A new technique for the diagnosis of fallopian tube patency by using hysteroscopy with ultrasound compared with hysterosalpingography in infertile women.

PURPOSE: To evaluate the effectiveness of hysteroscopy as a method for the diagnosis of tubal patency using saline distention media. METHODS: In this prospective study, 62 women between 21 and 38 years with a history of at least 1 year of infertility who underwent hysteroscopy and hysterosalpingography (HSG) on two consecutive cycles were studied. Transvaginal ultrasonography carried out before and after hysteroscopy in order to measure the abdominal fluid (in ml) in the peritoneal cavity of the cul-de-sac. The difference between the two results was calculated. A next cycle HSG was performed and patients were divided into three groups according to whether there was no tubal occlusion (group 1), a unilateral occlusion (group 2) or a bilateral occlusion (group 3): Peritoneal fluid measurements were compared among the three groups. Finally, pain and discomfort were recorded at the end of the process. RESULTS: According to the HSG, 34 women were in group 1, 13 in group 2 and 9 in group 3. Peritoneal fluid measurements were 6.88 +/- 2.7 ml in group 1, 4.21 +/- 0.9 ml in group 2 and 1.08 +/- 0.7 ml in group 3. Statistical differences were found between groups 1 and 3 and between groups 2 and 3 (P < 0.05). All of the patients reported significantly less pain during hysteroscopy in response to HSG. CONCLUSIONS: Using saline distension media during hysteroscopic evaluation was effective to allow measurement of the accumulating fluid in the peritoneal cavity and to confirm at least one patent tube with minimal pain.

Assessment of reproductive ageing patterns by hormonal and ultrasonographic ovarian reserve tests.

BACKGROUND: Tests to assess the change in ovarian reserve (OR) with age have been analysed only in monophasic or biphasic linear patterns. Our aim was to analyse an optimum curve that might define the relationship between different OR tests and age. METHODS: A total of 81 regularly menstruating women without a history of infertility were included in this prospective study. On cycle day 3, antral follicle (AF) counts, ovarian volume (OV), and serum FSH and estradiol levels were determined. Curve estimation was performed to determine the optimal relationship between age and OR tests. Optimum curves were also compared with monophasic and biphasic linear relationships. RESULTS: A quadratic model (y=a x x2+b x x+c) had the highest coefficient of determination for the AF count, OV and serum FSH level. The predictive power of this quadratic model was comparable with biphasic linear models for the OV and serum FSH level, but was better than that of the AF count. CONCLUSIONS: The pattern of reproductive ageing as assessed by hormonal and ultrasonographic OR tests does not appear to show an abrupt change at a certain age, but follows a continuously increasing rate of decline in the third decade of life. The changes in serum FSH levels and ultrasonographic OR tests follow a quadratic model in regularly menstruating women.

Recurrence rate of hirsutism after 3 different antiandrogen therapies.

BACKGROUND: Although antiandrogens are frequently and successfully used to treat hirsutism, little attention has been paid to optimal duration of treatment and recurrence rate after cessation of therapy. OBJECTIVE: Our purpose was to determine the recurrence rate of hirsutism after 3 different antiandrogen therapies. METHODS: Eighty-one hirsute women referred to a tertiary hirsutism clinic were assigned to one of three regimens: spironolactone 100 mg/day with an oral contraceptive, cyproterone acetate 50 mg/day on days 1 to 10 with an oral contraceptive, or flutamide 250 mg twice a day. Hirsutism scores according to the Ferriman-Gallwey scoring system and endocrine parameters were evaluated before, during, and 1 year after withdrawal of treatment regimens. RESULTS: Hirsutism scores decreased significantly and similarly in spironolactone, flutamide, and cyproterone acetate treatment groups. However, 1 year after withdrawal of treatment in all antiandrogen therapy groups, hirsutism returned. CONCLUSION: Antiandrogens are effective in the treatment of hirsutism. However, cessation of antiandrogen therapy is followed by recurrence.

Effect of initial gestagen treatment on bleeding patterns in postmenopausal women receiving continuous combined hormone replacement therapy.

OBJECTIVE: The purpose of this prospective study was to investigate the association of initial gestagen treatment with future breakthrough bleedings during continuous combined hormone replacement therapy. The predictability of progesterone challenge test on bleeding has also been investigated. DESIGN: Eighty-six naturally postmenopausal women, of whom 38 received initial gestagen treatment (5 mg medroxyprogesterone acetate, twice daily, for 10 days) and 48 did not, were included in this prospective study. Patients were followed for 6 months, and any bleeding occurring during therapy was recorded. RESULTS: Of the 48 patients who received continuous combined hormone replacement therapy without initial gestagen treatment, 23 (48%) had a bleeding episode. Of the 38 patients who received the same therapy with initial gestagen treatment, 13 (34.2%) had bleeding. There was a trend toward decreased breakthrough bleeding in the second group, which did not achieve significance. The mean time before bleeding was 6.76 weeks in the first group and 11.75 weeks in the second group; the difference was statistically significant (p < 0.05). Of the 28 patients with a negative progesterone challenge test at the onset of therapy, eight (28.6%) had bleeding during hormone replacement therapy. Of the 10 patients with a positive challenge, five (50%) had bleeding. The difference was not statistically significant. CONCLUSIONS: Patients who receive gestagen treatment before the onset of continuous combined hormone replacement therapy tend to experience breakthrough bleeding less frequently and later during the therapy. The response to progesterone challenge does not predict future bleeding during continuous combined hormone replacement therapy.

Endometrial disease diagnosed by transvaginal ultrasound and dilatation and curettage.

BACKGROUND: This study is designed to compare endometrial thickness measured by transvaginal ultrasound with endometrial pathology by dilatation and curettage. METHODS: Fifty-four women with postmenopausal bleeding were evaluated. Endometrial thickness, including both layers of the endometrium, was measured by transvaginal ultrasound after which fractional curettage was performed and samples taken were then dispatched for histologic examination. RESULTS: Median endometrial thicknesses of 5 mm, 8.5 mm and 6 mm were found for benign, hyperplastic and carcinomatous endometrium, respectively. Of the eight hyperplastic samples, two cases had 4 mm, and one case had 3mm endometrial thickness. Similarly, of the nine malignant samples, three cases had an endometrial thickness of 3 mm. Three mm has been found to be the best cut off point for endometrial abnormalities in postmenopausal bleeding with 100% sensitivity but low specificity (13%). CONCLUSION: Fractional curettage seems to be the best method for detecting endometrial abnormalities in women with postmenopausal bleeding.

Comparison of finasteride versus spironolactone in the treatment of idiopathic hirsutism.

OBJECTIVE: To compare the efficacy of finasteride and spironolactone in the treatment of idiopathic hirsutism. DESIGN: Prospective, randomized, single-blind study. SETTING: A tertiary hirsutism clinic. PATIENT(S): Forty women with idiopathic hirsutism were selected. INTERVENTION(S): Patients were assigned randomly to receive either 5 mg of finasteride or 100 mg of spironolactone for 9 months. MAIN OUTCOME MEASURE(S): Hirsutism scores were measured according to the Ferriman-Gallwey scoring system, and side effects were monitored for 9 months of treatment. Blood samples were taken at each visit for assessment of endocrine, biochemical, and hematologic parameters. RESULT(S): Hirsutism scores were decreased significantly in both groups at the end of 9 months. The mean percent change (+/- SD) in hirsutism scores in the finasteride and spironolactone groups was as follows: 5.91% +/- 7.18% and 20.60% +/- 12.59% at 3 months, 10.61% +/- 12.18% and 32.57% +/- 15.68% at 6 months, and 15.15% +/- 15.38% and 42.36% +/- 12.31% at 9 months, respectively. There was a significantly better response with spironolactone treatment at the end of 9 months. Eleven (55%) of 20 patients in the spironolactone group experienced side effects. However, none of them stopped treatment because of side effects. CONCLUSION(S): The present data suggest that both finasteride and spironolactone are effective in the treatment of idiopathic hirsutism. However, it appears that the spironolactone group responded significantly better.

Comparison of spironolactone-oral contraceptive versus cyproterone acetate-estrogen regimens in the treatment of hirsutism.

OBJECTIVE: To compare the efficacy of two antiandrogens, cyproterone acetate (CPA) and spironolactone, in the treatment of hirsutism. DESIGN: Prospective randomized single-blinded study. SETTING: A tertiary hirsutism clinic. PATIENTS: Forty-two premenopausal patients with hirsutism were selected. INTERVENTIONS: Subjects were randomized to receive either 100 mg spironolactone and an oral contraceptive (OC) containing 150 microg desogestrel and 30 microg ethinyl E2 or 50 mg CPA daily on days 1 to 10 of the menstrual cycle, which was administered with 35 microg ethinyl E2 daily on days 1 to 21. MAIN OUTCOME MEASURES: Hirsutism scores were measured according to Ferriman-Gallwey scoring system and side effects were monitored for 9 months of treatment. Blood samples were taken at each visit for assessment of endocrine, biochemical, and hematologic parameters. RESULTS: Hirsutism scores were decreaded significantly in both groups at the end of 9 months. The percent of change in hirsutism scores in CPA and spironolactone group were as follows: 19.23% +/- 14.77% and 24.48% +/- 14.27% at 3 months; 39.01% +/- 19.77% and 37.46% +/- 16.90% at 6 months; and 51.89% +/- 20.87% and 46.39% +/- 16.10% at 9 months, respectively. There was a trend toward a better response with CPA treatment, which did not achieve significance. None of the patients stopped treatment because of side effects. CONCLUSION: The present data suggest that both spironolactone and CPA were similarly effective in treatment of hirsutism.

PIP: The authors compared the efficacy of two antiandrogens, cyproterone acetate (CPA) and spironolactone, in the treatment of hirsutism. 42 premenopausal patients with hirsutism were randomized to receive either 100 mg spironolactone and an oral contraceptive (OC) containing 150 mcg desogestrel and 30 mcg ethinyl E2 or 50 mg CPA daily on the first 10 days of the menstrual cycle, which was administered with 35 mcg ethinyl E2 daily for the first 21 days. Hirsutism scores were measured according to the Ferriman-Gallwey scoring system and side effects monitored for nine months of treatment. Blood samples were taken at each visit to assess endocrine, biochemical, and hematologic parameters. Hirsutism scores were significantly lower in both groups at the end of nine months. The percent of change in hirsutism scores in the CPA and spironolactone groups were as follows: 19.23% and 24.48% at 3 months, 39.01% and 37.46% at 6 months, and 51.89% and 46.39% at 9 months, respectively. The trend toward a better response with CPA treatment was insignificant. No patient stopped treatment because of side effects.

Comparison of the efficacy of spironolactone versus flutamide in the treatment of hirsutism.

OBJECTIVE: To compare the efficacy of two antiandrogens, spironolactone and flutamide, in the treatment of hirsutism. PATIENTS, PARTICIPANTS: Twenty women with idiopathic hirsutism were randomized to receive either flutamide or spironolactone. DESIGN: Twenty hirsute women were recruited from patients presenting to the hirsutism clinic in Marmara University, Istanbul. Each patient underwent a complete medical and gynecological examination as well as endocrine profile, hematologic, hepatic, and renal function analyses. Hirsutism scores were determined according to the Ferriman-Gallwey scoring system. These tests were then repeated at 3, 6, and 9 months of therapy. Ten patients received 250 mg of flutamide two times per day, and 10 patients received 100 mg of spironolactone for 9 months. RESULTS: Ferriman-Gallwey scores were decreased significantly in both groups at the end of 9 months. The percent of change in hirsutism scores in flutamide and spironolactone group were as follows: 26.4% and 20.9% at 3 months; 39.5% and 32.9% at 6 months; and 46.4% and 39.6% at 9 months, respectively. There was a trend toward a better response with flutamide that did not achieve significance. None of the hormonal parameters changed significantly during this period of time. Irregular bleeding was observed in five patients (50%) of the spironolactone group, whereas none of the patients in the flutamide group experienced menstrual irregularity. Conversely, dry skin and increased appetite were experienced by two patients (20%) in the flutamide group but not in the spironolactone group. CONCLUSION: These data suggest that both spironolactone and flutamide were similarly effective in treatment of hirsutism, and the pure antiandrogen flutamide is a safe and effective alternative in treatment.

Evaluation of tubal patency by transvaginal sonosalpingography.

OBJECTIVE: To evaluate tubal patency by transvaginal sonosalpingography. DESIGN: Comparative study of transvaginal sonosalpingography with chromolaparoscopy in subjects with unknown tubal function. SETTING: Outpatient infertility clinic at Zeynep Kamil Maternity Hospital in Istanbul, Turkey. PATIENTS: Forty-two cases of unknown tubal function with infertility complaints were included. INTERVENTIONS: Isotonic saline was injected into the uterine cavity through a catheter. MAIN OUTCOME MEASURES: Transvaginal sonosalpingography is a safe, easy, and cost-effective procedure for screening tubal status. RESULTS: The results obtained from transvaginal sonosalpingography and laparoscopy were completely consistent for 29 cases (76.32%) and partially consistent for 8 cases (21.05%). Transvaginal sonosalpingography accurately showed patency in 26 patients and bilateral nonpatency in 3 patients. CONCLUSIONS: Transvaginal sonosalpingography, with its accuracy and safety, is a promising screening and diagnostic technique in the evaluation of tubal patency on ambulatory basis.

Laparoscopic cautery in the treatment of endometriosis-related infertility.

Life table analysis and the two-parameter exponential method have been applied to pregnancy rates in 72 patients undergoing laparoscopic cautery exclusively. Patients with male factor infertility were excluded. Estimated cure rates for patients with stage I and II disease were 98.2% and 76.6%, respectively (not significantly different). No significant difference was seen when anovulation complicated the endometriosis (68.6%). When greater than one infertility factor was present, a significant difference was observed (50.6%). Patients with stage I disease had an average fecundity of 10.30% with decreasing values observed in stage II (7.59%), anovulation (6.67%), and more than one infertility factor (3.33%). We conclude that laparoscopic cauterization is an effective mode of therapy for the treatment of stage I and II endometriosis associated with infertility.