Bernardo Portugal Lasmar

Endometrial polyp size and polyp hyperplasia

To assess the correlation between the size of endometrial polyps and the histopathologic diagnosis of hyperplasia or cancer.

Avaliação histeroscópica em pacientes com infertilidade

PURPOSE to describe hysteroscopy findings in infertile patients. METHODS this was a retrospective series of 953 patients with diagnosis of infertility evaluated by hysteroscopy. A total of 957 patients investigated for infertility were subjected to hysteroscopy, preferentially during the first phase of the menstrual cycle. When necessary, directed biopsies (under direct visualization during the exam) or guided biopsies were obtained using a Novak curette after defining the site to be biopsied during the hysteroscopic examination. Outcome frequencies were determined as percentages, and the χ2 test was used for the correlations. The statistical software EpiInfo 2000 (CDC) was used for data analysis. RESULTS a normal uterine cavity was detected in 436 cases (45.8%). This was the most frequent diagnosis for women with primary infertility and for women with one or no abortion (p<0.05). Abnormal findings were obtained in 517 of 953 cases (54.2%), including intrauterine synechiae in 185 patients (19.4%), endometrial polyps in 115 (12.1%), endocervical polyps in 66 (6.0%), submucosal myomas in 47 (4.9%), endometrial hyperplasia in 39 (4.1%), adenomyosis in five (0.5%), endometritis (with histopathological confirmation) in four (0.4%), endometrial bone metaplasia in two (0.4%), and cancer of the endometrium in one case (0.1%). Morphological and functional changes of the uterus were detected in 5.6% of the cases, including uterine malformations in 32 (3.4%) and isthmus-cervical incompetence in 21 (2.2%). CONCLUSIONS intrauterine synechiae were the most frequent abnormal findings in patients evaluated for infertility. Patients with a history of abortion and infertility should be submitted to hysteroscopy in order to rule out intrauterine synechiae as a possible cause of infertility.

Diagram to map the locations of endometriosis

To develop and test a visual map that corresponds practically and objectively to the anatomical areas affected by endometriosis.

Office hysteroscopic cervical myomectomy

IntroductionLeiomyomas are the most common tumors of the uterus andthe female pelvis, with an estimated prevalence of 40–50 %.The main symptom is transvaginal bleeding being responsi-ble for high levels of hysterectomy worldwide [1]. Othercomplaints are dyspareunia, abdominopelvic discomfort,and lower abdominal pain. They are benign tumors com-posed mainly of smooth muscle cellsassociated with fibrousconnective tissue in varying amounts. The clinical treatmentcan be accomplished with gestrinone, GnRH analogues, anddanazol in premenopausal women seeking improvement inbleeding until menopause. GnRH analogue may be a thera-peutic option for 3 to 6 months; when necessary for a longerperiod, it should be combined with gonadotropic hormonesto minimize the effects of bone demineralization.Thesurgicalapproach,myomectomy,isthedefinitivetreat-mentofdiseaseandmaybedonebylaparotomy,laparoscopy,or hysteroscopy, depending on the number, size, and locationof the nodules. In some cases, a hysterectomy may be indi-cated,particularlyinwomenwithnodesireoffuturepregnan-cy. Most fibroids are situated in the uterine body, with aminority (less than 5 %) in the cervical canal [2, 3]. Theapproach to the cervical myoma is complex, since it is closerto the ureters, bladder, rectum, and cervical vessels [3].Hysteroscopic myomectomy is a complex surgery indi-cated in cases of submucosal fibroids. The main complica-tions of the procedure are bleeding, uterine perforation, andoverload. The procedure can be done as office hysteroscopicmyomectomy using biopsy punch and scissors or bipolarelectrodes, or as hospital hysteroscopic myomectomy withcervical dilation using mono or bipolar resectoscope.In 2005, Lasmar et al. developed the STEPW classifica-tion [4, 5] which provides the degree of difficulty of hys-teroscopic myomectomy by classifying the fibroidspreoperatively. This classification includes intracavitary fib-roids only; cervical fibroids are not contemplated. Hystero-scopic myomectomy may be performed by differenttechniques: direct mobilization, slicing, or both [6, 7]. Itcan be used with U or L resectoscope handle, with orwithout energy, either monopolar or bipolar. In direct mobi-lization, the Collins electrode is used in shape of an “L” todissect the endometrium around the fibroid. The “cold elec-trode” is used to mobilize the fibroid in all directions, doingthe coagulation only of the vessels that are bleeding. Afterreleasing the nodule from the uterinewall, it can beremovedby grasping forceps. If the fibroid is too large, it can besliced in several pieces using the Collins electrode [6].Inofficehysteroscopicprocedure,weprefertousethedirectmobilization technique as well with biopsy punch, sectioningfibrousbeams of themyoma pseudocapsule as it is mobilized.Saline infusion is used as distension media. This technique issimilartothatinthehospitalsettingandallowstheresectionoffibroid very close to the uterine safely and efficiently [ 8, 9].Theliterature hasfewdata onthemanagement of cervicalmyomas, with most referrals regarding cervical myomec-tomy by laparoscopy route [3, 10]. The approach to cervicalfibroids by hysteroscopy is possible, mainly on those withlittle intramural component, and should be done cautiouslydue to the small wall thickness and short proximity toimportant structures of the pelvis [3]. The presence of largemasses leads to a dilatation of the cervical canal, difficultingits distension and making the procedure even harder.Case presentationA 46-year-old woman attended the gynecology ambulatoryof University Antonio Pedro Hospital, complaining of ab-normal uterine bleeding. Her gynecologic history was two

Validation of a score to guide endometriosis therapy for the non-specialized gynecologist.

To validate a tool—the ECO system—developed to guide non‐specialized gynecologists in the treatment of patients with suspected endometriosis in outpatient clinics.