Anna K. Parsons

Evaluation of the woman with postmenopausal bleeding: Society of radiologists in ultrasound-sponsored consensus conference statement

A panel of 14 physicians practicing medicine in the United States with expertise in radiology, obstetrics and gynecology, gynecologic oncology, hysteroscopy, epidemiology, and pathology was convened by the Society of Radiologists in Ultrasound to discuss the role of sonography in women with postmenopausal bleeding. Broad objectives of this conference were (1) to advance understanding of the utility of different diagnostic techniques for evaluating the endometrium in women with postmenopausal bleeding; (2) to formulate useful and practical guidelines for evaluation of women with postmenopausal bleeding, specifically as it relates to the use of sonography; and (3) to offer suggestions for future research projects.

A 12-month comparative study of raloxifene, estrogen, and placebo on the postmenopausal endometrium

Objective To determine the effects of a selective estrogen receptor modulator, raloxifene, on postmenopausal endometrium. Methods Healthy postmenopausal women (n = 415) were randomly assigned to one of the following four groups: 60 or 150 mg/day raloxifene hydrochloride, 0.625 mg/day conjugated equine estrogens, or placebo, and treated for 1 year. Endometrial biopsies were obtained in a blinded fashion at baseline and every 6 months after the ultrasound studies. Transvaginal ultrasound, with uterine size measurements, was done at baseline and at 3-month intervals. Saline-infusion sonohysterography was done at baseline and every 6 months. Results There were no statistically significant differences in baseline characteristics. Mean endometrial thickness, measured by transvaginal ultrasound, was unchanged from baseline to end point in the placebo and raloxifene groups, whereas in the estrogen group it was significantly thicker by 5.5 mm (P < .001). Mean uterine volume, calculated from transvaginal ultrasound measurements, was higher in the estrogen group only (22 cm3, P < .001). Of the 358 women with paired biopsies, endometrial hyperplasia was present in 2.1%, 0%, and 26.1% of the end-point biopsies in the placebo, raloxifene, and estrogen groups, respectively (P < .001). Proliferative endometrium was present in 2.1% of the end-point biopsies in the placebo group, 1.7% in the combined raloxifene groups, and 39.8% in the estrogen group (P < .001). Conclusion Raloxifene, at 60 or 150 mg/day for 1 year, did not stimulate the postmenopausal endometrium. End-point endometrial thickness, morphology, and uterine volume in the raloxifene groups were similar to those observed at baseline and in the placebo group.

Three- and 4-Dimensional Ultrasound in Obstetrics and Gynecology Proceedings of the American Institute of Ultrasound in Medicine Consensus Conference

The American Institute of Ultrasound in Medicine convened a panel of physicians and scientists with interest and expertise in 3‐dimensional (3D) ultrasound in obstetrics and gynecology to discuss the current diagnostic benefits and technical limitations in obstetrics and gynecology and consider the utility and role of this type of imaging in clinical practice now and in the future. This conference was held in Orlando, Florida, June 16 and 17, 2005. Discussions considered state‐of‐the‐art applications of 3D ultrasound, specific clinical situations in which it has been found to be helpful, the role of 3D volume acquisition for improving diagnostic efficiency and patient throughput, and recommendations for future investigations related to the utility of volume sonography in obstetrics and gynecology.

Terms, definitions and measurements to describe the sonographic features of the endometrium and intrauterine lesions: a consensus opinion from the International Endometrial Tumor Analysis (IETA) group

The IETA (International Endometrial Tumor Analysis group) statement is a consensus statement on terms, definitions and measurements that may be used to describe the sonographic features of the endometrium and uterine cavity on gray‐scale sonography, color flow imaging and sonohysterography. The relationship between the ultrasound features described and the presence or absence of pathology is not known. However, the IETA terms and definitions may form the basis for prospective studies to predict the risk of different endometrial pathologies based on their ultrasound appearance. Copyright

Effect of raloxifene on the response to conjugated estrogen vaginal cream or nonhormonal moisturizers in postmenopausal vaginal atrophy

OBJECTIVE To study the effect of raloxifene on the response to conjugated estrogen cream or nonhormonal moisturizer in postmenopausal women with preexisting signs of vaginal atrophy. METHODS Postmenopausal women with preexisting and untreated vaginal atrophy were enrolled in this parallel, placebo-controlled, randomized study. A total of 187 women were randomized to four treatment groups: daily oral raloxifene (60 mg per day) or a placebo in a double-blind manner plus one application of conjugated estrogen cream (0.5 g) or one applicator full of nonhormonal moisturizer, open label. The conjugated estrogen cream or non-hormonal moisturizer was applied daily for the first 2 weeks, and then twice weekly thereafter for 3 months. Efficacy of treatment regimens on signs and symptoms of vaginal atrophy was evaluated by monitoring objective and subjective parameters. RESULTS Signs and symptoms of vaginal atrophy improved in all four treatment groups. Raloxifene did not diminish the magnitude of improvement when administered with either vaginal preparation. Conjugated estrogen cream produced a statistically greater improvement in signs (P < .05) but not in individual symptoms or overall satisfaction relative to nonhormonal moisturizer. CONCLUSION Postmenopausal women with evidence of preexisting vaginal atrophy may use either low-dose conjugated estrogen cream or nonhormonal moisturizer to treat the atrophy concurrently with raloxifene (60 mg per day).

Absence of neuropathic pelvic pain and favorable psychological profile in the surgical selection of patients with disabling interstitial cystitis

PURPOSE We evaluated the results among patients with disabling interstitial cystitis treated by cystectomy, urethrectomy and creation of a continent colonic urinary reservoir (the Florida pouch). The value of psychological evaluation and pain localization techniques, as well as the use of a team approach in the evaluation of these patients were assessed. MATERIALS AND METHODS The 20 women and 2 men who underwent surgery for disabling interstitial cystitis ranged from 31 to 75 years old (mean age 48). The duration of symptoms ranged from 2 to 14 years (mean 7). All patients had undergone multiple prior therapies, including vesical hydrodistension, instillations, laser treatments, and use of tranquilizers and a variety of pain medications. Patients underwent a clinical, cystoscopic (with bladder biopsies) and urodynamic evaluation as well as examination by a gynecologist with expertise in vaginal ultrasonography. The last 5 patients underwent psychological evaluation and pain localization techniques. RESULTS Among the clinical parameters, the presence of a small capacity bladder with the patient under anesthesia (less than 400 cc) was associated with the best surgical results. Among 11 patients evaluated only clinically success was achieved in 64%, while all 5 (100%) who also underwent pain localization techniques and psychological evaluation had a successful outcome postoperatively. The overall surgical success rate in the 22 patients was 73%. Two patients undergoing psychological evaluation and pain localization techniques were not considered to be surgical candidates. Among 7 surgical failures 4 patients underwent postoperative psychological evaluation and pain localization techniques, and they would not have been considered candidates for surgery with the new parameters. CONCLUSIONS A team approach is essential in the evaluation of these patients. Following the initial selection of patients who had a small bladder capacity while under anesthesia, psychological evaluation and pain localizing techniques may assist surgeons in selecting those who would benefit from a radical operation.

Imaging the human corpus luteum.

Abbreviations CL, corpus luteum; hCG, human chorionic gonadotropin; LH, luteinizing hormone; PI, pulsatility index; PSV, peak systolic velocity; RI, resistive index; 3D, three-dimensional; VEGF, vascular endothelial growth factor Ultrasonography provides a wide array of morphologic information without invading or disturbing the tissues. Examinations can be done repeatedly over many days, or a dynamic event (e.g., ovulation) can be monitored in its entirety by continuous observation . . . . Inclusion of ultrasonic examinations in experimental protocols affords the opportunity to associate changing morphology with hormonal and other functional changes. If experimental testing is expected to involve changing morphology, ultrasonic imaging should be considered. End points can be measured or ranked and therefore data can be statistically analyzed for conventional hypothesis testing. The research potential of this technology and its adaptability for computer-assisted assessment go far beyond simplistic determination of ovulation, luteal formation, and pregnancy diagnosis. . . . ultrasonic imaging is a revolutionary advance in reproductive research that is destined to rival the impact of other technologic breakthroughs, including radioimmunoassay.1

ENDOMETRIOSIS IS ASSOCIATED WITH ALTERATIONS IN THE RELATIVE ABUNDANCE OF PROTEINS AND IL-10 IN THE PERITONEAL FLUID

A growing body of evidence suggests that endometriosis modulates the microenvironment of peritoneal cavity. Therefore, in this study, we compared the protein profile of peritoneal fluids from normal fertile women with those from patients with infertility, and patients with mild to severe endometriosis. Two-dimensional gel electrophoresis of peritoneal fluids from normal subjects exhibited a distinct and reproducible pattern of proteins in the size ranges of approximately 35 to 80 kD and pI close to 4.5 to 6.6. Infertility without evidence of endometriosis was not associated with changes in the relative abundance of proteins present in the peritoneal fluid. However, mild endometriosis was associated with a mild reduction in the amount of several peritoneal protein spots with the approximate molecular weights of 35-40 kD and pI close to 5.7-6.0. These changes became markedly apparent in the peritoneal fluid of patients who suffered from the severe form of this disease. Severe endometriosis was also associated with appearance of protein spots in the gels that were not detectable in the peritoneal fluids of normal subjects. Consistent with these data, enzyme-linked immunosorbent assay showed that moderate to severe endometriosis was associated with markedly elevated levels of IL-10 in the peritoneal fluid. Reverse transcription followed by polymerase chain reaction amplification using primers specific to IL-10 confirmed presence of IL-10 mRNA in cells derived from peritoneal fluids. These findings show that endometriosis is associated with disturbed secretion of proteins into the peritoneal cavity and with an elevated level of IL-10 in the peritoneal fluid. The studies also show cells resident in peritoneum as a major source of IL-10.

Human peritoneal macrophage and T lymphocyte populations in mild and severe endometriosis

PROBLEM: The aim of this study was to characterize the phenotype of peritoneal lymphocyte and macrophage populations in mild versus severe endometriosis.

Synergetic effects of doxycycline-loaded chitosan nanoparticles for improving drug delivery and efficacy

Introduction Doxycycline, a broad-spectrum antibiotic, is the most commonly prescribed antibiotic worldwide for treating infectious diseases. It may be delivered orally or intravenously but can lead to gastrointestinal irritation and local inflammation. For treatment of uterine infections, transcervical administration of doxycycline encapsulated in nanoparticles made of biodegradable chitosan may improve sustained delivery of the drug, thereby minimizing adverse effects and improving drug efficacy. Methods and materials As a first step toward assessing this potential, we used an ionic gelation method to synthesize blank and doxycycline-loaded chitosan nanoparticles (DCNPs), which we then characterized in terms of several properties relevant to clinical efficacy: particle size, shape, encapsulation efficiency, antibacterial activity, and in vitro cytotoxicity. Two particle formulations were examined, with one (named DCNP6) containing approximately 1.5 times the crosslinker concentration of the other (DCNP4). Results The two formulations produced spherically shaped drug-loaded nanoparticles. The spheres ranged in size from 30 to 220 nm diameter for DCNP4 and 200 to 320 nm diameter for DCNP6. Average encapsulation yield was 53% for DCNP4 and 56% for DCNP6. In terms of drug release, both formulations showed a burst effect within the first 4 to 5 hours, followed by a slow, sustained release for the remainder of the 24-hour monitoring period. The in vitro antibacterial activity against Escherichia coli was high, with both formulations achieving more than 90% inhibition of 4-hour bacterial growth. Cytotoxic effects of the DCNPs on normal human ovarian surface epithelial cells were significantly lower than those of unencapsulated doxycycline. After 5 days, cultures exposed to the unencapsulated antibiotic showed a 61% decrease in cell viability, while cultures exposed to the DCNPs exhibited less than a 10% decrease. Conclusion These laboratory results suggest that DCNPs show preliminary promise for possible eventual use in transcervical drug delivery and improved efficacy in the treatment of bacterial uterine infections.