The incidence of fibromyoma and polycystic ovary syndrome in women in Trinidad (2000-2003)

PROBLEM STATEMENT: Before this study was done there were no reports of similar studies in Trinidad whereas similar study had been reported from other parts of the World including the Caribbean sub-region. The present study was thus designed to investigate the incidence and demographics of leiomyomata and polycystic ovary syndrome in women in two health institutions in Trinidad during the period from 2000-2003, inclusive. The study also sought to establish the prevalence of the established risk factors viz. age, ethnicity, parity and gravidity and to examine their relationship with the two disease conditions. APPROACH: The study population included only women who were diagnosed with or treated for these conditions at the Mt. Hope Medical Science Complex and San Fernando General Hospital in Trinidad and Tobago during the specified period. RESULTS: The most common presenting complaints were vaginal bleeding and colicky lower abdominal pain for fibroids and polycystic ovarian syndrome respectively. The majority of the fibroid cases were aged between 40 and 49 years. Similarly most of the patients with polycystic ovary were aged between 20 and 29 years. Hysterectomy was the most frequent surgical intervention. Prior to this, patients were placed on haematinics for anaemia and analgesics for pain. CONCLUSION: The present study has provided the database that could be harnessed in improving the health care delivery system for the population of Trinidad in different ways as discussed in the text of the article.

Mullerian duct remnant fibroids: a case report

Uterine fibroids are the most common benign tumours in women and are particularly common in women of African descent. Mullerian dysgenesis is uncommon and the association of a pelvic mass rare. Only three cases of the association of this syndrome with fibroids have been described and none of these has been in a woman of African descent.(Au)

Complete non-puerperial uterine inversion as a result of a uterine sarcoma

Complete non-puerperial uterine inversion is rare and when present is usually associated with a prolapsed submucous fibroid. The inversion in this case was associated with a uterine sarcoma in an 88 year old diabetic patient, gravida 13, who presented with a four month history of intermittent vaginal bleeding. She was successfully managed with a total abdominal hysterectomy and some of the difficulties with diagnosis and management are highlighted.(Au)

An update on the management of uterine fibroids

Uterine fibroids are common especially in women of African ancestry. When they are symptomatic they need to be treated. Treatment with medical therapy alone, such as gonadotropin-releasing hormone (GnRH) agonists, has been disappointing. Hysterectomy is recommended in women who have completed their family. Myomectomy is done in women who wish to conserve their uterus, this can be done in some women by laparoscopy or by hysteroscopy. Most women with large fibroids still require laparotomy. Intraoperative haemorrhage is, however, still a major concern. Pretreatment with GnRH agonists and intraoperative perivascular vasopressin injections are new methods, which have been shown to be valuable in reducing the impact of this complication (AU)

Cotyledonous leiomyoma, a rare variant of uterine leiomyoma: case report

A postmenopausal woman admitted to Bayview Hospital for total abdominal hysterectomy for uterine leiomyoma had unusual frond-like vascular excrescences on the anterior wall. These were biopsied, a subtotal hysterectomy was subsequently performed and cotyledonous leiomyoma, a rare and unusual form of uterine leiomyoma, was diagnosed. The macroscopic and microscopic features were presented.(AU)

Transcaheter uterine artery embolisation to treat large uterine fibroids with MRI quantitative assessment

Fibroids are benign tumours of the uterus which occur more commonly and earlier in black women. We do not know what causes the fibroids to grow, but their growth seems to be hormone dependant. Some women may have asymptomatic fibroids and be unaware of their presence. However, many others seek help from gynaecologists due to menorrhagia, sometimes leading to anaemia and pressure symptoms leading to pain, sciatica, urinary infrequency and constipation. Fibroids may also contribute towards infertility and cause problems in pregnancy. Treatment of fibroids is notoriously difficult. Drug treatment has proved unsuccessful in the long term treatment of fibroids and has been reserved for preoperative treatment. Myomectomy is a difficult operation for women which may require blood transfusions, unacceptable to Jehovah's Witnesses and rarely lead to hysterectomy due to uncontrollable bleeding. Women above child bearing age are usualy offered hysterectomy, but many women are unhappy to loose their uterus as this has cultural and social implications. At St. Thomas' and Guy's Hospital we have pioneered a new treatment for fibroids whereby the uterine arteries are embolised bilaterally and by cutting off the blood supply to the fibroids, they shrink in size and degenerate. An interventional radiologist inserts a catheter into the femoral artery in the groin and passes a guide wire under x-ray control into the uterine artery. Non-biodegradable particles are introduced into the artery until flow is reduced or stopped. This is repeated on the second side. The procedure is performed under sedation and takes about an hour. The patients are admitted for 24-36 hours for analgesia. Ten women have been treated to date, nine were Afro-Caribbean and we have three month follow-up on eight. MRI scans were performed before the procedure and at three months to obtain quantitative assessment of reduction in volume. The uterine volume reduced by a mean of 51 percent and further shrinkage is expected. All but one of the patients noticed improvement in one or all of their symptoms. Patient satisfaction was high. The main side effects of the procedure were pain, controlled with simple analgesia and vaginal discharge. This seems a good treatment for women with symptomatic fibroids who are not suitable for or unwilling to undergo surgery. It avoids a general anaesthetic major surgery and blood transfusions. The procedure is tolerated well and has good symptomatic cure rates.(AU)

The use of gonadotrophin-releasing hormone (GnRH) agonist in anaemic subjects awaiting surgery - abstract

Gonadotrophin releasing hormone agonist (Goserelin) was used to induce amenorrhea in 27 women who were anaemic as a result of menorrhage due to uterine myomas (fibroids). The aim was to produce a three-month period of amenorrhoea which would be enough time for them to recover from the anaemic status and thus be fit for surgery. GnRH agonists supresses gonadotrophin release from the pituitary, thus inhibiting ovarian steroid secretion, resulting in amenorrhoea. Between March 1993 and May 1996, 27 women were injected with goserelin acetate (zoladex), 3.6 mg in the subcutaneous tissue of the anterior abdominal wall on a monthly basis for 3 months. Twenty three went on to have myomectomy. Haemoglobin (Hb) concentration and packed cell volume (PCV) were determined before initiation of treatment. Haemoglobin levels ranged from 4.7 g/dlto 9.9 g/dl and PCV ranged from 0.14 to 0.30 l/l. Three women did not have amenorrhea after the first injection and reported heavier periods, while three had prolonged light bleeding. All six, plus the other seventeen, had amenorrhoea after the second injection. All experienced hot flushed during the course of treatment and 5 (21.7 percent) had vaginal dryness by the third injection. Demineralization of done which is associated with these agents was not assessed. (Au)

Caesarean myomectomy: a safe procedure - abstract

The cases of 16 women who had Caesarean myomectomy between 1993 and 1996 were reviewed and compared with 16 women who had Caesarean section without this procedure during the same period. At Ceasarean secton fibroids were removed after delivery of the baby and placenta and after administration of oxytocin. Haemostasis was achieved by continuous interlocking sutures of the defects from fibroid removal. The parameters examined included pre and post operative haemoglobin levels, measured blood loss, need for transfusion, post operative febrile morbidity and length of stay in hospital. Caesarean mycomectomy resulted in mean blood loss of 494ml (range 200-1000ml) compared with 355 ml (range 150-900 ml) in the controls. The haemoglobin fall was 1.7 g/dl compared with 1.4 g/dl in the controls. There were no significant differences in the other paremeters examined. In conclusion we believe this procedure is safe but a larger study is required to determine this conclusively. (AU)

A randomized comparison of vasopressin and tourniquet as hemostatic agents during myomectomy

OBJECTIVE: To assess the comparative efficacy of perivascular vasopressin and tourniquet in minimizing bleeding and its sequelae at myomectomy. METHODS:between March 1994 and February 1995, 52 women with symptomatic uterine leiomyomas scheduled for myomectomy were entered into a randomized trial comparing vasopressin (26 patients) and tourniquet (26 patients) for hemostasis. Myomectomy was performed after either the perivascular injection of 20 U of vasopressin diluted to 20 mL with normal saline or with the use of a Foley catheter tourniquet around both uterine vessels. The efficacy of each method was measured by comparing differences in pre-and postoperative hemoglobin levels, intraoperative blood pressure, measured blood loss, need for blood transfusion, evidence of postoperative febrile morbidity, complications, and length of hospital stay. RESULTS: Vasopressin resulted in less blood loss (mean 287.3 mL [standard deviation (SD) 195] verus 512.7 mL [SD 400] for tourniquet [P = .036]. Six of 26 patients in the tourniquet lost more than 1000 mL of blood, whereas all of the vasopressin subjects lost less than this amount (P = .023). However, there were no significant differences between the two groups in the fall in the hemoglobin level, number of blood transfusion given, intraoperative blood pressure, highest postoperative pulse and temperature, or other complications. CONCLUSION: Vasopressin prevents blood loss better than using the tourniquet durIng myomectomy.(AU)

Vasopressin use in myomectomy a community hospital experience

Perivascular vasopressin as a haemostatic agent in myomectomy has recently been shown to be very useful in reducing the amount of bleeding during operation. The published data have, however, come from work done in university or large hospital settings. The aim of this case series was to establish that vasopressin can be used effectively in a small community hospital setting, to reduce the need for blood transfusion, especially in the small countries of the Caribbean where blood banking is not often available. Twenty-two patients were evaluated in this case series. Vasopressin 1 unit/ml solution was injected into the broad ligament posteriorly, inferior to the insertion of the ovarian ligament and anteriorly, inferior to the insertion of the round ligament. The drug was also injected along the line of of the incision in the myometrium. Of the twenty-two patients evaluated three were excluded, two because of degenerating fibroids while the other had adenomyosis. None of the nineteen patients required transfusion. The average blood loss was 240 ml; three patients had losses greater than 500 ml. Intraoperative changes in vital signs in these patients were minimal and no patient required reoperation because of post-operative haemorrhage. As has been reported previously, vasopressin can be used effectively as a haemostatic agent in myomectomy. The reduction in the need for blood transfusion in this community hospital setting is a major clinical advantage (AU)

Perivascular vasopressin versus tourniquet as haemostatic agents during myomectomy: a prospective randomised trial - abstract

This study sought to assess the efficacy of perivascular vasopressin compared to tourniquet in minimising bleeding and its sequelae at myomectomy. It was a prospective randomized trial carried out at the University Hospital of the West Indies, Kingston, Jamaica. Thirty-eight women with symptomatic uterine fibroids scheduled for myomectomy were recruited after satisfying eligibility criteria. There were 18 patients in the vasopressin group and 20 in the tourniquet group. Myomectomy was performed after the injection perivascularly of either 10 units vasopressin in 20 ml normal saline or with the use of a Foley catheter tourniquet around the uterine vessels. The efficacy of each method was measured by looking at differences in pre- and post-operative haemoglobin and haematocrit, changes in intraoperative pulse and blood pressure, measured blood loss, need for blood transfusion and evidence of post-operative febrile morbidity. Pre-operative variables were almost identical in both groups. The use of vasopressin resulted in less blood loss with a mean of 254 ml versus 401 ml for tourniquet (p = 0.09) approaching significance. This resulted in a similar fall in the haemoglobin mean, 1.7 versus 2.2 (p = 0.248). Of the 20 patients who received tourniquet 5 had to have blood transfusion compared to one of the 18 receiving vasopressin. There were no significant differences in highest post-operative pulse and temperature. The results suggest that vasopressin is as effective in preventing blood loss as the tourniquet and is probably better, reducing the need for transfusion during myomectomy (AU)

Intramyometrial vasopressin as a haemostatic agent during myomectomy

OBJECTIVE: To assess the efficacy of intramyometrical vasopressin for minimising bleeding and its sequelae at myomectomy. DESIGN: A randomised placebo controlled trial. SETTING: University Hospital of the West Indies, Kingston, Jamaica. SUBJECTS: Twenty women with symptomatic uterine fibroids scheduled for myomectomy who satisfied entry criteria: 10 randomised to the vasopressin group and 10 to the control group. INTERVENTION: Myomectomy was performed after the intramyometrial injection of either 20 units vasopressin diluted to 20 ml in normal saline or placebo (20 ml normal saline). MAIN OUTCOME MEASURES: The efficacy of vasopressin was measured by comparing pre- and post-operative haemoglobin levels and haematocrit, changes in intra-operative pulse and blood pressure, measured blood loss, need for blood transfusion post-operative febril morbidity in the treatment and control groups. RESULTS: The use of vasopressin resulted in median blood loss of 225 ml (range150-400ml) compared with 675 ml (range 500-800ml) in the placebo group (p<0.001). The vasopressin group had a correspondingly lower fall in haemoglobin level (median 1.7g/dl vs 5.3g/dl, P<0.001) and haematocrit (median 5 percent vs 13 percent, P<0.001) compared with the controls. Fifty percent of the placebo group had blood transfusions compared with none in the vasopressin group (P=0.03). There were no significant differences between the groups in intra-operative pulse and blood pressure or post-operative white blood cell counts or temperature. CONCLUSION: The results indicate that vasopressin is effective in preventing blood loss and reducing the need for blood transfusion during myomectomy (AU)

The results of abdominal myomectomy

A survey of the records of 103 consecutive patients who underwent abdominal myomectomy revealed that menorrhagia and infertility were the commonest presenting complaints. The overall successful pregnancy rate was only 28.8 percent, but the procedure was corrective in two-thirds of patients with leiomyomata-related infertility. Intra-operative blood loss, post-operative adhesion formation and recurrence of tumour remain major drawbacks of myomectomy (AU)

Co-existing leiomyoma and benign cystic teratoma of the ovary

A case of benign cystic teratoma and a leiomyoma in the same ovary is described. The leiomyoma was confirmed by immunohistochemical methods. The occurrence of leimyoma and a teratoma within the same ovary is very rare.

Intravenous leiomyomatosis with massive ascites

A case of intravenous leiomyomatosis with massive ascites is reported. This is the first such recorded case. The patient was treated with a subtotal abdominal hysterectomy and bilateral salpingo-onphorectomy, pathological examination established a vessel wall origin. There is no evidence of recurrence up to 20 months after initial treatment.(AU)

Indications and risks of abdominal hysterectomy

A retrospective analysis of 602 consecutive abdominal hysterectomies revealed that uterine fibroids served as the principal indication for the procedure. Malignant disease accounted for only 4.5 percent cases. The main complications encountered were at the abdominal wound and vaginal vault. The use of prophylactic antiobiotics is supported, but routine cross-matching of blood for all patients is questioned (AU)

Leiomyoma of the nasal cavity

Leiomyoma of the nasal cavity is described in a 32-year-old Trinidadian woman. This is the first such case to be reported in the Caribbean, and the ninth in the world literature (AU)

Leiomyoma of the trachea

A case of leiomyoma of the trachea is described. Only fourteen cases of this tumour have been previously reported in the literature. The importance of early diagnosis and treatment is discussed (AU)