A Single Injection of Platelet-Rich Plasma Injection for the Treatment of Stress Urinary Incontinence in Females: A Randomized Placebo-Controlled Trial.

OBJECTIVE: To determine the efficacy of a single injection of platelet-rich plasma (PRP) into the anterior vaginal wall at the mid-urethra compared to placebo, as there is emerging evidence that PRP may help treat female stress urinary incontinence (SUI). METHODS: This was a single-blind, randomized, placebo-controlled clinical trial at a single institution. Females with bothersome, demonstrable stress-predominant urinary incontinence were enrolled. Participants were randomized to either injection of 5 mL autologous PRP or saline at the anterior vaginal wall at the mid-urethra. The primary outcome was composite treatment success at 6 months, defined as a negative cough stress test and an answer of "much better" or "very much better" on the Patient's Global Impression of Improvement. RESULTS: Fifty patients were enrolled in the study and randomized to the PRP group (n = 25) or the saline placebo group (n = 25). There was no statistically significant difference in the primary outcome between the 2 groups. Adverse events were minor, and the rate of adverse events was similar between both groups. CONCLUSION: In this randomized placebo-controlled study, we were unable to demonstrate a difference in SUI treatment success between PRP and saline injections. At this time, there is insufficient evidence to offer a one-time PRP injection into the anterior vaginal wall for treatment of female SUI.

Evaluation of ChatGPT for Pelvic Floor Surgery Counseling.

IMPORTANCE: Large language models are artificial intelligence applications that can comprehend and produce human-like text and language. ChatGPT is one such model. Recent advances have increased interest in the utility of large language models in medicine. Urogynecology counseling is complex and time-consuming. Therefore, we evaluated ChatGPT as a potential adjunct for patient counseling. OBJECTIVE: Our primary objective was to compare the accuracy and completeness of ChatGPT responses to information in standard patient counseling leaflets regarding common urogynecological procedures. STUDY DESIGN: Seven urogynecologists compared the accuracy and completeness of ChatGPT responses to standard patient leaflets using 5-point Likert scales with a score of 3 being "equally accurate" and "equally complete," and a score of 5 being "much more accurate" and much more complete, respectively. This was repeated 3 months later to evaluate the consistency of ChatGPT. Additional analysis of the understandability and actionability was completed by 2 authors using the Patient Education Materials Assessment Tool. Analysis was primarily descriptive. First and second ChatGPT queries were compared with the Wilcoxon signed rank test. RESULTS: The median (interquartile range) accuracy was 3 (2-3) and completeness 3 (2-4) for the first ChatGPT query and 3 (3-3) and 4 (3-4), respectively, for the second query. Accuracy and completeness were significantly higher in the second query (P < 0.01). Understandability and actionability of ChatGPT responses were lower than the standard leaflets. CONCLUSIONS: ChatGPT is similarly accurate and complete when compared with standard patient information leaflets for common urogynecological procedures. Large language models may be a helpful adjunct to direct patient-provider counseling. Further research to determine the efficacy and patient satisfaction of ChatGPT for patient counseling is needed.

Radiation exposure during sacral neuromodulation lead placement: Multi-institutional descriptive study.

OBJECTIVES: Fluoroscopy has significantly improved lead placement and decreased surgical time for implantable sacral neuromodulation (SNM). There is a paucity of data regarding radiation and safety of fluoroscopy during SNM procedures. Our study aims to characterize fluoroscopy time and dose used during SNM surgery across multiple institutions and assess for predictors of increased fluoroscopy time and radiation dose. METHODS: Electronic medical records were queried for SNM procedures (Stage 1 and full implant) from 2016 to 2021 at four academic institutions. Demographic, clinical, and intraoperative data were collected, including fluoroscopy time and radiation dose in milligray (mGy). The data were entered into a centralized REDCap database. Univariate and multivariate analysis were performed to assess for predictive factors using STATA/BE 17.0. RESULTS: A total of 664 procedures were performed across four institutions. Of these, 363 (54.6%) procedures had complete fluoroscopy details recorded. Mean surgical time was 58.8 min. Of all procedures, 79.6% were performed by Female Pelvic Medicine and Reconstructive Surgery specialists. There was significant variability in fluoroscopy time and dose based on surgical specialty and institution. Most surgeons (76.4%) were considered "low volume" implanters. In a multivariate analysis, bilateral finder needle testing, surgical indication, surgeon volume, and institution significantly predicted increased fluoroscopy time and radiation dose (p < 0.05). CONCLUSIONS: There is significant variability in fluoroscopy time and radiation dose utilized during SNM procedures, with differences across institutions, surgeons, and subspecialties. Increased radiation exposure can have harmful impacts on the surgical team and patient. These findings demonstrate the need for standardized fluoroscopy use during SNM procedures.

Increased Maternal BMI at Time of Delivery Associated with Poor Maternal and Neonatal Outcomes.

OBJECTIVE: Current literature on the risks and outcomes of obesity in pregnancy almost exclusively utilizes prepregnancy body mass index (BMI). Given the rising obesity rate across the United States along with a paucity of available information on the relationship between delivery BMI and maternal and neonatal outcomes, our study aimed to determine the association of maternal BMI at delivery with antepartum, intrapartum, and neonatal complications at an academic referral hospital. STUDY DESIGN: This study is a secondary analysis of data collected for a prospective cohort study of Coronavirus Disease-2019 (COVID-19) in pregnancy. This analysis included all patients who delivered term singleton infants between May 1, 2020, and April 30, 2021, at the University of Iowa Hospitals and Clinics. Demographic and clinical data were obtained from the electronic medical record. The relationship between maternal BMI and maternal and neonatal characteristics of interest was assessed using logistic regression models. A statistical significance threshold of 0.05 was used for all comparisons. RESULTS: There were 1,996 women who delivered term singleton infants during the study period. The median BMI at delivery was 31.7 kg/m2 (interquartile range 27.9, 37.2), with 61.1% of women having a BMI ≥ 30.0 kg/m2. Increasing BMI was significantly associated with nonreassuring fetal status, unscheduled cesarean birth, overall cesarean birth rate, postpartum hemorrhage, prolonged postpartum stay, hypertensive diseases of pregnancy, neonatal hypoglycemia, neonatal intensive care unit admission, decreased APGAR score at 1 minute, and increasing neonatal birth weight. Even when controlling for preexisting hypertension in a multivariate model, increasing BMI was associated with gestational hypertension and preeclampsia. CONCLUSION: Increased maternal BMI at delivery was associated with adverse perinatal outcomes. These findings have implications for clinical counseling regarding risks of pregnancy and delivery for overweight and obese patients and may help inform future studies to improve safety, especially by examining reasons for high cesarean rates. KEY POINTS: · Sixty-one percent of delivering patients had a BMI330 kg/m2 at delivery.. · There was a higher cesarean rate with increasing delivery BMI.. · For every 5-unit increase in maternal BMI, neonatal weight increased by 0.47 g..

Impact of Sling at Time of Prolapse Surgery on Overactive Bladder.

IMPORTANCE: Prolapse surgery and sling surgery both lead to improvement in overactive bladder. However, less is known regarding how slings performed concurrently with less is know about how overactive bladder symptoms change in patients having prolapse surgery with a sling compared to prolapse surgery without a sling. OBJECTIVE: The primary aim was to compare change in postoperative overactive bladder symptoms in patients with preoperative overactive bladder who underwent sling placement versus no sling with prolapse surgery. STUDY DESIGN: This was a secondary analysis of a cohort study evaluating overactive bladder in patients undergoing prolapse surgery. Sling procedures were performed concomitantly for treatment or prevention of stress incontinence. Baseline and 3-month follow-up urinary symptoms were assessed with the Overactive Bladder Questionnaire Short Form (OAB-q SF) and Urinary Distress Inventory-6 (UDI-6). RESULTS: Of patients with overactive bladder, 26 (40.0%) underwent midurethral sling (MUS) placement and 39 (60.0%) no sling. Preoperative OAB-q SF bother (score [SD], 46.8 [20.2] vs 40.2 [22.1]; P = 0.23) was similar between groups, but UDI-6 scores (59.2 [28.8] vs 43.8 [29.1]; P = 0.04) were higher in the sling group. At 3 months, the change (improvement) in OABq-SF bother (-16.9 [24.1] vs -22.4 [23.0]; P = 0.36), OABq-SF health-related quality of life (22.8 [28.6] vs 22.9 [23.9]; P = 0.99), and UDI-6 (-38.8 [32.9] vs -34.0 [27.8]; P = 0.53) were similar in the MUS and no MUS groups. CONCLUSION: Patients with prolapse and overactive bladder undergoing prolapse surgery with a sling had similar improvements in OAB-q SF bother scores compared with those who did not have a sling.

Effects of rurality and distance to care on perinatal outcomes over a 1-year period during the COVID-19 pandemic.

PURPOSE: Our aim was to investigate the roles of rurality and distance to care on adverse perinatal outcomes and COVID-19 seroprevalence at the time of delivery over a 1-year period. METHODS: Data were collected from the electronic medical record on all pregnant patients who delivered at a single, large, Midwest academic medical center over 1 year. Rurality was classified using standard Rural-Urban Commuting Area codes. Geographic Information System tools were used to map outcomes. Data were analyzed with univariate and multivariate models, controlling for Body Mass Index (BMI), insurance status, and parity. FINDINGS: A total of 2,497 patients delivered during the study period; 20% of patients were rural (n = 499), 18.6% were micropolitan (n = 466), and 61.4% were metropolitan (n = 1,532). 10.4% of patients (n = 259) were COVID-19 seropositive. Rural patients did not experience higher rates of any measured adverse outcomes than metropolitan patients; micropolitan patients had increased odds of preterm labor (OR = 1.41, P = .022) and pre-eclampsia (OR = 1.78, P<.001). Patients living 30+ miles away from the medical center had increased odds of preterm labor (OR = 1.94, P<.001), pre-eclampsia (OR = 1.73, P = .002), and infant admission to the neonatal intensive care unit (OR = 2.12, P<.001), as well as lower gestational age at delivery (ß = -9.2 days, P<.001) and birth weight (ß = -206 grams, P<.001). CONCLUSION: Distance to care, rather than rurality, was the key predictor of multiple adverse perinatal outcomes in this cohort of deliveries over a 1-year period. Our study suggests that rurality should not be used as a standalone indicator of access to care without further knowledge of the specific barriers affecting a given population.

Pelvic Pain and Pelvic Floor Muscle Dysfunction in Women Seeking Treatment for Prolapse.

IMPORTANCE: Pelvic floor muscle dysfunction (PFMD) can cause pelvic pain, but its associations with pelvic organ prolapse (POP) and POP treatment outcomes are poorly understood. OBJECTIVES: The objectives of this study were to determine (1) if pelvic pain is associated with PFMD in women seeking POP treatment and (2) if baseline PFMD in women seeking management of POP is associated with improvement in pelvic pain at 12 months. STUDY DESIGN: This was an ambispective cohort study of women enrolled at one site of the Pelvic Floor Disorders Registry. Pelvic floor muscle dysfunction was identified if tenderness was reported on a standardized pelvic floor muscle examination at baseline. Outcomes included a pelvic pain questionnaire (score 0-70, assessed pain in the past 24 hours in 7 pelvic locations) and the Global Health-10 overall average pain rating (0-10). RESULTS: One hundred forty-four women planning surgery (118) or pessary (26) were included. Twenty (13.9%) had baseline PFMD. Women with PFMD versus no PFMD had greater baseline Pelvic Pain scores (median [IQR], 9.7 [4-23] vs 2.5 [0-7], P < 0.001) and overall average pain (4 [3-6] vs 1 [0-3], P < 0.001). In 107 women with 12-month treatment outcomes, those with PFMD at baseline had greater improvement in pelvic pain compared with those without PFMD (change score -6.5 [-15.2 to 0] vs 0 [-3 to 0] respectively, P = 0.03). Overall pain improved after treatment in the no PFMD group but not in the PFMD group. CONCLUSIONS: Patients with baseline PFMD vs none undergoing treatment for prolapse had higher baseline pelvic pain and greater improvement in pelvic pain at 12 months.

Urinary Biomarkers and Overactive Bladder Symptoms Before and After Prolapse Surgery.

IMPORTANCE: Women with pelvic organ prolapse (POP) have increased prevalence of overactive bladder (OAB) and the evaluation of urinary biomarkers associated with OAB in the setting of POP is limited. OBJECTIVE: The objective is to determine whether associations exist between urinary biomarkers measured before POP surgery with postoperative OAB symptoms. STUDY DESIGN: In this prospective cohort study, women with anterior and/or apical POP beyond the hymen undergoing POP surgery were assessed using the OAB Questionnaire Short Form (OAB-q SF) and the Urogenital Distress Inventory 6 (UDI-6) preoperatively and 3 months postoperatively. A first morning voided urine specimen was collected preoperatively and 3 months postoperatively. Urinary biomarkers for inflammation, neuroinflammation, and tissue remodeling were measured. Univariate generalized linear models measured the relationship between biomarkers and symptoms. Between- and within-cohort assessments were made using 2-sample paired and unpaired t tests, respectively. RESULTS: Seventy-seven participants with OAB (n = 67, 87.0%) and without OAB (n = 10, 13.0%) were enrolled. Seventy-four participants (96%) completed 3-month follow up. The OAB-q SF and UDI-6 scores significantly improved between preoperative and postoperative measures. Preoperative urinary biomarkers did not demonstrate significant correlations with postoperative OAB-q SF or UDI-6 scores. No significant differences were measured in preoperative biomarkers between patients with and without OAB or when comparing preoperative and postoperative biomarkers in patients with OAB. CONCLUSIONS: Urinary biomarkers for tissue remodeling, inflammation, and neuroinflammation were not significantly correlated with OAB symptoms in a population of patients with OAB and POP.

Prevalence of pelvic floor disorders in adult women being seen in a primary care setting and associated risk factors.

Determine the prevalence of pelvic floor disorders (PFD) stratified by age, race, body mass index (BMI), and parity in adult women attending family medicine and general internal medicine clinics at an academic health system. The medical records of 25,425 adult women attending primary care clinics were queried using International Classification of Diseases-10th Revision codes (ICD-10 codes) for PFD [urinary incontinence (UI), pelvic organ prolapse (POP), and bowel dysfunction (anal incontinence (AI) and difficult defecation)]. Prevalence and odds ratios were calculated using univariate and multivariate analysis for age, race, BMI, and parity when available. Multivariate logistic regression models were used to assess the impact of age, race, BMI, and parity on the likelihood of being diagnosed with a PFD. A separate model was constructed for each of the three PFD categories (UI, POP, and bowel dysfunction) as well as a model assessing the likelihood of occurrence for any type of PFD. The percentage of women with at least one PFD was 32.0% with bowel dysfunction the most common (24.6%), followed by UI (11.1%) and POP (4.4%). 5.5% had exactly two PFD and 1.1% had all 3 categories of PFD. Older age and higher BMI were strongly and significantly associated with each of the three PFD categories, except for BMI and prolapse. Relative to White patients, Asian patients were at significantly lower risk for each category of PFD, while Black patients were at significantly lower risk for UI and POP, but at significantly greater risk for bowel dysfunction and the presence of any PFD. Higher parity was also significantly associated with pelvic organ prolapse. Using multivariate analyses, age, race, and BMI were all independently associated with PFD. PFD are highly prevalent in the primary care setting and should be screened for, especially in older and obese women. BMI may represent a modifiable risk factor.

Prospective evaluation of genital hiatus in patients undergoing surgical prolapse repair.

INTRODUCTION AND HYPOTHESIS: Enlarged genital hiatus (GH) is associated with prolapse recurrence following prolapse repair. Perineorrhaphy is often performed to reduce GH. However, changes in GH between the time of surgery and follow up are poorly understood. Our primary aim was to compare the intra-operative resting GH at the conclusion of surgery with the resting GH 3 months post-operatively in patients who undergo perineorrhaphy. We hypothesized that the intra-operative resting GH would be sustained. METHODS: Patients planning apical prolapse surgery were prospectively enrolled. Perineorrhaphy was performed at the surgeon's discretion. GH was measured pre-operatively in clinic, intra-operatively before and after surgery (resting), and 3 months post-operatively (resting and Valsalva). RESULTS: Twenty-nine perineorrhaphy and 27 no perineorrhaphy patients completed 3-month follow-up. Groups were similar in age (63.9 y, SD 10.4), body mass index (28.3 kg/m2, SD 5.2) and prior prolapse surgery (19.6%). Median (interquartile range) baseline Valsalva GH was larger in the perineorrhaphy group (4.5 (4 - 5.5) vs 3.5 (3 - 4) cm, p < 0.01). Median resting GH at 3 months was 0.5 cm less than end of surgery in the perineorrhaphy group (p < 0.01). The median change in GH between baseline and 3-month follow up was greater with perineorrhaphy (-1.5 vs -0.5 cm, p < 0.01). This difference was not seen in the sacrocolpopexy subgroup (-1.75 vs -1.5, p = 0.14; n = 24). CONCLUSIONS: Surgeons can be reassured that the intra-operative change in GH resulting from perineorrhaphy is sustained 3 months after surgery and similar to the more commonly measured preoperative to postoperative change in Valsalva GH.

Prevalence of maternal obesity at delivery and association with maternal and neonatal outcomes.

INTRODUCTION: Maternal obesity has been linked to adverse outcomes for mothers and their offspring, including, but not limited to gestational hypertension (gHTN), gestational diabetes (GDM), pre-eclampsia, fetal macrosomia, and emergency cesarean section. Recent investigations have also shown that obesity, as defined by a body mass index (BMI) ≥ 30, especially severe obesity (BMI ≥ 40), is a risk factor for both hospitalization and death from COVID-19. OBJECTIVES: The objective of this study is to determine the prevalence and association of maternal obesity at delivery with adverse antenatal, intrapartum, and neonatal outcomes in a cohort of consecutive delivering patients at a tertiary care center in Iowa from May to September 2020. A secondary objective is to determine if maternal obesity has any relationship to past or current COVID-19 infection status at the time of delivery. This is a secondary analysis of a prospective cohort study to analyze obstetric outcomes among COVID-19 infected and uninfected patients. METHODS: We conducted a prospective cohort study using demographic and clinical data obtained from the electronic medical record. Excess plasma was collected from routine blood samples obtained at delivery admission to determine the seroprevalence of COVID-19 antibody using the DiaSorin and Roche antibody assays. Frequency variables were each calculated separately, and a comparison of maternal and neonatal outcomes was conducted using the generalized linear mixed modeling (GLMM) framework to account for varying distributions (normal and binary). RESULTS: 1001 women delivered during the study period and 89.7% met criteria for being overweight or obese; 17.9% met criteria for severe obesity. Women with obesity had 49.8% lower odds of possessing private insurance, and women with severe obesity were less than half as likely to plan to breastfeed at the time of discharge. Women with obesity of any kind had a significantly increased odds of GDM and gHTN, and an increased risk of an infant with macrosomia, hypoglycemia, and NICU admission. No significant association was found between BMI and COVID-19 infection or disease severity. CONCLUSION: This study provides insight into obstetric complications facing women with obesity, especially those with severe obesity. This report serves to highlight potential challenges, such as insurance status and labor complications, that impact women of high BMI to a greater degree when compared to their normal-weight counterparts.

SARS-CoV-2 Infection during Pregnancy in a Rural Midwest All-delivery Cohort and Associated Maternal and Neonatal Outcomes.

OBJECTIVE: This study aimed to estimate the prevalence of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) among pregnant patients at the time of delivery in a rural Midwest tertiary care hospital and to examine demographics, clinical factors, and maternal and neonatal outcomes associated with SARS-CoV-2 infection during pregnancy. STUDY DESIGN: This prospective cohort study included all delivering patients between May 1 and September 22, 2020 at the University of Iowa Hospitals and Clinics. Plasma SARS-CoV-2 antibody testing was performed. SARS-CoV-2 viral reverse-transcription polymerase chain reaction (RT-PCR) results and maternal and neonatal outcomes were collected from the electronic medical record. Data were analyzed using univariate statistical methods with clustering for multiple births. RESULTS: In total, 1,000 patients delivered between May 1 and September 22, 2020. Fifty-eight (5.8%) were SARS-CoV-2 antibody positive. Twenty-three also tested viral positive during pregnancy. Three of 1,000 (0.3%) were viral positive on admission but antibody negative. The median age was 30 years (interquartile range [IQR]: 26-33 years) and body mass index was 31.75 kg/m2 (IQR 27.7-37.5 kg/m2). The cesarean delivery rate was 34.0%. The study population was primarily white (71.6%); however, 41.0% of SARS-CoV-2 infected patients identified as Black, 18.0% as Hispanic/Latino, 3.3% as Native Hawaiian/Pacific Islander, and only 27.9% as White (p < 0.0001). SARS-CoV-2 infection was more likely in patients without private insurance (p = 0.0243). Adverse maternal and/or neonatal outcomes were not more likely in patients with evidence of infection during pregnancy. Two SARS-CoV-2 infected patients were admitted to the intensive care unit. There were no maternal deaths during the study period. CONCLUSION: In this largely rural Midwest population, 6.1% of delivering patients had evidence of past or current SARS-CoV-2 infection. Rates of SARS-CoV-2 during pregnancy were higher among racial and ethnic minorities and patients without private insurance. The SARS-CoV-2 infected patients and their neonates were not found to be at increased risk for adverse outcomes. KEY POINTS: · SARS-CoV-2 seroprevalence rate in pregnant population in Iowa is 5.8%.. · Infections are higher among minorities, non-English speakers, and patients without private insurance.. · No increased adverse maternal/neonatal outcomes observed for SARS-CoV-2 infected mothers..

Surgical Management of Pelvic Organ Prolapse in Ethiopian Women: What Is the Preferred Approach?

OBJECTIVES: The aim of this study was to determine the most effective approach to surgical repair of pelvic organ prolapse for Ethiopian women and to characterize this population. METHODS: This is a prospective cohort study of women presenting for prolapse repair. Demographics and assessments of prolapse were obtained preoperatively. Information surrounding the surgical encounter was collected. The same anatomic and symptomatic measures were ascertained postoperatively. Information regarding surgical complications was collected. RESULTS: Two hundred thirty-three women with stage III or IV prolapse underwent surgical prolapse repair between March 2015 and November 2017. Seventy-eight of these women participated with a median length of follow-up of 255 days. All of the sacrocolpopexy patients (n = 21) and 56 of 57 vaginal repair patients had follow-up anatomic data. Anatomic failure as defined by Pelvic Organ Prolapse-Quantification (Ba, C, or Bp > 0) occurred in 0% (0/21) of sacrocolpopexy patients and 34% (19/56) of vaginal repair patients (P = 0.005). Symptomatic failure, as defined by self-reported recurrence of vaginal bulge, occurred in 0% (0/21) of sacrocolpopexy patients and 23% (13/56) of vaginal repair patients (P = 0.015). A global assessment of improvement (worse, same, or improved) revealed that 100% (21/21) of sacrocolpopexy patients reported improvement, whereas 91% (50/55) of vaginal repair patients reported improvement, 7% (4/55) reported being the same, and 2% (1/55) reported being worse. There were 2 intraoperative complications and 3 postoperative complications. There were no cases of mesh erosion. CONCLUSIONS: Although both vaginal and abdominal routes of prolapse surgery seem to be safe, an abdominal approach with mesh augmentation may be the preferred surgical repair in Ethiopian women.

The Use of Transvaginal Ultrasound in Type II Endometrial Cancer.

OBJECTIVE: To determine the use of the transvaginal ultrasound (TVUS) in postmenopausal women with type II endometrial cancer. METHODS/MATERIALS: A retrospective review was conducted for 173 women with pathology proven type II endometrial cancer at a single institution. Those who underwent preoperative TVUS were included, and the following data were obtained: endometrial stripe (EMS) measurement, uterine and/or adnexal findings, and uterine size/volume. Clinicopathologic factors were abstracted. Descriptive and regression analyses were performed. RESULTS: Fifty-eight women comprised the cohort, and the median age was 66.5 years (50-85 years). The most commonly reported symptom was postmenopausal bleeding in 53 patients (91.4%). The EMS was reported as thin (≤ 5 mm) or indistinct in 16 patients (27.5%). Approximately 60% of patients had 1 or more ultrasound abnormalities: intracavitary mass (31%), intracavitary fluid (12.1%), myometrial lesion (31.03%), and adnexal mass (12.1%). Poorly differentiated endometrioid cancer (53.45%) represented the predominant histology. Of the 16 (27.5%) women with a thin/indistinct EMS, 5 women (8.6%) did not have any abnormal ultrasound findings whatsoever. CONCLUSIONS: Women with type II endometrial cancer had a thin/indistinct EMS on TVUS in approximately 25% of cases. Lack of any ultrasound abnormality, including a thickened EMS, was noted in approximately 10% of patients. The use of TVUS, which has been of value in type I cancer, is limited in type II endometrial cancer. Therefore, endometrial sampling should be included in the evaluation of all women with postmenopausal bleeding, regardless of EMS thickness.