Deep infiltrating endometriosis: cine magnetic resonance imaging in the evaluation of uterine contractility.

Objective: To evaluate uterine function by using cine magnetic resonance imaging to visualize the contractile movements of the uterus in patients with and without deep infiltrating endometriosis (with or without associated adenomyosis). Materials and Methods: This was a prospective case-control study. The study sample comprised 43 women: 18 in the case group and 25 in the control group. We performed cine magnetic resonance imaging in a 3.0 T scanner, focusing on the presence, direction, and frequency of uterine peristalsis. Results: The frequency of uterine peristalsis was higher in the case group than in the control group, in the periovulatory phase (3.83 vs. 2.44 peristaltic waves in two minutes) and luteal phase (1.20 vs. 0.91 peristaltic waves in two minutes). However, those differences were not statistically significant. There was a significant difference between the patients with adenomyosis and those without in terms of the frequency of peristalsis during the late follicular/periovulatory phase (0.8 vs. 3.18 peristaltic waves in two minutes; p < 0.05). Conclusion: The frequency of uterine peristalsis appears to be higher during the periovulatory and luteal phases in patients with deep infiltrating endometriosis, whereas it appears to be significantly lower during the late follicular/periovulatory phase in patients with adenomyosis. Both of those effects could have a negative impact on sperm transport and on the early stages of fertilization.

Objetivo: Avaliar a função uterina mediante visualização dos movimentos contráteis do útero por meio de cine-ressonância magnética em pacientes com e sem endometriose infiltrativa profunda (com ou sem adenomiose associada). Materiais e Métodos: Estudo caso-controle prospectivo. A amostra foi composta por 43 mulheres, sendo 18 mulheres no grupo caso e 25 mulheres no grupo controle. A cine-ressonância magnética foi realizada com magneto 3.0 T, com foco na presença, direção e frequência do peristaltismo uterino. Resultados: O peristaltismo uterino foi mais frequente nas pacientes do grupo endometriose do que no grupo controle na fase periovulatória (3,83 × 2,44 peristalses em dois minutos) e lútea (1,20 × 0,91 peristalse em dois minutos). No entanto, esses resultados não foram estatisticamente significantes. Nas pacientes com adenomiose, observou-se redução significativa na frequência de peristaltismo durante a primeira fase do ciclo menstrual (3,18 × 0,8 peristalses; p < 0,05). Conclusão: A frequência de peristaltismo uterino parece estar aumentada durante a fase periovulatória e lútea em pacientes com endometriose infiltrativa profunda e significativamente reduzida em pacientes com adenomiose durante a primeira fase do ciclo menstrual. Ambos os efeitos têm potencial de interferir negativamente no transporte de espermatozoides e nos primeiros estágios de fecundação.

The role of cine MR imaging in the assessment of uterine function.

PURPOSE: To review the literature on uterine contraction and to highlight magnetic resonance imaging using the cine technique as a useful method to evaluate these movements. METHODS: The literature research on PubMed database was done up to February 2019 with restriction to English language about articles regarding uterine peristalsis and cine MR. RESULTS: Infertility is a common clinical problem and a source of frustration for those who want to have children. Uterine movements are crucial elements in respect of successful conception, implantation, and the development of a healthy pregnancy. It is known that the direction and frequency of uterine peristalsis are closely related to the different phases of the menstrual cycle, and that changes in its activity may interfere with reproduction. One condition that has been linked with infertility by several studies is dysfunctional uterine contractility. Magnetic resonance imaging, using the cine technique, has been shown to be a useful tool in the evaluation of these movements, allowing the identification of patients with some type of dysfunction and establish strategies to increase pregnancy rates. CONCLUSION: Cine MR is an excellent imaging method for the evaluation of uterine peristalsis and identification of dysfunctional contractions.

Histological outcomes in conventional cervical cytology for invasive carcinoma: not always cancer.

The value of cytology for the detection of invasive cancer remains unknown. We performed a retrospective cohort study with 884 patients diagnosed of premalignant lesions and invasive carcinoma in cytology. 382 (43.2%) of them had cytological results of high-grade squamous intraepithelial lesions (HSIL), 244 (27.6%) showed low-grade squamous intraepithelial lesions (LSIL), 120 (13.6%) patients had atypical squamous cells of undetermined significance (ASC-US), 67 (7.6%) patients with atypical squamous cells, cannot exclude high-grade squamous intraepithelial lesion (ASC-H), 38 (4.3%) had invasive carcinoma and 33 (3.7%) patients presented with atypical glandular cells (ACG). From 38 patients with cytological results of invasive carcinoma, 24 had confirmatory histological results (63.2%). The other 14 had 4 benign lesions and 10 HSIL. The predictive positive value (PPV) was 63.2%. Cytology results of carcinoma do not confer a definitive diagnosis of invasive lesion, but it is strongly an indication of, at least, a precancerous lesion.

[Endometrial osseous metaplasia: clinical presentation and follow-up]. / Metaplasia óssea endometrial: quadro clínico e seguimento após tratamento.

PURPOSE: to describe the clinical signs and symptoms of patients with bone metaplasia and to assess the risk factors for changes in these symptoms after removal of the bone fragment. METHODS: a cross-sectional study was conducted on 16 patients with a diagnosis of bone fragments in the uterine cavity during the period comprising July 2006 to January 2009. The inclusion criterion was the detection of a bone fragment removed from the uterine cavity. The presence of bone tissue in the endometrial cavity was histologically confirmed in all patients. The data of all patients were obtained before and after removal by means of a questionnaire for the evaluation of the effect of removal on the symptoms and for the search of possible factors related to the onset of the disease. RESULTS: half the patients (8/16) had hemorrhagic symptoms and one third (6/16) were infertile. Removal of the fragments was quite effective in improving the complaints, with the disappearance of symptoms in all cases of hemorrhage and of pelvic pain. CONCLUSION: removal of bone fragments can restore the fertility of selected patients whose infertility is caused by bone metaplasia and is quite effective in leading to improvement in patients with pelvic pain and menorrhage.

Genetic analysis of the cause of endometrial osseous metaplasia.

OBJECTIVE: To analyze solitary bone fragments from the uterine cavity through DNA genotyping, thus elucidating whether they originate from metaplasia, from previous abortion, or both. METHODS: We conducted a case series study on 14 patients, of whom eight yielded bone DNA. The patients selected had histopathologic diagnoses of bone fragments inside the uterine cavity or previously removed samples available for analysis. We extracted DNA from blood and bone fragments. To identify the bone tissue origin, these materials were genotyped using polymerase chain reactions for DNA loci. Six mini short tandem repeat loci frequently used for human tissue identification were analyzed using automated sequencing. RESULTS: Among these eight patients, blood and tissue samples from the same individual produced exactly the same pair of alleles for all six loci. This indicated that the DNA profile was completely the same for the bone samples and the mother's blood (95% confidence interval 63-100%), thus confirming that the DNA had the same origin and that these were cases of metaplasia. CONCLUSION: In all of the eight cases, bone formation was caused by osseous metaplasia, because the DNA in the bone fragment and in the patient's blood was identical. Although all of the women had histories of previous abortion, no difference in DNA was detected in the bone tissue in any of the cases, as would be expected if abortion had occurred. This result was completely unexpected, differing greatly from what the literature suggests. LEVEL OF EVIDENCE: III.

Risk factors for abdominal scar endometriosis after obstetric hysterotomies: a case-control study.

OBJECTIVE: To identify risk factors that are associated with the development of scar endometriosis after obstetric hysterotomies. The hypothesis is that early hysterotomy in pregnancy (before 22nd week) is the main risk factor for the development of scar endometriosis. METHODS: The authors conducted a case-control study between April 2000 and June 2003. A total of 117 women were selected, including 39 cases and 78 controls. Exposure and confounding variables were measured by a standardized questionnaire, which included sociodemographic characteristics, reproductive/physiologic history, past pathological history, history of obstetric surgeries, family history, and social history. The odds ratio (OR) and its 95% confidence interval (CI) were calculated using bivariate analysis for each possible risk factor. These estimates were obtained by multivariate analysis using unconditional logistic regression. Tests were made to assess the fit of the final model. RESULTS: In the multivariate analysis, positive associations were observed between scar endometriosis and hysterotomy type (early versus late: OR = 42.99; CI 8.77-210.81), amount of the menstrual blood flow (heavy versus light/normal: OR = 11.97; CI 2.35-60.82), and alcoholic consumption (yes versus no: OR = 5.31; CI 1.22-23.11). Negative association was observed between scar endometriosis and parity (OR = 0.61; CI 0.31-1.23), however it was not statistically significant (p>0.05). CONCLUSIONS: Early hysterotomy in pregnancy is the main risk factor for scar endometriosis. Increased menstrual flow and alcohol consumption are also risk factors, while high parity may be a protecting factor.

Validation of hysteroscopic view in cases of endometrial hyperplasia and cancer in patients with abnormal uterine bleeding.

STUDY OBJECTIVE: To validate hysteroscopic view with histology in cases of endometrial hyperplasia and cancer in patients with abnormal uterine bleeding (AUB) DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: University teaching hospitals in Rio de Janeiro and São Paulo, and private office in Rio de Janeiro. PATIENTS: Four thousand and fifty-four patients with AUB in whom hysteroscopic views were complete and the histologic result was conclusive. INTERVENTION: Four thousand and fifty-four office hysteroscopies with complete views and conclusive histologic results. The material for histologic examination was obtained through biopsy of the lesion in an outpatient unit or through the resection of the entire lesion in patients who underwent surgery. Histology was considered the "gold standard" and compared with the hysteroscopic view. MEASUREMENTS AND MAIN RESULTS: In the histology of the 4054 examinations, 613 (15.2%) were endometrial hyperplasia, and 105 (2.6%) were endometrial cancer. The most frequent hysteroscopic finding was endometrial polyps (31.2%). In endometrial hyperplasia, the sensitivity of the hysteroscopic view was 56.3% (95% CI 52.2%-60.2%), specificity was 89.1% (95% CI 88.0%-90.1%), positive predictive value (PPV) was 48.0% (95% CI 44.3%-51.7%), negative predictive value (NPV) was 92.0% (95% CI 90.1%-92.9%), and accuracy was 72.7% (95% CI 70.7%-74.7%). Accuracy was defined as the proportion of correct results among the hysteroscopic examinations. In endometrial cancer, the sensitivity of the hysteroscopic view was 80.0% (95% CI 71.1%-87.2%), specificity was 99.5% (95% CI 99.2%-99.7%), PPV was 81.5% (95% CI 72.7%-88.5%), NPV was 99.5% (95% CI 99.2%-99.7%), and accuracy was 89.8% (95% CI, 85.9%-93.6%). In the 814 patients (20.0%) in whom the hysteroscopic view was normal, there were no false negatives for endometrial cancer; however, there were 37 (4.5%) false negatives for endometrial hyperplasia. In the histologic cases of endometrial cancer, 101 (96.2%) hysteroscopic views were compatible with cancer or hyperplasia (80.0% and 16.2%, respectively). Ninety-seven out of 103 hysteroscopic views with cancer findings (94.2%) had histologic diagnosis of cancer or hyperplasia (81.5% and 12.6%, respectively). CONCLUSION: It seems that even in face of good validity of hysteroscopic view for endometrial hyperplasia and cancer, histologic study is mandatory in the presence of any lesion as the hysteroscopic view cannot completely replace the histologic study in patients with AUB.