[Review from the scientific paper about the main respiratory diseases in metallurgical workers]. / Revisione dei principali contributi scientifici sulle patologie respiratorie dei lavoratori metallurgici.

The review of main scientific investigations about the work related diseases in metallurgy shows that the most studied pathologies regards lung cancer and pneumoconiosis, other cancers and cardiovascular diseases. These evidences are not univocal and have been and are critically evaluated due to the complexity and articulated structure of metals production which makes it very difficult to compare the risks and diseases among the different metallurgical activities and, in the same activity, among the different job tasks. In addition, due to the technological and organizational evolution investigations, appear to be necessary to better define the specific hazards (for example metal species, PAH and PoPs mixtures) and to put into a correct relation these and pathologies diagnosed by health surveillance procedures or epidemiological surveys, surely different from those of past decades.

[Work-related musculoskeletal disorders and diseases of the arm]. / Disturbi e patologie muscoloscheletriche dell'arto superiore correlati con il lavoro.

Among work-related diseases, musculoskeletal disorders of the upper extremities have obtained increasing attention in recent last decades. Because of their relevance, the Italian Society of Occupational Medicine and Industrial Hygiene has decided to draw up a set of National Guidelines on the subject. This paper discusses their production and contents, including definitions, rationale, physiopathogenesis, occupational physician's contribution to biomechanical overload risk evaluation, medical surveillance of exposed workers.

[Introduction: scope and purpose of the multicenter project " Assessment of effects due to low doses in inorganic mercury following environmental and occupational exposure: human and in vitro studies on specific toxicity mechanisms"]. / Introduzione: scopi e finalità del progetto multicentrico "Valutazione degli effetti conseguenti a basse dosi di mercurio inorganico da esposizioni ambientali ed occupazionali: studio dei meccanismi di tossicità specifica in vitro e nell'uomo".

The principal aims of the project financed by the Italian Ministry of University and Scientific and Technological Research were: to verify if at the current limit values early biological effects can be demonstrated; to identify the levels of internal dose that can cause early effects; to evaluate the non-occupational factors that can contribute to the levels of internal dose. In particular, the mercury intake derived from dental amalgams and fish consumption was considered. The internal dose was measured with the traditional biological indicators (urinary and blood mercury) and with the speciation of a large percentage of biological samples by ICP-MS. The central nervous system, neuroendocrine function, kidney and the immune system were considered as target organs and were examined using previously standardized indicators of effects. Two groups of subjects were included in the study: workers with occupational exposure to inorganic mercury in different industrial settings and control subjects identified from the general population. The first group was characterized by an exposure level to inorganic mercury clearly below the current limit values; whereas the HgU levels of a relevant number of control subjects were similar to those measured in the exposed subjects. The in vitro studies covered several issues: the percutaneous absorption of mercury using skin derived from human post-mortem samples in a standardized model; the release of the metal from dental amalgams in different physiological conditions of the oral cavity; the effects of increasing doses of mercury chloride on tubular renal cells. The project was realized with the cooperation of seven Research Units from six Italian Universities. Researchers belonging to Departments of Occupational Medicine, Industrial Hygiene, General Pathology, Biochemistry, Odontology, and Biostatistics were involved to achieve a multidisciplinary approach. The results of this research project are described and discussed in the following papers.

[Evaluation of the dose of mercury in exposed and control subjects]. / Valutazione delle dosi di mercurio negli esposti e nei controlli.

OBJECTIVES: The aim of this paper was to analyse the concentrations of HgU and HgB in three different groups: 122 workers exposed, 18 workers formerly exposed and 196 subjects not occupationally or environmentally exposed to mercury. METHODS: All the subjects filled out a questionnaire concerning personal data, lifestyle, occupational or non-occupational exposure to Hg and medical history. The amalgam fillings area was measured by a standardised method. RESULTS: Urinary mercury excretion was significantly greater in the group of the exposed workers respect to the group of subjects not occupationally exposed (Median value of 8.3 micrograms/g creatinine and the 5 degrees and 95 degrees percentile respectively of 2.66 e 23.50 micrograms/g creatinine against Median value of 1.2 micrograms/g creatinine and the 5 degrees and 95 degrees percentile respectively of 0.18 and 5.42 micrograms/g creatinine). U-Hg in formerly exposed workers were comparable to U-Hg in non-occupationally exposed subjects, with a median value of 1.6 micrograms/g creatinine. B-Hg values were similar in the three groups: the median value was 3.1 micrograms/l in the non-occupationally exposed, 4.0 micrograms/l in the exposed workers and 3.9 micrograms/l in the past exposed. These value were not significantly different. Among the considered variables (amalgam fillings, fish consumption, age, sex, alcohol intake, chewing-gum and smoking) dental amalgam and fish consumption were significantly related with the Hg urinary excretion and the B-Hg levels. This is particularly true considering the subjects altogether: for the exposed workers, indeed, the occupational exposure was the most relevant variable. CONCLUSIONS: The results of the present research confirmed that the U-Hg excretion in non-occupationally exposed subjects is influenced by amalgam dental fillings. Furthermore, in our study Hg urinary excretion was significantly related with fish consumption. This fact can be explained, according to several recent experimental human and animal trials, considering that methylmercury contained in fish is partially converted, through breakage of the carbon-Hg bond, into Hg inorganic forms, which accumulate in the kidney and have a urinary excretion pathway.

[Neurotoxic effect of exposure to low doses of mercury]. / Effetti neurotossici da esposizione a basse dosi di mercurio.

OBJECTIVES: To assess early effects on the Central Nervous System due to occupational exposure to low levels of inorganic mercury (Hg) in a multicenter nationwide cross-sectional study, including workers from chloro-alkali plants, chemical industry, thermometer and fluorescent lamp manufacturing. The contribution of non-occupational exposure to inorganic Hg from dental amalgams and to organic Hg from fish consumption was also considered. METHODS: Neuropsychological and neuroendocrine functions were examined in a population of 122 workers occupationally exposed to Hg, and 196 control subjects, not occupationally exposed to Hg. Neuropsychological functions were assessed with neurobehavioral testing including vigilance, motor and cognitive function, tremor measurements, and with symptoms concerning neuropsychological and mood assessment. Neuroendocrine functions were examined with the measurement of prolactin secretion. The target population was also characterized by the surface of dental amalgams and sea fish consumption. RESULTS: In the exposed workers the mean urinary Hg (HgU) was 10.4 +/- 6.9 (median 8.3, geometric mean 8.3, range 0.2-35.2) micrograms/g creatinine, whereas in the control group the mean HgU was 1.9 +/- 2.8 (median 1.2, geometric mean 1.2, range 0.1-33.2) micrograms/g creatinine. The results indicated homogeneous distribution of most neurobehavioral parameters among exposed and controls. On the contrary, finger tapping (p < 0.01) and the BAMT (Branches Alternate Movement Task) coordination test (p = 0.05) were associated with occupational exposure, indicating an impairment in the exposed subjects. Prolactin levels resulted significantly decreased among the exposed workers, and inversely related to HgU on an individual basis (p < 0.05). An inverse association was also observed between most neuropsychological symptoms and sea fish consumption, indicating a "beneficial effect" from eating sea fish. On the contrary, no effects were observed as a function of dental amalgams. CONCLUSIONS: In conclusion, this study supports the finding of early alterations of motor function and neuroendocrine secretion at very low exposure levels of inorganic Hg, below the current ACGIH BEI and below the most recent exposure levels reported in the literature.

[Immunologic effects of exposure to low levels of inorganic mercury]. / Effetti immunitari da esposizione a basse dosi di mercurio inorganico.

OBJECTIVE: The immune system is a target for the toxic effects of inorganic mercury, both in humans and animals. In humans it has been observed that occupational and environmental exposure to inorganic mercury may cause both clinical (autoimmunity, hypersensitivity) and subclinical effects (cellular and humoral immunologic variable modifications). To obtain a better definition of these effects with respect to the exposure levels, a multicentre study was performed on 117 workers exposed to very low doses of inorganic mercury and 172 subjects from the general population of the same geographical area with environmental exposure to mercury from dental amalgams and dietary fish intake. RESULTS: The white blood cell count was included in the normality range for all subjects and there was no difference between exposed and non exposed subjects. The immunologic variables studied showed an increase of the CD4+ and CD8+ number in exposed workers compared to non-exposed subjects, with a statistically significance only for CD4+, while no difference was observed regarding CD4+, CD8+, NK+ percentage and CD4+/CD8+ ratio. A significative decrease of serum IL-8 and an inverse correlation between serum levels of this cytokine and HgU were observed in exposed workers compared to non exposed subjects. No association between immunologic variables and both dental amalgams and dietary fish intake was found in subjects not occupationally exposed to inorganic mercury. DISCUSSION: The decrease in IL-8 serum levels observed in exposed workers might suggest an immunosuppressive effect of occupational exposure to very low doses of inorganic mercury. This result suggests the need to revise of current HgU BEI after further definition of its prognostic significance.

[Use of regression analysis in the study of the association between different mercury exposure routes and some functional variables]. / Impiego di metodi regressivi nello studio della associazione fra differenti modalità di esposizione a mercurio e alcune variabili funzionali.

AIMS: The "Mercury Multicentric Project" data-set was analysed with the aim to identify a group of biological variables associated with different types of Hg exposure (occupational exposure, fish dietary intake, exposure due to amalgam restorations). The distribution of socio-demographic, biological and surrogate outcome variables was rather different among the collaborating Units. METHODS: Mixed linear models (MLM) were used to overcome the problems related to the heterogeneity of variances among Units. MLM are a generalization of the standard linear models, the generalization being that the data are permitted to exhibit correlation and non constant variability. MLM therefore provide with the flexibility of modelling not only the means of the dependent variable, but also their variances and co-variances as well. This allows to represent the total variability of the dependent variable as a sum of two components: the first attributable to the Units and the other one to the random error. RESULTS AND CONCLUSIONS: A set of biological variables significantly associated with at least one of the Hg exposure variables or with the HgU/creatinine ratio (as surrogate variable for Hg exposure) was identified by means of MLM. This set includes beta 2-MG, sIL8, CD4+, sPRL, FT dominant, BAMT, and some variables related to neurological behaviour. An extension of this analysis will be performed with a structural equations approach in order to study the dose-response relationships among the various variables according to a hierarchical path defined on biological basis. One of the possible simplified general models including all the selected variables is described.

Assessment of reference values for mercury in urine: the results of an Italian polycentric study.

The results of a polycentric study to assess the reference values of urinary mercury (U-Hg) in four Italian cities are presented. A total of 383 subjects were selected on the basis of standardised criteria by a questionnaire on personal habits, lifestyle, occupational or non-occupational exposure to Hg, medical history, number and area of dental amalgams. U-Hg was determined by hydride generation atomic absorption method (HG-AAS), with a detection limit of 0.5 microg/l and by flow injection (FI) inductively coupled plasma mass spectrometry (ICP-MS), with a detection limit of 0.03 microg/l. The median value of U-Hg, determined by HG-AAS, was 0.78 microg/g creatinine (0.75 for males and 0.83 for females), with 5 degrees and 95 degrees percentiles, respectively, of 0.17 and 3.66 microg/g creatinine. When determined by FI ICP-MS, the median value was 0.79 microg/g creatinine (0.77 for males and 0.79 for females) with 5 degrees and 95 degrees percentiles of, respectively, 0.12 and 5.02 microg/g creatinine. Among the independent variables, city of origin, area of dental amalgams, fish intake and tobacco smoking significantly influenced the U-Hg levels. The U-Hg reference values from this survey are lower than those from other recent investigations, probably due to characteristics and selection of the examined individuals and to the strict control of pre-analytical and analytical factors of variability.

[A pilot study on training and information of workers exposed to biomechanical overload of the upper limb]. / Studio pilota sulla formazione ed informazione di lavoratori esposti a sovraccarico biomeccanico dell'arto superiore.

Health education (HE) is very important in the prevention of occupational diseases, particularly when exposure to risk factors can be reduced through working procedures and hygienic behaviours. This pilot study refers to a HE program for prevention of work related muscle-skeletal disorders of upper limbs, carried out in two groups of 15 and 12 workers, respectively employed in trimming and assembling of plastic and metal parts. The first phase of the program consisted of worksite inspections and video recording of working procedures, characteristics of tools and machinery. This was followed by an informative meeting with the workers, which began with the administration of a multiple choice questionnaire, designed to evaluate the baseline knowledge about risk factors, work related muscle-skeletal disorders of upper limbs, working specific procedures and preventive actions. Questionnaires and video recording were repeated after two months in the second phase of the program, as subjective and objective methods of evaluation of HE effectiveness. In both groups, the questionnaire score was significantly increased after the program and a clear improvement was shown in the correct working procedures. This HE program contributed to increase the level of knowledge of the workers and fostered the adoption of working behaviours suitable to reduce the strain for the upper limbs.

[Medical surveillance and occupational identification of workers exposed to repeated movements of the upper limbs]. / Sorveglianza sanitaria e idoneità lavorativa in esposti a movimenti ripetuti dell'arto superiore.

Repetitive motions of the upper limb at work can induce muskulo-skeletal alterations, therefore a specific medical surveillance is needed, according to the intensity of risk. In low risk conditions, the medical surveillance is aimed at the identification of hyper-susceptible individuals and the administration of specific information programs. When the risk intensity is higher, medical surveillance should add the recognition of early symptoms and signs of muskulo-skeletal disturbances, in order to remove workers showing early alterations from the exposure and allow medical rehabilitation. The diagnostic protocols with the adequate instrumental evaluation are provided, and the required legal reporting is discussed.

Assessment of neurobehavioral performance as a function of current and cumulative occupational lead exposure.

A cross sectional field study was planned to assess neurotoxic effects caused by low-level occupational lead exposure. Two groups of 66 workers and 86 controls were examined with a battery including a questionnaire on neurotoxic symptoms, the measure of performance at neurobehavioral testing, the detection of visual contrast sensitivity, and the dosage of serum prolactin. Both current and cumulative exposure to lead were defined. The average PbB was 27.50 +/- 28 microg/dl (median 28, range 6-61) in the exposed and 8.11 +/- 4.47 microg/dl (median 7, range 2-21). The test results were controlled for possible confounders including age, schooling, alcohol and coffee intake. Significant differences were observed between exposed and controls regarding neurotoxic symptoms reporting, the exposed reporting more frequently mood changes and abnormal fatigue. The exposed subjects showed a decreased visual contrast sensitivity, and a marked increase of prolactin secretion. No changes emerged regarding neurobehavioral testing. The alterations observed resulted associated to the current lead exposure and not to the cumulative indices. A safe exposure level was calculated on the basis of dose-response relationship with prolactin alteration, yielding a PbB value of 10 microg/dl.

One century of studies on lead poisoning in papers published in La Medicina del Lavoro.

One century of papers published in the Italian journal of occupational medicine, La Medicina del Lavoro, shows clearly that the study of lead is an exemplary topic for occupational physicians, enabling them to observe the evolution of research in the field of occupational health. The numerous pathological features of lead poisoning, doctors' successive therapeutic responses, and their gradual development of preventive techniques, form a paradigm that has subsequently been applied to all other fields of industrial toxicology. The evolution of the study of lead poisoning during this century is a complete example in the field of occupational toxicology for medical students: it will stimulate them in applying both clinical and preventive knowledge in the field of industrial toxicology.

[Prevalence of carpal tunnel syndrome in workers executing complex tasks with the upper extremities]. / Prevalenza di Sindrome del Tunnel Carpale in lavoratrici che effettuano operazioni complesse con gli arti superiori.

In 50 female workers of a manufacturing plant employed on the assembly line of metal and plastic products with cloth covering, we found a high prevalence of Carpal Tunnel Syndrome (16 cases, 32%, 5 of whom had already undergone surgical treatment). The subjects with positive diagnosis of Carpal Tunnel Syndrome also had a longer occupational exposure to repetitive movements, compared to the other subjects. Among the subjects with this disorder, the length of exposure was also significantly associated with the reported symptoms and the extension threshold measured on the 2nd finger of the dominant hand. Ergonomic assessment of the assembly lines revealed high-frequency repetitive movements and application of force, with insufficient rest intervals.

[100 years of lead poisoning studies from a reading of articles published in La Medicina del Lavoro]. / Cento anni di studi sul saturnismo attraverso la lettura degli articoli pubblicati su "La Medicina del Lavoro".

In preparing this paper we considered the articles published in La Medicina del Lavoro from 1901, its first year of publication. This scientific journal was founded in Milan, when an animated debate arose in Italy on the necessity of treating and, above all, preventing occupational diseases. In the same city, the "Clinica del Lavoro" (i.e. Institute of Occupational Medicine) was inaugurated in 1910. Its founder, Professor Luigi Devoto, had to overcome numerous obstacles caused by the hostility of the Rector of the University of Pavia--the future Nobel prize winner Camillo Golgi--and the clinicians of the main hospital of Milan, founded by Francesco Sforza in the XV century. From reading a century of articles which appeared in La Medicina del Lavoro, it is clear that for occupational physicians lead is an exemplary topic by which to evaluate the evolution of research in the field of occupational diseases. The numerous pathological features of lead poisoning, the successive therapeutic responses of physicians, and the gradual development of preventive techniques constitute a paradigm that has subsequently been applied to all other fields of industrial toxicology. Reading the papers of 100 years gives a clear picture of the evolution of clinical syndromes over the decades. The pathological picture of lead poisoning gradually became less serious and progressively changed into aspecific, subclinical manifestations. The categories of workers in which lead poisoning had a high incidence changed over the years: painters, printers and munition makers had the highest incidence in the first three decades of this century; afterwards, those engaged in lead smelting, alloy production, painters, and in the last few decades those employed in battery, ceramic and PVC production. Prevention consisted mainly of early diagnosis of lead poisoning and instruction in proper hygiene measures. Later, in 1929, insurance of occupational diseases was made compulsory in Italy, and among the few risk factors covered by law were lead and its compounds. This law was a great advance not only in the diagnostic and insurance fields but also for prevention. Two aspects of occupational lead poisoning are particularly instructive: treatment on the one hand and the use of laboratory analysis on the other. In treatment, the initial approach was mainly empirical and physicians insisted on evacuation of the bowel. Laboratory analysis started in the 20's with analysis of erythrocytes with basophilic stippling and continued with the study of urinary porphyrins. This was followed by the determination of lead in blood and urine. These tests were used initially as diagnostic tools, and only since the 60's they have been used for biological monitoring of workers for preventive purposes. The identification of indicators of dose, of critical/subcritical effect, and of critical organ started with studies on lead poisoning. Since then, following this model, biological monitoring has been applied to numerous other metals, solvents, and pesticides. The evaluation of the Italian scientific literature on lead over one hundred years in La Medicina del Lavoro has been a very exciting experience. It suggests that knowledge of the evaluation of lead poisoning and lead exposure should be taught to medical students and young physicians, thereby stimulating them to put into practice the maxim that was engraved on the foundation stone of the Clinica del Lavoro: in aliis vivimus, movemur et sumus.

Transvaginal ultrasonography versus uterine needle biopsy in the diagnosis of diffuse adenomyosis.

To assess the reliability of transvaginal ultrasonography and uterine needle biopsy, used singly or in combination, in the diagnosis of diffuse adenomyosis, a prospective study with pathological confirmation of the diagnosis was performed. A total of 102 premenopausal women scheduled for hysterectomy because of menorrhagia and/or pelvic pain underwent preoperative transvaginal ultrasonography. After removal of the uterus, a single full-thickness myometrial biopsy specimen was taken from along the median line in the upper third of the posterior uterine wall, using a 14-gauge Trucut needle. Adenomyosis was diagnosed by the sonographer by the presence of indistinctly demarcated heterogeneous myometrial areas with distorted echotexture, and by the pathologist when the distance between the lower border of the endometrium and the affected myometrial area was more than one-half of a low power field. The prevalence of adenomyosis was 28% (29/102 patients). The sensitivity and specificity of transvaginal ultrasonography were 82.7 and 67.1% respectively, compared with 44.8 and 95.9% for uterine needle biopsy. The positive predictive values of the two tests were 50.0 and 81.2% respectively, and the negative predictive values 90.7 and 81.4%, likelihood ratios of a positive test 2.5 and 10.9, likelihood ratios of a negative test 0.3 and 0.6, and kappa indexes of agreement 0.42 and 0.47. Combining the tests did not improve the overall diagnostic performance. Both transvaginal ultrasonography and uterine needle biopsy demonstrated suboptimal test characteristics.

Progestins for symptomatic endometriosis: a critical analysis of the evidence.

OBJECTIVE: To obtain estimates of the effects of progestin treatment for pelvic pain associated with endometriosis. DATA IDENTIFICATION: Information from studies published in the English-language literature between 1966 and 1996 was pooled. Articles were identified through hand and computerized searches using MEDLINE. STUDY SELECTION: A total of 27 trials that were published in peer-reviewed journals were identified, and 13 of these were excluded from the analysis because of methodologic limitations. Nine of the remaining 14 studies were noncomparative (8 prospective and 1 retrospective), 1 was quasi-randomized, and 4 were true randomized controlled trials. DATA EXTRACTION AND SYNTHESIS: The sample size was generally limited; the mean number of patients included was 26 in the noncomparative trials and 29 in the randomized controlled trials. The mean duration of treatment was 6 months. A total of 355 women had pain at entry. Considering all noncomparative studies, the pooled frequency of nonresponders at the end of treatment was 9% (18/203; 95% confidence interval [CI], 5.3% to 13.6%). The common odds ratio from the four randomized controlled trials comparing progestins with danazol or a GnRH agonist was 1.1 (95% CI, 0.4 to 3.1), suggesting equivalence in treatment effect. In the only double-blind, placebo-controlled trial, the frequency of nonresponders was not significantly different in the two arms. Only four studies assessed pain after drug withdrawal. The pooled frequency of pelvic pain at the end of follow-up was 50% (35/70; 95% CI, 37.8% to 62.2%). The overall crude conception rate after therapy among women who desired pregnancy was 44% (86/194; 95% CI, 37.2% to 51.6%). Side effects of limited clinical relevance were observed frequently. CONCLUSION(S): The available data suggest that the efficacy of progestins for temporary relief of endometriosis-associated pelvic pain is good and comparable to that of other, less safe treatments.

Levonorgestrel-releasing intrauterine device versus hysteroscopic endometrial resection in the treatment of dysfunctional uterine bleeding.

OBJECTIVE: To compare the effect of a levonorgestrel-releasing intrauterine device with that of endometrial resection on menstrual bleeding, patient satisfaction, and quality of life in menorrhagic women during 12 months of follow-up. METHODS: Seventy premenopausal women with dysfunctional uterine bleeding were enrolled in a prospective, open, parallel-group, controlled trial. They were randomized to either insertion of an intrauterine system releasing 20 micrograms/day of levonorgestrel (n = 35) or endometrial resection (n = 35). The women were evaluated at baseline, and thereafter, uterine bleeding was assessed monthly with a pictorial blood loss assessment chart. Clinical gynecologic examination was performed bimonthly, and the hematologic variables were measured at 6 and 12 months. On the latter occasion, the women were requested to rate the degree of satisfaction with the effect of their treatment and to complete the Short Form 36 General Health Survey questionnaire. RESULTS: Recurrent menorrhagia was observed at 12 months in four women in the intrauterine device group (including two with partial expulsion of the device) and in three women in the resection group. Compared with baseline values, at 1 year, the pictorial blood loss assessment chart score was reduced by 79% in the former group and by 89% in the latter. Amenorrhea or hypomenorrhea at 12 months was reported by 65% of the women with an intrauterine device compared with 71% who underwent endometrial resection. The degree of satisfaction with treatment was high in both groups, with 29 of 34 (85%) women being satisfied or very satisfied in the intrauterine device group versus 33 of 35 (94%) in the resection group. Health-related quality of life perception was not significantly different in the two treatment groups. CONCLUSION: Somewhat less satisfactory results were obtained with a levonorgestrel-releasing intrauterine system compared with endometrial resection for dysfunctional uterine bleeding at 1 year of follow-up.

The role of transvaginal ultrasonography and outpatient diagnostic hysteroscopy in the evaluation of patients with menorrhagia.

To verify the reliability of transvaginal ultrasonography in diagnosing intrauterine disease and in evaluating the operability of submucous myomas and to determine the feasibility, acceptability and validity of hysteroscopy for menorrhagia, we performed a prospective 5 year study on 793 women of mean age +/- SD of 41.5 +/- 7.8 years. All the patients referred for excessive menstrual bleeding with uterine volume <12 week pregnancy who underwent complete physical examination, transvaginal ultrasonography and outpatient hysteroscopy with endometrial biopsy were included in the study. Outpatient hysteroscopy was not completed due to intolerance or was unsatisfactory due to excessive bleeding in 23 cases (2.9%). Only 28 women (3.5%) declared they would have refused the procedure had they imagined the pain involved. One case of pelvic infection was observed. Compared with hysteroscopy, transvaginal ultrasonography had 96% sensitivity, 86% specificity, 91% positive predictive value and 94% negative predictive value in the diagnosis of intrauterine abnormality. The sensitivity, specificity, positive and negative predictive values of ultrasonography in identifying submucous myomas operable hysteroscopically (intramural extension <50%) were respectively 80, 69, 83 and 65% with a k index of agreement between ultrasonography and hysteroscopy of 0.48. Thus, considering the good specificity and high negative predictive value, transvaginal ultrasonography may be suggested as the initial investigation in menorrhagic patients, limiting hysteroscopy to cases with positive or doubtful sonographic findings.

Endometrial resection versus vaginal hysterectomy for menorrhagia: long-term clinical and quality-of-life outcomes.

OBJECTIVE: Our purpose was to compare patients' satisfaction with the effect of treatment, health-related quality of life, psychologic status, and sexual functioning 2 years after endometrial resection or vaginal hysterectomy for menorrhagia. STUDY DESIGN: Menorrhagic women < or = 50 years old with a mobile uterus smaller than a 12-week pregnancy were enrolled in a randomized trial to compare endometrial resection and vaginal hysterectomy. Two years after surgery the women were requested to rate the degree of satisfaction with the effect of the operation and to complete the Short Form 36 general health survey questionnaire, the Hospital Anxiety and Depression Scale, and the revised Sabbatsberg Sexual Rating Scale. RESULTS: Forty-one subjects underwent endometrial resection and 44 underwent vaginal hysterectomy without major complications. Of the 77 women attending the 2-year follow-up visit, 33 of 38 (86.8%) in the endometrial resection arm were very satisfied or satisfied with the treatment compared with 37 of 39 (94.8%) of those in the hysterectomy arm. According to the Short Form 36 questionnaire, social functioning and vitality scores were significantly better in the hysterectomy group than in the resection group. Significantly lower Hospital Anxiety and Depression Scale anxiety scores were observed in the former than in the latter subjects. The Sabbatsberg Sexual Rating Scale scores were similar in the two groups. CONCLUSIONS: In patients requiring surgical treatment for menorrhagia vaginal hysterectomy appeared slightly more satisfying and offered a better health-related quality of life than did endometrial resection at 2-year follow-up. Hysterectomy did not adversely affect psychologic status and sexual functioning.