Dimensional analysis of the endometrial cavity: how many dimensions sh

Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Bellville, Western Cape, South Africa

Background: The geometrical shape of the human uterus most closely approximates that of a prolate ellipsoid. The endometrial cavity itself is more likely to also have the shape of a prolate ellipsoid especially when the extension of the cervix is omitted. Using this information and known endometrial cavity volumes and lateral and vertical dimensions, it is possible to calculate the anteroposterior (AP) dimensions and get a complete evaluation of all possible dimensions of the endometrial cavity. These are singular observations and not part of any other study.
Methods: The AP dimensions of the endometrial cavity of the uterus were calculated using the formula for the volume of the prolate ellipsoid to complete a three-dimensional picture of the endometrial cavity.
Results: Calculations confirm ultrasound imaging which shows large variations in cavity size and shape. Known cavity volumes and length and breadth measurements indicate that the AP diameter may vary from 6.29 to 38.2 mm. These measurements confirm the difficulty of getting a fixed-frame intrauterine device (IUD) to accommodate to a space of highly variable dimensions. This is especially true of three-dimension IUDs. A one-dimensional frameless IUD is most likely to be able to conform to this highly variable space and shape.
Conclusion: The endometrial cavity may assume many varied prolate ellipsoid configurations where one or more measurements may be too small to accommodate standard IUDs. A one-dimensional device is most likely to be able to be accommodated by most uterine cavities as compared to two- and three-dimensional devices.

Keywords: intrauterine device, dimensions, endometrial cavity, prolate ellipsoid, variable space and shape

Introduction

The first clinically used intrauterine devices (IUDs) were introduced by Richter and Pust and later Grafenberg in Germany. ^1–3 All three made IUDs using the material which was available at the time. These materials were rigid and difficult to insert and their geometrical shape would have caused significant to extreme distortion of the endometrial cavity. This was naturally accompanied by pain, bleeding, and discomfort, and even infection.

The plastics revolution of the 1950s helped Lippes design the Lippes Loop IUD which was made of polyethylene impregnated with barium sulfate. It was malleable and would retain its shape and could be withdrawn into an inserter tube and injected into the endometrial cavity where it would resume its original shape.⁴ It worked because it had a surface area of at least 600 mm², which is about the surface area that plastic only IUDs require to be effective.⁵ The Loop came in four sizes which were crudely based on the uterine dimensions reported in Dickinson’s book on human sexual anatomy. These dimensions are too large for the dynamic uterine cavity in vivo. Although the insertion procedure was much more tolerable than that of the earlier devices, the experience during subsequent usage was still problematical due to distortion of the uterine cavity by the oversized loops. This was true even of the smallest size. The extent of this IUD-induced increase in menstrual blood loss (MBL) appears to be related to the size of the device. The greater the size of the device, the greater the amount of MBL. The Lippes Loop, one of the larger IUDs developed, has been shown to result in an increase of up to 140% in MBL during the first year after insertion.⁶ In the late 1960s, the antifertility effect of copper was discovered by Chang at the Worcester Institute in Massachusetts. Its antifertility effect was exploited for use as an intrauterine contraceptive by attaching it to a “7” shaped plastic frame (Zipper) or a “T” shaped plastic frame (Tatum). The anatomical basis for the shape and size of these frames was Dickinson’s work.⁷ With hindsight and the benefit of modern high-resolution ultrasound, we now know that the original size of most of these plastic frames was too large. ^8,9 More surprising is that these original sizes have gone largely unaltered in the light of this new evidence.⁸

A frame is like a skeleton – it gives stability and the ability to withstand collapsing and gravitational forces, which is why vertebrates have them. Invertebrates, like the octopus, do not have skeletons (frames) and cannot withstand these forces but can resist compressive forces by molding their bodies to fit very small and changing spaces. In order to successfully occupy a hollow muscular organ like the uterus, an IUD does not need to be able to resist collapsing and gravitational forces – it needs to be able to adapt to small liquid potential spaces. An IUD needs to be able to fit and adapt to these small liquid filled spaces which are continually changing with uterine muscular activity and contractions. Ideally, it needs to be able to mold and change its shape effortlessly to that of the endometrial cavity; in other words, it ideally really needs to be frameless and without a skeleton. Just how small and changeable is the endometrial cavity?

Methods

The uterus itself most closely approximates the geometrical shape of a prolate ellipsoid.¹⁰ The endometrial cavity is a hollowed-out space which appears to be fairly symmetrical within the uterus itself. Additionally, since we can eliminate the cervix and the cervical canal (which are not part of the endometrial cavity), the endometrial cavity itself can be assumed to also take the shape of a prolate ellipsoid, and in fact removal of the cervix ensures that the cavity more closely approximates a prolate ellipsoid than does the whole uterus. The volume of a prolate ellipsoid is given by the following formula:

where V = volume of the endometrial cavity (mL)

π~3.14

L = length (fundus to internal os of endometrial cavity)

W = width (between cornual ostia of endometrial cavity)

and AP = anteroposterior diameter of the endometrial cavity perpendicular to L.

Endometrial cavity volume has been measured and varies between 5 and 10 mL.¹¹

Transfundal endometrial cavity width varies widely from as little as 7 mm in very narrow cavities to the more usual 22–34 mm depending on parity. There is a wide variation in uterine measurements, but it is possible to calculate boundary values which will accommodate most sizes and volumes.

Results

Table 1 gives representative values for a range of volumes and for a range of endometrial cavity widths and lengths. It was obtained by using extreme values of volume and lateral longitudinal uterine cavity measurements to calculate AP dimensions using the prolate ellipsoid formula given in the previous section. For example, in a low-volume endometrial cavity of length 40 mm and width 38 mm, the equation shows that the AP diameter would be 6 mm.

During uterine contraction, the endometrial cavity is distorted even further, which can reduce the value of these dimensions. An IUD which has 2 or 3 dimensions needs a large enough size to anchor but should not be so large as to cause problems.¹² A one-dimensional IUD cannot form a dimensional anchor and needs to be tethered to the uterine wall if it is to remain in place, eg, Gynefix.¹²

Discussion

The external longitudinal and internal circular muscle fibers of the uterus are a continuation of the tubal muscle fibers. In addition, there are circular fibers which sweep around the uterus in both clockwise and counterclockwise directions.⁷ Uterine muscular contractions sweep down through the myometrium from the fundus to the cervix. This arrangement of the muscle fibers means that the endometrial cavity dimensions will change in all three axes (L, W, AP), ie, there will be three-dimensional change in the endometrial cavity.

While not all IUD-related problems are related to dimensional incompatibility between the IUD and the endometrial cavity, it is likely that mismatch between the size of the IUD and the uterine cavity is certainly not optimal and can only be detrimental to device performance.⁹ It follows logically therefore that the greater the number of dimensions an IUD has, the greater the chance it has of being incompatible with the endometrial cavity in one of its three dimensions. This is because it would have to be compatible with the length, width, and AP diameter of the endometrial cavity. Figure 1 shows a severely distorted uterine cavity due to a manifest discrepancy between the IUD and the endometrial cavity.

This also explains why the “Intrauterine ball,” a three-dimensional device with a flexible nitinol frame has been associated with expulsion problems (Figure 2).¹⁴

Our previous models have only examined static two-dimensional changes. While it is difficult for framed devices to accommodate to changing lateral (and sometimes linear) dimensions, it is virtually impossible for them to simultaneously adapt to changing AP dimensions as well, since they would be subject to changes of force in three dimensions. This produces a three-dimensional squeeze which, at worst, is possibly responsible for secondary perforation¹⁵ but leads to the user experiencing pain and discomfort, often accompanied by embedment (Figure 3).

Only a frameless IUD which behaves analogously to an invertebrate can adapt to the changing and very small spaces in an “octopus-like” manner. Thus, it is able to adapt to sit comfortably in low-volume, flexed, and/or distorted endometrial cavities (Figure 4). A multicenter study found a maximal cavity width <20 mm in 32% of nulliparous women. Due to the small volume of the frameless IUD, the impact on amount of MBL is also minimal.¹⁶

Conclusion

There are two main limitations to the dimensional approach toward IUD design. First, the size of the endometrial cavity is very variable, so an IUD of any one size is not able to fit a wide range of cavities. Second, the uterus will sometimes show tolerance to what appear to be ill-fitting devices. The problem of one-dimensional IUDs is that presently they are anchored by “harpooning” into the myometrium. This technique requires insertion training and is tissue invasive.¹⁵ However, proficiency is easily acquired for those who are skilled IUD providers. Evidently, a one-dimensional frameless IUD that is self-adherent to the endometrial cavity would appear to be optimal, but this may not be technically feasible.

Disclosure

The author reports no conflicts of interest in this work.

References

[Ultrasound detection of endometrial fluid in postmenopausal women]

The aim, of this prospective study was to estimate whether the presence of endometrial fluid detected by transvaginal ultrasound investigation was a marker for the pathological changes of the endometrium in postmenopausal women.

Material and methods:

128 postmenopausal women with uterine bleeding and 29 asymptomatic postmenopausal women underwent transvaginal ultrasound investigation, curettage and histopathological investigation of the curettage specimens.

Results:

There were significantly more asymptomatic women with endometrial fluid collection was found (41,4%) than those with uterine bleeding (7,8%) (p<0,001). We found 4 cases of carcinoma of the endometrium, 4 with hyperplasia and 1 with polyp of the endometrium in women with uterine bleeding and endometrial fluid collection. In the asymptomatic group of women we found 1 case with polyp and 1 with carcinoma of the endometrium. In the presence of endometrial fluid collection the least thickness of the endometrium measured by transvaginal ultrasound was 12 mm in postmenopausal women with carcinoma of the endometrium, 7 mm in women with hyperplasia and 5 mm with polyp. No pathological changes were found below the above values.

Conclusion:

The presence of endometrial fluid detected by transvaginal ultrasonography is a good marker for pathological changes of the endometrium in postmenopausal women if the endometrial thickness is greater than 4 mm. If the endometrial thickness is 4 mm or less, the presence of endometrial fluid is not an indication for further invasive investigation of endometrial cavity, but we must eliminate possible presence of ednexal or cervical malignant disease in some patients.

A Diagnostic Test Accuracy Study

Endometriosis is strongly associated with infertility. Endometrial polyps are prevalent in infertile women and they have similar pathological characteristics to endometriosis, suggesting a possible association. Uterine malformations as uterine septum and hypoplastic uterus are also linked to endometriosis. Hysterosalpingogram and transvaginal ultrasonography are used to diagnose endometrial lesions. Hysteroscopy can detect small lesions that might be missed. Recently, 4D ultrasonography is being used, but which is superior has not been established yet. We aim to compare 4D ultrasonography to office hysteroscopy in evaluating uterine cavity in cases with endometriosis; also we aim at correlating these findings with the stage of endometriosis. 50 cases of endometriosis diagnosed by laparoscopy were randomly selected from El Shatby fertility clinic, Alexandria University, Egypt, with exclusion of cases with any previous intrauterine surgery or any hormonal treatment. Transvaginal 4D ultrasonography and office hysteroscopy were done. 4D ultrasonography agreed with office hysteroscopy in diagnosing abnormal uterine findings in 14 cases and four additional cases were diagnosed by hysteroscopy alone. Conclusion. Endometrial polyps, septate uterus, and hypoplastic uterus are more prevalent among infertile women who happen to have endometriosis. 4D ultrasonography and office hysteroscopy are equally successful in assessing the uterine cavity.

1. Introduction

It is estimated that endometriosis occurs in 10% of women during the reproductive years [1]. It has been classified into superficial, deep, and ovarian types. The superficial type may be presented as classical implants and vesicular, popular, nodular, haemorrhagic, healed, and apparently normal peritoneum [2]. It commonly presents between 25 and 29 years of age [1]. It is strongly associated with infertility, which is attributed to distorted adnexal anatomy [3], interference with oocyte development or early embryogenesis [4], or reduced endometrial receptivity [5]. Several studies have suggested impairment of implantation which may be due to intrinsic deficiencies within the uterus [6] and structural or ultrastructural defects [7]. Endometrial polyps are common gynecological disorder whose prevalence is increased in infertile women [8]. The exact pathogenesis of these polyps is not yet known, but the similar pathological characteristics to endometriosis suggest a possible association [9]. Anatomical uterine malformations are also linked to endometriosis [10]. Uterine septum, the most common Müllerian duct anomaly, results in colicky uterine peristalsis and increased menstrual regurgitation through the fallopian tubes [11]. Hypoplastic uterus, a rare anomaly, may be also associated [12]. Both hysterosalpingogram and transvaginal ultrasonography are used to diagnose endometrial lesions but sometimes they are not enough [13]. Hysteroscopy, the gold standard for evaluation of uterine causes of infertility, can detect small lesions that might not otherwise be detected by other methods [14]. In the recent years, office hysteroscopy has been preferred to operative hysteroscopy in routine evaluation of the endometrial cavity [15]. Recently, 4D ultrasonography is being used for the same purpose but which is superior has not been established yet. In this study, we aim to compare between 4D ultrasonography and office hysteroscopy in evaluating uterine cavity in cases with endometriosis.

2. Patients and Methods

A prospective observational study was conducted on 50 cases of endometriosis which is the number needed to estimate the prevalence of uterine cavity abnormalities which is equal to 69% [16] with 12% precision (due to high variability at the estimated rates) using an alpha error of 5% [17]. The sample was selected randomly using the simple random technique.

All patients were recruited from El Shatby fertility clinic, Alexandria University. Endometriosis was diagnosed by laparoscopy (discrete endometriotic lesions, endometriomas, or adhesions) [18] or transvaginal ultrasonography for endometriomas (cystic lesion with low level internal echoes, occasional thick septations, thickened walls, and echogenic wall foci) [19]. Patients with history of any previous intrauterine cavity or those receiving any hormonal treatment for the previous six months were excluded.

2.1. Methods

Informed consent was signed by all participants; complete history was taken (age, gravidity, parity, menstrual history, and previous surgery; complete examination (general, abdominal, and vaginal) was done. Transvaginal 4D ultrasonography was done in the dorsal lithotomy position. Uterus was assessed in the transverse and sagittal planes, adnexa were scanned for cysts or endometriotic nodules, and tubes were scanned for hydrosalpinx.

Office hysteroscopy was done immediately after menstruation using normal saline as distention media and 5 mm continuous flow sheath with an operative channel for the use of scissors, grasping forceps, or biopsy forceps when necessary. Light was provided by normal cold light source. During the procedure, the patient was placed in the dorsal lithotomy position, vulva and vagina were cleaned with antiseptic solution, the technique avoided the use of a speculum or a tenaculum, the vagina as a cavity was distended using the hysteroscope introduced into its lower part, and the anatomy was followed up till the cervical canal onto the uterine cavity. The uterine cavity was inspected symmetrically and the tubal ostia were identified; then the hysteroscope was pulled backwards to obtain a panoramic view of the whole cavity, and cervical canal was inspected during withdrawal. Findings were recorded. Polyps, when seen, were biopsied with biopsy forceps introduced through the operative channel and the diagnosis was confirmed with histopathological examination.

2.1.1. Statistical Methodology

Data were collected and entered to the computer using SPSS (Statistical Package for Social Sciences) program for statistical analysis (ver. 21) [20]. Data were entered as numerical or categorical, as appropriate. When Kolmogorov-Smirnov test revealed no significance in the distribution of variables, parametric statistics were carried out, while in the not-normally distributed data the nonparametric statistics were carried out [21]:(i)Data were described using minimum, maximum, mean, and standard deviation for the normally distributed data.(ii)Interrater (interobserver) agreement was carried out using kappa and weighted kappa tests [20, 22]. Proportions of specific agreement were calculated according to Spitzer and Fleiss [23].An alpha level was set to 5% with a significance level of 95%, and a beta error was accepted up to 20% with a power of study of 80%.

2.1.2. Agreement Analysis

Magnitude guidelines have appeared in the literature. Perhaps the first were Landis and Koch [24] who characterized values < 0 as indicating no agreement and 0–0.20 as slight, 0.21–0.40 as fair, 0.41–0.60 as moderate, 0.61–0.80 as substantial, and 0. 81–1 as almost perfect agreement. This set of guidelines is, however, by no means universally accepted; Landis and Koch supplied no evidence to support it, basing it instead on personal opinion. It has been noted that these guidelines may be more harmful than helpful [25]. Fleiss’s [26] equally arbitrary guidelines characterize kappa over 0.75 as excellent, 0.40 to 0.75 as fair to good, and below 0.40 as poor.

3. Results

The study was conducted upon fifty cases of endometriosis; their age ranged from 23 to 38 years of age with a mean of years (Figure 1). 42 cases complained of primary infertility, while 8 cases complained of secondary infertility. By laparoscopy, we had 8 cases in stage I, 17 cases in stage II, 4 cases in stage III, 20 cases in stage IV, and one missing case. Endometriomas were found in 38 cases only (Table 1).

% Infertility      (i) Primary 42 84. 0  (ii) Secondary 8 16.0 Stage      (i) I 8 16.3  (ii) II 17 34.7  (iii) III 4 8.2  (iv) IV 20 40.8 Endometriosis      (i) Negative 38 76.0  (ii) Positive 12 24.0

By 4D ultrasonography, we had abnormal uterine findings in 14 cases and this was confirmed by office hysteroscopy. On the contrary, 36 cases were completely normal by 4D ultrasonography but, by office hysteroscopy, 3 cases had abnormal findings which are statistically significant (Table 2). 4D ultrasonography had sensitivity of 82.35% and specificity of 100% for diagnosing abnormal uterine findings with a positive predictive value of 100% and a negative predictive value of 91. 67% and an overall test accuracy of 94%.

Hysteroscopy Total Negative Positive 4D U/S        Negative 33 (66.0%) 3 (6.0%) 36 (72.0%)  Positive 0 (0.0%) 14 (28.0%) 14 (28.0%) Total 33 (66.0%) 17 (34.0%) 50 (100.0%) Kappa 0.860   Standard error 0.077   value 0.000   Weighted kappa 0.860   Standard error 0.077   95% CI 0. 709–1.000

Proportions of specific agreement: (i) negative agreement = ; (ii) positive agreement = . indicates significance.

Abnormal findings were in the form of polyps, septate uterus, and hypoplastic uterus. Endometrial polyps were found in 8 cases by 4D ultrasonography which was confirmed by hysteroscopy (positive agreement), and 4D ultrasonography diagnosed 42 cases as being normal which also agreed with hysteroscopy; only 2 cases were positive for the presence of polyps by hysteroscopy and they were diagnosed as free by 4D ultrasonography (Table 3). 4D ultrasonography had sensitivity of 80.00% and specificity of 95.24% for diagnosing endometrial polyps with a positive predictive value of 80% and a negative predictive value of 95.24% and an overall test accuracy of 92.31%.

Hysteroscopy Total Negative Positive 4D U/S        Negative 40 (80. 0%) 2 (4.0%) 42 (84.0%)  Positive 0 (0.0%) 8 (16.0%) 8 (16.0%) Total 40 (80.0%) 10 (20.0%) 50 (100.0%) Kappa 0.865   Standard error 0.093   value 0.000   Weighted kappa 0.865   Standard error 0.093   95% CI 0.683–1.000

Proportions of specific agreement: (i) negative agreement = ; (ii) positive agreement = . indicates significance.

Septate uterus was found in only 4 cases by 4D ultrasonography against 46 free cases. This was proven by hysteroscopy (positive agreement) in addition to one case which was diagnosed as free by 4D ultrasonography, but a septum was found on hysteroscopy (Table 4). 4D ultrasonography had sensitivity of 80.00% and specificity of 100.00% for diagnosing septate uterus with a positive predictive value of 100.00% and a negative predictive value of 97.83% and an overall test accuracy of 98.00%.

Hysteroscopy Total Negative Positive 4D U/S        Negative 45 (90.0%) 1 (2.0%) 46 (92.0%)  Positive 0 (0.0%) 4 (8.0%) 4 (8.0%) Total 45 (90.0%) 5 (10.0%) 50 (100.0%) Kappa 0. 878   Standard error 0.120   value 0.000   Weighted kappa 0.878   Standard error 0.120   95% CI 0.643–1.000

Proportions of specific agreement: (i) negative agreement = ; (ii) positive agreement = . indicates significance.

Hypoplastic uterus was found in only 2 cases by 4D ultrasonography against 48 free cases which was the same result obtained by hysteroscopy (positive agreement) (Table 5). 4D ultrasonography had sensitivity of 100.00% and specificity of 100.00% for diagnosing hypoplastic uterus with a positive predictive value of 100.00% and a negative predictive value of 100.00% and an overall test accuracy of 100. 00%.

Hysteroscopy Total Negative Positive 4D U/S        Negative 48 (96.0%) 0 (0.0%) 48 (96.0%)  Positive 0 (0.0%) 2 (4.0%) 2 (4.0%) Total 48 (96.0%) 2 (4.0%) 50 (100.0%) Kappa 1.000   Standard error 0.000   value 0.000   Weighted kappa 1.000   Standard error 0.000   95% CI 1.000-1.000

Proportions of specific agreement: (i) negative agreement = ; (ii) positive agreement = . indicates significance.

4. Discussion

Endometriosis is a common gynecological disorder; its association with infertility is complex and controversial. Virtually, every aspect of reproduction in women with endometriosis has been investigated. Although advanced stages may manifest easily recognizable infertility factors, such as tubal distortion or obstruction, the mechanisms underlying reproductive dysfunction in women with minimal or mild disease are more subtle [27]. Many studies were conducted on endometriosis patients and many hypotheses exist to explain the relation between it and infertility but still the precise mechanism remains unclear. Our study aimed at evaluating the uterine cavity in those patients by 4D ultrasonography and by hysteroscopy and we also aimed at comparing these two methods to each other. 4D ultrasonography has the advantage of exact volume measurement of endometrial polyps which cannot be achieved by 2D ultrasonography. We succeeded in proving that 4D ultrasonography could be a good diagnostic tool for diagnosing abnormal uterine findings with a positive predictive value of 100% and an overall test accuracy of 94%. Hypoplastic uterus was the main abnormal uterine finding that could be detected with 4D ultrasonography with an overall test accuracy of 100% but unfortunately this was not the case for endometrial polyps where the overall test accuracy was 92.31%

After searching the literature, we found two studies reporting high prevalence of endometrial polyps in endometriosis patients [16, 28] and one study reporting uterine anomalies [29]. These studies aimed at just finding a relation or an association between abnormal uterine cavity findings and endometriosis and they did not recommend a particular diagnostic tool but, on the other hand, they used 2D ultrasonography, hysterosalpingography, and hysteroscopy without showing which of these methods was superior to the others.

Functional endometrial polyps which are confined to hormonally responsive layer of the uterus are estrogen-dependent. The exact pathogenesis of these benign lesions is not well known, but hormonal dysfunction is the most accepted theory [30]. In a study done by Hinckley and Milki upon 1000 infertile patients in 2004, prevalence of endometrial polyps was 35% only [29]. A larger study conducted upon 2500 infertile patients in 2010 reported prevalence of 7.86% [8]. In this study, researchers recommended hysteroscopy in comparison to ultrasonography for diagnosing endometrial polyps but they used the 2D ultrasonography and not the 4D one. The similar characteristics of endometriosis and endometrial polyps suggest a possible association between them. In 2003, Kim et al. studied one hundred eighty-three infertile women: 92 of them had endometriosis and 91 were control. They found polyps in 43 women in the endometriotic group (46.7%) against 15 women in the control group (16.5%) [28].

In 2011, Shen et al. studied 431 cases: 158 cases with endometriosis and 273 cases without endometriosis. Endometrial polyps were found in 108/158 cases (68.35%) with endometriosis and in 56/273 cases of the control group (20.51%) [16]. These results agree with our results as regards the high prevalence of polyps in endometriosis patients. The difference in the prevalence could be due to the number of characteristics and the different population, as the studies were held in China with the consideration of the high prevalence of endometrial polyps in this population.

Our study also evaluated the uterine cavity for uterine anomalies and we reported five cases of septate uterus (10%) and two cases of hypoplastic uterus (4%). The incidence of congenital uterine anomalies in the general population is 0.1–3% [31].

Hinckley and Milki studied 1385 infertile cases, of which 7 cases (0.5%) had uterine septum [29]. Matalliotakis et al. studied 425 cases with endometriosis and 200 cases without endometriosis in 2010. They found 13 cases from 425 having a uterine septum, representing 3%. The control group had only one case, representing 0.5% of the studied group [32]. This agrees with our results, but they did not differentiate between the different diagnostic modalities as we did. Comparing 4D ultrasonography to office hysteroscopy, a positive agreement was found, where only one case of septate uterus was missed by 4D and reported by office hysteroscopy; otherwise both reported the same findings as regards polyps and hypoplastic uterus. This proves that 4D ultrasonography with its advantage as an easy noninvasive technique could be used instead of office hysteroscopy.

5. Conclusion

From the present study, we concluded that endometrial polyps, septate uterus, and hypoplastic uterus are more prevalent among infertile women who happen to have endometriosis. Both 4D ultrasonography and office hysteroscopy are equally successful in assessing the uterine cavity but ultrasonography has the advantage of being an easy noninvasive maneuver.

Conflicts of Interest

The author declares that there are no conflicts of interest.

The associated factors to endometrial cavity fluid and the relevant impact on the IVF-ET outcome | Reproductive Biology and Endocrinology

Patients

The study was approved by the Review Board of Women’s Hospital, Zhejiang University School of Medicine. The clinical data of 1557 cycles of infertility patients that enrolled in our IVF program between March 1, 2006 and February 28, 2007 was retrospectively reviewed. 46 patients were selected as the ECF group, in which there was a fluid accumulation equal or higher1.0 mm in the anterior-posterior diameter (APD) in the uterine cavity of each patient at the day of oocyte retrieval; and another 134 ones with a bilateral salpingectomy selected as the control group, in which no fluid accumulation was detected in their uterine cavities at the day of oocyte retrieval.

The cervical stenosis of each selected patient has been eliminated by the uterine exploration routinely carried out at the initiation of each IVF program. No other causes recorded influencing fertility, such as endometriosis, leiomyoma, etc., were found in each of the selected cases. Cycles that involved the use of frozen embryos, donor oocytes, or assisted hatching were excluded. All pregnancies were confirmed by the rising serum β-HCG levels and the gestational sacs identified by transvaginal sonographic examination.

IVF-ET procedures

All patients underwent pituitary desensitization followed by controlled ovarian hyperstimulation. Briefly, GnRH-agonist suppression in a standard long protocol by s.c. injections of triptorelin acetate (Decapaptyl, Ferring, Germany), 0.1 mg/day started on Day 21 of the prior menstrual cycle. Ovarian stimulation was then initiated with rFSH (Gonal-F; Serono, Aubonne, Switzerland) and/or HMG (Pergonal^®; Serono Menotropin Livzon). Follicular growth was monitored by assay of estradiol (E2) levels and ultrasonography. When at least two leading follicles reached to a diameter >16 mm, HCG (Pregnyl; Serono, Aubonne, Switzerland) was administered at a dose of 5000-10000 IU. Oocytes were retrieved by transvaginal ultrasound-guided follicular aspiration 34-36 h after HCG injection. The infertility due to severe male factors was treated with the intracytoplasmic sperm injection, while standard IVF techniques were used for others. All patients had at least one good-quality embryo for transfer on the second or third day after oocyte retrieval. The embryos were evaluated by a scoring system named cumulative embryos score which was based on blastomere number and fragmentation pattern [10]. The number of embryos transferred varied between patients. All ETs were performed with an Edward-Wallace catheter (k-OPSD-1635-ET, COOK, Queensland, Australia) under ultrasound guidance. Luteal support consisted of 50 mg progesterone in oil administered i.m. daily in patients who had ET performed.

Ultrasonography examination of ECF

Sonographic examinations were performed using an Ultramark^® 9 HDI (Advanced Technology Laboratories, Bothell, WA, USA) with a 5 MHz multi-frequency transvaginal probe. The endometrium was scanned sagittally along the mid-line axis of the uterus. Alterations in the endometrial thickness and echogenic pattern/structure were recorded respectively during gonadotrophin administration, on the day of oocyte retrieval and on the day of ET.

Fluid accumulation within the uterine cavity was defined as an echolucent ring configuration distended by a certain amount of fluid and detected by transvaginal ultrasound. Here, APD, the maximal fluid diameter between the anterior and posterior (A-P) endometrial linings in a sagittal view of uterine cavity, was used to assess the degree of fluid accumulation (Fig. 1). In cases of fluid accumulation, the thickness of endometrium was measured by subtracting the maximal fluid diameter from the maximal distance between the opposing myometrial/endometrial interfaces. The maximal fluid diameter and the surrounding endometrial thickness were used as indices for analysis.

Figure 1

Endometrial cavity fluid (ECF). Fluid accumulation in the uterine cavity detected by transvaginal ultrasound in a sagittal view (A-P diameter 2.5 mm) in a patient on the day of oocyte retrieval.

The charts of all patients undergoing IVF treatment were searched for the presence of fluid accumulation inside the uterine cavity on the day of oocyte retrieval. That fluid might have disappeared or persisted until the end of the cycle, but never aspirated. The cases whose fluids were detected only during the period of ovarian stimulation were excluded.

Statistics

Continuous data were presented as the mean ± SEM. Comparisons between groups were performed using the Mann-Whitney U-test or Student’s t-test as appropriate. The statistical test to analyze the reproductive outcomes was done using chi-square analysis. A P-value less than 0.05 was considered statistically significant.

What Is the Uterine Cavity? – Size & Definition – Video & Lesson Transcript

Structure

The uterine cavity is formed by the lateral walls of the uterus, as well as the bottom wall of the fundus, or top portion of the uterus. These walls contain muscle tissue known as the myometrium and a layer of cells that line the outside edges known as the endometrium. The cavity itself has a T-shaped appearance in general, although the exactness of this shape will change during the course of the menstrual cycle. The width of the uterine cavity is usually between 27 and 32 mm in women prior to menopause, though this can vary from individual to individual. Since the uterus is the location for fertilized eggs to implant for pregnancy, the walls of the uterus will grow throughout the course of the cycle, and this will change the amount of space found in the uterine cavity.

Function

The uterus is a muscular organ that is designed to facilitate several aspects of reproduction in the female body. During sex, it serves as a pathway for sperm cells as they travel towards the egg. It also contracts during orgasm, which helps increase the chances of fertilization. The cavity of the uterus is the key space where this takes place. Without this space, the pathway for sperm cells would be non-existent, and pregnancy would not occur.

Once an egg is fertilized, it will implant in the lining of the uterus. Here, the developing child will be able to receive nutrients from the blood vessels found in the endometrium. As the child continues to grow, the uterine cavity will serve as the space where that growth will be housed. This growth usually proceeds for roughly nine months, or until the child is large enough to press against the cervix found at the lower end. During labor, the muscle in the myometrium will contract to push the child through the cervix and out of the uterine cavity.

Lesson Summary

Let’s review. The uterine cavity is important in the act of sex, fertilization, and pregnancy. This space allows for sperm to travel towards eggs, and it also allows for a fertilized egg to implant and develop during pregnancy. Therefore, without the uterine cavity, the process of reproduction within the female body would not be possible.

Practice:

What Is the Uterine Cavity? – Size & Definition Quiz

Instructions: Choose an answer and click ‘Next’. You will receive your score and answers at the end.

The layer of cells that lines the outside edges of the uterine cavity is known as the ______.

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Does the endometrial cavity have a molecular microbial signature?

7.

Pezzlo, M. T., Hesser, J. W., Morgan, T., Valter, P. J. & Thrupp, L. D. Improved laboratory efficiency and diagnostic accuracy with new double-lumen-protected swab for for endometrial specimens. J Clin Microbiol 9, 56–59 (1979).

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What is an Endometrial Polyp?

An endometrial polyp is an overgrowth of the endometrial lining on the inside of the uterine cavity, most often found in women between 20 and 40 years of age. It contains no muscular tissue unlike a fibroid.

Again, while a fibroid originates from the muscular middle layer of the uterine wall, called the myometrium, and can therefore protrude outwards towards the outer serosal layer or inwards towards the inner endometrial layer, an endometrial polyp is always located within the uterine cavity. Their size varies from a few millimeters to centimeters, and they may occur singly or as multiples. The most common site for polyp formation is the fundus of the uterus.

Real Questions | Endometrial Polyps | UCLA OB/GYNPlay

Clinical Features

Many polyps are asymptomatic. Most often, a symptomatic uterine polyp causes spotting or bleeding at irregular intervals – either in between periods (which is called intermenstrual bleeding), or as irregularity of the periods themselves (termed metrorrhagia). Bleeding can also ensue following sexual intercourse (called postcoital bleeding) or after menopause. Moreover, they may cause uterine cramping during periods, which is called dysmenorrhea, and some studies report infertility as a result of uterine polyps.

Approximately 40% of women with bleeding from the uterus who have not reached menopause may have endometrial polyps, and they are found in up to about 30% of postmenopausal women with abnormal bleeding. The risk for malignant transformation in an endometrial polyp is about 3%.

Classification of uterine polyps. Image Credit: Marochkina Anastasiia / Shutterstock

Risk Factors

Women at increased risk for endometrial polyps are often:

• Older
• Obese
• Hypertensive
• On hormone replacement therapy (HRT)
• On tamoxifen for breast cancer
• Have a family history of Lynch or Cowden syndrome

Diagnosis and Management

While many endometrial polyps are diagnosed incidentally on imaging of the uterus for some other symptoms, others are suspected due to the presence of bleeding or pain. This may lead to examination of the uterine cavity using hysteroscopy. Other methods of evaluation may be used such as a Pap smear, examination of the cervical canal for a protruding polyp, a contrast examination called a hysterosalpingogram, an ultrasound scan of the pelvis, uterine curettage (scraping of the inner lining) or an endometrial biopsy. A specialized ultrasound called a hysterosonogram may also be performed.

However, diagnosis is by excising the growth and sending it for histopathologic examination. This will definitively distinguish these from uterine fibroids. Removal of the polyp is usually done by means of  a resectoscope, a slender instrument used to cast a wire noose around the base of the polyp, ensnare its blood supply, resect it, and retrieve it – all under direct vision. This can be introduced through the hysteroscope, thus avoiding the need for two separate procedures.

Recurrence rates are high, from 15-43% in premenopausal women, and this must be discussed with the patient. Follow-up and monitoring are essential. The use of an intrauterine device releasing levonorgestrel, such as the Mirena, or a surgical procedure called endomyometrial resection, are two pivotal steps recommended to reduce the risk of recurrence. The Mirena device can be removed when necessary to allow conception, making it possible to control conception as well as limit endometrial proliferation.

Again, further surgery is required in about half of women who request polyp removal because of menorrhagia. When removed, the base of the polyp must also be obtained because a third of malignancies occur at that spot. Endometrial damage must be limited to preserve the woman’s ability to conceive and carry a pregnancy successfully. If a polyp is found to be cancerous, hysterectomy is the only definitive mode of management.

Further Reading

ENDOMETRIOSIS – Women’s Health Clinic

Endometriosis is a disease in which benign proliferation of tissue occurs outside the uterine cavity, similar in morphological and functional properties to the endometrium.

Endometriosis is observed in 10-12% of women of reproductive age, in 25-50% of cases it is the cause of infertility, and in patients with chronic pelvic pain this figure reaches 45-82%.

CAUSES OF THE DISEASE

Questions of clinical picture, pathogenesis and methods of treatment of endometriosis are widely presented in the literature.However, to date, there is no consensus about the etiology and causes of this disease. The most widespread theory was proposed by Sampson in 1922, which involves the retrograde flow of menstrual blood through the fallopian tubes into the abdominal cavity, followed by adhesion, implantation and growth of endometrial cells on the pelvic peritoneum, sacro-uterine ligaments and other abdominal organs.

CLINICAL MANIFESTATIONS

The main clinical symptoms of endometriosis include: infertility, persistent pelvic pain, dysmenorrhea, dyspareunia, intermenstrual bleeding, chronic fatigue and depression.

Involvement in the pathological process of the rectum and bladder leads to pain during bowel movements and dysuric disorders.

DIAGNOSTICS

Ultrasound using a vaginal probe allows you to identify structural changes in the mucous and muscular membranes of the uterus, diagnose endometrioid ovarian cysts, combined determination of the most important tumor markers (CA-125, CEA and CA-19-9).

Endoscopic research methods include hysteroscopy, which allows assessing the state of the uterine cavity, the mouth of the fallopian tubes, identifying diffuse forms of endometriosis of the uterine body, and conducting a one-time diagnostic biopsy of the endometrium.The main method for making a diagnosis is laparoscopic imaging of endometrioid heterotopies with their subsequent histological confirmation.

Treatment

– removal of foci of endometriosis;

– relief of clinical symptoms;

– restoration of reproductive function;

– relapse prevention.

90,000 When is it better to do an ultrasound scan for endometriosis? – health articles

Table of Contents

Endometriosis is a disease of the female pelvic organs, which is characterized by a strong proliferation of tissues of the inner layer of the walls of the uterus into other structures (outside this organ).These cells enter the ovaries, vagina, and other areas through the fallopian tubes, blood, and other means. Cysts can form from them, which will lead to disturbances in the functioning of the genitourinary system.

Readings

Symptoms of this disease often coincide with signs of other ailments of the genitourinary system. In some cases, it may not appear at all, or the woman may not pay attention to the symptomatology, considering it unimportant or normal. Therefore, you should consult a doctor if the following phenomena are recorded:

• Prolonged and painful periods
• Presence of dark discharge for several days before or after menstruation
• Having discomfort during intercourse
• Unstable cycle
• Painful urination
• Infertility
• Weakness, frequent dizziness, fatigue, skin defects
• Increased temperature for a long time

Timing for Research

One ultrasound of the small pelvis with endometriosis is often not enough.But this type of survey can be useful if it is carried out at the right time.

For the diagnosis of other diseases – fibroids and the like – it is recommended to do an ultrasound examination in the first week after the end of menstruation (from the fifth to the seventh day), when the tissues of the intrauterine layer are the thinnest.

In the case of endometriosis, this principle does not work, since its formations are best seen with the thickest inner layer of the uterine walls.Therefore, for the best result, it is necessary to do this examination from the twenty-fifth to the twenty-eighth day, if the woman’s cycle is thirty days. During this period, the endometrium becomes the thickest, and, accordingly, the foci of the disease grow.

Since it is not always possible to unambiguously determine the presence of this ailment, it is recommended to undergo an ultrasound scan during several menstrual cycles and preferably on the same cycle days. This helps to identify the signs characteristic of such an ailment.

Structural changes in the endometrium

Three main stages of changes in the state of the inner layer of the uterine walls are noted, which are divided into several shorter mini-stages:

• First:
• Menstrual period – endometrial thickness is minimal, but some areas may be hyperechoic
• Second:
• Fifth-seventh days – a thin layer of the endometrium up to seven millimeters thick, with low echogenicity
• Eighth-tenth days – the thickness grows to ten millimeters
• Eleventh-fourteenth days – the layer grows to fifteen millimeters
• Third:
• Fifteenth-eighteenth days – echogenicity increases, the layer reaches seventeen millimeters
• Nineteenth to twenty-fourth days – the membrane thickens, increased echogenicity, and the tissue structure becomes heterogeneous
• Twenty-fourth to twenty-eighth days – the thickness may decrease to 11-17 mm, the echogenicity and structure remain the same

What will the ultrasound show?

On ultrasound of the pelvic organs, endometriosis is not always obvious, but ultrasound helps to determine its presence by some signs:

• Presence of endometrial cells in the perineum, vagina and external genitalia
• Presence of formations on the cervix
• Enlargement of the uterus, change in its shape (becomes spherical)
• Presence of cysts in the ovaries
• Thickening of the walls of organs

If the focus of the disease is in the ovaries, then the examination will show that:

• Various types of nodular inclusions are present in the tissues
• There is a round neoplasm behind or on the side of the uterus
• Tissue inhomogeneity

If the disease is localized in the uterus, then ultrasound will reveal the following changes:

• Blurred tissue of the endometrial layer
• Asymmetry of the walls of the uterus
• Presence of nodules

Types of disease

As endometriosis grows, its four degrees are determined:

• First – spot propagation
• Second – the foci are gradually expanding
• Third – cysts are formed, which gradually increase in size
• Fourth – extensive damage to organs and tissues

There is also a classification according to its localization:

• Internal – foci in the uterus and its cervix
• Outer – endometrial cells in the abdominal cavity, vagina, ovaries, etc.d.

Disease types are distinguished according to the shape and structure of neoplasms:

• Focal – a cyst with increased echogenicity up to 16 mm in size, the uterine walls are asymmetric
• Nodular – round neoplasms up to 30 mm in size, without clear outlines and localized in a specific organ
• Diffuse – the uterus acquires a rounded shape with calcium inclusions, its inner layer has vague boundaries, the posterior wall is enlarged, and the echogenicity is increased

Diagnostic methods

Ultrasound of the small pelvis can detect endometriosis, but doctors recommend several types of examinations to make the diagnosis more accurate.

To determine the presence of this disease, such types of ultrasound examination are used as:

• Abdominal – guided by a transducer through the wall of the abdominal cavity
• Transvaginal – examination by inserting a probe into the vagina
• Transrectal – with this type, the device is placed in the patient’s anus

For a more accurate identification of the type of neoplasm, the second and third types of examination are more suitable.They also allow you to take tissue samples for analysis.

As an additional method for clarifying the diagnosis, colposcopy (examination of the vagina and cervix using a device that includes a binocular) can be used.

Advantages of the procedure in MEDSI

• MEDSI clinics are equipped with modern devices Pro Focus 2202, Philips iU22 for thirty types of ultrasound
• Doctors of the highest qualification category will prescribe all the necessary types of examinations, qualitatively decipher the results and make an accurate diagnosis
• To get a consultation, you just need to call 8 (495) 7-800-500, and you will be assigned an appointment at a convenient time and place – MEDSI has a network of more than twenty clinics
• It is always possible to conduct an urgent study in case of bleeding or other emergency situations

Diagnostics of endometrial pathology (endometrial polyps, endometrial hyperplasia, adhesions, chronic endometritis)

Endometrial pathology

– a number of conditions in which the inner layer of the uterus (endometrium) cannot fully function and are accompanied by a number of complaints (intermenstrual bleeding, heavy, painful menstruation or, on the contrary, scanty, pain in the lower abdomen, the problem of getting pregnant).

What is this :

– polyps of the uterine cavity;

– thickening or hyperplasia of the endometrium;

– endometriosis;

– chronic endometritis;

– synechia;

– malignant disease (cancer) of the endometrium.

Ultrasound examination of the pelvic organs – allows you to assess the thickness, structure, blood flow of the endometrium in accordance with the day of the menstrual cycle, to exclude pathological formations in it.

Therapeutic and diagnostic hysteroscopy

– a hysteroscope is inserted through the external genital organs into the uterus through the cervical canal, with illumination and a video camera, which transmit to the monitor an enlarged image of the cervical canal, the internal uterine cavity, which allows the doctor to carefully study the structure and (if any) pathology of the inner wall of the uterus viewing them on the big screen.

Hysteroscopy is performed under intravenous anesthesia, which is painless and comfortable for patients.

Therapeutic and diagnostic curettage of the uterine cavity (or curettage) .

This is the removal of the mucous membrane of the uterus using a curette ( special instrument designed for scraping ). In this case, not the entire mucous membrane is removed, but only its functional ( surface ) layer.

Curettage can be performed for both diagnostic and therapeutic purposes. The use of curettage for diagnostic purposes involves the selection of samples, which are further subjected to histological examination.In addition, with the help of curettage, the pathologically altered epithelium, pathological formations of the uterine cavity are removed.

Pipel biopsy

– with its help, the inner lining of the uterus is examined without dilating the cervical canal.

Most often, a woman does not feel pain when taking material, which makes it possible to carry out diagnostics without painkillers and drugs in a gynecological office.

Technique for performing Paypel biopsy is done with a thin hollow tube, the diameter of which is 2.3 mm, 4 mm.The instrument is hollow inside, it is necessary for the collection of material for research.

You can make an appointment with a gynecologist by calling 8 (8352) 23-77-23 or independently via the MEDIK mobile application

90,000 Endometrial hyperplasia in peri- and postmenopausal women

Introduction

Hyperplastic processes in the endometrium represent a major medical-biological and socio-economic problem and occupy a significant place in the structure of gynecological morbidity [1-6].The high prevalence of hyperplastic processes in the endometrium, the lack of proper effectiveness from hormonal therapy, as well as the likelihood of malignancy, put endometrial hyperplasia (EH) among the most pressing problems of modern medicine. According to E.M. Vikhlyaeva, endometrial hyperplasia affects almost 50% of women of late reproductive age and during perimenopause [7].

The great clinical significance of hyperplastic processes in the endometrium is that they are one of the most common causes of uterine bleeding in women aged 45–55 years and their hospitalization [8–12].Another reason for close attention to HE is the possibility of their malignant transformation. According to the statistics of the Russian Federation, endometrial cancer (ER) ranks third in the structure of oncological morbidity in the female population [13, 14]. Malignancy of glandular hyperplasia and endometrial polyp occurs in 2-5% and reaches 10% in postmenopausal women [15-17]. Atypical hyperplasia progresses to invasive cancer with a frequency of up to 50% of cases [18, 19]. However, according to different authors, the EC according to the results of histological examination is confirmed in 1-10% of women with bleeding in postmenopausal women.In almost 60% of cases, endometrial atrophy is detected and with approximately the same frequency – endometrial polyps, HE and other benign endometrial changes [20, 21]. Thus, in most cases, benign endometrial changes are the cause of postmenopausal bleeding.

Risk factors for the development of ER are the elderly age of patients (over 50 years), obesity, late menopause, diabetes mellitus, prolonged estrogen stimulation, tamoxifen intake [22, 23].

With obesity and a body mass index (BMI) of more than 25 kg / m ² , the risk of developing ER increases by 200–400% [24]. Since more than 50% of postmenopausal women are overweight, cancer alertness is necessary in this age group.

Diagnosis of endometrial pathology

In screening diagnostics of endometrial pathology, the most informative non-invasive examination method is radiation-ultrasound examination (US) – a non-invasive, easily performed and highly informative method of examining patients to identify quantitative and qualitative characteristics of all layers of the endometrium with an assessment of their blood supply, which allows modern equipment [25, 26].Radiological methods, in the absence of clinical manifestations of the disease, can reveal various signs of diffuse (hyperplasia) or focal (polyps) changes in the endometrium [27, 28].

At present, according to the clinical recommendations of the Ministry of Health of the Russian Federation [29] and international protocols [30], 4 mm is taken as the upper limit of the norm for the M-echo thickness. If it is below this limit, then the probability of RE is less than 1% [31–34], in such cases an endometrial biopsy is not required.In some cases, an increase in the thickness of the endometrium according to ultrasound data is detected in postmenopausal women in the absence of symptoms of the disease. However, the tactics of conducting in such cases has not been finally determined. The latter circumstance is especially important, since the opinion that the thickness of the endometrium is the leading sign of hyperplasia is now firmly rooted among researchers [35]. However, in the literature there are data on the need to change the ultrasound criteria for endometrial thickness to determine the further management tactics for women in the absence of clinical manifestations in postmenopausal women, since the choice of treatment method and its application are sometimes limited due to the concomitant somatic pathology of patients.Particular difficulties arise in the treatment of patients with HE over 60 years of age due to the high risk of complications during surgery and the use of anesthesia. Therefore, it is necessary to distinguish between groups of patients with a thickened endometrium (by ultrasound in the absence of clinical manifestations), who must undergo further diagnostics and treatment, and groups of patients who can be under dynamic observation (without the risk of developing ER) due to age, the presence of somatic pathology or unwillingness (refusal) of the patient from further treatment (diagnostic examination).

Modern literature data on differential diagnosis and management tactics in peri- and postmenopausal women with endometrial pathology

In a study by A. Lev-Sagie et al. [36] under observation were 82 postmenopausal women with a thickening of the endometrium accidentally detected by ultrasound, all underwent hysteroscopy with scraping of the walls of the uterine cavity. According to the results of histological examination, 67 (82%) patients had inactive polyps, 7 had submucous nodes, 6 had endometrial atrophy, 1 had simple hyperplasia, and 1 had a polyp with simple hyperplasia.There was not a single case of complex hyperplasia or RE. At the same time, the incidence of complications of surgery was 3.6%: 2 perforations of the uterus, 1 complication of intubation.

R. Ozelci et al. [37] analyzed the medical histories of 266 postmenopausal women who underwent hysteroscopy and endometrial biopsy. The study included asymptomatic patients who, according to transvaginal ultrasound (TVUI), had an endometrial thickness equal to or greater than 6 mm.According to the results of histological examination, the most frequently detected focal lesions in asymptomatic patients were endometrial polyps, diagnosed in 168 (63.1%) cases. Simple hyperplasia was diagnosed in 24 (9%) patients, atypical hyperplasia in 4 (1%) and endometrial adenocarcinoma in 8 (3%) patients. According to the authors of the review, hysteroscopy and curettage of the walls of the uterine cavity are recommended for endometrial thickness ≥10.5 mm.

Other researchers [38] conducted a retrospective analysis (from January 2006.to January 2017) medical records of 488 postmenopausal women who did not have clinical manifestations, in whom, with TVUI, an endometrium ≥5 mm thick was identified and underwent hysteroscopy followed by endometrial biopsy. The most common pathological findings were polyps (51.0%) and normal endometrium (34.2%). Fifteen (3.1%) and 10 (2.0%) patients had intraepithelial neoplasia and carcinoma, respectively. However, patients with carcinoma had a thicker endometrium, in which blood flow was more often determined by color Doppler mapping (CDC).In the study, it was noted that in malignant neoplasms, the thickness of the endometrium was ≥12 mm, and blood flow loci in the endometrium were determined with CDC.

J. Alcázar et al. [39] examined the results of studies published between January 1990 and December 2016 and assessed the correlation between endometrial thickness, measured with TVUI, and histological findings in women who had no clinical manifestations in postmenopausal women. Research papers that included studies in female patients taking hormone replacement therapy, tamoxifen, or aromatase inhibitors were excluded.289 studies were identified, and data from 4,751 women were evaluated. The prevalence of ER or EH with atypia was 2.4%. As a result, the researchers concluded that the risk of developing ER or HE with atypia was 2.6 times higher in women with an endometrial thickness ≥11 mm, in contrast to that in women with an endometrial thickness of 5-10 mm, although there were significant differences in different research.

A. Ghoubara et al. in their study [40] also concluded that the use of a threshold for endometrial thickness ≥10 mm in women without clinical symptoms allows not to miss a single case of atypical HE or EC.

The aim of the study was M. Louie et al. [41] clarified the frequency of intrauterine pathology in 462 women with asymptomatic postmenopausal women who did not have its clinical manifestations, and ensure the optimal threshold for taking an endometrial biopsy from them. The study included women without symptoms of endometrial disease, if at TVUI they had an endometrial thickness of more than 4 mm.

Among 462 women, carcinoma was detected in 9 (1.9%), atypical hyperplasia – in 7 (1.5%).Endometrial thickness equal to or greater than 14 mm was significantly associated with typical hyperplasia (odds ratio – OR 4.29; 95% confidence interval – CI 1.30-14.20; p = 0.02), with a negative predictive value 98.3%. Thickness over 15 mm was associated with carcinoma (OR – 4.53; 95% CI – 1.20-17.20; p = 0.03), with a negative predictive value of 98.5% and a cancer risk 0.06%. Thus, the researchers concluded that an incidentally detected endometrial thickening of less than 15 mm cannot serve as a basis for taking an endometrial biopsy in postmenopausal women who do not have vaginal bleeding.

W. Wolfman et al. [42] studied the materials of publications published from 1970 to 2009 on the results of examining postmenopausal women without abnormal uterine bleeding, in whom ultrasound revealed a thickening of the endometrium. With a detailed assessment of the information content, risks and cost of diagnostic curettage, the authors came to the conclusion that the use of invasive research methods only on the basis of an increase in the M-echo index is an unnecessary (unjustified) procedure.

However, some researchers have a different point of view.The aim of the study M. Genc et al. [43] clarified the frequency of intrauterine pathology in 283 postmenopausal women admitted to the gynecological department for hysterectomy for reasons not related to endometrial pathology. According to the results of histological examination, in 75.6% of 209 patients who did not have bleeding in postmenopausal women, pathology of the uterine cavity was found, which was not suspected at the stage of preoperative preparation: HE, polyps, uterine myoma, adenomyosis – in 1 (0.5% ) observation, adenocarcinoma.Intrauterine pathology was found in 87.8% of 74 postmenopausal women with bleeding, including 13 (17.6%; p = 0.0001) EC observations. Thus, the pathology of the uterine cavity may also be present in postmenopausal women who do not have symptoms of the disease; therefore, the authors insist on annual screening and counseling of elderly and senile patients, without waiting for an episode of bleeding.

L.V. Adamyan et al. [44] in their study of patients without clinical manifestations of intrauterine diseases in postmenopausal women with suspected endometrial pathology according to TVUS (endometrial thickness more than 4 mm), most often endometrial polyps (63.9%), endometrial atrophy (30.5%) were detected and the incidence of adenocarcinoma was 2.1%.The authors of the study emphasize that the risk of malignant neoplasms is quite high, which indicates the importance of adequate examination and timely treatment of women in this age group, as well as the need for screening examination using ultrasound.

According to the literature, in patients without clinical manifestations of uterine disease in postmenopausal women with a thickened endometrium (according to ultrasound), endometrial polyps are most often detected during hysteroscopy and histological examination.However, the incidence of RE in women with endometrial polyps is 0.3–4.8% [45]. Most researchers insist on paying special attention to postmenopausal patients with polyps manifesting uterine bleeding. Thus, E. Ricciardi et al. [46] studied the prevalence of atypical polyps in postmenopausal women. In a retrospective study, data from 1,027 women with endometrial polyps in peri- and postmenopausal women were analyzed. Benign polyps were detected in 95.8% of cases, precancerous – in 2.67% and with atypia – in 1.54% of cases.In postmenopausal women (over 60 years old) and old age, the risk of developing ER was higher (OR 3.05; 95% CI 1.54-6.19; p <0.001 and OR 2.8; 95% CI 1, 38-5.56; p ≤0.003, respectively). In postmenopausal women with bleeding, the risk of developing ER increased more than 30 times (OR 31.1; 95% CI 10.3-111; p <0.001). According to the authors, special attention should be paid to patients with bleeding in postmenopausal women, and women without symptoms of the disease in postmenopausal women belong to the group of intermediate risk, therefore, an individual approach is necessary for them.

P. Gambadauro et al. [47] when analyzing the data of 1390 postmenopausal patients with suspected endometrial polyp (according to ultrasound) after hysteroscopy, they found that all cases of neoplasia were observed only in patients with bleeding. In 40.6% of women without bleeding, a benign endometrial polyp structure was histologically confirmed. The patients diagnosed with ER were significantly older than the patients with benign pathology, and also had a higher body mass index.According to the authors, a large number of postmenopausal women without symptoms of the disease with suspected polyps according to ultrasound examination are referred for hysteroscopy, although the risk of neoplasia in such cases is extremely low.

E. Ferrazzi et al. [48] ​​observed 1152 women without symptoms of the disease in postmenopausal women who, according to ultrasound and sonohysterography, revealed endometrial polyps, all women underwent hysteroscopy and curettage of the walls of the uterine cavity. According to the data of histological examination, 1 (less than 0.1%) case of EC was detected in a polyp with a diameter of more than 4 mm, while the incidence of neoplasia was 10 times lower than in patients with bleeding.The incidence of atypical hyperplastic polyps was 1.2% in asymptomatic patients and 2.2% in patients with bleeding. Revealed 3 (0.3%) cases of EC (not in a polyp), which were visualized during hysteroscopy in the form of polypoid changes. The risk of neoplasia detection in patients without clinical manifestations depended on the polyp diameter (more than 18 mm, OR 6.9; 95% CI 2.2-21.4 mm). Moreover, among the complications were 3 perforations, 7 ruptures of the cervix, 3 false moves.

Conclusion

In peri- and postmenopausal patients, pathological processes in the endometrium are most often asymptomatic, however, the risk of malignant neoplasms is higher than the general population indicators, especially in the presence of bleeding and recurrence of pathological processes in the endometrium.It should be noted that the diagnosis can be made on the basis of ultrasound screening. In the absence of a consensus on the rational diagnosis and observation of this contingent of women, this problem requires further study.

Contribution of authors:

Concept and research design – M.A. Chechnev;

Collection and processing of material – O.V. Kapitanova;

Statistical data processing – O.V. Kapitanova;

Text writing – O.V. Kapitanova;

Editing – M.A. Chechnev.

The authors declare no conflicts of interest.

Hysteroscopy | TS Clinic – Krasnodar

Hysteroscopy involves the examination of the walls and cavity of the uterus using optical instruments. It is used to solve a number of medical and diagnostic problems, especially to identify pathological processes in the endometrium.The value of hysteroscopy lies not only in the ability to visually assess the state of the uterine cavity, but also in the collection of the required amount of material for histological examination.

Indications for a diagnostic study

Diagnostic hysteroscopy is carried out under the following conditions:

• Menstrual irregularities in reproductive age
• Bloody and bloody discharge from the vagina in women in the postmenopausal period

doubts about its correct location, as well as in cases where the contraceptive was not removed in a timely manner

• If you suspect the presence of diseases of the uterus
• Infertility and inability to bear the fetus
• Complicated postpartum period (uterine bleeding, infectious and inflammatory processes).

A large group of indications is made up of control studies conducted to assess the effectiveness of the course of treatment (hormonal, operative, surgical). Uterine diseases requiring hysteroscopy include:

• Myoma
• Malignant processes in the endometrium
• Remains of the ovum and adhesions in the uterine cavity
• Foreign body
• Suspected organ wall perforation.

The most common indications for diagnostic hysteroscopy are various menstrual disorders.The second most common cause is pathological vaginal discharge of a bloody or purulent nature in postmenopausal women. In such cases, one should be wary of endometrial cancer, less often benign formations, such as polyps, are the cause of bleeding. The accuracy of diagnosing malignant tumors using hysteroscopy is 98-100%.

When the study is not carried out

Hysteroscopy involves intervention in the uterine cavity, therefore has a number of contraindications .Among them are:

• Acute infectious and inflammatory diseases of the reproductive system
• III – IV degree of purity of vaginal smears (corresponds to infections of the genital tract, bacterial vaginosis)
• Pregnancy.

For relative contraindications include severe concomitant diseases, viral and bacterial infections of the upper respiratory tract, a sharp narrowing of the cervical canal and advanced cervical cancer.

It is undesirable to carry out hysteroscopy with profuse bleeding due to low information content and poor visibility. According to most doctors, the study is also not recommended during menstruation, unless it is urgently needed.

Preparation for hysteroscopy

Depending on the indications and the patient’s condition, the study is performed in a planned or emergency manner. Routine hysteroscopy is performed after a gynecological examination and a standard laboratory and instrumental examination (blood and urine tests, vaginal smears for the degree of purity, etc.).

The last meal should be at least 12 hours before the hysteroscopy, and in the evening on the eve of the study, a cleansing enema is performed. On the day of the procedure, you should make a toilet of the external genital organs, and immediately before hysteroscopy, empty the bladder.

Usually, the study is performed on the 5-7th day of the menstrual cycle, when the endometrium is in the early proliferative phase: it is thin, and bleeding is insignificant. In the second phase of the cycle, it is highly undesirable to perform planned manipulation.First, the endometrium thickens significantly and interferes with a full examination. Secondly, in cases where the fertilization of the egg has occurred and it moves through the fallopian tube, hysteroscopy can disrupt the transport process and lead to an ectopic pregnancy.

In menopausal women, the time of the study does not matter. With profuse uterine bleeding, there is a threat to the patient’s life, therefore, hysteroscopy is urgent and is performed immediately, regardless of the phase of the cycle and other circumstances.

Normal and pathological hysteroscopic picture

The appearance of the endometrium depends on the day of the menstrual cycle. In the first week of the cycle, the endometrium is thin and even, has a pale pink color. In some areas of the endometrium, punctate hemorrhages and small unbroken areas are visible. By the tenth day, the endometrium thickens, and the vessels become invisible. Depending on the localization, it has a different thickness – it is maximum in the area of ​​the uterine fundus and minimum on the anterior wall and in the lower third of the uterine body.

In the second half of the menstrual cycle, the endometrium becomes edematous and forms polypoid folds. A few days before menstruation, the endometrium turns red and thickens significantly. During menstrual bleeding, the endometrium is rejected and the uterine cavity is filled with scraps of rich dark color.

In women with infertility, the method allows detecting abnormalities in the structure of the uterus, foreign bodies (for example, fragments of an intrauterine device), hyperplastic processes.Patients with diagnosed endometrial atrophy are examined twice annually. During hysteroscopy, it is also possible to assess the patency of the fallopian tubes and determine the presence of adhesions in their cavity. For this purpose, catheterization and examination of their lumen are used.

Imaging techniques for non-invasive diagnosis of endometriosis

Review Question

How accurate are medical imaging techniques for detecting endometriosis? Could any imaging technique be accurate enough to replace the need for surgery to diagnose endometriosis?

Relevance

In women with endometriosis, endometrial tissues (the tissues that line the uterus from the inside and are excreted during menstruation) grow outside the uterus – into the pelvic cavity, and cause chronic abdominal pain (pain in the lower abdomen), and problems with conception.Currently, the most reliable way to diagnose endometriosis is laparoscopic surgery to visually identify endometrial nodes in the abdominal cavity. Due to the costly and risky nature of the operation, imaging techniques are being evaluated for the non-invasive determination of endometriosis. An accurate imaging technique could diagnose endometriosis without the need for surgery, or reduce the need for surgery so that only those women who are most likely to have endometriosis would need it.Moreover, if imaging techniques could accurately locate endometriotic lesions, surgeons would have more information to better plan an operative approach to treatment. Other non-invasive methods for diagnosing endometriosis are urine, blood and endometrial examinations, and combinations of tests have been evaluated in separate Cochrane Reviews in this series.

Research characteristics

Data included in this review are current to April 2015.We included 49 studies with 4,807 women. 13 studies looked at pelvic endometriosis, 10 studies looked at ovarian endometrioma, 15 studies looked at deep infiltrating endometriosis (endometriosis deep in the tissues of the pelvis), and 33 studies looked at endometriosis in specific areas of the pelvic cavity. All studies included women of childbearing age who underwent diagnostic surgery for symptoms of endometriosis.

Main Findings

None of the imaging techniques were accurate enough to provide generalized information about endometriosis in the pelvic cavity.Transvaginal ultrasound (ultrasound) diagnoses ovarian endometriosis with sufficient accuracy to help surgeons determine the need for surgery. Magnetic resonance imaging (MRI) has proven to be accurate enough to replace surgery in diagnosing endometrioma, but only a small number of studies have evaluated the effectiveness of this method. Other imaging techniques have been evaluated in separate small studies but could not be meaningfully evaluated. Transvaginal ultrasound has found more anatomical loci with deep endometriosis than MRI, helping surgeons better plan for surgery.It turned out that endometriosis of the lower colon can be relatively accurately determined using both transvaginal and transrectal ultrasound, MRI or computed tomography with multiple rows of detectors and a contrast enema. Newer types of ultrasound and MRI show potential in detecting endometriosis, however, there are still few studies to clearly demonstrate the diagnostic value of these methods.

Quality of evidence

Studies were generally of low methodological quality, and most imaging modalities were evaluated by a small number of studies.Differences between studies included differences in study design, women groups, imaging techniques, and surgery.

Future research

More high-quality research is needed to assess the diagnostic potential of non-invasive imaging for the diagnosis of endometriosis.

Endometrial hyperplasia – treatment and symptoms

Benign overgrowth of the endometrium, in which changes appear in its structure.Endometrium is the mucous membrane of the uterine cavity that is rejected monthly in non-pregnant women in the form of menstruation. In pregnant women, the endometrium turns into an additional fetal membrane – the decidual. The growth of the endometrium occurs under the influence of estrogen hormones, which are produced in the growing follicle in the first phase of the menstrual cycle. In the middle of the menstrual cycle, ovulation occurs – the dominant follicle ruptures, the egg enters the abdominal cavity, is captured by the fallopian tube, where fertilization takes place.At the site of the bursting follicle, a corpus luteum is formed, which produces the hormone progesterone. Under the influence of progesterone, the endometrium begins to prepare for implantation. The embryo at this time descends through the fallopian tube into the uterine cavity. In the case of a healthy, full-fledged endometrium, pregnancy occurs, but if the mucous membrane is structurally changed, the likelihood of pregnancy is extremely low.

The causes of endometrial hyperplasia can be hormonal disorders or chronic inflammation.With long-term existence, this disease can turn into precancer and endometrial cancer.

Endometrial hyperplasia can be:

• Diffuse
• Focal

Diffuse hyperplasia changes the entire thickness of the endometrium. On ultrasound, a uniformly thickened endometrium of more than 15-17 mm is visualized.

Focal hyperplasia – growth of the endometrium in small or widespread areas, in which there are also structural changes.On ultrasound, these changes are not always possible to see.

A very informative diagnostic method is hysteroscopy, which allows you to examine the uterine cavity using a camera installed in a hysteroscope, with further examination of a suspicious tissue site.

• It is also possible to obtain tissue for research with the help of pipel biopsy of the endometrium.