Operative treatment of gynaecologic diseases in puberty: seven years of experience.

PURPOSE OF INVESTIGATION: The aim of this study is to present the incidence and surgical management of gynaecologic pathology in adolescence in the 1st Obstetrics and Gynecology Department of Aristotle University of Thessaloniki. METHODS: After a retrospective review of the medical records of over a seven year period (2004-2011), 32 adolescent patients with reported surgical gynaecologic procedures were identified and analysed. RESULTS: Fourteen out of the 16 adolescents with ovarian masses (eight neoplastic and eight non-neoplastic) were treated by laparoscopy. Congenital anomalies were diagnosed in seven patients and only one of them was treated by laparotomy. The rest were surgically treated for uterine leiomyoma (1), ectopic pregnancy (2), pelvic abscess (1), mesosalpingeal cysts (2), mesenterian cyst (1) and investigation of chronic pelvic pain. DISCUSSION: Although benign ovarian cysts and congenital anomalies represent the major indication for operative treatment of gynaecologic diseases in puberty, laparoscopy and/or hysteroscopy should be the gold standard procedure after careful preoperative investigation.

Hormonal replacement therapy in ovarian cancer survivors: a survey among Greek gynecologists.

PURPOSE OF INVESTIGATION: In this survey we evaluated the prescription attitude of Greek gynecologists towards hormone replacement therapy (HRT) for ovarian cancer survivors. METHODS: An anonymous questionnaire was sent to 900 members of the Hellenic Society of Obstetrics and Gynecology presenting a hypothetical case of an ovarian cancer survivor with indications for HRT followed by a series of relevant questions. RESULTS: Two hundred and ninety-eight responses were analyzed with regards to age, gender and practice setting. HRT would be prescribed by 48% of Greek gynecologists; regarding type of regimen, 60% would prescribe tibolone, 19% estrogen alone and 21% estrogen plus progestagen. In contrast, 52% of Greek gynecologists would not prescribe HRT due to the fear of ovarian cancer relapse (83%), or the development of breast cancer (6%), or both cancers (9%); among them, 21% would alternatively prescribe CNS medications, 9% SERMs, phyto-estrogens or bisphosphonates, while the remaining 70% would not prescribe anything. CONCLUSIONS: One out of two Greek gynecologists would prescribe HRT in ovarian cancer survivors. An alternative therapy, mainly CNS medications, would be suggested by 21% of the opposers.

Hormone therapy for postmenopausal endometrial cancer survivors: a survey among Greek obstetricians-gynaecologists.

PURPOSE OF INVESTIGATION: In this study we evaluated the prescription attitude of Greek obstetricians-gynaecologists towards hormone replacement therapy (HRT) for endometrial cancer survivors. METHODS: An anonymous questionnaire was sent to 900 members of the Hellenic Society of Obstetrics and Gynaecology, presenting a hypothetical case of an endometrial cancer survivor with indications for HRT, followed by a series of relevant questions. RESULTS: Three hundred and three valid responses were received and analysed according to age, gender and practice setting. HRT would be prescribed by 30.4% of gynaecologists; as far as type of regimen is concerned, 67.4% would prescribe tibolone, 22.8% estrogen-only and 9.8% estrogen plus progestagen. In contrast, 69.6% would not prescribe HRT due to the fear of endometrial cancer recurrence (88.2%), development of breast cancer (2.8%) or both (4.7%); among them, 28.4% would prescribe central nervous system (CNS) medications, selective estrogen receptor modulators (SERMs), phyto-oestrogens or biphosphonates, as alternates. CONCLUSIONS: One out of three Greek gynaecologists would prescribe HRT to endometrial cancer survivors. Alternative therapies, mainly CNS medications, would be suggested by the opposers.

Mucocele of the appendix mimicking an adnexal mass: a case report.

Mucocele of the appendix is a rare entity usually mimicking an adnexal tumour. There is no specific imaging or screening method to determine the diagnosis with certainty preoperatively. Appendiceal malignancy can be the underlying cause, although it is not common. We present a case of an appendiceal mucocele mimicking an ovarian tumour by both clinical and imaging (TVS and MRI) methods. This pathological condition should be considered by all the gynaecologists in the differential diagnosis of a right-sided pelvic mass.

Hormone therapy for postmenopausal breast cancer survivors: a survey among obstetrician-gynaecologists.

PURPOSE OF INVESTIGATION: To investigate the attitude of Greek obstetrician-gynaecologists towards prescription of hormone therapy to postmenopausal breast cancer survivors. METHODS: An anonymous questionnaire was sent to members of the Hellenic Society of Obstetrics and Gynaecology with a hypothetical case and a series of relevant questions. RESULTS: Three hundred valid answers were received. Hormone therapy would be prescribed to a breast cancer survivor by only 8%; 80% of these would prefer tibolone. In contrast, 92% would not prescribe hormone therapy; 97% would do so due to the risk of disease recurrence; 70% would not prescribe any alternative therapy, 21% would prescribe CNS-active compounds and 7% SERMs. CONCLUSIONS: The vast majority of Greek obstetrician-gynaecologists would not prescribe hormone therapy for menopausal symptoms in breast cancer survivors due to the theoretical risk of disease recurrence. Among those who would not prescribe hormone therapy, 21% would opt to CNS-active compounds.

Primary ovarian angiosarcoma--review of the literature and report of a case with coexisting chylothorax.

BACKGROUND: Primary ovarian angiosarcoma is a very rare gynaecologic malignancy with poor prognosis and uncertain, up-to-date, treatment options. Its exact diagnosis is challenging for surgeons and difficult for pathologists. There are only a few cases reported in the international literature. CASE: We report a case of primary pure ovarian angiosarcoma with coexisting chylothorax which is, to the best of our knowledge, the first reported case. An extensive review of the literature analyzing all clinical and pathological parameters related to this condition is presented. RESULT: In spite of all therapeutic efforts, surgical and medical, prognosis of ovarian angiosarcoma remains very poor in most cases. CONCLUSION: Primary ovarian angiosarcoma is a rare and aggressive malignancy. The report of such cases is interesting in order to exchange knowledge and experience, and possibly to further improve our diagnostic and therapeutic capabilities.

Ovarian remnant syndrome: a case report and review of the literature.

The ovarian remnant syndrome in an unusual complication of bilateral oophorectomy, usually presenting with pelvic mass and pain. A case of the syndrome is described in a 35-year-old woman with a history of abdominal hysterectomy and bilateral oophorectomy. We suggest that ovarian remnant syndrome should be considered in the differential diagnosis of chronic pelvic pain after recorded oophorectomy.

Growth hormone response to oral glucose tolerance and insulin tolerance tests in patients with PCOS.

Polycystic ovary syndrome (PCOS) is characterized by its heterogeneity. This is the reason for the diversity in the clinical manifestations and laboratory findings. In this study we examined the serum levels of growth hormone (GH) in 15 women with PCOS and 5 healthy volunteers following oral administration of 75 gr glucose (OGTT) and intravenous administration of insulin (ITT). The OGTT produced no significant difference between the two groups of women, in the ITT there was a difference between the GH response of the women with PCOS and that of the healthy women. The group with PCOS showed a later, more prolonged, higher response, indicating that the hypothalamus is probably involved in PCOS.

Etiopathology of endometriosis.

Although endometriosis is one of the most frequent problems in gynecology, its pathogenesis remains controversial and poorly understood. Many theories relating to the etiopathology of this disorder have been proposed. The celomic metaplasia hypothesis states that peritoneal mesothelium undergoes metaplasia, forming typical endometrial-like glands and stroma. The transplantation theory suggests implantation and subsequent growth of retrogradely shed, viable endometrial cells. The induction theory states that unknown substances released from shed endometrium induce undifferentiated mesenchyma to form endometriotic tissue. Regardless of which theory is correct, additional factors may be responsible for the expression of the disease. The possibility that the development and progression of endometriosis is associated with abnormal immune function and an inadequate response of the peritoneal defense system is currently the most recent hypothesis for the etiopathology of this disease.

Treatment of endometrial hyperplasias with gonadotropin-releasing hormone agonists: pathological, clinical, morphometric, and DNA-cytometric data.

On the basis of the recently reported observation that gonadotropin-releasing hormone agonists (GnRH-a) can affect endometrial cell proliferation, both indirectly, through the hormonal axis, and directly, by acting on the GnRH-a receptors, we investigated how far GnRH-a can be used as a new treatment mode for endometrial hyperplasias. Forty-two women, aged 28-60 years, with histologically confirmed simple (n = 30) or complex (n = 12, 2 with atypias) hyperplasia of the endometrium were involved in the study. According to the protocol they were treated for 6 months with GnRH-a (leuprolide acetate or triptorelin), and each patient underwent uterine curettage in the third and the sixth month of treatment, and 6 and at least 12 months after cessation of the treatment, for histological examination and morphometric and DNA-cytometric evaluation of the endometrium (mean pathological follow-up, 19.2 months; mean clinical follow-up, 30.7 months). During treatment, most of the women first revealed endometrial atrophy, and, after cessation of the treatment, again an atrophic or mainly functional endometrium; in 7 women, all with initial diagnosis of simple hyperplasia, the endometrial hyperplasia reappeared, which led in all 7 cases to hysterectomy. The mean values of almost all morphometric and DNA-cytometric parameters during and after treatment showed statistically significant changes in relation to pretreatment values, indicating a decrease in the proliferative activity of the endometrial cells; the GnRH-a antiproliferative effect was still active for a long time after cessation of the therapy. Our results, based for the first time not only on histological but also on serial nuclear morphometric and DNA-cytometric examinations of the endometrial cells and on the longest follow-up time, support the view that in cases of endometrial hyperplasia, especially of complex type, the use of GnRH agonists, which decrease the proliferative tendency of endometrial cells, could represent an alternative conservative therapeutic approach, which, however, requires close monitoring of the endometrium.

The effect of transdermal estradiol on the conjunctiva in postmenopausal women.

OBJECTIVE: To evaluate the effect of hormonal replacement therapy on the conjunctiva in postmenopausal women. STUDY DESIGN: A prospective clinical study in the setting of a tertiary-care university hospital. Eleven postmenopausal women received hormonal replacement therapy (transdermal estradiol or transdermal estradiol plus medroxyprogesterone acetate) for 4 months. Serum estradiol levels as well as vaginal and conjunctival maturation value (a cytological parameter) were measured before and after the treatment. Data were analysed using the Wilcoxon matched pairs signed-Rank test. RESULTS: A significant increase of serum estradiol levels (P < 0.01) and of vaginal maturation value (P < 0.01) were found. Cytological maturation changes in conjunctival epithelium were also observed. These changes, although mild, were statistically significant (P < 0.01). CONCLUSION: These data support the view that the hormonal replacement therapy induces cytological maturation changes in conjunctival epithelium in postmenopausal women.

Adenomyosis at hysterectomy: prevalence and relationship to operative findings and reproductive and menstrual factors.

In order to estimate the frequency and risk factors for adenomyosis, the clinical records of 594 women undergoing hysterectomy were retrieved. Data were collected on indications for the intervention, age at surgery, age at menarche, parity, abortions, mode of delivery, abnormal uterine bleeding, dysmenorrhea, and menopausal status at surgery. Adenomyosis was found in 116 of the 594 patients (19.5%). A pathologic condition was present in 63 patients with fibroids (20.5%), 11 with genital prolapse (25.6%), 11 with benign ovarian tumors (17.8%), six with endometrial hyperplasia (13.6%), two with cervical cancer (18.2%), ten with endometrial cancer (16.1%), and 13 with ovarian cancer (21.3%). No relationship was found between adenomyosis and endometriosis. On the contrary, a strong relationship was found between adenomyosis and parity, cesarean section, induced abortions, dysmenorrhea, abnormal uterine bleeding, and late age at menarche. These results show that adenomyosis is a common pathologic finding, significantly related to reproductive and menstrual characteristics of the patients.

Does postprandial hypersinsulinemia contribute to hyperandrogenism in patients with polycystic ovary syndrome?

Twenty patients with polycystic ovarian syndrome and with or without insulin resistance, and 20 healthy women (controls) underwent an oral glucose tolerance test, which resulted in a short duration but significant increase of serum insulin levels. Serum testosterone, androstenedione and dehydroepiandrosterone sulfate levels were estimated before and 180 minutes after administration of 75 gr. dextrose. Our results, three hours after dextrose administration, showed that: (1) serum testosterone levels decreased significantly, (2) serum androstenedione levels decreased but not significantly, and (3) serum dehydroepiandrosterone sulfate levels were not altered. The observation of decreased ovarian androgen levels after induced hyperinsulinemia is very interesting, the explanation, however, is quite difficult. This unexpected ovarian androgen response needs further investigation.

Squamous cell carcinoma arising from mature cystic teratoma: a report of three cases.

Cases of squamous cell carcinoma arising from mature cystic teratomas of the left ovary are presented. Two of the carcinomas occurred in postmenopausal women 54 and 71 years old and the third in a menstruating woman 42 years old. The two women with well-differentiated squamous cell carcinomas, who had extra ovarian extension of the tumor, died four and eight months postoperatively. The third woman with a poorly-differentiated squamous cell carcinoma, which was confined to the ovary, was alive two years after the operation. The special importance in the prognosis and spreading of tumors is emphasized.

Histopathological findings of the endometrium in patients with dysfunctional uterine bleeding.

The histopathological examination of the endometrium in cases of abnormal functional uterine bleeding frequently reveals the type of functional disturbance and assists correct treatment. On this basis, 7,000 endometrial curettages from patients with abnormal uterine bleeding were studied. The 1,282 cases with no endometrium in phase, organic changes, or systemic disorders were defined as dysfunctional uterine bleeding; the endometrial lesions were then classified and the histological findings correlated with the patients' ages. The endometrial curettages revealed an anovulatory cycle in 984 (77%) of the patients, and an ovulatory cycle in 298 (23%). Of the cases with an anovulatory cycle, 446 patients (47.5%) showed endometrial hyperplasia, 412 (41.86%) showed abnormal endometrial proliferation due to prolonged persistence of a follicle, while 106 (10.77%) showed deficient endometrial proliferation. Three hundred and thirty four cases (71.67%) of endometrial hyperplasia were (simple) cystic hyperplasias, 124 (26.60%) were (complex) adenomatous hyperplasia, and 8 (1.71%) were atypical hyperplasia. Of the cases with an ovulatory cycle, 252 (84.56%) showed deficient endometrial secretion due to a prolonged proliferative phase, while the other 46 (15.43%) showed deficient secretion due to luteal phase defect. Seven hundred and thirty six patients with an anovulatory cycle and 212 with an ovulatory cycle-i.e. 948 (74%) of the 1282 patients studied-were at the climacteric. The conclusions may be summarised as follows. i) Dysfunctional abnormal uterine bleeding was found more often at the climacteric and chiefly in the form of an anovulatory endometrium; ii) 88.14% of cases (1130 patients) presented histological signs of oestrogen influence in the form of either an anovulatory endometrium or an ovulatory endometrium; iii) Cystic (simple) hyperplasia was the most common form of endometrial hyperplasia.

Conjunctiva is an estrogen-sensitive epithelium.

BACKGROUND: To investigate whether the conjunctival epithelium shows cyclical maturation changes during the ovarian cycle and to study the cytological appearance of the conjunctiva in postmenopausal and pregnant women. PATIENTS: Fifteen menstruating women with ovulatory cycles, ten postmenopausal women, and twelve pregnant women in the second or the third trimester of their pregnancy. INTERVENTIONS: Conjunctival and vaginal smears were taken on a near-daily basis. MAIN OUTCOME MEASURES: The percentage of the parabasal, the intermediate and the superficial cells (Maturation Index) in each specimen was determined. RESULTS: In the conjunctival smears of the menstruating women cyclical maturation changes were noted. These changes were parallel to those of the vaginal smears, but to a minor degree. No cyclical changes were found in either the postmenopausal women or in the pregnant women, showing an extreme shift to the left in the Maturation Index. CONCLUSION: Conjunctiva appears to be a relatively estrogen-sensitive epithelium.

Hypothalamic-pituitary deficiency after Weil's syndrome: a case report.

A case of male hypogonadism after Weil's syndrome is described. Hypogonadism was the result of complete hypothalamic-pituitary deficiency. The relationship between leptospirosis and the endocrinopathy, the incidence that leptospira attacks hypothalamic-pituitary axis, and the mechanism with which the microorganism may cause damage to the pituitary and/or the hypothalamus are discussed.

Familial blepharophimosis with ovarian dysfunction.

Three cases including two sisters and one brother with blepharophimosis are described. Their father also had blepharophimosis. Moreover, the elder sister initially presented with resistant ovary syndrome and thereafter true premature menopause, while the younger one presented with resistant ovary syndrome. The explanation for the association of blepharophimosis with primary ovarian dysfunction is unknown, but the possibility of a microdeletion of genetic material containing two geographically associated, but independent genes could not be confirmed or excluded. All families affected by blepharophimosis should be counselled about the high incidence of ovarian dysfunction and female infertility, at least in one form of the syndrome.

[SHBG serum level in women with endometriosis before, during and after long-term danazol therapy]. / SHBG-Serumspiegel bein Frauen mit Endometriose vor, während und nach Danazol-Langzeittherapie.

Ten patients with endometriosis, aged from 21 to 37 years, were treated with danazol at a dosage level of 200 mg three times daily for 6 months. Three blood samples were drawn 60 min apart for evaluation of the sex hormone binding globulin (SHBG), before danazol administration (4th day of the cycle), during the last two weeks of the six-month therapy and three months after the cessation of treatment (4th day of the cycle). In contrast to that, SHBG levels were also evaluated in ten normal women, aged 21-37 years (4th day of the cycle). It was found that: a) SHGB values were significantly higher in patients with endometriosis than in the control group (p < 0.01), b) danazol resulted in significant decrease of SHBG levels (p < 0.001), c) there was no correlation between SHBG levels before and during danazol administration, and d) SHBG levels were significantly lower three months after the cessation of danazol than before the administration of the medication (p < 0.05), while these levels were not significantly different, compared with those of normal women. Our results support the view, that SHBG production disturbances might interfere with the possible pathogenetic mechanisms of infertility observed in endometriosis.