Isthmocele: an overview of diagnosis and treatment

SUMMARY An isthmocele, a cesarean scar defect or uterine niche, is any indentation representing myometrial discontinuity or a triangular anechoic defect in the anterior uterine wall, with the base communicating to the uterine cavity, at the site of a previous cesarean section scar. It can be classified as a small or large defect, depending on the wall thickness of the myometrial deficiency. Although usually asymptomatic, its primary symptom is abnormal or postmenstrual bleeding, and chronic pelvic pain may also occur. Infertility, placenta accrete or praevia, scar dehiscence, uterine rupture, and cesarean scar ectopic pregnancy may also appear as complications of this condition. The risk factors of isthmocele proven to date include retroflexed uterus and multiple cesarean sections. Nevertheless, factors such as a lower position of cesarean section, incomplete closure of the hysterotomy, early adhesions of the uterine wall and a genetic predisposition may also contribute to the development of a niche. As there are no definitive criteria for diagnosing an isthmocele, several imaging methods can be used to assess the integrity of the uterine wall and thus diagnose an isthmocele. However, transvaginal ultrasound and saline infusion sonohysterography emerge as specific, sensitive and cost-effective methods to diagnose isthmocele. The treatment includes clinical or surgical management, depending on the size of the defect, the presence of symptoms, the presence of secondary infertility and plans of childbearing. Surgical management includes minimally invasive approaches with sparing techniques such as hysteroscopic, laparoscopic or transvaginal procedures according to the defect size.

RESUMO A istmocele ou nicho uterino é representada por uma descontinuidade miometrial ou um defeito anecoico triangular na parede uterina anterior, com a base se comunicando com a cavidade uterina no local de uma cicatriz anterior de cesárea. O defeito pode ser classificado como pequeno ou grande, dependendo da espessura da parede miometrial deficiente. Embora geralmente assintomático, seu principal sintoma é o sangramento uterino anormal ou pós-menstrual; a dor pélvica crônica também pode ocorrer. Infertilidade, placenta acreta ou prévia, deiscência de cicatriz, ruptura uterina e gravidez ectópica em cicatriz de cesárea prévia também podem aparecer como complicações dessa condição. Os fatores de risco para desenvolvimento da istmocele comprovados até o momento incluem útero retroverso e múltiplas cesarianas. No entanto, fatores como localização mais inferior de uma cesárea prévia, fechamento incompleto da histerotomia, aderências precoces na parede uterina e predisposição genética também podem contribuir para o desenvolvimento de um nicho. Como não existem critérios definitivos para o diagnóstico de uma istmocele, vários métodos de imagem podem ser usados para avaliar a integridade da parede uterina e, assim, diagnosticar uma istmocele. Entretanto, ultrassonografia transvaginal e sono-histerografia com infusão salina surgem como métodos específicos, sensíveis e custo-efetivos para o diagnóstico de istmocele. O tratamento inclui manejo clínico ou cirúrgico, dependendo do tamanho do defeito, da presença de sintomas, da presença de infertilidade secundária e de planos de gravidez. O manejo cirúrgico inclui abordagens minimamente invasivas como histeroscopia, laparoscopia ou transvaginal, de acordo com o tamanho do defeito.

Sangrado y terapia hormonal en la menopausia (THM) / Bleeding during menopause hormone therapy (MHT)

La definición de sangrado ginecológico anormal durante terapia hormonal de la menopausia es aquel sangrado no programado durante el uso de la terapia. Este artículo es un pauteo que describe: 1) cuándo diagnosticar unsangrado anormal, ya que difiere según el tipo de esquema hormonal utilizado; 2) eldiagnóstico diferencial del origen del sangrado anormal; 3) los métodos de evaluación para diagnosticar el origen del sangrado. Se destacan los aspectos principales para el diagnóstico diferencial entre patología orgánica versus disrupción endometrial debida al tratamiento hormonal. Además, se describen los ajustes posibles para resolver el sangrado cuando éste se debe a disrupción del endometrio.

Abnormal bleeding related to menopausal hormone therapy is defined as unscheduled bleeding during the use of the therapy. This article outlines when to diagnose an abnormal bleeding -as this differs according to the type of hormonal scheme used-, the differential diagnosis of the origin of abnormal bleeding, and the methods of evaluation to assess the origin of the bleeding. The main aspects are highlighted on the differentiation of organic pathology versus disruption of the endometrium due to treatment. Also, treatment adjustments to resolve bleeding when it is due to disruption of the endometrium are outlined.

Malformación arteriovenosa uterina: a propósito de un caso / Arteriovenous uterine malformation: a case report

Paciente de 37 años que acudió a urgencias por metrorragia, G3P1A2, el último de ellos un aborto tardío en gestación gemelar monocorial biamniótica de 20 semanas hacía dos meses. En la ecografía destaca en zona miometrial un área de marcada vascularización de 67 x 45 mm. Tras descartar proceso residual gestacional y ante la sospecha de malformación arteriovenosa uterina se solicitó resonancia magnética nuclear y angiotac, tras confirmar la malformación vascular se programó para embolización de ambas arterias uterinas con el fin de preservar la fertilidad.

A 37-year-old patient came to the emergency due to metrorrhagia, G3P1A2, the last of them a late abortion in a 20 weeks monochorionic diamniotic twin pregnancy two months ago. Ultrasound revealed an intramiometrial area of 67 x 45 mm with increased vascularization area. A diagnosis of an arteriovenous malformation was considered. In order to confirm the diagnosis pelvic magnetic resonance and angiogram was performed. Once the vascular malformation was confirmed the patient was scheduled for transcatheter arterial embolization in order to preserve fertility.

Coriocarcinoma postgestacional / Post-pregnancy choriocarcinoma

El coriocarcinoma es una patología infrecuente pero potencialmente fatal si no se trata. Se incluye dentro de las neoplasias trofoblásticas gestacionales, un grupo de tumores malignos altamente invasivos, metastáticos y muy vascularizados. Su presentación tras una gestación a término conlleva peor pronóstico que tras un aborto o una mola hidatiforme porque refleja un retraso en el diagnóstico y tratamiento. Describimos el caso de una paciente que acudió al servicio de urgencias, refiriendo metrorragia escasa desde un parto normal hace dos meses y posteriormente presentó un sangrado grave durante su hospitalización. Los elevados niveles de β-hCG, la ecografía-Doppler, las pruebas de imagen y las manifestaciones clínicas fueron suficientes para diagnosticar un coriocarcinoma postparto. El tratamiento precoz con poliquimioterápicos permitió una evolución favorable de la paciente.

Choriocarcinoma is an infrequent disease but potentially fatal if untreated. It is included in trophoblastic gestational neoplasia, a range of malignant tumors highly invasive, metastatic and very vascular. Its presentation after term pregnancies carries a worse prognosis than after a miscarriage or a hydatidiform mole because it reflects a delay in diagnosis and treatment. We report the case of a patient who presented to the emergency department referring little metrorrhagia from a normal delivery two months ago and severe bleeding later during her hospital stay. The high serum β-hCG level, the Doppler ultrasonography, the imaging test and the clinical manifestation were enough to diagnose a non-metastatic postpartum choriocarcinoma. Early treatment with polychemotherapy allowed a favorable evolution of the patient.

Capacidad diagnóstica de la ecografía para detectar cáncer de endometrio en mujeres posmenopaúsicas sintomáticas y asintomáticas: experiencia de la universidad católica de chile / Diagnostic capability of ultrasound to detect endometrial cancer in postmenopausal women: experience of the catholic university of chile

Antecedentes: El 10 por ciento de las mujeres postmenopáusicas con sangrado uterino anormal (SUA) tendrán cáncer de endometrio. Se recomienda efectuar una biopsia endometrial en toda mujer postmenopáusica con SUA y grosor endometrial ecográfico >5 mm. Estudios recientes sugieren que el uso de un valor menor (3 mm) mejora la capacidad diagnóstica de la ecografía. En mujeres postmenopáusicas asintomáticas se ha sugerido efectuar biopsia endometrial si se detecta un endometrio >11mm. Objetivo: Determinar la capacidad diagnóstica de la ecografía para detectar cáncer de endometrio, utilizando los valores de corte de 3 y 5 mm en mujeres posmenopáusicas sintomáticas y de 11 mm en mujeres postmenopáusicas asintomáticas. Método: Revisión retrospectiva de biopsias de endometrio e historia clínica de mujeres atendidas en la Red de Salud UC (2007-2012). Resultados: Se analizó 132 casos, 63,6 por ciento presentaron SUA. Hubo 17 casos de cáncer de endometrio (12,9 por ciento), con un grosor endometrial promedio de 18 mm, el 8 por ciento presentó SUA. En mujeres sintomáticas la sensibilidad para el diagnóstico de cáncer de endometrio fue de 100 por ciento y de 93 por ciento para valores de corte 3 y 5 mm respectivamente. En mujeres asintomáticas, el punto de corte 11 mm, tuvo una sensibilidad de 50 por ciento y una especificidad de 65 por ciento para el diagnóstico de cáncer de endometrio. Conclusión: Recomendamos efectuar biopsia endometrial a toda mujer postmenopáusica con SUA y endometrio >3 mm. En postmenopáusicas sin SUA, no recomendamos la evaluación ecográfica endometrial de rutina.

Introduction: 10 percent of postmenopausal women with abnormal uterine bleeding (AUB) have endometrial cancer. Endometrial biopsy is recommended in all postmenopausal women with AUB and endometrial thickness >5 mm on ultrasound. Recent studies suggest that the use of a lower value (3 mm) improves the ability of ultrasound to detect endometrial cancer. In asymptomatic postmenopausal women, endometrial biopsy is recommended if the endometrial thickness is >11mm. Objective: To determine the diagnostic accuracy of ultrasound for detecting endometrial cancer, using a cutoff value of 3 and 5 mm in symptomatic and 11 mm in asymptomatic postmenopausal women. Methods: Retrospective review of endometrial biopsies and clinical history of women attending UC Health Network (2007-2012). Results: 132 cases were analyzed, 63.6 percent had AUB. There were 17 cases of endometrial cancer (12.9 percent), with a mean endometrial thickness of 18 mm. 88 percent of women with endometrial cancer had SUA. In symptomatic women the sensitivity for the diagnosis of endometrial cancer was 100 percent and 93 percent using a cutoff value of 3 and 5 mm respectively. In asymptomatic women, the cutoff value of 11 mm, had a sensitivity of 50 percent and a specificity of 65 percent for endometrial cancer. Conclusion: We recommend endometrial biopsy in all postmenopausal women with AUB and endometrial thickness >3 mm. In postmenopausal women without AUB we do not recommend routine endometrial ultrasound evaluation.

Evolución inusual de fibroadenomas mamarios múltiples en adolescente con metrorragia disfuncional / Unusual evolution of multiple breast fibroadenomas in adolescent with dysfunctional uterine bleeding

Se describe la inusual evolución de fibroadenomas (FA) mamarios múltiples en una adolescente de 11 años en tratamiento con progestinas cíclicas por metrorragia disfuncional. Inicialmente la ecografía mamaria mostró más de 10 lesiones sólidas en cada mama de hasta 2,6 cm, compatibles con fibroadenomas. Al cabo de 13 meses las lesiones se redujeron en número y tamaño. Se discute la historia natural de los FA, la influencia hormonal en la etiología de los FA y finalmente el diagnóstico ecográfico y manejo de este cuadro en la adolescencia. Se plantea, a modo de hipótesis, que existe un desbalance estrógeno-progesterona (E-P) dado por ciclos anovulatorios en el periodo posmenárquico, que se manifestó con metrorragia disfuncional y la presencia de FA. Al administrar progesterona cíclica se reequilibra la relación E-P explicando el control del ciclo y la involución de las lesiones mamarias.

We describe the unusual evolution of multiple fibroadenomas (FA) in a 11-years old adolescent during treatment of an abnormal uterine bleeding with cyclic progestins. Inicially ultrasound demonstrated more than 10 masses in each breast, up to 2,6 cm diameter, compatible with fibroadenomas. After 13 month follow up lesions decreased in number and size. We discuss the natural history of FA, the hormonal influence in FA etiology, the ultrasound diagnosis and the managment of this pathology in adolescents. We hypothesized that there is an estrogen/progestin imbalance, due to the anovulatory cycles of the post menarche period that caused the AUB and FA. Cyclic progesterone balanced the E/P relation, thus managing both AUB and causing regression of the breast masses.

Malformación arterio-venosa uterina y hemorragia obstétrica: diagnóstico y manejo en tres casos clínicos / Uterine arteriovenous malformation and obstetric hemorrhage: diagnosis and management in three cases

Las malformaciones vasculares uterinas son muy infrecuentes y se presentan asociadas a metrorragia con riesgo vital. Su incidencia no es conocida porque las series son de pocos casos. Presentamos tres pacientes con hemorragia obstétrica cuyo estudio diagnóstico con ultrasonido y angiografía, demostró malformación arteriovenosa uterina. En un caso, dada la extensión de la lesión, el tratamiento fue con embolización bilateral de arterias uterinas seguida de histerectomía. Otras dos pacientes, por preservación de fertilidad, fueron sometidas solo a embolización. La evolución clínica y las imágenes confirmaron que los procedimientos fueron exitosos. Se discute la importancia de la interpretación correcta de las imágenes para el diagnóstico, la adaptación de los métodos terapéuticos al caso individual y el manejo multidisciplinario.

The uterine vascular malformations are very infrequent and associated to maternal hemorrhage with vital risk. The incidence is unknown because the published series are little with few cases. We described three cases with obstetrical hemorrhage and the image study with ultrasound and angiography showed an arteriovenous malformation. One patient, for the extensive lesion, was treated with bilateral embolization of uterine arteries and then, histerectomy. The others patients, for preservation her fertility, were treated with embolization only. The clinical evolution and the vascular images study confirm the success of the procedures. We discuss the importance of images analysis for the diagnosis, the individual application of therapeutic methods and a multidisciplinary approach for this scope.

Pólipo endometrial, una causa infrecuente de sangrado genital anormal en la adolescencia / Endometrial polyp, a rare cause of abnormal genital bleeding in adolescence

Antecedentes: El sangrado genital anormal es una causa frecuente de consulta en la adolescencia. En este período, la principal causa de sangrado es la metrorragia asociada a ciclos anovulatorios producto de la inmadurez del eje hipotálamo-hipofisario-gonadal. Dentro de las causas infrecuentes de sangrado genital anormal en ese período está el pólipo endometrial. Caso clínico: Presentamos el caso de una niña de 13 años cuya causa de sangrado correspondió a un pólipo endometrial, sospechado por ultrasonografía, resecado mediante histeroscopia y confirmado mediante estudio histológico. Discusión: Pese a su baja incidencia, los pólipos endometriales deben ser considerados como parte del diagnóstico diferencial en adolescentes que consultan por trastorno menstrual, particularmente en aquellos casos sin respuesta a la terapia hormonal y donde la ultrasonografía muestra engrosamiento endometrial.

Background: Abnormal genital bleeding is a common cause of medical consultation in patients during adolescence. In this period, the main cause of genital bleeding is metrorrhagia in relation to anovulatory cycles due to immaturity of hypothalamus- pituitary-gonadal axis. Among the uncommon causes of bleeding at this age is the endometrial polyp. Case report: We report a 13 year old girl with abnormal uterine bleeding due to endometrial polyp, suspected during a pelvic ultrasound, removed by hysteroscopy, and confirmed by histological analysis. Discussion: Despite its low incidence, endometrial polyps should be included in the differential diagnosis of adolescents presenting menstrual disorders, particularly in those with no response to hormonal therapy and endometrial thickness in ultrasound.

Adenocarcinoma de endometrio de patrón sertoliforme / Sertoliform carcinoma of the endometrium

Se presenta el caso de una paciente que consultó por metrorragia posmenopaúsica. En la biopsia histeroscópica dirigida se informó de adenocarcinoma de endometrio endometrioide bien diferenciado. Se practicó histerectomía, doble anexectomía y lavados peritoneales. Durante el acto quirúrgico se valoró el grado de infiltración miometrial, que al revelar afectación del útero hasta la serosa, implicó la realización de linfadenectomía de espacios pélvicos y paraaórtico. El diagnóstico definitivo anatomopatológico fue de adenocarcinoma de endometrio tipo endometrioide de patrón sertoliforme moderadamente diferenciado. El estadío FIGO fue IIIA, por lo que se indicó quimioterapia y radioterapia como tratamiento adyuvante. A los 2 años la paciente presenta recidiva ganglionar y metástasis pulmonares con progresión a pesar del tratamiento quimioterápico, por lo que finalmente fallece.

We report a case of a patient with postmenopausal bleeding. In hysteroscopic directed biopsy was reported endometrioid endometrial adenocarcinoma well differentiated, so that she underwent total hysterectomy, both salpingo-oophorectomy and peritoneal washings. In the surgery, we evaluated the miometrial infiltration, with report invasion until serosa, so we practised pelvic and paraaortic lymphadenectomy. The pathologic diagnosis was sertoliform endometrioid carcinoma of the endometrium with moderate differentiation. The FIGO stage was IIIA, and we indicated chemotherapy and radiotherapy. Two year after, the patient presented nodal recurrence and lung metastases with no response to the chemotherapy drugs, so she dies.

Tumores müllerianos mixtos malignos uterinos / Uterine malignant mixed mullerian tumors

Los tumores müllerianos mixtos malignos o carcinosarcomas son neoplasias poco frecuentes y altamente agresivas que suelen presentarse en pacientes mayores de 60 años, generalmente en forma de metrorragia posmenopáusica y/o presencia de masas uterinas. Entre los factores de riesgo reconocidos está descrita la historia de irradiación previa del área pélvica. Presentamos 3 casos clínicos de pacientes diagnosticadas y tratadas de tumores müllerianos mixtos uterinos malignos, existiendo en todos ellos el antecedente de neoplasias que habían precisado radioterapia pélvica como parte de su tratamiento.

The malignant Mullerian mixed tumors are rare and highly aggressive, these tumors usually occur in women over 60 years and the most common clinical appearance is that of postmenopausal vaginal bleeding or the presence of uterine mass. As a risk factor is described the history of prior irradiation of the pelvic area. We reported the case of three patients with mullerian mixed tumors, in all these cases the patients have a history of cancer who required pelvic radiation as part of their treatment.

Cicatriz da cesariana: implicações ginecológics e aspectos atuais / Cesarean scar: gynecologic implications and current aspects

A cicatriz de cesariana como causa de morbidades ginecológicas, algo até pouco tempo ignorado pelos ginecologistas, é atualmente foco de importante discussão. O aumento atual da via abdominal para o parto faz desse tópico um assunto de extrema importância no cotidiano médico. O sangramento pós-menstrual sem causa aparente tem, na maioria das vezes, a cicatriz de cesariana como fator causal. Pode ocorrer, também, o comprometimento da fertilidade ou pela dificuldade de implantação embrionária ou pela piora da qualidade do muco cervical, em razão do sangramento uterino anormal. Discute-se, hoje em dia, qual o melhor método para o diagnóstico das alterações uterinas decorrentes da cicatriz de cesárea. A investigação pode ser feita inicialmente pela utrassonografia transvaginal, mas a histeroscopia tem maior acurácia além de permitir o tratamento específico. Em todas as situações, a investigação e o bom planejamento terapêutico só podem ser feitos quando o ginecologista conhece bem essa afecção.

The cesarean scar as cause of gynecological morbity, fact that used to be ignored by gynecologists, is the subject of an important discussion nowadays. The current increase in the number of abdominal delivery makes this subject a constant in our daily pratice. The post-menstrual uterine bleeding without an apparent cause has, in the majority of cases, the cesarean scar as only predisponent factor. There might also be infertility due to the difficulty of embryonic implantation or to the presence of the blood making the cervical mucus hostile. Currently, there is a discussion on the best method for the diagnosis of uterine alterations due to cesarean scar. The investigation may be initially accomplished by means of transvaginal ultrasound, but only the hysteroscopy may be precise in the diagnosis and allow specific treatment. In all situations, the investigation and adequate therapeutic planning can only be made if the gynecologist has ample knowledge on this pathology.

[Placenta percreta: a rare aetiology of metrorrhagies in the first and second trimesters of pregnancy about two cases and review literature]

The placenta percreta is an abnormal placentar adhesion with invasion of all the uterine wall with sometimes an extension to the organs bordering the womb by chorial villiosities. It is a pathology rarely diagnosed during the first trimester of pregnancy. We report in this work two cases of placenta percreta diagnosed in the first trimester of pregnancy in the A service of the centre of maternity and of neonatology of Tunis. After a review of the literature we tried to make lignt on risk factors inherent to this pathology and to propose a practical behaviour. The first patient of the study was 28 years old, with bicicatricial uterus. She was admitted in urgency for abundant metrorragies in the tenth week of pregnancy, A molar pregnancy was suspected and an attempt of uterin evacuation failed. In front of the importance of bleeding an haemostais hysterctomy was made. The second patient was 39 years old, and had as antecedents of cures of uterine synechy. She was admitted in the 19[th] week of pregnancy, for a late abortion. In front of the complete placentar retention and the aggravation of bleeding, the diagnosis of placenta accreta was evoked and a haemostasis hysterectomy was realized. In both cases histological exam confirmed peroperative discoveries and concluded the diagnosis of placenta percreta. The difficulty of the management of the placenta percreta is due to the fact that this pathology is almost always met in a unexpected way in an urgent context. Antenatal diagnosis is recently described as possible in the first trimester of pregnancy

[Epitheloid leiomyosarcoma of the uterine cervix. About two cases]

The epithelioid Ieiomyosarcoma of the uterine cervix is a rare tumor. Usually, the presenting symptoms are vaginal bleeding and pelvic pain. Surgery is the standard treatment. To present the characteristic of this rare pathology by mean of two cases handled in the Institut Salah AzaIz. Two patients, aged 51 and 42 years, were referred to our institution for vaginal bleeding. Tumors were classified stage II proximal and H distal [FIGO classification modified by Gustave Roussy Institute].The patients had total hysterectomy with pelvic lymph node dissection. Histological exams confirmed the diagnosis of epitheloid leiomyosarcoma of the uterine cervix. Adjuvant external radiotherapy was performed. At 12 and 36 months, the patients are alive with no evidence disease

Clinical manifestations of benign ovarian tumours

To examine the cases of Benign Ovarian Tumours and their clinical manifestations. Prospective study of consecutive cases of Ovarian tumours, identified using gynaecological case records. Tertiary care teaching hospital affiliated with Fatima Jinnah Medical College Lahore, managing more than 1500 gynaecological cases annually. 50 cases of Ovarian tumours managed in Department of Gynaecology and Obstetrics Sir Ganga Ram Hospital, Lahore between 1st May 2004 to 1st May 2005. The most common presenting complaints were abdominal pain or discomfort and palpable tumour causing abdominal distension. Abdominal pain was present in 70% of benign ovarian tumours. 20% of the patients had pain due to torsion of ovarian cyst. The complaint of a palpable tumour was found in 4 7% of cases. Vague abdominal and bowel complaints were present in 2 2.5% of cases. 6[15%] patients were asymptomatic. Of these 2 were diagnosed by ultrasound and 3 at the time of emergency Cesarean section and one on routine pelvic examination. Menstrual irregularity and urinary complaints were present in a small number of patients. None of the patient complaint of weight loss or post menopausal bleeding. Benign Ovarian Tumours are most common cause of ovarian enlargement and a very common cause of hospital admission. Symptoms and signs are non specific and presentation is a late stage

Alternativa quirúrgica en la hemorragia grave del puerperio / Surgical alternative int he serius hemorrhage of puerperium

Se presenta caso clínico de una paciente de 32 años de edad, primípara, puérpera de cesárea, con diagnóstico de inercia uterina refractaria a tratamiento médico, se comenta manejo y técnica quirúrgica conservadora.

Histeroscopía quirúrgica / Surgical hysteroscopy

Se presentan 42 histeroscopias quirúrgicas, la mayoría corresponden a pólipos endometriales y miomas submucosos, causantes de sangramiento uterino anormal. Se enfatiza la eficacia del procedimiento y se discute la utilidad del uso del misoprostol para facilitar la dilatación cervical

Vigilancia endometrial y terapia de reemplazo hormonal / Endometrial surveillance and hormonal replacement therapy

Se revisa la literatura en el tema de vigilancia endometrial respecto de la ecografía transvaginal, histerosonografía, biopsia aspirativa e histeroscopia. Se propone un flujograma de manejo ante alteración de flujo rojo y terapia de reemplazo hormonal

El útero doble asociado a hemivagina ciega y agenesia renal homolateral en adolescentes: evaluación de 12 casos / Double uterus associated with blind hemivagina and ipsi lateral renal agenesis: evaluation of 12 cases

La duplicidad completa del canal útero-vaginal asociado a la obstrucción de una de las dos hemivaginas con agenesia renal homolateral (Wunderlich-Herlyn-Werner Syndrome) es una malformación mülleriana infrecuente. Los síntomas dependen de la obstrucción y de la posible existencia de comunicaciones entre los dos canales; pero en casi todos los casos el dolor cíclico es el síntoma predominante. La presencia de menstruaciones normales confunde y retrasa el diagnóstico. Material y métodos: se revisaron 12 casos de adolescentes portadoras de éste síndrome que consultaron en nuestro servicio entre 1992 y 1998, con una edad entre 13-20 años. En todas se realizó historia clínica, exámen pélvico completo y ecografía. En 4 casos se completó con RMN; además en todas se constató la agenesia renal por ecografía o pielografía. En todos los casos se removió el septo vaginal por vía transvaginal, mientras que en algunas (8 casos) por vía translaparoscópica se comprobó la presencia o no de endometrosis, infección u otras secuelas en el aparato genital. Resultados: el 100 por ciento consultó por dolor abdominal o pelviano de intensidad variable, el 25 por ciento presentó también pérdidas intermenstruales o metrorragias de poca intensidad, el 100 por ciento presentaban masa pelviana paravaginal de tamaño variable, el 50 por ciento presentaban antecedentes quirúrgicos recientes en relación a sus cuadros dolorosos (apendicectomías, anexectomías y quistectomías de ovario). En la mitad de los casos el diagnóstico fue realizado con mucho retraso después de la menarca. La corrección quirúrgica empleada remitió los síntomas en el 100 por ciento. Dos de estas pacientes se embarazaron con posterioridad al tratamiento con buena evolución del embarazo y parto por cesárea, una de ellas prematuramente en la semana 32, la otra con dos embarazos a término. Discusión: ésta anomalía mülleriana debe ser siempre considerada en adolescentes con menstruaciones regulares, algomenorrea progresiva y masa pelviana paravaginal. En ésta presentación se discuten las dificultades diagnósticas existentes así como la conducta terapeútica necesaria que como hemos comprobado si se implementa con rapidez, logra que no se comprometa la fertilidad futura

Patologías ginecológicas frecuentes en pediatría / Frequent gynecologic pathologies in pediatrics

Los problemas ginecológicos en las diferentes edades de las pacientes pediátricas constituyen una patología que el pediatra debe manejar adecuadamente, diferenciando las situaciones normales o fisiológicas, de las que requieren mayor estudio o control de la evolución. En este artículo, el médico encuentra una útil orientación y recuerdo de la fisiología para el enfrentamiento de trastornos frecuentes, de las cuales a veces las madres por diferentes razones no consultan o la adolescente con dificultad llega a la consulta