Patterns of ambulatory care use for gynecologic conditions: A national study

OBJECTIVE

This study was undertaken to describe the site of ambulatory care visits for gynecologic conditions in the United States and to identify patient factors associated with the site of care for these conditions.

STUDY DESIGN

We conducted a national cross-sectional study using data from the 1995-1996 National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys. Visits to private physician offices, hospital outpatient departments, and emergency departments were selected if the principal diagnoses were consistent with 1 of 9 gynecologic categories. Multiple logistic regression was used for all diagnoses to identify factors associated with visits to emergency departments or hospital-based outpatient departments compared with factors associated with visits to private physician offices. Separate regression models were developed for individual diagnoses to test the hypothesis that the factors associated with the site of care would vary across different gynecologic conditions.

RESULTS

There were 23,194,000 visits for gynecologic conditions during the 2-year study period. Genital dysplasia, ovarian disorders, and uterine disorders were associated with greater use of hospital outpatient departments and emergency departments compared with physician offices. There was a 30% to 50% reduction in emergency room use for visits by women aged 45 years and older compared with visits by women aged 18 to 29 years. Emergency department use for several gynecologic conditions was 5 to 8 times greater for visits by women with household income <$29,000 than for visits by women with household income > or =$40,000.

CONCLUSION

Specific gynecologic diagnoses and patient factors are associated with greater use of emergency departments or hospital outpatient departments compared with physician offices. The association of these factors with the site of care varies across different gynecologic conditions.

[Bilateral ovary massive edema. Unusual gynecologic pathology. Report of 2 cases]

We report two cases of bilateral massive ovarian edema occurred in a concentration hospital in the last five years. This condition was first described by Kalstone et al. in 1969. It may be uni or bilateral, the last one is very uncommon, until the moment of this work there have been reported only ten cases in the world literature. The main symptoms are: abdominal pain or distention, menstrual irregularity and infertility. Two features are characteristic of this pathology: 1) Fast growing in size and volume of the ovary, and 2) Abscense of neoplastic changes with extensive edema of the stroma particularly in the medulla. The current treatment is oophorectomy. In bilateral cases may be intended a conservative management with wedge resection and fixation of the ovaries to the uterus in order to prevent further torsion. We conclude that massive ovarian edema is an uncommon pathology more frequent as a cause of abdominal pain and fast growing anexial mass in young women.

Efficacy of ethanol sclerotherapy for ovarian endometriomas

OBJECTIVE

To evaluate the efficacy and limitations of ethanol sclerotherapy for ovarian endometriomas.

METHODS

Retrospective investigation was made on 83 women with ovarian endometriomas who underwent transvaginal aspiration and ethanol sclerotherapy at Hiroshima City Hospital between 1993 and 1998. Furthermore, 30 who underwent laparoscopic cystectomy for ovarian endometriomas during the same period were investigated.

RESULTS

Of the 74 women who were followed for more than 6 months, 11 (14.9%) had recurrent cysts. The recurrence rate of laparoscopic cystectomy was 3.8% (NS). The recurrence rate of cases instilled for less than 10 min was 62.5% (5/8), and that for 10 or more than 10 min was 9.1% (6/66) (P<0.001). The recurrence rate of cases having one cyst was 7.5% (4/53) and that of cases having two or more cysts was 33.3% (7/21) (P<0.05).

CONCLUSION

Ethanol sclerotherapy is an effective and safe procedure and can be indicated for almost all ovarian endometriomas. Conduct of ethanol instillation for more than 10 min particularly for a case with a single endometrial cyst is considered most effective from the standpoint of recurrence.

The clinical course of unresected ovarian torsion

The authors report the clinical course of a young girl with ovarian torsion who was treated conservatively. This case shows that detorsion of the ovary may be associated with immediate postoperative febrile morbidity and slow resolution of ovarian enlargement. The authors emphasize that these signs can be associated with viable ovarian tissue and are not necessarily an indication for oophorectomy.

Conservative management of bilateral asynchronous adnexal torsion with necrosis in a prepubescent girl

Conservative management of ovarian torsion consisting of detorsion and surgical stabilization of the involved ovary, and possibly including the uninvolved ovary, has been described in the adult population. A 6-year-old girl with a history of prior ovarian torsion resulting in oophorectomy presented with 72 hours of intermittent abdominal pain, anorexia, and 1 episode of vomiting. The patient had torsion of her remaining ovary diagnosed surgically and was managed with detorsion and oophoropexy, despite the severely necrotic appearance of the ovarian tissue. Postoperative serial ultrasound scans confirmed the viability and position of the ovary. In the prepubertal girl, ovaries may torse despite the absence of enlarging lesions such as tumors or cysts. To maximize the potential success of conservative therapy, torsion always must be included in the differential diagnosis of abdominal pain. Surgical management should attempt to salvage the torsed ovary, despite possible necrotic appearance, and also consider interventions to prevent recurrence, because bilateral torsion is a rare but potentially devastating complication.

PID: clinical and laparoscopic aspects

Clinical signs of pelvic inflammatory disease (PID) are not constant and are often limited to slight pelvic pain. Laparoscopy can lead to a rapid and correct diagnosis of PID. Intrapelvic bacteriologic samples can be obtained so as to administer the proper antibiotic. The exact nature of the lesions can be evaluated, and in severe cases, recent abscesses can be treated with good results for fecundity. Because the results in cases of long-standing abscess are not so good, laparoscopy should be performed at the onset of infection and not be reserved until after some weeks of inefficient medical treatment, especially in young women who have not completed their family. In primary chronic salpingitis, the lack of any clinical signs usually leads to a delay in diagnosis until women consult for fertility problems. The ideal point would be to detect some biologic or clinical change that may lead to diagnosis such as a positive anti-Chlamydia trachomatis (CT) serology or, in the future, positive anti-CT Hsp 60 antibody could be the key to detecting and treating silent salpingitis in young women, CT being the main microorganism involved in chronic salpingitis. Screening for C. trachomatis low genital tract infection is mandatory in young people in order to control the epidemic.

A tale of two syndromes: ovarian hyperstimulation and abdominal compartment

Abdominal compartment syndrome complicated severe ovarian hyperstimulation in a 35 year old woman with multiple bowel resections due to Crohn's disease. Pain from ovarian enlargement necessitated hospital admission. Despite intravenous fluid administration and heparin prophylaxis, ilio-femoral deep vein thrombosis developed. Treatment by intravenous heparin was complicated by repeated intra-ovarian bleeding, anaemia and acute renal failure requiring haemodialysis. Intra-abdominal pressures were elevated. After placement of an inferior vena caval filter and discontinuation of heparin, there was slow spontaneous recovery without surgery.

[Therapeutic management of ovarian dystrophy and insufficiency in abortion disorders: recent data]

Many reports suggested that the high rate of miscarriage in women with polycystic ovaries may be due to increased urine and/or plasma LH concentration. In fact, with the exception of pulsatile GnRH, any treatment likely to increase the plasma LH level results in unchanged or rather low miscarriage rates. Conversely, a reduction in this rate by GnRH agonists is not conclusive. Excess weight may also increase the risk of miscarriage. In women with incipient ovarian failure, the miscarriage rate is mainly linked to age. No stimulation has been found to be effective in these patients. There is a need for more extensive evaluation in GnRH analog microdoses, recombinant FSH and GnRH antagonists. Oocyte donations from younger women are difficult to obtain because of the lack of donors in France.

[Persistent follicle syndrome: a forgotten clinical entity?]

There is no evidence that morphologic alterations of the ovaries cause symptoms of hormonal imbalance and a deficit in ovarian hormones in a case of micro-cystic degeneration of the ovaries. Similarly, fertility does not have to be impeded, since follicular development may be unaffected. In absence of functional disturbances, such as amenorrhea or anovulation, no therapy is needed. A different approach is, however, required when the ovaries contain larger, hormone-producing cysts which can persist for a long time. In contrast to micro-cystic ovaries the presence of persistent ovarian follicles can entail marked risks of endometrial hyperplasia, severe uterine bleeding, and anemia.

[Pelvic endometriosis with urologic involvement. Therapeutic principles: apropos of 2 cases]

The authors report 2 clinical cases of vesicopelvic endometriosis. The urinary symptoms and the radiological appearance of endometriosis of the bladder are nonspecific. The diagnosis was established by histological examination of the resection specimen. The authors describe the therapeutic approach based on radical surgery designed to eradicate the endometriosis, while remaining as conservative as possible in order to allow subsequent pregnancy, and the place of urological surgery combined with medical treatment with LHRH analogue.

Embolization of the ovarian veins as a treatment for patients with chronic pelvic pain caused by pelvic venous incompetence (pelvic congestion syndrome)

Ovarian and pelvic (internal iliac) varices have long been recognized as a source of chronic pelvic pain in women. The technique of transcatheter embolotherapy for ovarian and pelvic varices requires selective catheterization of the ovarian and internal iliac veins, followed by contrast venography and embolization. The long-term effects of treatment are the subject of ongoing investigation. This article provides a concise background on ovarian and pelvic varices and reviews the recently published literature on their embolization for the treatment of pelvic venous incompetence (also known as pelvic congestion syndrome).

Reoperation after laparoscopic treatment of ovarian endometriomas by excision and by fenestration

OBJECTIVE

To compare the reoperation rate after laparoscopic treatment of ovarian endometriomas by excision and by fenestration.

DESIGN

Retrospective study.

SETTING

University-affiliated teaching hospital.

PATIENT(S)

Two hundred thirty-one premenopausal women with ovarian endometriomas treated laparoscopically.

INTERVENTION(S)

Seventy women were treated with fenestration and ablation of the cyst wall and 161 women were treated with excision.

MAIN OUTCOME MEASURE(S)

The reoperation rates of the two groups of women were evaluated using life-table analysis.

RESULT(S)

The cumulative probability of reoperation was significantly higher after fenestration than after excision. The reoperation rates at 18 months and 42 months of follow-up were 6.1% and 23.6% after excision and 21.9% and 57.8% after fenestration, respectively. In the fenestration group, the age of the patient and the diameter of the endometrioma were not associated with a higher reoperation rate. In the excision group, a larger cyst was associated with a higher reoperation rate, but age had no influence on the reoperation rate.

CONCLUSION(S)

Laparoscopic excision of ovarian endometriomas is associated with a lower reoperation rate than that of fenestration. The reoperation rate after fenestration is independent of the size of the endometrioma and the age of the patient. However, after excision, the reoperation rate is higher in those with larger cysts.

Puerperal ovarian vein thrombosis with extension into the inferior vena cava

The incidence of puerperal ovarian vein thrombosis is estimated to range between 1 in 600 and 1 in 2000 deliveries. The cardinal signs of puerperal ovarian vein thrombosis include fever, leukocytosis, and right lower quadrant abdominal pain, most often in a recently delivered female patient. These patients are classically described as failing to improve with intravenous antibiotic therapy alone; resolution of symptoms and presumptive diagnosis is made on defervescence with the addition of intravenous heparin therapy. Objective diagnostic modalities include venography, ultrasound, laparoscopy, and MRI, although CT remains the gold standard for the identification of this under-diagnosed entity. We present a case report of a 20-year-old female treated at our facility for puerperal ovarian vein thrombosis. She was transferred to our vascular surgery service after developing the classic signs of puerperal ovarian vein thrombosis and undergoing CT demonstrating ovarian vein thrombosis with extension of free-floating thrombus into her inferior vena cava (IVC). This degree of thrombosis was particularly concerning when one considers the 3 to 33 per cent rate of pulmonary embolism reported in patients with puerperal ovarian vein thrombosis. Treatment modalities for such extensive degrees of thrombosis are described in the literature and range from hysterectomy and thrombectomy to ligation of the IVC. In our case, we prophylactically placed a suprarenal IVC Greenfield filter to protect against pulmonary embolism and proceeded with the standard regimen of anticoagulation and antibiotics. This treatment approach has been reported only twice previously in the literature, to our knowledge.

Treatment of estrogen deficiency symptoms in women surviving breast cancer. Part 2: Hormone replacement therapy and breast cancer

There are several million breast cancer survivors worldwide. In the United States, 180,000 women were diagnosed with breast cancer in 1997, and approximately 97,000 of these women have an extremely low chance of suffering a recurrence of their cancer. With an average age at diagnosis of 60 years and a 25-year expected duration of survival, the current number of breast cancer survivors in the United States may approach 2.5 million women. Since breast cancer is now being detected at an earlier stage than previously and since adjuvant chemotherapy may cause ovarian failure, an increasing number of women are becoming postmenopausal at a younger age after breast cancer treatment. This conference was convened in September 1997 to consider how menopausal breast cancer survivors should be treated at the present time and what future studies are needed to develop improved therapeutic strategies. A total of 59 breast cancer experts and patient advocates participated. The proceedings of the conference will be published in six installments in successive issues of ONCOLOGY. The first part, published last month, defined the problem and explored its magnitude and ramifications for patient management. This second part focuses on the benefits and risks of hormone replacement therapy (HRT) in patients with breast cancer.

Transvaginal ultrasound-guided aspiration of pelvic abscesses

OBJECTIVE

To assess the utility of a less invasive approach to the care of women with a pelvic abscess, we retrospectively reviewed the outcome of women with pelvic abscesses managed by transvaginal ultrasound-guided aspiration.

METHODS

A retrospective analysis of 27 pelvic abscesses in 22 consecutive women undergoing transvaginal drainage, including 13 tuboovarian abscesses (TOAs) and 14 postoperative abscesses (POAs). All patients received broad-spectrum intravenous antibiotics from the time infection was diagnosed to resolution of signs and symptoms. Chart review and examination of ultrasound files were utilized to extract demographic clinical, laboratory, and outcome data.

RESULTS

The mean age for the study group was 30 years old. Mean duration from diagnosis to drainage was 5.6 days (TOA) and 2.0 days (POA), P < 0.01. The mean diameter of the abscesses was 86 mm. The volume of purulent material drained ranged from 70-750 mL. Perceived adequacy of drainage was correlated with lack of abscess septation. Cultures for aerobic and anaerobic pathogens were positive in 51% of cases (79% POA versus 23% TOA, P < 0.05) with 1.9 organisms/ positive culture. Transvaginal drainage was successful in 25 of 27 abscesses. No complications were reported.

CONCLUSION

In skilled hands, transvaginal guided aspiration of pelvic abscess is a highly successful technique with minimal risk to the patient. Follow-up studies are needed to assess the long-term sequelae, such as frequency of infertility, ectopic pregnancy, and chronic pelvic pain.

Sonographically guided therapeutic aspiration of benign-appearing ovarian cysts and endometriomas

OBJECTIVE

The purpose of this study was to investigate the feasibility of therapeutic aspiration of symptomatic benign-appearing ovarian cysts and to show that endometriomas can be successfully aspirated when aspirated in conjunction with hormonal suppression therapy.

MATERIALS AND METHODS

Forty-three women referred for sonographically guided aspiration of symptomatic ovarian cysts were considered for the study cohort. Criteria for selection included sonographic changes consistent with a simple cyst (n = 32) or endometrioma (n = 9). In two patients, sonography revealed cysts suggestive of malignancy, and these patients were therefore excluded. Seven of the patients were pregnant. Forty-nine aspirations were attempted in 41 patients, 14 using a transabdominal approach and 35 transvaginal. Forty-eight aspirations were successful, and one attempted aspiration was technically unsuccessful. After aspiration, hormonal suppression therapy was recommended for all patients who had endometriomas.

RESULTS

Of the 40 patients who successfully underwent aspiration, all experienced relief from symptoms immediately after aspiration. Eleven of the 40 patients eventually experienced recurrence of symptoms. The overall recurrence rate was 27.5%. The recurrence rate for benign-appearing cysts was 16.1%. None of the seven pregnant patients had recurrence of symptoms. The recurrence rate for endometriomas was 66.6%; however, only one of these nine patients complied with hormonal suppression therapy. Those who did ultimately comply after undergoing a second aspiration experienced sustained relief of symptoms.

CONCLUSION

Sonographically guided therapeutic aspiration of symptomatic ovarian cysts is a viable alternative to surgical extirpation, even in pregnant women. Aspiration of endometriomas may alleviate symptoms when hormonal suppression therapy is also instituted.

Ovarian abscess after ovum retrieval for in-vitro fertilization

An ovarian abscess is an uncommon surgical emergency that could be lethal. The causes of an ovarian abscess vary, and treatment thereof may unfortunately lead to an oophorectomy. In order to draw the attention of physicians to this rare entity, we present a case of ovarian abscess resulting from follicle aspiration for in-vitro fertilization. Furthermore, with correct preoperative diagnosis and prompt surgical intervention at an early stage, the affected ovary may be salvageable.

Massive bilateral ovarian edema: report of 2 cases

PURPOSE OF INVESTIGATION

Diagnostic and therapeutic approaches in two cases of bilateral massive ovarian edema were evaluated.

METHODS

Two cases were retrospectively evaluated with the help of the medical reports.

RESULTS

Both patients presented with left lower abdominal quadrant pain. Cystic pelvic masses were detected during abdomino-pelvic examination and confirmed with transabdominal ultrasonography. There were no abnormal laboratory results. Explorative laparotomy was performed with the diagnosis of torsion or rupture of ovarian tumor. Bilateral wedge resection with subsequent frozen section was performed. The final pathology was reported as bilateral massive ovarian edema.

CONCLUSION

A diagnostic bilateral wedge resection with subsequent frozen section is essential in the management and confirmation of the diagnosis. As the vast majority of the cases are young, a conservative surgical management is mandatory to preserve ovarian function.

Medically sound, cost-effective treatment for pelvic inflammatory disease and tuboovarian abscess

OBJECTIVE

Our purpose was to determine the clinical effectiveness and cost-effectiveness of three antibiotic regimens for the treatment of pelvic inflammatory disease and tuboovarian abscess.

STUDY DESIGN

A review of all patients' hospitalized at Hutzel Hospital, Detroit, Michigan, for treatment of pelvic inflammatory disease and tuboovarian abscess between Jan. 1, 1993, and April 30, 1997, was performed. Demographic data, antibiotic choices, changes in therapy, operative interventions, and cost of therapy were assessed.

RESULTS

Two hundred three patients were admitted for treatment of pelvic inflammatory disease during the study period. We were able to evaluate the clinical efficacy of antibiotic treatment in 179 patients, including 105 patients with pelvic inflammatory disease alone (uncomplicated pelvic inflammatory disease) and 74 women whose infection was complicated by tuboovarian abscess. The three antibiotic regimens evaluated were cefotetan plus doxycycline, clindamycin plus gentamicin, and ampicillin plus clindamycin plus gentamicin. All regimens demonstrated comparable efficacy in treating uncomplicated genital tract infections. Ampicillin plus clindamycin plus gentamicin was significantly better than clindamycin plus gentamicin and cefotetan plus doxycycline in treatment of tuboovarian abscess (p = 0.001). Fifteen women with tuboovarian abscess responded to a change to ampicillin plus gentamicin plus clindamycin antibiotic therapy alone. The hospital stay was prolonged by approximately 3 days in women failing to respond to initial antibiotic therapy, and operative interventions were common in this group of patients.

CONCLUSIONS

Cefotetan plus oral doxycycline is the most cost-effective regimen for treating uncomplicated pelvic inflammatory disease, whereas triple-antibiotic therapy is the treatment of choice in women with tuboovarian abscess.

Transvaginal ultrasonographically controlled aspiration of ovarian endometriomas

Evaluation of the results of the fine needle ultrasonographically directed aspiration of ovarian endometriomas in relation to the efficacy of aspiration of the content, invasiveness, recurrences and complications. The investigation included 30 patients--28 with unilateral and 2 with bilateral ovarian endometriosis in whom 36 aspirations have been performed. Total evacuation of the content was achieved during the first effort in 26 patients versus 4 patients in whom a repeated procedure had to be done. All the patients were controlled during the 1 year post-aspiration period, on average. The recurrence rate was 56.66%. Complications have not been recorded. The transvaginal ultrasonographic fine needle aspiration of the ovarian endometriomas is associated with a high incidence of recurrences but it proved to be a simple, safe, cheap and minimally invasive technique which can be repeated for several times if necessary, in selected patients.

Double oocyte aspiration may be a solution for empty follicle syndrome: case report

OBJECTIVE

To assess the possibility of salvaging the cycle in a case of empty follicle syndrome by scheduling a second retrieval.

SETTING

Miami IVF/Intracytoplasmic Sperm Injection Center, Alexandria, Egypt. It is a private center.

PATIENT(S)

A 24-year-old female with a 6-year history of primary infertility. Intracytoplasmic sperm injection was performed because of her partner's obstructive azoospermia. No oocytes could be retrieved despite normal ultrasonic and hormonal responses and the presence of 25 mature follicles.

INTERVENTION(S)

Serum hCG on the day of the first retrieval. A second dose of hCG was given after the first retrieval, and a second retrieval was scheduled 24 hours later.

MAIN OUTCOME MEASURE(S)

Number of oocytes retrieved, fertilization and cleavage rates, and pregnancy outcome.

RESULT(S)

Serum beta-hCG level on the day of the first retrieval was 300 IU/mL. Eleven oocytes were retrieved, (7 were metaphase II, 3 fertilized, and 2 cleaved) and two embryos were transferred. No pregnancy resulted.

CONCLUSION(S)

In a variant of empty follicle syndrome, the cycle could be salvaged by giving another dose of hCG and scheduling another retrieval 24 hours later.

Tubo-ovarian abscess caused by multidrug resistant Bacteroides gracilis

Bacteroides gracilis infections are very rare and have always been reported to have a polymicrobial etiology. The majority of these infections occur in the head and neck areas, the pleuropulmonary system, and the abdominal cavity. We report a case of tubo-ovarian abscess caused by B. gracilis. A literature search revealed no previous reports. Our patient, a 29-year-old woman, experienced fever and lower abdominal pain caused by a tubo-ovarian abscess. Her treatment consisted of surgical drainage and prolonged intravenous antibiotic therapy. Initial therapy with cefotaxime and metronidazole failed and she remained febrile after the laparotomy. Her clinical condition improved slowly after initiation of imipenem therapy. Culture of a pus specimen obtained during surgery yielded B. gracilis, which was resistant to imipenem but susceptible to clindamycin. Combination therapy with imipenem and clindamycin was then administered and she recovered completely. Clindamycin was subsequently prescribed for long-term bacterial suppression. The potential difficulties in treating B. gracilis infections were a major clinical concern in the treatment of this patient.

Non-operative management of idiopathic ovarian hemorrhage with massive intraabdominal hemorrhage

Although most previous reports recommended operative treatments for ovarian hemorrhages, management of idiopathic ovarian hemorrhage with massive intraabdominal hemorrhage has not been established yet. In order to evaluate effectiveness of non-operative management for idiopathic ovarian hemorrhage, 3 patients with idiopathic ovarian hemorrhage and massive intraabdominal hemorrhage (700-1,400 ml) were managed conservatively and monitored by ultrasonography. Non-operative management had successful results in two of the three patients and the other case showed a spontaneous hemostasis of ovarian bleeding at operation. As the first therapy for idiopathic ovarian hemorrhage without any severe complications, non-operative management should be chosen to avoid pelvic adhesions. 700-1,000 ml of intraabdominal hemorrhage were found to be naturally absorbed in a week by ultrasonography. This is the first to report that natural absorption of massive intraabdominal hemorrhage associated with idiopathic ovarian hemorrhage was captured in details by ultrasonography.

Decrease in the size of ovarian endometriomas during ovarian suppression in stage IV endometriosis. Role of preoperative medical treatment

OBJECTIVE

To evaluate the effect of hormonal suppression on the size of ovarian endometriomas and to develop a predictive model for changes in the size of these lesions.

STUDY DESIGN

The study consisted of 80 women of reproductive age with the diagnosis of stage IV pelvic endometriosis, according to the revised American Fertility Society (rAFS) classification, and included 48 women with endometriomas > or = 3 cm. After the initial laparoscopic and sonographic evaluation, ovarian suppression was achieved with either danazol or a gonadotropin-releasing hormone agonist (GnRH-a) for six months. In all patients, pretreatment and posttreatment pelvic sonograms were performed, and at the end of treatment residual disease was evaluated and resected by laparotomy or laparoscopy. Seven of 80 women with endometriomas > or = 3 cm had serial sonograms during the course of therapy. Serial pelvic sonograms in this subgroup were used to develop a statistical model for predicting the size of endometriomas after treatment. The model was then tested in another subgroup of 41 women with endometriomas > or = 3 cm.

RESULTS

At the end of treatment, there was a significant decrease in the r-AFS score in both the danazol and GnRH-a groups. Medical treatment facilitated surgical resection of residual disease and preservation of ovarian tissue. There was no difference in this respect between danazol and GnRH-a. Endometriomas decreased by 51% in both treatment groups. The predictive model, when tested on 41 patients, underestimated the actual change by 11%, but the difference was within the 95% confidence limits.

CONCLUSION

This study documented, for the first time, that ovarian endometriomas decrease in size during hormonal suppression. Both danazol and GnRH-a were equally effective.

Early ultrasound-guided transvaginal drainage of tubo-ovarian abscesses: a randomized study

A prospective study of 40 women diagnosed as suffering from tubo-ovarian abscesses was carried out in order to compare the outcome after treating these abscesses with intensive antibiotic therapy alone or in association with early ultrasound-guided vaginal drainage. Patients were assigned to two groups, distributed on a random basis, with a clinical and ultrasound diagnosis of tubo-ovarian abscess of less than 10 cm maximal diameter. Both groups received an antimicrobial combination of clindamycin and gentamicin. In the study group, we performed, in addition, early transvaginal drainage of the abscess. Both short-term (48-72 h) and medium-term (4 weeks) responses to the treatment were evaluated. In the study group we observed a favorable short-term response in 90% of the cases, whereas this was 65% in the control group. In the medium-term follow up, one patient in the study group and three in the control group had an adnexal mass on transvaginal sonography.

Sonographically guided aspiration: an alternative therapy for tubo-ovarian abscess

Our objective was to evaluate the role of single-step ultrasound-guided aspiration in conjunction with intracavitary antibiotic instillation for the treatment of tubo-ovarian abscess. Ten women with the clinical and sonographic diagnosis of tubo-ovarian abscess, who failed to respond to systemic antibiotic therapy, were treated by ultrasound-guided aspiration of the abscess followed by intracavitary instillation of a combination of antibiotics. All ten women improved clinically and none required surgery. The mean time from aspiration to hospital discharge was 3.1 days with mean duration of hospitalization 7.8 days. No major complications were observed. The average time interval between aspiration of the lesion and resolution on sonographic follow-up was 9.5 weeks. In three cases, pelvic inflammatory disease recurred, but none needed surgical intervention. The average follow-up period of the patients was 12 months. One-step sonographically guided aspiration of tubo-ovarian abscess followed by intracavitary antibiotic instillation may serve as an easy and safe alternative therapy in patients in whom treatment with systemic antibiotics has failed.

Use of a gonadotropin-releasing hormone agonist in the evaluation of postmenopausal virilization due to ovarian hyperthecosis. A case report

BACKGROUND

Hyperthecosis in a postmenopausal woman is a very rare cause of virilization, and only five cases have been reported previously.

CASE

A woman presented with a nine-year history of increasing hirsutism and a mild virilization beginning in the perimenopausal period. Initial androgen metabolite concentrations suggested attenuated late-onset adrenal hyperplasia, but a trial of dexamethasone treatment was ineffective. Subsequent use of leuprolide acetate resulted in a biochemical and clinical improvement in the signs and symptoms.

CONCLUSION

This case is unique because gonadotropin-releasing hormone agonist administration was utilized as both a diagnostic and therapeutic modality.

Malacoplakia. Two case reports and a comparison of treatment modalities based on a literature review

Malacoplakia is a rare infectious disease that has been almost exclusi vely reported in urology and pathology journals. We studied two cases of malacoplakia that were primarily referred to the department of internal medicine because of fever and abdominal masses. In one patient, malacoplakia was diagnosed in the unusual ovarian location, while in the other patient a large renal mass was found and ciprofloxacin therapy failed because of bacterial resistance. The clinical and radiologic appearance of malacoplakia often mimics that of a malignant tumor. The principal disorder is probably a monocytic-macrophagic bactericidal defect. A definitive diagnosis depends on microscopic detection of Michaelis-Gutmann bodies by means of von Kossa stain. We outlined treatment strategies on the basis of a review of the literature since 1981, which included 140 cases. If possible, immunosuppressive drugs should be stopped. Quinolone antibiotic treatment and surgical excision or incision and drainage lead to the highest cure rates (90% and 81%, respectively). Specific intracellular penetration of quinolone antibiotics is a possible reason for the higher cure rate achieved with these antibiotics. Bethanechol has been suggested to correct the supposed fundamental disturbance by increasing the intrecellular cyclic guanosine monophosphate concentration, but there is still no convincing evidence of its clinical efficacy.

The use of GnRH agonists in the treatment of endometriomas with or without drainage

To assess the efficacy of GnRH-agonist therapy in the treatment of endometriomas with or without surgical intervention, 26 women with laparoscopically proven endometriomas larger than 3 cm were recruited to the study. Fourteen women with 19 endometriomas (5 bilateral), had drainage of endometrioma at initial laparoscopy. After the procedure, ovarian suppression was done with GnRH-a therapy for 6 months. The second group which consisted of 12 women, had 17 endometriomas. No surgical procedure was performed. They received only GnRH-a therapy for 6 months. On repeat laparoscopy, in the first group, the rates of decrease in ovarian AFS scores of endometriomas and complete resolution were found as 100% and 37% respectively. In the second group the response was only 18% (p < 0.0001). It was concluded that drainage of the cyst (surgical therapy) combined with postoperative GnRH-a suppression is a better treatment modality than the use of GnRH-a (medical therapy) alone for endometriomas.

[Tubo-ovarian abscess. An analysis of 20 cases]

The authors make a 3-year retrospective analysis of the tubo-ovarian abscess cases admitted to the Gynecology Ward of Dr Alfredo da Costa Maternity Hospital. In the period studied (1991 through 1993) there were 20 such cases. The incidence in nulliparous patients was 25%. A significant percentage (30%) of the patients had recently undergone uterine instrumentation. A prior history of pelvic inflammatory disease was obtained in only 15% of the cases. In the IUD users the incidence of unilateral and bilateral abscesses was identical. Most patients (85%) became apyretic within 48 hours of instituting intravenous antibiotics. In most cases (90%) the patients underwent surgical therapy. The mean time elapsed between instituting antibiotics and the surgical procedure was 3 days. There was one case of intra-abdominal rupture of the abscess. Intraoperatively, an appendiceal abscess was found in 3 (15%) patients. In 30% of the cases a total hysterectomy with unilateral or bilateral adnexectomy was performed. One of the 2 (10%) patients treated solely with medical therapy presented abscess recurrence one month after hospital discharge. Although the management of tubo-ovarian abscesses has become more conservative it still includes, in most cases, surgical drainage or extirpation after appropriate antibiotic therapy.

Transvaginal ultrasound-guided aspiration in the treatment and follow-up of tubo-ovarian abscess: a report of two cases

Two cases of tubo-ovarian abscess are presented in this study; treatment and follow-up were undertaken by transvaginal ultrasound. Transvaginal ultrasound-guided aspiration with anti-microbial therapy may be a useful alternative for treatment of unruptured tubo-ovarian abscess.

Pasteurella multocida isolation from a tuboovarian abscess. A case report

BACKGROUND

Human infection with Pasteurella multocida occurs most commonly following a nonhuman animal bite wound or cat scratch, with local skin and soft tissue infections the most frequent posttraumatic manifestations. Genitourinary tract pathology attributable to this organism occurs infrequently, with only one previous reported case of P multocida infection presenting in the form of a tuboovarian abscess.

CASE

A 44-year-old woman with an acute abdomen underwent exploratory laparotomy, revealing a right-sided tuboovarian abscess. Following a total abdominal hysterectomy and bilateral salpingo-oophorectomy with a seven-day postoperative course of intravenous metronidazole, ampicillin and gentamicin, the patient was sent home on a regimen of cephradine, only to return with sepsis three days later. A course of intravenous aqueous penicillin sodium, metronidazole and cefotaxime was administered for the treatment of P multocida sepsis since this organism was identified in the intraoperative pelvic fluid culture 24 hours after the patient's initial discharge. After 13 days of the above regimen, the patient achieved full defervescence and was discharged on hospital day 15.

CONCLUSION

In the setting of a tuboovarian abscess, the clinician should consider P multocida as a potential etiologic agent, especially in a patient with extensive exposure to nonhuman animals. In the treatment of an acute adnexal infection secondary to this organism, one should employ perioperative therapy with the appropriate antibiotics for a duration of at least 14 days.

Ovarian disorders of pregnancy

Hormonal ovarian disorders are uncommon during pregnancy and present primarily as ovarian masses. The two most common conditions are luteomas and hyperreactio luteinalis. The most common clinical manifestation is maternal virilization, which occasionally affects the fetus also. Rarely, an acute abdomen can result from hemorrhage or torsion of the mass. Because most of the entities regress spontaneously following delivery, a conservative management approach that includes preserving the ovaries is warranted.

[Ovarian varicocele: percutaneous treatment. A preliminary note]

Incontinence of ovarian veins and development of adnexal varicosities (pelvic varicocele) seems to cause pelvic pain syndrome in about 50% of the cases. Whereas the diagnosis of male varicocele is usually clinical, the same diagnosis in a woman needs instrumental methods; therefore the number of diagnosed cases is lower than the real incidence of the disease. In the last 18 months 2 patients with ovarian varicocele and chronic pelvic pain have been successfully treated by percutaneous sclerotization of the gonadal veins with resolution of the pelvic pain syndrome. We preferred this interventional procedure to the surgical one, as is usually the case with male varicocele, where percutaneous therapy is considered the treatment of choice on the basis of long-term results, since its first attempt in 1977. Considering the effectiveness of this simple and non-surgical therapy for chronic pelvic pain, we stress the importance of correct and early diagnosis of pelvic varicocele.

Ovarian endometrial cysts: the role of gonadotropin-releasing hormone agonist and/or drainage

OBJECTIVE

To evaluate the role of GnRH agonist (GnRH-a) and/or drainage in the management of large endometriomas.

DESIGN

This prospective clinical study was conducted in a parallel and randomized design.

SETTING

Department of Gynecology, Cliniques Universitaires St. Luc, Brussels, Belgium.

PATIENTS

Eight infertile women with laparoscopically confirmed ovarian endometriotic cysts. After laparoscopic drainage of the ovarian cyst, patients were randomized. Patients in group I (n = 40) received no therapy. Patients in group II (n = 40) received GnRH-a therapy for 12 weeks. A second-look laparoscopy was performed after 12 weeks in each woman.

RESULTS

After drainage, a quick recurrence of the endometrial cyst was observed in only group I. Indeed, the score and the cyst size were similar to the values observed before the first laparoscopy. In group II, a significant decrease in score and cyst diameter was observed. Ovarian biopsies revealed significant reduction in the stromal vascularization and a significant reduction in the mitotic activity in the group of women treated with GnRH-a.

CONCLUSION

The quick recurrence of the ovarian cyst after drainage proved that drainage alone is ineffective. Drainage followed by GnRH-a was effective in the reduction of cyst size and the glandular mitotic activity.

Treatment of deeply infiltrating endometriosis

Deep endometriosis has been defined as endometriosis infiltrating deeper than 5 mm under the peritoneum. A model for the development and propagation of endometriosis is presented. Subtle and non-pigmented lesions are suggested to occur intermittently in all women. Infiltration occurs generally to a few millimeters of depth only, and these lesions become typical, burnt out lesions. In some 20% of women, severe endometriosis develops either as deeply infiltrating disease or as cystic ovarian disease. Arguments are given to consider deep endometriosis and cystic ovarian endometriosis as two specific entities of endometriotic disease. A possible causal relationship with dioxin pollution is discussed. Diagnosis of deep endometriosis is made by clinical examination and palpation during surgery. Clinical examination during menstruation and CA-125 concentrations in plasma are useful to help in the diagnosis of smaller deep lesions. Surgical excision can be carried out by laparoscopy, laparotomy or vaginally using sharp dissection, electrosurgery or with the use of a CO2 laser. Excision is the treatment of choice because of a high pregnancy rate, a complete cure of pain in most women, and a low recurrence rate. Medical treatment is probably less effective to treat infertility, but highly effective in relieving pelvic pain. Medical therapy, by luteinizing hormone-releasing hormone agonists, danazol, or gestrinone, also seems useful as a pretreatment for surgery. The choice of treatment will therefore depend on the local expertise with minimal invasive surgery, certainly if a first excision has been incomplete and pain symptoms recur.