Malignancy risk factors based on endometrial polyp

Introduction: Postmenopausal bleeding (PMB) is defined as bleeding that occurs after 1 year of amenorrhea in a woman who is not receiving hormone replacement therapy (HRT).1 About 10% of women with postmenopausal bleeding have a primary or secondary malignancy. Common malignancies among them are endometrial cancer (80%), cervical cancer or an ovarian tumour.1 Endometrial cancer is the second most common cancer associated with hereditary non-polyposis colorectal cancer.2 Ninety percent of patients have benign causes. Objective: The objective of this study was to determine the frequency of endometrial carcinoma in patients with post-menopausal bleeding. Study Design: Descriptive case series study. Setting: Department of obstetrics and gynaecology, Lady Willingdon, Lahore. Duration of Study: This study was conducted over a period of six months from 1st January 2009 to 30th June 2009. Subjects and Methods: 50 cases with postmenopausal bleeding. Results: During the period of this study a total number of 50 consecutive patients who met inclusion criteria were enrolled in the study. Ages of the patients who presented with PMB ranged between 48 years and 80 years with a mean age of 59 years. Malignancy was found in 18 out of 50 cases (36%).Cases with endometrial CA were 14 out of 50 cases (28%) and CA cervix constituted 4 out of 50 cases (8%). Benign pathology was more frequent (64%). 13 of 50 cases (26%) had hyperplasia out of which 1 case (2%) was of atypical hyperplasia. Endometrial polyp was found in 4 of 50 cases (8%). 3 of 50 cases (6%) had chronic endometritis. 5 of 50 cases (10%) had chronic cervicitis. While 7 cases (14%) had postmenopausal bleeding due to decubitus ulcer of uterovaginal prolapse. Among malignancies (36%), endometrial cancer is the most frequent malignancy in women with postmenopausal bleeding with mean age of 65years. Conclusion: In this study it was concluded that the majority of cases of PMB would be expected to be suffering from benign problems. The main aim of evaluation of cases of PMB is to exclude or identify endometrial or cervical carcinoma and atypical endometrial hyperplasia. Key Words: Postmenopausal bleeding, menopause, endometrial carcinoma.

Objective: To determine the prevalence of premalignant or malignant (atypical hyperplasia or endometrial cancer) disease that develops in polyps or coexist it and the relationship between the demographic and clinical characteristics of the patients and malignancy by examining the pathology results of patients who underwent hysteroscopy for a preliminary diagnosis of endometrial polyp. Patients and Methods: We retrospectively evaluated 527 patients whose preliminary diagnoses made by transvaginal ultrasonographic findings or with clinical suspicion and tissue samples taken by hysteroscopy between June 2012 and June 2017. The demographic and clinical data of patients who were reported as pathologic diagnosis of benign endometrial pathologies and premalign (polyp + atypical hyperplasia) or malign (polyp + endometrial cancer) were evaluated. Results: We detected endometrial polyp in 405 (76.8%) patients, polyp and endometrial hyperplasia without atypia in 51 (9.6%) patients, other benign conditions in 60 (11.3%) patients (leiomyoma uteri, proliferative/secretory/atrophic endometrium), polyp and atypical endometrial hyperplasia in 4 (0.8%) patients and endometrium adenocarcinoma in 7 (1.3%) patients. The incidence of premalignant or malignant disease associated with endometrial polyp was 2.1%. Conclusions: Endometrial polyps are quite common and are not often considered to be cancerous lesions but rarely associated with cancer, especially with advancing age. The most risky group of patients with endometrial polyps for endometrial cancer who have postmenopausal bleeding consists of those with additional risk factors for this malignancy. The management of endometrial polyp cases should be individualized considering the patient’s age, menopausal status, symptoms and clinical risk factors.

Postmenopausal bleeding is a clinically important complaint in general gynecologic practice. The incidence of spontaneous postmenopausal bleeding in the general population is approximately 10 % immediately after menopause, and 5 % in all menopausal women. The study was aimed to reveal the histopathologic diagnosis of postmenopausal uterine bleeding, and to investigate the correlation between various clinical factors and endometrial carcinoma. We also evaluated the role of endometrial volume calculation in the clinical use for the endometrial histopathologic findings. In this prospective observational study, we recruited 163 postmenopausal women with abnormal uterine bleeding from January 2008 through December 2010. Women who had hematologic disease, or had nonuterine pelvic diseases were excluded. Clinical characteristics such as age, body mass index (BMI), associated diseases, and previous postmenopausal hormone therapy were checked. They were evaluated by transvaginal ultrasonography and underwent endometrial biopsy for the endometrial histopathologic examination. Among the endometrial histopathologic findings, atrophic endometrium was the most common finding (32.7 %), followed by hyperplastic endometrium (10.4 %), endometrial carcinoma (10.4 %), and endometrial polyp (9.2 %). The prevalence of endometrial hyperplasia and cancer was not significantly different at the 5 mm cut-off thickness of the endometrium, but significantly higher in women with ≥ 3 mL of endometrial volume. However, the incidence of endometrial cancer and hyperplasia in women with endometrial bleeding was not significantly different with or without previous or current hormone therapy. Endometrial biopsy should be performed to exclude endometrial hyperplasia and carcinoma in postmenopausal women with endometrial bleeding to perform proper and prompt treatment, especially in old aged women (> 60 years) and in patients with endometrial volume ≥ 3 mL.

This study aimed to investigate risk factors of progression to endometrial cancer (EC) in women with non-atypical and atypical endometrial hyperplasia (EH). The data of 62,333 women with EH diagnostic codes from 2007 to 2018 were sourced from the Korean Health Insurance Review and Assessment Service databases. The data from 11,525 women with non-atypical EH and 2,219 women with atypical EH who met the selection criteria were extracted for analysis. Risk of EC in women with EH decreased in 40-49 year olds compared to other ages (non-atypical EH: [≤39 vs. 40-49 years] HR, 0.557; 95% CI, 0.439-0.708; P<0.001; [≤39 vs. ≥50 years] P = 0.739; atypical EH: [≤39 vs. 40-49 years] HR, 0.391; 95% CI, 0.229-0.670; P = 0.001; [≤39 vs. ≥50 years] P = 0.712). Risk of EC increased with increase in number of follow-up biopsies in women with non-atypical EH (1 biopsy: HR, 1.835; 95% CI, 1.282-2.629; P = 0.001; ≥2 biopsies: HR, 3.644; 95% CI, 2.585-5.317; P<0.001) and in women receiving ≥2 follow-up biopsies with atypical EH (HR, 3.827; 95% CI, 1.924-7.612; P = 0.001). Time of progression to EC decreased in women ≥50 years old with non-atypical EH compared to other ages (P = 0.004) and showed no differences among ages in women with atypical EH (P = 0.576). Progestational agents were a protective factor for EC in women with non-atypical EH (HR, 0.703; 95% CI, 0.565-0.876; P = 0.002). In this claim data analysis, women ≤39 and ≥50 years old with EH were at a high risk for progression to EC, and repeat follow-up biopsy after a diagnosis of EH increased detection of EC. Progestational agents were an effective modality to prevent EC in women with non-atypical EH.

Introduction: Exogenous or endogenous estrogen induces hyperplastic endometrium which presents with abnormal uterine bleeding. Atypical endometrial hyperplasia is the precursor for endometrial carcinoma. In case of invasive carcinoma, Rstrogen Receptor (ER) and Progesterone Receptor (PR) expressions are commonly diminished but their expressions are generally increased in high grade and high stage endometrial carcinomas. Vascular Endothelial Growth Factor (VEGF), a crucial promoter of angiogenesis in endometrial carcinogenesis, is associated with poor prognosis. This study is needed for assessment of biological behaviour of endometrial epithelial neoplasms and application of targeted antiangiogenic therapy. Aim: 1. Immunohistochemical expression of ER, PR, and VEGF in normal endometrium, hyperplastic endometrium and endometrial carcinoma. 2. Association of the changes in immunohistochemical expression with grade and stage of endometrial carcinoma. Materials and Methods: The present cross-sectional, non interventional, retrospective study was conducted in the Department of Pathology along with Department of Obstetrics and Gynaecology of N R S Medical College, Kolkata, from 1st January 2018 to 30th June 2019 comprising of 51 cases. In the present study, histopathological diagnosis was made for each endometrial lesion with grading and staging of endometrial carcinoma followed by immunohistochemical evaluation, performed on the representative sections using monoclonal antibody. Chi-square test and Z-test were used to observe the association of different study variables and to see the significant difference between two proportions. The p value of&lt;0.05 was taken as statistically significant. Results: Out of 51endometrial samples, eight cases had proliferative endometrium, 14 cases had endometrial hyperplasia without atypia, five cases had atypical endometrial hyperplasia and 24 cases had endometrial carcinoma. ER and PR expression was seen less in endometrial hyperplasia and endometrial carcinoma than in benign proliferative endometrium and there was statistically significant association present between PR expression and histopathological diagnosis. All cases of grade-1 endometrial carcinoma showed ER and PR positivity and decreasing expression in higher grades-2 and 3, but were not statistically significant. Expression of VEGF in the groups of endometrial carcinoma (91.7%) and atypical hyperplasia (80%) was significantly increased in comparison with the groups of normal proliferative endometrium (37.5%) showing a significant statistical association. VEGF expression had no statistical association with grade and stage of endometrial carcinoma. Conclusion: ER, PR and VEGF were effectively associated with prognosis in patients with endometrial carcinoma.

The aim of present study was to determine expression of cyclin E in endometrial hyperplasia without atypia, atypical endometrial hyperplasia and endometrial cancers in comparison with expression of cyclin E in atrophic endometrium of postmenopausal women. We have also estimated relationship between cyclin E expression and prognostic factors for endometrial cancer such as: histological type, cancer stage and histological grade. 154 women were enrolled into study Women were divided into 4 groups. The first group consist of 38 women with endometrial hyperplasia without atypia, the second group consist of 18 women with atypical endometrial hyperplasia. The third group comprise 62 women with endometrial cancer and the forth 36 women with atrophic endometrium. Cyclin E expression was estimated in formalin-fixed, paraffin-embedded tissues obtained from enrolled women with the use of immunohistochemical techniques. We estimated labelling index (LI) - the number of cells that stained for cyclin E in relation to all cells at the certain field of view. Medians of labelling indices of cyclin E in atrophic endometrium, endometrial hyperplasia with atypia, atypical endometrial hyperplasia end endometrial cancer were 13.7%, 34.7%, 62%, 72.2% respectively These differences were statistically significant. In our study we haven't found relationship between cyclin E expression and histological type of tumour (p = 0.186), cancer stage (p = 0.186) and histological grade (p = 0.539) CONCLUSIONS: In the carcinogenesis of endometrial tumours in postmenopausal women there is a progressive disorder in mechanisms regulating cell cycle. It seems impossible to use cyclin E as prognostic factor for endometrial cancer.

Objective To explore the clinical efficacy and safety Diane-35 and metformin combined treatment for endometrial atypical hyperplasia (EAH) and early endometrial carcinoma (EEC) in polycystic ovary syndrome (PCOS) patients. Methods PCOS patients with endometrium lesion were re-cruited. All patients were treated with Diane-35 (1 tablet per day, for 21 d per month) plus metformin (1 000 mg, qd) for 6 months. Endometrial biopsies for pathological evaluation before, during and after treatment were conducted. Other clinical parameters included body weight (BW), body mass index (BMI), follicle-stimulating hormone (FSH), luteinizing hormone (LH), total testosterone (TT), sex hormone-binding globulin (SHBG), free androgen index (FAI), insulin area under curve (IAUC), homeostasis model assessment of insulin resistance (HOMA-IR) were detected as well. After successful conversion of endometrial lesions, we continued to give patients with Dydrogesterone (10 mg/d, for 14 d per month) and metformin. Results Totally 43 PCOS patients with endometrium lesion (30 EAH and 13 EEC) were re-cruited. After 6-month treatment, the endometrium in all PCOS patients was confirmed by pathological evaluation to be reversed to normal epithelia with Diane-35 plus metformin treatment. By the end of 6-month treatment, mean BMI, TT, FAI, HOMA-IR were decreased respectively (P<0.05), while SHBG were increased (P<0.05). The complete response (CR) rate was 100%. During 6-18 months of follow-up, 2 EAH patients relapsed, and both of whom did not continue to use progesterone therapy monthly; 2 EEC relapsed, who had complicated with ovary tumor. Conclusion Diane 35, a low-dose oral contraceptives with anti-androgen activity, when used in combination with metformin can completely revert the EEC and EAH to normal endometrial cell in PCOS patients, even in those who have been failure to high-dose progestin treatment before. Diane-35 with metformin combination treatment may be a good choice for the EAH and EEC in PCOS patients, which enables these patients to preserve the fertility. Key words: Polycystic ovary syndrome (PCOS); Endometrial atypical hyperplasia (EAH); Early endometrial carcinoma (EEC); Diane-35 combined with metformin

Guideline No. 447: Diagnosis and Management of Endometrial Polyps

Aim. To determine the informativeness of genealogical and morphological characteristics of patients with endometrial hyperplasia and cancer. Methods. Clinical and genealogical analysis, mathematical and statistical method, method of selection of informative factors – Kullback informativeness criterion. Results. Information about the health of 243 first- and 413 second-degree relatives was received from 50 patients with endometrial hyperplasia. Data on 2026 first- and 3685 second-degree relatives was also obtained from 413 patients with endometrial cancer. It was found that the most significant clinical indicators (I&gt;0,5) for risk of endometrial cancer are the next: age over 60 years (I=2,76); presence of cancer of female reproductive organs and gastrointestinal tract in pedigrees of patients with atypical hyperplasia (I=1,51); duration of menopause more than 11 years (I=1,40); dysfunctional uterine bleeding (I=0,85); III–IV class of obesity (I=0,59); bleeding in menopause (I=0,55). Conclusions. Predicative effectiveness of studies of family histories of patients with atypical endometrial hyperplasia was substantiated that has clinical value and allow assessing the personalized risk of endometrial cancer. Keywords: endometrial hyperplasia and cancer, clinical and genealogical analysis, pedigrees.

In women with endometrial hyperplasia, there is a risk for co-existent endometrial cancer when patients are subjected to immediate surgical treatment. The aim of this study was to investigate the frequency of endometrial cancer and the accuracy of frozen section analysis at the time of hysterectomy among patients with endometrial hyperplasia, to reveal whether or not a preoperative diagnosis of endometrial hyperplasia necessitates frozen section consultation. Retrospective cross-sectional study. A department database review was performed to identify patients who were subjected to hysterectomy with a preoperative diagnosis of endometrial hyperplasia, during the period from 2007 to 2014. The study group included 189 cases. The final pathological examination revealed endometrial cancer in 16 women (8.4%). The risk of cancer in patients with endometrial hyperplasia was 1 of 125 (0.8%) in simple hyperplasia without atypia, 1 of 21 (4.8%) in complex hyperplasia without atypia and 14 of 43 (32.5%) in atypical hyperplasia. Of women with cancer, 2 of 16 (12.5%) had high-risk features. Frozen section analysis was requested in 46 cases. Frozen sections helped to identify six out of 11 cases of endometrial cancer (54.5%). The sensitivity, specificity and positive and negative predictive values of frozen section analysis for the detection of endometrial cancer among women with endometrial hyperplasia were 54.4%, 97.2%, 85.7% and 87.5%, respectively. Although a significant proportion of patients with atypical endometrial hyperplasia are diagnosed with endometrial cancer following hysterectomy, most of these cases have low-risk features and do not require surgical staging. Additionally, intraoperative frozen section analysis if not helpful for diagnosing concurrent endometrial cancer in patients with endometrial hyperplasia. Therefore, it seems that patients with endometrial hyperplasia can be operated upon in settings with no available method for obtaining frozen sections intraoperatively.

The endometrial–myometrial junction: a fresh look at a busy crossing

OBJECTIVE: To compare endometrial biopsy results in patients with postmenopausal bleeding or menometrorrhagia METHOD: A retrospective analysis of probe curettage performed by a single doctor for diagnostic purposes in symptomatic patients at Yozgat Sorgun State Hospital between January 2015 and June 2016 RESULTS: The results of 128 patients were evaluated. The mean age of 14 menopausal patients and 114 premonopausal women were 56.6 + 9.3 and 44 + 6.7, respectively. The endometrial thickness was statistically significantly thicker in premenopausal than postmenopausal patients. The most common pathologies in symptomatic premenopausal women were endometrial polyp and endometrial atrophy. In postmenopausal patients, normal pathologic result, endometrial polyp, cervical polyp were observed equally. No endometrial carcinoma was detected in any case. CONCLUSION: The menstrual cycle normally lasts for 28 ± 7 days. Vaginal bleeding occurs approximately 2-6 days. The amount of bleeding is circa 20-60 ml. Any deviation from these values is called menstrual disorders. Menometrorrhage defines intermenstruel bleeding together with bleeding more than 80 ml and six days. Menometrorrhagia can be a symptom of many different spectrum of diseases. These diseases may also change with aging. In particular, endometrium cancer may occur with this symptom. Menorrhagia can also be seen in cases such as endometrial polyps, endometrial hyperplasia, endometrial atrophy, endometritis, submucous myomas, adenomyosis, ovarian cysts, haemostasis diseases. Postmenopausal vaginal bleeding occurs after the ceasing of menstruation for one year. Endometrial atrophy, endometrial polyp, endometrium cancer, hormone replacement therapy, endometrial hyperplasia, other genital cancers may be the causes of postmenopausal bleeding. It is interesting that no case of cancer has been detected in our study. However, pathologies such as endometrial polyps, endometrial hyperplasia, and cervical polyps were detected and treated at the same time. Endometrial biopsy in symptomatic pre- and postmenopausal patients is effective not only in cancer diagnosis but also in the diagnosis and treatment of benign conditions.

Endocervical polyps are benign, pedunculated growths from the cervix. They are usually an incidental finding on examination of the cervix, though sometimes they can cause intermenstrual or postcoital bleeding. We present two case reports of asymptomatic endocervical polyps. In the first case, the endocervical polyp was noted in the colposcopy clinic. The woman had been referred with a mild dyskaryotic smear. Histology of the polyp showed CIN 2 and 3. In the second case, the polyp showed severe dysplasia. Hysteroscopy was performed to rule out endometrial carcinoma. CIN 3 can progress to invasive cancer in 12 % of cases. Atypical endometrial hyperplasia is an ominous finding on histology. 10-20% of all cases with atypia will have an underlying carcinoma. Invasive cancer develops in up to 50% of cases. As far as we are aware, these are the first case reports of CIN 3 and severe dysplasia reported in endocervical polyps. We recommend that all asymptomatic endocervical polyps be removed and sent for histological examination. CASE REPORT 1 A 46 year old, P0+0, was referred to the colposcopy clinic with a mildly dyskaryotic smear. She had no intermenstrual or postcoital bleeding or any other symptoms. She had regular menstrual cycles. She was on the combined contraceptive pill. She had no significant past medical or surgical history and was a non-smoker. On colposcopy, the entire squamocolumnar junction was seen. Colposcopy was complete with a type 1, small transformation zone. There were no acetowhite or iodine negative areas. There was a small 1 cm by 1 cm long endocervical polyp, which was removed and sent for histology. Histology of the polyp showed extensive squamous metaplasia. Squamous epithelium on the surface and the lining crypts showed cytological atypia indicating CIN 2 and focal CIN 3. The patient was recalled to the colposcopy clinic. She had a large loop excision of the transformation zone (LLETZ) under local anaesthetic. The histology of the loop specimen showed CIN 3 with complete excision. CASE REPORT 2 A 57-year-old woman, P2+0, was referred by to the gynaecology clinic with an endocervical polyp. The polyp had been noted by her GP while taking a routine cervical smear. She had no symptoms. She was postmenopausal with no significant past medical or surgical history. She was not on HRT. The polyp was removed in the gynaecology outpatient clinic and sent for histological examination. Histology reported the polyp as an endometrial polyp in which a few glands showed severe dysplasia with severe cytological atypia. The patient was recalled to the clinic. She had a hysteroscopy examination, which showed multiple endometrial polyps. The polyps were removed. Histology showed benign endometrial polyps. DISCUSSION Endocervical polyps are small, pedunculated growths of the endocervix. It is the most common cervical growth especially in the multigravids. It is usually asymptomatic and found incidentally. Occasionally the polyp may cause Should All Asymptomatic Endocervical Polyps Be Removed: Two Case Reports 2 of 3 intermenstrual, postcoital or postmenopausal bleeding. On histology, the polyp is characterised by overgrowth of benign stroma covered by epithelium. Endocervical polyps are covered by endocervical, squamocolumnar or squamous metaplastic epithelium. The clinical behaviour is essentially benign. In the first case, the histology of the endocervical polyp showed CIN 2 to CIN 3. The colposcopy was normal and did not show any acetowhite changes. The UK guidelines for colposcopy suggest a colposcopy and punch biopsy for mild dyskaryosis but a ‘see and treat' policy for higher-grade abnormal cervical smears.1 CIN 3 can progress to invasive cancer in 12 % of cases. Regression rates without treatment are only 32% and persistence rates about 56%.2 The CIN 3 would have been missed had the polyp not been removed. In the second case, histology of the endocervical polyp was reported as an endometrial polyp with severe dysplasia with atypia. Atypical endometrial hyperplasia is an ominous finding on histology. 10-20% of all cases with atypia will have an underlying carcinoma. Invasive cancer develops in up to 50% of cases.3 Hysteroscopy was performed to rule out adenocarcinoma. Hysteroscopy showed presence of multiple, benign endometrial polyps. We recommend that all asymptomatic endocervical polyps should be removed and sent for histological examination.

Endometrial cancer is the fifth most common cancer in women and atypical endometrial hyperplasia is a precancerous lesion. Obesity is an important risk factor for endometrioid endometrial adenocarcinoma and endometrial hyperplasia. Progesterone is recommended as first-line treatment in endometrial cancer or atypical endometrial hyperplasia in women who wish to preserve fertility, but optimal treatment schedules have not been defined. Metformin or bariatric surgery may also be useful in these women. The effectiveness and safety of fertility-preserving treatments being used for women with atypical endometrial hyperplasia and stageIA grade1 endometrial cancer is unclear. Therefore, the systematic review aims to determine this point. We will search the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trial registers, conference proceedings, abstracts, cooperative trial groups and reference lists. We will include randomised controlled trials (RCTs) that compare fertility-preserving therapy including orally administered progesterone versus a levonorgestrel-releasing intrauterine system (IUS), metformin, other pharmacological interventions or bariatric surgery, and any of these interventions with womb-removing surgery. Quasi-randomised trials, non-randomised trials and cohort studies will be included. Two review authors will independently assess study eligibility and risk of bias and extract data. The primary outcomes are complete pathologic response and live birth rate. Secondary outcomes include overall survival, progression-free survival, pregnancy rate, need for hysterectomy, adverse events, psychological symptoms and quality of life. This review aims to clarify the effectiveness and risks of fertility-preserving treatments, including complete pathologic response rate, live birth rates, need for surgical treatment, adverse events, psychological symptoms and quality of life. The broad scope of the review includes the use of progesterone, metformin to reverse insulin resistance, and bariatric surgery or operative hysteroscopy. The results may help to determine the optimal fertility-sparing treatment in endometrial cancer and atypical endometrial hyperplasia. Prospero 2019 number CRD42019145991.

Diagnostic hysteroscopy can be used to directly investigate intrauterine lesions and localize them for biopsy, so it is more intuitive, accurate, and reliable than traditional diagnostic dilatation and curettage (D&C), hysterosalpingography (HSG), and ultrasonography. Hysteroscopy can reduce the rate of missed diagnosis, significantly improve the accuracy of diagnosis, and has been reputed to be the golden standard of modern diagnosis of intrauterine lesions. Dotto et al. classified the endometrial images under hysteroscope into five categories: normal endometrium, benign lesions, low-risk endometrial hyperplasia, high-risk endometrial hyperplasia, and endometrial cancer, which were highly consistent with the findings of endometrial biopsy. Clark et al. reviewed 65 articles and studied the accuracy of hysteroscopy in diagnosis of endometrial cancer and hyperplasia in women with abnormal uterine bleeding. They found that in all patients included, the pretest probability of endometrial cancer was 3.9%, which was increased to 71.8% by a positive result of hysteroscopy and was reduced to 0.6% by a negative result. Thus, it was considered that the accuracy of hysteroscopy for endometrial cancer was high, but was only applicable to endometrial disease. Agostini et al. made a review and analysis of 17 cases who were diagnosed pathologically to have endometrial atypical hyperplasia after hysteroscopic resection. One case was discovered to have endometrial adenocarcinoma, with the risk of 5.9% (1/17). Nowadays, diagnostic hysteroscopy has become a new and valuable gynecological diagnostic technique. Applications of micro-devices and non-invasive techniques have expanded the use of hysteroscopy from out-patient clinic to movable stations. Nagele et al. suggested that outpatient hysteroscopy had a high detection rate for intrauterine lesions and simple hysteroscopic surgeries could be performed at the same time. Therefore, just as D&C in the twentieth century, hysteroscopy has been considered as a routine method for diagnosis of intrauterine lesions in the twenty-first century.