Surgical removal of multiple mesenteric fibroids (Kg 4,500) by abdominal spread of previous laparoscopic uterine myomectomy.

INTRODUCTION: Huge and multiple mesenteric fibroids (4,500 Kg weight) are very unusual. In many cases they are mistaken for subserosal fibroids of the womb due to the proximity with uterine walls. When they have a rapid growth, the risk of becoming malignant (sarcoma) has not to be underestimated. Surgery is challenging to remove abdominal nodes. CASE REPORT: A case of a 40-year old woman, admitted to the hospital with abdominal masses occupying the entire cavity was reported. Both computerized tomography (CT) and ultrasounds (US) were not diriment for belonging of tumours. Clinical history of patient reports a laparoscopic removal of uterine fibroids, using the morcellator. Laparoscopy was performed four years before. Open surgery by means of a large transversal suprapubic laparotomy according to Pfannestiel was carried out. Multiple and huge mesenteric, peritoneal and intestinal tumours spread in the whole abdominal cavity were found, removed and examined by frozen section histology; in addition a series of small conglomerated myomas in the site of previous laparoscopic transumbilical route was taken away as well (the largest fibroid weighed Kg 3.500 and the all tumors removed 4,500 Kg); the result was benign (fibroids) and genital apparatus was preserved. Operation was challenging. Postoperative course was uneventful; after five days patient was discharged. CONCLUSIONS: This case is very interesting for many factors: A) many extra-uterine fibroids spread throughout abdominal cavity; B) considerable weight of the masses C) intraoperative and postoperative danger. Finally, due to involvement of previous laparoscopic transumbilical incision together with other findings, the hypothesis of post laparoscopic dissemination has to be considered. A case of so large extragenital abdominal fibroids following laparoscopic uterine myomectomy has never been published so far.

Endometrial carcinoma: MR staging and causes of error.

PURPOSE: This study was undertaken to prospectively determine the diagnostic capabilities of magnetic resonance (MR) imaging in detecting myometrial and cervical invasion and lymph node involvement in endometrial carcinoma and to identify the causes of errors in staging endometrial carcinoma. MATERIALS AND METHODS: Twenty consecutive patients with a histological diagnosis of endometrial carcinoma underwent preoperative MR imaging. MR findings were compared with surgical staging, considered as the standard of reference. RESULTS: In assessing myometrial invasion, MR imaging showed 70% accuracy, 80% sensitivity, 40% specificity, 80% positive predictive value (PPV), and 40% negative predictive value (NPV). In detecting cervical invasion, MR imaging had 95% accuracy, 100% sensitivity, 94.4% specificity, 66.7% PPV, and 100% NPV. In evaluating lymph node involvement, MR imaging showed 100% accuracy, sensitivity, specificity, PPV and NPV. Errors in evaluating myometrial invasion were caused by polypoid tumour, adenomyosis and leiomyomas, whereas those in evaluating cervical invasion were caused by dilatation and curettage. CONCLUSIONS: MR imaging is a reliable technique for preoperative evaluation of endometrial carcinoma. Its main limitation is differentiating between stage IA and IB carcinomas, which is not highly important for surgical planning. Cooperation between the gynaecologist and radiologist is mandatory to avoid staging errors.

[Chronic pelvic pain in patients with endometriosis: results of laparoscopic treatment]. / Dolore pelvico cronico nell'endometriosi: risultati del trattamento laparoscopico.

AIM: The chronic pelvic pain (CPP) linked to endometriosis, relatively frequent condition in women of reproductive age, often represents the main complaint for which the patient seeks medical advice. The purpose of this prospective study was to evaluate if and to which extent systematic ablation of endometriotic lesions causes an improvement and/or disappearance of pain in patients with ascertained endometriosis and in whom the main preoperative symptom is chronic pelvic pain. METHODS: This study examined 109 patients, affected by chronic pelvic pain secondary to endometriosis, underwent laparoscopic treatment. All patients in the preoperative phase and only the 92 coming back for follow up, were asked both to fill out an anonymous questionnaire about their quality of life and to indicate on a numeric visual analogue scale (VAS) the intensity of the perceived pain. RESULTS: Overall the median of the VAS score for pain decreased from 7.5 before surgery to 2.5 at one-year postoperative-follow up, which was consistent (Wilcoxon test) with a statistically significant regression (P<0.0001) of the intensity of perceived pain (disappearance or marked reduction) in the operated patients, independently from the stage of the disease and the type of pain; also data on quality of life during work and social activity indicated a relevant improvement respectively in 82% and in 83% of patients following the laparoscopic procedure. CONCLUSION: For this reason and as suggested by the present international guidelines, when the medical therapy against pain fails and/or in the presence of an adnexal mass (chocolate cyst) or deep endometriotic lesion, it is generally correct to rely on surgical ablation of the lesions preferably by laparoscopy.

Primary adenocarcinoma of the fallopian tube.

Primary carcinoma of the Fallopian tube is one of the rarest malignancies of the female genital tract. The Authors report a case of primary carcinoma of the uterine tube and review the treatment of this disease reported in literature. Since this tumor is so rare, debatable viewpoints remain and thus new proposals and modifications of methods of staging continue to emerge. The Authors conclude by suggesting that the setting up of a National Registry for collection of data available in Italy should be organized.

Pure dysgerminoma of the ovary.

Five cases of dysgerminoma are reported. All patients underwent unilateral salpingo-oophorectomy for FIGO Stage 1 dysgerminoma; five-year follow-up showed no recurrence of illness. A review of current work-up for staging, prognosis, and controversial therapeutic modalities for FIGO Stage 1 is presented.

The effects of tamoxifen therapy on the endometrium.

From January 1992 to December 1998, 219 women (aged between 30 and 81 yrs; average 55 years) affected by breast cancer were treated. These women in addition to the usual adjuvant therapy, were treated with TAM 20 mg/day, for a period between 24 and 72 months (average 40). In this group there were 84 postmenopausal and 31 premenopausal women. In 8 fertile patients ovarian activity was suppressed with GnRh analogue therapy and one patient underwent attinic castration. Before performing TAM therapy, a hysteroscopic exam was done and patients were followed-up with an annual check-up. None had any endometrial side-effects after the first check-up. After two years, 31 women (26.9%) complained of endometrial alterations (hyperplasia, polyps and endometrial cancer). One women only after 6 years of follow-up, had metrorrhagia; an endometrial adenocarcinoma was found. We would like to point out the necessity of monitoring these patients with an annual check-up (transvaginal sonography and/or hysteroscopy).

Endometrial cancer: preoperative evaluation of myometrial infiltration magnetic resonance imaging versus transvaginal ultrasonography.

From January 1996 to December 1998, 33 patients with endometrial carcinoma were preoperatively examined in our department; 30 women underwent transvaginal ultrasonography (TVUS) and magnetic resonance imaging (MRI), and 3 only TVUS. Diagnosis was obtained by histopathological examination of the tissue removed by hysteroscopically controlled biopsy or by curettage of the uterine cavity. TVUS and MRI were performed a few days before surgery. After surgery the uterus was histopathologically examined by a pathologist in order to evaluate the depth of myometrial invasion. The results were compared with TVUS and MRI data to determine sensibility and specificity, positive predictive value (PPV) and negative predictive value (NPV) of the two methods. According to the results of the present study we conclude that: TVUS is a low cost, easily performed and reliable method in a high percentage of cases if carried out by a skilled ecographist. MRI, is more expensive and has a lower specificity and sensibility index; it is a valid method if the cervical canal is involved and/or myometrial invasion is > 50% (M2) and if lymphatic invasion has to be investigated.

[Dysfunctional uterine bleeding: medical therapies]. / Sanguinamento uterino disfunzionale. Terapia medica.

About a third of all gynecological consultations are carried out for abnormal uterine bleeding and this ratio rises to 70% in women in peri- and postmenopause. The diagnosis of dysfunctional uterine bleeding (DUB) which is generally due to a chronic anovulatory condition, is only arrived at after objective examination has excluded transvaginal echography, sonohysterography, hysteroscopy and if necessary biopsy to check for the presence of organic pathology. The drugs commonly used in DUB are methylergometrine, the antifibrinolytics, the FANS, estrogens, progesterone and its derivaties, the estroprogestinics, danazol and the superagonist analogues of GnRH. Following these simple guidelines, all derived from evidence-based medicine, medical treatments for DUB are certainly together with patient satisfaction but there is also a marked reduction in costs linked above all to the diminution in the number of hysterectomy operations.

Effects of estriol administration on human postmenopausal endometrium.

Forty eight women with atrophic endometrium were treated with estriol, 1 mg twice daily, by mouth for a minimum of 10 days and a maximum of 25 days. Vaginal hysterectomy was then performed and specimens were examined histologically. Results showed that estriol produces endometrial hyperplasia in 70.8% of the examined women; only 29.2% of the patients retained atrophic endometrium after treatment.

Management of high-risk pregnancy.

Today, 88% of pregnancies has a physiological course during which just basic care, while in 12% of cases there is a high-risk pregnancy that requires additional assistance and specific. The approach that should be used is that of supervision in all pregnant women considering their potential to have a normal pregnancy until there is no clear evidence to the contrary. Pregnancy is considered at risk if there are medical conditions that may affect maternal or fetal health or life of the mother, fetus or both. Among the risk factors for pregnancy there is first the woman's age, in fact the increase in high-risk pregnancies in the last 20 years is attributable to the increase in the average age of women who face pregnancy. In addition, the diet is very important during pregnancy and diabetes or autoimmune diseases often lead to the failure of a pregnancy. Risk factors for pregnancy, also, are the complications that occur during its course as hypertension during pregnancy, and infectious diseases. Fears and anxieties typical of a high-risk pregnancy prevent the couple to live happily in the months of gestation. Effective communication, control and early detection are important tools that doctors must be able to ensure that women in order to plan the best treatment strategies and to minimize the risks of maternal and / or fetal.

Ovulation induction with clomiphene citrate and metformin in women with polycystic ovary syndrome.

AIM: Polycystic ovary syndrome (PCOS) is one of the most common causes of ovulatory infertility. It is an endocrine disorders characterized by a high level of male hormones (androgens) and frequent anovulatory cycles associated with multiple ovarian microcysts. The aim of this paper was to evaluate effects of a Clomiphene citrate alone versus a combined treatment (Metformin and Clomiphene citrate). METHODS: A total of 60 women with PCOS and infertility were evaluated. Inclusions criteria were: age 26-34 years, nulliparity, above 3 years of sterility, multiple ovarian microcysts, BMI>27.5, oligomenorrhea/amenorrhea, hyperandrogenism and normal male fertility. Four patients were excluded (renal damage 2, tubal occlusion 1 and Pelvic Inflammatory Disease 1). The remaining 56 were divided into 2 groups: group A were inducted with Clomiphene Citrate alone, while group B were inducted with Clomiphene citrate and Metformin. RESULTS: In group A we obtained ovulation in 20 women (71.4%), 8 pregnancies (28.5%) and one (3.5%) spontaneous abortion. In group B we obtained ovulation in 24 women (85.7%), 15 pregnancies (53.5%) and no spontaneous abortions. CONCLUSION: Combined treatment was found to be more effective (53.5) in improving pregnancy rate compared to monotherapy (28.5%).

Unexplained infertility and ovulatory induction with menopausal gonadotropins.

AIM: Unexplained infertility affects 30% of infertile couples. Management depends on duration of infertility and age of female partner. Ovulation induction, together with intrauterine insemination, is commonly offered to couples with infertility of unknown origin. Intrauterine insemination gained its popularity because it is simple, non-invasive and cost-effective technique. The association with pharmacological stimulation is suitable to induce follicular maturation. The most used drugs to induce ovulation are clomiphene citrate and menopausal or recombinant gonodotropins. The aim of this paper was to evaluate the success rate after homologous intrauterine insemination (IUI) combined with menopausal gonadotropins stimulation. METHODS: A total of 90 couples were evaluated. Twelve couples (13.3%) were excluded from the treatment (6 vaginal infections, 4 tubal occlusions and 2 male infertility). Informed consent was applied for every couple. The remaining 78 couples were divided in two groups: group A (39 couples) were inducted with menopausal gonadotropins, while group B (39 couples) underwent placebo (multivitamin). RESULTS: In group A (gonadotropins) 25 (64.1%) pregnancies and 2 (5.1%) abortion were registered, while in group B (placebo) there were 7 (17.9%). pregnancies and 1 (2.5%) abortion. CONCLUSION: Ovulation inductions with menopausal gonadotropins, together with intrauterine insemination, improves fecundity in patients with infertility of unknown origin without recur to more invasive techniques.

Ovulation induction with clomiphene citrate for infertile couple.

AIM: Among couples unable to conceive without any identifiable cause, 30% are defined as having unexplained infertility. Management depends on duration of infertility and age of female partner. In order to increase pregnancy rate, couples with infertility of unknown origin can undergo ovulation induction and intrauterine insemination. These techniques are able to increase pregnancy rate in case of unexplained infertility. Clomiphene citrate and menopausal or recombinant gonodotropins are the most used drugs to induce ovulation. Aim of the present study was to evaluate the success rate after homologous intrauterine insemination (IUI) combined with clomiphene citrate (CC) stimulation. METHODS: A total of 77 couples were evaluated. Nine couples (11.6%) were excluded from the treatment (vaginal infections 4, tubal occlusions 3 and male sterility 2). Informed consent was applied for every couple. The remaining 68 couples were divided in two groups: group A (34 couples) were inducted with CC, while group B (34 couples) underwent placebo (multivitamin). RESULTS: In group A (CC) 15 (44.1%) pregnancies and 3 (8.8%) abortion were registered, while in group B (placebo) there were 4 (11.7%) pregnancies and 1 (2.9%) abortion. CONCLUSION: Ovulation inductions with CC, together with intrauterine insemination, improves fecundity in patients with infertility of unknown origin with no need to recur to more invasive techniques.

Comparative study on the acceptability of two modern monophasic oral contraceptive preparations: 30 microgram ethinyl estradiol combined with 150 microgram desogestrel or 75 microgram gestodene.

Cycle control and tolerability of two monophasic oral contraceptive pills containing 30 microg ethinyl estradiol (EE) with either 150 microg desogestrel (DSG) or 75 microg gestodene (GSD) were compared in women starting oral contraception. A minimum of 200 healthy women at risk for pregnancy were to be treated for a total of 6 cycles per patient in a prospective, randomized open parallel-group multicenter trial. Two hundred and forty-one subjects were randomized, 115 to DSG/EE and 126 to GSD/EE. Compliance to the study preparation was high (around 95%) in both groups and no pregnancies occurred during the study. Cycle control was excellent; there were no differences between the two groups with regard to incidence of spotting and breakthrough bleeding or duration and intensity of withdrawal bleeding. Side-effects were mild and in general comparable in the two groups. Both at baseline and during treatment, a higher proportion of women taking GSD/EE complained about breast tenderness. This resulted in more early withdrawals because of breast tenderness in the GSD/EE group. It was concluded that monophasic DSG/EE and GSD/EE are equally effective, have similar cycle control and both are generally well tolerated.