Ozone therapy ameliorates inflammation and endometrial injury in rats with pelvic inflammatory disease.

As a common cause of infertility, pelvic inflammatory disease (PID) is characterized by chronic pain, ectopic pregnancy as well as inflammation and infection of the female upper genital tract. Ozone water, also known as O3, has been previously reported to be a distinctly effective agent in treating inflammation. During the present study, we asserted the hypothesis that O3 could be applied by pelvic inflammation and works to regulate the expression of inflammatory factors including interleukin-6 (IL-6), IL-2 and tumor necrosis factor-α (TNF-α). In an attempt to evaluate the effect of O3 on PID, an acute PID rat model was subsequently established. O3 at concentrations of 45 µg/mL and 60 µg/mL in addition to levofloxacin (LVLX) was injected respectively into the PID rats in a bid to alter the contents of inflammatory factors and immunologic markers. Hematoxylin-eosin (HE) staining was applied to analyze endometrial inflammation. Reductions to the contents of IL-6 and TNF-α were recorded, while that of IL-2, IgA, IgG, IgM, C3 and C4, and E rosette formation rate and transformation rate of T lymphocytes exhibited notably elevated levels after the PID rats had been injected with 45 µg/mL O3, 60 µg/mL O3 or LVLX. The pathological condition of the endometrium in rats with PID was alleviated among the PID rats after injected with the 45 µg/mL O3, 60 µg/mL O3 or LVLX. Taken together, the key findings of the current study present evidence demonstrating that the administration of O3 to the pelvic cavity ameliorated the PID conditions among rat models via inhibition of the necrosis of the endometrial epithelial cells as well as alleviated the inflammatory reactions, highlighting a potential novel PID treatment target.

Is Pelvic Inflammatory Disease a Risk Factor for Ovarian Cancer?

BACKGROUND: Pelvic inflammatory disease (PID) has been proposed as a risk factor for ovarian cancer. However, the existing literature on the association between PID and ovarian cancer risk is inconclusive, and only few cohort studies have been conducted. METHODS: Using nationwide Danish registries, we conducted a population-based cohort study including all women from the birth cohorts 1940 to 1970 in Denmark during 1978-2012 (n = 1,318,929) to investigate the association between PID and subsequent risk of epithelial ovarian cancer. Among women in the cohort, 81,281 women were diagnosed with PID and 5,356 women developed ovarian cancer during follow-up through 2012. Cox regression models were used to estimate HRs and 95% confidence intervals (CI) for the association between PID and ovarian cancer, both overall and according to histotype. RESULTS: For ovarian cancer overall, we observed no association with PID (HR, 1.05; 95% CI, 0.92-1.20). However, in histotype-specific analyses, we found a statistically significantly increased risk of serous ovarian cancer among women with PID (HR, 1.19; 1.00-1.41; P = 0.047). Conversely, PID was not convincingly associated with risk of any of the other histotypes of ovarian cancer. CONCLUSIONS: PID was associated with a modestly increased risk of serous ovarian cancer, but not other histotypes. IMPACT: Our results indicate that PID is not a strong risk factor for ovarian cancer. Whether PID is slightly associated with risk of serous ovarian cancer has to be confirmed in other studies. Cancer Epidemiol Biomarkers Prev; 26(1); 104-9. ©2016 AACR.

Chronic Pelvic Inflammation Diminished Ovarian Reserve as Indicated by Serum Anti Mülerrian Hormone.

OBJECTIVE: To explore the potential damaging effect of chronic pelvic inflammation on ovarian reserve. DESIGN: Case-control study. PATIENTS: A total of 122 women with bilateral tubal occlusion, diagnosed by hysterosalipingography (HSG) and 217 women with normal fallopians were recruited. MEASUREMENTS: Serum anti-Mullerian hormone (AMH), basic follicle-stimulating hormone (FSH), luteining hormone (LH), estradiol (E2), and testosterone (T) were measured; and antral follicle counts (AFCs) were recorded. RESULTS: Significantly lower level of AMH was observed in women with bilateral tubal occlusion compared to control group [2.62 (2.95) ng/ml vs. 3.37 (3.11) ng/ml, P = 0.03], and the difference remained after adjustment of BMI (Padjust = 0.04). However, no statistical difference was found in the levels of FSH [7.00 (2.16) IU/L vs. 6.74 (2.30) IU/L], LH [4.18 (1.52) IU/L vs. 4.63 (2.52) IU/L], E2 [35.95 (20.40) pg/ml vs. 34.90 (17.85) pg/ml], T [25.07±11.46 ng/dl vs. 24.84±12.75 ng/dl], and AFC [6.00 (4.00) vs. 7.00 (4.00)] between two groups (p>0.05). CONCLUSIONS: Women with bilateral tubal occlusion showed decreased AMH level, suggesting that chronic pelvic inflammation may diminish ovarian reserve. More caution should be paid when evaluating the detriment of PID on female fertility.

Smoking, poor nutrition, and sexually transmitted infections associated with pelvic inflammatory disease in remote North Queensland Indigenous communities, 1998-2005.

BACKGROUND: Indigenous women in remote North Queensland have a high prevalence of unhealthy lifestyle behaviors and associated health conditions such as sexual transmitted infections (STI). The association of severe pelvic inflammatory disease (PID) with these factors has not been studied. The purpose of this study is to associate the factors with severe PID, as indicated by hospitalization in a high risk population in North Queensland Indigenous communities. METHODS: A cross-sectional association of 1445 Indigenous women using linked hospital separation and survey data during 1998-2005. RESULTS: The mean age of participating women was 37.4 years, 60% were of Aboriginal and 40% were Torres Strait Island (TSI) people. More than half of them (52.5%) were smokers, 9.3% had chlamydia and 2.6% had gonorrhoea with the overall prevalence of STI among those less than 25 years of age being 23.9%. Among the 47 participants diagnosed with PID in the study period, 42.5% were under 25 years and 95.7% (45 cases) were under 55 years (OR 2.5, 95% CI 1.2-4.1 among women younger than 25 compared to those 25 years and over). PID was strongly associated with smoking (OR 3.1, 95% CI 1.4-9.2) independent of age, ethnicity, STI and folate status. Low red cell folate increased PID hospitalization by 4 times (95% CI 1.5-13.2 of lowest quartile compared to the highest quartile) regardless of age. Having a STI significantly increased the likelihood of severe PID by 2.2 times (95% CI: 1.03-4.5) in Indigenous women younger than 45 years, independent of smoking and folate level. The risk of PID hospitalization was higher for gonorrheal infections (OR 3.2, 955 CI 1.1-9.6) compared to chlamydial infections (OR 1.5 95% CI 0.7-3.5). CONCLUSIONS: Young Indigenous women in North Queensland communities are at very high risk for STI and PID. Smoking, low folate, and STI are clustered, and are associated with PID hospitalizations. Much of this can be prevented with improved nutrition and access to preventive services, especially tobacco control, regular STI screening and treatment, as well as more investment in sexual health education and awareness.

The sensitivity and specificity of transvaginal ultrasound with regard to acute pelvic inflammatory disease: a review of the literature.

PURPOSE: This review aims to sum up current knowledge on the sensitivity and specificity of ultrasound features suggestive of acute pelvic inflammatory disease (PID). METHODS: A PubMed database search was undertaken, using the MeSH terms "(pelvic inflammatory disease or salpingitis or adnexitis) and ultrasonography". We included original articles evaluating the performance of vaginal ultrasound in detecting acute PID. RESULTS: Seven articles were selected, including between 18 and 77 patients each. The golden standard used was laparoscopy/endometrial biopsy in six studies and mostly clinical evaluation in one. "Thick tubal walls" proved to be a specific and sensitive ultrasound sign of acute PID, provided that the walls of the tubes can be evaluated, i.e., when fluid is present in the tubal lumen (100 % sensitivity). The cogwheel sign is also a specific sign of PID (95-99 % specificity), but it seems to be less sensitive (0-86 % sensitivity). Bilateral adnexal masses appearing either as small solid masses or as cystic masses with thick walls and possibly manifesting the cogwheel sign also seems to be a reasonably reliable sign (82 % sensitivity, 83 %specificity). Doppler results overlap too much between women with and without acute PID for them to be useful in the diagnosis of acute PID, even though acutely inflamed tubes are richly vascularized at color Doppler. CONCLUSIONS: Even though the results of our review suggest that transvaginal ultrasound has limited ability to diagnose acute PID, it is likely to be helpful when managing women with symptoms of acute PID, because in some cases the typical ultrasound signs of acute PID can be detected.

Unusual ectopic pregnancies: a retrospective analysis of 65 cases.

AIM: The aim of this study was to retrospectively investigate unusual ectopic pregnancies (EP) and compare them with fallopian ones. MATERIAL AND METHODS: A total of 1000 cases of ectopic pregnancies were analyzed, including 65 unusual cases. We discussed distribution, incidence, risk factors, examinations, treatments and prognoses. RESULTS: Ovarian pregnancy was associated with placement of intrauterine device and pelvic inflammatory diseases. Extratubal EP have a high rate of misdiagnosis and presented more serious manifestations. Some unusual EP could be diagnosed by ultrasonography. Ovarian pregnancy was usually manifested as positive culdocentesis. Most of the unusual EP underwent surgery, except some early cervical and corneal pregnancies. CONCLUSION: Although extratubal pregnancies are difficult to diagnose, some histories and auxiliary examinations could make diagnosis easier for clinical physicians. Surgery is still the most effective approach for treatment of unusual EP, while conservative treatment of mifepristone combined with methotrexate or curettage could be used for early diagnosis and treatment of cervical pregnancy.

[Optical introscopy is a new diagnostic technique in reproductive medicine].

The WHO classification's concept "infertility of unclear genesis" is due to a number of circumstances. On the one hand, this is a preponderance of the subtle forms of diseases, which are a cause of female infertility, including the subclinical forms of small pelvic inflammatory diseases (SPID). On the other hand, this is an imperfection of existing diagnostic methods. Laparoscopy considered to be the gold standard demonstrates a not very high efficiency in diagnosing SPID because of its low sensitivity. In practice, laparoscopic diagnosis of SPID is combined with ultrasound study, computed tomography, and magnetic resonance tomography. This paper proposes to use optical coherent tomography (OCT) in addition to laparoscopy. OCT makes it possible to noninvasively in real time obtain information on the internal structure of biological tissues with a resolution of 10-15 pm at a depth of at least 2 mm. Removable endoscopic probes make OCT compatible with standard endoscopic studies. The use of OCT during laparoscopy yielded optical images of the internal structure of the fallopian tube wall in different conditions: unaltered fallopian tubes; an acute inflammatory process with pronounced changes; minimal manifestations of fallopian tube inflammatory changes. Based on the comparative analysis of OCT data and histological findings, the authors elaborated OCT criteria for health and disease. A blind test indicated the high diagnostic efficacy of the technique. The additional processing of images makes it possible to objectify the data and to automate the optical introscopic technique proposed by the authors.

Pelvic inflammatory disease.

Pelvic inflammatory disease is a polymicrobial infection of the upper genital tract. It primarily affects young, sexually active women. The diagnosis is made clinically; no single test or study is sensitive or specific enough for a definitive diagnosis. Pelvic inflammatory disease should be suspected in at-risk patients who present with pelvic or lower abdominal pain with no identified etiology, and who have cervical motion, uterine, or adnexal tenderness. Chlamydia trachomatis and Neisseria gonorrhoeae are the most commonly implicated microorganisms; however, other microorganisms may be involved. The spectrum of disease ranges from asymptomatic to life-threatening tubo-ovarian abscess. Patients should be treated empirically, even if they present with few symptoms. Most women can be treated successfully as outpatients with a single dose of a parenteral cephalosporin plus oral doxycycline, with or without oral metronidazole. Delay in treatment may lead to major sequelae, including chronic pelvic pain, ectopic pregnancy, and infertility. Hospitalization and parenteral treatment are recommended if the patient is pregnant, has human immunodeficiency virus infection, does not respond to oral medication, or is severely ill. Strategies for preventing pelvic inflammatory disease include routine screening for chlamydia and patient education.

Role of D-dimer testing in severe pelvic inflammatory disease: a new usable marker to assess the need for fertility-impairing surgery?

Pelvic inflammatory disease (PID), like many other inflammatory diseases, can be characterized by an inflammation-induced activation of the coagulation cascade, resulting in the production of D-dimers. In this study it is demonstrated how high levels of D-dimers, assayed at the time of hospitalization, are encountered in patients diagnosed with PID and how the levels of this parameter are significantly higher in patients, which due to the severity of the disease, needed surgical treatment. Therefore the d-dimer is shown to be an important parameter to be considered in the therapeutic counseling of severe forms of PID.

[Pelvic inflammatory diseases]. / Physiopathologie, diagnostic et prise en charge des infections génitales hautes.

Pelvic inflammatory diseases (PID) include salpingitis and endometritis. They usually result from the infection of upper genital tract by pathogens ascending from the cervix or the vagina. Since the clinical signs of uncomplicated forms are frequently mild or misleading, diagnosis require other exams such as microbiology (samples from the cervix and, if applicable, from the pelvis) and laparoscopy. Acute complications (pelvic abscesses, peritonitis) can occur, that call for both surgical drainage and antibiotics. Pelvic sequelae with permanent tubal alterations due to immuno-allergic reactions can also happen, that lead to chronic pelvic pain and infertility. Treatment consists in broad-spectrum antibiotics by oral route, combined with non steroid anti-inflammatory drugs. Atraumatic laparoscopic procedure can also be performed.

Association of pelvic tuberculosis with tubal factor infertility.

Tubal block is a common cause of infertility. Therefore Laparoscopy or Hysterosalphingoraphy or Hydrosonosalphingography are accepted methods for diagnosis of tubal block. Genital tuberculosis has a world wide distribution, more common in developing countries. Tubal block is the sequel of that disease. This prospective study by determination of Acid Fast Bacilli (AFB) in the endometrium of infertility patients was carried out in 60 patients at the Infertility unit, department of Obstetrics & Gynecology Bangabandhu Sheikh Mujib Medical University (BSMMU) during January 2005 to December 2006. In this study AFB positive in endometrium was in 14(46.7%) cases and 4(13.3%) in control. Out of 30 cases 60% had primary sub-fertility and 40% had secondary sub fertility. Most common tubal pathology was adhesion in 11(36%) cases. Others were beaded and tortuous in 8(26.7%) and hydrosalphix in 6(20%) and tube was dilated in 2(6.7%) cases. There were bilateral tubal block in 18(60%) and unilateral tubal block in 12 (40%) cases.

[Effect of pelvic inflammatory disease grades on in vitro fertilization-embryo transfer outcome].

OBJECTIVE: To evaluate the effect of different grades of pelvic inflammatory disease (PID) and of salpingectomy on outcomes of in vitro fertilization-embryo transfer (IVF-ET). METHODS: Two hundred and twenty three cycles of IVF-ET were divided into three groups, including mild group, moderate group and severe group, according to different grades of sequelae of PID finding in exploratory operations before IVF. Patients in each group were divided into two subgroups according to receiving salpingectomy or not. The data of total dose of gonadotrophin (Gn), oocyte number, low response rate, fertilization rate, good embryo number and pregnancy rate were analysed between three groups and the two subgroups of each group, respectively. RESULTS: All parameters were related to PID grades except fertilization rate. The total dose of Gn, oocyte number, good embryo number, low response rate and pregnancy rate were (2057 +/- 503) IU/L, (16 +/- 6), (6.0 +/- 4.3), 4.2%, 63.9% in mild group; (2204 +/- 603) IU/L, (12 +/- 6), (4.5 +/- 3.5), 13.9%, 46.8% in moderate group; and (2372 +/- 1018) IU/L, (9 +/- 6), (3.1 +/- 2.9), 33.8%, 41.2% in severe group. The total dose of Gn and low response rate increased with the aggravation of the grades of PID (P < 0.05). The oocyte number, good embryo number and pregnancy rate also had significant differences between three groups (P < 0.01, P < 0.01, P < 0.05, respectively). In mild and severe groups, the salpingectomy had no contribution to the outcome of IVF-ET treatment. In moderate group, patients receiving salpingectomy had more oocytes and good embryos and higher pregnancy rate than the others who retained oviducts (P < 0.05). CONCLUSIONS: Grades of PID have an adverse effect on IVF-ET outcomes. Receiving salpingectomy or not should be based on different grades of PID, but operations of ovary-free should be performed in all patients.

[Using GnRH-agonists (Zoladex) in the treatment of genital endometriosis].

METHODS AND MATERIALS: The study is prospective and involves 112 patients suffering from pelvic endometriosis aging from 19-38 years. (28.6 average age). The disease was diagnosed via laparoscopy and the stage was determined using the revised AFS classification. Zoladex (Goserelin depot--3.6 mg) is being applied every 28 days for 6 months in the hypodermic tissue of the front abdomen wall. All patients are being examined monthly after every Zoladex application (for subjective complaints--dysmenorrheal, dyspareunea, pelvic pain; serum estradyol-E2; amenorrhea; side effects) and every 24 months (recuperation of the menstrual cycle, pregnancy). RESULTS: In 88% of the patients amenohrea is obsereved in the first eight weeks of therapy. The menstrual cycle takes an avarege of 68 (31-139) after the last Zoladex application to reappear. At the end of the first month after the first application the serum level of estradyol E2 is lowered to a menopause level (from 750-800 to 120-130 Pmol/L) and it remains as low till the end of the treatment. Eight weeks after the completion of the therapy it goes back to its normal values. During the course of the first month of amenorrhea condition a 38% fall in the level of complaints (dysmenorrheal, dyspareunea, pelvic pain) is observed. After the 6th month 88% of the patients have no complaints. Side effects observed during the course of treatment include warm waves, sweating, vaginal dehydration (60-80%) which do not in any way disturb the patients to the point of quitting the therapy and do disappear with its end. The focus group contains 54 infertile patients with endometrioses willing to get pregnant. In 12 months after the completion of the treatment 16 of the patients become pregnant, followed by 12 more in the next one year. CONCLUSION: Zoladex causes amenorrhea, which lasts till the end of the treatement. It causes a rapid drop of the serum consentration to a menopause level. Causes a strong and durable treatment of the symptoms of endometriosis. The side effects disappear with the end of the therapy. The treatment is easy to go through and there no cases of a quitting patient. The treatment has a curable effect over the endometriosys and in cases of infertility provides a possibility for pregnancy.

Irritable bowel syndrome, chronic pelvic inflammatory disease and endometriosis: a comparison of symptomatology.

BACKGROUND AND OBJECTIVES: Both irritable bowel syndrome and some gynaecological diseases can give rise to lower abdominal pain, which may result in diagnostic confusion. Disorders such as endometriosis and chronic pelvic inflammatory disease can be diagnosed definitively only by laparoscopy, which is seldom undertaken in the gastroenterological setting. It was the aim of this study to compare the symptomatology of irritable bowel syndrome with that of laparoscopically confirmed chronic pelvic inflammatory disease and endometriosis. PATIENTS AND METHODS: A symptom questionnaire was administered to 50 women with irritable bowel syndrome and 51 gynaecological patients (30 patients with endometriosis, 21 patients with chronic pelvic inflammatory disease). As the symptoms of the two gynaecological conditions were so similar, the groups were combined for the purposes of comparison with irritable bowel syndrome. RESULTS: Patients with irritable bowel syndrome suffered significantly more upper abdominal pain, colicky pain and exacerbation of pain by food or stress. They also experienced more disturbance of bowel habit, distension and nausea. In contrast, the only gynaecological features that were more common in the gynaecological patients were intermenstrual bleeding, premenstrual exacerbation of pain and forniceal tenderness. CONCLUSION: The presence of gastrointestinal symptomatology, especially bowel dysfunction, in a woman with lower abdominal pain is suggestive of irritable bowel syndrome. However, the history may not be so helpful in detecting gynaecological disease.

[VEGF, TNF-alpha and IL-6 in the peritoneal fluid of women with unexplained infertility]. / VEGF, TNF-alpha i IL-6 w plynie otrzewnowym kobiet z nieplodnoscia niejasnego pochodzenia.

Unexplained infertility is an important problem in diagnosis and therapy in everyday gynecologist's practice. Looking for possible reasons of the unexplained infertility we studied the concentrations of selected cytokines (VEGF, TNF-alpha and IL-6) in the peritoneal fluid of women suffering from the unexplained infertility. We compared the results in the studied group with the control group and with the patients with endometriosis. Immunological disorders of the peritoneal fluid in endometriosis are thought to take part in its pathomechanism. Our results suggest that the levels of one of the main factors of endothelium proliferation (VEGF) in the peritoneal fluid from women with unexplained infertility and women with endometriosis are comparable. Concentration IL-6 and TNF-alpha in the peritoneal fluid in case of unexplained infertility and control group was lower than in the endometriosis patients.

Transvaginal power Doppler findings in laparoscopically proven acute pelvic inflammatory disease.

OBJECTIVES: To evaluate the usefulness of power Doppler transvaginal sonography (TVS) in the diagnosis of pelvic inflammatory disease (PID) and to assess the diagnostic reliability of specific sonographic findings. POPULATION: The study population consisted of 30 women admitted for suspected acute PID. The reference group consisted of 20 women with proven hydrosalpinx formation. METHODS: Both conventional TVS and power Doppler TVS were performed. All patients with suspected acute PID underwent laparoscopy in order to confirm the diagnosis. Sonographic criteria described earlier were used for the diagnosis of acute PID. Power Doppler was used to assess the vascularity of any adnexal mass. RESULTS: Laparoscopy confirmed the diagnosis of PID in 20 (67%) of the 30 women with clinically suspected acute PID. Specific TVS findings, including wall thickness > 5 mm, cog-wheel sign, incomplete septa, and the presence of cul-de-sac fluid, discriminated women with acute PID from the control women with hydrosalpinx formation. Power Doppler TVS revealed hyperemia in all women with acute PID, but in only two women with hydrosalpinx (P = 0.01). Pulsatility indices were significantly lower in the acute PID group than in the control group (pulsatility index 0.84 +/- 0.04 vs. 1.50 +/- 0.10; P < 0.01). CONCLUSION: Power Doppler TVS was 100% sensitive and 80% specific in the diagnosis of PID (overall accuracy 93%). Specific sonographic landmark findings and power Doppler findings augment the clinical diagnosis of PID and allow simple classification of the severity of the disease.

[Vaginal infections and sexually transmitted diseases]. / Infections vaginales et maladies sexuellement transmissibles.

The diagnosis and treatment of vaginal and sexually transmitted infections constitute an important part of the activity of the gynaecologist and of the general practitioner. In this review article, we will describe various clinical entities, including bacterial vaginosis, vulvovaginal Candidiasis, trichomoniasis, gonorrhea, syphilis, genital herpes, Chlamydial infection, and pelvic inflammatory disease. The acquired immunodeficiency syndrome will not be described here.