Management of abnormal uterine hemorrhage with atypical endometrial hyperplasia by transcervical resection of endometrium

The aim of the study was to assess the feasibility and effect of treating atypical endometrial hyperplasia (AEH) with transcervical resection of endometrium (TCRE). Five cases of AEH incapable of hysterectomy for various reasons were treated with TCRE. All patients were followed up for 3-4 years postoperation to evaluate the thickness of endometrium, uterine cavity, and prognosis of the disease. All the patients provided informed consent for TCRE. In all five cases treated with TCRE, case 1 was for senility, hypertension, diabetes mellitus, and obesity; case 4 for senility, obsolete cerebral infarction, and hemiplegia; case 5 for uremia and chronic dysfunction of coagulation after renal transplantation; cases 2 and 3 for rejection of hysterectomy. All cases were followed up for more than 3 years after operation. Four had amenorrhea and one had dropping menses. The thickness of endometrium was no more than 5 mm in all the cases. TCRE is one available microinvasive surgery alternative to hysterectomy for AEH patients contraindicated to hysterectomy.     

156例宫腔镜下子宫纵隔切除术后的生殖预后

目的探究和分析宫腔镜下子宫纵隔切除术(TCRS)的手术指征及生殖预后。方法采用回顾性研究方法,选择北京市平谷区医院及首都医科大学附属北京天坛医院2013年1月至2019年12月接收的156例纵隔子宫患者为主要对象,所有患者均实施宫腔镜下子宫纵隔切除术治疗,术后随访2~6年,分析患者术后妊娠及分娩结局。结果(1)25例有生育要求的患者行预防性切除子宫纵隔,术后22例(88.0%)妊娠,其中16例分娩(64.0%),6例流产(24.0%);(2)术中无1例发生子宫穿孔,出血及经尿道前列腺电切(TURP)综合征。术后无妊娠期子宫破裂发生。发生宫腔粘连5例(3.2%),均为轻微粘连;(3)不孕率、自然流产、稽留流产率分别由术前的21.9%、22.8%、29.8%降至8.4%、10.8%、7.2%,足月分娩率及活产率由术前的1.8%、2.6%升至66.3%、69.9%,术后妊娠率72.5%,手术前后比较差异有统计学意义(P<0.05)。结论对于诊断为子宫纵隔并且有生育要求的患者,建议进行预防性切除子宫纵隔;宫腔镜下子宫纵隔切除手术(TCRS)微创、安全、有效,能够明显改善其妊娠结局。     

Uterine myomas and factors associated with hysterectomy in premenopausal women

OBJECTIVE: Our purpose was to describe clinical characteristics in premenopausal women with uterine myomas and to identify factors associated with hysterectomy.STUDY DESIGN: Data were collected by chart abstraction in 421 premenopausal women with myomas and analyzed by univariate and multivariable regression.RESULTS: Over a median follow-up period of 29 months, 86% of women had symptoms associated with myomas and 40% had an increase in uterine size of >2 gestational weeks. By multivariable regression, bleeding symptoms at presentation and previous surgical history of cholecystectomy and adhesiolysis were significantly associated with greater odds of hysterectomy. There was a significant interaction between age and uterine size, so that as age increased, uterine size had a greater impact on the likelihood of hysterectomy.CONCLUSIONS: In this cohort of premenopausal women myomas were associated with symptoms in almost all women over the follow-up period. Hysterectomy was performed in 22% of women overall. (Am J Obstet Gynecol 1997;176:1213-9.)     

门诊宫腔镜对10565例异常子宫出血患者PALM-CORIN病因分类的应用

目的:探讨门诊宫腔镜及PALM-CORIN病因分类方法对异常子宫出血(AUB)患者病因、诊断、临床治疗的价值。方法:回顾分析2008年1月1日至2015年12月31日在湖北省妇幼保健院妇科门诊宫腔镜诊治中心因异常子宫出血就诊的10565例患者的临床资料,分析其就诊原因、阴道出血模式及宫腔镜检结果,并重新进行PALMCORIN分类,梳理其诊治流程。结果:10565例AUB患者的就诊原因和阴道出血模式依次为:月经频发、月经过多、月经期延长、不规律月经、月经异常合并不孕、经期间出血、月经过少、月经稀发,分别具有不同的PALM-CORIN病因分类。按PALM-COEIN病因分类系统,10565例AUB患者中,存在结构异常者4318例,占40.9%;存在非结构异常者6247例,占59.1%;非结构异常者的年龄显著高于结构异常者(P0.05)。结构异常的患者中,病因分类排序依次为AUB-P、AUB-L、AUB-A、AUB-M;非结构异常的患者中,病因分类排序依次为AUB-O、AUB-I、AUB-E、AUB-N、AUB-C。结论:门诊宫腔镜和PALM-COEIN病因分类系统在AUB的诊治、分流中扮演着重要角色,有助于急慢性AUB患者的流行病学、病因学和治疗等多方面的研究。     

Levonorgestrel-releasing intrauterine system vs. transcervical endometrial resection for dysfunctional uterine bleeding.

OBJECTIVE: To compare the acceptability, efficacy, adverse effects, and user satisfaction of a levonorgestrel intrauterine system (LNG-IUS) and transcervical resection of the endometrium (TCRE) for the treatment of dysfunctional uterine bleeding. METHOD: Of 50 women with a pictoral blood loss assessment chart (PBAC) score of 100 or greater, 25 had a LNG-IUS inserted (Mirena; Schering, Berlin, Germany) and 25 underwent TCRE. Procedure-related complications, PBAC score, hemoglobin levels, adverse effects, and rates of acceptability and satisfaction were recorded at 3-month intervals for a period of 12 months. RESULTS: At the end of 1 year there were a 97% and a 94% reduction in menstrual blood loss in the LNG-IUS and TCRE groups, respectively, and hemoglobin concentration had increased by 5.5% in the LNG-IUS group and 5.2% in the TCRE group. Adverse effects were similar in both groups except for systemic effects, which were seen only in the LNG-IUS group. Satisfaction rates were about 80% in the 2 groups. CONCLUSION: Both treatments were found to be equally effective but LNG-IUS placement requires less operator skill and entails no operative hazards, and the device provides effective contraception.     

Long-term results of hysteroscopic myomectomy in 235 patients

OBJECTIVE: To assess the efficacy of transcervical resection of submucous fibroids according to type and size. MATERIALS AND METHODS: Retrospective follow-up of 235 women with submucous fibroids at outpatient hysteroscopy who underwent a hysteroscopic transcervical resection. The main indications were the abnormal uterine bleeding and fertility problems. Thirty-seven percent of patients had an associated endometrial ablation and 32% had a polyp resection. Fifty-one percent of women were menopausal. In cases of incomplete resection a repeat procedure was offered. RESULTS: Intra-operative complications were rare (2.6%) and there was no major complication. Eighty-four percent of cases were followed-up. The median follow-up was 40 months (range 18-66 months). The procedure was classed as a success in 94.4% of patients. Among the cases that were classed as a failure, four patients had a repeated hysteroscopic procedure, three patients had a subsequent hysterectomy and four patients presented with abnormal uterine bleeding at follow-up. CONCLUSION: The hysteroscopic transcervical resection of submucous fibroids is a safe and highly effective long-term therapy for carefully selected women presenting with abnormal uterine bleeding and fertility problems. It produces satisfactory long-term results with few complications.     

Selective uterine artery embolization in the management of uterine myomas

OBJECTIVE: To evaluate the effectiveness of uterine artery embolization in women with uterine myomas in terms of the clinical results for the relief of related symptoms. DESIGN: A pilot study on 26 women affected by uterine single myoma. SETTING: Tertiary level care in an university hospital. PATIENT(S): Twenty-six patients, aged 32 to 54 years, suffering of menorrhagia, pelvic pain, and abdominal mass for single myoma, intramural localization. INTERVENTION(S): Selective uterine artery embolization performed under peridural anesthesia. MAIN OUTCOME MEASURE(S): We measured the x-ray dose to which patients were exposed. Color power Doppler ultrasound examinations were performed during the follow-up evaluations at 1 to 6 months and 1 year after the procedure. RESULT(S): Uterine artery embolization was successfully performed in 100% of cases. The mean fluoroscopy time was of 20 minutes during the procedure. The mean dose of x-ray absorbed by the ovary was estimated at 18.7 cGy and the mean dose of x-ray absorbed by the skin was 126.7 cGy. A reduction of myoma volume of 55% was found at 6 months' ultrasound examination and 75% at the 1-year examination. CONCLUSION(S): Patients are well satisfied and have short recovery times with this procedure. Uterine artery embolization may be a valid alternative to traditional surgery.     

宫腔镜子宫中隔切除术后辅助治疗对妊娠结局的影响

目的：探讨宫腔镜子宫中隔切除术(TCRS)后辅助治疗对妊娠结局的影响。方法：收集2007年1月至2008年12月首都医科大学附属复兴医院行TCRS 的患者共216例,随访到195例。术后患者分为无辅助治疗组(60例,术后无辅助治疗)、人工周期组(33例,术后予人工周期3个月)、人工周期+宫内节育器(IUD)组(102例,术后予人工周期3个月同时放置IUD 3个月)。随访20～44个月,随访内容为3组患者的自然流产、早产、胎死宫内和足月分娩情况。结果：3组术后自然流产率、早产率、胎死宫内率和足月分娩率分别为无辅助治疗组28.57%、2.86%、2.86%和60.00%;人工周期组14.29%、5.71%、0和65.71%;人工周期+IUD组27.27%、6.49%、0和48.05%。3组差异无统计学意义(P>0.05)。结论：TCRS术后传统的辅助治疗(人工周期;人工周期+IUD)与无辅助治疗相比,在改善妊娠结局方面差异不大。     

Use of strict sonohysterographic methods for preoperative assessment of submucous myomas

OBJECTIVE: To assess the diagnostic accuracy of sonohysterography (SHG) and transvaginal sonography versus diagnostic hysteroscopy in preoperative assessment of submucous myomas. DESIGN: Prospective pilot study. SETTING: University hospital outpatient center. PATIENT(S): Forty-eight symptomatic (bleeding, infertility) premenopausal patients with submucous myomas. INTERVENTION(S): Preoperative grading of submucous myomas with a strict SHG methodology and standard transvaginal sonography compared with hysteroscopic grading of submucous myoma before hysteroscopic myomectomy. MAIN OUTCOME MEASURE(S): SHG and sonographic agreement with hysteroscopic findings. RESULT(S): Forty-eight patients were enrolled (mean age +/- SD = 41 years +/- 10.2). The median duration of SHG was 12 minutes (interquartile range, 9-16). The mean number of submucous myomas was 1 (range, 1-3) per woman. In all cases, a successful SHG was performed, with no, mild, or moderate pain in 38 (79%), 8 (17%), and 2 (4%) patients, respectively. No patients experienced severe pain or vasovagal reaction. All cases were correctly diagnosed by SHG compared with the final hysteroscopic diagnosis (kappa = 1.0; SE = 0.105). Simple transvaginal ultrasound was inaccurate in six cases (kappa = 0.81; SE = 0.103). CONCLUSION(S): Strict and reproducible SHG diagnostic procedures proved to be as effective as hysteroscopy and well tolerated in preoperative grading of submucous myomas.     

Fertility rates after hysteroscopic treatment of submucous myomas depending on their type

The objective was too evaluate the pregnancy rate and the chance of term pregnancy following hysteroscopic myomectomy depending on the type of the myoma. Between February 2000 and October 2005, a total of 25 patients under 36 years of age (mean 30.1±5.8 SD) with a diagnosis of primary or secondary infertility and menstrual disorders due to submucous myoma underwent hysteroscopic myomectomy. The subgroups of the patients depending on the type of the myomas were: Type 0, 14 patients; type I, 7 patients; and type II, 4 patients. For the subgroup of patients with type II myomas there was a control group of 8 patients with infertility but without menstrual disorders who did not consent to undergoing operative hysteroscopic treatment and received expectant management. Mean myoma size was 22.6±14.7 mm, mean duration of the procedure was 28±17 min, and mean follow-up was 18±12.5 months. Menstrual pattern was reestablished in 84% of patients. Hysteroscopic myomectomy was associated with an increase in pregnancy rate: 57.1% for patients with type 0 myoma and 42.8% for patients with type I myoma. Patients with type II myoma, after hysteroscopic myomectomy, had a 25% pregnancy rate, while patients who received expectant management had a 50% rate. Delivery at term was achieved by 35.7% of patients with type 0 myoma, by 28.5% of patients with type I myoma, and by 25% of patients with type II myoma, after hysteroscopic myomectomy. Patients with type II myoma without menstrual disorders had a 37.5% term delivery rate receiving expectant management. Three patients had a spontaneous abortion during the first trimester (12%) and one patient had premature labor at 34 weeks’ gestation (4%). Fertility rates appear to increase after hysteroscopic myomectomy of type 0 and type I myomas in previously infertile patients. In patients with type II myomas fertility rates did not increase, in contrast with patients with type II myomas who received expectant management. No difference in fertility rates was observed between patients with different types of submucous myomas after myomectomy, while the complication rate for these procedures is low. Patients’ age and type of infertility (primary or secondary) are factors that do not affect fertility rates after hysteroscopic myomectomy.

Role of a bipolar resectoscope in subfertile women with submucous myomas and menstrual disorders

AIM: To evaluate the role of the Gynecare (Ethicon, Somerville, NJ, USA) bipolar resectoscope in resecting fibroids, and the effect of hysteroscopic myomectomy on infertility and pregnancy outcomes. METHODS: From January 2000 to December 2005, we studied 59 women of reproductive age with menorrhagia, submucous myomas and one or more infertility factors. All women who participated had been subfertile for over 2 years. Fifteen of the 59 women displayed submucous myoma type O (intracavitary), 34 displayed submucous myoma type I (less than 50% within the myometrium) and the remaining 10 women displayed myoma type II (over 50% being within the myometrium).The mean age and standard deviation of these patients was 34.6 +/- 4.4 years and the average size of myomas was 15 +/- 10 mm. Treatment of these myomas was by hysteroscopic resection using a bipolar resectoscope. RESULTS: Menorrhagic incidents improved in 20 of 32 women (62.5%). Twenty-five women (42.4%) succeeded in becoming pregnant. The pregnancy rate was notably higher when the sole reason of subfertility was the presence of myoma (54.16%), and when the size of the myoma was equal to 2.5 cm (75%) or more. CONCLUSION: The use of the bipolar resectoscope in hysteroscopic removal of small submucous myomas is shown to be both feasible and effective in controlling menorrhagia and increasing the pregnancy rate in subfertile women, when submucous myomas are the only reason of infertility.     

Changes in myometrial thickness during hysteroscopic resection of deeply invasive submucous myomas.

STUDY OBJECTIVE: To evaluate the efficacy of hysteroscopy in resecting submucous myomas with deep intramural invasion. DESIGN: Prospective, observational study (Canadian Task Force classification II-2). SETTING: Department of gynecology at a general hospital. PATIENTS: Sixteen women with a solitary submucous myoma, in which myometrial thickness between the outer edge of the myoma and inner edge of the serosa was between 5 and 10 mm. INTERVENTION: One-step hysteroscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: Median myoma diameter and weight were 3.3 cm and 30 g, respectively. Myometrial thickness between the myoma and serosa increased gradually and significantly from 6.7 mm before, to 8.9 mm during, to 16.1 mm immediately after hysteroscopic myomectomy (p <0.001). The thickness of the opposite uterine wall increased from 10.1 mm before, to 11.4 mm during, to 18.8 mm after operation (p <0.001). CONCLUSION: One-step hysteroscopic myomectomy may be performed to remove deeply infiltrating submucous myomas when myometrial thickness at the implantation site is as thin as 5 mm.