T Justin Clark

Ultrasonographic endometrial thickness for diagnosing endometrial pathology in women with postmenopausal bleeding: a meta-analysis

Our aim was to determine the diagnostic accuracy of endometrial thickness measurement by pelvic ultrasonography for predicting endometrial carcinoma and disease (hyperplasia and/or carcinoma) during an investigation of postmenopausal bleeding. We performed a systematic quantitative review of the available published literature, which consisted of online searching the MEDLINE and EMBASE databases (1966–2000) coupled with scanning of bibliography of known primary and review articles. The selection of studies, assessment of study quality, and extraction of data were performed in duplicate under masked conditions. Included in the analyses were 57 studies with 9031 patients . Accuracy data were summarized using likelihood ratios for various cut‐off levels of abnormal endometrial thickness. The commonest cut‐offs were 4 mm (9 studies) and 5 mm (21 studies), measuring both endometrial layers. None of the nine studies using the ≤ 4 mm cut‐off level were of good quality. Only four studies (out of the 21) used the ≤ 5 mm cut‐off level, which employed the best‐quality criteria. Using the pooled estimates from these four studies only, a positive test result raised the probability of carcinoma from 14.0% (95% CI 13.3–14.7) to 31.3% (95% CI 26.1–36.3), while a negative test reduced it to 2.5% (95% CI 0.9–6.4). In conclusion, ultrasound measurement of endometrial thickness alone, using the best‐quality studies cannot be used to accurately rule. However, a negative result at ≤ 5 mm cut‐off level measuring both endometrial layers in the presence of endometrial pathology rules out endometrial pathology with good certainty.

Accuracy of outpatient endometrial biopsy in the diagnosis of endometrial cancer: a systematic quantitative review

Objective To determine the accuracy of outpatient endometrial biopsy in diagnosing endometrial cancer in women with abnormal uterine bleeding.

Prenatal bladder drainage in the management of fetal lower urinary tract obstruction: a systematic review and meta-analysis

OBJECTIVE To estimate the effect of prenatal bladder drainage on perinatal survival in fetuses with lower urinary tract obstruction. DATA SOURCES Relevant articles were identified by searching the databases MEDLINE (1966–2002), EMBASE (1988–2002), and the Cochrane library (2000;4). METHODS OF STUDY SELECTION Studies were selected if the effect of prenatal bladder drainage (vesicocentesis, vesicoamniotic shunt, or open fetal bladder surgery) on perinatal survival was reported in fetuses with ultrasonic evidence of lower urinary tract obstruction. Study selection, quality assessment, and data abstraction were performed independently and in duplicate. TABULATION, INTEGRATION, AND RESULTS Sixteen observational studies that included nine case series (147 fetuses) and seven controlled series (195 fetuses) were identified. Study characteristics and quality were recorded for each study. Data on the effect of bladder drainage on perinatal survival were abstracted. Where controlled data were available, 2 × 2 tables were generated to compare the effects of bladder drainage versus no bladder drainage on perinatal survival. Pooled odds ratios (ORs) were used as summary measures of effect, and the results were stratified according to predicted fetal prognoses (based on ultrasound features and fetal urinary electrolytes). Among controlled studies, bladder drainage appeared to improve perinatal survival relative to no drainage (OR 2.5; 95% confidence interval [CI] 1.1, 5.9; P = .03). However, this observation was largely because among the subgroup of fetuses with a poor prognosis there was a marked improvement (OR 8.1; 95% CI 1.2, 52.9; P = .03). Improved perinatal outcome was also suggested in those fetuses considered to have a good prognosis (OR 2.8; 95% CI 0.7, 10.8; P = .13). CONCLUSION There is a lack of high quality evidence to reliably inform clinical practice regarding prenatal bladder drainage in fetuses with ultrasonic evidence of lower urinary tract obstruction. The limited available evidence suggests that prenatal bladder drainage may improve perinatal survival in these fetuses, particularly those with poor predicted prognoses. Further research in the form of a multicenter randomized controlled trial is required to assess the short- and long-term effects of this intervention.

Endometrial thickness measurement for detecting endometrial cancer in women with postmenopausal bleeding: a systematic review and meta-analysis

OBJECTIVE: To estimate the accuracy of endometrial thickness measurement in the detection of endometrial cancer among women with postmenopausal bleeding with individual patient data using different meta-analytic strategies. DATA SOURCES: Original data sets of studies detected after reviewing the included studies of three previous reviews on this subject. An additional literature search of published articles using MEDLINE databases was preformed from January 2000 to December 2006 to identify articles reporting on endometrial carcinoma and sonographic endometrial thickness measurement in women with postmenopausal bleeding. METHODS OF STUDY SELECTION: We identified 90 studies reporting on endometrial thickness measurements and endometrial carcinoma in women with postmenopausal bleeding. TABULATION, INTEGRATION, AND RESULTS: We contacted 79 primary investigators to obtain the individual patient data of their reported studies, of which 13 could provide data. Data on 2,896 patients, of which 259 had carcinoma, were included. Several approaches were used in the analyses of the acquired data. First, we performed receiver operator characteristics (ROC) analysis per study, resulting in a summary area under the ROC curve (AUC) calculated as a weighted mean of AUCs from original studies. Second, individual patient data were pooled and analyzed with ROC analyses irrespective of study with standardization of distributional differences across studies using multiples of the median and by random effects logistic regression. Finally, we also used a two-stage procedure, calculating sensitivities and specificities for each study and using the bivariate random effects model to estimate summary estimates for diagnostic accuracy. This resulted in rather comparable ROC curves with AUCs varying between 0.82 and 0.84 and summary estimates for sensitivity and specificity located along these curves. These curves indicated a lower AUC than previously reported meta-analyses using conventional techniques. CONCLUSION: Previous meta-analyses on endometrial thickness measurement probably have overestimated its diagnostic accuracy in the detection of endometrial carcinoma. We advise the use of cutoff level of 3 mm for exclusion of endometrial carcinoma in women with postmenopausal bleeding.

The effectiveness of a levonorgestrel-releasing intrauterine system (LNG-IUS) in the treatment of endometrial hyperplasia--a long-term follow-up study.

OBJECTIVES Medical treatment of non-atypical endometrial hyperplasia with oral progestogens has limited efficacy and poor compliance. A levonorgestrel-releasing intrauterine system (LNG-IUS) has been shown to successfully treat hyperplasia in small-sized studies. Our aim was to examine the effectiveness of LNG-IUS in a larger study with long-term follow up. STUDY DESIGN Prospective observational study of 105 women diagnosed with endometrial hyperplasia and treated with LNG-IUS between 1999 and 2004 at a University Teaching hospital. Baseline characteristics and outpatient endometrial Pipelle sampling were undertaken at 3 and 6 months post LNG-IUS insertion and 6-monthly intervals thereafter in all cases. Outcome included histological data derived from both Pipelle and uterine histologies at 1 and 2 years LNG-IUS therapy. RESULTS LNG-IUS achieved endometrial regression in 90% (94/105) of cases by 2 years, with a significant proportion (96%, 90/94) achieving this within 1 year. Regression occurred in 88/96 (92%) of non-atypical and 6/9 (67%) of atypical hyperplasias, and in all 22 cases of endometrial hyperplasia associated with HRT. Regression rates did not differ between histological types of hyperplasia. Twenty-three women (22%) underwent hysterectomy of which 13 were indicated and 10 were performed at patient request despite regressed endometrium. Two cases of cancer (one uterine and one ovarian) were identified. CONCLUSION LNG-IUS is highly effective in treating endometrial hyperplasia. Beneficial effects are observed by the majority within 1 year. Treatment can be reliably monitored through regular 6-montly outpatient endometrial Pipelle surveillance. LNG-IUS treatment of non-atypical hyperplasias is likely to reduce the number of hysterectomies performed in this subgroup.

REVIEW: Accuracy of laparoscopy in the diagnosis of endometriosis: a systematic quantitative review

Endometriosis is a common gynaecological condition found in women of reproductive age. – 3 The condition is associated with chronic pelvic pain and infertility, which can result in reduced quality of life, psychological morbidity and work absenteeism. Diagnosis is invariably made following laparoscopic inspection of the pelvis. The appearance of endometriosis varies, but classically is seen as areas of discolouration (so-called implants or deposits) or peritoneal defects and scarring. More extensive disease can lead to formation of adhesions and cysts. Both medical and surgical treatments for endometriosis are associated with considerable morbidity and frequently short term relief of chronic pelvic pain symptoms. In subfertility, laparoscopic ablative treatment is associated with improved reproductive outcome. Accurate diagnosis is therefore essential to optimally target women likely to benefit from treatment, to reduce unnecessary morbidity and to efficiently use health service resources. Advances in endoscopic instrumentation have facilitated peritoneal tissue biopsy for histological assessment. The existing data supporting the use of laparoscopy in visual diagnosing endometriosis have seldom been validated against histological findings confirmed independently using an established gold standard. Individual studies on this subject are small, leading to imprecise estimates of diagnostic accuracy. We therefore undertook a quantitative systematic review to obtain more precise accuracy estimates and to explore reasons for heterogeneity.

Accuracy of outpatient endometrial biopsy in the diagnosis of endometrial hyperplasia.

Background. To determine the accuracy of outpatient endometrial biopsy in diagnosing endometrial hyperplasia in women with abnormal uterine bleeding.

Current practice for the treatment of benign intrauterine polyps: a national questionnaire survey of consultant gynaecologists in UK

OBJECTIVE To determine current practice regarding removal of endometrial polyps. STUDY DESIGN A self-administered questionnaire to all 1509 UK consultant gynaecologists to enquire about their current practice and potential willingness to participate in a randomised trial. RESULTS Treatment methods varied considerably. Inpatient polypectomy was used by 91% and the favoured method was blind removal of polyp following hysteroscopic localisation (53%). Direct hysteroscopic polypectomy was more commonly performed by 46% members of endoscopic societies compared to 33% of non-members. Outpatient polypectomy was performed by 19% of users of outpatient diagnostic hysteroscopy compared to 2.5% of non-users. One-third of respondents were willing to enter patients into a randomised controlled trial to determine the optimal intrauterine polyp removal technique. CONCLUSION Opinion regarding the relative roles of inpatient or outpatient, and blind or hysteroscopic methods, is divided and a randomised trial comparing the efficacy and safety of these methods is practicable.

Probability analysis for diagnosis of endometrial hyperplasia and cancer in postmenopausal bleeding: an approach for a rational diagnostic workup

Objective.  To develop an analytical approach to estimate the probability of endometrial hyperplasia and cancer in women with postmenopausal bleeding, using a combination of patient history and tests.

Hysteroscopic treatment of symptomatic submucous fibroids using a bipolar intrauterine system: a feasibility study

OBJECTIVE To determine the feasibility (safety, potential efficacy and cost effectiveness) of a miniature endoscopic bipolar electrosurgical intrauterine system in the treatment of symptomatic submucous fibroids. STUDY DESIGN A total of 37 women with symptomatic submucous fibroids were identified on outpatient hysteroscopy. All underwent hysteroscopic excision or ablation using a bipolar intrauterine system (Versapoint). The main outcomes measures were change in uterine bleeding symptoms measured on a continuous and ordinal scale, patient satisfaction, time of work and use of health service resources at 6 months following treatment. RESULTS 36/37 (97%) women returned completed outcome questionnaires. The mean amount of abnormal uterine bleeding was reduced at 6 months compared to immediately prior to treatment (P=0.0001). Improvement in bleeding symptoms was reported by 28/36 (78%) women and satisfaction with treatment by 33/36 (92%) women. All procedures were successfully completed, there were no serious operative complications and at 6 months no repeat hysteroscopic procedures were necessary. The mean cost of diagnosis and treatment of submucous fibroids using an endoscopic bipolar intrauterine system was 40% cheaper at 6 months follow-up than a hysterectomy or open myomectomy ( pound 1266 versus pound 2123). CONCLUSION Hysteroscopic treatment of symptomatic submucous fibroids appears to be safe, efficacious and cost effective. It seems feasible to launch a randomised controlled trial to confirm these provisional results in both the short and longer term.