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Title: Towards an improved diagnosis of uterine pathology
Other Titles: Verbeteringen in de diagnosestelling van uteriene pathologie
Authors: Van den Bosch, Thierry
Issue Date: 26-Apr-2007
Abstract: This work evaluates the use of different strategies in the diagnosis ofuterine pathology, more specifically of lesions in the uterine cavity and in the myometrium. In a first part, the value of ultrasound is discussed. Endometrial cancer is associated with a thickening of the endometrium and this can be measured by ultrasound. Contrariwise, if a thin andregular endometrium is visualized, malignancy is most unlikely. To allow for reliable evaluation of the endometrium, ultrasound examination has to be performed before endometrial sampling.Endometrial polyps are relatively prevalent in peri- and postmenopausalwomen; most polyps remain asymptomatic. Polyps are more easily visualized in the proliferative phase of the cycle against a hypoechogenicendometrial background. Using color Doppler imaging, the visualization of a distinct pedicle artery running deep into the endometrial lining is strongly suggestive for an endometrial polyp. To enhance the diagnostic accuracy for focal intracavity lesions such as endometrial polyps or submucous myomas, a negative contrast agent suchas saline may be injected into the uterine cavity during ultrasound: the hydrosonography.Areas of enhanced vascularity within the myometrium (EMV) are frequently seen in the early postpartum and tend to disappear within 6 to 10 weeks after delivery. EMV reflect delayed involution of the vessels ofthe placental bed and is mostly physiological.Placental remnants may be detected using ultrasound with color Doppler imaging. Providing the patient is stable and without signs of infection, expectant management may be proposed in case retained products ofconception are seen on scan.(Sub)endometrial hyperechogenic foci are common after pregnancy and usually are not associated with instrumental removal of the placenta or curettage. Osseous lesions within the uterus are rare and originate from either osseous metaplasia or retained fetal bones. Unless bonetissue is located in the uterine cavity, it does not necessarily interfere with fertility.The occurrence of abnormal uterine bleeding in women on Implanon® may be caused by incomplete ovarian suppression leading to follicle growth and endometrial stimulation. In the second part of this thesis possible algorithms for the diagnosisof uterine pathology are discussed.Different office based tests may – as such or in combination with ultrasound – optimize the diagnostic accuracy for uterine disease. Cervical cytology may incidentally give a hint as to the presence of an intracavity lesion but cannot rule out uterine malignancy or other uterine pathology. Office endometrial sampling, e.g. using a Pipelle®, is accurate in the diagnosis of endometrial hyperplasia and endometrial malignancy. However, most focal lesions such as polyps will be missed. Office hysteroscopy is very reliable in the diagnosis of focal lesions such as endometrial polyps and intracavity myomas, but is accuratefor diagnosing endometrial hyperplasia and cancer.When investigating the patients’ preference, vaginal ultrasound was thebest accepted procedure, followed by respectively hydrosonography, outpatient hysteroscopy and office endometrial sampling.The combined use of ultrasound and office endometrial sampling was implemented in a “single examiner” setting. This approach was both feasible and reliable in the detection of endometrial malignancy. Theuse of predictive models could help the clinician in counselling the patient about her individual risk for endometrial cancer of hyperplasia.A more comprehensive algorithm for the diagnosis of uterine pathology in a “one stop clinic” setting was build based on ultrasound with color Doppler imaging as initial investigation. Hydrosonography and/or Pipelle® endometrial sampling to exclude respectively focal intracavity lesions and more diffuse pathology such as endometrial hyperplasia and malignancy, may be added at the same visit. In cases where ultrasound, hydrosonography or endometrial biopsy do not provide conclusive information a diagnostic office hysteroscopy is indicated.
Publication status: published
KU Leuven publication type: TH
Appears in Collections:Clerkships Office, Faculty of Medicine - miscellaneous
Section Woman - Miscellaneous (-)
Electrical Engineering - miscellaneous

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