Novasure impedance control system versus microwave endometrial ablation for the treatment of dysfunctional uterine bleeding: a double-blind, randomized controlled trial.

PURPOSE OF INVESTIGATION: To compare the efficacy and safety of two different second-generation ablation devices, Novasure impedance control system and microwave endometrial ablation (MEA), in cases of abnormal uterine bleeding (AUB). MATERIALS AND METHODS: This is a randomized controlled trial that took place in a single Gynecological Department of a University Hospital. Sixty-six women with dysfunctional uterine bleeding (DUB), unresponsive to medical treatment, were included in the trial. The ratio of women allocated to bipolar radio-frequency ablation or MEA was 1:1. Follow-up assessments were carried out at three and 12 months post-ablation. The present main outcome measure was amenorrhea rates 12-months post-treatment. RESULTS: The rate of amenorrhea at 12-months post-ablation was significantly higher in women treated by Novasure (25/33; 75.8%) as compared to those treated by MEA (8/33; 24.2%) (rate difference: +51.5%, 95% CI: +27.8 to +67.7). CONCLUSION: In women with DUB, endometrial ablation with Novasure bipolar radiofrequency impedance-controlled system is associated with increased rates of amenorrhea at 12-months post-treatment as compared to the MEA method.

The role of hysteroscopy in the current management of the cervical polyps.

The current management of patients with cervical polyps may include different approaches and protocols, such as a simply removal of the polyp in most cases at an office setting, surgical dilatation and curettage, electrosurgical excision or hysteroscopic polypectomy. Exploration of the cervical canal and uterine cavity by hysteroscopy determines the exact origin of the polyp pedicle (cervical or endometrial) and if there is any concurrent endometrial pathology. The majority of cervical polyps are asymptomatic, and their incidence is increasing with age. Symptomatic cervical polyps may cause intermenstrual bleeding, postcoital bleeding, heavy menses, postmenopausal bleeding and vaginal discharge. Cervical polyps may be detected by routine gynaecological examination, colposcopy, filling defects on hysterosalpingogram, gynaecological ultrasound (abdominal, transvaginal or sonohysterography) or endometrial biopsy. The location, number, and size of cervical polyps are best determined with diagnostic hysteroscopy. In the past, simple twisting or avulsion of the polyp or blind curettage was the standard surgical treatment of choice. However, this treatment often leaves residual polyp fragments in the cervical canal. Difficulty may also occur in differentiating endocervical from endometrial lesions. In addition, up to 25% of patients who have cervical polyp, have also a coexisting endometrial polyp, so there is a need for evaluation of the endometrial cavity. It is important to note the usefulness of hysteroscopy to manage a patient with a cervical polyp, especially when she presents abnormal uterine bleeding, in order to make an accurate diagnosis and offer appropriate treatment.

Results after hysteroscopic management of premenopausal patients with dysfunctional uterine bleeding or intrauterine lesions.

AIM: The purpose of this study was to evaluate the efficacy, safety and benefits of hysteroscopic surgery in the management of dysfunctional uterine bleeding or intrauterine lesions causing menstrual disorders in premenopausal women. METHODS: We enrolled in this study 228 patients who underwent operative hysteroscopy because of metrorrhagia due to endometrial polyps or submucous myomas diagnosed by hysterosalpingography, transvaginal ultrasound and diagnostic hysteroscopy. In addition, the study population included 27 patients who presented dysfunctional uterine bleeding resistant to medical therapy. These patients underwent total or partial transcervical resection of endometrium (TCRE). RESULTS: Operative hysteroscopy was a successful procedure in 250 of the 255 cases (98%) but it needed to be repeated in three cases with large submucous myomas of type I and II and after two polypectomies. Mean duration of the procedure was 26.1 min (range 4-58) and mean postoperative hospital stay was six hours (range 2-48 hours). There were two cases with fluid overload and five with postoperative uterine bleeding reported in this study. During postoperative follow-up (12-36 months) the majority of patients (246/255 or 96.5%) were free of symptoms. After total or partial TCRE, 23/27 patients (85.2%) reported eumenorrhea or hypomenorrhea, 2/27 (7.4%) amenorrhea and 2/27 (7.4%) metrorrhagia (due to adenomyosis). CONCLUSION: Hysteroscopic surgery is an effective and safe method for the management of benign intracavitary pathology or the treatment of dysfunctional uterine bleeding. In addition, it has the advantages of quick recovery, early return to normal activities and reduced hospital stay for the patient. Careful monitoring of the patients avoids serious complications.

The up-to-date evidence on colposcopy practice and treatment of cervical intraepithelial neoplasia: the Cochrane colposcopy & cervical cytopathology collaborative group (C5 group) approach.

This overview presents the up-to-date evidence on colposcopy practice and other diagnostic modalities such as HPV DNA test and cytology for cervical intraepithelial neoplasia (CIN). Current evidence supports the use of colposcopy for the detection of intraepithelial lesions as a second line tool. CIN treatment involves either excisional or destructive techniques, usually performed under local anesthesia. Although a debate exists about the most efficient approach, the currently available evidence reveals no differences in efficacy among the available conservative methods of treatment. New evidence supports treatment by destructive rather than excisional techniques, at least for low grade lesions in women wishing future childbearing, as they appear to have no apparent pregnancy-related morbidity. Treatment failures rates might increase in cases of involved excision margins, older age or glandular involvement. There is no worldwide consensus on the optimal follow-up policy, interventions or frequency in surveillance after treatment. HPV DNA test combined with either colposcopy or cytology is a promising combination for the early detection of treatment failures due to residual disease. Existing guidelines should probably be updated incorporating the new information emerged from recently published work.

Ovarian cancer screening.

PURPOSE: This review presents the current knowledge on ovarian cancer screening (OCS) together with a cumulative evaluation of the efficacy across diverse screening approaches based on up-to-date results. MATERIALS AND METHODS: An electronic literature search was conducted targeting reports on the effectiveness of the various screening strategies. RESULTS: Twenty-two prospective studies, 18 cohorts and 4 randomised control trials (RCTs) were retrieved. Where possible, sensitivity, specificity and predictive values, as well as the number needed to treat for each cancer (NNT) and each stage I disease [NNT (I)] detected are reported. CONCLUSION: The multimodal approach that incorporates CA125 as a primary and ultrasound as a secondary test appears to be superior to other strategies. However, the conclusive end-point that would provide the acceptable level of evidence for the introduction of screening should be a reduction in mortality. Up-to-date, there is no such evidence to justify this.

Results on the treatment of uterine cervix cancer: ten years experience.

The aim of the study is to present our experience in the treatment of uterine cervix cancer over the last decade. This is a retrospective study of 90 patients with cervical cancer treated in a University Department of Obstetrics and Gynecology from 1993 to 2002. After the disease was histologically confirmed and staged the patients were treated according to stage with surgery (S) radiotherapy (RT), RT alone or Chemoradiaton (C-RT). The course of the disease and follow-up was traced from patient notes and after a structured telephone questionnaire. Mean age of patients was 48 +/- 14.3 years (29-84). Nine of 90 patients (10%) were lost to follow-up. FIGO (1994) staging was I in 50% of patients, II in 33.5%, III in 13.5% and IV in 3%. The size of tumor was < or = 4 cm in 75%. Of the tumors 87% were of squamous histology and 13% adenocarcinomas. Patients were treated with cone biopsy (5.5%), type I hysterectomy pelvic RT (10%), radical (type II-III) hysterectomy and pelvic lymphadenectomy +/- radiotherapy (41%), RT alone in 38% and C-RT in 5.5%. Incidence of complications after surgery was 19.5% and after RT 12.5%. Mean follow-up was 41 +/- 19 months (6-110). Five-year survival in Stage I was 84%, Stage II 64% and Stage III 40%. A single patient with Stage IV disease is alive with disease after two years. In conclusion uterine cervical cancer has improved survival because of early diagnosis. Treatment should be individualized according to the status of disease. Surgery and RT had similar rates of complications.

Endometriotic uterocutaneous fistula after cesarean section. A case report.

Endometriosis outside the pelvis is rare and most cases occur in surgical scars after operations involving the female genital tract. Fistulae involving the uterus are also very rare, usually being the result of postpartum and postoperative complications. In the present report, a case of a 44-year-old patient with an endometriotic uterocutaneous fistula is described. The patient presented 6 years after her fourth cesarean section with a painful nodule on the cesarean scar, which was bleeding during menstruation. The lesion extended to the uterine fundus, connecting the endometrial cavity with the skin. This is merely the second case of a uterocutaneous fistula to be reported in the literature and the first case developed on grounds of endometriosis.

Surgical management of early stage cervical cancer: ten years experience from one Greek health region.

PURPOSE OF INVESTIGATION: Cervical cancer is the second most common malignancy in women, in both incidence and mortality. In the present study, we report our results of treating 93 consecutive patients with early invasive cervical cancers (Stages I-IIA). METHODS: The patients of this study comprised all women recognized with stage I-IIA cervical cancer during 1991-2000. Patients with stage IA1 cervical cancer without lymphvascular space involvement underwent either conservative management by means of large loop conization or simple hysterectomy. The remaining patients underwent radical hysterectomy and lymphadenectomy or radiation therapy. Mean (+/- SD) duration of follow-up was 6 (+/- 1.7) years. RESULTS: The mean (+/- SD) age of patients with stage I-IIA cervical cancer was 41.3 (+/- 9.1) year. Thirty-five patients with stage [A1 disease were managed conservatively with loop excision and 19 patients subsequently became pregnant. Fifty-two patients with stage IA2, IB and IIA cervical carcinoma underwent radical hysterectomy and lymphadenectomy. CONCLUSION: Young women with stage IA1 cervical carcinoma wishing future fertility who undergo loop excision have a 100% cure rate. Women with stage IA2, IB, and IIA cervical cancer should undergo radical hysterectomy and lymphadenectomy or radiation therapy.

Outcomes of carbon dioxide laser conization for the treatment of cervical intraepithelial neoplasia grade III.

PURPOSE: The aim of this study was to determine the rates of incomplete excision of cervical intraepithelial neoplasia (CIN) III after carbon dioxide laser conization, and the risk of reappearance of CIN depending on the excision margins. METHODS: A total of 153 women who underwent carbon dioxide laser conization for CIN III between 1988 and 1998 at our hospitals were eligible for inclusion in the study and their notes were retrospectively studied. RESULTS: Histological examination of the excision margins revealed complete excision in 134 (87.6%), uncertain margins in one, and extension of CIN to the margins in 18 (11.8%) cases. The treatment failure rate in the cases with clear margins was 2.2% (3 of 134), and in the cases with involved margins 44.4% (8 of 18) (p < .001). CONCLUSION: Carbon dioxide laser conization despite the worldwide use of LLETZ still has a place in the treatment of CIN. Very high rates of complete excision were achieved. As incomplete excision does not always result in treatment failure, neither do clear margins always indicate eradication of the disease.

The influence of long-term administration of conjugated estrogens and antiandrogens to serum leptin levels in women with polycystic ovary syndrome.

It is well known that a strong exponential relationship exists between leptin levels and body mass index (BMI). The different serum leptin levels, however, that are observed for each BMI value, suggest that other factors, as well, interfere with leptin secretion. This study was designed in order to estimate serum leptin levels in patients with polycystic ovary syndrome (PCOS), before and after long-term treatment with conjugated estrogens and antiandrogens. Sixteen women with PCOS were included in the study. They were divided into two groups: the first group comprised 11 non-obese women (BMI 21.6 +/- 0.5 kg/m2), aged 23.5 +/- 1.1 years; the second consisted of five obese women (BMI 28.9 +/- 1.5 kg/m2), aged 22.8 +/- 1.9 years. Blood samples for leptin measurement were drawn before and 2, 4, 6, 9 and 12 months after administration of conjugated estrogens and antiandrogens. Our results showed that obese women exhibited higher serum leptin levels in all blood samples. Moreover, the administration of conjugated estrogens and antiandrogens caused an increase in serum leptin levels in the 2nd, 4th, 6th and 9th month in both groups of women. Finally, leptin concentrations during the 12th month of the treatment returned to basic levels in both groups of women with PCOS. Our results support the view that BMI is the main variable that influences serum leptin levels, and that the effect of conjugated estrogens and antiandrogens on serum leptin concentrations is poor.

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.

Experience with the MLCu250 IUD.

One thousand and thirty eight patients were fitted with MLCu250 IUDs over a six year period. The women were divided into three groups: group A, 224 women in whom the IUD was inserted postpartum; group B, 352 patients who had the IUD inserted immediately after an abortion; and group C, 462 women in whom insertions were performed at the end of menstruation. All women were followed up every six months for up to 24 months. All women experienced good contraceptive effects. The mean unexpected pregnancy rate was 2.1% (group A = 2.6%, group B = 2.0% and group C = 1.7%). The mean expulsion rate was 1.8% (group A = 2.2%, group B = 2.0% and group C = 1.3%). The bleeding-pain symptom was apparent in 5.5%. The mean rate for planning pregnancy was 3.8%. Removals for medical and personal reasons were 3.6% and 1.9% respectively. The continuation rate was considered very satisfactory (mean value 78.5%, group A = 76%, group B = 77.6% and group C = 82%). In the present study no perforations or ectopic pregnancies occurred.