Outcomes in women age 40 years and older with cytologically benign endometrial cells

Research www.AJOG.org

GENERAL GYNECOLOGY

Outcomes in women age 40 years and olderwith cytologically benign endometrial cellsPetra M. Casey, MD; Mary M. Gallenberg, MD; Thomas M. Kastner, MD; Brigitte A. Barrette, MD;Paula D. M. Chantigian, MD; Lynne T. Shuster, MD; Kathy L. MacLaughlin, MD;Sumer K. Allensworth, MD; Amy L. Weaver, MS

OBJECTIVE: We sought to estimate cytologically benign endometrialcell (CBEC)-associated endometrial hyperplasia and cancer rates, anddescribe clinical and histologic outcomes.

STUDY DESIGN: Medical records of women age �40 years with CBECin 2005 through 2010 were reviewed for clinical characteristics; as-sessment with endometrial biopsy, ultrasound, or hysteroscopy; andconsequent outcomes.

RESULTS: Of 658 women, 281 (42.7%) were assessed: 39.4% of 330premenopausal, and 46.0% of 328 postmenopausal women. Amongthese, cancer rate was 3.6% and differed between premenopausal
(0.8%) and postmenopausal (6.0%) women (P � .019). Hyperplasia
Obstet Gynecol 2012;207:379.e1-6.

dil

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http://dx.doi.org/10.1016/j.ajog.2012.08.018

rate was similar in premenopausal (3.9%) and postmenopausal (3.3%)women. Of 20 assessed women with endometrial pathology, 4 (1 pre-menopausal) women with cancer and 4 (2 premenopausal) women withhyperplasia had no abnormal bleeding.

CONCLUSION: Cancer was more common in postmenopausal womenwith assessed CBEC while hyperplasia was comparably distributed be-tween premenopausal and postmenopausal women. Findings supportCBEC assessment regardless of menopausal status or abnormalbleeding.

Key words: cytologically benign endometrial cells, endometrial
cancer, endometrial hyperplasia
Cite this article as: Casey PM, Gallenberg MM, Kastner TM, et al. Outcomes in women age 40 years and older with cytologically benign endometrial cells. Am J

Csp

The finding of cytologically benignendometrial cells (CBEC) outside

the proliferative phase of the menstrualcycle in premenopausal women or atanytime in postmenopausal women hasbeen associated with endometrial malig-nancy.1-3 This association has been re-

From the Departments of Obstetrics andGynecology (Drs Casey, Gallenberg, Kastner,Barrette, and Chantigan), Internal Medicine (DrShuster), and Family Medicine (DrMacLaughlin), the Women’s Health Clinic (DrShuster), and the Division of BiomedicalStatistics and Informatics (Ms Weaver), MayoClinic, Rochester, MN, and the Obstetrics andGynecology Residency Program, University ofColorado, Denver, CO (Dr Allensworth).

Received May 4, 2012; revised July 11, 2012;accepted Aug. 8, 2012.

The authors report no conflict of interest.

Presented as a poster at the Biennial ScientificMeeting of the American Society forColposcopy and Cervical Pathology, SanFrancisco, CA, March 15-17, 2012.

Reprints: Petra M. Casey, MD, Mayo Clinic,200 First St. SW, Rochester, MN [email protected].

0002-9378/$36.00© 2012 Mosby, Inc. All rights reserved.

ported as uncommon in premenopausalwomen.4 Simsir et al5 reported 1 of 96premenopausal women with CBEC andabnormal vaginal bleeding was found tohave complex endometrial hyperplasiawith atypia.

While most women with endometrialmalignancy present with abnormal vag-inal bleeding, 1 series reported that 2.1%of premenopausal women had CBEC asthe only sign of endometrial pathology.6

Among postmenopausal women withCBEC, Simsir et al5 noted an 8% inci-

ence of endometrial pathology and 5%ncidence of endometrial cancer. Of theatter, 33% women were asymptomatic.5

Some studies report an association be-tween CBEC and hormone therapy,while others do not.5,7 Further, an in-creased incidence of endometrial malig-nancy has been shown in women withCBEC using tamoxifen.8

There are few large studies focusing onthe assessment and outcomes of CBEC.The largest series reported by Moroneyet al6 had a 15% (370/2494) rate of endo-

etrial sampling for CBEC. While sev-ral studies suggest endometrial sam-

ge �40 years with

NOVEMBER 2012 Americ

BEC,6,9 others support sampling forymptomatic premenopausal and allostmenopausal women only.1,5,10,11

The 1991 Bethesda System for cytologicabnormalities recommended reportingCBEC in postmenopausal women only.12

The Bethesda 2001 System modifiedCBEC reporting to include all women �40yearsbecausemenopausal statusandexog-enous hormone use are often unknown orunclear in perimenopausal women.13 TheBethesda 2006 System affirmed CBEC re-porting in women �40 years, noting that0.5-1.8% of cervical cytology specimensfrom this group will include endometrialcells.14

In our study, we estimate the rate ofendometrial malignancy and hyperpla-sia in a large cohort of US women withassessment for CBEC. We describe theclinical presentation, current manage-ment, and outcomes of CBEC, therebyproviding a view of clinical practicepatterns.

MATERIALS AND METHODSCervical cytology performed at MayoClinic from Jan. 2, 2005, through Oct.
20, 2010, and reported as “benign endo-
an Journal of Obstetrics & Gynecology 379.e1

mailto:[email protected]

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Research General Gynecology www.AJOG.org

metrial cells present in women age 40and older” was reviewed. As part of clin-ical practice, the date of last menses wasprovided to the pathologist, allowing re-porting of CBEC in women not currentlymenstruating (termed “out of phase”)and all postmenopausal women.

Women with a history of hysterec-tomy at the time of the cervical cytologyand women who denied access to theirmedical records for research purposeswere excluded. Medical record reviewswere completed by 1 of 8 physician in-vestigators. An initial subset of medicalrecords was reviewed by multiple in-vestigators for assessment of reliabilityand internal validity of the data collec-tion instrument. The study was ap-proved by the Mayo Clinic Institu-tional Review Board.

Medical records were abstracted forage, parity, race, body mass index (BMI),contraception, menopausal status, hor-mone therapy, presence and duration ofvaginal bleeding, and clinical risk factorsfor endometrial pathology including di-abetes, hypertension, and polycysticovary syndrome at the time of first CBEC(index).

Women were classified as having ab-normal bleeding if they were premeno-pausal and had reported bleeding otherthan menses; postmenopausal, receivinghormone therapy, and had reportedbleeding other than withdrawal bleed-ing; or postmenopausal and receivinghormone therapy without cyclic with-drawal bleeding or not receiving hor-mone therapy and had reported any vag-inal bleeding. Diagnostic assessmentmodalities and indicated interventionscompleted within 2 months before or atanytime following the index CBEC wereabstracted. Assessment included �1 ofthe following: endometrial sampling, pel-vic ultrasound, hysteroscopy, dilation andcurettage, or hysterectomy. The 2-monthpreindex CBEC inclusion interval reason-ably assured that only assessment perti-nent to CBEC were included. Endometrialhyperplasia and cancer as well as findingspertinent to vaginal bleeding such as endo-metrial polyp, fibroids, and thickenedendometrium were reported. Thickenedendometrium was defined as �4-mm

ouble-layer thickness in postmenopausal

379.e2 American Journal of Obstetrics & Gynecolo

omen only.13 There is no clear definitionof thickened endometrium in premeno-pausal women, therefore it was not in-cluded among the abnormal findings forthis group. In the subset of women withendometrial pathology, medical and surgi-cal outcomes were collected along with adescription of clinical symptoms includingabnormal vaginal bleeding where present.The case of the less common nonendo-metrioid cancer received a confirmatorypathologic review. The subset of womenwith repeated CBEC was reviewed to de-scribe evaluation and outcomes.

All information was recorded ina Research Electronic Data Capture(REDCap) database. REDCap is a secureWorld Wide Web–based application forcapturing and managing research studydata.15 The data were summarized usingtandard descriptive statistics, includingrequency and percentage, mean, SD, me-ian, and interquartile range (IQR). Pa-ient characteristics at the time of the indexBEC were compared between postmeno-ausal and premenopausal women usinghe2-sample t test forageandthe�2 test forhe categorical variables. The percentage ofomen with abnormal findings was com-ared between postmenopausal and pre-enopausal women using the �2 test. A

2-sided P value � .05 was considered sta-tistically significant. Analysis was per-formed using a software package (SAS,version 9.2; SAS Institute Inc, Cary, NC).

RESULTSA total of 658 women met the study in-clusion criteria. At index CBEC, 330(50.2%) women were premenopausaland 328 (48.8%) were postmenopausal.Their clinical characteristics are summa-rized in Table 1. Of the women included,281 (42.7%) had assessment with �1 ofthe following: pelvic ultrasound, endo-metrial biopsy, or hysteroscopy. Of thosewith assessment, 130 women were pre-menopausal (39.4% of all premeno-pausal women) and 151 were postmeno-pausal (46.0% of all postmenopausalwomen). Based on these 281 women, themedian interval from the index CBEC tostart of assessment was 1 day (IQR, 0 –20days). The median interval to comple-
tion of assessment was 9 days (IQR, 0 –39 1
gy NOVEMBER 2012

days). An additional 111 women hada repeat cervical cytology only, 118women had a clinical visit only, and 148did not have further relevant health careprovider contact at Mayo Clinic.

The results of post-CBEC assessmentare summarized in Table 2. Of the 658women, endometrial biopsy was ob-tained in 213 (32.4%), while 83 (12.6%)had hysteroscopy and 165 (25.1%) hadultrasound. All patients with endome-trial pathology had endometrial biopsyobtained with or without hysteroscopicguidance. A comparable proportion ofabnormal ultrasound and endometrialbiopsy findings and a higher proportionof abnormal hysteroscopic findings werenoted in the postmenopausal group ascompared to the premenopausal group(P � .037).

In the 330 premenopausal women,bleeding status was not recorded in 21.Of these, 6 had assessment, which wasabnormal in 2 (33.3%) women. Another260 premenopausal women had no ab-normal bleeding as defined in the “Ma-terials and Methods” section. Of these,77 had assessment, which was abnormalin 27 (35.1%) women. Of the remaining49 premenopausal women who pre-sented with abnormal bleeding, 47 hadassessment, which was abnormal in 20(42.6%) women.

In the 328 postmenopausal women,bleeding status was not recorded in 5. Ofthese, 2 had assessment, which was abnor-mal in 1 woman. Another 264 postmeno-pausal women had no abnormal bleedingas defined in the “Materials and Methods”section. Of these, 94 had assessment, whichwas abnormal in 27 (28.7%) women. Theremaining 59 postmenopausal womenpresented with abnormal bleeding. Ofthese, 55 had assessment, which was ab-normal in 30 (54.6%) women.

The specific abnormal findings for the49 premenopausal and 58 postmeno-pausal women with abnormal outcomesare summarized in Table 3. Endometrialhyperplasia (n � 10) or cancer (n � 10)

as identified in 6 premenopausal and 14ostmenopausal women with assessments summarized in Table 4. Four womenith endometrial cancer had no abnormalaginal bleeding at index CBEC, including
premenopausal woman. Four women

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with endometrial hyperplasia had no ab-normal vaginal bleeding at index CBEC,including 2 premenopausal women.Therefore, 8 of 20 (40.0%) women, 3 of 6(50%) premenopausal and 5 of 14 (35.7%)postmenopausal, with endometrial pa-thology had no abnormal vaginal bleedingat index CBEC. Within the subset of 171women with assessment and no abnormalbleeding, 2.9% had endometrial pathol-ogy. Within the same subset, 3 (2.3%) ofthe 77 premenopausal and 5 (3.3%) of the94 postmenopausal women had endome-trial pathology.

In women with CBEC and assessment(n � 281), the rate of endometrial cancerwas 3.6% (95% confidence interval, 1.4 –5.7%). This rate was higher in post-menopausal as compared to premeno-pausal women (6.0% vs 0.8%; P � .019).

he rate of endometrial hyperplasia inomen with CBEC and assessment was.6%: 3.9% in premenopausal and 3.3%n postmenopausal women.

Among the 130 premenopausal and51 postmenopausal women with assess-ent, there was a tendency for thoseith elevated BMI to have endometrialathology. Specifically, 4 of 42 (9.5%)remenopausal women with BMI �30g/m2 had endometrial hyperplasia or

cancer, as compared to 2 of 88 (2.3%)premenopausal women with BMI �30kg/m2 (�2 test, P � .065). Similarly, en-

ometrial hyperplasia and cancer ratesf 12.7% and 6.5%, respectively, wereeported for these 2 BMI categoriesn postmenopausal women (�2 test,

P � .19).Four (of 5) postmenopausal women

with hyperplasia and no postmenopausalwoman with cancer used hormone ther-apy at index CBEC. None of the premeno-pausal women with endometrial pathol-ogy used hormonal contraception.

A total of 6 women had a repeat cervi-cal cytology indicating CBEC at least 1month after index CBEC. Of the 4 pre-menopausal women, 1 had a hysteros-copy that identified endometrial polypsand a normal endometrial biopsy. Theother 3 premenopausal women had nofurther assessment. Of the 2 postmeno-pausal women, both had thickened en-dometrium on ultrasound and normal
endometrial biopsies.
TABLE 1Patient characteristics at index cytologically benign endometrial cells

CharacteristicTotal(n � 658)

Premenopausal(n � 330)

Postmenopausal(n � 328)

P valuea

(n � 658)

Mean age, y (SD) 53.5 (7.6) 49.2 (3.8) 57.9 (7.9) � .001.....................................................................................................................................................................................................................................

Age range, y 40.0-91.8 40.0-58.4 40.5-91.8..............................................................................................................................................................................................................................................

Nulliparous, n (%) 97 (14.7) 51 (15.5) 46 (14.0) .60..............................................................................................................................................................................................................................................

Race, n (%) .86.....................................................................................................................................................................................................................................

White 617 (93.8) 307 (93.0) 310 (94.5).....................................................................................................................................................................................................................................

Non-white 23 (3.5) 11 (3.4) 12 (3.7).....................................................................................................................................................................................................................................

Not recorded 18 (2.7) 12 (3.6) 6 (1.8)..............................................................................................................................................................................................................................................

BMI, kg/m2, n (%) .083.....................................................................................................................................................................................................................................

�25 243 (36.9) 136 (41.2) 107 (32.6).....................................................................................................................................................................................................................................

25-29.9 202 (30.7) 98 (29.7) 104 (31.7).....................................................................................................................................................................................................................................

�30 207 (31.5) 95 (28.8) 112 (34.2).....................................................................................................................................................................................................................................

Not recorded 6 (0.9) 1 (0.3) 5 (1.5)..............................................................................................................................................................................................................................................

Contraception at index CBEC,n (%)

—

.....................................................................................................................................................................................................................................

Yes 161 (48.8)............................................................................................................................................................................................................................

Combined hormonal 27/161 (16.8)............................................................................................................................................................................................................................

Progestin 8/161 (5.0)............................................................................................................................................................................................................................

Nonhormonal 110/161 (68.3)............................................................................................................................................................................................................................

Other 16/161 (9.9).....................................................................................................................................................................................................................................

No 58 (17.6).....................................................................................................................................................................................................................................

Not recorded 111 (33.6).....................................................................................................................................................................................................................................

HT at index CBEC, n (%) 129 (39.3) —............................................................................................................................................................................................................................

Systemic combined HT 89/129 (68.9)............................................................................................................................................................................................................................

Systemic ET 6/129 (4.7)............................................................................................................................................................................................................................

Local ET 24/129 (18.6)............................................................................................................................................................................................................................

Tamoxifen 8/129 (6.2)............................................................................................................................................................................................................................

Other HT 2/129 (1.6)..............................................................................................................................................................................................................................................

Abnormal bleeding at indexCBEC, n (%)b

.42

.....................................................................................................................................................................................................................................

Yes 108 (16.4) 49 (14.8) 59 (18.0).....................................................................................................................................................................................................................................

No 524 (79.6) 260 (78.8) 264 (80.5).....................................................................................................................................................................................................................................

Not recorded 26 (4.0) 21 (5.4) 5 (1.5)..............................................................................................................................................................................................................................................

Comorbidities, n (%).....................................................................................................................................................................................................................................

Diabetes mellitus 41 (6.2) 18 (5.5) 23 (7.0) .41.....................................................................................................................................................................................................................................

Hypertension 131 (19.9) 41 (12.4) 90 (27.4) � .001.....................................................................................................................................................................................................................................

PCOS 5 (0.8) 4 (1.2) 1 (0.3) .18..............................................................................................................................................................................................................................................

BMI, body mass index; CBEC, cytologically benign endometrial cells; ET, estrogen therapy; HT, hormone therapy; PCOS,polycystic ovary syndrome.a Comparisons between 2 groups were evaluated based on 2-sample t test for age and �2 test for all other patient characteristics.

Patients with “not recorded” values were excluded from each comparison; b Women were classified as having abnormal bleedingif they were premenopausal and had reported bleeding other than menses; postmenopausal, receiving HT, and had reportedbleeding other than withdrawal bleeding; or postmenopausal and receiving HT without cyclic withdrawal bleeding or not receivingHT and had reported any vaginal bleeding.

Casey. Outcomes of women over age 40 years with cytologically benign endometrial cells. Am J Obstet Gynecol 2012.

NOVEMBER 2012 American Journal of Obstetrics & Gynecology 379.e3

b

ically


COMMENTIn a large cohort of 658 US women age�40 years with CBEC, 42.7% receivedassessment for CBEC, a higher propor-tion in comparison with the largest pre-viously reported cohort.6

In women with CBEC and assessment,the rate of endometrial cancer was 3.6%and was higher in the postmenopausalgroup. The rate of endometrial hyper-plasia in women with CBEC and assess-ment was comparable in premenopausaland postmenopausal groups. These find-ings are consistent with rates of cancerand hyperplasia in women with CBECand assessment reported in prior stud-ies4,5 and support the recommendation

y Moroney et al6 and Fadare et al9 that aconsistent assessment strategy be ad-

TABLE 2Assessment of index cytologically

Assessment type

Of 330 premenopauswomen with CBEC

No. ofpatientsa

No. (%) owith abnfindingsb

Ultrasound 84 29 (34.5)...................................................................................................................

Hysteroscopy 42 14 (33.3)...................................................................................................................

Endometrial biopsy 100 21 (21.0)...................................................................................................................

CBEC, cytologically benign endometrial cells.a Some patients had �1 evaluation modality; b Includes thick

endometrial polyp, fibroid, endometrial hyperplasia, or endo

Casey. Outcomes of women over age 40 years with cytolog

TABLE 3Outcomes in women with cytologicendometrial cells and assessment

OutcomePremenopano. (% of 1

Endometrial cancer 1 (0.8)...................................................................................................................

Hyperplasia..........................................................................................................

Complex, with atypia 1 (0.8)..........................................................................................................

Complex, without atypia 1 (0.8)..........................................................................................................

Simple, without atypia 3 (2.3)...................................................................................................................

Thickened endometrium N/A...................................................................................................................

Polyp 20 (15.4)...................................................................................................................

Fibroids 23 (17.7)...................................................................................................................

Overall 49 (37.7)...................................................................................................................

N/A, not applicable.

Casey. Outcomes of women over age 40 years with cytologically


opted regardless of menopausal status inwomen �40 years with CBEC.

Four of 10 findings of hyperplasia and4 of 10 findings of cancer were not asso-ciated with abnormal bleeding, and therate of abnormal assessment was compa-rable in premenopausal and postmeno-pausal women with CBEC in the pres-ence and absence of abnormal bleeding.Further, the rate of endometrial pathol-ogy in premenopausal (2.3%) and post-menopausal (3.3%) women with assess-ment and no abnormal vaginal bleedingwas consistent with prior reports.5,6

CBEC rate unaccompanied by abnormalbleeding yet associated with endometrialpathology was frequent in both premeno-pausal and postmenopausal women con-sistent with Simsir et al.5 Our findings

ign endometrial cells

Of 328 postmenopausalwomen with CBEC

atientsal No. of

patientsa

No. (%) of patientswith abnormalfindingsb

81 38 (46.9)..................................................................................................................

41 23 (56.1)..................................................................................................................

113 23 (20.4)..................................................................................................................

endometrium (�4 mm; for postmenopausal patients only),al cancer.

benign endometrial cells. Am J Obstet Gynecol 2012.

y benign

l, Postmenopausal,no. (% of 151)

Total, no.(% of 281)

9 (6.0) 10 (3.6)..................................................................................................................

..................................................................................................................

3 (2.0) 4 (1.4)..................................................................................................................

1 (0.7) 2 (0.7)..................................................................................................................

1 (0.7) 4 (1.4)..................................................................................................................

27 (17.9) 27 (17.9)..................................................................................................................

14 (9.3) 34 (12.1)..................................................................................................................

3 (2.0) 26 (9.3)..................................................................................................................

58 (38.4) 107 (38.1)..................................................................................................................


gy NOVEMBER 2012

underscore the need for assessment ofwomen with CBEC regardless of associ-ated abnormal bleeding and menopausalstatus suggested by Moroney et al.6

This report also included hysteroscopicevaluation in assessment of CBEC. Therate of abnormal hysteroscopic findingswas higher in postmenopausal women.This was likely due to the inclusion ofthickened endometrium among abnormalfindings in postmenopausal women. Therate of abnormal endometrial biopsy andultrasound findings was comparable in thepremenopausal and postmenopausalgroups. An initial evaluation with endo-metrial biopsy seems prudent given that allpatients with endometrial pathology hadan abnormal endometrial biopsy result.This approach is feasible in settings wherehysteroscopy may not be available.

Lastly, CBEC would not be found ifwomen had undergone human papillo-mavirus (HPV) testing alone to followconcurrent cervical cytologic lesions.Therefore, it makes sense to avoid HPVtesting alone in women with cervical cy-tologic lesions and prior CBEC. Thesewomen may have persistent endometrialpathology that would be missed on sub-sequent HPV testing without concurrentcytology.

The frequency of assessment is com-parable in premenopausal and post-menopausal women indicating an op-portunity for improvement in provisionof assessment in both groups. This studyrepresents collaboration among majorclinical groups providing health care forwomen at Mayo Clinic and has resultedin practice change. The following infor-mation is printed on every CBEC report:“Cytologically benign endometrial cellsafter age 40, particularly out of phase orafter menopause, may be associated withbenign endometrium, hormonal altera-tions, and (less commonly) endometrial/uterine abnormalities.”

The study had the inherent limitationsassociated with retrospective analyses in-cluding differing practice patterns. Weare unable to make recommendationsfor one evaluation modality over an-other based on this study. Numbers ofwomen in certain subsets such as thoseon tamoxifen therapy or those with re-

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www.AJOG.org General Gynecology Research

analyses. We would prefer not to specu-late about the rate of abnormal histologywithin the unassessed group. However, itis reassuring that only 6 patients were re-ported to have repeat CBEC and of thesethe 3 who received assessment did nothave endometrial cancer or hyperplasia.We are unable to confirm or refute thepreviously reported association betweenendometrial pathology and postmeno-pausal hormone therapy use.5,7 Lastly, aignificant proportion of women (57%)id not receive additional assessment forBEC. This represents a potential under-iagnosis of endometrial pathology related

TABLE 4Presentation and outcomes of wom

Age,y Menopause

BMI atindexCBEC(kg/m2)

Bleedingat indexCBEC

46 Pre 22.4 Y...................................................................................................................

50 Pre 30.6 N...................................................................................................................

52.5 Pre 40.5 Y...................................................................................................................

53.9 Pre 32.3 Y...................................................................................................................

56 Pre 29.8 Y...................................................................................................................

51.8 Post 19.4 Y...................................................................................................................

53.5 Post — Yc

...................................................................................................................

56.1 Post 20.5 Y...................................................................................................................

56.9 Post 22.3 Y...................................................................................................................

66.5 Post 26.4 Y...................................................................................................................

...................................................................................................................

49.2 Pre 34.6 N...................................................................................................................

52.5 Post 27.9 N...................................................................................................................

57.1 Post 41.3 Y...................................................................................................................

60.8 Post 32.1 N...................................................................................................................

62.9 Post 37.8 Y...................................................................................................................

64.2 Post 30.2 Yd

...................................................................................................................

66.8 Post 42.5 Y...................................................................................................................

67.1 Post 34.7 Y...................................................................................................................

68.3 Post 47.2 N...................................................................................................................

77.6 Post 24.4 Y...................................................................................................................

BMI, body mass index; BSO, bilateral salpingo-oophorectomabdominal hysterectomy; VH, vaginal hysterectomy; Y, yes.a Women were classified as having abnormal bleeding if they w

withdrawal bleeding; or postmenopausal and receiving HT witendometrioid carcinoma; c Right lower quadrant pain; d Hem

Casey. Outcomes of women over age 40 years with cytolog

o CBEC, and constitutes another limita- t

ion to the formulation of specific manage-ent recommendations. Moreover, with

dditional assessed CBEC patients, the as-ociation of elevated BMI and premeno-ausal endometrial pathology may haveeached statistical significance.

A future prospectively designed studyandomizing women with CBEC to 1 of

2 initial assessment modalities alongith a cost-benefit analysis may help elu-

idate best practices for CBEC manage-ent. Similarly, an expanded retrospec-

ive study may help evaluate the rate ofssessment for CBEC before and afterhe implementation of added cytopa-

with cytologically benign endometr

edingth)

Firstbleedingepisode

Abnormalbleedinga HT

Outcom

Hyperp

1 N N C atypia.........................................................................................................................

N Simple.........................................................................................................................

2 N Y Simple.........................................................................................................................

1-3 Y Y Simple.........................................................................................................................

1-3 Y Y C no at.........................................................................................................................

1-3 N Y Y C atypia.........................................................................................................................

1 Y Y N C atypia

.........................................................................................................................

1 N N Y C no at.........................................................................................................................

1 Y N Y Simple.........................................................................................................................

1-3 Y Y Y C atypia.........................................................................................................................

Tumor t.........................................................................................................................

N Endome.........................................................................................................................

N N Endome.........................................................................................................................

2 N Y N Endome.........................................................................................................................

N N Endome.........................................................................................................................

1 Y Y N Clear ce.........................................................................................................................

1-3 Y Y N Endome.........................................................................................................................

1 Y Y N Endome.........................................................................................................................

2 N Y N Endome.........................................................................................................................

N N Endome.........................................................................................................................

4-6 N Y N Endome.........................................................................................................................

complex; CBEC, cytologically benign endometrial cells; D&C, di

premenopausal and had reported bleeding other than menses; pocyclic withdrawal bleeding or not receiving HT and had reported ania.


hology report information. f

NOVEMBER 2012 Americ

ACKNOWLEDGMENTSWe gratefully acknowledge the thoughtful re-view of the manuscript by Dr Michael Henry ofthe Mayo Clinic Rochester Department of Pa-thology. Dr Henry has no financial conflicts ofinterest or funding sources to disclose.

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cells and endometrial pathology

Tumor

Treatmenta Grade Stage

1b VH BSO..................................................................................................................

VH BSO..................................................................................................................

Progestin..................................................................................................................

D&C hysteroscopy (�)..................................................................................................................

D&C (�)..................................................................................................................

VH BSO..................................................................................................................

Robotic hysterectomyBSO

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Progestin..................................................................................................................

Progestin..................................................................................................................

VH BSO..................................................................................................................

..................................................................................................................

id 2 IV TAH/BSO staging..................................................................................................................

id 1 1A TAH/BSO staging..................................................................................................................

id 1 1B TAH/BSO staging..................................................................................................................


3 1A TAH/BSO staging..................................................................................................................






and curettage; HT, hormone therapy; N, no; TAH, total

nopausal, receiving HT, and had reported bleeding other thaninal bleeding; b C hyperplasia with atypia bordering on grade-1

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Outcomes in women age 40 years and older with cytologically benign endometrial cells

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