Ricciarda Raffaelli

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.

Ultrasonographic measurement of thymus size in IUGR fetuses: a marker of the fetal immunoendocrine response to malnutrition

To test the hypothesis that intrauterine growth restriction (IUGR) is associated with decreased thymus size in the human fetus.

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.

Effects of female sex hormones and contraceptive pill on the diagnostic work-up for primary aldosteronism.

Objectives Due to the widespread use of the aldosterone to renin ratio (ARR), primary aldosteronism is currently recognized as a frequent cause of secondary hypertension. After a positive screening, primary aldosteronism diagnosis needs confirmation by an inhibitory test such as intravenous saline load (ivSLT). The aim of the present study was to investigate the role of female hormones in primary aldosteronism diagnosis, by evaluating possible differences by sex on ARR screening, on the rate of ivSLT response and analyzing the influence of free and oral contraceptive-induced menstrual cycle on ARR. Methods We examined ARR in 103 healthy normotensive volunteers, 81 hypertensive patients who underwent ivSLT, 33 healthy women during free menstrual cycle and after oral contraceptive therapy. Results A significantly higher proportion of normotensive women than men had an elevated ARR (13.6 versus 2.3%, P < 0.05). In 44 out of 81 hypertensive patients, diagnosis of primary aldosteronism was confirmed by ivSLT. Patients with positive and negative ivSLT differed only for sex distribution: 85.2% of men had the primary aldosteronism diagnosis confirmed, compared with 38.9% of women. In healthy women, renin and aldosterone concentrations increased from the follicular to luteal phase of menstrual period, with unchanged ARR. By contrast, renin nearly halved, aldosterone slightly decreased and ARR doubled after oral contraceptive therapy. Conclusion ARR screening fails to predict positive ivSLT in most (60.2%) hypertensive women as compared with 14.8% of hypertensive men. ARR is more often increased in normotensive women than men. Oral contraceptive may affect ARR contributing to the diagnostic inaccuracy in women.

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.

Preoperative assessment of intestinal endometriosis: a comparison of Transvaginal Sonography with Water-Contrast in the Rectum, Transrectal Sonography, and Barium Enema

To evaluate the accuracy of Transrectal Sonography (TRS) and a new technique, Transvaginal Sonography with Water-Contrast in the Rectum (RWC-TVS), in the diagnosis of rectosigmoid endometriosis, and the accuracy of Barium Enema (BE) and RWC-TVS in the detection of intestinal stenosis due to endometriosis. In a prospective study, we compared the findings of TRS and RWC-TVS performed before surgery with the operative and pathologic findings in 61 consecutive patients who underwent laparoscopy or laparotomy for suspected rectosigmoid endometriosis. The accuracy of BE and RWC-TVS in the detection of intestinal stenosis was evaluated comparing the radiologic and ultrasonographic results with the macroscopic findings at surgery and pathology. RWC-TVS diagnosed rectosigmoid endometriosis with the same accuracy of TRS and was equally efficient as BE in the detection of a significant intestinal lumen stenosis. For the diagnosis of rectosigmoid endometriosis the sensitivity, specificity, positive and negative predictive values of TRS and RWC-TVS were 88.2% and 96%, 80%, and 90%, 95.7%, and 98%, and 57.1% and 81.8%, respectively. For the detection of intestinal stenosis the sensitivity, specificity, positive and negative predictive values of BE and RWC-TVS were 93.7% and 87.5%, 94.2% and 91.4%, 88.2% and 82.3%, and 97% and 94.1%, respectively. RWC-TVS is a new, simple technique for a single-step and accurate preoperative assessment of rectosigmoid endometriosis.

Assessment of pelvic endometriosis: correlation of US and MRI with laparoscopic findings.

Purpose.The purpose of this study was to evaluate the contribution of ultrasound (US) and magnetic resonance (MR) imaging in the diagnosis and local staging of endometriosis by comparing results with laparoscopic findings.Materials and methods.We evaluated 36 consecutive women with suspected or clinically diagnosed endometriosis. Thirty–two out of 36 patients met the following inclusion criteria: transabdominal and endocavitary (US) examination and MR imaging, followed by laparoscopy performed within 2 weeks. US and MR findings were classified based on location, number and morphology (small nodules, large nodules, laminar lesions, cystic lesions, complex lesions, adhesions, cul–de–sac obliteration).Results.Laparoscopy, considered the gold standard, identified 143 lesions in 32 patients. US detected 101 lesions, and MR detected 92 lesions, which were subsequently divided by morphologic appearance. Sensitivity and specificity of the two imaging techniques in the recognition of the different locations were 58% and 25%, respectively, for US and 56% and 50%, respectively, for MR imaging. Results of the two techniques in the different locations examined were similar, with the exception of lesions in the rectovaginal septum, which were better detected by US, and for adhesions and cul–de–sac obliteration, which were more easily detected by MR.Conclusions.Both US and MR are accurate in the diagnosis of endometriosis. There are no significant differences in staging of pelvic endometriosis between US and MR. US examination is the primary evaluation in cases of suspected disease and for the rectovaginal septum. MR examination is recommended for correct classification in doubtful cases and in cases of suspected extrapelvic lesions and adhesions.

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.