1. Diagnostic & Operative Hysteroscopy in Endometrial Hyperplasia Franklin D. Loffer. M.D. Associate Clinical Professor – University of Arizona Executive Vice President/Medical Director American Association of Gynecological Laparoscopists

12. Methods of Working Up Abnormal Uterine Bleeding

16. Adequacy of Specimens From Pipelle Compared to Novak Endometrial Biopsies*

17. Sensitivity of Pipelle Sampling in Detection of Known Endometrial Cancer*

18. Comparison of Surface Area Sampled by Pipelle Biopsy vs Aspiration Curettage*

19. Adequacy of D&C in Sampling Endometrium (60 pts)*

20. Adequacy of D&C in Emptying the Uterine Cavity (124 pts)*

23. Reduction in Blood Loss After D&C in 22 Patients Hayes, et al, B J ObGyn, 1977

24. Reduction in Blood Flow After D&C MP After Percent D&C Reduced 1 - 69.0 2 +33.6% 3 -8.4 4 -4.0 Nisson & Rybo, AJ OBG, 110:713, 1971

26. How Good Is A Hysteroscopic View Alone? (4064 Patients) Hyperplasia (613 pts) Endometrial CA (105 pts) Sensitivity 56.3% 80.0% Specificity 89.1% 95.5% PPV 48.0% 81.5% NPV 92.0% 99.5% Accuracy 72.7% 89.8% Lasmar RB et al, J Minim Invasive Gynecol 2006; 13:409-412

27. Accuracy of Hysteroscopy vs. D&C* H/S Bx = D&C 271 (79%) H/S Bx > D&C 60 (18%) H/S Bx < D&C 11 (3%) Total 342 *Gimpelson RJ et al; AJ OBG 168:489, 1988

28. D&C Less Accurate Than Hysteroscopy* (60/342 cases 18%) Polyps 17 Fibroids 22 Benign endometrium 14 Atypical 5 Miscellaneous 2 Gimpelson RJ, AJ OBG, 158;489 1988

29. D&C More Accurate Than Hysteroscopy* (11/342 cases 3%) Anovulatory 4 pts Atrophic 3 pts Endometritis 2 pts Hyperplastic 1 pt Polyp 1 pt Gimpelson RJ, AJ OBG, 158;489 1988

31. D&C vs Aspiration Curettage* D&C A.C. N=13,598 (N=5851) Safety (per 1,000) Hemorrhage 4 0 Infection 3-5 0-4 Perforation 6-13 0-4 Emergency lap 0.3-5 0 Adequate specimen 77-94% 85-99% Location out/in pt. Office Therapeutic effect nil nil *Grimes D., Am J ObG, 142:1, 1982

33. Hysteroscopy With Tissue Sampling vs D&C – Sensitivity, Specificity and Predictive Value H/S D&C Sensitivity 98% 65% Specificity 100% 100% Predictive Value Positive 100% 100% Negative 1% 17% Loffer FD. Obstet Gynecol 1989; 73:16 Frankl

34. Hysteroscopy 1992-1996 Diagnostic 296 pts Office < 50 y/o 193 (65.2%) > 50 y/o 60 (20.3%)* Out pt < 50 y/o 9 (3.0%) > 50 y/o 14 (4.7%) ** Out pt & other surg 20 (6.8%) Operative 218 pts * 3 failed, ** 1 failed

35. Non-Office Diagnostic Hysteroscopy <50 y/o >50 y/o (N=9) (N=14) Cervical Stenosis 4 1 Vaginal Stenosis 0 6 Heavy Bleeding 2 1 Abnormal Ultrasound 1 2 Patient preference 2 3 Inpatient 0 1

36. Significance of Hyperplasia With and Without Atypia

37. Untreated Atypical Endometrial Hyperplasia (mean 13.4 years) Regressed 29 pts 60% Persisted 8 pts 17% Progressed 1 pt 23% Kurman RJ et al, Cancer 1985 56:405

38. Risk of Carcinoma When Biopsy is Atypical Hyperplasia At hysterectomy 36 of 78 (46.2%) cases had invasive endometrial carcinoma. Miller C et al Am J OBG 199: 1-4,2008

39. Risk of Carcinoma When Pathology Report for Biopsy is Atypical Hyperplasia Path Report # Pts # CA AEH 48 18 37.5% AEH – CA 30 18 60.0% Miller C et al Am J OBG 199: 1-4, 2008

40. Polypoid Endometrium is not the same as Endometrial Polyp Hysteroscopic Polypectomy

43. Endometrial Polyps Containing Atypical Hyperplasia or Cancer In Polyps In Non Polyp Area CA Microinvasive AHP (29 pts) 19 pts (66%) 9 pts (31%) 4 pts CA (8 pts) 7 pts (88%) − 3 pts Mittal K et al. Int J Gynecol Pathol. 2008; 27:45-8

48. Thank You For Your Attention © 2003 Michael Paulson