Efthimios Deligeoroglou

Creation of a neovagina following Williams vaginoplasty and the Creatsas modification in 111 patients with Mayer- Rokitansky-Kuster-Hauser syndrome

OBJECTIVE Evaluation of the Creatsas modification of Williams vaginoplasty for the creation of neovagina in patients with Mayer-Rokitansky-Küster-Hauser syndrome (MRKH syndrome). DESIGN Record of perioperative and postoperative results and complications. Follow-up evaluations of patients yearly after the operation. SETTING Division of Pediatric-Adolescent Gynecology and Gynecologic Corrective Surgery, University of Athens (tertiary referral center). PATIENT(S) One hundred eleven patients with MRKH syndrome. INTERVENTION(S) Surgical creation of neovagina using the Williams vaginoplasty technique (group A: 10 patients) or the Creatsas modification of the previous method (group B: 101 patients). MAIN OUTCOME MEASURE(S) Length and width of the neovagina, and the quality of sexual life postoperatively. RESULT(S) A functioning vagina of 10 to 12 cm depth and 5 cm width was created in eight of the patients in group A (80%) and in 98 of those in group B (97.02%). A vagina of 7 to 9 cm depth and 2 to 3 cm width was created in the rest of the patients in both groups. In group A, two wound openings were reported (20%); in two of the patients hemorrhage occurred during the first intercourse, compared to none in group B. A satisfactory sexual life was reported from 94.4% of the patients and an adequate one from 4.16% of them. CONCLUSION(S) The Creatsas modification of Williams vaginoplasty is a simple and effective technique for the creation of a functioning neovagina in young women with vaginal aplasia.

Oral Contraceptives and Reproductive System Cancer

Abstract: Extensive research during the last 20 years has shown that oral contraceptives are safe. Several recent epidemiological studies have confirmed that combined oral contraceptives (COCs) provide substantial protection against endometrial and ovarian cancer, and this protection is long‐lasting and may persist for 15 or more years after termination of OC use. In many studies COCs have been associated with an increased risk of cervical abnormalities and cervical cancer, but there might be alternative explanations for these epidemiological associations (COC users can start having sexual intercourse at an earlier age, they have more sexual partners, and they rarely use barrier methods of contraception), so OCs act as a promoter for HPV‐induced carcinogenesis. Finally, women who are currently using COCs or have used them in the past 10 years are at a slightly increased risk of having breast cancer during the next 10 years, although the additional cancers diagnosed tend to be localized to the breast and they are less advanced clinically than the cancers diagnosed in those who have never used COCs.

Ovarian masses during adolescence: clinical, ultrasonographic and pathologic findings, serum tumor markers and endocrinological profile.

This retrospective study was undertaken to assess the epidemiological and clinical features, laboratory findings, preoperative work-up, surgical treatment and pathologic findings in adolescents with ovarian cysts. All adolescents who were referred to our institution and had been operated on because of a diagnosed ovarian mass, from January 1997 to June 2003, were included in this study. Forty-four cases of women with an ovarian mass were retrospectively analyzed. These patients, aged between 12 and 21 years, had 47 ovarian masses (three patients had bilateral lesions), of which 49% were non-neoplastic and 51% were neoplastic. Of the neoplastic lesions, 62.5% were germ cell tumors, 20.8% were epithelial and 16.7% were sex cord–stromal tumors. Of the neoplastic tumors, 95.8% were benign while 4.2% were malignant. Procedures included 30 operative laparoscopies (68.2%) and 14 exploratory laparotomies (31.8%). Simple excision of the ovarian cyst was performed in 39 cases (88.6%). According to our study, most of the adolescents with an ovarian cyst underwent an operation because of a neoplastic lesion. The majority of ovarian tumors occurring in adolescents are non-epithelial in origin, and germ cell tumors are the most common histological type. Ultrasound examination is one of the most important diagnostic tools. Preoperative diagnostic approach of these patients should always include careful history taking, physical examination, imaging and evaluation of serum assays. Gynecologists who care for young girls must be familiar with the differential diagnosis of ovarian masses whose surgical treatment should be conservative when appropriate, so that hormonal status and future fertility are not compromised in this group of patients.

Anxiety and depression in adolescents with polycystic ovary syndrome and Mayer-Rokitansky-Küster-Hauser syndrome

Purpose. The purpose of this study was to assess self-reported depressive and anxiety symptoms in adolescents with polycystic ovary syndrome (PCOS) and those with the rare Mayer-Rokitansky-Küster-Hauser Syndrome (MRKHS), compared with healthy adolescents. Material and methods. The participants were 49 adolescent girls, of whom 27 were patients with confirmed menstrual disorder, 22 with PCOS and 5 with MRKHS; and 22 were healthy eumenorrheic adolescents (control group) matched by age and school grade. The Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI-Gr) were used to measure depression and anxiety, respectively. Results. The results showed that it was 1.08 times more likely for the PCOS group (p = 0.043) and 1.12 times more likely for the MRKHS group (p = 0.039) to have higher scores than healthy adolescents on the anxiety scale. The MRKHS group was 1.40 times more likely to have a higher number of depressive symptoms (p = 0.040) than the control group. Conclusions. These findings, although based on a small sample, suggest a relationship between PCOS and MRKHS and the presence of psychological problems, such as anxiety and depressive symptoms in adolescents. This study is among the first to examine psychological difficulties in adolescents with such a rare menstrual syndrome as MRKHS.

Evaluation and management of adolescent amenorrhea

During the first years of menstruation it is not rare for a girl to present with an irregular menstrual pattern. The complete absence or cessation of menses, which is defined as amenorrhea, requires careful evaluation and management. It is divided into primary and secondary types that describe the occurrence of amenorrhea before and after menarche, respectively. The list of causes is long and includes anatomical or functional anomalies of the genital tract, hormonal disorders, and multifactorial reasons. The most common causes are hypothalamic amenorrhea, polycystic ovarian syndrome, hyperprolactinemia, and ovarian failure. A thorough medical history and careful clinical examination of the young girl is absolutely essential. The distinction between primary and secondary amenorrhea, together with the presence, or not, of secondary sexual characteristic development will guide the physician to the differential diagnosis of amenorrhea. Essential laboratory examinations include follicle‐stimulating hormone (FSH), luteinizing hormone (LH), thyroid‐stimulating hormone (TSH), and prolactin measurements; while in the presence of acne or hirsutism, androgen levels should also be measured. Management should focus on the restoration of ovulatory cycles and the prevention of short‐ and long‐term consequences of hormonal imbalance.

Creation of a neovagina after Creatsas modification of Williams vaginoplasty for the treatment of 200 patients with Mayer-Rokitansky-Kuster-Hauser syndrome

OBJECTIVE To present and evaluate the results of the Creatsas modification of Williams vaginoplasty for the creation of a neovagina in young women with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome. DESIGN Retrospective study. SETTING Division of Pediatric-Adolescent Gynecology and Reconstructive Surgery, Second Department of Obstetrics and Gynecology, University of Athens, Aretaieion Hospital, Athens, Greece. PATIENT(S) Two hundred patients with the MRKH syndrome. INTERVENTION(S) Clinical examination, pelvic ultrasound, intravenous urography and/or renal ultrasound, laparoscopy, karyotyping, orthopedics and ears, nose, and throat examination, magnetic resonance imaging, and Creatsas modification of Williams vaginoplasty. MAIN OUTCOME MEASURE(S) Neovaginal functional dimentions, neovaginal axis deviation, and quality of sexual life. RESULT(S) A functioning vagina of 10-12 cm in depth and 5 cm in width was created in 191 cases (95.5%). A vagina between 7 and 9 cm in depth and 2 and 3 cm in width was created for the remaining nine patients (4.5%). In addition, 94.5% declared themselves to have a satisfactory quality of sexual life, while only 5% of the cases reported an adequate one. CONCLUSION(S) Creatsas modification of Williams vaginoplasty is a simple, quick, and effective method for the treatment of vaginal agenesis.

Genetic variants in TCF7L2 and KCNJ11 genes in a Greek population with polycystic ovary syndrome.

Polycystic ovary syndrome (PCOS), the most common reproductive endocrine disorder of premenopausal women, is strongly associated with hyperinsulinemia and type 2 diabetes mellitus (T2DM). Given the phenotypic overlap between PCOS and T2DM, our objective was to investigate whether the TCF7L2 rs7903146(C/T) and the KCNJ11 E23K variants are involved in susceptibility to PCOS and related traits in a Greek population. A total of 183 PCOS patients and 148 healthy controls participated. All participants were Greeks. Blood was taken before hormonal therapy. PCOS patients and healthy controls were genotyped for the TCF7L2 and KCNJ11 variants. The T allele of the TCF7L2 rs7903146 variant was found to be marginally over-represented in Greek patients with PCOS. There was no association between KCNJ11 E23K polymorphism and PCOS in the present study. In addition, there were no associations observed between hormone levels and insulin resistance in PCOS carriers of TCF7L2 rs7903146 and KCNJ11 E23K variants. These data provide evidence that the rs7903146 variant of the TCF7L2 gene might influence PCOS predisposition, while no association is observed between the E23K variant of KCNJ11 and susceptibility to PCOS and related traits.

Dysfunctional Uterine Bleeding

Dysfunctional uterine bleeding (DUB) is a frequent gynecological problem during adolescence and the most frequent cause of urgent admission to the hospital over this period of life. In about 95% of cases it is caused by the late maturation of the hypothalamic-pituitary-ovarian axis (HPO), leading to anovulatory cycles. These adolescents lack the E2 positive feedback on LH. Thus, the continuous production of estrogen with endometrial stimulation is the basic cause of dysfunctional uterine bleeding. The initial step in the evaluation of DUB includes detailed clinical history, followed by complete physical examination. Laboratory tests should include coagulation profile, complete blood count with platelet evaluation, and sometimes a serum pregnancy test. The treatment of DUB is related to the severity of symptomatology with the objective of stopping bleeding and preventing recurrences. Modern hormonal and other medical therapies enable physicians to treat DUB effectively, regardless of the cause. Surgical treatment, such as dilatation and curettage, is rarely indicated in the adolescent patient. The importance of continued follow-up in DUB cases should be underlined, until stabilization of ovulatory menstrual cycles.

Activin A and Follistatin as Biomarkers for Ectopic Pregnancy and Missed Abortion

Activin A as a predictor of pregnancy failure has been the focus of heated debate, but the value of a combined activin A and follistatin (FS) measurement in serum to predict pregnancy failure has not been reported yet. We assessed whether a single serum measurement of the two physiological antagonists at 6–8 weeks gestation could differentiate ectopic pregnancies (EP) or missed abortions (MA) from healthy intrauterine pregnancies (IUP). activin A concentrations were significantly lower in women with EP (n = 30, median value of 264 pg/mL) and women with MA (n = 30, median value of 350 pg/mL) compared to IUP (n = 33, median value of 788 pg/mL); P < 0.001. At a threshold value of 505 pg/mL, activin A had 87.9% sensitivity and 100% specificity and negative predictive value of 0.974 for discriminating an ectopic pregnancy from viable pregnancies. FS was able to discriminate IUP from EP (ROC curve P < 0.001) as was their ratio (ROC curve P = 0.008), but was unable to discriminate a MA from an EP. In EP, activin A did not correlate with beta HCG levels. The present findings support the thesis that activin A or FS could be considered promising biomarkers for the discrimination between an IUP and a failed pregnancy (MA or EP).

Vaginal aplasia and reconstruction

Congenital vaginal agenesis, with a prevalence of 1 in 4000 females, occurs mainly as a feature of the Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. Management of patients with MRKH syndrome includes, along with the proper psychological support, the creation of a neovagina to give them the opportunity to have a normal sexual life. Both surgical and non-surgical techniques have been suggested during the past century, for neovagina creation. Among them, the most widespread non-surgical techniques performed are the Frank technique and its modification by Ingram, while the surgical techniques include the McIndoe operation, the Vechietti procedure and its laparoscopic modification and the Williams vaginoplasty and its Creatsas modification. The Creatsas vaginoplasty is a simple, fast and safe technique that has been performed in 178 patients in our Institution over the past 22 years and has provided excellent results in the vast majority of patients.