Frequency of menstrual abnormalities and their associated neuroimaging findings in women with focal refractory epilepsy.

Patients with refractory epilepsy can suffer from psychological and physical problems. Epilepsy can also be associated with menstruation abnormalities in women. In this paper, we aim to survey women with focal refractory epilepsy who also suffer from menstrual abnormalities. This cross-sectional study was performed in 2018 in Tertiary Epilepsy Center in Kashani Hospital, Isfahan, Iran and Milad hospital, Isfahan, Iran. A total number of 381 patients diagnosed with refractory epilepsy joined the study based on an inclusion and exclusion criteria. Clinical characteristics of epilepsy, menstrual issues and brain MRI findings were assessed. Among 381 women with refractory epilepsy, 250 had refractory focal epilepsy (65.61%), and the others (34.39%) had generalized refractory epilepsy. 132 patients out of 381 had menstrual abnormalities (34.65%). Among 132 women with coexisting refractory epilepsy and menstrual abnormalities, 86 (65.15%) were diagnosed with refractory focal epilepsy, and 46 (34.86%) had generalized refractory epilepsy (p value = 0.041). Oligomenorrhea-hypomenorrhea was the most common type of menstrual abnormality in women with refractory epilepsy seen in 83 (62.87%) (p value = 0.039). The most common brain MRI pathology in women with refractory focal epilepsy was mesial temporal sclerosis (MTS) (39.20%, p = 0.00). We report that almost one-third of women with refractory epilepsy suffer from menstrual disorders, and the most common disorder was Oligomenorrhea-hypomenorrhea, and the most common brain pathology was MTS. It has also been a hypothesis that reproductive dysfunctions are connected to temporal lobe malfunctions, and more specific studies are required in this issue.

Anti-Müllerian Hormone and Ovarian Morphology in Women With Hypothalamic Hypogonadism.

CONTEXT: Different phenotypical features of women with hypothalamic hypogonadism (HH), also known as World Health Organization-1 anovulation, including ovarian morphology, have been scarcely described in large cohorts. Some studies have reported increased levels of anti-Müllerian hormone (AMH) in women with HH. OBJECTIVE: To assess whether women with HH, compared with healthy controls, have increased serum levels of AMH and what proportion of these women erroneously meet the Rotterdam Criteria for Polycystic Ovarian Syndrome (PCOS). DESIGN, SETTING AND PARTICIPANTS: Retrospective cohort study in a Dutch academic medical center including 83 women with neither anovulation nor menstrual cycle disorders (healthy controls), 159 women with HH and 3640 women with PCOS. Age matching was used between the HH and PCOS group (1:2 ratio) to create a second group consisting of 318 age-matched women with PCOS. INTERVENTION: None. MAIN OUTCOME MEASURES: AMH levels and ovarian morphology. RESULTS: Median AMH serum levels for the HH group were 3.8 (<0.1-19.8), compared with 7.5 (<0.1-81.0) in the PCOS group and 1.9 (<0.1-21.5) in the control group (P < 0.001). In the HH group, 58 (36%) erroneously met the Rotterdam Criteria for PCOS (meeting 2 of 3 criteria). CONCLUSIONS: AMH levels are increased in women with HH. We hypothesize that this increase, although there was no increase in follicle count, may be explained by the presence of a relatively large pool of antral follicles smaller than 2 mm in diameter, that are undetectable by transvaginal ultrasound. This study highlights the importance of measuring gonadotropins and estradiol before diagnosing a patient with PCOS.

Acute urinary retention in two adolescent girls with imperforate hymen.

Acute urinary retention is rare symptom in young adolescent girls. Imperforate hymen can be a cause of acute urinary retention possibly due to the pressure effect of the distended vagina (hematocolpos) on the lower urinary tract. However, the mechanism of progression to urinary retention is unknown. We report on two cases of adolescent girls with imperforate hymen who presented with acute urinary retention. A series of volume tolerance tests of the urinary bladder and urodynamic studies before operation revealed highly elevated urethral resistance, which was induced by interaction of large amount of urinary volume in the bladder and the large size of hematocolpos. After operation, urinary retention could not be observed and the urethral pressure returned to normal.

Pelvic pain in young girls: not only dysmenorrhoea!

Imperforate hymen is the most frequent cause of haematocolpos, although it is a rare malformation (1:2000). We present two cases of young girls with cyclic abdominal pain and urinary symptoms. At gynaecological examination, they all presented imperforate hymen and ultrasound revealed significant vaginal distension. X-shaped hymenectomy was performed in all patients. The later the diagnosis of imperforate hymen, the higher the risk of complications like haematometra, haematosalpinx, haemoperitoneum and infections such as tubo-ovarian abscesses, peritonitis and endometriosis (retrograde menstruation theory).

Fetal hydrometrocolpos and congenital imperforate hymen: Prenatal and postnatal imaging features.

Congenital imperforate hymen is probably the most common obstructive anomaly of the female reproductive tract. The accumulation of fluid in the genital tract leads to a distended uterus and vagina, causing hydrometrocolpos. Prenatal diagnosis of fetal hydrometrocolpos is uncommon, with only 22 cases reported in the literature and only a few cases of prenatal imaging of this condition available to date. The main ultrasound finding is a fetal pelvic mass posterior to the bladder and anterior to the rectum. We present the case of a 37-week female fetus with a fetal pelvic mass detected in a routine obstetric ultrasound examination, and the correlation between the prenatal and postnatal findings.

Female genital tuberculosis and infertility: serial cases report in Bandung, Indonesia and literature review.

BACKGROUND: Female genital tuberculosis (FGTB) is a Mycobacterium infection in the reproductive organs which often leads to infertility. FGTB is either asymptomatic or causes uncharacteristic clinical presentations, making an early diagnosis is challenging. Our aims were to evaluate the clinical presentations, the process to confirm the diagnosis and followed-up the patients who had undergone laparoscopy at our center. FGTB has been reported from many countries, but has never been reported from Indonesia. Here we present case studies to document the presence of FGTB in Indonesia. CASES PRESENTATION: There were three patients admitted to our center; two patients were admitted with irregular menstrual cycle as their chief complaint, while one patient came due to infertility. The results from laparoscopy were suggestive of FGTB; including the presence of caseating granulomas surrounded by epithelioid cells, lymphocytes, plasma cells, and Langhans giant cells. Additionally, PCR testing confirmed presence of MTB. Subsequent to diagnosis, continuous TB medications was administered with excellent clinical outcome in two patients (pregnant in 18 months after under gone laparoscopy). The infertile patient remain in one of the treated patient above. CONCLUSION: In infertile patients who live in countries where Tuberculosis is an endemic disease, such as Indonesia, a comprehensive history taking, along with ultrasonography results can be used to diagnose FGTB. Confirmation of this diagnosis can be achieved through polymerase chain reactions result. Timely diagnosis and treatment are imperative to prevent any permanent injury to patient's reproductive organs.

MRI in the evaluation of obstructive reproductive tract anomalies in paediatric patients.

AIM: To outline the anatomical variations of obstructive reproductive tract anomalies (ORTA) using magnetic resonance imaging (MRI) and its role in preoperative evaluation. MATERIALS AND METHODS: MRI and treatment of 21 paediatric patients with ORTA were reviewed and analysed. MRI findings were correlated with ultrasound and surgical findings. RESULTS: Patients presented in two distinct ways: primary amenorrhoea with cyclic pelvic pain, or progressive dysmenorrhoea. MRI showed haematocolpos, haematocervix, haematometra, and/or haematosalpinx; it also provided detailed information regarding uterine morphology, ipsilateral kidney absence, and endometriosis. Diagnosis at MRI of the obstruction sites correlated completely (100%) with the surgical diagnosis. Obstruction occurred at different levels of the genital tract, and surgical treatment was given based on the obstruction sites. One patient underwent excision of the hymen tissue for imperforate hymen. Four cases of lower vaginal atresia were treated with vaginoplasty. Three patients with typical Herlyn-Werner-Wunderlich (HWW) syndrome underwent resection of the vaginal septum, and one patient with concurrent post-partum placenta increta was treated accordingly; one patient with atypical HWW syndrome had the left uterus resected. There were 11 cases of cervical agenesis or cervicovaginal dysgenesis, eight of which were complicated with uterine anomalies, and in all cases the uterus was removed. Among the 10 obstructive cervical anomalies, there were three cases of cervical agenesis and seven cases of cervical dysgenesis, including five obliterated cervical os (cervical obstruction), one cervical fibrous cord, and one cervical fragmentation. CONCLUSION: ORTA can occur from the hymen to the lower segment of the uterus and requires surgical intervention. The preoperative evaluation is vital to guide proper surgery. MRI, with its imaging advantages, is the imaging technique of choice to assess the obstructed sites and complicated anomalies of ORTA.

[Imperforate hymen ­ an often missed diagnosis]. / Hymen imperforatus är en diagnos som ofta missas - Risk för långdragna symtom om adekvat undersökning inte genomförs.

Imperforate hymen - an often missed diagnosis Imperforate hymen is the most common congenital malformation in the female reproduction system that give rise to obstructive symptoms. If the diagnosis is not made in the newborn girl, symptoms often first arise at menarche. The diagnosis is easy to make but has to be suspected. This case reports describes the typical clinical picture of a late diagnosed imperforate hymen. As shown in this case and from a review of the literature, these girls often have symptoms for a long time before the diagnosis is made. Further, they are often initially misdiagnosed, and a thorough history and examination is seldom performed despite repeated contacts with the primary care.

Sonographic markers of ovarian morphology, but not hirsutism indices, predict serum total testosterone in women with regular menstrual cycles.

OBJECTIVE: To determine whether sonographic markers of ovarian morphology or male pattern hair growth scores predict androgen levels in women with regular or irregular menstrual cycles. DESIGN: Cross-sectional observational study. SETTING: Clinical research unit. PATIENT(S): Seventy-six women of reproductive age (18-39 years) were evaluated for male-pattern hair growth (using a modified Ferriman-Gallwey scoring system), ovarian morphology (by transvaginal ultrasonography), and total serum testosterone (T) (by liquid chromatography tandem mass spectrometry). INTERVENTION(S): Not applicable. MAIN OUTCOME MEASURE(S): Regional and total modified Ferriman-Gallwey scores, number of follicles per follicle size category, follicle number per ovary, ovarian volume, ovarian area, stromal to ovarian area ratio, stromal echogenicity index, total testosterone (total T), and menstrual cycle length. RESULT(S): Neither regional nor total modified Ferriman-Gallwey scores correlated with total T concentrations in women with regular or irregular menstrual cycles, as judged by the Least Absolute Shrinkage and Selection Operator technique. By contrast, a sonographic marker (follicle number per ovary 6-9 mm) significantly predicted total T concentrations in women with regular menstrual cycles but not in women with irregular menstrual cycles. CONCLUSION(S): Sonographic markers of ovarian morphology, but not hirsutism scores, predicted total T levels. However, the predictive value of ovarian morphology for total T differed by menstrual cycle status. That sonographic markers did not predict androgen levels in a diverse cohort of women with cycle irregularity suggests the potential for distinct variations in ovarian morphology for androgenic and nonandrogenic types of cycle irregularity. Overall, our findings support that an assessment of ovarian morphology may be helpful in reflecting total T levels.

Unique Case of Imperforate Hymen.

BACKGROUND: Imperforate hymen typically presents in adolescence with pain, hematocolpometra and primary amenorrhea. This case documents a previously unreported etiology for an atypical presentation with a history of recent menstruation. CASE: A female adolescent presented with symptoms of urinary retention and leg pain. She reported a history of irregular, painful menses. Clinical examination revealed a pelvic mass and imperforate hymen. Sonography was consistent with hematocolpometra. Before a planned hymenectomy, the patient began to pass dark blood through a fistulous opening in her vulva. Hymenectomy resulted in complete resolution of the pain and hematocolpometra. SUMMARY AND CONCLUSION: Identification of the fistulous tract explained the patient's history of menstrual bleeding despite an imperforate hymen. Spontaneous rupture of hematocolpometra through a fistulous tract to the vulva is a previously unreported atypical presentation of imperforate hymen in a "menstruating" adolescent with pain and a pelvic mass.

Transvaginal ultrasound assessment of women presenting with infertility and menstrual irregularity in Calabar, Nigeria.

AIMS AND OBJECTIVES: This study was designed to document the Transvaginal Scan (TVS) findings in women presenting with infertility and menstrual irregularities at the University of Calabar Teaching Hospital. MATERIALS AND METHODS: Subjects were women of reproductive age presenting at the University of Calabar Teaching Hospital with menstrual irregularities and infertility over a two year period, February 2011-January 2013. As part of their management, transvaginal scans were done and findings included a substantial number with polycystic ovarian cysts. Therefore the ovaries were further analysed with controls. RESULTS: Out of seventy-one women with age distribution of 22 to 46years, twenty- four(33.8%) presented with infertility, the rest presented with either menstrual irregularity alone or in combination with infertility. Polycystic ovaries (PCO), chronic pelvic inflammatory disease and fibroids were the main pathologies seen. PCO was by far the commonest. Ovarian volumes and follicular numbers were significantly higher in women with PCO than in controls, whereas their average follicular sizes were lower. CONCLUSION: PCO is the major finding in women with menstrual irregularity and infertility in the Calabar area. This hitherto poorly recorded pathology should be actively investigated in women representing with these symptoms by the use of TVS.

Emergency point-of-care ultrasound diagnosis of hematocolpometra and imperforate hymen in the pediatric emergency department.

A 12-year-old girl presented to the pediatric emergency department with a history of difficulty voiding and was found to have a firm, tender suprapubic mass on examination. Transabdominal emergency point-of-care ultrasound was used at the bedside to diagnose hematocolpometra due to an imperforate hymen. The diagnosis was confirmed by a comprehensive abdominal ultrasound and magnetic resonance imaging in the radiology suite. The patient was discharged on oral contraceptive medication and scheduled for an outpatient surgical hymenectomy following consultation with the gynecology service.

The utility of transrectal ultrasound in adolescents when transabdominal or transvaginal ultrasound is not feasible.

STUDY OBJECTIVE: To present the indications and diagnosis in adolescents undergoing transrectal ultrasound (RU). DESIGN: Retrospective chart review. PARTICIPANTS: Adolescents presenting to gynecology clinic between January 1, 2005 and December 31, 2012. MAIN OUTCOME MEASURES: Detection of RU, transvaginal, and transabdominal (AU) ultrasound indications, and final diagnosis. RESULTS: The main indications for RU were menstrual abnormalities, pelvic pain-dysmenorrhea, and vulvovaginitis. When compared according to final diagnosis adolescents with vulvovaginitis (13.9%) and amenorrhea (8.3%) were evaluated more with RU. CONCLUSION: RU is highly acceptable and it provides images superior to AU. It can be used in adolescents to visualize the pelvic organs and to exclude genital abnormalities and mass lesions.

Study of endometrial thickness by ultrasonography in regular and irregular menstrual cycles.

Endometrium is the mucosal layer of uterus. Throughout the reproductive age endometrium undergoes cyclical changes during each lunar month to prepare the uterus for implantation. Endometrium proliferates and regenerates during menstrual cycle. The most common cause of abnormal vaginal bleeding during a woman's reproductive years is dysfunctional uterine bleeding. Aim of this study was to compare endometrial thickness in regular and irregular menstrual cycles. A total of 111 patients with regular and irregular menstrual bleeding were selected. Age, duration of menstrual cycle, detailed menstrual history, endometrial thickness, difference in endometrial thickness before and after treatment were recorded. Endometrial thickness was recorded by ultrasonography. In patients with abnormal uterine bleeding, if endometrial thickness was less than 8mm first medical line of treatment was advised. If endometrial thickness was greater than 8mm, line of treatment depended on age and pattern of bleeding.