Context.—Postmenopausal vaginal bleeding is a common clinical problem. Endovaginal
ultrasound (EVUS) is a noninvasive diagnostic test that may help determine
which women should undergo endometrial biopsy.Objective.—To determine the accuracy of EVUS in detecting endometrial disease in
postmenopausal women with vaginal bleeding according to hormone replacement
use.Data Sources.—Literature search of English-language and non–English-language
articles published from 1966 through November 1996 using MEDLINE and by a
manual search of bibliographies of published articles.Study Selection.—Studies were included if they prospectively collected EVUS measurements
of endometrial thickness prior to obtaining endometrial tissue for histologic
evaluation in postmenopausal women with vaginal bleeding. Of 85 studies that
included data on EVUS and endometrial histology, 35 were included in the meta-analysis
and included 5892 women.Data Extraction.—Articles were reviewed and independently selected and abstracted by
2 reviewers. Disagreement was resolved by consensus.Data Synthesis.—The overall summary mean weighted estimates of sensitivity and specificity
were calculated for thresholds of endometrial thickness from 3 to 10 mm. Using
a 5-mm threshold to define abnormal endometrial thickening, 96% (95% confidence
interval [CI], 94%-98%) of women with cancer had an abnormal EVUS result,
whereas 92% (95% CI, 90%-93%) of women with endometrial disease (cancer, polyp,
or atypical hyperplasia) had an abnormal result. This did not vary by hormone
replacement use. However, the number of women with normal histology who had
an abnormal EVUS result did vary by hormone replacement use. In women who
were not using hormone replacement therapy, 593 (8%) with normal histological
findings had an abnormal EVUS result (specificity, 92%; 95% CI, 90%-94%),
whereas 1544 (23%) using hormone replacement therapy had an abnormal EVUS
result (specificity, 77%; 95% CI, 75%-79%). For a postmenopausal woman with
vaginal bleeding with a 10% pretest probability of endometrial cancer, her
probability of cancer is 1% following a normal EVUS result.Conclusion.—Endovaginal ultrasound has a high sensitivity for detecting endometrial
cancer and other endometrial disease and can reliably identify postmenopausal
women with vaginal bleeding who are highly unlikely to have significant endometrial
disease so that endometrial sampling may be unnecessary.

https://jamanetwork.com/journals/jama/articlepdf/188122/jma80013.pdf

Endovaginal ultrasound to exclude endometrial cancer and other endometrial abnormalities

Recurrent implantation failure refers to failure to achieve a clinical pregnancy after transfer of at least four good-quality embryos in a minimum of three fresh or frozen cycles in a woman under the age of 40years. The failure to implant may be a consequence of embryo or uterine factors. Thorough investigations should be carried out to ascertain whether there is any underlying cause of the condition. Ovarian function should be assessed by measurement of antral follicle count, FSH and anti-Mullerian hormone. Increased sperm DNA fragmentation may be a contributory cause. Various uterine pathology including fibroids, endometrial polyps, congenital anomalies and intrauterine adhesions should be excluded by ultrasonography and hysteroscopy. Hydrosalpinges are a recognized cause of implantation failure and should be excluded by hysterosalpingogram; if necessary, laparoscopy should be performed to confirm or refute the diagnosis. Treatment offered should be evidence based, aimed at improving embryo quality or endometrial receptivity. Gamete donation or surrogacy may be necessary if there is no realistic chance of success with further IVF attempts. Recurrent implantation failure is an important cause of repeated IVF failure. It is estimated that approximately 10% of women seeking IVF treatment will experience this particular problem. It is a distressing condition for patients and frustrating for clinicians and scientists. In this review, we have discussed the definition and management of the possible underlying causes of recurrent implantation failure.

https://www.rbmojournal.com/article/S1472-6483(13)00475-6/pdf

Recurrent implantation failure: definition and management

Screening for ovarian cancer: a pilot randomised controlled trial

Progress and Challenges in Screening for Early Detection of Ovarian Cancer

An explanation of the different surgical techniques used preoperatively, during the operation or immediately after, to eliminate postoperative pain or reduce the anesthetic level required. An elevation according to such general factors as atmosphere, posture, sedatives, as well as various local or trunk infiltrations and epidural or subarachnoidal blocks.

The prevention of postoperative pain

Aim: To determine if the incidence of small endometrial polyps detected hysteroscopically in an infertile eumenorrheic population differed from that in an apparently fertile eumenorrheic population. Evidence was sought to determine whether removal of such lesions would enhance reproductive performance.



Methods:  In a prospective study, 266 consecutive infertile women had undergone complete fertility evaluation. None of the women had experienced any change in their menstrual cycle. They were divided into two groups; 235 infertile patients (group 1) and 31 requesting a reversal of a previous tubal sterilization (group 2). All patients were examined by simultaneous combined laparoscopy and hysteroscopy as part of their routine infertility evaluation. When endometrial polyps were noted they were removed by hysteroscopy and histopathologically examined. Patients in whom the only apparent finding was endometrial polyps were followed up to determine their reproductive outcomes subsequent to removal of the polyps.



Results:  Of the 224 uterine cavities successfully visualized in the infertile group, 134 were judged to be normal (60%) and 90 were abnormal (40%). Endometrial polyps were noted in 35 patients of group 1 and in one patient of group 2 (P < 0.01). Most polyps were located in the region of the utero-tubal junction and proved to be functional. A 50% pregnancy rate was achieved by hysteroscopic polypectomy. Fertility-related factors in women whose only apparent finding was endometrial polyps before and after hysteroscopy were comparable.



Conclusion:  Diagnostic hysteroscopy should be used routinely in the work-up of infertile woman, even in the presence of eumenorrhea. Persistent functional endometrial polyps, even if small, are likely to impair fertility in this select patient group. Removal of such lesions may improve subsequent reproductive performance.

Significance of endometrial polyps detected hysteroscopically in eumenorrheic infertile women

Transvaginal ultrasound, color flow, and Doppler waveform of the postmenopausal adnexal mass.

Endometrial carcinoma in postmenopausal women : evaluation by transvaginal color Doppler ultrasonography

Several screening procedures have been proposed to detect ovarian and endometrial cancer. However, none of them is sensitive and specific enough to be used in population-based screening programs. During our 5 year long study, 5013 asymptomatic women (44% premenopausal and 56% postmenopausal women) were scanned by transvaginal color and pulsed Doppler ultrasonography in an attempt to detect malignancy. These women had 404 adnexal cysts; 70 had resolved spontaneously on follow-up scans and 18 persisted. Another 316 sonographically benign cysts are still in the procedure of follow-up second scans. Of 5013 women, four women had stage I ovarian carcinoma and six had stage I endometrial carcinoma. There was one false-positive case encountered with an endometrioma. Only 14 women were subjected to major operative intervention; others underwent minor procedures based on the benign scan findings. No medical or surgical complications were reported. Transvaginal color Doppler ultrasonography, a noninvasive procedure, can detect ovarian and endometrial carcinoma in asymptomatic women and may be used as a screening procedure for these diseases.

An attempt to screen asymptomatic women for ovarian and endometrial cancer with transvaginal color and pulsed Doppler sonography.

https://www.gynecologiconcology-online.net/article/S0090-8258(85)79965-9/pdf

Hesham Shalan

Papers

Significance of endometrial polyps detected hysteroscopically in eumenorrheic infertile women

Transvaginal ultrasound, color flow, and Doppler waveform of the postmenopausal adnexal mass.

Endometrial carcinoma in postmenopausal women : evaluation by transvaginal color Doppler ultrasonography

An attempt to screen asymptomatic women for ovarian and endometrial cancer with transvaginal color and pulsed Doppler sonography.

Uterine Sarcoma: A Report of 10 Cases Studied by Transvaginal Color and Pulsed Doppler Sonography