Ohad Rotenberg

Ultrasound‐Guided Endometrial Aspiration and Immunohistochemistry for Detecting Focal Metastatic Cancer

ABSTRACT At our institution, we offer a one‐step office endometrial evaluation using the simultaneous endometrial aspiration and sonohysterography (SEAS) method. This involves pelvic ultrasound and sonohysterography, followed by ultrasound‐guided endometrial aspiration with the same catheter. The aspirated specimens are sent for histological analysis, and in difficult or inconclusive cases, immunohistochemistry (IHC) is performed to refine the diagnosis. In this manuscript, we present a case demonstrating the utility of ultrasound‐guided endometrial aspiration supported by IHC. This method should be considered in the evaluation of focal endometrial lesions and/or persistent endometrial bleeding.

The significance of “atrophic endometrium” in women with postmenopausal bleeding

We evaluated the interpretation of atrophic endometrium (AE) histology as the most common cause for postmenopausal bleeding (PMB). This theory has been accepted for several generations by gynecologists and gynecologic oncologists and has been published in past and current major gynecology textbooks. In our review of the literature, we did not find sufficient histological or clinical proof for this concept. In our view, AE is not a cause of PMB and we back this up with a review of old and current medical literature. The old studies are based on information which was obtained prior to the existence of transvaginal sonogram, sonohysterogram and hysteroscopy. Focal lesions are notorious for being missed by endometrial sampling and curettage. Recent studies show that focal endometrial lesions are a crucial cause for PMB and some of those lesions can harbor cancer. In our opinion, AE is the most common histology found because it is physiologic and a ubiquitous finding in postmenopausal women, but it is not a cause of PMB. Referring to AE as a cause of PMB may result in misdiagnosis of cancer, management delay and unnecessary intervention. To avoid misdiagnosis of cancer, transvaginal sonogram should be considered in all women with PMB and AE on pathology. If endometrial thickness is found, AE is unlikely to be the cause of the PMB and further workup is warranted to reveal the true etiology for the bleeding.

Long‐term outcome of postmenopausal women with non‐atypical endometrial hyperplasia on endometrial sampling

ABSTRACTObjectiveTo assess the long‐term outcome of postmenopausal women diagnosed with non‐atypical endometrial hyperplasia (NEH).MethodsThis was a retrospective study of women aged 55 or older who underwent endometrial sampling in our academic medical center between 1997 and 2008. Women who had a current or recent (< 2 years) histological diagnosis of NEH were included in the study group and were compared with those diagnosed with atrophic endometrium (AE). Outcome data were obtained until February 2018. The main outcomes were risk of progression to endometrial carcinoma and risk of persistence, recurrence or new development of endometrial hyperplasia (EH) (‘persistent EH’). Logistic regression analysis was used to identify covariates that were independent risk factors for progression to endometrial cancer or persistent EH.ResultsDuring the study period, 1808 women aged 55 or older underwent endometrial sampling. The median surveillance time was 10.0 years. Seventy‐two women were found to have a current or recent diagnosis of NEH and were compared with 722 women with AE. When compared to women with AE, women with NEH had significantly higher body mass index (33.9 kg/m2 vs 30.6 kg/m2; P = 0.01), greater endometrial thickness (10.00 mm vs 6.00 mm; P = 0.01) and higher rates of progression to type‐1 endometrial cancer (8.3% vs 0.8%; P = 0.0003) and persistent NEH (22.2% vs 0.7%; P < 0.0001). They also had a higher rate of progression to any type of uterine cancer or persistent EH (33.3% vs 3.5%; P < 0.0001). Women with NEH had a significantly higher rate of future surgical intervention (51.4% vs 15.8%; P < 0.0001), including future hysterectomy (34.7% vs 9.8%; P < 0.0001). On multivariable logistic regression analysis, only NEH remained a significant risk factor for progression to endometrial cancer or persistence of EH.ConclusionsPostmenopausal women with NEH are at significant risk for persistent EH and progression to endometrial cancer, at rates higher than those reported previously. Guidelines for the appropriate management of postmenopausal women with NEH are needed in order to decrease the rate of persistent disease or progression to cancer. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.