Seth Granberg

Mifepristone for treatment of uterine leiomyoma. A prospective randomized placebo controlled trial

BACKGROUND Uterine leiomyomas are widely prevalent and frequently cause menorrhagia. The major therapeutic option today is hysterectomy. Medical options are of highest interest. METHODS A total of 30 women with uterine leiomyomas scheduled for surgical intervention were randomized to receive either 50 mg mifepristone or placebo every other day during 3 months prior to surgery. Uterine blood flow and leiomyoma volume were evaluated once a month until surgery. Endometrial biopsies were obtained prior to and at end of treatment. Relevant biochemistry, symptoms and bleeding were recorded. Primary outcome was reduction in uterine leiomyoma size. RESULTS There was a significant percentual decrease (P = 0.021) in the total leiomyoma volume in the mifepristone-treated group, -28 (-48, -8) % (mean +/- 0, 95 confidence interval), compared with the control group values 6 (-13, 25) %. Mifepristone treatment significantly reduced the bleeding days (P = 0.001) and increased serum haemoglobin values (P = 0.046). Serum cortisol levels remained unchanged, while a mild increase in serum androgens was noted. Endometrial biopsies showed no premalignant changes or changes in mitotic indices. CONCLUSION Mifepristone may offer an effective treatment option for women with uterine leiomyoma and the associated pronounced uterovaginal bleeding. Clinical Trials identifier: www.clinicaltrials.gov: NCT00579475.

The management of pelvic abscess

The optimum treatment for pelvic abscess would be an approach that is safe, efficacious, cost-effective, minimally invasive, and which affects the womans fertility potential as little as possible. In women of reproductive age tubo-ovarian abscess is one of the most common types of pelvic abscess. Tubo-ovarian abscesses are classically treated with broad-spectrum antibiotics. Frequently this approach fails and surgical intervention becomes necessary in about 25% of all cases. Surgical procedures include laparotomy or laparoscopy with drainage of abscess, unilateral or bilateral salpingo-ophorectomy, and hysterectomy. However, surgery for tubo-ovarian abscess is often technically difficult and associated with complications. An alternative approach is the use of imaging-guided drainage of abscess in combination with antibiotics. Combined data from several studies indicate that ultrasound-guided transvaginal drainage with concomitant antibiotics is especially safe and efficacious. This chapter discusses the management of pelvic abscess with a special focus on transvaginal ultrasound-guided drainage of tubo-ovarian abscess.

Can ultrasound-based investigations replace laparoscopy and hysteroscopy in infertility?

OBJECTIVES To compare the use a simplified ultrasound based infertility investigation of the infertile couple with the current use of laparoscopy and hysteroscopy. STUDY DESIGN Thirty-three infertile couples underwent transvaginal ultrasound and hystero-salpingo-contrast-sonography. A diagnosis was formulated based on the results of the ultrasound investigations, a semen analysis and endocrine parameters. The following day, all subjects underwent a laparoscopic chromotubation and hysteroscopy by a surgeon unaware of the ultrasound findings. A diagnosis based on the findings at laparoscopy and hysteroscopy, the same semen analysis and endocrine parameters, was then made. The two diagnoses were compared. RESULTS A 90.9% agreement was found between the diagnoses made from the two methods used. When considering laparoscopic diagnosis the Gold Standard of tubal patency, the sensitivity to diagnose occluded tubes using hystero-contrast-sonography was 92.8%. The corresponding figures for specificity, PPV and NPV were 96.2%, 92.8% and 98.1%, respectively. CONCLUSIONS A simple, ultrasound based approach to investigate the infertile couple, can be used effectively as an initial examination modality during the couples work-up. However, there is a need for a larger study to confirm these results.

A new computer-aided diagnostic tool for non-invasive characterisation of malignant ovarian masses: results of a multicentre validation study.

ObjectivesTo prospectively assess an innovative computer-aided diagnostic technology that quantifies characteristic features of backscattered ultrasound and theoretically allows transvaginal sonography (TVS) to discriminate benign from malignant adnexal masses.MethodsWomen (n = 264) scheduled for surgical removal of at least one ovary in five centres were included. Preoperative three-dimensional (3D)-TVS was performed and the voxel data were analysed by the new technology. The findings at 3D-TVS, serum CA125 levels and the TVS-based diagnosis were compared with histology. Cancer was deemed present when invasive or borderline cancerous processes were observed histologically.ResultsAmong 375 removed ovaries, 141 cancers (83 adenocarcinomas, 24 borderline, 16 cases of carcinomatosis, nine of metastases and nine others) and 234 non-cancerous ovaries (107 normal, 127 benign tumours) were histologically diagnosed. The new computer-aided technology correctly identified 138/141 malignant lesions and 206/234 non-malignant tissues (98% sensitivity, 88% specificity). There were no false-negative results among the 47 FIGO stage I/II ovarian lesions. Standard TVS and CA125 had sensitivities/specificities of 94%/66% and 89%/75%, respectively. Combining standard TVS and the new technology in parallel significantly improved TVS specificity from 66% to 92% (p < 0.0001).ConclusionsComputer-aided quantification of backscattered ultrasound is a highly sensitive for the diagnosis of malignant ovarian masses.

EARLY DETECTION OF PRIMARY CARCINOMA OF THE FALLOPIAN TUBE BY ENDOVAGINAL ULTRASOUND

About 0.5% of all gynecological malignancies in Sweden are primary fallopian tube carcinomas. Early diagnosis is difficult due to the paucity of symptoms. However, the diagnosis should be entertained in the presence of abnormal vaginal bleeding not explained by gynaecological examination and biopsy of the cervix and endometrium. The possibility of tubal carcinoma should be considered in patients with persistent vaginal discharge and lower abdominal pain without apparent explanation. An early case of fallopian tube carcinoma detected by endovaginal ultrasound is described.

Pregnancies following ultrasound-guided drainage of tubo-ovarian abscess

OBJECTIVE To study fertility among women treated by means of ultrasound-guided drainage and antibiotics for tubo-ovarian abscess (TOA). DESIGN Retrospective cohort study. SETTING A tertiary referral center. PATIENT(S) One hundred women of reproductive age treated for TOA between June 1986 and July 2003. INTERVENTION(S) Transvaginal ultrasound-guided drainage of TOA was performed in all patients. The procedure was repeated if a substantial amount of pus was seen using ultrasonography 2-5 days after the initial aspiration, and repeated later if necessary. MAIN OUTCOME MEASURE(S) Frequency of naturally conceived pregnancies. RESULT(S) Twenty of 38 (52.6%; 95% CI 36.5-68.9%) women who intended to have a child achieved pregnancy naturally and became mothers. In addition, 7 (50%) of 14 women who were not on birth control on a regular basis became pregnant. No ectopic pregnancies were registered. CONCLUSION(S) Ultrasound-guided drainage of TOA in combination with antibiotics seems to preserve fertility in approximately half of the patients.

Abnormal uterine bleeding refractory to medical therapy assessed by saline infusion sonohysterography

Objective. The primary aim of the study was to assess the incidence of intracavitary pathology visualized by saline infusion sonohysterography (SIS) in premenopausal women suffering from abnormal uterine bleeding refractory to medical therapy. Secondary aims were to evaluate the clinical course when a minimally invasive therapeutic approach was applied and to examine the need for hysterectomy in this group of women over a follow‐up period of two years. Design. Prospective cohort study. Setting. Tertiary referral university hospital. Population. Between February 2004 and June 2006, 104 premenopausal women suffering from abnormal uterine bleeding refractory to medical treatment were included. Methods. Transvaginal ultrasonography and SIS were performed as first line procedures of the investigation. Hysteroscopy was undertaken for removal of focal intrauterine anomalies. Hysterectomy was only carried out when other approaches failed or were regarded as unsuitable. Women who did not undergo hysterectomy had regular follow‐up consultations for at least two years. Main outcome measures. Incidence of intrauterine focal anomalies, clinical course, and need for hysterectomy. Results. Following saline infusion sonohysterograhy intracavitary anomalies were visualized in 58 (55.8%) women. Over the follow‐up period 80 women had successful minimally invasive treatment, while 24 women underwent hysterectomy. Conclusions. The study shows that focal intracavitary lesions are common in premenopausal women with abnormal uterine bleeding refractory to medical treatment. By applying minimally invasive diagnostic and therapeutic approaches acceptable bleeding patterns can be re‐established in most cases, thereby resulting in a low rate of hysterectomies.

The Use of Ultrasound to Assess the Morphology of Ovarian Tumours

The rapid development of ultrasound technology has led to an increase in the detection rate of ovarian cysts. Such cysts can be diagnosed at any age or stage of a woman’s life, from as early as the fetal stage to as late as the postmenopause. A high number of cystic structures are seen in the ovaries, even in postmenopausal women. Many of these regress spontaneously or remain unchanged. The clinical dilemma that these cystic structures cause for the clinician is well documented. Furthermore, it is also well known that transvaginal sonography plays an important role, not only in the detection of ovarian cysts, but also in the characterisation of these lesions. The problem for the clinician remains the same. Which cystic structures on the ovaries can be managed conservatively, and which need to be removed? Advances in surgery have now led to a further issue. If there is an ovarian cyst, is it suitable for minimal access surgery or are the services of a gynaecological oncologist required? This chapter will discuss some of the problems that appear at a clinical practice when using B-mode ultrasound and will also try to explain the significance of certain morphological features of ovarian tumours.

Ultrasound in the diagnosis and treatment of ovarian tumors

Ultrasound has been increasingly used during the last few years to evaluate tumors in the lower pelvis of women of all ages. Most of our knowledge of the ultrasound image of such tumors is based on abdominal ultrasound scanning. With the introduction of high-resolution endovaginal ultrasound, a new diagnostic tool has become avajlable for studying ovarian tumors. Most sonographers agree that endovaginal ultrasound is superior to abdominal scanning for the diagnosis of early pregnancy, ectopic pregnancy and incomplete abortions. Endovaginal ultrasound has also proved to be very useful in the work-up of the infertile patient for monitoring of follicular and endometrial development and for oocyte retrieval. Endovaginal ultrasound also seems to be a very suitable technique for studying the endometrium in postmenopausal women. Simple cystic ovarian tumors are common in menstruating women and not infrquently found in postmenopausal women. One might then ask: what are the chances of a simple ovarian cyst’s being malignant and is endovaginal ultrasound an accurate method for characterizing such a tumor‘? It is well known that laparotomy carries a high risk of causing infertility problems in menstruating women and a higher risk of postoperative complications in older women. Ultrasound-guided puncture of cystic ovarian tumors could thus be an alternative to laparoscopic puncture or surgery. By means of ultrasound, it was possible to identify and measure 87% of the postmenopausal ovaries, as compared with 30% identified at the ordinary gynecological examination. Volumes less than 1 cm3 could not be palpated, which indicates that a gynecological examination wil have very little prospect of detecting smaller ovarian tumors. Ultrasound examination of the ovary is, however, probably not the solution for