Lisa Barrie Schwartz

Ultrasonography-based triage for perimenopausal patients with abnormal uterine bleeding

OBJECTIVE Abnormal perimenopausal bleeding is common and accounts for much medical and surgical intervention. This study was undertaken to evaluate an ultrasonography-based triage paradigm for perimenopausal patients with abnormal uterine bleeding. STUDY DESIGN Four hundred thirty-three perimenopausal patients with abnormal uterine bleeding (either metrorrhagia, menorrhagia, or both) were evaluated. In lieu of undergoing a sampling procedure they were brought back on days 4 to 6 of the subsequent bleeding cycle, when the endometrium was expected to be its thinnest. If a distinct endometrial echo < or = 5 mm (double layer) was imaged by endovaginal ultrasonography, dysfunctional uterine bleeding was diagnosed. If a thickened endometrial echo > 5 mm or no endometrial echo was reliably visualized, a saline infusion sonohysterography was performed. If saline infusion sonohysterography revealed a symmetric single-layer endometrial thickness < 3 mm, dysfunctional uterine bleeding was diagnosed. If focal lesions were noted (polyps, submucous myomas, focal thickening), the patient was scheduled for curettage with hysteroscopy. If the endometrium was globally thickened, nondirected office biopsy was performed. RESULTS A total of 341 patients (79%) had ultrasonographic evidence of no anatomic abnormality, and dysfunctional uterine bleeding requiring no further studies was diagnosed. Fifty-eight patients (13%) had focal polypold masses, all of which were removed hysteroscopically and confirmed pathologically. Twenty-two patients (5%) had submucous myomas; 10 patients (23%) had globally thickened endometrium on saline infusion sonohysterography, and then nondirected office sampling revealed hyperplasia in 5 and proliferation in 5. Two patients had technically inadequate saline infusion sonohysterography, and thus we proceeded to hysteroscopy with curettage. CONCLUSION Nondirected office biopsy alone without imaging would have potentially missed the diagnosis of focal lesions such as polyps, submucous myomas, and focal hyperplasia in up to 80 patients (18%). Our clinical algorithm for perimenopausal patients with abnormal uterine bleeding used unenhanced endovaginal ultrasonography followed by saline infusion sonohysterography for selected patients. This approach allowed for no endometrial sampling, nondirected sampling, or directed sampling depending on whether the ultrasonography-based triage revealed no anatomic abnormalities, globally thickened endometrial tissue, or focal abnormalities, respectively.

Does pelvic magnetic resonance imaging differentiate among the histologic subtypes of uterine leiomyomata

OBJECTIVE To evaluate if pelvic magnetic resonance imaging (MRI) is reliable for differentiating leiomyoma subtypes. DESIGN Prospective study. SETTING Academic center. PATIENT(S) Forty-five patients underwent MRI before surgery for leiomyomata. INTERVENTION(S) One radiologist blinded to patient history and histologic diagnosis recorded the MRI characteristics and classification of the largest leiomyoma. MAIN OUTCOME MEASURE(S) Comparison of MRI and histologic diagnoses. RESULT(S) Leiomyoma subtypes were diagnosed accurately by MRI in 69% of cases. Magnetic resonance imaging had a 95% sensitivity and 72% specificity for diagnosing an uncomplicated leiomyoma and a 10% sensitivity and 100% specificity for a cellular leiomyoma. For cystic leiomyomata, the sensitivity was 80% and specificity was 98%, and for hemorrhagic leiomyomata, 100% and 86%, respectively. Magnetic resonance imaging correctly diagnosed all malignant tumors and did not incorrectly diagnose a leiomyoma as a leiomyosarcoma in any case. Ill-defined MRI margins were significantly more likely to be leiomyosarcoma, whereas well-defined margins were characteristic of benign lesions. Hemorrhagic leiomyomata were significantly more likely to be hyperintense on T1-weighted images than other subtypes. CONCLUSION(S) Although MRI is only fairly accurate in differentiating the subtypes of benign uterine smooth muscle tumors, signal intensities and margin characteristics are useful to distinguish accurately benign from malignant tumors.

Alterations in steroid hormone receptors in the tamoxifen-treated endometrium

OBJECTIVE: Our purpose was to evaluate whether tamoxifen has estrogenic endometrial effects as defined by histologic study or alterations in steroid hormone receptor expression. STUDY DESIGN: Nineteen postmenopausal tamoxifen-treated breast cancer patients who also had endometrial sampling were identified from files in the Department of Obstetrics and Gynecology. To examine the subgroup of 15 polyps, age-matched, non-hormonally treated patients with polyps (n = 8) or atrophic endometria (n = 5) served as comparison groups. Proliferative (n = 3) and secretory (n = 5) endometria served as procedural controls. Immunohistochemical studies for steroid receptors (estrogen, progesterone) were performed. RESULTS: Glandular cell progesterone receptor was significantly increased and stromal cell estrogen receptor was significantly decreased in tamoxifen-treated versus atrophic endometria. Progesterone receptor staining was not significantly different in tamoxifen-treated versus control polyps, although staining was high in both groups. Stromal cell estrogen receptor staining was significantly reduced in tamoxifen-treated versus control polyps, although there were no histologic differences. Reduced stromal cell estrogen receptor and increased glandular cell progesterone receptor staining was found in all tamoxifen-treated endometria regardless of the diagnosis. CONCLUSION: The tamoxifen-associated changes in endometrial steroid receptors support an estrogenic effect that is independent of histologic diagnosis and duration of use. This may contribute to the pathogenesis of tamoxifen-associated polyps and carcinomas.

Use of transvaginal ultrasonography to monitor the effects of tamoxifen on uterine leiomyoma size and ovarian cyst formation.

To evaluate the effects of tamoxifen on leiomyomas and ovarian cysts in postmenopausal breast cancer patients, uterine and leiomyoma volumes were monitored sonographically in 17 postmenopausal women receiving postoperative tamoxifen for breast cancer; patients were examined twice with a mean of 1.18 +/‐ 0.17 years between examinations. The mean increase in leiomyoma volume was 1.26 +/‐ 0.73 cm3. The mean myoma volume was significantly larger at follow‐up evaluation than at initial ultrasonography (5.75 +/‐ 1.09 cm3 versus 4.36 +/‐ 0.817 cm3, respectively; Wilcoxon signed rank test, P = 0.0218). Six women developed new leiomyomas. Of the 21 leiomyomas initially detected, 13 increased, six decreased, and two were unchanged in volume. The mean increase in uterine volume was 17.45 +/‐ 8.49 cm3. Three patients had simple ovarian cysts at initial ultrasonographic examination, two of which remained unchanged in size, and the third resolved. Two patients had newly developed simple ovarian cysts. The increase in uterine and leiomyoma volumes with the development of new leiomyomas and the persistence or development of ovarian cysts in some patients support the existence of agonistic tamoxifen effects. Serial measurements of uterine and leiomyoma volumes and surveillance for ovarian cysts is recommended for tamoxifen users.

Does the Use of Postmenopausal Hormone Replacement Therapy Influence the Size of Uterine Leiomyomata? A Preliminary Report

&NA; To determine if the use of hormone replacement therapy (HRT) in postmenopausal women influences the size of uterine leiomyomas, we report a series of 14 cases of postmenopausal women with uterine leiomyomas that were monitored with transvaginal pelvic ultrasound before and then at a mean of 19.7 ± 6.3 months after initiating HRT. A small group of seven postmenopausal women with uterine leiomyomas not treated with HRT were also evaluated at two time points (9.6 ± 1.7 months apart). There were no significant changes in mean uterine or myoma volumes from the time of the initial to follow‐up ultrasound in the postmenopausal women treated with HRT. Neither the type of estrogen or progestin preparation nor the HRT regimen (sequential versus continuous combined) affected the mean uterine or myoma volume. There were also no significant changes in the mean myoma volume in the small group of postmenopausal women not on HRT during this interval of time: however, the mean uterine volume decreased. The use of HRT in postmenopausal women with uterine leiomyomas does not seem to significantly increase uterine or myoma size, but may prevent the overall uterine size from shrinking postmenopausally. although larger prospectively designed studies are needed to confirm these findings. Therefore, perhaps following the less timeconsuming sonographic measurement of the overall uterine volume is adequate, and may be even preferable, for monitoring these patients rather than using the more labor‐intensive serial measurement of the volume of each individual myoma.

Evaluation of Abnormal Vaginal Bleeding in Perimenopausal Women with Endovaginal Ultrasound and Saline Infusion Sonohysterography

Saline infusion sonohysterography enhances endovaginal ultrasound examination of the uterine cavity in perimenopausal patients with abnormal uterine bleeding. It is easily and rapidly performed at minimal cost, is extremely well tolerated by patients, and is virtually devoid of complications. Its use can prevent invasive diagnostic procedures in some patients as well as optimize the preoperative triage process for those patients who will require therapeutic intervention.

A tenaculum improves ovarian accessibility during difficult transvaginal follicular aspiration: a novel but simple technique

OBJECTIVE To evaluate the use of a cervical tenaculum to improve ovarian access during oocyte retrieval. DESIGN Description of a new technique. SETTING Normal human volunteer in an academic research environment. PATIENT An infertile woman undergoing controlled ovarian hyperstimulation and ultrasound-guided oocyte retrieval. Access to her right ovary was obstructed by her uterus. INTERVENTIONS During the retrieval procedure, a tenaculum was applied to the patients cervix and downward traction was applied. RESULTS The ovary became closer to the vaginal wall. CONCLUSION Applying downward cervical traction with a tenaculum can bring an ovary closer to the vaginal wall, avoiding possible uterine injury and facilitating oocyte collection.

Don't Forget AIDS at Any Age

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Evaluating menopausal women with histories of thrombotic and phlebitic symptoms for HRT

Abstract We studied the use of a complete hemostatic profile for evaluating postmenopausal (PMP) women with histories of thrombosis or phlebitis who were presenting for hormone replacement therapy (HRT). Eighteen PMP women with histories of thrombotic or phlebitic symptoms who presented to our Menopausal Unit for HRT underwent complete hemostatic profiles, and decisions regarding HRT use were made based on the results and concurrent risk-factor analysis. Nine of 18 women had a hemostatic abnormality: one protein C, six protein S, one activated protein C resistance, and one anticardiolipin (ACA) antibody. None of the patients with protein C or S deficiencies subsequently received HRT. The patient with a positive ACA has used HRT with coumadin, without incident. Five of the nine patients with normal profiles have been treated with HRT without any short-term complications. A complete hemostatic evaluation thus aids in diagnosing underlying hypercoagulable states and may be useful for directing medical decisions regarding HRT for PMP women with histories of thrombosis or phlebitis.

A user-friendly, time-efficient form for eliciting pertinent information from perimenopausal and menopausal women

Abstract We report the development and clinical application of a patient history form geared specifically toward perimenopausal and menopausal women and designed to generate detailed medical and social histories from these patients in a standardized and expedient manner.