Risk Factors for Endometrial Carcinoma in Women with Postmenopausal Bleeding.

OBJECTIVES: Most patients with postmenopausal bleeding do not have endometrial cancer. The primary objective was to evaluate risk factors for endometrial cancer among postmenopausal women with bleeding. METHODS: This was a retrospective cross-sectional study. Women with postmenopausal bleeding presenting to a gynecology clinic were included in the study. Data on potential risk factors for endometrial cancer or atypical hyperplasia were collected. Univariate and multivariate analyses were performed to assess the risk factors. RESULTS: Among 212 women studied, 24 (11.3%) women had endometrial cancer. There were 38 (17.9%) with cervical cancer and 3 (1.4%) with ovarian cancer. Women 55 or older had an odds ratio of 7.5 (95% CI 2.2 to 26.2) as compared to women below 55 years (p value = 0.002). Women with 2 or more episodes of postmenopausal bleeding had an odds ratio of 4.9 (95% CI 1.1 to 23.0) and those who had either diabetes or hypertension had an odds ratio of 3.1 (95% CI 1.3 to 7.4) of endometrial cancer as compared to those who did not. CONCLUSIONS: A third of patients with postmenopausal bleeding had a gynecological cancer. Age, frequency of bleeding, diabetes and hypertension, and increased endometrial thickness were independent risk factors for endometrial cancer.

Vitamin D deficiency in postmenopausal women with pelvic floor disorders.

INTRODUCTION: The aim of this study is to evaluate the association of vitamin D deficiency and pelvic floor disorders (PFD) including pelvic organ prolapse (POP) and stress urinary incontinence in postmenopausal women. MATERIALS AND METHODS: This is a prospective case control study on 120 women with or without symptoms of PFD. Relevant history and clinical examination were conducted. Serum 25-hydroxy vitamin D levels were measured in all women. Chi square and student t test were used to test significance of association. Logistic regression was used to adjust for age. Odds ratios and 95% confidence intervals were calculated. RESULTS: Of the 120 postmenopausal women included, 51 had PFD on clinical examination. Of the 51 cases, 28 women had POP and 14 women had stress incontinence (SUI) while nine women had both POP and SUI. The study showed that vitamin D levels were significantly lower in women with PFD than those without PFD. Menopausal status of more than 5 years was also significantly associated with PFD. CONCLUSION: Findings suggest association of vitamin D deficiency and PFD in postmenopausal women. In addition, postmenopausal women have a high prevalence of vitamin D deficiency indicating a need to evaluate vitamin D levels in these women.

Bowel vaginoplasty in children and young women: an institutional experience with 55 patients.

INTRODUCTION AND HYPOTHESIS: Absence of a vagina owing to congenital Mullerian defects or other acquired causes requires reconstruction of the female genital passage. We present our experience using various bowel segments. METHODS: Bowel vaginoplasty was performed in 55 patients from January 2004 through May 2014 for cervicovaginal atresia (20), Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome (20), distal vaginal atresia (8), cloaca (2), cervical atresia (1), complex urogenital sinus (1), transverse vaginal septum (1), rhabdomyosarcoma of the vagina (1), and traumatic stricture of the vagina (1). The bowel segments used were sigmoid (50), ileum (2), anorectovestibular fistula ( 2), and loop rectovaginoplasty (1). RESULTS: Thirty-nine patients who had the proximal vagina or uterus anastomosed to the bowel segment reported regular menstrual flows. Three patients are sexually active with satisfactory coital function. None of our patients developed pyometra. Five patients had neovaginal mucosal prolapse. Two patients had severe stenosis requiring excision of the neovagina. Seven patients had mild stenosis requiring dilatations in 6 patients and V-Y meatoplasty for 1 patient. One patient had a descending colon anastomotic leak requiring a diversion ileostomy. CONCLUSIONS: Genital reconstruction with bowel vaginoplasty is a highly skilled operation that provides a durable and lubricated replacement of the vagina with good outcomes. Utero-coloneovaginoplasty is a safe procedure preserving the menstrual flow in patients with a functional uterine fundus.

Cervicovaginal atresia with hematometra: restoring menstrual and sexual function by utero-coloneovaginoplasty.

BACKGROUND: Cervicovaginal atresia is a rare Mullerian anomaly. The management of cervicovaginal atresia has evolved from historical recommendations of hysterectomy to various reconstructive procedures more recently. The latter carries a risk of significant morbidity and unknown fertility. We present our experience in the management of this complex anomaly. METHODS: Twenty patients with cervicovaginal atresia were operated in our hospital from January 2004 through December 2013. The details of their anatomical variations and functional outcomes were analyzed. RESULTS: Eighteen out of twenty patients had cervical agenesis. Two patients had cervical hypoplasia. All patients underwent utero-coloneovaginoplasty. Post operatively, all patients have regular menstrual cycles. One patient is married, sexually active and has satisfactory coital function. One patient had a bowel anastomotic leak that required a diversion ileostomy. Two patients developed mild stenosis. One patient has mild neovaginal mucosal prolapse. No patient has developed pyometra. CONCLUSION: Patients with cervicovaginal atresia need to be counselled about the various reconstructive options available and the potential risks. Social and economic factor play a significant role in determining the plan of management. For patients from conservative societies, utero-coloneovaginoplasty provides a safe conduit for the passage of menstrual flow and coitus, at the cost of permanent infertility.

Rectovestibular fistula with vaginal atresia: our experience and a proposed course of management.

BACKGROUND: Rectovestibular fistula with coexisting vaginal atresia poses a surgical dilemma with regard to the timing and type of reconstruction. We present our experience and suggest an appropriate course of management. METHODS: Seven patients with rectovestibular fistula and coexisting vestibular atresia were operated in our hospital during January 2004 through December 2013. The details of their bowel, menstrual and sexual functions were recorded. RESULTS: Five of the seven patients who underwent anoplasty in childhood presented to us in their teens with primary amenorrhea and cyclical abdominal pain. All five had sigmoid colon neovaginoplasty. Four of these had the uterus or its remnants anastomosed to the neovagina. All four have regular menstrual cycles. One patient is sexually active and has satisfactory sexual function. The bowel function in all the five patients is good. The remaining two patients presented in their infancy and had the anorectovestibular fistula left as the neovagina. The recto-sigmoid was pulled down to form the neoanus. Both these patients have bowel incontinence. CONCLUSION: We recommend the rectovestibular fistula be used as the neoanus and not as the neovagina. Delayed bowel vaginal replacement has excellent results and allows for optimal assessment of functioning uterine body or remnants.

Menouria due to congenital vesicovaginal fistula associated with complex genitourinary malformation.

BACKGROUND: Congenital vesicovaginal fistula (VVF) is a very uncommon condition rarely suspected at initial presentation. It is usually seen in association with complex malformations of the genitourinary tract. CASE: A bifid insertion of the solitary ureter causing an uretero-VVF was associated with an obstructing transverse vaginal septum manifesting as menouria. Also seen were solitary crossed renal ectopia, bicornuate uterus and skeletal anomalies. CONCLUSION: In women with menouria without vaginal menstruation, pre-operative evaluation to detect an obstructive vaginal anomaly and unusual uretero-vesicovaginal fistulous communications is necessary before surgical intervention.

Transobturator tapes are preferable over transvaginal tapes for the management of female stress urinary incontinence: For.

Tension-free midurethral slings have proven to have low morbidity and high success rates in the management of female stress urinary incontinence. Among midurethal slings, the transobtuator tapes has comparable success and satisfaction rates as the transvaginal tapes but with reduced risk of intra-operative bladder injury, shorter operating time and quicker return to activities. Thus, the transobturator tapes may be recommended as the primary choice for the treatment of female stress urinary incontinence.

Amnioinfusion for relief of recurrent severe and moderate variable decelerations in labor.

OBJECTIVE: To determine whether intrapartum amnioinfusion (AI) relieves recurrent moderate and severe variable decelerations in laboring women with clear or grade I meconium-stained amniotic fluid and reduces cesarean section rate for fetal distress. STUDY DESIGN: A randomized controlled trial was conducted in labor unit of Christian Medical College Hospital, Vellore, India, between October 2003 and September 2004. Women were randomized to receive AI (group I) and not to receive it (group II). RESULTS: A total of 150 women (75 in each group) were included in the study. There was significant relief of variable decelerations in group I and no difference in overall cesarean section rate but significant reduction in cesarean section rate for fetal distress in group I, and significant reduction in cesarean section rate for fetal distress in nulliparous women of group I. Neonatal acidemia was also significantly reduced in the nulliparous women receiving AI. The duration of maternal postpartum hospital stay was significantly reduced in group I. There were no adverse maternal or neonatal outcomes. CONCLUSION: AI was a beneficial therapeutic intervention in women patients showing fetal distress in first stage of labor, and it reduced cesarean section for fetal distress and neonatal acidemia.

Bartholin abscess masquerading as an unusual vaginal prolapse: a case report.

BACKGROUND: Vaginal wall cysts and pelvic organ prolapse, although commonly encountered, rarely occur together. Typically, the differential diagnosis of vaginal wall prolapse includes anterior and/or posterior wall support defects. Although large vaginal cysts have the potential to disturb normal vaginal supports, these coexisting abnormalities are rarely reported. CASE: A 39-year-old multipara woman presented with a progressively enlarging vaginal bulge for 6 years, erroneously diagnosed as an enterocele with a unilateral paravaginal support defect. The enterocele was subsequently confirmed to be a 10 x 5-cm, thick-walled cystic mass histologically confirmed to be a Bartholin gland abscess. CONCLUSION: Unusual forms of vaginal prolapse require adequate ancillary investigation such as imaging to avoid diagnostic error and to improve preoperative planning and treatment.

HIV and obstetric complications and fetal outcomes in Vellore, India.

Antenatal prevalence is more than 1% in parts of India, yet little is known about the complications and fetal outcomes in this region. We reviewed the records of 23,386 women who delivered at the Christian Medical College Hospital in Vellore, India from 2000 through 2002. HIV-infected women were more likely than HIV-uninfected women to have pregnancy-induced hypertension, anaemia, breech presentations, stillborn babies and fetal deaths. HIV-infected women who did not receive mother-to-child transmission prophylaxis or had breech fetal presentation were more likely to have fetal deaths (P = 0.001). HIV prophylaxis and optimal prenatal care should be a priority for HIV-infected pregnant women in resource-limited countries.

Dapsone, danazol, and intrapartum splenectomy in refractory ITP complicating pregnancy.

Currently there is no consensus on the treatment of refractory idiopathic thrombocytopenic purpura (ITP) complicating pregnancy. Our patient with chronic ITP complicating pregnancy, who was refractory to steroids, dapsone, and danazol, was treated successfully with intrapartum splenectomy.