Laparoscopic excision of posterior vaginal fornix in the treatment of patients with deep endometriosis without rectum involvement: surgical treatment and long-term follow-up

BACKGROUND

The objective of the study is to evaluate the short- and long-term efficacy of complete laparoscopic excision of deep endometriosis, without rectum involvement, with the opening and partial excision of the posterior vaginal fornix.

METHODS

Thirty-one patients were included in the study with symptomatic extensive disease including involvement of the cul-de-sac, rectovaginal space and posterior vaginal fornix without rectum involvement. Endoscopic surgery was performed with complete separation of rectovaginal space and in-block resection of the diseased tissue, opening and partial excision of the posterior vaginal fornix and vaginal closure either by laparoscopic or by vaginal route. Patients filled in questionnaires on pain before and 12, 24, 36, 48 and 60 months after surgical treatment.

RESULTS

No intraoperative complications were observed; 65% were free of analgesic on post-operative day 2, 38% had total remission of chronic pain and 22% were improved; 38% had total remission of dysmenorrhoea and 22% were improved; 45% had total remission of dyspareunia and 25% were improved. Follow-up improvement of symptoms was statistically significant and was maintained for 5 years without recurrence of the disease or repeated surgery (P < 0.001).

CONCLUSION

Complete surgical resection of deep infiltrative endometriosis with excision of the adjacent tissue of the posterior vaginal fornix improves quality of life with persistence of results for long time in patients not responsive to medical treatment.

Reduction of postoperative adhesions with an auto-crosslinked hyaluronan gel in gynaecological laparoscopic surgery: a blinded, controlled, randomized, multicentre study

BACKGROUND

Following myomectomy, postoperative adhesions occur in many patients with adverse effects on fertility. This study investigated the applicability, safety and efficacy of an auto-crosslinked hyaluronan gel in preventing adhesion formation after laparoscopic myomectomy.

METHODS

Fifty-two patients aged 22-42 years, undergoing surgery at four centres, were randomly allocated to receive either the gel or no adhesion prevention. The incidence and severity of postoperative adhesions were assessed laparoscopically after 12-14 weeks in a blinded, scored fashion. The primary efficacy variable was the presence/absence of postoperative adhesions at second-look.

RESULTS

A nonsignificantly higher proportion of patients receiving the gel were free from adhesions (13 of 21; 62%) compared with control patients (9 of 22; 41%), with a statistically significant difference between the severity of uterine adhesions at baseline and at second-look (0.3 +/- 0.9 versus 0.8 +/- 1.0, P < 0.05). In subjects undergoing myomectomy without concomitant surgery, the proportion of adhesion-free patients was 8 of 12 (67%) and 4 of 11 (36%) (not significant) in the gel and control groups, respectively, with a significant difference in the mean severity scores (P < 0.05). In subjects without uterine adhesions before myomectomy, 12 of 18 (67%) and 8 of 20 (40%) patients in the gel and control groups, respectively were adhesion-free (not significant), with a significant difference in the severity of uterine adhesions (P = 0.05).

CONCLUSIONS

Our results suggest that the auto-crosslinked hyaluronan gel may have a favourable safety profile and efficacious antiadhesive action following laparoscopic myomectomy.

A Comparison of the Cycle Control, Safety, and Efficacy Profile of a 21-Day Regimen of Ethinylestradiol 20??g and Drospirenone 3mg with a 21-Day Regimen of Ethinylestradiol 20??g and Desogestrel??150??g

OBJECTIVE

To compare the cycle control, efficacy, and safety of a new low-dose combined oral contraceptive containing ethinylestradiol 20mug and drospirenone 3mg with an established formulation containing ethinylestradiol 20mug and desogestrel 150mug.

METHODS

This was a randomized, open-label, parallel-group, multicenter study of healthy women (aged 18-35 years) over seven treatment cycles. Both combined oral contraceptives were administered once daily for 21 consecutive days followed by a 7-day hormone-free interval.

RESULTS

A total of 445 women were randomized to treatment; of these, 441 (ethinylestradiol 20mug/drospirenone 3mg, n = 220; ethinylestradiol 20mug/desogestrel 150mug, n = 221) went on to receive study medication. There was a trend towards reduced intracyclic bleeding with continued treatment in both treatment groups, consistent with clinical experience. Intracyclic bleeding was highest during the first treatment cycle in both treatment groups, but was generally much lower in subsequent cycles. More than 90% of women in each of the groups experienced withdrawal bleeding during the study. The duration of withdrawal bleeding remained fairly constant throughout the study. The maximum intensity was mainly bleeding, rather than spotting. Overall, cycle control, efficacy, and safety profiles were comparable between both groups. Adverse events were generally of mild-to-moderate intensity and were those typical of hormonal contraceptive use.

CONCLUSION

In conclusion, both ethinylestradiol 20mug/drospirenone 3mg and ethinylestradiol 20mug/desogestrel 150mug are effective and well tolerated contraceptives that provide good cycle control.

Does quantitative analysis of three-dimensional power Doppler angiography have a role in the diagnosis of malignant pelvic solid tumors? A preliminary study

OBJECTIVE

To investigate the role of a simplified method for the three-dimensional (3D) quantification of tumor vascularity in the differential diagnosis of solid pelvic masses.

METHODS

Twenty-four patients with a solid pelvic mass on B-mode ultrasound evaluation underwent 3D power Doppler evaluation before surgery. The volume of interest was obtained by drawing the largest section of the mass in three orthogonal planes. The following 3D vascular parameters were calculated for all patients: relative color, average color and flow measure. Receiver-operating characteristics curve analysis was used to choose the best cut-off value. The overall agreement between the test result and the actual outcome was calculated using kappa statistics.

RESULTS

Fifteen of 24 subjects were found to have pelvic malignancy. The relative color and the flow measure were significantly higher in malignant (9.7 (8.98) and 8.95 (8.78) (median (interquartile range (IQR)), respectively) than in benign masses (2 (4.42) and 1.79 (4.71), respectively; P < 0.05) but there was no difference in the average color. The best cut-off values of relative color and flow measure were 3.2 and 2.8, respectively. The use of relative color showed a sensitivity of 80% with a specificity of 67% with an overall agreement that was higher, though only marginally so, than that of qualitative 3D power Doppler (kappa = 0.47 and 0.44, respectively).

CONCLUSIONS

In a small group of pelvic masses that appear malignant on B-mode ultrasonography, the use of 3D quantification of tumor vascularity yields a diagnostic accuracy that is similar to that of subjective evaluation of vascularity. We suspect, however, that the quantitative method will produce more consistent results between operators.

Hemoglobin levels correlate with interleukin-6 levels in patients with advanced untreated epithelial ovarian cancer: role of inflammation in cancer-related anemia

Anemia occurs in more than 30% of patients with epithelial ovarian cancer before any surgery. High levels of proinflammatory cytokines and increased oxidative stress may contribute to the development of cancer-related anemia. We assessed a population of previously untreated patients with advanced epithelial ovarian cancer to evaluate whether there was a correlation between hemoglobin (Hb) and parameters of inflammation and oxidative stress, stage of disease, and performance status (PS). In 91 patients with epithelial ovarian cancer and 95 healthy women matched for age, weight, and height, levels of Hb, C-reactive protein (CRP), fibrinogen (Fbg), proinflammatory cytokines, leptin, reactive oxygen species (ROS), and antioxidant enzymes were assessed at diagnosis before treatment. The correlations between Hb, parameters of inflammation and oxidative stress, stage, and PS were evaluated. Hb levels were lower in patients with advanced epithelial ovarian cancer than in control subjects and inversely related to stage and PS. Hb negatively correlated with CRP, Fbg, interleukin 1beta (IL-1beta), IL-6, tumor necrosis factor alpha (TNFalpha), and ROS, and positively correlated with leptin and glutathione peroxidase (GPx). Multivariate regression analysis showed that stage and IL-6 were independent factors determining Hb values. This evidence suggests that anemia in epithelial ovarian cancer is common and its presence is related to stage of disease and markers of inflammation.

Ultrasonography and color Doppler-based triage for adnexal masses to provide the most appropriate surgical approach

OBJECTIVE

This study was undertaken to identify whether ultrasonography with color Doppler can identify and triage the patients with adnexal masses to the most appropriate surgical approach.

STUDY DESIGN

Four hundred fifty-three pelvic masses were included in the study and underwent ultrasonography before surgical treatment for adnexal masses. Masses that showed a typical benign pattern at B-mode ultrasonography (very low risk of malignancy) were treated by conventional laparoscopy without further evaluation. Masses that extended above the umbilicus were consider at very high risk and treated by laparotomy. All other adnexal masses were evaluated with power Doppler. Masses with central vascularization (high risk of malignancy) were submitted to laparotomy or laparoscopy with additional tools, whereas masses with peripheral or absent flow (low risk of malignancy) were submitted to conventional laparoscopy.

RESULTS

Among 284 very low-risk, 32 low-risk, 46 high-risk, 91 very high-risk masses, the rate of malignant masses were 0%, 0%, 52%, and 78%, respectively. The use of color Doppler increases the diagnostic accuracy of B-mode ultrasonography in the diagnosis of adnexal malignancies because of a significantly higher specificity (0.91 vs 0.82, P < .001).

CONCLUSION

The evaluation of vessel distribution by color Doppler seems a safe diagnostic procedure, permitting to treat by laparoscopy 91% of benign masses.

Low androgenization index in elderly women and elderly men with Alzheimer's disease

The authors investigated whether testosterone levels and testosterone availability differ between older lean subjects with and without Alzheimer's disease (AD). Sex hormone binding globulin (SHBG) and estradiol levels were higher, whereas the free androgenization index (FAI) was lower, in lean subjects with AD than in lean subjects without AD. Factors involved in the increase of SHBG secretion could have an important role in the lower testosterone availability of subjects with AD.

Puerperal vulvovaginal hematoma: sonographic findings with MRI correlation

Puerperal hematomas are a major complication of delivery. Little information about the role of sonography in the management of puerperal hematomas is available in the English literature. We report a case of a vulvovaginal hematoma that developed subsequent to vaginal delivery and that was managed conservatively using sonography. Our report includes the sonographic follow-up of the lesion with MRI correlation. The present case report suggests that sonography has a role in the detection and follow-up of the condition, with MRI providing a more detailed mapping of the lesion and excluding any retroperitoneal involvement.

Short-term variations in bone remodeling markers of an oral contraception formulation containing 3 mg of drospirenone plus 30 μg of ethinyl estradiol: Observational study in young postadolescent women

The clinical study of treated subjects and nontreated controls was made in healthy eumenorrheic young postadolescent women volunteers in the Department of Obstetrics and Gynaecology at Cagliari University, to investigate whether an oral contraceptive (OC) containing drospirenone (3 mg) plus ethinyl estradiol (30 microg) (DRSP+EE) can affect bone metabolism. Control group (n = 26) and OC group (n = 28) women did not differ in age, body mass index, waist-to-hip ratio and main outcome measures [urinary levels of deoxypyridinoline and pyridinoline, serum levels of osteocalcin, bone specific alkaline phosphatase (bSAP), total testosterone (total-T), sex hormone-binding globulin (SHBG), progesterone and bone mineral density (BMD) at the heel]. The control group was studied at the luteal phase (LP) during both the first and the sixth menstrual cycle; the OC group was studied during the first cycle at the LP, and on days 16-18 of the sixth cycle of DRSP+EE treatment. At the sixth cycle, in the control group, the main outcome measures did not change compared to baseline. In the OC group, deoxypyridinoline, pyridinoline, osteocalcin, bSAP, total-T and progesterone levels were reduced, whereas SHBG levels were increased. The BMD was unchanged compared to baseline. The results suggest that 6-month DRSP+EE treatment decreases bone turnover.

Role of transvaginal sonography in the diagnosis of peritoneal inclusion cysts

OBJECTIVE

The aim of this prospective study was to investigate the accuracy of B-mode transvaginal sonography alone and combined with color Doppler imaging and cancer antigen 125 (CA 125) plasma concentrations in differentiating peritoneal cysts from other adnexal masses.

METHODS

Between September 1999 and September 2003, 213 adnexal masses underwent transvaginal sonography combined with power Doppler evaluation. Plasma concentrations of CA 125 were measured before surgery. The sonographic suspicion of peritoneal cysts (the presence of a bizarre lump-shaped cyst with a thin wall and fine internal septations with or without an ovary suspended among adhesions) was then compared with the surgical diagnosis. The overall agreement between the sonographic test results and the surgical findings was calculated by the kappa index. The diagnostic value of each test was also evaluated with likelihood ratios (LRs).

RESULTS

Thirteen of 213 patients were found to have peritoneal cysts. Specificity and sensitivity of B-mode sonography for differentiating peritoneal cysts from other adnexal masses were 96% (95% confidence interval, 94%-97%) and 62% (95% confidence interval, 35%-83%), respectively. The value of the negative LR (0.40) indicated a good clinical test, whereas the positive LR (15) indicated an excellent test. Power Doppler imaging did not seem to increase the accuracy of B-mode transvaginal sonography (kappa = 0.51 and 0.52, respectively), nor did the association of CA 125 plasma concentration (kappa = 0.34).

CONCLUSIONS

Transvaginal sonography alone is a useful method for detection of peritoneal cysts.

[Duloxetine in the treatment of urinary incontinence in women]

Urinary incontinence is a disease able to decrease the quality of life of affected women. It shows a prevalence of about 35% among adult women. Pharmacological treatment can be used when pelvic floor muscle training has failed or when it could be better to postpone or avoid surgery. Duloxetine, a selective serotonin and noradrenaline reuptake inhibitor (SNRI), can act effectively in treating stress urinary incontinence.

Menopause induced by oophorectomy reveals a role of ovarian estrogen on the maintenance of pressure homeostasis

OBJECTIVES

Following spontaneous menopause women show a greater increase in systolic and diastolic blood pressure than men of the same age. The aim of the present study was to assess the effect of acute ovarian hormone withdrawal and replacement on blood pressure and forearm blood flow.

METHODS

We studied 18 fertile middle-aged normotensive women (48 +/- 1.5 years, range 46-51 years) 1 week prior and 1 month subsequent to bilateral oophorectomy by means of 24-h blood pressure monitoring and strain-gauge venous occlusion plethysmography. Eighteen subjects who had undergone hysterectomy with ovarian sparing, matched for age and biophysical characteristics, were used as a control group. All women were free from cardiovascular risk factors or disease.

RESULTS

Oophorectomy increased the mean values of 24 h (P < 0.001), daytime (P < 0.05), and nighttime (P < 0.01) diastolic blood pressure and nighttime systolic blood pressure (P < 0.01). Blood pressure increase was associated with a rise in forearm vascular resistance (P < 0.01). No significant changes in either blood pressure or forearm vascular resistance values were observed in hysterectomized women. In 16 oophorectomized women a 3-month estrogen replacement therapy (ERT) (17beta-estradiol, 100 mcg/day by transdermal patches) brought blood pressure and forearm vascular resistance values to a level comparable to that recorded before intervention.

CONCLUSIONS

Surgically-induced menopause causes an increase in peripheral vascular resistance and blood pressure suggesting a role of ovarian hormones in the homeostatic pressure modulation. Recovery of the baseline condition after ERT suggests that the accelerated increase in blood pressure after menopause is due to ovarian and above all estrogen insufficiency.

Psychological effect of the oral contraceptive formulation containing 3 mg of drospirenone plus 30 microg of ethinyl estradiol

OBJECTIVE

To investigate in healthy eumenorrheic young women whether an oral contraceptive (OC) containing drospirenone (DRSP) (3 mg) + ethinyl estradiol (EE) (30 microg) (DRSP + EE) could modify psychological symptoms and whether it could modify steroids interfering with the gamma-aminobutyric acid (GABA)-A receptors.

DESIGN

Clinical study of treated subjects and nontreated controls.

SETTING

Healthy volunteers in the Department of Obstetrics and Gynecology at Cagliari University.

PATIENT(S)

Control group (n = 12) and OC group (n = 10) women with similar age, body mass index, and main outcome measures.

INTERVENTION(S)

The control group was studied during the first menstrual cycle at the follicular phase (FP) and at the luteal phase (LP) and during the third cycle at the LP; the OC group was studied during the first cycle, as described above, and on day 16-18 of the third cycle of treatment with DRSP + EE.

MAIN OUTCOME MEASURE(S)

Psychometric scale (SCL-90), DHEAS, P, allopregnanolone (AP), and allotetrahydrodeoxy-corticosterone (THDOC).

RESULT(S)

SCL-90 and DHEAS did not vary throughout the menstrual cycle. P, AP, and THDOC values were higher during the LP than the FP. At the third cycle, in the control group the main outcome measures were similar to those at LP. In the OC group, the SCL-90 global score, the intensity of anxiety and phobic anxiety, the levels of anxiolytic steroids (P, AP, THDOC) and the anxiety-inducing steroid DHEAS were reduced.

CONCLUSION(S)

The results suggest beneficial effects of DRSP + EE on psychological symptoms by decreasing DHEAS.

The treatment of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is one of the most common endocrine disorders in women in reproductive age. As for the treatment of this disease the lack of a clear etiology for PCOS has led to a symptom-orientated treatment. However, the overall aims of treatment are to induce ovulation for women desiring conception, to reduce androgen levels, to reduce body weight and to reduce long-term health risks of diabetes mellitus and cardiovascular disease. Clomiphene citrate (CC) is recommended as first line treatment for induction of ovulation in patients with PCOS by virtue of its efficacy, safety, and ease of administration. Alternatives for CC-resistant patients include gonadotrophin therapy (better with low-dose step-up protocol) and laparoscopic ovarian diathermy. Recently, recombinant FSH (rFSH) has been introduced in clinical practice and it seems more effective than urinary FSH as demonstrated by a significantly higher number of follicles recruited and embryos obtained with a shorter treatment period. The addition of GnRH-agonist to the stimulation protocol for women affected by PCOS could reduce premature luteinization and increase cycle fecundity. Other drugs under investigation are metformin and cabergoline. Hirsutism is the manifestation of hyperandrogenemia in PCOS. The primary goal of the treatment of hirsutim is central or peripheral androgen suppression using 3 groups of drugs: inhibitors of androgen production (oral contraceptives, GnRH analogues), peripheral androgen blockers (cyproterone acetate, flutamide, finasteride and spironolactone), and insulin-sensitizing agents (metformin). Weight reduction and exercise could also improve not only menstrual disturbances and infertility, but also insulin resistance and its adverse metabolic con-sequences.

Observational study on the efficacy of tibolone in counteracting early carotid atherosclerotic lesions in postmenopausal women

OBJECTIVE

To study whether tibolone affects lipid profile and diffused intima media thickness (IMT) of the common carotid arteries (CCA) in postmenopausal women (PMW).

METHODS

Twenty-two PMW and 20 premenopausal women participated in the study. The PMW were randomly divided into 11 women who did not receive any treatment and 11 women who received tibolone (2.5 mg once a day).

RESULTS

After 6 months the treated women had lipoprotein(a) (Lpa), total-cholesterol (total-C), and LDL-cholesterol (LDL-C) levels lower than before, while in the non-treated women Lpa was increased. The IMT of CCA was unmodified in the treated women, whereas it increased in non-treated women.

CONCLUSIONS

This preliminary study suggests that a 6-month tibolone treatment could counteract the increase of the IMT of CCA observed in untreated PMW.

The diagnosis of functional ovarian cysts using transvaginal ultrasound combined with clinical parameters, CA125 determinations, and color Doppler

OBJECTIVES

To investigate the role of transvaginal ultrasound combined with clinical parameters, CA125 determinations, and color Doppler in the differentiation between functional cysts and other adnexal masses.

STUDY DESIGN

Two hundred and eighty-seven consecutive persistent adnexal masses were submitted to B-mode transvaginal ultrasonography associated with color and power Doppler imaging. Plasma CA125 concentrations were measured before surgery.

RESULTS

According to the obtained logistic regression equation, the presence of anechoic tumors without echogenic portions or septa and CA125 <25IU/ml was associated with a 75% probability of presence of follicular cysts. The visualization of fine trabecular jelly-like content or of a heterogeneous mass with hypoechoic content, absent or only peripheral arterial flow, and age <40 years was associated with a 56% probability of presence of luteal cysts.

CONCLUSIONS

Addition of findings to B-mode ultrasonography can help to differentiate functional cysts from other adnexal masses.

Glucose metabolism and insulin resistance in women with polycystic ovary syndrome during therapy with oral contraceptives containing cyproterone acetate or desogestrel

Oral contraceptives slightly deteriorate insulin sensitivity. The present study investigated whether they may further unbalance the glucose metabolism of lean women with polycystic ovary syndrome (PCOS). Women with PCOS were assigned to receive for 6 months the biphasic association of 40/30 micro g ethinyl estradiol (EE) and 25/125 micro g desogestrel (DSG; n = 10) or the monophasic association of 35 micro g EE and 2 mg cyproterone acetate (CPA; n = 10). Glucose tolerance was investigated by an oral glucose tolerance test (OGTT). Glucose utilization dependent [insulin sensitivity (SI)] or independent (Sg) of insulin was investigated by the minimal model method applied to a frequently sampled iv glucose tolerance test. EE/DSG increased the response of C peptide to OGTT (1413 +/- 113 vs. 2053 +/- 213 area under the curve; P < 0.009) and the C peptide/insulin ratio (0.085 +/- 0.01 vs. 0.134 +/- 0.01 area under the curve; P < 0.003). It also increased the Sg (0.026 +/- 0.002 vs. 0.034 +/- 0.003; P < 0.04) and decreased the SI (2.40 +/- 0.26 vs. 1.68 +/- 0.27; P < 0.01). EE/CPA did not modify responses to OGTT of glucose, insulin, C peptide, or C peptide/insulin ratio. It did not modify Sg and significantly increased SI (1.47 +/- 0.38 vs. 3.27 +/- 0.48; P < 0.04). The present study indicates that EE/CPA improves SI, whereas EE/DSG impairs SI, but improves insulin clearance. The long-term metabolic effects of these two compounds on women with PCOS require further investigations.