Terms, definitions and measurements to describe the sonographic features of the endometrium and intrauterine lesions: a consensus opinion from the International Endometrial Tumor Analysis (IETA) group.

The IETA (International Endometrial Tumor Analysis group) statement is a consensus statement on terms, definitions and measurements that may be used to describe the sonographic features of the endometrium and uterine cavity on gray-scale sonography, color flow imaging and sonohysterography. The relationship between the ultrasound features described and the presence or absence of pathology is not known. However, the IETA terms and definitions may form the basis for prospective studies to predict the risk of different endometrial pathologies based on their ultrasound appearance.

Urinary ascites with pelvic urinoma presenting as ovarian neoplasm: clinical and ultrasonographic features.

BACKGROUND: The majority of ureteric injuries associated with an operation are the result of gynecologic surgery. Thus, gynecologists must be aware of this risk and appreciate that ureteric injury can present late and in an unusual manner. CASE: A 26-year-old woman presented with gross abdominal distention 4 months after total abdominal hysterectomy. Ultrasonography demonstrated a large volume of ascitic fluid and a complex cyst arising from the left ovary. Serum blood urea nitrogen and creatinine were normal. Laparotomy showed a mass of 1-2-cm cysts (urinomas) on the pelvic peritoneum and tubo-ovarian surfaces and a right hydroureter with a right ureteric fistula at the level of the ureteric tunnel. A ureteroneocystostomy was performed. CONCLUSION: Ureteroperitoneal fistula with urinary ascites is a rare complication of pelvic surgery. Intravenous urography or computed tomography scan would have helped establish the diagnosis.

A prospective series of unruptured ectopic pregnancies treated by tubal injection with hyperosmolar glucose.

OBJECTIVE: To evaluate the safety and efficacy of hyperosmolar glucose injection in select unruptured tubal gestations with hCG levels less than 2500 mIU/mL. METHODS: In this prospective series, 16 patients with an hCG titer less than 2500 mIU/mL and an unruptured ectopic pregnancy were treated by tubal injection with hyperosmolar (50%) glucose. Hyperosmolar glucose was injected transabdominally into the antimesenteric site of the tubal pregnancy, using a 20-gauge spinal needle. The main outcome measures evaluated were duration of surgery, success rate, time to resolution, and follow-up tubal patency rates. RESULTS: Ninety-four percent (15) of the subjects were treated successfully with a median time to resolution of 24 days (range 5-78). The one treatment failure required methotrexate because of rising hCG titers and worsening pain 4 days after the patient was treated with hyperosmolar glucose. The mean (+/- standard error) duration of surgery was 45 +/- 6 minutes. So far, all ten patients undergoing postoperative hysterosalpingograms have demonstrated tubal patency in the treated tube. CONCLUSION: Laparoscopic injection with hyperosmolar glucose is an effective, systemically nontoxic alternative treatment for select unruptured ectopic pregnancies (hCG less than 2500 mIU/mL) that achieves tubal patency rates comparable to other conservative medical and surgical treatments.

Appendectomy at cesarean section: a prospective study.

Appendectomy was performed on 40 consecutive consenting patients undergoing elective cesarean section in a clinic population. The control group consisted of all other patients undergoing elective cesarean section during the period of study. The populations were similar. Clinical infection, blood loss, gastrointestinal tract recovery rates were equal in both groups. Appendectomy added 15 minutes to the operation time and extended the hospital stay by about one-half day. There were no wound infections or serious morbidity. A fifth of the appendixes removed were abnormal, including two with inflammation and one with a carcinoid tumor. Prophylactic appendectomy does not seem to add to the risk of elective cesarean section.

A 12-month comparative study of raloxifene, estrogen, and placebo on the postmenopausal endometrium.

OBJECTIVE: To determine the effects of a selective estrogen receptor modulator, raloxifene, on postmenopausal endometrium. METHODS: Healthy postmenopausal women (n = 415) were randomly assigned to one of the following four groups: 60 or 150 mg/day raloxifene hydrochloride, 0.625 mg/day conjugated equine estrogens, or placebo, and treated for 1 year. Endometrial biopsies were obtained in a blinded fashion at baseline and every 6 months after the ultrasound studies. Transvaginal ultrasound, with uterine size measurements, was done at baseline and at 3-month intervals. Saline-infusion sonohysterography was done at baseline and every 6 months. RESULTS: There were no statistically significant differences in baseline characteristics. Mean endometrial thickness, measured by transvaginal ultrasound, was unchanged from baseline to end point in the placebo and raloxifene groups, whereas in the estrogen group it was significantly thicker by 5.5 mm (P < .001). Mean uterine volume, calculated from transvaginal ultrasound measurements, was higher in the estrogen group only (22 cm3, P < .001). Of the 358 women with paired biopsies, endometrial hyperplasia was present in 2.1%, 0%, and 26.1% of the end-point biopsies in the placebo, raloxifene, and estrogen groups, respectively (P < .001). Proliferative endometrium was present in 2.1% of the end-point biopsies in the placebo group, 1.7% in the combined raloxifene groups, and 39.8% in the estrogen group (P < .001). CONCLUSION: Raloxifene, at 60 or 150 mg/day for 1 year, did not stimulate the postmenopausal endometrium. End-point endometrial thickness, morphology, and uterine volume in the raloxifene groups were similar to those observed at baseline and in the placebo group.

Laparoscopic removal of mullerian remnants in a woman with congenital absence of the vagina.

Most women with mullerian agenesis do not have cyclic pain and therefore do not require surgery. When surgery is necessary, we recommend a laparoscopic approach as described in this report because of the decreased morbidity and cost compared with laparotomy. Results from this case suggest that outpatient laparoscopic treatment of this condition is safe and effective. Regardless of the surgical approach used, a preoperative IVP is essential to limit the risk of damage to the urinary tract.

Hydrogynecography: a new technique enables vaginal sonography to visualize pelvic adhesions and other pelvic structures.

Vaginal ultrasonography, done after the transcervical injection of isotonic saline into the cul-de-sac, is a new technique we named hydrogynecography. This was prospectively used in patients suffering from infertility and pelvic pain. In 84% of patients we were able to identify pelvic adhesions confirmed by laparoscopy. In 16% the procedure provided false-negative results.

Altered interleukin-6 production by peritoneal leukocytes from patients with endometriosis.

OBJECTIVES: To investigate the ability of peritoneal leukocytes to produce interleukin-6 (IL-6) in vitro and to determine whether IL-6 is present in the peritoneal fluid (PF) in vivo. DESIGN: Peritoneal leukocytes were assessed for spontaneous versus stimulated IL-6 production. Interleukin-6 in the PF was also quantitated. SETTING: Leukocytes were recovered from PF obtained at the time of diagnostic laparoscopy for pain and infertility or from women undergoing bilateral tubal ligation. PATIENTS: The study population included a total of 24 women. Experimental groups consisted of women undergoing tubal ligations (n = 6), patients with postinflammatory pelvic adhesions unrelated to endometriosis (n = 6), and women with minimal to mild endometriosis (n = 6), or moderate to severe disease (n = 6). RESULTS: Peritoneal leukocytes from normal control women and patients with severe endometriosis spontaneously produced low levels of IL-6. In contrast, cells from women with mild disease or adhesions spontaneously released twofold to fourfold higher levels of this cytokine. Peritoneal leukocytes from patients with both mild and severe endometriosis were refractory to additional cytokine release directly in response to stimulation with endotoxin. Bioactive IL-6 was present in the PF of all patient groups, whereas immunoreactive IL-6 was not detected in this fluid. CONCLUSIONS: These data demonstrate that IL-6 was present in the PF of all patient groups. However, the ability of peritoneal leukocytes to produce IL-6 in vitro differed according to stage of disease. We hypothesize that altered leukocyte IL-6 production in vivo may contribute to the pathophysiology of endometriosis.

Screening and early diagnosis of gynecologic cancers.

Gynecologic malignancies remain an important health concern for women. The primary care practitioner plays a valuable role in performing regular Pap smears and pelvic examinations. Although routine screening for asymptomatic women for ovarian and endometrial cancer cannot be recommended at this time, vaginal ultrasound is a valuable tool for the evaluation of postmenopausal bleeding and ovarian masses.

Composite and classified color display in MR imaging of the female pelvis.

Because of its superior soft-tissue-imaging capabilities, MRI has proved to be an excellent modality for visualizing the contents of the female pelvis. In an effort to potentially improve gynecological MRI studies, we have applied color composite techniques to sets of spin-echo and gradient-echo gray-tone MR images obtained from various individuals. For composite generation, based on tissue region of interest calculated mean pixel intensity values, various colors were applied to spatially aligned images using a DEC MicroVAX II computer with interactive digital language (IDL) so that tissue contrast patterns could be optimized in the final image. The IDL procedures, which are similar to those used in NASA's LANDSAT image processing system, allowed the generation of single composite images displaying the combined information present in a series of spatially aligned images acquired using different pulse sequences. With our composite generation techniques, it was possible to generate seminatural-appearing color images of the female pelvis that possessed enhanced conspicuity of specific tissues and fluids. For comparison with color composites, classified images were also generated based on computer recognition and statistical separation of distinct tissue intensity patterns in an image set using the maximum likelihood processing algorithm.

Laparoscopic treatment of ectopic pregnancy. Residents' learning experience.

Although operative laparoscopy is a safe and effective method of treating ectopic pregnancy, its widespread acceptance requires appropriate operator training and experience. This retrospective study correlated operative results with experience of the resident performing surgery. Thirteen postgraduate year 3 and 4 gynecology residents treated 60 ectopic pregnancies by laparoscopy. There were four complications: two cases of atelectasis and two of persistent human chorionic gonadotropin titers. There were no blood transfusions. We found that the duration of surgery decreased as operator experience increased, and residents who had experience with five or more cases required a mean operative time of 74 minutes. We conclude from our results that the minimal amount of supervised training necessary for gynecology residents to safety and expeditiously treat ectopic pregnancy laparoscopically is five cases. Furthermore, the minimal morbidity in this study supports our continued recommendation that each resident have prior training experience of at least 10 laparoscopic sterilizations before attempting his or her first case of ectopic pregnancy.

Sonohysterography for endometrial abnormalities: preliminary results.

In examinations where the etiology of an abnormal endometrial sonographic image is not clear, saline infusion through a fine flexible catheter during transvaginal sonography provides visual contrast and uterine expansion. In 39 women, polyps, myomata, synechiae, endometrial hyperplasia, and cancer were correctly described as verified at surgery. Hyperplasia and neoplasia are not distinguishable, but the approach for biopsy and therapy is established by this simple and well-tolerated technique, which is here called sonohysterography.

PC-based multiparameter full-color display for tissue segmentation in MRI of adnexal masses.

OBJECTIVE: Our purpose was to apply full-color composite generation methods to multiparameter MRI to assess the ability of the technique to quantitatively segment clinically important anatomic and pathologic tissues. MATERIALS AND METHODS: With use of a personal computer with a 386 microprocessor and full-color (24 bit) graphics display capabilities, custom and commercially available image-processing softwares were applied to spatially aligned multiparameter SE MR image sets obtained from six patients undergoing diagnostic work-up for suspected adnexal or pelvic masses to generate intensity-based color composites. To quantitatively assess the ability of this technique to differentially segment anatomically and pathologically confirmed tissue types into unique color regions within the full-color spectrum, color image analysis was performed on the multiparameter color composites within each patient case, and the results were compared using 95% confidence intervals. RESULTS: Based on the results of pathologic correlation and color image analysis, the generation of full-color composites represents a feasible technique for compressing the diverse tissue contrast data present in multiparameter MR images of adnexal masses. CONCLUSION: With this technique, it is possible to generate composites that simultaneously display uniquely color-coded anatomic and pathologic tissue information within the context of partially natural-appearing images.

Human peritoneal macrophage and T lymphocyte populations in mild and severe endometriosis.

PROBLEM: The aim of this study was to characterize the phenotype of peritoneal lymphocyte and macrophage populations in mild versus severe endometriosis. METHOD: Using dual staining, antigen expression on peritoneal leukocytes from 24 women with endometriosis and 21 control patients was analyzed by flow cytometry. RESULTS: All groups had CD4:CD8 ratios of 0.6, with subpopulations of CD8+ cells expressing cytotoxic marker S6F1. Mild and severe endometriosis patients had increased CD3/DR+ cells, relative to controls. Two populations of macrophages were identified by size in all groups. Mild endometriosis patients had increased percentages of small macrophages expressing CD14 and HLA DQ, compared to controls and severe disease patients. In severe disease patients, antigen expression on small macrophages did not differ from controls, but decreased percentages of large macrophages expressed CD14 relative to controls and mild disease patients. CONCLUSION: All women with endometriosis exhibit activated peritoneal lymphocytes, whereas macrophage expression of CD14 is differentially expressed as a function of disease stage. Alterations in the functional capacity of these cells may contribute to the pathophysiology of this disease.

Atrial natriuretic peptide, oestradiol and progesterone in women undergoing spontaneous and gonadotrophin-stimulated ovulatory cycles.

The objective of this study was to examine the relationship between the concentrations of oestradiol and progesterone on the one hand and atrial natriuretic peptide (ANP) concentrations on the other, during the follicular and luteal phases of spontaneous and gonadotrophin-stimulated ovulatory menstrual cycles. A total of 27 ovulatory women undergoing either a spontaneous (n = 9) or a gonadotrophin-stimulated (n = 18) cycle were selected for inclusion in this study. In comparison with spontaneous cycles, gonadotrophin-stimulated cycles had increased peak follicular oestradiol (mean +/- SE; 937 +/- 150 versus 195 +/- 18 pg/ml; P < 0.05) and midluteal progesterone (mean +/- SE; 44.0 +/- 7.4 versus 14.1 +/- 2.4 ng/ml; P < 0.05) concentrations. There were no differences in the circulating ANP concentrations between the follicular and luteal phases of the menstrual cycle. Despite the increased oestradiol and progesterone concentrations following gonadotrophin stimulation, no difference in ANP concentrations was seen between stimulated and spontaneous cycles. There was no correlation between circulating concentrations of oestradiol, progesterone (at physiological and supraphysiological concentrations) and ANP throughout the menstrual cycle.

Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in Ultrasound-Sponsored Consensus Conference statement.

OBJECTIVES: A panel of 14 physicians practicing medicine in the United States with expertise in radiology, obstetrics and gynecology, gynecologic oncology, hysteroscopy, epidemiology, and pathology was convened by the Society of Radiologists in Ultrasound to discuss the role of sonography in women with postmenopausal bleeding. Broad objectives of this conference were (1) to advance understanding of the utility of different diagnostic techniques for evaluating the endometrium in women with postmenopausal bleeding; (2) to formulate useful and practical guidelines for evaluation of women with postmenopausal bleeding, specifically as it relates to the use of sonography; and (3) to offer suggestions for future research projects. SETTING: October 24 and 25, 2000, Washington, DC, preceding the annual Society of Radiologists in Ultrasound Advances in Sonography conference. PROCEDURE: Specific questions to the panel included the following: (1) What are the relative effectiveness and cost-effectiveness of using transvaginal sonography versus office (nondirected) endometrial biopsy as the initial examination for a woman with postmenopausal bleeding? (2) What are the sonographic standards for evaluating a woman with postmenopausal bleeding? (3) What are the abnormal sonographic findings in a woman with postmenopausal bleeding? (4) When should saline infusion sonohysterography or hysteroscopy be used in the evaluation of postmenopausal bleeding? (5) Should the diagnostic approach be modified for patients taking hormone replacement medications, tamoxifen, or other selective estrogen receptor modulators? CONCLUSIONS: Consensus recommendations were used to create an algorithm for evaluating women with postmenopausal bleeding. All panelists agreed that because postmenopausal bleeding is the most common presenting symptom of endometrial cancer, when postmenopausal bleeding occurs, clinical evaluation is indicated. The panelists also agreed that either transvaginal sonography or endometrial biopsy could be used safely and effectively as the first diagnostic step. Whether sonography or endometrial biopsy is used initially depends on the physician's assessment of patient risk, the nature of the physician's practice, the availability of high-quality sonography, and patient preference. Similar sensitivities for detecting endometrial carcinoma are reported for transvaginal sonography when an endometrial thickness of greater than 5 mm is considered abnormal and for endometrial biopsy when "sufficient" tissue is obtained. Currently, with respect to mortality, morbidity, and quality-of-life end points, there are insufficient data to comment as to which approach is more effective. The conference concluded by identifying several important unanswered questions and suggestions that could be addressed by future research projects.