Infantile or hypoplastic uterus? A proposal for a modification to the ESHRE/ESGE classification of female genital tract congenital abnormalities.

We argue that the graphical depiction of "infantile uterus" in the ESHRE/ESGE classification of Mullerian anomalies does not fall under class U1b, i.e. uterine corpus anomalies with a normal external contour. The verbal description of "infantile uterus" by the ESHRE/ESGE classification seems to better suit a hypoplastic uterus and as such, arguably, can be omitted from this classification. We also suggest the inclusion of a "Y shaped" uterus under Class U1.

"Chromohysteroscopy" for evaluation of endometrium in recurrent miscarriage.

PURPOSE: "Chromoendoscopy" results in 34 recurrent miscarriage (MR) patients in whom conventional hysteroscopy did not show any apparent endometrial pathology. METHOD: 5 ml of 1% methylene blue dye was introduced through the hysteroscopic inlet. RESULTS: The study group was classified according to the staining characteristics. Group I included 19 patients in whom focal dark staining was observed. Group II included 15 patients in whom diffuse light blue staining was observed. There was no significant difference between the two groups in age, smoking, status, BMI, number of miscarriages and in mean gestational age of the miscarriages. Time to hysteroscopy after the last miscarriage was shorter in Group I (63.9 vs 95.3 days). Then, the study group was classified according to the histopathology result. Group I included ten cases of endometritis while Group II included 24 cases with a normal histopathology. The mean number of miscarriages was higher in Group I (3.4 vs 2.5). CONCLUSION: Chromohysteroscopy improves the efficacy of hysteroscopy in RM cases and is warranted after three miscarriages in two cycles time.

Can "chromohysteroscopy" help target endometrial biopsy in postmenopausal bleeding?

A preliminary study was conducted to evaluate the value of endometrial dying during diagnostic hysteroscopy. Twenty-two postmenopausal bleeding cases without hysteroscopic findings were included in the study. Before the random endometrial biopsy 5 ml of methylene blue (1%) was instilled into the uterine cavity. Staining was observed in 19 of the cases. Tissues were obtained from both stained and non-stained areas with grasping forceps. "Chromohysteroscopy" led the diagnosis of three more endometrial pathologies; two more cases of endometritis and one more case of endometrial hyperplasia. In conclusion, chromohysteroscopy seems like a new avenue worth pursuing for better diagnoses of unexplained endometrial pathologies.

Continuous oral or intramuscular medroxyprogesterone acetate versus the levonorgestrel releasing intrauterine system in the treatment of perimenopausal menorrhagia: a randomized, prospective, controlled clinical trial in female smokers.

OBJECTIVE: To compare the efficacy of three progestin regimens in perimenopausal menorrhagia. DESIGN: One hundred thirty-two women with menorrhagia were included in this prospective, randomized, comparative trial. Women were randomized to three groups of 44 in each, either to get a single shot of depot medroxyprogesterone acetate, intramuscularly (Group 1), or medroxyprogesterone acetate in a daily dose of 5 mg orally (Group 2), or the levonorgestrel releasing intrauterine system (LNG-IUS) (Group 3). The Mann-Whitney U-test was applied to compare independent groups. RESULTS: Pictorial blood loss assessment chart (PBAC) score, the duration of bleeding and mean hemoglobin level were improved in all groups. Comparing the groups we noted that for the PBAC, there was no statistically significant difference between groups 1 and 2, while group 3 was superior to both groups 1 and 2 (p < 0.05 and p < 0.05, respectively). Mean duration of menstruation showed no differences among the groups. Hemoglobin levels were no statistically significant differences between groups 1 and 2, while group 3 was superior to both groups 1 and 2 (p < 0.05 and p < 0.05, respectively). CONCLUSION: The efficacies of oral and intramuscular medroxyprogesterone acetate in the treatment of menorrhagia were comparable each other, however, the efficacy of LNG-IUS was superior to both.

Hormone replacement therapy in postmenopausal women with benign fibrocystic mastopathy.

OBJECTIVE: To compare the effects of five different hormone replacement regimens on fibrocystic mastopathy in postmenopausal women. DESIGN: This was a randomized, prospective, clinical, case-control study. METHODS: Two hundred and twelve women with benign cystic mastopathy were studied. The largest diameters of the breast cysts were measured using ultrasonography at study entry. Forty-eight women were randomized to the control group and did not take any medication. One hundred and sixty-four women were randomized to the following study groups. Group I (n = 46) were given conjugated estrogen (0.625 mg/day) and medroxyprogesterone acetate (5 mg/day) continuously. Group II (n = 22) were given only conjugated estrogens (0.625 mg/day) continuously; these were hysterectomized women. Group III (n = 32) were given transdermal estrogen (50 microg/day) and medroxyprogesterone acetate (5 mg/day) continuously. Group IV (n = 32) were given only transdermal estrogen (50 microg/day) continuously; these were also hysterectomized women. Group V (n = 32) were given tibolone (2.5 mg/day) continuously. Hormone therapy was continued for 12 months. Every 3 months the women were rescanned using ultrasonography to determine cyst diameters and examine characteristics such as internal echogenicity, and thickness and regularity of the cyst wall. Statistical assessment used Students' t test and Friedman analysis. RESULTS: In the control group, there was no statistically significant change in cyst dimensions. However, tibolone was associated with a decrease in cyst dimensions which was statistically significant, but none of the other four hormone replacement therapy regimens caused any significant negative effect on the benign cystic mastopathy.

Yolk sac size and shape as predictors of poor pregnancy outcome.

Two hundred and fifty women, underwent endovaginal sonography in the first trimester to establish the normal size and shape of the secondary yolk sac and to assess the value of yolk sac evaluation in predicting poor pregnancy outcome. We calculated the correlation coefficients between yolk sac and menstrual age, yolk sac and crown-rump length and between yolk sac and mean gestational yolk sac diameter as r: 0.9581 (p < 0.001), r: 0.9427 (p < 0.0001) and r: 0.8855 (p < 0.0001), respectively. Of 250 cases, 219 had a normal pregnancy course through the end of the first trimester (Group I) while 31 had a poor prognosis such as abortion or embryonic demise (Group II). Eight of 219 in Group I and 20 of 31 in Group II had an abnormal yolk sac size. A yolk sac diameter out of two standard deviations of the mean for the menstrual age allowed prediction of an abnormal pregnancy outcome with a sensitivity of 65%, a specificity of 97%, a positive predictive value of 71%, and a negative predictive value of 95%. Ten of 219 and 9 of 31 had abnormal yolk sac shape. An abnormal yolk sac shape allowed prediction of an abnormal pregnancy outcome with a sensitivity of 29%, a specificity of 95%, a positive predictive value of 47% and a negative predictive value of 90.5%. We concluded that secondary yolk sac evaluation is a valuable tool to predict pregnancy outcome.

Clomiphene citrate-resistant polycystic ovary syndrome. Preventing multifollicular development.

OBJECTIVE: To determine the efficiency and comparison of two different protocols, human menopausal gonadotropin (hMG) plus gonadotropin-releasing hormone analog (GnRH-a) and low-dose hMG to reduce multifollicular development in clomiphene-resistant polycystic ovary syndrome (PCOS) patients. STUDY DESIGN: Prospective comparative and pilot study in 20 patients for 31 cycles. The first group (n = 10) was treated with buserelin acetate, 600 micrograms/d, for six weeks before ovulation induction with hMG in conventional doses for 14 cycles. The other group (n = 10) was treated only with low-dose hMG for 17 cycles. All cycles were compared in terms of the number of follicles per cycle, cycles human chorionic gonadotropin withheld, estradiol level on ovulation day, treatment duration and number of ampules used per cycle. In addition, the outcome of cycles and complications of multifollicular development, ovarian hyperstimulation syndrome (OHSS) and multiple pregnancy were determined. RESULTS: As compared with the GnRH-a + hMG protocol, the low-dose hMG protocol yielded less multifollicular (57.1% vs. 17.6%) and more monofollicular (35.7% vs. 70.6%) development. Consequently, less OHSS (21.4% vs. 0%) and multiple pregnancy (10% vs. 0%) occurred in the low-dose group. CONCLUSION: Low-dose hMG therapy has distinct advantages in eliminating multifollicular development and related complications in clomiphene citrate-resistant PCOS patients. The addition of GnRH-a to gonadotropins does not change the incidence of multifollicular development.

Three sisters with septate uteri: another reference to bidirectional theory.

A case report of three sisters with different degrees of septate uteri, a rare familial aggregation, is presented. The youngest sister was diagnosed with a complete uterine septum with cervical duplication and complete longitudinal vaginal septum. She also had a bilateral partial ureteral duplication. Investigation of the family showed that the eldest sister had a complete uterine septum and her pregnancy had terminated with a vaginal delivery following premature rupture of the membranes. The asymptomatic middle sister showed an incomplete uterine septum. Finally, the mother was normal with respect to urogenital anatomy. These types of Müllerian anomalies cannot be explained by the classical theory of unidirectional Müllerian duct development; the alternative bidirectional theory is proposed instead. Additionally, the results are suggestive that the prevalence of major uterine malformations may be higher than generally thought, due to asymptomatic cases.