Abnormal uterine bleeding (AUB) is one of the most common presenting complaints in our medical system with up to 30% of females affected by this condition. The current evaluation and management of AUB often requires multiple lengthy visits to both general practitioners and specialists. Advances in endoscopic technology have allowed clinicians to diagnose and treat women presenting with AUB in a single-visit within an outpatient uterine assessment and treatment unit (UATU). Unfortunately, the UATU is not the standard of care with very few locations in Canada providing this type of service. This thesis project aimed to synthesize data pertaining to efficacy and safety as well as to evaluate the cost-effectiveness of a UATU service model compared to usual care in diagnosing and treating AUB. To address the main aim for this thesis project, the first manuscript focuses on the hysteroscopic procedures that may be offered in a UATU. The manuscript includes a systematic review that synthesizes outcome measures surrounding efficacy, patient safety, and cost data of outpatient hysteroscopy compared to hysteroscopy performed in the operating room. The second manuscript is a cost-effectiveness modelling study that compares cost and effectiveness outcomes, including time to diagnosis and time to treatment of a UATU versus usual care for women who present with AUB. Data used to populate the cost-effectiveness model were obtained from a retrospective review of patient charts and the published literature. The systematic review found no statistically significant difference in the safety, efficacy, or patient tolerability between outpatient and intraoperative hysteroscopy procedures. This review helps provide further support for performing procedures outside of a traditional operating room without increasing patient harm or compromising efficacy. However, given the current available evidence and limited number of studies, findings should be interpreted with caution. The cost-effectiveness analysis found that a UATU is cost-effective when compared to usual care in diagnosing and treating patients who present with AUB. These two studies combined provide evidence to support that the UATU has the potential to improve gynecologic care by reducing wait-times to receiving diagnosis and treatment and to lower overall costs to the health care system.

OBJECTIVE: The objective of this study was to evaluate outcomes for women following endometrial ablations due to abnormal uterine bleeding (AUB). These outcomes included patient-reported quality of life, satisfaction with the procedure, and treatment failure. Women experiencing heavy/regular bleeding were compared with women experiencing heavy/irregular bleeding. DESIGN: The study was designed as a prospective cohort study of women aged 18-55 years presenting to Women and Infants Hospital (WIH) in Providence, Rhode Island, for endometrial ablations due to AUB. Sixty-three participants in the study completed the Baseline Health Form, the Short Form-36 Health Survey (SF-36), and the Menstrual Bleeding Questionnaire (MBQ) upon enrollment. At the 3-month, 6-month, and 1-year follow-ups participants completed the SF-36 and the MBQ. RESULTS: Baseline responses from the participants who were undergoing endometrial ablation found that 95.2% of women (n = 60) identified their periods as being heavy. From the total participants, 60.3% of women (n = 38) indicated their periods as being irregular. The SF-36 total score results demonstrate women with heavy/irregular bleeding experienced a greater negative impact in their quality of life. When broken down to the physical component score (PCS) and the mental component score (MCS) this difference, between women with heavy/regular bleeding and women with heavy/irregular bleeding, was minimized. Results from the MBQ revealed that women with heavy/irregular menstrual bleeding experienced a greater negative impact on their quality of life compared with women with heavy/regular bleeding. DISCUSSION: Heavy bleeding is one of the defining factors in determining whether women seek further treatment for their menstrual bleeding, and when they do, they will usually attempt other therapies before pursuing surgery. The MBQ revealed a difference in quality of life between women with heavy/irregular bleeding and women with heavy/regular bleeding because this questionnaire measures bleeding and its impact on a woman’s life. The SF-36 total scores also showed a difference between heavy/irregular bleeding and heavy/regular bleeding. Breaking down the total SF-36 total score into the PCS and MCS minimized this difference. This questionnaire focused more on overall general health rather than bleeding and this focus may account for the smaller scoring differences among bleeding patterns. CONCLUSION: Similar proportions of women experiencing heavy/regular and heavy/irregular bleeding pursue endometrial ablations as a treatment for AUB. The SF-36 demonstrated a greater burden on women’s general health when they have heavy/irregular bleeding. The MBQ provides a better measure to compare both bleeding patterns, aspects of bleeding, and demonstrates a more negative impact on quality of life for women with heavy/irregular bleeding.

Η αυτόματη επεξεργασία εικόνων του ενδομητρίου αποτελεί ένα δύσκολο και πολυδιάστατο πρόβλημα, το οποίο έχει απασχολήσει πλήθος ερευνητών και για το οποίο έχει αναπτυχθεί μεγάλος αριθμός τεχνικών. Στην παρούσα διατριβή, παρουσιάζεται μια μεθοδολογική προσέγγιση, η οποία βασίζεται στη χρήση αλγορίθμων ψηφιακής επεξεργασίας και ανάλυσης εικόνων, για την αυτόματη εκτίμηση χαρακτηριστικών που περιγράφουν την αγγείωση και την υφή εικόνων του ενδομητρίου. Αφορμή της μελέτης αποτελεί ο ρόλος που διαπιστώνεται ότι διαδραματίζει η μεταβολή των τιμών των εν λόγω χαρακτηριστικών στην έγκαιρη διάγνωση των παθήσεων του ενδομητρίου. Στα πλαίσια της διατριβής, υλοποιήθηκε κατάλληλη μεθοδολογία για τον υπολογισμό ενός συνόλου χαρακτηριστικών τόσο για υστεροσκοπικές εικόνες, όσο και για ιστολογικές εικόνες του ενδομητρίου. Ιδιαίτερη βαρύτητα δόθηκε στην προ – επεξεργασία των εικόνων προκειμένου να προκύψει βελτίωση της ποιότητας καθώς και ενίσχυση της αντίθεσης αυτών. Στη συνέχεια, ανιχνεύτηκαν τα σημεία που αποτελούν τους κεντρικούς άξονες των υπό εξέταση αγγείων με χρήση διαφορικού λογισμού για τις υστεροσκοπικές εικόνες και υπολογίστηκε ένα σύνολο χαρακτηριστικών μεγεθών που περιγράφουν την αγγείωση και την υφή των εικόνων τόσο για τις υστεροσκοπικές όσο και για τις ιστολογικές εικόνες. Τέλος, εφαρμόστηκαν κατάλληλοι αλγόριθμοι με σκοπό την κατηγοριοποίηση των υστεροσκοπικών και των ιστολογικών εικόνων και συγκεκριμένα τον διαχωρισμό των παθολογικών και των φυσιολογικών εικόνων του ενδομητρίου. Παράλληλα, χρησιμοποιήθηκε η ROC ανάλυση στην απεικόνιση και ανάλυση της συμπεριφοράς των εν λόγω κατηγοριοποιητών. / Automatic analysis of the endometrial images is a difficult and multidimensional problem. For this reason, the number of papers and techniques regarding this issue is numerous. In this Thesis, a methodology is presented, based on advance image processing techniques in order to automatically estimate texture and vessel’s features in endometrial images. Motivation for the Thesis is the fact that the variation of the measurements of the specific features plays significant role in the seasonable diagnosis of endometrial disorders. Throughout this Thesis, an appropriate methodology is developed in order to estimate the features for the hysteroscopical and histological images of the endometrium. An important step is the pre – processing of the images in order to enhance the image quality and the image contrast. Then, the pixels that constitute the centerlines of vessels are detected by using differential calculus for the hysteroscopical images, only. Furthermore, the texture and vessel’s features in hysteroscopical and histological images are estimated. Finally, appropriate algorithms are applied in order to classify the hysteroscopical and histological images and distinguish pathological and normal endometrial images. ROC analysis is used in order to evaluate the discrimination power of the features that were estimated.