Ricardo Bassil Lasmar

Feasibility of a new system of classification of submucous myomas: a multicenter study.

OBJECTIVE To evaluate the performance of the STEPW (size, topography, extension, penetration, wall) classification system in predicting partial or complete fibroid removal on hysteroscopic myomectomy. DESIGN Multicenter, prospective study (Canadian Task Force classification II-2). SETTING Four hysteroscopy centers in Brazil, China, Italy, and the United States. PATIENT(S) Four hundred forty-nine women who underwent hysteroscopic resection of 465 submucous fibroids. INTERVENTION(S) Resection of the submucous fibroids (hysteroscopic myomectomy). Fibroids were scored according to the European Society for Gynaecological Endoscopy (ESGE) and STEPW classifications. The validation of the two classifications was assessed using sensitivity and specificity of each classification, with their best cutoff point. A test of equality of the two areas under the receiver operating characteristic curves was performed for correlated samples. MAIN OUTCOME MEASURE(S) Correlation of ESGE and STEPW classifications with complete or incomplete removal of submucous fibroid. RESULT(S) Removal of the myoma was complete in 432 (92.9%) of 465 myomectomies and incomplete in 33 (7.1%). All 320 fibroids (100%) with a score≤4 in the STEPW classification were completely removed, and 112 of 145 fibroids (77.2%) with a score>4 were removed. All 33 cases of incomplete hysteroscopic myomectomy (100%) had a STEPW score>4. Using the ESGE classification, 85 of 86 cases (98.9%) of type 0 fibroids, 278 of 298 (93.3%) of type 1, and 69 of 81 (85.2%) of type 2 were completely resected. CONCLUSION(S) Classifying submucous fibroids using the STEPW classification permits greater correlation with complete or incomplete removal of the myoma by hysteroscopic myomectomy.

Endometrial polyp size and polyp hyperplasia

To assess the correlation between the size of endometrial polyps and the histopathologic diagnosis of hyperplasia or cancer.

Avaliação histeroscópica em pacientes com infertilidade

PURPOSE to describe hysteroscopy findings in infertile patients. METHODS this was a retrospective series of 953 patients with diagnosis of infertility evaluated by hysteroscopy. A total of 957 patients investigated for infertility were subjected to hysteroscopy, preferentially during the first phase of the menstrual cycle. When necessary, directed biopsies (under direct visualization during the exam) or guided biopsies were obtained using a Novak curette after defining the site to be biopsied during the hysteroscopic examination. Outcome frequencies were determined as percentages, and the χ2 test was used for the correlations. The statistical software EpiInfo 2000 (CDC) was used for data analysis. RESULTS a normal uterine cavity was detected in 436 cases (45.8%). This was the most frequent diagnosis for women with primary infertility and for women with one or no abortion (p<0.05). Abnormal findings were obtained in 517 of 953 cases (54.2%), including intrauterine synechiae in 185 patients (19.4%), endometrial polyps in 115 (12.1%), endocervical polyps in 66 (6.0%), submucosal myomas in 47 (4.9%), endometrial hyperplasia in 39 (4.1%), adenomyosis in five (0.5%), endometritis (with histopathological confirmation) in four (0.4%), endometrial bone metaplasia in two (0.4%), and cancer of the endometrium in one case (0.1%). Morphological and functional changes of the uterus were detected in 5.6% of the cases, including uterine malformations in 32 (3.4%) and isthmus-cervical incompetence in 21 (2.2%). CONCLUSIONS intrauterine synechiae were the most frequent abnormal findings in patients evaluated for infertility. Patients with a history of abortion and infertility should be submitted to hysteroscopy in order to rule out intrauterine synechiae as a possible cause of infertility.

Genetic analysis of the cause of endometrial osseous metaplasia.

OBJECTIVE: To analyze solitary bone fragments from the uterine cavity through DNA genotyping, thus elucidating whether they originate from metaplasia, from previous abortion, or both. METHODS: We conducted a case series study on 14 patients, of whom eight yielded bone DNA. The patients selected had histopathologic diagnoses of bone fragments inside the uterine cavity or previously removed samples available for analysis. We extracted DNA from blood and bone fragments. To identify the bone tissue origin, these materials were genotyped using polymerase chain reactions for DNA loci. Six mini short tandem repeat loci frequently used for human tissue identification were analyzed using automated sequencing. RESULTS: Among these eight patients, blood and tissue samples from the same individual produced exactly the same pair of alleles for all six loci. This indicated that the DNA profile was completely the same for the bone samples and the mother’s blood (95% confidence interval 63–100%), thus confirming that the DNA had the same origin and that these were cases of metaplasia. CONCLUSION: In all of the eight cases, bone formation was caused by osseous metaplasia, because the DNA in the bone fragment and in the patient’s blood was identical. Although all of the women had histories of previous abortion, no difference in DNA was detected in the bone tissue in any of the cases, as would be expected if abortion had occurred. This result was completely unexpected, differing greatly from what the literature suggests. LEVEL OF EVIDENCE: III

Clinical Assessment of Tribulus terrestris Extract in the Treatment of Female Sexual Dysfunction

This is a qualitative–quantitative study based on hospital records of female patients of reproductive age, presenting sexual dysfunction, and treated with 250 mg Tribulus terrestris extract (1 tablet thrice daily for 90 days). Safety monitoring included vital signs, physical examination, laboratory tests, and occurrence of adverse events. Efficacy analysis included results of the Female Sexual Function Index (FSFI), dehydroepiandrosterone (DHEA) levels together with total and free testosterone, and the patient and physician assessments. There was a statistically significant improvement in total FSFI scores (P < 0.0001) post-treatment, with improvement among 106 (88.33%) subjects. There was a statistically significant (P < 0.0001) increase in the level of DHEA, while the levels of both serum testosterone (P = 0.284) and free testosterone decreased (P < 0.0001). Most adverse events recorded were related to the gastrointestinal tract. Physical examination showed no significant changes post-treatment. Based on the results, it is concluded that the T. terrestris extract is safe and effective in the treatment of female sexual dysfunction.

Diagram to map the locations of endometriosis

To develop and test a visual map that corresponds practically and objectively to the anatomical areas affected by endometriosis.

The role of leiomyomas in the genesis of abnormal uterine bleeding (AUB)

Abnormal uterine bleeding (AUB) is the major complaint in approximately one-third of gynecological visits in premenopausal women, and in >70% of appointments of perimenopausal and postmenopausal women. Uterine myoma is one of the main causes of AUB during menacme, especially when it is submucosal. The association of myoma and AUB may be related to several factors, from local alterations of angiogenic and vasoactive substances to changes in uterine contractility. The objective of this paper is to show the different associations of myoma and AUB.

Metaplasia óssea endometrial: quadro clínico e seguimento após tratamento

PURPOSE to describe the clinical signs and symptoms of patients with bone metaplasia and to assess the risk factors for changes in these symptoms after removal of the bone fragment. METHODS a cross-sectional study was conducted on 16 patients with a diagnosis of bone fragments in the uterine cavity during the period comprising July 2006 to January 2009. The inclusion criterion was the detection of a bone fragment removed from the uterine cavity. The presence of bone tissue in the endometrial cavity was histologically confirmed in all patients. The data of all patients were obtained before and after removal by means of a questionnaire for the evaluation of the effect of removal on the symptoms and for the search of possible factors related to the onset of the disease. RESULTS half the patients (8/16) had hemorrhagic symptoms and one third (6/16) were infertile. Removal of the fragments was quite effective in improving the complaints, with the disappearance of symptoms in all cases of hemorrhage and of pelvic pain. CONCLUSION removal of bone fragments can restore the fertility of selected patients whose infertility is caused by bone metaplasia and is quite effective in leading to improvement in patients with pelvic pain and menorrhage.

The value of hysteroscopic biopsy in the diagnosis of endometrial polyps.

Several studies have demonstrated that the combination of hysteroscopy with endometrial biopsy is more accurate in differentiating endometrial polyps from endometrial hyperplasia and cancer. However, blind biopsy not always confirms hysteroscopic findings due to high rates of inadequate or insufficient material. The objective of this clinical, prospective, and comparative study was to establish a correlation between the histological results of office-based endometrial biopsies (hysteroscopically guided and blind) with the surgical polypectomy specimens. We evaluated 82 patients with hysteroscopic diagnosis of endometrial polyp, who randomly underwent hysteroscopically guided biopsy or blind biopsy, referred for surgical resection. A total of 36 women (43.9%) underwent hysteroscopically guided biopsy and 46 women (56.1%) underwent blind biopsy. The sensitivity of hysteroscopically guided biopsy for the diagnosis of endometrial polyps ranged between 35.3 and 36.8%, when carried out at the apex and base of the lesion, compared with 29.2% for blind biopsy. Specificity was 33.3, 50, and 60%, respectively, for each biopsy. The positive predictive values were 75, 77.8, and 87.5%, and negative predictive values were 8.3, 14.3, and 8.1% respectively, compared with surgical polypectomy specimens. The office-based endometrial biopsies had low diagnostic accuracy for endometrial polyps compared with surgical polypectomy specimens.

Office hysteroscopic cervical myomectomy

IntroductionLeiomyomas are the most common tumors of the uterus andthe female pelvis, with an estimated prevalence of 40–50 %.The main symptom is transvaginal bleeding being responsi-ble for high levels of hysterectomy worldwide [1]. Othercomplaints are dyspareunia, abdominopelvic discomfort,and lower abdominal pain. They are benign tumors com-posed mainly of smooth muscle cellsassociated with fibrousconnective tissue in varying amounts. The clinical treatmentcan be accomplished with gestrinone, GnRH analogues, anddanazol in premenopausal women seeking improvement inbleeding until menopause. GnRH analogue may be a thera-peutic option for 3 to 6 months; when necessary for a longerperiod, it should be combined with gonadotropic hormonesto minimize the effects of bone demineralization.Thesurgicalapproach,myomectomy,isthedefinitivetreat-mentofdiseaseandmaybedonebylaparotomy,laparoscopy,or hysteroscopy, depending on the number, size, and locationof the nodules. In some cases, a hysterectomy may be indi-cated,particularlyinwomenwithnodesireoffuturepregnan-cy. Most fibroids are situated in the uterine body, with aminority (less than 5 %) in the cervical canal [2, 3]. Theapproach to the cervical myoma is complex, since it is closerto the ureters, bladder, rectum, and cervical vessels [3].Hysteroscopic myomectomy is a complex surgery indi-cated in cases of submucosal fibroids. The main complica-tions of the procedure are bleeding, uterine perforation, andoverload. The procedure can be done as office hysteroscopicmyomectomy using biopsy punch and scissors or bipolarelectrodes, or as hospital hysteroscopic myomectomy withcervical dilation using mono or bipolar resectoscope.In 2005, Lasmar et al. developed the STEPW classifica-tion [4, 5] which provides the degree of difficulty of hys-teroscopic myomectomy by classifying the fibroidspreoperatively. This classification includes intracavitary fib-roids only; cervical fibroids are not contemplated. Hystero-scopic myomectomy may be performed by differenttechniques: direct mobilization, slicing, or both [6, 7]. Itcan be used with U or L resectoscope handle, with orwithout energy, either monopolar or bipolar. In direct mobi-lization, the Collins electrode is used in shape of an “L” todissect the endometrium around the fibroid. The “cold elec-trode” is used to mobilize the fibroid in all directions, doingthe coagulation only of the vessels that are bleeding. Afterreleasing the nodule from the uterinewall, it can beremovedby grasping forceps. If the fibroid is too large, it can besliced in several pieces using the Collins electrode [6].Inofficehysteroscopicprocedure,weprefertousethedirectmobilization technique as well with biopsy punch, sectioningfibrousbeams of themyoma pseudocapsule as it is mobilized.Saline infusion is used as distension media. This technique issimilartothatinthehospitalsettingandallowstheresectionoffibroid very close to the uterine safely and efficiently [ 8, 9].Theliterature hasfewdata onthemanagement of cervicalmyomas, with most referrals regarding cervical myomec-tomy by laparoscopy route [3, 10]. The approach to cervicalfibroids by hysteroscopy is possible, mainly on those withlittle intramural component, and should be done cautiouslydue to the small wall thickness and short proximity toimportant structures of the pelvis [3]. The presence of largemasses leads to a dilatation of the cervical canal, difficultingits distension and making the procedure even harder.Case presentationA 46-year-old woman attended the gynecology ambulatoryof University Antonio Pedro Hospital, complaining of ab-normal uterine bleeding. Her gynecologic history was two