c-Fos expression after neonatal handling in social brain regions: Distinctive profile of RHA-rat schizophrenia model on a social preference test.

Neonatal handling (NH) is an environmental manipulation that induces long-lasting changes in behavioural, neuroendocrine, and neuroanatomical processes in rodents. We have previously reported that NH treatment increases social interaction preference in an animal model of schizophrenia-relevant features, the Roman high-avoidance (RHA) rats. The present study was aimed at evaluating whether the increase of social behaviour/preference due to NH treatment in RHA rats is associated with differences in c-Fos expression levels in some of the brain areas that integrate the "social brain". To this aim, we evaluated the performance of adult male rats from both Roman rat strains (RHA vs. RLA -Roman low-avoidance- rats), either untreated (control) or treated with NH (administered during the first 21 days of life) in a social interaction task. For the analyses of c-Fos activation untreated and NH-treated animals were divided into three different experimental conditions: undisturbed home cage controls (HC); rats exposed to the testing set-up context (CTX); and rats exposed to a social interaction (SI) test. It was found that, compared with their RLA counterparts, NH treatment increased social behaviour in RHA rats, and also specifically enhanced c-Fos expression in RHA rats tested for SI in some brain areas related to social behaviour, i.e. the infralimbic cortex (IL) and the medial posterodorsal amygdala (MePD) regions.

Surgical versus medical treatment for endometriosis-associated severe deep dyspareunia: I. Effect on pain during intercourse and patient satisfaction.

STUDY QUESTION: Does surgical or medical treatment for endometriosis-associated severe deep dyspareunia achieve better results in terms of patients' satisfaction (main study outcome), variation of coital pain and frequency of intercourse? SUMMARY ANSWER: Surgery and progestin therapy were equally effective in the treatment of deep dyspareunia in women with rectovaginal endometriosis, whereas medical therapy performed significantly better than excisional treatment in those without deeply infiltrating lesions. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: Conservative surgery and hormonal therapies have been used independently for endometriosis-associated deep dyspareunia with inconsistent results. This study reports a direct comparison between the two treatment options in women with severe pain during intercourse. DESIGN: Patient preference, parallel cohort study with a 12-month follow-up. The effect of conservative surgery at laparoscopy was compared with treatment with a low-dose of norethisterone acetate per os (2.5 mg/day) in women with persistent/recurrent severe deep dyspareunia after first-line surgery. PARTICIPANTS AND SETTING: A total of 51 patients chose repeat surgery and 103 progestin treatment. Patient satisfaction was graded according to a five-category scale. Variations in pain during intercourse were measured by means of a 100-mm visual analogue scale. MAIN RESULTS AND THE ROLE OF CHANCE: In the surgery group, a marked and rapid short-term dyspareunia score reduction was observed, followed by partial recurrence of pain. The pain relief effect of the progestin was more gradual, but progressive throughout the study period. At a 12-month follow-up, the frequency of intercourse per month (mean ± SD) was 4.6 ± 1.8 in the surgery group and 5.3 ± 1.5 in the norethisterone acetate group (P = 0.02). A total of 22/51 (43%) women were satisfied in the surgery group compared with 61/103 (59%) in the progestin group [adjusted odds ratios (OR), 0.36; 95% confidence interval (CI), 0.16-0.82; P = 0.015]. Corresponding figures in women with and without rectovaginal endometriotic lesions were, respectively, 13/24 (54%) versus 18/35 (51%; adjusted OR, 0.77; 95% CI, 0.22-2.67; P = 0.68), and 9/27 (33%) versus 43/68 (63%; adjusted OR, 0.23; 95% CI, 0.07-0.76, P = 0.02). BIAS, CONFOUNDING, AND OTHER REASONS FOR CAUTION: Treatments were not randomly assigned, and distribution of participants as well as of dropouts between study arms was unbalanced. However, the possibility of choosing the treatment allowed assessment of the maximum potential effect size of the interventions. GENERALIZABILITY TO OTHER POPULATIONS: Caucasian patients able to choose their treatment. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by a research grant from the University of Milan School of Medicine (PUR number 2009-ATE-0570). None of the authors have a conflict of interest.

Gynecological endoscopy for symptomatic endometriosis.

The best available evidence on surgery for endometriosis-associated pain has been reviewed in order to define the benefit of various interventions in the most frequently encountered clinical conditions, and discuss the robustness of the reported data in light of the quality of the relevant study design. Methodological drawbacks limit the validity of observational, non-comparative studies on the effect of laparoscopy for stage I to IV disease. The results of three randomized, controlled trials, indicate that the absolute benefit increase of destruction of lesions compared with sham operation in terms of proportion of women reporting pain relief was between 30% and 40% after short follow-up periods. The effect size decreased with time and the reoperation rate, based on long-term follow-up studies, was as high as 50%. In most case series on excisional surgery for rectovaginal endometriosis, substantial short-term pain relief was experienced by about 70-80% of the subjects who continued the study. However, at one-year follow-up approximately 50% of the women needed medical treatments. Major complications were observed in 3-10% of the patients. Medium-term recurrence of lesions was observed in about 20% of the cases, and around 25% of the women underwent repetitive surgery. Routine complementary performance of denervating procedures cannot be recommended based on the quality of the available information, as only a few symptomatic patients complain of exclusively midline, hypogastric pain. Pain recurrence and reoperation rates after conservative surgery for symptomatic endometriosis are high and probably underestimated. Clinicians and patients should be aware that the expected benefit is operator-dependent and, especially in complex conditions, acceptable results can be assured in referral centers.

Fibroids and female reproduction: a critical analysis of the evidence.

Observational epidemiological studies aimed at elucidating the relationship between fibroids and infertility are inconclusive due to methodological limitations. However, two main pieces of clinical evidence support the opinion that the fibroids interfere with fertility. First, in IVF cycles, the delivery rate is reduced in patients with fibroids but is not affected in patients who have undergone myomectomy. Second, even if randomized studies are lacking, surgical treatment appears to increase the pregnancy rate: approximately 50% women who undergo myomectomy for infertility, subsequently conceive. Available evidence also suggests that submucosal, intramural and subserosal fibroids interfere with fertility in decreasing order of importance. Although more limited, some data supports an impact of the number and dimension of the lesions. Drawing clear guidelines for the management of fibroids in infertile women is difficult due to the lack of large randomized trials aimed at elucidating which patients may benefit from surgery. At present, physicians should pursue a comprehensive and personalized approach clearly exposing the pros and cons of myomectomy to the patient, including the risks associated with fibroids during pregnancy on one hand, and those associated with surgery on the other hand.

Differential activation of dopamine release in the nucleus accumbens core and shell after acute or repeated amphetamine injections: a comparative study in the Roman high- and low-avoidance rat lines.

The selectively bred Roman high- and low-avoidance rats differ in emotionality and responsiveness to the motor effects of acute and repeated psychostimulant administration. These lines also show drastic differences in the neurochemical responses of their mesolimbic dopamine systems to addictive drugs. The nucleus accumbens is critically involved in the locomotor activation produced by psychostimulants and in the augmentation of this effect observed upon repeated drug administration (i.e. behavioral sensitization), although there is not a general consensus as to whether the nucleus accumbens-core or the nucleus accumbens-shell is preferentially involved in such alterations. This study was designed to evaluate the effects of acute amphetamine (0.20 mg/kg, s.c.) on dopamine output in the nucleus accumbens-shell and nucleus accumbens-core of the Roman lines under basal conditions (i.e. naïve rats) and after the repeated administration of amphetamine (1 mg/kg, s.c. x 10 days) or saline. We show that (1) in naïve rats, amphetamine caused a larger increment in dopamine output in the nucleus accumbens-shell vs the nucleus accumbens-core only in the Roman high-avoidance line; (2) repeated amphetamine elicits behavioral sensitization in Roman high-avoidance, but not Roman low-avoidance, rats; (3) in sensitized Roman high-avoidance rats, amphetamine provokes a larger increment in dopamine output in the nucleus accumbens-core, and an attenuated dopaminergic response in the nucleus accumbens-shell, as compared with Roman high-avoidance rats repeatedly treated with saline; and (4) such neurochemical changes are not observed in the mesoaccumbens dopaminergic system of the sensitization-resistant Roman low-avoidance line. We propose that (1) Roman high-avoidance and Roman low-avoidance rats differ in the vulnerability to develop psychostimulant sensitization, (2) the nucleus accumbens-core and nucleus accumbens-shell subserve distinct functional roles in this phenomenon, and (3) comparative studies in the Roman lines may provide insight into the influence of neural substrates and genetic background on the individual vulnerability to addiction.

Differential neurochemical properties of central serotonergic transmission in Roman high- and low-avoidance rats.

The selective breeding of Roman high- (RHA/Verh) and low-avoidance (RLA/Verh) rats for rapid versus poor acquisition of active avoidant behaviour has produced two behavioural phenotypes with different performances in a variety of animal models of anxiety, in which RLA/Verh rats are consistently more fearful than RHA/Verh rats. In addition, these two lines display different functional properties of brain neurotransmitters like serotonin (5-HT), known to be involved in the expression of anxiety- and depression-related behaviours. Therefore, we used brain microdialysis and [3H]-citalopram binding autoradiography to characterize further the neurochemical properties of 5-HTergic transmission in the two lines. No significant line-related differences were detected in the basal 5-HT output in the frontoparietal cortex (FPCx). In contrast, the increase in the cortical 5-HT output elicited by the systemic administration or the local application, via reverse dialysis, of chlorimipramine and fluoxetine was more robust in RHA/Verh than in RLA/Verh rats. Moreover, the binding signal of [3H]-citalopram to 5-HT re-uptake sites was more intense in the FPCx of RHA/Verh rats than in their RLA/Verh counterparts. These findings suggest that the functional tone of the 5-HTergic projection to the FPCx is stronger in the RHA/Verh line relative to the RLA/Verh line. It is proposed that RLA/Verh rats may be used as a model with heuristic value for studying the role of 5-HTergic transmission in anxiety and in the anxiolytic effects of monoamine re-uptake inhibitors.

Dissociation between mesocortical dopamine release and fear-related behaviours in two psychogenetically selected lines of rats that differ in coping strategies to aversive conditions.

The mesocortical and mesolimbic dopaminergic (DAergic) pathways are activated by either aversive or rewarding stimuli. The functional tone of these DAergic neurons also increases during the execution of cognitive tasks. The present study was designed to examine the relationship between mesocortical and mesolimbic DAergic function and the expression of fear-related behaviours as compared with attention- and cognition-related mechanisms (e.g. coping strategies), in response to aversive conditions. To this aim, we used two psychogenetically selected rat lines, Roman high-avoidance (RHA/Verh) and Roman low-avoidance (RLA/Verh), which display drastically different emotion- and coping-related behaviours in response to stressors: RLA/Verh rats are 'reactive copers' and more fearful than RHA/Verh rats, which are 'proactive copers'. Brain dialysis experiments demonstrated that tail-pinch (TP) and the anxiogenic compounds pentylenetetrazol (PTZ) and ZK 93426 increased DA output in the medial prefrontal cortex (PFCX) of RHA/Verh but not RLA/Verh, rats. In contrast, in the shell compartment of the nucleus accumbens (NAC shell), TP caused a small increase in DA output only in RLA/Verh rats, whereas PTZ and ZK 93426 had no significant effect on either line. RHA/Verh rats displayed more robust and longer lasting coping activity and less frequent freezing and self-grooming episodes than did RLA/Verh rats after TP, PTZ or ZK 93426. This dissociation between fear-related behaviour and cortical DAergic activation argues against the view that the latter may be involved in the control of fear-like responses. We therefore propose that the activation of mesocortical DAergic projections by aversive stimuli underlies the cognitive mechanisms that are triggered in an attempt to gain control over the stressor.

Prognostic significance of hysteroscopic imaging in endometrioid endometrial adenocarcinoma.

OBJECTIVE: The aim of this study was to relate hysteroscopic features of endometrioid endometrial adenocarcinoma to stage, grade and overall survival. METHODS: Sixty women with endometrioid adenocarcinoma underwent laparotomy and staging according to current FIGO classification. Before surgery hysteroscopy was performed in all patients to establish the morphology of neoplasia, the extent of endometrial lining involvement, and endocervical spreading. These hysteroscopic parameters were related to overall survival, surgical stage, and grade of disease. RESULTS: First-stage carcinomas were found in 50 patients, second-stage in 4, third-stage in 3, and fourth-stage in 3 patients. Well-differentiated tumors were detected in 32, moderately differentiated in 21, and poorly differentiated in 7 patients. The cumulative 48-month probability of survival was 86.6%. The morphology of adenocarcinomas was unrelated to both their stage and their grade; no relationship to survival was found. The extent of carcinomatous spread within the endometrial cavity was significantly related to stage, grade, and survival. Endometrial lining involvement of less than 50% was associated with 100% survival, 97.1% of first-stage diseases, and 96.6% of low-grade carcinomas. These percentages dropped to 73.1, 65.3 (Fisher's exact test, P = 0.001), and 76.9% (Fisher's exact test, P = 0.035), respectively, when tumoral growth involved more than half of the endometrium. Hysteroscopy detected all carcinomas metastasizing to the cervix; in 8 patients we overdiagnosed endocervical spreading, although histology was negative. From these figures, hysteroscopy showed a sensitivity and specificity in predicting cervical spread of 100 and 87.3%, respectively. CONCLUSIONS: The extent of endometrial lining involvement in patients with endometrioid carcinoma provides preoperative information on the risk of extrauterine spread. We confirm the high accuracy of hysteroscopy in excluding cervical spread.

Surgical management of endometriosis.

A systematic literature review of the last two decades was performed to evaluate the effect of pelvic denervations in addition to conservative surgery on dysmenorrhoea and deep dyspareunia associated with endometriosis. Chronic pelvic pain relief after hysterectomy or adhesiolysis was also assessed. In the five non-comparative studies on the effect of pre-sacral neurectomy, the frequency of dysmenorrhoea recurrence or persistence after treatment ranged from 4 to 40%. The pooled frequency of non-responders at the end of follow-up was 23% (95% confidence interval (CI), 19 to 27%). Only two of the three comparative, non-randomized trials demonstrated a significant treatment benefit of pre-sacral neurectomy, and the results of the two identified randomized controlled trials are discordant. Significant quantitative heterogeneity among studies prevented pooling of data on dysmenorrhoea. The common odds ratio of deep dyspareunia persistence was 0.69 (95% CI, 0.31 to 1.54). In the 10 non-comparative studies on the effect of uterosacral ligament resection, the frequency of dysmenorrhoea and deep dyspareunia persistence after treatment ranged, respectively, from 0 to 50% and from 6 to 42%. The pooled frequency of non-responders at the end of follow-up was 23% (95% CI, 20 to 27%) and 13% (95% CI, 8 to 18%), respectively. Routine performance of complementary denervating procedures cannot be recommended based on the quality of the evidence available. The results of the five studies on the effect of hysterectomy on chronic pelvic pain of presumed uterine origin consistently demonstrated that 83-97% of operated women reported pain relief or improvement 1 year after surgery. There is no consensus on the outcome of adhesiolysis in patients with chronic pain, and the role of pelvic adhesions in causing symptoms is under scrutiny.

6,3'-dibromoflavone and 6-nitro-3'-bromoflavone: new additions to the 6,3'-disubstituted flavone family of high-affinity ligands of the brain benzodiazepine binding site with agonistic properties.

6,3'-dibromoflavone and 6-nitro-3'-bromoflavone inhibited [(3)H]flunitrazepam binding to the benzodiazepine binding site of the gamma amino butyric acid receptor complex with K(i) values between 17 and 36 nM in different brain regions. Their gamma amino butyric acid ratio for [(3)H]flunitrazepam binding to cerebral cortex membranes indicated partial agonistic properties. Both compounds had similar pharmacological effects: they produced anxiolytic-like effects at low doses but did not alter locomotor activity or muscle tonicity; sedation was caused only at doses higher than 30 mg/kg in mice. These synthetic flavone derivatives join an existing family of 6,3'-disubstituted flavone compounds with high affinity for the benzodiazepine binding site and partial agonistic profiles.

A levonorgestrel-releasing intrauterine system for the treatment of dysmenorrhea associated with endometriosis: a pilot study.

OBJECTIVE: To evaluate the efficacy and safety of an intrauterine system releasing 20 microg of levonorgestrel per 24 hours in the long-term treatment of recurrent dysmenorrhea in women already operated on conservatively for endometriosis. DESIGN: A prospective noncomparative pilot study. SETTING: A tertiary care and referral academic center for patients with endometriosis. PATIENT(S): Twenty parous women with recurrent moderate or severe dysmenorrhea after conservative surgery for endometriosis who did not want further children. INTERVENTION(S): A levonorgestrel-releasing intrauterine system was inserted in each woman within 7 days of the start of a menstrual cycle. MAIN OUTCOME MEASURE(S): Variations in severity of dysmenorrhea during treatment according to a 100-mm visual analogue scale and a 0-3-point verbal rating scale, modification of a pictorial blood-loss assessment chart devised to evaluate the amount of menstrual flow, and degree of satisfaction after 12 months of therapy. RESULT(S): One woman was lost to follow-up after achieving amenorrhea and expressing satisfaction, and 1 requested system removal because of weight gain and abdominal bloating. In another subject, the levonorgestrel intrauterine system was expelled 3 months after insertion. The menstrual patterns in the remaining 17 women were characterized by amenorrhea in 4 cases, hypomenorrhea or spotting in 8, and normal flow in 5. Baseline and 12-month follow-up mean +/- SD blood loss scores were 111+/-36 and 27+/-26, respectively. At the same time, mean +/- SD visual analogue and verbal rating scale scores dropped, respectively, from 76+/-12 to 34+/-23 points and from 2.5+/-0.5 to 1.2+/-0.5 points. Four women were very satisfied with treatment, 11 were satisfied, 2 were uncertain, and 3 were dissatisfied at 12-month follow-up. CONCLUSION(S): Because of the amenorrhea or hypomenorrhea induced in most women, a levonorgestrel intrauterine system greatly reduced menstrual pain associated with endometriosis and achieved a high degree of patient satisfaction.

Randomized comparison of vaporizing electrode and cutting loop for endometrial ablation.

OBJECTIVE: To compare endometrial ablation using a vaporizing electrode with resection using a standard cutting loop, evaluating distension fluid absorption, operating time, and ease of procedure. METHODS: Premenopausal menorrhagic women with normal hysteroscopic and endometrial biopsy findings were allocated randomly to endometrial vaporization (n = 47) or resection (n = 44). Distension medium deficit, operating time, and degree of difficulty of the procedure were determined at surgery. Menstrual pattern of women in both groups was also assessed after 1-year follow-up. RESULTS: Mean +/- standard deviation (SD) distension fluid deficit was 109+/-126 mL in the vaporization and 367+/-257 mL in the resection group (mean difference 258 mL; 95% confidence interval 175, 341 mL; P < .001, unpaired t test). Mean +/- SD operating time was, respectively, 9.2+/-3.1 minutes versus 10.7+/-2.5 minutes. The surgeon classified intraoperative difficulties as none in 32, minimal in 11, moderate in four, and severe in none in the vaporization group, and 17, 14, seven, and six in the resection group. Menstrual pattern at 1 year in the former group was amenorrhea in 17 (36%) cases, hypomenorrhea or spotting in 20 (43%), normal flows in 10 (21%), and menorrhagia in none compared with, respectively, 21 (48%), 14 (32%), seven (16%), and two (5%) in the latter group. CONCLUSION: Endometrial ablation with the vaporizing electrode limited fluid absorption compared with resection by the standard cutting loop. Long-term effects on uterine bleeding were similar.

Hysteroscopic myomectomy: long-term effects on menstrual pattern and fertility.

OBJECTIVE: To determine the effects of hysteroscopic myomectomy on menorrhagia and infertility and the influence of intramural extension on surgical feasibility and long-term outcomes. METHODS: We studied 108 women who had first-line hysteroscopic resection of submucous pedunculated (n = 54), sessile (n = 30), or intramural (n = 24) leiomyomas over 7 years at an academic department specializing in endoscopic surgery. RESULTS: The mean (+/- standard deviation) operating time and distension medium deficit were 18+/-7 minutes and 204+/-276 mL in the pedunculated lesion group, 23+/-9 minutes and 278+/-269 mL in the sessile lesion group, and 32+/-8 minutes and 335+/-272 mL in the intramural lesion group, respectively. More than one procedure was required to complete myoma removal in 14 (26%) of 54, eight (26%) of 30, and 12 (50%) of 24 subjects in the pedunculated, sessile, and intramural lesion groups, respectively. After a mean follow-up of 41 months, myomas recurred in 27 subjects, with a 3-year cumulative rate of 34%. Twenty women had recurrent menorrhagia, with a 3-year cumulative probability of 30%. The 3-year cumulative probability of conception was 49% in women with pedunculated lesions, 36% in those with sessile lesions, and 33% in those with intramural lesions. The study had 80% power to detect five- and three-fold increases in menorrhagia recurrence and conception rates, respectively, in the mainly intramural myoma group compared with the completely or mainly intracavitary myoma group. CONCLUSION: Hysteroscopic resection of submucous myomas gives satisfactory menorrhagia control and limited recurrence, but the benefit for infertility was less impressive. Myoma intramural extension did not have a substantial influence on any of the long-term outcomes but affected operating time and the number of procedures needed for complete removal.

[Endometriosis of the ileum and colon complicated by intestinal obstruction. Report of two cases]. / Endometriosi dell'ileo e del colon complicata da occlusione intestinale. Due casi clinici.

The authors report two cases of intestinal occlusion, one ileal and the other colic, caused by endometriosis. Both patients underwent surgery. Following a review of data in the literature regarding the frequency, pathogenesis, diagnosis and management, the authors conclude that pre- and intraoperative diagnosis is often impossible in these cases and must be postponed to histological analysis. Full remission was achieved after surgery.

Determinants of reproductive outcome after abdominal myomectomy for infertility.

OBJECTIVE: To determine the effect of myomectomy as a therapy for infertility and to define the factors that influence reproductive outcome. DESIGN: Retrospective study of a case series. SETTING: An academic department specializing in conservative surgery. PATIENT(S): A total of 138 infertile women who underwent first-line conservative surgical treatment at laparotomy for uterine leiomyomas over an 8-year period. INTERVENTION(S): Data were collected on baseline clinical characteristics, surgical details, and subsequent reproductive history. MAIN OUTCOME MEASURE(S): Cumulative pregnancy rates at 24 months according to selected clinical and fibroid characteristics. RESULT(S): Pregnancy occurred in 76 women. The 24-month cumulative probability of conception according to the Kaplan-Meier method was 87% in patients <30 years of age, 66% in patients 30-35 years of age, and 47% in patients >35 years of age. The pregnancy rates in women with and without minor infertility factors in addition to myomas were 56% and 71%, respectively, and those in women with <2 years versus > or =2 years of infertility were 84% and 51%, respectively. The size and site of the largest myoma and the total number of tumors removed did not influence the outcome. CONCLUSION(S): Our results suggest a benefit of myomectomy in infertile patients. However, women should be counseled carefully before surgery because the determinants of outcome appear to be independent of treatment.

Treatment with a gonadotrophin releasing hormone agonist before hysterectomy for leiomyomas: results of a multicentre, randomised controlled trial.

OBJECTIVES: To ascertain whether uterine shrinkage induced by a gonadotrophin releasing hormone agonist before hysterectomy for fibroids increases the possibility of a vaginal procedure. DESIGN: A multicentre, prospective, randomised, controlled study. PARTICIPANTS: One hundred and twenty-seven premenopausal women with a uterine volume of 12 to 16 gestational weeks. INTERVENTIONS: Twelve weeks of triptorelin depot treatment before hysterectomy or immediate surgery. MAIN OUTCOME MEASURES: Number of vaginal and abdominal hysterectomies, operating time, blood loss, degree of difficulty of the procedure, perioperative serum haemoglobin and haematocrit levels, hospital stay, and patients' overall satisfaction with treatment. RESULTS: After randomisation, four women withdrew from the study, leaving 60 women in the triptorelin arm and 63 in the immediate surgery arm. At baseline evaluation a vaginal hysterectomy was indicated in seven women allocated to pre-operative medical therapy (12%), and in 10 of those allocated to immediate surgery (16%). Clinical assessment after the 12-week GnRH agonist course showed that abdominal hysterectomy was no longer indicated in 25/53 women (47%) as a vaginal procedure appeared appropriate. Thus the overall rate of indication for a vaginal procedure in the pre-operative medical treatment arm was 32/60 cases (53%), with a between-group difference of 37% (95% CI, 26% to 51%; chi2(1) = 19.18, P < 0.0001; OR 6.06; 95% CI, 2.60 to 14.10). Pre- and post-operative serum haemoglobin and haematocrit levels were significantly higher in the GnRH agonist than in the immediate surgery arm. No appreciable difference was observed between the groups in the other intra- and post-operative variables, including patients' satisfaction. CONCLUSIONS: Pre-operative GnRH agonist therapy increased the rate of vaginal hysterectomy in selected women with fibroids and uterine volume of 12 to 16 gestational weeks.

Transvaginal ultrasonography versus uterine needle biopsy in the diagnosis of diffuse adenomyosis.

To assess the reliability of transvaginal ultrasonography and uterine needle biopsy, used singly or in combination, in the diagnosis of diffuse adenomyosis, a prospective study with pathological confirmation of the diagnosis was performed. A total of 102 premenopausal women scheduled for hysterectomy because of menorrhagia and/or pelvic pain underwent preoperative transvaginal ultrasonography. After removal of the uterus, a single full-thickness myometrial biopsy specimen was taken from along the median line in the upper third of the posterior uterine wall, using a 14-gauge Trucut needle. Adenomyosis was diagnosed by the sonographer by the presence of indistinctly demarcated heterogeneous myometrial areas with distorted echotexture, and by the pathologist when the distance between the lower border of the endometrium and the affected myometrial area was more than one-half of a low power field. The prevalence of adenomyosis was 28% (29/102 patients). The sensitivity and specificity of transvaginal ultrasonography were 82.7 and 67.1% respectively, compared with 44.8 and 95.9% for uterine needle biopsy. The positive predictive values of the two tests were 50.0 and 81.2% respectively, and the negative predictive values 90.7 and 81.4%, likelihood ratios of a positive test 2.5 and 10.9, likelihood ratios of a negative test 0.3 and 0.6, and kappa indexes of agreement 0.42 and 0.47. Combining the tests did not improve the overall diagnostic performance. Both transvaginal ultrasonography and uterine needle biopsy demonstrated suboptimal test characteristics.

Efficacy of preoperative medical treatment in facilitating hysteroscopic endometrial resection, myomectomy and metroplasty: literature review.

The evidence of the efficacy of preoperative medical treatment with danazol, gonadotrophin releasing-hormone agonists (GnRHa) or progestins in facilitating surgery and improving the long-term results of myomectomy, hysteroscopic metroplasty and endometrial resection has been reviewed. Sixteen randomized and non-randomized controlled clinical trials, published in the English literature between 1990 and 1996, were identified. In all studies comparing GnRHa or danazol versus no treatment, fluid absorption during surgery was less in subjects who underwent medical treatment independently of the drug used and the type of intervention, the reduction ranging from 142 to 572 ml. A reduction in operating time (between 2 and 25 min) was observed in both the danazol and GnRHa-treated groups in comparison with untreated controls, regardless of the type of operation (endometrial resection, myomectomy or metroplasty). With regard to long-term results, amenorrhoea tended to be more frequent in patients who received GnRHa: the pooled odds ratio (OR) of amenorrhoea for GnRHa-treated women compared with untreated controls was 2.0 [95% confidence interval (CI), 1.1-3.8]. In studies comparing GnRHa with danazol, no marked differences were observed in mean operating time, but the OR of amenorrhoea at 6-12 months after surgery was 1.9 (95% CI 1.0-3.3).

Is cystic ovarian endometriosis an asymmetric disease?

OBJECTIVE: To investigate whether asymmetry exists in the left- and right-handed distribution of ovarian cystic lesions in a large series of women with endometriosis. DESIGN: Retrospective evaluation of a case series. SETTING: Tertiary care and referral academic centre for the study and treatment of endometriosis. POPULATION: A total of 1054 consecutive women undergoing first-line surgical treatment for endometriosis in an eight-year period. METHODS: Data were collected on indication for the intervention, age at surgery, parity and disease stage as well as side and size of ovarian endometriomas. MAIN OUTCOME MEASURE: Frequency of left- and right-sided ovarian endometriomas. RESULTS: Histologically confirmed endometriotic ovarian cysts were present in 561 women, which were on the left side in 255 instances, on the right in 148, and bilateral in 158. In the patients with unilateral endometriomas, the observed proportion of left cysts (255/403, 63%; 95% confidence interval, 58% to 68%) was significantly different from the expected proportion of 50%, (chi2(1), 28.41, P<0.001). Including also the bilateral endometriotic cysts gave a total of 413/719 (57%) left-sided and 306/719 right-sided endometriomas. The magnitude of these proportions did not vary appreciably during the eight years considered. The difference in proportion of left- and right-sided endometriotic cysts was virtually similar in subgroups of women with different indications for surgery. Cyst side was not related to age, parity or cyst diameter. CONCLUSIONS: The finding of a lateral asymmetry in the occurrence of ovarian endometriotic cysts is compatible with the anatomical differences of the left and right hemipelvis and supports the menstrual reflux theory.

Endometrial ablation with a vaporizing electrode. II. Clinical outcome of a pilot study.

BACKGROUND: As a vaporizing electrode has been successfully used to treat submucous myomas, we evaluated its safety and efficacy in performing endometrial ablation. METHODS: Forty consecutive women with established menorrhagia with (n=26) and without (n=14) submucous myomas were enrolled in a prospective, noncomparative, pilot study. Hysteroscopic endometrial vaporization was performed with pure cutting current set at 200 watts. RESULTS: All procedures were completed without complications. Median (interquartile range, IQR) fluid deficit was 90 (0-200) ml and median (IQR) operating time 10 (7-12.5) min. A significant correlation was observed between operating time and fluid absorption (Spearman's test by ranks, r=0.47; p=0.002). The degree of difficulty of the operation was classified as none on 28 (70%) occasions, mild on 11 (27.5%) and moderate on one (2.5%). After a mean+/-s.d. follow-up of 20.3+/-2.4 months, amenorrhea or spotting were reported by 23 (57.5%) subjects, hypomenorrhea by 10 (25%), normal flows by six (15%), and menorrhagia by one (2.5%). The median (IQR) menstrual score calculated according to a pictorial blood loss assessment chart dropped from 282.5 (199-383) to 0 (0-15) (p<0.0001). Six (15%) subjects were very satisfied with the effect of surgery, 30 (75%) satisfied, two (5%) uncertain, one (2.5%) dissatisfied and one (2.5%) very dissatisfied. CONCLUSIONS: The vaporizing electrode seems to combine the benefits of the cutting loop (speed, efficacy and possibility of removing myomas) and the roller-ball electrode (safety and limited fluid absorption) while avoiding their respective disadvantages, and may be considered an interesting alternative in the hysteroscopic treatment of menorrhagia.