J.A. Pinotti

A randomized study of total abdominal, vaginal and laparoscopic hysterectomy

Objectives: To evaluate operative time, blood loss and inflammatory response in patients submitted to hysterectomy. Methods: Sixty patients referred for hysterectomy were prospectively randomized to total abdominal hysterectomy (n=20), vaginal hysterectomy (n=20), or laparoscopic hysterectomy (n=20). The operative time, blood loss (variation in erythrocyte and hemoglobin) and inflammatory answer (CRP and interleukin‐6 dosages) were compared by using Kruskal–Wallis, Dunn non‐parametric test and variance analysis with repeated measurements. Results: Operative time was shorter for vaginal hysterectomy, and there was no significant difference between total abdominal hysterectomy and laparoscopic hysterectomy. Reduction in erythrocyte and hemoglobin was more noticeable after vaginal hysterectomy, followed by total abdominal hysterectomy and laparoscopic hysterectomy. CRP levels increased steadily from vaginal hysterectomy to laparoscopic hysterectomy and then to total abdominal hysterectomy. The increase in interleukin‐6 was substantially higher in total abdominal hysterectomy, whereas no difference was noted between vaginal and laparoscopic hysterectomy. Conclusions: Vaginal hysterectomy presents superior results in terms of operative time and inflammatory response when compared with total abdominal and laparoscopic hysterectomy and it should be the first option for hysterectomy. Laparoscopic hysterectomy should be considered when the vaginal approach is unfeasible, showing clear advantages over abdominal hysterectomy.

The effects of systemic hormonal replacement therapy on the skin of postmenopausal women

Objective: The aim of this study was to determine the effects of hormonal replacement therapy on the skin of postmenopausal women. Method: Forty‐one postmenopausal women were randomly allocated to receive either hormonal replacement (valerate estradiol — 2 mg/day for 21 days and cyproterone acetate — 1 mg/day for 10 days) or placebo, both in a cyclic scheme for 6 months. Neither patients nor investigators were aware of the group allocation. Histologic changes were evaluated by skin biopsy of the left upper arm at baseline and after 6 months of treatment, utilizing computerized image analysis to assess the ratio area of epidermis/basement membrane length (AE/BML), ratio area of keratin/basement membrane length (AK/BML) and collagen and elastic fibers content. Result: Collagen content of the left upper arm increased after 6 months of treatment only in the hormonal group (+6.49%; P<0.05). Other parameters did not present any significant alteration after treatment in both groups. Conclusion: Hormonal replacement for climacterics increases skin collagen content.

A double‐blind trial of four medications to treat severe premenstrual syndrome

Objective: To determine the efficacy of fluoxetine (10 mg), alprazolam, propanolol and pyridoxine in the treatment of severe premenstrual syndrome (PMS). Method: One‐hundred and twenty women were divided into four groups of 30 patients. Patients were submitted to a randomized, double‐blind, placebo‐controlled treatment and were given 3 months of placebo and 3 months of active drug. The active drug was pyridoxine (300 mg/day) in group 1; alprazolam (0.75 mg/day) in group 2; fluoxetine (10 mg/day) in group 3; and propanolol (20 mg/day and 40 mg during the menstrual period) in group 4. Results: Fluoxetine in 10‐mg doses obtained a mean reduction of 65.4% in symptoms, followed by propanolol (58.7%), alprazolam (55.6%), pyridoxine (45.3%) and placebo (39.4–46.1%). Conclusion: Fluoxetine in 10‐mg doses presented the best results for treating premenstrual syndrome.

Histological classification of endometriosis as a predictor of response to treatment.

Objectives: To evaluate the usefulness of the histological classification of endometriosis in predicting responses to treatment. Methods: We evaluated 412 biopsy specimens from 241 patients with pelvic endometriosis. Pain and infertility were evaluated before surgery. Disease location and stage of development were analyzed according to the 1985 American Society of Reproductive Medicine (ASRM) classification. Histological findings were classified as stromal, well‐differentiated, undifferentiated, and mixed endometriosis. Clinical response to pain or infertility was evaluated. Results: Histological findings, disease location and stage of development, and response to treatment were compared. Undifferentiated endometriosis was more frequently associated with stages III/IV than the well‐differentiated and stromal histological types. Pure or mixed undifferentiated patterns were more frequently associated with rectovaginal endometriosis. When considering pain symptoms, patients presenting well‐differentiated or stromal histological patterns responded better to therapeutic treatment than those who presented undifferentiated histological patterns. There were no significant differences in cases related to sterility. Conclusions: The histological categorization of endometriosis can help predict the behavioral patterns of the disease.

Laparoscopic tubal anastomosis

Objectives: To evaluate the pregnancy outcome after laparoscopic tubal anastomosis. Methods: From December 1998 to December 2001, 26 patients with bilateral tubal ligation who underwent laparoscopic tubal anastomosis were prospectively evaluated. Patients’ age varied from 28 to 37 years. Results: Laparoscopic tubal reversal was performed in 23 patients. Bilateral reversal was possible in all but two patients. The operation time ranged from 95 to 155 min and all patients were discharged in the following morning after surgery. After 3 months, tubal patency was confirmed in 15 patients (15/23). Pregnancy rate was 56.5% (13/23), without ectopic pregnancies. The average time from tubal reversal and pregnancy was 6 months. Conclusions: In selected cases, laparoscopic tubal reversal can be offered to patients who had been submitted to tubal sterilization and desire new pregnancies. Patient selection as well as meticulous surgical technique are key factors in achieving satisfactory pregnancy rates.

Tumor markers in endometriosis

Objectives: The objective of the present study was to determine the concentrations of CA 125, CA 15‐3, CA 19‐9, carcioembryogenic antigen (CEA), alpha‐fetoprotein (AFP) and beta‐2 microglobulin (B2MG) in patients with pelvic endometriosis. Method: Fifty women were divided into two groups: group A (control) had no endometriosis or other diseases, and group B consisted of 35 women with pelvic endometriosis. All women were submitted to serum determination of CA 125, CA 15‐3, CA 19‐9, CEA, AFP and B2MG. Samples were collected during the menstrual cycle and 1 week later. Results: Mean CA 125 concentrations were altered in patients with endometriosis, but all 50 patients studied presented normal CEA, AFP and B2MG concentrations. Small variations detected in CA 19‐9 and CA 15‐3 had no statistical significance. Conclusion: CA 125 is the only important marker in the diagnosis of stages III/IV of endometriosis, especially when blood samples for its determination are obtained during the first 3 days of the menstrual cycle.

HPV prevalence among partners of women with cervical intraepithelial neoplasia

Objectives: The objective of this study was to find HPV DNA incidence in women with CIN and normal women and in their respective partners, as well as the relation between the virus groups found in women with CIN or normal women and in their respective partners. Methods: Partners of 30 women with CIN at several grades and of 60 normal women were prospectively assessed. In men, HPV search was performed by collecting samples through penile scraping for Hybrid Capture, followed by peniscopic evaluation and biopsy of acetowhite lesions. Results: The presence of HPV DNA in male partners does not necessarily implicate the presence of HPV or even CIN in their female partners. Conclusions: If these results are confirmed by other authors, obtaining a peniscopy, a penile biopsy, and a HPV DNA search in partners that present with no clinical lesions, but in couples with women having CIN, would not be warranted.

Uterine artery embolization for the treatment of uterine leiomyomata

Objectives: To evaluate the results of the uterine artery embolization (UAE) for the treatment of uterine fibroids. Methods: Twenty‐six patients with ultrasonographic diagnosis of uterine leiomyomata were submitted to UAE with polyvinyl alcohol particles. Imaging and clinical follow‐up was performed before the procedure, at 3 months, and 1 year after. Results: All procedures but one were technically successful. Control of menorrhagia and pelvic pain were reported after UAE by 87.5% and 84.2% of patients, respectively. The initial medium uterine volume was 385 cm3, after 3 months 255 cm3 and after 1 year 202 cm3. The mean uterine volume decrease was 29% after 3 months and 41% after 1 year of follow‐up (P<0.001). Clinical and biochemical findings consistent with ovarian failure were observed in three patients (12% of the patients). Conclusions: UAE represents a new therapeutic approach in the treatment of uterine leiomyomata. The procedure appears effective in controlling symptoms and represents an alternative to hysterectomy.

Sexuality in healthy postmenopausal women

Objective: To assess the influence of psychosocial factors, behavior and hormones on postmenopausal sexuality. Methods: Nine hundred and ninety-nine women (age range 41-60 years) underwent physical and supplementary tests and answered questionnaires regarding sexual behavior. Sixty healthy women with 1 or more years of amenorrhea, without hormone replacement therapy and with a partner capable of intercourse were chosen from this group. Logistic regression models with dependent variables (sexual satisfaction and orgasmic capacity) and independent variables (sexual initiation, psychosocial factors, behavior, relationship, menopause and hormones) were developed. Results: Important variables for sexual satisfaction were: good self-esteem (p< 0.01), first orgasm obtained by masturbation (p = 0.004), major personal income (p = 0.007), sexual initiation in adulthood (p = 0.008), value physical contact with partner (p = 0.021) and major orgasmic capacity p = 0.040). The following contributed (towards orgasmic capacity with the partner: sexual initiation in adulthood (p = 0.012), regular physical activity (p = 0.040) and higher testosterone levels (p = 0.050). Conclusions: The importance of relationship, psychological, hormonal, economic and behavioral factors confirm the complexity of sexuality, and we note that current as well as prior events seem to affect the sexual satisfaction and orgasmic capacity of healthy postmenopausal women.

Morphologic hysteroscopic criteria suggestive of endometrial hyperplasia

Objectives: To evaluate the morphologic hysteroscopic criteria leading to a diagnosis of endometrial hyperplasia and compare their accuracy with that of histology. Methods: A total of 95 hysteroscopic examinations were evaluated. Of these, 37 had a histologic diagnosis of normal endometrium and the remaining 58 of simple or complex endometrial hyperplasia. We compared the morphologic hysteroscopic criteria for the two groups using Pearsons chi‐squared and Fishers exact test. Results: Only the presence of endometrial glands presenting a cystic pattern at hysteroscopy gave statistically significant results (P < 0.05), with low sensitivity (15.79%), high specificity (97.29%) and a relative risk of 6.75. With a prevalence of endometrial hyperplasia of 22.97% in a population of women with metrorrhagia, the positive predictive value was 63.53% and the negative predictive value was 79.40%. Conclusion: Additional, prospective studies are needed to determine the real value of the diagnostic morphologic parameters under consideration.