The detection of psychiatric illness by questionnaire

▪Purpose:To critically review the risks and benefits of hormone therapy for asymptomatic postmenopausal women who are considering long-term hormone therapy to prevent disease or to prolong...

Hormone Therapy To Prevent Disease and Prolong Life in Postmenopausal Women

The polycystic ovary syndrome (PCOS) is a heterogeneous condition, the pathophysiology of which appears to be both multifactorial and polygenic. The definition of the syndrome has been much debated. Key features include menstrual cycle disturbance, hyperandrogenism and obesity. There are many extra-ovarian aspects to the pathophysiology of PCOS, yet ovarian dysfunction is central. At a recent joint ASRM/ESHRE consensus meeting, a refined definition of the PCOS was agreed, encompassing a description of the morphology of the polycystic ovary (PCO). According to the available literature, the criteria fulfilling sufficient specificity and sensitivity to define the PCO should have at least one of the following: either 12 or more follicles measuring 2-9 mm in diameter, or increased ovarian volume (> 10 cm3). If there is a follicle > 10 mm in diameter, the scan should be repeated at a time of ovarian quiescence in order to calculate volume and area. The presence of a single PCO is sufficient to provide the diagnosis. The distribution of follicles and a description of the stroma are not required in the diagnosis. Increased stromal echogenicity and/or stromal volume are specific to PCO, but it has been shown that the measurement of ovarian volume (or area) is a good surrogate for quantification of the stroma in clinical practice. A woman having PCO in the absence of an ovulation disorder or hyperandrogenism ('asymptomatic PCO') should not be considered as having PCOS, until more is known about this situation. Three-dimensional and Doppler ultrasound studies may be useful research tools but are not required in the definition of PCO. This review outlines evidence for the current ultrasound definition of the polycystic ovary and technical specifications.

Ultrasound assessment of the polycystic ovary: international consensus definitions.

Design of the prostate, lung, colorectal and ovarian (PLCO) cancer screening trial

Interim analysis of the incidence of breast cancer in the Royal Marsden Hospital tamoxifen randomised chemoprevention trial

Objective

The aim of the study was to evaluate the subjective assessment of ultrasonographic images for discriminating between malignant and benign adnexal masses.



Study design

The study was prospective. Initially, one ultrasonographer preoperatively assessed 300 consecutive patients with adnexal masses. Subsequently, the recorded transparent photographic prints were independently assessed by five investigators, with different qualifications and level of experience, who were also given a brief clinical history of the patients (i.e. the age, menstrual status, family history of ovarian cancer, previous pelvic surgery and the presenting symptoms). The diagnostic performance of the observers was compared with the histopathology classification of malignant or benign tumors. The end-points were accuracy, interobserver agreement and the possible effect of experience.



Results

The first ultrasonographer and the most experienced investigator both obtained an accuracy of 92%. There was very good agreement between these two investigators in the classification of the adnexal masses (Cohen's kappa 0.85). The less experienced observers obtained a significantly lower accuracy, which varied between 82% and 87%. Their interobserver agreement was moderate to good (Cohen's kappa 0.52 to 0.76).



Conclusion

Experienced ultrasonographers using some clinical information and their subjective assessment of ultrasonographic images can differentiate malignant from benign masses in most cases. The accuracy and the level of interobserver agreement are both correlated with experience. About 10% of masses were extremely difficult to classify (only < 50% of assessors were correct). Copyright © 1999 International Society of Ultrasound in Obstetrics and Gynecology

https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.1046/j.1469-0705.1999.13010011.x

Subjective assessment of adnexal masses with the use of ultrasonography: an analysis of interobserver variability and experience

OBJECTIVE--To assess the value of transvaginal ultrasonography with colour blood flow imaging in detecting early ovarian cancer in women with a family history of the disease. DESIGN--Study of self referred symptomless women with a close relative who had developed the disease. Each woman was screened to detect persistent lesions and defined changes in ovarian volume. Morphological score and pulsatility index were recorded. SETTING--Ovarian screening clinic. SUBJECTS--1601 self referred women. INTERVENTIONS--Women with a positive screening result were recommended to have further investigations. MAIN OUTCOME MEASURES--Findings at surgery and histology of abnormal ovaries. Morphological score > or = 5 and pulsatility index < 1.0 at last scan. RESULTS--Women were aged 17 to 79 (mean 47) years; 959 (60%) were premenopausal, 469 (29%) were naturally postmenopausal, and 173 (11%) had had a hysterectomy. 157 women had a pedigree suggestive of the site specific ovarian cancer syndrome and 288 of multiple site cancers. 61 women had a positive screening result (3.8%, 95% confidence interval 2.9 to 4.9%), six of whom had primary ovarian cancer detected at surgery (five stage Ia, one stage III). Use of a high morphological score or a low pulsatility index increased the odds of finding ovarian cancer from 1:9 to about 2:5 (1:1 in the highest risk groups). Five interval cancers were reported (three ovarian and two peritoneal). Eight of the 11 cancers developed in women with pedigrees suggestive of inherited cancer. CONCLUSIONS--Transvaginal ultrasonography with colour flow imaging can effectively detect early ovarian cancer in women with a family history of the disease. The screening interval should be less than two years.

https://www.bmj.com/content/bmj/306/6884/1025.full.pdf

Screening for early familial ovarian cancer with transvaginal ultrasonography and colour blood flow imaging.

Uterine arterial blood flow was studied at defined times during the ovarian or menstrual cycles. Transvaginal colour pulsed ultrasound was used to identify the vessels in 23 healthy women. Blood flow impedance as reflected by the pulsatility index (PI) was determined for both arteries on 132 occasions. There was no significant difference in the PI values between the right and left arteries. The average PI value was used for subsequent analysis (range 0.5-5.6; mean 2.8). Peak mean PI values occurred on day 1 of menses (4.6), the day of the plasma oestradiol peak (3.7) and the day of the LH peak plus 3 (2.9). The lowest mean PI values (indicating the least impedance to blood flow) occurred on the day of the LH peak minus 6 (2.6), and the day of the LH peak plus 9 (1.9). There are complex temporal relationships between uterine blood flow, ovarian morphology, the concentrations of plasma oestradiol and progesterone and the thickness of the endometrium.

Transvaginal colour flow imaging of the uterine arteries during the ovarian and menstrual cycles

The availability of advanced hysteroscopic surgical techniques has changed the management of abnormal uterine bleeding. The aim of this study was to evaluate the use of transvaginal sonography (TVS), sonohysterography (SH) and diagnostic hysteroscopy (DH) for the preoperative assessment of the uterine cavity. The plan was to investigate 100 patients with abnormal uterine bleeding despite conventional medical treatment. The endpoints were uterine abnormalities detected by operative hysteroscopy and histology, and subjective estimates of discomfort during TVS and SH. A total of 104 patients (aged 26-79 years) were recruited and 98 (94%) underwent all three diagnostic procedures. Uterine abnormalities were present in 52 patients (53%). There were 25 cases with at least one endometrial polyp, 17 with submucous fibroids, seven with endometrial hyperplasia and three with an adenocarcinoma. The overall sensitivity of TVS improved after SH from 67 to 87% and the specificity from 89 to 91%. The positive predictive value increased from 88 to 92% and the negative predictive value from 71 to 86%. The use of SH also improved the quality of information about the location and size of polyps and submucous fibroids. Increased endometrial thickness associated with adenocarcinoma was detected in all cases (three of three) by TVS and in four of seven cases of hyperplasia (five of seven cases after SH). Most patients reported minor discomfort during TVS or SH and no side-effects were apparent. The sensitivity of DH was 90% (92% for polyps, 88% for fibroids); two cases with a polyp, two with a submucous fibroid and one with endometrial hyperplasia were not detected. The use of saline infusion to enhance visualization of the endometrium increases the diagnostic accuracy of transvaginal sonography to approach that of diagnostic hysteroscopy and also provides some additional information. This development has implications for the management of uterine bleeding disorders.

https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1046/j.1469-0705.1998.11050337.x

An evaluation of sonohysterography and diagnostic hysteroscopy for the assessment of intrauterine pathology

The aim of the study was to assign a probability of malignancy for any patient with an adnexal tumor by the application of multivariate logistic regression analysis to variables recorded at the time of pelvic sonography. Sixty-seven women with known adnexal masses were examined using transvaginal B-mode and color Doppler imaging. For each patient the variables included: (1) age, (2) maximum tumor diameter, (3) tumor volume, (4) unilocularity (presence (0) or absence(1)), (5) papillary projections (presence (1) or absence (0)), (6) random echogenicity (presence (1) or absence (0)), (7) highest peak systolic velocity (PSV), (8) time-averaged maximum velocity (TAMXV), (9) pulsatility index (PI) and (10) resistance index (RI). The TAMXV, PI and RI were those associated with the highest PSV. These ten independent variables and the final histological diagnosis for each patient (the dependent variable) were used for the regression analysis. Approximately 75% of the entire dataset was randomly selected for generating the regression model. The remaining 25% was used as the testing set for cross-validation of the model. In the entire dataset there were 52 women with benign, three with borderline and 12 with invasive ovarian tumors. Regression analysis on the ten variables resulted in the retention of only 'age', 'papillary projection score' and 'TAMXV' as significantly contributing to predicting the presence or absence of malignancy. The probability of malignancy for any patient was given by solving the equation: Probability = 1/(1 + e-z) where e is the base value for natural logarithms and z = (0.1273 x Age) + (0.2794 x TAMXV) + (4.4136 x Papillary projections score) - 14.2046. Cross-validation of the model on the test set of data gave a 100% sensitivity and specificity. However, for the entire dataset the best sensitivity and specificity were 93.3 and 90.4%, respectively, at a cut-off value of 25% probability of malignancy. In conclusion, multivariate logistic regression analysis enables the calculation of probability of malignancy for any patient with a known adnexal mass. The accuracy of this prediction appears to be better than that of morphological or Doppler criteria when the latter are used independently. The value of this model needs to be tested prospectively.

W. P. Collins

Papers

Subjective assessment of adnexal masses with the use of ultrasonography: an analysis of interobserver variability and experience

Screening for early familial ovarian cancer with transvaginal ultrasonography and colour blood flow imaging.

Transvaginal colour flow imaging of the uterine arteries during the ovarian and menstrual cycles

An evaluation of sonohysterography and diagnostic hysteroscopy for the assessment of intrauterine pathology

Sonographic prediction of malignancy in adnexal masses using multivariate logistic regression analysis