Francisco José Candido-dos-Reis

Abdominal myofascial pain syndrome must be considered in the differential diagnosis of chronic pelvic pain.

Chronic pelvic pain is lower abdominal pain lasting at least 6 months, occurring continuously or intermittently and not associated exclusively with menstruation or intercourse. The involvement of the musculoskeletal system in chronic pelvic pain has been increasingly demonstrated. However, few studies exclusively examining abdominal myofascial pain syndrome as a cause of chronic pelvic pain in women are available. Therefore the objective of this manuscript is to describe the association between abdominal myofascial pain syndrome and chronic pelvic pain in women, and comment on methods for diagnosis and therapeutic options. There is evidence that the musculoskeletal system is compromised in some way in most women with chronic pelvic pain and that in 15% of these cases chronic pelvic pain is associated with abdominal myofascial pain syndrome but the scarcity of published data impairs the definition of protocols for the diagnosis and treatment of this disease. Abdominal myofascial pain syndrome is a highly prevalent disease associated with CPP, and because of this physicians should get used to make a precise and early diagnosis in order to avoid additional and unnecessary investigation.

Uterine leiomyoma: understanding the impact of symptoms on womens' lives.

BackgroundMost women report negative experience about the symptoms of uterine leiomyoma (UL) in their lives, such as abnormal uterine bleeding and pelvic pain. Many studies have been conducted about efficacy of UL treatment, but little research has been performed about womens health related quality of life (HRQL).MethodsThis is a semi-structured, descriptive, observational, qualitative study that was performed during eight months. Focus group (FG) interviews were performed with women attending at a tertiary hospital in Brazil, who were consecutively included in the study. Seventy women with symptomatic UL were recruited to this study. FG duration was one hour with mediators with 5-6 women at each group. Collected data from discussions was processed according to thematic analysis and stored at a qualitative software.ResultsWomen were negatively influenced by the presence of symptomatic UL. The major themes that were noticed during analysis were: beliefs and attitudes towards UL; limitation to social and professional activities; sensation of fear/unfairness/discouragement towards the symptoms and adverse effects during treatment with GnRH analogs.ConclusionsSymptomatic UL has a negative impact on womens HRQL. Health providers should consider such impact when counseling women on their treatment options, since it may have an important influence in these patients’ decision-making process. While current pharmacological treatments may improve disease specific outcomes, such as bleeding intensity and tumor volume, they fail on actually improving quality of life.

Endometriosis in postmenopausal women without previous hormonal therapy: report of three cases

Introduction Endometriosis is a benign, estrogen-dependent, chronic gynecological disorder associated with pelvic pain and infertility. The disease most commonly affects women during the reproductive age, although postmenopausal patients do rarely present it. These rare occurrences are generally associated with hormonal use. Material and methods We present three cases of endometriosis in postmenopausal patients who have no history of hormone therapy and no previous history of endometriosis or infertility. Case reports In case 1, a 62-year-old woman presented with acyclic pelvic pain and a left ovarian homogeneous cystic mass. After laparoscopic salpingoophorectomy and histological analysis, an ovarian endometriotic cyst was confirmed. In case 2, a 78-year-old woman presented with a painful abdominal wall mass that was confirmed by ultrasound and tomography. Her past medical history included an abdominal hysterectomy 20 years prior to the discovery of this mass. The lesion was surgically excised and histological analysis showed areas of endometrial stroma and glands surrounded by fibrosis, compatible with endometriosis. In case 3, a 54-year-old woman presented with chronic pelvic pain and a nodule in the rectovaginal septum was noted during gynecological examination. Menopause occurred at 48 years of age. She had no previous dysmenorrhea. Ultrasound confirmed the nodule in the rectovaginal septum. The patient was submitted to a diagnostic colonoscopy that revealed a friable lesion, which was subsequently biopsied. The histological diagnosis was endometriosis. Conclusions These three cases of postmenopausal endometriosis support the celomic metaplasia theory for the genesis of this disease.

Pain pressure threshold algometry of the abdominal wall in healthy women

The objective of this study was to determine the inter- and intra-examiner reliability of pain pressure threshold algometry at various points of the abdominal wall of healthy women. Twenty-one healthy women in menacme with a mean age of 28 ± 5.4 years (range: 19-39 years) were included. All volunteers had regular menstrual cycles (27-33 days) and were right-handed and, to the best of our knowledge, none were taking medications at the time of testing. Women with a diagnosis of depression, anxiety or other mood disturbances were excluded. Women with previous abdominal surgery, any pain condition or any evidence of inflammation, hypertension, smoking, alcoholism, or inflammatory disease were also excluded. Pain perception thresholds were assessed with a pressure algometer with digital traction and compression and a measuring capacity for 5 kg. All points were localized by palpation and marked with a felt-tipped pen and each individual was evaluated over a period of 2 days in two consecutive sessions, each session consisting of a set of 14 point measurements repeated twice by two examiners in random sequence. There was no statistically significant difference in the mean pain threshold obtained by the two examiners on 2 diferent days (examiner A: P = 1.00; examiner B: P = 0.75; Wilcoxon matched pairs test). There was excellent/good agreement between examiners for all days and all points. Our results have established baseline values to which future researchers will be able to refer. They show that pressure algometry is a reliable measure for pain perception in the abdominal wall of healthy women.

Effect of the aromatase inhibitor anastrozole on uterine and leiomyoma Doppler blood flow in patients scheduled for hysterectomy: a pilot study

The term ‘right aortic arch’ (RAA) refers to a congenital abnormal position of the aortic arch, that is, to the right of the trachea, with or without an abnormal branching pattern, and is one of the least frequently prenatally diagnosed cardiac abnormalities1–3. The main clue for the detection of RAA in large population studies and small case series has been absence of the normal ‘V’shaped confluence of the ductal and aortic arches (both to the left of the trachea) in the axial three vessels and trachea (3VT) view1–7, as a RAA and left ductus form an abnormal ‘U’-shape. Reviewing papers that have evaluated the associated conditions and outcomes of the different types of RAA, its occurrence with a right ductus arteriosus (RDA) has been reported with severe cardiac anomalies (tetralogy of Fallot, pulmonary atresia with ventricular septal defect, common arterial trunk)3,7,8 and high rates of 22q11 deletions7,9,10. We describe here a case of RAA with a RDA in which the heart was normal. This was easily recognizable in the 3VT view from the first trimester onwards, independent of the angle of insonation. Sonographic evaluations and image acquisitions were performed transabdominally using a Voluson 730 ultrasound machine (GE Medical Systems, Zipf, Austria). A 31-yearold low-risk pregnant woman, gravida 1 para 0, attended for first-trimester screening at our center. A cardiac transverse sweep showed an anatomically and functionally normal fetal heart, but a right-sided aortic arch and a V-shaped confluence with a patent RDA were observed on the 3VT view (Figure 1). Offline analysis by examiners experienced in fetal echocardiography resulted in similar conclusions. Invasive tests ruled out karyotype and 22q11 abnormalities. During the second and third trimesters normal views of the fetal heart were found on the standard axial approach (situs, area, axis, cardiac chambers, emergence of great vessels) (Figures 2a–c and Videoclip S1) and, in accordance with previous findings, an RAA and patent RDA were identified as a V-shaped

Increased cell proliferation in experimentally induced endometriosis in rabbits

OBJECTIVE To characterize the pattern of cell proliferation and apoptosis of eutopic and ectopic endometrium in rabbits after endometrium implantation for the experimental induction of endometriosis. DESIGN Animal experimental study. SETTING Sector of experimental surgery. ANIMAL(S) Twenty-female New Zealand rabbits. INTERVENTION(S) All animals underwent laparotomy for endometriosis induction by resection of one uterine horn, isolation of the endometrium, and fixation of tissue segment to the pelvic peritoneum. Two groups of 10 animals were sacrificed 4 and 8 weeks after endometriosis induction. The lesion was excised together with the opposite uterine horn for endometrial gland and stroma determination. MAIN OUTCOME MEASURE(S) Cell proliferation and apoptosis were determined in the eutopic and ectopic endometrium, and the cell proliferation index (CPI) and apoptotic index (AI) were calculated as the number of labeled cells per 1,000 cells. The tissue homeostasis index was the CPI/AI ratio. Glands and stroma were analyzed separately. RESULT(S) The CPI for ectopic tissue was increased compared with eutopic tissue, but there was no difference in the ectopic lesions between 4 and 8 weeks of induction. Considering only the AI, eutopic and ectopic endometrium did not differ after 4 weeks, but differed significantly in glandular tissue after 8 weeks. The tissue homeostasis index revealed cell proliferation in these tissues, with a CPI/AI more than 1. CONCLUSION(S) Ectopic lesions seem to have a higher CPI than eutopic endometrium, with uncontrolled tissue growth occurring in induced endometriotic lesions.

Low-dose progestin-releasing contraceptives are associated with a higher pain threshold in healthy women

OBJECTIVE To determine the pain thresholds of women taking different formulations of hormonal contraceptives. DESIGN Cross-sectional study. SETTING Basic health care unit. PATIENT(S) Eighty-nine healthy nonusers and 188 users of hormonal contraceptives. INTERVENTION(S) Subject interviews were followed by the application of a semistructured questionnaire, including a psychometric assessment with the Beck Depression Inventory and the State-Trait Anxiety Inventory. After the interview, a 10-mL peripheral blood sample was collected. Pain thresholds were obtained by performing pressure algometry. MAIN OUTCOME MEASURE(S) Serum concentrations of E2, P, and T (free fraction) were determined via chemoluminescence. The menstrual cycle phase was determined according to hormonal level and identification of an LH surge in urine. Pain threshold was evaluated with a dynamometer applied to the forearm skin of the nondominant limb and abdominal wall. RESULT(S) Progestin-only contraceptive users showed a higher pain pressure threshold in the forearm (2.94 ± 0.96 vs. 2.74 ± 0.89 vs. 2.62 ± 0.92) and right (2.11 ± 0.87 vs. 1.83 ± 0.81 vs. 1.78 ± 0.77) and left abdomen (2.12 ± 0.88 vs. 1.79 ± 0.76 vs. 1.73 ± 0.70) than did combined hormonal contraceptive users and nonusers of hormonal contraceptives, respectively. Users of contraceptives that continuously release etonogestrel (subcutaneous implant, vaginal ring) or levonorgestrel (intrauterine devices) had higher pain thresholds. CONCLUSION(S) Women who used hormonal contraceptives enabling continuous release of etonogestrel or levonorgestrel tended to have higher pain thresholds than did nonusers of hormonal contraceptives.

Motivational factors for women undergoing hysterectomy for uterine leiomyoma

diastasis from postpartum trauma. Orthopedics. 2008;31:493. 3. Burgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990;30:848–56. 4. Kefi A, Cimen S, Aslan G, Cihan A, Secil M, Esen AA. Urethral injury as a complication of isolated diastasis pubis: case report. Int Urol Nephrol. 2006;38:501–3. 5. Jain N, Sternberg LB. Symphyseal separation. Obstet Gynecol. 2005;105:1229–32.

Endometriosis of the soleus and gastrocnemius muscles

OBJECTIVE To document a rare case of endometriosis in the soleus and gastrocnemius muscles. DESIGN Case report. SETTING Tertiary care center. PATIENT(S) A 30-year-old fertile woman presented with moderate dysmenorrhea associated with calf pain and bulging that had been gradually worsening over the last years, particularly during menses. A mass in the soleus and gastrocnemius muscles was identified in ultrasonography and magnetic resonance imaging. INTERVENTION(S) Endometriosis was diagnosed by incisional biopsy on the basis of histopathology, and wide excisional biopsy was performed. MAIN OUTCOME MEASURE(S) Unusual clinical presentation of endometriosis. RESULT(S) The patient was disease free for 2 months. Recurrence of the lesion was then diagnosed, and a new surgical approach was planned. CONCLUSION(S) Endometriosis in muscles is a rare event, and existing theories are not totally sufficient in explaining it.

Using a search-volume tool (Google Trends) to assess global interest for uterine fibroids

Activity at all other time periods was presented relative to that peak. we recorded mean search activity from 2004 to 2012 and evaluated both parameters on an annual basis with analysis of variance and the student t test. we also looked for the number of websites directly and indirectly related to UF at Google search engine (www.google.com) from 2004 to 2012. Mean global search activity for “uterine fibroids” has decreased significantly on an annual basis (Fig. 1; p < 0.01). In 2004, mean search was 77.25 % and decreased to 64.41 % in 2012. The greatest volume of search activity was found in the United states, Canada, Australia, India and United Kingdom. Most prevalent related terms were myoma, uterine leiomyoma. However, the number of websites associated with UF has increased during this period, from 5,680 results to almost 70,600. Journals started to publish articles for non-medical communities after 2007, with some concentration during 2013. Decreased search activity does not always represent a trend for low popularity; we should differentiate popularity with the absolute number of searches, which actually has increased. Our interpretation is that UF has received many technologies that are not available yet for most of people, and maybe its search activity has decreased. However, the increased number of websites may represent the growing number of people interested to divulge this disease. Google trends is a search tool that has been used to investigate several diseases [4–6] and may integrate diseases into a “cybersurveillance” when trying to understand how certain diseases are behaving. Research at UF should focus on low-cost, effective treatments to target the majority of affected women and probably it will get more popular with the public. Uterine fibroids (UF) or uterine leiomyoma is the most prevalent benign gynecological tumors and despite many advances in non-surgical treatment, invasive treatments are still being performed worldwide [1]. Many theories have been developed about its origin, and newer clinical and minimally invasive treatments are being tested (selective progesterone receptor modulators, high-intensity focused ultrasound). However, women feel a negative impact when UF cause symptoms and usually are motivated to operate when possible [2, 3]. Media (television, radio and internet) has an important task as an informative tool for patients and health professionals to spread knowledge; of these categories, the Internet is a communication vehicle which has been rapidly growing and people are becoming frequent users. This study aimed to perform a retrospective study of global trends for UF on the Internet from 2004 to 2012, using the recently developed Google Trends search Application (www.google.com/trends) with all possible synonyms of UF. This is a “search-volume” tool that provides information on Internet searches that generate a significant volume of results [4]. Data were normalized to a reference population and scaled from 0 to 100 %. Peak search activity is considered the 100 % value; in this study, November 2004 had the biggest interest during this timeframe.