Beyond the brain-Peripheral kisspeptin signaling is essential for promoting endometrial gland development and function

Uterine growth and endometrial gland formation (adenogenesis) and function, are essential for fertility and are controlled by estrogens and other regulators, whose nature and physiological relevance are yet to be elucidated. Kisspeptin, which signals via Kiss1r, is essential for fertility, primarily through its central control of the hypothalamic-pituitary-ovarian axis, but also likely through peripheral actions. Using genetically modified mice, we addressed the contributions of central and peripheral kisspeptin signaling in regulating uterine growth and adenogenesis. Global ablation of Kiss1 or Kiss1r dramatically suppressed uterine growth and almost fully prevented adenogenesis. However, while uterine growth was fully rescued by E2 treatment of Kiss1^−/− mice and by genetic restoration of kisspeptin signaling in GnRH neurons in Kiss1r^−/− mice, functional adenogenesis was only marginally restored. Thus, while uterine growth is largely dependent on ovarian E2-output via central kisspeptin signaling, peripheral kisspeptin signaling is indispensable for endometrial adenogenesis and function, essential aspects of reproductive competence.

Burden of symptomatic uterine fibroids in Canadian women: a cohort study

OBJECTIVE

Due to variability in size, number, and location of uterine fibroids (UFs), symptoms can range widely among women. We sought to characterize burden of illness and quality of life (QoL) among women with symptomatic UFs.

RESEARCH DESIGN AND METHODS

An online survey queried the gynecologic health and menstrual cycle of Canadian women aged 20 to 49. Respondents reporting current UFs were assigned an Overall Severity Score based on a validated health-related QoL questionnaire (the UFS-QOL) and were dichotomized as having mild or moderate/severe UF. Subjects with moderate/severe UFs were matched 1:3 to non-UF subjects on age, race, and parity.

RESULTS

Of 9413 women with complete data, 384 (4.1%) reported physician-diagnosed UFs; of these, 50.6% met criteria for moderate/severe symptoms. Compared with matched non-UF respondents, moderate/severe UF respondents reported significantly greater mean menstrual duration (6.2 vs 5.0 days), more healthcare visits (emergency department, walk-in, family doctor, and specialist; total 10.5 vs 4.9 visits/6 months), and greater use of prescription analgesics (47.7% vs 26.7%) and iron supplements (29.7% vs 12.2%) (P < 0.05 for all). They spent more on feminine hygiene products ($32.0 vs $21.6/month) and reported losing nearly a full day of work/month (mean 7.6 hours) due to UFs. Women with moderate/severe UFs also scored lower on all QoL domains, compared to those with mild UF symptoms. Survey responses consistent with moderate/severe UFs were also identified in women who made no report of physician-diagnosed UFs, some of whom may be experiencing substantial burden due to undiagnosed UFs or other gynecologic conditions with related symptoms.

LIMITATIONS

All outcomes recorded in this online survey were based on self-report. Therefore, respondents' claims of medical diagnoses, including medical history, UF status and the presence or absence of potentially confounding comorbidities, could not be confirmed clinically.

CONCLUSIONS

Women experienced significant healthcare utilization, medication use, and financial and QoL burdens as a result of moderate/severe UF symptoms. Prevalence of moderate/severe UFs may be conservatively estimated at 2%, based on this cohort of reproductive-age Canadian women. The extent of UF underdiagnosis in the general population remains to be elucidated.

Post-uterine artery embolization pain and clinical outcomes for symptomatic myomas using gelfoam pledgets alone versus embospheres plus gelfoam pledgets: a comparative pilot study

BACKGROUND

To evaluate the efficacy and post-procedural pain associated with uterine artery embolization (UAE) using Gelfoam alone versus Embospheres plus Gelfoam in women with symptomatic uterine fibroids.

METHOD

We conducted a prospective, non-randomized pilot study. Fluoroscopy-guided trans-femoral artery UAE was performed using Gelfoam pledgets alone or Embospheres (500 to 700 mg) plus Gelfoam under conscious sedation and local anaesthesia. This was followed by patient-controlled analgesia (PCA) using a morphine pump overnight. Post-procedural pain was assessed by the mean amount of self-administered morphine delivered by PCA pump (mL) from 0 to 19 hours in each group. The mean volumes of the uterus and the dominant fibroid were calculated by ultrasound at baseline, three months, six months, and 12 months.

RESULTS

A total of 17 women participated in the study. Bilateral uterine artery occlusion was performed in eight women using Gelfoam alone, and in nine women using Embosphere + Gelfoam. One woman in the Embosphere + Gelfoam group developed a puncture-site hematoma requiring further intervention one week later. The mean (SD) amount of morphine self-administered by PCA pump at time 0, 1, and 2 hours was 3.4 mg (3.1), 2.9 mg (2.2), and 2.4 mg (3.3) in the Gelfoam-only group and 6.1 mg (3.0), 9.6 mg (7.1), and 5.3 mg (4.4) in the Embosphere + Gelfoam group, respectively. After three hours, the amount of morphine used was equal in both groups. The mean (SD) total dose of morphine used was 29.5 mg (18.6) in the Gelfoam group and 41.1 mg (19.3) in the Embosphere + Gelfoam group (P = 0.228). At 12 months, the reduction in median total uterine volume and median dominant fibroid volume in each group was equal.

CONCLUSION

Clinical outcomes were equivalent after uterine artery embolization using Gelfoam alone versus Gelfoam + Embospheres. Although the amount of immediate post-procedure pain may be less with Gelfoam alone, we could not demonstrate this objectively using morphine use as a measure of pain.

Long-term clinical outcomes following resectoscopic endometrial ablation of non-atypical endometrial hyperplasia in women with abnormal uterine bleeding

STUDY OBJECTIVE

To determine the feasibility, efficacy, and long-term clinical outcomes of resectoscopic endometrial ablation as primary treatment of simple endometrial hyperplasia (SH) and complex endometrial hyperplasia (CH) without atypia in women with abnormal uterine bleeding (AUB).

DESIGN

Prospective follow-up study (Canadian Task Force classification II-2).

SETTING

Teaching hospital.

PATIENTS

One hundred sixty-one women with hyperplasia, either SH (n = 107) or CH (n = 54).

INTERVENTIONS

From January 1990 through December 2012, one of us performed 4729 primary resectoscopic endometrial ablation procedures in women with AUB. This group included 161 women with endometrial hyperplasia, identified either at office biopsy (n = 62) or incidentally during routine hysteroscopic endometrial ablation (n = 99). Endometrial tissue obtained at dilation and curettage and/or resected during resectoscopic surgery enabled identification of atypical hyperplasia in 6 patients (4 CH, 2 SH) and 1 patient with adenosarcoma. One patient with atypical CH and the patient with adenosarcoma underwent hysterectomy. The remaining 159 women, including 5 with atypical hyperplasia (3 CH, 2 SH), underwent resectoscopic endometrial ablation (102 SH, 52 CH) as primary treatment. Patient median age was 50 years (range, 30-87 years), and body mass index was 32 (range, 17-59). Comorbidities included hypertension in 25 patients, diabetes in 14, cerebrovascular disease in 3, cardiovascular disease in 7, and hypothyroidism in 8. Office biopsy demonstrated proliferative endometrium in 68 patients, SH in 43, CH in 19, and inadequate findings in 13. In 18 women, we were unable to perform biopsy because of cervical stenosis, morbid obesity, or patient intolerance. Endometrium was resected in 120 patients, electrocoagulated in 34, and a combination of procedures in 5, using a 9-mm (26F) resectoscope, 1.5% glycine, and 120W power. Patients were followed up annually. Three patients were lost to follow-up, and 1 died of an unrelated cause 5 years after surgery.

MEASUREMENTS AND MAIN RESULTS

One uterine perforation occurred, which required no additional treatment. After endometrial ablation, SH was identified in 70 patients, and CH in 35 patients. At a median follow-up of 7 years (range, 1.5-18), 12 patients underwent hysterectomy to treat persistent bleeding (n = 6), benign ovarian cyst (n = 2), pelvic organ prolapse (n = 1), chronic pelvic pain (n = 2), or myomas (n = 1). Uterine histopathology in 11 patients demonstrated no residual endometrial hyperplasia. We were unable to obtain a pathology report for 1 patient. The remaining 138 women were satisfied with the treatment, with no further bleeding or pain in 132 (95.7%). Six patients (4.3%) had monthly spotting.

CONCLUSION

When performed by surgeons experienced in hysteroscopy, resectoscopic endometrial ablation is feasible, safe, and effective for treatment of SH and CH without atypia in women with AUB.

Retroperitoneal pelvic cyst: a diagnostic and therapeutic challenge

BACKGROUND

Retroperitoneal cysts can be asymptomatic or can present with vague symptoms such as abdominal pain or distension. Their clinical implications vary significantly.

CASE

A 45-year-old woman, gravida 2, para 2, presented with vague, non-specific pelvic symptomatology. Imaging indicated a right-sided pelvic cyst 5 cm in diameter. At laparoscopy a retroperitoneal cyst was identified, with a normal pelvis and intra-abdominal organs. No attempt was made at laparoscopy to drain, biopsy, or excise the cyst. CT-guided biopsy of the cyst was performed and small intestine mucosa was identified with goblet cells and smooth muscle. Repeat biopsy confirmed areas of tissue necrosis and small intestine mucosa, with additional tissue containing respiratory epithelium. Following laparotomy and excision of the cyst, the final pathologic diagnosis was benign epithelial cyst consistent with a duplication or hindgut cyst.

CONCLUSION

Although most retroperitoneal cysts are benign, surgical excision is required to rule out malignancy definitively.

Uterine smooth muscle tumors of uncertain malignant potential: diagnostic challenges and therapeutic dilemmas. Report of 2 cases and review of the literature

Morphologically, there exist variants of uterine smooth muscle tumors that cannot be clearly interpreted and classified as benign or malignant. Because their behavior and clinical prognosis is also uncertain, the World Health Organization has termed these "smooth muscle tumors of uncertain malignant potential" (STUMP). Herein we describe 2 cases, present a review of the literature, and highlight the diagnostic challenges and therapeutic dilemmas associated with uterine STUMP in myomectomy specimens from women who wish to maintain or enhance their fertility. The clinical course of residual STUMP remains speculative.

Granulosa cells in the uterosacral ligament: case report and review of the literature

Granulosa cells are components of the sex cord-stromal cells in the ovary responsible for steroidogenesis. Uncommonly, extraovarian granulosa cells have been reported to be associated with malignant processes of the ovary. We report a unique case of benign granulosa cells, found during routine laparoscopic evaluation, in the uterosacral ligaments in a 20-year-old patient with chronic pelvic pain and infertility. Possible mechanisms include implantation of released granulosa cells from a normal ovary or arising from a focus of müllerianosis. Of note, a focus of endosalpingiosis and endometriosis was also identified within the specimen.

Ureter in histopathologic specimen: a gynecologist's nightmare

An 18-year-old woman presented with a large right-sided ovarian cyst. After further evaluation and counselling, the patient underwent laparotomy and oophorectomy. The pathology report described a large mature cystic teratoma with a tubular structure consistent with a cross-section of ureter. Subsequent evaluation of the urinary tract system was normal indicating that the ureter was an element of the mature cystic teratoma.

Effect of body habitus and parity on insufflated CO2 volume at various intraabdominal pressures during laparoscopic access in women

STUDY OBJECTIVE

To determine height, weight, body mass index (BMI), parity, and age effect on the volume of CO2 pneumoperitoneum during laparoscopic access in women.

DESIGN

Prospective observational cohort study (Canadian Task Force classification II-1).

SETTING

University-affiliated teaching hospital.

PATIENTS

From January through June 2004, 100 healthy women underwent operative laparoscopic surgery consecutively by the senior author (GAV). Indications were: chronic pelvic pain (CPP, n = 66), pelvic mass (n = 7), CPP and pelvic mass (n = 4), infertility (n = 23). Median (range) height, weight, BMI, parity and age were 1.65 m (1.45-1.85 m), 70 kg (43-118 kg), 25.5 kg/m2 (17-39 kg/m2), 1.1 (0-5), and 34 years (19-58 years), respectively.

INTERVENTIONS

While in supine position, patients received general endotracheal anesthesia and muscle relaxants. Pneumoperitoneum was established by reusable Veres needle. The insufflated CO2 volume was serially recorded at intraperitoneal insufflation pressures (IPIPs) of 10, 15, 20, 25, and 30 mm Hg. The primary 10-mm trocar was introduced at IPIP of 30 mm Hg. Upon entering the peritoneal cavity, the abdominal contents were visualized with the laparoscope to ensure there was no injury, and the IPIP was immediately reduced back to the operating pressure of 15 mm Hg before switching the patient to the Trendelenburg position.

MEASUREMENTS AND MAIN RESULTS

The mean (SD) insufflated CO2 volumes at 10, 15, 20, 25, and 30 mm Hg were 1.7 (0.74) L, 3.1 (0.9) L, 3.96 (1.05) L, 4.42 (1.1) L and 4.72 (1.14) L, respectively. Using multivariate analysis, we demonstrated that at 20 to 30 mm Hg the insufflated CO2 volume correlated positively with the height, weight and BMI of women. Parity correlated positively at all pressures. There was no correlation with age at any pressure.

CONCLUSIONS

Higher CO2 volume is required to establish appropriate pneumoperitoneum in tall, overweight, and parous women at 20 to 30 mm Hg. Setting the IPIP at 20 to 30 mm Hg before primary trocar insertion eliminates the need to monitor CO2 insufflated volume regardless of women's age, parity, and body habitus.

Administration of goserelin acetate after uterine artery embolization does not change the reduction rate and volume of uterine myomas

OBJECTIVE

To determine if goserelin immediately after uterine artery embolization (UAE) affected myoma reduction.

DESIGN

Randomized pilot study (level 1).

SETTING

Teaching hospital.

PATIENT(S)

Twenty-six women.

INTERVENTION(S)

All patients underwent UAE, and then 12 patients received 10.8 mg of goserelin 24 hours later. The treatment group was 5 years older: 43 versus 37.7 years. Uterine and myoma volumes were measured by ultrasound 2 weeks before UAE and at 3, 6, and 12 months.

MAIN OUTCOME MEASURE(S)

Uterine and fibroid volumes.

RESULT(S)

Pretreatment uterine volume was 477 versus 556 cm3, and dominant fibroid volume was 257 versus 225 cm3 in the control versus goserelin groups. Analysis of variance measurements indicated that the change over time did not significantly differ between the two groups. By 12 months, the control group had a mean uterine volume reduction of 58%, while the goserelin group had a reduction of 45%. Dominant fibroid changes over time did not differ between the two groups. At 12 months, the mean fibroid volume had decreased by 86% and 58% in the control and goserelin groups, respectively.

CONCLUSION(S)

The addition of goserelin therapy to UAE did not alter the reduction rate or volume of uterine myomas.

Effect of body habitus and parity on the initial Veres intraperitoneal CO2 insufflation pressure during laparoscopic access in women

STUDY OBJECTIVES

Since most gynecologists use the Veres/trocar entry, and because the Veres intraperitoneal (VIP) pressure appears to be the most reliable indicator of correct Veres needle placement, the objective of this study was to determine the effect of height, weight, body mass index (BMI), parity, and age on the initial Veres intraperitoneal CO2 insufflation pressure during laparoscopic access in women.

DESIGN

Prospective observational cohort study (Canadian Task Force classification II-1).

SETTING

University affiliated teaching hospital.

PATIENTS

We prospectively collected data on 356 women undergoing laparoscopy for a variety of indications by the senior author (G.A.V.). The median and (range) for height, weight, BMI, parity, and age were 1.64 m (1.45-1.85 m), 65 kg (40-120 kg), 24.3 kg/m2 (16-47 kg/m2), 1 (0-5) and 34 years (18-87 yrs), respectively.

INTERVENTION

Under general endotracheal anesthesia including muscle relaxants and with the patient in appropriate stirrups in the horizontal position, a nondisposable Veres needle was inserted at the umbilicus or left upper quadrant (Palmer's point) with CO2 flowing at 1 L/min. The initial Veres intraperitoneal insufflation pressure was recorded once the Veres needle was believed to be in the peritoneal cavity.

MEASUREMENTS AND MAIN RESULTS

The mode and the median VIP pressure was 4 mm Hg with a range of 2 to 10 mm Hg. With multivariate analysis, the VIP pressure correlated positively with the weight (r = 0.518, p <.001) and BMI (r = 0.545, p <.001) and negatively with the parity (r = -0.179, p <.001) of women. The correlation of the VIP pressure with height and age was r = 0.029 (p = .591) and r = -0.044 (p = .411), respectively.

CONCLUSION

A VIP pressure < or =10 mm Hg indicates intraperitoneal placement of the Veres needle. The VIP pressure correlates positively with the weight and BMI and negatively with the parity of women. There is no correlation of the VIP pressure with women's height and age.

Characterization and mitigation of stray radiofrequency currents during monopolar resectoscopic electrosurgery

STUDY OBJECTIVE

To determine patterns and range of stray radiofrequency (RF) currents flowing through the working element of monopolar resectoscopes during routine endometrial rollerball ablation or resection; and to determine whether straightforward modifications of the uterine resectoscope and the application of RF monitoring could provide a safe pathway for such currents.

DESIGN

Prospective in vivo measurements (Canadian Task Force classification II-1).

SETTING

University-affiliated teaching hospital.

PATIENTS

Twelve women undergoing resectoscopic surgery.

INTERVENTIONS

During routine resectoscopic surgery using 1.5% glycine irrigant solution, three modified 26F Storz resectoscope working elements (model 27070E) were adapted to be continuously monitored with an Encision AEM device for excessive capacitive coupling and other stray currents from insulation failure. Active electrodes used were 3 mm and 5 mm rollberballs and 8 mm-diameter cutting loops powered by ERBE or Valleylab generators at 120 W. Active and working element currents were monitored by Pearson current transformers followed by root-mean-squared detectors based on the Analog Devices AD-637 integrated circuit. Data were recorded using a Fluke 199C oscilloscope, then serially transferred to a notebook computer and analyzed using Flukeview, Excel, and Minitab software.

RESULTS

Typical values of working element currents ranged from 0.10 to 0.20 A. Active electrode currents were typically in the range of 0.50 to 1.10 A. Frequently, the working element current exceeded the typical values and ranged up to 0.60 A. These current surges produced a heat factor (I(2)t) of 0.45 A(2).sec in a 10-second period.

CONCLUSIONS

During resectoscopic electrosurgery, baseline, most likely capacitive coupled, currents were always present. In addition, high values of working element currents occurred frequently, and they surged up to 0.60 A for significant periods of time. Without the modification of the resectoscopic device, these currents have the capability of flowing through the patient's genital tract and causing burns. Since monopolar electrosurgery remains an integral part of most hysteroscopic procedures, active electrode monitoring may offer a solution in protecting the patient and the surgeon from stray electrosurgical burns.

High-pressure laparoscopic entry does not adversely affect cardiopulmonary function in healthy women

STUDY OBJECTIVE

To determine hemodynamic and pulmonary compliance changes during laparoscopic entry using transient hyperinsufflated pneumoperitoneum.

DESIGN

Prospective observational cohort study (Canadian Task Force classification II-1).

SETTING

University-affiliated teaching hospital.

SUBJECTS

From January through June 2004 one hundred healthy women underwent operative laparoscopy consecutively. Indications included chronic pelvic pain (CPP, N=66), pelvic mass (N=7), CPP and pelvic mass (N=4), primary or secondary infertility (N=23). The mean age was 34 years (range, 19-58) and the mean BMI 25.5 kg/m2 (range, 17.1-39.4).

INTERVENTIONS

With the patients under general anesthesia, muscle relaxants, and in supine position, pneumoperitoneum was established using a Veres needle. The following information was prospectively collected at different intraperitoneal insufflation pressures (IPIP): CO2 volume, heart rate, blood pressure, and pulmonary compliance. At IPIP of 30 mm Hg the primary trocar was inserted and the IPIP was immediately reduced back to the operating pressure of 15 mm Hg.

MEASUREMENTS AND MAIN RESULTS

The mean initial IPIP was 4.7 mm Hg (range, 2-9 mm Hg). The mean volume of CO2 at IPIP of 10, 15, 20, 25, and 30 mm Hg was 1.7, 3.1, 4, 4.4, and 4.7 L, respectively. There was no statistically significant change in the heart rate or pulse pressure between IPIP of 15 and 30 mm Hg. The difference in CO2 volume (1.6 L) required to achieve IPIP of 15 and 30 mm Hg was statistically significant (p<0.0001). A statistically significant increase of 7 mm Hg in the mean arterial pressure (MAP) was found between IPIP of 15 & 30 mm Hg (p<0.0001). The additional 21% drop in pulmonary compliance from IPIP 15 to 30 mm Hg was statistically significant (p<0.0001). This decrease in pulmonary compliance was well tolerated by the patients, and the oxygen saturation remained above 92% in all cases. The elevated MAP was not clinically significant.

CONCLUSION

The use of transient hyperinsufflated pneumoperitoneum caused minor hemodynamic alterations which were not clinically significant. The alterations in pulmonary compliance were statistically significant; however, they had no clinical significance and were tolerated well by healthy women.

Safe laparoscopic entry guided by Veress needle CO2 insufflation pressure

Laparoscopy was performed in 259 women. Under general anesthesia, after administering muscle relaxants, and with the patient in stirrups and horizontal position, a nondisposable Veress needle was inserted at the umbilicus or left upper quadrant site with carbon dioxide (CO2) flowing at 1 L/minute. We measured initial intraabdominal pressure in the first 52 women (group 1), pneumoperitoneum pressure (up to 15 mm Hg) at 1-L intervals in the next 102 women (group 2), and CO2 volume required for pressures of 10, 15, 20, and 25 mm Hg in the final 102 women (group 3). In three patients the procedure was abandoned. The primary trocar and laparoscope were introduced at pressure of 25 mm Hg and the entry site and abdominal contents were inspected before desufflation to 15 mm Hg and Trendelenburg position. Medians and means of initial intraabdominal pressure were 4 and 4.09 mm Hg (SD 1.34 mm Hg, range 2-8 mm Hg). This was always below interstitial pressures measured in the abdominal wall and during inadvertent insertion into omentum (5) and colon (2). Correlation between initial intraperitoneal pressure and patients' parity, weight, and body mass index was minimal. Mean CO2 volumes at 10, 15, 20, and 25 mm Hg were 3.7, 5.1, 5.9, and 6.5 L, respectively. No major complications were encountered. An initial intraabdominal pressure of 8 mm Hg or below always indicates correct placement of the Veress needle regardless of the patient's body habitus. Pressures greater than 8 mm Hg indicate interstitial placement including colon. Adequate pneumoperitoneum is determined by CO2 insufflation to a pressure of 25 mm Hg and not by a preconceived volume of CO2.