Menopausia y terapia hormonal de la menopausia. Las recomendaciones 2018 de la Unidad de Endocrinología Ginecológica de Clínica Alemana de Santiago -Sociedad Italiana de la Menopausia y la Sociedad Chilena de Endocrinología Ginecológica / Menopause and menopausal hormone therapy. The 2018 recommendations of the Gynecological Endocrinology Unit of Clínica Alemana de Santiago -Italian Society of Menopause and the Chilean Society of Gynecological Endocrinology

ABSTRACT In the last decade, the risk benefits ratio of MHT has been evaluated mainly in terms of cardiovascular risk. Present Consensus Statement is largely inspired by the Global Consensus on Menopausal Hormone Therapy in 2013 and 2016 by leading global menopause societies (The American Society for Reproductive Medicine, The Asia Pacific Menopause Federation, The Endocrine Society, The European Menopause and Andropause Society, The International Menopause Society, The International Osteoporosis Foundation and The North American Menopause Society). The aim of these Recommendations is to provide a simple and updated reference on postmenopausal MHT. The term MHT typically includes estrogen replacement therapy (ERT) and estrogen-progestogen therapy (EPT). EPT can be sequential (Seq) when progestogen is added to ERT for 10-14 days a month, or continuous combined (CC) when progestogen is administered continuously every day along with a fixed amount of estrogen. MHT also includes Tibolone and the Tissue Selective Estrogen Complex (TSEC).

Pro-inflammatory M1/Th1 type immune network and increased expression of TSG-6 in the eutopic endometrium from women with endometriosis.

OBJECTIVE: The study aimed to explore the type 1 and type 2 cytokines expression in the endometrium from women affected by endometriosis compared to controls. The expression of TSG-6, a multifunctional protein involved in several inflammatory disease, was also evaluated. Study Design SETTING: Experimental clinical study. PATIENTS: 10 patients affected by endometriosis and 11 controls. INTERVENTIONS: Patients underwent to an ultrasound transvaginal examination and a diagnostic hysteroscopy in order to exclude any uterine abnormality. All patients underwent endometrial biopsy using a Novak's curette. MAIN OUTCOME MEASURES: The endometrial expression of type 1 (IL- 1 ß TNF-α, IL-8) and type 2 (IL-10) cytokines, and of TSG-6 was evaluated by immunohistochemistry and by real time PCR. The expression of TSG-6 was confirmed by western blot. RESULTS: Results of PCR analysis and of immunohistochemistry revealed an increased expression of IL-1ß, TNF-α, IL-8 and of TSG-6 in the endometrium of endometriosic patients. IL-10 expression did not show any difference. CONCLUSIONS: An increased expression of pro-inflammatory type 1 cytokines was demonstrated in the endometrium from endometriosic patients, suggesting an endometrial environment harmful for implantation due to the prevalence of Th1 related immunity. An increased expression of TSG-6 was also demonstrated for the first time. Our findings concur to better define the inflammatory imbalance and the abnormal endometrial receptivity, reported in literature, of the eutopic endometrium of women affected by endometriosis.

2D and 3D Ultrasonographic Evaluation of Fetal Midface Hypoplasia in Two Cases with 3-M Syndrome.

This paper highlights the utility of 2D and 3D ultrasonography in the prenatal diagnosis of facial dysmorphisms suggestive of very rare syndromes such as 3-M syndrome. Two pregnant women at risk for fetal skeletal dysplasias were referred to our clinic for 2D/3D ultrasound scan in the second trimester of pregnancy. Only one of the patients had a familial history of 3-M syndrome. Karyotyping and genetic testing of abortion material were performed in both cases. 2D ultrasonography revealed growth retardation of the long bones in both cases. In the case without a familial history of the syndrome, 2D and 3D ultrasonography showed an absence of nasal bones and a flat malar region suggestive of 3-M syndrome, although the difficult differential diagnosis included other dysmorphic growth disorders with prenatal onset. The karyotype was normal but the pregnancy was terminated in both cases. Postmortem examination confirmed 3-M syndrome as indicated by prenatal findings. In high-risk cases with a familial history of 3-M syndrome, prenatal diagnosis of 3-M syndrome is possible by analyzing fetal DNA. In the absence of risk, a definitive prenatal diagnosis is often not possible but may be suspected in the presence of shortened long bones, normal head size and typical flattened malar region (midface hypoplasia) shown on complementary 2D and 3D sonograms. 2D and 3D ultrasonography has been shown to offer reliable information for the prenatal study of skeletal and facial anomalies and can be useful if there is a suspicion of 3-M syndrome in a pregnancy not known to be at risk.

Soy isoflavones, inulin, calcium, and vitamin D3 in post-menopausal hot flushes: an observational study.

PURPOSE OF INVESTIGATION: To evaluate the effect of soy isoflavones and inulin (SII) on hot flushes (HF) and quality of life in a clinical setting, the authors conducted an observational study. MATERIALS AND METHODS: The authors performed an observational, prospective, multicentric study on women in peri-/post-menopause treated or untreated with a product present on the Italian market, consisting in a mixture of calcium (500 mg), vitamin D3 (300 IU), inulin (3 g) and soy isoflavones (40 mg). RESULTS: A total of 135 patients, 75 (55.6%) in the SII group and 60 (44.4%) in the untreated group entered the study. After three months, the mean number of HF declined of 2.8 (SD 3.7) in the SII group and 0.0 in the untreated one. The corresponding values after six months were -3.7 (SD 2.7) in the SII group and -0.9 (SD 5.3) in the control group (p = 0.02). CONCLUSION: This observational trial suggests a possible beneficial effect of a dietary soy supplement containing 40 mg of isoflavone/day plus inulin in the management of menopausal symptoms such as hot flashes.

Uterine leiomyosarcoma: report of three cases and review of the literature.

This is the report of three cases of unsuspected uterine leiomyosarcoma diagnosed by pathologist after hysteroscopic resection. The literature on this issue has been reviewed. Mesenchymal uterine tumors are rare malignancies, occurring in only 17 per one million women annually. The three most common variants of uterine sarcoma are endometrial stromal sarcoma, leiomyosarcoma, and malignant mixed Müllerian tumour. Less than one percent of women believed to have a leiomyoma actually have a sarcoma at hysterectomy. According to the authors' experience and the available literature reviewed, the removal of the whole myomatosus lesion, even if its appearance suggests a typical submucosal myoma, represents the only method to definitively rule out the presence of sarcomatous tissue.

Effects of anodal TDCS stimulation of left parietal cortex on visual spatial attention tasks in men and women across menstrual cycle.

Sex hormonal variations have been shown to affect functional cerebral asymmetries in cognitive domains, contributing to sex-related differences in functional cerebral organization. The aim of this study was to investigate spatial attention by means of a bisection line test and computer-supported attention task during the menstrual cycle in healthy women compared to men, in basal condition and under Transcranial Direct Current Stimulation (TDCS) of the left parietal cortex. Women were studied during the menses, follicular and luteal phases, ascertained by transvaginal ultrasounds. In basal conditions, women showed a clear deviation toward the right in the bisection line test during the menstrual phase, similarly to men. The midpoint recognition in the computer-supported attention task was not influenced by the menstrual cycle for women, while men showed a significant increase in errors toward the left side. The anodal activation of the left parietal cortex did not affect the line bisection task, while in men it reduced the total amount of errors in midpoint recognition observed in the computer supported attention task. The hand-use effect demonstrated by the bisection-line test could be influenced by estrogen fluctuations, while the right hemisphere prevalence in spatial attention appears to be gender-related and scarcely influenced by the menstrual cycle. The left parietal cortex seems to exert a scarce effect on hand-use effect, while its activation is able to revert sex related right hemisphere supremacy.

Frequency of human papillomavirus infection and genotype distribution among women with known cytological diagnosis in a Southern Italian region.

INTRODUCTION: In the Puglia region (South Italy) about 200 new hospitalizations for cervical cancer are registered every year. The study investigated the frequency of Human Papillomavirus (HPV) infection and the genotype distribution of HPV in a sample of women with known cytology attending the outpatient clinics of four Gynecological Departments of the University of Bari over a four-year period (2005-2008). METHODS: Cervical samples from 1,168 women were analyzed for the presence of HPV-DNA through Polymerase Chain Reaction (PCR) in L1 region and reverse hybridization. The cytological results were associated with HPV positivity and type-specific prevalence. RESULTS: Overall, HPV infection was found in 355 (30.4%) women. HPV-DNA was found in 34.4% of women with a cytological diagnosis of ASCUS, in 46.8% of women with Low-grade Squamous Intraepithelial Lesion (LSIL) and in 87.0% of women with High-grade Squamous Intraepithelial Lesion (HSIL)/carcinoma. Also 16.0% of women with normal Pap smear were found to be HPV-DNA positive. The most common HPVgenotype was type 16 found in 27.3% of positives, followed by type 53 (11.5%), type 66 (9.2%) and type 31 (9.0%). HPV genotype 18 was found in 6.4% of positives. Types 16 or 18 were detected in about 34% (120/355) of all infected women, in about 33% of LSIL and in 60% of HSIL/ carcinoma HPV-positive women. Among low risk (LR) genotypes, type 61 was found in 10.7% of HPV positive women, type 62 in 8.4%, type 42 in 8.1% and type CP6108 in 7.8%. DISCUSSION AND CONCLUSIONS: The findings of the study give evidence that HPV infection is frequent in the studied cohort of women. The most widespread genotypes found were 16 and 53. These data may represent a benchmark for future evaluation after the recent introduction of vaccination against HPV in 12-year-old girls.

[Reliability of the diagnostic fluid mini-hysteroscopy in the diagnosis of intrauterine pathologies]. / Affidabilità della mini-isteroscopia diagnostica a liquido per la diagnosi delle patologie intrauterine.

AIM: The aim of this study was to determine the diagnostic accuracy of minihysteroscopy with fluid distention and vaginoscopic approach for the diagnosis of endometrial pathologies. METHODS: This controlled clinical study was conducted on 930 women with endometrial abnormalities who referred to our Department of Obstetrics and Gynecology, University Medical School of Bari, to perform hysterectomy. One week before hysterectomy all the patients underwent minihysteroscopy with fluid distention. Histological diagnoses were compared with the hysteroscopic findings, and the sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were determined. RESULTS: Hysteroscopy was technically successful in all women and revealed sensitivity of 98%, specificity of 99%, a positive predictive value of 92%, a negative predictive value of 99%, and diagnostic accuracy of 99% for the diagnosis of endometrial carcinoma. CONCLUSIONS: Size reduction of the hysteroscope is of greatest importance for reducing pain and risk of vasovagal reaction. In conclusion, the best approach in terms of ease, reliability, acceptability, and safety to patients in whom intrauterine exploration is indicated should be simple diagnostic mini-hysteroscopy using a small-diameter, rod lens hysteroscope with a single-flow diagnostic sheath, vaginoscopic approach, and fluid distention. In this way in about 90% of patients, a correct diagnosis and proper choice for eventual subsequent operative strategy can be obtained, without discomfort and risk.

Gastrointestinal stromal tumors mimicking gynecological masses on ultrasound: a report of two cases.

Gastrointestinal stromal tumors (GISTs) are among the most common mesenchymal tumors of the gastrointestinal tract. Diagnosis of GIST on ultrasound examination can be difficult because of their similarity in appearance to gynecological neoplasms. We present two cases of GIST originating from the small bowel and the stomach, which were preoperatively misdiagnosed as a uterine leiomyoma and an ovarian tumor, respectively. The ultrasonographic differential diagnosis of these pelvic masses is discussed.

Peritoneal fluid as an unrecognised vector between female reproductive tissues.

This essay discusses the potential contribution of peritoneal fluid to the regulation of reproductive processes in female mammals. After noting the relatively high concentrations of diverse hormones in peritoneal fluid, and accepting that it bathes the surface of all the internal reproductive organs, peritoneal fluid is then proposed as a means of communication between the two ovaries. It could act to influence both the hierarchy of Graafian follicles and the rate and extent of development of a newly-formed corpus luteum. Cytokines in peritoneal fluid are considered in this context, as are the differing populations of leukocytes. Circumstantial evidence is offered for entry of peritoneal fluid into the Fallopian tubes, especially close to the time of ovulation, with the suggestion that such entry could modify the nature of endosalpingeal secretion and transudation. Thereafter, the spectrum of gonadal hormones in peritoneal fluid could be influencing uterine tissues in a local manner. Finally, reference is made to regional differences in the concentration of steroid hormones in the peritoneal fluid of women, likewise to regional differences in domestic animals.

Pregnancy outcome and recurrence after conservative laparoscopic surgery for borderline ovarian tumors.

BACKGROUND: The aim of this study was to evaluate the safety and efficacy of conservative laparoscopic management of borderline ovarian tumors, and to assess pregnancy outcome and recurrence after fertility-sparing surgery. METHODS: From 1995 to 2005, 43 patients of reproductive age presented with adnexal mass, which was subsequently diagnosed as a borderline tumor of the ovary. These patients were treated by conservative laparoscopic surgery, with intraoperative staging of the disease. Patients were evaluated every 3 months for the first 2 years, and then every 6 months thereafter, to determine the best modality for following patients after conservative surgery. RESULTS: Three (7%) patients developed a recurrence after conservative treatment. Among the 43 patients who had conservative surgery, 21 (49%) became pregnant during the follow-up period; 12 (57%) conceived spontaneously, and the remaining 9 (43%) patients underwent caesarean section. CONCLUSIONS: In our opinion, conservative laparoscopic treatment of borderline ovarian tumors is an appropriate and reasonable therapeutic option for young women with low-stage disease who wish to preserve their childbearing potential, because the fertility results are encouraging. Recurrence can be noted after this type of treatment, but the cases of recurrent disease can be detected with close follow-up and treated accordingly. Careful selection of candidates for this kind of treatment is, of course, necessary, and close follow-up is required.

Influence of human menopausal gonadotrophin treatment on testicular blood flow and on seminal plasma nitric oxide levels in infertile males.

Gonadotrophin treatment is capable of increasing intratesticular blood flow and improving sperm fertilization potential. A nitric oxide (NO)-mediated mechanism may play a role. This study aimed at evaluating whether the increase in intratesticular blood flow, in response to human menopausal gonadotrophin (hMG) treatment, is accompanied by an increase in seminal plasma NO levels in 20 normogonadotropic males affected by severe oligoasthenoteratozoospermia. Patients received 150 IU of hMG, three times a week for 3 months. Before starting treatment and at month 3 of therapy, levels of NO in the seminal plasma were determined, followed by ultrasound scanning of testis, Doppler evaluation of intratesticular vascular resistance, serum hormone and conventional semen evaluation. Statistical analysis was performed by using Wilcoxon test; the limit of statistical significance was p<0.05. At the end of treatment, seminal plasma concentration of NO, conventional semen parameters and testicular volume did not increase significantly. Follicle-stimulating hormone serum level significantly increased (p=0.014) after treatment, whereas luteinizing hormone, testosterone and oestradiol values did not change. The resistance index of both intratesticular arteries significantly decreased (p=0.012 and 0.005 for right and left testes respectively). The results of this study confirmed the positive effect of exogenous hMG on testicular blood flow, but failed to demonstrate any effect of hMG treatment on NO levels in the seminal plasma in infertile males.

[Urinary incontinence in postmenopausal period: clinical and pharmacological treatments]. / Incontinenza urinaria in menopausa: trattementi clinici e farmacologici.

Urinary incontinence is a common clinical problem in female sex and occurs especially in postmenopausal women; this disease, that represents an economical problem for society, begins in young age, arises in middle age and increases in women more than 65 years old. Studies carried out on etiological factors involved in urinary incontinence show that estrogens enhance the trophism and vascularization of the muscular and fascial support of the pelvic floor, the growth of fibroblasts and the collagen metabolism in the superficial fascia in postmenopausal women. The postmenopausal estrogenic deficit could be related to many urogenital problems, but many researches performed on the effects of estrogens in urogenital postmenopausal homeostasis and of hormonal replacement therapy in postmenopausal incontinent women, did not show conclusive findings; for this reason, even if many authors attributed to menopause a role of major risk factor for incontinence, a direct correlation has never been confirmed. The treatment of postmenopausal female incontinence may be clinical and pharmacological, and includes a first step therapy (bladder training, biofeedback techniques, electrical pelvic floor stimulation) and a second step therapy (pharmacological therapy, bladder devices and surgical operations). In this review the clinical and pharmacological treatments, their efficacy and their application in incontinent postmenopausal women are described.

A dominant ovarian follicle induces unilateral changes in the origin of the blood supply to the tubal corner of the uterus.

BACKGROUND: The blood supply to the tubal corner of the uterus may originate from the uterine and ovarian arteries. The border of supply from the arteries has been found to move in young women; the change seemed dependent on ovarian steroid production. The present work investigated whether the border of supply could differ between the two sides of the uterus in the same woman having one dominant follicle (>10 mm). METHODS: Vagina was flushed with saline of room temperature in 15 women with a dominant follicle >10 mm. The temperature was measured in the mid-uterine lumen and in the tubal corner of the uterus at 2, 5 and 7 min after starting cooling. The investigation was repeated 30 min later measuring the temperature in the other tubal corner. RESULTS: The temperature decrease was, as found in previous investigations, more pronounced in the uterine cavity than in the tubal corners. However, a difference was found between the two tubal corners. At all measurement times the decrease was significantly smaller in the tubal corner corresponding to the dominant follicle than in the contralateral side. CONCLUSIONS: In our model, 'cold' is transferred from the vaginal venous blood to the uterine artery and the cooling defines the supply area of the uterine artery. Therefore, the results indicate that the area of supply from the ovarian artery in the tubal corner ipsilateral to the dominant follicle is greater than that in the contralateral side. It is possible to speculate that this difference is related to the hormonal production of the dominant follicle.

Effects of vaginal progesterone on pain and uterine contractility in patients with threatened abortion before twelve weeks of pregnancy.

Fifty women with previous diagnosis of inadequate luteal phase and threatened abortion underwent a prospective, randomized, double-blind study in one medical center carried out with a parallel trial. The primary objective was to establish the effects of vaginal progesterone (Crinone 8%) in reducing both pain and uterine contractions (UCs). The gel with or without (placebo) vaginal progesterone was administered once a day since the diagnosis of threatened abortion and for 5 days. The efficacy on pain symptom amelioration was evaluated by a 5-score intensity gradation, while the UCs were evaluated by ultrasound. The secondary objective of the study was to evaluate the outcome of the pregnancies. The use of progesterone was effective both on pain relief and on the frequency of the UCs that decreased after 5 days of vaginal progesterone administration (P < 0.005). The evaluation of the ongoing pregnancy and spontaneous abortion in both study groups after 60 days showed that 4 patients of group A and 8 patients of group B miscarried (P < 0.05). In conclusion, patients with threatened abortion benefit from vaginal progesterone by a reduction of UCs and pain. The use of vaginal progesterone improved the outcome of pregnancies complicated by threatened abortion and previous diagnosis of inadequate luteal phase.

Uterine first pass effect in postmenopausal women.

BACKGROUND: Vaginally administered drugs distribute preferentially to the uterus; counter-current transfer from the vaginal veins to the uterine artery probably plays a pivotal role. In each side, the ovarian and uterine arteries form arterial anastomoses and controversy exists regarding the origin of the arterial supply to the Fallopian tube and tubal part of the uterus, and consequently whether these tissues can be reached through vaginal administration. METHODS: A thermocatheter with four measurement points, each separated by 5 mm, was inserted under endoscopic control into the tubal corner of uterus in 10 conscious, menopausal women and the temperatures registered every 2 s. The vagina was then flushed for 15 min with 1.5 l of saline at room temperature, after which the probe position was re-assessed by the endoscope. RESULTS: The lowest measurement point (15 mm from the tip) cooled significantly more than the other points (P < 0.0001). At 15 min, mean temperature reduction at point 4 was significantly greater than at all other measurement points (P < 0.05) due to local transfer of cold from vaginal vein blood to the uterine arterial blood (but not the ovarian artery). CONCLUSIONS: The results support the theory that, at least in postmenopausal women, the uterine artery supplies most of the uterus while the corneal part of cavity (up to 5-10 mm from the ostium) receives the blood supply from the ovarian artery. This finding represents a rationale for vaginal administration of drugs when a local effect on the uterus (e.g. progestational or relaxation) in postmenopausal women is requested.

Absorption and preferential vagina-to-uterus distribution after vaginal administration of (99m)Tc-pertechnetate in postmenopausal women.

OBJECTIVE: To investigate in vivo and in humans the mechanisms and kinetics of vagina-to-uterus distribution. DESIGN: Controlled clinical study. SETTING: Volunteers in an academic research environment. PATIENT(S): Six postmenopausal women undergoing transabdominal hysterectomy were selected. INTERVENTION(S): Women received 0.2 mL of (99m)Tc-pertechnetate vaginally. In three patients the cervical canal was previously sealed by means of surgical glue. Six postmenopausal women who had received (99m)Tc-pertechnetate intravenously for a thyroid scintigraphy were considered as a control. MAIN OUTCOME MEASURE(S): Radioactivity was assessed every 30 minutes for 6 hours in the pelvis and in body regions where (99m)Tc-pertechnetate normally accumulates (thyroid, salivary glands, and stomach). RESULT(S): Uterine activity appeared after 60 minutes and peaked between 120 to 210 minutes. These same times were observed in the patients who had a sealed cervix. Thyroid uptake appeared after 180 minutes and peaked between 210 and 330 minutes. Uterine uptake did not occur in any of the intravenous patients; their thyroid uptake was rapid, appearing after 30 minutes. CONCLUSION(S): Preferential vagina-to-uterus distribution, at least in postmenopausal women, is not simply due an intracanalicular passage but is mediated by absorption of substances and probably by a countercurrent transfer mechanism.

Model of counter-current transfer from vagina to urethra in postmenopausal women.

BACKGROUND: Low-dose vaginal oestrogens are effective in treating post-menopausal urogenital atrophy without inducing endometrial proliferation. We aimed to assess whether this dichotomic effect could be the result of a preferential vagina-to-urethra transfer via a counter-current transfer of oestrogens from vagina to the arterial blood supplying the urethra. Due to the impossibility of obtaining blood samples from urethral arteries, and since the nature of counter-current exchange of substances is similar to the transfer of heat, we investigated cold transfer throughout the anterior vaginal wall to the vesical trigone and urethra. METHODS: Plastic tubes filled with cold saline were inserted into the vagina of 30 menopausal women. Temperatures were recorded at the vesical trigone and at three different urethral sites. Comparisons were performed 2 and 4.5 min after starting of cooling, and 4.5 min after removal of tubes. RESULTS: The urethra cooled significantly more than the bladder. Urethral cooling was not homogeneous; distal sites of the urethra cooled significantly more than proximal site and bladder despite a larger distance to the vaginal cooling device. CONCLUSIONS: Distribution of cold from the vagina to the urethra is not the result of simple diffusion and mechanisms of preferential distribution may exist from the vagina to the middle and low part of the urethra.

Endometriosis: absence of recurrence in patients after endometrial ablation.

BACKGROUND: The present study was undertaken to evaluate differences between patients with and without eutopic endometrium in the recurrence of ectopic endometriotic implants. METHODS: Endometrial ablation (EA) was carried out in 14 women out of 28 laparoscopically treated for endometriosis and recurrence of the disease was evaluated 24 months later. Data were compared using paired Student's t-test and chi2 test. RESULTS: Patients undergoing EA procedures did not exhibit recurrence of endometriosis while nine patients without that procedure had recurrence of the disease (P < 0.001). The endometrial cells found in the debris of the cul de sac of eight patients who did not undergo EA were both stromal and epithelial cells. No blood or blood cells were found in the cul de sac of patients undergoing EA. CONCLUSIONS: The present study supports a role of eutopic endometrium in the recurrence of endometriosis through tubal dissemination of endometrial debris and implantation of endometrial cells into the abdomen.

Tolerability of the mini-pan-endoscopic approach (transvaginal hydrolaparoscopy and minihysteroscopy) versus hysterosalpingography in an outpatient infertility investigation.

OBJECTIVE: To compare the acceptance and tolerability of the mini-pan-endoscopic approach (transvaginal hydrolaparoscopy [THL] combined with minihysteroscopy) versus hysterosalpingography (HSG) for evaluating tubal patency and the uterine cavity in an outpatient infertility investigation. DESIGN: Randomized controlled study. SETTING: University hospital. PATIENT(S): Twenty-three infertile patients without obvious pelvic pathology. INTERVENTION(S): Women were randomly divided into two groups. One group underwent minihysteroscopy and THL with tube chromoperturbation as first investigation and HSG within the following 7 days, while in the other group the investigation sequence was inverted. Women reported pain experienced before and at the end of procedures. MAIN OUTCOME MEASURE(S): Mean duration of procedures, level of pain experienced, diagnostic agreement about tubal patency and uterine cavity normality. RESULT(S): THL and minihysteroscopy took significantly more time but was significantly less painful than HSG. Regarding tubal patency, in 95.5% of cases THL agreed with HSG. In one case, HSG diagnosed a bilateral obstruction of tubes, whereas at THL a bilateral spreading of methylene blue was seen. Agreement on intrauterine pathologies between minihysteroscopy and HSG was poor (43%); the number of intrauterine abnormalities found at hysteroscopy was significantly greater than at HSG. CONCLUSION(S): THL in association with minihysteroscopy provided more information and was better tolerated than HSG in an outpatient infertility investigation.