A. Chryssikopoulos

The diagnostic value of laparoscopy in 2365 patients with acute and chronic pelvic pain

Objective: To discriminate the etiology in 2365 patients with acute and chronic pelvic pain (APP, CPP). Methods: Diagnostic laparoscopy was carried out in 736 patients (31.1%) with APP and in 1629 (68.9%) with CPP. In 315 patients (13.3%) the diagnostic procedure was extended to operative laparoscopy. Results: The most frequent laparoscopic findings in patients with APP were acute salpingitis and pelvic adhesions (22.8%) and ectopic pregnancy (19%), while in patients with CPP the most frequent findings were pelvic adhesions (35.4%) and endometriosis (24.6%). In 7.5% of patients with APP and 24% with CPP, laparoscopy did not reveal any pathological finding in the pelvis. Among the 315 patients in whom operative laparoscopy was carried out, 40% suffered from APP and 60% from CPP. In the 446 patients (18.9%) without laparoscopic findings no treatment was given, while of the remaining 905 patients 40% were subjected to laparotomy and 60% received conservative treatment. The total incidence of side effects reached 4.7% and serious side effects resulting from emergency laparotomy occurred in 0.15% of patients with pelvic pain. Conclusion: Our results in a large group of patients with pelvic pain show that there are discrepancies in the incidence of laparoscopic findings between patients with APP and CPP. Discrepancies between the two groups of patients were also found during operative laparoscopy, the treatment administered after laparoscopic diagnosis and the complications encountered.

The Relationship between the Immune and Endocrine Systems

Increasing evidence links the immune and endocrine systems. Cytokines produced by activated immune and immune accessory cells can affect, positively or negatively, the secretion of hormones from the hypothalamic-pituitary-adrenal or hypothalamic-pituitary-ovarian axes. On the other hand, adrenal and ovarian hormones affect the secretion of cytokines by cells of the immune system. The interaction also occurs at a local level in paracrine or autocrine fashion. Cytokines produced by resident ovarian macrophages or ovarian cells can affect the follicle and the corpus luteum and, consequently, ovarian steroidogenesis at both phases of the menstrual cycle. Conversely, the ovarian steroids influence, positively or negatively, the secretion of cytokines from both the resident macrophages and local endocrine cells.

Gonadotropin ovulation induction and pregnancies in women with Kallmann's syndrome

Only 17 cases of pregnancy in women with Kallmanns syndrome have been reported in the literature, eight as case reports. In our clinic, we diagnosed seven women with complete Kallmanns syndrome in a 16-year period. In five cases (unprimed patients) the diagnosis was established for the first time, while in the other two cases diagnosis had been established earlier. The five unprimed patients received hormone therapy (HRT) immediately after diagnosis. The other two patients had already been on HRT. Four patients wanted to bear children. Follicular evolution and maturation was induced with daily human menopausal gonadotropin (hMG) administration. The results were monitored through plasma estradiol (E2) determinations and ultrasonography. Ovulation was induced with hCG administration. Five pregnancies were achieved in three patients, resulting in four healthy neonates. Two women achieved a second pregnancy. Nausea and vomiting did not occur in any of our five pregnancies. We found no significant differences between the total hMG dose needed for ovulation induction, the number of stimulation days, estradiol plasma concentrations and the number of follicles with diameter > or = 17 mm, in either conceptional or non-conceptional cycles. In fact, the total hMG dose administered was lower and the days of stimulation were significantly fewer in women on their second pregnancy. There was no difference in plasma estradiol concentrations and the number of follicles with diameter > or = 17 mm. In conclusion, ovulation induction and pregnancy in women with complete Kallmanns syndrome is not such a difficult procedure as was believed in the past. A previous pregnancy seemed to augment ovarian sensitivity to gonadotropins.

Cervical incompetence: a 24-year review.

Three hundred nineteen cervical cerclages performed in 264 pregnant women were retrospectively studied. The diagnosis of cervical incompetence was established by the obstetrical history, hysterosalpingography, ultrasound screening and vaginal examination. All cervical cerclages were applied between 14 and 17 weeks gestation according to Shirodkars technique except 49 emergency cases between 18 and 26 weeks gestation for which other techniques were chosen. The incidence of preterm deliveries (26–37 weeks gestation) decreased from 39.7% to 14.23% (P < 0.001) and that of full term pregnancies increased from 20.04% to 75.74% (P < 0.001). The number of neonates weighing ⩽2000 g decreased from 44.20% to 11.38% (P < 0.001) and those weighing ⩾2500 g increased from 44.83% to 75.82% (P < 0.001). Perinatal mortality after cerclage declined from 28.21% to 5.52% (P < 0.001). There was no increase in congenital defects. An increased rate of breech presentation (5.32%) and cesarian section (20.38%) was noticed. The repeated cerclage in consequent pregnancies did not seem to influence the duration of gestation. In emergency cases the rate of preterm deliveries was 53.06%, of full term pregnancies 12.25%, of newborns with birthweight ⩽2500 g 31.77% and of those with birthweight ⩾2500 g 19.23%. Perinatal mortality in emergency cases was 42.3%. An increase in aerobic and anaerobic pathological flora was noticed in postoperative cervical cultures.

The Incidence of 21α-Hydroxylase Deficiency in Greek Hyperandrogenic Women: Screening and Diagnosis

The purpose of this prospective study was to determine the incidence of any form of 21α.-hydroxylase deficiency among Greek women with hyperandrogenic symptoms, and to test the predictive value of basal serum 17-hydroxyprogesterone (17-OHP) in the early follicular phase as a screening index for patient preselection to adrenocorticotropic hormone (ACTH) testing. Eighty-eight unselected women with hyperandrogenic symptoms were examined in the Gynecological Endocrinology Unit of the Second Department of Obstetrics and Gynecology of Athens University. Using the ACTH-stimulated 17-OHP values at 60 minutes (17-OHP60) the study population was divided into four groups (A, B, C and D). Clinical and basal hormonal parameters as well as serum 17-OHP60 values and human leukocyte antigens were studied. Both clinical and basal hormonal parameters could be used to distinguish only patients with severe 21α-hydroxylase deficiency (group A). In contrast, patients with moderate non-classical congenital adrenal hyperplasia (...

The Potential Role of Intraovarian Factors on Ovarian Androgen Production

Abstract: The circuit of gonadotropins (FSH, LH) and ovaries (theca and granulosa cells) in ovarian estrogen and androgen production is well established. Recent research has revealed an intraovarian network that may ultimately prove relevant to the understanding of ovarian hyperandrogenism. Most of these substances, such as growth factors and cytokines, do not have independent effects on basal androgen production, but exhibit their regulatory potential by modulating hCG‐ or LH‐stimulated steroid production. Precise understanding of the regulatory role of intraovarian factors in ovarian androgen production would shed new light on the pathophysiology and therapy of hyperandrogenemic excess in women.

Vaginal Fluid and Serum CEA, CA125 and SCC in Normal Conditions and in Benign and Malignant Diseases of the Genital Tract

Carcinoembryonic antigen (CEA), CA125, and squamous cell carcinoma antigen (SCC) were evaluated in paired vaginal fluid and serum samples from 69 women, mean age 40.6 (20-78) years. Fifteen of the subjects were normal females (controls), 12 were pregnant, 20 had benign gynecological diseases, 5 presented severe cervical dysplasias and 17 suffered from cancer of the genital tract. Highly elevated CEA, CA125 and SCC concentrations (median, range) were found in vaginal fluid: 186 ng/ml (12-5420); 890 U/ml (54-65000); 1600 ng/ml (27-13000) respectively, compared with those in the paired serum samples: 1 ng/ml (0.5-8.6); 12 U/ml (3.0-1590); 1 ng/ml (0.3-19). Vaginal fluid CEA, CA125 and SCC values were significantly different among the five studied groups (p < 0.0002; p < 0.02: p < 0.002 respectively), being significantly higher in the patients with benign gynecological diseases, compared with those in the patients with malignancies of the genital tract (p < 0.0001; p < 0.02; p < 0.005), and those in controls (p < 0.02; p < 0.007; p < 0.02 respectively). The results of this study suggest that: 1) CEA, CA125 and SCC seem to be normal constituents of vaginal fluid. 2) The distribution of CEA, CA125 and SCC between vaginal fluid and the circulation is affected by pregnancy, inflammation and cancer of the genital tract.

Hormonal patterns in a successful pregnancy of a patient with late-onset 21-OH deficiency taking methylprednisolone; a case report

A successful pregnancy of a young woman with late-onset congenital adrenal hyperplasia (LOCAH) is reported. Exogenous glucocorticoids are the most commonly used regimen in such cases both for suppression of adrenal overstimulation and avoiding masculinization of a female fetus. In our LOCAH patient methylprednisolone has been used for treatment. We present the management and the outcome of this pregnancy, as well as the hormonal follow-up.

New reliable biochemical marker for screening 21α-hydroxylase deficiency without index person among hirsute women in agreement with HLA-haplotyping

Late onset congenital adrenal hyperplasia due to 21α-hydroxylase deficiency (LO21OH def), as many other diseases, is the cause of hirsutism, menstrual disorders, infertility (PCO-like symptoms). We evaluated the reliability of a new biochemical marker for screening LO-21OH def in 47 women with PCO-like symptoms and 11 men, members of their families, comparing the results of separation using this new marker with those of HLA-haplotyping in 21 members of the patient population. All subjects were stimulated with 0.25 mg synthetic ACTH iv. Serum progesterone (P), 17-hy-droxyprogesterone (17-OHP) and cortisol (F) at 0, 15, 30, 45 and 60 min following ACTH administration were determined and the new marker, namely the difference between 60min and 0min of the ratio F/17-OHP [Δ F/17-OHP (60 min–0 min)] was calculated. According to the established biochemical criteria for the detection of LO-21OH def cases, (Gutai 30 min ≥12 ng/dl/min and 17-OHP 60 min ≥12 ng/ml for severe 21-OH def and Gutai 30 min<6.5 ng/dl/min and 17-OHP 60 min<5 ng/ml for “healthy” individuals regarding 21-OH def) two groups, A and B respectively, were separated from the patient population. In group A (n=8), with LO-21 OH def, the new marker showed negative values in all cases, while in group B (n=9), without LO-21 OH def, this marker was positive. The remaining subjects, depending on the results of the new marker were separated in 2 subgroups, Cneg (n=28), with negative values, composed, consequently, of members with 21-OH def and Cpos (n=13), with positive values, composed, consequently, of subjects with absence of LO-21OH def. HLA-typing was in agreement with the results of screening by the new marker, in 20 out of 21 cases, while there was only one false negative result. In conclusion, the proposed biochemical marker ΔF/17-OHP (60 min–0 min) seems to be a reliable parameter for the LO-21OH def detection among young women with PCO-like symptoms as well as males suspected for congenital adrenal hyperplasia.

Cyclic and individualized administration of gonadotropin-releasing hormone agonists plus progestogens: An alternative protocol for contraception

Twenty-one women presenting with different diseases, with absolute or relative contraindications to hormonal contraception or the use of intrauterine devices, received 300-600 micrograms/day buserelin intranasally from the 1st to the 21st day, and 5 mg/day norethisterone acetate orally from the 16th to the 23rd day of the cycle for a total of 245 cycles. Serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol and testosterone were determined on days 3-5 and 13-15 of the cycle, while progesterone determinations and ovarian sonography were performed during the second half of the cycle. According to progesterone values, 92.7% of the treatment cycles were anovulatory, while in one cycle pregnancy was detected (0.4%). Values of serum LH, FSH and estradiol were low, and in most of the cycles ovarian follicular development was limited to follicles < or = 11 mm. In 21 treatment cycles (9%), statistically significant increases in FSH (p < 0.0001) and LH (p < 0.02), as well as ovarian proliferation to preovulatory follicles or luteinized follicles, were found. It appears that in spite of the high cost of medication and monitoring of patients, this regimen could be useful as an alternative in cases where other forms of contraception are contraindicated or have failed.