Reliability of narrow-band imaging (NBI) hysteroscopy: a comparative study.

OBJECTIVE: To evaluate the usefulness of narrow-band imaging (NBI) technology for improving the diagnostic reliability of hysteroscopy. DESIGN: Prospective controlled clinical study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENT(S): Three hundred ninety-five outpatient women undergoing diagnostic hysteroscopy were enrolled. INTERVENTION(S): All patients underwent fluid minihysteroscopy with white light (WL) and NBI exploration with endometrial eye-directed biopsy. MAIN OUTCOME MEASURE(S): Hysteroscopic findings with WL and NBI were compared with histology, which was considered the gold standard. RESULT(S): Overall, the number of correct diagnoses with NBI was significantly higher than with WL. For differentiating normal from abnormal endometrial histopathology, the use of NBI showed a significantly higher specificity (0.93 vs. 0.78) and negative predictive value (0.92 vs. 0.81); NBI hysteroscopy significantly improved the sensitivity for the diagnosis of proliferative endometrium (0.93 vs. 0.78), chronic endometritis (0.88 vs. 0.70), low-risk hyperplasia (0.88 vs. 0.70), and high-risk hyperplasia (0.60 vs. 0.40). CONCLUSION(S): The use of NBI improved the reliability of diagnostic hysteroscopy. The high specificity and the low number of false negatives may reduce the number of unnecessary biopsies or of those performed in wrong areas. Moreover, compared with WL observation, NBI hysteroscopy showed significantly higher sensitivity for the detection of chronic endometritis and low-risk and high-risk hyperplasia.

Risk of long-term pelvic recurrences after fluid minihysteroscopy in women with endometrial carcinoma: a controlled randomized study.

OBJECTIVE: Concerns exist about the risk of endometrial cancer cells spreading into the peritoneal cavity after fluid minihysteroscopy. The aim of our study was to evaluate the 5-year incidence of pelvic recurrences in women affected by early-stage endometrial carcinoma (stage IA or IB) who did or did not undergo preoperative hysteroscopy with low pressure (<70 mm Hg) saline uterine distention. METHODS: A total of 140 women were randomized into two groups of 70 women who underwent or did not undergo diagnostic fluid minihysteroscopy before surgical staging. Women were followed up every 6 months for at least 5 years. Diagnosis of pelvic recurrence was based on a positive result at clinical examination and/or at vaginal cytology and/or at magnetic resonance imaging/positron emission tomography scan. Univariate analysis of disease-free survival was performed with the Kaplan-Meier method and survival curves were compared using the long-rank test. RESULTS: No difference in peritoneal cytology was observed between the two groups (5.7% and 8.5% of cases in the hysteroscopy and control group, respectively). After a mean duration of follow-up of 62 months, 2 (2.85%) pelvic recurrences in the hysteroscopy group and 3 (4.28%) in the control group were found. No significant difference was found between the two groups when the recurrence rate was compared. Overall survival rates and disease-free survival projected by Kaplan-Meier curves were not significantly different for the two groups. CONCLUSIONS: Preoperative low-pressure fluid minihysteroscopy does not increase the risk of intraperitoneal transport of endometrial carcinoma cells during the examination or the risk of pelvic recurrence at the 5-year follow-up. It does not seem to modify the recurrence rate, disease-free survival, and overall survival, although multicenter randomized trials and long-term follow-up are required to evaluate the overall oncologic outcomes of this procedure.

Laparoscopy vs minilaparotomy in women with symptomatic uterine myomas: a prospective randomized study.

OBJECTIVE: To compare outcomes in patients with symptomatic uterine myomas who underwent laparoscopic (LPS) or minilaparotomic (MLPT) myomectomy. DESIGN: Prospective randomized study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Eighty patients with no more than 3 uterine myomas of maximal diameter of 7 cm. INTERVENTION: Either LPS or MLPT myomectomy. MEASUREMENTS AND MAIN RESULTS: Mean blood loss, mean duration of postoperative ileus, and mean decrease in hemoglobin were significantly lower in the LPS compared with the MLPT group (p < .001). Mean operative time was not significantly longer in the LPS group compared with the MLPT group. Duration of hospitalization was significantly shorter in the LPS compared with the MLPT group (p < .001). No intraoperative complications were observed during MLPT. In 1 patient, conversion from LPS to MLPT was necessary because of difficulty in reconstructing the uterine wall. CONCLUSION: Laparoscopic myomectomy is a suitable alternative to MLPT in women with 1 to 3 myomas. However, preoperative careful evaluation of the size and sites of the myomas is necessary to avert conversion and prevent complications.

Peritoneal fluid concentrations of progesterone in women are higher close to the corpus luteum compared with elsewhere in the abdominal cavity.

OBJECTIVE: To investigate the potential role of peritoneal fluid activity for the local delivery of gonadal steroid hormones. DESIGN: Prospective clinical study. SETTING: University hospital. PATIENT(S): Nine women undergoing tubal sterilization during laparoscopic surgery. INTERVENTION(S): Peritoneal fluid was collected during laparoscopic surgery by means of sterile cotton swabs on the surface of the peritoneum facing the ovary with an active corpus luteum and on the contralateral side, at the right and left paracolic gutter, and at the pouch of Douglas; simultaneous systemic blood sampling was performed. MAIN OUTCOME MEASURE(S): P was quantified by competitive immunochemical assay. Final steroid concentrations were calculated relative to the standard recovery rate. RESULT(S): P concentrations in the peritoneum close to the corpus luteum were 4 times (range, 1.4-9.2) higher than in the other peritoneal samples and about 5 times (range, 3.9-9.5) higher than in the systemic blood. CONCLUSION(S): The results indicate that P enters the peritoneal cavity locally and may therefore influence the function of other nearby tissues, especially those of the ipsilateral fallopian tube and proximal region of the uterus. Indeed, the peritoneal cavity and its fluid contents may be a powerful yet overlooked component of the regulatory systems within the body.

Successful management of a cervical twin pregnancy: neoadjuvant systemic methotrexate and prophylactic high cervical cerclage before curettage.

OBJECTIVE: To report our experience in managing a case of viable cervical twin pregnancy with systemic methotrexate and 2 weeks later with endocervical curettage after placing prophylactic high cervical cerclage. DESIGN: Case report. SETTING: University medical center. PATIENT(S): A 36-year-old woman, gravida 2, para 0, complaining of vaginal bleeding and pelvic pain, in whom cervical twin pregnancy was diagnosed at the sixth week of gestation. INTERVENTION(S): Systemic methotrexate was given as first-line treatment. Two weeks later because of persisting bleeding, endocervical curettage was performed after closing cervical arteries and placing but not tightening high cervical cerclage. MAIN OUTCOME MEASURE(S): Pregnancy termination, bleeding control, and preservation of fertility. RESULT(S): Notwithstanding the ligature of cervical arteries at curettage, heavy bleeding occurred, which was controlled rapidly by tightening the cerclage. Curettage then was completed successfully. Postoperative period was uneventful. Two years later the woman delivered vaginally. CONCLUSION(S): In case of cervical twin pregnancy methotrexate pretreatment and prophylactic placement of high cervical cerclage, but not ligature of cervical arteries, before curettage showed to be effective in terminating pregnancy ensuring effective bleeding control and preservation of fertility.

Tubercular endometritis: a rare condition reliably detectable with fluid hysteroscopy.

A rare case of tubercular endometritis occurred in a 63-year-old nullipara, postmenopausal woman, who was referred to our institute with vaginal bleeding and hyperechoic endometrial lesions at transvaginal sonography. At hysteroscopy the endometrial mucosa was lightly hyperemic and almost completely covered by multiple whitish and irregular deposits resulting in a "geographic map-like" aspect of the endometrial surface. The deposits had irregular borders and surface. Their size showed a wide range from less than 1mm to several millimeters. When touched by the tip of hysteroscope they did not bleed and peeled off easily. Diagnosis was performed with histologic examination and by using polymerase chain reaction. At follow-up hysteroscopy 6 months after antitubercular therapy, the endometrial mucosa appeared normal.

Reliability of diagnostic fluid hysteroscopy in the assessment of cervical invasion by endometrial carcinoma: a comparative study with transvaginal sonography and MRI.

OBJECTIVE: This study aimed at comparing the reliability of diagnostic fluid hysteroscopy, transvaginal sonography (TVS), and magnetic resonance imaging (MRI) to assess pre-operatively the presence of cervical involvement by endometrial carcinoma. METHODS: Cervical involvement was assessed by diagnostic fluid mini-hysteroscopy, TVS and MRI before surgery in 100 patients with histological diagnosis of endometrial carcinoma. Results were compared with pathological examination on surgical specimen. The sensitivity, the specificity, the positive and negative predictive values, the accuracy, the positive and negative likelihood ratios (LR) of the three techniques for recognizing the cervical involvement by the carcinoma were calculated. RESULTS: At histology cervical involvement was found in 15 cases. Compared to TVS and MRI, hysteroscopy showed the highest sensitivity (0.53, 0.67 and 0.93, respectively). The specificity of MRI was significantly higher than both hysteroscopy and TVS (0.95, 0.88 and 0.82, respectively). The diagnostic accuracy of hysteroscopy (0.89) and MRI (0.91) was similar and significantly higher than TVS (0.78). The LR for a positive result of MRI was 14.16, that was 2.08 and 4.68 times higher than that of hysteroscopy and TVS, respectively. CONCLUSIONS: In conclusion, this study demonstrates that in women with endometrial carcinoma the exclusion of cervical canal involvement at hysteroscopy is more reliable than at MRI and TVS while MRI is the most reliable technique for predicting cervical involvement. In the pre-surgical work-up of patients affected by endometrial carcinoma hysteroscopy and MRI are both useful for staging and planning the correct surgical strategy.

Chronic endometritis: correlation among hysteroscopic, histologic, and bacteriologic findings in a prospective trial with 2190 consecutive office hysteroscopies.

OBJECTIVE: To evaluate the type and etiopathogenic role of infectious agents detected in endometrial cultures obtained from women with chronic endometritis (CE). DESIGN: Prospective controlled study. SETTING: University hospital. PATIENT(S): 2190 women undergoing hysteroscopy for different indications. INTERVENTION(S): Vaginal and endometrial samples were collected from 438 women with a CE diagnosis at hysteroscopy and 100 women with no signs of CE (controls). MAIN OUTCOME MEASURE(S): Histology and cultures for common bacteria, Neisseria gonorrhoeae and Mycoplasma, and molecular biology testing for Chlamydia were performed. RESULT(S): We compared results of vaginal and intrauterine cultures obtained from women with and without CE. Histologic results were positive in 388 of these cases (88.6%), and at least one microorganism was found in 320 endometrial samples (73.1%). In the control group, histologic results and endometrial culture were positive in only 6% and 5% of cases, respectively. The most frequent infectious agents detected at the endometrial level were common bacteria (58% of cases). Ureaplasma urealyticum was detected in 10% and Chlamydia in only 2.7% of positive endometrial cultures. In only 143 (32.6%) cases were the same infectious agent isolated in endometrial and vaginal cultures. CONCLUSION(S): More than 70% of CE cases resulted from nongonococcal, nonchlamydial infections. Common bacteria and Mycoplasma were the most frequent etiologic agents. Vaginal cultures have low concordance with endometrial cultures.

Long-term effects of tibolone on circulating levels of vascular cell adhesion molecules and E-selectin in postmenopausal women.

OBJECTIVE: Adherence of lymphocytes and monocytes to cell adhesion molecules (vascular cell adhesion molecules [VCAMs]) expressed by activated endothelial cells is the first step in the development of atherosclerotic disease. It is known that administration of tibolone for 8 weeks reduces serum levels of VCAMs in postmenopausal women. We evaluated the effects of the administration of tibolone in postmenopausal women for 1 year. DESIGN: Randomized, placebo-controlled, crossover trial. SETTING: Healthy volunteers in an academic environment. PATIENT(S): Thirty-six healthy women in postmenopause since 1-4 years. INTERVENTION(S): Group A received 2.5 mg/d of tibolone and group B received placebo for 12 months; treatment was subsequently crossed over for 1 month. MAIN OUTCOME MEASURE(S): Serum concentrations of VCAM-1, intercellular adhesion molecule-1 (ICAM-1), and E-selectin were evaluated at baseline and at 6, 12, and 13 months. RESULT(S): Baseline concentration of VCAM-1, ICAM-1, and E-selectin were similar in both groups. At months 6 and 12, mean concentrations of VCAM-1, ICAM-1, and E-selectin decreased significantly in group A but not in group B. At month 13, levels returned to baseline in group A, whereas they decreased significantly in group B. CONCLUSION(S): Tibolone causes a rapid and sustained decrease in circulating levels of VCAMs; the effect is lost soon after stopping the treatment. Tibolone induces favorable changes in endothelial function and may exert a direct cardiovascular protective effect in postmenopausal women.

Detection of chronic endometritis at fluid hysteroscopy.

STUDY OBJECTIVE: Chronic endometritis is a subtle condition that is difficult to detect; however, it may cause abnormal uterine bleeding and infertility. Few data exist about the appearance of chronic endometritis at fluid hysteroscopy and about the value of diagnostic fluid hysteroscopy in the detection of this condition. In our experience, at fluid hysteroscopy chronic endometritis is characterized by consistent association of stromal edema and either focal or diffuse hyperemia; in some cases, this finding is associated with endometrial micropolyps (less than 1 mm in size). This study attempted to describe diagnostic criteria for chronic endometritis at fluid hysteroscopy and assess the diagnostic accuracy of fluid hysteroscopy in the detection of this condition. DESIGN: Retrospective Study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS: Nine hundred-ten women in whom hysteroscopy was indicated. INTERVENTIONS: Fluid hysteroscopy followed by endometrial biopsy. MEASUREMENTS AND MAIN RESULTS: Sensitivity, specificity, positive and negative predictive values, and accuracy of fluid hysteroscopy in the detection of chronic endometritis, based on the association of edema; hyperemia; and, if present, micropolyps were calculated. Based on the presence of hyperemia and edema, chronic endometritis was diagnosed in 158 patients (17.4%); in 61 patients (6.7%), micropolyps also were present. Histology confirmed the diagnosis in 101 patients (63.9% of positive cases at hysteroscopy) and was positive in 9 additional cases not detected by hysteroscopy. Chronic endometritis at histology was found in approximately 30% of infertile women and 35% of cases related to abnormal uterine bleeding. The sensitivity, specificity, and positive and negative predictive values of hysteroscopy for chronic endometritis based on detection of only hyperemia and edema were 91.8%, 92.9%, 63.9%, and 98.8%, respectively; the diagnostic accuracy was 92.7 %. The combination of hyperemia, edema, and micropolyps had sensitivity, specificity, and positive and negative predictive values of 55.4%, 99.9%, 98.4%, 94.5%, respectively, with a diagnostic accuracy of 93.4%. CONCLUSIONS: Fluid hysteroscopy is very reliable in diagnosing no inflammation, while detection of micropolyps is a very reliable sign of inflammation. When performing hysteroscopy for abnormal uterine bleeding or infertility, signs of chronic endometritis should always be sought.

Endometrial effects, bleeding control, and compliance with a new postmenopausal hormone therapy regimen based on transdermal estradiol gel and every-other-day vaginal progesterone in capsules: a 3-year pilot study.

In a 3-year prospective study, 30 postmenopausal women received transdermal E2 gel and every-other-day vaginal P in capsules. At study completion, endometrial thickness was significantly reduced as compared with baseline (2.7 +/- 0.5 vs. 3.4 +/- 0.9 mm), endometrial biopsy showed endometrial atrophy in all cases, and amenorrhea was achieved in 92.6% of cycles, while excellent patient satisfaction was achieved.