Faculty Bibliography

Selective estrogen receptor modulators (SERMs) can act as estrogen agonists or estrogen antagonist depending on the target tissue. Tamoxifen was the first clinically available SERM and is highly effective for the prevention and treatment of breast cancer. Tamoxifen however has estrogen agonistic activity in the uterus and has been associated with an increased risk of endometrial hyperplasia and malignancy. Thus endometrial safety has been an important consideration in the development of all SERMs since then. Raloxifene, which is currently approved for prevention and treatment of postmenopausal osteoporosis, and for the prevention of breast cancer, does not result in endometrial hyperplasia or cancer. It does result in a slight increase in endometrial polyps. Lasofoxifene which has been shown to reduce fracture risk and decrease the incidence of breast cancer did not increase endometrial cancers or endometrial hyperplasia but did result in an increased incidence in vaginal bleeding, endometrial polyps ( all of which were inactive and atrophic) and endometrial "thickening" on transvaginal ultrasound. Ospemefene has been shown to have beneficial effects on the vaginal epithelium but does not cause endometrial cancer or hyperplasia. Bazodoxifene is effective in preventing and treating postmenopausal osteoporosis and does not cause endometrial thickening on ultrasound nor any hyperplasia or cancer. Arzoxifene was evaluated in a phase III trials for treating osteoporosis but its clinical development program was suspended. Further investigation of newer SERMs is warranted to more clearly define the endometrial safety of each of these agents

Objective: Ospemifene, a novel, selective estrogen receptor modulator (SERM) that exerts estrogenic, pharmacologic activity in the vaginal epithelium, is presently being studied for treatment of symptoms of vulvovaginal atrophy (WA) in postmenopausal women. This study assessed the efficacy, safety and tolerability of ospemifene 60 mg/d in the treatment of WA symptoms. Design: A 12-wk, 1:1 randomized, double-blind, placebo-controlled, parallel-group study enrolling 919 postmenopausal women 40 to 80 years of age with WA in two strata based on their self-reported most bothersome symptom (MBS) of vaginal dryness or vaginal pain (dyspareunia). Two study populations were analyzed: the intent-to-treat (TTT) (primary analysis) and per protocol (PP). Subjects in each stratum were randomized to receive 60 mg/d ospemifene or placebo and were provided with a nonhormonal vaginal lubricant to use as needed (PRN). For each stratum, changes from baseline to Wk 12 (LOCF) for the four co-primary endpoints were assessed: vaginal pH, percentages of superficial cells and parabasal cells in the maturation index and the severity of the MBS. This abstract reports the Dryness Stratum results. Results: In the TTT analysis, at Wk 12 ospemifene demonstrated significant efficacy vs placebo for 3 of 4 co-primary endpoints from baseline. Significant mean changes from baseline to Wk 12 for vaginal pH and percentages of superficial (LS mean) and parabasal cells (Median) were evident (Table 1). Significant improvement was observed as early as 4 wks. Improved mean change was observed for the MBS vaginal dryness at Wk 12, which approached statistical significance (P=0.0803). A higher % of subjects treated with ospemifene reported no vaginal dryness, and the subjects' self-reported symptom severity, which was assessed on a 4-point scale improved by 2 to 3 points in 46.3% ospemifene vs 34.4% placebo subjects. The PP analysis showed statistically significant improvement for all 4 co-primary endpoints (pH, % superficial and % parabasal cells, all P<0.0001 and vaginal dryness, P=0.0143) and similar improvements in dryness severity. The main difference between the ITT and the PP populations was in study drug compliance, which was higher in the PP population. The numbers of subjects with >1 adverse event (AE) at Wk 12 in both strata combined is summarized in Table 2. Discontinuation rates were similar in the ospemifene (10.2%) and placebo (11.6%) groups. Endometrial histology assessments showed no cases of hyperplasia and 2 (1.0%) cases of active proliferation in the ospemifene group vs 0% in the placebo group. Vaginal bleeding was reported in 2 (0.4%) and 4 (0.9%) subjects in the ospemifene and placebo groups, respectively; 1 subject on ospemifene experienced deep vein thrombosis was discontinued from the study. There were no cases of myocardial infarction, breast cancer or death. Conclusion: In postmenopausal women with the self-reported MBS of vaginal dryness, these data demonstrate that treatment with ospemifene 60 mg/d provides clinically and statistically significant efficacy and was well tolerated. With greater improvement in symptom severity scale changes and in markers of vaginal health, this novel SERM may prove to be the first non-estrogen to effectively treat the symptoms of WA. (Table Presented)

The ascertainment of diagnostic medical information through most of the 20th Century relied on techniques like inspection, palpation, and auscultation as noninvasive ways to obtain information about internal anatomy, both normal and abnormal, as well as physiology which when not normal we call "pathology". Sensitivity of imaging modalities has become so refined that we are seeing structures either never before appreciated or sometimes appreciated but not with such precision. This lecture will deal with my observations of this issue in gynecology using transvaginal ultrasound (TV U/S), although the problems associated with increased sensitivity of imaging exist in many other clinical fields as well. My thesis is that as we see more and more detail the response to what we see has often been based on old and thus preconceived notions, and not on newer well-organized and well-designed studies to determine the prevalence of particular findings and their clinical significance. Information obtained with increasingly refined technology cannot simply be handled according to old established principles. Newer studies must be made before clinical recommendations can be made. We must be careful not to over interpret such findings that may be much more common and less ominous that previously believed. The vaginal probe has revolutionized gynecology. Higher frequency probes in close proximity to the structure being studied have created a degree of image magnification that is as if we are doing ultrasound through a low power microscope (sonomicroscopy). We are seeing things with ultrasound that you cannot see with the naked eye. Furthermore, the ease of performing TV U/S, and its increasingly routine use for surveillance, has resulted, in my opinion, in an explosion of incidental findings that are much more common and more innocuous than previously realized. There are many examples in gynecology but I will concentrate on two that are very common and relevant to menopausal patients. These are 1) Simple ovarian cystic structures and 2) Incidental endometrial "thickening" in non bleeding postmenopausal women. Forty years ago the dictum that a palpable postmenopausal ovary was abnormal was put forth by Dr. Hugh Barber. When ultrasound (then transabdominal ultrasound) began to see postmenopausal cystic structures these were promptly removed as potentially malignant. 25 years ago the first small observational study began to suggest that unilocular unilateral cysts were invariably benign and could be managed expectantly. Abundant data from prospective screening studies have confirmed that observation. They have also shown the incidence of unilocular cystic adnexal structures in postmenopausal women can be as high as 18%. The field has "matured" to where almost all clinicians will now counsel such patients for conservative management. Twenty years ago the first reports of a thin distinct endometrial echo in postmenopausal patients with bleeding surfaced. Abundant prospective data from multicentered trials showed that the incidence of malignancy in postmenopausal patients with bleeding when the endometrial echo measures < 4mm on transvaginal ultrasound is 1/917. In 2009 ACOG stated "when transvaginal ultrasound is performed for patients with postmenopausal bleeding and an endometrial thickness <4mm is found endometrial sampling is not required". Unfortunately most clinicians who understood that a thin distinct endometrial echo in such patients excludes malignancy, have still inappropriately assumed that a thick echo in non-bleeding patients is abnormal and requires intervention. The prevalence of non thin endometrial echo on TV U/S in asymptomatic postmenopausal women is 10-17%. Furthermorel3% of asymptomatic postmenopausal women will have an endometrial polyp on TV U/S. The risk of malignancy is such imaged structures, absent bleeding, is less than 1 in 250 yet the complication rate from operative hysteroscopy in this elderly group is as high as 3.6%. The increasing sensitivity of the vaginal probe can and should be a wonderful tool for the gynecologist. However studies on the prevalence and significance of the things one can see on such imaging must be carried out if it is to be incorporated appropriately. Remember the credo -"above all else do no harm".

Objective: Currently, only estrogen-based preparations have received regulatory approval for prescription treatment of vulvovaginal atrophy (VVA) in postmenopausal women; therefore, exploring alternative treatments for WA is imperative. Ospemifene, a novel, selective estrogen receptor modulator (SERM), is unique compared with other SERMs due to its estrogenic activity in the vaginal epithelium and is under investigation in postmenopausal women with VVA symptoms. This study assessed the efficacy, safety, and tolerability of ospemifene 60 mg/d in the treatment of WA symptoms in postmenopausal women. Design: This 12-wk, randomized, double-blind, placebo-controlled, parallel-group study included 919 subjects. Two study populations were analyzed: intent-to-treat (ITT), the primary analysis, and per protocol (PP). Women (4080 years of age) were assigned to one of 2 VVA symptom strata (vaginal dryness or dyspareunia) based on their self-reported most bothersome WA symptom (MBS);and within each stratum were randomized 1:1 to receive either ospemifene 60 mg/d or placebo. Data from each stratum were independently analyzed. All subjects were provided with a nonhormonal vaginal lubricant to be used as needed (PRN). For each stratum, co-primary efficacy endpoints were measured for change from baseline to Wk 12 (LOCF) in: vaginal pH, % superficial cells and % parabasal cells in the maturation index, and the severity of the MBS. This abstract reports the dyspareunia stratum results. Results: At Wk 12 ospemifene demonstrated significant efficacy vs placebo for each co-primary endpoint. Changes in the ITT population for vaginal pH (LS mean),% of superficial cells (median), and % of parabasal cells (LS mean) all were p<0.0001 (Table 1); a significant effect was observed as early as 4 wks. Significant mean improvement was also observed for the MBS, dyspareunia (p=0.0001) at Wk 12. A higher percentage of subjects treated with ospemifene reported no, or mild dyspareunia and self-reported symptom severity that improved by 2-3 points on a 4-point Likert scale in 52.8% of ospemifene vs 38.8% of placebo subjects. The PP analysis also demonstrated statistically significant findings for each co-primary endpoint, confirming ll'i analysis. The % of subjects with at least 1 adverse event (in the ITT population) at Wk 12 for both strata combined is summarized in Table 2. Discontinuation rates were similar in the ospemifene and placebo groups, 10.2% vs 11.6%, respectively. Endometrial histology assessments showed no cases of hyperplasia and 2 (1.0%) cases of active proliferation in the ospemifene group vs 0% in the placebo group. Vaginal bleeding was reported in 2 (0.4%) and 4 (0.9%) subjects in the ospemifene and placebo groups, respectively. One subject in the ospemifene group experienced a deep vein thrombosis following an 8-hour car ride and was discontinued from the study. Conclusion: In postmenopausal women with self-reported MBS of dyspareunia, this unique study demonstrated that, despite the PRN use of lubricants, treatment with ospemifene 60 mg/d demonstrated clinically and statistically significant efficacy and was well tolerated. (Table Presented)

Postmenopausal bleeding is 'cancer until proven otherwise.' A thin distinct endometrial echo on transvaginal ultrasound has a risk of malignancy of 1 in 917 and does not require an endometrial biopsy. If the endometrial echo is poorly visualized, then in such women, saline infusion sonohysterography is an appropriate next step. The prevalence of asymptomatic endometrial thickening (mostly due to inactive polyps) is high, approximately 10% to 17% of postmenopausal women. The risk of malignancy in such polyps is low (approximately 0.1%), and in structures that mimic polyps, it is also low (0.3%). The incidence of serious complications from an operative intervention in such postmenopausal women is not insignificant (1.3%-3.6%). Thus, automatic intervention in such women, without any high-risk status, is not warranted

OBJECTIVE: To improve the interpretation of future studies in women who are initially diagnosed with a pregnancy of unknown location (PUL), we propose a consensus statement with definitions of population, target disease, and final outcome. DESIGN: A review of literature and a series of collaborative international meetings were used to develop a consensus for definitions and final outcomes of women initially diagnosed with a PUL. RESULT(S): Global differences were noted in populations studied and in the definitions of outcomes. We propose to define initial ultrasound classification of findings into five categories: definite ectopic pregnancy (EP), probable EP, PUL, probable intrauterine pregnancy (IUP), and definite IUP. Patients with a PUL should be followed and final outcomes should be categorized as visualized EP, visualized IUP, spontaneously resolved PUL, and persisting PUL. Those with the transient condition of a persisting PUL should ultimately be classified as nonvisualized EP, treated persistent PUL, resolved persistent PUL, or histologic IUP. These specific categories can be used to characterize the natural history or location (intrauterine vs. extrauterine) of any early gestation where the initial location is unknown. CONCLUSION(S): Careful definition of populations and classification of outcomes should optimize objective interpretation of research, allow objective assessment of future reproductive prognosis, and hopefully lead to improved clinical care of women initially identified to have a PUL

OBJECTIVE: The aim of this study was to establish the gynecological effects of 5 years of treatment with lasofoxifene versus placebo in postmenopausal osteoporotic women. METHODS: A total of 8,556 women aged 59 to 80 years with femoral neck or spine bone mineral density T scores of -2.5 or lower were randomized to receive lasofoxifene 0.25 mg/day, or lasofoxifene 0.5 mg/day, or placebo, for 5 years. RESULTS: Endometrial cancer was confirmed for two women in each lasofoxifene group and for three women in the placebo group. Endometrial hyperplasia occurred in three, two, and zero women in the lasofoxifene 0.25 mg/day, lasofoxifene 0.5 mg/day, and placebo groups, respectively. Vaginal bleeding occurred in 2.2% (P = 0.012 vs placebo), 2.6% (P = 0.001 vs placebo), and 1.3% of women treated with 0.25 mg/day lasofoxifene, 0.5 mg/day lasofoxifene, and placebo, respectively. Lasofoxifene treatment resulted in a small increase in endometrial thickness versus placebo (least-squares mean change from baseline 1.19 mm [P = 0.001], 1.43 mm [P < 0.001], and -0.72 mm for 0.25 mg/day lasofoxifene, 0.5 mg/day lasofoxifene, and placebo). Similar numbers of women required surgery for pelvic organ prolapse or urinary incontinence in the placebo and 0.5 mg/day lasofoxifene groups (1.2% vs 1.6%, P = 0.224; 0.25 mg/day group: 1.9%, P = 0.036). The absolute incidence rates of endometrial polyps were 8.8%, 5.5%, and 3.3% for lasofoxifene 0.25 mg/day (P = 0.003 vs placebo), lasofoxifene 0.5 mg/day (P = 0.163 vs placebo), and placebo groups, respectively. CONCLUSION: These findings indicate that 5 years of lasofoxifene treatment result in benign endometrial changes that do not increase the risk for endometrial cancer or hyperplasia in postmenopausal women

The Society of Radiologists in Ultrasound convened a panel of specialists from gynecology, radiology, and pathology to arrive at a consensus regarding the management of ovarian and other adnexal cysts imaged sonographically in asymptomatic women. The panel met in Chicago, Ill, on October 27-28, 2009, and drafted this consensus statement. The recommendations in this statement are based on analysis of current literature and common practice strategies, and are thought to represent a reasonable approach to asymptomatic ovarian and other adnexal cysts imaged at ultrasonography.