Long-term clinical significance of benign endometrial cells identified on routine cervical cytology in women aged more or equal to 45 years.

INTRODUCTION: Within the Bethesda System, the recommendation of describing benign-appearing endometrial cells (BECs) has changed over recent years. Since the 2014 revision, their presence in cervical cytology reports has been deemed essential, beginning with age 45. Recent studies have suggested rising the reporting age to 50 years. Does the presence of these cells necessitate further assessment? MATERIALS AND METHODS: This retrospective cohort study included patients aged between 45 and 65 years in whom BECs were present on cervical cytology between January 2001 and December 2010, with a follow-up at 5 and 10 years. Women who had abnormal cervical cells or atypical endometrial cells on cervical cytology were excluded, as well as women with a history of cervical or endometrial cancer, or a history of hysterectomy and incomplete follow-up data. RESULTS: One hundred seventy-six women were included. Of these, 31% were postmenopausal of which 65% used hormonal substitution therapy. Twenty-eight percent presented with abnormal uterine bleeding at inclusion. During the follow-up period of 10 years, 87.5% had a normal gynecological follow-up and 11.4% underwent a hysterectomy for benign pathology. One percent (2 patients) had been diagnosed with endometrial malignancy, both presenting with postmenopausal bleeding and aged over 60 years. CONCLUSIONS: Our study confirmed that the presence of BECs is not a reason for concern when no additional clinical indicator is recognized, especially with normal ultrasonographic examination. Further invasive exploration may be controversial. If reporting BECs in cervical cytology continues, we strongly agree on rising the reporting age to 50 years or postmenopausal state.

Ultrasonographic appearance of the endometrium after saline infusion in women presenting with PRM-associated endometrial changes, due to the use of ulipristal acetate.

Ulipristal acetate (UPA), used for the treatment in women with symptomatic fibroids, is associated with endometrial changes visualised on ultrasound as thickening up to more than 16 mm in approximately 10% of the patients. Is saline infusion sonography (SIS) a good alternative for more invasive techniques, to evaluate the presence of intrauterine pathology? Ten patients, presenting with UPA associated endometrial changes at their follow up ultra-sonographic evaluation, were included. Our study demonstrated that SIS is feasible and painless in patients presenting with UPA associated endometrial changes. The thickened endometrium appears to divide at the midline, making it possible to study both layers separately and exclude any suspected intrauterine pathology. Our findings suggest that SIS may be a first choice, non-invasive, painless technique to provide a proper visualisation to rule out intrauterine pathology when UPA associated endometrial changes are diagnosed after fibroid treatment. This is especially of clinical interest in front of assisted reproductive technology treatment. Invasive techniques can be withheld for patients in whom SIS examination is not contributive.Impact StatementWhat is already known on this subject? Reversible endometrial changes after ulipristal acetate (UPA) treatment in patients with symptomatic fibroids have been described. In patients who receive UPA, especially if planned to undergo ART, assessment of potential endometrial pathology is important as such interfere with proper implantation after ART. Consequently, clinicians may consider ruling out intrauterine pathology by invasive examinations such as biopsy or hysteroscopy after visualisation of the thickened endometrium.What do the results of this study add? Saline infusion sonography (SIS) was feasible and painless in patients presenting with UPA associated endometrial changes.What are the implications of these findings for clinical practice and/or further research? SIS may be a first choice, non-invasive, painless technique to provide a proper visualisation to rule out intrauterine pathology when UPA associated endometrial changes are diagnosed after fibroid treatment. This is especially of clinical interest in front of assisted reproductive technology treatment. Invasive techniques can be withheld for patients in whom SIS examination is not contributive in excluding intrauterine pathology.

Gigantic parasitic leiomyoma of 19 kg in a postmenopausal woman: A case report and review of the literature.

Parasitic leiomyomas are a rare subtype of subserosal uterine leiomyomas and are mostly found incidentally. Diagnosis is challenging and treatment consists out of complete surgical resection. Cases are few in women without history of uterine surgery. In this extraordinary case, a 56-year-old menopausal female suffering from backache and abdominal swelling, was suspected to have a huge malignant ovarian tumor. She underwent a resection of the mass along with hysterectomy and bilateral salpingo-oöphorectomy. Histopathology revealed a gigantic leiomyoma of 19.1 kg in the broad ligament. This unique case suggests taking this diagnosis into account in future clinical cases presenting with large abdominal masses even without previous uterine surgery.

A rare cause of postmenopausal hyperandrogenism.

We present an unusual case of mucinous cystadenoma presenting with severe virilisation in a postmenopausal woman. A 71-year-old woman was referred to our outpatient endocrinology clinic because of rapidly progressive androgenic alopecia, clitoromegaly and male pattern pubic hair growth for 1 year. Her medical history was unremarkable. The serum testosterone level was 3.35 µg/L (normal range, <0.4 µg/L), and the dehydroepiandrosterone sulfate level was 267 µg/L (normal range, 100-800 µg/L). MRI of the abdomen revealed a 4×4 cm cystic ovarian mass. A bilateral salpingo-oophorectomy was performed, and histopathology showed a unilocular cystic structure with a yellowish content, compatible with mucinous cystadenoma. Postoperative testosterone levels quickly normalised (<0.4 µg/L).Rapidly developing postmenopausal hyperandrogenism easily turns into a diagnostic challenge for the clinician. Hormone-secreting neoplasms of the ovary are most commonly of sex cord stromal derivation, but atypical causes must be recognised as well. Cystadenomas are among the most common benign ovarian neoplasms and are classically considered 'non-functional' tumours. Most of these tumours are asymptomatic and found incidentally on pelvic examination or with ultrasound. To date and to the best of our knowledge, there are only five cases of mucinous adenoma causing virilisation in postmenopausal women identified in the literature. This sixth case adds strength to the link between ovarian mucinous cystadenoma and severe, rapidly progressive hyperandrogenism during menopause. In this case, surgical resection is the treatment of choice.

Effect on surgical decisions: Ulipristal acetate as key player in Belgian phase IV registration trial.

OBJECTIVE: To observe alterations in surgical planning that were due to the use of ulipristal acetate (UPA) 5 mg daily for symptomatic uterine fibroids. METHODS: A prospective cohort trial involving women with symptomatic fibroids was undertaken in 23 clinical practice sites within Belgium between October 1, 2014, and March 31, 2016, to compare initial surgical planning to performed surgical procedures following the use of UPA 5 mg daily for 3 months. Secondary outcomes were surgical complications, reduction in fibroids, bleeding control, and adverse effects. RESULTS: Two hundred and twenty-two women were recruited for the trial. The requirement for surgery decreased with the use of UPA, with 54% of women undergoing surgery after treatment. The reduction in surgery performed was lower for women willing to conceive (40%) compared to women who were not (49%). The volume of the fibroids decreased significantly, with the largest measured fibroid decreasing by 50%. Bleeding and pain were significantly decreased with the use of UPA. No major complications were recorded, and no liver function abnormalities were reported during the treatment and in follow-up. CONCLUSION: By administering UPA, the required rate of surgery was significantly decreased. Also, the resulting reduction in size of the fibroids could have the potential benefit of reducing surgery-related complications, and long-term use may be warranted to avoid surgery completely.

Perception and knowledge of early pregnancy assessment units among perinatal practitioners in Europe.

OBJECTIVE: To investigate perceptions of early pregnancy assessment units (EPAUs) among perinatal practitioners working in Belgium, France, and Switzerland. METHODS: A prospective multinational survey was conducted between September 1, 2015, and May 21, 2016. Obstetricians, gynecologists, medical doctors, radiologists, and midwives were recruited during meetings, via e-mail invitations, or through the websites of regional obstetrics and gynecology scientific societies. The survey comprised 17 questions that assessed the participants' knowledge, interest, and management of early pregnancy. RESULTS: Of the 871 individuals invited to participate in the survey, 306 (35.1%) responded. Most of the participants were gynecologists and/or obstetricians (225 [73.5%]). A total of 258 (84.3%) participants had no or limited knowledge about EPAUs. Furthermore, 211 (69.0%) participants reported incorrect management when they visualized a gestational sac without embryo and 265 (86.6%) misinterpreted changes in serum levels of chorionic gonadotropin during early pregnancy. In all, 201 (65.7%) participants were interested in collaboration with an EPAU; however, only 125 (40.8%) had sufficient time and resources available to support a patient's psychological distress after early pregnancy loss or salpingectomy. CONCLUSION: Knowledge about early management of pregnancy was limited among the perinatal practitioners surveyed; however, the concept of EPAUs was welcomed by many.

Necessity of appendectomy for mucinous borderline ovarian tumors. Systematic review.

OBJECTIVE: The benefit of performing an appendectomy during the surgical treatment of a mucinous borderline ovarian tumor (mBOT) is still controversial, even though clinical guidelines recommend this procedure. PURPOSE: Our aim was to systematically assess the available evidence on appendectomy in the case of diagnosis of mBOT. METHODS: A comprehensive search of the literature was conducted using electronic databases using the search terms: (borderline OR low malignant potential) AND (appendectomy OR appendix). RESULTS: A total of 12 articles were retained after systematic review, including a total of 667 patients with borderline ovarian tumor. Appendectomy was performed in 232 of the patients presenting with a mBOT. Two (0.86 %) appendiceal carcinomas were confirmed on pathological examination. Both appendices were grossly abnormal at the time of surgery. CONCLUSION: Our systematic review demonstrates that available evidence regarding the role of appendectomy in mBOT is fragmented and weak. Nevertheless, this review provides adequate evidence to highlight that appendiceal involvement in mBOTs appears to be extremely rare and microscopic appendiceal involvement is highly unlikely in apparently normal appendices. In spite of the diversity of the included studies, the lack of appendiceal involvement in all cases with apparently normal appendix is strikingly common. We can conclude that in the case of normal appearance of the appendix at the time of primary surgery, appendectomy is not mandatory. Furthermore, a patient with a normal appendiceal appearance during primary surgery with post-operative diagnosis of mBOT addition of a second look intervention seems unnecessary and even hazardous.

Limited ability of circulating anti-Müllerian hormone to predict dominant follicular recruitment in PCOS women treated with clomiphene citrate: a comparison of two different assays.

The present retrospective cohort study was conducted to investigate whether serum anti-Müllerian hormone (AMH) levels, determined by either the Immunotech (IOT) or the second generation (Gen II) assay, can predict follicular recruitment in women with polycystic ovary syndrome (PCOS) undergoing ovulation induction with clomiphene citrate (CC). Patients received 50 mg CC daily for ovulation induction followed by natural intercourse or intrauterine insemination. Overall, 84 women had their serum AMH levels tested before treatment [42 patients with Immunotech (IOT), and 42 patients with the Gen II assay]. The primary outcome was to determine dominant follicle (>10 mm) recruitment in relation to AMH levels. Thirty-three (79%) patients in the IOT and 34 (81%) patients in the Gen II assay group developed a dominant follicle within 15 days after initiation of CC. Circulating AMH levels did not differ between women with or without dominant follicular recruitment in the both groups. By using either the AMH IOT or the Gen II assay, serum AMH levels were not predictive of the development of a dominant follicle. In conclusion, serum AMH levels measured by IOT or Gen II assay, has limited value to predict PCOS patients who will develop a dominant follicle following ovulation induction with CC.