Giovanni Zanconato

Use of a levonorgestrel-releasing intrauterine device in the treatment of rectovaginal endometriosis.

OBJECTIVE To evaluate the effectiveness of a levonorgestrel-releasing IUD as therapy for endometriosis of the rectovaginal septum. DESIGN Prospective therapeutic non-randomized, self-controlled clinical trial analyzing changes in pain symptoms and size of lesions induced by the levonorgestrel-releasing IUD over 12 months. SETTING Tertiary referral center for treatment of deep endometriosis. PATIENT(S) Eleven symptomatic patients with rectovaginal endometriosis. INTERVENTION(S) A levonorgestrel-releasing IUD was inserted and maintained for 12 months. MAIN OUTCOME MEASURE(S) Severity of dysmenorrhea, pelvic pain, and deep dyspareunia were assessed before insertion of the IUD and throughout treatment. The size of rectovaginal endometriotic lesions were evaluated by using transrectal and transvaginal ultrasonography. RESULT(S) Dysmenorrhea, pelvic pain, and deep dyspareunia greatly improved and the size of the endometriotic lesions was significantly reduced by treatment. CONCLUSION(S) Insertion of a levonorgestrel-releasing IUD alleviates pain and reduces the size of lesions in patients with endometriosis of the rectovaginal septum.

Laparoscopic creation of a neovagina in patients with Rokitansky syndrome: analysis of 52 cases

OBJECTIVE To evaluate the surgical feasibility and the long-term anatomic and functional results of a new procedure that uses the endoscopic approach to treat uterovaginal agenesis, known as Rokintansky syndrome. DESIGN Evaluation of surgical feasibility and recording of clinical data over a 12-month follow-up. SETTING Tertiary referral center for the treatment of female genital malformations. PATIENT(S) Fifty-two patients with vaginal agenesis. INTERVENTION(S) The laparoscopic version of the Vecchietti method was used to create a neovagina. MAIN OUTCOME MEASURE(S) Anatomic success was defined as a neovagina >/=6 cm long, allowing easy introduction of two fingers, within 6 months after corrective surgery. Functional success was considered achieved if the patient reported satisfactory sexual intercourse starting from 6 months after surgery. RESULT(S) The surgical procedure was performed with no major complications and with 100% anatomic success; functional success was obtained in 98.1% of the study population. CONCLUSION(S) In patients with Rokitansky syndrome, the laparoscopic approach for creating a neovagina by the Vecchietti method is simple, safe, and effective.

Paternal and maternal smoking habits before conception and during the first trimester: Relation to spontaneous abortion

PURPOSE This study examined the association between maternal smoking before and during the first trimester of pregnancy and spontaneous abortion. METHODS We have been conducting a hospital-based case-control study on risk factors for spontaneous abortion in the greater Milan area. We collected information from 782 cases of spontaneous abortions and 1543 controls (women who delivered at term healthy infants). RESULTS With respect to never smokers, the odds ratio (OR) were 0.7 (95%, confidence interval (CI), 0.5-1.0) for women who quit smoking and 1.3 (95% CI, 1.0-1.6) for those who continued during pregnancy. Women who smoked more than 10 cigarettes/day in the first trimester were at increased risk of miscarriage, with an OR of 1.4 (95% CI, 1.0-2.1). No relationship was evident between the number of cigarettes smoked before conception and the risk of abortion. Likewise, no association emerged between paternal smoking and miscarriage. Moreover, no significant interaction or modification effect was obtained when strata of age and other major characteristics were investigated. CONCLUSIONS The risk of abortion associated with cigarette smoking during the first trimester of pregnancy was measurable and noticeable in this population, and accounted for 9% (95% CI, 6-13%) of all cases. The increased risk of spontaneous abortion in women smoking during pregnancy is a further reason to encourage pregnant women to quit.

Bipolar Electrocoagulation versus Suture of Solitary Ovary after Laparoscopic Excision of Ovarian Endometriomas

STUDY OBJECTIVE To compare the functional ovarian damage associated with the use of bipolar coagulation versus ovarian suture after laparoscopic excision of ovarian endometriomas in patients with a solitary ovary. DESIGN Retrospective study (Canadian Task Force classification II-3). SETTING Tertiary care center. PATIENTS Forty-seven consecutive women with a single ovary and regular menses who underwent laparoscopic stripping of one or more ovarian endometriomas between June 1996 and June 2001. Intervention. Twenty-one patients had bipolar electrocoagulation (group A), while 26 had suturing of the ovary (group B). Plasma follicle-stimulating hormone (FSH) and estradiol levels were determined before surgery and re-evaluated at 3-, 6-, and 12-month follow-up. MEASUREMENTS AND MAIN RESULTS At 12-month follow-up, six patients (29%) in group A had oligo-amenorrhea versus three patients (12%) in group B (p = .14). Follicle-stimulating hormone levels between 10 and 20 mlU/mL were found in five patients (24%) in group A and in three patients (12%) in group B, whereas FSH levels above 20 mlU/mL were found in three patients (14%) in group A and in no patient in group B. Eight patients (38%) in group A had FSH levels greater than 10 mlU/mL versus three patients (12%) in group B (p = .042). Overall, repeated analysis of variance showed a marginally significant difference (p = .06) in FSH values between the two groups. CONCLUSION Our results suggest that bipolar electrocoagulation of the ovarian parenchyma after laparoscopic stripping of an endometriotic ovarian cyst adversely affects ovarian function.

Comparison of transdermal estradiol and tibolone for the treatment of oophorectomized women with deep residual endometriosis

STUDY OBJECTIVE To compare the effect of HRT with transdermal estradiol and that of treatment with tibolone in post-menopausal women with residual endometriosis. MATERIALS AND METHODS 21 women with residual pelvic endometriosis after bilateral oophorectomy with or without hysterectomy were enrolled in the study and were randomized to HRT with transdermal estradiol 50 mg twice weekly (n = 10) associated with cyclic medroxyprogesterone acetate 10 mg daily in women who preserved uterus, and to treatment with tibolone 2.5 mg administered orally once a day (n = 11). The duration of both treatments was scheduled to last at least 12 months. Residual endometriosis was located in the bowel wall in four patients, in the rectovaginal septum in six and deeply in the retroperitoneal pelvic space in six. All women were symptomatic before oophorectomy. RESULTS All the women were followed for 12 months. No patient suspended therapy because of side effects. Four patients of the estradiol group experienced moderate pelvic pain during treatment compared with only one patient in the tibolone group. One patient in the estradiol group reported severe dyspareunia. CONCLUSION Although our series is very small, it seems that tibolone may be a safe hormonal treatment for post-menopausal women with residual endometriosis.

A randomized study of the effects of tibolone and transdermal estrogen replacement therapy in postmenopausal women with uterine myomas.

OBJECTIVE To evaluate the effects of two types of hormone replacement therapy, an estrogen-progestin combination and tibolone, on uterine myomas in menopausal women. STUDY DESIGN Thirty-eight menopausal women with one or more uterine myomas were randomized to treatment with a transdermal system continuously releasing estradiol 50 microg/day combined with oral medroxyprogesterone acetate (MPA) 10 mg/day for 12 days/month or tibolone tablets 2.5 mg/day. The scheduled duration of both treatments was 12 months. Physical examination and abdominal/transvaginal ultrasonography were performed before entering the study and at 3, 6 and 12 months of treatment. At each ultrasonography the overall uterine volume was determined as well as the size of each myoma and the endometrial thickness and characteristics. RESULTS No statistically significant difference was detected between the two groups at any time during treatment. However, within-group analysis showed a significant increase of uterine volume and of myoma number and size in the estrogen-progestin group, whereas no such increase occurred in the patients treated with tibolone. Also, the mean endometrium width increased significantly from baseline to the end of treatment in the estrogen-progestin group, but not in the tibolone group. CONCLUSIONS Tibolone seems a valid alternative in menopausal patients with uterine myomas as it provides adequate relief from menopausal symptoms and avoids volume increase of the uterus and myomas.

Prevalence of syphilis infection in Mozambican women with second trimester miscarriage and women attending antenatal care in second trimester.

OBJECTIVES--To elucidate whether recent syphilis infection is significantly more prevalent among women with mid-trimester miscarriage than among antenatal care attenders in midtrimester pregnancy. DESIGN--Two categories of pregnant women were compared regarding serological signs of syphilis. Rapid Plasma Reagin (RPR) analyses were done in Mozambique and Veneral Disease Research Laboratory (VDRL) tests in Sweden. In case of RPR and/or VDRL positivity, Treponema pallidum haemagglutination (TPHA) and Captia Syphilis-M were performed. SETTING--A suburban antenatal care clinic and the emergency ward at the Department of Obstetrics and Gynecology at the Central Hospital in Maputo, Mozambique, were studied June-August 1991. SUBJECTS--Randomly selected women seeking antenatal care in midtrimester pregnancy (N = 202) were compared with 114 women consecutively entering with clinical signs of midtrimester miscarriage. RESULTS--Among antenatal care attenders, 37/202 (18.3%), and among women with midtrimester miscarriage, 37/114 (32.5%), had syphilis confirmed with the Treponema pallidum haemagglutination test (p < 0.01). Significant titres of IgM antibodies tended to be more prevalent among women with miscarriage (7.0%) than among women attending antenatal care (4.5%), though the difference only approached statistical significance. CONCLUSION--The findings suggest a potential association between syphilis seropositivity and midtrimester miscarriage. Present findings justify more extensive studies to establish whether or not recent syphilis infection is a risk factor for midtrimester miscarriage.

Dietary factors and risk of spontaneous abortion.

OBJECTIVE This study examines the association between dietary habits and risk of spontaneous abortion. DESIGN Hospital-based case-control study. SETTING Obstetric hospitals in Milan, Italy. SUBJECTS Cases were: 912 women admitted for spontaneous abortion (within the 12th week of gestation). Controls were: women who gave birth at term to healthy infants on randomly selected days at the same hospitals where cases had been identified. RESULTS The risk of spontaneous abortion was inversely and significantly related to green vegetables, fruit, milk, cheese, eggs and fish consumption. The multivariate odds ratios (OR), for highest versus lowest levels of intake, were 0.3 for fruit, 0.5 for cheese, 0.6 for green vegetables and milk and 0.7 for fish and eggs. The major type of seasoning fats have showed a direct association with risk of miscarriage. Comparing the highest with the lowest intake, the ORs were 2.0 (95% confidence interval, CI 1.1-3.6) and 1.6 (95% CI 1.1-2.3) for butter and oil, respectively. No consistent association emerged between meat, liver, ham and carrots intake and the risk of spontaneous abortion. CONCLUSIONS This result suggests that a diet poor in several aspects, including vegetables and fruit, milk and dairy products, but rich in fats, may be a determinant or a correlate of increased risk of spontaneous abortion.

Phantom endometriosis of the sciatic nerve

OBJECTIVE To assess the efficacy and diagnostic value of GnRH agonist (GnRH-a) therapy in cases of hidden sciatic nerve endometriosis. DESIGN Case report. SETTING Academic tertiary referral center for endometriosis treatment. PATIENT(S) Three patients with cyclic, catamenial sciatica associated with pelvic endometriosis who had electromyographic evidence of sciatic nerve damage but negative computed tomography and magnetic resonance imaging findings. INTERVENTION(S) Monthly administration of the GnRH-a leuprolide acetate plus daily transdermal E2 (25 microg). MAIN OUTCOME MEASURE(S) Relief of pain symptoms and improvement in motor function. RESULT(S) All three patients had clear decreases in pain and partial amelioration of claudication. CONCLUSION(S) Endometriosis of the sciatic nerve may be hard to diagnose with the use of current imaging techniques but may be proved by clinical response to GnRH analogue treatment and may be more frequent than previously thought.

Maternal and fetal epoxyeicosatrienoic acids in normotensive and preeclamptic pregnancies.

BACKGROUND Epoxyeicosatrienoic acids (EETs) and 20-hydroxyeicosatetraenoic acid (20-HETE) are cytochrome P450 metabolites of arachidonic acid posited to act in the circulatory adaptation to pregnancy and the development of preeclampsia. Red blood cells (RBCs) may function as major contributors of cis- and trans-EETs. METHODS We performed paired analyses of EETs, dihydroxyeicosatrienoic acids (DHETs), and 20-HETE in RBCs, plasma, and urine from preeclamptic and normotensive pregnant and nonpregnant women. Blood from fetal and maternal circulation was collected. EETs, DHETs, and 20-HETE were analyzed by gas chromatography and liquid chromatography mass spectrometry. Vascular function and inflammation indices were analyzed. RESULTS Plasma EET is higher in normotensive (median, range; 9.9, 6.3-25.2ng/mL n = 29) and preeclamptic (10.9, 6.0-48.0ng/mL, n = 19) women than in nonpregnant controls (7.3, 3.7-10.2ng/mL, n = 19) and correlate with RBC EETs, C-reactive protein, and arterial stiffness. Renal production of EETs, measured as urinary DHETs, was reduced in preeclamptic (4.5, 1.6-24.5ng/mg creatinine) compared to normotensive (11.4, 1.6-44.5ng/mg creatinine) pregnancies. EETs are 3- to 5-fold greater in fetoplacental than in maternal circulation (RBCs 36.6, 13.1-69.4 vs. 12.5, 6.4-12.0ng/10(9) cells; plasma 31.6, 8.5-192.6 vs. 12.0, 6.8-48.0ng/mL). Both cis- and trans-EETs are present in fetal RBCs. CONCLUSIONS RBCs contribute to elevated levels of EETs in the fetoplacental circulation. EETs may modulate systemic and fetoplacental hemodynamics in normal and preeclamptic pregnancies. Decreased renal EET generation may be associated with the development of maternal renal dysfunction and hypertension in preeclampsia.