Carmine Nappi

Effectiveness of auto-crosslinked hyaluronic acid gel in the prevention of intrauterine adhesions after hysteroscopic surgery: a prospective, randomized, controlled study.

BACKGROUND A prospective, randomized, controlled study was performed to assess the efficacy of auto-crosslinked hyaluronic acid (ACP) gel to prevent the development of de-novo intrauterine adhesions following hysteroscopic surgery. METHODS One hundred and thirty-two patients with a single surgically remediable intrauterine lesion (myomas, polyps and uterine septa, subgroups I-III) completed the study. Patients were randomized to two different groups: group A underwent hysteroscopic surgery plus intrauterine application of ACP gel (10 ml) while group B underwent hysteroscopic surgery alone (control group). The rate of adhesion formation and the adhesion score was calculated for each group and subgroup 3 months after surgery. RESULTS Group A showed a significant reduction in the development of de-novo intrauterine adhesions at 3 months follow-up in comparison with the control group. Furthermore, the staging of adhesions showed a significant decrease in adhesion severity in patients treated with ACP gel. CONCLUSIONS ACP gel significantly reduces the incidence and severity of de-novo formation of intrauterine adhesions after hysteroscopic surgery.

Reproductive endocrine disorders in women with primary generalized epilepsy.

Summary: It is known that women suffering from temporal lobe epilepsy may frequently present reproductive endocrine disorders (REDs). We hypothesized that a high occurrence of REDs could be found also in primary generalized epilepsy (PGE), and therefore investigated the hormonal and ovarian echographic profiles in 20 PGE female patients of reproductive age. Fourteen reported normal menstrual cycles, while 6 complained of longstanding menstrual irregularities. All but three patients were receiving antiepileptic drug (AED) therapy. In all subjects, the basal levels of gonadotropins, prolactin, and gonadal steroids were assayed. The response of luteinizing hormone (LH) to gonadotropin‐releasing hormone was also investigated and ovarian ultrasonographic findings were evaluated. In five of six patients with menstrual problems (25% of the group), a well‐defined RED was diagnosed (polycystic ovarian disease in three cases and hypothalamic ovarian failure in two). The 14 patients with normal menstrual cycles showed an elevation of mean basal follicle‐stimulating hormone and prolactin, and a blunting of mean LH response. Our results suggest that a high occurrence of REDs may be found also in PGE. We hypothesize that a neurotransmitter dysfunction might be the common pathogenetic mechanism resulting in both REDs and PGE. The hormonal alterations observed in the patients with normal menstrual cycles seem to support our hypothesis. Previous data seem to rule out a possible AED effect accounting for the hormonal findings observed in our series. However, further studies are needed to confirm our preliminary results.

Effects of postmenopausal hypoestrogenism on skin collagen

OBJECTIVE The aim of our study was to evaluate the effect of aging and postmenopausal hypoestrogenism on skin collagen content. METHODS Thirty-two women (mean age 48.78 +/- 9.86; year +/- S.D., range 28-68), 14 in premenopause and 18 in postmenopause, underwent skin biopsies performed during laparotomic operation. The amount of collagen type I, III and type III/type I ratio was evaluated by immunohistochemistry and computerised image analysis, and was related to age and years of postmenopause. RESULTS In the postmenopausal patients, a significant (P < 0.01) decrease of percentage of skin collagen type I, type III and type III/type I ratio was observed in comparison to premenopausal women. The percentages of collagen type I, type III and type III/I ratio of all patients studied was significantly (P < 0.01) correlated with chronological age (r = 0.88, 0.89 and 0.61, respectively). Considering only postmenopausal subjects, the correlation with chronological age was significant (P < 0.01) for collagen type I and type III of postmenopausal women (r = 0.59, r = 0.64, respectively), but not for the type III/I ratio (r = 0.37, P = 0.131). The percentages of collagen type I, type III and type III/I ratio of postmenopausal women showed a significant (P < 0.01) inverse correlation with years of postmenopause (r = 0.76, 0.73 and 0.73, respectively). CONCLUSIONS Our data suggest that the decrease of skin collagen is an estrogen-related phenomenon.

The effect of a levonorgestrel-releasing intrauterine device in the treatment of myoma-related menorrhagia

In this open observational study we evaluated the effectiveness of a levonorgestrel-releasing intrauterine device (LNG-IUD) in the treatment of myoma-related menorrhagia. Nineteen patients with recurrent menorrhagia lasting more than 3 months and with fibromyomatosus uterus were treated for 12 months with a LNG-IUD releasing 20 micro g/day of levonorgestrel. Menstrual blood loss, measured objectively by the pictorial blood loss assessment chart score (PBAC), level of serum hemoglobin and pattern of uterine bleeding were recorded at 3, 6, 9 and 12-month follow-up visits. Median monthly PBAC score during the two menstrual cycles before treatment was 310. After LNG-IUD, the PBAC score gradually decreased from a median value of 186 at 3 months to a median value of 155, 108 and 96 at 6, 9 and 12 months of treatment, respectively. Despite the statistically significant reduction of PBAC score, persistent menorrhagia, defined as a monthly PBAC score of 100 or higher, was observed at 12 months in 14 patients, whereas only one woman was amenorrheic and 4 were hypomenorrheic. In conclusion our study demonstrates the clinical reduced effectiveness of LNG-IUD in the treatment of myoma-related menorrhagia.

MATERNAL SERUM AND UMBILICAL CORD BLOOD LEPTIN CONCENTRATIONS WITH FETAL GROWTH RESTRICTION

OBJECTIVE To ascertain whether fetal growth restriction is associated with alterations of leptin concentrations in umbilical cord blood and maternal serum. METHODS Maternal serum and umbilical cord blood leptin concentrations were determined by immunoradiometric assay at term in 43 women with uncomplicated singleton pregnancies (group A) and in 27 women with singleton pregnancies complicated by fetal growth restriction (group B), all with normal pregravid body mass index (BMI). RESULTS Maternal serum leptin concentrations were significantly higher in group B compared with group A (45.0 ng/mL [range 34.2–54.9] versus 29.0 ng/mL [range 24.7–33.3]; P < .01). Umbilical cord blood leptin levels were significantly lower in group B compared with group A (8.4 ng/mL [range 3.6–13.2] versus 13.1 ng/mL [9.7–16.5]; P < .01). Maternal serum leptin levels were not significantly correlated with maternal BMI or with neonatal birth weight in either group. Umbilical cord blood leptin concentrations were significantly correlated with neonatal birth weight in both groups. CONCLUSION Growth restricted fetuses at term show umbilical cord blood leptin concentrations significantly lower than those in normal fetuses, suggesting that fetal adipose tissue is a major source of leptin. Maternal serum leptin concentrations are higher in the presence of a growth restricted fetus. This increase might be due to an intrinsic placental mechanism, by which small placentas produce more leptin as a compensatory mechanism, or to early hypoxia.

Effects of a low-dose and ultra-low-dose combined oral contraceptive use on bone turnover and bone mineral density in young fertile women: a prospective controlled randomized study

In this prospective, controlled, randomized study, we compared the effect of a low-dose 21-day combined oral contraceptive (COC) containing 20 microg ethinyl estradiol (EE) and 75 microg gestodene (GTD) (Group A; n = 19) with an ultra-low-dose 24-day COC containing 15 microg EE and 60 microg GTD (Group B; n = 18) on bone turnover and bone mineral density (BMD) in young, fertile women. Nineteen healthy fertile women were used as untreated controls (Group C). At 3, 6, 9 and 12 months of the study serum osteocalcin (BGP), urinary pyridinoline (PYD) and deoxypyridinoline (D-PYD) were measured in all subjects. At baseline and after 12 months BMD was determined at lumbar spine by dual-energy X-ray absorptiometry in all patients. In both Groups A and B, urinary levels of PYD and D-PYD at 6, 9 and 12 months, were significantly reduced in comparison with basal values and with control subjects (p < 0.05). No significant differences in urinary PYD and D-PYD levels were observed between Groups A and B during the entire period of treatment. At 12 months, no statistically significant difference in spinal BMD values was detected between the three groups and in comparison with basal values. The present study suggests that the two COCs could exert a similar positive effect on bone turnover in young postadolescent women, without any significant and appreciable modification of BMD.

Metalloproteinases, vascular endothelial growth factor, and angiopoietin 1 and 2 in eutopic and ectopic endometrium

OBJECTIVE To evaluate the expression of vascular endothelial growth factor (VEGF), angiopoietin 1 and 2 (ANGPT1/ANGPT2), and matrix metalloproteinases 1, 2, and 9 (MMP-1, MMP-2, MMP-9) in eutopic and ectopic endometrium. DESIGN Experimental retrospective study. SETTING University hospital. PATIENT(S) Eutopic and ectopic endometrium samples from 30 women with endometriosis and endometrium biopsy samples from 30 healthy women. INTERVENTION(S) Biopsies of ovarian endometriomas and eutopic endometrium. MAIN OUTCOME MEASURE(S) Immunohistochemical staining to evaluate the expression of VEGF, ANGPT1, ANGPT2, MMP-1, MMP-2, and MMP-9, and real-time polymerase chain reaction analysis to quantify mRNA expression. RESULT(S) Patients with endometriosis had higher levels of angiogenic factors and metalloproteinases in endometriotic cysts than in eutopic endometrium. These substances were also overexpressed in eutopic endometrium of patients with endometriosis when compared with normal controls. CONCLUSION(S) Overexpression of angiogenic factors and metalloproteinases may be the characteristic feature of endometrium with greater potential to transform into endometriotic lesions in the peritoneal cavity. Structural and/or functional differences of eutopic endometrium could have a role in the pathogenesis of endometriosis secondary to the backward passage of endometrial cells into the peritoneal cavity. Whether these local factors may induce, promote, and/or regulate this transformation remains to be determined.

Effects of hormone replacement therapy on ocular function in postmenopause.

ObjectiveTo evaluate the effect of hormone replacement therapy on climacteric ocular complaints, lacrimal secretion, intraocular pressure (IOP), and corneal thickness. DesignA prospective, controlled, randomized study on 50 healthy women (mean age 53.4 ± 3.8 years) at least 1 year after spontaneous menopause. Twenty-five women (group A) were treated with transdermal 17&bgr;-estradiol (50 &mgr;g/day) and medroxyprogesterone acetate (10 mg/day) for 12 days per cycle. Twenty-five untreated women (group B) were used as a control group. All participants underwent eye examination at the beginning of the study and after 3 and 6 months of therapy to detect ocular diseases and to measure lachrymal secretion, IOP, and corneal thickness. ResultsNo significant differences were observed between the two groups at the beginning of the study. After 3 and 6 months of treatment, we observed a significant reduction in the percentage of women in group A affected by ocular symptoms and in the severity of symptomatology in comparison with baseline and with group B (P < 0.01). A significant increase of both basal and stimulated lachrymal secretion was observed after 3 months of therapy in group A in comparison with baseline (P < 0.01). There was a significant decrease of IOP (P < 0.01) after 3 months of therapy in group A (P < 0.01), and a slight, nonsignificant increase of corneal thickness was observed in group A at 3 and 6 months in comparison with basal values. ConclusionOur data suggest that hormone replacement therapy may exert a beneficial effect on ocular symptomatology, increase lachrymal secretion, reduce IOP, and increase corneal thickness.

Review of New Office-Based Hysteroscopic Procedures 2003–2009

Office operative hysteroscopy is a recent technique that enables treatment of uterine pathologic disorders in the ambulatory setting using miniaturized hysteroscopes with mechanical or electric instruments. The available international literature from 1990 to 2002 has clearly demonstrated that such technique enables performance of hysteroscopically directed endometrial biopsy and treatment of uterine adhesions, anatomic disorders, polyps, and small myomas safely and successfully without cervical dilation and the need for anesthesia. This review provides a comprehensive survey of further advancements of office operative hysteroscopy in the treatment of other gynecologic pathologic conditions that have not been included in the schema of treatment indications for office procedures proposed in 2002. A search of MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews identified articles published from 2003 to 2009. Eighteen articles were identified: 9 on hysteroscopic sterilization; 1 on office-based metroplasty, 8 on office-based treatment of some uncommon gynecologic pathologic conditions (e.g., hematometra, diagnosis and treatment of vaginal lesions, treatment of uterine cystic neoformations, bleeding from the cervical stump, diagnosis and treatment of endocervical ossification, and removal of uterovaginal packing). All performed procedures were carried out safely and successfully in the office setting, with high patient tolerance and minimal discomfort. The success of the procedures has been confirmed by resolution of symptoms and at follow-up ultrasonographic and hysteroscopic examinations. Currently, as a result of technologic advancements and increased operator experience, an increasing number of gynecologic pathologic conditions traditionally treated in the operating room may be treated safely and effectively using office operative hysteroscopy.

Carbon dioxide versus normal saline as a uterine distension medium for diagnostic vaginoscopic hysteroscopy in infertile patients: a prospective, randomized, multicenter study.

OBJECTIVE To evaluate the satisfaction rate, efficacy, and complication rate of carbon dioxide (CO(2)) versus normal saline as a uterine distension medium for outpatient diagnostic vaginoscopic hysteroscopy in infertile patients. DESIGN Prospective, randomized multicenter study. SETTING Hysteroscopy units in two university hospitals and in a private center. PATIENT(S) One hundred eighty-nine infertile women undergoing outpatient hysteroscopy. INTERVENTION(S) Outpatient hysteroscopy was performed with CO(2) (group A) or normal saline (group B) and with endometrial biopsy when indicated. MAIN OUTCOME MEASURE(S) Quality of the visualization of the uterine cavity, procedure time, complications, patient discomfort, and satisfaction rate. RESULT(S) Significantly lower abdominal and shoulder tip pain and a lower incidence of vasovagal reactions were observed in group B in comparison with group A. A higher satisfaction rate and a lower operative time were obtained in the normal saline group in comparison with the CO(2) group. Moreover, group A required significantly more analgesics after the procedure than group B. CONCLUSION(S) Uterine distension with normal saline seems to have less adverse effects and is better tolerated by patients. Moreover, it allows operative procedures to be performed with the new bipolar instruments.