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Introduction: The aim of this study is to evaluate the quality of the endometrial sample obtained by office endometrial aspiration when performed before or after saline contrast sonohysterography (SCSH) in women with postmenopausal bleeding and a thickened endometrium. To conduct a complete, minimally invasive and cost-effective diagnostic workup in women with postmenopausal bleeding and a thickened endometrium, ideally both the office endometrial sampling and SCSH are performed. However, it is not known whether both tests affect each other when performed one after another., Material and Methods: Women with postmenopausal bleeding and an endometrial thickness >4 mm were eligible. Women were randomized into two groups: one group received endometrial aspiration before SCSH, the other group received SCSH before endometrial aspiration. The primary outcome was the proportion of sufficient endometrial samples. Reliability of the SCSH images and pain during procedures were secondary outcomes., Results: During the inclusion period, 513 eligible women with postmenopausal bleeding visited the participating hospitals, 293 of whom received information about the study. Of these women, 232 (79%) agreed to participate. In the SCSH-aspiration group, 65 women (59%) had a sufficient endometrial sample compared with 70 (67%) in the aspiration-SCSH group (odds ratio 1.46, 95% CI 0.83-2.54, P = .19). The proportion of reliable sonographic images was significantly higher in the SCSH-aspiration group (n = 88, 87%) compared with the aspiration-SCSH group (n = 71, 74%) (OR 2.38, 95% CI 1.38-4.99, P = .02) in the per protocol analysis., Conclusions: This study shows that the quality of an endometrial sample in women with postmenopausal bleeding is not affected by SCSH. Both procedures can be performed in one outpatient visit to perform an optimal diagnostic workup., (© 2021 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Postmenopausal bleeding can be the first clinical sign of an endometrial abnormality. Because of an increased risk of malignancy, evaluation is advocated. Polyps are reported up to 40% in women with postmenopausal bleeding. These polyps carry a risk of 6% for a focal (pre-) malignancy. To perform complete diagnostic work-up, recent guidelines recommend endometrial sampling and a saline infusion sonography if a previous transvaginal ultrasound shows an endometrial thickness of more than 4 mm. The current guideline shows no consensus of the sequence of both diagnostic procedures. Hypothetically, the fluid of the saline infusion sonography (SIS) could affect the quality of the endometrial sample. We designed a randomized trial (the ESPRESSO Trial; Trial Registration No. NTR5690) to investigate the quality of the endometrial sample (Pipelle®) when performed before or after SIS in postmenopausal women. We will perform a randomized trial comparing two diagnostic work-ups (SIS and subsequent Pipelle® versus Pipelle® and subsequent SIS) in women with postmenopausal bleeding. The study will be performed in one teaching and one Academic hospital in the Netherlands. Women with postmenopausal bleeding and an endometrial thickness of more than 4 mm are eligible. The gynecologist will evaluate quality of the SIS and the quality of the Pipelle® will be evaluated by a pathologist (possible to diagnose or not). Furthermore, the incidence and intensity of pain will be evaluated. The results will give insight whether the quality of the Pipelle® is influenced by the SIS or not.

Postmenopausal bleeding (PMB) can be the first sign of endometrial cancer. In case of thickened endometrium, endometrial sampling is often used in these women. In this systematic review, we studied the accuracy of endometrial sampling for the diagnoses of endometrial cancer, atypical hyperplasia and endometrial disease (endometrial pathology, including benign polyps). We systematically searched the literature for studies comparing the results of endometrial sampling in women with postmenopausal bleeding with two different reference standards: blind dilatation and curettage (D&C) and hysteroscopy with histology. We assessed the quality of the detected studies by the QUADAS-2 tool. For each included study, we calculated the fraction of women in whom endometrial sampling failed. Furthermore, we extracted numbers of cases of endometrial cancer, atypical hyperplasia and endometrial disease that were identified or missed by endometrial sampling. We detected 12 studies reporting on 1029 women with postmenopausal bleeding: five studies with dilatation and curettage (D&C) and seven studies with hysteroscopy as a reference test. The weighted sensitivity of endometrial sampling with D&C as a reference for the diagnosis of endometrial cancer was 100% (range 100-100%) and 92% (71-100) for the diagnosis of atypical hyperplasia. Only one study reported sensitivity for endometrial disease, which was 76%. When hysteroscopy was used as a reference, weighted sensitivities of endometrial sampling were 90% (range 50-100), 82% (range 56-94) and 39% (21-69) for the diagnosis of endometrial cancer, atypical hyperplasia and endometrial disease, respectively. For all diagnosis studied and the reference test used, specificity was 98-100%. The weighted failure rate of endometrial sampling was 11% (range 1-53%), while insufficient samples were found in 31% (range 7-76%). In these women with insufficient or failed samples, an endometrial (pre) cancer was found in 7% (range 0-18%). In women with postmenopausal bleeding, the sensitivity of endometrial sampling to detect endometrial cancer and especially atypical hyperplasia and endometrial disease, including endometrial polyps, is lower than previously thought. Therefore, further diagnostic work-up for focal pathology is warranted, after a benign result of endometrial sampling., (Copyright © 2015. Published by Elsevier Ireland Ltd.)

Objective: Previously, we have reported that, at both 12months and 5 years after treatment, bipolar endometrial ablation is superior to balloon ablation in the treatment of heavy menstrual bleeding. In this article, we evaluate the results at 10 years after these interventions., Design: Ten-year follow-up of a double-blind randomised controlled trial., Setting: A teaching hospital in the Netherlands., Population: Premenopausal women suffering from heavy menstrual bleeding., Method: A follow-up questionnaire was sent to women 10 years after randomisation for bipolar ablation and balloon ablation (2: 1 ratio)., Main Outcome Measures: Amenorrhoea rates, re-intervention and patient satisfaction., Results: At 10 years of follow-up, the response rate was 69/83 (83%) in the bipolar group and 35/43 (81%) in the balloon group. Amenorrhoea rates were 50/69 (73%) in the bipolar group and 23/35 (66%) in the balloon group [relative risk, 1.1 (95% CI, 0.83-1.5)]. Further treatment following initial ablation was reported in 21 cases, 14 in the bipolar group and nine in the balloon group [relative risk, 0.9 (95% CI, 0.63-1.3)]. Eight of these women required further treatment after 5 years, including two hysterectomies. Patient satisfaction in the bipolar group was 81% (56/69) compared with 77% (27/35) in the balloon group [relative risk, 1.1 (95% CI, 0.82-1.2)]., Conclusion: Ten years after treatment, the superiority of bipolar ablation over balloon ablation in the treatment of heavy menstrual bleeding was no longer evident., (© 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2013 RCOG.)

Objective: To evaluate the relative effectiveness of hysterectomy, endometrial destruction (both "first generation" hysteroscopic and "second generation" non-hysteroscopic techniques), and the levonorgestrel releasing intrauterine system (Mirena) in the treatment of heavy menstrual bleeding., Design: Meta-analysis of data from individual patients, with direct and indirect comparisons made on the primary outcome measure of patients' dissatisfaction., Data Sources: Data were sought from the 30 randomised controlled trials identified after a comprehensive search of the Cochrane Library, Medline, Embase, and CINAHL databases, reference lists, and contact with experts. Raw data were available from 2814 women randomised into 17 trials (seven trials including 1359 women for first v second generation endometrial destruction; six trials including 1042 women for hysterectomy v first generation endometrial destruction; one trial including 236 women for hysterectomy v Mirena; three trials including 177 women for second generation endometrial destruction v Mirena). Eligibility criteria for selecting studies Randomised controlled trials comparing hysterectomy, first and second generation endometrial destruction, and Mirena for women with heavy menstrual bleeding unresponsive to other medical treatment., Results: At around 12 months, more women were dissatisfied with outcome with first generation hysteroscopic techniques than with hysterectomy (13% v 5%; odds ratio 2.46, 95% confidence interval 1.54 to 3.9, P<0.001), but hospital stay (weighted mean difference 3.0 days, 2.9 to 3.1 days, P<0.001) and time to resumption of normal activities (5.2 days, 4.7 to 5.7 days, P<0.001) were longer for hysterectomy. Unsatisfactory outcomes were comparable with first and second generation techniques (odds ratio 1.2, 0.9 to 1.6, P=0.2), although second generation techniques were quicker (weighted mean difference 14.5 minutes, 13.7 to 15.3 minutes, P<0.001) and women recovered sooner (0.48 days, 0.20 to 0.75 days, P<0.001), with fewer procedural complications. Indirect comparison suggested more unsatisfactory outcomes with second generation techniques than with hysterectomy (11% v 5%; odds ratio 2.3, 1.3 to 4.2, P=0.006). Similar estimates were seen when Mirena was indirectly compared with hysterectomy (17% v 5%; odds ratio 2.2, 0.9 to 5.3, P=0.07), although this comparison lacked power because of the limited amount of data available for analysis., Conclusions: More women are dissatisfied after endometrial destruction than after hysterectomy. Dissatisfaction rates are low after all treatments, and hysterectomy is associated with increased length of stay in hospital and a longer recovery period. Definitive evidence on effectiveness of Mirena compared with more invasive procedures is lacking.

Objective: To evaluate the safety, feasibility and efficacy of endometrial ablation under local anesthesia., Study Design: A prospective cohort study was performed at the gynecology department of a large teaching hospital. Women with dysfunctional uterine bleeding were included to undergo NovaSure endometrial ablation with paracervical block. We measured the acceptability, pain score (visual analog score scale), amenorrhea, and patients' satisfaction after the procedure., Results: We treated 33 patients. No complications occurred during the procedure or postoperatively. Of the 33 women, 28 found treatment with NovaSure endometrial ablation under local anesthetics acceptable. After 24 hours, 23 of 33 women reported to be pain free, whereas 10 women still had mild pain. Twenty women developed amenorrhea (60.6%) and 13 women hypomenorrhea (39.4%). All women were satisfied with the treatment result and would recommend it to a friend., Conclusion: NovaSure endometrial ablation performed under local anesthesia is a safe, feasible and efficacious procedure.

Objective: We have previously reported that NovaSure was more effective than balloon ablation at 12 months follow up in the treatment of menorrhagia. In this paper, we report the 5-year outcome of this study. The objective was to evaluate amenorrhoea rates, hysterectomy rate, and quality of life associated with the bipolar impedance-controlled endometrial ablation technique (NovaSure) in comparison with balloon ablation technique (ThermaChoice) at 5 years after administration., Design: Double-blind randomised controlled trial, 2:1 randomisation NovaSure versus ThermaChoice., Setting: A teaching hospital with 500 beds in The Netherlands., Population: A total of 126 premenopausal women suffering from menorrhagia with a pictorial blood loss assessment count > or = 150 without intracavitary abnormalities., Methods: Women were randomly allocated to bipolar radio-frequency ablation and balloon ablation in a 2:1 ratio., Main Outcome Measures: The main outcome measures were amenorrhoea rate, hysterectomies, and health-related quality of life (HRQol) as reported at 5 year follow up., Results: At 5 years of follow up, the total response rate was 96% in the bipolar group and 90% in the balloon group. Amenorrhoea was reported in the bipolar group by 48% of women and in the balloon arm by 32% (relative risk 1.6 [.93-2.6]). There were eight women in the bipolar group (9.8%) and five in the balloon group (12.9%) who had undergone a hysterectomy. Furthermore, there was a significant equal improvement of HRQoL over time in both groups., Conclusions: At 5 years follow up, bipolar thermal ablation was superior over balloon ablation in the treatment of menorrhagia.

Objective: To investigate patient preferences for endometrial ablation and a levonorgestrel-releasing intrauterine device (IUD) as alternatives to hysterectomy in the treatment of dysfunctional uterine bleeding., Design: Comparative study based on structured interviews., Setting: A large teaching hospital with 500 beds in the Netherlands., Patient(s): Ninety-six patients who were scheduled for endometrial ablation, 25 patients who were scheduled for hysterectomy, and 23 patients who were scheduled for a levonorgestrel-releasing IUD were interviewed. All of the women had dysfunctional uterine bleeding., Intervention(s): Patients were asked to state their most significant complaints and their reasons for choosing a particular treatment. Subsequently, the preference for endometrial ablation and a levonorgestrel-releasing IUD as alternatives to hysterectomy was assessed during a structured interview. Women were informed about the advantages and disadvantages of all three treatment options. Patients rated their preferences according to different hypothetical success rates. The success rates after endometrial ablation and levonorgestrel-releasing IUD were varied until patients found an acceptable treatment outcome., Main Outcome Measure(s): Patient preference of endometrial ablation and the levonorgestrel-releasing IUD over hysterectomy., Result(s): The main reason for the treatment of choice differed between the three groups. Most of the patients in the hysterectomy group wanted a definite solution to their problems, whereas patients in the levonorgestrel-releasing IUD group and in the ablation group put greater emphasis on a minimally invasive intervention with or without a short hospital stay. In women undergoing ablation, 70% of the patients preferred this treatment and the levonorgestrel-releasing IUD to hysterectomy in cases in which the success rate of noninvasive treatment was presumed to be 50%. In women having a levonorgestrel-releasing IUD inserted, 95% of the patients preferred this approach over hysterectomy in cases in which the success rate of this device was presumed to be 50%, whereas 35% of patients preferred ablation over hysterectomy in cases in which the success rate of ablation was presumed to be 50%. In women undergoing hysterectomy, 30% would have opted for ablation and 45% would have opted for a levonorgestrel-releasing IUD in cases in which success rates were 50%. Of patients who opted for hysterectomy, however, 60% stated that they would have preferred a noninvasive treatment if the success rate of this type of treatment were >80%., Conclusion(s): A majority of the patients who had dysfunctional uterine bleeding and who were scheduled for an endometrial ablation or a levonorgestrel-releasing IUD were inclined to take a risk of 50% likelihood of treatment failure to avoid a hysterectomy. As a consequence, research of treatment for dysfunctional uterine bleeding should focus on this 50% success level.

Objectives: We performed a review of the treatment modalities for dysfunctional uterine bleeding., Methods: Dysfunctional uterine bleeding can be treated medically or surgically. Medical treatment consists of anti-fibrinolytic tranexamic acid, non-steroidal anti-inflammatory drugs, the combined contraception pill, progestogen, danazol, or analogues of gonadotrophin releasing hormone. The levonorgestrel releasing intra uterine device is developed for contraception, but is also effective in the treatment of dysfunctional uterine bleeding. Surgical treatment includes endometrial ablation of the first and second-generation, and hysterectomy. This review contains current available evidence on the effectiveness of these therapies., Results: Antifibrinolytic tranexamic acid is the most effective medical therapy to treat dysfunctional uterine bleeding. In general medical therapy is not as effective as endometrial resection in terms of patient satisfaction and health related quality of life. The levonorgestrel releasing intra uterine device is an effective treatment for dysfunctional uterine bleeding. No difference in quality of life was observed in patients treated with a levonorgestrel releasing intra uterine device as compared to hysterectomy. Ablation techniques of the first generation are effective and safe when used by trained surgeons, but have a learning curve. Ablation techniques of the second generation are effective, but long-term follow-up data are not available. Similarly, there are no large randomised controlled trials comparing the levonorgestrel releasing intra uterine device to first and second-generation ablation techniques. Hysterectomy, the traditional standard of care, has a relatively high complication rate, but it generates a high satisfaction rate and good health related quality of life scores., Conclusion: Since none of the treatments for dysfunctional bleeding is superior to one of the others, and since all treatments have their advantages and disadvantages, counselling of patients with dysfunctional bleeding should incorporate medical approach, levonorgestrel releasing IUD, endometrial ablation and hysterectomy.

Objective: To evaluate the diagnostic accuracy of transvaginal ultrasonography for endometrial abnormalities in women with abnormal uterine bleeding., Methods: In a prospective study, 136 consecutive patients underwent transvaginal ultrasonography, hysteroscopy, and endometrial sampling through suction curettage or directed biopsy. The ultrasonographic findings were evaluated on the basis of the final diagnosis established by hysteroscopy and histologic examination. Receiver operating characteristic curve analysis and likelihood ratios were used. Likelihood ratios algebraically combine sensitivity and specificity to describe more than the independent values themselves, specifically the change in odds favoring disease given a particular test result., Results: In 21 of the 136 patients, hysteroscopy detected polyps or submucous myomas, which curettage failed to detect. In 67 premenopausal women, ultrasonography demonstrated a sensitivity in diagnosing endometrial abnormalities of 88% and a specificity of 68%, using a cutoff point of 5 mm of single-layer endometrial thickness. The positive likelihood ratio was 2.8 (95% confidence interval [CI] 1.66-4.55) and negative likelihood ratio 0.18 (95% CI 0.07-0.46). In 69 postmenopausal women, using a cutoff point of 3 mm, the sensitivity, specificity, positive likelihood ratio and negative likelihood ratio were 97%, 74%, 3.7 (95% CI 2.18-6.38), and 0.04 (95% CI 0.01-0.28) respectively., Conclusions: Transvaginal ultrasonography is an excellent first-step diagnostic method of excluding the endometrial abnormalities in women with postmenopausal bleeding but is of limited use in premenopausal women with irregular bleeding. Ultrasonography may reduce the number of invasive endometrial investigations by approximately 40%.

Our objective was to evaluate the effect of endometrial thinning by GnRH agonists on the results of hysteroscopic endometrial electrosurgical resection. In a prospective study, 32 women were treated with the GnRH agonist goserelin (Zoladex) before hysteroscopic endometrial resection. Endometrial thickness was measured before and after GnRH-a therapy by ultrasound. Short-term results in diminished vaginal blood loss and patient satisfaction were registered. The mean endometrial thickness (ET) before GnRH-a is 3.7 mm and after GnRH-a is 1.9 mm. In 24 cases, ET was reduced by a mean of 2.6 mm, in 1 case, no change was seen, and in 7 cases, ET increased by a mean 1.1 mm. The mean thickness rate (TR = ET before and after GnRH) is 2.7 (range 0.3-11). Fluid resorption during hysteroscopic surgery does not relate to ET or TR. Although the ET after GnRH-a therapy is not related to success or failure of the endometrial resection, there is some evidence that the TR is, probably expressing a more active state of the endometrium. Endometrial thinning by GnRH-a may have an effect on the results of hysteroscopic endometrial resection. In light of the present study and the literature, there seems to be no justification for abandoning preparation of the endometrium before hysteroscopic surgery.

Objective: The aim of this study was to evaluate the incidence of endometrial carcinoma, proven after hysterectomy, in patients diagnosed with atypical endometrial hyperplasia confined to a polyp. A secondary aim was to establish factors associated with (pre‐)malignant alterations in a polyp. Design: A retrospective cohort study. Setting: Maastricht University Medical Centre (MUMC+) and Máxima Medical Centre in Eindhoven/Veldhoven (Máxima MC). Population: Women who underwent a hysteroscopic polyp resection between 2008 and 2016. Methods: Patient characteristics and histopathology results of the polyp and, in the case of a hysterectomy, uterus were collected from patients' charts. Results: A total of 1445 complete hysteroscopic polyp resections were included. Of those, 1390 polyps showed benign histopathology results, 39 polyps contained atypical hyperplasia and 16 polyps contained endometrial carcinoma. A hysterectomy was performed in 35 women who were diagnosed with atypical hyperplasia confined to a polyp after hysteroscopic polyp resection. Histopathological assessment showed no additional (pre‐)malignant changes of the endometrium in 12 women (30.8%), atypical hyperplasia in 11 women (28.2%) and endometrial carcinoma in 12 women (30.8%). None of the prognostic factors under consideration were significantly associated with (pre‐)malignant changes in a polyp. Conclusion: The incidence of endometrial carcinoma in the surrounding endometrium after complete resection of a polyp with atypical hyperplasia is 30.8% in this study. This supports the current advice to perform a hysterectomy and bilateral salpingo‐oophorectomy. No prognostic factor for (pre‐)malignant changes in a polyp was established. The incidence of endometrial carcinoma after complete resection of a polyp with atypical hyperplasia is high. The incidence of endometrial carcinoma after complete resection of a polyp with atypical hyperplasia is high. [ABSTRACT FROM AUTHOR]