Transvaginal ultrasonographic evaluation of the endometrium related to the histological findings in pre- and perimenopausal women

OBJECTIVE

To evaluate the clinical usefulness of high-resolution transvaginal ultrasonography in pre- and perimenopausal women suspected to have endometrial pathology.

PATIENTS AND METHODS

196 women, aged between 32 and 57 years, were referred to the outpatient clinic for a dilatation and curettage (D&C). In 81% the clinical indication was irregular vaginal bleedings. Before the D&C an examination with transvaginal ultrasonography was performed, and the endometrial thickness and texture were determined. The ultrasonographic results were later compared with the histological diagnosis obtained from the D&C specimen.

RESULTS

Ultrasonographically both normal and pathological endometrial changes could be detected, and 82% of the women had an endometrium characterized as normal. The endometrial phase determination correlated with the histological findings in approximately 50% of the women. Histologically 83% of the women had a normal endometrium. Endometrial hyperplasia was found in 12% and endometrial polyps in 4%. There were no malignancies found in this study. The hormone users (33% of the women) had no higher incidence of hyperplasias than non-users.

CONCLUSION

Our data indicate that transvaginal ultrasonography is as effective as the D&C for depicting the endometrium in pre- and perimenopausal women with irregular bleedings.

Prevalence of postmenopausal symptoms in two age groups of elderly women in relation to oestrogen replacement therapy

A cross-sectional study of the whole female population of ages 71 and 81 years in a defined part of Sweden was undertaken to investigate the prevalence of oestrogen treatment and postmenopausal symptoms. A questionnaire was mailed to 2245 women, of whom 1084 (87%) aged 71 years and 611 (62%) aged 81 years left evaluable responses. Of the responding 71- and 81-year-old women 25 and 16%, respectively were receiving oestrogen, and 4 and 2% of all women of the respective age groups were on systemic treatment. Nearly half of all the women reported urinary incontinence, which was considerate for approximately half of these women. Five and 11% of the respective age groups had experienced more than two urinary tract infections (RUTI) in the last year. RUTI had occurred both in the oestrogen-treated group and in the non-treated group. Vegetative symptoms were still encountered among these elderly women. Previous fractures were frequent, being experienced after menopause by 29 and 39% of the 71- and 81-year-old women respectively. Thirty-five and 39% of the women in respective age group had sought medical help for postmenopausal symptoms. Of the women with moderate, severe or unbearable urinary incontinence, 60 and 66% of the respective age groups had sought medical help. In only few of the totals of women on oestrogen had the treatment a complete effect. Only 2 and 1% of all women in respective age group had been offered and undergone surgery for their urinary incontinence.

DiHA Dextran Copolymer, a new biocompatible material for endoscopic treatment of stress incontinent women. Short term results

BACKGROUND

This study was undertaken to investigate the safety and effect of DiHA, dextranomers in hyaluronan, a new biocompatible material for endoscopic treatment of stress incontinence, and to further develop the injection technique.

METHODS

Twenty women aged 38 to 90 years with genuine stress incontinence participated. Seventeen were followed for a minimum of 6 months after treatment and three for a minimum of 3 months. The DiHA implants were administrered by transurethral endoscopically controlled submucosal injections under local anesthesia. Safety was assessed mainly in terms of infection, need for catheterization, residual urine and dysuria. The treatment efficacy was estimated objectively by a short-term pad test with standardized physical exercise and a 48 h pad-test, 7 days, and 1, 3 and 6 months after treatment. The patient's subjective experience of the effect was also studied.

RESULTS

The implantation procedure was well accepted by the patients. Four patients required catheterization due to voiding problems during the first 24 postoperative hours. One patient had urinary retention 14 days postoperatively. No UTI or local infection was detected. Some patients had transient urgency. In 17 or 20 patients the treatment resulted in objective cure or improvement.

CONCLUSIONS

This substance shows promising qualities for endoscopic treatment of stress incontinence.

Prevalence of genitourinary and other climacteric symptoms in 61-year-old women

In a population-based cohort study, 1280 women, aged 61, were interviewed regarding their genitourinary and other postmenopausal symptoms by means of an anonymous questionnaire. The group selected was to constitute all women of 61 years of age living in Uppsala county, Sweden. The response rate was 84%. All were postmenopausal women. Seventy-three percent of the women answering admitted some degree of urinary incontinence and 33% more severe degree. Forty-nine percent reported some degree of stress incontinence, 25% a more severe degree. Thirty-one percent experienced urge incontinence, 14% severely. A minority (4%), had had more than two urinary infections during the last year. The majority (67%) had changed urinating habits, going to the toilet at night and a minority complained of increased frequency of micturation (8%). Of the participating women, 59% were still sexually active, 43% had trouble with vaginal dryness and 10% with vaginal burning. Vasomotor problems such as hot flushes (30%), daily (33%) and nightly sweating (36%) were all common troubles. Forty-seven percent of the women had asked for medical help for estrogen deficiency problems, 82% were satisfied with the help they had received. Thirty-four percent were on estrogen therapy, 16% had systemic therapy 18% low dose estrogen treatment.

A national center for sexually abused women in Sweden

Sexual violence is a significant global problem. The unequal power between men and women is considered to be the main reason for violence against women. Women who are exposed to sexual assault are great consumers of medical and social care. The Swedish government has reacted to the problem by establishing an expert center for battered and raped women. The center has three main tasks: treatment in a professional and empathic way; research into and development of medical and psychosocial treatment of patients and the underlying causes of sexual violence; education and information of the general public.

[Health service's responsibility for sexually abused victims]

The abuse of women is a global problem, a women's health problem, and an egalitarian issue. In Sweden alone, 15,000 cases of the abuse of women, where victim and perpetrator were acquainted, were reported in 1994. In 1995, the National Women's Centre was inaugurated at the University Hospital, Uppsala, for the care of woman exposed to assault, abuse and sexual violence. Both care, research and training of personnel are carried out at the centre. Every abused woman coming to the hospital is now taken care of by specially trained personnel. The centre works in close cooperation with the police and the voluntary crisis centre, where battered women can receive support and help--for instance with temporary accommodation.

Effects of vaginally delivered estrogens

Atrophic condition in the vagina and lower parts of the urethral tract are common in elderly women. From population based surveys it has been estimated that 40% or more of women over 60 complain of insufficient control of micturation. In addition, lower urinary tract infections are common in this age group and recurrent cystitis is a scourge for many women (1, 2). Vaginal problems such as vaginal dryness, dyspareunia as well as infectious and non infectious disorders in the vagina may be even more common in elderly women (3) Vasomotor symptoms such as sweats and hot flushes commonly commence around the time of the menopause. In the majority of cases urogenital dysfunction does not become a problem until a decade later. Endogenous estrogens decline during the climacteric and the fall of estradiol levels from the time of onset of vasomotor symptoms until commencement of urogenital problems cannot be disregarded. In other words, it seems as if urogenital integrity can be maintained at lower estrogen levels than those required to resist vasomotor symptoms and conserve bone mass. Further evidence for this concept is achieved from numerous clinical studies in which various estrogens have been administered both orally and vaginally to elderly women with signs of urogenital atrophy which have resulted in amelioration. Such an alleviation of urogenital symptoms can be achieved without provoking endometrial growth.

New kinetic data on estradiol in light of the vaginal ring concept

The principal estrogen produced by the functioning premenopausal ovary is 17 beta-estradiol. At the point of irreversible ovarian failure, at menopause, the production of estradiol decreases dramatically, which results in circulating serum levels less than 120 pmol/l. It is important to recognise the pharmacokinetic and metabolic outcomes associated with dosage and route of delivery of estrogen. One of the most promising methods of administering estrogen replacement therapy (ERT) for local effects is the estradiol vaginal ring designed for a controlled continuous low release (7.5 micrograms estradiol/24 h) over a period of 90 days. The present study was undertaken to characterise the basal endogenous turnover of estradiol in postmenopausal women. Information on the disposition of estradiol after an intravenous dose formed the base of the kinetic model. The rate of extent of absorption of estradiol was assessed after ring application. Individual serum concentrations of estradiol were analysed without subtraction of the basal estradiol levels. The results indicate a rapidly eliminated compound (plasma clearance 2 l/min) with a distribution of approximately 50 l, resulting in an efficient half-life of about 20 min. The endogenous production was highly variable (< 1-44 micrograms/24 h). The steady-state estradiol levels following ring application did not increase and were well within the normal basal estradiol range seen in untreated women. In light of the present findings, the low daily dose, the low availability of estradiol across the vaginal wall and the controlled local delivery, favour the use of the estradiol vaginal ring.

The prevalence of urogenital symptoms in postmenopausal women

Lower urogenital tract disorders, such as vaginal athropy, urethritis, dyspareunia, recurrent urinary tract infections and urinary incontinence symptoms, are more prevalent in postmenopausal women. While these disorders are attributed to the ageing process as well as estrogen deficiency, knowledge of the relationship between estrogen status and symptomatology is scarce and hard to investigate due to the complexity of the problem. Little is known about the epidemiology of urogenital symptoms and their relationship to estrogen status and treatment. Studies of the prevalence of urogenital symptoms in postmenopausal women have been rare and results divergent. Through reviewing existing literature and relating findings to our own prevalence studies of 61-, 71- and 81-year-old women, we can conclude that many of the symptoms accounted for in our study are those known to be due to the loss of estrogen and easily dealt with by estrogen therapy. However, there is a need for more adequate information about postmenopausal symptoms and the effect of estrogens, as only a minority of postmenopausal women are currently treated.

Low-dose 17 beta-oestradiol during maintenance therapy--a pharmacokinetic and pharmacodynamic study

The vaginal absorption of oestradiol was studied during maintenance therapy with low-dose oestradiol. Six women with severe vaginal atrophy due to oestrogen deficiency were treated with a vaginal tablet containing 25 micrograms 17 beta-oestradiol. Initially, a daily dose was given for 2 weeks, followed by maintenance therapy with twice weekly treatment for another 10 weeks. The plasma concentrations of unconjugated oestrone and oestradiol were measured before oestrogen treatment was started at the beginning of the study. After 3 months of treatment frequent plasma sampling over a period of 24 h was performed. Gonadotrophins, vaginal and urethral cytology, clinical findings and subjective symptoms were assessed at the beginning and end of the study. Plasma concentrations of unconjugated oestradiol were at all times within the limits of postmenopausal values, but showed a slight but not statistically significant elevation after 3 months compared to pretreatment values. Plasma concentrations of unconjugated oestrone were in the low postmenopausal range throughout the study. LH levels were unaffected during the study, while FSH was somewhat lowered, but still well within the postmenopausal range. Vaginal and urethral cytology showed maturation with almost complete disappearance of parabasal cells. Clinical and subjective improvement was statistically significant during the treatment period.

The vaginal epithelium in the postmenopause--cytology, histology and pH as methods of assessment

In the study of postmenopausal vaginal oestrogen deficiency, an objective assessment of the vaginal epithelium is necessary. The present study was undertaken to evaluate different methods for assessing the vaginal epithelium, during atrophic and mature conditions. The vaginal epithelium was assessed by clinical examination, pH and vaginal cytology, including morphometric analysis, before and after oestrogen treatment. Biopsies of the vaginal wall were studied using descriptive histology and immunohistochemistry methods. The antigen Ki-67, a sensitive marker of cell proliferation, was detected using the monoclonal antibody MIB1. When comparing pre- and post-treatment values from the methods, a shift towards mature values was observed, but the magnitude of the shift differed to a considerable extent. Vaginal cytology, expressed as mean maturation index (MI) shifted significantly from 94/6/0 to 0/65/35. Likewise, mean pH was significantly shifted from 6.2 to mean 4.5. The increased presence of Ki-67 positive cells could be demonstrated after oestrogen treatment, but the range of data was wide, which was also found for the thickness of the epithelium and the number of cell layers. For objective assessment of the vaginal epithelium maturation index and pH can be recommended.

Transvaginal ultrasonography for identifying endometrial pathology in postmenopausal women

The objective of this study was to evaluate the usefulness of transvaginal ultrasonography in postmenopausal women with a clinical indication for a dilatation and curettage (D&C). Of the 167 postmenopausal women included in the study, 88% were referred for a D&C because of vaginal bleeding and 12% of the women had other clinical indications such as myomas, gynecological pain or suspected gynecological tumors. Hormone replacement therapy (HRT) was used by 37% of the women. The women were examined with transvaginal ultrasonography before the D&C. The endometrial thickness and texture were used as indicators of endometrial abnormalities. The ultrasonographical findings were related to the histological diagnosis obtained from the D&C. Histologically, 31% of the women had an atrophic endometrium and the corresponding ultrasonographically mean endometrial thickness was 4.6 mm (range 0-14 mm). Endometrial cancer was histologically found in 10% of the women and the endometrial thickness of the malignant endometrium, measured by ultrasonography, was 13.9 mm (range 6-31 mm). All the malignancies were found in the group of women with vaginal bleeding, but only one was in the group of women on HRT. Histologically, endometrial hyperplasia was found in 6.5% of the women and endometrial polyps in 8.5% after the D&Cs. In these postmenopausal women it was demonstrated that if the endometrium was < 6 mm thick, no endometrial cancer was found at histopathological investigation. By using a cut-off point of 6 mm of ultrasonographically measured endometrial thickness for identification of endometrial pathology in our study, at least 50% of the D&Cs could be spared.

Transvaginal sonography of the internal genital organs in postmenopausal women on low-dose estrogen treatment

Thirty healthy postmenopausal women with symptoms and signs of atrophic vaginitis due to estrogen deficiency were examined with transvaginal ultrasound. The endometrial thickness, the uterus and the ovaries were measured before and after 6 months of treatment with a low dose of estradiol released from a vaginal ring. The mean endometrial thickness, before and after the treatment, was 2.9 mm and 2.5 mm, respectively. There were no changes in endometrial volume or uterine thickness and volume during the treatment period. The mean volume of the postmenopausal ovary before treatment was 4.2 ml, and there was no difference after treatment or between the right and the left side. With a low dose of estradiol, administered locally, all the women were relieved from their deficiency symptoms, without any effect on the endometrium, the uterus or the ovaries when measured by transvaginal ultrasound.

Localization of steroid hormone receptors in the pelvic muscles

After the menopause the pelvic floor becomes progressively weaker, one consequence of which is the increasing incidence of prolapse and urinary incontinence. It is plausible that the reduction in estrogen levels postmenopausally is an etiological factor in these problems. For the pelvic floor muscles to be considered as target organs for estrogen, demonstration of the presence of estrogen receptors is required. The present study aims to confirm previous findings of estrogen and progesterone receptors in the levator ani muscle, and to further localize them histologically. In seven women biopsies from the levator ani muscle were taken and analyzed immunohistologically with monoclonal antibodies for estrogen and progesterone receptors. The receptors were detected in the nuclei of connective tissue cells and striated muscle cells. These findings provide a scientific basis for a possible beneficial effect of estrogen therapy, as a complement to other therapies, in prolapse and urinary incontinence.

The round ligament: a target organ for steroid hormones

Samples of the round ligament from pre- and post-menopausal women were analyzed immunohistochemically for estrogen and progesterone receptors. The steroid hormone receptors were localized in the smooth muscle cell nuclei, with stronger staining for progesterone receptors and somewhat weaker for estrogen receptors. Our findings support the view that the round ligament is a target organ influenced by hormones, which has implications for the changes in the ligament during pregnancy and pre- and postmenopausally.

Oestradiol-releasing vaginal ring for treatment of postmenopausal urogenital atrophy

A silicone vaginal ring releasing 5-10 micrograms oestradiol/24 h for a minimum of 90 days has been developed for treatment of urogenital mucosal atrophy. The efficacy, safety and acceptability of the oestradiol-releasing ring were studied in 222 postmenopausal women with symptoms and signs of atrophic vaginal mucosa. The maturation of the vaginal epithelium, as measured by cytological parameters, was significantly improved during treatment. No proliferation of the endometrium was encountered. The therapy had a significant effect on symptoms (vaginal dryness, pruritus vulvae, dyspareunia, urinary urgency) and on signs of atrophic vaginitis, with cure/improvement registered in > or = 90%. The patient acceptability was high, since > or = 90% did not report any discomfort with the ring. Almost all of the sexually active women had the ring in place during coitus and in < or = 2% of cases discomfort was noticed by them or the partner. It is concluded that a vaginal silicone ring giving a continuous release of an ultra-low dose of oestradiol is an effective and safe treatment for urogenital oestrogen deficiency. No addition of progestagen is needed.

Low-dose oestradiol in the treatment of urogenital oestrogen deficiency--a pharmacokinetic and pharmacodynamic study

Twenty-four postmenopausal women with vaginal atrophy due to oestrogen deficiency were treated with 17 beta-oestradiol administered as vaginal tablets containing 10 and 25 micrograms, respectively, in a slow-release system (Vagifem, Novo Nordisk, Denmark). All the women were treated for 2 weeks with each dose in a double-blind, cross-over study. Plasma concentrations of unconjugated oestradiol and unconjugated oestrone were measured at regular intervals for 24 h on days 1 and 14 of each treatment regimen. Cytological and clinical evaluations of the vaginal and urethral epithelium were also carried out. Initially, when the epithelium was still atrophic, dose-dependent absorption of oestradiol was demonstrated. After 14 days of treatment maturation of the vaginal epithelium was seen with both regimens and the absorption of oestradiol then declined significantly on both the 10 and the 25 micrograms dose. Oestrone levels remained unchanged and gonadotrophin levels were unaffected during treatment. Vaginal cytology showed maturation on both the 10 and the 25 micrograms dose, whereas urethral cytology showed a reduction in parabasal cells that was significant only on 25 micrograms. Clinical and subjective improvement was apparent on both doses and acceptance of treatment was good.

Endogenous estrogen levels in postmenopausal women with severe urogenital atrophy

In order to be able to evaluate the systemic influence of exogenous estrogen therapy in different conditions, it is important to have knowledge of the endogenous estrogen levels. The present study was undertaken to assess the basic levels and possible fluctuations of endogenous estrogen in postmenopausal women with urogenital estrogen deficiency. Plasma concentration levels of unconjugated estrone and estradiol were measured at regular intervals during 24 h in 5 postmenopausal women without estrogen treatment. All women had very low levels of estradiol. No diurnal fluctuation was found. Estrone levels were not measurable with a sensitive RIA technique.

Diagnosis and prevalence of persistent chlamydia infection in infertile women: tissue culture, direct antigen detection, and serology

Specimens for chlamydial culture, direct fluorescent antibody (DFA) test, two enzyme immunoassays (EIA) for antigen detection, and serum for chlamydial antibodies were collected from 256 infertile women. Specimens were taken from the tubes during tuboplasty and from the cervix and endometrium during laparoscopy or tuboplasty. Antibodies to Chlamydia trachomatis were found four times more often in patients with signs of prior pelvic inflammatory disease (PID) than in infertile women with normal pelvic findings. Only 48 (37%) of 131 patients with signs of prior PID had a history of PID. Ten or more C. trachomatis elementary bodies (EBs) per smear were found in 21 (8.2%) of 256 patients. Six patients had a positive culture or a positive antigen EIA test. All six had high numbers of EBs in the DFA test. We conclude that routine culture and EIA antigen tests detect only a minority of persistent chlamydia infections in this population, but subjective factors in the interpretation of DFA methods must be considered.

Transvaginal ultrasound for identifying endometrial abnormality

Transvaginal ultrasound was used preoperatively to evaluate the endometrium in 96 patients referred for dilatation and curettage. The sonographic display was correlated to the histopathologic diagnosis. In 45 patients with postmenopausal bleeding, 4 patients had adenocarcinoma of the endometrium. All were identified by ultrasound. None of the 22 patients with a normal sonographic appearance had an abnormal histopathologic diagnosis. An endometrial thickness (single layer) cut-off point of greater than or equal to 4 mm precluded any missed malignancies but halves the number of dilatations and curettages in this postmenopausal group. The sensitivity of ultrasound in diagnosing endometrial pathology was 100% and the specificity was 61%. The positive and negative predictive values were 39% and 100% respectively. In 51 premenopausal women there was good agreement between histology and ultrasound. In this group a cut-off point of greater than or equal to 8 mm was used. The sensitivity in diagnosing endometrial pathology was 67% and the specificity 75%. The positive and negative predictive values were 14% and 97%. With further experience, transvaginal ultrasound might be used in clinical routine for diagnosing endometrial pathology.

Uterine myoma causing uremia in a 15-year-old girl

Uterine myoma leading to uremia in young women below 16 years of age is an extremely rare condition. On reviewing the literature we have not been able to find any case similar to the one described below.

Steroid hormone receptors in pelvic muscles and ligaments in women

Using monoclonal antibody assay techniques estrogen receptors (ER) and progesterone receptors (PgR) were quantitated in female pelvic floor muscles, urogenital ligaments and uterus (myometrium). Receptors were detected in all these structures. In addition qualitative assessment showed distinct nuclear staining in the same structures. ER and PgR were not found in the musculus rectus abdominis with either method. The findings provide a rationale for estrogen treatment in women with urogenital disorders.

Estriol: absorption after long-term vaginal treatment and gastrointestinal absorption as influenced by a meal

This study was designed to evaluate the vaginal absorption of estriol when given as a 21-day treatment. Vaginal absorption was compared with the oral absorption of a known estriol preparation (TriovexR, Leo AB, Sweden). One mg of estriol was administered intravaginally once a day for 21 days to 6 menopausal women. Plasma concentrations of unconjugated estriol were measured by a specific RIA-method at frequent intervals during 24 hours on the first and 21st day of treatment. One month later, 10 mg of estriol was given once orally and plasma estriol concentrations were measured in the same way. At vaginal administration, the absorption of estriol was very effective. When measured on the 21st day, the absorption had declined significantly but was still nearly in the same range as after oral administration of 10 mg of estriol. At oral administration, there was an initial plasma estriol elevation for 3 hours only followed by a second one immediately postprandially. It is concluded that estriol is readily absorbed from the vagina, but the absorption does decline significantly during prolonged treatment. A large single oral dose of estriol provides initially a high plasma estriol concentration but also a second one induced by eating a meal, possibly indicating an enterohepatic recirculation of estriol.