Milena Dorta

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.

Transvaginal ultrasonography in the diagnosis of diffuse adenomyosis

OBJECTIVE To evaluate the diagnostic capability of transvaginal ultrasonography in detecting diffuse adenomyosis. DESIGN We compared the preoperative transvaginal ultrasound (US) findings and the pathological findings of the surgical specimen in a series of women who underwent hysterectomy for menorrhagia. PATIENTS Forty-three women (mean [+/- SD] age of 46 +/- 5) with recurrent menorrhagia and enlarged uterus, without evidence of uterine leiomyomas at abdominal US and of endometrial disease at vabra curettage. SETTING Tertiary care center, university medical school. MAIN OUTCOME MEASURES Sensitivity, specificity, predictive positive and negative values of transvaginal US in the diagnosis of diffuse adenomyosis. RESULTS The sonographer diagnosed adenomyosis in 22 patients, whereas the pathologist found adenomyosis in 20 women, confirming the US findings in 16 cases and making an ex novo diagnosis in 4. The sensitivity of transvaginal US was 80%, the specificity 74%, the predictive value of a normal test 81%, and that of an abnormal test 73%. CONCLUSIONS Transvaginal US seems to represent a real advance in the preoperative diagnosis of diffuse adenomyosis.

Transrectal ultrasonography in the assessment of rectovaginal endometriosis

Objective To evaluate the validity of transrectal ultrasonog-raphy in the assessment of rectovaginal endometriosis. Methods We compared the findings of transrectal ultrasonographic examination performed before surgery with the operative and pathologic findings in 140 women who underwent laparoscopy or laparotomy for suspected endometriosis. The ultrasonographer was asked to investigate whether any deep endometriotic lesions were present in the rectovaginal septum and to define the lateral extension on the basis of involvement of the uterosacral ligaments. In addition, infiltration of the rectal and vaginal walls was evaluated. Results Thirty-four women had endometriosis infiltrating the rectovaginal septum confirmed by combined operative and pathologic findings. Ultrasonography showed a sensitivity and specificity of 97% and 96%, respectively, in the diagnosis of the presence of rectovaginal endometriosis. The sonographer identified infiltration of the rectal and vaginal walls correctly in all cases in whom it was present, but also reported rectal infiltration in three cases not confirmed by the surgeon and pathologist. The sensitivity and specificity in the diagnosis of uterosacral ligament infiltration were 80% and 97%, respectively. Conclusion If our preliminary results are confirmed by a larger series, transrectal ultrasonography will be considered a valid diagnostic tool in the evaluation of rectovaginal endometriosis.

Treatment with GnRH agonists before myomectomy and the risk of short‐term myoma recurrence

Summary. Twenty‐four women with symptomatic multiple uterine myomas were allocated randomly to treatment with buserelin, 1200μg/day intranasally, for 3 months followed by myomectomy (n = 8) or to immediate myomectomy (n = 16). Pre‐operative treatment with buserelin reduced the mean uterine volume from 432 (SD 165) to 242 (SD 82) ml (P < 0.01) but intra‐operative blood loss and postoperative morbidity were not significantly less in this group. Six months after operation, pelvic examination was normal in all the patients. However, ultrasonography with transvaginal probe demonstrated the presence of myomas of < 1.5 cm in five women (63%) treated pre‐operatively with the analogue and in two women (13%) who underwent immediate surgery (P < 0.05). Induction of a period of hypo‐oestrogenism before myomectomy seems to favour short‐term recurrence of uterine myomas, limiting the efficacy of surgery.

Ultrastructural aspects of endometrium in infertile women with septate uterus

OBJECTIVES To evaluate the endometrial surface morphology in patients with septate uterus and primary infertility in an attempt to throw light on the question of whether endometrial anomalies are involved in the pathogenesis of infertility in women with mullerian malformations. DESIGN Endometrial biopsies were performed in eight women with septate uterus and primary infertility during hysteroscopy scheduled in the preovulatory phase of the cycle (when a follicle > 17 mm was identified by ultrasonography and E2 levels were >200 pg/mL [conversion factor to SI unit, 3.671]). Two samples were obtained from each patient, one from endometrium covering the septum and the other from endometrium lining the lateral wall of the uterus. All specimens were examined by scanning electron microscopy. MAIN OUTCOME MEASURES The number of glandular ostia, the ciliated:nonciliated cell ratio, and the number of cilia on ciliated cells were analyzed in endometrial specimen from both the covering of the septum and the corresponding uterine lateral wall. RESULTS In five patients septal endometrium showed the following defective preovulatory changes with respect to endometrium of the lateral uterine wall: a reduced number of glandular ostia, irregular nonciliated cells with rare microvilli, incomplete ciliogenesis on ciliated cells, and decrease in the ciliated:nonciliated cell ratio (1:52 +/- 11 versus 1:21 +/- 8). CONCLUSIONS Our results indicate a decrease in the sensitivity of endometrium covering the septa of malformed uteri to preovulatory hormonal changes. This could play a role in the pathogenesis of primary infertility in patients with septate uterus.

Transvaginal ultrasonography in the differential diagnosis of adenomyoma versus leiomyoma

OBJECTIVE We evaluated the reliability of transvaginal ultrasonography in the differential diagnosis of adenomyoma versus leiomyoma. STUDY DESIGN Preoperative transvaginal ultrasonographic results were compared with postoperative pathologic findings in 405 women who underwent surgery for symptomatic uterine nodularity. RESULTS For adenomyoma diagnosis, transvaginal ultrasonography demonstrated a sensitivity of 87%, a specificity of 98%, a positive predictive value of 74.1%, and a negative predictive value of 98.6%, compared with a sensitivity of 96.1%, a specificity of 83.3%, a positive predictive value of 98.4%, and negative predictive value of 35.7% for leiomyoma diagnosis. CONCLUSION Transvaginal ultrasonography is an effective, noninvasive, and relatively inexpensive procedure for the preoperative differential diagnosis of adenomyoma versus leiomyoma.

Reproductive performance of women with unicornuate uterus

The reproductive history of 19 women with a diagnosis of unicornuate uterus confirmed by laparoscopy or laparotomy is analyzed. The patients were followed for 2 to 10 years. One patient had a cavitary communicating rudimentary horn, four a cavitary noncommunicating rudimentary horn, seven a noncavitary rudimentary horn, and seven no rudimentary horn. Six of the patients presented with primary infertility. The other 13 women had a total of 29 pregnancies, 1 (3.4%) in a rudimentary horn determining rupture; abortions occurred in 17 (58.6%), premature labor in 3 (10.3%), and term births in 8 (27.6%), with a live birth rate of 38%. Of the 11 births, 6 (54.5%) were breech presentations, and 9 (81.8%) were cesarean sections. In five cases the rudimentary horn was removed, with associated salpingooophorectomy in three patients. Cervical cerclage was not performed in any of the patients.

Structural and ultrastructural defects in preovulatory endometrium of normo-ovulating infertile women with minimal or mild endometriosis

To investigate whether a primary endometrial factor is involved in the pathogenesis of infertility in patients with minimal or mild endometriosis, we compared light, scanning, and transmission electron microscopic studies of preovulatory endometria of 15 endometriotic patients with 12 normal controls. All the women were infertile and normo-ovulating by standard criteria. Six morphometric indexes were considered. The scanning electron microscopic analysis revealed heterogeneity of the endometrial surface epithelium in 77% of the patients with endometriosis and in 16% of the controls. Glandular and stromal mitoses, basal vacuolated cells, and the ciliated:nonciliated cell ratio were significantly reduced in the endometriosis group compared with the controls. Further studies are needed to clarify the role of the observed endometrial anomalies in the pathogenesis of infertility associated with endometriosis.

Re-examination of the anatomic indications for hysteroscopic metroplasty

Until now the indication for hysteroscopic metroplasty has been based on laparoscopic findings and thus depended on the operators experience. Using ultrasound and magnetic resonance images of double uteri it should be possible to find more objective indications for this operation. When three points are identified on longitudinal scans of the uterine fundus, the two tubal ostia and the mid-point of the fundal perimetrium, hysteroscopic metroplasty is indicated only in uteri in which the third point is at least 5 mm above a straight line drawn between the tubal ostia. This classification criterion includes more cases than laparoscopic criteria in this study; we performed hysteroscopic metroplasty in 23 double uteri and had we followed the laparoscopic criteria the operation would have been performed only in 19.

A NEW LAPAROSCOPIC PROCEDURE FOR THE CORRECTION OF VAGINAL VAULT PROLAPSE

PURPOSE We verified the feasibility and results of a new laparoscopic technique for repairing vaginal vault prolapse. MATERIALS AND METHODS Laparoscopic repair of vaginal vault prolapse was done in 12 women 46 to 82 years old. Stage 1 consisted of culdoplasty similar to that of Moschowitz. Stage 2 included a transverse incision of the peritoneum covering the vaginal vault to expose the vaginal fascia. Two sutures were then fixed to the vaginal corners, passed through the subperitoneal connective tissue and attached to the fascia of the abdominal muscles with multiple stitches. RESULTS No intraoperative or postoperative complications occurred and anatomical repair was complete in all women. Followup ranged from 9 to 28 months. Sexual function was recovered in all cases. CONCLUSIONS If these results are confirmed in larger series with a longer followup, our laparoscopic approach would be considered a valid alternative to current surgical techniques.