Creation of a neovagina following Williams vaginoplasty and the Creatsas modification in 111 patients with Mayer-Rokitansky-Küster-Hauser syndrome.

OBJECTIVE: Evaluation of the Creatsas modification of Williams vaginoplasty for the creation of neovagina in patients with Mayer-Rokitansky-Küster-Hauser syndrome (MRKH syndrome). DESIGN: Record of perioperative and postoperative results and complications. Follow-up evaluations of patients yearly after the operation. SETTING: Division of Pediatric-Adolescent Gynecology and Gynecologic Corrective Surgery, University of Athens (tertiary referral center). PATIENT(S): One hundred eleven patients with MRKH syndrome. INTERVENTION(S): Surgical creation of neovagina using the Williams vaginoplasty technique (group A: 10 patients) or the Creatsas modification of the previous method (group B: 101 patients). MAIN OUTCOME MEASURE(S): Length and width of the neovagina, and the quality of sexual life postoperatively. RESULT(S): A functioning vagina of 10 to 12 cm depth and 5 cm width was created in eight of the patients in group A (80%) and in 98 of those in group B (97.02%). A vagina of 7 to 9 cm depth and 2 to 3 cm width was created in the rest of the patients in both groups. In group A, two wound openings were reported (20%); in two of the patients hemorrhage occurred during the first intercourse, compared to none in group B. A satisfactory sexual life was reported from 94.4% of the patients and an adequate one from 4.16% of them. CONCLUSION(S): The Creatsas modification of Williams vaginoplasty is a simple and effective technique for the creation of a functioning neovagina in young women with vaginal aplasia.

Tissue polypeptide specific antigen (TPS) throughout normal pregnancy.

AIM: TPS concentrations were measured throughout normal pregnancy in maternal serum (MS) and amniotic fluid (AF), in order to evaluate the usefulness of TPS in the follow-up of pregnancy breast cancer patients. PATIENTS AND METHODS: Following informed consent, 30 pregnant women during the 2nd trimester, 28 during the 3rd and 26 at parturition were included in the study. For comparison, 28 women in the 1st trimester and 28 healthy, non pregnant women (controls) were also studied. Both MS and AF antigen values were measured by an enzyme immunoassay (BEKI Diagnostics). RESULTS: Maternal serum TPS concentrations increased significantly with gestational age (p < 0.0001), being significantly higher in the 3rd trimester and during labor than those in the controls (p < 0.0001). Amniotic fluid TPS values were markedly elevated, compared with those in MS (p < 0.0001, paired-t-test), declining significantly from the 2nd to the 3rd trimester (p < 0.0015) and labor. Both MS and AF TPS values during labor depended on the mode of delivery, being higher in the cases terminated by vaginal delivery, compared to those by elective cesarean section. CONCLUSION: Maternal serum TPS values are influenced significantly by pregnancy, and thus, this antigen, as tumor marker seems to be reliable only during early pregnancy.

Breast cancer markers during normal pregnancy.

AIM: To measure MCA and CA153 concentrations in maternal serum (MS) and amniotic fluid (AF) paired samples during normal pregnancy, in order to evaluate the usefulness of these markers in monitoring pregnant patients with a history of breast cancer. PATIENTS AND METHODS: Serum and AF MCA and CA153 values were measured in 20 pregnant women during the 1st trimester, 29 cases in the 2nd, 26 in the 3rd and 20 at parturition and compared with those of 20 healthy, age-matched, non pregnant women (controls). RESULTS: MS values of MCA increased significantly with gestational age (p < 0.0001), being higher in the 3rd trimester and in labor than in control values (p < 0.0001). MCA values in AF were remarkably higher than those in MS and increased significantly with advancing gestation (p < 0.0001). In contrast, CA153 values in AF, which were marginally higher than in MS, did not differ significantly with the progression of pregnancy. CONCLUSIONS: Maternal serum MCA values are significantly influenced during pregnancy. Thus, this marker seems to be reliable only during early pregnancy. In contrast, CA153 remains a useful marker in monitoring pregnant breast cancer patients.

Expression of CEA, CA-125 and SCC antigen by biological fluids associated with pregnancy.

Carcinoembryonic antigen (CEA), cancer antigen 125 (CA-125) and squamous cell carcinoma (SCC) antigen were measured in 56 full-termed pregnancies by enzyme-immunoassays (EIA-MEIA). The measurements were done in maternal serum (MS), umbilical cord blood (UCB) and amniotic fluid (AF) samples, during delivery. Very high antigen levels were found in AF samples (median: CEA = 124 ng/ml; CA-125 = 710 U/ml; SCC = 710 ng/ml) compared to UCB and MS. CEA and SCC showed significantly lower values in MS (0.6 and 1.7 ng/ml, respectively) than in UCB (1.6 ng/ml, P = 7.7 x 10(-9); 3.55 ng/ml, P = 6.5 x 10(-6), respectively), while CA-125 had significantly higher values in MS (6 U/ml) than in UCB (0.0 U/ml, P = 17 x 10(-6); Wilcoxon paired test). All CEA values in MS were below cut-off (less than or equal to 5 ng/ml), while 10% of CA-125 and 30% of SCC values were above cut-off (less than or equal to 35 U/ml and less than or equal to 2.5 ng/ml, respectively). Amniotic fluid CEA with meconium had higher values (P = 0.0002), while the highest CA-125 values in AF samples were found in primiparae (P = 0.02). Moreover SCC in AF samples from vaginal delivered pregnancies showed significantly higher values, compared to those from cesarean section (P = 4.2 x 10(-7); Mann-Whitney U-test). Thus, our findings suggest that pregnancy has an influence on maternal serum SCC and CA-125 values, while CEA is independent of gestation and seems to conserve its diagnostic value during pregnancy as well.

Vaginal fluid prolactin: a reliable marker for the diagnosis of prematurely ruptured membranes. Comparison with vaginal fluid alpha-fetoprotein and placental lactogen.

The aim of this study is the evaluation of the reliability of vaginal fluid (VF) prolactin (PRL) for detecting prematurely ruptured membranes (PROM) and the comparison of this marker with vaginal fluid alpha-fetoprotein (AFP) and placental lactogen (HPL). In 21 pregnant women with recent or prolonged PROM from 20 to 41 weeks' gestation, in whom intact membranes were never found subsequently VF- and MS-PRL, -AFP and -HPL were measured by enzyme immunoassays, which are sensitive and very rapid. The same markers were also measured in MS, VF and urine samples (U) in 12 pregnant women of the same gestational age, without PROM, in whom the membranes were ruptured later during labor. In PROM, independently of prematurity and duration of PROM VF-PRL levels were significantly higher (2-10-fold) than the paired MS-PRL (p less than 0.0001) and ranged from 130 to 2315 ng/ml. In contrast, VF-PRL and urine PRL concentrations in pregnancies without PROM were very low or undetectable (range: 0-5 ng/ml and 0.15-1 ng/ml, respectively). Vaginal fluid AFP values in PROM from 20th to the 33rd week of pregnancy were significantly higher (5-50-fold) than the paired MS-AFP (p less than 0.01) and ranged from 103 to 5500 ng/ml. In PROM after the 33rd week of pregnancy, VF-AFP values were either lower (1/3), or equal to, or even higher (up to 2-fold) than MS-PRL. On the contrary in pregnancies with intact membranes, VF-AFP were always less than 9 ng/ml and urine AFP was undetectable (range: 0.2-1.1 ng/ml).(ABSTRACT TRUNCATED AT 250 WORDS)

Genuine stress incontinence: prospective randomized comparison of two operative methods.

Eighty-one women with clinical and urodynamic findings of genuine stress incontinence and genital prolapse were randomly selected to be surgically treated with either anterior colporrhaphy or Burch colposuspension. Each patient had a complete clinical and urodynamic evaluation before surgery and at 2 months and 3 years after surgery. Differences in cure rates between the two procedures at the 2-month post-operative evaluation were insignificant; however, at the 3-year post-surgical evaluation, the cure rate of women who had undergone Burch colposuspension was significantly higher than that of women who had undergone anterior colporrhaphy (cure rates were 88% and 57%, respectively; P < 0.001). The Burch colposuspension was more effective than the anterior colporrhaphy in the stabilization of the bladder base, neck and proximal urethra as confirmed by transvaginal sonography. Post-operative spontaneous voiding was uneventful in both procedures. Results of this study demonstrate that the Burch colposuspension in our hands was more effective in treating genuine stress incontinence and pelvic relaxation than was anterior colporrhaphy.

hCG regression after treatment in active and regressed extrauterine pregnancies.

The regression of hCG levels was studied in the maternal serum of 15 cases of tubal pregnancies (6 regressed and 9 active). Measurements of the hCG values were made before the operation and after 12, 24, 48, 72, 96, 120 and 192 hours. The mean hCG values in the groups of the regressed and active cases, before treatment, were 479.4 +/- 266.4 mIU/ml and 6334.0 +/- 932.1 mIU/ml, and after 192 h 4.8 +/- 0.4 mIU/ml and 115.8 +/- 37.9 mIU/ml, respectively. The hCG mean values in both groups showed the same exponential regression pattern and the percentage decrease in the hormone level in the period of time between 0 and 192 h was 98%. The mean values of the hormone in both groups showed significant differences (p less than 0.001) during the whole time interval observed.

Clearance pattern of maternal serum pregnancy specific beta 1-glycoprotein after treatment in active and regressed tubal pregnancy.

The clearance pattern of maternal serum pregnancy specific beta 1-glycoprotein (SP1) was studied in 16 cases of tubal pregnancy (9 active and 7 regressed) after 12, 24, 48, 72, 96, 120 and 192 h following surgery. The mean values of the hormone in both groups showed a statistically highly significant difference in all measurements before and after treatment (P less than 0.001), but they followed the same exponential regression pattern. The half-life of SP1 in active tubal pregnancies after salpingectomy was 36.2 h and in regressed tubal pregnancies after salpingostomy was 37.5 h.

The diagnostic value of laparoscopy in 2365 patients with acute and chronic pelvic pain.

OBJECTIVE: To discriminate the etiology in 2365 patients with acute and chronic pelvic pain (APP, CPP). METHODS: Diagnostic laparoscopy was carried out in 736 patients (31.1%) with APP and in 1629 (68.9%) with CPP. In 315 patients (13.3%) the diagnostic procedure was extended to operative laparoscopy. RESULTS: The most frequent laparoscopic findings in patients with APP were acute salpingitis and pelvic adhesions (22.8%) and ectopic pregnancy (19%), while in patients with CPP the most frequent findings were pelvic adhesions (35.4%) and endometriosis (24.6%). In 7.5% of patients with APP and 24% with CPP, laparoscopy did not reveal any pathological finding in the pelvis. Among the 315 patients in whom operative laparoscopy was carried out, 40% suffered from APP and 60% from CPP. In the 446 patients (18.9%) without laparoscopic findings no treatment was given, while of the remaining 905 patients 40% were subjected to laparotomy and 60% received conservative treatment. The total incidence of side effects reached 4.7% and serious side effects resulting from emergency laparotomy occurred in 0.15% of patients with pelvic pain. CONCLUSION: Our results in a large group of patients with pelvic pain show that there are discrepancies in the incidence of laparoscopic findings between patients with APP and CPP. Discrepancies between the two groups of patients were also found during operative laparoscopy, the treatment administered after laparoscopic diagnosis and the complications encountered.

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.

Hypothalamic-pituitary-thyroidal axis dysfunction and cortisol secretion in patients with nonclassical congenital adrenal hyperplasia.

OBJECTIVE: The purpose of this study was to evaluate thyroid function and TSH and cortisol (F) secretion in hyperandrogenemic women with nonclassical congenital adrenal hyperplasia (NC-CAH) due to 21-hydroxylase deficiency (Group A) when compared with women with hyperandrogenemic symptoms (menstrual irregularities, hirsutism, acne, seborrhea and sterility) of other etiologies (Group B). METHODS: Seventy-two women were subjected to stimulation of the adrenal cortex with i.v. ACTH administration in the early proliferative phase of the menstrual cycle. Basal plasma TSH, T3, T4, and FTI as well as basal and ACTH-stimulated plasma F and 17-hydroxyprogesterone levels were determined. RESULTS: According to internationally accepted criteria and HLA haplotyping, we diagnosed 28 NC-CAH patients as well as affected heterozygotes of the disease. No significant difference was found in the plasma T3, T4, or FTI or F concentrations between the women of the two groups. On the contrary, plasma TSH levels were significantly lower in patients with 21-hydroxylase deficiency when compared to the women with hyperandrogenemic symptoms of other etiologies. CONCLUSION: The results of this study support a dysfunction of the hypothalamic-pituitary-thyroidal axis due to altered ACTH secretion patterns.

Peritoneal fluid volume parameters in infertile patients.

The peritoneal fluid volume (PFV) and its cellular and acellular components have been repeatedly associated with infertility. The PFV from 88 infertile women was analyzed in relation to endometriosis, pelvic adhesions, tubal patency, luteinization, endometrial cells and macrophages. The independent existence of parameters such as the onset of luteinization, the increased population of macrophages and the presence of endometriosis increase statistically significantly the PFV. In the presence of peritoneal adhesions or/and obstructed tubes the PFV was significantly decreased.

Amniotic fluid hormone profiles during normal and abnormal pregnancy.

Amniotic fluid (AF) and maternal serum (MS) chorionic gonadotropin (HCG), placental lactogen (HPL), pregnancy-specific beta 1-glycoprotein (SP1), total estrogens (ET), alpha-fetoprotein (AFP) and prolactin (PRL) were measured by enzyme-immunoassays, in 50 normal (A) and in 37 abnormal (B) pregnancies, from 16th to 40th weeks. A: the proteins HCG, AFP and PRL showed a similar decreasing trend after the 20th week, while HPL and SP1 rose progressively throughout the 2nd trimester, thereafter remaining constant. On the contrary ET showed an increasing pattern until term. Chorionic gonadotropin HPL and SP1 in MS were higher than in AF, while AF values of AFP and PRL were higher than in MS, but the ratio MS/AF of all hormone values increased significantly from the 2nd to the 3rd trimester (p < 0.005-p < 0.000001). Estrogens had about the same concentration in AF and MS during the 2nd trimester, but at term of pregnancy, their AF values were double those of MS. B: in polyhydramnios, elevated AF placental hormones were found, while PRL was very low. In erythroblastosis and diabetes, AFP was very low, but placental hormones, PRL and ET were both high and low. In toxemia, SP1, hCG and PRL were elevated, while HPL and ET were very low. In anencephaly and hydrocephaly with spina bifida, AFP was markedly elevated and ET were very low, but in simple hydrocephalus, very low AFP was found. In chromosomal anomalies very high placental hormones and very low AFP and ET were found.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Laparoscopic evaluation and management of chronic pelvic pain during adolescence.

Chronic pelvic pain (CPP) is a common symptom and a difficult condition to manage especially during adolescence. The aim of this study was to evaluate the role of laparoscopy in the diagnosis and treatment of CPP during this period of life. From January 1993 to December 1997, 98 patients, selected from a group of 180 patients who were referred to our clinic underwent laparoscopy. In most cases (60%) no abnormalities were observed. Endometriosis was found in 25% of cases, followed by ovarian cysts 7%, parovarian cysts 3%, pelvic inflammatory disease 3% and adhesions 2%. Laparoscopic treatment was performed as indicated by laparoscopic findings. We conclude that laparoscopy is a valuable and effective procedure in the diagnosis and management of CPP in a selected group of patients.

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.

Cyclic and individualized administration of gonadotropin-releasing hormone agonists plus progestogens: an alternative protocol for contraception.

Twenty-one women presenting with different diseases, with absolute or relative contraindications to hormonal contraception or the use of intrauterine devices, received 300-600 micrograms/day buserelin intranasally from the 1st to the 21st day, and 5 mg/day norethisterone acetate orally from the 16th to the 23rd day of the cycle for a total of 245 cycles. Serum luteinizing hormone (LH), follicle-stimulating hormone (FSH), estradiol and testosterone were determined on days 3-5 and 13-15 of the cycle, while progesterone determinations and ovarian sonography were performed during the second half of the cycle. According to progesterone values, 92.7% of the treatment cycles were anovulatory, while in one cycle pregnancy was detected (0.4%). Values of serum LH, FSH and estradiol were low, and in most of the cycles ovarian follicular development was limited to follicles < or = 11 mm. In 21 treatment cycles (9%), statistically significant increases in FSH (p < 0.0001) and LH (p < 0.02), as well as ovarian proliferation to preovulatory follicles or luteinized follicles, were found. It appears that in spite of the high cost of medication and monitoring of patients, this regimen could be useful as an alternative in cases where other forms of contraception are contraindicated or have failed.