Postoperative morphologic changes of the isthmocele and clinical impact in patients treated by channel-like (360°) hysteroscopic technique.

OBJECTIVE: To evaluate the changes in (1) residual myometrial thickness (RMT), (2) cesarean scar defect (CSD) size, and (3) clinical symptoms, before and after channel-like (360°) hysteroscopic resection for the treatment of CSD. METHODS: A single-center, observational, prospective, cohort study was carried out enrolling all symptomatic patients of childbearing age, diagnosed with CSD and routinely scheduled for channel-like (360°) hysteroscopic resection from July 2020 to July 2021 at the Division of Gynecology and Human Reproduction Physiopathology, Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Univeristaria di Bologna. University of Bologna, Italy. The primary outcome was the difference in mean RMT before and after the procedure. Secondary outcomes were the differences before and 4 months after the surgery in: (1) CSD size measured by transvaginal ultrasound, (2) visual analog scale (VAS) scores for the symptoms, and (3) abnormal uterine bleeding (AUB) rate. Lastly, patients' satisfaction was assessed by the global impression of improvement (PGI-I) score. RESULTS: We found a significant difference before and after the procedure in: (1) mean RMT (+2.0 mm; P < 0.001); mean size of the CSD (base: +1.6 mm; height: -2.5 mm; transverse diameter: -3.2 mm; volume: -263.7 mm3 ; P < 0.001); (2) mean VAS score for dyspareunia (-5.84; P < 0.001), dysmenorrhea (-8.94; P < 0.001), pelvic pain (-2.94; P < 0.001); (3) AUB rate (91% vs. 3%; P < 0.001). Lastly, the mean PGI-I score ± SD was 1.7 ± 0.9. CONCLUSION: Channel-like (360°) hysteroscopic resection for the treatment of patients with symptomatic CSD may lead to an increase in RMT, decrease in CSD, and improvement of symptoms after the procedure, with high patient satisfaction.

International Consensus Statement for Recommended Terminology Describing Hysteroscopic Procedures.

OBJECTIVE: To develop a consensus statement of recommended terminology to use for describing different aspects of hysteroscopic procedures that can be uniformly used in clinical practice and research. DESIGN: Open forum discussion followed by online video meetings. SETTING: International community of hysteroscopy experts PATIENTS: Not applicable. INTERVENTIONS: Series of online video meetings to complete a previously established agenda until a final agreement for standardized nomenclature was obtained. MEASUREMENT AND MAIN RESULTS: The adoption and implementation of a common terminology to standardize reporting of hysteroscopic procedures was proposed to cover five domains: pain management, healthcare setting, model of care, type of hysteroscopic procedure and the hysteroscopic approach to the uterine cavity. A final agreement was obtained after 3 online video meetings. CONCLUSION: Hysteroscopy is the gold standard technique for the evaluation and management of uterine disorders. A clear definition and understanding of the terminology used to describe hysteroscopic procedures is lacking. The production of this international consensus statement for terminology to describe hysteroscopic procedures, covering pain management, setting, model of care, type of procedure and hysteroscopic approach, has the potential to enable more effective communication for both clinical and research purposes with the ultimate aim of improving patient care and clinical outcomes.

Comparison of Hysteroscopic Cesarean Scar Defect Repair with 26 Fr Resectoscope and 16 Fr Mini-resectoscope: A Prospective Pilot Study.

STUDY OBJECTIVE: Several studies have been published on hysteroscopic treatment of cesarean scar defect using the 26 Fr resectoscope. This study compared the effects of the 26 Fr resectoscope with those of the 16 Fr mini-resectoscope in terms of efficacy, safety profile, and peri- and postoperative complications. DESIGN: A prospective cohort study. SETTING: Tertiary care university hospital (S. Orsola-Malpighi, Bologna, Italy). PATIENTS: Three hundred and nine women having symptoms and with a cesarean scar defect diagnosis were divided into 2 groups according to a temporal criterion: from March 2012 to March 2015, 155 consecutive women (control group) underwent isthmoplasty with the 26 Fr resectoscope (Karl Storz, Tuttlingen, Germany), whereas from April 2015 to March 2018, 154 consecutive women (study group) underwent isthmoplasty with the 16 Fr mini-resectoscope (Gubbini system, Tontarra Medizintechnik, Tuttlingen, Germany). INTERVENTIONS: One hundred and fifty-five women (control group) underwent isthmoplasty with the 26 Fr resectoscope, and 154 women (study group) underwent isthmoplasty with the 16 Fr mini-resectoscope. The so-called "channel-like" 360° endocervical resection technique was applied. MEASUREMENTS AND MAIN RESULTS: The isthmoplasty time with the 2 resectoscopes, excluding cervical dilatation, was similar (p = .25), whereas the overall surgical time was shorter in the case of the mini-resectoscope. The use of the 16 Fr mini-resectoscope was significantly associated with a reduced volume of distension medium used (p <.001) and a lower fluid absorption (p <.001). A significant increase (p = .01) in postoperative complications in the control group (9/155; 5.8%) compared with the study group (1/154; 0.7%) was also found. No significant reduction in discharge time was observed between the 2 groups (p = .13). Patient satisfaction immediately after surgery was significantly higher (p <.001) in the study group than in the control group. CONCLUSION: Isthmoplasty with a 16 Fr mini-resectoscope seems to be as effective as isthmoplasty with a 26 Fr resectoscope in reducing postmenstrual abnormal uterine bleeding and suprapubic pelvic pain. It is associated with a significant reduction in overall surgical time owing to the non-necessity of performing cervical dilatation. The 16 Fr mini-resectoscope facilitates surgery in small anatomical spaces such as the cervical canal and reduces the complication rate linked to blind maneuvers not respecting the uterine anatomy.

Comparison of endometrial polyp recurrence in fertile women after office hysteroscopic endometrial polypectomy using two widely spread techniques.

AIM: To compare the recurrence of benign endometrial polyps after office hysteroscopic polypectomy performed with a bipolar electrode (BE) or a small diameter hysteroscopic tissue removal system (HTRs). METHODS: From July 2018 to December 2019 we evaluated the charts of 114 asymptomatic fertile women who underwent office hysteroscopic polypectomy, 1 year before, for a single large benign endometrial polyp (size between 10 and 20 mm) using a 4 mm continuous flow hysteroscope with a BE or a 5 mm HTRs. Patients, divided into two groups according to surgical procedure, each performed exclusively by one expert gynecologist, were scheduled for a 12-month postoperative transvaginal sonography to evaluate the recurrence of endometrial polyps. RESULTS: Forty-eight women of the BE group and 42 of the HTRs group were considered for the 1-year transvaginal sonography follow-up. Five polyps were identified in the BE group and three in the HTRs group (5/48 vs 3/42, P = n.s.). All polyps were removed hysteroscopically (in three out of five and in two out of three cases, respectively, in the same places of the previous polypectomy) and evaluated as 'benign' by the pathologist. CONCLUSION: Office hysteroscopic endometrial polypectomy with small HTRs compared to BE revealed at a 1-year follow-up no difference in terms of complete removal and recurrence of polyps. HTRs polypectomy resulted in less pain and significantly quicker time of procedure compared to BE. This data should be kept in mind for patient comfort any time hysteroscopic polypectomy is planned in an office setting.

Ulipristal acetate in symptomatic uterine fibroids. A real-world experience in a multicentric Italian study.

Surgery is the most frequent treatment in women with symptomatic uterine fibroids. A new medical approach with ulipristal acetate (UPA) has been suggested. The aim of this study was to provide data on effectiveness and safety of UPA in premenopausal women with symptomatic uterine fibroids. This was a multicenter retrospective cohort study. Data on all consecutive premenopausal women with symptomatic uterine fibroids referred to three Italian centers were included in a dedicated merged database. Women aged 18-55 years, who received pharmacologic therapy with UPA 5 mg orally once a day, were included in the study. The primary outcome was the percentage of women who underwent surgery after UPA treatment. One hundred and forty-two premenopausal women with uterine fibroids were included in this study. The mean age was 43.2 years. Eighty-one (57.0%) of 142 women treated with UPA had only medical treatment and did not undergo surgery. Surgical treatment occurred in 70, 23, 32, and 8% of the women who received one course, two courses, three courses, or four courses, of UPA treatment, respectively. The incidence of side effects was 10.6%. The effectiveness and safety of repeated UPA treatment courses in reducing number of women requiring surgery is confirmed by real-world data.

Channel-like 360° Isthmocele Treatment with a 16F Mini-Resectoscope: A Step-by-step Technique.

STUDY OBJECTIVE: To show the technique of hysteroscopic channel-like 360° repair of a cesarean scar defect performed with a Gubbini 16F miniresectoscope (GUBBINI system; Tontarra Medizintechnik, Tuttlingen, Germany). DESIGN: A step-by-step demonstration of the surgical technique using slides, pictures, and a video (an instructive video [Video 1]). SETTING: A university hospital (Bologna University Hospital, Sant'Orsola-Malpighi Polyclinic, Bologna, Italy). PATIENTS: A 35-year-old woman with a history of a previous cesarean section complaining of pelvic pain and postmenstrual spotting. INTERVENTIONS: With the vaginoscopic approach, the isthmocele was localized; a high-frequency 90° angled circular loop electrode and pure cutting current of 100 W were used to resect the fibrotic tissue of the proximal (step 1) and distal (step 2) part of the niche. We performed resection not only of the fibrotic tissue underneath the niche but also of the inflamed tissue placed around the niche and on the opposite site (the so-called channel-like 360° endocervical ablation). A high-frequency angled ball electrode was used to obtain focused coagulation of all residual inflamed tissue still present on the niche surface and on the cervical canal walls (step 3); the aim of this step is to facilitate the re-epithelialization of the cervical canal walls by the paraphysiological endocervical epithelium. The procedure was ended by controlling any bleeding of the endocervical vessels by reducing the inflow and pressure of the distending medium and by focused electrocauterization with a ball electrode (step 4). MEASUREMENTS AND MAIN RESULTS: The operative time was 14 minutes. The small diameter of a 16F resectoscope and the use of a miniaturized loop without cervical dilation allow the operative procedures to be performed without cervical dilation and without anatomic distortion of the defect, reducing the risk of complications. The small diameter of the sheaths also makes the surgical gesture faster with an easier and faster approach to the niche compared with isthmocele hysteroscopic standard surgery. CONCLUSION: The presence of a uterine scar defect is usually asymptomatic or refers to postmenstrual spotting with dark red or brown discharge, dysmenorrhea, dyspareunia, chronic pelvic pain, infertility, or a dull sensation after menstruation. Several factors may play a role in isthmocele development such as a low uterine incision, a deficient suturing technique of the uterine incision, and patient-related factors that impair wound healing or increase inflammation or adhesion formation. Different techniques were used as reconstructive therapies of the cesarean scar defect including laparoscopic or robot-assisted laparoscopic excision, vaginal repair, or hysteroscopic treatment. All of these procedures remove or ablate the niche fibrotic tissue with the aim of relieving symptoms. Asymptomatic cases should not be treated. According to the most recent literature, hysteroscopic repair of a cesarean scar represents an effective and safe surgical option in cases of a symptomatic isthmocele. The persistence of symptoms has been reported in up to 18% of cases, so adequate counseling should be performed before the procedure.

Prevalence of Infections After In-Office Hysteroscopy in Premenopausal and Postmenopausal Women.

STUDY OBJECTIVE: To estimate the incidence of infection after diagnostic and operative hysteroscopic procedures performed in an in-office setting with different distension media (saline solution or CO2). DESIGN: Prospective, multicenter, observational study (Canadian Task Force classification II-2). SETTING: Tertiary women's health centers. PATIENTS: A total of 42,934 women who underwent hysteroscopy between 2015 and 2017. INTERVENTIONS: Of the 42,934 patients evaluated, 34,248 underwent a diagnostic intervention and 8686 underwent an operative intervention; 17,973 procedures used CO2 and 24,961 used saline solution as a distension medium. Patients were contacted after the procedure to record postprocedure symptoms suggestive of infection, including 2 or more of the following signs occurring within the 3 weeks after hysteroscopy: fever; lower abdominal pain; uterine, adnexal, or cervical motion tenderness; purulent leukorrhea; vaginal discharge or itchiness; and dysuria. Vaginal culture, clinical evaluation, transvaginal ultrasound, and histological evaluation were completed to evaluate symptoms. MEASUREMENTS AND MAIN RESULTS: Operative hysteroscopies comprised polypectomies (n = 7125; 82.0%), metroplasty (n = 731; 15.0%), myomectomy (n = 378; 7.8%), and tubal sterilization (n = 194; 4.0%). Twenty-five of the 42,934 patients (0.06%) exhibited symptoms of infection, including 24 patients (96%) with fever, 11 (45.8%) with fever as a single symptom, 7 (29.2%) with fever with pelvic pain, and 10 (41.7%) with fever with dysuria. In 5 patients with fever and pelvic pain, clinical examination and transvaginal ultrasound revealed monolateral or bilateral tubo-ovarian abscess. In these patients, histological examination from surgical specimens revealed the presence of endometriotic lesions. CONCLUSION: The present study suggests that routine antibiotic prophylaxis is not necessary before hysteroscopy because the prevalence of infections following in-office hysteroscopy is low (0.06%).

Office treatment of large endometrial polyps using truclear 5C: Feasibility and acceptability.

AIM: This retrospective multicenter study was carried out to evaluate feasibility, effectiveness and patient acceptability of a small diameter hysteroscopic tissue removal system in the treatment of large endometrial polyps (≥20 mm), usually not removed in an office setting. METHODS: Hundred and forty-six women with a single greater than 10-mm diameter polyp considered for polypectomy between April 2016 and August 2017. Sixty-five of these patients had a polyp size greater than 20 mm. All hysteroscopic polypectomy, using Hysteroscopic Tissue Removal system (TruClear 5C System Medtronic), were performed in an office setting with vaginoscopic approach. RESULTS: Procedural success, time to complete the polypectomy and patient pain scores were evaluated. Polyps less than 20 mm were completely removed in 79/81 cases (97.53%). The completeness of greater than or equal to 20-mm polyp removal was achieved in 63/65 cases (96.92%). The median time for polypectomy was 4.19 ± 1.03 min for polyps less than 20 mm and 4.97 ± 1.30 min for polyps greater than or equal to 20 mm, respectively. Pain was minimal and brief, and the mean pain score measured on a 10-point visual analog scale at the end of polypectomy showed no significant difference between the two groups. In 4/79 (5.06%) cases with polyps less than 20 mm and in 4/63 (6.35%) cases with polyps greater than or equal to 20 mm women reported moderate pain. All specimens were adequate for pathologic measurements. CONCLUSION: Hysteroscopic treatment of polyps greater than or equal to 20 mm in size with TruClear 5C is feasible and well tolerated in an office setting with no significant difference regarding completeness compared to polyps less than 20 mm, but with a minimal increase in procedure times.

Hysteroscopic Endometrial Polypectomy: Clinical and Economic Data in Decision Making.

STUDY OBJECTIVE: To compare the costs of hysteroscopic polypectomy using mechanical and electrosurgical systems in the hospital operating room and an office-based setting. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Tertiary referral hospital and center for gynecologic care. PATIENTS: Seven hundred and fifty-four women who underwent endometrial polypectomy between January 20, 2015, and April 27, 2016. INTERVENTIONS: Hysteroscopic endometrial polypectomy performed in the same-day hospital setting or office setting using one of the following: bipolar electrode, loop electrode, mechanical device, or hysteroscopic tissue removal system. MEASUREMENTS AND MAIN RESULTS: The various costs associated with the 2 clinical settings at Palagi Hospital, Florence, Italy were compiled, and a direct cost comparison was made using an activity-based cost-management system. The costs for using reusable loop electrode resection-16 or loop electrode resection-26 were significantly less expensive than using disposable loop electrode resection-27, the tissue removal system, or bipolar electrode resection (p = .0002). Total hospital costs for polypectomy with all systems were significantly less expensive in an office setting compared with same-day surgery in the hospital setting (p = .0001). Office-based hysteroscopic tissue removal was associated with shorter operative time compared with the other procedures (p = .0002) CONCLUSION: The total cost of hysteroscopic polypectomy is markedly higher when using disposable equipment compared with reusable equipment, both in the hospital operating room and the office setting. Same-day hospital or office-based surgery with reusable loop electrode resection is the most cost-effective approach in each settings, but requires experienced surgeons. Finally, the shorter surgical time should be taken into consideration for patients undergoing vaginal polypectomy in the office setting, owing more to patient comfort than to cost savings.

Essure Permanent Birth Control, Effectiveness and Safety: An Italian 11-Year Survey.

STUDY OBJECTIVE: To describe safety, tolerability, and effectiveness results through a minimum 2-year follow-up of patients who underwent permanent sterilization with the Essure insert. DESIGN: A retrospective multicenter study (Canadian Task Force classification II2). SETTING: Seven general hospitals and 4 clinical teaching centers in Italy. PATIENTS: A total of 1968 women, mean age 39.5 years (range, 23-48 years) who underwent office hysteroscopic sterilization using the Essure insert between April 1, 2003, and December 30, 2014. INTERVENTION: The women underwent office hysteroscopic bilateral Essure insert placement, with satisfactory device location and tube occlusion based on hysterosalpingography or hysterosalpingo-contrast sonography (HyCoSy). MEASUREMENTS AND MAIN RESULTS: Placement rate, successful bilateral tubal occlusion, perioperative adverse events, early postoperative (during the first 3 months of follow-up), and late complications were evaluated. Satisfactory insertion was accomplished in 97.2% of women and, in 4, perforation and 1 expulsion were detected during hysterosalpingography. Three unintended pregnancies occurred before the 3-month confirmation test. Two pregnancies were reported among women relying on the Essure inserts. Postprocedure pain was minimal and brief; in 9 women, pelvic pain became intractable, necessitating removal of the devices via laparoscopy. On telephone interviews, overall satisfaction was rated as "very satisfied" by the majority of women (97.6%), and no long-term adverse events were reported. CONCLUSION: The findings from this extended Italian survey further support the effectiveness, tolerability, and satisfaction of Essure hysteroscopic sterilization when motivated women are selected and well informed of the potential risks of the device. Moreover, the results do not demonstrate an increased incidence of complications and pregnancies associated with long-term Essure use. Patients with a known hypersensitivity to nickel may be less suitable candidates for the Essure insert.

Fertility-enhancing hysteroscopic surgery.

Anatomical uterine element and functional components play a fundamental role in the enhancing of fertility are the major actors. Uterine pathologies, including congenital or acquired lesions, have been reported in 21 to 47% of patients undergoing in vitro fertilization cycles. Hysteroscopy is an important procedure in the study of one of the most important element of fertility: the uterus, even if its use in the world of infertility is discussed. There are many studies on safety and feasibility of the procedure and on patient compliance, but there is no consensus on its systemic use. This study, thanks to the wide literature about the use of hysteroscopic surgery to enhance fertility in most of the congenital and acquired problems affecting women in fertility age, allows defining that diagnostic and operative hysteroscopy is a rapid and safety technology to improve fertility.

Hysteroscopic polypectomy in an office setting: specimen quality assessment for histopathological evaluation.

OBJECTIVE: Polypectomy under hysteroscopic guidance is the treatment of choice for most endometrial polyps, but mechanical or electrical effects at the time of surgery may result in artifactual displacement of tissue with obvious resultant diagnostic problems. The purpose of this study was to record qualitative and quantitative histopathological artifacts and to assess differences between artifacts found in specimens obtained by different surgical polypectomy techniques. STUDY DESIGN: During the period from November 2012 to March 2013, 90 retrospective consecutive polyp histopathological slides and their reports were identified for this study. Initially reported slides were reviewed blind by two histopathologists, who were not provided with any surgical details. The issued reports and those of the reviewing pathologists were then compared. RESULTS: Of the 90 reviewed polyp slides, there was complete agreement on the initial issued report in all cases. CONCLUSIONS: Removal of endometrial polyps in an office setting using mechanical instruments, bipolar electrode or a hysteroscopic morcellator provides adequate tissue for histological diagnosis, and there is no difference between these three techniques for adequacy of histological examination, despite the effects of thermal injury or tissue fragmentation.

Hysteroscopic treatment of the cesarean-induced isthmocele in restoring infertility.

PURPOSE OF REVIEW: To review the treatments of the cesarean-induced isthmocele in restoring infertility, associated techniques, and the risks of complications associated with their use. RECENT FINDINGS: Isthmocele is a reservoir-like pouch defect on the anterior wall of the uterine isthmus located at the site of a previous cesarean delivery scar. The flow of menstrual blood through the cervix may be slowed by the presence of isthmocele, as the blood may accumulate in the niche because of the presence of fibrotic tissue, causing pelvic pain in the suprapubic area. Moreover, persistence of the menstrual blood after menstruation in the cervix may negatively influence the mucus quality and sperm quality, obstruct sperm transport through the cervical canal, interfere with embryo implantation, leading to secondary infertility. The removal of the local inflamed tissue may be performed by laparoscopic, combined laparoscopic-vaginal, or vaginal surgery, and operative hysteroscopy, a minimally invasive approach to improve symptoms and restore fertility. SUMMARY: Isthmocele occurs after cesarean section, a common method of delivery and one of the most frequent surgical procedures, so that its upward incidence appears likely to continue in the near future. Because of its minimal invasiveness, resectoscopy may be the better choice for treatment, yielding good therapeutic results.

The practicability and surgeons' subjective experiences with vaginal danazol before an operative hysteroscopy.

This randomized, double blind, placebo-controlled study compared the usefulness of danazol 400mg vaginally versus 600mg orally in women as a preoperative preparation for hysteroscopic surgery. Ninety-one fertile women were randomly allocated to Group A (46 patients received 400mg of danazol placed into the posterior vaginal fornix and three oral tablets of commercially available folic acid as a placebo), and Group B [45 women treated with 600mg of danazol orally (200mg three times daily) and two vaginal tablets of Lactobacillus rhamnosus as a placebo]. The patients underwent an operative hysteroscopy, transvaginal sonography, blood tests, and a histological assay. A visual analog scale (VAS) score to compute the degree of the surgeon's satisfaction was used. The outcome measures were as follows: an evaluation of the changes in the endometrial thickness, the prevalence of endometrial atrophy, changes in the blood tests, any collateral effects, the degree of difficulty and view, the duration of the surgical procedure, any complications during the operative hysteroscopy and associated side effects, and the surgeon's satisfaction with the endometrial preparation. The vaginal administration route was associated with a more pronounced effect on the endometrial thickness. Significantly more patients receiving vaginal danazol (45/46) had a hypotrophic endometrium than those receiving oral danazol (37/45, P<0.01). In addition, the patients receiving danazol vaginally had a shorter operating time, lower infusion volume, fewer side effects, and a higher surgeon satisfaction. Vaginal danazol adequately prepares the endometrium for an operative hysteroscopy by thinning the endometrium effectively with few side effects and little impact on the metabolic parameters.

Essure transcervical tubal sterilization: a 5-year x-ray follow up.

OBJECTIVE: To evaluate the x-ray appearance of Essure microinserts 5 years after their insertion. DESIGN: Prospective controlled study. SETTING: Tertiary referral centers for gynecologic care. PATIENT(S): Forty-five consecutive women with successful hysteroscopic bilateral placement of the Essure devices and postprocedure satisfactory hysterosalpingography confirmation test. INTERVENTION(S): Pelvic anteroposterior x-ray. MAIN OUTCOME MEASURE(S): Stability and and symmetric appearance of Essure microinsert positions; measurement of the intrauterine distance between the two devices. RESULT(S): After 5 years from their placement, no detachment nor fracture of devices was observed. x-Ray recognition of the device after 5 years showed findings similar to those recorded at 3 months' follow-through hysterosalpingography. CONCLUSION(S): x-Ray evaluation of findings related to stability of position, symmetric appearance, and distance between the two Essure microinserts corroborates the irreversibility and the reliability of the fibrotic reaction that ensured tubal occlusion after devices placement.

The use of nomegestrol acetate in rapid preparation of endometrium before operative hysteroscopy in pre-menopausal women.

The presence of a thin endometrium has an important role in allowing the best conditions for hysteroscopic surgery. Here, we explored the efficacy of a 14-day administration of nomegestrol acetate, a progestogen with high progestogen potency effects, in rapid endometrial preparation to operative hysteroscopy. A total of 86 fertile women selected for operative hysteroscopy received for 14 days either 5mgday(-1) of nomegestrol acetate (n=43; group A) or 4mgday(-1) of folic acid (n=43; group B), starting on day 1 of the subsequent menstrual cycle. Before treatments on days 12-14 of the menstrual cycle, all patients underwent endometrial thickness measurement; ultrasonography of the ovaries to measure the appearance of a dominant follicle; diagnostic hysteroscopy with endometrial biopsy; plasma estradiol (E2), progesterone (P), luteinising hormone (LH) and follicle-stimulating hormone (FSH) levels measurements. On the day of surgery, patients repeated endometrial and ovarian ultrasonography and, E2, P, LH and FSH measurement. At enrolment, endometrial thickness, mean follicular diameter and E2, P, LH and FSH concentrations did not differ between groups. At the time of operative hysteroscopy (i.e., after 14 days' treatment) group A, but not group B, showed significant (all P<0.001) reduction of endometrial thickness, mean diameter of dominant follicle, E2, P and LH concentrations. Endometrial preparation was judged more effective in group A than B, since the endometrial mucosa in all of the women of group A appeared to be very thin, hypotrophic, regular and pale. In conclusion, administration of nomegestrol acetate was effective in reducing endometrial thickness, also acting on the hypothalamus-pituitary-ovarian axis, thus allowing highly favourable operative hysteroscopic conditions.

Human papillomavirus infection and risk factors in a cohort of Tuscan women aged 18-24: results at recruitment.

BACKGROUND: There is conclusive evidence that human papillomavirus (HPV) infections of the cervix are a necessary cause of cervical cancer. In Italy there are consistent data of HPV prevalence in women aged 25 - 64 years, but there is limited data for younger women. The objective of this on-going 3-year prospective cohort study is to investigate the prevalence, acquisition, clearance and persistence of HPV infections in young Tuscan women and the risk factors correlated with such events. METHODS: One thousand and sixty-six women aged between 18 and 24 years were enrolled and received an initial HPV test. They were asked to return to the clinic over the study period for further tests every 12 months, if their HPV HR result was negative, or every 6 months, if positive. Additionally, women with an HPV positive result were given a cytological examination and if the cytological diagnosis was ASC-US or more severe, only women with HPV HR, were referred for colposcopy. RESULTS: We present here data for the enrollment phase of the study. At baseline, within the study sample, just under 30% of women were infected by HPV and 19.3% of women were infected with oncogenic types. A relationship was highlighted between HPV infection, number of sexual partners (in particularly in the last 3 years) and the lifetime number of partner's partners. Condom use showed a slight protective effect in univariate analysis but these data were not statistically significant in multivariate analysis. The association between HPV infection and demographic and behavioural variables were tested by crude odds ratio (OR). Multivariate logistic regression was applied to compute the adjusted odds ratios. CONCLUSIONS: The prevalence of oncogenic HPV types was high in young Tuscan women. The 3-year follow-up of this cohort may provide a better understanding of the processes of acquisition, clearance and persistence of infection and the correlated risk factors.

Tubal sterilization by laparoscopy or hysteroscopy: which is the most cost-effective procedure?

By using the activity-based cost/management (ABC/M) system we computed and compared costs needed for laparoscopic tubal sterilization (LTS) and Essure hysteroscopic tubal occlusion (EHTO). We found that total health costs related to consultation and presurgery did not differ between LTS and EHTO; EHTO has low recovery unit costs but is more costly for the operating theater, mainly due to Essure microinserts.