Aspects particuliers des myomes utérins en IRM multimodale en milieu tropical / Features of uterine myomas explored with multimodal MRI in a tropical environment

Objectif. Décrire les caractéristiques de la prise en charge des myomes utérins dans une unité d'IRM multimodale en Afrique subsaharienne. Matériels et méthodes. Étude transversale descriptive rétrospective, d'une durée de 08 mois, réalisée au service d'imagerie médicale de l'hôpital mère enfant de Bingerville. Nous avons inclus les patientes dont le motif et ou les résultats des examens faisaient mention de myomes utérins. Les paramètres étudiés étaient l'âge des patientes, le motif d'examen et les résultats de l'examen d'IRM. Résultats. Nous avons recruté 103 patientes. Leur âge moyen était de 40 ans. Dans 95,1% des cas, les indications portaient sur la cartographie et l'exploration des myomes utérins déjà connus. Les myomes étaient de découverte fortuite dans 5% des cas. Les myomes étaient uniques dans 9% et en nombre supérieur à 5 dans 61% des cas. Ils étaient majoritairement hyalins, en isosignal homogène T1 FSE (86%), en hyposignal homogène T2 PROPELLER et diffusion (97%) avec rehaussement homogène (85%). Il y avait des complications dégénératives dans 12% des cas et mécaniques dans 3% des cas. Elles étaient corrélées à un nombre de myomes supérieur à 5 (p=0,05), mais pas à la taille des myomes ni à l'âge des patientes. Les pathologies pelviennes associées (53%) étaient : lésions ovariennes non tumorales (45%), adénomyose (30%) et cancer du col utérin (25%). Conclusion. À Abidjan, les myomes utérins sont une pathologie de la femme en activité génitale, en période préménopausique. L'IRM est utilisée quasi exclusivement en seconde intention après l'échographie pour la cartographie préopératoire ou pré embolisation. La découverte de pathologies associées dont le cancer du col, devrait faire préférer l'IRM pour toute exploration diagnostique et pré thérapeutique

Objective. To describe the characteristics of the management of uterine myomas in a multimodal MRI unit of Sub-Saharan Africa. Methods. This was a cross sectional retrospective descriptive study of eight months duration that was carried out in the medical imaging department of the mother and child hospital in Bingerville. The patients whose indications and/or results of the MRI mentioned uterine myomas were included. The parameters studied were the age of the patients, the reason and the results of the MRI examination. Results. We studied 103 patients. Their average age was 40 years. In 95.1% of the cases, the indications were for mapping and exploring already known uterine myomas. Incidental myomas accounted for 5%. The myomas were unique in 9% and more than 5 in 61%. They were mostly hyaline, in homogeneous T1 FSE isosignal (86%), in homogeneous T2 PROPELLER and diffusion hyposignal (97%) with homogeneous enhancement (85%). Degenerative complications were noted in 12% and mechanical complications in 3%. They were correlated with a number of myomas greater than 5 (p=0.05) but not with size of myomas or age of patients. Associated pelvic diseases (53,4%) were mainly non tumoral ovarian lesions (45%), adenomyosis (30%) and cervical cancer (25%). Conclusion. In our setting, uterine myomas affect mainly the genitally active woman in the premenopausal period. MRI is used almost exclusively as a second line after ultrasound, for preoperative or preembolization mapping. The discovery of associated pathologies, including cervical cancer, should make MRI preferable for all diagnostic and pre-therapeutic exploration.

Sangrado Uterino Anormal: hallazgos ecográficos / Abnormal Uterine Bleeding: ultrasound findings

Describir los hallazgos ecográficos de las pacientes que acudieron por sangrado uterino anormal al servicio de Ginecología y Obstetricia del Hospital Dr. Domingo Luciani durante el período enero 2021 a enero 2022. Métodos: Estudio observacional-descriptivo, de tipo retrospectivo. Muestra no probabilística e intencional, integrada por 99 pacientes. Variables involucradas: edad, raza, paridad, antecedentes personales, ciclo menstrual, duración del período menstrual, fecha última de menstruación, uso de algún medicamento, método anticonceptivo y hallazgos ecográficos. Resultados: Los hallazgos ecográficos evidenciaron diferentes causas que explican el sangrado uterino anormal de las pacientes que integraron la muestra de estudio; las tres más frecuentes fueron: miomatosis uterina, sangrado uterino anormal por leiomioma o por endometrio, sangrado uterino anormal tipo L y tipo E(AU)

Objective: To describe the ultrasound findings ofpatients who came for abnormal uterine bleeding to theGynecology and Obstetrics service of the Dr. Domingo LucianiHospital during the period January 2021 to January 2022.Methods: This was an observational-descriptive, retrospectivestudy. The sample was non-probabilistic and intentional,consisting of 99 patients. The data were collected in an Excelsheet for analysis to determine their percentage frequencyaccording to the variables involved: age, ethnicity, parity,personal history, menstrual cycle, duration of menstrual period,last date of menstruation, use of some medication, contraceptivemethod and ultrasound findings. Results: The ultrasoundfindings showed different causes to explain the abnormal uterinebleeding of the patients who made up the study sample; however,the three most frequent were: uterine myomatosis, sangradouterino anormal tipo L y tipo E(AU)

Bloqueio do Nervo Hipogástrico Superior (BNHS) para o manejo da dor após Embolização de Artérias Uterinas (EAU): revisão de literatura / Superior Hypogastric Nerve Block (SHNB) for pain management in Uterine Artery Embolization (UAE): a literature review

Introdução: a embolização de artérias uterinas (EAU) é uma opção terapêutica no tratamento de miomas uterinos sintomáticos; todavia, a dor pós-procedimento representa um grande desafio para essa técnica. Nesse contexto, o Bloqueio do Nervo Hipogástrico Superior (BNHS), já utilizado no tratamento de dor pélvica crônica associada à malignidade, apresenta-se como opção de intervenção intraprocedimento para melhorar a recuperação das pacientes e fomentar o uso da EAU na prática clínica. Objetivo: realizar uma revisão integrativa da literatura disponível sobre o BNHS no manejo de dor pós EAU. Métodos: bases de dados PubMed, The Cochrane Library, Lilacs e Medline foram avaliadas a partir da combinação dos termos "uterine artery embolization", "pain" e "superior hypogastric block". Foram incluídos estudos clínicos, disponíveis em texto completo, com pacientes adultas, submetidas à EAU, cujo objetivo era avaliar o uso do BNHS e seu impacto na dor pós-procedimento. Foram excluídos artigos de revisão, carta ao editor, e publicação em anais de congresso. Resultados: 8 artigos, em maior parte retrospectivos, indicaram consistência do BNHS em termos de sucesso terapêutico a curto prazo e redução da dor. Apenas uma complicação foi relatada, e evoluiu de forma satisfatória. Conclusões: BNHS tem potencial de aprimorar o manejo da dor após EAU, podendo impactar positivamente no tempo e na qualidade da recuperação, com redução da dor e consumo de opiodes no período pós-operatório. Esses benefícios valorizam o procedimento de embolização como uma alternativa a ser considerada no tratamento de leiomiomas sintomáticos para mulheres candidatas à preservação uterina.

Introduction: Uterine Artery Embolization (UAE) is a therapeutic option in the treatment of symptomatic uterine fibroids; however, post-procedure pain imposes as a great challenge in this technique. In this context, the Superior Hypogastric Nerve Block (SHNB), already used in the treatment of chronic pelvic pain associated with malignancy, presents itself as an option for intraprocedural intervention, to improve patients' recovery and to promote UAE in the clinical setting. Objective: to perform an integrative literature review about the effectiveness of SHNB in pain management after UAE. Methods: databases PubMed, The Cochrane Library, Lilacs and Medline were assessed using the combination of the terms "uterine artery embolization", "pain" and "superior hypogastric block". Clinical studies were included once available in full text, with adult patients submitted to UAE, whose objective was to evaluate the use of SHNB and its impact in post-procedure pain. Review articles, letters to the editor, and publication in conference proceedings were excluded. Results: 8 articles were found, most of them retrospective, indicated SHNB's consistency in terms of short-term therapeutic success and pain reduction. The single reported complication evolved satisfactorily. Conclusions: SHNB has the potential to improve pain management after UAE, which can positively impact recovery time and quality, with reduced pain and consumption of opioids in the postoperative period. Benefits like these can enhance the embolization procedure as an alternative to be considered for the treatment of symptomatic fibroids for women candidates for uterine preservation.

Evaluación de la efectividad y satisfacción de las pacientes tras miomectomía histeroscópica en consulta / Evaluation of effectiveness and patient satisfaction of hysteroscopic myomectomy in office

OBJETIVO: Analizar la efectividad de las miomectomías histeroscópicas en consulta realizadas con minirresector y conocer si hay factores relacionados con el grado de satisfacción de las pacientes. MÉTODO: Estudio observacional, transversal y prospectivo, de mujeres sometidas a miomectomía histeroscópica en consulta durante el año 2018. Las pacientes recibieron medicación para la preparación cervical, analgesia oral y anestesia paracervical. La miomectomía se realizó con un minirresector de 5.8 mm. Se registraron el tiempo y el dolor en una escala visual analógica (EVA) durante la entrada y la resección, así como la satisfacción de las pacientes a los 3 meses con el cuestionario validado CSQ-8. RESULTADOS: El estudio incluyó 59 pacientes. El tiempo medio de entrada fue menor de 1 minuto (47,93 segundos) y el de resección fue de 13,51 minutos. El dolor referido por las pacientes en la EVA durante la entrada y la resección puntuó en torno a 3 y 4, respectivamente. Se consiguió un 74.6% de resecciones completas de los miomas y la puntuación media de satisfacción de las pacientes fue de 27.17. La resección completa del mioma se asoció con una mayor satisfacción total de las pacientes. CONCLUSIONES: La miomectomía histeroscópica en consulta llevada a cabo con un minirresector de 5.8 mm con analgesia paracervical obtiene buenos resultados clínicos, con buena satisfacción de las pacientes. Esta última se relaciona con una resección completa del mioma, sin que influyan el tiempo necesario para su exéresis ni el dolor.

OBJECTIVE: To analyze the effectiveness of hysteroscopic myomectomy in office performed with mini-resectoscope, and to know if there is any variable related with patient satisfaction. METHOD: Observational and prospective transversal study, which included all women who underwent a hysteroscopic myomectomy in office in 2018. Patients received drugs for cervical preparation and pain management, as well as paracervical block. We used the 5.8 mm mini-resectoscope. We kept record of time and AVS pain during entrance and resection, as well as patient satisfaction 3 months after the procedure using the CSQ-8. RESULTS: The study included 59 patients. Mean entrance time was less than 1 minute (47.93 seconds), while mean resection time was 13.51 minutes. AVS pain during entrance and resection was around 3 and 4, respectively. We achieved 74.6% rate of complete resection. Mean patient satisfaction rate was 27.17 points. We found that a complete myoma resection is related to higher patient satisfaction. CONCLUSIONS: Hysteroscopic myomectomy in office performed with the 5.8 mm mini-resectoscope, using cervical block, achieves good clinical results and a good patient satisfaction. Patient satisfaction is associated with a complete resection of the myoma, without any influence of pain experienced or time required.

Miomectomía múltiple por vía abdominal / Multiple abdominal myomectomy

RESUMEN Se presentaron dos pacientes a las cuales se les realizó una miomectomía en los meses de enero y marzo de 2017, en la localidad de Luanda, Angola. Ambas fueron atendidas en la consulta de Ginecología por: aumento de volumen del abdomen, sangramiento genital durante la menstruación y fuera de ella, síntomas compresivos caracterizados por urgencia miccional y estreñimiento, además de infertilidad. Se les realizaron: exámenes de laboratorio, ultrasonido ginecológico y renal, así como histerosalpingografía. Después del análisis de estos exámenes se les diagnosticó una miomatosis uterina múltiple; fueron remitidas al salón de operaciones con previo consentimiento informado y se les practicó una miomectomía múltiple sin complicaciones transoperatorias. Se conservó el útero en ambas pacientes, las cuales tuvieron una recuperación postoperatoria satisfactoria. Una de estas pacientes logró un embarazo cinco meses después de la cirugía.

ABSTRACT We present two patients who had a myomectomy in January and March 2017, in Luanda, Angola. Both were treated in the Gynecology consultation due to increased abdominal volume, genital bleeding during and between periods, compressive symptoms characterized by urinary urgency, constipation and infertility. Laboratory tests, gynecological and renal ultrasound, as well as hysterosalpingography were performed. After the analysis of these tests, they were diagnosed with multiple uterine myomas, referred to the operating room with prior informed consent and underwent a multiple myomectomy without transoperative complications. The uterus was preserved in both patients, who had a satisfactory postoperative recovery. One of these patients got pregnant five months after surgery.

Extracellular matrix metalloproteinase expression in endometrial tissue after arterial embolization of myomas

OBJECTIVES: Arterial embolization of myomas (AEM) is controversial because of the changes that occur in the extracellular matrix (ECM) of the endometrium and its effect on gestational success in infertile patients desiring reproductive capability. Therefore, we performed this study on the expression of genes in the ECM of the endometrium, such as those coding metalloproteinases (MMP), before and 6 months after embolization of the uterine arteries. METHODS: Seven women with leiomyomas were evaluated, and MMP3 and MMP10 levels were measured. The women underwent pelvic nuclear magnetic resonance (NMR), examination, and endometrial biopsy between the 20th and 24th day of the menstrual cycle, and pre- and post-AEM (after 6 months). For data analysis, the Cq comparative method, also known as the 2-ΔΔCT method, was used to calculate the relative quantities of MMP gene expression among the samples collected. RESULTS: There was a significant decrease by 9.52 times in the expression of MMP3 (p=0.007), and a non-significant change in the expression of MMP10 (p=0.22) in post-AEM-treated women than pre-AEM-treated women. CONCLUSIONS: The results suggest that ECM continues to undergo tissue remodeling 6 months after AEM, at least with regard to MMP3 expression, suggesting that AEM affects the ECM for at least 6 months after the procedure.

Leiomioma celular gigante con degeneración roja, hidrópica y quística: reporte de un caso / Giant cellular leiomioma with red, hydropic and cystic degeneration: report of a case

Los miomas uterinos son neoplasias bastante comunes, se clasifican según su localización en el miometrio; subseroso, intramural, transmural y submucoso. A su vez existen diferentes variantes morfológicas y cambios degenerativos que son un fenómeno frecuente en los miomas, especialmente entre mayor tamaño tenga éste: como la apoplejía, atrofia, hialinización, degeneración roja, quística, calcificación periférica, necrosis, degeneración hidrópica y la degeneración maligna o sarcomatosa. Se expone el caso de una paciente de 53 años sometida a una laparotomía donde se identificó una masa tumoral de 8150 gramos, que dio como resultado anatomopatológico un leiomioma gigante con 3 diversos tipos de degeneración: roja, hidrópica y quística. Se informa este caso por la rareza en su conformación y debido a la falta de reportes en la literatura mundial, siendo este el primer caso presentando y permitiendo realizar algunos comentarios sobre la patología.

Uterine myomas are quite common neoplasms. They are classified according to their location in the myometrium; subserosa, intramural, transmural and submucosal; At the same time, there are different morphological variants and degenerative changes that are a frequent phenomenon in myomas, especially the larger it is: as the apoplexy, atrophy, hyalinization, red degeneration, cystic, peripheral calcification, necrosis, hydropic degeneration and malignant degeneration or sarcomatous. We present the case of a 53-year-old patient who underwent a laparotomy where a tumor mass of 8150 grams was identified, which resulted in a pathological result of a giant leiomyoma with 3 different types of degeneration: red, hydropic and cystic. This case is reported due to the rarity of its conformation and due to the lack of reports in the world literature, this being the first case presenting and allowing some comments on the pathology.

A propósito de un caso: útero miomatoso gigante torsionado / Torsion of a giant miomatous uterus: report of a clinical case autores

OBJETIVO: Reportar el caso de una torsión de útero, trompas y ambos ovarios a nivel de cuello uterino. Describir la patogenia, sintomatología y tratamiento, como un caso infrecuente y potencialmente grave, en la práctica clínica diaria. MATERIAL Y MÉTODOS: Analizar el curso de esta extremadamente rara patología, en una mujer postmenopáusica de 59 años. Se trata de un caso raro de torsión uterina en un útero no gestante, reportando los hallazgos en los exámenes previos a la cirugía y los hallazgos intraoperatorios e histopatológicos postcirugía. La resonancia magnética fue fundamental en el diagnóstico de la paciente y la laparotomía realizada demostró una torsión de cuerpo uterino de 360 ° a nivel de cérvix, y un gran mioma pediculado con signos de necrosis. Hemos revisado los últimos artículos de esta rara patología RESULTADOS Y DISCUSIÓN: La paciente fue operada. Se realizó una histerectomía total mediante una laparotomía media supra e infraumbilical. Los ovarios no tenían signos de necrosis. CONCLUSIONES: Debemos tener en cuenta esta posibilidad diagnóstica, en pacientes con aumento de tamaño uterino y clínica de dolor abdominal, ya que aunque es muy infrecuente, su diagnóstico es importante, ya que puede ser peligroso para la vida de la paciente.

OBJECTIVE: To report a case of torsion of the uterus, fallopian tubes and both ovaries around the uterine collum and the symptomatology, pathogenesis and treatment of this uncommon pathology. MATERIAL AND METHODS: The article analyses the course of this extremely rare pathology in a postmenopausical woman of 59 years. It is a rare case like a non gravid uterine torsion in a postmenopausical woman. We have the exams previous to the surgery, the finds intraoperative and the histolopathological reports postsurgery. RMN was the most important in diagnosis and the laparotomy showed a 360° an uterus increased on size and a big pedunculated myoma with signs of necrosis We have reviewed the latest articles on this strange pathology RESULTS AND DISCUSSION: The patient was operated. A infra-supra medium laparotomy was practiced and a total hysterectomy was made. Ovarians had not signs of necrosis. CONCLUSIONS: We must take into account, in patients with pathologies that increase uterine size and abdominal pain, the possibility of uterine torsion. Although it is a very infrequent pathology, its diagnosis is important, since it can be dangerous for the life of the patient

Robotic-assisted laparoscopic myomectomy: the feasibility in single-site system

OBJECTIVE: To evaluate the feasibility of robotic single-site myomectomy (RSSM). METHODS: Medical records of 355 consecutive women who underwent robotic-assisted laparoscopic myomectomy were retrospectively reviewed. Clinical characteristics were compared between multi-site and single-site systems. After 1:1 propensity score matching for the total myoma number, largest myoma size, and total tumor weight (105 women in each group), surgical outcomes were also compared between the 2 systems. RESULTS: A total of 105 (29.6%) and 250 (70.4%) women underwent RSSM and robotic multi-site myomectomy (RMSM), respectively. RSSM was more commonly performed in women with lower body mass index (21.6 vs. 22.5 kg/m2, P=0.014), without peritoneal adhesions (7.6% vs. 24.8%, P < 0.001), and less (2.6 vs. 4.6, P < 0.001) and smaller (6.3 vs. 7.7 cm, P < 0.001) myomas compared to RMSM. After propensity score matching, the largest myoma size (P=0.143), total myoma number (P=0.671), and tumor weight (P=0.510) were not significantly different between the 2 groups. Although the docking time was significantly longer in the RSSM group (5.1 vs. 3.8 minutes, P=0.005), total operation time was similar between RSSM and RMSM groups (145.9 vs. 147.3 minutes, P=0.856). Additionally, hemoglobin decrement was lower in the RSSM group than in the RMSM group (1.4 vs. 1.8 g/dL, P=0.009). No surgical complication was observed after RSSM, while 1 ileus and 2 febrile complications occurred in women that underwent RMSM (0% vs. 2.9%, P=0.246). CONCLUSION: Although RMSM is preferred for women with multiple large myomas in real clinical practice, RSSM seems to be a feasible surgical method for less complicated cases, and is associated with minimal surgical morbidity.

Posterior reversible encephalopathy syndrome in a woman who used gonadotropin-releasing hormone agonists: a case report

Posterior reversible encephalopathy syndrome (PRES) is a newly described adverse effect possibly associated with gonadotropin-releasing hormone (GnRH) agonist therapy. We report a case of PRES after 2 doses of depot GnRH agonists in a 44-year-old woman with a huge myoma uteri and iron-deficiency anemia. Brain magnetic resonance imaging showed high signal lesions in both occipital lobes on fluid-attenuated inversion-recovery (FLAIR) images, compatible with PRES. After treatment with anticonvulsant, she recovered both radiographically and clinically. The association between PRES and GnRH agonist use is still enigmatic, and thus should be further clarified.

Sonographic and Clinical Characteristics of Uterine Sarcoma Initially Misdiagnosed as Uterine Fibroid in Women in the Late Reproductive Age

OBJECTIVES: Uterine sarcoma is a rare malignant tumor, which is usually diagnosed in postmenopausal women. These sarcomas are occasionally misdiagnosed as uterine fibroids, thereby leading to delayed diagnosis in the advanced stages. We analyzed the sonographic and clinical characteristics of unexpected uterine sarcomas detected after surgery in women in the late reproductive age.METHODS: The medical records of 61 patients preoperatively diagnosed with uterine leiomyomas through sonography but confirmed as uterine sarcomas after surgery from January 2005 to December 2018 at Asan Medical Center were retrospectively analyzed. We evaluated the clinical symptoms, sonographic findings, and Doppler indexes, and investigated whether there were any significant characteristics that could clearly differentiate uterine sarcoma from fibroids.RESULTS: The most common clinical finding was increased mass size (15 patients, 24.6%), while 9 patients (14.8%) showed no symptoms. Ultrasonography showed that the maximum diameter of most fibroids was > 5 cm (49 patients, 80.3%), and the average diameter was 75.6 ± 36.3 mm. All the patients showed heterogeneous echogenicity in sonographic imaging. Secondary degeneration of the myomas was reported in 36 patients (59%), and approximately 90% (32/36, 88.9%) showed cystic changes. Of the 40 patients who underwent the evaluation of vascularity, 35 showed increased vascularity of the mass.CONCLUSIONS: In this study, sarcomas misdiagnosed as leiomyomas were usually > 5 cm, and ultrasonography showed heterogeneous echogenicity and irregular cystic degeneration. No definite clinical symptoms were helpful; a thorough evaluation is necessary to rule out uterine sarcomas in women having uterine mass with these characteristics.

Artificial Neural Network Analysis of Spontaneous Preterm Labor and Birth and Its Major Determinants

BACKGROUND: Little research based on the artificial neural network (ANN) is done on preterm birth (spontaneous preterm labor and birth) and its major determinants. This study uses an ANN for analyzing preterm birth and its major determinants.

Lack of Haptic Feedback Is Replaced by More Developed Visual Sense during Robotic Myomectomy / 이화의대지

In the reproductive age, many women have several uterine myomas and present with abnormal uterine bleeding, dysmenorrhea, and occasionally infertility. There are three surgical approaches to perform myomectomy, including robotic-assisted, laparoscopic, and abdominal myomectomy. Compared to laparoscopic procedures, robotic myomectomy allows free approach of myoma bases using fine instruments and endoscopes. Fine uterine wall sutures can be performed layer-by-layer with robots. However, robotic surgery is difficult to perform because there is no sense of touch during the operation. We report two clinical myomectomy cases with replaced lack of haptic feedback during robot surgery. The patients received robotic myomectomy with/without right ovarian cystectomy and adhesiolysis. Sixty-five leiomyomas were removed in case 1. Forty-six leiomyomas were removed in case 2. Lack of haptic feedback is replaced by more developed visual sense during robot myomectomy of multiple tiny intramural myomas, and robotic surgery can be performed much more effectively even in complicated cases.

Hysteroscopic myomectomy without anesthesia

OBJECTIVE: Scarce literature about myoma removal without anesthesia has been published. The aim of this paper is to evaluate the feasibility of a new alternative for a hysteroscopic myomectomy in a conventional office setting, without need for anesthesia. METHODS: Step-by-step description of the surgical technique has been provided, based on video images. An office hysteroscopy was performed in a Gynecological Endoscopy Department of a tertiary European hospital. RESULTS: A 49-year-old woman was referred for management of severe hypermenorrhea. Consent and approval were received from the patient and the institutional review board, respectively. The introduction of a Truclear® hysteroscopic polyp morcellator of 5.5 mm with optic of 0 degrees into the uterine cavity did not require any kind of anesthesia or cervical dilatation. The use of saline flow helped distend the cavity and identify a submucosal myoma. Under direct vision, a full myomectomy was performed via mechanical energy with continuous cutting movements, without any complication. After the procedure was completed, the excised material was aspirated through the device into a collecting pouch. A successful complete morcellation of a Type-0 submucosal leiomyoma with a polyp morcellator device was performed in an outpatient setting. Good medical results, good tolerance by the patient besides lower surgical risks due to mechanical instead of electrical energy are shown. CONCLUSION: In conclusion, this video demonstrates that a hysteroscopic myomectomy can be performed successfully in office with lower risk of complications from the procedure and without use of general anesthesia besides good tolerance by the patient.

Clinical Characteristics Indicating Uterine Leiomyoma, Adenomyosis, and Uterine Leiomyoma Coexisting with Adenomyosis: Retrospective Study

OBJECTIVE: This study is to compare the baseline characteristics and symptoms between groups with leiomyoma only (group M; myoma group), adenomyosis only (group A; adenomyosis group), and leiomyoma and adenomyosis together (group B; group for both disease). METHODS: Selected patients were who received total abdominal hysterectomy, laparoscopy-assisted vaginal hysterectomy, or total laparoscopic hysterectomy from January 2014 to December 2015, and whose pathology result showed leiomyoma (n=74), adenomyosis (n=27), or both (n=63). Baseline characteristics and symptoms were reviewed from the medical records. Researched characteristics included patients' age, degeneration of leiomyoma, endometrial hyperplasia, endometriosis, weight of the removed uterus, menopause before the surgery, method of the surgery, necessity for blood transfusion before and after the surgery, difference of hemoglobin level before and after the surgery, and number of gravida, para, and abortion. RESULTS: Eleven symptoms were checked. Thirty-eight point four percent of total subject had uterine leiomyoma and adenomyosis at the same time. Number of abortion was higher in the group B. The group B showed a tendency of presenting more menorrhagia, dysfunctional uterine bleeding, acute lower abdominal pain, and urinary frequency. Symptoms related to mass effect seem to be relative to uterine leiomyoma, and symptoms related to menorrhagia seems to be relative to adenomyosis. The group M showed suddenly growing mass symptoms, and was more likely to have massive hemorrhage during the surgery. It is hard to differentiate coexistence of uterine leiomyoma and adenomyosis from each disease. CONCLUSION: Coexistence of two disease exhibits mixed symptoms of each disease, but shows different tendency.

Endometrial thickness cut-off value by transvaginal ultrasonography for screening of endometrial pathology in premenopausal and postmenopausal women

OBJECTIVE: To assess the clinical usefulness and diagnostic accuracy of ultrasonographic measurement of endometrial thickness (ET) in women with endometrial hyperplasia or cancer (EH+). METHODS: This retrospective cohort study included 29,995 consecutive women who underwent transvaginal ultrasonography (TVS) for an incidental finding of a thickened endometrium at the health screening and promotion center at Asan Medical Center between 2006 and 2010. Among 959 patients with endometrial abnormalities, 92 patients were included in this study. A total of 867 patients were excluded: 416 were lost to follow-up; 263 did not undergo endometrial biopsy; 155 had endometrial polyps; 17 had submucosal myomas; and 16 had insufficient tissue samples. Endometrial histology was the reference standard for calculating accuracy. RESULTS: Of the 92 patients, 78 (84.8%) had normal pathology, while 14 (15.2%) had endometrial pathology (EH+), including 5 patients (35.7%) with simple hyperplasia without atypia, 3 (21.4%) with complex hyperplasia, and 6 (42.9%) with endometrial carcinoma, all stage Ia. The area under the receiver-operating characteristic curve was 0.75 (95% confidence interval [CI], 0.593–0.906). The cut-off value for ET was 8 mm, indicating that TVS ET had a fair accuracy in diagnosing carcinoma, had a sensitivity of 100% (95% CI, 62.9–100.0%) and a specificity of 24.3% (95% CI, 15.2–36.3%). CONCLUSION: TVS is useful for detecting EH+, with a cut-off value for ET of 8 mm having a high sensitivity for detecting endometrial pathologies and the ability to identify women highly unlikely to have EH+, thereby avoiding more invasive endometrial biopsy.

Polycystic ovarian morphology is associated with primary dysmenorrhea in young Korean women

OBJECTIVE: This study was aimed at identifying a correlation between polycystic ovarian morphology (PCOM) and the severity of primary dysmenorrhea in young Korean women. METHODS: A total of 592 patients who visited a tertiary hospital from March 2008 to March 2015 for dysmenorrhea were examined. After excluding those with secondary causes of menstrual pain (for example, myoma, adenomyosis, endometriosis, and pelvic inflammatory disease), 361 women were recruited and retrospectively analyzed. Severe dysmenorrhea was defined as a visual analog scale (VAS) score ≥6. RESULTS: The mean patient age was 23.0±4.0 years, the average menstrual cycle length was 34.4±23.7 days, and the average pain intensity was VAS 6.7±0.1 at baseline. PCOM was assessed by ultrasound in 54 women (15%). Patients with severe menstrual pain were more likely to have irregular menstrual cycles (P=0.03) and heavy menstrual flow (P=0.01) than those with mild menstrual pain. After adjusting for weight, height, menstrual cycle interval, and menstrual flow in the logistic regression analysis, PCOM (odds ratio [OR], 2.26; 95% confidence interval [CI], 1.05–4.97; P=0.04) and heavy menstrual flow (OR, 1.85; 95% CI, 1.05–3.28; P=0.04) were found to be significant independent factors influencing pain. CONCLUSION: Our study shows that PCOM may have a correlation with the severity of primary dysmenorrhea. Since PCOM may play a role in the development of menstrual pain, patients with PCOM should be under active surveillance with resources for prompt pain management readily available. It may also be necessary to further investigate the molecular mechanisms of pain development in primary dysmenorrhea.

Incarceration of early gravid uterus with adenomyosis and myoma: report of two patients managed with uterine reduction

Although gravid uterine incarceration is typically diagnosed during the early second trimester, we encountered two unusual cases in early pregnancy. A 34-year-old multiparous woman with adenomyosis presented at 7 + 2 weeks of gestation with increased urinary frequency and a sensation of incomplete bladder emptying. The uterine incarceration was successfully reduced by manual reduction and pessary insertion, and she delivered a normal infant at term. In the second case, a 31-year-old nulliparous woman with a large myoma complained of dysuria, acute urinary retention, and intense back pain at 6 weeks of gestation. Manual reduction was successful in the knee-chest position. Subsequent pessary insertion failed; however, a slight reduction in pain was achieved. After a week, the fetus spontaneously aborted. In summary, gravid uterine incarceration is a rare but potentially fatal condition for the fetus, and a suspicion of this condition in patients with urinary symptoms, especially urinary retention and pelvic pain, is important in the early gestation period.

Aberrant uterine leiomyomas with extrauterine manifestation: intravenous leiomyomatosis and benign metastasizing leiomyomas

OBJECTIVE: Intravenous leiomyomatosis (IVL) and benign metastasizing leiomyoma (BML) are uncommon variants of benign uterine leiomyomas with extrauterine manifestations. Categorizing the extent of disease allows clinicians to delineate the clinical spectrum and the level of sophistication for complete surgical resection. METHODS: Twelve patients with IVL and BML were reviewed. They were divided into early versus late stage disease groups, and initial manifestation, clinical characteristics, laboratory values, surgical pathology, and follow up data were summarized. RESULTS: Patients were mostly pre- or peri-menopausal and parous. Patients with late stage disease were more likely to present with cardiac symptoms or abnormal findings on chest X-ray, whereas those with early stage disease presented with classical leiomyoma symptoms including heavy menstrual bleeding, increased myoma size, or lower abdominal discomfort. Tumor marker levels were within normal ranges. A trend of higher neutrophil to leukocyte ratio was observed in the late versus the early stage group (10.4 vs. 1.51, P=0.07); the platelet leukocyte ratio was statistically higher in patients with late stage IVL (0.23 vs. 0.13, P=0.04). The overall recurrence rate was 25%. No recurrence was observed in stage I or stage III IVL groups, while 50% of the stage II IVL group showed recurrence in the pelvic cavity. CONCLUSION: IVL and BML are benign myoma variants with paradoxically metastatic clinical presentation. Careful inquiry of systemic symptoms, the presence of underlying systemic inflammation, and a high index of suspicion are required for preoperative diagnosis. Furthermore, a multidisciplinary approach is necessary to improve outcomes of surgical resection.