Tehran University Medical Journal

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Background: Post-menopausal hemorrhage is one of the most common complains in gynecologic clinics. More than 60% of these cases have abnormal findings in diagnostic work ups. There is contraversy about the best diagnostic method for evaluating post-menopausal hemorrhage. The aim of this study was to evaluate the results of Trans-Vaginal Ultrasonography and compare its result to ones derived from direct endometrial biopsy and Hysteroscopy findings.

Methods: In a cross-sectional study, menopausal women who attended the outpatient clinic of Arash Hospital, Tehran University of medical Sciences, from April 2005 to March 2006 with the complain of hemorrhage were evaluated. In all of these patients, after getting informed consent, Trans-Vaginal Ultrasonography, Dilatation and Curettage and Hysteroscopy were performed.

Results: The total number of 90 women was recruited to the study with the age range of 41-80 years. The mean age of participants was 53.84 ± 6 years and 4.3 ± 5.1 years had passed from their menopause. The mean thickness of endometrium, measured by Trans Vaginal ultrasonography was 6.25 ± 3.7 millimeter. In the biopsy derived specimens, the most finding pathological presentation was atrophy (48.9%) and the Proliferative endometrium had the second prevalence (36.7%). Atrophy (44.4%) and Proliferative endometrium (33.3%) were the most prevalent finding in Hysteroscopy. There was a significant difference in endometrial thickness between groups of different pathological findings. A significant difference in endometrial thickness was also seen between groups with different Hysteroscopic finding. By grouping the data according to endometrial thickness, it became evident that endometrial thickness can predict the outcome of endometrial biopsy and Hysteroscopic finding efficiently. We used ROC curves to find the best grouping threshold for endometrial thickness to achieve the best sensitivity and specificity.

Conclusion: Measuring the endometrial thickness by Trans-Vaginal Ultrasonography is an appropriate non-invasive test for screening post-menopausal hemorrhage. 

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Background: As an important diagnostic and therapeutic procedure for patients with intrauterine diseases, hysteroscopy permits a good view of the uterine cavity, thereby increasing diagnostic accuracy. Complications often encountered during hysteroscopy primarily concern problems with cervical dilatation and include uterine perforation, cervical tears, and the creation of false tracts. In this study, we investigate the utility of vaginal misoprostol for cervical dilatation in women undergoing hysteroscopy.

Methods: This triple-blind, randomized, placebo-controlled study was carried out at Mirza Khoochak Khan Hospital, Tehran, Iran. We excluded women who were pregnant, had genital tract infection, or history of cervical trauma. We randomly assigned 80 women with abnormal uterine bleeding or intrauterine lesions to receive either 200 μg vaginal misoprostol or placebo. Ten to twelve hours prior to hysteroscopy, the placebo or misoprostol was administered to the posterior vaginal fornix. Data regarding cervical response and outcome of operative hysteroscopy, as well as complications, were analyzed.

Results: The mean cervical width, as estimated by Hegar dilator, was significantly greater in the treated group (7.8±1.6mm) than that in the control group (5.6±2.2mm, p<0.001). In the misoprostol group, 28 (70%) patients required cervical dilatation, compared with 38(95%) in the placebo group (p=0.001). A significantly shorter median time of cervical dilatation to Hegar number 9 was found in the treated subjects than in the controls (60 vs. 180 seconds, p<0.001). The mean operative time was significantly shorter in the treated group (8.8±8.7 minutes) compared with that of the control group (13.1±10.1 minutes, p=0.043).

Conclusions: Vaginal misoprostol before operative hysteroscopy lessens the need for cervical dilatation, facilitating hysteroscopic surgery.

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Background: Septate uterus is the most common congenital malformation of the uterus in normal population and also patients with recurrent abortions. Pathogenesis of the disease is incompletely elucidated. It is clarified that incomplete absorption of paramesonephric ducts in the first trimester is responsible for septum formation. Hysteroscopy is known as the standard diagnostic and therapeutic procedure for septate uterus. In this study, our aim was to evaluated the effects of hysteroscopic septal resection in improving pregnancy outcomes in patients with unexplained infertility or recurrent abortion. Methods: Prospective cohort study was conducted in a Tehran University Medical Sci-ences affiliated hospital from April 2012 to May 2013. Eight patients were excluded from the study because of non-reproductive related complains. The other 40 patients went through a prospective cohort study and were treated for septate uterus. All patients had complete history taken and underwent physical examination. Septum size was measured by hysteroscopy. Patients underwent hysteroscopic metroplasty with resectoscope with an equatorial semicircular loop cutting 12 with monopolar energy. Some septum resected by 5 french hysteroscopic scissor. The patients were visited 2 month later for evaluated surgical outcome. This assessment was done by hysterosalpingography (HSG). Patient’s reproductive outcome were followed for 10.33 (SD:±6.43) months. Results: The mean age in patients was 31.5 (SD±3.02) years. In whole, 48 patients un-derwent hysteroscopic metroplasty. In 52.1% length of septum occupied two third of uterine cavity. Eight patients were excluded from the study because of non-reproductive related complains. There were 29 pregnant patients (72.5%). Fifteen patients became pregnant without intervention (51.7%). 14 patients had pregnancy under ART, while the pregnancy did not occur in 11 patients (27.5%) during this period. Among pregnant population there were 9 miscarriage (31%), 3 preterm (13.3%) and 17 term delivery (50%). Live birth rate in our study was 68.9%. In control hysterosalpingography (HSG), no patients had adhesion or residual ridge. Conclusion: The findings of this study indicate that hysteroscopic septoplasty is ac-ceptable for improving reproductive outcomes in patients with septate uterus.

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Background: Preterm premature rupture of membranes (PPROM) occurs in 17% of pregnancies, which leads to 20% of perinatal death. According to previous studies uterine anomalies are one of the risk factors for preterm birth, PPROM and pregnancies complications. The aim of this study was to evaluate the relationship between PPROM and rupture of membrane (ROM) with uterine cavity anomalies based on hysteroscopic findings. Methods: This cross-sectional study was conducted in Imam Khomeini Hospital, Ahvaz, Iran, from May 2011 to May 2012. After conducting a pilot study, 66 nulliparous pregnant women at 14-37 weeks of pregnancy with PPROM and ROM were selected randomly. Then the women were evaluated by hysteroscopy at least six weeks after delivery or miscarriage. The control group includes 66 women with at least one normal pregnancy (without history of PPROM, secondary infertility or recurrent abortion), who underwent diagnostic or therapeutic hysteroscopy for other reasons than PPROM. The hysteroscope instrument specifications were KARL STORZ model (KARL STORZ GmbH & Co. KG, Tuttlingen, Germany), inner sheet 26153 BI, outer sheet 26153 BO, and BA lens with 30 degree. Normal saline solution (Sodium Chloride 0.9%) also was applied as distention medium. The study was approved by Ethic Committee of Ahvaz Jundihspur University of Medical Sciences. Informed consent was obtained for all participants. Results: Overall, the frequency of uterine anomalies in case and control groups was 12.12% and 3%, respectively (P<0.05 based on Chi-square test). Possibility of uterine cavity anomalies in the women with preterm premature rupture of membranes (PPROM) was significantly higher than the women with normal pregnancy (OR=4.41, CI 95%: 0.9-21/63). About 3% of patients in the case group had undefined uterine anomalies. This anomaly was not in mentioned uterine anomalies classification of American fertility association. We did not observe such anomaly in control group. Conclusion: In conclusion, we found that the possibility of occurring PPROM in women with uterine cavity anomaly was four-fold more than women without these anomalies. Hence, we recommend women with history of PPROM to undergo diagnostic hysteroscopy for detecting uterine anomalies before next pregnancy.