Robotic versus laparoscopic surgery in gynecology: which should we use?

This review of the literature aims at assessing the safety and effectiveness of robotic versus laparoscopic surgery in benign and malignant gynecological diseases. Robotic-assisted laparoscopy is already widely used in the United States and Europe for the main gynecological procedure - hysterectomy - and has proved feasible and comfortable for other benign and malignant gynecological procedures. However, the clinical effectiveness and safety of robotic surgery compared with standard laparoscopy have not been undoubtedly established. We reviewed the literature by searching in the Ovid/MEDLINE, PubMed, Cochrane Library, and Google Scholar databases for all the articles published from January 1995 to September 2015. More rigorous experimental studies are needed, that compare robotic-assisted surgery and laparoscopic surgery for gynecological diseases. However, current data seem to encourage the use of minimally-invasive surgery to treat benign and malignant gynecological diseases.

Expressions of NDRG1, VEGF and Ki-67 in Condyloma Acuminatum

The objective of this study was to explore the expressions and significance of NDRG1 (N-myc downregulated gene family 1), VEGF (vascular endothelial growth factor) and Ki-67 in lesions of Condyloma Acuminatum (CA). Immunohistochemistry was adopted to measure the expressions of NDRG1, VEGF and Ki-67 in 48 cases of CA and 18 normal skin controls. The positive rates of NDRG1, VEGF and Ki-67 were 63. 83.33% (40/48), 93.75% (45/48) and 85.42% (41/48) in the CA tissues, and 27.78% (5/18), 94.44%(17/18) and 61.11% (11/18) in the controls, respectively. The intensities of the expressions of NDRG1, VEGF and Ki-67 in CA tissues were significantly higher than those in the controls. There were significant differences both in the positive rates and the expression intensities of NDRG1, VEGF and Ki-67 between the two groups (P less than0.05). The Spearman’s Rank-Order Correlation analysis indicated that the expressions of NDRG1 protein and VEGF protein were positively correlated by the Spearman’s Rank-Order Correlation analysis (r = 0.346, P=0.016). For the CA tissues with high expressions of NDRG1 and VEGF, NDRG1 and VEGF influenced both the occurrence and development of CA.

PREGNANCY AND CROHN'S DISEASE WITH EXTRAINTESTINAL MANIFESTATIONS OF PERIANAL REGION AND EXTERNAL GENITALIA

The article presents a clinical case of observation of the course of pregnancy and delivery in women with a rare manifestation of Crohn's disease with a primary lesion of the anal canal with extraintestinal manifestations (perianal region and external genitalia). Prospective clinical observation demonstrates the possibility of work with adequate outpatient and inpatient obstetric services in collaboration with relevant specialists, a favorable course and outcome of pregnancy in women with Crohn's disease of moderate severity with extraintestinal manifestations in the phase of incomplete remission and the birth of healthy full-term newborns, It should be noted that the use of drugs for the treatment of Crohns disease and related complications (anemia) had no teratogenic effects on the growth and development of the fetus, and on and on the health of the newborn Joint management of these patients by the obstetrician-gynecologist, gastro-enterology and a proctologist in the form ofjoint inspections and allows councils, in a timely manner to verify diagnosis of the disease and its complications, and provide adequate correction treatment patient to obtain a favorable pregnancy outcome, birth and the postnatal period.

Subsequent Oophorectomy and Ovarian Cancer after Hysterectomy for Benign Gynecologic Conditions at Chiang Mai University Hospital

This study was undertaken to determine the incidence of subsequent oophorectomy due to ovarian pathology or ovarian cancer in women with prior hysterectomy for benign gynecologic conditions at Chiang Mai University Hospital. Medical records of women who underwent hysterectomy for benign gynecologic diseases and pre-cancerous lesions between January 1, 2004 and December 31, 2013 at Chiang Mai University Hospital were retrospectively reviewed. The incidence and indications of oophorectomy following hysterectomy were analyzed. During the study period, 1,035 women had hysterectomy for benign gynecologic conditions. Of these, 590 women underwent hysterectomy with bilateral salpingo-oophorectomy and 445 hysterectomy with bilateral ovarian preservation or unilateral salpingo-oophorectomy. The median age was 47 years (range, 11-75 years). Ten women (2.45 %) had subsequent oophorectomy for benign ovarian cysts. No case of ovarian cancer was found. The mean time interval between hysterectomy and subsequent oophorectomy was 43.1 months (range, 2-97 months) and the mean follow-up time for this patient cohort was 51 months (range, 1.3-124.9 months). According to our hospital-based data, the incidence of subsequent oophorectomy in women with prior hysterectomy for benign gynecologic conditions is low and all present with benign conditions.

Reflectance confocal microscopy for mucosal diseases

Non-invasive, real-time microscopic imaging using in vivo reflectance confocal microscopy (RCM) has been demonstrated to be a useful tool for the evaluation of skin diseases and in particular for skin neoplasms. Recently, the RCM devices dedicated to the skin have also been applied to perform "virtual biopsies" of the oral, genital and ocular mucosa. In fact, mucosa is a sensitive area where non invasive imaging techniques are of high interest in order to spare biopsies and excisions. Mucosa is particularly suitable for RCM because of its thin or absent cornified layer and its thin epithelium that allows a deeper penetration of the laser with the consequent possibility of exploring deeper tissue levels. Besides, being useful for the diagnosis, RCM may be helpful to identify the area to be biopsied in case of large or multifocal lesions and may be regarded as a complementary technique for non invasive assessment of treatment efficacy. The RCM features of healthy mucosa are described and a revision of the literature of the mucosal diseases that can be diagnosed by RCM has been performed.

The first step toward diagnosing female genital schistosomiasis by computer image analysis

Schistosoma haematobium causes female genital schistosomiasis (FGS), which is a poverty-related disease in sub-Saharan Africa. Furthermore, it is co-endemic with human immunodeficiency virus (HIV), and biopsies from genital lesions may expose the individual to increased risk of HIV infection. However, microscopy of urine and hematuria are nonspecific and insensitive predictors of FGS and gynecological investigation requires extensive training. Safe and affordable diagnostic methods are needed. We explore a novel method of diagnosing FGS using computer color analysis of colposcopic images. In a cross-sectional study on young women in an endemic area, we found strong associations between the output from the computer color analysis and both clinical diagnosis (odds ratio [OR] = 5.97, P < 0.001) and urine microscopy for schistosomiasis (OR = 3.52, P = 0.004). Finally, using latent class statistics, we estimate that the computer color analysis yields a sensitivity of 80.5% and a specificity of 66.2% for the diagnosis of FGS.

EXPRESSION AND CLINICAL SIGNIFICANCE OF APOPTOSIS-ASSOCIATED PROTEINS SURVIVIN AND LIVIN IN CONDYLOMA ACUMINATUM

The objective of the present study was to explore the expression and significance of survivin and Livin in lesions of Condyloma acuminatum (CA). Streptavidin-peroxidase (SP) immunohistochemistry method was used to measure the expression of survivin, Livin and Ki-67 in 48 cases of CA and 25 cases of normal foreskin tissues. The positive expression rates of survivin, Livin and Ki-67 were 72.91% (35/48), 77.08% (37/48) and 85.42% (41/48) in CA tissues, and 4% (1/25), 4% (5/25) and 60% (15/25) in the control group, respectively. The expression intensity of survivin, Livin and Ki-67 in CA tissues (++ ~ +++) was significantly higher than that in the normal control group (- ~ ++). There were significant differences (P <0.05) both in the positive rates and the expression intensity of survivin, Livin and Ki-67 between the two groups. There was positive correlation between the expression of survivin and Livin in CA group (P < 0.01); the expressions of survivin and Ki-67 were positively correlated with each other (P < 0.01); Livin and Ki-67 expressions were positively correlated with each other (P < 0.01). There were over-expressions and excessive proliferations of survivin and Livin in CA tissues, and apoptosis suppressors survivin and Livin were correlated with CA.

Patterns of Lesions in Hysterectomy Specimens in a Tertiary Care Hospital

INTRODUCTION

Hysterectomy is one of the most common gynaecological procedures performed all over the world. The most frequent indications for hysterectomy are fibroids, abnormal uterine bleeding uterovaginal prolapse and endometriosis. The objective of this study was to present the histopathological patterns of various uterine and adnexal pathologies in the hysterectomy specimens and also to correlate its pre-operative clinical diagnosis with histopathology.

METHODS

This is a two-year descriptive study of hysterectomy specimens carried out in the Department of Pathology, Patan Academy of Health Sciences (PAHS), Lalitpur, Nepal. Data of all the hysterectomy specimens collected during this period was analyzed.

RESULTS

Out of the 533 cases, fibroid was the most common indication for hysterectomy that was seen in 229 (42.94%) cases followed by uterovaginal prolapse in 101 (18.93%) cases. Leiomyoma was the most common pathology reported in 250 (46.90%) hysterectomy specimens, followed by ovarian tumours in 95 (17.82%) cases. In 17.82% (95/533) cases, no pathology was seen. Overall, the pre-operative indications in 533 cases of hysterectomy were histopathologically verifiable in 487 (91.37%) cases.

CONCLUSIONS

Though the histopathological examination correlates well with the pre-operative clinical diagnosis, a number of lesions were also encountered as pure incidental findings. Hence, it is mandatory that every hysterectomy specimen should be subjected to histopathological examination so as to ensure better post-operative management.

The role of dendritic cells in driving genital tract inflammation and HIV transmission risk: are there opportunities to intervene?

Effective prevention of new HIV infections will require an understanding of the mechanisms involved in HIV acquisition. HIV transmission across the female genital tract is the major mode of new HIV infections in sub-Saharan Africa and involves complex processes, including cell activation, inflammation and recruitment of HIV target cells. Activated CD4(+) T-cells, dendritic cells (DC) and macrophages have been described as targets for HIV at the genital mucosa. Activation of these cells may occur in the presence of sexually-transmitted infections, disturbances of commensal flora and other inflammatory processes. In this review, we discuss causes and consequences of inflammation in the female genital tract, with a focus on DC. We describe the central role these cells may play in facilitating or preventing HIV transmission across the genital mucosa, and in the initial recognition of HIV and other pathogens, allowing activation of an adaptive immune response to infection. We discuss studies that investigate interventions to limit DC activation, inflammation and HIV transmission. This knowledge is essential in the development of novel strategies for effective HIV control, including microbicides and pre-exposure prophylaxis.

The colposcopic atlas of schistosomiasis in the lower female genital tract based on studies in Malawi, Zimbabwe, Madagascar and South Africa

BACKGROUND

Schistosoma (S.) haematobium is a neglected tropical disease which may affect any part of the genital tract in women. Female genital schistosomiasis (FGS) may cause abnormal vaginal discharge, contact bleeding, genital tumours, ectopic pregnancies and increased susceptibility to HIV. Symptoms may mimic those typical of sexually transmitted infections (STIs) and women with genital schistosomiasis may be incorrectly diagnosed. An expert consensus meeting suggested that the following findings by visual inspection should serve as proxy indicators for the diagnosis of schistosomiasis of the lower genital tract in women from S. haematobium endemic areas: sandy patches appearing as (1) single or clustered grains or (2) sandy patches appearing as homogenous, yellow areas, or (3) rubbery papules. In this atlas we aim to provide an overview of the genital mucosal manifestations of schistosomiasis in women.

METHODOLOGY/PRINCIPAL FINDINGS

Photocolposcopic images were captured from women, between 1994 and 2012 in four different study sites endemic for S. haematobium in Malawi, Zimbabwe, South Africa and Madagascar. Images and specimens were sampled from sexually active women between 15 and 49 years of age. Colposcopic images of other diseases are included for differential diagnostic purposes.

SIGNIFICANCE

This is the first atlas to present the clinical manifestations of schistosomiasis in the lower female genital tract. It will be freely available for online use, downloadable as a presentation and for print. It could be used for training purposes, further research, and in clinical practice.

Genes involved in epithelial differentiation and development are differentially expressed in oral and genital lichen planus epithelium compared to normal epithelium

Lichen planus (LP) is a chronic mucocutaneous disease with unknown cause. Patients with LP often have both oral and genital lesions, but these conditions are often considered as separate diseases and treated accordingly. To find out which genes are differently expressed in mucosal LP compared to normal mucosa and establish whether oral and genital LP are in fact the same disease, whole genome expression analysis was performed on epithelium from 13 patients diagnosed with oral and/or genital LP and normal controls. For confirmation of keratin 4 and corneodesmosin expression, quantitative reverse-transcription PCR and immunohistochemistry were used. Many genes involved in epithelial development and differentiation are differently expressed in epithelium from LP compared to normal epithelium. Several of the differentially expressed genes are common for oral and genital LP and the same biological processes are altered which supports the fact that oral and genital LP are manifestations of the same disease. The change in gene expression indicates that differentiation is altered leading to changes in the epithelial barrier.

[Influence of previous abdominopelvic surgery on gynecological laparoscopic operation]

OBJECTIVE

To investigate the influence of previous abdominopelvic surgery on gynecological laparoscopic operation.

METHODS

A retrospective analysis of 3 283 cases of gynecological diseases by laparoscopic operation patients in Peking University First Hospital from 2007 January to 2012 December, among them, 719 (21.90%) patients with previous abdominopelvic surgery history (study Group), 2 564 (78.10%)patients have no history of abdominopelvic surgery (control group). Study group 719 patients, previous operation times: one time in 525 cases, 194 cases were multiple; previous operation: 185 cases of gynecological surgery, 305 cases of obstetric surgery, 108 cases of general surgery, and 121 complex surgery (include at least two kinds of surgery); previous operative approach: 650 cases laparotomy and 69 cases laparoscopy. Compared two groups of patients with abdominopelvic adhesion and the gynecologic laparoscopic operation situation, analyzed the influence of previous abdominopelvic surgery on abdominopelvic adhesion on and gynecological laparoscopic operation.

RESULTS

The incidence of abdominopelvic adhesion in the patients with previous abdominopelvic surgery was 51.2% (368/719), which was significantly higher than that of 8.2% (211/2 564)in patients without previous abdominopelvic surgery (P < 0.01). But the study group score (median 3) and the degree of abdominopelvic adhesion [mild 49.7% (183/368), moderate 36.1% (133/368), severe 14.1% (52 /368)] compared with the control group score (median 2) and degree [mild 55.0% (116/211), moderate 25.6% (54/211), and severe 19.4% (41/211)] were no statistical difference (P = 0.930, P = 0.684). Super-umbilical primary trocar site were chosen more common in patients with previous abdominopelvic surgery (23.1%, 166/719) was significantly higher than that in the control group (3.3% , 85/2 564;P < 0.01). And the rate of conversion to laparotomy was 0.6% (4/719) significantly more than the control groups (0.1%, 2/2 564; P = 0.023). Compared with other groups, patients with gynecological or complex surgery or multiple operation history presented more severe abdominopelvic adhesion both in the score and degree (P < 0.01). The rate of super-umbilical primary trocar site, hospitalization time, operation time and bleeding during operation in patients with multiple operation history were significantly higher than those with single operation history (P < 0.05); the rate of blood transfusion, postoperative complication and conversion to laparotomy showed no statistical difference between the two groups (P > 0.05).

CONCLUSION

The laparoscopic operation could be carried out successfully and safely in patients with a history of various abdominopelvic operations, but the conversion rate increases, for patients with a history of multiple operation because of pelvic adhesion increases the difficulty of the laparoscopic operation.

Therapeutic Evaluation of Intralesional 5% 5-Fluorouracil in Condyloma Acuminata

Condyloma acumianata is one of the most common virally transmitted diseases. Its prevalence has increased many fold throughout the world. Because all the currently available treatments yield low cure rates with side effects, the search for a new alternative continues. Topically, 5-fluorouracil (5-FU) has been in used for many years to treat various skin diseases. When applied topically in condyloma acuminata, 5-FU results in low cure rates with high recurrences. Therefore, intralesional 5% 5-FU is being evaluated to determine its therapeutic efficacy in condyloma acuminata.

[Bacterial lipopolsaccharides in pathogenesis of gynecological diseases and obstetric complications]

Analysis of literature data and author studies on the role of lipopolysaccharides (endotoxin) of Gram negative bacteria in women genital tract pathology and obstetric complications is presented. The role of endogenous infection associated with altered microecology of intestinal tract and vaginal biotopes of women in the development of endotoxinemia is discussed. The participation of endotoxin in embryo resorption, delay of intrauterine development and antenatal death of fetus, premature birth, pre-eclampsia, placental dysfunction is examined. The level of endotoxinema and pro-inflammatory cytokines is a marker of chronic endogenous infectious-inflammatory disease of various parts of genital tract with damage of a network of female reproduction system organs.

[Cervical adenocarcinoma with lymphatic spread presenting as carcinoma "en cuirasse"of the vulva: case report]

We report the case of a patient with carcinoma "en cuirasse" of the vulva.

CASE REPORT

A female patient presented complaining of inguinal lymphadenopathy. Lymph node excision, immunohistochemistry analyses, and further exams showed the presence of cervical adenocarcinoma. The cancer was surgically removed and the patient was treated with radiotherapy and chemotherapy with a good initial response. Some months later she presented with intense edema of the lower limbs, hardening and thickening of the labia majora, and pelvic and genital ulceration. A cutaneous biopsy with subsequent immunohistochemical staining showed lymphatic dissemination of adenocarcinoma to the vulva.

DISCUSSION

Carcinoma "en cuirasse" is a rare presentation of cutaneous metastasis in which the affected skin shows hardening and induration, acquiring a sclerodermoid appearance. This is, to the best of our knowledge, the first report in Brazil of carcinoma "en cuirasse" of the vulva associated with cervical adenocarcinoma.

Benign breast and gynecologic conditions, reproductive and hormonal factors, and risk of thyroid cancer

The higher incidence of thyroid cancer in women compared with men suggests an influence of sex steroid hormones in the etiology of this malignancy. We investigated a comprehensive set of potential indicators of lifetime sex steroid hormone exposure in relation to thyroid cancer risk. Using data from the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, which enrolled 70,047 women, 50 to 78 years old, we prospectively examined associations of self-reported history of benign breast and gynecologic conditions, reproductive factors, and exogenous sex hormone use with thyroid cancer risk. Multivariable-adjusted HRs and 95% confidence intervals (CI) were calculated in models using age as the time metric. During follow-up (median, 11 years), 127 women were diagnosed with first primary thyroid cancer. Older age at natural menopause (≥55 vs. <50 years; HR, 2.24; 95% CI, 1.20-4.18), greater estimated lifetime number of ovulatory cycles (≥490 vs. <415 cycles; HR, 2.40; 95% CI, 1.33-4.30), greater number of live births (≥5 vs. 1-2; HR, 1.72; 95% CI, 1.05-2.82), and history of uterine fibroids (HR, 1.72; 95% CI, 1.18-2.50) were associated with an increased risk of thyroid cancer. Earlier age at menarche, greater number of reproductive years, history of a tubal ligation, and history of ovarian cysts were nonsignificantly associated with increased thyroid cancer risk. No associations were observed for oral contraceptive use, menopausal hormone therapy, or history of benign breast disease or endometriosis. In general, we found that factors reflecting a greater length of exposure to endogenous hormones, particularly during the reproductive years, were associated with risk of postmenopausal thyroid cancer.

Imaging in gynecological disease (9): clinical and ultrasound characteristics of tubal cancer

OBJECTIVES

To describe clinical history and ultrasound findings in patients with tubal carcinoma.

METHODS

Patients with a histological diagnosis of tubal cancer who had undergone preoperative ultrasound examination were identified from the databases of 13 ultrasound centers. The tumors were described by the principal investigator at each contributing center on the basis of ultrasound images, ultrasound reports and research protocols (when applicable) using the terms and definitions of the International Ovarian Tumor Analysis (IOTA) group. In addition, three authors reviewed together all available digital ultrasound images and described them using subjective evaluation of gray-scale and color Doppler ultrasound findings.

RESULTS

We identified 79 women with a histological diagnosis of primary tubal cancer, 70 of whom (89%) had serous carcinomas and 46 (58%) of whom presented at FIGO stage III. Forty-nine (62%) women were asymptomatic (incidental finding), whilst the remaining 30 complained of abdominal bloating or pain. Fifty-three (67%) tumors were described as solid at ultrasound examination, 14 (18%) as multilocular solid, 10 (13%) as unilocular solid and two (3%) as unilocular. No tumor was described as a multilocular mass. Most tumors (70/79, 89%) were moderately or very well vascularized on color or power Doppler ultrasound. Normal ovarian tissue was identified adjacent to the tumor in 51% (39/77) of cases. Three types of ultrasound appearance were identified as being typical of tubal carcinoma using pattern recognition: a sausage-shaped cystic structure with solid tissue protruding into it like a papillary projection (11/62, 18%); a sausage-shaped cystic structure with a large solid component filling part of the cyst cavity (13/62, 21%); an ovoid or oblong completely solid mass (36/62, 58%).

CONCLUSIONS

A well vascularized ovoid or sausage-shaped structure, either completely solid or with large solid component(s) in the pelvis, should raise the suspicion of tubal cancer, especially if normal ovarian tissue is seen adjacent to it.

Female genital schistosomiasis: pathological features and density infestation

OBJECTIVES

To study the percentage distribution and Average Tissue Density (ATD) of schistosoma infestation in different parts of the Female Genital System (FGS).

DESIGN

A retrospective explorative study of all surgical pathology cases examined from January to December of 2000.

SETTING

Public Health Laboratories, Parirenyatwa Hospital, Harare, Zimbabwe.

SUBJECTS

All archive slides cases positive for schistosoma ova were examined.

INTERVENTION

To generate awareness of female genital schistosomiasis, often under diagnosed, despite causing dysmenorrhea, chronic pelvic pain, infertility, genital ulcer disease and mimicking cancer.

MAIN OUTCOME MEASURES

Female genital schistosomiasis is underdiagnosed as of all forty seven (47) cases found positive microscopically, the clinicians had not raised it in their differentials.

RESULTS

Forty seven (47) cases of Schistosomiasis were found with an ATD of six (6) to thirty nine (39) schistosoma ova per 10 hpf. In the lower genital tract, the cervix accounted for thirty two (68%) cases. Interestingly fifteen (47%) of cases showed association with cervical dysplasia, invasive squamous cell carcinoma or human papilloma virus koliocytosis. Presentations in the lower genital tract were of ulceration, polyps or abnormal vaginal bleeding. Surprisingly of the total forty seven (47) cases three (3%) cases were in leiomyomata. Significantly tubal ectopic pregnancy was associated with 3 (50%) cases out of six (6) cases of fallopian tube.

CONCLUSION

Schistosomiasis needs more recognition as a cause of disease of the female genital tract. Its association with tubal ectopic pregnancies can be catastrophic. Further molecular studies towards its association with cervical cancer need to be done.

The Lower Anogenital Squamous Terminology Project and its implications for clinical care

Based on a growing need for unified terminology to describe the pathologic and clinical spectrum of lesions, the American Society for Colposcopy and Cervical Pathology and the College of American Pathologists Pathology and Laboratory Quality Center convened the Lower Anogenital Squamous Terminology (LAST) Project to reassess and harmonize the terminology used to describe human papillomavirus-associated squamous lesions of the lower anogenital tract as manifested in a variety of end organs. The distinction between cancer precursors and those without malignant potential leads to consistency in the interpretation of management guidelines and the therapeutic options.

Development of squamous cell carcinoma on an inflammatory linear verrucous epidermal nevus in the genital area

Inflammatory linear verrucous epidermal nevus is a rare cutaneous disorder characterized by pruritic, erythematous, and verrucous papules and plaques along the lines of Blaschko. Histopathologically, there is a benign verrucous proliferation of keratinocytes together with alternating parakeratosis and orthokeratosis as well as inflammatory changes. We report a patient who developed squamous cell carcinoma (SCC) on an inflammatory linear verrucous epidermal nevus and we discuss the importance of regular follow-up of patients with epidermal nevi.

Coexistence of adenomyosis in women operated for benign gynecological diseases

BACKGROUND

To compare demographic, clinical and histopathological characteristics of women diagnosed with adenomyosis (AG) after hysterectomy to those of women diagnosed with leiomyoma (LG) and to investigate the predisposing factors for AG.

METHODS

This study was carried out on 204 patients who underwent gynecologic surgery for various indications except for gynecologic malignancy between January 2005 and December 2009 and whose histopathological analysis of hysterectomy/myomectomy specimen revealed either AG or LG. Women with AG and those with LG were compared with respect to age, parity, menstrual pattern, history of induced abortion, history of prior uterine surgery, smoking, dysmenorrhea, dyspareunia, chronic pelvic pain and coexisting endometrial and ovarian pathologies.

RESULTS

The mean age of our patients was 51 ± 8 years (range 28-85), 40% of them were postmenopausal, and 64% had a history of uterine surgery. The mean age (p = 0.014), gravida (p = 0.018), parity (p = 0.017) and previous endometrial sampling (p < 0.01) were significantly higher in AG. Main symptoms were abnormal uterine bleeding (39%), dysmenorrhea (63%) and nonmenstrual pelvic pain (62%). Age (p = 0.01), menometrorrhagia (p = 0.02) and endometrial sampling (p < 0.01) were the significant covariants in binary logistic regression for AG.

CONCLUSION

AG is an enigmatic disease frequently causing gynecologic complaints and endomyometrial junction deterioration during endometrial sampling may be a trigger point for developing AG.