Hrgović Z, Kulas T, Habek D, Izetbegović S, Hrgović I.

Univerzistetska Ginekoloska klinika J.W. Goethe Univerzitet, Frankfurt, Njemacka.

Myoma accounts for nearly 95% of all benign tumors of female genital organs and is the most common neoplasm of female genital tract. Along with thorough history and gynecologic examination, ultrasound study is of utmost importance in the diagnosis of myoma; magnetic resonance (MR) study may also be required in rare cases. A number of therapeutic options are available for the management of myoma, ranging from medicamentous therapy through operative procedures (e.g., total or supracervical hysterectomy or myoma enucleation) and novel non-operative procedures (e.g., embolization of uterine artery (EUA) and magnetic resonance guided focused ultrasound (MRgFUS). Discomforts caused by a myoma are an absolute indication for treatment. Therapeutic option to be chosen is determined by the number, size and location of myomas, and the patient's preferences. Therapeutic choice should rely on the patient's decision for or against treatment, sparing the uterus. An individualized treatment protocol should be tailored for each patient.

Three-dimensional power Doppler ultrasound scanning for the prediction of endometrial cancer in women with postmenopausal bleeding and thickened endometrium. Alcazar JL, Galvan R.

Department of Obstetrics and Gynecology, Clinica Universitaria de Navarra, University of Navarra School of Medicine, Pamplona, Spain.

OBJECTIVE: The purpose of this study was to evaluate the role of 3-dimensional power Doppler angiography (3D-PDA) to discriminate between benign and malignant endometrial disease in women with postmenopausal bleeding and thickened endometrium. STUDY DESIGN: Ninety-nine postmenopausal women (median age, 63.1 years; range, 48-84 years) with uterine bleeding and a thickened endometrium (>or= 5 mm) at baseline transvaginal sonography were assessed by 3D-PDA before endometrial biopsy. Endometrial volume, vascularity index (VI), flow index, and vascularity-flow index were calculated with the virtual organ computer-aided analysis method. RESULTS: Histologic diagnoses were endometrial cancer (44 cases), hyperplasia (13 cases), polyp (23 cases), cystic atrophy (14 cases), and submucous myoma (5 cases). Endometrial volume, VI, and vascularity-flow index were significantly higher in malignant vs benign conditions. Receiver operating characteristic analysis revealed that VI was the best parameter for the prediction of endometrial cancer. CONCLUSION: The findings show that 3D-PDA may be useful for the prediction of endometrial cancer in women with postmenopausal bleeding and thickened endometrium at baseline sonography.

Transvaginal radiofrequency thermal ablation: a day-care approach to symptomatic uterine myomas. Cho HH, Kim JH, Kim MR.

Department of Obstetrics and Gynecology, Catholic University Medical College, Seoul, South Korea.

BACKGROUND: In patients with myoma, the traditional surgical treatment of choice is myomectomy for women who wish to retain their uterus. However, myomectomy must be performed under general anaesthesia, and the patient requires a long time to recover. AIMS: In the present study, we report our experience with a group of patients who underwent transvaginal radiofrequency (RF) thermal ablation of uterine myomas, with emphasis on the safety and efficacy of this procedure. METHODS: Premenopausal women with symptomatic uterine myoma or recently growing myoma were included in this study. The pre- and postoperative myoma volumes were measured by 3D ultrasonography. The impact of the symptoms on health-related quality of life (HRQL) was assessed using the Uterine Fibroids Symptom and Quality of Life questionnaire. RESULTS: The mean initial size of the dominant myoma was 5.3 cm (standard deviation +/- 1.58). The reoperation rate was 4.3%. The final reduction rate of the volume of the dominant fibroid was 73%. The symptom scores and HRQL scores showed great improvement after 18 months of myolysis. CONCLUSIONS: The results of this study suggest that RF ablation may represent a safe, well-tolerated, and effective day-care alternative to conventional surgery for the treatment of uterine myomas.

Leiomyomata uteri: hormonal and molecular determinants of growth. Blake RE.

Department of Obstetric and Gynecology, Howard University College of Medicine, Washington, DC, USA.

OBJECTIVE: To review the available English literature that examines the biology of leiomyoma uteri in African-American women and other ethnic groups. Factors that influence the growth and development of leiomyomas are examined to understand the basis for larger myomas in African-American women. DESIGN: Literature review of 176 articles regarding the pathobiology of leiomyoma in various ethnic groups. RESULTS: The initiating factor(s) associated with the transformation of a normal myometrial cell into a leiomyoma cell remain(s) to be determined. Epidemiological studies have confirmed that different ethnic groups develop leiomyomas. However, African-American ethnicity is a risk factor for the development of leiomyomas. Studies have examined diet, genetics, hormonal, growth, enzymatic and molecular determinants of myoma biology, with critical advances in some of these areas. The best radiological tools to identify and monitor leiomyomas are ultrasonography and/or magnetic resonance imaging. Evidence supports progesterone and growth factors (e.g., transforming growth factor-B), have significant impact on the development of leiomyomas. CONCLUSIONS: Early monitoring and intervention should become standard for African-American women who are at greater risk for developing leiomyomas. There are plausible biological mechanisms that explain the predisposition for developing larger leiomyomas in African-American women as compared with other ethnic groups.

Predictors of leiomyoma recurrence after laparoscopic myomectomy. Yoo EH, Lee PI, Huh CY, Kim DH, Lee BS, Lee JK, Kim D.

Department of Obstetrics and Gynecology, East West Neo Medical Center, KyungHee University Medical College, 149 Sang-II Dong Kang-Dong Gu, Seoul, Korea.

STUDY OBJECTIVE: To evaluate recurrence and reoperation rate after laparoscopic myomectomy in relation to risk factors and identify suitable candidates for laparoscopic myomectomy to decrease recurrence. DESIGN: Multicenter retrospective cohort study (Canadian Task Force classification II-2). SETTING: Five university hospitals and a university-affiliated teaching hospital. PATIENTS: Five hundred and twelve women who underwent laparoscopic myomectomy between 1995 and 2004. All patients had a follow-up with clinical examination and transvaginal sonography for a median 13 months after surgery. INTERVENTION: Laparoscopic myomectomy. MEASUREMENTS AND MAIN RESULTS: Recurrence was defined as the appearance of a leiomyoma on ultrasound examination or identification of leiomyoma during subsequent surgery after the initial surgery. Cox regression (full model) analysis of the possible risk factors for recurrence followed by a stepwise variable selection was performed to eliminate confounding factors. The cumulative probability of leiomyoma recurrence increased steadily during the follow-up period, 11.7% after 1 year, 36.1% after 3 years, 52.9% at 5 years, and reached 84.4% at 8 years. The cumulative probability of reoperation for recurrent leiomyoma was much lower: 6.7% at 5 years and 16% at 8 years. Significant risk factors that were independently associated with cumulative recurrence were age, preoperative number of myoma, preoperative uterine size by pelvic examination, presence of associated pelvic disease, and delivery after laparoscopic myomectomy. The operative time and change of hematocrit were associated with the reoperation. Those who had fewer than 2 myomas before surgery, uterus size less than 13 gestational weeks measured by pelvic examination, no childbirth after laparoscopic myomectomy, and age at index surgery less than 35.5 years showed the lowest recurrence after laparoscopic myomectomy from Classification and Regression trees analysis. CONCLUSION: The risk of recurrence of leiomyoma after laparoscopic myomectomy is linked with the age, preoperative number of leiomyoma, preoperative uterine size, presence of associated pelvic disease, and childbirth after surgery.

Three-dimensional power Doppler in the evaluation of painful leiomyomas and focal uterine thickening in pregnancy. Degani S, Tamir A, Leibovitz Z, Shapiro I, Gonen R, Ohel G.

Ultrasound Unit, Department of Obstetrics and Gynecology, Bnai-Zion Medical Center, Ruth and Baruch Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel.

Objective: To determine the usefulness of 3-dimensional (3D) power Doppler ultrasound in distinguishing painful leiomyomas from focal myometrial contractions or nonpainful leiomyomas in pregnancy. Methods: A 2D section of the area of interest in the uterine wall was first obtained in 29 patients to determine whether the pain originated from a myoma or a uterine contraction. Then, volume acquisition was activated and Doppler indices (vascularization index, flow index, and vascularization-flow index) were calculated for thickened and normal uterine wall. Results: Of 15 patients found to have uterine myomas, 11 had multiple tumors and 4 had single tumors. In the remaining 14 patients the painful uterine thickening proved to be a focal contraction. Painful segments of uterine thickening were associated with lower Doppler indices. Painful myomas were found to have significantly lower indices than normal uterine wall (P=0.008, 0.03, and 0.01 for VI, FI, and VFI, respectively, vs. 0.001, 0.003, and 0.01). However, the differences in indices between nonpainful myomas and uterine wall on the one hand, and nonpainful myomas and focal uterine contractions on the other, were not statistically significant. Conclusion: Three-dimensional power Doppler ultrasound may be a sensitive and reliable tool for distinguishing painful uterine myomas from focal myometrial contractions and nonpainful myomas.

*** Flexible outpatient hysterofibroscopy without anesthesia: a feasible and valid procedure. Wang CJ, Mu WC, Yuen LT, Yen CF, Soong YK, Lee CL.

Division of Gynecologic Endoscopy, Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Taipei, ROC.

BACKGROUND: To evaluate the feasibility and validity of a large series of outpatient diagnostic hysteroscopies using a 4.9 mm flexible hysterofibroscope without anesthesia. METHODS: In this observational clinical study, 2033 consecutive women referred with various indications underwent an outpatient hysteroscopy without analgesia or anesthesia. A 4.9 mm flexible hysterofibrescope (Olympus Corporation, Shinjuku-ku, Tokyo, Japan) was used to perform the examination. The diagnostic efficacy and patient tolerance were evaluated. RESULT: The whole procedure was finished within 3 minutes. The hysteroscopy could not be completed in 41 (2.2%) women. Three hundred sixty-six patients (18.0%) required cervical dilatation before insertion of the hysteroscope. Severe discomfort including vagal reflex and ascending infection occurred in 4 (0.19%) women. Normal results were found in 60.1% of women with premenopausal and 59.3% with postmenopausal abnormal uterine bleeding. In women who underwent transvaginal ultrasound and hysteroscopic examination concomitantly, the accuracy of ultrasound diagnosis of an intrauterine mass was 83.3%, and the predictive rate for submucosal myoma was significantly higher than that for endometrial polyps (91.2% vs. 76.2%, p = 0.001). Correlation between histological and hysteroscopic diagnoses showed the accuracy of hysteroscopic diagnosis of submucosal myoma was higher than that for endometrial polyps (81.3% vs. 68.4%, p = 0.034). Physiologic endometrial changes were misdiagnosed as endometrial hyperplasia more often than they were misdiagnosed as endometrial cancer (39.5% vs. 4.2%, p = 0.027). CONCLUSIONS: Low failure and complication rates indicate that flexible hysterofibroscopy is feasible when performed in an outpatient setting without anesthesia. Extensive experience and histological confirmation are necessary for accurate endometrial evaluation.

The use of levonorgestrel - IUD in the treatment of uterine myoma in Thai women. Jindabanjerd K, Taneepanichskul S.

Department of Obstetric and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand.

OBJECTIVE: This study was designed to evaluate the potential usefulness of the levonorgestrel-releasing intrauterine device (LNG - IUD ; Mirena) in treating women with uterine myomas. DESIGN: Prospective before-and-after (comparing) study. SETTING: Department of Obstetrics and Gynecology King Chulalongkorn Memorial Hospital. SUBJECTS: Sixteen women with uterine myomas who intended to receive treatment with the LNG IUD. INTERVENTION(S): Clinical and ultrasound examinations were performed prior to and at 1, 3 and 6 months after the LNG IUD insertion. MAIN OUTCOME MEASURES: Myoma and Uterine volume, menstrual blood loss assessed with pictorial blood loss assessment charts and hematocrit. RESULTS: Use of the LNG IUD was associated with a statistically significant reduction in the total myoma volume, average uterine size and marked reduction in menstrual blood loss. After 6 months of use, the median total myoma volume decreased from 19.82 mL to 11.63 mL (p < 0.05), median pictorial blood loss assessment chart score declined from 89 to 3 (p < 0.05). Hematocrit level increased over 6 months of use. The most common side effects were bleeding disturbances (68.8%). No pregnancies occurred during the study. CONCLUSION: The LNG IUD was associated with a profound reduction in myoma and uterine volume. For women with myomas of this size, the LNG IUD provides effective medical treatment of bleeding.

Efficacy of office diagnostic hysterofibroscopy. Chang CC.

E-Da Hospital of Kaohsiung County, Taiwan.

STUDY OBJECTIVE: To evaluate the feasibility and efficacy of hysterofibroscopy as an office diagnostic tool. DESIGN: Prospective cohort study (Canadian Task Force classification 3.PA-3.QZ). SETTING: Private university hospital as a tertiary referral medical center. PATIENTS: All the patients referred to the hospital for diagnostic hysterofibroscopy were enrolled in this study, irrespective of their indications, from January 2002 through December 2004. INTERVENTIONS: All diagnostic hysterofibroscopy procedures were performed on an outpatient basis and without analgesics or anesthetic. MEASUREMENTS AND MAIN RESULTS: Feasibility of hysterofibroscopic diagnosis was evaluated by: (1) the ability of the hysterofibroscope to pass through the cervical canal; (2) the quality of vision in the uterine cavity; (3) the severity of pain experienced by the patients; and (4) the complications of the procedures. If an intrauterine mass was revealed during the procedure, the patient was referred for further transcervical resectoscopy (TCR). The efficacy of the hysterofibroscopic diagnosis was evaluated by comparison with the histopathologic diagnosis after the TCR. Overall 2111 patients were enrolled in this study; 78 (3.69%) patients did not complete the procedures because of cervical stenosis, intractable pain during dilation, or poor visibility in the uterine cavity. Of the 2033 remaining, the postprocedure complication rate was low, with only 8 (0.38%) patients experiencing severe vagal reflex with dizziness and nausea and another 35 (1.66%) patients suffering from a short period of moderate to severe uterine contractile pain after the completion of procedures. In this study, 634 (31.19%) patients had submucosal myoma or endometrial polyps and needed additional TCR. The diagnostic accuracy of hysterofibroscopy was 74% in comparison with a traditional histopathologic examination. The most common diagnostic errors happened between the diagnosis of endometrial polyp and the submucosal myoma. CONCLUSION: Hysterofibroscopy is feasible for the investigation of the uterine cavity in an outpatient setting without anesthesia with acceptable reliability, although some confusion may occur when differentiating between endometrial polyps and submucosal myoma. Postprocedural complications were mostly attributed to vigorous dilation of the cervix.

Three-dimensional hysterosonography versus hysteroscopy for the detection of intracavitary uterine abnormalities. Makris N, Kalmantis K, Skartados N, Papadimitriou A, Mantzaris G, Antsaklis A.

First Department of Obstetrics and Gynecology, University of Athens, Alexandra Hospital, Athens, Greece.

OBJECTIVE: To compare 3-dimentional hysterosonography (3-DHS) and diagnostic hysteroscopy for the evaluation of intrauterine lesions. METHODS: In this prospective study 124 women with suspected intrauterine abnormality on 2-D ultrasonography or on hysterosalpingography were scheduled to undergo hysteroscopy, 3-DHS, and 3-D power Doppler (3-DPD) examination. However, 3-DHS could not be performed in 3 of the women because of cervical stenosis. The sensitivity and specificity of 3-DHS and 3-DPD were compared with those of hysteroscopy. RESULTS: Of the 121 women found to have an intracavitary abnormality, 20 had polyps, 11 had myomas, 2 had Müllerian duct anomalies, and 6 had synechiae on hysteroscopy. There was agreement between hysteroscopy and 3-DHS in 19 of the polyp cases, 11 of the myoma cases, 2 of the Müllerian anomaly cases, and 4 of the synechiae cases. Examination with 3-DHS and 3-DPD reached a sensitivity of 91.9% and specificity of 98.8%, with a positive predictive value of 97.1% and a negative predictive value of 96.5%, respectively. CONCLUSIONS: Examination with 3-DHS and 3-DPD both allows for accurate assessment of intrauterine abnormalities.

Sonohysterography versus transvaginal sonography for screening of patients with abnormal uterine bleeding. Alborzi S, Parsanezhad ME, Mahmoodian N, Alborzi S, Alborzi M.

Department of Obstetrics and Gynecology, Shiraz University of Medical Sciences, Shiraz, Iran.

OBJECTIVES: To compare the accuracy of saline infusion sonohysterography (SIS) with transvaginal sonography (TVS) for the screening of causes of abnormal uterine bleeding (AUB) in out-patients. METHODS: 81 patients with AUB were studied. All cases who were examined with TVS, were further investigated with SIS using saline as contrast medium, finally hysteroscopy was used as the gold standard. RESULTS: TVS had sensitivity of 72%, specificity of 92%, positive predictive value of 94% and negative predictive value of 65%, while SIS had sensitivity of 94.1%, specificity of 95%, positive predictive value of 96% and negative predictive value of 90%. TVS had kappa measure of agreement of 0.60 while 0.86 was reported for SIS. CONCLUSIONS: In this study SIS was more sensitive and specific in diagnosing polyp, myoma and adenomyosis with high positive and negative predictive value. Furthermore, results obtained by SIS demonstrate more agreement with that obtained by hysteroscopy than TVS.

Transvaginal ultrasound for diagnosis of adenomyosis: a review. Dueholm M.

Department of Gynecology and Obstetrics, Aarhus University Hospital, DK-8000 Aarhus, Denmark.

The objective of this chapter is to relate the image findings of transvaginal ultrasound (TVS) to structural changes of adenomyosis; in order to clarify the present clinical diagnostic approach in the diagnosis of adenomyosis, the performance of TVS is evaluated in comparison to other diagnostic modalities. A Medline search of papers in English on the use of TVS and needle biopsy for the diagnosis of adenomyosis was carried out. It was found that TVS is highly observer-dependent, but in the hands of experienced investigators it has an adequate diagnostic accuracy in clinically suspected cases. The diagnostic accuracy of TVS is at an intermediate level but is in line with that of magnetic resonance imaging (MRI) in unselected patients without myomas undergoing surgery. TVS is a sufficiently accurate tool for diagnosis of adenomyosis in clinically suspected cases, but not in unselected premenopausal women with myomas. Resectoscopic hysteroscopic biopsy has not been sufficiently evaluated but could be a useful diagnostic tool, whereas needle biopsy is not. In conclusion, in clinically suspected adenomyosis cases TVS should be favoured as the primary diagnostic tool. Substantial experience and specific training is required for TVS to be a useful diagnostic tool in adenomyosis. MRI may be considered when TVS is inconclusive. Clinicians should above all be observant of image findings of adenomyosis in patients with no wish to preserve fertility.

Complications in laparoscopic myomectomy. Altgassen C, Kuss S, Berger U, Löning M, Diedrich K, Schneider A.

Department of Obstetrics and Gynaecology, University of Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany.

BACKGROUND: An increasing number of patients with fibroids wish to retain their uterus without improving fertility. We evaluated the rate of complications in our teaching hospital and its association with patients' age. METHODS: Chart records of 351 patients were evaluated according to patients' age. RESULTS: A total of 654 fibroids were removed. Mean size of fibroids was 5.3 cm; mean duration of surgery was 113.2 min. Blood transfusion was necessary in one patient. The intraoperative complication rate was 2.6% and postoperative complications occurred in 5.7% of patients. Sonographic evaluation showed a hyperechogenic scar in 29.2%. A total of 57.1% pregnancies ended in term infants. No uterine rupture was reported. As a sign of contentment, 87% of patients would choose the same procedure again. Indication for myomectomy in elder women was more often associated with uncertain sonographic findings due to intraligamentary localization. CONCLUSION: Morbidity was low. Age had no impact. Laparoscopic myomectomy can be offered to all women.

[Uterine endosonography with sterile serum infusion in infertile women] [Article in Bulgarian]

Pŭnevska M.

Infusion of sterile serum in the uterine cavity during ultrasound examination is useful for investigation bout polyps, submucous myoma, adhesion and anatomical malformation. Examination of the patients with ultrasound is suitable to be with medicine in the infusion, menometrorrhagia sterility, all changes in the endometrium. Contraindications: genital infection, pregnancy, neoplasma of cavum uteri. Techniques: investigation was between 7th and 12th day of the cycle. We used insemination catheter to put in the cervical canal. There is a syringe with infusion on the other end. The speculum was took of the vagina and put on the transducer. We performed examination of the uterus in the different scans. When the infusion was fulfilled the avum uteri we observed different findings. 24 patients with sterility were passed for ultrasound examination with sterile serum for the period of 1 year (2003–2004). We diagnosed normal cavum uteri thiken endometrium, endometrial polyp, submucous myoma amd malformation uteri.

Transcervical resection of myoma in treatment of hysteromyoma, experience in 962 x\cases.] [Article in Chinese]

Xia EL, Duan H, Huang XW, Zheng J, Yu D.

Hysteroscopy Center, Fuxing Hospital, Beijing 100038, China.

OBJECTIVE: To study the technique and effect of transcervical resection of myoma (TCRM) in treatment of hysteromyoma. METHODS: 962 women suffering type 0 hysteromyoma (n = 281), 316 type 1 hysteromyoma (n = 316), type 2 hysteromyoma (n = 282), submucous and intramural myoma (n = 34), cervical myoma (n = 11), prolapse myoma (n = 23), and adenomyoma (n = 15) underwent TCRM with “five-step technique”, monitored by B-ultrasound or laparoscopy, Follow-up lasted more than 6 months. RESULTS: The primary operation successful rate was 99.77%. The mean size and depth of uterus were 7.44 +/- 1.3 gestation weeks and (8.31 +/- 1.43) cm, the diameter of the biggest myoma was 7.2 cm. The mean weight of the resected tissues was (22.63 +/- 31.41) g, and the mean operation time and blood loss during the operation were 32.50 +/- 172.72 minutes and (7.75 +/- 19.49) ml. No transfusion was needed. The complications included postoperative fever (3 cases), uterine bleeding (1 case), uterine perforation (1 case), and TURP syndrome (2 cases). Postoperative scanty menstrual rate was 100% in the type 0 hysteromyoma group, 99.1% in the type I hysteromyoma group, 94.02% in the type II hysteromyoma group, 100% in the cervical myoma and prolapse myoma group, 84% in the multiple myoma and intramural myoma group, and 87% in the adenomyoma group respectively. The alleviation rates of dysmenorrhea and anemia were 78% and 82.95% respectively. Those who have severe complications of internal medicine showed obvious improvement. The residual myoma of 2 cases were resected during the secondary operation 9 days and 3 months after the primary operation. 455 cases (52.17%) resumed their work in 1 month postoperatively. 32 living infants were delivered. CONCLUSION: Safe and highly effective, TCRM can be the first choice in treatment of submucous and intramural hysteromyoma.

The significance of intrauterine lesions detected by ultrasound in asymptomatic postmenopausal patients. Lev-Sagie A, Hamani Y, Imbar T, Hurwitz A, Lavy Y.

Department of Obstetrics and Gynecology, Hadassah University Hospital-Mt. Scopus, Jerusalem 91240, Israel.

A retrospective study on 82 women with an incidental sonographic finding suspected to be intrauterine polyps was undertaken to assess the histopathologic characteristics of such polyps utilising operative hysteroscopy. Endometrial polyps were found in 68 patients, submucousal myomas in 7, atrophic endometrium in 6 and thickened proliferative endometrium was found in 1 patient. Simple hyperplasia was found in one polyp but neither endometrial carcinoma nor complex hyperplasia was found. The total complication rate was 3.6%. It appears that the risk of endometrial carcinoma in postmenopausal women with asymptomatic endometrial polyps is low, although a larger series is required to confirm this finding.

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