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Vercellini P, Salmeri N, Somigliana E, Piccini M, Caprara F, Viganò P, De Matteis S. Müllerian anomalies and endometriosis as potential explanatory models for the retrograde menstruation/implantation and the embryonic remnants/celomic metaplasia pathogenic theories: a systematic review and meta-analysis. Hum Reprod 2024:deae086. [PMID: 38733102 DOI: 10.1093/humrep/deae086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 04/05/2024] [Indexed: 05/13/2024] Open
Abstract
STUDY QUESTION Does endometriosis prevalence differ in patients with obstructive Müllerian anomalies (OMA) versus those with nonobstructive Müllerian anomalies (NOMA), and in patients with NOMA versus those without Müllerian anomalies? SUMMARY ANSWER The quantitative synthesis of published data demonstrates a substantially increased prevalence of endometriosis in patients with OMA compared with those with NOMA, and a similar prevalence in patients with NOMA and those without Müllerian anomalies. WHAT IS KNOWN ALREADY The pathogenesis of endometriosis has not been definitively clarified yet. A higher prevalence of endometriosis in patients with OMA than in those with NOMA would support the retrograde menstruation (RM)/implantation theory, whereas a higher prevalence of endometriosis in the NOMA group than in the group without Müllerian anomalies would support the embryonic remnants/celomic metaplasia hypothesis. STUDY DESIGN, SIZE, DURATION This systematic review with meta-analysis was restricted to full-length, English-language articles published in peer-reviewed journals between 1980 and 2023. The PubMed and EMBASE databases were searched using the keyword 'endometriosis' in combination with 'Müllerian anomalies', 'obstructive Müllerian anomalies', 'female genital malformations', 'retrograde menstruation', 'infertility', 'pelvic pain', and 'classification'. References from relevant publications were screened, and PubMed's 'similar articles' and 'cited by' functions were used. PARTICIPANTS/MATERIALS, SETTING, METHODS Studies were selected if they reported the prevalence of surgically confirmed endometriosis in either individuals with OMA compared to those with NOMA, or patients with NOMA compared to those without Müllerian anomalies. Cohort and case-control studies and case series were deemed eligible for inclusion. Noncomparative studies, studies not reporting both the number of individuals with endometriosis and the total number of those with Müllerian anomalies or with other gynecological conditions, those including exclusively data on patients with absent or uncertain menstrual function (e.g. complete Müllerian agenesis category), or with imperforate hymen were excluded. Two reviewers independently abstracted data. The risk of bias was assessed with the Risk of Bias In Non-randomized Studies of Exposures tool. The overall certainty of the evidence was graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines. MAIN RESULTS AND THE ROLE OF CHANCE Seven retrospective studies were included. The overall mean estimate of endometriosis prevalence was 47% (95% CI, 36-58%) in patients with OMA, and 19% (95% CI, 15-24%) in patients with NOMA, with a common odds ratio (OR) of 4.72 (95% CI, 2.54-8.77). The overall mean estimate of endometriosis prevalence in patients with NOMA was 23% (95% CI, 20-27%), and that in patients without Müllerian anomalies was 21% (95% CI, 20-22%), with a common OR of 0.95 (95% CI, 0.57-1.58). The overall certainty of the evidence according to GRADE guidelines was judged as low for both comparisons. LIMITATIONS, REASON FOR CAUTION Some NOMA subtypes may create a partial obstacle to menstrual efflux and/or generate dysfunctional myometrial contractions that favor transtubal reflux, thus increasing the risk of endometriosis and limiting the difference between OMA and NOMA. As infertility and pelvic pain are strongly associated with endometriosis, women with these symptoms are inappropriate controls. Confounding by indication could explain the lack of difference in endometriosis prevalence between patients with NOMA and those without Müllerian anomalies. WIDER IMPLICATIONS OF THE FINDINGS The results of this meta-analysis support the validity of the RM theory but do not definitively rule out alternative hypotheses. Thus, RM may be considered the initiator for the development of endometriotic lesions, while not excluding the contribution of both inheritable and tissue-specific genetic and epigenetic modifications as disease-promoting factors. STUDY FUNDING/COMPETING INTEREST(S) No funding was received for this review. P.Ve. is a member of the Editorial Board of Human Reproduction Open, the Journal of Obstetrics and Gynaecology Canada, and the International Editorial Board of Acta Obstetricia et Gynecologica Scandinavica; has received royalties from Wolters Kluwer for chapters on endometriosis management in the clinical decision support resource UpToDate; and maintains both a public and private gynecological practice. E.S. discloses payments from Ferring for research grants and honoraria from Merck-Serono for lectures. All other authors declare they have no conflict of interest. REGISTRATION NUMBER N/A.
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Affiliation(s)
- Paolo Vercellini
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi, Milano, Italy
- Department of Maternal, Infant, and Child Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Noemi Salmeri
- Department of Obstetrics and Gynaecology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Edgardo Somigliana
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi, Milano, Italy
- Department of Maternal, Infant, and Child Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Martina Piccini
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi, Milano, Italy
| | - Francesca Caprara
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi, Milano, Italy
| | - Paola Viganò
- Academic Center for Research on Adenomyosis and Endometriosis, Department of Clinical Sciences and Community Health, Università degli Studi, Milano, Italy
- Department of Maternal, Infant, and Child Health, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sara De Matteis
- Department of Obstetrics and Gynaecology, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Health Sciences, Università degli Studi, ASST Santi Paolo e Carlo, Milano, Italy
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Bunnell ME, Cipres DT, Laufer MR. Case Series of Reproductive Outcomes after Surgical Correction of Obstructed Hemivagina in OHVIRA. AJP Rep 2024; 14:e26-e30. [PMID: 38269126 PMCID: PMC10805572 DOI: 10.1055/a-2208-0032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 10/19/2023] [Indexed: 01/26/2024] Open
Abstract
Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) is a rare congenital developmental syndrome manifested by uterine duplication, lower genital tract obstruction, and unilateral renal anomaly. Literature on reproductive outcomes in this patient population is limited. The aim of this study is to describe obstetric outcomes after surgical correction of obstructed hemivagina in a longitudinal cohort of patients with a diagnosis of OHVIRA. All cases of OHVIRA presenting to a single tertiary care children's hospital from 1990 to 2021 were retrospectively reviewed. Three cases demonstrating a variety of clinically important reproductive outcomes are described in detail including risks such as retained products, endometritis, preterm labor, and malpresentation. Understanding the reproductive outcomes associated with this diagnosis is important for practitioners seeking to counsel and care for patients with this diagnosis. This case series demonstrates a wide array of potential gynecologic and obstetric risks, though ultimately with successful term and near-term pregnancies.
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Affiliation(s)
- Megan E. Bunnell
- Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Danielle T. Cipres
- Department of Pediatric and Adolescent Gynecology, Boston Children's Hospital, Boston, Massachusetts
| | - Marc R. Laufer
- Department of Pediatric and Adolescent Gynecology, Boston Children's Hospital, Boston, Massachusetts
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Murphy C, Wilcox A, Vash-Margita A. Diagnostic and surgical approaches to congenital uterine anomalies for the minimally invasive gynecologic surgeon. Curr Opin Obstet Gynecol 2023; 35:328-336. [PMID: 37266575 DOI: 10.1097/gco.0000000000000886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
PURPOSE OF REVIEW Congenital uterine anomalies (CUAs) impact the physical and psychosocial wellbeing of affected patients. Managing these conditions depends on the clinical scenario, and in some cases, can involve the use of minimally invasive surgical techniques. The purpose of this review is to provide an update of the diagnosis, perioperative considerations, and treatment of CUAs. RECENT FINDINGS The American Society for Reproductive Medicine (ASRM) updated the guidelines for classification of CUAs to provide practitioners with a standardized classification system and have created an interactive tool designed for provider use. SUMMARY Gynecologic surgeons are likely to encounter CUAs during their career. This review provides updated guidance for the workup and treatment of CUAs.
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Affiliation(s)
| | | | - Alla Vash-Margita
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut, USA
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Kapczuk K, Zajączkowska W, Madziar K, Kędzia W. Endometriosis in Adolescents with Obstructive Anomalies of the Reproductive Tract. J Clin Med 2023; 12:jcm12052007. [PMID: 36902794 PMCID: PMC10003989 DOI: 10.3390/jcm12052007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 02/14/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND This study aimed to assess the prevalence and course of endometriosis in adolescents with obstructive Müllerian anomalies. METHODS The study group involved 50 adolescents undergoing surgeries (median age 13.5 (range 11.1-18.5)) for rare obstructive malformations of the genital tract: 15 girls had anomalies associated with cryptomenorrhea and 35 were menstruating. The median follow-up period was 2.4 (ranging from 0.1 to 9.5) years. RESULTS We diagnosed endometriosis in 23 of the 50 subjects (46%), including 10 of the 23 patients (43.5%) with obstructed hemivagina ipsilateral renal anomaly syndrome (OHVIRAS), six of eight patients (75%) with a unicornuate uterus with a non-communicating functional horn, two of three patients (66.7%) with distal vaginal aplasia, and five of five patients (100%) with cervicovaginal aplasia. Persistent dysmenorrhea, following treatment, affected 14 of the 50 adolescents (28%), including 8 of the 17 subjects (47.1%) diagnosed with endometriosis at the time of surgical correction and six adolescents diagnosed with endometriosis during the follow-up. CONCLUSIONS Endometriosis affects about half of young adolescents undergoing surgical treatment of obstructive Müllerian anomalies after menarche. The incidence of endometriosis is highest in girls with cervical aplasia. The risk of developing endometriosis decreases after surgical correction of obstruction but is still significant in patients with uterine anomalies.
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Affiliation(s)
- Karina Kapczuk
- Division of Gynecology, Poznan University of Medical Sciences, Polna 33, 60-535 Poznan, Poland
- Correspondence: or
| | - Weronika Zajączkowska
- Gynecology and Obstetrics Clinical Hospital of Poznan University of Medical Sciences, Polna 33, 60-535 Poznan, Poland
| | - Klaudyna Madziar
- Division of Gynecology, Poznan University of Medical Sciences, Polna 33, 60-535 Poznan, Poland
| | - Witold Kędzia
- Division of Gynecology, Poznan University of Medical Sciences, Polna 33, 60-535 Poznan, Poland
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Zarfati A, Lucchetti MC. OHVIRA (Obstructed Hemivagina and Ipsilateral Renal Anomaly or Herlyn-Werner-Wunderlich syndrome): Is it time for age-specific management? J Pediatr Surg 2022; 57:696-701. [PMID: 35487798 DOI: 10.1016/j.jpedsurg.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/18/2022] [Accepted: 04/04/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND OHVIRA (Obstructed Hemivagina and Ipsilateral Renal Anomaly or Herlyn-Werner-Wunderlich syndrome) is a rare Müllerian malformation. Usually, symptoms begin with worsening dysmenorrhea in post-menarche adolescents. The management in pre-menarche period is controversial and has only recently been subject of study. AIMS To review the experience of a pediatric tertiary center and to propose an age-specific management protocol for patients diagnosed before menarche. METHODS A retrospective cohort study (review of medical records - period 2009-2021). RESULTS Twenty-eight patients were diagnosed (mean age 11.9 years), seven (25%) before menarche, one (3%) perinatally. One patient had Floating-Harbor syndrome. Twenty-three patients had ipsilateral renal agenesis, while five had a multicystic-dysplastic kidney. The contralateral kidney showed hypertrophy in 25 patients, pelvicalyceal ectasia in 8 and dysplasia in 1. Twenty-four patients were symptomatic. Three of the seven diagnosed prior to menarche had symptoms. All post-menarche diagnosed patients were symptomatic. Twenty-six patients underwent surgery (one-stage drainage, vaginal septal resection, and vaginoplasty). Asymptomatic pre-menarche patients were followed-up until surgery after menarche onset. No patient underwent surgery prior to menarche solely for OHVIRA diagnosis. At follow-up (median 3.5 years, 3 lost to follow-up), eighteen patients were asymptomatic, one developed endometriosis, one had impaired renal function, two needed reoperations. CONCLUSIONS Pre-menarche OHVIRA patients, without symptoms, should undergo regular follow-up until the onset of menarche. Surgery must be considered in post-menarche or symptomatic patients. Post-operative, long-term follow-up is required, evaluating both renal and gynecological issues. LEVEL-OF-EVIDENCE IV.
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Affiliation(s)
- Angelo Zarfati
- Department of Pediatric Surgery, Bambino Gesù Pediatric Hospital, Piazza di Sant'Onofrio, 4, Roma 00165, Italy; University of Rome Tor Vergata, Via Cracovia, 50, Roma 00133, Italy.
| | - Maria Chiara Lucchetti
- Department of Pediatric Surgery, Bambino Gesù Pediatric Hospital, Piazza di Sant'Onofrio, 4, Roma 00165, Italy
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A case report: Common channel anomaly with vaginal agenesis and rectal stone after posterior sagittal anorectoplasty (PSARP). Int J Surg Case Rep 2021; 83:106032. [PMID: 34090199 PMCID: PMC8182425 DOI: 10.1016/j.ijscr.2021.106032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 05/22/2021] [Accepted: 05/23/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction and importance We reported a case of common channel anomaly complicated with vaginal agenesis and rectal stone, which is a long-term complication of PSARP, a combination of very rare conditions with high morbidity and especially difficult treatment. Presentation of case A 15-year-old female presented with a chief complaint of cyclic abdominal pain. The patient had no history of menstruation before. Physical examination showed a common channel. The diameter of the common channel was approximately 1 cm and 0.3 cm in length. A sound (±2 mm thickness) was inserted to the small opening between the urethra and anal mucosa with the length of the canal 6 cm. At the end of the opening, a stone-like structure was felt. The management of this case was abdominal hysterectomy with right salpingectomy and stone evacuation. Discussion Cloacal malformation is thought to be associated with vaginal agenesis since both malformations are considered to have a similar pathophysiologic background. Treatment can be performed using posterior sagittal combined with laparotomy approach. After surgery, patients will need a long-term follow-up since the conditions may be associated with many possible urologic and gynecologic comorbidities, including recurrent urinary tract infections, hematosalpinx, and vesicourethral reflux, including stone formation. Conclusion Our case was considered one of the most complex common channel anomalies because it was complicated with a rare condition called vaginal agenesis and rectal stone after PSARP. A multidiscipline approach was necessary. Common channel anomaly with vaginal agenesis and rectal stone after PSARP is a complex rare condition. Requiring multiple diagnostic modalities Multidiscipline approach was needed.
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Liu D, Yang N, Liang Y, Chen M, Yang F, Liu L, Yao S. Increased expression of epithelial cell adhesion molecule and its possible role in epithelial-mesenchymal transition in endometriosis. J Obstet Gynaecol Res 2020; 46:2066-2075. [PMID: 32715572 DOI: 10.1111/jog.14401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 05/17/2020] [Accepted: 06/28/2020] [Indexed: 12/19/2022]
Abstract
AIM To study the involvement and interrelationship of epithelial cell adhesion molecule (EpCAM) and epithelial-mesenchymal transition (EMT) in endometriosis. METHODS Samples from 114 patients undergoing endometrial biopsy or operation for endometriosis and 23 premenopausal women undergoing endometrial biopsy for non-endometriotic benign disease. Immunohistochemistry was used to detect expression level of EpCAM, E-cadherin and N-cadherin in endometrium from patients with (n = 24) and without endometriosis (n = 23), and in lesions from bowel (n = 46), peritoneal (n = 20) and ovarian (n = 24) endometriosis. RESULTS There was no significant difference in the expression level of EpCAM, E-cadherin and N-cadherin, respectively, between endometrium from women with and without endometriosis (P > 0.05). There was also no significant difference in the expression level of EpCAM, E-cadherin and N-cadherin, respectively, among lesions from the bowel, peritoneal and ovarian endometriosis (P > 0.05). We found that the immunoreactivity of endometriotic epithelial cells to EpCAM and N-cadherin was significantly higher than that of eutopic endometrium, but decreased to E-cadherin (P < 0.05). According to the expression level of EpCAM, the expression level of E-Cadherin was significantly lower in endometriotic lesions with EpCAM expression above the mean level compared with that of endometriotic lesions with EpCAM expression below mean level, while the expression level of N-cadherin was contrary (P < 0.001). EpCAM staining level was negatively correlated with E-cadherin but positively correlated with N-cadherin (P < 0.001). CONCLUSIONS These data suggest that overexpression of EpCAM, accompanied by an EMT, might be involved in endometriosis. EMT may be induced by the overexpression of EpCAM, thus promoting the development of endometriosis, which needs future studies to confirm for the pathogenesis of endometriosis.
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Affiliation(s)
- Duo Liu
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Na Yang
- Department of Operating Room, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Yanchun Liang
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Ming Chen
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Fan Yang
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Lin Liu
- Department of Clinical Research, Yangtze River Pharmaceutical Group, Taizhou, China
| | - Shuzhong Yao
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
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Abstract
The association between obstructed müllerian duct anomalies and endometriosis has been well established and the pathogenesis is attributed to the theory of retrograde menstruation. However, this relationship with endometriosis is less clear in women with unobstructed müllerian duct anomalies and in those with rudimentary uterine structures that lack functioning endometrial tissue. This article reviews the embryology, genetics, pathophysiology, and American Society for Reproductive Medicine (ASRM) classification for müllerian duct anomalies together with the genetics and pathophysiology of endometriosis to provide a framework for understanding the complex relationship between these two entities. Available published data examining the coexistence of endometriosis in relationship to müllerian duct anomalies, including studies that stratify this relationship according to specific classes of anomalies, are reviewed and organized. Awareness of the increased prevalence of endometriosis among patients with uterine anomalies, particularly those with outflow obstruction, may facilitate early diagnosis of endometriosis and subsequent intervention, with the potential to reverse disease symptoms and arrest disease progression.
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Abstract
Congenital gynecologic anomalies result from interruption of embryologic development of the female reproductive tract. The anomalies may be hymenal, vaginal, cervical, or uterine. The impact of these anomalies is variable: some are asymptomatic, incidental findings that require no intervention, others require simple surgical management, while some complex anomalies may require a multidisciplinary approach with extensive surgical expertise for optimal outcomes. Uterovaginal anomalies may occur in isolation or in association with other malformations, such as renal anomalies. The origin, presentation, evaluation and treatment of these conditions are reviewed here.
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Management of Acute Obstructive Uterovaginal Anomalies: ACOG Committee Opinion, Number 779. Obstet Gynecol 2020; 133:e363-e371. [PMID: 31135762 DOI: 10.1097/aog.0000000000003281] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Obstructive uterovaginal anomalies may present after puberty with amenorrhea, dysmenorrhea, pelvic pain, recurrent vaginal discharge, or infertility. The evaluation of a patient with a suspected obstructive reproductive anomaly should include a detailed medical history, physical examination, and imaging. The genital examination is critical to differentiate a patient with an imperforate hymen from a patient with labial adhesions, urogenital sinus, transverse vaginal septum, or distal vaginal atresia. Pelvic ultrasonography is the initial imaging method recommended for a patient with cyclic pain and amenorrhea or a patient with persistent dysmenorrhea. It is important to note that diagnosis of a uterine or vaginal anomaly by imaging before puberty can be challenging and misleading because of the small size of the prepubertal uterus and the lack of endometrial stimulation and menstrual distention of the vagina. Consultation with a radiologist experienced with imaging of uterovaginal anomalies may be helpful to determine the most accurate diagnosis. In general, obstructive vaginal and uterine anomalies are not surgical emergencies, and the complexities of these conditions are best managed by gynecologic care providers familiar with the surgical management of these conditions. Given the high risk of stenosis and complications associated with transverse vaginal septum, distal vaginal atresia, and cervical atresia, referral to a center with expertise in the management of these anomalies is paramount. The best long-term outcome is achieved with a complete evaluation, clear understanding of the anomaly, mobilization of appropriate surgical resources, sufficient preoperative counseling, and planned surgical intervention.
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Abstract
At puberty, a patient with an imperforate hymen typically presents with a vaginal bulge of thin hymenal tissue with a dark or bluish hue caused by the hematocolpos behind it. Other findings that may be present include an abdominal mass, urinary retention, dysuria, constipation, and dyschezia. On evaluation, the goal is to differentiate an imperforate hymen from other obstructing anatomic etiologies, such as labial adhesions, urogenital sinus, transverse vaginal septum, or distal vaginal atresia. Surgical intervention is necessary only in symptomatic prepubertal patients. After confirmation of the diagnosis, surgical intervention usually is deferred until pubertal estrogenization has occurred because the imperforate hymen may open spontaneously at puberty. It is important to complete an abdominal and a perineal examination. If the physical examination reveals a bulging hymen and ultrasonography reveals hematocolpos, further imaging is not required. However, if the diagnosis is not certain or there is a concern for a distal vaginal atresia, cervical atresia, an obstructed uterine horn, or transverse or longitudinal vaginal septum, magnetic resonance imaging is recommended. The ideal time for surgical intervention on hymenal tissue is before the onset of pain and after onset of pubertal development, when the vaginal tissue is estrogenized. Surgical management of clinically significant hymenal variations involves excision of the hymenal tissue and rarely is associated with long-term sequelae. If there is concern that the patient has a distal vaginal atresia or a transverse vaginal septum, the patient should be referred to a center with expertise in the management of these conditions.
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Stewart B, Reddington C, Cameron M. Laparoscopic Hemihysterectomy for Obstructive Uterine Didelphys with Unilateral Vaginal Hypoplasia. J Minim Invasive Gynecol 2020; 27:1225-1227. [PMID: 31917329 DOI: 10.1016/j.jmig.2019.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 12/31/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Bridie Stewart
- Department of Gynaecology, The Royal Women's Hospital, Parkville, Victoria, Australia (all authors)..
| | - Charlotte Reddington
- Department of Gynaecology, The Royal Women's Hospital, Parkville, Victoria, Australia (all authors)
| | - Melissa Cameron
- Department of Gynaecology, The Royal Women's Hospital, Parkville, Victoria, Australia (all authors)
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ACOG Committee Opinion No. 760: Dysmenorrhea and Endometriosis in the Adolescent. Obstet Gynecol 2018; 132:e249-e258. [DOI: 10.1097/aog.0000000000002978] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kapczuk K, Friebe Z, Iwaniec K, Kędzia W. Obstructive Müllerian Anomalies in Menstruating Adolescent Girls: A Report of 22 Cases. J Pediatr Adolesc Gynecol 2018; 31:252-257. [PMID: 29030159 DOI: 10.1016/j.jpag.2017.09.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 09/26/2017] [Accepted: 09/28/2017] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE To assess the clinical course of obstructive Müllerian anomalies found in girls after menarche. DESIGN A retrospective case series of adolescents who, between 2009 and 2016, were treated for vaginal or uterine obstructive malformations diagnosed after menarche. SETTING Division of Gynecology, Poznań University of Medical Sciences, Poznań, Poland. PARTICIPANTS AND INTERVENTIONS Twenty-two patients who, at the age range between 11.4 and 18.2 (median, 13.1) years, between 2 and 74 (median 7.5) months after menarche, underwent surgical repair of obstructive genital anomaly. MAIN OUTCOME MEASURES Müllerian defect type, presentation, radiologic findings, pre- and postoperative course. RESULTS Eighteen patients (18 of 22; 81.8%) were diagnosed with obstructed hemivagina ipsilateral renal anomaly syndrome. One patient (1 of 22; 4.5%) was diagnosed with uterus didelphys and unilateral cervical atresia. Three patients (3 of 22; 13.6%) had unicornuate uterus with a cavitated, noncommunicating rudimentary horn. The right side was affected in 13 patients (13 of 22; 59.1%), and the left side in 9 patients (9 of 22; 40.9%; P > .05). All but 1 patient had renal agenesis on the side of obstruction. Before repair of the obstructive genital anomaly, 4 patients underwent unnecessary surgeries for misdiagnosed ovarian cysts. Serious complications (pelvic inflammatory disease, vesicovaginal fistula) occurred in 2 patients with microperforated pyocolpos. Pelvic endometriosis was found in 4 of our patients. CONCLUSION Our case series suggests that obstructed hemivagina ipsilateral renal anomaly syndrome is the most common obstructive Müllerian anomaly diagnosed in adolescents after menarche. The differential diagnosis for unilateral kidney agenesis accompanied by dysmenorrhea in adolescent girls should include obstructive genital tract anomaly. Accurate diagnosis of an obstructive genital anomaly early after menarche might help prevent unnecessary surgeries and infection-related complications. Meanwhile, prompt surgical correction of an obstructive genital tract anomaly results in relief of symptoms and might reduce the risk of endometriosis.
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Affiliation(s)
- Karina Kapczuk
- Division of Gynecology, Department of Perinatology and Gynecology, Poznań University of Medical Sciences, Poznań, Poland.
| | - Zbigniew Friebe
- Division of Gynecology, Department of Perinatology and Gynecology, Poznań University of Medical Sciences, Poznań, Poland
| | - Kinga Iwaniec
- Division of Gynecology, Department of Perinatology and Gynecology, Poznań University of Medical Sciences, Poznań, Poland
| | - Witold Kędzia
- Division of Gynecology, Department of Perinatology and Gynecology, Poznań University of Medical Sciences, Poznań, Poland
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Boujenah J, Salakos E, Pinto M, Shore J, Sifer C, Poncelet C, Bricou A. Endometriosis and uterine malformations: infertility may increase severity of endometriosis. Acta Obstet Gynecol Scand 2016; 96:702-706. [PMID: 27861710 DOI: 10.1111/aogs.13040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 10/09/2016] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The aim of our study was to compare the stage and severity of endometriosis in fertile and infertile women with congenital uterine malformations. MATERIAL AND METHODS We performed an observational study from September 2007 to December 2015 in a tertiary care university hospital and assisted reproductive technology center. A total of 52 patients with surgically proven uterine malformations were included. We compared 41 infertile patients with uterine malformations with 11 fertile patients with uterine malformation. The main outcome was the stage, score and type of endometriosis in regard to infertility and class of uterine malformation. RESULTS The rate of endometriosis did not differ between the two groups (43.9 vs. 36.4%). The mean revised American Fertility Society score was higher in infertile patients with uterine malformations (19.02 vs. 6, p < 0.05). No significant difference was found in the rate of superficial peritoneal endometriosis (43.9 vs. 37.5%). Endometrioma and deep infiltrating endometriosis were associated with uterine malformations in infertile women, respectively 14.6 and 0%. No difference in the characteristics of endometriosis was found regarding the class of malformation. CONCLUSIONS The association of uterine malformations and infertility may increase the severity of endometriosis and raise the issue of their diagnosis and management.
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Affiliation(s)
- Jeremy Boujenah
- Department of Obstetrics, Gynecology and Reproductive Medecine, University Hospitals Paris Seine-Saint-Denis, Public Assistance Hospitals Paris, CHU Jean Verdier, Bondy, France.,University Paris 13, Sorbonne Paris City, UFR SMBH, Bobigny, France
| | - Eleonora Salakos
- Department of Obstetrics, Gynecology and Reproductive Medecine, University Hospitals Paris Seine-Saint-Denis, Public Assistance Hospitals Paris, CHU Jean Verdier, Bondy, France
| | - Mélodie Pinto
- Department of Obstetrics, Gynecology and Reproductive Medecine, University Hospitals Paris Seine-Saint-Denis, Public Assistance Hospitals Paris, CHU Jean Verdier, Bondy, France
| | - Joanna Shore
- Department of Obstetrics, Gynecology and Reproductive Medecine, University Hospitals Paris Seine-Saint-Denis, Public Assistance Hospitals Paris, CHU Jean Verdier, Bondy, France
| | - Christophe Sifer
- Department of Obstetrics, Gynecology and Reproductive Medecine, University Hospitals Paris Seine-Saint-Denis, Public Assistance Hospitals Paris, CHU Jean Verdier, Bondy, France.,University Paris 13, Sorbonne Paris City, UFR SMBH, Bobigny, France
| | - Christophe Poncelet
- Department of Obstetrics, Gynecology and Reproductive Medecine, University Hospitals Paris Seine-Saint-Denis, Public Assistance Hospitals Paris, CHU Jean Verdier, Bondy, France.,University Paris 13, Sorbonne Paris City, UFR SMBH, Bobigny, France
| | - Alexandre Bricou
- Department of Obstetrics, Gynecology and Reproductive Medecine, University Hospitals Paris Seine-Saint-Denis, Public Assistance Hospitals Paris, CHU Jean Verdier, Bondy, France
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An Atypical Presentation of Vaginal Agenesis. J Pediatr Adolesc Gynecol 2015; 28:e123-6. [PMID: 26051587 DOI: 10.1016/j.jpag.2014.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 10/13/2014] [Accepted: 10/19/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Vaginal agenesis is rare and generally presents with primary amenorrhea and cyclic abdominal pain. We describe a case in which the diagnosis was delayed due to lack of initial pelvic examination and atypical findings on imaging. CASE A 13-year-old girl with a known renal anomaly presented to the emergency department with primary amenorrhea and cyclic abdominal pain. She declined a pelvic examination and had normal laboratory testing and pelvic magnetic resonance imaging results. At 16 months later, she presented again and was diagnosed with vaginal agenesis and a large endometrioma. SUMMARY AND CONCLUSION This case illustrates the importance of the physical examination in the evaluation of primary amenorrhea. Further, it demonstrates that hematometra may not be present on imaging. Here, an endometrioma was the only abnormality noted on magnetic resonance imaging after 18 months of retrograde menstruation.
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Herlyn–Werner–Wunderlich syndrome: pre- and post-surgical MRI and US findings. ACTA ACUST UNITED AC 2015; 40:2667-82. [DOI: 10.1007/s00261-015-0421-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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18
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Abstract
BACKGROUND Approximately 7% of girls will have an anatomic abnormality in their reproductive tract, diagnosed before or after puberty. OBJECTIVE It is important for providers to be aware of the obstructive reproductive tract conditions, the way in which various conditions present, and the way in which such conditions should be managed. DESIGN Systematic review of the literature using the GRADE evidence system. RESULTS There is limited data in most areas of obstructive reproductive tract anomalies; however, some retrospective and prospective series with small numbers are still useful to guide clinical practice. CONCLUSIONS Recommendations are based on limited or inconsistent scientific evidence. Recommendations are based primarily on consensus and expert opinion.
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Tong J, Zhu L, Chen N, Lang J. Endometriosis in association with Herlyn-Werner-Wunderlich syndrome. Fertil Steril 2014; 102:790-4. [DOI: 10.1016/j.fertnstert.2014.05.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2014] [Revised: 05/15/2014] [Accepted: 05/15/2014] [Indexed: 10/25/2022]
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