Alteración ecográfica del endometrio en mujeres menopáusicas sin metrorragia

Objective

To determine the incidence of endometrial cancer in asymptomatic postmenopausal women with a sonographic endometrial thickness above 5 mm.

Materials and methods

We performed a retrospective study of 270 asymptomatic postmenopausal women with endometrial thickness > 5 mm on sonography. All women underwent hysteroscopy with histological evaluation if required. The incidence of endometrial cancer was evaluated.

Results

Five cases of endometrial cancer were diagnosed in the 270 women, representing an incidence of 1.85%. Of the 106 patients with a sonographic image leading to suspicion of polyp, four were diagnosed with endometrial cancer (3.77%), all of which were stage I tumors. None of the 270 women was receiving hormone replacement therapy.

Conclusions

The incidence of endometrial cancer in asymptomatic postmenopausal women with sonographic suspicion of polyp was 3.77%. Patients with this sonographic finding should undergo thorough hysteroscopy and biopsy to rule out malignancy. We believe that the cut-off value for endometrial thickness in postmenopausal women without vaginal bleeding should be determined.     

Campaña de lucha contra el cáncer de cuello uterino en Guinea-Bissau. Estudio de las citologías de un trimestre

Objective

To study 300 cytologies from a single trimester, within a campaign against uterine cervical cancer in Guinea-Bissau.

Design

We compared 300 cytologies from Guinea-Bissau with 880 cytologies performed in a single month in autochthonous women attending our hospital for vaginal infections and cervical lesions.

Results

Significant differences between women in Guinea-Bissau and autochthonous women were found in Trichomonal infection (2% versus 0,34%, respectively; P < .001) and in low-grade squamous intraepithelial lesions (2% versus 0,68%, respectively; P = .05). One case of cervical cancer was detected in a 75-year-old multiparous woman. The mean number of deceased children in these women was 2 (range 1-8).

Conclusions

To avoid both cervical cancer and neonatal mortality, a permanent program for the early detection of cervical cancer in Guinea-Bissau is clearly needed, together with family planning, prenatal care and obstetric assistance.     

Self-collection for high-risk HPV detection in Brazilian women using the careHPV™ test

Objective

Cervical cancer is the second most common cancer among Brazilian women. High-risk human papillomavirus (hr-HPV) persistence is the primary cause of cervical neoplasia. Early detection of hr-HPV is important for identifying women at risk for developing cervical lesions. Approximately 85% of new cases of cervical cancer worldwide and 50% of the total cervical cancer deaths occurred in developing countries. Here, a new methodology to support a cervical cancer screening program was evaluated in women from various Brazilian regions.

Methods

Two thousand women aged 18–77 years were enrolled in an opportunistic cervical cancer screening program and were randomized into self-vaginal or health professional-guided cervical sampling groups. The Qiagen careHPV™ test was performed on all samples. Pap tests were performed on all women using liquid-based cytology.

Results

Positive hr-HPV results were obtained in 12.3% (245/2000) of women; similar rates were observed in self- or health professional-collected samples. Eighty-nine percent (1719/2000) of cervical cytologies classified as normal were negative to hr-HPV. Among the cytological samples, 36.6% classified as ASC-US + were positive to hr-HPV, 78.8% were LSIL and 75.0% were HSIL.

Conclusions

Self-sampled and health professional-sampled vaginal/cervical specimens did not differ in their rates of detection of hr-HPV. Therefore, HPV DNA testing in self-sampled vaginal cells is an alternative to primary screening in low-resource settings.     

Selektive Östrogenrezeptormodulatoren (SERM)

Background

Selective estrogen receptor modulators (SERMs) belong to a heterogeneous, nonsteroidal drug class that have estrogenic or anti-estrogenic properties, respectively.

Indications

Drug-specific indications are breast cancer treatment (tamoxifen), osteoporosis prevention and therapy (raloxifene, bazedoxifene), and infertility treatment (clomiphene). Furthermore, in some countries, tamoxifen and raloxifene are approved for breast cancer prevention in high-risk women. The newly approved combination of bazedoxifene and conjugated estrogens is an interesting possibility for the treatment of postmenopausal women suffering from vasomotor symptoms and presenting simultaneously an increased osteoporosis and breast cancer risk. A promising SERM is ospemifene which was approved by the U.S. Food and Drug Administration in 2013 for dyspareunia due to postmenopausal vaginal atrophy.

     

Laser-skinning colpectomy for extended vaginal intraepithelial neoplasia and microinvasive cancer

Objective

The aim of this study is to analyze the efficacy of colposcopic-guided laser-skinning colpectomy to treat extended high-grade vaginal intraepithelial neoplasia (VaIN).

Methods

Retrospective review of 33 heavily pretreated patients with high-grade VaIN extending over 20–100% of the vaginal surface treated between 2003 and 2013 with colposcopic-guided laser-skinning colpectomy. The vaginal epithelium including all VaIN lesions was excised in one piece with a depth of 2–3 mm.

Results

Vaginal cancer was diagnosed in 10 patients (nine microinvasive squamous cell carcinoma and one vaginal carcinoma). No serious adverse events related to laser-skinning colpectomy were observed. Of 33 patients, 23 were followed up with cytology and colposcopy for at least 12 months at our institution (median follow 26.5 months; range 12–104 months), while five had a shorter follow-up, four an external follow-up and one patient was lost. Of 23 patients with follow-up ≥ 12 months, 20 were disease free after a single laser-skinning colpectomy (overall cure rate 87.0%). Moderate shortening of the vagina was observed in two patients and another two required reconstruction of vaginal strictures during long-term follow-up.

Conclusion

Laser-skinning colpectomy appears to be a feasible treatment for extended high-risk VaIN3. The procedure avoids the mutilation associated with colpectomy and allows early diagnosis and staging of invasive disease.     

Valoración ecográfica del endometrio en pacientes tratadas con tamoxifeno

Objective

To measure endometrial thickness and characterize ultrasonographic endometrial images induced by tamoxifen, as well as to determine changes in ultrasonographic patterns throughout treatment.

Patients and methods

We analyzed 278 patients with breast cancer between 1995 and 2000 under adjuvant therapy with tamoxifen for 5 years. Annual ultrasonographic examination was performed. Endometrial thickness and the morphological endometrial patterns in stored ultrasonographic images were retrospectively analyzed.

Results

Endometrial thickness significantly increased during treatment from a mean of 7.84 mm in the first year to 16.67 mm in the fifth year. Five endometrial patterns were found on ultrasonography in patients receiving tamoxifen: linear, heterogeneous-hyperechoic, homogeneoushyperechoic, endometrial polyp, and suspicious for malignancy. The homogeneous-hyperechoic pattern predominated in the first year and the heterogeneous-hyperechoic pattern in the fifth year.

Conclusions

Tamoxifen increases endometrial thickness in the course of treatment and induces five ultrasonographic patterns which change year-by-year.     

Ensayo clínico aleatorizado para evaluar la eficacia y seguridad de la administración de 25 μg de misoprostol por vía vaginal frente a 50 μg por vía sublingual para la inducción del trabajo del parto en gestantes con diabetes

Objective

To evaluate the safety and efficacy of misoprostol 50 μg administered sublingually versus 25 μg administered vaginally for labor induction at term in pregnant women with diabetes.

Methods

Three hundred pregnant women with diabetes were randomly allocated to receive misoprostol 25 μg vaginally or 50 μg sublingually every 4 hours up to 4 doses. The main variable assessed was the rate of vaginal deliveries in 24 hours.

Results

Vaginal delivery in 24 hours was achieved in 109/150 (72.7%) women in the sublingual group and in 104/150 (69.3%) in the vaginal group, with no statistically significant differences (p = 0.611; RR = 1.176; 95% CI for RR, 0.714-1.938). Tachysystole was significantly more frequent in the sublingual misoprostol group (RR = 0.474; 95% CI for RR, 0.233-0.968). The indications for cesarean section were similar in both groups. Uterine rupture occurred in one patient in the sublingual group who was administered the third misoprostol dose in the active phase of labor.

Conclusions

No statistically significant differences were found in the vaginal delivery rates between sublingual and vaginal misoprostol, although adverse effects were more frequent with the sublingual route.     

Associations with asymptomatic colonization with candida in women reporting past vaginal candidiasis: an observational study

Objective

Asymptomatic vaginal colonization with Candida species is a known risk factor for vulvovaginal candidiasis (VVC). Taking known risk factors for symptomatic VVC, the authors sought to identify factors associated with asymptomatic colonization.

Study design

As part of a randomized controlled trial which compared vaginal candidal colony counts in women taking garlic tablets or placebo, 192 asymptomatic women collected a baseline screening swab for Candida species. Eligibility for this study included at least one self-reported episode of VVC in the previous 12 months and age 18–50 years. Known risk factors for VVC were compared in women colonized with candida and those without colonization.

Results

37% of asymptomatic women who self-reported VVC in the previous 12 months were colonized with vaginal Candida species. Using multivariate analysis, two factors were associated with asymptomatic colonization: a current sexual partner (P = 0.02) and being born outside of Australia (P = 0.05). Use of oral contraceptives was not statistically significant (P = 0.27).

Conclusions

Clinical relevance of asymptomatic colonization with vaginal yeast and its link to episodes of VVC warrants further investigation.     

Incidence of corneal abrasions during pelvic reconstructive surgery

Objectives

To compare the incidence of corneal abrasions after robotic/laparoscopic sacral colpopexies versus vaginal apical suspensions, and to determine risk factors associated with the development of corneal abrasions.

Study design

This retrospective cohort study included all women undergoing robotic/laparoscopic sacral colpopexy or vaginal apical suspensions over a 5-year period. The incidence of corneal abrasions was compared between groups and statistical analysis was performed.

Results

5/216 (2.3%) patients developed corneal abrasions in the sacral colpopexy group compared to 1/332 (0.3%) in the vaginal group (p = 0.04). Eye protection was more frequently documented in the sacral colpopexy group compared to the vaginal group (98.6% vs. 83.4%, p < 0.001). Women in the sacral colpopexy group were younger, with longer operating times, more intravenous fluids, and lower estimated blood loss. Risk factors for corneal abrasion could not be identified due to the low number of patients with corneal abrasions.

Conclusion

More corneal abrasions occurred with laparoscopic and robotic sacral colpopexy compared to vaginal apical suspension procedures. Risk factors could not be identified in this study.     

Preoperative genetic testing affects surgical decision making in breast cancer patients

Objectives

Our aim was to determine if BRCA mutation status changes surgical decision making in women who undergo genetic testing after the diagnosis of breast cancer.

Methods

This is a retrospective cohort study of breast cancer patients who had BRCA mutation testing performed prior to surgery. We compared surgical choice and change in surgical choice in women who tested positive for a BRCA mutation with those who tested negative. Surgery was considered the most definitive surgery within a year of diagnosis. Other data collected included age, race, stage, histology, receptor status, adjuvant treatment, gravity, parity, and family history. Variables were compared by BRCA status using Fisher's exact test and logistic regression.

Results

Three hundred and two women were included. Thirty-two (10.6%) were identified as carrying a BRCA mutation. Most women had early stage disease (55.6% T1 lesions, 72.8% node negative); 55.6% had breast-conserving surgery, and the remaining had unilateral or bilateral mastectomy. BRCA mutation carriers were more likely to have both a personal history of breast cancer (RR 2.74, 95% CI = 1.08–6.98) and hormone receptor-negative tumors (56.0% vs. 26.2%, p = 0.002). BRCA mutation carriers were more likely to choose bilateral mastectomy with reconstruction (56.3% vs. 15.9%, p < 0.0001); 71.9% of BRCA mutation carriers opted for a different surgery than what was initially planned by their surgeon as compared to 29% of mutation-negative patients (p < 0.0001).

Conclusions

BRCA mutation testing strongly influences surgical decision making in newly diagnosed breast cancer patients. For women who meet NCCN referral guidelines, genetic evaluation should be performed prior to surgical intervention.     

Effects of vaginal discharge on female sexual function

Objective

To assess the effects of vaginal discharge on female sexual dysfunction (FSD) by using the Female Sexual Function Index (FSFI).

Methods

In a study at a university hospital in Canakkale, Turkey, women affected by vaginal discharge and age-matched healthy control women were recruited between January and December 2012. Women were grouped in accordance with their vaginal discharge complaints and each participant completed the FSFI questionnaire.

Results

A total of 114 women were included in the study. Women in the first group (n = 58) had no vaginal discharge or had physiologic vaginal discharge, those in the second group (n = 29) had abnormal vaginal discharge with itching, and those in the third group (n = 27) had abnormal vaginal discharge without itching. Compared with the first group, women in the second and third groups had higher FSFI scores for desire, arousal, orgasm, and pain, in addition to higher overall FSFI scores. Women with genital malodor had significantly higher FSFI scores than patients without genital malodor (23.83 ± 5.07 vs 21.15 ± 4.78; P = 0.008).

Conclusion

Women with abnormal vaginal discharges were found to have better FSFI scores for some domains. This finding may be attributed to the adverse effects of sexual intercourse on vaginal infections.     

Continence outcomes following partial excision of vaginal mesh exposure after mid-urethral tape insertion

Objective

To assess the incidence of recurrent stress urinary incontinence (SUI) following vaginal excision of exposed mid-urethral tape (MUT).

Study design

This was a retrospective observational study in a tertiary urogynaecology unit of an inner city teaching hospital. The population consisted of 41 consecutive women seen with a vaginal mesh exposure following MUT insertion between 2000 and 2009, which failed to resolve with conservative measures. The primary outcome measure was the presence of symptoms of stress urinary incontinence following surgical excision of exposed mesh.

Results

The incidence of recurrent SUI following tape excision was 34.1%. Type of mid-urethral tape, menopausal status, and the time interval between tape insertion and excision were not found to be significantly associated with the risk of recurrent SUI.

Conclusions

Over a third of women experience recurrent SUI after surgical management of vaginal mesh exposure following MUT insertion. Risk factors may be more comprehensively studied using prospectively collected cohorts.     

Endometrial polyps in obese asymptomatic pre and postmenopausal patients with breast cancer: Is screening necessary?

Objective

To evaluate the prevalence of endometrial polyps in obese asymptomatic pre and postmenopausal patients with breast cancer and to know if a baseline pretamoxifen endometrial assessment should be taken into consideration in these women at high risk.

Methods

A cross-sectional study was carried out with 201 women with breast cancer. A diagnostic hysteroscopy was performed in all women. All formations suspected as polyps were removed. The prevalence of endometrial polyps was analyzed in all patients (n = 182) and in premenopausal (n = 49) and postmenopausal (n = 118) women with estrogen receptor (ER) positive breast cancer (BC) according to their body mass index (BMI) and other risk factors.

Results

Hysteroscopic evaluation was possible in 182 cases (90.5%). Of the total of women, 160 (87.9%) were ER(+)BC patients, 133 (73.1%) postmenopausal women and 41.5% were obese (BMI ≥ 30 kg/m²). Endometrial polyps were found in 52 cases (28.5%) (3 cases of simple hyperplasia harbored within a polyp). In premenopausal patients with ER(+)BC, there were no statistical differences in endometrial polyps according to their BMI (22.3% in non-obese women vs 31.7% in obese) while in all patients (26.4% in non-obese vs 44.0% in obese) and in postmenopausal women with ER(+)BC (25.9% in non-obese vs 48.6% in obese) there were statistical differences. In all women the relative risk (RR) of endometrial polyps in obese patients was 2.24 (1.01–4.83), in obese postmenopausal women with ER(+)BC was 2.75 (1.01–7.40) and in obese premenopausal patients with ER(+)BC was 1.42 (0.80–3.29).

Conclusions

Asymptomatic women with breast cancer have a high prevalence of baseline subclinical endometrial polyps and it is very high in obese postmenopausal patients with estrogen receptor positive breast cancer. Therefore, there may be a future role for baseline pretamoxifen screening of some sort for the obese asymptomatic postmenopausal patient, especially if they are elderly and ER positive.     

Ensayo clínico,aleatorizado y controlado para evaluar la eficacia y la seguridad de la administración de 25 μg de misoprostol vaginal frente a 50 μg de misoprostol sublingual para la inducción del trabajo del parto

Objectives

To compare the safety and efficacy of 25 μg of vaginal misoprostol versus 50 μg of sublingual misoprostol for induction of labor.

Patients and methods

Four hundred fifty women were randomly assigned to receive 25 μg of vaginal misoprostol or 50 μg of sublingual misoprostol every 4 h for up to four doses. The main outcome assessed was the number of vaginal deliveries in 24 h.

Results

A total of 155/225 (68.9%) patients in the sublingual group and 154/225 (68.4%) women in the vaginal group delivered vaginally (p = 0.920; RR = 1.021; 95% CI for RR, 0.685-1.521). The mean time (± standard deviation) for starting labor was 2.75 ± 2.20 h in the sublingual group and 3.8 ± 2.77 h in the vaginal group (p < 0.001). The mean number (± standard deviation) of doses was 1.9 ± 0.8 in the vaginal group and 1.6 ± 0.8 in the sublingual group (p = 0.010). Indications for cesarean section and the frequency of tachysystole were similar in both groups. There was a greater need for oxytocin in the vaginal group (22.7%) than in the sublingual group (14.7%) (p = 0.020).

Conclusions

No statistically significant differences were found between the 2 treatment groups in the main variable: the number of vaginal deliveries in 24 h.     

Pectineal ligament suspension of prolapsed vaginal vault

Objective

To report on a collective pectineal ligament suspension experience acquired over 12 years in India with 119 women who presented with prolapsed vaginal vault. The feasibility and effectiveness of the procedure was assessed for the open and laparoscopic routes.

Methods

The prolapsed vaginal vault was suspended unilaterally to the pectineal ligament using polyester tape at 3 urban and 3 rural hospitals. The procedure was done through a Cherney incision in 104 women. In the remaining 15 women, it was done laparoscopically at a single urban center.

Results

There were no intraoperative complications. The mean follow-up was 5.5 years (range, 0.5–12 years). Only 2 women had vaginal prolapse recurrence, at 3 and 5 years. Two had asymptomatic tape erosion, at 2 and 5 years, and a mild cystocele appeared in 5 women and a low rectocele in 4. However, none of these women required further vaginal surgery during their follow-up period.

Conclusion

The present study demonstrates the long-term safety and effectiveness of pectineal ligament suspension for vaginal vault prolapse by the open and the laparoscopic routes. As it was done by surgeons of varying experience at centers with varying resources, the procedure can be readily mastered by any gynecologic surgeon.     

Comparison of urine and self-collected vaginal samples for detecting human papillomavirus DNA in pregnant women

Objective

To investigate the utility of urine sampling for detecting human papillomavirus (HPV) DNA among pregnant women and to compare HPV DNA detection in urine with detection in vaginal samples.

Methods

In a cross-sectional study, urine and vaginal samples were self-collected from pregnant women attending prenatal care at Hospital Divina Providencia, Frederico Westphalen, Brazil, between October 2006 and August 2007. Part of the L1 region of the HPV genome was amplified via GP5⁺/bioGP6⁺ primers. Positive urine was genotyped for high-risk HPV genotypes (HPV16, HPV18, HPV31, HPV33, HPV39, HPV45, and HPV59).

Results

During the study period, urine samples were obtained from 133 pregnant women, 63 of whom also self-collected vaginal samples. HPV DNA was detected in 54.0% (34/63) and 61.9% (39/63) of urine and vaginal samples, respectively. HPV infection was significantly associated with first intercourse at younger than 20 years of age (P = 0.008). There was substantial agreement in HPV DNA test results between the urine and vaginal samples (κ value, 77.3%; P < 0.0001). HPV31 and HPV16 accounted for 80.7% of the oncogenic types identified.

Conclusion

Detection of HPV DNA in urine showed good agreement with detection in self-collected vaginal samples, indicating that urine might be a reliable sample for HPV testing among pregnant women.     

Comparison of four malignancy risk indices in the preoperative evaluation of patients with pelvic masses

Objective

The aim of this study was to evaluate the ability of four malignancy risk indices (RMI 1, RMI 2, RMI 3, and RMI 4), incorporating menopausal status, serum CA125 levels, and ultrasound findings, to discriminate a benign from a malignant pelvic mass.

Study design

This is a retrospective study of 253 women admitted to the Department of Obstetrics and Gynecology of Kochi Medical School, between January 2002 and April 2005 for surgical exploration of pelvic masses. To diagnose ovarian cancer, the sensitivity, specificity, and positive predictive value of serum CA125, ultrasound findings and menopausal status were taken separately and combined into RMI 1, RMI 2, RMI 3, and RMI 4.

Results

This study confirms that, for the diagnosis of malignancy, four malignancy risk indices were more accurate than menopausal status, serum CA125 levels, and ultrasound findings separately. The accuracy of the RMI 4 was better than RMI 1 (P = 0.0013), RMI 2 (P = 0.0009) and RMI 3 (P = 0.0013). The RMI 4 at a cutoff level of 450 yielded a sensitivity of 86.8%, a specificity of 91.0%, a positive predictive value of 63.5%, a negative predictive value of 97.5%, and an accuracy of 90.4%.

Conclusion

We found that, in the discrimination between benign and malignant pelvic disease, the RMI 4 method was more reliable than RMI 1, RMI 2 and RMI 3. The RMI 4 method is a simple technique that can be used in gynecology clinics as well as less-specialized centers.     

Sexual dysfunction after a first trimester induced abortion in a Chinese population

Objective

To evaluate the short-term effect of a first trimester induced abortion on sexuality in a Chinese population.

Study design

This is a cross-sectional study. One hundred and four women attending the post-abortion clinic 3–4 months after a first trimester induced abortion were recruited. They completed a self-administered questionnaire anonymously. The associations of various factors with sexual behavior after abortion were analyzed by the Chi-square test.

Results

More than 30% of the women reported a reduction in both frequency of vaginal intercourse and sexual desire. Their partners also had a reduction in sexual desire. The reduction of vaginal intercourse is more significant among young, unmarried women and those not having sterilization (P = 0.01). In addition, the prevalence of reduction in sexual desire and enjoyment among those women who had repeated abortion was significantly higher (P < 0.01).

Conclusion

The sexuality of both women and their partners are affected after abortion. It may be due to both psychological trauma and the worry of another unwanted pregnancy. Proper counseling may relieve their anxiety and improve sexual lives.     

Cáncer de mama en la mujer joven

Objective

To review the characteristics of breast cancer in young women.

Material and methods

The scientific literature was reviewed, indicating the etiological factors, diagnostic methods and treatment options, with special reference to the factors that can concur in young patients such as premature menopause, loss of fertility, pregnancy after breast cancer and breast cancer during pregnancy.

Results

Importantly, breast cancer in young women is very rare but is on the increase. Tumors are larger in young women and have positive margins, making the disease more aggressive and leading to higher mortality. Diagnosis is more difficult than in older women and the triple test (mammography, ultrasound and biopsy) is of great importance. Treatment options are the same as in older women.

Conclusions

Breast cancer in young women shows certain characteristics that differentiate it in some respects from breast cancer diagnosed in older women.