Total weight loss rather than preoperative body mass index correlates with remission of irregular menstruation after sleeve gastrectomy in patients with polycystic ovary syndrome

Introduction

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy affecting reproductive-aged women. Some retrospective studies with small sample sizes have reported that bariatric metabolic surgery is effective in remission of irregular menstruation in patients with PCOS and obesity. However, the correlation between preoperative body mass index (BMI), postoperative weight loss, and remission of irregular menstruation in patients with obesity and PCOS after sleeve gastrectomy (SG) is lack of consensus.

Methods

We enrolled 229 participants with obesity and PCOS who underwent SG. All patients were followed up for one year after surgery. Remission of irregular menstruation was defined as a spontaneous consecutive six-month menstrual cycle in one year. Subgroup analysis was conducted using tertiles of preoperative BMI and postoperative total weight loss (TWL)% to determine their correlation with the remission of irregular menstruation after SG.

Results

79.03% (181/229) patients achieved remission of irregular menstruation one year after SG with a TWL% of 33.25 ± 0.46%. No significant difference was detected in the remission rate among the subgroups with different BMI (P=0.908). TWL% was correlated with the remission of irregular menstruation (OR 1.78, 95% CI 1.18-2.69, P<0.05).

Conclusions

SG had a significant effect on the remission of irregular menstruation in patients with obesity and PCOS. Preoperative BMI did not emerge as a decisive factor correlated with remission; instead, TWL% showed potential as a key factor.

Reproductive health challenges of an African school girl: a case report on non-bulging imperforate hymen with haematocolpometra during Covid-19 pandemic

Background

Several schoolgirls attain reproductive age with undiagnosed gynaecological problems which pose challenges in their livelihood. These conditions include precocious puberty, congenital reproductive tract abnormalities, and delayed sexual development. Many children with these conditions face additional challenges including physical pain, psychological trauma and delayed diagnosis.

Methods

A 14-year-old girl presented with acute on chronic pelvic pain and haematocolpometra due to imperforate hymen during COVID-19 pandemic. She has not undergone cultural virginity test in her community. The hymenal membrane was unusually non-bulging despite the haematocolpometra. A partial hymenotomy with a narrow margin of excision was performed.

Results

The hymenal orifice later obliterated and resulted in a repeat partial hymenectomy where a wide surgical margin of the hymen was excised.

Conclusions

A wide rather than narrow partial hymenectomy prevents obliteration of the hymenal orifice after surgery for imperforate hymen. There is a need for timely interventions such as counselling and community awareness that prevent undue consequences of an imperforate hymen and its treatment including pain and possible inability to pass cultural virginity test in some African communities.

Congenital vaginal atresia: A report of 39 cases in a regional Obstetrics and Gynecology Hospital

To investigate the clinical course and management of congenital vaginal atresia. This retro-spective analysis included patients with congenital vaginal atresia treated from March 2004 to August 2014 at the Obstetrics and Gynecology Hospital of Fudan University. Thirty-nine patients were included in this study. Their average age was 16.87±2.2 years when they came to our hospital. Totally, 51% of the patients had isolated congenital vaginal atresia with a normal cervix, whereas the others had either cervical atresia or imperforate hymen. The primary presenting signs and symptoms included primary amenorrhea (71.8%), periodic abdominalgia (41.0%), abdominal pain (36.0%), dyspareunia (10.3%), menstrual disorders (5.1%), and pelvic mass (5.1%). Ultrasound and magnetic resonance imaging (MRI) were effective inspection methods for the screening of urogenital tract-associated anomalies. Vagi-noplasty mainly included simple vagina reconstruction with insertion of a mold (n=22) and split-thickness skin grafting (n=4). In 64% of surgical patients, normal menstrual bleeding was achieved. Four of the patients subsequently became pregnant and delivered at term. Primary amenorrhea, periodic abdominalgia and abdominal pain are the main reasons for the post pubertal patients to visit doctors. Surgical methods can successfully provide these patients an opportunity for subsequent conservative management, can result in normal menstrual bleeding, resolve cyclic pelvic pain, and provide some po-tential for fertility.

[Hematocolpos : an unappreciated diagnosis of hymen imperforation]

The imperforation of the hymen is a relatively rare congenital malformation. It usually manifests itself in adolescence by a hematocolpos. Hematocolpos is the vaginal retention of menstrual blood at puberty. It results clinically in painful amenorrhea and more rarely in a pelvic mass syndrome. The diagnosis is easy, it is primarily clinical. Pelvic ultrasound and nuclear magnetic resonance are the complementary examinations to be performed as a preoperative assessment and to detect any associated genito-urinary malformations.

[Nutrition management in obese patients with type 2 diabetes mellitus after laparoscopic sleeve gastrectomy]

OBJECTIVE

To explore the value of nutrition management in obese patients with type 2 diabetes mellitus(T2DM) after laparoscopic sleeve gastrectomy(LSG).

METHODS

Clinical data of 22 obese T2DM patients undergoing LSG from March 2013 to July 2015 in Fudan University Pudong Medical Center were collected. All the patients strictly followed the specialized instruction by nutritionists: diabetic and low calorie diet 3347.2 to 5020.8 kJ (800 to 1200 kcal) per day before the operation; low calorie liquid diet 2510.4 kJ(600 kcal) per day before operation for promoting gastric emptying; fasting diet before postoperative ventilation; clear liquid diet 1673.6 to 2510.4 kJ (400 to 600 kcal) per day after postoperative ventilation (liquid intake >2000 ml); low fat liquid diet 2928.8 to 3765.6 kJ (700 to 900 kcal) per day (protein 60 g per day at least, 2000 ml liquid) 2 weeks after the operation; semi-liquid diet 1 month after operation and gradually normal diet. All the 22 patients were followed up at 1 week, 1, 3, 6 months after operation on time. Changes of body weight, waist circumference, hip circumference, body mass index(BMI), blood glucose indexes induding fasting blood glucose(FBG), 2-hour postparandial blood glucose(PBG), fasting C-peptide, 2-hour postprandial C-peptide, fasting serum inculin(FINS), 2-hour postprandial inculin(INS), HbAlc, blood pressure and blood lipid indexes were observed and analyzed before and 1 week, 1, 3, 6 months after operation.

RESULTS

The average age of 22 patients (10 men and 12 women) was 38.6 years (18 to 66 years). The duration of diabetes varied from 1 month to 15 years. Comorbidity included 12 patients of high blood pressure, 14 of fatty liver, 1 of coronary heart disease, 1 of gout, 1 of chronic thyroiditis and 1 of menstrual disorder. LSG was performed successfully in all the patients and no severe complications and transference to laparotomy occurred. As compared to pre-operation, at 6 months after operation, the average body weight decreased from (103.9±20.2) kg to (80.9±12.6) kg (t=6.294, P=0.000), waist circumference from (118.6±13.8) cm to (96.4±8.0) cm (t=6.331, P=0.000), hip circumference from (116.9±12.6) cm to (104.0±7.7) cm (t=3.854, P=0.000), BMI from (36.2±5.9) kg/m² to (27.9±3.5) kg/m² (t=5.630, P=0.000), showing a decreasing trend over time. There was no underweight patient after 6 months follow-up. As compared to pre-operation, at 6 months after operation, the average FBG reduced from (7.4±1.4) mmol/L to (6.0±0.9) mmol/L (t=3.172, P=0.003), 2 h PBG from (14.1±4.9) mmol/L to (7.5±2.2) mmol/L (t=7.026, P=0.000), FINS from (160.0±71.9) mIU/L to (43.8±20.8) mIU/L (t=7.259, P=0.000), 2-hour postprandial INS from (437.6±261.4) mIU/L to (140.5±104.6) mIU/L (t=5.858, P=0.000), fasting C-peptide from (1.1±0.6) μg/L to (0.7±0.3) μg/L (t=3.560, P=0.000), 2-hour postprandial C-peptide from (2.5±0.9) μg/L to (1.5±0.7) μg/L (t=3.865, P=0.000), HbAlc from (8.0±1.6)% to (5.9±0.6)% (t=5.953, P=0.000), showing a decreasing trend over time except FBG, 2h postprandial C-peptide and HbAlc(all P<0.05). FBG and 2-hour PBG of 16 patients returned to normal 3 months after the operation. Blood pressure and trigly ceride decreased obviously 6 months after operation compared to pre-operation with significant difference(P<0.05). At 6 months after operation, blood pressure of 8 comorbidity patients with high blood pressure became normal (8/12, 66.7%) and of 4 patients improved(4/12, 33.3%); B ultrasound examination revealed normal in 11 comorbidity patients with fatty liver(11/14,78.6%) and improvement in 3 patients (3/14,15.4%). Blood uric acid of the gout patient and the menstruation of the menstrual disorder patient returned to normal 3 months and 1 month after the operation respectively.

CONCLUSION

As for obese patients with T2DM undergoing LSG, reasonable nutrition management is helpful to decrease body weight, and to obtain an ideal improvement of blood glucose and blood lipid levels.

[Imperforate hymen – an often missed diagnosis]

Imperforate hymen - an often missed diagnosis Imperforate hymen is the most common congenital malformation in the female reproduction system that give rise to obstructive symptoms. If the diagnosis is not made in the newborn girl, symptoms often first arise at menarche. The diagnosis is easy to make but has to be suspected. This case reports describes the typical clinical picture of a late diagnosed imperforate hymen. As shown in this case and from a review of the literature, these girls often have symptoms for a long time before the diagnosis is made. Further, they are often initially misdiagnosed, and a thorough history and examination is seldom performed despite repeated contacts with the primary care.

Clinical characteristics and reproductive outcome following hysteroscopic adhesiolysis of patients with intrauterine adhesion--a retrospective study

The authors performed a retrospective clinical analysis of 153 patients with intrauterine ashesion (IUA) who underwent hysteroscopic adhesiolysis. A follow-up office hysteroscopy was performed in all cases after three months. On follow-up hysteroscopy, 22 patients showed reformation of adhesions and required a repeat procedure. The primary risk factor for IUA was uterine curettage associated with pregnancy termination. The follow-up study revealed that the rate of pregnancy after IUA treatment was 51%. The conception rate in women who had reformation of IUA was significantly lower than that of women who had a normal cavity following adhesiolysis. Therefore the authors conclude that prevention is more important than therapy in IUA. Increasing education about avoiding curettage is necessary to reduce the incidence of IUA. Outreach is particularly important for older women with less education. However, hysteroscopic adhesiolysis for IUA is a safe and effective method of choice for restoring menstrual function and fertility.

Study of endometrial tissue in dysfunctional uterine bleeding

Dysfunctional uterine bleeding (DUB) is defined as heavy and or irregular menstruation in the absence of recognizable pelvic pathology, pregnancy or general bleeding disorder. Hyperplastic endometrium is abnormal histology finding found in DUB. Out of three type of hyperplasia, atypical type is associated with co-existent ca endometrium and the chance of progression to ca endometrium is very high. Thus this study was conducted to see the incidence of hyperplasia of endometrium in cases of DUB and to see the risk factors for endometrial hyperplasia. It was a prospective study carried out in span of two years (2010 JULY- 2013 Jan) in Nepal Medical College and Teaching Hospital. Hundred cases DUB who under went D&C or hysterectomy were included to study the age range, the relation of parity, patient symptom, contraceptive method and medical disease with the type of endometrial histology. It was found that DUB was common in perimenopusal age (49%) and the incidence increase with the increase of parity. Abnormal endometrial finding (hyperplasia) was found in 31% of the cases. Atypical and complex hyperplasia were associated with irregular menstruation and one third of the hyperplastic patient had hypertension (32.26%). Thus perimenopausal age, irregular menstruation and hypertension are risk factors for hyperplasia. So it is mandatory to do endometrial sampling in cases of perimenopausal age with irregular menstruation withor without hypertension.

Imperforate hymen with elevated serum CA 125 and CA 19-9 levels

OBJECTIVE

To report the clinical characteristics of 14 patients with imperforate hymen and their levels of tumor markers (CA 19-9 and CA 125).

STUDY DESIGN

Fourteen patients with imperforate hymen who followed-up between September 2006 and September 2010 in the Department of Obstetrics and Gynecology, Dicle University School of Medicine, Diyarbakir, Turkey, were evaluated retrospectively. The clinical features and the management of the patients are discussed.

RESULTS

The mean age of the patients was 13.8 years. All patients had primary amenorrhea and pelvic pain. The most common clinical symptoms were cryptomenorrhea in 14 patients, pelvic pain in 11, palpable abdominal mass in 6, voiding difficulties in 7, and defecation problems in 2. In 6 patients with palpable pelvic mass, the mean + standard deviation values of tumor markers were as follows: CA 125, 84.0 +/- 23.7 and CA 19-9, 162 +/- 189. One week after surgery we measured CA 125 and CA 19-9 levels once again. The postoperative mean CA 125 level was 13.8 +/- 3.6, and the mean postoperative CA 19-9 level was 17.5 +/- 3.5. Preoperative levels of CA 125 and CA 19-9 were significantly higher than those of the postoperative period (p < 0.001 for both comparisons). Six patients were treated by T-shaped incision and 8 patients by a central surgical incision through the hymenal membrane.

CONCLUSION

Diagnosis of imperforate hymen is very important before undergoing surgery in a different clinic. Many patients have seen several doctors before receiving a clear diagnosis and have had tumor markers evaluated because the presence of pelvic mass in patients suggests the possibility of a gynecologic malignancy. Imperforate hymen is one of the benign conditions that increase serum CA 125 and CA 19-9 levels and which is not listed in the classical medical textbooks. These markers are not needed for the diagnosis.

Cervical dysgenesis with transverse vaginal septum with imperforate hymen in an 11 year old girl presenting with acute abdomen

This case highlights the importance of careful evaluation of girls presenting with imperforate hymen as this is accompanied by other female reproductive tract anomalies. It is of utmost importance that a correct timely diagnosis is made so that the right treatment can be chosen with the perspective of future fertility. Cervical dysgenesis associated with vaginal septum and imperforate hymen has not been reported in literature so far. Present case highlights the simple mode of management with a successful outcome.

Understanding clinical features of adenomyosis: a case control study

Adenomyosis is largely under diagnosed before hysterectomy and commonly co-exists with uterine fibroid. Thus this study aimed to elicit the clinical profile of adenomyosis by comparison with uterine fibroid. This is a hospital based prospective case-control study carried out from 1st April 2010 to 31st May 2011 which comprise of women undergoing hysterectomy with a histological diagnosis of sole adenomyosis without fibroid, women with both adenomyosis and fibroid and women with fibroid but no adenomyosis. Ambulatory records were performed. The study comprised 150 women, 78 (52%) women with adenomyosis without fibroid, 27 (18%) women with both adenomyosis and fibroid, 45 (30%) women with fibroid but no adenomyosis. Among women with adenomyosis alone, 78.2% had menorrhagia, 73.1% had dysmenorrhoea, 76.9% had chronic pelvic pain and women with adenomyosis and fibroid had menorrhagia in 85.2%, dysmenorrhoea in 51.9%, chronic pelvic pain in 48.1% compared with women of fibroid alone had menorrhagia in 75.6%, dysmenorrhoea in 66.77%, chronic pelvic pain in 51.1%. Women with adenomyosis group had significantly more of chronic pelvic pain (p-value: 0.003) and had significantly greater parity (p-value: 0.002). Size of uterus was significantly smaller in adenomyosis group (p-value: 0.018) as well as significantly more tender uterus was found in adenomyosis group (p-value: 0.000). Adenomyosis is more frequent among women reporting dysmenorrhoea, menometrorrhagia, chronic pelvic pain and along with bulky uterus. Women with fibroid alone has more of menorrhagia than pain and is associated with enlarge uterus. If women have small fibroid uterus but have more symptoms--think about co-existence of "ADENOMYOSIS".

A retrospective case-control study comparing hysteroscopic resection versus hormonal modulation in treating menstrual disorders due to isthmocele

In a retrospective case-control study, we compared the effectiveness of hysteroscopic correction and hormonal treatment to improve symptoms [postmestrual abnormal uterine bleeding (PAUB), pelvic pain localized in suprapubic site] associated with isthmocele. Women (n = 39; mean age ± SD, 35 ± 4.1 years) were subdivided in Group A [patients (n = 19) subjected to hysteroscopic surgery (isthmoplasty)] and, Group B [women (n = 20) undergoing hormonal treatment consisting of one oral tablet containing 0.075  mg of Gestodene and 0.030 mg of Ethynylestradiol for 21 days, followed by 7 days of suspension]. Resolution and/or improvement of menstrual disorders; patients degree of satisfaction with the treatment were measured 3 months later, by office hysteroscopy (Grop A) or phone call. PAUB and pelvic pain resolution was achieved in all patients: Group A had significant lower numbers of days of menstrual bleeding (P < 0.001), prevalence of pelvic pain in the suprapubic area (P = 0.04) and, higher degree of satisfaction (P < 0.001) compared to Group B. In conclusion, resectoscopic surgery is a valid way to treat patients with symptoms of prolonged postmenstrual uterine bleeding caused by isthmocele. Data from this study also indicate that resectoscopy may be the first choice because it is minimally invasive and yields good therapeutic results.

Clinical inquiries. Menstrual disturbances in perimenopausal women: what's best?

It's best to start with nonsteroidal anti-inflammatory drugs (NSAIDs), which effectively reduce heavy menstrual bleeding. Perimenopausal women with heavy bleeding not controlled by NSAIDs, or other forms of dysfunctional uterine bleeding, can benefit from continuous, combined hormonal therapy with estrogen and progestin; hormonal therapy with estrogen and a cyclical progestin; or a cyclical progestin alone. Intrauterine devices (IUDs) containing levonorgestrel also effectively reduce bleeding and may avoid surgical intervention. If medical management fails, endometrial ablation offers an effective, minimally invasive alternative to hysterectomy. Hysterectomy should be considered when medical management or endometrial ablation fails.

Growth hormone excess with onset in adolescence: clinical appearance and long-term treatment outcome

BACKGROUND

Limited data are available on clinical presentation and treatment strategy in patients with GH-secreting adenomas with onset in adolescence.

OBJECTIVE

To report results of diagnosis and treatment in adolescents with GH and IGF-I excess.

DESIGN

Analytical, observational, retrospective.

SUBJECTS

Thirteen patients (five females and eight males, age 15-20 years) all with macroadenoma (two extrasellar, 11 invasive).

MAIN OUTCOME MEASURES

Height, body mass index (BMI), GH and IGF-I levels, tumour volume at diagnosis and after treatment.

INTERVENTIONS

Transsphenoidal surgery, octreotide subcutaneous (OCT, 0.3-0.8 mg/day), octreotide-LAR i.m. (LAR, 20-30 mg/q28 days), lanreotide i.m. (LAN, 60-90 mg/q28 days), bromocriptine (BRC, 5 mg/day), cabergoline (CAB, 1-2 mg/week).

RESULTS

Concomitant hyperprolactinaemia was found in eight patients (61.5%). All girls presented with amenorrhoea, which was associated with galactorrhoea in two patients; all boys presented with symptoms of tumour mass compression such as visual disturbance or headache; two girls also had these symptoms. Height at diagnosis was above the 97th centile in four of five girls and in six of eight boys. None of the patients had altered lipid profile while homeostasis model assessment of insulin resistance (HOMA-IR; 2.8 +/- 0.9) and beta-cell function (HOMA-beta, 207.6 +/- 98.1%) were higher than predicted (1% and 100%, respectively). First-line treatment was surgery in two patients and somatostatin analogues associated with dopaminergic drugs in 11 patients. None of the patients operated on were cured while six of 11 patients receiving pharmacotherapy (6-24 months) were controlled. In these six, tumour volume was reduced by 51.0 +/- 25.2% (median 51.5%). As second-line treatment, all the 11 patients treated with somatostatin analogues underwent surgical removal of their tumours. Surgery was successful in four patients and second-line pharmacotherapy in six patients. One patient was lost at follow-up and two patients maintained active acromegaly despite different treatment schedules; both patients were then treated with radiotherapy. At the last follow-up, there was a significant decrease in insulin levels, HOMA-IR and HOMA-beta without any change in lipid profile.

CONCLUSIONS

The clinical presentation of GH-secreting adenomas in adolescent girls is associated with menstrual disturbances and in boys with symptoms of mass effects; tall stature is characteristic in both. First-line treatment with depot somatostatin analogues followed by surgery and then by a second course of somatostatin analogues was successful and safe in 11 of 13 patients.

Amnion graft following hysteroscopic lysis of intrauterine adhesions

AIM

To evaluate the safety and efficacy of amnion grafting after hysteroscopic lysis of intrauterine adhesions.

METHODS

In a pilot study involving 25 patients with moderate or severe intrauterine adhesions, hysteroscopic adhesiolysis was followed by intrauterine application of a fresh amnion graft over an inflated balloon of a Foley's catheter for 2 weeks. Follow-up hysteroscopy was performed after 4 months. Outcome measures included recurrence of adhesions, achievement of normal menstrual flow, and improvement in the uterine length.

RESULTS

Moderate (group A) and severe (group B) adhesions were found in 12 and 13 subjects, respectively. Uterine perforation occurred in two patients in group B, one treated conservatively and the other via laparoscopy. No clinical evidence of infection was observed, and spontaneous expulsion of the balloon occurred within days in three patients, with easy removal after 2 weeks in the rest of the subjects. Significant improvement in uterine length was found in both groups. Despite improvement, failure to achieve normal menstrual flow was found in 16.7% in group A versus 23.1% in group B. Follow-up hysteroscopy revealed adhesion reformation in 48%, all belonging to group B, all with minimal adhesions. Moderate adhesions were found in only two subjects with previous tuberculous endometritis.

CONCLUSION

Hysteroscopic lysis of intrauterine adhesions with amnion grafting seems to be a promising procedure for decreasing recurrence of adhesions and encouraging endometrial regeneration. Randomized comparative studies are needed to validate its benefits, including reproductive outcome.

Congenital vesicovaginal fistula with transverse vaginal septum and ectopic ureter opening in proximal vagina: case report and brief review

Congenital vesicovaginal fistula is an extreme rarity. We report on a case of a 22-year-old lady who presented with menouria and infertility. On evaluation, she was found to have congenital vesicovaginal fistula, a nonfunctioning right kidney with ectopic ureter and transverse vaginal septum. Abdominal repair of the fistula, right nephroureterectomy, and excision of the vaginal septum was performed.

Comparison of clinical outcomes and spectral Doppler indices of uterine and ovarian stromal arteries in women undergoing myomectomy with or without hypogastric arterial ligation

OBJECTIVE

To compare clinical outcomes and hemodynamic alterations of uterine and ovarian stromal arteries between patients with symptomatic myomas undergoing myomectomy preceded by arterial ligation and those undergoing myomectomy alone.

METHODS

In this prospective, non-randomized comparative study, myomectomy was performed on 69 women with symptomatic myomas. Myomectomy alone was performed in 31 patients (Group I) and myomectomy with concomitant bilateral hypogastric arterial ligation was performed in 38 patients (Group II). In both groups, surgical results and clinical outcomes were evaluated by peripheral hemoglobin levels, a pictorial blood-loss assessment chart, and visual analog scales. Spectral Doppler indices of uterine and ovarian stromal arteries, including peak systolic velocity, end-diastolic velocity, pulsatility index and resistance index were performed preoperatively, and 1 day and 1 or more months postoperatively.

RESULTS

Twenty-two patients in Group I and 31 patients in Group II received regular follow-up examinations for a mean follow-up period of 10.1 months. Menstrual flow, dysmenorrhea and hemoglobin levels improved significantly after surgery in both groups. Blood loss during surgery was less in Group II than it was in Group I (P=0.02). Doppler indices of uterine and ovarian stromal arteries from preoperation to mean follow-up point were not significantly different between the groups, except for a significantly lower uterine artery pulsatility index in Group II (P=0.01).

CONCLUSIONS

Myomectomy with hypogastric arterial ligation for symptomatic myomas is as efficient as is myomectomy alone and reduces blood loss during surgery. Serial Doppler studies showed that hypogastric ligation does not block uterine and ovarian perfusion, and even reduces the impedance of the uterine arteries. The long-term recurrence rate after myomectomy with hypogastric arterial ligation remains to be determined.

Repair of Uterocutaneous Fistula

BACKGROUND

Uterocutaneous fistula is a rare condition that may be difficult to manage.

CASE

A young woman who underwent surgical intervention for cryptomenorrhea 3 years ago developed menstrual discharge from the abdominal scar. A fistulous tract leading from the infraumbilical midline scar to the uterus was demonstrated on contrast study. Genital examination revealed vaginal agenesis. A vaginoplasty was performed as the first stage. This was followed one year later by excision of the fistulous tract and establishment of cervicovaginal communication. The patient is now menstruating from the vaginal passage.

CONCLUSION

This case shows that a stepwise, well-planned, and well-executed procedure can lead to a satisfactory repair of an uterocutaneous fistula.

Left-side catamenial pneumothorax with endometrial tissue on the visceral pleura

We present here a rare case of left-side catamenial pneumothorax, in which endometrial tissue pleura was found on the visceral pleura histologically. A chest roentogenogram confirmed the left pneumothorax, but did not reveal bullae or any associated anomalies, in a 41-year-old woman with three documented episodes of left-side pneumothorax occurring every menstruation. Video-assisted thoracoscopic surgery revealed not only tiny holes in the diaphragm, but also a scattered small brown spots on the visceral pleura. Histological examination of the lung sections revealed the existence of endometrial tissue on the visceral pleura with disrupted pleural elastic fibers. Our case suggests that cyclic erosion of the visceral pleura by the implanted endometrial tissue caused air leakage from the lung, in addition to the most accepted concept that air is aspirated into the thoracic cavity via the abdomen through the acquired fenestration of the diaphragm.

What we see is not what we get in catamenial haemoptysis

Catamenial haemoptysis is rare entity, a part of thoracic endometriosis syndrome. We present a young woman who was timely diagnosed, successfully treated using video-assisted thoracoscopic surgery and pathologically confirmed the case. The change in lung parenchyma over time in the computed tomography is highlighted.

Thermal ablation performed in a primary care setting: the South Warwickshire Experience

OBJECTIVE

To assess the feasibility of performing outpatient thermal ablation in a primary care setting.

DESIGN

Prospective study.

SETTING

A small peripheral hospital in the UK used by local general practitioners and visiting hospital practitioners for its outpatient facilities.

POPULATION

The area of South Warwickshire serves a population of 270,000.

METHODS

Two general practitioners were trained to perform outpatient thermal ablation using the Thermachoice thermal ablation system (Thermachoice II). The unit functioned autonomously with support from a local gynaecologist and radiologist, accepting referrals from hospital consultants and general practitioners.

MAIN OUTCOME MEASURES

Severity of menstrual loss, premenstrual symptoms, dysmenorrhoea and quality of life assessed by visual analogue scales before treatment and at one month, two months, one year and two years.

RESULTS

Eighty-seven women were treated. No major complications were encountered from the procedure. Reduction of menstrual loss or cure was reported by over 94% of women. Premenstrual syndrome (PMS) and symptoms of dysmenorrhoea were also improved by treatment. The majority of women were satisfied with the operation at one month (96%), two months (93%), one year (92%) and two years (94%).

CONCLUSIONS

Thermal ablation is a simple procedure well suited to an outpatient setting. There are few complications as a result of the use of the thermal ablation catheters, and this study has shown that the procedure can be undertaken in a primary care setting with excellent results.

Vaginohysteroscopy, a patient-friendly technique for outpatient hysteroscopy: experience of the first 100 cases

OBJECTIVE

To evaluate the feasibility and tolerability of the vaginoscopic approach for office hysteroscopy.

DESIGN

Prospective observational study.

SETTING

Tertiary care hospital.

SUBJECTS

Unselected, consecutive 100 patients scheduled for diagnostic hysteroscopy.

INTERVENTION

Hysteroscopy with a vaginoscopic approach using a 5-mm rigid hysteroscope with single inflow channel, and normal saline for distension.

OUTCOME MEASURES

Successful hysteroscopy by the vaginoscopic approach; operative time; and degree of pain experienced.

RESULTS

The vaginoscopic technique was successful in 79% of the patients. The median operative time was 120 seconds in successful cases and 360 seconds in those in which the vaginoscopic approach was unsuccessful and had to be performed by the conventional technique with or without dilatation, the difference being statistically significant (P < 0.001). The procedure took < or = 2 minutes in 91.1% (72/79) of the successful cases. No pain or mild pain was experienced by 97.5% (77/79) of patients in whom vaginohysteroscopy was successful.

CONCLUSION

Hysteroscopy with the vaginoscopic approach is the ideal method for outpatient hysteroscopy. It is feasible, quick, and very well tolerated, obviating the need for any analgesia or local anesthesia.

Variations in vaginal and abdominal hysterectomy by region and trust in England

OBJECTIVE

To examine variations between regions and hospitals in the proportion of hysterectomies performed abdominally.

DESIGN

Analysis of routine hospital data.

SETTING

All National Health Service hospitals in England.

POPULATION

Women aged 18+ hospitalised between April 1998 and March 2001.

METHODS

Logistic regression, adjusting for age and diagnosis.

MAIN OUTCOME MEASURE

Use of the abdominal rather than the vaginal route.

RESULTS

The adjusted proportion of hysterectomies performed abdominally varied from 75-89% between regions, and from 25-99% between hospitals. Diagnosis accounted for nearly a third of the total variation, dwarfing the contributions of age and hospital. About two-thirds of the variation remained unaccounted for.

CONCLUSION

Despite evidence suggesting that the majority of hysterectomies may be performed vaginally, very few English trust match this.

[Laparoscopic supravaginal hysterectomy--in our own experience]

INTRODUCTION

The role of laparoscopic supravaginal hysterectomy has increased a minimal invasive surgery. The reason for this is that the intact pericervical ring and neurovascular supply play an important role in pelvic floor support. Also, women's health awareness has increased.

OBJECTIVES

The objective of this article was a retrospective analysis of 50 laparoscopic supracervical hysterectomies and advantages of this new surgical method. MATERIALS AND METHODS/DESIGN: These surgical procedures were performed in Sw. Rodziny Hospital and Gynecology of Obstetric in Warsaw in years 2002-2003. The duration of surgical procedure, complications, and duration of hospitalization were evaluated on the basis of retrospective patients case histories.

RESULTS

The medium duration of surgical procedure was 95 minutes, the medium duration of hospitalization after the surgical procedure was 3,3 days. There were not any severe complications.

CONCLUSIONS

At the end it was stated that laparoscopic supravaginal hysterectomy is minimal invasive surgical technique, which can be recommended if vaginal hysterectomy is contraindicated and there are no indications to cervix excision.

Outpatient Laparoscopic Hysterectomy in a Rural Ambulatory Surgery Center

STUDY OBJECTIVE

To evaluate a cost-optimized operative technique for outpatient laparoscopic hysterectomy in a rural ambulatory surgery center focusing on shortening hospital stay and substitution of expensive disposable laparoscopic instruments with standard surgical techniques.

DESIGN

Prospective feasibility and observational study (Canadian Task Force classification II-3).

SETTING

Rural ambulatory surgery center in Lamar, Alabama.

PATIENTS

Fifty-two women.

INTERVENTION

Outpatient laparoscopic hysterectomy.

MEASUREMENTS AND MAIN RESULTS

From September 2001 through September 2003, 52 consecutive procedures with a modified classical intrafascial supracervical hysterectomy (CISH) technique without disposable instruments have been performed on patients with an average age of 42.2 years (range 25-62 years) and a follow-up of 12.5 months (range 0.4-23.6 months). Mean postoperative length of stay was 6 hours, 79 minutes (range 3 hours, 10 minutes-17 hours, 30 minutes), and overall length of stay was 11 hours, 37 minutes (range 6 hours, 45 minutes-22 hours, 50 minutes). Five patients (9.6%) stayed overnight, three for medical and two for social reasons. With an average of 2 hours, 14 minutes, the operating room time was about 1 hour longer than with disposable instruments. Health insurance reimbursement for the ambulatory surgery center was on average $1814.11. No complications occurred, and no readmission to the hospital was necessary.

CONCLUSION

Outpatient laparoscopic hysterectomy is feasible and safe and can be performed cost effectively in ambulatory surgery centers, even in rural areas. Development of a protocol with patient selection, preoperative and postoperative patient teaching, caring family environment, and round-the-clock medical telephone backup is necessary.

[Catamenial pneumothorax--a case report]

Catamenial pneumothorax is a recurrent condition, predominantly affecting the right lung, of women of childbearing age, which is closely related to the menstruation cycle. Additional endometriosis and a defect of the right diaphragm is found relatively frequently. The case of a patient with a history of endometriosis, and a surgically confirmed defect of the diaphragm with prolapsed liver tissue, in whom pneumothorax first occurred at the age of 46, is presented.

[Analysis of the efficiency of transcervical resection of endometrium for treating dysfunctional uterine bleeding and factors reducing the efficiency of the operation]

OBJECTIVE

To investigate the efficiency and factors related to the recurrence of transcervical resection of endometrium (TCRE) in treating women with dysfunctional uterine bleeding (DUB).

METHODS

Two hundred and twenty women with DUB were selected for TCRE. Specimens from removed endometrium were obtained during the procedures and their menstruation and menorrhagia after the operations were followed up. We also studied the uterine specimens obtained from the recurrent cases undergoing hysterectomies. The specimens were stained by hematoxylin-eosin and immuno-histochemistry respectively to evaluate the depth of removed myometrium and the histopathologic changes in relapsed cases.

RESULTS

The follow up period after operation was 24 to 114 months. (1) Overall effective rate was 94.5%, in which amenorrhea rate was 25.9%, menstruation reduction rate was 68.6%. (2) The effective rate of corrective anemia was 97.3% and the satisfaction rate for the operation was 92.3%. (3) Thirty-eight cases required subsequent treatment as a result of recurrence, of which 10 cases underwent hysterectomy and 3 cases underwent repeat TCRE and 25 cases were given medicine treatment. (4) The average depth of myometrium in removed endometrium strip was 2.12 approximately 3.26 mm. (5) Endometrium regrowth was seen in the resected uterine specimens from relapsed cases and adenomyosis was also found in the intra-uterine wall in some cases.

CONCLUSIONS

(1) TCRE is a safe and effective alternative treatment for DUB. (2) The main factor reducing the efficiency is either incomplete removal of endometrium or adenomyosis. (3) Standardizing the procedures and strengthening postoperative management are essential requirements for improving the efficiency of TCRE.

The impact of hysterectomy on lower urinary tract symptoms

The aim of this study was to prospectively evaluate the effect of vaginal and abdominal hysterectomy on lower urinary tract symptoms. We interviewed 120 patients undergoing hysterectomy for benign conditions preoperatively using a standardized questionnaire. At 6.6 and 12.7 months, 119/120 and 115/120 patients completed the follow-up questionnaire. Forty-four patients underwent vaginal and 76 abdominal hysterectomy. At 6 months follow-up there was a decrease ( p<0.05) in symptoms of stress urinary incontinence in the abdominal cohort, but this did not remain at 12 months' follow-up. There were no significant changes in symptoms of stress urinary incontinence in the vaginal cohort at either 6 or 12 months' follow-up. Postoperative micturition frequency was reduced in both cohorts. No significant differences were found regarding symptoms of urge urinary incontinence, urge complaints or voiding difficulties. The present study does not support the assumption that abdominal or vaginal hysterectomy is associated with de novo or deteriorating symptoms of urinary incontinence.

Long-Term Gynecological Outcome of Patients with Persistent Cloaca

PURPOSE

Persistent cloaca is a complex malformation that remains a difficult reconstructive challenge, and data on long-term outcome are scarce. Gynecological abnormalities are common with cloaca but may remain asymptomatic until puberty or adult life. We evaluate long-term gynecological sequelae in these patients with persistent cloaca.

MATERIALS AND METHODS

The records and radiographs of postpubertal patients (mean age 16.8 years, range 10 to 32) treated for cloacal malformation at 1 institution from 1970 to 2001 were retrospectively reviewed. Outcome data at puberty were available in 41 patients. Of the patients 24 are currently older than 16 years and outcome data for sexual activity were available in 21 with 3 lost to followup.

RESULTS

All 41 patients were evaluated at puberty, and 28 (68%) had uterine function, 13 (32%) were menstruating normally and 15 (36%) presented with hematometra/hematocolpos. All 15 girls with an obstructed uterus required surgery, which included hysterectomy in 2, partial hysterectomy with vaginoplasty in 3 and vaginoplasty in 9. There was 1 complex case of fistula. Etiology of the obstructed uterus was vaginal stenosis after reconstruction in 3 cases, stenosis of persistent urogenital sinus (no previous reconstruction) in 11 and cervical stenosis in 1. Ten patients experienced primary amenorrhoea, which was confirmed in 8 (20%) while 2 (5%) continue to be followed for possible cryptic obstruction. In 10 girls the diagnosis of absent/vestigial uterus was made at early laparotomy but this was erroneous in 6 in whom uterine function developed at puberty. Of the 21 older girls (age at review 17 to 32 years, mean 24) 12 are or have been sexually active and 6 have been examined by a gynecologist and have an adequate vagina but are not sexually active. To date 4 patients have required revision vaginal surgery in adulthood to facilitate intercourse (re-do vaginoplasty in 3, introitoplasty in 1). One woman has postponed vaginal reconstructive procedures and 2 others are currently being followed. There have been no pregnancies in this series to date.

CONCLUSIONS

Patients born with persistent cloaca have a high incidence of gynecological problems at the onset of menses and in early adult life. Therefore, it is necessary to reassess these girls at early puberty by ultrasound/magnetic resonance imaging and vaginoscopy. Additional surgery may then be necessary to create a vagina for menstruation and sexual intercourse.

The long-term effectiveness of endometrial laser ablation: a survival analysis

OBJECTIVES

To assess the long-term effectiveness of endometrial laser ablation and factors that predict long-term outcome.

SETTING

A university teaching hospital.

STUDY DESIGN

Postal questionnaires were sent to all women who underwent endometrial laser ablation between 1992 and 1998.

RESULTS

Of 215 patients who underwent endometrial laser ablation, 174 (80.9%) returned the questionnaire. Duration of follow-up was 1.5-9 years. The procedure was reported as a success by 138 (79.3%) and a failure by 36 (20.7%). Twenty-four patients (13.8%) subsequently underwent hysterectomy for excessive bleeding. Using survival curve estimates the percentage that remained free of failure was 95.3% at 1 year and 76.2% at 4 years. Increasing patient age was significantly associated with reduced risk of failure (hazard ratio 0.91 for every year increase in age). An inexperienced operator significantly increased the hazard of failure.

CONCLUSION

Endometrial laser ablation is effective in the long-term in the majority (76.2%) of patients. Older women can expect to have a lower risk of failure.

Listening to patients with unexplained menstrual symptoms: what do they tell the gynaecologist?

OBJECTIVES

To describe how women present unexplained menstrual symptoms to gynaecologists; to find out whether presentation reflects how intense their symptoms feel or how much benefit they expect from gynaecological treatment; and to test the prediction that surgical treatment decisions are more likely to follow specific types of presentation.

DESIGN

A cross sectional cohort study.

SETTING

Gynaecological outpatient clinics in a teaching hospital.

SAMPLE

Fifty-nine patients, referred for menstrual problems, in whom investigations had excluded physical disease.

METHODS

Patients indicated symptom intensity and expectations of treatment before consultation on self-completed questionnaires. Audiotape recordings of consultations with the gynaecologist were transcribed and patients' use of specific communication strategies was coded according to a previously reported scheme.

MAIN OUTCOME MEASURES

Treatment decision was noted.

RESULTS

In a third to a half of patients, presentation extended beyond symptom report to include catastrophisation about consequences of symptoms, reference to other individuals to substantiate the patient's problems, criticism of previous or possible future interventions or request for hysterectomy. Those with greatest expectations of gynaecological treatment were more likely to catastrophise and request hysterectomy. Those with most intense subjective symptoms were more likely to catastrophise, refer to other individuals and request hysterectomy, and these strategies were more likely to be followed by surgical treatment decisions.

CONCLUSIONS

Surgical treatment for unexplained menstrual problems is not driven by gynaecologists. Reduction in unnecessary hysterectomies will require training in communication skills that reflects the challenging nature of many patients' presentation in the gynaecology clinic.

Endometriosis causing cyclic compression of the right external iliac vein with cyclic edema of the right leg and thigh

A case report of endometriosis encircling the right external iliac vein, causing catamenial edema of the right leg and thigh, is presented. Successful surgical treatment is described. A literature review of extraperitoneal endometriosis will further the reader's awareness of unusual presentations of endometriosis.

Transvaginal sonography, saline contrast sonohysterography and hysteroscopy for the investigation of women with postmenopausal bleeding and endometrium > 5 mm

OBJECTIVES

To determine the ability of transvaginal ultrasound, with or without saline infusion, to detect focally growing lesions in the uterine cavity in women with postmenopausal bleeding and endometrium > 5 mm, and to determine the accuracy of conventional ultrasound, saline contrast sonohysterography and diagnostic hysteroscopy under general anesthesia to diagnose endometrial polyps, submucous myomas and uterine malignancy.

DESIGN

In a prospective study, 105 women with postmenopausal bleeding and endometrium > 5 mm underwent conventional ultrasound examination and saline contrast sonohysterography. Diagnostic and operative hysteroscopy under general anesthesia was then performed. The presence of focally growing lesions and the type of lesion (endometrial polyp, submucous myoma, malignancy or unclear focal lesion) were noted at ultrasound examination and at hysteroscopy.

RESULTS

There was almost perfect agreement (96%) between saline contrast sonohysterography and hysteroscopy in the diagnosis of focally growing lesions. Saline contrast sonohysterography and hysteroscopy both had a sensitivity of approximately 80% with regard to diagnosing endometrial polyps (false-positive rates of 24% and 6%, respectively), whereas conventional ultrasound missed half of the polyps (sensitivity, 49%; false-positive rate, 19%). Hysteroscopy was superior to both saline contrast sonohysterography and conventional ultrasound with regard to discriminating between benign and malignant lesions (sensitivity, 84%, 44%, and 60%; false-positive rate, 15%, 6% and 10%, respectively). The risk of malignancy was increased seven-fold (odds ratio, 7.3; 95% confidence interval, 1.9-27.8) in women with distension difficulties at saline contrast sonohysterography, and two thirds of the women with a poorly distensible uterine cavity had a malignant diagnosis.

CONCLUSION

Saline contrast sonohysterography is as good as hysteroscopy at detecting focally growing lesions in the uterine cavity in women with postmenopausal bleeding. However, neither hysteroscopy nor saline contrast sonohysterography can reliably discriminate between benign and malignant focal lesions. Distension difficulties at saline contrast sonohysterography should raise a suspicion of malignancy.

Video-assisted thoracoscopic surgery for catamenial hemoptysis

Catamenial hemoptysis is a rare condition, and only 36 cases have been reported since the first published case. We describe a woman with catamenial hemoptysis recurring over 8 years. The lesion was diagnosed using chest CT scan during menses and was also visualized clearly via thoracoscopy. The patient was treated successfully with a partial resection of the lung using video-assisted thoracic surgery (VATS) and has been asymptomatic for 14 months since the operation. We suggest that VATS for catamenial hemoptysis is a more effective treatment than medical therapy.

Obstructive Müllerian anomalies: case report, diagnosis, and management

Many factors affect the development of the female reproductive tract. Obstructive anomalies prevent normal menstruation, allow for collection of blood in the uterus and the vagina, and may increase the incidence of retrograde menstruation. A high index of suspicion is necessary to diagnose these disorders, and an adequate workup is essential. This report will present a case of obstructive longitudinal vaginal septum. The workup and operative findings will be described, followed by a classification and discussion of other obstructive Müllerian anomalies. The incidence, workup, and management will be reviewed.

Transvaginal sonography combined with saline contrast sonohysterography in evaluating the uterine cavity in premenopausal patients with abnormal uterine bleeding

OBJECTIVES

To evaluate whether saline contrast sonohysterography (SCSH) adds additional information to that obtained by transvaginal sonography (TVS) for predicting endometrial abnormality in premenopausal patients with abnormal uterine bleeding.

PATIENTS AND METHODS

This was a two-center prospective study at a university clinic and a central hospital in Denmark. The uterine cavity was evaluated with TVS and SCSH in 470 premenopausal patients with abnormal uterine bleeding. One hundred and eighty-nine of the patients had operative hysteroscopy or hysterectomy within 4 months which provided a detailed description of the uterine cavity and was used as the true value for exclusion of polyps and submucous myomas.

RESULTS

Based on normal endometrial morphology alone, the results for detection of an abnormal uterine cavity were as follows: sensitivities of TVS 0.92, SCSH 0.99; specificities of TVS 0.62, SCSH 0.72; positive predictive values of TVS 0.80, SCSH 0.85; negative predictive values of TVS 0.82, SCSH 0.98. Transvaginal sonography combined with SCSH was superior to TVS for detection of intracavitary abnormalities (McNemar test, P = 0.008). The post-test probability of there being an abnormal cavity after normal findings on TVS alone was 0.18 (0.10-0.32) and after TVS and SCSH it was 0.02 (0.01-0.11). When normal endometrial morphology was combined with an endometrial thickness of < 12 mm for evaluation of all abnormalities including hyperplasia, the diagnostic potential of TVS or SCSH was almost unchanged except for specificities, which were markedly lower (TVS 0.54; SCSH 0.57). In all the patients referred, TVS had a negative predictive value of 0.94 for identification of polyps and myomas when findings at subsequent SCSH were accepted as the true value. Transvaginal sonography reduced the pretest probability of polyps or submucous myomas from 0.35 to a post-test probability of 0.06, but missed 21% of the polyps.

CONCLUSIONS

Sonohysterography was a sensitive tool and was superior to TVS used alone for evaluation of the uterine cavity in patients who underwent operative surgery for abnormal uterine bleeding. All abnormalities except one were found at SCSH, while TVS alone missed polyps and had almost one in four equivocal findings. The use of TVS, without saline contrast, left one in five of the polyps undiagnosed in referred patients with abnormal bleeding.

[Hysterectomy for benign lesions in the north of France: epidemiology and postoperative events]

OBJECTIVE

We conducted an inquiry on hysterectomy practices in gynecology and obstetric units of general hospitals in the north of France (North and Picardy regions) focusing on procedures made for benign lesions of non-prolapsed uteri.

MATERIAL

and methods: Two studies supported this inquiry. The first was a retrospective study in 1997 concerning 21 gynecology and obstetric units in general hospitals among the 24 units belonging to the general hospital network in the North and Picardy regions. The series included 1293 hysterectomies for benign lesions on non-prolapsed uteri, accounting for 68.6% of all hysterectomies performed during the study period. Surgical route, indications and duration of hospital stay were recorded. The second study was a prospective study conducted in 1998 in 9 voluntary units among the 24 units in the hospital network. This study included 423 hysterectomies and recorded techniques, indications, and complications as well as late complications and social and psycho-sexual impact assessed during a telephone interview at 3 months. The 5 University Hospitals in the North, Picardy and Champagne regions also participated in the inquiry and provided data on 191 hysterectomies performed during a three-month period.

RESULTS

Twenty-seven hysterectomies were performed per year and per operator. The main indications for hysterectomy were, for the two studies respectively: fibroid uterus 66.7% and 60%, menstrual disorders 13.8% and 27.2%, endometriosis 10.6% and 5%, and hyperplasia of the endometrium 3.9% and 5%. Surgical routes recorded in the second study were: vaginal 64.8%, abdominal 30.5%, vaginal laparoscopy 4.7%. Reductions were performed to facilitate vaginal hysterectomy in 25% of the cases. The vaginal route was used for adnexectomy in 30% of the cases. The rate of peroperative complications were observed in 3 - 4.8% of the vaginal, 4.8 - 10.7% of the abdominal and 15% of the laparoscopic vaginal hysterectomies. Bleeding was reported in 0.4% and 9.3% of the vaginal and abdominal hysterectomies respectively (p<0.001). The rate of postoperative complications was 0.8 - 4.9%, 1.6 - 19.4%, and 5% for vaginal, abdominal and vaginal laparoscopic hysterectomies respectively. Duration of convalescence was 4.4 weeks for vaginal and 6.1 weeks for abdominal (p<0.00001) and 5.3 weeks for vaginal laparoscopic procedures. The quality of sexual intercourse was improved in 30% of the patients irrespective of the surgical rout but was found to be deteriorated in 20% of those who had laparoscopic vaginal hysterectomy.

DISCUSSION

It is difficult to ascertain the exact number of hysterectomies performed in France. The computerized information system currently in use in France (PMSI) should provide interesting data. Reports from North America, Great Britain and the Scandinavian countries have found comparable data. Complication rate, duration of hospitalization and social impact are in favor of vaginal hysterectomy.

Visualization of diaphragmatic fenestration associated with catamenial pneumothorax

Catamenial pneumothorax is a rare entity of unknown etiology characterized by recurrent accumulation of air in the thoracic space during or preceding menstruation. We documented the presence of a diaphragmatic fenestration during thoracoscopy, lending support for hypotheses involving diaphragmatic defects as possible avenues of air collection in the thorax.

Intermenstrual bleeding secondary to cesarean scar diverticuli: report of three cases

BACKGROUND

The differential diagnosis of intermenstrual bleeding includes structural lesions of the endometrium and cervix.

CASES

Discrete diverticuli were noted in the endocervical canals of three women presenting with histories of multiple cesareans and chief complaints of intermenstrual bleeding. On ultrasound, diverticuli were diagnosed as cavities filled with heterogeneous material consistent with blood. In one case, the diverticulum was also visualized on hysterosalpingogram. Hysterectomy specimens in two cases showed diverticuli lined with fibrous tissue in previous uterine scars; in one case, this also contained endometrium.

CONCLUSION

Uterine scar diverticuli may cause intermenstrual bleeding in women with previous cesareans. When performing ultrasound in this clinical setting, physicians should look for these defects.