Minas Paschopoulos

Association of estrogen receptor gene polymorphisms with endometriosis

OBJECTIVE To explore the association of the estrogen receptor two-allele (point) polymorphism and multiallele (microsatellite) polymorphism with endometriosis. DESIGN Case-control study. SETTING Genetics and Endoscopy Unit, Department of Obstetrics and Gynecology, Ioannina University HOSPITAL, Ioannina, Greece. PATIENT(S) Fifty-seven women with surgically and histologically diagnosed endometriosis of stages I-IV. INTERVENTION(S) Diagnostic laparoscopy. MAIN OUTCOME MEASURE(S) Frequency and distribution of the estrogen receptor gene polymorphisms. RESULT(S) There was a statistically significant difference between the patients and the controls in the frequency of the two-allele Pvu II polymorphism (0.72 vs. 0.49) and in the median repeats of the (TA)n multiallele polymorphism (15 vs. 20 repeats). In both groups, linkage was found between the fewer (TA)n repeats (range, 12-19) and the positive Pvu II polymorphism. CONCLUSION(S) The variability of the estrogen receptor gene likely contributes to the pathogenesis of endometriosis.

Vaginoscopic approach to outpatient hysteroscopy.

STUDY OBJECTIVE To evaluate a new method of outpatient hysteroscopy. DESIGN Prospective observational study. SETTING Departments of Obstetrics and Gynecology, Medical School of Ioannina, Greece, and Brooklyn Hospital Center, Brooklyn, New York. PATIENTS Three hundred twenty-four women, 316 of whom were symptomatic and 8 asymptomatic. INTERVENTIONS Hysteroscopic vaginoscopy with directed endometrial biopsies. MEASUREMENTS AND MAIN RESULTS The procedure was successful and well tolerated in 211 (65%) women. In 90 (27.9%) women, the procedure was successful but with significant pelvic pain, and in the remaining 23 (7.1%) it was complicated by either vagal reaction or complete intolerance. Hysteroscopic findings were in agreement with histopathologic results in 290 (89.5%) patients. In all 12 women with endometrial adenocarcinoma, hysteroscopic findings were identical with histopathologic results. CONCLUSION The vaginoscopic approach is effective for outpatient hysteroscopy.

Human papillomavirus DNA and mRNA positivity of the anal canal in women with lower genital tract HPV lesions: Predictors and clinical implications

OBJECTIVE Women with HPV related pathology of the lower genital tract are at higher risk for AIN and anal cancer than the general population. A strategy to identify anal disease in these women has not been formulated. The aim of this study is to examine the feasibility of HPV related biomarker testing on anal smears, to identify the risk factors for anal HPV positivity and to provide information of the clinical implications of anal HPV infection in this population. METHODS In women referred for colposcopy because of HPV related pathology of the lower genital tract (cervical cancer, CIN, VIN, warts) a detailed questionnaire, an anal smear and a cervical smear were taken. On each sample morphological cytology, flow cytometric evaluation of E6&7 mRNA, and HPV DNA detection and typing were performed. Women with a positive anal result were referred for high resolution anoscopy. RESULTS So far 235 women have been included (mean age 34.3). HPV DNA, high-risk HPV DNA, high-risk mRNA was detected in 45%, 31% and 8% of the anal smears and in 56%, 39% and 25% of the cervical smears respectively. Absolute or partial concordance of the types between the cervix and the anus was seen in 74%. Positivity for mRNA was significantly lower in the anus than the cervix (8% vs 25%). Logistic regression analysis revealed risk factors for the presence of anal HPV DNA (>3 lifetime sexual partners and presence of cervical HPV DNA), hr HPV DNA (presence of cervical hr HPV DNA), and hr mRNA (presence of cervical hr mRNA). Twelve months after LLETZ 53% of women were cervical HPV negative, but 25% of those were still HPV positive in the anus. CONCLUSIONS HPV infection of the anus is common in this group and is interlinked with the cervical infection. Anal HPV E6&7 mRNA expression is less common than in the cervix. Possible clinical implications of anal infection could be the development of AIN and recurrence of CIN after treatment due to cervical reinfection from the anal reservoir. The use of HPV biomarkers is feasible in anal smears, although especially DNA testing as triage method for referral to anoscopy is probably inappropriate due to high positivity rate.

Safety Issues of Hysteroscopic Surgery

Abstract:  The term hysteroscopy is used to determine the procedure during which an endoscopic view of the endometrial cavity is achieved with the help of a type of endoscopic device called “the hysteroscope.” Hysteroscopy is used to assist the diagnosis for a series of female pathology. Apart from its diagnostic value, hysteroscopy can also be used for operative procedures including ablation and resection. Both diagnostic and operative hysteroscopy have been used for a number of years and various studies have been published to describe their success and complication rates throughout this period. Diagnostic hysteroscopy is relatively safe, whereas complications occur more frequently when operative hysteroscopy is used. These complications include uterine perforation, hemorrhage, fluid overload, gas embolization, and hyponatremia. The rate in the appearance of these complications is dependent on the type of the hysteroscopic procedure, the distending medium, and the experience of the hysteroscopist. To avoid any problems concerning the application of hysteroscopic procedures, it is important to take the necessary precautions both preoperatively and intraoperatively. For example, the preoperative use of thinning agents of the endometrium and the reduction of the operating time, or the avoidance of cutting too deeply into the myometrium, are some of the parameters to be considered when hysteroscopy is in argument.

Cervical regeneration after diathermy excision of cervical intraepithelial neoplasia as assessed by transvaginal sonography

OBJECTIVE To evaluate regeneration in cervical craters following large loop excision of the transformation zone (LLETZ) and to investigate possible differential healing patterns depending on the cones size. STUDY DESIGN A prospective study of 100 nulliparous women who underwent LLETZ. They underwent transvaginal scanning estimation of the cervical craters (diameter, depth) immediately post-operatively and at 3, 6 and 12 months. The crater dimensions of the women with the 25 largest cones were compared to those of the women with the 25 smallest cones in each of the above points of time. RESULTS The mean crater size of all women at 12 months was significantly smaller from the crater size immediately post-operatively. Although, there was a statistically significant difference in mean crater dimensions between the two quartile groups immediately post-operatively, no difference was found at 6 and 12 months. CONCLUSION There is a healing process of the cervical crater, which is almost completed by the sixth post-treatment month. The defect remaining in the cervix is similar whether a large or small excision was performed.

A systematic review and meta-analysis of randomized studies comparing misoprostol versus placebo for cervical ripening prior to hysteroscopy

OBJECTIVE(S) Hysteroscopy is an effective method for examining the uterine cavity but has some limitations, including the occasional need for cervical dilatation. Misoprostol is routinely used for cervical dilatation in various procedures but has not gained wide acceptance for use before hysteroscopy. STUDY DESIGN This review includes randomized controlled trials which compare the use of misoprostol versus placebo by different routes and doses before diagnostic or operative hysteroscopy. The MEDLINE database and the Cochrane Central Register of Controlled Trials were searched for articles published from January 1970 to April 2010. The outcome measures studied were related either to the facilitation of the hysteroscopic procedure (need for cervical dilatation, cervical width at the beginning of hysteroscopy, duration of the procedure and complications such as cervical tear and uterine perforation) or to the medication side-effects. With regard to side-effects, we studied the incidence of nausea, diarrhea, abdominal pain, bleeding, and fever. RESULTS Vaginal misoprostol reduced the need for cervical dilatation in the total population of pre- and post-menopausal women to a statistically significant degree. In the subgroup of operative hysteroscopy the need for dilatation and the duration of the procedure were also significantly reduced. Most other outcomes relating to the facilitation of the procedure did not reach statistical significance. The side effects in the misoprostol group were significantly more frequent than in the placebo group. CONCLUSION(S) There is insufficient evidence to recommend the routine use of misoprostol before every hysteroscopy. As the lack of serious benefit from misoprostol is unlikely to be due to type II error, its use should be reserved for selected cases.

Effects of ball cauterization following loop excision and follow-up colposcopy

Objective To investigate whether central diathermy ball cauterization after loop excision affects satisfactory colposcopy at follow-up. Methods One hundred one consecutive women with the squamocolumnar junction visible at the ectocervix scheduled for loop excision were assigned alternately into two groups. In group A, diathermy ball cauterization was applied to the entire crater following excision. In group B, cauterization was avoided in a 2–3-mm zone around the new os. The women were re-examined 4 months postoperatively by colposcopy and microcolpohysteroscopy with specific intention to identify the location of the squamocolumnar junction. The examiners performing colposcopy and microcolpohysteroscopy were not aware of each others interpretation, or of the method of cauterization used. Results Follow-up colposcopy was satisfactory in 12 women in group A (24%) and 47 women in group B (92.2%) (P < .001). Forty-three women (86%) in group A and ten in group B (19.6%) had the squamocolumnar junction partly or fully located within the cervical canal (P < .001). Microcolpohysteroscopy located the squamocolumnar junction at a mean depth of 4.5 ± 2.4 mm (± standard deviation [SD]) in the women in group A and 1 ± 0.9 mm in group B (P < .001). Microcolpohysteroscopy could not be performed in 13 women in group A (26%) and one woman in group B (2%) (P < .001). Conclusion Diathermy ball cauterization at the new cervical os after loop excision results in a shift of the squamocolumnar junction toward the endocervical canal, and predisposes to cervical stenosis, thereby decreasing satisfactory colposcopy rates.

Vaginoscopic Hysteroscopy and Transvaginal Sonography in the Evaluation of Patients with Abnormal Uterine Bleeding

STUDY OBJECTIVE To compare accuracy of vaginoscopic hysteroscopy, a new method of outpatient hysteroscopy, with that of transvaginal sonography in diagnosing intracavitary pathology in women with abnormal uterine bleeding. DESIGN Retrospective comparative study (Canadian Task Force classification II-2). SETTING Department of gynecology in a tertiary care university hospital. PATIENTS Three hundred ninety-seven consecutive patients. INTERVENTIONS Vaginoscopic hysteroscopy, transvaginal sonography, and histologic evaluation of endometrium. MEASUREMENTS AND MAIN RESULTS Findings at hysteroscopy and sonography were compared with histopathologic results, considered the gold standard diagnosis. Sensitivity, specificity, and positive and negative likelihood ratios were 92%, 95%, 18.4, and 0.08 for vaginoscopic hysteroscopy and 67%, 87%, 5.15, and 0.38 for transvaginal sonography, respectively. CONCLUSION Vaginoscopic hysteroscopy is quick and well tolerated, and more accurate in detecting intracavitary uterine pathology than transvaginal sonography. More research is required to determine its place in patients with abnormal uterine bleeding, especially premenopausal women.

Fetal Anal Atresia Presenting as Transient Bowel Dilatation at 16 Weeks of Gestation

Congenital anal atresia is a rare abnormality which in two thirds of the cases is associated with other congenital abnormalities or syndromes. Prenatal diagnosis is usually achieved in cases with coexisting abnormalities. The diagnosis of isolated anal atresia is extremely difficult and can be suspected in the presence of colon dilatation. We present the case of a fetus in which marked dilatation of the colon was diagnosed at 16 weeks of gestation. Four weeks later the sonographic appearance of the bowel was normal and remained normal for the rest of the pregnancy. Anal atresia was diagnosed immediately after birth and corrected surgically. No other abnormalities were present. This case report illustrates that in anal atresia, bowel dilatation may be only transient.

Uterine artery Doppler velocimetry with leiomyomas

Abstract. The study was conducted to establish a correlation between Doppler velocimetry in relation to uterine weight in any phase of the menstrual cycle and symptoms in women who have leiomyomas. Doppler velocimetry was carried out on both uterine arteries in 18 pre-menopausal women and one post-menopausal woman prior to undergoing abdominal hysterectomy at Winthrop University Hospital in Mineola, NY and at Ioannina University Hospital. The t-test was used for statistical analysis. Changes in flow velocity correlatd directly with uterine size. When a division at 500 g was used, S/D ratio was 2.74±0.53 for larger uteri vs. 4.2±1.24 for smaller uteri, p<0.006. Eight women presented heavy bleeding and the mean S/D ratio was 3.75±1.36 while eleven women presented mild bleeding and the mean S/D ratio was 3.51±1.2 (p>0.5). Thus the study has demonstrated that in cases of uterine leiomyomas, the uterine artery flow increases although angiography had previously shown decreased vascularity within the tumor.