodología diagnóstica rápida eficaz frente a la metrorragia de la posmenopausia

Perfil clínico-patológico de la mola hidatiforme parcial / Clinical-pathological profile of the hydatiform partial mole

Entre enero de 1979 y diciembre de 1991 se estudiaron 63 mujeres con enfermedad trofoblástica del embarazo. Seis de ellas fueron molas parciales que evolucionaron desfavorablemente: tres como abortos consumados y tres que desarrollaron hipertensión arterial con síndrome nefrótico (una de ellas con tensión arterial de 210/130 mm.Hg. y convulsiones). Del total de molas parciales la mitad fueron estudiadas genéticamente. Dos tuvieron cariotipo diploide y una triploide. Las que cursaron con hCG más elevada fueron tratadas con metotrexito. Ninguna de ellas se embarazaron durante los cinco años subsiguientes.

Diagnóstico histeroscópico das metrorragias causadas por patologias uterinas benignas / Hysteroscopic diagnosis of uterine hemorrhages caused by benign uterine pathologies

Considerando que a metrorragia no climatério representa 31,6% a 64,8% das consultas ginecológicas, pretendemos demonstrar a utilidade da histeroscopia, como procedimento diagnóstico, em suas duas variantes, a panorâmica e a de contato, no diagnóstico de lesöes orgânicas intracavitárias benignas e que säo causadoras da metrorragia. Trezentos e sessenta e três pacientes foram avaliados em Valência (270) (*) e em Campinas (93) (**), com técnicas e propostas semelhantes. Neste trabalho apresentamos os resultados das 270 pacientes de Valência que foram submetidas a uma técnica exploratória para atendimento ambulatorial, sendo que em 26 casos utilizamos a histeroscopia de contato. As confirmaçöes diagnósticas foram feitas através do estudo ecográfico, da biópsia dirigida, da curetagem e do exame anatomopatológico. Do total de histeroscopias, 50,2% apresentavam um tumor benigno intracavitário, diagnóstico que foi confirmado, por outras técnicas, em 84,7% dos casos. Houve 7,8% casos de diagnósticos falsos positivos e 6,8% de falsos negativos. Näo incluímos os casos de lesöes malignas. Realizamos também histeroscopias em casos sem metrorragia, para diagnosticar outras lesöes 366 em Valência e 377 em Campinas (24)