First International Consensus Report on Adnexal Masses: Management Recommendations
The First International Consensus Conference on Adnexal Masses was convened to thoroughly examine the state of the science and to formulate recommendations for clinical assessment and management. The panel included representatives of societies in the fields of gynecology, gynecologic oncology, radiology, and pathology and clinicians from Europe, Canada, and the United States. In the United States, there are approximately 9.1 surgeries per malignancy compared to the European International Ovarian Tumor Analysis center trials, with only 2.3 (oncology centers) and 5.9 (other centers) reported surgeries per malignancy, suggesting that there is room to improve our preoperative assessments. The American College of Obstetricians and Gynecologists Practice Bulletin on "Management of Adnexal Masses," reaffirmed in 2015 (Obstet Gynecol 2007; 110:201-214), still states, "With the exception of simple cysts on a transvaginal ultrasound finding, most pelvic masses in postmenopausal women will require surgical intervention." The panel concluded that patients would benefit not only from a more conservative approach to many benign adnexal masses but also from optimization of physician referral patterns to a gynecologic oncologist in cases of suspected ovarian malignancies. A number of next-step options were offered to aid in management of cases with sonographically indeterminate adnexal masses. This process would provide an opportunity to improve risk stratification for indeterminate masses via the provision of alternatives, including but not limited to evidence-based risk-assessment algorithms and referral to an "expert sonologist" or to a gynecologic oncologist. The panel believed that these efforts to improve clinical management and preoperative triage patterns would ultimately improve patient care.
Modern evaluation of the endometrium
Abnormal uterine bleeding in women older than age 35 years, and certainly in menopausal patients, mandates evaluation, mainly to exclude cancer and hyperplasia, but also to better diagnose the source of the bleeding to appropriately manage the patient. In the past, dilation and curettage was the mainstay of diagnosis. This gave way to in-office suction pump-generated biopsies. Most recently, disposable biopsy instruments with their own internal piston to generate suction have become the standard of care. Rarely has such a technique received such widespread acceptance with such limited validation. Transvaginal ultrasonography, when technically feasible, is a noninvasive way to image the endometrial cavity. Saline-infusion sonohysterography is a subset of transvaginal ultrasonography reserved for patients in whom an adequate endometrial echo is not seen or when an endometrial echo is seen but not sufficiently thin. Appropriate understanding and use of transvaginal ultrasonography and addition of sonohysterography when necessary can allow a clinical algorithm that can triage patients with abnormal uterine bleeding to 1) no anatomic pathology best treated expectantly; 2) a global endometrial process, in which case random blind endometrial sampling is appropriate; or 3) a focal endometrial abnormality in which case endometrial sampling should be done with the visualization offered by hysteroscopy. Finally, the incidence of thick endometrial echo found incidentally in postmenopausal women with no bleeding is extremely high (10-17%) and should not trigger invasive endometrial sampling automatically
The conundrum of asymptomatic adnexal masses: a clinician's opinion [Editorial]
Ability to successfully image the endometrial echo on transvaginal ultrasound in asymptomatic postmenopausal women
OBJECTIVES/OBJECTIVE:Women who experience postmenopausal bleeding (PMB) are considered to have endometrial cancer (EC) until proven otherwise. Initially, dilatation and curettage (D&C) was the gold standard of diagnosis. This was largely replaced by blind endometrial (EM) biopsy. However, recently, the relatively high false negative rate of such blind sampling in women with EC has become understood. Concomitantly, numerous studies indicate that an EM echo of â‰¤â€‰4â€‰mm on transvaginal ultrasound (TV U/S) is a reliable enough test to exclude EC such that biopsy is not needed in initial cases of PMB. However, not all PM women will have anatomy that lends itself to a meaningful determination of EM thickness. This study was undertaken to evaluate the frequency of, and reasons for, an inability to adequately visualize an EM echo. METHODS:472 consecutive asymptomatic PM women had TV U/S as part of routine gynecologic care. Their charts and TV U/S were reviewed, and, if adequate, EM thickness was recorded. If EM thickness was not adequately visualized the reason, as judged by the examiner, for inadequacy was recorded. Other demographics included years since menopause, body mass index (BMI), and current use of hormone therapy. RESULTS:Of the 472 women, 292 (61.9%) had an EM echo that was well visualized and reliably measured (mean 3.0â€‰mm, range 1.0 -28.0). Thus, in 180 PM women (38.1%), a distinct measurable EM echo was unable to be adequately visualized. The reasons were: fibroids (n=95, or 20.1% of overall cohort), adenomyosis (n=35, or 7.4% of overall cohort), axial uterus (n=50, or 10.6% of cohort). Mean years since menopause was 14.0 in those visualized (range 1-50), and 14.1 in non-visualized (range 1-40) (N.S.). Mean BMI was 23.9 in those visualized (range 16-41) and 25.4 (range 18-40) in those non-visualized (p=.015). CONCLUSIONS:TV U/S has become an accepted first step in the evaluation of PMB. However, in this cohort 39.8% of women had anatomic reasons for non-visualization of a reliable EM measurement including fibroids, adenomyosis, and axial uterus. There was no significant difference between groups based on years since menopause or current use of hormone therapy, but the mean BMI of the non-visualized group was significantly higher than those visualized. Clinicians should be cognizant of these potential limitations of TV U/S in the initial evaluation of women with PMB. This article is protected by copyright. All rights reserved.
Selective estrogen receptor modulators and bone health
Selective estrogen receptor modulators (SERMs) are synthetic molecules that bind to the estrogen receptor and can have agonistic activity in some tissues while being estrogen antagonistic in others. While not all SERMs are clinically available in all parts of the world, this article will review preclinical and clinical effects of various SERMs on bone. These include tamoxifen, used as adjuvant therapy in breast cancer patients as well as for breast cancer prevention; raloxifene, approved for osteoporosis prevention and treatment as well as breast cancer prevention; bazedoxifene, approved for prevention of osteoporosis and also in combination with conjugated equine estrogen for treatment of vasomotor symptoms and prevention of bone loss in postmenopausal patients; and ospemifene, approved for treatment of dyspareunia due to vulvovaginal atrophy/genitourinary syndrome of menopause. Thus, these SERMs are a diverse group of estrogen agonist/antagonists that seem to have class effects in the bone and breast, although the amount of clinical trial data is quite variable. However, there does not seem to be the same unidirectional class activity in tissues like the uterus or vagina. Health-care providers should be cognizant of all available information in helping patients make the best possible shared decision-making choices.
A core outcome set for genitourinary symptoms associated with menopause: the COMMA (Core Outcomes in Menopause) global initiative
A core outcome set for vasomotor symptoms associated with menopause: the COMMA (Core Outcomes in Menopause) global initiative
Update on bone health: the International Menopause Society White Paper 2021
Osteoporosis and associated fractures present a major challenge in improving global health outcomes. Key clinical aspects are the definition of osteoporosis and associated fractures, fracture risk prediction, stratification of risk of fracture, intervention thresholds and the most appropriate intervention based on integration of aforementioned. Correct understanding and application of these concepts are essential to stem the increasing tide of fragility fractures associated with an aging population. The role of muscle strength and function, sarcopenia, and the newly emerging concept of osteosarcopenia in maintaining bone health are discussed in detail.
The IMS: charting a course forward [Editorial]
Uterine bleeding with hormone therapies in menopausal women: aÂ systematic review
Uterine bleeding is a common reason why women discontinue menopausal hormone therapy (HT). This systematic review compared bleeding profiles reported in studies for continuous-combined HT approved in North America and Europe for moderate to severe vasomotor symptoms in postmenopausal women with a uterus. Non-head-to-head studies showed that uterine bleeding varies by formulation and administration route, with oral having a better bleeding profile than transdermal formulations. Cumulative amenorrhea over a year ranged from 18 to 61% with oral HT and from 9 to 27% with transdermal HT, as reported for continuous-combined HT containing 17Î²-estradiol (E2)/progesterone (P4) (56%), E2/norethisterone acetate (NETA) (49%), E2/drospirenone (45%), conjugated equine estrogens/medroxyprogesterone acetate (18-54%), ethinyl estradiol/NETA (31-61%), E2/levonorgestrel patch (16%), and E2/NETA patch (9-27%). Amenorrhea rates and the mean number of bleeding/spotting days improved over time. The oral E2/P4 combination was amongst those with lower bleeding rates and may be an appropriate alternative for millions of women seeking bioidentical HT and/or those who have bleeding concerns with other HT.