A.-G. Pourcelot

Office hysteroscopy: A report of 2402 cases

INTRODUCTION Hysteroscopy is the gold standard for evaluation of uterine cavity. It can be performed either as office setting or as day care procedure under general anaesthesia. Objective of this study is to assess feasibility and acceptability of office hysteroscopy without anaesthesia. MATERIALS AND METHODS This retrospective observational study took place in the gynaecologic unit of a teaching hospital. Women who had had an office hysteroscopy from 2010 to 2013 were included. RESULTS Two thousand four hundred and two office hysteroscopies were carried out. Indications were menorrhagia (32.2%), postoperative evaluation (20.8%), infertility (15.8%), postmenopausal bleeding (10.9%) and other indications (20.3%). Womens mean age was 39.4 [39.0-39.9] and significantly higher among women with a failure of the office hysteroscopy (47.3 vs. 38.6, P<0.01). The failure rate was 9.5%, significantly higher in women with postmenopausal bleeding and lower in women for a postoperative evaluation. Assessment of an abnormal uterine cavity was done in 56.0% of cases with 28.7% of myomas, 27.2% of polyps, 17.7% of synechiaes, 14.7% of endometrial hypertrophies, 9.0% of trophoblastic retentions and 7.7% of uterine malformation. The complication rate of office hysteroscopy was 0.05%. Mean pain score during the examination was 3.57 out of 10 [3.48-3.66] and 0.89 [0.83-0.95] five minutes later. CONCLUSION Office hysteroscopy is safe and feasible with little pain. A failure rate of 9.5% is reported, mainly for older women with postmenopausal bleeding.

Hysteroscopic resection of type 3 myoma: a new challenge?

OBJECTIVE Type 3 myomas are intramural within contact with the endometrium but lack any cavity deformation. There is no guideline for management of symptomatic type 3 myoma. The aim of this study was to evaluate the feasibility of symptomatic type 3 myoma hysteroscopic resection. METHOD This retrospective study included symptomatic women (mainly pain, infertility or bleeding) who obtained an operative hysteroscopy for type 3 symptomatic myoma from June 2010 to December 2014 in the gynaecological unit of a teaching hospital. RESULT Thirteen women with an operative resection using bipolar electrosurgery of type 3 myoma during the study period (June 2010 to December 2014) were included in the study. Two women had a hysterectomy 6 and 12 months after the procedure and one woman had an open myomectomy 30 months after the procedure for the recurrence of abnormal bleeding. Postoperative office hysteroscopy show a postoperative synechiae in 3 women out of 8. Incomplete resection was also obtained in 3 women out of 8. CONCLUSION Hysteroscopic resection is a potential alternative to traditional surgery for type 3 myoma. This procedure must be confined to skilled surgeons because it is a difficult procedure. A postoperative office hysteroscopy is recommended in women of reproductive age.

Fertilité après résection hystéroscopique de myomes sous-muqueux chez des patientes infertiles

OBJECTIVES Myoma is the most frequent benign uterine tumor and might have a negative impact on fertility. In 5 to 10% of cases, infertility is associated with myoma and in 1 to 3% myoma is the only infertility factor. Even if effect of myomectomy on fertility is controversial, benefit of hysteroscopic myomectomy for submucosal myoma on fertility has already been shown. The aim of this study is to evaluate fertility of infertile women less than 46years old after hysteroscopic resection of submucosal myoma. MATERIAL AND METHODS This retrospective unicentric study took place in the gynecologic unit of a teaching hospital. All infertile women with a hysteroscopic myomectomy for submucosal myoma between March 2009 and May 2013 were included. A phone questionnaire was conducted to evaluate pregnancy rate, eventual medical assistance, time between submucisal resection and pregnancy and issue of pregnancies. RESULTS Seventy-one infertile women with a hysteroscopic resection of submucosal myoma were included. Pregnancy rate was 33.8% with 50% of live births, 41.6% of miscarriages and 8.4% of late fetal losses with a mean follow-up of 28.7months. Mean time between hysteroscopic resection and pregnancy was 9.9months. A medical assistance was necessary for 6 women (25% of pregnancy). CONCLUSION This study reports hysteroscopic resection of submucosal myoma for infertile women. The rate of pregnancy after treatment is 33.8%.

Are synechiae a complication of laparotomic myomectomy

Laparotomic myomectomy is often the only realistic solution for symptomatic women with multiple or large myomas who wish to retain their fertility. The aim of this study was to document the rate of uterine synechiae and their associated risk factors after laparotomic myomectomy. This prospective observational study took place in a teaching hospital from May 2009 to June 2014. It included all women aged 18-45 years who had laparotomic myomectomies (without diagnostic hysteroscopy at the time of surgery) for myomas and a postoperative diagnostic office hysteroscopy 6-8 weeks later. The study included 98 women with a laparotomic myomectomy and a postoperative hysteroscopic follow-up. Women with a laparotomic myomectomy for a subserosal myoma were excluded. The intrauterine adhesion rate after laparotomic myomectomy was 25.51% (25/98); 44% (11/25) of them were complex intrauterine adhesions. Opening the uterine cavity was a major risk factor for these complex adhesions, with an OR of 6.42 (95% CI 1.27 to 32.52). Office hysteroscopy could be carried out after surgery in such cases.

Cystic Adenomyosis: Place of Hysteroscopic Approach

Cystic adenomyosis is not very common. Primary complains are chronic pelvic pain, severe dysmenorrhea, and heavy menstrual bleeding when they are associated with superficial or diffuse adenomyosis. The introduction of 3D-TransVaginal UltraSound (3D-TVUS) with coronal view and/or Magnetic Resonance Imaging (MRI) increased the number of cases reported. Despite the severity of symptoms in symptomatic forms, it is unclear whether cystic adenomyosis impairs reproductive outcome. Therefore, for women wishing to become pregnant, evaluation of uterine cavity by hysteroscopy and exploration of the sub-endometrial zone by 3D-TVUS is becoming a gold standard.

Office hysteroscopy for postmenopausal women: Feasibility and correlation with transvaginal ultrasound

OBJECTIVE To evaluate feasibility of office hysteroscopy in postmenopausal women and correlation between transvaginal ultrasound (TV-US) and hysteroscopy. METHODS Postmenopausal women addressed at office hysteroscopy for postmenopausal bleeding or increase endometrial thickness were included. A 3.5-mm rigid hysteroscope was used without cervical dilatation or local anaesthesia. Speculum was never used. Data concerning womens symptoms and TV-US findings were collected. RESULTS Four-hundred-seventy postmenopausal women referred for office hysteroscopy were included in this descriptive study. Three-hundred-fifty women (74.5%) experienced abnormal uterine bleeding. The success rate of office hysteroscopy was 76.4% and was significantly higher in cases of postmenopausal bleeding (80.9%) than in women without postmenopausal bleeding (63.3%) (p=0.01). Three-hundred-sixteen women had both a successful hysteroscopy and TV-US. The correlation between hysteroscopy and TV-US was 68.5% for the diagnosis of increased endometrial thickness, polyps and submucosal myoma (Kappa=0.28). The rate of endometrial cancer for women with postmenopausal bleeding was 12.6% (n=44) while it was 1.7% (n=2) for asymptomatic women. Two (4.3%) out of these 46 women with endometrial cancer had normal hysteroscopy, while 7 (15.2%) had a normal TV-US (including endometrial thickness below 5mm). Among the 54 women without bleeding and with a thickened endometrium, one (1.8%) had endometrial cancer. CONCLUSION Office hysteroscopy is successful without anaesthesia for 76.4% of postmenopausal women. The correlation between TV-US and hysteroscopy is low, and we recommend to practice both sonography and hysteroscopy in women with postmenopausal bleeding.

Are 3D ultrasound and office hysteroscopy useful for the assessment of uterine cavity after late foetal loss

OBJECTIVE To assess the efficacy of office hysteroscopy and 3D ultrasound for the diagnostic of uterine anomalies after late foetal loss. METHOD This retrospective observational study took place in the gynaecologic unit of a teaching hospital from 2009 to 2014. Women with late foetal loss (<22 weeks of gestation) had an office hysteroscopy and 3D ultrasound within three months after delivery. The results of the ultrasound and hysteroscopy were recorded and compared. RESULTS Eighty women were included with a mean age of 29.8 years (28.2-31.4). Forty-seven women had both hysteroscopy and 3D ultrasound, and a uterine cavitys anomaly (bicornuate uterus, T-Shape uterus and septate uterus) was found in ten women (21%) at 3D sonography and in 13 women (28%) at office hysteroscopy. Concordance between the two exams was very good with a kappa at 0.83. In three cases, a uterine cavitys anomaly was found at hysteroscopy whereas sonography was normal. Anomalies at ultrasound (uterine cavitys anomaly, myometrium anomaly or ovarian anomaly) were found in 27.6% of cases. CONCLUSIONS Both 3D ultrasound and office hysteroscopy are useful for assessment of the uterine cavity after late foetal loss. The application of these two exams is important, as hysteroscopy is generally used for assessment of the uterine cavity and endometrium, while 3D ultrasound is generally used to identify the precise type of uterine malformation and for the examination of the myometrium and annexes.

Place of ulipristal acetate in the management of uterine fibroids: Preoperative treatment or sequential treatment?

Symptomatic uterine fibroids affect 25% of women of childbearing potential and are responsible for various symptoms, mainly menometrorrhagia, pelvic pain and infertility. No currently available medical treatment is able to eradicate fibroids. Two treatments are indicated preoperatively to reduce bleeding and decrease the size of fibroids: GnRH agonists and ulipristal acetate. Ulipristal acetate, a selective progesterone receptor modulator, exerts an antagonist effect on fibroid tissue, inducing apoptosis. It rapidly induces amenorrhoea (after an average of seven days of treatment) and reduces fibroid volume. It causes few adverse effects and, in particular, is associated with a low rate of hot flashes compared to GnRH agonists. Due to its partial antagonist effect on endometrial tissue, endometrial thickening with no glandulocystic atypia is commonly observed during treatment and is reversible after stopping treatment. These specific histological changes are called Progesterone receptor modulator-Associated Endometrial Changes (PAEC). Since February 2012, ulipristal acetate has been approved in Europe for preoperative treatment of symptomatic fibroids for two three-month cycles. The use of ulipristal acetate facilitates surgery or allows modification of the surgical approach (due to a reduction of fibroid volume) and restores normal preoperative hemoglobin. In some cases, the reduction of menometrorrhagia induced by treatment can allow surgery to be postponed. Since May 2015, ulipristal acetate is also indicated as repeated sequential treatment for moderate-to-severe symptoms due to uterine fibroids.

Update on the management of abnormal uterine bleeding

Abnormal uterine bleeding (AUB) is a common complaint that affects large numbers of women from puberty to menopause. It negatively affects health by causing anemia, and impacts the quality of life of women affected. AUB also has an economic impact for both women and society. Therefore, it should not be under- or overestimate and diagnosis, investigations and treatment should be proposed, taking into account the scientific data available in the current state of medical knowledge. Using the new terminology and etiologic classification of AUB is essential to communicate properly around the subject. The evaluation of the bleeding includes self-report and more objective methods. Work out should focus on diagnosing anemia and researching for causal factors. It is important to differentiate AUB caused by anatomical changes and functional causes, and the PALM-COIEN classification has been developed on that dichotomy. Investigations may include blood test, ultrasound, hysteroscopy and endometrial sampling is required in a certain number of situations. Treatment for AUB can be medical and/or surgical depending on the cause. Medical treatment is based on iron supplementation, hormonal and non-hormonal therapies. Surgical treatments include removal of a focal lesion, endometrial resection or destruction and hysterectomy. Age, desire for future pregnancy and etiology for AUB are key factors to consider before initiating a treatment. Treatment efficiency can be assessed using the same tools as pretherapeutic evaluation, and improvement of quality of life has now become the main goal for most international guidelines addressing the subject.

Uterine fibroids and fertility: current management strategy

Si les myomes alterent systematiquement la fertilite, la myomectomie ne la restaure que dans le cas des myomes de type 0, 1 ou 2. Ainsi, pour ces myomes de type 0 a 2, l’exerese par hysteroscopie operatoire est recommandee chez toute patiente desireuse d’une grossesse, prise en charge ou non pour infertilite. Pour les myomes de type 3 a 5, la chirurgie est recommandee si la taille est superieure a 5 cm, en fonction du type de l’infertilite et des inconvenients potentiels engendres par l’intervention (elle doit etre realisee autant que possible par cœlioscopie lorsque cela est possible). La presence de myomes de type 6 et 7 ne doit pas amener a une chirurgie (excepte lorsque ceux-ci peuvent rendre difficiles des ponctions ovocytaires par exemple). Peu importe la technique de myomectomie utilisee, il est imperatif de prevenir au mieux les adherences extra- et intra-uterines : en voie haute par l’utilisation d’agents antiadherentiels et apres hysteroscopie operatoire par la realisation d’une hysteroscopie diagnostique de controle systematique, quatre a six semaines apres la resection. Les traitements medicaux (acetate d’ulipristal et agonistes de la gonadoliberine [GnRH]) peuvent etre une alternative a la chirurgie en permettant une diminution de la taille des myomes et une modification des rapports de ceux-ci avec la cavite uterine. Cependant, aucune etude n’a valide leur usage dans cette indication d’infertilite. Enfin, l’embolisation ne doit pas etre utilisee chez les patientes ayant un projet de grossesse en raison du risque de diminution de la reserve ovarienne et de synechies.