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Research Question: What influence does an intramural myoma have on the endometrium, and how is this mediated?, Design: Endometrium was collected from 13 patients with non-cavity-distorting intramural myomas (diameter ≤4 cm; International Federation of Gynecology and Obstetrics type 4) and 13 patients without myomas undergoing hysterectomy for benign cervical diseases with a similar clinical baseline. Endometrial organoids were established in vitro and induced to reach the secretory phase by oestrogen and progesterone. Transcriptome sequencing was conducted on endometrial organoids in both untreated and secretory stages from three individuals with myomas and three control participants. Immunofluorescence and real-time quantitative PCR (RT-qPCR) were performed on endometrial organoids from another 10 myoma patients and 10 control patients for validation., Results: The data revealed abnormally increased hormone receptor (PGR) levels in the untreated endometrial organoids with myomas, resulting in potentially abnormal glandular and vascular development. The aberrant responses to oestrogen and progestogen prompted further investigation into the secretory phase. The secretory endometrial organoids with myomas exhibited greater changes in acetyl-α-tubulin, ODF2 and TPPP, demonstrating likely decreased cilia, and COL6A1, used as a marker for increased extracellular matrix (ECM) modelling. Both untreated and secretory endometrial organoids with myoma showed an up-regulation of genes and pathways related to ECM mechanotransduction. The expression pattern of receptivity-related genes was disturbed in endometrial organoids with myoma., Conclusions: This study is the first to reveal that intramural myomas create an abnormal hormonal and mechanical environment in the untreated and secretory endometrial organoids. The intramural myomas negatively impacted gene expression relating to endometrial glands, blood vessels, cilia and ECM, indicating that intramural myomas impair endometrial decidualization and receptivity., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

I ntroduction: The morphological characteristics of the endometrium in patients with choriocarcinoma have not been well described. We described the endometrial morphology patterns in 46 choriocarcinomas and analyzed their relationship with the clinicopathological characteristics of these patients. Methods: Forty-six patients diagnosed with choriocarcinoma that had sufficient endometrial tissues for histopathological diagnosis were selected. Diagnoses of choriocarcinoma and secretory status of endometrium were reviewed. LHCGR expression of endometrium was evaluated by immunostaining. Results: Endometrial morphology was classified as secretory or nonsecretory. The 15 secretory specimens included 2 highly secretory and 13 common secretory specimens. The 31 nonsecretory patterns included 1 hyperplasia without atypia, 7 disordered proliferations, 13 typical proliferations, and 10 resting endometria. Among these, 11 specimens with overall nonsecretory patterns showed focally weak secretory changes surrounding the choriocarcinoma lesion. Secretory patterns were observed in classic choriocarcinomas (8/17) and monomorphic choriocarcinomas (7/21) but not in scanty-trophoblast choriocarcinomas (0/8). Secretory changes appeared significantly less frequently in patients who received multi-agent chemotherapy (4/25) than in those who did not (7/14) or received single-agent chemotherapy (4/7) ( P  = 0.030). The differences in age, months since the last pregnancy, pregnancy type, recurrence, specimen type, gross diameter, human chorionic gonadotropin (hCG) levels, and expression of hCG receptors were not statistically significant. Conclusions: The endometrial morphologies in choriocarcinoma were diverse, including various proliferative and secretory changes, but rarely hypersecretory changes, compared to the prevailing hypersecretory endometrium in hydatidiform moles. The variety in endometrial morphology was the consequence of ovarian hormonal disturbances of the hypothalamic-pituitary-gonadal axis by hCG from choriocarcinoma. Therefore, the endometrium may serve as a clue for histopathological diagnosis of choriocarcinoma. Our study presents the largest cohort reported to date to describe the diverse spectrum of endometrial changes in choriocarcinoma patients., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: To assess the ability of the International Endometrial Tumor Analysis (IETA)-1 polynomial regression model to estimate the risk of endometrial cancer (EC) and other intracavitary uterine pathology in women without abnormal uterine bleeding., Methods: This was a retrospective study, in which we validated the IETA-1 model on the IETA-3 study cohort (n = 1745). The IETA-3 study is a prospective observational multicenter study. It includes women without vaginal bleeding who underwent a standardized transvaginal ultrasound examination in one of seven ultrasound centers between January 2011 and December 2018. The ultrasonography was performed either as part of a routine gynecological examination, during follow-up of non-endometrial pathology, in the work-up before fertility treatment or before treatment for uterine prolapse or ovarian pathology. Ultrasonographic findings were described using IETA terminology and were compared with histology, or with results of clinical and ultrasound follow-up of at least 1 year if endometrial sampling was not performed. The IETA-1 model, which was created using data from patients with abnormal uterine bleeding, predicts four histological outcomes: (1) EC or endometrial intraepithelial neoplasia (EIN); (2) endometrial polyp or intracavitary myoma; (3) proliferative or secretory endometrium, endometritis, or endometrial hyperplasia without atypia; and (4) endometrial atrophy. The predictors in the model are age, body mass index and seven ultrasound variables (visibility of the endometrium, endometrial thickness, color score, cysts in the endometrium, non-uniform echogenicity of the endometrium, presence of a bright edge, presence of a single dominant vessel). We analyzed the discriminative ability of the model (area under the receiver-operating-characteristics curve (AUC); polytomous discrimination index (PDI)) and evaluated calibration of its risk estimates (observed/expected ratio)., Results: The median age of the women in the IETA-3 cohort was 51 (range, 20-85) years and 51% (887/1745) of the women were postmenopausal. Histology showed EC or EIN in 29 (2%) women, endometrial polyps or intracavitary myomas in 1094 (63%), proliferative or secretory endometrium, endometritis, or hyperplasia without atypia in 144 (8%) and endometrial atrophy in 265 (15%) women. The endometrial sample had insufficient material in five (0.3%) cases. In 208 (12%) women who did not undergo endometrial sampling but were followed up for at least 1 year without clinical or ultrasound signs of endometrial malignancy, the outcome was classified as benign. The IETA-1 model had an AUC of 0.81 (95% CI, 0.73-0.89, n = 1745) for discrimination between malignant (EC or EIN) and benign endometrium, and the observed/expected ratio for EC or EIN was 0.51 (95% CI, 0.32-0.82). The model was able to categorize the four histological outcomes with considerable accuracy: the PDI of the model was 0.68 (95% CI, 0.62-0.73) (n = 1532). The IETA-1 model discriminated very well between endometrial atrophy and all other intracavitary uterine conditions, with an AUC of 0.96 (95% CI, 0.95-0.98). Including only patients in whom the endometrium was measurable (n = 1689), the model's AUC was 0.83 (95% CI, 0.75-0.91), compared with 0.62 (95% CI, 0.52-0.73) when using endometrial thickness alone to predict malignancy (difference in AUC, 0.21; 95% CI, 0.08-0.32). In postmenopausal women with measurable endometrial thickness (n = 848), the IETA-1 model gave an AUC of 0.81 (95% CI, 0.71-0.91), while endometrial thickness alone gave an AUC of 0.70 (95% CI, 0.60-0.81) (difference in AUC, 0.11; 95% CI, 0.01-0.20)., Conclusion: The IETA-1 model discriminates well between benign and malignant conditions in the uterine cavity in patients without abnormal bleeding, but it overestimates the risk of malignancy. It also discriminates well between the four histological outcome categories. © 2023 International Society of Ultrasound in Obstetrics and Gynecology., (© 2023 International Society of Ultrasound in Obstetrics and Gynecology.)

Aim: The effectiveness of hysteroscopy in diagnosing endometrial lesions has been demonstrated, showing high diagnostic accuracy for malignant endometrial lesions. Although the characteristic appearances of atypical and malignant endometria have been reported, they are not definitive and sometimes complicated. This study aimed to identify a small number of characteristic features to detect endometrial abnormalities using a simple judgment system and analyze the diagnostic characteristics and their accuracy in endometrial malignancy diagnosis., Methods: We performed a retrospective analysis of hysteroscopy video data of 250 patients, of which we selected for analysis based on pathology examination 152 cases with benign changes, 16 with atypical endometrium, and 18 with carcinoma in situ or endometrial cancer. Endometrial characteristics assessed included protrusion, desquamation, extended vessel, atypical vessel, and white/yellow lesion., Results: Multivariable analysis revealed that desquamation (p = 0.001, odds ratio [OR] 5.28), atypical vessels (p < 0.001, OR 8.50), and white/yellow lesions (p = 0.011, OR 1.37) were significant predictors for endometrial malignancy. From their contribution status, scoring points of 4, 6, and 1 were settled according to the odds ratio proportions. When scores ≥5 (at least both desquamation and white/yellow lesions or only atypical vessels) were used to define endometrial malignancy, sensitivity and specificity were 100% and 92%, respectively. When detecting cancer, atypical, and benign cases, sensitivity and specificity were 88% and 90%, respectively., Conclusion: Our characteristics hysteroscopic findings showed a higher predictive ability in detecting endometrial malignancies. However, further examination with more cases would be needed to accurately diagnose endometrial malignancy by hysteroscopy., (© 2024 The Authors. Journal of Obstetrics and Gynaecology Research published by John Wiley & Sons Australia, Ltd on behalf of Japan Society of Obstetrics and Gynecology.)

Objective: To compare survival measures of women with Stage I high-grade endometrial cancer who underwent either hysteroscopy or a non-hysteroscopic procedure as a diagnostic procedure., Study Design: 298 patients with stage I high grade endometrial cancer who underwent surgery between 2002 and 2014. Patients were divided into two groups: hysteroscopy and non-hysteroscopy (curettage or office endometrial biopsy). Clinical, pathological, and survival measures were compared between the groups. High grade histology included endometroid grade -3, uterine serous papillary carcinoma, clear cell carcinoma, and carcinosarcoma., Results: There were 71 patients in the hysteroscopy group and 227 patients in the non-hysteroscopy group. The median follow-up was 52 months (range 12-120 months). There were no differences between the groups in the 5-year recurrence-free survival (73.9 % vs. 79.7 %; p = 0.65), disease-specific survival (79.3 % vs. 83.6 %; p = 0.87), and overall survival (65.7 % vs. 80.3 %; p = 0.35)., Conclusion: Hysteroscopic diagnosis in women with early-stage and high-grade endometrial cancer does not adversely affect the survival outcomes., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

This article presents a comprehensive review of factors that increase the risk of malignancy in ultrasound findings of an endometrial polyp. We collected original studies, reviews, and meta-analyses that dealt with the topic of endometrial polyps and the risk of developing endometrial cancer. Each presumed risk factor was analysed individually. According to searched studies, abnormal uterine bleeding, old age, and body mass index are valid risk factors for developing endometrial cancer in endometrial polyps. Lynch syndrome patients are also in a high-risk group for endometrial cancer. On the other hand, the number of polyps, their size, diabetes mellitus, hypertension, and positive family history are factors with inconclusive results. There are either not enough data or different results among several studies.

Post-menopausal bleeding (PMB) accounts for 5% of gynecologic office visits and is the presenting symptom in 90% of women with endometrial cancer, which requires prompt evaluation. The most common etiology of PMB is vaginal or endometrial atrophy and endometrial polyps, while endometrial hyperplasia and carcinoma account for less than 10% of PMB. Transvaginal ultrasonography measurement of an endometrial thickness (EMT) less than or equal to 4 mm has a 99% negative predictive value for endometrial carcinoma. Endometrial sampling is required if EMT >4 mm or persistent bleeding occurs. Further evaluation can be accomplished with saline infusion sonography, magnetic resonance imaging, and hysteroscopy., (Copyright © 2023. Published by Elsevier Inc.)

Purpose: Uterine serous carcinoma (USC) is a rare endometrial cancer representing less than 10% of uterine cancers but contributing to up to 50% of the mortality. Delay in diagnosis with this high-grade histology can have significant clinical impact. USC is known to arise in a background of endometrial atrophy. We investigated endometrial stripe (EMS) thickness in USC to evaluate current guidelines for postmenopausal bleeding in the context of this histology., Methods: Retrospective chart review was conducted using ICD-9 and ICD-10 codes over an 18-year period. We included 139 patients with USC and compared characteristics of patients with EMS ≤ 4 mm and EMS > 4 mm. Chi-square or Fisher's exact tests were used to compare proportions and two-tailed t-tests to compare means. A p-value of < 0.05 was considered statistically significant., Results: Most patients were white, obese, and multiparous. Thirty-two (23%) had an EMS ≤ 4 mm; 107 (77%) had an EMS > 4 mm. There were no statistically significant differences in age at diagnosis or presenting symptoms between groups, and postmenopausal bleeding was the most common symptom in each group., Conclusion: Nearly 25% of patients with USC initially evaluated with transvaginal ultrasound were found to have an EMS ≤ 4 mm. If transvaginal ultrasound is used to triage these patients, one in four women will potentially experience a delay in diagnosis that may impact their prognosis., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Objective: To study the long-term risks of postmenopausal women with proliferative endometrium developing benign uterine pathologies (endometrial polyps and uterine fibroids) and requiring future gynecological interventions, and to compare them with women with atrophic endometrium., Design: Retrospective cohort study of all women aged 55 or over who underwent endometrial biopsy between 1/1997 and 12/2008. Outcome data were available through to 2/2018. Women with proliferative endometrium were compared with those with atrophic endometrium for the presence of endometrial polyps, uterine fibroids, future endometrial biopsy for recurrent vaginal bleeding, and future hysteroscopy or hysterectomy. Logistic regression models were used to evaluate the association of endometrial histology and other covariates with the risk of morbidities., Main Findings: Postmenopausal women with proliferative endometrium are at higher risk of developing endometrial polyps, uterine fibroids and need for surgical intervention. Of 1808 women who underwent endometrial biopsy during the study period, 962 met inclusion criteria: 278 had proliferative and 684 had atrophic endometrium. Length of surveillance was similar in the two groups (11.9 vs. 11.5 years, p = 0.2). Compared with women with atrophic endometrium, women with proliferative endometrium had significantly higher rates of endometrial polyps (17.3 % vs 9.7 % p = 0.001). Multivariable logistic regression confirmed that women with proliferative endometrium had more fibroids on ultrasound (62.1 % vs 50.3 % 3 = 0.02), and had increased risks of developing endometrial polyps (aOR 1.9, 95 % CI 1.28-3.07, p = 0.002), repeat endometrial biopsy (34.9 % vs. 16.8%p < 0.001) and future hysterectomy or hysteroscopy (26.6 % vs 16.2 % p < 0.001)., Conclusions: In addition to the long-term increased risk of cancer, postmenopausal women with proliferative endometrium are more likely to have future bleeding, surgical interventions and diagnosis of endometrial polyps. Medical management to reduce estrogenic activity and associated risks may be considered in these cases., Competing Interests: Declaration of competing interest The authors declare that they have no competing interest., (Copyright © 2023. Published by Elsevier B.V.)

Objectives: To investigate whether the number and size of endometrial-leiomyoma fistulas (ELFs) change following uterine artery embolization (UAE) for leiomyoma and the correlation between ELFs and vaginal discharge (VD)., Materials & Methods: This study was a retrospective analysis of 100 patients who underwent UAE at a single institution between May 2016 and March 2021. They all underwent MRI at baseline, 4 months, and 1 year after UAE. The number and size of the ELFs were compared with the MRI images each time. The ELF tumor characteristics and the correlation between the ELFs and VD were assessed. Additional gynecologic interventions due to VD associated with ELFs were evaluated., Results: No ELF was observed at baseline. Ten ELFs were noted in nine patients at 4 months, and 35 ELFs were noted in 32 patients 1 year after UAE. The ELFs significantly increased over time (p = 0.004, baseline vs. 4 months; p < 0.001, 4 months vs. 1 year). The ELF size did not significantly change over time (p = 0.941). The tumors developing ELFs after UAE were mainly located at the submucosal or intramural area contacting the endometrium at baseline, with a mean size of 7.1 (2.6) cm. Nineteen patients (19%) had VD 1 year after UAE. There was no significant correlation between VD and the number of ELFs (p = 0.80). No patients underwent additional gynecologic interventions due to VD associated with ELFs., Conclusion: ELFs increased in number and did not disappear over time after UAE in most tumors., Clinical Relevance Statement: Despite the MR imaging findings, within the limited data of this study, ELFs were not seemingly associated with clinical symptoms, including VD., Key Points: • Endometrial-leiomyoma fistula (ELF) is a complication of uterine artery embolization (UAE). • ELFs increased in number over time after UAE and did not disappear in most tumors. • Most tumors developing ELFs after UAE were located near/contacted the endometrium and were larger., (© 2023. The Author(s), under exclusive licence to European Society of Radiology.)

As an emerging surgical technology, tissue removal systems have been widely used in the treatment of endometrial polyps due to its characteristics of less endometrial damage, shorter learning curve and clearer vision of the operative field. There are few cases in the literature reporting serious complications after endometrial polypectomy using tissue removal systems. As known, septic shock is a rare complication following hysteroscopic polypectomy. Now, we present the case of a 23-year-old woman who developed septic shock after polypectomy with tissue removal system. The patient had a history of recurrent vaginitis for more than half a year. Due to endometrial polyps, she was admitted to our hospital and scheduled to undergo hysteroscopic endometrial polypectomy. Three hours after the endometrial polypectomy using the tissue removal system, the patient had shock symptoms such as increased body temperature, decreased blood pressure and increased heart rate. Then, the patient was successfully treated and discharged after anti-infection and anti-shock treatments. The purpose of this case report is to remind clinicians to consider the possibility of serious infection and comprehensively evaluate the risk of infection before choosing hysteroscopic devices for endometrial polyps, especially for patients who choose the mechanical hysteroscopic tissue removal systems. Furthermore, the mechanical hysteroscopic tissue removal systems should be used with caution in patients with previous recurrent vaginitis., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Rationale: Endometrial vascular dystrophy refers to abnormal vessels that are very tortuous, dilated, and sometimes thrombosed. Endometrial vascular dystrophy is rare under hysteroscopy., Patient: All three patients had a history of abnormal uterine bleeding. The duration of vaginal bleeding ranged from 1 month to 2 years. There was no history of unusual diseases, alcohol or drug abuse, or genetic history., Diagnoses: Endometrial vascular dystrophy., Intervention: Three patients underwent hysteroscopy and curettage under intravenous general anesthesia. Pathological examination showed secretory endometrium, with one case coexisting with endometrial polyps., Outcomes: No recurrence was found during postoperative follow-up at 12 months., Lessons: Endometrial vascular dystrophy is a rare hysteroscopy phenomenon shown in the secretory endometrium. We believe that it was a capillary loop with different manifestations., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: The present study aimed to evaluate the impact of endometrial polyps (EPs) on the endometrium of patients with unexplained infertility using stanniocalcin-1 and -2 proteins (STC), whose effects on endometrial receptivity have been reported recently., Materials and Methods: A case-control study was performed, consisting of 26 patients who underwent endometrial sampling for diagnosis and/or treatment and diagnosed with EP on biopsy and/or excision material, and 23 patients with normal endometrial findings in the pathology, for a total of 49 patients with unexplained infertility. An immunohistochemistry examination was performed on paraffin-embedded tissue samples from both groups to understand whether there was a relationship between EP and STC. Staining results of the polyp and control groups for STC-1 and STC-2 were compared, and it was investigated whether STCs were predictive for EP., Results: In the comparison performed between the H-score evaluation results of the control and polyp groups after the immunohistochemical staining method, the staining in the polyp group was significantly higher for both STC-1 (p < 0.001) and STC-2 (p < 0.001). There was more staining with STC-1 than STC-2 in all groups (STC-1: 15.08; STC-2: 8.27; p < 0.05). In the logistic regression analysis established with STC-1, STC-2, and age, the predictive effect of STC-1 for EP was statistically significant (p = 0.040; odds ratio: 1.66; 95% confidence interval: 1.02-2.68). In EP, according to receiver operating characteristic curve analysis, area under the curve was 0.980 (likelihood ratio: 20.35; p < 0.05), and the cut-off value was 18 for STC-1., Conclusion: In infertile patients, since STC-1, which affects endometrial receptivity, is found to be significantly higher in polyps and has a predictive effect on polyps, in patients with unexplained infertility, routine uterine cavity evaluation and routine excision of polypoid lesions detected during this period may have a positive effect on endometrial receptivity., (© 2023 Japan Society of Obstetrics and Gynecology.)

Cholangiocarcinoma is an uncommon and aggressive malignancy of intrahepatic and extrahepatic bile ducts. We present a case of a 37-year-old woman with cholangiocarcinoma metastatic to the endometrium that mimicked a primary endometrial adenocarcinoma at resection. The patient is status-post orthotopic liver transplant for cholangiocarcinoma. She presented for evaluation of a clear, odorless vaginal discharge of 6 months' duration. Endometrial biopsy demonstrated an adenocarcinoma with mucinous features similar to primary endometrial adenocarcinoma, but with an immunophenotype consistent with metastatic cholangiocarcinoma. Subsequent hysterectomy demonstrated complete replacement of the native endometrium, a presentation that represents, to our knowledge, the first such reported in the literature. Overall, extragenital metastatic disease to the uterine corpus is rare and involvement of the endometrium even less common. Metastatic cholangiocarcinoma represents a small subset of these metastases to the uterus., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 by the International Society of Gynecological Pathologists.)

This practice guideline provides updated evidence for the gynecologist who performs endometrial biopsy (EB) in gynecologic clinical practice. An international committee of gynecology experts developed the recommendations according to AGREE Reporting Guideline. An adequate tissue sampling is mandatory when performing an EB. Blind methods should not be first choice in patients with suspected endometrial malignancy. Hysteroscopy is the targeted-biopsy method with highest diagnostic accuracy and cost-effectiveness. Blind suction techniques are not reliable for the diagnosis of endometrial polyps. In low resources settings, and in absence of the capacity to perform office hysteroscopy, blind techniques could be used for EB. Hysteroscopic punch biopsy allows to collect only limited amount of endometrial tissue. grasp biopsy technique should be considered first choice in reproductive aged women, bipolar electrode chip biopsy should be preferred with hypotrophic or atrophic endometrium. EB is required for the final diagnosis of chronic endometritis. There is no consensus regarding which endometrial thickness cut-off should be used for recommending EB in asymptomatic postmenopausal women. EB should be offered to young women with abnormal uterine bleeding and risk factors for endometrial carcinoma. Endometrial pathology should be excluded with EB in nonobese women with unopposed hyperestrogenism. Hysteroscopy with EB is useful in patients with abnormal bleeding even without sonographic evidence of pathology. EB has high sensitivity for detecting intrauterine pathologies. In postmenopausal women with uterine bleeding, EB is recommended. Women with sonographic endometrial thickness > 4 mm using tamoxifen should undergo hysteroscopic EB., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Objective: To present a new technique for complete endometrial polypectomy, using the bipolar loop hysteroscope, but without the activation of electrical energy, and follow its efficiency and safety for the patient., Study Design: This is a prospective descriptive study conducted at a university hospital. Forty four patients were recruited to the study according to an intra uterine polyp diagnosed by transvaginal ultrasound (TVS). Out of them 25 really had an endometrial polyp which was inspected by hysteroscopy. Eighteen were at menopause age and seven in their reproductive age. The hysteroscopic removal of the endometrial polyp was performed using the operative loop resectoscope without using electricity, meaning by cold loop. We called this unique technique SHEPH: Shaving of Endometrial Polyp by Hysteroscopy., Results: The range age was 21-77 years old. All patients with apparently endometrial polyp, underwent a complete removal of the polyp which could be directly seen through hysteroscopy. No bleeding was seen in all cases. The other nineteen patients had normal uterine cavity, so a biopsy was taken according to the indication. The specimen from all cases were sent to histological evaluation. An endometrial polyp was histologically confirmed in all cases who underwent the SHEPH technique, while fragments of an endometrial polyp was revealed by histology in six cases from the group that had normal uterine cavity. No complications were noted for the short and long periods., Conclusions: Nonelectric Shaving of Endometrial Polyp by Hysteroscopy (SHEPH technique) is a safe and effective procedure which allows the surgeon to achieve a complete endometrial polypectomy but without using electrical energy within the body of the patient. The technique which is easy to learn, is new and unique by eliminate thermal damage in a very common gynecologic indication., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Uterine endometrial stromal sarcomas (ESS) with YWHAE::NUTM2 gene fusions are typically morphologically high-grade tumors composed of atypical round cells, sometimes associated with a low-grade fibromyxoid component; they are currently included in the category of high-grade ESS (HGESS). We report 5 morphologically pure low-grade endometrial stromal tumors harboring YWHAE::NUTM2 fusions, including 1 endometrial stromal nodule (ESN) and 4 low-grade endometrial stromal sarcomas (LGESS), an association only occasionally reported previously. Patients ranged from 30 to 51 (mean=43) years and tumors from 4.5 to 7.5 cm (mean=5.7). All were stage I at diagnosis (confined to the uterus). Microscopically, the 4 LGESS showed extensive "tongue-like" invasion of the myometrium, and the ESN was entirely confined to the endometrium with no myometrial invasion. All tumors were composed entirely of morphologically uniform bland ovoid cells resembling proliferative endometrial stroma. A fibromyxoid component was seen in 1 LGESS and the ESN; in the LGESS, this was the sole component. Atypical round cells characteristic of YWHAE::NUTM2 HGESS were not identified. Mitotic count ranged from <1 to 13 per 10 high-power fields (mean: 3). CD10 was positive in 2/4 (focal), estrogen receptor in 5/5 (focal=1; diffuse=4), progesterone receptor in 5/5 (focal=1; diffuse=4) and cyclin D1 was diffusely positive in 3/4. Follow-up was available in all 5 patients and ranged from 6 to 159 months (mean=72). Two patients with LGESS had recurrent disease at 15 and 155 months; 1 showed predominantly LGESS with rare round cells in the initial recurrence and pure HGESS in a subsequent recurrence, while the other patient's recurrent tumor was predominantly HGESS (90%) in a background of focal fibromyxoid LGESS (10%). Both patients rapidly progressed and died of disease within 5 months of high-grade recurrence. We show that rare cases of morphologically pure low-grade endometrial stromal tumors, some but not all with a fibromyxoid component, harbor YWHAE::NUTM2 fusions and may recur rapidly, with transformation to HGESS and aggressive behavior. Our findings suggest that at least a subset of YWHAE::NUTM2 HGESS evolves from LGESS. We suggest that cyclin D1 and CD10 staining should be performed in all LGESS. Diffuse staining for cyclin D1 and/or negative or focal staining for CD10 should suggest the possibility of a YWHAE::NUTM2 fusion, and appropriate molecular testing should be undertaken. Since no single morphological or immunohistochemical parameter is entirely sensitive for fusion status, we also suggest that testing for a YWHAE::NUTM2 gene fusion should be considered in all cases of LGESS and, if a fusion is present, this should raise the possibility of subsequent high-grade transformation and aggressive behavior, even though such cases should still be categorized as LGESS. Although seemingly rare, ESN and LGESS with YWHAE::NUTM2 fusions may be under-recognized due to a lack of routine fusion testing., Competing Interests: Conflicts of Interest and Source of Funding: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Choriocarcinoma coexisting with endometrial carcinoma is rare. To the best of our knowledge, only one case of choriocarcinoma coexisting with endometrial carcinoma has been reported., Case Presentation: Here, we present this case and provide a literature review. A 38-year-old unmarried nulliparous woman presented to the clinic with a menstrual disorder for more than 3 months. She then underwent a hysteroscopic procedure. The pathological findings were malignant, two types of carcinoma, and no transitional lesions were observed; about 85% of them were choriocarcinoma with smooth muscle infiltration and intravascular investigation of the thrombus; about 15% were highly differentiated endometrioid adenocarcinoma; Immunohistochemistry (endometrioid/choriocarcinoma): Vim (+ + / +  + +), P40 (+ ±), CK5/6 multifocal ( ±), CK7 ( ±), EMA (+ ±), P16 multifocal ( ±), P53 (+ / + +), WT-1 (-/ + +), hCG (-/ +  + +), CD138 (-/ +  + +), Gly-3 (-/-), ER ( ±), PR (+ ±), Sall-4 (-/-), P21 (-/ +), P27 (-/ +  + +), CyclinE (-/ + +), Ki67 positivity rate (10%/95%). We performed a laparoscopic hysterectomy, bilateral adnexectomy, and pelvic and para-abdominal lymph node dissection after five cycles of chemotherapy. She was diagnosed with choriocarcinoma with endometrial cancer, stage IVb choriocarcinoma and stage IA endometrial cancer. Postoperative radiochemotherapy was administered. The patient was disease-free 40 months after the treatment ended., Conclusion: We report a case of choriocarcinoma coexisting with endometrial carcinoma and provide a literature review that may help inspire additional studies in the future., (© 2023. The Author(s).)

Autophagy is implicated in normal pregnancy and various pathologic pregnancy conditions. Its presence in hydatidiform moles (HM) is unknown. We immunohistochemically studied 36 HM for LC3B and p62 to precisely determine their expression in the decidua, endometrium, and villi. Nineteen nonmolar pregnancies were also studied. LC3B was found in almost half of the villi and p62 was found in almost all villi. LC3B expression was significantly higher in complete HM than in partial HM. LC3B showed different expression patterns in trophoblast layers. LC3B and p62 expression was higher in molar than nonmolar pregnancies. Autophagic markers are present in HM and their expression differs between complete and partial moles., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 by the International Society of Gynecological Pathologists.)

Purpose: To evaluate whether different measurements of endometrial thickness pre-IVF cycle and during the IVF cycles as measured by transvaginal ultrasound are associated with the absence or presence of endometrial polyps., Design: A retrospective cohort study was conducted in a university-affiliated fertility center. Patients were women who underwent two embryo transfer cycles and failed to conceive., Interventions: hysteroscopic evaluation and resection of any masses., Results: There was no difference on comparing the groups with and without polyps in the mean endometrial thicknesses at baseline scans pre-treatment or during IVF cycle. For women who failed two embryo transfer cycles, at any given endometrial thickness the probability of the presence of a polyp was 30-40%. ROC curves failed to detect an actionable relationship with different endometrial thicknesses and the relationship with an endometrial polyp, with most areas under the curve being just above 0.5. However, once the maximum stimulated endometrial thickness was ≥ 13 mm, there was a 70% chance of a polyp being noted at hysteroscopy. This was a statistical difference in the probability of a polyp being present as compared to the lesser thicknesses (p = 0.05)., Conclusion: Baseline or maximum stimulated endometrial thickness at IVF fails to predict with accuracy the presence of a polyp. However, if the maximum stimulated thickness was at least 13 mm, there was a higher probability of a uterine polyp being present. Such a cutoff would nevertheless miss most polyps. At any baseline thickness on CD 2-5, a polyp has a 30-40% probability of being present in women who failed two embryo transfers. ROC curves suggest that at baseline, or maximum stimulated endometrial thickness, the ability to predict a polyp is no better than flipping a coin. As such, endometrial cavity evaluation for polyps is legitimate in women with two embryo transfers irrelevant of the baseline or stimulated thickness., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Endometrial vascular dystrophy is quite rare, and there is very little literature regarding this subject. We present the unusual case of a 38-year-old woman who experienced vaginal bleeding after menstruation for 3 months. Hysteroscopically, the uterine cavity was filled with tiny, curved blood vessels, the bottom of the cavity was obvious, and polyps were visible. No curved vessels or polyps were identified after curettage. The diagnosis was endometrial hemodystrophy with endometrial polyps. Endometrial vascular dystrophy is a hysteroscopically uncommon benign lesion of the endometrial vessels.

Context.—: Endometrial serous carcinoma is well known for its high risk of extrauterine spread, even when the intrauterine tumor is minimal in volume and limited to the endometrium. Representing the earliest recognizable forms of endometrial serous carcinoma, minimal uterine serous carcinoma (MUSC) includes serous endometrial intraepithelial carcinoma and superficial serous carcinoma., Objective.—: To discuss the pathogenetic relationship between MUSC and endometrial polyp, and to review the pathologic diagnosis and clinical implication of MUSC., Data Sources.—: Sources are a literature review and the author's personal practice and perspective., Conclusions.—: A close topographic relationship between MUSC and endometrial polyp has been consistently observed in many studies: more than two-thirds of MUSCs involve an endometrial polyp and >50% of MUSCs are confined to an endometrial polyp at the time of staging hysterectomy, indicating that most if not all MUSCs arise in an endometrial polyp. Timely diagnostic recognition of MUSC is clinically critical because the patients without extrauterine tumor spread have an excellent prognosis and those with extrauterine involvement have a dismal outcome. Further investigations into the endometrial polyp harboring MUSC may elucidate the key cellular and molecular alterations underpinning the pathogenesis of uterine serous carcinoma., (© 2023 College of American Pathologists.)

Background: Polycystic ovary syndrome (PCOS) is characterized by anovulation, insufficient progesterone, hyperandrogenism, and insulin resistance. These factors can disrupt the endometrium of PCOS patients and can lead to chronic low-grade inflammation in the endometrium, endometrial hyperplasia, or even endometrial cancer., Objective: The aim of this study was to investigate the prevalence of premalignant and malignant endometrial polyps in premenopausal women and to further explore whether PCOS is associated with premalignant and malignant changes in endometrial polyps., Methods: This study was conducted by retrieving the medical data of 4236 premenopausal women who underwent hysteroscopic polypectomies between January 2015 and December 2021. Demographic and clinical data regarding age, height, weight, parity, hormone replacement therapy, oral contraceptives, abnormal uterine bleeding, hypertension, diabetes mellitus, PCOS, number of polyps, and size of polyps were collected, and their associations with premalignant and malignant changes in endometrial polyps were analysed., Result: Among the endometrial polyps removed by hysteroscopic polypectomy in premenopausal women, the prevalence of premalignant and malignant polyps was 2.15%, which comprised hyperplasia with atypia at 1.13% and endometrial carcinoma at 1.02%. PCOS was associated with a higher risk of premalignant and malignant endometrial polyps in premenopausal women after adjustment for potential confounding factors., Conclusion: PCOS is associated with a higher risk of premalignant and malignant endometrial polyps in premenopausal women. Therefore, it is important to evaluate the endometrium in PCOS patients with ultrasonography or hysteroscopy, and active management involving hysteroscopic polypectomy should be offered to PCOS patients diagnosed with endometrial polyps regardless of symptoms., (© 2023. The Author(s).)

Background: The reported recurrence rate of endometrial polyps (EPs) after hysteroscopic polypectomy varied widely, and the factors influencing the recurrence of EPs are still controversial. Furthermore, the known definite independent risk factors are almost unchangeable, such as the number of EPs and previous polypectomy history. The aim of this study was to evaluate the impact of chronic endometritis (CE) on the recurrence of EPs in premenopausal women who underwent hysteroscopic polypectomy., Methods: A retrospective study was conducted at a university-affiliated hospital. Premenopausal women who underwent hysteroscopic polypectomy were enrolled, and those with definite confounding factors for polyp recurrence were excluded, including endometriosis and previous polypectomy history. A total of 233 women were enrolled in this study, including 64 (27.5%) cases with CE and 169 (72.5%) cases without CE. CE was diagnosed via immunohistochemical detection of CD138 on the endometrial specimen. Comparison of the recurrence rate of EPs was performed in women with or without CE at each monitoring stage (i.e., at 3, 6, 9 and 12 months) after hysteroscopic polypectomy., Results: The recurrence rates of EPs at one year in patients with and without CE were 26.6% (95% confidence interval [CI] 15.8-37.4%) and 9.5% (95% CI 5.0-14.0%), respectively, with an overall recurrence rate of 14.2% (95% CI 9.7-18.7%). The hazard ratio (HR) for EPs recurrence in the EPs with CE cohort versus the EPs without CE cohort was 3.08 (95% CI 1.56-6.09) (P = 0.001). Similarly, the recurrence rate of EPs was significantly higher in women with CE than in those without CE at each monitoring stage (i.e., 3, 6 and 9 months). CE and multiple EPs were risk factors for EPs recurrence. The HR for EPs recurrence in the EPs with CE cohort compared with the EPs without CE cohort was 3.06, after adjustment for the number of EPs., Conclusions: CE was a harmful factor for the recurrence of EPs in premenopausal women after hysteroscopic polypectomy. Thus, routine screening for CE during hysteroscopic polypectomy was needed. Frequent monitoring was needed for multiple EPs as the number of EPs also contributed to polyp recurrence., (© 2023. The Author(s).)

Purpose: To investigate the feasibility of percutaneous intrauterine instillation of chilled saline to protect the endometrium during microwave ablation (MWA) treating types 1-3 uterine fibroids., Materials and Methods: Twenty-six patients with types 1-3 uterine fibroids were prospectively enrolled in an intrauterine saline instillation group (study group). The same number of patients with types 1-3 uterine fibroids who previously received MWA without endometrial protection were retrospectively included in a control group. Endometrial impairment was evaluated by hysteroscopy and magnetic resonance imaging (MRI)., Results: In the study group, hysteroscopy revealed an intact endometrium in 17 patients, congestion and reddening of the endometrium due to heat in 8 patients, and a burnt necrosis with a size < 1 cm on the functional layer of the endometrium in 1 patient. On MRI, in the study group, there were 17 (65.4%), 6 (23.1%), and 3 (11.5%) patients with grades 0, 1, and 2 endometrial impairment, respectively, but no grade 3 endometrial impairment. In the control group, there were 8 (30.8%), 8 (30.8%), 7 (26.9%), and 3 (11.5%) patients with grades 0, 1, 2, and 3 endometrial impairment, respectively. Endometrial impairment in the study group was significantly better than that in the control group ( p  = 0.006). One patient had puncture tunnel bleeding and no other complications occurred in the study group., Conclusion: Intraoperative percutaneous intrauterine instillation of chilled saline may be effective and safe in reducing the thermal damage to the endometrium caused by MWA for treating types 1-3 uterine fibroids.

Background: Clear cell carcinoma is an uncommon histologic subtype of ovarian and endometrial carcinoma with poor response to Platinium-based chemotherapy agents at high stages. Blockage of Programmed cell Death Ligand-1 (PD-L1), can be used in targeted immunotherapy. This study investigated Mismatch Repair Deficiency (MMR-D) status, PD-L1 expression, and the correlation between PD-L1 expression and microsatellite instability (MSI) status in ovarian and endometrial clear cell carcinomas., Methods: Ovarian clear cell carcinoma (OCCC) (n = 28) and endometrial clear cell carcinoma (ECCC) (n = 28) samples were evaluated for PD-L1 (in tumoral and peri-tumoral inflammatory cells), MSH6 and PMS2 expression by immunohistochemistry (IHC) study. PD-L1 expression > 1% in tumor cells and > 5% in peritumoral inflammatory cells were considered positive., Results: The prevalence of PD-L1 expression was higher in ECCC (20/28, 71.43%) compared to OCCC tumor cells (16/28, 57.15%) (p > 0.05), while expression in peritumoral inflammatory cells was significantly higher in ECCC (25/28, 89.29%) compared to OCCC (11/28, 39.28%) (p < 0.05). MMR-D was observed in 5 cases, four OCCCs and one ECCC, among which, four (80%) showed PD-L1 expression in peritumoral inflammatory and tumor cells. The only OCCC case with extensive PD-L1 expression in tumor cells (> 50%) exhibited MSH6/MSH2 loss. No significant correlation was noted between PD-L1 expression and the pathologic stage or survival., Conclusion: PD-L1 expression was significantly associated with clear cell morphology, especially in the endometrium, independent of MMR protein status., (© 2022. The Author(s).)

Objective: To investigate whether surgical removal of intramural fibroids makes any changes in the expression of endometrial tumor necrosis factor alpha (TNF-α) and nuclear factor kappa B (NF-κB)., Patients and Methods: 20 patients who had no pathology other than intramural fibroid as a cause of subfertility were included in the study. 6 patients who planned tubal ligation were considered as the control group. Type 3 or 4 fibroid diagnosis was made according to the revised International Federation of Gynecology and Obstetrics (FIGO). At the end of the diagnostic and confirmatory tests, 8 patients were diagnosed with type 3 and 12 patients with type 4 fibroids. While the patients in the fibroid group went to myomectomy, the patients in the control group went to tubal ligation. Before the myomectomy, endometrial sampling was performed with a pipelle cannula under anesthesia. The same procedure was repeated three months after the treatment. The same endometrial sampling procedure was also performed on the patients in the control group. TNF-alpha and NF-κB levels were measured with enzyme-linked immunosorbent assay (ELISA) in endometrial samples taken before and three months after myomectomy., Results: Pre-myomectomy TNF-α levels of the patients in the type 3 fibroid group were significantly higher than the control group (5.10±1.30 vs. 2.50±0.11, p<0.01). Similarly, the pre-myomectomy TNF-α levels of the patients in the type 4 fibroid group were significantly higher than the control group (4.73±1.76 vs. 2.50±0.11, p<0.01). There was no significant difference between pre-myomectomy endometrial TNF-α levels of patients in type 3 and 4 fibroid groups (5.10±1.30 vs. 4.73±1.76, p>0.05). Removal of type 3 fibroids by myomectomy significantly decreased TNF-α levels (5.10±1.30 vs. 2.20±0.44, p<0.03). Similarly, removal of type 4 fibroids by myomectomy significantly decreased TNF-α levels (4.73±1.76 vs. 2.60±0.30, p<0.04). Pre-myomectomy NF-κB levels of the patients in the type 3 fibroid group were significantly higher than the control group (2.42±0.39 vs. 1.09±0.60, p<0.02). Similarly, the pre-myomectomy NF-κB levels of the patients in the type 4 fibroid group were significantly higher than the control group (2.04±0.50 vs. 1.09±0.60, p<0.01). There was no significant difference between the pre-myomectomy endometrial NF-κB levels of the patients in the type 3 and 4 fibroid groups (2.42±0.39 vs. 2.04±0.50 p>0.05). Removal of type 3 fibroids by myomectomy significantly decreased NF-κB levels (2.42±0.39 vs. 1.02±0.33, p<0.01). Similarly, removal of type 4 fibroids by myomectomy significantly decreased NF-κB levels (2.04±0.50 vs. 0.97±0.02, p<0.02)., Conclusions: Surgical removal of type 3 or type 4 fibroids contributes positively to receptivity by down-regulating endometrial TNF-α and NF-ƙB.

Objective: To evaluate the relative rates of malignancy in women with single and multiple polyps presenting to a UK Cancer Centre with postmenopausal bleeding (PMB)., Study Design: A retrospective review of patients treated at Royal Derby Hospital (RDH) for PMB who underwent outpatient hysteroscopy based on ultrasonographic suspicion of endometrial polyps between May 2014 to December 2019. The main outcome measure was the rates of precancerous and malignant histology for single or multiple polyps. The secondary outcomes assessed the influence of risk factors on the rates of malignancy within the single and multiple polyps groups., Results: The study population was 851 women of which 533 were in the single polyp group and 318 in the multiple polyps group. The multiple polyps group (mean age 65.2 years) was older compared to the single polyp group (mean age 62.1 years), P = 0.0001. Elevated rates of cancer was driven most significantly by endometrioid cancer in the multiple polyps compared to single polyp group, with rates of 50/314 (16 %) and 28/512 (5.5 %) respectively, P=< 0.00001. For rarer histologies there was no significant difference between the proportion of serous, carcinosarcomas and clear cell cancers between those with single compared to multiple polyps (P > 0.05). Significantly more endometrial hyperplasia with atypia (AEH) was found in the multiple polyps compared to single polyp group, with rates of 18/314 (5.7 %) and 15/512 (2.9 %) respectively, P = 0.046., Conclusion: Our study found increased rates of endometrioid cancer and its precursor, AEH within the multiple polyps compared to the single polyps groups. Future risk predicting algorithms should consider incorporating single and multiple polyps as part of their risk model., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: To assess the efficacy of dysdrogesterone in the treatment of chronic endometritis (CE) treated with antibiotic in premenopausal women with endometrial polyps (EPs)., Methods: Routine detection of endometrium was simultaneously conducted to determine whether there was CE by syndecan-1 (CD138), while women underwent hysteroscopic polypectomy in our hospital. Antibiotic was given for the treatment of CE. A total of 235 premenopausal women with CE who underwent hysteroscopic polypectomy were enrolled in the retrospective observational study. In the control group, single antibiotic was given for the treatment of CE form January 2016 to December 2018, and in the treatment group additional dydrogesterone was used from January 2019 to November 2020. Comparison of cure rates of CE with different treatment regimens was performed., Results: The cure rates of CE in dydrogesterone and antibiotic combination group and the single antibiotic group were 85.2% and 74.3%, respectively, with overall cure rate of 80.0% (188/235). The combination group showed better effects regarding the cure rate of CE (P &lt; .05). Multivariate analysis confirmed that the cure rate of CE was not affected by age, body mass index, number of EPs, the status of estrogen receptor and the status of progesterone receptor. Conversely, dydrogesterone and endometrial scratching were beneficial factors for cure rate increase with antibiotic treatment., Conclusion: Combination of dydrogesterone and antibiotic was more effective for cure rate of CE than antibiotic alone in premenopausal women after hysteroscopic polypectomy. Endometrial scratching also contributed to the cure rate increase with antibiotic treatment., (© 2022. The Author(s).)

Aim: Endometrial biopsy is generally performed with a metal uterine curette sonde; however, recently, many types of vacuum aspirators are available, including the manual vacuum aspiration (MVA) system. We used the women's MVA system for endometrial sampling and evaluated its effectiveness in determining the presence of endometrial malignancy., Methods: Forty-seven samples were examined using the following procedures after measuring endometrial thickness by transvaginal ultrasonography: fractional curettage biopsy (Bx; 20 samples), total curettage under general anesthesia (T/C; 13 samples), and MVA (14 samples). The quality of the endometrial samples was classified into four types: 1-4, where 1 denoted poor and 4, good quality., Results: The mean score of the MVA group was significantly higher than that of the partial curettage biopsy group (p = 0.0065). No differences were observed between the MVA and total curettage groups (p = 1.00). When patients were divided into two groups according to endometrial thickness (<10 mm or ≥10 mm) and analyzed, both the MVA and T/C groups did not show a significant difference in their scores compared to the Bx group when the endometrial thickness was <10 mm. However, when the endometrial thickness was ≥10 mm, the MVA and T/C groups had significantly better scores than the Bx group (p = 0.0225 and p = 0.0244, respectively). Vagal reflex, as an adverse event, was observed only in two patients in the Bx group (2/20, 10%)., Conclusion: Considering its quality and safety, Karman-type MVA for endometrial sampling could be an alternative to fractional curettage using a metallic uterine curette sonde., (© 2022 The Authors. Journal of Obstetrics and Gynaecology Research published by John Wiley & Sons Australia, Ltd on behalf of Japan Society of Obstetrics and Gynecology.)

Endometrial polyps (EMPs) are common exophytic masses associated with abnormal uterine bleeding and infertility. Unlike normal endometrium, which is cyclically shed, EMPs persist over ovulatory cycles and after the menopause. Despite their usual classification as benign entities, EMPs are paradoxically associated with endometrial carcinomas of diverse histologic subtypes, which frequently arise within EMPs. The etiology and potential origins of EMPs as clonally-derived neoplasms are uncertain, but previous investigations suggested that EMPs are neoplasms of stromal origin driven by recurring chromosomal rearrangements. To better define benign EMPs at the molecular genetic level, we analyzed individual EMPs from 31 women who underwent hysterectomy for benign indications. The 31 EMPs were subjected to comprehensive genomic profiling by exome sequencing of a large panel of tumor-related genes including oncogenes, tumor suppressors, and chromosomal translocation partners. There were no recurring chromosomal rearrangements, and copy-number analyses did not reveal evidence of significant chromosome-level events. Surprisingly, there was a high incidence of single nucleotide variants corresponding to classic oncogenic drivers (i.e., definitive cancer drivers). The spectrum of known oncogenic driver events matched that of endometrial cancers more closely than any other common cancer. Further analyses including laser-capture microdissection showed that these mutations were present in the epithelial compartment at low allelic frequencies. These results establish a link between EMPs and the acquisition of endometrial cancer driver mutations. Based on these findings, we propose a model where the association between EMPs and endometrial cancer is explained by the age-related accumulation of endometrial cancer drivers in a protected environment that-unlike normal endometrium-is not subject to cyclical shedding., (© 2022. The Author(s).)

Due to the increasing popularity of minipigs as pets, the frequency of presentation to the veterinarian is increasing as well. In addition to routine measures such as claw trimming, vaccination and antiparasitic treatment, diagnostics, and therapy of diseased minipigs are also common activities in the veterinary practice. In recent years, we have noticed more and more pathological changes of the female genital tract of uncastrated minipigs. There are also some case reports available in the international literature in this regard. The following case report describes the diagnostic procedures and ovariohysterectomies of 2 13-year-old female minipigs in detail. In these cases, uterine adenocarcinoma, and uterine carcinoma, respectively, combined with cystic endometrial hyperplasia (CEH) of the endometrium were diagnosed., Competing Interests: The authors declare no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

The risk of undertreating occult endometrial cancer is a problem faced by gynecologists when treating endometrial hyperplasia. The objective of this study is to highlight diagnostic adjuncts to endometrial sampling techniques to improve preoperative detection of co-existing cancer. A systematic search of databases till July 2021: PubMed, ISI-Clarivate Web of Science, Scopus, and CENTRAL. A search of the related literature was also carried out. Two authors screened potential studies. Studies were included if they examined the diagnostic performance of any predictors of concurrent cancer in patients diagnosed with endometrial hyperplasia. Authors charted variables related to literature characteristics (e.g., authors, year of publication), population characteristics (e.g., preoperative diagnoses), and variables related to our research questions (e.g., postoperative diagnoses, risk predictors). After screening 591 potential studies, 28 studies were included. Studies included the data of 7409 endometrial hyperplasia patients with 2377 concurrent endometrial cancer cases (32.1%). Forty potential predictors of concurrent cancer were investigated. We examined three categories of potential predictors: clinical (22 studies), histopathologic/imaging (16 studies), and molecular (six studies) predictors. The proposed predictors, age, menopausal status, diabetes, WHO and endometrial intraepithelial neoplasia histopathologic criteria, pelvic magnetic resonance imaging, and molecular profiling are promising diagnostic adjuncts., (© 2022 International Federation of Gynecology and Obstetrics.)

Objective: To investigate the association between personal history, anthropometric features and lifestyle characteristics and endometrial malignancy in women with abnormal vaginal bleeding., Methods: Prospective observational cohort assessed by descriptive and multivariable logistic regression analyses. Three features-age, body mass index (BMI; calculated as weight in kilograms divided by the square of height in meters), and nulliparity-were defined a priori for baseline risk assessment of endometrial malignancy. The following variables were tested for added value: intrauterine contraceptive device, bleeding pattern, age at menopause, coexisting diabetes/hypertension, physical exercise, fat distribution, bra size, waist circumference, smoking/drinking habits, family history, use of hormonal/anticoagulant therapy, and sonographic endometrial thickness. We calculated adjusted odds ratio, optimism-corrected area under the receiver operating characteristic curve (AUC), R 2 , and Akaike's information criterion., Results: Of 2417 women, 155 (6%) had endometrial malignancy or endometrial intraepithelial neoplasia. In women with endometrial cancer median age was 67 years (interquartile range [IQR] 56-75 years), median parity was 2 (IQR 0-10), and median BMI was 28 (IQR 25-32). Age, BMI, and parity produced an AUC of 0.82. Other variables marginally affected the AUC, adding endometrial thickness substantially increased the AUC in postmenopausal women., Conclusion: Age, parity, and BMI help in the assessment of endometrial cancer risk in women with abnormal uterine bleeding. Other patient information adds little, whereas sonographic endometrial thickness substantially improves assessment., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Endometrial cancer is a common malignancy affecting women worldwide. Usually, it clinically manifests with uterine bleeding, although identical clinical manifestations occur in benign conditions as well, with several endometrial biopsies being conducted unnecessarily. Therefore, an accurate, non-invasive diagnostic test is needed for first-line assessment, so as unnecessary biopsies are limited as much as possible. This systematic review aims to assess the diagnostic accuracy of three-dimensional ultrasound, a relatively novel method in gynecologic assessment, compared to two-dimensional ultrasound and three-dimensional Doppler in the prediction of uterine malignancy in women with abnormal uterine bleeding. The accuracy of endometrial volume, as a diagnostic parameter assessed by three-dimensional ultrasound is compared to diagnostic parameters from the other two methods, namely endometrial thickness and 3D Doppler indices (vascularization index, flow index and vascularization flow index). Articles relevant to our research question were systematically sought in the Web of Science, Scopus and MEDLINE/PubMed databases and underwent rigorous evaluation for inclusion according to the PRISMA 2020 guidelines. Eligible studies were thoroughly assessed for risk of bias and relevant data was extracted and analyzed. Studies were heterogenous and extracted data varied from study to study. Data on endometrial volume was compared to other diagnostic parameters. Forest plots with pooled percentages and hierarchical summary receiver operating characteristic curves were constructed for each comparison. Relative sensitivity and specificity ratios were calculated for each comparison to test for statistical significance. Endometrial volume and thickness comparison showed sensitivity 83% for both parameters and specificity 75% and 69% respectively, with volume being more specific than thickness (p < 0.05). Endometrial volume and Doppler indices comparison showed that sensitivity was 73%, 82%, 81% and 82%, while specificity was 72%, 76%, 75% and 76% for endometrial volume, vascularization index, flow index and vascularization-flow index respectively. All three Doppler indices were significantly more sensitive in the diagnosis of malignancy compared to endometrial volume (p < 0.05) While endometrial thickness remains a reliable predictor of uterine malignancy, endometrial volume appears promising as a method with higher specificity and more reliable measurements. Similarly, vascular indices seem as competent and even more sensitive than endometrial volume as predictors, with the added advantage of semi-automated and reproducible measurements that reflect the whole organ. More comparative studies with standardized protocols should be established, so as reliable cut-off values can be determined and thus standardize and streamline the diagnostic algorithm via the implementation of the three-dimensional modalities in the settings that they are available., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022. Published by Elsevier B.V.)

Aim: To compare the detection rate of magnetic resonance imaging (MRI) and ultrasound relative to endometrial biopsy for endometrial abnormalities in both pre- and post-menopausal women., Materials and Methods: The present study was an institutional review board-approved, single-institution retrospective analysis of patients who underwent pelvic MRI within 1 year of diagnostic-quality biopsies from 2008-2018 (n=668). There were 303 patients who received uterine artery embolisation (UAE) and 478 patients who received pelvic ultrasound within the study period. Medical records were evaluated for radiological-histopathological correlation, demographics, laboratory studies, and clinical follow-up., Results: In this cohort of 668 patients, there were 37 biopsies positive for malignancy; women with malignancy were older (58 versus 47 years, p<0.0001) and more likely to be post-menopausal (66% versus 12%, p<0.0001). There were 303 patients who underwent UAE and underwent a diagnostic-quality endometrial biopsy during the pre-procedural evaluation, none of whom were post-menopausal and had a mean age of 45 years. In women with abnormal uterine bleeding (AUB) or post-menopausal bleeding (PMB), the sensitivity of MRI for detecting endometrial cancer was 96.2%, with a negative predictive value (NPV) of 99.8%, compared to 68% and 97% for ultrasound, respectively. The receiver operating characteristic (ROC) curve of pre-biopsy MRI in identifying pre-malignant and malignant endometrial pathology demonstrated an AUC of 0.8920 (p<0.0001)., Conclusion: In women with AUB or PMB, MRI has a 99.8% NPV in ruling out endometrial cancer. Further consideration should be made towards optimising pre-procedural evaluation for UAE., (Copyright © 2022 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

A variety of endometrial lesions may contain mucinous cells. Herein, the author reviews the literature on the classification and clinicopathologic significance of uterine corpus proliferations with a significant mucinous component, assesses the 2020 World Health Organization classification of such lesions, and presents a diagnostic framework. The key epithelial mucinous lesions include mucinous metaplasia, atypical mucinous glandular proliferation and mucinous carcinoma. Each of these categories are classifiable into "usual" and gastrointestinal subtypes, the latter being indicative of intestinal (presence of goblet cells) and/or gastric-type (abundant, pale eosinophilic or clear cytoplasm and well-defined cell borders) morphology. It has been proposed that at least focal expression of gastrointestinal immunohistochemical markers be required for all gastrointestinal type lesions, and for gastrointestinal type atypical mucinous glandular proliferation and carcinoma, minimality or absence of estrogen receptor expression, and the absence of an endometrioid component. Mucinous carcinomas of the usual type, in which >50% of the tumor is comprised of a mucinous component, are the most common. Morphologic subtypes include mucinous carcinoma with microglandular features and mucinous carcinoma with signet rings (signet ring carcinoma). Endometrioid carcinomas with a less than a 50% mucinous component are classified as endometrioid carcinoma with mucinous differentiation. Several studies have directly compared endometrioid and mucinous carcinomas, the latter presumably of the usual type, with respect to patient outcomes after treatment. All have found no difference in overall and disease free survival between these groups. However, three major studies have found mucinous carcinomas to be associated with a higher risk of lymph node metastases. Nineteen cases of mucinous carcinoma of the gastrointestinal type have been reported, and the limited data on their follow-up after primary treatment suggests that this subtype is more clinically aggressive and should accordingly be classified separately from mucinous carcinomas of the usual type. The morphologic spectrum of mucinous carcinoma of the gastrointestinal type is unclear and continues to evolve. Mucinous change, which may sometimes be extensive, may also be associated with papillary proliferation of the endometrium, adenomyoma of the endocervical type, atypical, and typical adenomyomas. In a curettage or biopsy, intestinal type mucinous epithelium may be indicative of any of the gastrointestinal lesions mentioned above, but may also represent samplings of uterine teratomas, yolk sac tumors, genital and extragenital adenocarcinomas with intestinal differentiation, or low-grade appendiceal mucinous neoplasms that secondarily involve the endometrium., Competing Interests: The author has no funding or conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To analyze the clinical and pathological features of asymptomatic postmenopausal women with an incidentally detected increase in endometrial thickness (ET) by transvaginal ultrasound examination and discuss the cutoff value of ET for the timely discovery of endometrial malignancy., Methods: This was a retrospective study of postmenopausal women with asymptomatic thickened endometrium (greater than or equal to 5 mm) screened by transvaginal ultrasound who were referred to the gynecology department at Xuanwu Hospital between January 2018 and March 2021. Data on participant demographics, clinical characteristics, and histopathology outcomes were collected. We stratified the participants into the benign group and malignant group according to pathology results and assessed differences between the two groups. A receiver operating characteristic curve was used to identify the cutoff value of ET for predicting endometrial malignancy in postmenopausal women with asymptomatic thickened endometrium., Results: A total of 163 eligible cases were included in the analysis. The results showed that only ET was significantly different between the two groups. The median ET was significantly higher in the malignant group than in the benign group (1.20 vs 0.80, P = 0.023). The optimal cutoff value of ET was 10 mmwith the maximum AUC (0.881, 95% CI 0.810-0.952, P = 0.024), and the sensitivity and specificity for the diagnosis of endometrial malignancy were 100%and 80%, respectively. Among the 47 women with ET ≥ 10mm, the prevalence of endometrial malignancy was 6.3%, which was significantly higher than that among women with ET < 10mm ( P = 0.023)., Conclusion: For postmenopausal women with asymptomatic endometrial thickening, the prevalence of endometrial malignancy is significantly higher when ET is ≥ 10 mm. If ET is ≥ 10mm, further histopathological testing should be recommended to exclude endometrial malignancy. Further large-sample and prospective studies are needed to determine the predictive value of ET., Competing Interests: Financial disclosures/conflicts of interest: None reported., (Copyright © 2022 by The North American Menopause Society.)

Therapeutic options and clinical management of cervical and endometrial cancers differs significantly. When clinical and histological analysis of a uterine mass are unable to differentiate between an endocervical or endometrial origin, magnetic resonance imaging (MRI) plays a pivotal role in discriminating the anatomical origin, supporting the clinician in the treatment planning. Cervical adenocarcinomas are more likely to be centered in the cervical region and involving both cervical canal and stromal ring, with possible parametrial invasion. Endometrial adenocarcinomas usually present an elongated morphology and are centered in the endometrial cavity predominantly involving endometrium and myometrium. On contrast-enhanced sequences, cervical cancers are more frequently hypervascular compared to endometrial cancers. In cases of uncertain findings, diffusion-weighted imaging (DWI) can provide additional helpful information with significantly higher apparent coefficient diffusion (ADC) values in cervical adenocarcinomas compared to endometrial adenocarcinomas. However, even when MRI cannot precisely reveal the origin of the tumor, it provides valuable information on several prognostic factors that can help treatment planning., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Type II uterine tumors often present with very large, necrotic tumor burden in the uterus that leads to dilation and effacement of the cervix. In patients with this presentation, conventional hysterectomy poses a much greater challenge as the ureters are composed of the mass of the tumor and are at an increased risk for injury. Given this surgical challenge, many of these patients may begin with neoadjuvant chemo-radiation. However, these treatment modalities are associated with significant toxicity and negatively impact patient quality of life. Therefore, we describe a minimally invasive robotic surgical approach that aims to optimize quality of life without sacrificing prognosis. Outcomes of 4 patients are presented., (© 2021. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

Objective: To evaluate the possibility of referring women with uterine polyps larger than 1.5 cm directly to surgical hysteroscopy., Methods: This retrospective cohort study included all women referred to a university-affiliated tertiary medical center for hysteroscopy, with the diagnosis of endometrial polyp, from 01/2013 to 05/2016. Women were referred for surgical hysteroscopy based on TVUS findings. PPV of TVUS for detecting intrauterine polyps was evaluated relating to pathology as gold standard, with sub-group analysis relating to polyp size and other parameters., Results: We selected 1.5 cm as a cutoff size for subgroup analysis of endometrial polyps. PPV of TVUS for the entire cohort of 295 cases eligible for analysis, was 79.3%. TVUS describing polyps ≥1.5 cm had PPV of 92.1%, higher than the PPV for smaller polyps. Among post-menopausal women in this group, PPV was as high as 96.2%. Use of doppler or saline was found to improve PPV in the entire cohort. Indication for performing TVUS did not affect the PPV., Conclusion: TVUS describing polyps ≥1.5 cm may suffice for direct referral of women to surgical hysteroscopy. A personalized approach based on the initial diagnosis may avoid unnecessary invasive procedures for patients., (© 2021 International Federation of Gynecology and Obstetrics.)

Objectives: The primary aim of this study was to describe the ultrasound features of various endometrial and other intracavitary pathologies in women without abnormal uterine bleeding (AUB) using the International Endometrial Tumor Analysis (IETA) terminology. The secondary aim was to compare our findings with published data on women with AUB., Methods: This was a prospective observational study of women presenting at one of seven centers specialized in gynecological ultrasonography, from 2011 until 2018, for indications unrelated to AUB. All patients underwent transvaginal ultrasound using the IETA examination and measurement techniques. Ultrasonography was performed as part of routine gynecological examination or follow-up of non-endometrial pathology, or as part of the work-up before undergoing treatment for infertility, uterine prolapse or ovarian pathology. Ultrasound findings were described using the IETA terminology. Endometrial sampling was performed after the ultrasound scan. The histological endpoints were endometrial atrophy, proliferative or secretory endometrium, endometrial hyperplasia without atypia, endometrial polyp, intracavitary leiomyoma, endometrial intraepithelial neoplasia (EIN), endometrial cancer (EC) and insufficient tissue. The findings in our cohort of women without AUB were compared with those in a published cohort of women with AUB who were examined with transvaginal ultrasound between 2012 and 2015 using the same IETA examination technique and terminology., Results: In this study (IETA3), we included 1745 women without AUB who underwent a standardized transvaginal ultrasound examination followed by either endometrial sampling with histological diagnosis (n = 1537) or at least 1 year of clinical and ultrasound follow-up (n = 208). Of these, 858 (49.2%) women were premenopausal and 887 (50.8%) were postmenopausal. Histology showed the presence of EC and/or EIN in 29 (1.7%) women, endometrial polyps in 1028 (58.9%), intracavitary myomas in 66 (3.8%), proliferative or secretory changes or hyperplasia without atypia in 144 (8.3%), endometrial atrophy in 265 (15.2%) and insufficient tissue in five (0.3%). Most cases of EC or EIN (25/29 (86.2%)) were diagnosed after menopause. The mean endometrial thickness in women with EC or EIN was 11.2 mm (95% CI, 8.9-13.6 mm), being on average 2.4 mm (95% CI, 0.3-4.6 mm) thicker than their benign counterparts. Women with malignant endometrial pathology manifested more frequently non-uniform echogenicity (22/29 (75.9%)) than did those with benign endometrial pathology (929/1716 (54.1%)) (difference, +21.8% (95% CI, +4.2% to +39.2%)). Moderate to abundant vascularization (color score 3-4) was seen in 31.0% (9/29) of cases with EC or EIN compared with 12.8% (220/1716) of those with a benign outcome (difference, +18.2% (95% CI, -0.5% to +36.9%)). Multiple multifocal vessels were recorded in 24.1% (7/29) women with EC or EIN vs 4.0% (68/1716) of those with a benign outcome (difference, +20.2% (95% CI, +4.6% to +35.7%)). A regular endometrial-myometrial junction was seen less frequently in women with EC or EIN (19/29 (65.5%)) vs those with a benign outcome (1412/1716 (82.3%)) (difference, -16.8% (95% CI, -34.2% to +0.6%)). In women with endometrial polyps without AUB, a single dominant vessel was the most frequent vascular pattern (666/1028 (64.8%)). In women with EC, both in those with and those without AUB, the endometrium usually manifested heterogeneous echogenicity, but the endometrium was on average 8.6 mm (95% CI, 5.2-12.0 mm) thinner and less intensely vascularized (color score 3-4: difference, -26.8% (95% CI, -52.2% to -1.3%)) in women without compared to those with AUB. In both pre- and postmenopausal women, asymptomatic endometrial polyps were associated with a thinner endometrium, and they manifested more frequently a bright edge, a regular endometrial-myometrial junction and a single dominant vessel than did polyps in symptomatic women, and they were less intensely vascularized., Conclusions: We describe the typical ultrasound features of EC, polyps and other intracavitary histologies using IETA terminology in women without AUB. Our findings suggest that the presence of asymptomatic polyps or endometrial malignancy may be accompanied by thinner and less intensely vascularized endometria than their symptomatic counterparts. © 2022 International Society of Ultrasound in Obstetrics and Gynecology., (© 2022 International Society of Ultrasound in Obstetrics and Gynecology.)

In order to explore the ability of vaginal ultrasound combined with bleeding pattern to predict factors related to abnormal uterine bleeding (AUB), a total of 205 patients with abnormal uterine bleeding were selected as experimental subjects. According to the corresponding diagnostic criteria, patients were divided into the endometrial polyp group (56 cases), endometrial hyperplasia and canceration group (84 cases), and normal cycle endometrial group (65 cases). The efficiency of the method was determined by comparing the prediction efficiency of the single/joint model. The results showed that there were statistically significant differences in the body mass index, dysmenorrhea, endometrial thickness, diabetes, hypertension, and polycystic ovary syndrome among the three groups, P < 0.05. The sensitivity, specificity, positive predictive value, negative predictive value, and Youden index of endometrial polyp diagnosis were 86.89%, 88.12%, 83.54%, 90.11%, and 0.74, respectively. The sensitivity, specificity, positive predictive value, negative predictive value, and JordAn index in diagnosing endometrial hyperplasia and canceration were 96.71%, 98.40%, 96.54%, 98.24%, and 0.96, respectively. In summary, the body mass index, dysmenorrhea, endometrial thickness, diabetes, hypertension, and polycystic ovary syndrome were related factors, and the combination of vaginal ultrasound and bleeding pattern had a stronger predictive power for abnormal uterine bleeding., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2022 Yan Xu and Dan Xie.)

Objective: To evaluate the clinical importance of endometrial polyp size measured using saline infusion sonohysterography (SIS) before performing a hysteroscopic resection in predicting premalignant/malignant lesions., Methods: A retrospective observational study analysis was conducted of 365 patients, who underwent SIS, in a reference hospital. The longest plane of the polyp size was taken as base. Polyps were classified as benign, premalignant, or malignant., Results: The rates of premalignant and malignant lesions were 7.4% and 0.9%, respectively. The mean polyp size was 17.7 ± 0.5 mm in benign patients and 23.7 ± 1.8 mm in premalignant/malignant individuals (P < 0.001). In the group of polyps that were 0-10, 10-20, 20-30, and >30 mm, premalignancy/malignancy rates were 0.0%, 4.8%, 13.3%, and 18.8%, respectively. The cut-off value for polyp size to be able to predict lesions was calculated as 22.5 mm (sensitivity: 63%, specificity: 80%) on receiver operating characteristics curve analysis (P = 0.001, area under the curve 0.732). The power of the study was calculated as 90.86%., Conclusion: During the female reproductive years, endometrial polyps smaller than 10 mm, as measured in SIS, can be followed. However, when the polyp size is 22.5 mm or more, especially in postmenopausal women, treatment should be planned., (© 2021 International Federation of Gynecology and Obstetrics.)

Objective: This study aimed to evaluate risk factors for endometrial intraepithelial neoplasia/malignancy in premenopausal women with abnormal uterine bleeding or oligomenorrhea. Specifically, we aimed to elucidate whether body mass index (BMI) or age confers a higher risk., Study Design: A retrospective cohort study was performed at a large academic center examining risk factors for endometrial hyperplasia/malignancy in premenopausal women undergoing endometrial sampling., Results: Of the 4170 women ages 18-51 who underwent endometrial sampling from 1987 to 2019, 77 (1.85%) were found to have endometrial intraepithelial neoplasia or malignancy. Clinical predictors of EIN/malignancy in this population included obesity (OR: 3.84, 95%, p  < .001), Body mass index [(OR30 vs. 25:2.11, p  < .001) and OR35 vs. 30: 1.65, p  < .001], Diabetes (OR: 3.6, p -value <.001), hormonal therapy use (OR: 2.93, p  < .001), personal history of colon cancer (OR: 9.90, p  = .003), family history of breast cancer (OR: 2.65, p  < .001), family history of colon cancer (OR: 3.81, p  < .001), and family history of endometrial cancer (OR: 4.92, p  = .033). Age was not significantly associated with an increased risk of disease. Adjusting for other factors, a model using BMI to predict the risk of EIN/malignancy was more discriminative than a model based on age., Conclusions: Increased BMI, may be more predictive of endometrial hyperplasia/malignancy than age in premenopausal women with abnormal uterine bleeding. Modification of evaluation guidelines in a contemporary demographic setting could be considered.

Objective: To investigate the effect of hysteroscopy surgery combined with Mirena on postoperative adverse reactions and recurrence rate of endometrial polyps (EP)., Methods: A total of 312 patients who underwent hysteroscopic polypectomy of EP in our hospital from June 2017 to November 2020 were enrolled retrospectively. Among them, 42 patients did not take any treatment after the operation (control group), 156 patients were treated with levonorgestrel intrauterine birth control system (Mirena group), and 114 patients were treated with oral spironolone ethinylestradiol tablets (oral group). The clinical data of 312 patients were recorded and followed up regularly. All patients were followed up through an outpatient clinic or telephone to 12 months after the operation. The patients' age, disease course, number of pregnancies, clinical manifestations, endometrial thickness before the operation, duration of operation, amount of bleeding during the operation, and number and size of polyps were analyzed. The recurrence and postoperative side effects of EP in the three groups were followed up within 12 months after the operation., Results: There was no significant difference in endometrial thickness among the three groups before treatment ( P > 0.05). After 3 months, 6 months, and 12 months of treatment, the endometrial thickness of the three groups decreased, while the decrease in the Mirena group and the oral group was better compared to the control ( P < 0.05). The decrease in the Mirena group was better than that in the oral group ( P < 0.05). There was no significant difference in hemoglobin levels among the three groups before treatment ( P > 0.05). After 3, 6, and 12 months of treatment, the hemoglobin levels of the three groups increased to varying degrees, while the levels of the Mirena group and oral group were better compared to the control ( P < 0.05). Three months after the operation, the improvement of clinical symptoms was similar in the three groups, and there was no significant difference among the three groups ( P > 0.05). At 6 and 12 months after the operation, the improvement of clinical symptoms in the oral group and Mirena group was better compared to the control group ( P < 0.05), but there was no significant difference between the oral group and Mirena group ( P > 0.05). After the operation, some patients had complications such as lower abdominal pain, breast distension pain, irregular vaginal bleeding, and abnormal liver function. There was no significant difference in the number of complications among the three groups ( P > 0.05). During the follow-up to 12 months after the operation, the recurrence rate in the oral group and Mirena group was lower compared to the control ( P < 0.05), and the recurrence rate in the Mirena group was lower than that in the oral group ( P < 0.05)., Conclusion: Placing Mirena immediately after hysteroscopic polypectomy of EP can reduce the recurrence rate of endometrial polyps, increase the level of hemoglobin, and reduce the thickness of the endometrium, which can be employed and popularized according to the condition of patients in clinical work., Competing Interests: The authors declare that they have no conflicts of interest., (Copyright © 2022 Yanli Shen et al.)

Background: The overall clinical significance of the finding of endometrial abnormalities in predicting premalignant/malignant endometrial lesions is still incompletely determined. For this reason the management, surgical or expectant, of women in which an endometrial abnormality has been detected is debated., Methods: This retrospective study was carried out on 1020 consecutive women, 403 premenopausal and 617 postmenopausal, who underwent operative hysteroscopy in a University Hospital for suspected endometrial abnormalities, which were detected by transvaginal ultrasound (TVS) and/or office hysteroscopy. In these women, the clinical characteristics and findings at TVS and hysteroscopy were evaluated in relation to the presence/absence of premalignant/malignant endometrial lesions at pathology report., Results: The clinical characteristics considered were significantly different when the study women were compared according to their menopausal status. Premalignant/malignant lesions were found in 34/1020 (3.33%) women. Complex hyperplasia with atypia and endometrial cancer were detected in 22 (2.15%) and 12 (1.17%) cases, respectively. The postmenopausal women had a significantly higher risk of premalignant/malignant lesions than premenopausal women (O.R. = 5.098 [95% C.I.: 1.782-14.582], P < 0.005). This risk was even higher when abnormal uterine bleeding (AUB) was present (O.R. = 5.20 [95% C.I.: 2.38-11.35], P < 0.0001). The most significant associations with premalignant/malignant endometrial lesions were BMI, AUB in postmenopause, overall polyp size, atypical aspect of endometrial polyps at hysteroscopy, postmenopausal status, diabetes mellitus and patient age., Conclusions: The results of the present study suggest that the proper, aggressive or expectant, management of endometrial abnormalities should take into account both ultrasonographic and hysteroscopic findings together with the specific clinical characteristics of the patients., (© 2022. The Author(s).)