Vaginal ultrasound of the endometrium in postmenopausal women with symptoms of urogenital atrophy on low-dose estrogen or tibolone treatment: a comparison.

OBJECTIVE: The objective of this study was to compare the efficacy of locally administered low-dose estrogens (0.625 mg of conjugated estrogens) and orally administered tibolone in postmenopausal women with symptoms and signs of atrophic vaginitis. Vaginal ultrasound was performed for the evaluation of endometrial or ovarian abnormalities. METHODS: A 6-month comparative randomised prospective study of women taking tibolone and locally administered low-dose estrogens. Seventy two postmenopausal women with symptoms of atrophic vaginitis were examined with vaginal ultrasound. The endometrial thickness, the endometrial volume, the uterus and the ovaries were measured before and after 6 months of treatment with low-dose estrogens or tibolone. RESULTS: In group A (low-dose estrogens treatment) the mean endometrial thickness, before and after treatment, was 3.0 +/- 0.1 mm and 2.9 +/- 0.8 mm, respectively. The mean ovarian volume was 3.9 ml. There were no changes in uterine volume during the treatment period. In group B (treated with tibolone) endometrial thickness was 3.2 +/- 0.3 mm and 3.2 +/- 0.7 mm, respectively. One women experienced vaginal bleeding. The volume of corpus uteri was unchanged after treatment. The volume of both ovaries was 4.2 ml and 3.9 ml, respectively. The overall acceptability of both types of administration was good. CONCLUSIONS: This study, using vaginal ultrasound, has shown that either hormone replacement therapy with tibolone or symptomatic treatment with low-dose estrogens, gives no sign of endometrial proliferation measured as endometrial thickness.

A comparative study of an estradiol-releasing vaginal ring versus tibolone in postmenopausal women: a transvaginal color Doppler study.

OBJECTIVE: To evaluate endometrial blood flow characteristics in response to estrogen replacement therapy (ERT) and tibolone in postmenopausal women and to correlate the resistance index (RI) with plasma estradiol levels. MATERIALS AND METHODS: Transvaginal color Doppler ultrasound examinations were performed in 72 asymptomatic, postmenopausal women who demonstrated endometrial thickness < or = 5 mm. Thirty-six women receiving tibolone and 36 patients receiving ERT by a vaginal ring comprised the study groups. RESULTS: All postmenopausal women treated with tibolone or ERT showed continuous forward end-diastolic flow. The lowest RI was obtained in women with the vaginal ring inserted. The plasma concentrations of estradiol were found to be significantly higher in the vaginal ring group than those of tibolone. CONCLUSIONS: The data observed suggest that ERT and tibolone modify normal postmenopausal endometrial perfusion. Tibolone had a weaker estrogenic effect on endometrial blood flow resistance, and vaginal ring treatment enhanced endometrial blood perfusion through vasodilatation.

Transvaginal color Doppler and CA125 as tools in the differential diagnosis of postmenopausal ovarian masses.

OBJECTIVE: To evaluate whether transvaginal color Doppler and CA125 are valid in differentiating malignant from benign postmenopausal ovarian masses. METHODS: Sixty-two women with ovarian masses were studied with transvaginal color Doppler ultrasound before surgery. Serum CA125 levels were also measured. Resistance index (RI) and pulsatility index (PI) were calculated from the waveforms generated from blood flow within the ovary. RESULTS: Benign tumors had a significantly higher pulsatility index (mean 1.23 +/- 1.02; range 0.65-2.99) and resistive index (mean 0.78 +/- 0.22; range 0.5-1.1) than did malignant tumors. However some overlap in individual values for benign and malignant lesions was found. RI and PI sensitivity were significantly higher than those with CA125 (P < 0.05). Blood flow was detectable by color Doppler imaging in 95% of cases with malignant masses. CONCLUSION: Doppler sonographic evaluation of resistance and pulsatility indexes in the vessels of ovarian masses together with CA125 increased the sensitivity of prediction of malignancy for pelvic masses, but further work is needed before the validity of these factors is proved.

Transdermal estrogen with a levonorgestrel-releasing intrauterine device for climacteric complaints versus estradiol-releasing vaginal ring with a vaginal progesterone suppository: clinical and endometrial responses.

OBJECTIVE: Our purpose was to compare the effects of a new estradiol-releasing vaginal ring with progesterone given as a vaginal suppository, versus the efficacy, safety and acceptability of an intrauterine device releasing levonorgestrel combined with estradiol, delivered transdermally from a patch. Climacteric symptoms, bleeding pattern and endometrial histologic features were studied. METHODS: Fifty six parous, postmenopausal women with urogenital symptoms were allocated in two groups for one year: 28 women receiving estradiol by a vaginal ring and a 100 mg vaginal progesterone suppository 7 days every month and 28 women receiving a continuous transdermal daily dose of 50 micrograms of estradiol with a levonorgestrel-releasing intrauterine device inserted. All the patients were subjected to vaginosonographic examination followed by thorough pathological examination of the uterine curetting samples. RESULTS: A mean endometrial thickness (double layer) of 2.9 and 3.0 mm, respectively, was found to be predictive of normal endometrium. Both treatment regiments effectively relieved climacteric symptoms. Endometrial proliferation was not observed. Spotting was more common in the intrauterine device group than in the vaginal ring group. CONCLUSIONS: Treatment of urogenital symptoms in postmenopausal women with these two forms of hormone replacement therapy is shown to be an effective and safe method, exhibiting advantages over other methods of treatment.

Prophylactic oophorectomy in ovarian cancer prevention.

OBJECTIVE: To evaluate prophylactic oophorectomy in the prevention of ovarian cancer. METHOD: Between 1970 and 1990, 5262 hysterectomies were performed at Areteion Hospital, Athens. RESULTS: Ovarian cancer was subsequently diagnosed in 520 women (9.9%). The mean interval from hysterectomy to diagnosis of ovarian cancer was 7.2 years. If prophylactic bilateral oophorectomy had been practiced routinely in women undergoing hysterectomy at age 40 or above, 9.4% of cases would have been prevented. CONCLUSION: We recommend bilateral oophorectomy for all women with a positive family history of ovarian carcinoma and for all women undergoing hysterectomy after the age of 40. The decision for prophylactic oophorectomy as a complementary procedure to other indicated gynecologic surgeries should depend on the individual patient and her ability to comply with lifelong estrogen replacement therapy.

Histological changes induced by tibolone and estrogen/glucocorticoid on aging skin.

OBJECTIVE: The aim of this study was to investigate the oral effects of tibolone and mestranol plus paramethasone on the skin of postmenopausal women. A second purpose was to determine endometrial thickness with transvaginal ultrasound. MATERIALS AND METHODS: This randomized study was carried out in 39 healthy postmenopausal women. Skin biopsies were obtained from the thigh area by a single punch, before and after treatment, and the sections were evaluated. Current characteristics of both groups were measured at follow-up. RESULTS: No gross differences were observed in size, distribution or imaging of collagen, elastic or reticular fibers. Statistically significant changes were found in the papillar dermis thickness. There were no statistically significant differences in the sonographic measurements. CONCLUSION: The estrogen/glucocorticoid combination provides a way to evaluate in parallel the cellular metabolism effects on the irreversible aging process. The current results encourage widening these observations of the possible advantage of this combination, in order to alleviate the cellular degenerative process.

Comparison of surgical and postoperative complications of vaginal hysterectomy and Manchester procedure.

OBJECTIVE: The Manchester procedure (MP) was compared to vaginal hysterectomy (VH). Surgical and postoperative complications were evaluated. MATERIAL AND METHODS: A retrospective review of women undergoing VH and MP for uterine prolapse was performed. All the operations were performed between 1974-1994. MP was performed in 190 patients and VH (Heaney technique) in 231 women. RESULTS: MP patients, when compared to VH patients, were more likely to be older and postmenopausal at the time of surgery. Statistically significant differences were found for operative time and blood loss. This difference was not dependent on the performance of anterior or posterior repair. CONCLUSIONS: We suggest the use of MP as an alternative to VH in the absence of uterine pathology in appropriate candidates with uterine prolapse.

Primary adenocarcinoma of the fallopian tube with tuberculosis (short communication).

A case of primary adenocarcinoma and tuberculosis of the Fallopian tube is presented. The clinical symptoms of the patient were pelvic pain and primary infertility. The gynecologic examination revealed a palpable tubal mass and the diagnosis was performed from the laparotomy and the pathology report.

Vaginal intraepithelial neoplasia (VAIN) following hysterectomy in patients treated for carcinoma in situ of the cervix.

OBJECTIVE: To determine the number of patients with carcinoma in situ of the cervix treated by hysterectomy who proceeded to develop vaginal intraepithelial neoplasia (VAIN) and define whether the subsequent development of VAIN justifies intensive cytology and colposcopy follow-up. MATERIALS AND METHODS: Nine hundred and ninety-three women who were subjected to hysterectomy with CIN, (793 patients had completed 10 years of cytology and colposcopy follow-up) were identified. RESULTS: Forty-one patients with VAIN presented with CIN 3 after hysterectomy. The upper one half of the vagina was the area more affected. The middle age group developed VAIN in the shortest time. Atypical Cells (ASCUS) were found in 42% of these patients. Colposcopy revealed VAIN involving the vault angles of the suture line in 54% of the cases. In 51% of the cases the grade of vaginal abnormality was the same as that of the original lesion in the cervix. CONCLUSION: With such data we would propose screening over a 5-year period. Follow-up should also include colposcopic review during every examination.

Predictive factors used to justify hysterectomy after loop conization: increasing age and severity of disease.

OBJECTIVE: To determine the interpretability and significance of the traditional factors used to predict residual dysplasia in hysterectomy specimens after loop conization. MATERIALS AND METHODS: Loop electrosurgical cervical conization was performed on 372 patients. Ninety three women had a hysterectomy within 6 months of the loop conization. Residual disease was defined as cervical intraepithelial neoplasia or cancer in the hysterectomy specimen. RESULTS: Of the 93 patients having a subsequent hysterectomy, 36 (38.7%) has residual disease in their hysterectomy specimen. The mean age of the patients with residual disease in the post loop conization hysterectomy specimen was 42.22. The mean age of those free of residual disease was 29.42. By multivariate analysis, dysplasia involving the ectocervical margin (p = 0.34) and the endocervical margin (p = 0.35) was not predictive of disease in the hysterectomy specimens. Endocervical curettage (p = 0.005), glandular involvement (p = 0.01), loop conization pathology findings (p < 0.05) and cytological examination (p < 0.001) were predictive of residual dysplasia. CONCLUSIONS: Cytological reports, increasing age, severity of disease, gland involvement and endocervical curettage were the only factors that accurately predicted residual dysplasia. The presence or absence of dysplasia in the loop conization, ectocervical margin and endocervical margin was not predictive of residual dysplasia in post loop conization hysterectomy specimens.

Comparison of abdominal and vaginal hysterectomy. Study of complications.

BACKGROUND: To compare patent characteristics, diagnoses and complications associated with vaginal or abdominal hysterectomy in the last two decades. STUDY DESIGN: From 1974 to 1994, 6,420 women were included in the study. Complications were classified in two categories: intraoperative and postoperative, and psychosexual complications. RESULTS: Women who underwent vaginal hysterectomy experienced significantly fewer complications than women who had undergone abdominal hysterectomy. Vagina hysterectomy was associated with less febrile morbidity, bleeding requiring transfusion and convalescence than abdominal hysterectomy. CONCLUSIONS: Hysterectomy is highly effective for relief of symptoms associated with common non-malignant gynecologic conditions. There is a minimal risk of complications among women undergoing hysterectomy by the abdominal and vaginal route.

Serum changes of Ferroxidases and iron-binding capacity in pregnancy.

Serum changes of Ferroxidase I and II well as the total iron binding capacity (TIBC) and unsaturated iron binding capacity (UIBC) were measured throughout their gestation in 32 normal pregnant women. Significantly higher concentrations for all the above mentioned parameters were found as pregnancy advanced. Moreover, a significant and positive correlation between the weeks of gestation and a) serum Ferroxidase I (r:0.568 p < 0.001), d) serum Ferroxidase II (r:0.619 p < 0.001), c) serum TIBC (r:0.549 p < 0.01), and d) serum UIBC (r:0.424 p < 0.05) was found. The parallel serum changes of both ferroxidase with those of TIBC and UIBC are also shown in this study. The correlation of Ferroxidase I with TIBC (r:0.734 p < 0.001) and UIBC (r:0.536 p < 0.01) as that of Ferroxidase II with TIBC(r:0.634 p < 0.001) and UIBC (r:0.513 p < 0.01) was significant and positive. In conclusion, serum Ferroxidase I and II are progressively increased with serum TIBC and UIBC as pregnancy advances.

Power Doppler ultrasound: a potentially useful alternative in diagnosing pelvic pathologic conditions.

INTRODUCTION: To evaluate the efficacy of power Doppler sonography in depicting soft-tissue hyperemia in endometriosis and other pelvic inflammatory conditions thirty-one patients with predominantly pelvic inflammatory symptoms were evaluated. MATERIALS AND METHODS: Power Doppler sonography at 5 MHz and a pulse repetition frequency of 800 Hz was used. All the women underwent laparoscopy after 10 days. RESULTS: Soft-tissue hyperemia was seen on power Doppler sonograms in 22 of the symptomatic patients. In these women Doppler demonstrated a diffused "blush" of almost or the entire symptomatic sites. Specificity was 52.4%, sensitivity 47.1% and the positive predictive value was 53.2%. CONCLUSION: Power Doppler sonography showed hyperperfusion in many cases associated with pelvic inflammatory pathology. It is a potentially useful adjunct to standard color Doppler imaging in depiction of vascular flow.

Transvaginal Doppler ultrasound with color flow imaging in the diagnosis of luteal phase defect (LPD).

OBJECTIVE: Our purpose was to determine whether color flow pulsed Doppler could predict a luteal phase defect (LDP). METHOD: Twenty-one women with regular menstrual cycles and at risk for luteal phase defect were examined by transvaginal color Doppler during the follicular and luteal phase of the menstrual cycle. Progesterone was measured on the day of the Doppler exam. Ovulation was determined from the lutenizing hormone (LH) surge. Endometrial biopsy during the late luteal phase was performed on each patient. RESULT: Six patients (28.5%) were diagnosed with luteal phase defect. Mean resistance index in patients with luteal phase defect was significantly higher only throughout the luteal phases (p = 0.02). Mean progesterone levels were significantly lower for patients with LPD than for normal women (p < 0.001). Mean pulsatility index in luteal phase deficient cycles was significantly higher throughout the follicular and luteal phases (p = 0.03). CONCLUSION: Color Doppler may aid in assessing luteal phase adequacy. Doppler indices of corpus luteum blood flow in combination to plasma progesterone may be a useful index of luteal function.

Is color Doppler necessary in the evaluation of tubal patency by hysterosalpingo-contrast sonography.

BACKGROUND: To evaluate the diagnostic efficacy of hysterosalpingo-contrast sonography (HyCoSy) and to establish whether, in doubtful cases, the additional use of transvaginal Color Doppler can improve the tubal diagnosis reached with gray scale imaging alone. STUDY DESIGN: Ninety-six cases of unknown tubal function with infertility complaints were included. Within four weeks after sonographic hydrotubation, hysterosalpingography was performed. The diagnostic efficacy of gray scale and Color Doppler were compared with each other and against HSG. RESULTS: We calculated a sensitivity value of 82.9% and a specificity value of 86.1% for both tubes. The concordance value was of 83.5%. The total number of Color Doppler examinations compared with those of HSG showed a sensitivity of 91% for the right tube and 93% for the left tube and a specificity of 100% for both tubes. CONCLUSIONS: HyCoSy provides reproducible findings for the evaluation of uterine abnormalities and tubal patency. The additional use of Color Doppler is recommended as a supplement to gray scale imagin in cases of suspected tubal occlusion.

Evaluation of combined endoscopic and pharmaceutical management of endometriosis during adolescence.

Laparoscopy is the most frequent surgical approach in gynecologic patients with acute or chronic pelvic pain. The symptomatology is frequently related to a specific gynecological pathology such as endometriosis or associated adhesive disease. During an eight year period, January 1990 to December 1997, 26 patients (aged 16-20 years) with endometriosis were diagnosed endoscopically and managed pharmaceutically in our clinic. The disease was evaluated and staged according to the American Society of Reproductive Medicine. The disease was evaluated as first stage in 16 patients (61.6%), as second stage in eight patients (30.8%), as third stage in one patient (3.8%) and as fourth stage in one patient (3.8%). Patients underwent adhesiolysis and management according to their laparoscopic findings. Postoperative pharmaceutical treatment (Danazol, GnRH analogues, Oral Contraceptives) was given. Patients were followed for the evaluation of the treatment. The efficacy of the combination of endoscopic and pharmaceutical management of the disease is discussed.

Vaginal hysterectomy: technique and results in the last twenty years.

The objective of this work was to describe patient characteristics and the effect of vaginal hysterectomy in a University hospital in the last two decades. A retrospective review of women undergoing vaginal hysterectomy was performed. The type of hysterectomy and complications were determined. From 1974 to 1994, a total of 6420 hysterectomies were performed. The vaginal route was used for 1530 patients. In the last decade, the Heaney method was used. A comparison of the periods 1974-1984 and 1984-1994 revealed that with the Heaney technique, we had significantly fewer complications, including less febrile morbidity, bleeding requiring transfusion, and injuries. Vaginal hysterectomy, specially using the Heaney method, is a rewarding challenge for any gynecologic surgeon. There are a low postoperative morbidity rate and a low mortality rate, which is well below the average mortality rate associated with abdominal hysterectomy.

Management of uterine adhesions with 'Massouras Duck's Foot' and 'Butterfly' IUDs.

The Massouras Duck's Foot (MDF) IUD and the Butterfly IUD have been clinically evaluated. The MDF, which is Y-shaped, has 2 or 3 horizontal arms on a vertical stem and 2 triangular wings, in between the 'V'. When inserted after curettage, it prevents intrauterine or intracervical adhesions. The fan-shaped Butterfly IUD has 2 overlapping wings, thereby facilitating adjustment of the IUD to variable uterine cavities. Its wing span occupies the entire uterine cavity when inserted according to the instructions. Both IUDs are made of polyethylene plastic with barium sulfate. Several substitutions for barium sulfate are suggested, e.g., copper, silver, hormones, biodegradable polymers. The high antifertility action of these IUDs is due primarily to their occupancy of the entire uterine cavity.

Adenomyoma and leiomyoma: differential diagnosis with transvaginal sonography.

PURPOSE: The purpose of this study was to evaluate the capability of transvaginal sonography to differentiate adenomyomas from leiomyomas. METHODS: Two hundred six patients scheduled for surgery for symptomatic uterine masses underwent preoperative transvaginal sonography. Sonographic findings were compared with pathologic findings. Pathologic findings showed that 111 patients had leiomyomas, 48 had diffuse adenomyosis, 31 had adenomyomas, and 4 had leiomyosarcomas. RESULTS: For the diagnosis of adenomyoma, transvaginal sonography demonstrated a sensitivity of 82.0%, specificity of 88.3%, positive predictive value of 84.6%, and negative predictive value of 87.5% compared with a sensitivity of 95.1%, specificity of 82.0%, positive predictive value of 90.7%, and negative predictive value of 85.7% for the diagnosis of leiomyoma. Two sonographic characteristics, lesion margin (p = 0.0001) and lacunae (p = 0.0001), allowed the differentiation of adenomyoma from leiomyoma. CONCLUSIONS: Transvaginal sonography is an effective procedure for the preoperative differentiation of adenomyoma from leiomyoma. If the status of the lesion's margins and the presence or absence of hypoechoic lacunae were selected for analysis, leiomyomas could be correctly diagnosed with transvaginal sonography in 95% of cases.