Gynaecological correlates of hysterectomy in Danish women

BACKGROUND

The aim has been to assess the gynaecological characteristics of importance for hysterectomy performed for benign diseases.

METHODS

In a prevalence study, 2301 Danish women aged 30, 40, 50, or 60 years, were selected at random in 1982, and self-report questionnaires were collected from 77%. Information about gynaecological and obstetric history, social background, weight and dieting history, and various lifestyles were recorded. Weight and height were measured. In an incidence study, the cohort was followed during 1982-1990 via central registers to assess the incidence of hysterectomy. Logistic and Cox regression were used to analyse data.

RESULTS

In the prevalence study, 85% of the hysterectomies were performed for benign conditions. Early menarche (< or = 11 years old) and short-term use of oral contraceptives (OC) (1-4 years) were independent correlates of these hysterectomies by multivariate analyses, whereas multiparity (> or = 4 childbirths) was confounded by education and weight-related factors. Long-term use of OC was associated with lower prevalence of hysterectomy. In the incidence study, short-term use of OC and ever use of progestogen-only minipills were independent risk factors for hysterectomy performed recently for benign diseases in women under 50 in the multivariate analyses. Abortions did not reach significance, and neither multiparity, long-term use of OC, nor early menarche were important.

CONCLUSION

The most important gynaecological characteristics related to premenopausal hysterectomy performed for benign diseases are hormonal contraceptives. These findings imply that the decision-making process concerning hysterectomy might depend on women's choice of contraception and compliance with OC as medical treatment.

Immunity to Chlamydia trachomatis is mediated by T helper 1 cells through IFN-gamma-dependent and -independent pathways

Mucosal immunity to Chlamydia trachomatis in a mouse model of female genital tract infection is mediated predominantly by Th1-type cells, as shown by in vivo neutralization of cytokines involved in the Th1 vs Th2 pathways. Neutralization of IL-12 was associated with an apparent decrease in the infiltration of CD4+ T cells into infected tissues, systemic reductions in the production of IFN-gamma, and prolonged shedding of high levels of bacteria. Neutralization of IL-4 had no detectable effect on host immunity or on bacterial clearance. To dissociate the protective role of IL-12 from that of IL-12-induced IFN-gamma, resistance to C. trachomatis was compared in IL-12-depleted and IFN-gamma-deficient animals. IL-12-depleted mice displayed minimal bacterial clearance for 1 mo post-infection but eventually resolved genital tract infections completely. IFN-gamma-deficient mice, on the other hand, cleared 99.9% of genital Chlamydia within the first 3 wk but then developed systemic disease associated with dissemination of bacteria to multiple organs. Animals surviving this stage often maintained low level persistent infections within the urogenital tract. These results indicate that the bulk of chlamydial clearance from the genital mucosa is mediated by an IL-12-dependent, IFN-gamma-independent mechanism, while prevention of disseminated disease requires the action of IFN-gamma.

[Electron microscopic and immunomorphologic study of the placenta in genital mycoplasmosis]

Peculiar ultrastructural features allowed the authors to reveal M. Homminis corpuscles in placental tissues of women with genital mycoplasmosis. Mycoplasma was found in the amniotic epithelium, chorionic plate, in the lumen of villous capillaries, this showing possible hematogenic way of the infection from mother to fetus. In the placenta of women with genital mycoplasmosis immunopathological processes develop in association with formation of pathogenic immune complexes (PIC) that are fixing the C3 complement fraction. Location of PIC on the syncytiotrophoblast membranes and vascular endothelium causes immunological inflammation with the involvement of immunocompetent cells resulting in the destruction of syncytial membranes and membranes of the placental barrier. Damage to the placental barrier membranes promotes the development of placental failure, a complicated course of pregnancy and delivery, deterioration of the state of the fetus and newborn infant.

External anogenital lesions in organ transplant recipients. A clinicopathologic and virologic assessment

BACKGROUND AND DESIGN

In a series of patients treated at a university department of dermatology, we assessed the clinicopathologic features of external anogenital lesions in organ transplant recipients. For 6 years, 1002 recipients with various dermatologic problems underwent assessment for the presence of proliferative external anogenital lesions; these lesions were examined histologically and virologically for the presence of human papillomaviruses (HPV).

RESULTS

Twenty-three patients (2.3%) presented with anogenital lesions, women being more often involved. Clinicopathologic examination revealed 18 anogenital warts, 3 cases of bowenoid papulosis, 1 giant condyloma, and 1 in situ carcinoma. Other viral coinfections were frequent. The lesions were extensive and refractory to treatment in 13 patients, but lesions in 7 were cured alter the immunosuppressive treatment was tapered of discontinued. Dysplastic changes were frequent on histologic examination. Twenty-one lesions contained HPV; 6 of 13 patients with HPV DNA in their lesions harbored oncogenic types that predominated in dysplastic lesions. In some patients, the same HPV types were detected within cutaneous and anogenital lesions, suggesting self-contamination.

CONCLUSIONS

External anogenital lesions are more rare than cutaneous lesions in organ transplant recipients. These lesions may represent a marker of immunosuppression, especially when they are extensive. Their clinical aspect is often misleading; furthermore, because of the presence of dysplastic histologic aspects and oncogenic HPV types, they could be susceptible to malignant transformation, necessitating regular surveillance.

Pathology of female infertility

This review concentrates on the structural and functional aspects of lesions of the female genital tract that cause infertility, including cervical changes after treatment for neoplasia, uterine malformations, leiomyoma, endometrial aberrations, infection-related tubal lesions, ovarian disorders (oocyte defects, premature ovarian failure, corpus luteum dysfunction, and polycystic ovary-related abnormalities), and endometriosis.

A new method of completing the difficult vaginal phase of laparoscopic-assisted hysterectomy

A combination of posterior cervicocolpotomy and sutureless en masse division of the paracervical attachments can safely and effectively allow for systematic transvaginal extirpation of uteri difficult to remove by conventional techniques. Significant bleeding is not encountered and vaginal cuff reconstruction is uncomplicated.

Cervical cytopathology reporting systems. Helping or hindering patient management?

OBJECTIVE

When a Pap smear is reported, the general practitioner needs to know whether it was technically satisfactory and, if abnormal, what kind of abnormality was found, in order to arrange appropriate management. A random survey of non hospital based cytology reporting laboratories in NSW was undertaken to determine the efficiency of this process.

METHOD

This study examines the types of cytopathology reporting protocols used, the means provided by the laboratory to assist general practitioners in assessing the quality of their Pap smears and what, if any, management advice was given to general practitioners.

RESULTS

Not only do different laboratories use different terminologies to report on Pap smears, but the majority use terms from at least two different reporting systems. Seven of the 10 laboratories provided feedback on the adequacy of the Pap smears while only 4 of the 10 laboratories provided management advice.

CONCLUSIONS

If the 1993 National Health and Medical Research Council recommendations are followed, cytopathology reporting will be primarily Bethesda based with the pathology laboratories providing feedback on technical aspects of Pap smears taking as well as management advice.

Detection of clonality and genetic alterations in endometrial pipelle biopsy and its surgical specimen counterpart

Carcinoma of the endometrium is the most frequently diagnosed gynecologic malignancy in the western world. Because endometrial carcinoma is monoclonal in origin, the small samples obtained in endometrial pipelle biopsies can be used in PCR clonal studies to distinguish cancerous from noncancerous lesions. The method used for clonal analysis was based on RFLP of the X chromosome-linked phosphoglycerokinase gene and random inactivation of one X chromosome by methylation in women. Among 50 endometrial pipelle biopsies, 26 (52%) were found to be heterozygous for the above-mentioned polymorphism. Of the samples taken from these informative (ie, heterozygous) patients, six were monoclonal including five cases of endometrial carcinoma and one of endometrial atypical hyperplasia. In each case, the same pattern of monoclonality was present in the surgical specimen counterpart. All of the remaining samples were polyclonal and, when the anatomical pathology data were contrasted, they correlated with nonmalignant endometrium (five secretory, five proliferative, seven atrophic, and three simple hyperplasias). In addition, genetic alterations study of monoclonal endometrial samples revealed a K-ras point mutation and a c-erbB2/neu gene amplification in two different endometrial carcinomas. Both alterations were also detected in the surgical specimens. In addition, a diagnosed set of 10 samples of simple hyperplasia and 5 of atypical hyperplasia were subjected to clonal assay. Among eight informative cases, the three that showed that showed the monoclonal pattern corresponded with cases of atypical hyperplasia. No other genetic alterations were detected in these samples. In conclusion, our data indicate that the detection of clonality in endometrial biopsy samples obtained by pipelle would be a useful application for the early diagnosis of endometrial cancer.

Schistosomiasis in women: manifestations in the upper reproductive tract

Female genital schistosomiasis (FGS) is a neglected disease entity which may give rise to considerable suffering among women of child-bearing age in areas where schistosomiasis (especially due to Schistosoma haematobium) is prevalent. The close relation between the vessels in genital organs and the urinary bladder enables the parasite to easily change location to virtually any organs in the female pelvic area. Symptoms concur with the anatomical location of worm pairs and their ova. Lesions of the lower female genital tract can easily be investigated by cytology, histology or direct demonstration of eggs in scrapings or biopsies whereas schistosomiasis of the upper genital tract is clinically indecipherable and less accessible for examination. In the literature there are references to FGS as a cause of infertility, complications of pregnancy, menstrual disorders, problems related to sexual intercourse, diagnostic similarities to STDs and cancer, unspecified complaints related to blood loss, chronic abdominal pain, social segregation and related psychological problems. The diagnosis of female upper genital schistosomiasis is difficult and the authors point out possible diagnostic procedures which might be helpful for further understanding of this complex entity.

Reversibility of lower reproductive tract abnormalities in women with Schistosoma haematobium infection after treatment with praziquantel--an interim report

Little is known whether and to what extent antiparasitic treatment cures female genital schistosomiasis (FGS). Using a standard protocol, of twenty-one women with FGS nine were re-examined at two to nine weeks after they had been treated with praziquantel at a single dose of 40 mg/kg. Symptoms related to pathology of the urinary tract and to a lesser extent of genital pathology subsided in most patients. Schistosoma haematobium ova were no longer detectable in urine of any of the patients post-treatment. Efficiency of chemotherapy against adult worms was confirmed by the disappearance of circulating anodic antigen (CAA) in serum. Sandy patches showed resolution in two of four cases after chemotherapy. Papillomata due to schistosomiasis alone improved, but persisted in mixed infection with human papilloma virus (HPV) or when HPV was the only underlying cause. In one patient ulcera could not be related with certainty to schistosomiasis at admission, but resolved after treatment with parziquantel. Leukoplakia (two cases) was not influenced by chemotherapy, or even increased during follow-up, regardless of whether ova had been detected or not. Although the follow-up period was rather short, time intervals were not standardized, and a relatively small number of patients was investigated, it could be shown that genital pathology due to sequestered S. haematobium ova is, at least partially, reversible already two to nine weeks after killing the adult worms by praziquantel. This is paralleled by a normalization of inflammatory immune responses detectable in histological sections and vaginal lavage.

Female genital schistosomiasis (FGS): relationship between gynecological and histopathological findings

Schistosomiasis of the lower female reproductive tract manifests itself in a broad spectrum of clinical features. However, clinical and histopathological findings have never been studied in a synoptic manner. Based on the assumption that any type of pathology present in the female reproductive tract is the expression of a complex pathophysiological reaction towards eggs sequestered in the genital tissues, we decided to analyze colposcopic and histopathological findings in a comprehensive manner. Thirty-three women in Malawi with urinary and genital schistosomiasis were examined parasitologically and gynecologically. A thorough colposcopic examination with photodocumentation was performed and biopsies were taken from the cervix, the vagina and/or the vulva for histological sectioning and immunohistochemistry. The predominant colposcopic findings were sandy patches on the cervical surface similar to those seen in the bladder and polypous/papillomatous tumors with irregular surface on the vaginal wall and in the vulvar area. The histopathological sections of sandy-patch-like lesions demonstrated only a small cellular reaction around S. haematobium eggs in various stages of disintegration. In contrast, in the case of polyps the histology revealed a more pronounced immunological reaction characterized by a heavy cellular infiltrate. One case of invasive squamous cell carcinoma of the cervix was diagnosed. We conclude that colposcopy is a useful tool in the detection of FGS related pathology in the lower female reproductive tract and that the synoptic assessment of surface and of corresponding histological sections helped to understand the pathophysiology of S. haematobium associated disease in genital tissue.

Female genital schistosomiasis due to Schistosoma haematobium. Clinical and parasitological findings in women in rural Malawi

A total of 51 women with urinary schistosomiasis haematobium were examined in order to identify diagnostic indicators for female genital schistosomiasis (FGS). Patients were selected at random from the outpatient department of the Mangochi District Hospital, Malawi. The medical histories were recorded according to a pre-designed questionnaire and the women were subjected to a thorough gynaecological examination including colposcopy and photographic documentation of lesions. Microscopy of genital biopsies revealed that 33 of the 51 women had S. haematobium ova in cervix, vagina and/or vulva in addition to the presence of ova in urine. The most sensitive diagnostic procedure was beside microscopic examination of a wet cervix biopsy crushed between two glass slides, which revealed 25 of the 33 genital infections. There was a significant correlation between the size of genital lesions and the number of ova counted per mm2 of crushed tissue. Women with FGS had significantly more tumours in the vulva than women with schistosomiasis limited to the urinary tract. Most of the observed genital pathology could easily be identified by the naked eye, but colposcopic examination yielded valuable additional information like the demonstration of neovascularisation around cervical sandy patches. Few of the symptoms previously regarded as indicators for FGS could be linked to the presence of schistosome ova in genital tissue. Husbands of infertile women with FGS had children with other women significantly more often than husbands of women who only had urinary schistosomiasis. This, together with the finding that the majority of the divorced women had FGS, indicates that the manifestation of this disease may have implications for the marital and sexual life of the affected women.

The management of genital condylomas, intraepithelial neoplasia, and vulvodynia

The natural history of HPV-related disease still is poorly understood. Screening of apparently healthy populations suggests that most HPV exposure results only in latent infection; that is, there is no active HPV DNA replication, but the HPV copy number is held at a steady state because viral replication parallels cell division. Unfortunately, knowledge of the cell-virus interaction and the host-immune response has not yet provided an effective medical therapy or a preventive vaccine. Rather, the management of HPV-induced disease remains rooted to the strategy of repeated local destruction. The physician should work methodically through a series of strategic decisions before committing to a management plan.

Clinical manifestations and natural history of genital human papillomavirus infections

Over the past decade, the ever-increasing volume of evidence implicating HPV types in genital neoplasia has stimulated much research interest into all aspects of the biology of this interesting group of viruses. This research has led to the identification of growing heterogeneity of HPV types. It is not surprising, therefore, that the clinical profile of disease associated with genital HPV types is much broader than previously recognized. Knowledge of this clinical spectrum is mandatory to the understanding of the possible role of specific HPV types in human carcinogenesis.

Fascia--defects and repair

Endopelvic fascia contributes to the support of the uterus and vagina. There is increasing evidence that alteration in the fascial extracellular matrix may lead to weakening of the fascia and development of prolapse. Other workers have identified discrete defects in endopelvic fascia that can be rectified to cure prolapse. This paper reviews fascial defects and their repair.

Differences in clinical manifestations of genital chlamydial infections related to serovars

OBJECTIVES

To study the association of serovars of Chlamydia trachomatis with clinical manifestations of genital tract infection and socio-demographic characteristics.

METHODS

In 1986-88 the C trachomatis isolates from 159 heterosexual men and 116 women attending a sexually transmitted disease (STD) clinic were collected and typed accordingly. A medical history was recorded, a physical examination took place and samples were taken for laboratory diagnostics.

RESULTS

Serovars E, F and D were the most common for both men (75%) and women (67%). Men infected with serovars of the C-complex had more often a history of STD (p = 0.06). The opposite was demonstrated in women (p = 0.07). In addition, women younger than 18 years at first intercourse were more often infected with C-complex serovars (p = 0.05). For men, the serovars F/G less often produced symptoms of urethral discharge (p = 0.01) than the serovars of the B-complex and C-complex and were less often associated with the presence of 10 or more leukocytes in a Gram-stained smear (p = 0.04).

CONCLUSIONS

In this study, infections with serovars F and G caused less obvious symptoms and signs of inflammation in men; in women no differences were found in the clinical manifestation of infections with different serovars.

[Applicability of the dual interval echo train (DIET) method for female pelvic diseases]

Dual interval echo train fast SE (DIET-FSE) is a modified fast SE technique. It attenuates fat signals by applying a time interval between an excitation pulse and the first echo, which is the odd-number of the following echo interval, and by decreasing the number of high frequency refocusing pulses before collecting echoes in the center of the k space, which determines the contrast. Unlike many other fat-suppression methods, this technique is less affected by susceptibility effects. In this study, we compared DIET-FSE with FSE and conventional SE of the female pelvis. The results of DIET-FSE showed a stable, obvious fat suppression effect which resulted in the easy detection of pelvic organs such as the intestines and ovaries, as compared with FSE. The reductions in imaging time and motion artifacts also permitted more precise differentiation between the normal pelvic organs and lesions than conventional T2-weighted SE. These results imply that the DIET-FSE is useful for the diagnosis of female pelvic disorders.

Clinical and pathologic characteristics of women undergoing hysterectomy after tubal sterilization

OBJECTIVE

To examine differences in clinical and pathologic characteristics between women undergoing hysterectomy who had had prior tubal sterilization and those who had not.

METHODS

One thousand eight hundred fifty-one women undergoing hysterectomy were enrolled as part of a multicenter, prospective cohort study. We used logistic regression to describe the association between prior tubal sterilization and patient characteristics at hysterectomy.

RESULTS

Although sterilized women were not more likely than nonsterilized women to have a menstrual disorder as a presenting complaint, they were more likely to have a primary discharge diagnosis of menstrual disorder (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.2-2.0). After adjustment for menstrual indices, sterilized women had an increased probability of having normal findings on pathologic examination, which differed by age (women less than 30 years: OR 3.4, 95% CI 2.0-5.8; women 30 years of age and older: OR 1.7, 95% CI 1.3-2.3).

CONCLUSION

Differences in clinical and pathologic characteristics between sterilized and nonsterilized women suggest that nonbiologic factors may influence decision making regarding hysterectomy among sterlized women.

False positive malignant peritoneal cytology and psammoma bodies in benign gynecologic disease

OBJECTIVE

To determine the incidence of false positive malignant peritoneal cytology and psammoma bodies associated with benign gynecologic disorders.

STUDY DESIGN

Pelvic peritoneal fluid was prospectively collected for cytologic examination from 119 women undergoing laparoscopy for benign conditions (infertility, 67; pelvic pain, 35; elective sterilization, 17). The median age was 30. No patient had laparoscopic gross cancer or histologic evidence of cancer.

RESULTS

The peritoneal cytology of 2 of 119 cases (2%) contained cells with features suggestive of malignancy, and 6 of 119 cases (5%) contained psammoma bodies. Both cases of false positive peritoneal cytology and four of six with psammoma bodies were associated with endometriosis. All cases were followed for a minimum of two years, and no patient had developed cancer.

CONCLUSION

Peritoneal fluid from cases of benign gynecologic disorders, especially endometriosis, can contain psammoma bodies and cells suggestive of malignancy.

[Analysis of the validity of vaginal-cervical cytologic examination in 162 pre- and post-menopausal patients]

The authors examine 162 cervico-vaginal smears of women in peri-menopause presenting cellular alterations (ASCUS). These patients were treated with a local topic therapy as the persistence of these alterations in 23 cases (14.2%) second level analyses were performed: gynecological visit, colposcopy and biopsy. In addition to inflammatory aspects 2 in situ carcinomas and 2 moderate dysplasias were recorded. We believe therefore that cytology could be a valid aid also in pre-menopausal women in the cervico-vaginal pathology.

Amoebiasis of the female genital tract: a case report

In 1994, a 56-year-old Burmese woman presented with bloody discharge per vaginam had undergone pelvic examination disclosing multiple small ulcerated and friable lesions with contact bleeding at vulva, vagina and cervix. Wet smears from vaginal discharge showed typical Entamoeba histolytica trophozoites. The patient was treated with metronidazole 750 mg three times daily for 7 days, resulting in complete recovery of the lesions in 10 days. The pathology, risk factors, diagnosis and management of the disease are discussed.