Ettore Cicinelli

Direct transport of progesterone from vagina to uterus.

Objective To compare progesterone concentrations in serum and endometrial tissue from hysterectomy specimens after vaginal or intramuscular (IM) administration of progesterone gel. Methods This was a randomized open study of 14 post-menopausal women undergoing transabdominal hysterectomies. Participants received either vaginal progesterone gel, 90 mg, or IM progesterone, 50 mg, at 8:00 AM and 8:00 PM on the day before surgery and at 6:00 AM on the day of surgery. Venous blood samples for progesterone measurement were collected at 8:00 AM on the day before surgery (baseline) and during surgery. After removal of the uterus, the endometrium was sampled from the anterior and posterior walls. Results were expressed as ratios of endometrial to serum progesterone concentrations × 100. Results Ratios of endometrial to serum progesterone concentrations were markedly higher in women who received vaginal progesterone (14.1 median, 8.5–59.4 range; 95% confidence interval [CI] 9.89, 38.79) compared with IM injections (1.2 median, 0.5–13.1 range; 95% CI −0.48, 7.39) (P < .005). Conclusion Ratios of endometrial to serum progesterone concentrations were higher after vaginal administration of progesterone than after IM injections. Our findings in endometrial tissue specimens from hysterectomies excluded the possibility of contamination by progesterone that remained in the vagina.

Topical anaesthesia for diagnostic hysteroscopy and endometrial biopsy in postmenopausal women: a randomised placebo‐controlled double‐blind study

OBJECTIVE To evaluate the efficacy and safety of topical anaesthesia in reducing pain and incidence of vasovagal reactions during diagnostic hysteroscopy with endometrial biopsy in postmenopausal women. DESIGN Randomised placebo-controlled double-blind study. SETTING University hospital. PARTICIPANTS Eighty postmenopausal women undergoing diagnostic hysteroscopy and endometrial biopsy. INTERVENTIONS Two millilitres of 2% mepivacaine or saline solution were injected transcervically into the uterine cavity before performing the procedures. MAIN OUTCOME MEASURES Evaluation of pain reduction on a visual analogue scale and continuous monitoring of heart rate and blood pressure. RESULTS The use of the anaesthetic significantly reduced the pain experienced at hysteroscopy and endometrial biopsy. The occurrence of vasovagal reactions was significantly lower in the anaesthetised group. CONCLUSIONS Topical anaesthesia attenuated pain and effectively prevented the occurrence of vasovagal reactions during hysteroscopy and endometrial biopsy in postmenopausal women.1 Flannelly G, Langhan H, Jandial L, Mann E, Campbell M, Kitchcner H. A study of treatment failures following large loop excision of the transformation zone for thc treatment of cervical intraepithelial neoplasia. Br JObstet GynaecolI997; 104: 71 8722. Prendiville W, Cullimore J, Nonnan S. Large Loop excision of the transformation zone (LLETZ): a new method of management for women with cervical intraepithelial neoplasia. Br J Ohstet Gynaecol 2

Reliability, feasibility, and safety of minihysteroscopy with a vaginoscopic approach: experience with 6,000 cases

OBJECTIVE To assess the reliability, feasibility, and safety of lens-based minihysteroscopy. DESIGN Retrospective comparative study. SETTING Academic research environment. PATIENT(S) Women with different indications for hysteroscopy. INTERVENTION(S) Six thousand seventeen outpatient diagnostic hysteroscopies with a minihysteroscope (2.7-mm outer diameter [OD] telescope with 3.5-mm OD single-flow diagnostic sheath) and 4,204 with traditional hysteroscope (4-mm OD telescope with 5-mm OD single-flow diagnostic sheath). All hysteroscopies were performed using a vaginoscopic approach and saline to distend the uterus. MAIN OUTCOME MEASURE(S) Rate of successful introduction of the hysteroscope, rate of satisfactory examinations, pain intensity experienced using an arbitrary pain scale (0 = no pain; 1 = low pain; 2 = moderate pain; 3 = severe pain), and number of side effects and complications. RESULT(S) In the minihysteroscopy, group rates of successful introduction and satisfactory examinations were significantly higher than in the traditional hysteroscope group (99.52% vs.72.53% and 98.53% vs. 92.33%, respectively), while pain and vagal reactions were significantly lower (0.10 +/- 0.34 vs.1.09 +/- 0.53 and 2.25% vs.17.12%, respectively). CONCLUSION(S) Hysteroscopy with lens-based minihysteroscopes was easier, less painful, more reliable, and safer than with 5-mm hysteroscopes. Minihysteroscopy with a vaginoscopic approach is a very well tolerated, effective, and safe outpatient procedure.

Myomas, Pregnancy Outcome, and In Vitro Fertilization

Abstract: Uterine fibroids have been reported in 27% of infertile women, and 50% of women with unexplained infertility become pregnant after myomectomy. The age at which a first pregnancy occurs is increasing from the thirties to the forties. This increase and the recurrence rate of leiomyomas from 15 to 30% points to the effect of myomas on the infertility. Mechanisms by which myomas may cause infertility are abnormal uterine contractility, elongation of the uterine cavity, and distortion of uterine vascularization. Surgery may have beneficial or adverse effects without clear data on its effect on the assisted reproductive technology (ART) procedures. The present study was undertaken to establish the impact of surgical removal of myomas on fertility and infertility of patients undergoing ART procedures. Patients who underwent surgical removal of myomas before in vitro fertilization (Group A) had a cumulative success rate of 33% for one to three procedures (28 clinical pregnancies in 84 patients) and delivery rate of 25% (21 live births in 84 patients). Patients who underwent in vitro fertilization without previous surgery (Group B) had a 15% clinical pregnancy rate (13 pregnancies in 84 patients) (P < 0.05) and 12% delivery rate (10 deliveries in 84 pregnancies) (P < 0.05). Abortion rates were 7% (8 deliveries in 84 patients) and 4% (3 deliveries in 84 patients) in Groups A and B, respectively. This study confirms the beneficial effect of surgical removal of fibroids before undergoing ART procedures.

Acute effects of transdermal estradiol administration on plasma levels of nitric oxide in postmenopausal women

OBJECTIVE To investigate the acute effects of transdermal E2 administration on nitric oxide (NO) plasma levels in postmenopausal women. DESIGN Randomized, placebo-controlled trial. SETTING Normal human volunteers in an academic research environment. PATIENT(S) Twenty healthy postmenopausal women. INTERVENTION(S) Transdermal administration of 100 micrograms/d E2 or placebo. MAIN OUTCOME MEASURE(S) Plasma concentrations of NO stable oxidation products and serum concentrations of E2 were assessed before and 24 hours after the administration. RESULT(S) In the group treated with E2 mean concentration of NO metabolites 24 hours after patch application (37.31 +/- 7.62 mumol/L) resulted significantly higher than baseline (21.04 +/- 5.71 mumol/L) and the control group (23.50 +/- 4.03 mumol/L). The correlation between the mean percent increase in NO metabolites and absolute E2 concentrations 24 hours after the E2 administration was statistically significant. CONCLUSION(S) Transdermal administration of E2 to healthy postmenopausal women increases the plasma levels of NO and this supports the hypothesis that a NO-related mechanisms may contribute to the cardiovascular protective effect of estrogens in postmenopause.

Tolerability of the mini-pan-endoscopic approach (transvaginal hydrolaparoscopy and minihysteroscopy) versus hysterosalpingography in an outpatient infertility investigation

OBJECTIVE To compare the acceptance and tolerability of the mini-pan-endoscopic approach (transvaginal hydrolaparoscopy [THL] combined with minihysteroscopy) versus hysterosalpingography (HSG) for evaluating tubal patency and the uterine cavity in an outpatient infertility investigation. DESIGN Randomized controlled study. SETTING University hospital. PATIENT(S) Twenty-three infertile patients without obvious pelvic pathology. INTERVENTION(S) Women were randomly divided into two groups. One group underwent minihysteroscopy and THL with tube chromoperturbation as first investigation and HSG within the following 7 days, while in the other group the investigation sequence was inverted. Women reported pain experienced before and at the end of procedures. MAIN OUTCOME MEASURE(S) Mean duration of procedures, level of pain experienced, diagnostic agreement about tubal patency and uterine cavity normality. RESULT(S) THL and minihysteroscopy took significantly more time but was significantly less painful than HSG. Regarding tubal patency, in 95.5% of cases THL agreed with HSG. In one case, HSG diagnosed a bilateral obstruction of tubes, whereas at THL a bilateral spreading of methylene blue was seen. Agreement on intrauterine pathologies between minihysteroscopy and HSG was poor (43%); the number of intrauterine abnormalities found at hysteroscopy was significantly greater than at HSG. CONCLUSION(S) THL in association with minihysteroscopy provided more information and was better tolerated than HSG in an outpatient infertility investigation.

Chronic Endometritis Due to Common Bacteria Is Prevalent in Women With Recurrent Miscarriage as Confirmed by Improved Pregnancy Outcome After Antibiotic Treatment

Recurrent miscarriage (RM) is defined as 3 or more miscarriages before 20 weeks’ pregnancy. In recent years, interest has been focused on chronic endometritis (CE), a subtle inflammation thought to be associated with RM. We aimed to evaluate the relationships between CE and RM. The records of 360 women with unexplained RM were retrospectively analyzed. Data from hysteroscopy, endometrial histology, endometrial culture, and polymerase chain reaction for chlamydia, performed before and after antibiotic treatment for CE, were analyzed. The occurrence of successful pregnancies within 1 year after treatment was also evaluated. Results showed that 208 (57.8%) women with RM showed CE at hysteroscopy; 190 (91.3%), positive at hysteroscopy, were also positive at histology, and 142 (68.3%) had positive cultures. Common bacteria were found in 110 (77.5%) patients. Mycoplasma and Ureaplasma were found in 36 (25.3%) patients and Chlamydia in 18 patients (12.7%). In 102 (71%) women, antibiogram-based antibiotic treatment normalized hysteroscopy, histology, and cultures (group 1); while in 40 (28.2%) patients, CE was still present at hysteroscopy (group 2). In 16 of the 66 patients positive at hysteroscopy, but not at cultures, the hysteroscopy becomes normal (group 3) after a Centers for Disease Control and Prevention-based therapy; while in 50 women, CE was still present (group 4). One year after treatment, group 1 showed a significantly higher number of pregnancies (78.4%) compared to group 2 (17.5%; P < .001) and group 4 (15.3%; P = .005). The CE is frequent in women with RM. Antibiotic treatment seems to be associated with an improved reproductive outcome.

The patterns of uterine contractility in normal menstruating women: From physiology to pathology

Abstract: The nonpregnant uterus shows uterine activity throughout the menstrual cycle. This uterine activity was detected both by single strep tissue and by using intrauterine pressure recordings in vitro and in vivo. Today, ultrasound has made it possible to study this activity with a noninvasive approach and to assess uterine contractions (UCs) in real‐time movements of the uterus. Throughout the menstrual cycle, wavelike activity patterns of the reproductive organ were established. These patterns are under control of steroid hormones. Adequate UCs may provide for gamete/embryo transportation throughout the uterotubal cavities and successful embryo implantation in spontaneous and/or assisted reproduction. Inadequate UCs may produce ectopic pregnancy, miscarriages, retrograde bleeding with dysmenorrhea, and endometriosis.

Sonohysterography versus hysteroscopy in the diagnosis of endouterine polyps

The objective of this retrospective study was to evaluate the usefulness of abdominal and vaginal sonohysterography (SHG; considered both singly and in combination) for the diagnosis of uterine polyps. Fifty fertile women hospitalized for hysterectomy for benign gynecologic indications were enrolled. Main outcome measures were preoperative conventional vaginosonography, transabdominal and vaginal SHG, hysteroscopy and histologic evaluation of the surgical specimen. Conventional vaginosonography had a sensitivity of 33.3% and a specificity of 100%; the predictive values of abnormal and normal scans were 100 and 79.5%, respectively. Transabdominal SHG had a sensitivity of 75% and a specificity of 100%. The predictive value of an abnormal scan was 100%; that of a normal scan 91.2%. Vaginal SHG had a sensitivity of 58.3% and a specificity of 100%; the predictive value of an abnormal scan was 100%, that of a normal scan 86.1%. The combination of the two kinds of SHG had a sensitivity of 91.7% and specificity of 100%; the predictive value of an abnormal test was 100% and that of a normal test 96.9%. The sensitivity, specificity and predictive values of abnormal and normal hysteroscopic examination were all 100%. In conclusion, the presence of endouterine polyps can be effectively investigated by SHG; nevertheless, hysteroscopy is more sensitive, being capable of detecting even very small endouterine neoformations.

Resectoscopic treatment of uterus didelphys with unilateral imperforate vagina complicated by hematocolpos and hematometra: case report

OBJECTIVE To describe a technique for treating hematocolpos and hematometra in patients with uterus didelphys and unilateral imperforate vagina involving the use of resectoscopy under ultrasonographic control. DESIGN Case report. SETTING University hospital. PATIENT(S) A 13-year-old girl with uterus didelphys with unilateral hematometra, hematocolpos, and ipsilateral renal agenesis. The girl complained of severe abdominal pain, which appeared with each of her menses. INTERVENTION(S) The intervention was performed by a vaginoscopic approach to preserve the integrity of the hymen. The first incision on the vaginal wall was performed in correspondence with the hematocolpos under continuous ultrasonographic guidance with the use of a straight resectoscopic loop. Resection of the vaginal septum was continued with the use of an angled resectoscopic loop until almost complete excision of the septum was achieved. MAIN OUTCOME MEASURE(S) Clinical, echographic, and vaginoscopic findings before the operation and 2 and 6 months after the operation. RESULT(S) The surgical procedure was easy to perform. Almost complete excision of the septum was achieved with just a few passages of the resectoscope. Complete drainage of both the hematocolpos and the hematometra was confirmed by ultrasonography. The postoperative period was completely uneventful. Clinical and vaginoscopic evaluations 6 months after the operation confirmed the integrity of the hymen, the complete resolution of clinical symptoms, and the persistence of a large communication between the two vaginas. CONCLUSION(S) Resectoscopic excision under ultrasonographic guidance of the vaginal septum in a girl with uterus didelphys with unilateral hematometra and hematocolpos was effective and easy to perform, and it fully respected the integrity of the reproductive system.