William R. Meyer

Thermal Balloon and Rollerball Ablation to Treat Menorrhagia: A Multicenter Comparison ☆

Objective To compare the clinical efficacy and safety of a thermal uterine balloon system with hysteroscopic rollerball ablation in the treatment of dysfunctional uterine bleeding. Methods Two hundred fifty-five premenopausal women were treated in a randomized multicenter study comparing thermal uterine balloon therapy with hysteroscopic rollerball ablation for the treatment of menorrhagia. Preproce-dural and postprocedural menstrual diary scores and quality-of-life questionnaires were obtained. Twelve-month follow-up data are presented on 239 women. Results Twelve-month results indicated that both tech-niques significantly reduced menstrual blood flow with no clinically significant difference between the two groups as reflected by return to normal bleeding or less (balloon 80.2% and rollerball ablation 84.3%). Multiple quality-of-life ques-tionnaire results were also similar, including percent of patients highly satisfied with their results (balloon 85.6% compared with rollerball 86.7%). A 90% decrease in diary scores was seen in more than 60% of patients in both groups. Procedural time was reduced significantly in the uterine balloon therapy group. Intraoperative complications oc-curred in 3.2% of the hysteroscopic rollerball patients, whereas no intraoperative complications occurred in the thermal balloon group. Conclusion In the treatment of dysfunctional uterine bleeding, uterine balloon therapy is as efficacious as hysteroscopic rollerball ablation and may be safer.

Use of integrins to date the endometrium.

OBJECTIVE To compare traditional histologic dating criteria of the endometrium with immunohistochemical criteria based on epithelial integrin expression during the menstrual cycle. DESIGN Prospective clinical study. SETTING An academic teaching hospital. PATIENT(S) Fertile and infertile women undergoing endometrial biopsy. MAIN OUTCOME MEASURE(S) Immunohistochemical staining intensity and distribution (HSCORE) of three integrins and traditional histologic endometrial dating. RESULT(S) In 1,501 endometrial specimens, phase assignment-based integrin staining was 95% and 85% concordant with histology for the proliferative and early secretory phase, respectively, but only 54% and 49% concordant for the middle and late secretory phase, respectively. The greatest disagreement occurred during the midluteal phase. Of 1,090 patients who underwent sampling 6-10 days after detection of a urinary LH surge (corresponding to cycle days 20-24), multiple logistic regression analysis revealed that endometriosis was positively correlated and male factor infertility was negatively correlated with absent beta3 integrin subunit expression. Diagnosis and absent epithelial alpha4beta1 expression were not related. Patient age was not correlated with the incidence of abnormalities in integrin expression. CONCLUSION(S) Traditional histologic dating of the endometrium has remained the gold standard for nearly 50 years. Although the use of marker proteins provides additional information and may reflect endometrial function or receptivity, such markers cannot yet replace traditional methods of endometrial assessment.

Impaired glucose tolerance in pregnant women with polycystic ovary syndrome.

OBJECTIVE To determine whether women with polycystic ovary syndrome (PCOS) are more likely to develop gestational diabetes mellitus compared with age- and weight-matched controls. METHODS This retrospective cohort study compared reproductive-age women with and without PCOS who received prenatal care at the University of North Carolina Hospitals between April 1989 and June 1998. We reviewed the medical charts of 22 women with PCOS diagnosis before pregnancy based on menstrual histories, elevated androgen levels, and LH-FSH ratios greater than 2. These women were compared with 66 women without PCOS matched for age and weight. Gestational diabetes mellitus (GDM) was diagnosed in women if they had abnormal results on a 50-g glucose screening test and at least two abnormal plasma glucose values during a 100-g glucose tolerance test. Medical complications of pregnancy, pregnancy complications, and birth outcomes were compared between women with and without PCOS. RESULTS Nine of 22 women with PCOS also had GDM diagnosis, compared with two of 66 controls (odds ratio [OR] 22.2; 95% confidence interval [CI] 3.8, 170.0), and these women exhibited increased plasma glucose values for all measurements except fasting. Five of 22 women with PCOS developed preeclampsia compared with one of 66 controls (OR 15.0; 95% CI 1.9, 121.5). CONCLUSION Women with PCOS are at increased risk of glucose intolerance and preeclampsia during pregnancy.

Thermal balloon and rollerball ablation to treat menorrhagia: Two-year results of a multicenter, prospective, randomized, clinical trial

STUDY OBJECTIVE To evaluate 2-year follow-up results in patients participating in a randomized, clinical trial comparing uterine balloon therapy with rollerball endometrial ablation. STUDY DESIGN Prospective, randomized, clinical trial (Canadian Task Force classification I). SETTING Fourteen university-affiliated and private practice sites. PATIENTS Two hundred fifty-five women with menorrhagia. INTERVENTIONS Patients were randomized to rollerball or uterine balloon endometrial ablation. MEASUREMENTS AND MAIN RESULTS Patient satisfaction with both treatments was consistently high. Only 15 hysterectomies had been performed (6 for menorrhagia) at the end of 2 years, 11 in the rollerball group, 4 in the balloon therapy group. CONCLUSION Endometrial ablation by both procedures was highly successful in avoiding hysterectomy and relieving symptoms of menorrhagia. Additional benefits were reduction in dysmenorrhea and premenstrual syndrome.

Temporal and morphologic characteristics of pinopod expression across the secretory phase of the endometrial cycle in normally cycling women with proven fertility

OBJECTIVE To assess the temporal and morphologic characteristics of pinopod expression on the surface of endometrium across the secretory phase, in LH-timed endometrial samples in normal, healthy women. DESIGN Prospective, randomized study. SETTING Academic teaching hospital. PATIENT(S) Sixty-eight healthy volunteers with proven fertility. INTERVENTION(S) Urinary LH-timed endometrial and blood sampling was performed on each subject on a randomly selected day of the secretory phase. MAIN OUTCOME MEASURE(S) Histologic dating, assessment of pinopods using scanning electron microscopy, and comparison with serum P levels. RESULT(S) Eighty-six endometrial tissue samples obtained from 68 subjects were evaluated under scanning electron microscopy. Pinopods were first observed on luteal day 5, corresponding with the onset of the midluteal phase increase in serum P levels. Pinopods persisted for the entire duration of the secretory phase, but their morphology changed as the cycle advanced. CONCLUSION(S) The present findings demonstrate that pinopods are a characteristic feature of the mid to late secretory phase endometrial epithelium, exhibit cycle-dependent changes in morphology, and are most prominent during the putative implantation interval.

Effect of exogenous gonadotropins on endometrial maturation in oocyte donors

OBJECTIVE To determine the effects of controlled ovarian hyperstimulation (COH) on endometrial maturation. DESIGN Prospective, before and after evaluation of midluteal endometrial biopsies in oocyte donors spontaneous and subsequent COH cycles. SETTING Tertiary academic medical center assisted reproductive technologies clinic. PATIENT(S) Nineteen oocyte donors. INTERVENTION(S) Exogenous gonadotropins, endometrial biopsies. MAIN OUTCOME MEASURE(S) Endometrial histology and an immunohistochemical marker of uterine receptivity, the alphavbeta3 vitronectin. RESULT(S) Glandular and stromal dyssynchrony was more common after COH in 16 (80%) of 20 cycles than 6 (30%) of 20 spontaneous cycles (P <.05). Glandular lag was more frequent in COH cycles and unaffected by progesterone administration. The beta3 subunit of the alphavbeta3 vitronectin receptor was present in 9 (45%) of 20 spontaneous and 2 (10%) of 20 COH cycles (P <.05). CONCLUSION(S) Exogenous gonadotropin use in healthy reproductive age women did not result in endometrial evidence of a luteal phase defect. A greater incidence of glandular-stromal dyssynchrony resulted from the use of exogenous gonadotropins. The presence of alphavbeta3 was noted in most endometrial specimens demonstrating in phase glandular maturation. We conclude that endometrial dyssynchrony that results from delayed glandular development most likely represents a normal histologic variant.

Advanced maternal age and perinatal outcome : Oocyte recipiency versus natural conception

Objective To compare perinatal outcome in older oocyte recipients with that in women of advanced maternal age who conceived without assisted reproductive technologies. Methods We performed a retrospective cohort study of 46 oocyte recipients and 49 women who conceived without assisted reproductive technologies. The obstetric courses in singleton and multiple gestations in the two groups of women were compared. Results Among singleton pregnancies, a comparable obstetric course was noted between the groups. Fifty percent of the oocyte recipients experienced multiple gestations, resulting in an increased risk for placenta previa, premature rupture of membranes, preterm labor and delivery, glucose intolerance of pregnancy, pregnancy-induced hypertension, and cesarean delivery. However, only the risks for pregnancy-induced hypertension and cesarean delivery were significantly increased in the pregnancies of oocyte recipients with multiple gestations. Conclusions Perinatal complications in women receiving oocyte donation may be related to their higher incidence of multiple gestation.

Combined abdominal-perineal sonography to assist in diagnosis of transverse vaginal septum

Background Transperineal sonography has been used to detect incompetent cervices, placenta previa, cervical pregnancy, and vaginal and cervical atresia. Case Transperineal sonography was used to investigate primary amenorrhea in a 14-year-old girl. A mid-transverse septum was found and confirmed surgically. Conclusion Transperineal or translabial sonography assisted in the differentiation of primary amenorrhea, when adequate vaginal access was prohibited.

Oil-soluble contrast during hysterosalpingography in women with proven tubal patency

OBJECTIVE: To determine if there are therapeutic advantages to oil‐soluble contrast medium compared with watersoluble medium during hysterosalpingography. METHODS: A randomized, controlled trial including 56 infertile patients undergoing hysterosalpingography was performed. After a hysterosalpingogram with water‐soluble contrast demonstrated tubal patency, 30 patients were randomized to receive oil‐soluble contrast medium (oil group) and 26 patients received no additional contrast medium (control group). The outcome was pregnancy and timing of pregnancy in relation to hysterosalpingography. RESULTS: There were 18 (64%) pregnancies in the oil group and 14 (56%) pregnancies in the control group. Mean time to achieve pregnancy was shorter in the oil group: 3.8 months in the oil group compared with 6.1 months in the control group (P = .06) There was a clinically meaningful improvement in pregnancy rates between the oil group and the control group at 1 month postprocedure (relative risk [RR] 2.1, 95% confidence interval [CI] 0.6, 7.2). However, at 12 months postprocedure, the advantage was diminished. (RR 1.3, CI 0.8, 2.1) CONCLUSION: Eighteen months after hysterosalpingography, contrast does not appear to influence cumulative pregnancy rates; however, the addition of oil‐soluble contrast medium to water‐soluble contrast medium may have the potential to reduce the time to conception. (Obstet Gynecol 2003;101:109‐13.

Effect of sex steroids on β-endorphin levels at rest and during submaximal treadmill exercise in anovulatory and ovulatory runners☆

OBJECTIVE To examine the interaction between circulating beta-endorphin levels and sex steroids during sustained submaximal exercise in runners who are either anovulatory and oligomenorrheic (AO) or ovulatory and eumenorrheic (EO). DESIGN Controlled clinical study. SETTING General clinical research center at an academic medical center. PATIENT(S) Three AO and four EO runners. INTERVENTION(S) The athletes underwent 60 minutes of submaximal treadmill exercise on three separate occasions. Anovulatory and oligomenorrheic runners underwent exercise at baseline and after physiologic estrogen and combined estrogen and progesterone replacement. Ovulatory and eumenorrheic runners underwent exercise in the follicular and luteal phases and after GnRH agonist desensitization. MAIN OUTCOME MEASURE(S) Serum cortisol, beta-endorphin, progesterone, estrogen, and gonadotropin levels at rest and during exercise. RESULT(S) Serum levels of E2 increased in response to exercise in both EO and AO runners during sex steroid replacement. Baseline peripheral beta-endorphin and cortisol levels were not different between the EO and AO groups. A significant increase in beta-endorphin levels in response to exercise occurred only in the EO group after GnRH agonist desensitization. CONCLUSION(S) Alterations in menstrual cyclicity and ovulation in conditioned runners probably are not due to an increase in opioid tone. The hypothalamic-gonadotropic axis appears to be intact in AO runners, as measured by the gonadotropic response to exogenous exposure to estrogen and progesterone. Sex steroid administration had no effect on basal beta-endorphin levels, but this probably was not due to preexisting increased opioid tone.