Luigi Fedele

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.

Treatment of adenomyosis-associated menorrhagia with a levonorgestrel-releasing intrauterine device

OBJECTIVE To evaluate the efficacy and tolerability of treatment with a levonorgestrel-releasing intrauterine device (IUD) in women affected by adenomyosis-associated menorrhagia. SETTING Tertiary care center. DESIGN Prospective, open, noncomparative study. PATIENT(S) Twenty-five women aged 38 to 45 years with recurrent menorrhagia associated with adenomyosis diagnosed at transvaginal ultrasonography participated in this study. INTERVENTION(S) An IUD releasing levonorgestel 20 mcg/day was inserted in each patient within 7 days of the start of menstrual flow. All of the patients were requested to compile a pictorial blood loss assessment chart each month. They underwent clinical and transvaginal ultrasound examinations 3, 6, and 12 months after IUD insertion. MAIN OUTCOME MEASURE(S) Menstrual pattern; serum hemoglobin, ferritin, and iron level changes. RESULT(S) One patient experienced IUD expulsion 2 months after device insertion and another requested removal of the IUD 4 months after insertion because of persistent irregular blood loss. Six months after IUD insertion, amenorrhea was observed in 2 patients and oligomenorrhea in another, spotting occurred occasionally in 7, and 13 had scanty but regular flow. One year of follow-up has been completed by the remaining 23 women: 2 with amenorrhea, 3 with oligomenorrhea, 2 with spotting, and 16 with regular flows. Significant increases in hemoglobin, hematocrit, and serum ferritin have been observed, but the lipid metabolism and clotting variables have remained unchanged. CONCLUSION(S) Our findings indicate that marked and safe relief from adenomyosis-associated menorrhagia can be obtained with the use of a levonorgestrel-releasing IUD.

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.

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.

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.

Laparoscopic creation of a neovagina in women with pelvic kidney

Laparoscopic modification of Vecchiettis technique for creating a neovagina was carried out in four women with Rokitansky syndrome and renal anomalies. All four patients had pelvic kidney, and in two it was associated with contralateral renal agenesis. The procedure was specifically modified to reduce the risks inherent in the most difficult step, passing the thread-bearing cutting needle from the abdominal wall to the retrohymenal fossa, through the vesicorectal space. In all patients this was done successfully on the side contralateral to the pelvic kidney or in the hemipelvis in which the ureter was absent. Our experience proves that Vecchiettis technique for creating a neovagina, performed by laparoscopy, is feasible in patients with pelvic kidney, and laparotomy is unnecessary. (J Am Assoc Gynecol Laparosc 6(3):327-329, 1999)

Reproductive factors and risk of endometrial cancer

Reproductive hormone levels in gynecologic oncology patients undergoing surgical castration after spontaneous menopause Hughes CL Jr; Wall LL; Crcasman WT Dqwtn~en~ of’ Ohsic~rrics cm/ Gwcwh~~~. Dulic Uniwxit). M~hul Cc17tcv. Dwl~onr. NC 27710. USA GYNECOL ONCOL I991 40/l (42-45) The endocrine function of the ovary after menopause is perhaps less well understood than at any other time in the female life cycle. To evaluate the hormonal function of the ovary further at this stage of life, reproductive hormone levels were measured in I I postmenopausal women admitted to the gynecologic oncology service for pelvic surgery which would involve bilateral oophorcctomy. Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) levels. along with estradiol. testosterone. dehydroepiandrosterone sulfate (DHEA-S). and androstenedione levels, were measured preoperatively. on Postoperative Days I and 4. and at 6 weeks following surgery. Testosterone and androstenedione levels fell by half in these patients. whereas estrddio) levels were unaffected. LH and FSH showed a fall in the immediate postoperative period, with a subsequent return to baseline levels by 6 weeks after surgery. DHEA-S levels were unaffected by surgery. There are no discernible differences in subjective menopausal symptoms postoperatively in postmenopausal women undergoing bilateral oophorectomy compared to their preoperative state. The data show that the long-held but inadequately proven thesis that postmenopausal oophorectomy dramatically reduces androgen levels is in fact true. This is further evidence that the postmenopausal ovary is an important source of potent and potentially aromatizdble androgens.