Hysteroscopy Newsletter is an opened forum to all professionals who want to contribute with their knowledge and even share their doubts with a word-wide gynecological community

Endometrial Cancer. Hysteroscopy Newsletter

1154-_5.jpgEndometrial cancer is the most common gynecological cancer in developed countries and is the 5th most frequent cancer affecting woman. The estimated frequency is 19.1 / 100,000 cases in the USA and Canada and 15.6 / 100,000 in Europe.

It is usually associated with menopause, although up to 14% of cases are diagnosed in premenopausal women and up to 5% of cases in patients under the age of 40 years. It is usually diagnosed in early stages and with the tumor usually confined to the uterine cavity, which generally gives it a good prognosis

The main risk factor is continued unopposed exposure to elevated estrogen levels. Among the different causes related to endometrial cancer are:

1- Obesity: is present in 40-50% of endometrial carcinomas in developed countries. Obese women are 2-4 times more likely to develop endometrial cancer than non-obese women.

2- Unopposed estrogen therapy (UET). The use of UET greatly increases the formation of endometrial hyperplasia and endometrial carcinoma. This risk increases in relation to the dose and duration of the exposure. The administration of progesterone during HRT eliminates the risk of both endometrial hyperplasia and carcinoma.

3- Tamoxifen: It is a selective estrogen receptor modulator (SERM) that is commonly used as an adjuvant hormone treatment in women with breast cancer. The use of tamoxifen is associated with a 2-5-fold increased risk of developing endometrial pathology, including polyps and endometrial cancer.

4- Hereditary: Endometrial carcinoma may appear in the context of a Lynch II syndrome or hereditary colorectal cancer not associated with polyposis (HNPCC). It is an autonomic dominant disorder with incomplete penetrance. Women with HNPCC have a risk of about 50% developing endometrial cancer.

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Hysteroscopy Pictures: Uterine septum


The septate uterus is the result of a failure in the process of resorption of the medial septum that can range from a minimal septum in the uterine fundus to a complete one dividing the uterine cavity completely or even asociating double cervix and vaginal septum. The proposed mechanism by which the uterine septum regresses is apoptosis, the presence of Blc-2 protein protects from apoptosis. The absence of Blc-2 in the embryonal uterine septum may indicate a lack of protection from apoptosis in this area. On the other hand different studies have allowed the identification of several genes that can be implicated in the development of uterine malformations

In an interesting study comparing the use of resectoscope to VersaPoint in 63 women for the treatment of septum (Resectoscope or Versapoint for hysteroscopic metroplasty. Int J Obstet Gynaecol 2008 Apr; 101 (1):39-42) Dr. Litta concludes that the VersaPoint system does not require cervical dilation, avoiding potential cervical incompetence, cervical lacerations and uterine perforation related to the dilation process. The use of VersaPoint is a safe alternative to the use of resectoscope, especially in nulligravid or patients with cervical stenosis.


what is an Endometrial Hyperplasia?

Endometrial Complex HyperplasiaEndometrial hyperplasia is an overgrowth of endometrial glands, with different shapes and sizes, which causes increased endometrial thickness which results in a greather gland / stroma ratio than observed in normal endometrium.

The term endometrial hyperplasia includes different pathologies that have the common feature to increased endometrial thickness. Some of these pathologies have virtually no potential for malignancy while others are clearly premalignant lesions. The pathological diagnosis is the key to the diagnosis of this entity.

Little is known on the actual incidence of endometrial hyperplasia although it is estimated to affect about 8/1000 in asymptomatic menopausal patients and 15% of patients with postmenopausal bleeding. There are different classifications, perhaps the most accepted is that of the International Society of Gynecological Pathologists that defines the following types:

1-Simple hyperplasia without atypia: Glandular dilatation and increased evidence glands and stroma.

2-Complex hyperplasia without atypia: Great growth of the endometrial glands with little stroma. The distribution pattern is irregularly glandular.

3-Simple hyperplasia with atypia: There are atypical cells present in the lining of the glands.

4-Complex hyperplasia with atypia: pattern of complex hyperplasia with atypical cells in the lining of the glands.


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Hysteroscopic Pictures: Chronic Endometritis

Chronic endometritis is usually presents in a silent way, becoming an incidental finding when performing endometrial biopsy for other reasons.

The use of hysteroscopy with liquid distention media of the uterine cavity has been shown to be an effective method for the diagnosis of chronic endometritis. A common hysteroscopic finding in chronic endometritis is the presence of a thickened endometrial edematous mucosa. Also, a thin hyperemic micropolyps layer (less than 1 mm) that appears to float in the endometrial cavity can be seen.

Using these criteria, the hysteroscopic diagnosis of chronic endometritis has a sensitivity up to 93%.

Chronic endometritis


Hysteroscopic view of vaginal endometriosis

Vaginal endometriosis

Recto-vaginal deep infiltrating endometriosis (DIE) is defined by the presence of endometrial tissue, muscle hyperplasia and fibrosis of more than 5 mm in depth located on the rectovaginal septum. The most common described DIE locations are uterosacral ligaments, rectosigmoid, the vagina and the bladder. Often patients with DIE report symptoms such as chronic pelvic pain, dysmenorrhea and dyspareunia. The presence of DIE in the vagina is rare, accounting for 5-10% of cases of endometriosis. The etiology is attributed to endometrial tissue metaplasia of group of cells of the recto-vaginal septum.

Vaginal endometriosis is classified as superficial and deep. Superficial vaginal endometriotic implants are usually located in the vaginal fornix and have no association with DIE of the recto-vaginal septum. Deep vaginal endometriosis is more common; it is usually associated with endometriosis of the recto-vaginal septum and appears as nodule or polyp in the posterior vaginal fornix between the insertion of the uterosacral ligaments. The nodules may have cystic areas of brownish or bluish color due to the presence of retained blood components. This type of lesions usually goes unnoticed during hysteroscopy.

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Endometrial Polyps: Should they always be removed?

The simplest answer to this clinical question would be a resounding yes. The concern is the possibility of malignancy located in the polyp. However, the presence of cancer cells in endometrial polyps is very rare. Dockerti Ferris in 1944 established diagnostic criteria for adenocarcinoma originated in an endometrial polyp. First, the carcinoma must be limited to a portion of the polyp, second, the base of the polyp should be free of cancer cells and third, the endometrium surrounding the base of the polyp should be normal.Endometrial polyp 2 copia.jpg

The recommended procedure is hysteroscopy polypectomy and the risk of encountering a malignant lesion should not be the only criteria to value when deciding to offer polypectomy. Therefore, several questions arise when considering a polypectomy:

1. What are the suggested clinical indications for endometrial polypectomy?

2. What is the rate of atypical endometrial hyperplasia and endometrial cancer in asymptomatic women with endometrial lining less than 4mm?

3. What is the incidence of atypical endometrial hyperplasia and endometrial cancer in patients with hysteroscopically benign appearing endometrial polyps?

4-Cost of hysteroscopy compared to expectant management

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Septated uterus with cervical duplication and vaginal septum

Uterine congenital malformations affect 3-4% of women. Septated uteri represent 35% of the total abnormalities. It is considered the most common uterine malformation, with a prevalence of 1-2% in the general population.

Septation of the uterus occurs as a result of incomplete absorption of the fused area of the two Müllerian ducts, this may lead to a complete or partial septum formation. The complete septum reaches the os, completely dividing the uterus into two cavities. The partial septum or sub-septum divides the uterus partially sparing the OS. Complete septated uteri are classified as class Va and partially septated uteri are class Vb.

The complete septate uterus with cervical duplication and vaginal septum is not included in the classification of Buttram and Gibbon or in the American Fertility Association classification of uterine malformations.

Although some authors advocate respect the cervix and do not cut the intercervical septum with the intention to minimize the risk of developing cervical incompetence, recent studies have shown that there is no cervical incompetence in a group of women undergoing intercervical section of the septum. In a randomized study Dr. Parsanezhad et al compared 28 women who were randomized to two groups: in one group, section of intercervical septum was performed, while in the other group the septum remained intact. The section of septum was noted to be the safest method and reproductive outcomes were similar in both groups with no significant differences in rates of abortion, preterm delivery and pregnancy carried to term between the two groups.

STEP-W or Lasmar’s Classification

In 2005, we developed an Hysteroscopic myoma classification, the “STEPW or Lasmar”Classification. Our purpose was to develop a new preoperative classification of submucous myomas for evaluating the viability and the degree of difficulty of hysteroscopic myomectomy. The ESGE classification considers only the degree of penetration of the myoma into the myometrium, and some times it not a good predictor of myomectomy difficulty. Our classification considers not only the degree of penetration of the myoma into the myometrium, but also adds in such parameters as the distance of the base of the myoma from the uterine wall, the size of the nodule (cm), and the topography of the uterine cavity. Each parameter receives a score, and the total sum of them indicates the myoma group.

A major advantage of the STEPW classification is in its ability to group the submucous fibroids by score, identifying a group in which 100% of the myomectomies will be complete and another group in which some incomplete myomectomies will occur. This will permit the surgeon to plan and better prepare for the surgery, to better inform the patient prior to consenting to the procedure, and guide the assignment of cases for the purposes of teaching operating technique to students and trainees in accordance with their degree of experience.”

New Treatment submucous myomas

Uterine fibroids are considered the most common benign uterine tumor of the female genital tract. It is estimated that fibroids are present in 30% of women at age 35 and up to 70% in women 50 years old and older. From a hysteroscopic standpoint, submucosal fibroids are very important, representing between 5.5% and 16.6% of all fibroids. Symptoms that are most frequently associated with submucosal fibroids are abnormal menstrual bleeding, pelvic pain and infertility. The most effective treatment is hysteroscopic resection. The technique called “Resectoscopic slicing” continues to represent the gold standard for the treatment of submucosal fibroids.

In recent years there have been different alternatives to resectoscopic fibroid resection. These techniques are based on extracting the myoma after reducing it into small fragments (miniresector, morcellators and shaver) or destroying the myoma inside the uterine cavity (laser vaporization).

Recently, a group of researchers from the Autonomous University of Barcelona led by Dr. Haimovich has presented a prospective study, which has the potential to change the classic approach to this pathology in the coming years.

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