| 1. |
- Epstein, Elisabeth, et al.
(författare)
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An algorithm including results of gray-scale and power Doppler ultrasound examination to predict endometrial malignancy in women with postmenopausal bleeding.
- 2002
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Ingår i: Ultrasound in Obstetrics & Gynecology. - : Wiley. - 1469-0705 .- 0960-7692. ; 20:4, s. 370-376
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To determine if power Doppler ultrasound examination of the endometrium can contribute to a correct diagnosis of endometrial malignancy in women with postmenopausal bleeding and endometrium >/= 5 mm. METHODS: Eighty-three women with postmenopausal bleeding and endometrium >/= 5 mm underwent gray-scale and power Doppler ultrasound examination using predetermined, standardized settings. Suspicion of endometrial malignancy at gray-scale ultrasound examination (endometrial morphology) was noted, and the color content of the endometrium at power Doppler examination was estimated subjectively (endometrial color score). Computer analysis of the most vascularized area of the endometrium was done off-line in a standardized manner. Stepwise multivariate logistic regression analysis was carried out to determine which subjective and objective ultrasound and power Doppler variables satisfied the criteria to be included in a model to calculate the probability of endometrial malignancy. RESULTS: Endometrial thickness, vascularity index (vascularized area/endometrial area), and use of hormone replacement therapy (HRT) satisfied the criteria to be included in the model used to calculate the 'objective probability of endometrial malignancy'. Endometrial morphology, endometrial color score and HRT use satisfied the criteria to be included in the model to calculate the 'subjective probability of malignancy'. Endometrial thickness >/= 10.5 mm had a sensitivity with regard to endometrial cancer of 0.88 and a specificity of 0.61. At a fixed sensitivity of 0.88, the specificity of the 'objective probability of malignancy' (0.81) was superior to all other ultrasound and power Doppler variables (P = 0.001-0.02). The 'objective probability of malignancy' detected more malignancies at endometrium 5-15 mm than endometrial morphology (5/7 vs. 1/7, i.e. 0.71 vs. 0.14; P = 0.125) with a similar specificity (49/57 vs. 51/57, i.e. 0.86 vs. 0.89). CONCLUSION: Power Doppler ultrasound can contribute to a correct diagnosis of endometrial malignancy, especially if the endometrium measures 5-15 mm. The use of regression models including power Doppler results to estimate the risk of endometrial cancer deserves further development.
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| 2. |
- Epstein, Elisabeth, et al.
(författare)
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Comparison of Endorette and dilatation and curettage for sampling of the endometrium in women with postmenopausal bleeding
- 2001
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Ingår i: Acta Obstetricia et Gynecologica Scandinavica. - : Wiley. - 1600-0412 .- 0001-6349. ; 80:10, s. 959-964
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Tidskriftsartikel (refereegranskat)abstract
- MAIN QUESTION: To compare the diagnostic properties of Endorette and D&C in women with postmenopausal bleeding, to relate the properties to endometrial thickness as measured by ultrasound, and to assess the women's experiences of the two methods. METHODS: In a prospective study, 133 consecutive women with postmenopausal bleeding were examined with transvaginal ultrasound. After measuring the endometrial thickness, Endorette sampling was performed without anesthesia. Dilatation and curettage (D&C) was carried out under general anesthesia within six weeks. After completion of each sampling procedure the women filled in a questionnaire regarding their experience of the sampling. RESULTS: Endorette sampling failed in 16% (21/133) of the women. More than half (56%) of the women experienced moderate or strong pain during Endorette sampling, and the doctor underestimated the pain in 62% of the women. Endorette failed to diagnose two of seven (29%) endometrial cancers found at D&C. In one of these two cases, the examiner suspected that the Endorette device had not reached the uterine fundus. In women with endometrium < 7 mm, Endorette and D&C showed similar results with regard to obtaining a sufficient endometrial sample and to distinguishing normal endometrium, benign pathological endometrium and malignancy. In women with endometrium > or =7 mm, Endorette yielded insufficient samples significantly more often than D&C (23% vs 6%, p=0.02; the McNemar test) and missed all polyps and most (77%) hyperplasias diagnosed by D&C. CONCLUSION: Endorette and D&C have similar diagnostic properties in women with postmenopausal bleeding and endometrium < 7 mm. D&C is superior to Endorette in women with endometrium > or =7 mm.
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| 3. |
- Epstein, Elisabeth, et al.
(författare)
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Dilatation and curettage fails to detect most focal lesions in the uterine cavity in women with postmenopausal bleeding
- 2001
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Ingår i: Acta Obstetricia et Gynecologica Scandinavica. - : Wiley. - 1600-0412 .- 0001-6349. ; 80:12, s. 1131-1136
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To determine the prevalence of focally growing lesions in the uterine cavity in women with postmenopausal bleeding and endometrium > or = 5 mm and the extent to which such lesions can be correctly diagnosed by D&C. METHODS: In a prospective study, 105 women with postmenopausal bleeding and endometrium > or = 5 mm at transvaginal ultrasound examination underwent diagnostic hysteroscopy, D&C and hysteroscopic resection of any focally growing lesion still left in the uterine cavity after D&C. Twenty-four women also underwent hysterectomy. If the histological diagnosis differed between specimens from the same patient, the most relevant diagnosis was considered the final one. RESULTS: Eighty percent (84/105) of the women had pathology in the uterine cavity, and 98% (82/84) of the pathological lesions manifested a focal growth pattern at hysteroscopy. In 87% of the women with focal lesions in the uterine cavity, the whole or parts of the lesion remained in situ after D&C. D&C missed 58% (25/43) of polyps, 50% (5/10) of hyperplasias, 60% (3/5) of complex atypical hyperplasias, and 11% (2/19) of endometrial cancers. The agreement between the D&C diagnosis and the final diagnosis was excellent (94%) in women without focally growing lesions at hysteroscopy. CONCLUSION: If there are focal lesions in the uterine cavity, hysteroscopy with endometrial resection is superior to D&C for obtaining a representative endometrial sample in women with postmenopausal bleeding and endometrium > or = 5 mm.
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| 4. |
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| 5. |
- Epstein, Elisabeth
(författare)
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Management of postmenopausal bleeding in Sweden: a need for increased use of hydrosonography and hysteroscopy.
- 2004
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Ingår i: Acta Obstetricia et Gynecologica Scandinavica. - : Wiley. - 1600-0412 .- 0001-6349. ; 83:1, s. 89-95
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Tidskriftsartikel (refereegranskat)abstract
- Background. The objective was to determine how postmenopausal bleeding (PMB) is managed in Sweden today, and to relate the findings to a new evidence-based algorithm for the management of PMB. Methods. A questionnaire regarding the role of ultrasound and the use of different endometrial biopsy methods in the management of PMB was sent to all 61 gynecologic departments in Sweden. Results. Fifty-nine of the 61 departments (97%) satisfactorily answered the questionnaire. Ultrasound was either always (n = 54, 92%) or most commonly (n = 5, 8%) used in the diagnostic work-up of PMB. In women with endometrial thickness <=4 mm, 18 of the departments (31%) routinely sampled the endometrium; 12 (15%) followed the women with ultrasound; three (5%) did both sampling and follow-up with ultrasound; and the remaining 29 (49%) used expectant management (i.e. no biopsy or routine follow-up). In women with endometrium >=5 mm, hydrosonography was performed routinely in two departments (3%), occasionally in 37 departments (63%), and never in 20 departments (34%). In women with endometrium >=5 mm, endometrial biopsy was obtained routinely by Endorette®/Pipelle® in 39 departments (66%), while in 26 departments (44%) operative hysteroscopy was never performed. Conclusion. More than one-third of the gynecologic departments in Sweden never perform hydrosonography to rule out focal lesions or operative hysteroscopy for the removal of such lesions. Hydrosonography and hysteroscopy have a central role in the new guidelines for the management of PMB. Therefore, a need exists to broaden the use of hydrosonography and hysteroscopy.
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| 6. |
- Epstein, Elisabeth, et al.
(författare)
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Managing women with post-menopausal bleeding.
- 2004
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Ingår i: Best Practice and Research: Clinical Obstetrics Gynaecology. - : Elsevier BV. - 1878-156X .- 1521-6934. ; 18:1, s. 125-143
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Tidskriftsartikel (refereegranskat)
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| 7. |
- Epstein, Elisabeth, et al.
(författare)
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Rebleeding and endometrial growth in women with postmenopausal bleeding and endometrial thickness <5 mm managed by dilatation and curettage or ultrasound follow-up: a randomized controlled study
- 2001
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Ingår i: Ultrasound in Obstetrics & Gynecology. - : Wiley. - 1469-0705 .- 0960-7692. ; 18:5, s. 499-504
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: To compare the frequency of rebleeding and endometrial growth during a 12-month follow-up period between women with postmenopausal bleeding and an endometrial thickness < 5 mm managed by dilatation and curettage, and those managed by ultrasound follow-up. DESIGN: Consecutive women with postmenopausal bleeding and an endometrial thickness < 5 mm were randomized to ultrasound follow-up after 3, 6, and 12 months (n = 48) or to primary dilatation and curettage with ultrasound follow-up at 12 months (n = 49). At all follow-up examinations, the endometrial thickness was measured and the women were asked about rebleeding. The endometrium was sampled at the 12-month examination, if sampling had not been performed previously because of rebleeding or endometrial growth. RESULTS: Rebleeding was reported by 33% (16/48) of the women in the ultrasound group and by 21% (10/48) of those in the dilatation and curettage group (P = 0.17). Endometrial growth to >or= 5 mm was found in 21% (10/48) of the women in the ultrasound group and in 10% (5/48) of those in the dilatation and curettage group (P = 0.16). No endometrial pathology was found in women with isolated rebleeding. Endometrial pathology during follow-up was found more often in women with endometrial growth than in those without (33% vs. 4%; P = 0.008). CONCLUSION: Rebleeding and endometrial growth are common during a follow-up period of 12 months in women with postmenopausal bleeding and an endometrial thickness < 5 mm, irrespective of whether or not dilatation and curettage is primarily carried out. If these women are managed by ultrasound follow-up, endometrial sampling should be performed if the endometrium grows, but not necessarily in the case of rebleeding without endometrial growth.
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| 8. |
- Epstein, Elisabeth, et al.
(författare)
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Transvaginal sonography, saline contrast sonohysterography and hysteroscopy for the investigation of women with postmenopausal bleeding and endometrium > 5 mm
- 2001
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Ingår i: Ultrasound in Obstetrics & Gynecology. - : Wiley. - 1469-0705 .- 0960-7692. ; 18:2, s. 157-162
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVES: To determine the ability of transvaginal ultrasound, with or without saline infusion, to detect focally growing lesions in the uterine cavity in women with postmenopausal bleeding and endometrium > 5 mm, and to determine the accuracy of conventional ultrasound, saline contrast sonohysterography and diagnostic hysteroscopy under general anesthesia to diagnose endometrial polyps, submucous myomas and uterine malignancy. DESIGN: In a prospective study, 105 women with postmenopausal bleeding and endometrium > 5 mm underwent conventional ultrasound examination and saline contrast sonohysterography. Diagnostic and operative hysteroscopy under general anesthesia was then performed. The presence of focally growing lesions and the type of lesion (endometrial polyp, submucous myoma, malignancy or unclear focal lesion) were noted at ultrasound examination and at hysteroscopy. RESULTS: There was almost perfect agreement (96%) between saline contrast sonohysterography and hysteroscopy in the diagnosis of focally growing lesions. Saline contrast sonohysterography and hysteroscopy both had a sensitivity of approximately 80% with regard to diagnosing endometrial polyps (false-positive rates of 24% and 6%, respectively), whereas conventional ultrasound missed half of the polyps (sensitivity, 49%; false-positive rate, 19%). Hysteroscopy was superior to both saline contrast sonohysterography and conventional ultrasound with regard to discriminating between benign and malignant lesions (sensitivity, 84%, 44%, and 60%; false-positive rate, 15%, 6% and 10%, respectively). The risk of malignancy was increased seven-fold (odds ratio, 7.3; 95% confidence interval, 1.9-27.8) in women with distension difficulties at saline contrast sonohysterography, and two thirds of the women with a poorly distensible uterine cavity had a malignant diagnosis. CONCLUSION: Saline contrast sonohysterography is as good as hysteroscopy at detecting focally growing lesions in the uterine cavity in women with postmenopausal bleeding. However, neither hysteroscopy nor saline contrast sonohysterography can reliably discriminate between benign and malignant focal lesions. Distension difficulties at saline contrast sonohysterography should raise a suspicion of malignancy.
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| 9. |
- Epstein, Elisabeth
(författare)
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Ultrasound in the management of women with post-menopausal bleeding
- 2001
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- The aim of this thesis was to investigate how ultrasound can be used in the diagnostic work-up of women with post-menopausal bleeding (PMB) to optimise and individualise their management. The thesis is based on six studies comprising post-menopausal women with (Study I-VI) and without (Study VI) abnormal bleeding. The clinical value of conventional ultrasound, with or without saline infusion (hydrosonography), and of power Doppler ultrasound, was determined, and the performance of different endometrial biopsy techniques was compared and correlated with sonographic findings. Re-bleeding and endometrial growth were common during a follow-up period of 12 months in women with PMB and endometrium < 5 mm, irrespective of whether dilatation and curettage (D&C) was carried out or not. Endometrial pathology was only found in women with endometrial growth to >/= 5 mm. If these women are managed by ultrasound follow-up, endometrial sampling should be performed if the endometrium grows to a thickness of >/= 5 mm, and perhaps also in cases of re-bleeding. Endorette® (a simple endometrial sampling device) and D&C had similar diagnostic value in women with PMB and endometrium < 7 mm, whereas D&C was superior to Endorette® in women with endometrium >/= 7 mm. However, in another study on women with PMB and endometrium >/= 5 mm, we found that D&C failed to diagnose about half of the focal lesions in the uterine cavity that were removed by operative hysteroscopy. Thus, the presence or absence of focal lesions should determine the diagnostic procedure. Hydrosonography was found to be as good as hysteroscopy with regard to detecting focal lesions, but neither method was accurate enough in discriminating benign from malignant lesions. Distension difficulties at hydrosonography were more common in women with endometrial cancer and should therefore raise a suspicion of malignancy. A multivariate logistic regression model including clinical information, conventional ultrasound variables, and power Doppler variables seems to be superior to endometrial ultrasound morphology in correctly diagnosing endometrial cancer in cases where the endometrium measures 5-15 mm. The reproducibility of endometrial measurements allows reliable discrimination between post-menopausal women with endometrium < 5 mm and >/= 5 mm.
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| 10. |
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