Francisco Quereda

Abdominal myomectomy: results of a simple operative technique

OBJECTIVES To report a simple and safe procedure of abdominal myomectomy and our results performing this technique. DESIGN The operative technique comprises the incision on the most prominent part of the myoma, the use of a hooked clamp to hold the tumor, and a surgical knife to peel it, without removing the apparent excess of myometrium or serosa. SETTING University Medical Centers and private practice. PATIENTS Eighty patients, 9 of whom were operated between 10 and 26 weeks of pregnancy, 3 during cesarean section, and 22 others who had infertility. RESULTS Myomectomy was performed successfully in all patients for whom it was scheduled. Eight of nine pregnant patients had successful deliveries at term. The cumulative 10-year reoccurrence and reoperation rates of life-table analysis were 38% and 18%, respectively. The cumulative conception rates were 100% for otherwise unexplained infertility at 2 years, and 63% and 79% at 5 years for all infertile and all patients attempting conception after myomectomy, respectively. An age > 30 years, infertility > 3 years, and multiple fibroids negatively affected these rates, whereas the use of an absorbable adhesion barrier (Interceed; Johnson & Johnson AB, Somerville, NJ) had a positive effect. CONCLUSIONS This procedure is an appropriate alternative for most women who want to preserve or enhance fertility potential, and if necessary, for pregnant women.

Intraperitoneal and subcutaneous treatment of experimental endometriosis with recombinant human interferon- α-2b in a murine model

OBJECTIVE To determine the effect of human interferon (IFN)-alpha-2b on experimental endometriosis in rats. DESIGN Experimental, controlled, double-blind randomized study. SETTING Experimental surgery laboratory in a university department. ANIMAL(S) Ninety-six Wistar rats with endometriosis, induced by transplanting four endometrial fragments into the peritoneal cavity. INTERVENTION(S) One third of the animals served as controls (group A). The others were randomly divided into two groups and were given IFN-alpha-2b either as a single intraperitoneal dose (group B) or as three SC doses (on alternate days) (group C). MAIN OUTCOME MEASURE(S) Laparotomy was performed to measure the size of each implant at various times (days 0, 6, 12, 20, and 120 after treatment). RESULT(S) There were no differences among the groups in the size of the average implants before IFN was administered (17.3+/-6.7, 19.7+/-7.8, and 18.1+/-9.2 mm for groups A, B, and C, respectively). These values were significantly smaller after treatment in group B (14.9+/-8.0 mm) and group C (14.0+/-9.5 mm) than in the control group (17.6+/-7.5 mm) (P<.05). Intraperitoneal IFN produced an initial maximum decrease in the size of the implants (40% reduction on day 6), which diminished until day 20 (20%) and then was maintained on a plateau until day 120 (25%). By contrast, group C showed an initial minimal reduction (13% at day 6), which increased up to day 20 (19%), after which a plateau was reached (23% at day 120). Thus, the effects in both treatment groups were similar in the long term. CONCLUSION(S) Two short regimens of human IFN-alpha-2b reduced the size of experimental endometriosis in rats.

Use of intraperitoneal interferon α-2b therapy after conservative surgery for endometriosis and postoperative medical treatment with depot gonadotropin-releasing hormone analog: a randomized clinical trial☆

OBJECTIVE To evaluate the possible therapeutic effects of interferon alpha-2b left in the peritoneum after surgery, followed by or not followed by treatment with GnRH analogs. DESIGN A prospective, randomized clinical trial. SETTING University hospital. PATIENT(S) Fifty-two infertile patients with moderate or severe endometriosis. INTERVENTION(S) Laparotomic conservative surgery and either interferon alpha-2b or saline alone left in the pouch of Douglas followed by administration of either GnRH analogs depot or oral indomethacin with transvaginal echography and analysis of CA-125, immunoglobulins, and lymphocyte populations. MAIN OUTCOME MEASURE(S) Recurrence of endometriosis was considered clinically, echographically, and laparoscopically. RESULT(S) Recurrence of endometriosis in four cases without interferon (15.4%) versus 11 patients (42.3%) with interferon alpha-2b. Life table analysis showed significant differences between the groups with and without interferon 21 months after conservative surgery. There were no differences in the recurrence between the groups with or without GnRH analogs. Likewise, there were no significant changes in immunoglobulins and lymphocyte populations among patients with and without recurrence of endometriosis. The patients that received GnRH analogs depot showed a decrease in the number of CD16 and an increase of CD11b cells after treatment. CONCLUSION(S) The use of interferon alpha-2b within the peritoneal cavity after conservative surgery may be inappropriate because it increased later recurrence of endometriosis. The postoperative treatment with GnRH analogs did not significantly reduce the recurrence rate. Immunoglobulins and lymphocyte populations did not change in relation to the recurrence of endometriosis.

GnRH Analogues, Transvaginal Ultrasound-Guided Drainage and Intracystic Injection of Recombinant Interleukin-2 in the Treatment of Endometriosis

We performed a double-blind, randomised controlled trial to evaluate the results of ultrasound-guided aspiration of endometriomas under the effect of GnRH analogues and a possible additional beneficial effect by leaving 600,000 IU of recombinant interleukin-2 (rIL-2) in the cysts. Twenty-four women with endometriosis-related symptoms, increased values of CA-125 and transvaginal ultrasonography showing endometriomas >3 cm who were initially sent to us for laparotomy and conservative surgery for endometriosis were included. Main outcome measures were severity of symptoms, size and percentage of echographical reduction of endometriomas and CA-125 levels after 2 menses post-GnRH analogues. Secondary outcome measures were the time until recurrence of abnormal parameters and the need for surgery after treatment. We found moderate clinical results after treatment with drainage plus GnRH analogues and significantly improved results in women having received rIL-2 intracystically. There were no side effects. Two out of 3 previously infertile patients became pregnant after therapy. Though the rates of recurrence of endometriomas ≧3 cm were similar in both groups, the period until recurrence was significantly greater when rIL-2 was used, and the rates of recurrence of symptoms and increased CA-125 values were also significantly lower in patients who received rIL-2. Surgery was finally performed on 10 patients (4 with and 6 without previous rIL-2 treatment) during follow-up (30 ± 12.7 months). These findings led to the conclusion that transvaginal ultrasound-guided puncture and aspiration of endometriomas under endometrial suppressive therapy with GnRH analogues have some value for endometriosis treatment, improving the clinical manifestations and avoiding some surgical therapies, and that rIL-2 left in the cyst increases these beneficial effects significantly.

Impact of anthropometric parameters on quality of life during menopause.

OBJECTIVE To investigate whether body mass index (BMI), abdominal obesity, and fat distribution in postmenopausal women influence quality of life. DESIGN Cross-sectional survey. SETTING Outpatient clinics in the hospital setting and private practices. PATIENT(S) 274 postmenopausal Spanish women, distributed by body phenotype, fat distribution (android or gynoid), and BMI. INTERVENTION(S) The Cervantes scale, a specific health-related quality of life (HRQOL) questionnaire. MAIN OUTCOME MEASURE(S) The quality of life of the obese and overweight patients was compared by age, sex, education, marriage, and municipality with matched healthy normal-weight controls. RESULT(S) Women of the pyknoid phenotype have worse general HRQOL, menopausal symptoms, and psychological and sexuality scores than athletic or lean women. Android fat distribution is also related to low global Cervantes scale scores. All scores on the Cervantes scale worsened with increasing BMI (>or=25). CONCLUSION(S) Pyknoid phenotype, android fat distribution, and a higher BMI are related to poor HRQOL.

Individual and combined effects of triptoreline and gestrinone on experimental endometriosis in rats

OBJECTIVES To evaluate the effects of triptoreline, gestrinone, and both, on experimental endometriosis in rats. STUDY DESIGN Experimental endometriosis was surgically induced in 225 Wistar rats. Of these, 202 rats showed at least one grown implant, 22 of which composed the control group, while 180 were treated with triptoreline, gestrinone, or both, for 28 days. The implants were evaluated again after 25 days. RESULTS There were no changes in size in the control group. About 73% of the implants treated with triptoreline showed a high reduction (> 50%), vs. 51% with gestrinone (P < 0.0005) and 65% with both (P < 0.005). Triptoreline caused macroscopic resolution in 40% of the implants vs. 31% for gestrinone (not significant) and 26% for both substances (P < 0.05). In the triptoreline group, the mean size of the implants decreased by 65% between the 25th and 28th days, 58% between the 29th and the 35th, and 39% after the 36th day. This reduction was 51%, 36%, and 33%, respectively, in gestrinone group. CONCLUSIONS Triptoreline was more effective than gestrinone, but perhaps not in the long run. Their association did not improve the results.

Is a bowel resection necessary for deep endometriosis with rectovaginal or colorectal involvement

Background The purpose of this paper is to report the long-term results of surgery without bowel resection in patients suffering from deep infiltrating endometriosis with rectovaginal or colorectal involvement. Methods This retrospective observational study identified 42 patients suffering with deep infiltrating endometriosis who underwent surgery. Conservative surgery was performed in 23 women (only one of them with bowel resection), and 19 women underwent a hysterectomy and bilateral salpingo-oophorectomy (HBSO). In the conservative surgery group, a later HBSO was performed in eight patients as a second operation. Pregnancies, recurrences, reoperations, use of hormone replacement therapy, and outcomes during long-term follow-up were analyzed. Results The average follow-up duration was 7 ± 5.7 years in conservative surgery cases. Only one patient was treated with sigmoid bowel resection in 1997 and had complications. In this conservative surgery group, 13 patients (56%) received medical treatment after surgery, 10 patients wanted to get pregnant (of whom seven [70%] were successful), and eight patients underwent a subsequent HBSO because of recurrent symptoms and/or endometrioma. Therefore, HBSO was performed in 27 patients, of whom 14 (51.8%) used hormone replacement therapy for 5.6 ± 3.6 years. No recurrences or complications were observed in patients after HBSO with or without hormone replacement therapy. Conclusion Good clinical results can be obtained by performing only conservative surgery and/or HBSO without bowel resection, an alternative that could reduce the number of colorectal resections that are performed very frequently nowadays. After HBSO, patients may use hormone replacement therapy for several years with total satisfaction and well-being.

Treatment of Endometriosis with Transvaginal Ultrasound-Guided Drainage under GnRH Analogues and Recombinant Interleukin-2 Left in the Cysts

Background: To analyze the therapeutic results of one dose of 3 million IU of recombinant interleukin-2 (rIL-2) left intracyst (group I) versus two doses with a 1-month interval (group II) after transvaginal ultrasound (US)-guided drainage of endometriomas under the effect of GnRH analogues. Methods: Prospective and randomized clinical trial (helped by a random number table) at a University Hospital. Twenty-four consecutive patients with endometriomas initially sent to us for laparotomy and conservative surgery for endometriosis were included. Interventions: Treatment with GnRH analogues every 28 days, 3 doses. Under their effect, one or two transvaginal US-guided punctures were performed in order to aspirate the endometriomas, and 3 million IU of rIL-2 were left in the aspirated cysts each time. Main outcome measures: Clinical results: two menstruations after GnRH analogues. Other secondary outcome measures were: the time until recurrence of cysts, symptoms and CA-125 >35 U/ml, and the need for further medical or surgical treatment. Results: They were moderate or good in >50% of cases with one drainage and one dose of 3 million IU of rIL-2 intracyst, but were better with a second drainage and two doses of rIL-2 (25 vs. 58.3% ‘good results’). There were fewer recurrences and the interval before recurrence was longer after two doses but differences were not significant. Six patients from group I (50%) and 3 from group II (25%) needed laparotomy and conservative surgery at 17.5 ± 8.7 months (total time of follow-up = 33 ± 8.8 months). Conclusions: Treatment of endometriomas with transvaginal US-guided drainage and rIL-2 left in the cysts under endometrial suppressive therapy with GnRH analogues has beneficial effects, improving clinical manifestationsand avoiding some surgical therapies. The use of a higher dose of rIL-2 does not produce better results, whereas drainage + rIL-2 twice does.

Spanish Menopause Society position statement: use of tibolone in postmenopausal women.

AbstractTibolone is a drug with complex tissue-specific action that exhibits a combination of estrogenic, progestogenic, and slight androgenic activity. Its variable profile explains its clinical effects, depending on the target tissue where it is metabolized, its metabolites’ affinity for and potency in hormone receptors, and probable enzymatic activity modulation.In recent reviews and clinical trials, the effectiveness of tibolone in alleviating different hot flush menopause symptoms, mainly in mood and sexuality disorders, has been noted. In Spain, tibolone is the most prescribed hormonal treatment, and one of the most common complaints among postmenopausal women is change in sexual drive. For such reason, a panel of experts from the Spanish Menopause Society met to develop usage recommendations based on the best evidence available.

Position of the Spanish Menopause Society regarding the management of menopausal symptoms in breast cancer patients

Breast cancer is the most common female cancer in Spain. Its high prevalence, its high survival rate, and its incidence are the reasons treatment is increasingly sought for common problems by young women who have survived it. Besides the contraception and fertility issues, many breast cancer survivors develop sexual disorders and menopausal symptoms, whether as a consequence of treatment-induced menopause or side effects of treatment. For such reasons, a panel of experts from the Spanish Menopause Society has met to develop usage recommendations for the relief of vasomotor symptoms and for sexual and reproductive health in patients with breast cancer based on the best evidence available.